By three to four years of age the number of referrals for difficult behavior rises (Weiss & Hechtman, 1987). This is most likely because of society's expectations for this age child, which rise and exceed the ability of a difficult child to conform to the expected norm. It is also the time when the mother encounters community rejection of her child's behavior-e.g., in the neighborhood, play group, or preschool. Certainly the widespread publicity about children with behavioral difficulties in the lay press may also account for these referrals.
To avoid the negative effect of labeling a child, some authors have described these children by other names. Although the names are different, the characteristics are similar and so is the recommended handling of these children. Linda Budd, a St. Paul, Minnesota, psychologist and family therapist, has described and studied the "Active/Alert" child (Boyd, 1988). She says these children are "movers and shakers," but they are not hyperactive.
Active/Alert children can sit still for an activity such as television which interests them, but may have difficulty settling down for sleep. These children are alert to all the sights and sounds around them and have difficulty screening out what is not important. They have no sense of boundaries for themselves or others. Budd recommends consistent routines and the establishment of firm rules. The group of children that she has studied are also described as very bright, perhaps gifted. However, they may have learning differences in reading and may be more auditory than visual learners.
Randy Lee Comfort, Ph.D., Social Worker and Director of the Learning Place in Denver, Colorado, describes a child who experiences learning and living difficulties as the "Unconventional Child" (Comfort, 1992) These are children who learn, behave, think, react, and play differently from most of their peers. These children do everything that other children do, but with greater intensity, more erratically, and with more inconsistency. They are able to concentrate on a task for only a few minutes. Comfort recommends organization and structure for these children because they often feel that the daily world is not in their control.
The "Difficult Child" has been described by Dr. Stanley Turecki, M.D. (Turecki & Tonner, 1985). This is a child with a high activity level whom he prefers to call "difficult" so as to consider the total child. Activity level, according to Turecki, is just one of the nine dimensions of temperament; activity level most often gets singled out because it is the most socially visible trait. Characteristically, these children are defiant, tend to whine and complain, throw temper tantrums, are stubborn and do not listen, are loud and active, and have irregular eating and sleeping patterns. Turecki believes that even if the child's diagnosis is hyperactivity, having knowledge and understanding of temperament factors can help parents and teachers cope better and manage the child's behavior more successfully.
The nine temperament traits were first defined by Drs. Alexander Thomas, Stella Chess, and Herbert Birch of New York University in their New York longitudinal study in 1956. The traits include Activity Level, Distractibility or Perceptiveness, Persistence, Adaptability, Approach/ Withdrawal or First Reaction, Intensity, Regularity, Sensitivity, and Mood. Temperament traits are placed on a continuum from easy to difficult. The more of the traits that fall on the difficult end of the continuum, the harder it is to raise that child. Turecki's book discusses management of these children on the basis of temperament.
The "Spirited Child" is more intense, persistent, perceptive, and uncomfortable with change than other children. He or she possesses these characteristics to more depth and range than others, says Mary Sheedy Kurcinka, M.A., licensed teacher and family educator (1991). She prefers the term "spirited" because it sounds good and communicates the exciting potential of these kids. This term focuses on strengths rather than weaknesses and is not a label but a tool for understanding. Like Turecki, Kurcinka describes the spirited child using the nine dimensions of temperament. Also included in her book is a temperament scale for parents to use as a tool for comparing their own temperament style with the child's so as to understand parent-child interactions better.
Whether a child is called "Active/Alert," "Unconventional," "Difficult," or "Spirited," most would agree that sometimes a child's behavior may be outside the realm of normal behavior. At this point, the label that these authors resist may have to be ruled out. Turecki admits that the diagnostic label of Hyperactivity or Attention Deficit/Hyperactive Disorder (ADHD) may be appropriate for some children who are extremely active no matter where they are (Turecki, 1985). These children virtually never sit still. Their actions are haphazard rather than goal-directed. They are always touching things, have trouble paying attention to almost anything, do not follow directions, and are always interrupting.
Kurcinka distinguishes the Spirited Child from the ADHD child when she describes the ADHD child as not being able to focus energy and attention to complete a task; overwhelmed by stimuli (verbal and nonverbal); and unable to sort out which information is most important to listen to (Kurcinka, 1991). Unlike the ADHD child, the Spirited Child can be aware of multiple stimuli but can process the information more quickly, stay tuned to the most important part, and ultimately complete the task.
What is an Attention-Deficit/Hyperactivity Disorder? It is a chronic behavior disorder characterized by a variety of observable symptoms. These symptoms include the following:
- Inability to sustain attention over time with resulting incomplete work.
- Acting without thinking and having difficulty delaying gratification.
- Inability to regulate or modulate activity to fit the demands of the situation.
- Being physically restless and having nonproductive activity.
- Variable behavior from task to task or day to day, implying laziness or having manipulative behavior.
In the preschool setting, ADHD children are seen as the kids who change their activity more frequently and in a shorter period of time than their peers. They have more difficulty in a group than in a one-to-one situation. ADHD children can be accident-prone because of increased activity, and display poor motor control or poor coordination. These children are rejected by peers because of their increased activity and inability to respect the boundaries and/or personal space of others. They have significant mood swings and have difficulty handling change or transitions.
Most studies suggest that there are multiple routes to the development of difficult behavior and/or ADHD in childhood. Many parents, when confronted with a difficult child, initially feel that they are to blame. They believe that they have been inadequate in their parenting skills. Although parenting techniques may certainly interact with and affect a child's behavior, these techniques in themselves are not the cause of difficult behavior and/or ADHD. Carlson, Jacobvitz, and Stroufe looked at the quality of caregiving as a factor in the development of inattention and hyperactivity in children (1994). As a result of their longitudinal study of 191 participants from birth to 12 years of age, they concluded that while maternal caregiving style proved significant in their sample, it is not a direct cause. More research needs to be done to explore the interaction of this variable with others.
Evidence suggests that a child is born with a genetic tendency to develop ADHD and that he or she inherits this tendency from his or her parents. It is not unusual when reviewing the family history of an ADHD child to find parents and relatives claiming to have had or still exhibiting the same behavioral symptoms as the child. Unfortunately, at this time geneticists have not been able to isolate the specific gene or genes that are directly linked to behavioral disorders such as ADHD.
Sanson, et. al., found in their study that children who showed more aggressive and hyperactive behaviors later were as infants more irritable and less manageable, with aspects of a negative mood, nonadaptability, and high intensity (1993). The authors hasten to add that infant temperament alone is not a predictor of later behavioral problems, but it seems the occurrence of this factor with other environmental stresses creates the risk situation.
Recent biochemical studies have focused on the brain. There is speculation that there is an imbalance of two key neurotransmitters (brain chemicals), dopamine and norepinephrine, in the brains of persons with ADHD. These chemicals appear to influence those areas of the brain which control activity, impulses, and emotionality. Drugs used to treat hyperactivity are known to act at the level of these transmitters, suggesting that this chemical imbalance may be a cause of ADHD. Other exploratory studies have looked at brain metabolism, comparing adult ADHD males and adolescents to normal subjects. They found decreased metabolic activity in the areas of the brain known to regulate attention and motor activity in the ADHD subjects, compared to the normal controls. This, perhaps, is the first evidence of a neurobiological difference between hyperactive and normal people. However, more studies need to be done to confirm these results.
There is value in learning about and understanding the multiple factors that may be instrumental in the development of behavioral problems and/or ADHD. Even though these factors are still speculative theories, recognizing them should facilitate and guide appropriate assessment and diagnosis. In addition, this knowledge should encourage preventive approaches which emphasize the development of early parenting skills and social/emotional supports for parents.
Preschool teachers and child care providers are in a very good position to recognize difficult behaviors. Play is one of the most important activities of childhood. Patterns of play and interaction with peers are areas in which difficulties in attention, activity, and impulse control can be expressed. The teacher's factual observations of a child's play are an important contribution to the assessment process. Some pertinent documentations of a child's activity may include the following:
- Moving from one activity to another with very little sustained involvement.
- Frequent need for teacher redirection and verbal warnings of punishment.
- Disorganized, nonconstructive, and non-goal-directed play activity.
- Difficulty sharing with peers and being able to wait for turn.
- Mood swings and behavioral outbursts.
The more the teacher can describe the behavior relative to frequency, time of day, and associated activities, the more helpful the information. Providing factual information regarding a specific child's behavior relative to other children is appropriate for the teacher to communicate to parents. It is not helpful for the teacher to suggest a diagnosis or treatment but rather to communicate concern and determine whether the parent has had similar concerns. Parents must then decide if they want to pursue appropriate evaluation of their child's behavior.
Diagnosis of a preschool child is more difficult to establish because behavior like hyperactivity can be typical of two- to five-year-old children, and behavior changes rapidly during this developmental period. Most resources will not test a child until he or she is three years old. According to established societal norms, a three-year-old child, developmentally, should be able to play cooperatively, listen to adult instructions, and use symbolic language.
Before any treatment is implemented, it is wise to pursue a comprehensive evaluation to determine the diagnosis as well as eliminate the possibility of other reasons that may cause the behavioral condition. Unfortunately, there is no single objective measure, such as a blood test, that confirms the diagnosis of ADHD. Rather, a battery of tests and a gathering of information from several sources with clinical observations by a multidisciplinary team provide the most complete and varied perspective of the child's condition.
Since difficult behaviors such as hyperactivity, poor impulse control, and inattention may be present because of other physical reasons, the health care provider needs to rule out other diagnoses. Prenatal incidents such as fetal exposure to drugs and alcohol, maternal toxemia, long labor, or fetal distress may, in some cases, cause a child to have later behavioral problems. Lead poisoning, depending of the degree of exposure, may result in developmental difficulties. Other illnesses that may cause similar symptoms are thyroid deficiencies, low blood sugar, seizures, sleep disorders, and mental and emotional problems. A complete physical and neurological examination is necessary, along with an assessment of vision and hearing.
Many children who have behavioral problems also have learning difficulties or delays in their development. A psychological evaluation of a child's verbal and nonverbal abilities is an important part of this comprehensive assessment. An in-depth interview with the parents for family and behavioral history is important in determining the presence of any risk factors and social or emotional problems.
The diagnostic team incorporates the behavioral information from the teacher and parents along with any other reports and provides their interpretation of the data. The diagnosis of ADHD is based on the criteria established by the American Psychiatric Association and put forth in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994). These criteria require that the behavior be more frequent and severe than is typically observed in individuals of the same age or stage. Six or more symptoms must be present in each of the two categories of inattention and hyperactivity-impulsivity. The symptoms must have been present before age seven and persisted for at least six months. There must be impairment from the symptoms in two or more settings such as school, home, or work. There must be evidence of interference with developmentally appropriate social, academic, or occupational functioning.
Frequently, ADHD is not the only diagnosis that a child will have. In the preschool child, it is not uncommon to have an accompanying condition of a language disorder, other developmental delays, and/or an oppositional defiant disorder. Whether a child has one or more diagnoses, the treatment should be directed toward the management of the symptoms with a variety of approaches.
Treatment of ADHD and/or its commonly associated developmental and behavioral disorders is usually in the form of symptomatic relief rather than a cure. There is no cure for ADHD and there are instances where the symptoms continue into adulthood.
No one can accurately predict the outcome for an individual child with ADHD. It does appear that many people continue to be troubled by the symptoms of ADHD. However, many children are also able to leave the disorder behind, either because the symptoms diminish over time or because they learn to compensate for their difficulties (Bain, 1991).
Because children with ADHD have multiple areas of difficulty, it is necessary to use a multimodal approach. The treatment should include environmental adaptations, individual and family education and counseling, behavior management techniques, social/recreational skill development programs, and appropriate medication.
In the list of treatment strategies, medication is purposely listed last. It is the author's opinion that medication, alone, is the smaller part of the intervention for a child with ADHD. This is particularly true with the preschool child. In this author's experience, preschool children are very difficult to medicate, most likely because of their neurological immaturity and developmental variability.
Studies of medication with preschoolers have shown variable results. Some children improved; others have had difficulty with side-effects of anxious clinging behavior, sleep problems, and reduced appetite (Conners, 1975). However, children can benefit from medication when it is used in conjunction with other interventions such as modification of the environment and appropriate behavioral management strategies.
A preschool program should provide a developmentally appropriate curriculum with activities that are appropriate for the age of the group as well as the developmental levels of each individual child. Having small groups of children work at self-selected activities is preferable to teacher-directed, large-group instruction. A high teacher-to-child ratio seems to be more beneficial for a difficult child.
Small groups are quieter, less dangerous, and conducive to fewer problems. A variety of interest areas, separated by low dividers, invites small groups to play together. Having an adequate supply of play equipment discourages disputes over a single item. A preschool should provide structure, but also room to run and play freely. A child who has problems with change needs a school with a flexible approach that allows him or her time to adapt.
Maintaining self-esteem is paramount in dealing with children with difficult behavior. A teacher's accepting, nonjudgmental, positive style is extremely important, since the difficult child is not able to change or control certain behaviors merely by "trying harder."
Accentuate the positive when giving directions, versus shouting "No." For example, when a child is painting on another child's paper, say, "Here, let's use your paper for your picture." Letting a distractible, inattentive child know what you want him to do rather than what you do not want him to do is more constructive and informative. Look for frequent opportunities to reward or praise a child for good behavior and performance.
An alert teacher style is also important to spot trouble before it happens and intervene appropriately. Rules should be clear and simple. Similarly, the consequences should be reasonable. The presentation of these should be conveyed with good eye contact, in a tone that says you are in control, serious, and neutral. When problems occur, remind the child of the rule. Do not argue or negotiate. Simply explain, "That's the rule!"
Provide structure that involves consistency and routines. Maintain a daily schedule of events. Frequent changes or surprises are not comfortable for the difficult child. When change is necessary or when changing to a new activity, provide this child with a warning. "We are going out in ten minutes" has little meaning for the preschool child. Instead relate time to the current activity, e.g., "When we finish coloring the pumpkin, we will get ready to go outside." Have step-by-step explanations of jobs. These can be described in a picture chart for such activities as going to the bathroom, getting ready for lunch, mealtime, naptime, or clean-up time. The difficult child will need frequent reminders.
It is not that the difficult child does not understand the rules, but there are times when she will not be able to apply them because of her inherent variability of performance. The teacher will need to be more vigilant, plan carefully, and be more available to this child. Other behavior management techniques could include these:
- Keep choices to a minimum and age appropriate. "Do you want a red cup or a blue cup?"
- Have several toys/activities, etc. available. Sharing does not come easily to the difficult child.
- Break a task down into its parts when introducing a distractible child to a new skill. Unlike regular children, his poor observation skills have not allowed him to gain the needed information naturally to proceed with this skill.
- Respond to a problem situation immediately and treat the child fairly. If a spill occurs by mistake, it needs cleaning up. If it is an intentional spill, it requires a consequence.
- Provide pillows, balls, beanbags, or punchbags for appropriate hitting, throwing, and kicking when angry.
- Use warm fuzzies, cuddlies, or blankets for security and loving as well as kisses, hugs, and encouragement.
- Use a chair for time out in a non-interesting area when a child is not doing well. Present it as a time to gain control versus a punishment. The length of time should be just enough to be able to apply praise for compliance and allow the child to gain some composure.
An understanding, patient teacher who is firm yet loving can go a long way in preserving the self-esteem of a difficult preschool child. Although he or she is a daily challenge of inconsistencies and frustrating regressions of behavior, how the difficult child survives this developmental stage will affect his or her next stage of development.
A challenging preschool child may be described in a variety of terms or names. Care or management of this child should be focused on the specifically observed behaviors rather than the name or label that is being used to describe his behavior. Some of his or her behaviors may be similar to those of other children of the same age. The distinguishing factors for the difficult child are the extreme intensity, frequency, and inconsistency of his or her behavior. A competent, comprehensive evaluation of a child with difficult behavior is imperative to ascertain the source of the problem and be sure there are no other physical, emotional, or behavioral reasons for his or her problems. No matter what the eventual diagnosis or cause of the child's behavior, treatment should include management by understanding, accepting, and cooperating parents and teachers in collaboration with other health care providers.
Patricia Woodbury, MSN, CPNP, is a pediatric nurse practitioner at Children's Health Care St. Paul.
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Boyd, C. (February 13,1988). Active alerts a challenge.St. Paul Pioneer Press Dispatch.
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