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David Baxter PhD

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Bratty or behavior disorder? Help for parents
By Linda Carroll, MSNBC
Thurs., Nov. 15, 2007

Researchers offer clues on where ?terrible twos? end and real trouble begins

The first time her 3-year-old fainted in the middle of an argument, Suzanne Miller got scared. Worried that it might be the sign of a serious health problem, Miller rushed Brianna to the family?s pediatrician.

The diagnosis was reassuring and at the same time distressing: Brianna had simply held her breath so long that she passed out.

?The doctor said it was just a normal run-of-the-mill temper tantrum,? remembers the 42-year-old nurse from Alloway, N.J. ?He told us she?d outgrow it and the best thing we could do was to ignore it. The only thing we could do was stop her from hurting herself when she went down.?

Parents caught off guard by the willfulness of their toddlers sometimes find themselves staring down at their offspring wondering if they?ve inadvertently produced the next Damien: How could this little ball of anger, screaming and wildly pitching anything within reach, be normal? And, they ask, just where do the ?terrible twos? end and mental-health problems begin?

Scientists around the country are trying to figure out the answers to those very questions.

Diagnosis of more serious behavior disorders, including oppositional defiant disorder and conduct disorder, are currently based on signs and symptoms, such as stealing, vandalism and rape, that would only be seen in older kids.

But ?there?s more and more evidence that these kinds of mental health problems emerge early in childhood,? says Lauren S. Wakschlag, an associate professor at the Institute for Juvenile Research at the University of Illinois at Chicago.

If the bad behavior can be caught in the preschool years before it becomes ingrained, researchers say, the parents can be given tools that may help their children get back on track before it escalates into juvenile delinquency or criminal acts.

But first, specialists need a straightforward way to find troubled kids early. That?s not as easy as it sounds when you consider that antisocial behavior is all in a day?s work for most toddlers. As many as 75 percent of 2-year-olds, for instance, regularly display aggression and throw tantrums.

?Sometimes parents ? especially when it?s a first child ? don?t know what the norm is for that age group,? says John R. Weisz, a professor of psychology at the Harvard Medical School and president of the Judge Baker Children?s Center.

Wakschlag and her colleagues devised a way to evaluate preschoolers for what they call disruptive behavior disorder, or DBD, an umbrella term for a range of behavior problems including severe defiance, agression and more which can lead to even bigger trouble as the child ages. During a 50-minute evaluation, children are observed interacting first with parents and then with a trained examiner in situations that are fairly typical, but would put any toddler to the test, according to a report published recently in the Journal of Child Psychology and Psychiatry.

?The kids are asked to perform very simple tasks that might lead to frustration,? Wakschlag explains. ?They have to clean up their toys. They have to take turns. They have to wait.?

Overall, the researchers found some fundamental differences between kids with the DBD diagnosis and the typical tempestuous ? but normal ? toddlers.

Often, it simply comes down to a matter of degree. While it?s completely normal for a kid to explode when denied a candy bar at the grocery store, parents should worry when a toddler?s outbursts are ?very frequent, very intense or very inflexible,? Wakschlag explains. ?If your every request gets a ?no? before you?ve even gotten the words out of your mouth, that?s a problem.?

Telling the difference
Toddlers with DBD can get ?stuck? in an emotion, Wakschlag says. ?They get so upset, they can?t come down,? she adds. And while it?s normal for any toddler to have meltdowns, kids with the disorder can have 20-minute tantrums as many as 10 times a day, according to Wakschlag.

The Chicago researcher notes another sign that can spell trouble: when a toddler is physically aggressive ? hitting, biting, or kicking ? not just with other children, but also with adults.

While unruly toddlers can be challenging for parents, they generally turn out OK without any formal interventions, experts say.

Brianna Miller, for example, quit having fainting episodes within a year. And at 15, she?s a typical teen, according to her mom. ?But, she?s still got a strong personality,? Suzanne Miller adds.

No more blaming the parents
While it used to be popular to blame parents for problem kids, that isn?t so much the case today.

Scientists often can?t say exactly why a particular kid turned out to be more difficult than her kindergarten-mates, says Alan Kazdin, John M. Musser Professor of Psychology and Child Psychiatry and director of the Parenting Center and Child Conduct Clinic at Yale University.

One thing is clear: Without help, kids with DBD or other behavior disorders are much more likely to drop out of school, engage in criminal acts or commit suicide, says Dr. Joyce Nolan Harrison, an assistant professor at the Johns Hopkins School of Medicine and director of Preschool Clinical Programs at the Johns Hopkins Bayview Medical Center. Studies have shown that to be effective, interventions must start before a child is 9 years old.

Often the solution needs a two-pronged approach, experts say.

?Sometimes it takes a behavioral intervention for the kids; sometimes what?s needed is parent education; sometimes it?s a combination of both,? Harrison says.

Behavioral interventions can focus on teaching youngsters to better control anger and to express emotions verbally rather than physically, she adds.

Occasionally kids turn out to have a biological issue also, which may call for medication. ?I have some kids who come from stable homes with solid parents,? Harrison says. ?But they?re emotional or behavioral messes. In these cases I prescribe medication.?

Often that means Ritalin, a drug which studies recently showed to be safe and effective in preschool-age children, she adds.

'Managing in the moment'
For many kids, though, the most effective therapy is education for parents, Harrison says.

That?s because even the best-intentioned parents may not be up to the demands of a particularly difficult toddler, agrees Patrick H. Tolan, director of the Institute for Juvenile Research and professor in the department of psychiatry and School Public Health at the University of Illinois at Chicago

?We help parents raise challenging children,? Tolan says. ?And we teach them how to manage in the moment, when things are particularly difficult or stressful. We teach them to teach their children that aggression doesn?t get you anywhere. We teach them how to be patient and not to lose confidence.?

Another big area for parents to work on is positive reinforcement, experts say. Parents can forget to applaud good behavior, Tolan says, adding that the bad behaviors are the ones that tend to stand out.

Gretchen Blitz saw warning signs of big behavior problems in her daughter Kendra at an early age. It routinely took half an hour just to get the toddler settled into her car seat. ?She would just fight and fight and fight,? the 30-year-old engineer from Scottsdale, Ariz., remembers.

Things got worse and worse, says Biltz. Kendra was suspended from kindergarten after she slammed a fellow student against a wall. By first grade, she?d developed a reputation as a problem kid, screaming obscenities at teachers and kicking the assistant principal in the stomach.

As with Kendra, parents will sometimes show up in the specialist?s office after having tried over and over again, unsuccessfully, to get their child to stop doing something.

?What we find is that the parent tries to intercede and the kid escalates,? Tolan says. ?The parent withdraws and then that increases the probability it will happen again.?

It may help to watch a therapist deal with the child, Tolan says. Once parents see that the battle of wills can be won, they are more apt to succeed themselves the next time.

For Kendra, now 9, the solution turned out to be a combination of therapy for her, parenting help for her mom and medications to help control angry aggressive outbursts. The medications were prescribed after Kendra?s therapist witnessed several exceptionally violent explosions in the office.

These days, Gretchen Blitz has learned to make a fuss over the good behavior and to ignore the bad, though not dangerous, infractions.

?Kendra?s a lot more willing to do things when I ask instead of throwing a fit and screaming and crying,? she says. ?She?s starting to recognize her triggers and to walk away when she starts getting angry. Sometimes she?ll verbalize what she?s feeling or sometimes I?ll say, ?You?re starting to get angry; you need to take some time out and calm down.? I?d say these days, it?s only about one in four times that she?ll really let it rip.?

Signs to watch for
It can be hard for parents to tell whether a child is just being unruly or truly showing signs of a severe behavior problem. A study by Lauren S. Wakschlag, an associate professor at the Institute for Juvenile Research at the University of Illinois at Chicago noted these differences:

  • Defiance: It's in the normal range of behavior for a child to be defiant, but healthy children will give in after prompting from an adult. Kids showing signs of behavior disorders may remain persistently defiant even after much prompting.
  • Temper loss: It's normal for kids to recover quickly from a temper tantrum or even have mild difficulty (requiring support from an adult) in returning to a good mood. But kids showing signs of behavior disorders need a lot of adult support and even then may have a hard time getting over a temper tantrum.
  • Aggression toward adults: Kids in the normal range either aren't aggressive at all toward adults or have mild aggression that seems impulsive. Those showing signs of behavior disorders have multiple incidents of being aggressive toward adults and may throw, bite, hit or kick.
Getting help
Early intervention can be key in keeping a behavior problem from turning into something worse as the child is older, say experts.

Kids who are show signs of a behavior disorder can often benefit from getting professional help in learning to control anger and express their emotions in healthy ways, says Dr. Joyce Nolan Harrison, an assistant professor at the Johns Hopkins School of Medicine.

Experts can also help teach parent how to "manage in the moment." And, in some cases, Harrison says, the child may need medication.

Patrick Tolan, director of the Institite for Juvenile Research at the University of Illinois at Chicago, says that if you are concerned about whether your child is exhibiting normal behavior or a sign of something serious:

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