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Community Paediatric Review - Child behaviour and emotional regulation

  • Community Paediatric Review

    Vol 24 No. 2, May 2016

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    Child development and behaviour

    As children grow and develop, they learn to regulate their emotions and manage their behaviour. On the way to learning those skills, young children express their wide range of emotional responses in ways that can create stress and anxiety for parents and caregivers – sometimes their behaviour will include aggression, defiance and/or hyperactivity.

    Child and family health nurses can play an important role in helping parents to nurture their child’s developing mind and, along the way, help their children to develop their emotional regulation skills.

    In the early years, children learn to regulate their reactions and feelings through emotional connections with significant others and learned self-understanding. Children use their face, voice and body to communicate their reactions to others. If the child receives appropriate responses then they will establish an emotional connection that supports their learning, and enriches their development. This connection requires the parent or caregivers to help the child to recognise and balance their emotions, feel valued and gain a sense of belonging. Parents or caregivers need to be able to read the emotional responses that infants and toddlers are expressing, and to model coping skills for the child.

    Stages of behaviour development

    CPR vol 23 no 2 mainIn the first three years:

    • Children’s behaviour is influenced by increasing mobility and language skills.
    • Children experience a wide range of powerful emotions.
    • Children learn to imitate peers or siblings and start to alternate roles when involved in play.
    • Staying close to the parent remains important, which is balanced with increasing desire for autonomy.
    • By the time children are 2 years old they have some self-awareness.
    • Children learn that disappointment, frustration, and anger are bearable emotions that do not lead to alienation.
    • Children begin to learn right from wrong.

    Preschool-aged children (4-5 years)

    • Children start to remember past experiences with others and incorporate these into their concept of self.
    • Children begin to develop an understanding of social rules.
    • Children develop greater empathy.
    • Alongside these, there is a systematic increase in pro-social behaviour, which is accompanied by a natural decrease in aggressive behaviour.
    • Children will develop a preference for specific peers, which introduces the possibility of being rejected.

    Despite the challenge that isolated behavioural problems can present for a parent or caregiver, they are usually a product of age-related conflict, frustration, or inability to understand adult expectations.

    When child behaviour is a concern

    Common everyday behavioural difficulties in children include:

    • whining and tantrums
    • bedtime resistance
    • kicking and fighting (with parents, siblings, or other children)
    • biting
    • swearing.

    All parents will have a different level of tolerance for their child’s everyday behavioural difficulties, but if they are concerned about their child’s behaviour, that is sufficient reason for them to discuss their concerns with a professional.

    Australian statistics suggest that parental concern about children’s behaviour is relatively common. In one study 10 per cent of parents expressed concern about the behaviour of a child who was under 18 months old; 20 per cent had concerns about a child who was 18 months to 3 years; 30 per cent had concerns about a child who was 3 to 4.5 years; and 34 per cent had concerns about a child older than 4.5 years (Campbell, 1995). Behaviour problems in childhood are a risk factor for antisocial behaviour and violence in later life (Dadds, 2016).

    Whining and tantrums

    Since whining and tantrums are a natural part of growing up they are not usually cause for serious concern, and will typically diminish of their own accord. This sort of behaviour is particularly common in children under the age of 3 years, but as children mature and their self-control and understanding of the world increase, their frustration levels are likely to decrease, which results in fewer tantrums.

    Most toddlers grow out of typical challenging behaviours (such as tantrums) by the time they reach preschool age (Tremblay, 2005). Aggressive behaviours are more likely to persist and develop into externalising behaviour problems if:

    • parents respond using angry, harsh or abusive discipline (Brenner and Fox, 1998)
    • parents are experiencing stress, depression and/or family conflict (Shaw et al., 2006).

    Bedtime resistance

    Resisting bedtime is a behaviour that is commonly experienced by parents and caregivers of young children. Developing a positive routine for the 20 minutes prior to bedtime, and paying careful attention to children’s tired signs, can help parents to manage this sort of behaviour.

    Kicking and fighting

    Kicking and pushing others is common in young children. When a young child kicks or fights with another child, it is likely that they are having trouble expressing feelings in words. Such behaviour is very normal for children in the early years, as they are only beginning to expand their language and are having their first experiences of exerting their own will and dealing with strong emotions.

    The first 5 years of a child’s life involve many changes and challenges that can result in strong negative feelings. The emergence of new verbal skills, self awareness and goal-directed behaviour all coincide with parents and carers beginning to impose rules and limits. Clashes are therefore likely to be common during this period as children express frustration and anger physically.

    Behaviours that might be labelled physical aggression typically peak between 2 and 3 years. Most children learn to regulate such behaviours and use alternatives by the time they reach middle childhood.

    Biting

    Biting can occur for many reasons other than being unable to express feelings. Biting behaviour and its meaning change with age:

    • At 4 to 5 months infants may bite the mother’s breast while being breastfed as they use their newly emerged teeth.
    • Around 12 to 14 months, infants develop an interest in exploring the experience of biting and may bite the parent’s or carer’s face or shoulder to get a reaction.
    • Between 16 and 24 months, toddlers may engage in exploratory behaviour with other children that involves trying out biting, hair pulling and scratching as the child tries to figure out other children and how to gain their attention. It often occurs in a new or potentially stressful situation.
    • Between 18 and 30 months, children develop a natural surge toward independence and want to make their own decisions. This is the age when temper tantrums and very negative behaviour, which could possibly include biting, are likely to appear.

    Swearing

    Swearing in and of itself is not a sign of behavioural disturbance. If other problems are associated with the swearing, then intervention may be required. For example, children who persistently kick and fight, as well as swear, may be showing signs of a behavioural disorder. Similarly, children who are swearing, lying and having difficulty with peers may be showing signs of an antisocial disorder. Where behaviour appears to be symptomatic of a serious disturbance, child and family health nurses may recommend referral.

    Parents can find it affirming and reassuring to learn about these normal rates of challenging behaviours, as well as receiving acknowledgement that these normal behaviours can still be very testing.

    Managing normal aggressive behaviour

    There are ways that parents can help to reduce young children’s normal challenging behaviours (Barlow et al., 2005; Hiscock et al., 2005). Parents can create a supportive daily environment for their child:

    • Maintain or establish a daily routine for young children.
    • Respect daily sleep or quiet times to prevent children from becoming over tired.
    • Toddler proof the house to allow the young child to explore freely. This is not just for safety, but reduces conflict as parents don’t need to be saying “No!” all the time.
    • Create a list of safe, fun, engaging activities to have on hand to offer the child. Toddlers who are engaged are less likely to misbehave. A few examples of simple engaging activities for toddlers are:
      • scrunching garden leaves
      • climbing in cardboard boxes
      • sliding ice cubes on a plate
      • visiting the playground.

    A key part of preventing young children from developing aggressive behaviour problems is to maintain a warm parent-child relationship. Encourage parents to spend quality time each day doing what their child enjoys. It helps for parents to take an approach in play of ‘watch, wait, and wonder’ at their young child’s chosen interests and activities. For example, when children approach with a toy, parents can also take these immediate opportunities to share in play for a few minutes. Remind parents how important it is to hug, praise and cuddle their child every day. When parents encourage desirable behaviours, this helps to increase the frequency over time of good behaviours.

    Parenting skills to encourage desirable child behaviours:

    • Multiple short bursts of one on one time can be more effective than one long playtime.
    • Seek opportunities to notice the child when being good every day.
    • Tell the child exactly what they are doing well.
    • When praising the child get down to their level and tell them exactly what they have done well (so they can learn) – “You’ve been so good being quiet while mummy was on the phone”.
    • Follow up with a hug.

    This article has been adapted from the revised Practice Brief: Everyday Behavioural Difficulties (Centre for Community Child Health, 2016).

    View the references for this article.  

      

    Behaviour and emotional regulation

    In recent years there has been a significant volume of research into the nature, development and functioning of the brain; this has helped created new knowledge about the extent of neuroplasticity, and the role that emotions play in neurodevelopment. This research has significant implications for the way that child and family health nurses work with parents and caregivers to manage children’s development of social and emotional skills, which underlie their behaviour (Moore, 2014).

    In the early years, much of the important emotional and interpersonal learning happens before children have the verbal and cognitive skills to process what they are observing (Cozolino, 2006). The result is that much of the learning about how to react and respond becomes reflex behaviour. This adds increased importance to the relationship that parents and caregivers have with the child and with each other, as it provides a mould for the sort of behaviour that children will go on to express. Children’s later behaviour comes from their earliest learning about managing emotions through these relationships.

    Children’s social and emotional development

    CPR Vol 24 no 2 secondaryChildren’s emotional development begins early in life. As children develop skills to manage their emotions, they build the foundation for their future and for the way that they function with their parents, teachers and peers. The National Scientific Council on the Developing Child (2004) described the core features of emotional development as the ability to:

    • identify and understand one’s own feelings
    • accurately read and comprehend emotional states in others
    • manage strong emotions and their expression in a constructive manner
    • regulate one’s own behaviour
    • develop empathy for others
    • establish and sustain relationships.

    Parents establish the environment in which children develop their ability to manage their behaviour, therefore, the response that parents and caregivers model for the child is critical:

    “If they [feelings] are seen as dangerous enemies then they can only be managed through exerting social pressure and fear. Alternatively, if every impulse must be gratified, then relationships with others become only a means to your own ends. But if feelings are respected as valuable guides to the state of your own organism, as well as that of others, then a very different culture arises in which others’ feelings matter, and you are motivated to respond.”

    (Gerhardt, 2004).

    Caring and responsive relationships are fundamental components of promoting children’s emotional development. The way that parents and caregivers are with their babies is important, but so is the way that professionals are with parents. Your respectful, attentive, consistent and available behaviour is as important as your work to inform, support, guide and counsel (Gowen and Nebrig, 2001).

    Responses that undermine emotional development

    There are three ways that adults respond to children that act to undermine those children’s emotional development:

    • Dismissive: this sort of response serves to ignore or trivialise negative emotions.
    • Disapproval: through disapproval, adults are critical of children’s displays of emotions and act to reprimand and punish.
    • Laissez-faire: a casual response serves to acknowledge children’s emotions without providing any opportunity for learning and development.

    (Gottman, 1997).

    By working with parents to develop strategies to avoid these sorts of responses when interacting with their children, child and family health nurses support children’s emotional development.

    Achieving emotional balance

    As part of their development, children need to experience the full range of human emotion; from anger and sadness to joy. However, being able to express and experience that emotional range is not enough for development. Children also need to develop the skill of returning to a sense of equilibrium in the wake of an experience that provokes a strong emotional reaction. Children’s ability to recognise and express feelings and not be overwhelmed by them is an important developmental milestone (Greenspan, 2007).

    There are strategies that parents can use to promote their child’s emotional range and balance:

    • Fully accept every kind of emotion that the child expresses, without assuming that some emotions are good and some are bad.
    • Avoid children becoming overwhelmed by their emotions by providing structure, guidance and limits.
    • Be cognisant of the child’s innate temperament in order to safely broaden their emotional range.

    Experiencing negative emotions in a safe environment – where children feel safe and do not feel judged – allows them to develop the skills to express their feelings without becoming overwhelmed. (Greenspan, 2007).

    Physical aggression

    Concerns about physical aggression tend to peak in adolescence and are mostly concentrated on the behaviour of adolescent boys. The traditional explanation for violent behaviour in adolescence is that violence is a learned response to frustration, and that the models for this sort of behaviour come from family, peers, the child’s neighbourhood, mass media, or violent pornography (Reiss and Roth, 1993). However, the seed of adolescent physical aggression is sown much earlier; research in the last decade or so has shown that early childhood is the time when models of later physically aggressive behaviour are learnt and set (Tremblay, 2008).

    Longitudinal studies have shown that for the majority of children, violent behaviour steadily reduces over the time from when they begin school until they leave high school (Tremblay, 2000; Tremblay and Nagin, 2005). A Canadian longitudinal study followed a large, representative group of children over six years to track the trajectory of physical aggression from toddlerhood to pre-adolescence (Cotê et al, 2006). The study showed that, in terms of physically aggressive behaviour, children fell into three groups:

    • One third of children displayed a low-desisting trajectory where physical aggression was used infrequently in the toddler years and virtually unused by pre-adolescence.
    • A little more than half of children displayed a moderate-desisting trajectory. These children displayed occasional use of physical aggression in their toddler years, which was infrequent by pre-adolescence.
    • The remaining group of children had a high-stable trajectory. They used physical aggression more frequently than their peers in their toddler years and their levels of physical aggression use remained comparatively high and stable through preschool and primary school.

    (Cotê et al, 2006).

    This study indicates that a small, but significant minority of children use physical aggression much more frequently than their peers. This is supported by data which shows that physical aggression is the most common reason for preschool children to be referred to specialist services for behaviour problems (Keenan and Wakschlag, 2000).

    Cotê et al (2006) looked further at those children who were on a high-stable trajectory to try to identify the factors that distinguished them from their peers in the low-desisting and moderate-desisting categories, and found that the high-stable group were more likely to be boys. Additional factors that increase the likelihood of children displaying aggressive behaviour are:

    • young maternal age
    • a history of behaviour problems
    • coming from a low-income family
    • parental separation
    • smoking during pregnancy
    • low levels of maternal education.

    (Cotê et al, 2006; Liben and Bigler, 2002; Tremblay et al, 2004; Nagin and Tremblay, 2001; Keenan & Shaw, 1994).

    The use of physical aggression is not something that children learn (Hebb, 1972). Instead, choosing not to use physical aggression in the face of frustration or anger is the skill that children need to develop (Tremblay, 2006).

    Positive behavioural intervention

    A tiered model to promote social-emotional competence and address challenging behaviour during the early years has been developed by Hemmeter, Fox and Snyder (2013). This tiered model provides for three levels of support to prevent behavioural problems arising in the early years and address those children and families who are at risk, or where problems have already arisen. 

    CPR vol 24 no 2 Figure 1 

    Figure 1, Pyramid Model for Supporting Social and Emotional Competence in Infants and Young Children (adapted from Hemmeter, Fox and Snyder, 2013).

    This model embeds early intervention in a larger framework of prevention, providing a tiered framework to address children and families that is directed at the level of need perceived by the family (Positive Behavioral Interventions and Supports, 2016).

    The pyramid divides primary or universal intervention into two areas: high-quality, supportive relationships, and nurturing and responsive relationships. Relationships are critical to children’s ability to develop their social and emotional skills. The relationships that children have with adults – and that adults have with each other, child and family health nurses and other health professionals, and early years educators – provide important models for children to acquire social competencies (Positive Behavioral Interventions and Supports, 2016).

    For children who are at risk of developing behavioural problems, the researchers have nominated secondary interventions. At this level, children are systematically and intentionally taught social skills and emotional competencies. These can be taught through incidental teaching, small group activities and instruction, peer coaching and buddy skill training, and adult-directed instruction (Moore, 2014).

    There will be some children who demonstrate persistent and intensive challenging behaviour and require intensive, tertiary intervention. While a behavioural disorder may be present, that is not necessarily the case. Intensive intervention includes strategies for preventing challenging behaviours occurring; teaching new behaviours to replace existing challenging ones; and changing the way that adults respond to both the new skills and the challenging behaviours (Moore, 2014).

    Implications for practice

    Building positive relationships is a foundation stone of child and family health nursing, and of helping children to develop the skills needed for emotional regulation. Without positive relationships between practitioners and clients there is a reduced likelihood that the work that you do to support families will be experienced as helpful.

    The positive relationships that you build in your work act as a model for parents of how they can relate to their child, further supporting children to develop their social and emotional skills

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    References: Child development and behaviour

    Barlow, J., Parsons, J., & Stewart-Brown, S. (2005). Preventing emotional and behavioural problems: the effectiveness of parenting programs for children less than three years of age. Child: Care Health and Development, 31, 33-42.

    Brenner, V., & Fox, R.A. (1998). Parental discipline and behaviour problems in young children. Journal of Genetic Psychology, 159, 251-256.

    Campbell, S. B. (1995). Behavior Problems in Preschool Children: A Review of Recent Research. Journal and Child Psychology and Child Psychiatry, 36 (1), 113-149.

    Dadds, M. (2016, February). Like father, like son. Presentation at The Royal Children’s Hospital Mental Health Week, Melbourne, Australia.

    Hiscock, H., Bayer, J.K., & Wake, M. (2005). Preventing toddler externalising behaviour problems: pilot evaluation of a universal parenting program. International Journal of Mental Health Promotion, 7, 54-60.

    Shaw, D.S., Dishion, T.J., Supplee, L.H., Gardner, F., & Arnds, K. (2006). Randomised trial of a family-centered approach to the prevention of early conduct problems: 2-year effects of the Family Check-Up in early childhood. Journal of Consulting and Clinical Psychology, 74, 1-9.

    Tremblay, R. E. (2005). Developmental Origins of Aggression. NY: Guilford Press.

    References: Behaviour and emotional regulation

    Campbell, S. B. (1996). Behavior Problems in Preschool Children: A Review of Recent Research. Journal of Child Psychology and Psychiatry, 36: 113-149.

    Cotê, S. M., Vaillancourt, T. LeBlanc, J. C., Nagin, D. S. & Tremblay, R. E. (2006). The Development of Physical Aggression from Toddlerhood to Pre-Adolescence: A Nation Wide Longitudinal Study of Canadian Children. Journal of Abnormal Child Psychology, Vol. 34, No. 1, pp. 71–85 DOI: 10.1007/s10802-005-9001-z

    Cozolino, L. (2006). The Neuroscience of Human Relationships: Attachment and the Developing Social Brain. New York: W. W. Norton & Co.

    Gerhardt, S. (2004). Why Love Matters: How Affection Shapes a Baby’s Brain. London, Routledge.

    Gottman, J. & DeClaire, J. (1997). The Heart of Parenting: Raising an Emotionally Intelligent Child. New York City, New York, Simon & Schuster.

    Gowen, J.W. & Nebrig, J.B. (2001). Enhancing Early Emotional Development: Guiding Parents of Young Children. Baltimore, Maryland: Paul H. Brookes.

    Greenspan, S. (2007). 2007. Great Kids: Helping Your Baby and Child Develop the Ten Essential Qualities for a Healthy, Happy Life. Boston, Massachusetts, Da Capo Press.

    Hebb, D. O. A textbook of psychology, 3rd edition. Philadelphia, PA: Saunders.

    Hemmeter, M. L., Fox, L., & Snyder, P., (2013). A tiered model for promoting social-emotional competence and addressing behavior. In V. Buysse & E. Peisner-Feinberg (Eds.), Handbook of Response to Intervention in Early Intervention (pp. 85-102). Baltimore, MD: Brookes Publishing Co.

    Fox, L. & Hemmeter, M-L. (2014). Implementing Positive Behavioral Intervention and Support: The Evidence-Base of the Pyramid Model for Supporting Social Emotional Competence in Infants and Young Children. Pyramid Model Consortium. Retrieved fromhttp://challengingbehavior.fmhi.usf.edu/do/resources/documents/PBIS_Pyramid_evidence.pdf 20 April 2016.

    Keenan K. & Shaw D.S. (1994). The development of aggression in toddlers: a study of low-income families. Journal of Abnormal Child Psychology;22(1):53-77.

    Keenan, K. & Wakschlag, L. S. (2000). More than the terrible twos: The nature and severity of behavior problems in clinic-referred preschool children. Journal of Abnormal Child Psychology 28(1):33-46.

    Liben, L., & Bigler R, eds. (2002). The developmental course of gender differentiation: conceptuality, measuring and evaluating constructs and pathways. Malden, Mass : Blackwell Publishing; 2002. Monographs of the Society for Research in Child Development.

    Moore, T. (2014, November). Promoting positive behaviour in early childhood services. Collaborative Learning Program Twilight Workshop.

    Nagin, D. S., & Tremblay R, E. (2001). Parental and early childhood predictors of persistent physical aggression in boys from kindergarten to high school. Archives of General Psychiatry;58(4):389-394. 21.

    National Scientific Council on the Developing Child. (2004). Young Children Develop in an Environment of Relationships: Working Paper No. 1. Retrieved from www.developingchild.harvard.edu

    Positive Behavioral Interventions and Supports. (2016). Early Childhood PBIS. Retrieved 20 April 2016 from http://www.pbis.org/community/early-childhood

    Reiss, A. J. Jr & Roth, J. A (eds). (1993). Panel on the Understanding and Control of Violence Behavior. Understanding and Preventing Violence. Vol 1:7. Washington, DC. National Academy Press.

    Tremblay R. E., Nagin, D. S., Séguin, J. R., Zoccolillo, M., Zelazo P. D., Boivin, M., Pérusse, D., & Japel, C. (2004). Physical aggression during early childhood: Trajectories and predictors. Pediatrics;114(1):e43-e50.

    Tremblay, R. E. (2008). Development of physical aggression from early childhood to adulthood. Rev ed. In: Tremblay RE, Barr RG, Peters RDeV, Boivin M, eds. Encyclopedia on Early Childhood Development [online]. Montreal, Quebec: Centre of Excellence for Early Childhood Development;1-7. Available at: http://www.child-encyclopedia.com/documents/TremblayANGxp_rev.pdf. Accessed 18 April 2016.  

     

    About Community Paediatric Review

    Community Paediatric Review supports health professionals in caring for children and their families through the provision of evidence-based information on current health issues. 

    Articles prepared by Eliza Metcalfe, Murdoch Childrens Research Institute.

    Editorial panel

    Carolyn Briggs
    Karen Coffield
    Libby Dawson
    Dr Anastasia Gabriel

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    Eliza Metcalfe

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The Centre for Community Child Health is a department of The Royal Children’s Hospital and a research group of Murdoch Childrens Research Institute.