February 2009

What's Normal? What's Not?

Sorting Out Your Preschooler's Behavior

By Nicky Lankerani, D.O.

For children, the preschool period, between ages 2 and 5, can be an exciting time of getting ready to start school, making friends, playing pretend, improving balance and coordination, learning to dress and feed themselves, writing their names, using the toilet, and mastering communication skills. At the same time, this is a challenging period of learning to separate from parents, regulating very strong feelings, sharing with friends and respecting rules that may seem unfair.

With the controversies surrounding mental health in children, it can be difficult for parents to tease out what's developmentally normal versus what's an actual problem. This article will review normal development and common disorders arising in the preschool period and describe when to seek help from a professional.

Normal Development

Between the ages of 2 and 5, children begin to use make-believe play and may have imaginary friends. Language becomes more important to express feelings, communicate needs and make friends. Children at this age think in a self-centered way and can't understand others' views.

At the same time, kids have intense emotions that are short lived. One of the most common issues becomes temper tantrums. As part of normal development, children learn to frequently say "No" at around 18 to 24 months. Anger peaks at age 2 and is often accompanied by limit testing. Rules are seen as laws imposed by parents without good reason.

Additionally, preschoolers begin to develop fears. Separation anxiety is experienced between 6 to 7 months of age, peaks at 18 months and should normally go away by 30 months.

If developmental stages exceed their normal duration or behaviors are so intense that they disturb normal day-to-day functioning, we become concerned about an underlying disorder. Common disorders arising in the preschool period include disruptive behavior disorder (including attention deficit hyperactivity disorder), anxiety and mood disorders and autistic spectrum disorders.

Disruptive Behavior Disorders

Behavioral problems (such as fighting, aggression, tantrums and bullying) amongst preschoolers are emerging as a national issue. Although some of the stubborn and irrational behavior can be normal, this type of behavior is at times maladaptive and inconsistent with expected normal development. The underlying reasons for abnormal disruptive behaviors can range from anxiety with school demands and transitions, lack of verbal skills to express frustrations, family problems and learning difficulties due to attention deficit hyperactivity disorder (ADHD) and developmental delays.

Symptoms of ADHD include being forgetful, appearing not to listen, not following directions, being disorganized, losing things often, being fidgety, running or climbing excessively, not waiting to take a turn, and often interrupting others. Onset has to be before age 7, symptoms last at least six months and there should be problems in multiple settings (like school, home, day care, etc.).

The diagnosis of ADHD remains a controversial issue, as parents, teachers and clinicians are often left wondering how much of the behavior is developmentally normal and if treatment is really warranted. The main distinction between normal development and a disorder comes in how the child's behavior compares to others his own age and how much symptoms affect his functioning. In general, since this is a developmental disorder, we expect that symptoms will decrease with time. In fact, two-thirds of those diagnosed as children will not need treatment as adults. However, research has also shown that untreated ADHD increases the risk of substance abuse, motor vehicle accidents, poor academics and conduct problems.

Anxiety Disorders

"Abnormal" or clinical anxiety causes a lot of distress for the child and his family. It can lead to avoiding situations that are feared and being afraid to try new things. Anxiety disorders in preschool children come in many types. Almost 10 percent of preschoolers fit the diagnostic criteria for some form of anxiety disorder, most commonly generalized anxiety.

Children with generalized anxiety disorder worry excessively for at least 6 months. They may have a lot of "what if" questions (such as, "What if we get into an accident?" "What if you die?" "What if it snows?"). They're also often restless, irritable, easily fatigued, have difficulty concentrating and experience muscle tension and sleep problems.

Kids with separation anxiety disorder often worry about their parents or themselves getting hurt. They may be extra clingy, fearful of sleeping alone, have repeated nightmares or experience physical symptoms (such as headaches, stomachaches or nausea) when anticipating a separation from a parent. Symptoms last for at least four weeks.

After a traumatic event, children may develop post-traumatic stress disorder (PTSD). Symptoms include trouble sleeping, nightmares, new separation anxiety, increased fussiness and tantrums, new fears and loss of interest. They may appear more withdrawn and sad and may even lose previously acquired developmental skills (such as language or toileting).

Mood Disorders

Because preschoolers don't have the language skills and vocabulary to verbalize their emotions, signs of depression are usually based on ongoing external behaviors and observations. Young children with clinical depression most often appear sad, have sleep and appetite changes, show new play themes involving death and killing, may whine or cry excessively and sometimes appear to have slowed movements.

Bipolar disorder is rarely diagnosed in very young children and remains very controversial. Some have suggested explosive temper tantrums, sexual joking and nightmares with violent imagery as warning signs for later development of the disorder.

Autism Spectrum Disorders

Yet another hot topic in the area of mental health, autism spectrum disorders include autism, Asperger's syndrome and pervasive developmental disorder not otherwise specified.

Symptoms of these disorders include delays in walking or talking, poor social interactions, limited empathy, poor eye contact, communication deficits, repeating things over and over, restricted interests, nonimaginative play, and odd behaviors (such as hand flapping and body rocking).

The main points about autism spectrum disorders to be aware of are:

Help Is Available

If you are concerned that your child is showing symptoms that are:

You should contact his school, pediatrician or local mental health providers for resources and a comprehensive evaluation. If you are concerned, don't be afraid to ask questions, and do your research. The best time to intervene is when your child is very young. This will identify any areas of need, help him build skills to face the challenges ahead and put into place supports that will help him meet his full potential.

Nicky Lankerani is a board certified psychiatrist working with adults, adolescents and children at the Ross Center in Washington, D.C.