Behavioural Problems in Childhood

General behaviour-management principles and common developmental behaviours. See also ADHD & ODD for more significant/ persistent behavioural presentations.

Managing unwanted behaviour

Consequences (works from age >3)

Overuse reduces effectiveness and can damage family relationships. In decreasing order of usefulness:

• Natural consequences — the result flows naturally from the behaviour (refuses dinner → goes to bed hungry).
• Related (“logical”) consequences — a link between behaviour and result (makes a mess → cleans it up; fighting over a toy → toy removed temporarily).
• Losing a privilege — powerful but more punitive, with no logical link; use sparingly and warn beforehand.

Time-outs (useful from age 2–3)

Defuse the situation for both parent and child. Should be consistent, prompt, calm (even empathetic), and short — roughly 1 minute per year of age.

Ineffective responses: screaming, constant explaining, repeated warnings, threats, pleading, arguing, bribing/giving in, smacking.

Tantrums

More common in toddlers (especially 18 months–3 years) who haven’t yet learned alternative emotional responses (ignoring, negotiating, reframing). May be a pointer to autism.

Tantrums usually appear toward the end of the first year of life, are most common at age 2 (the terrible twos) to 4, and are infrequent after age 5. Frequent tantrums after age 5 may persist throughout childhood. Causes include frustration, tiredness, boredom and hunger; children also tantrum to seek attention, obtain something, or avoid doing something — the underlying driver is more often a combination of the child’s temperament, the immediate circumstance and developmentally normal behaviour than poor parenting. An underlying medical, mental or social problem is more likely if a tantrum lasts more than 15 minutes or tantrums occur multiple times a day. Some children voluntarily hold their breath for a few seconds mid-tantrum before resuming normal breathing — distinct from the involuntary breath-holding spells below.

Strategies: divert from predictable triggers; scaffold” the event (e.g. a 5-minute warning); distraction/active listening before a tantrum builds. Once mid-tantrum, negotiation is ineffective. “In most cases, addressing the source of the tantrum only prolongs it — it is preferable to redirect the child to an alternative activity, and the child may also benefit from being physically removed from the situation. A time-out (a safe setting for the child to compose themselves) is often effective, though many children have difficulty stopping a tantrum on their own. Afterward, a calm, unemotional response teaches that tantrums don’t work. Build the child’s skills for handling emotional situations outside the moment (“what else could you have done?”). Rousing at the child is counterproductive — risks demoralising them and lowering self-esteem.

Breath-holding attacks

Common (~5% of children); age 6 months–6 years (peak age 2). Frightening to watch but harmless — no treatment or action required. Breath-holding spells were once considered attention-seeking behaviour, but studies have shown these episodes are involuntary and result from a reflex rather than intent. The prognosis is excellent — spells usually resolve by age 6 and do not affect the child’s subsequent neurodevelopment.

• Blue spells (more common) — after being upset/angry; cries loudly then holds breath at end of expiration. The cyanotic type accounts for over 60% of episodes.
• Pale spells — after pain or fright. The pallid type follows an increased parasympathetic (vagal) response causing reduced cerebral blood flow.

Last 10–60 seconds; can cause fainting or (rarely) a fit, but is self-limiting; a spell lasting longer than 60 seconds should prompt a workup for an alternative diagnosis. No need to blow air or splash water on the face — treat as if it didn’t happen (no discussion, no punishment); don’t change disciplinary approach because of them.

Iron deficiency anaemia is commonly identified in children with breath-holding spells, and iron supplementation (3–6 mg/kg/day) can reduce spell frequency even in children who are not iron-deficient. Reassurance and behavioural support remain the mainstay of treatment given the self-limiting course; iron studies and an ECG (to exclude long QT syndrome) are reasonable first-line investigations for recurrent or atypical spells, and an EEG is not routinely needed without red flags suggesting a seizure disorder.

Head banging and rocking

Common before sleep — head banging in up to 30% of normal infants/ toddlers, rocking even more common. More frequent and pervasive throughout the day in children with developmental disability or autism.

Stuttering/stammering

Usually begins age 2–4 as vocabulary/sentence length increases; can start suddenly or develop gradually. Up to 12% of children stutter by age 4. Developmental stuttering is the most prevalent form, affecting an estimated 5–10% of preschoolers. Repetitions, prolongations (“aaaand”), blocks, or combinations.

Refer to a speech pathologist as soon as possible — early treatment is more successful, and referral becomes more urgent if the disfluency persists a year or more, or if parents report worsening severity or increasing frequency. The Lidcombe Program is the most common Australian treatment, often successful and can sometimes stop the stutter entirely — parents are trained to praise fluent speech and respond consistently to stuttered speech. Other programs used internationally include RESTART-DCM (reducing speech demands on the child) and the Palin Parent-Child Interaction approach (family-based interaction strategies); all are speech-pathologist-led. Most developmental stuttering resolves over time, with resolution rates of 65–87% regardless of treatment, though rates fall in children who continue to stutter into later childhood.

Dyspraxia (developmental coordination disorder, DCD)

A disorder of planning, organising and executing motor tasks. It can affect articulation/speech and perception/thought. It is not associated with reduced intelligence. Ranges from simple movements (waving goodbye, clapping) to complex ones (handwriting, riding a bike). DCD affects 1.8–6% of children and is around 7 times more common in boys than girls; prematurity and low birth weight are the strongest known risk factors. DCD co-occurs with ADHD in 30–50% of cases, and overlaps with autism spectrum disorder, language disorder and specific learning disorder — diagnosis (per DSM-5) requires excluding these and other neurological/musculoskeletal causes of the motor difficulty.

If motor delay occurs without associated social/communication delay, refer to physiotherapy, OT and/or speech pathology depending on the specific motor issues. Task-oriented approaches, motor-training programs and physical/occupational therapy are the most effective interventions, tailored to the child’s individual goals rather than a generic motor-skills program. Delayed fine/gross motor skills can be a barrier to socialisation (team sports) or academic achievement (writing), with flow-on effects on self-esteem and mood.