QUESTION:
Our four-year-old son has always been a bit difficult – certainly more so than his siblings – but things seem to be taking a real turn for the worse of late. When things do not go his way, he can have a complete meltdown and throw a serious tantrum. Even if it is not an absolute refusal to grant him his wish – for example, “We can’t go to the park now but we will go later” – he will have a noisy and aggressive tantrum that frequently involves firing things, especially if he is sent to his room to calm down.

We try to remain calm but it is not always easy, and we are exhausted from trying to placate him and bring him round. Sometimes it’s hard not to lose it with him, especially if we are tired or in company, and that makes everyone feel a lot worse.

Do you think we need to have him assessed for behavioural problems or is there a way we can work through this? In reading about ADHD, our gut feeling is that he does not have it or, if he does, it is a mild form, but is it something we need to have assessed?

We do feel we need some sort of urgent intervention because at the moment it feels like he is ruling the household and we are on tenterhooks waiting for the next outburst. It is badly affecting the whole family – we have turned down a lot of get-togethers with relatives and keep visitors to the house to an absolute minimum as it is embarrassing and very difficult if he starts acting up.

ANSWER
Though defiance, tantrums and “meltdowns” are common behaviours for toddlers and two year olds, normally children grow out of these as they get older and are more able to manage their feelings.

However, for a significant number of children these behaviours can become severe in the preschool years and present great challenges for parents. Sometimes there are specific underlying causes such as developmental delay or Attention Deficit Hyperactivity Disorder (ADHD). However, frequently there are no specific causes and a self-reinforcing pattern of oppositional or aggressive behaviour simply gets established over time, which easily becomes destructive for parent and child.

Given that your son is four years of age and you feel things are getting worse rather than better, I think you are right to seek help. Many studies show that behavioural problems that start in the preschool years can endure or get worse unless there is some intervention or a concerted effort on the part of the parents to implement consistent and positive discipline.

Certainly, it is not a good sign if you feel that your son’s behaviour is putting you on tenterhooks and impacting normal family life. In addition, when dealing with behaviour problems, it is generally easier to act to change things when children are younger rather than waiting until they are older and the problems could be more fixed. In seeking help, you should contact your GP or public health nurse (PHN) and seek a referral to your primary care team, family resource centre or to a specialist child mental health service.

In turning around behavioural problems, the strongest evidence is for approaches that support parents adopting a balanced authoritarian approach to parenting. This should include both a positive, warm and supportive parenting style as well as consistent and clear discipline.

Because of how challenging behaviour problems are to manage, it is easy to feel angry and resentful at the child, which in turn causes them to feel rejected and over time to develop low self-esteem. This, in turn, can increase their use of negative behaviours and strategies.

To counteract this, children need frequent encouragement and support from their parents. Listening to them, helping identify their feelings, praising any examples of good behaviour, setting aside special one-to-one enjoyable playtime are all important to reversing negative expectations and ensuring a positive parent-child relationship which is the platform to solve the behaviour problems.

In addition, a positive consistent approach to discipline is crucial. Essentially, this means focusing on core rules in the home, particularly around being respectful, and then establishing a clear set of consequences for when your son breaks the rules.

As you have discovered, creating the right consequences can be the hardest part, as many children can thwart your plans (for example, messing up his room when you place him there as a time out).

In those situations you need to think through a clear step-by-step discipline plan that allows you to positively respond and calmly follow through in a way that you don’t give in and your child learns the rule. For example, this might mean placing your son in a different room for time out where there is nothing to throw or using a different consequence altogether such as losing a treat.

Crucially, it also means learning to act earlier, before problems escalate, and making small everyday rewards dependent on respectful behaviour. For example, if you son rudely asks for something you insist, “When you use a polite voice, then I will help you” or “Only when you pick up the toy, can the TV come on”.

Rather than using big consequences or removing all treats, it is more effective to make sure you have a range of small repeatable consequences that you never run out of – “If you throw another toy, you will lose one of your sweets after dinner or spend an extra minute in time out”. You need to be always one step ahead of your child and to have a plan of action for every “what if” or eventuality.

As it takes a great deal of time and patience to implement a good discipline plan, often the best way to learn these ideas is in a structured and evidence-based parenting course which you attend over several weeks in a supportive group to give you plenty of time to tailor the ideas to your family.  When you contact your GP, PHN or local primary care services ask for a recommendation of such a course. For a full explanation of a positive discipline system to manage behaviour problems, see my book, Positive Parenting.

John Sharry, Irish Times, September 2011. John writes in The Irish Times Health+ every Tuesday.
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