Clinical Problems of the Preschool Child PDF

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All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or Page 260 Chapter 14— Clinical Problems of the Preschool Child Carolyn S. Schroeder and Betty N. Gordon The preschool years (age 2–5) are considered to be one of the most important developmental periods of childhood. It is during this period that the foundation for later competence in many areas is laid. The emergence of language, self­awareness, peer relationships, autonomy and independence, and the increasing complexity of cognitive, play, social, and motor skills all set the stage for new and often intense interactions between children and their environments. As children's capacity to interact with the environment increases, so do the concerns of their parents. Yet, many of the problems seen in the preschool years, such as temper tantrums, overactivity, noncompliance, and aggression as well as problems with separation anxiety, shyness, sleep, toileting, feed­ing/eating, tics, headbanging, and more, can reflect transitory age­appropriate difficulties that will resolve with time. Nonetheless, some of these behaviors predict problems that will persist into later childhood or even adulthood. Understanding the factors that place children at risk for significant problems and why some children are able to overcome early difficulties and others continue to suffer is important for planning prevention and early intervention strategies. This chapter focuses on behavior problems and their relationship to development in the preschool years. Further, some of the influences that affect the trajectory of these problems and the development of child psychopathology are considered. The first part of the chapter speaks to the methods used to diagnose problems during the preschool years. The prevalence of problems is also discussed and child, parent, and environmental factors that influence children's risk of developing persistent problems are reviewed. This is followed by discussion of the assessment issues that are important for this age range, including a brief review of developmental milestones, areas to assess, and assessment methods. Last, an overview of some common but troublesome behavior problems that occur during the preschool years is given and intervention strategies are discussed. Copyright 2000. John Wiley & Sons, Inc. [US]. Diagnostic Methods The most commonly used classification system in the United States is the Diagnostic and Statistical Manual of Mental Disorders (DSM­IV; American Psychiatric Association [APA], 1994). DSM­IV is a categorical classification system in which an individual meets or does not meet criteria for a particular disorder. This method of classification is particularly problematic when talking about preschool children because their rapid development makes it difficult to determine which behaviors are applicable copyright law. transient developmental problems and which will be clinically significant (Campbell, 1990). Although the recent DSM EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY AN: 56347 ; Walker, C. Eugene, Roberts, Michael C..; Handbook of clinical child psychology Account: s3674628.main.ehost  Page 261 revision encourages the clinician to view individuals with a particular disorder as heterogeneous and to gather information that goes beyond the diagnosis, it still does not provide adequate guidelines for determining the developmental and clinical significance of those symptomatic behaviors that define a problem during the preschool years. In addition, parent­child relationships are very important in diagnosing problems among preschoolers and, although both parent­child and sibling relational problems can be coded as ''other conditions that may be the focus of clinical intervention" (APA, 1994, p. 675), the diversity of these problems are not adequately taken into account (Volkmar & Schwab­Stone, 1996). Despite these continuing concerns about the use of the DSM­IV with preschool children, it is widely used in clinical practice. It is, therefore, worthwhile to review the disorders that specifically have their onset during infancy, childhood, or adolescence. Table 14.1 provides a summary of these disorders. As shown in Table 14.1, eight of these childhood DSM­IV disorders have an age of onset during the preschool years. With the exception of enuresis, which is not actually considered a disorder until age 5, the problems listed are uncommon and do not reflect the range of behavioral concerns seen by most child clinicians, especially during the preschool years. Nonetheless, clinicians are encouraged to use the DSM­IV V­codes for insurance purposes. These codes cover problems or conditions that may be the focus of clinical attention, such as parent­child relational problem or sibling relational problem (APA, 1994), when a mental disorder is not present. The American Academy of Pediatrics (Wolraich, Felice, & Drotar, 1996) recently published the Diagnostic and Statistical Manual for Primary Care (DSMPC). Their goal was to develop a diagnostic system that was comprehensive and developmentally appropriate to help primary care pediatricians recognize, manage, and refer a wide spectrum of children's behavioral and developmental problems as well as stressful family and environmental situations (Drotar, 1999). Some of the critical underlying assumptions of this system include (1) symptoms viewed along a continuum from normal variations to severe mental disorders that is divided into clinically meaningful graduations; (2) the quality of children's environment recognized as having a critical impact on their mental health and taken into account in assessing problems; (3) children's expression of symptoms and response to stressful environmental situations varies as a function of age and level of development; and (4) the system is based on objective data where possible and professional consensus in cases where data are not yet available. In addition, the system was developed to be fully compatible with DSM­IV (APA, 1994) and the International Classification of Diseases (ICD­10; World Health Organization [WHO], 1992). Although this system is currently not yet in wide clinical use and much research must be done to support it, it holds promise in describing not only problem behavior but its significance within a particular developmental and environmental context. Another approach to classification is quantitative or dimensional. This approach assumes that behavior occurs along a continuum rather than dichotomously (i.e., either you have a disorder or you do not). Differences in types of problems are examined statistically through methods such as factor analysis (Achenbach, 1991, 1992; Achenbach & Edelbrock, 1978). Dimensional diagnosis allows one to describe multiple behavior patterns for any individual child. Dimensional systems do not lead to a statement that a child has a particular disorder but rather describe the degree to which one or more behavioral characteristics are present. Cutoff scores are used to determine the clinical significance of specific behaviors for different age groups. Although normative developmental considerations can more readily be taken into account with dimensional systems, they generally do not address important relational and cross­situational issues, the length of time the behavior has occurred, or how the behavior impairs functioning. Arend, Lavigne, Rosenbaum, Binns, and Christoffell (1996) examined the DSM approach to diagnosis and a dimensional one based on the Child Behavior Checklist and profile (CBCL; Achenbach, 1991, 1992). Focusing on disruptive disorders in 510 2­ to 5­year­olds selected from pediatric primary care settings, they compared DSM­III­R (APA, 1987) diagnoses derived from semistructured parent interviews, parent questionnaires, play observations, and developmental testing with parent responses to the CBCL. The greatest convergence between the two approaches was found when there was clearly no problem. Children who received scores below the clinical cutoff on the CBCL but were given a DSM diagnosis were compared with those who EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 262 EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 263 were below the CBCL cutoff but did not receive a diagnosis. These two groups differed in the severity of their behavior and in the number of situations in which the behavior occurred. Arend et al. also found that children's lack of cooperation across settings indicated a greater likelihood of more severe behavior problems. So, the addition to the CBCL of questions regarding the cross­situational nature of the child's behavior or having both the teacher and the parent complete the CBCL would enhance the utility of the CBCL dimensional diagnostic system in identifying children with significant problems that might otherwise be missed. It is remarkable that 28 different DSM­III­R diagnoses were used with this sample of preschoolers (Arend et al., 1996). This raises the question of the ability of the DSM categories to differentiate children in this preschool group. Not surprisingly, problems appeared to be better differentiated among the 4­ to 5­year­olds than among the 2­ to 3­year­olds. Although the authors indicate that interviewing may allow for a greater amount and richness of information with which to make a categorical diagnosis, they also point out that the utility of the study depends on the validity of the DSM­III­R diagnosis. This is an important cautionary note, particularly with preschool children who exhibit a significant number of problem behaviors that are age­appropriate and transient. Although the authors indicate that they have few data to recommend either the categorical or dimensional approach over the other, it appears that clinical judgment is enhanced when information is gathered through multiple methods and sources and across situations. Prevalence The prevalence of problems in preschool children is difficult to determine due to the variety of nonstandardized criteria used to identify the presence of a particular problem as well as the varying labels and definitions of problem behavior. In addition, the wide variability in development and behavior among children during the preschool years makes it difficult to say that a certain behavior or set of behaviors represents a clinical disorder except in extreme cases, for example, mental retardation or autism. Table 14.1 indicates prevalence rates for the DSM­IV disorders that have their onset during infancy, childhood, or adolescence. More generally, large­scale studies in health care settings indicate that 5% to 25% of all children seen in primary health care evidence significant behavioral or emotional problems (Costello et al., 1988; Goldberg, Regier, McInery, Pless, & Roghmann, 1984; Goldberg, Roghmann, McInery, & Burke, 1984; Starfield et al., 1980). In the Arend et al. (1996) study discussed previously, over 21.4% of the preschool­age participants had DSM disorders and 9.1% had severe disorders. In a follow­up study, these authors found that a substantial number of these children's problems persisted over 42 to 48 months (Lavigne et al., 1999). Other large­scale surveys estimate that 7% to 14% of preschoolers have serious behavioral problems (Achenbach, Edelbrock, & Howell, 1987; Rich­man, Stevenson, & Graham, 1982; Rose, Feldman, Rose, Wallace, & McCarton, 1992). Richman, Stevenson, and Graham (1975), for example, interviewed mothers of 3­year­old children in London and estimated that 7% of the children had moderate­to­severe problems and 15% had mild problems. Furthermore, 66% of the children with problems continued to present problems a year later, compared with 15% of the control group (Richman et al., 1982). Hooks, Mayes, and Volkmar (1988) examined records of 193 children less than 5 years of age who were seen during a two­year­period at the Yale Child Study Center. The DSM­III diagnoses for those children included 10.9% parent­child problems, 17.1% pervasive developmental delay, 32.1% emotional disorders, 4.1% disruptive behavior disorder, 22.3% specific developmental delay, and 6.3% global developmental delay; 29% had no diagnostic label. It is interesting to note that 59% of the children were experiencing severe to extreme psychosocial stresses, which is consistent with other studies (e.g., Earls, 1982; Lee, 1987). Other work indicates that the prevalence of problems may vary depending on the age or developmental status of the child. Jenkins, Bax, and Hart (1980), for example, found that the percentage of parents who worried about their preschoolers was highest when the children were 3 years old (23%). The problems reported included difficulty in management, demanding too much attention, and temper tantrums. Although food fads and poor appetite were more common at the age of 3, parents did not view these as significant problems. Mesibov, Schroeder, and Wesson (1977) found similar results in a study of parental concerns reported to EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 264 a consultation service in a pediatric office. The greatest number of concerns was among the parents of 2­ and 3­year­olds, with negative behavior, toileting, and developmental delays being the most frequent problems/concerns. Overall, prevalence studies indicate that behavior problems are relatively common in the preschool years and are most often associated with a particular developmental period. Thus, issues with toileting, sleep, and eating are more likely to occur during the first three years, and struggles for independence and autonomy at age 3 often result in increased disobedience and defiance. For most children, these problems are transient and decrease in meaningful and predictable ways with development, yet some appear to persist and may even worsen (Campbell, 1997). Understanding the factors that predict increased severity is important for assessment and treatment of these children. Risk/Protective Factors The factors that place children at risk for continuing and/or severe emotional and behavioral problems have received increasing attention in the past 10 years. One way of categorizing risk factors is to view them as (1) established risk factors, such as a frank genetic disorder (i.e., Fragile X syndrome or Down syndrome); (2) biological risk factors, such as poor prenatal care, drug and/or alcohol abuse by the mother during pregnancy, prematurity, anoxia, and low birthweight; and (3) environmental risk factors, such as poor responsivity or lack of sensitivity by the mother to her child, low level of language stimulation, or family socioeconomic status (SES) (Odom & Kaiser, 1997). It is recognized that it is the dynamic and complex interplay of these factors (e.g., the individual child, his or her developmental status, the social background, and the cultural context) that ultimately determines the child's risk for developmental and/or behavior problems (Haggerty, Sherrod, Garmezy, & Rutter, 1996). Rutter (1996) points out that it is not the isolated life event or stressor but rather the aggregated accumulation of events that contributes to psychological vulnerability for the individual child. Conversely, it is recognized that protective factors are also on a continuum, and when accumulated and present across time, these factors can increase the probability of a positive outcome for children in high­risk situations (Goodyer, 1990). Even for children with known genetic disorders, the negative effects associated with the disability can be reduced through early and ongoing intervention programs that focus on both the child and his or her family. Though this chapter primarily focuses on environmental risk/protective factors, it is important to recognize that it is the interplay of genetic, biological, and environmental factors over time that ultimately determines the developmental trajectory of the child. Type and Severity of Early Childhood Problems Externalizing behaviors, such as inattention, aggression, and noncompliance, have received the greatest amount of attention regarding their stability and durability when the age of onset is in the preschool years. Longitudinal studies show that about half of these hard­to­manage children identified as preschoolers continue to have significant behavioral difficulties at follow­up periods of 1 to 13 years (Campbell & Ewing, 1990; Campbell, Ewing, Breaux, & Szumowski, 1986; Campbell, Szumowski, Ewing, Gluck, & Breaux, 1982; Egeland, Kalkoske, Gottesman, & Erickson, 1990; Pierce, Ewing, & Campbell, 1999; Richman et al., 1982). Factors associated with persistent externalizing problems include early onset; initial problem severity; cognitive deficits; parenting that is uninvolved, rejecting, and harsh; and ongoing family adversity, especially low SES, that is associated with less stable, supportive, and involved caretaking in early childhood (Campbell, 1995). According to Campbell, the children showing a combination of hyperactivity and aggression/noncompliance appear to have the most severe and pervasive problems with the worst prognosis, in part because they tend to live in the most dysfunctional families and have a very early onset of problems. Other work has shown that externalizing problems in combination with low IQ may result in more persistent problems (Sonuga­Barke, Lamparelli, Stevenson, Thompson, & Henry, 1994). Clearly, this combination of problems places children at risk for even greater difficulties as they enter school. Further, children rated by both teachers and parents as having significant externalizing problems have been observed to be more difficult to handle when interacting with peers, teachers, EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 265 and parents in both structured and unstructured situations (Campbell, Pierce, March, Ewing, & Szumowski, 1994; Schaughency & Fagot, 1993). This further increases the risk for both learning and peer­relationship problems. Parent­Child Interaction and Socialization For preschool children, the quality of parenting seems to be an especially important factor, as these youngsters are ''both vulnerable and dependent on their families for nurturance, guidance and support" (Campbell, 1996, p. 375). Parenting behavior and parent­child interaction have been associated with a variety of child behavior problems. For example, maternal behavior that is arbitrary, inconsistent, negative, or uninvolved is associated with noncompliance and low internal control in preschoolers (Webster­Stratton, 1990). Conversely, maternal responsiveness to child requests and a history of a warm, positive relationship appear to be important for the development of mother­child reciprocity and later prosocial behavior with peers (Sroufe & Fleeson, 1986). Further, mothers of preschool children with behavior problems have been observed to initiate a smaller proportion of activities, make fewer contributions to keeping the activity going, and be less responsive to the child's contributions during spontaneous joint play (Gardner, 1994). In contrast to control children, problem children play a greater role than their mothers in initiating and maintaining activities (Gardner, 1994). So, maternal involvement in play may be an important factor in the development of behavior problems. The nature of the parent­infant attachment relationship has also been shown to be an important risk factor for preschool children. There is ongoing work demonstrating that the quality of early attachment relationships bears directly on adaptation during the preschool years (M. Greenberg, Cicchetti, & Cummings, 1990). Secure attachments have been found "to foster favorable self­images, satisfying relationships outside the family, and a stable basis for exploring the environment and mastering new developmental tasks" (Easterbrooks & Goldberg, 1990, p. 238). Conversely, insecure parent­infant attachments can place the preschool child at risk for problems with motivation, emotional regulation, and peers, especially if the environment continues to be unstable over time (Sroufe & Fleeson, 1986; see Greenberg et al. for a review of attachment in the preschool years). Family Children in families coping with adverse circumstances such as low SES, single or stepparenting, conflicted family relationships (including disagreement over child rearing), or parent psychopathology (especially maternal depression) are at increased risk of behavior problems (Campbell, 1995). In a study of the relative impact of maltreatment, SES level, physical health problems, cognitive ability, and the quality of parent­child interaction on behavioral dysfunction, 206 children were assessed at both preschool and school age (Herrenkohl, Herrenkohl, Rupert, Egolf, & Lutz, 1995). The results indicated that socioeconomic level and the family climate in which the child was raised were strongly related to children's behavioral functioning. Interestingly, physical and emotional maltreatment were significant but less powerful influences on behavior. SES appeared to be the most critical factor in predicting behavioral functioning. It was associated with patterns of teaching, communicating with, stimulating, and guiding children, as well as with the resources available to families for support in facilitating children's development. The next most important construct associated with child dysfunction was the quality of the mother's interaction with the child, including the degree of rejection, hostility, and control exhibited (Herrenkohl et al., 1995). Conversely, a supportive family environment, less invasive control, and greater amounts of encouragement given to independence and experimentation in problem solving was associated with better behavior functioning among the children. Other studies support the impact of low SES on parent­child interactions (Herrenkohl, Herrenkohl, Toedter, & Yanushefski, 1984), cognitive maturity, and the encouragement of autonomy and independence in the child (Trickett, Aber, Carlson, & Cicchetti, 1991). The relationship between SES and behavioral functioning appears to be a linear one, with the risk of behavior problems increasing linearly with decreasing SES. Dodge, Pettit, and Bates (1994), found that SES was significantly negatively correlated with eight factors in the child's socialization and social context: harsh discipline, lack of maternal warmth, exposure to aggressive adult models, maternal aggressive values, family life stresses, EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 266 mother's lack of social support, peer group instability, and lack of cognitive stimulation. These factors accounted for over half of the total effect of SES on outcomes that, in turn, significantly predicted teacher­rated externalizing problems and peer­nominated aggression (over 60% of low SES children received a score in the clinical risk range sometime during elementary school). Thus, the effect of SES on children's externalizing behavior problems may be mediated by status­related socializing experiences. These studies clearly indicate that being a preschooler in a family living in poverty can have far­reaching negative effects on development. Maternal Depression Maternal depression has long been known to be a risk factor for child development. In a recent review, however, Cummings and Davies (1994) conclude that the effects of maternal depression on development cannot be viewed independently of the family's psychosocial circumstances as a whole. Although parental (especially maternal) depression increases the likelihood of family discord, impairments in parenting, marital conflict, and, consequently, child disturbance, the effects of these adverse family circumstances have a similar effect in families without depression. Thus, although maternal depression is one risk factor, it is actually a combination of risk factors that predict child disturbance. Leadbeater and Bishop (1994) find support for this conclusion in a study of 83 disadvantaged Afro­American and Puerto Rican adolescent mothers of 28­ to 36­month­old children. They found that maternal depressive symptoms in the first year were predictive of significant behavior problems in 13% of the children. However, those depressed mothers who had higher levels of emotional support and lived with maternal grandparents had children with fewer behavior problems. Intelligence Level A few studies of children prior to or at entry into school have shown a relationship between behavioral problems, such as aggression and disruptiveness, and lower IQ (Campbell, 1994; Richman et al., 1982). Cole, Usher, and Cargo (1993), for example, found that preschoolers with lower intellectual functioning were more likely to be rated by their parents or teachers as showing moderate to high levels of externalizing behaviors than were children who had average or above­average intellectual functioning. Furthermore, low verbal and visuospatial scores were associated with above­average behavioral difficulty and greater problems with behavioral regulation. Dietz, Lavigne, Arend, and Rosenbaum (1997) examined the relationship between intelligence and psychopathology in a nonclinical sample of 510 children, age 2 to 5 years. Both the CBCL (Achenbach, 1991, 1992) and the DSM­III­R (APA, 1987) were used to measure psychopathology. Results indicated that lower McCarthy (McCarthy, 1972) general, verbal, and perceptual performance IQ scores were associated with various types of psychopathology. Similarly, Sanson, Prior, and Smart (1996) conducted a large (1,251 children) longitudinal study of children from infancy to 6 years and found that at age 7 years, children with a combination of reading and behavior problems differed from a group of children with only reading problems from infancy onwards. For boys especially, difficult temperament and behavior, poor mother­child relationship, lower educational stimulation, and relative social disadvantage increased the risk of developing behavior problems and later emergence of reading disabilities. These results are consistent with those of clinical samples of preschool children. Hyperactive preschoolers have lower IQs than nonhyperactive preschoolers (Sonuga­Barke et al., 1994), and children with speech and language delay are at risk for ADHD, oppositional defiant disorder, and anxiety (Cantwell, Baker, & Mattison, 1979; Love & Thompson, 1988). Finally, Campbell (1994), using a mixed clinical and school­based sample of preschool boys, found that lower IQ predicted persistent problems two years later. The pathway for the association between cognitive deficits and psychopathology is not clear. It could be that cognitive deficits cause psychopathology, or vice versa, or they may share a common cause such as neural system damage (Goodman, 1993). In summary, the literature on behavior problems during the preschool years suggests that isolated problem behaviors or a constellation of mild symptoms are likely to disappear with development. Constellations of more severe problems in early EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 267 childhood, particularly externalizing problems, may signify difficulties that are likely to persist at least to middle childhood. Further, low SES, low intelligence, ongoing family disruption, and poor mother­child relationships are often associated with continued difficulties, especially among boys who are hyperactive and aggressive. Although there is increasing evidence to support the continuity of preschoolers' behavior problems, only in rare cases can the clinician identify causal mechanisms in the development of disorders in children. Furthermore, predicting future outcome and delineating the specific factors that contribute to or mediate outcome remains difficult (Campbell, 1990). Assessment Issues Assessment of problems in the preschool years is a complex task. To begin the process, it is important to have knowledge of the developmental processes and what would be expected of the ''typically" developing child. This, in combination with knowledge of risk and protective factors, sets the stage for developing hypotheses about the origins of the behavior of concern and planning intervention strategies. This section covers some important developmental milestones, areas that should be assessed, and assessment methods. Developmental Milestones Previously, the importance given to any aspect of development during the preschool years depended to a great extent on one's theoretical perspective. Psychoanalytic theory, for example, emphasizes the emergence of independence and psychosexual development, and social learning theory focuses on the development of self­control and self­efficacy. However, the failure of any one theory to adequately explain the complexity of development across areas has led to general acceptance of a transactional and/or ecological perspective that attempts to account for factors within the child, family, and society that influence development either directly or indirectly (Campbell, 1990; Mash & Terdal, 1997). Within this perspective, developmental gains in each area (social, cognitive, motor, language, etc.) are thought to be related to progress in other areas. Further, competencies or problems in any area of development early in life are seen as setting the stage for later development. In considering developmental milestones, inter­ and intra­individual differences should be kept in mind. Individual differences in the rate of development are nowhere more apparent than during the preschool years. Some children, for example, have extensive language before the age of 2, whereas other, "normal" children do not acquire speech until 3 years of age. An individual child's rate of development in various areas can vary as much as the rate of development between children. Some of these inter­ and intra­individual differences are primarily the result of genetic­organic factors, and others seem to be more the result of environmental influences. It is, of course, the unique interaction of these two factors—the child and the environment— that ultimately determines each child's developmental progress. This section briefly touches on some of the important developmental milestones that occur during the preschool years. The reader is referred to Davies (1999) and Lyman and Hembree­Kigin (1994) for more in­depth reviews of preschool development. Motor Development In an article on a new synthesis of motor development, Esther Thelen (1995) states that recent work "restores the primacy of perception and action in the evolving mental and social life of the child" (p. 80). She describes how even young infants possess dynamic systems that can integrate information from all their senses. It is through the process of exploration and selection that infants gain the ability to generate behavior that provides a variety of perceptual­motor experiences and to differentially retain those correlated actions. So, repeated cycles of perception and action, which are primary to the developing child, give rise to emergent new forms of behavior that is the link between "the simple activities of the infant and the growing life of the mind" (p. 93). There is strong support for this view, and it changes the long­held views on the unfolding developmental process and especially of the importance of motor behavior in that process. Although further discussion of this view of development is beyond the scope and purpose of this chapter, it would be remiss to not mention this important work. For our purposes, we restrict this section to simply describing motor behaviors that most children accomplish during the preschool years. EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 268 By the age of 2 years, children can walk, run, and jump smoothly and their balance is improving. They like to pull and ride toy vehicles and roll, bounce, and catch a ball. By age 3, they can stand on either foot for a brief period of time and are beginning to hop. They can also throw and catch a ball and pedal a tricycle. Four­year­ olds like to climb, hop, skip, and dance. They can also play simple ball games and respond to a sequence of motor directions. By age 5, most children are strong and confident in their movements, can move in many ways, quickly following directions, and may be riding a bicycle with training wheels. Motor development is essential for active exploration, learning, and mastery of the environment, and as preschoolers become stronger and more coordinated, they seem to thrive on physical activity. This increased activity often increases parental concerns about overactivity (Campbell, 1990). Activity level for most children, however, peaks at age 3 and then begins to decrease around age 5, when expectations to sit and listen increase (Routh, Schroeder, & O'Tuma, 1974). Improving eye­hand coordination promotes cutting with scissors, drawing circles and squares, and, by age 5, drawing a recognizable human figure. Between 4 and 5 years, most children are able to dress themselves, including managing buttons, zippers, and Velcro. Cognitive Development The area of cognitive development is so complex that only a brief discussion is possible in this chapter. Cognitive development involves qualitative changes in the ability to reason about environmental and social events and is driven by the motivation to explore and experience the environment (Flavell, 1977; Thelen, 1995). Children's cognitive processing skills are ever­changing, as shown by recent work on developmental changes in speed of information processing. The speed at which children are able to process information follows a global developmental trend, with speed increasing with age in relatively simple nonverbal and verbal tasks (Miller & Vernon, 1997). In contrast to Thelen's (1995) dynamic systems theory described previously, Piaget (Piaget & Inhelder, 1969) proposed that children progress through a universal sequence of stages in understanding the physical world. Piaget described preschool children as preoperational; they are beginning to think representationally or symbolically and to understand cause­ and­effect relationships. Preschoolers lack the ability to take another's perspective (described as egocentric), have trouble coordinating information from more than one source, and cannot attend to more than one dimension of a stimulus array at a time (i.e., they classify according to one dimension). Other work, however, suggests that Piaget underestimated the capabilities of preschoolers (Gelman & Baillargeon, 1983). When tasks and materials are familiar and do not require sophisticated language skills, children appear less egocentric and better able to reason. Recent research indicates that children as young as 3 and 4 years have the ability to understand mental representation as demonstrated in studies of pretense and reality (Golomb & Galasso, 1995). Even though they can be deeply engaged in pretend play and its elaboration, many preschoolers differentiate it from reality and describe it as ''thoughts" versus reality. Likewise, preschool children have demonstrated that they have considerable ability in reasoning about permission rules (e.g., you may go outside if you wear a coat). By the ages of 3 and 4, it has been demonstrated that children know when rules have been violated and can give reasons for the violations (Harris & Nunez, 1996). Thus, there is the clear implication that when most children at these ages violate a permission rule, they do it knowingly. Other theories and research in cognitive development have viewed social influences as having a major impact on cognitive development, with the parent­child interaction seen as the primary arena for the development of cognitive skills (Fagot & Gauvain, 1997; Hart & Risley, 1995, 1999; Vygotsky, 1978). During early childhood, much of children's problem­solving efforts are done in social situations under the guidance and supervision of their parents, who structure and model ways to solve problems (Rogoff, 1990). Through these interactions, the parents provide the child with cognitive opportunities that encourage and support learning and growth. The history of these interactions as well as the characteristics that both the child and parent bring to these interactions have been shown to predict the child's cognitive problem­solving skills over time and the cognitive outcomes, as measured by IQ tests, at age 5 years (Fagot & Gauvain, 1997). These authors found that children whose parents gave limited assistance to their problem­solving tasks EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 269 were more likely to be rated by teachers at age 5 years as having learning problems. Other work points to the importance of maternal social support networks for children's cognitive development. Melson, Ladd, and Hsu (1993) found that both the size and quality of the maternal network during preschool years directly predicted the cognitive performance of the child. Larger, more supportive networks have been associated with a less restrictive, less intrusive style of interaction and warmer and more nurturant parenting (Jennings, Stagg, & Conners, 1991). Children who do not evidence normal cognitive development are commonly identified during the preschool years. Frequently, these children are referred for evaluation because of slow or atypical language development, behavior problems such as noncompliance, short attention span or distractibility, because a preschool teacher or day care worker senses that ''something is not quite right," or because parents become concerned that the child will not be ready to start school. The resulting diagnosis is often mental retardation. At the opposite end of the spectrum from the child with mental retardation, but no less exceptional, is the gifted child. Gifted children are also most often identified during the preschool years because they go beyond developmental expectations. Robinson (1987) suggests that precocious development of language or reading skills is an important marker in the identification of gifted children. Although gifted children have been thought to be at risk for adjustment problems, some work indicates that this is not necessarily the case. Chamrad and Robinson (1986), for example, report that young gifted children often have higher self­esteem and more energy, enthusiasm, and curiosity than average children. Language Development The period between 2 and 6 years of age represents a time of enormous growth in children's language abilities, with acquisition of word meanings as the hallmark of the preschool years. Rapin (1996), in a synopsis of language development in the first 6 years of life, states that in the first year, infants go from cooing vowel sounds to producing repetitive consonant/vowel syllables such as "mama" or "baba" to producing meaningful but imperfect words. In the second year, words are initially acquired, one by one, and then vocabulary takes off.After they acquire a few dozen words, children start to produce two­word utterances. These utterances are the root for grammar, which allows children to understand and produce meaningful sentences. In the third year, vocabulary increases to hundreds of words and syntactic knowledge from the production of two­word utterances to full sentences. From then on, language acquisition involves the comprehension and production of ever more complex sentences such as passive and embedded grammatical constructions and increased vocabulary to thousands of words; by school age, children start to master written language. Rice (1989) states that without explicit teaching, preschoolers acquire as many as 14,000 new word meanings as they encounter them in meaningful situations and conversations, and that this phenomenon is the foundation for later reading skills. It is during the preschool years that children begin to be able to use language to develop cognitive skills, to facilitate their understanding of the world, to aid their remembering, and to organize their thoughts (Rice, 1989). Hart and Risley's (1995, 1999) two volumes of meticulously collected data from a longitudinal study of the development of language in 42 children demonstrates the profound effect that responsive parenting has on a child's acquisition of language and on intellectual performance. They found that children living in poverty, children born into middle­class families, and children with professional parents all had the same kind of language experience. However, the children born into homes with fewer economic resources had fewer of these experiences. In other words, the amount or frequency of talking the parents engaged in was a crucial factor in the later development of these children. This increased frequency provided greater language diversity through lots of talk, increased proportional amounts of encouragement and discouragement, and provided greater opportunity for symbolic emphasis on names, relations, and recall. Hart and Risley also documented the importance of a parental guidance style that focused on asking rather than demanding and a responsiveness that stressed the importance of the child's behavior during interactions. Thus, children whose parents talked a lot had far more experience with every quality feature of language and interaction. These findings suggest far­reaching recommendations for early intervention programs and the importance of EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 270 talking by parents and children in children's overall development. Given the importance of language development in mediating cognitive and social development (e.g., Hart & Risley, 1995, 1999; Simon, Larson, & Lehrer, 1988), it seems evident that delays or disorders of language will impede development in other areas. Any of the major categories of speech and language disorders can be seen in preschool youngsters, and these are also often significantly associated with other disabilities, such as mental retardation, externalizing and internalizing disorders (particularly hyperactivity and attention problems), peer rejection, and learning problems (Benasich, Curtiss, & Tallal, 1993). In fact, it is often because parents are concerned that their preschool child is not developing language as expected that they seek professional help. Table 14.2 outlines the ages and indicators for referral to a communication specialist (Wang & Baron, 1997). Social Development In the area of social development, the tasks for the preschooler are to learn social skills, prosocial behaviors, and values and to learn how to play with peers and develop friendships (Davies, 1999). Research in the area of social development has focused more recently on the cognitive and emotional factors that regulate or inhibit prosocial actions, with agreement that children can exhibit prosocial behavior early in life (Hay, 1994). There is research to support a genetic basis for temperamental differences in sociability and extroversion (Plomin, 1989), and there is also research to support the importance of a child's experiences in early caregiving relationships (M. Greenberg et al., 1990; Hartup, 1989; Rubin & Stewart, 1996) as well as later peer relationships (Bukowski, Newcomb, & Hartup, 1996) in developing social competence. Reasoning about the physical world is thought to provide the basis for reasoning about the social world. Thus, the constraints in preschoolers' understanding of the characteristics of the environment also apply to their understanding of social situations and relationships (Crick & Dodge, 1994). Social competence is dependent, for example, on the development of specific cognitive skills such as representational or symbolic thinking and social perspective taking (Howes, 1987). It is also dependent on past experience with the family and parents, who serve as models for children's developing relationships with others (Parke & Ladd, 1992). For example, healthy infant­parent attachment is important to later development of children's ''working models" of themselves and others (Greenberg et al., 1990). Also, parents who provide warmth, nurturance, and clear limits encourage the development of similar prosocial behaviors and values (Davies, 1999). Peer relationships also play a critical role during the preschool years in fostering the development of more complex and effective social behavior (Bierman & Welsh, 1997). Peer relationships begin to develop around age 2 as solitary play decreases and parallel play increases. Gradually, play becomes more cooperative and reciprocal between 3 and 5 years, and by age 5 or 6, most children enjoy simple, competitive, EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 271 rule­governed play activities with other children. Friendships that involve reciprocity, liking, affection, and fun also begin to develop during the preschool years (Bukowski et al., 1996). Having friends is clearly a ''developmental advantage" (Hartup, 1989), as social rejection in childhood is consistently found to be related to later adjustment problems (Boivin, Hymel, & Bukowski, 1995; Coie, 1990). Personality and Emotional Development Temperament, or the behavioral style of a child's interaction with the environment, is an important aspect of early personality development. The work of Thomas and Chess (1977) demonstrated individual differences in temperament as early as the first few weeks of life, and other research in behavioral genetics suggests that many aspects of personality may be inborn (H. Goldsmith, Buss, & Lemery, 1997). Temperamental characteristics of infants and preschoolers have been related to the development of behavior problems, adjustment to preschool and kindergarten, peer relationships, IQ scores, and academic achievement (Earls & Jung, 1987; Keogh & Burstein, 1988; Palisin, 1986; Schmitz & Fulker, 1994; Skarpness & Carson, 1987). Thomas, Chess, and Birch (1968) derived a cluster of traits (irregularity of biological functions, withdrawal from novel stimuli, slow to adapt, intense responses, and predominantly negative in mood), called "difficult temperament," that has been shown to be clinically significant. The "difficult" child is harder to parent and at higher risk for developing behavior problems (J. Goldsmith et al., 1987). In a sample of 350 preschool children, McDevitt and Carey (1978) found almost 19% to be difficult. Not all difficult children develop adjustment problems, however, and Thomas et al. also introduced the idea of "goodness­of­fit" to account for this phenomenon. Goodness­offit describes the interrelationship between the child's characteristics and environmental demands and expectations. A "good fit" facilitates optimal development; a "poor fit" interferes with it. Thus, a difficult infant born to a highly stressed, unresponsive mother would be considered at higher risk than a difficult infant born to a responsive, sensitive, calm mother (Campbell, 1990; Davies, 1999). Another important aspect of personality development during the preschool years is the development of the self­system, which includes self­concept, self­control, and self­esteem (Harter, 1983). Although the self­system is only just beginning to emerge during the preschool years, it is central to later social­emotional adjustment (Achenbach & Edelbrock, 1978; Pope, McHale, & Craighead, 1988). For preschoolers, identifying with their parents is a primary means of identifying themselves (Davies, 1999; M. Greenberg et al., 1990). Consistent with their cognitive developmental level, the self­concept of preschool children consists primarily of concrete attributes such as physical characteristics and possessions. Preschoolers also tend to think of themselves in either/or terms, that is, as nice or mean, good or bad (Pope et al., 1988). Increasingly with age, self­concept is derived from comparisons with peers. Not surprisingly, preschoolers are very much aware of how other children behave and how they are treated. In large part, how preschool children perceive of and evaluate themselves (self­esteem) is the result of the perceptions and behavior of significant adults. Clearly, a sense of mastery over environmental events also contributes to self­esteem, but during the preschool years, this too is mediated by significant adults (Davies, 1999). As Campbell (1990) states, adults can provide or thwart opportunities for children to explore the environment and experience mastery, and they can reward, punish, or ignore successful experiences, thus influencing the child's perceptions of self. The expression of emotion during the preschool years is usually uninhibited because the child is in the process of learning how to express emotions in a socially acceptable way. Anger is usually expressed physically in response to an immediate stimulus by biting, scratching, or kicking, but is typically short­lived (Davies, 1999). Temper outbursts occur most often around 2 to 3 years of age and then gradually diminish during the later preschool years (Mesibov et al., 1977). Children's ability to label emotions, to talk about emotions, and to use language about emotions to guide their own behavior increases during the preschool years (Davies, 1999; Kopp, 1989). This ability, however, is greatly influenced by family practices, which can accelerate or impede the child's appreciation of the privacy of emotion (Harris, 1994). In a review of the literature on children's understanding of the subjectivity of emotions, Harris found that individual differences were influenced by the emotional atmosphere of the home, the amount of discussion about emotions, the availability of a sibling close in age, and the involvement in pretend play. EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 272 This ability to regulate emotions or self­control is related both directly and indirectly to self­esteem (Davies, 1999; Pope et al., 1988). Children who have good self­ control feel better about themselves and also receive more positive feedback from adults. Further, the authoritative parenting style that has been shown to be related to the development of self­control in children also fosters self­esteem. A number of studies have focused on the attachment of preschoolers to a soft object or ''transitional object" and the importance of this behavior to the development of separation­individuation and emotional regulation (S. Brody, 1980; Kopp, 1989). Recent work demonstrates that a secure, healthy mother­infant relationship is an important condition that leads to the later attachment to a soft object versus some other object such as a pacifier (Lehman, Denham, Moser, & Reeves, 1992). Kopp proposes that the use of transitional objects can function as a mechanism for young children to gain control over stress and emotional arousal, with the soft object providing the soothing and comfort previously given by the mother. Passman (1987) suggests that transitional objects serve to reduce anxiety or arousal for the child because they are associated with positive consequences. Thus, it is generally accepted that the use of transitional soft objects has positive value in the child's move to greater independence and is not associated with maladjustment or insecurity. Assessment Process The task of the child clinician is to identify and treat those children who suffer from emotional and/or behavioral problems that significantly interfere with their development or functioning and are likely to persist. The assessment process can help the clinician determine which problems are clinically significant and which are only annoying but transient behaviors. Campbell (1990) suggests five criteria to help identify those children who are exhibiting potentially significant difficulties or disorders: (1) the presence of a pattern or constellation of problem behaviors (e.g., aggression, hyperactivity, attention deficit, and noncompliance, or withdrawal, anxiety, and sadness); (2) a pattern of problem behavior that persists beyond a transient adjustment to stress or change, such as entry into school or the hospitalization of a parent; (3) a cluster of symptoms that occur across settings and people; (4) behaviors that are relatively severe; and (5) behaviors that interfere with the child's ability to handle developmental transitions or impair functioning. In addition to determining if particular behaviors are clinically significant, the assessment process must also determine factors contributing to the behavior problems and target areas for intervention. Therefore, the assessment of preschoolers must take into account the developmental level of the child and potential biological influences, as well as broader ecological (familial, social, cultural) factors that interact with children's characteristics. In assessing problems of the preschool child, the following general areas should be covered: 1. The presenting problem should be described in detail, including an objective description of the type of behavior; the severity, frequency, and situation specificity of the behavior (i.e., does it occur in only one setting or across settings); the persistence of the behavior; changes from previous behavior; and if the behavior is isolated or part of a cluster of behaviors. 2. The developmental status of a child's physical, cognitive, emotional, and social behavior should be determined. Is the child functioning at the expected level in each area? 3. Familial factors should be reviewed, including a history of medical, learning/intellectual problems or psychopathology, parental attitudes and expectations for child development, ethnic and cultural issues, marital adjustment, parenting style, and social support system. 4. Environmental factors such as socioeconomic level, sociocultural setting, and life circumstances should be reviewed. 5. The consequences of the presenting problem behavior for the child, his or her family, and their community should be determined. Methods to assess these variables are necessarily multimodal and may include (1) interviews with parents and/or other significant adults in the child's life; (2) parent questionnaires; (3) direct observation of the child in the clinic, home, day care, or any other setting in which the child spends time; (4) observation and objective measurement of parent­child interaction in free play and structured EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 273 settings; (5) standardized developmental tests and rating scales; and (6) referral to an allied health professional for further assessment of a specific area, such as language or motor development. Gathering general background information and ratings on standardized scales from the parents before interviewing them can be very helpful in planning the assessment process. This information allows the clinician to be more specific in the interview. It also alerts the clinician to potential problems in the parent­child relationship and the possible need for additional assessment methods such as a home visit, observation of the child with the teacher or other caregiver, use of standardized developmental instruments, or further assessment of parental characteristics. Samples of general parent questionnaires that gather demographic, developmental, medical, and behavioral information and are useful for the preschool child can be found in Culbertson and Willis (1993) and Schroeder and Gordon (1991). Three age­appropriate, standardized, and reliable parent rating scales are recommended for use with preschool children. The Child Behavior Checklist (CBCL; Achenbach, 1991, 1992) provides multiple behavior­problem scales derived separately for boys and girls in different age groups, starting with 2­year­olds. The Eyberg Child Behavior Inventory (ECBI; Eyberg, 1999) is a 36­item behavioral inventory of conduct problems for children age 2 to 16 years. The Parenting Stress Index (PSI; Abidin, 1995) contains 126 items divided into two major domains that focus on child and parent characteristics; the items reflect stress in the parent­child relationship. When completed by both parents, the CBCL and the ECBI give a good picture of the similarities and differences in parents' perceptions of their child's adjustment, how this perception relates to that of parents of similar­age children, and if the behavior is in a clinically significant range. The PSI allows a broader look at the context of the parent­child relationship and the potential stresses on that relationship. Interviewing parents is an essential part of the assessment process; for a guide, the reader is referred to Schroeder and Gordon (1998). For preschool children, an unstructured interview is recommended as this allows the clinician more freedom to explore the nature and context of a particular problem as well as the opportunity to investigate contributing factors, such as parental expectations and environmental conditions. In addition to the previously mentioned areas to be covered, the parent interview should include (1) a clarification of the referral question (so there is a mutual understanding of the concerns to be addressed); (2) a determination of the social context of the problem (e.g., who is concerned and why; ways they have tried to handle the problem; their expectations, hopes, and fears in seeking help); and (3) a determination of areas for intervention or plans for further evaluation. Direct observations of the child in his or her environment (home and/or preschool or day care) and observation of parent­child interaction in both a structured and unstructured play setting are especially important for preschool children. These observations can provide information on possible etiologies and/or factors in the environment that maintain problems (Crowell, Feldman, & Ginsberg, 1988; Sattler, 1988). Observation can, thus, give a wealth of information about intervention strategies. The assessment of the preschool child in a free play situation can give information about the child's intellectual, emotional, social, and language development, and fantasy play may reflect current concerns and anxieties. It also allows observation of how a child uses his or her time and organizes play activities. Eyberg and colleagues have developed a coding system for parent­child interactions that is very helpful in both the assessment and treatment process (Eyberg, Bessmer, Newcomb, Edwards, & Robinson, 1994). Standardized assessment of the preschool child is often necessary when there is a question of developmental problems. Doing this work involves special training not only in the administration and interpretation of the instruments but also in learning to interact with the child so as to maximize his or her performance. The reader is referred to Culbertson and Willis (1993) and Nuttall, Romero, and Kalesnik (1999) for information on the specific assessment instruments and techniques available for assessing preschool children. In summary, assessment of problems during the preschool years is a complex task that requires a knowledge base cutting across a number of areas and disciplines. Questions should include: Is it a developmental problem? Is the expected behavior absent or occurring at a rate that is too high or too low? Are parental expectations, attitudes, or beliefs appropriate for the social situation, the age, and the developmental level of the child? Are parental EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 274 characteristics and/or marital discord contributing to the problem or to the perception of the behavior? Are child­rearing styles appropriate for the child in question? Are environmental conditions contributing to the behavior problem or to the perceptions of the behavior? What are the setting conditions for the behavior? Will the behavior cause the child, parents, or others to suffer now or in the future? Should a referral to an allied health professional be made to determine a possible physical or organic problem? Data gathered in the assessment process should answer these questions, giving information on the nature of the behavior problem, the target of intervention, and the selection of appropriate intervention strategies. Common Behavior Problems During the course of the preschool years, children are sure to exhibit behavior problems at one time or another. Although it is true that most of these problems are transitory and may require little or no intervention, recent research has shown clearly that many can set the stage for later, more serious difficulties. As a result, treatment approaches to problems in the preschool years often emphasize prevention of later problems. In our experience, the concerns of parents of preschool children are most often about sleep, toileting, eating, fears, noncompliance and aggression, habits, and sibling rivalry. Child maltreatment, including neglect and physical, sexual, and psychological abuse, is also a major problem during the preschool years. Given that the National Center on Child Abuse and Neglect (NCCAN, 1996) in a review of 41 states found that nearly 80% of the perpetrators of child maltreatment were parents (as cited in Reppucci, Britner, & Woolard, 1997), the consequences of maltreatment for preschool children can be particularly devastating to their cognitive, social­emotional, and language development. The reader is referred to the chapter on maltreatment in this volume for more information on this important social problem. This section briefly reviews some of the common problems as they manifest during the preschool years. Most, if not all, of the problem behaviors covered in this chapter are covered in depth in other chapters in this volume. Sleep Problems The sleeping patterns of children change with age, and consequently, the types of sleep problems seen in children vary along developmental lines. During the preschool years, sleep problems are often initiated by a transient difficulty such as an ear infection or other illness, traveling, or overnight visitors and then are maintained or exacerbated by parental management to the extent that professional consultation and/or intervention may be required. It is estimated that as many as 25% of preschoolers evidence significant sleep disturbances of one type or another (Mindell, 1993; Pollock, 1994). The significance of these problems is illustrated by recent research that indicates that early sleep disturbance can be associated with a variety of other difficulties, including behavior management problems, parental depression, attention­deficit disorder, and difficult temperament (Lyman & Hembree­Kigin, 1994; Stores, 1996). Moreover, in the absence of intervention, the continuity between early and later sleep problems has been documented (Butler & Golding, 1986; Pollock, 1994). Although treatment will vary depending on the specific problem, assessment of sleep problems typically involves having parents complete a sleep diary/log for one to two weeks (see Schroeder & Gordon, 1991, for an example). This information should include 24 hours of data on eating and sleeping schedules and routines, time and characteristics of the sleep disturbance, and parents' responses to the child's behavior. The importance of prevention through establishment of consistent bedtime routines is emphasized in the literature (Lyman & Hembree­Kigin, 1994; Stores, 1996), and efforts to prevent sleep problems through parent training during early infancy have been effective (Wolfson, Lacks, & Futterman, 1992). Sleep problems during the preschool years most often include fear of the dark and/or of sleeping alone (discussed in the section on fears), nightmares, and sleep terrors and other confusional arousals such as sleep walking, sleep apnea, refusal to go to bed, and night waking. Nightmares Children's nightmares usually begin to occur between the ages of 3 and 6 years. In contrast to sleep terrors, nightmares are associated with REM sleep EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 275 (irregular pulse and respiratory rate, rapid eye movements, and waking/drowsy sleep pattern) and typically happen during the last third of the sleep cycle, when REM sleep is predominant (Anders & Eiben, 1997). Nightmares are vivid, elaborate, and usually clearly remembered. Chronic nightmares are generally thought to result from emotional stress, either ongoing, such as marital conflict, birth of a sibling, or toilet training, or a specific traumatic event, such as an accident or injury (Lyman & Hembree­Kigin, 1994; Stores, 1996). Treatment of nightmares is typically focused on physical comfort and reassurance of the child in the child's own room/bed, some explanation of the nature of dreams geared to the child's level of understanding, and reduction of stresses in the child's life (Ferber, 1985; Lyman & Hembree­ Kigin, 1994). Severe cases may require individual and/or family psychotherapy. Behavior therapy (including contingency management, relaxation therapy, and systematic desensitization) and bibliotherapy (reading stories about children who have nightmares) can also be useful in dealing with children's nightmares (Barclay & Whittington, 1992; Greening & Dollinger, 1989). Sleep Terrors and Confusional Arousals Sleep terrors and other confusional arousals such as sleep walking occur during the first one to three hours of sleep during transitions from deep sleep or NREM to REM sleep (Anders & Eiben, 1997). They are thought to be manifestations of central nervous system arousal and are more common in boys than girls. Sleep terrors occur in about 3% of children age 18 months to 6 years and only rarely in older children (Anders & Eiben, 1997). In sleep terrors, the child sits up in bed or cowers in a corner, has a glassy stare, screams or cries inconsolably, and cannot be awakened. Other signs of autonomic arousal, such as tachycardia, rapid breathing, and sweating, are often present (Lyman & Hembree­Kigin, 1994). In contrast to nightmares, the child typically has no memory of the event the next morning. Confusional arousals are thought to be more common than sleep terrors, with almost all preschool children experiencing a mild form every now and then (Ferber, 1989). Confusional arousals typically begin with some movement and crying out, but instead of looking terrified as in sleep terrors, the child appears confused and agitated. Sleep walking is a form of confusional arousal wherein the child wanders around the house, may attempt to leave the house, and may engage in unusual behavior such as urinating in an inappropriate place. Similar to sleep terrors, the child who is experiencing confusional arousal cannot be awakened and does not remember the episode. Sleep terrors and confusional arousals are not associated with emotional or behavioral disturbance and typically disappear without intervention (Ferber, 1985). Thus, treatment is usually a brief parent consultation in which parents are reassured and given information about sleep and development. Safety precautions may be recommended in cases of sleep walking. In severe cases, systematic waking 15 to 30 minutes before the typical time of sleep walking or sleep terrors for up to one month has been shown to be effective in reducing the incidence of this problem (Frank, Spirito, Stark, & Owens­Stively, 1997; Lask, 1988). Resistance to Sleeping and Night Waking Bedtime struggles and waking during the night are very common among preschool children, with estimates of prevalence ranging from 25% to 50% of 1­ to 3­year­ olds (Anders & Eiben, 1997; Johnson, 1991; Pollock, 1994). Bedtime rituals and routines that promote relaxation and drowsiness are very important at this age and, when used consistently, can often prevent bedtime problems from developing (Stores, 1996). When the child resists sleep despite these routines, firmness and consistency in not responding to cries is usually all that is needed. Older preschoolers respond well to the addition of a story to let the child know what is expected and what the parent is going to do (ignore), plus a sticker in the morning for good nighttime behavior (Schroeder & Gordon, 1991). Although this extinction approach can be difficult for parents, it is very effective in eliminating bedtime struggles and night wakings. Further, there is no evidence that it results in detrimental effects on the child's emotional well­being (France, 1992). Ferber (1985) and Lawton, France, and Blampied (1991) describe more gradual approaches to extinction. Sleep Apnea Sleep apnea is the one sleep disorder seen in preschool children that results from physical abnormality: a blockage of the airways that prevents EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 276 passage of oxygen (Hansen & Vandenberg, 1997). Apnea episodes can occur once or twice or hundreds of times a night and last from 10 seconds to 2 minutes. Obviously, frequent or lengthy episodes can have serious consequences for the young child. Specifically, daytime difficulties that interfere with the child's cognitive, social, and emotional functioning, including irritability especially upon awakening, difficult behavior, impaired attention, memory, and visual­motor performance, and poor progress in school have been documented (Stores, 1996). The primary symptom of sleep apnea is snoring. However, up to 10% of children snore, yet only 1% to 2% actually have sleep apnea. Other symptoms include mouth breathing, profuse sweating, and unusual sleeping positions, especially with the neck extended (Stores, 1996). Evaluation of sleep apnea is recommended for children who are experiencing learning and/or behavioral problems, especially those that are similar to attention­deficit disorder (Hansen & Vandenberg, 1997). Assessment may involve physical examination with special attention to tonsils and adenoids as well as a sleep history. Typical treatment is removal of tonsils and adenoids. Eating Problems Feeding difficulties are among the most common concerns of parents of preschool children, with estimates of prevalence ranging from 24% to 45% of 2­ to 4­year­ olds (Beautrois, Fergusson, & Shannon, 1982; Bentovim, 1970). Specific problems most common to this age group include food refusal, obesity, failure to thrive, and pica. Food Refusal Of all the feeding problems seen in preschool children, food refusal is the most common. It can range from simple picky eating to total food refusal resulting in life­ threatening malnutrition. Food refusal can be a consequence of medical procedures that interfere with normal eating development, but more typically, parent­child interaction around mealtimes is implicated (Sanders, Patel, LeGrice, & Shepherd, 1993). Assessment of food refusal problems requires information about the interplay of environmental, physical, and behavioral factors. Observation of parent­child interaction during mealtimes is considered critical (Lyman & Hembree­Kigin, 1994). Even severe cases of food refusal can be successfully treated with behavioral methods, including differential attention to appropriate behavior, shaping, reinforcement contingent on desired behavior, and gradual exposure/desensitization (Lyman & Hembree­Kigin, 1994). Obesity It is estimated that 5% to 10% of preschoolers are obese, and these rates appear to be increasing despite the well­known health risks (Maloney & Klykylo, 1983). Obesity in the preschool years is highly associated with obesity in adulthood. Furthermore, there is a strong correlation between parent and child obesity that suggests a genetic link. Research shows, however, that this association is primarily due to family eating and activity patterns (Lyman & Hembree­Kigin, 1994). Most cases of obesity occur in the absence of family dysfunction or psychopathology, although if the condition persists into later childhood and adolescence, children can develop significant problems with self­esteem and peer relations. Behavioral methods have been most successful in treating obesity, and parent involvement is necessary in treating preschoolers. These methods include self­monitoring, stimulus control, reinforcement procedures (including response cost and contingency contracting), and cognitive restructuring (Lyman & Hembree­Kigin, 1994). Also important are exercise programs and nutritional information. Failure to Thrive Failure to thrive is defined as failure to gain weight or weight loss with adequate nutrition. The etiology of failure to thrive is not entirely clear, although parental and family factors such as low SES, lack of nutritional knowledge, improper feeding, alcoholism, and stress have been implicated. Others suggest that characteristics of the infant such as prematurity, difficult temperament, and cognitive deficits play a role. Lyman and Hembree­Kigin (1994) conclude, ''It appears that both organismic and environmental variables are significant in the interaction that produces the failure­to­thrive syndrome" (p. 70). Treatment most frequently involves hospitalization; altering parent­child interactions, particularly around feeding; role­modeling appropriate feeding techniques; nutritional education; and environmental intervention to reduce levels of stress (Lyman & Hembree­Kigin, 1994). EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 277 Pica Although most young children mouth objects during the early years of life, some persist in this behavior beyond the age of 18 months and actually eat inedible substances, resulting in a diagnosis of pica (Lyman & Hembree­Kigin, 1994). Pica is more common among children from lower socioeconomic backgrounds and those with mental retardation and tends to disappear by age 4 or 5 in those with normal intelligence. Pica is a serious disorder because of its association with accidental poisoning, especially lead poisoning, which can lead to neurological damage and cognitive deficits. Treatment of pica typically involves parent education and behavioral methods such as overcorrection (brushing with mouthwash) and differential reinforcement of other, more appropriate behaviors (Lyman & Hembree­Kigin, 1994). Fears During the preschool years, fears are an almost inevitable occurrence, although some children may be predisposed to be more fearful than others as a result of temperamental characteristics or family history of anxiety (Stevenson­Hinde & Shouldice, 1995). In a parent survey done through a pediatrician's office, parents perceived fears as a ''problem" most often in their 2­year­olds and less often in their 3­ to 5­year­old children (Schroeder & Wool, 1979). The types of stimuli evoking fear reactions in children is clearly linked to the development of cognitive skills such as the ability to differentiate reality from fantasy. Two­year­olds, for example, tend to be afraid of concrete objects (animals, trains) or loud noises (thunder, vacuum cleaners), whereas 3­ to 5­year­olds increasingly develop more abstract fears of imaginary creatures, being alone in the dark, and bad dreams (Marks, 1987). Most childhood fears are transitory (Marks, 1987), and it typically is not possible to determine the origins of a child's specific fear. It is, however, very easy for parents to inadvertently reinforce fearful behavior in the attempt to comfort and support the child. If fears persist, generalize, or intensify to the extent that they interfere with the child's functioning and/or development, professional intervention may be indicated. Among other types of general information, assessment of preschool fears should include a family history of anxiety and observations (if possible) or descriptions of the parents' response to the child's behavior. Behavioral techniques are most effective in treating intense fear in preschool children. The literature suggests that modeling (with models that closely match the child's age, gender, and fear level) and in vivo desensitization are the most effective methods. Parents can easily be taught to conduct desensitization programs in the home (Klesges, Malott, & Ugland, 1984; Matson, 1983), although they may need support and encouragement to make their child confront the feared stimulus directly—a critical and necessary component of successful treatment. Other useful treatment methods include contingency management with rewards for interacting with the feared stimulus and symbolic modeling through stories or doll play of how to cope with fears. Separation Anxiety Separation anxiety is typical during the course of normal development at around 12 to 20 months of age and may reappear between 2 and 4 years as children go off to preschool or day care. This type of separation anxiety usually resolves successfully among securely attached children who have had the opportunity to experience repeated parental separation and reunion and have learned to cope with parental absence. Campbell (1990) notes that it is difficult to distinguish "excessive" separation anxiety from that which is adaptive in preschoolers. She states that preschool children may be most vulnerable to separation anxiety during those times when it is normative developmentally and an "attachment altering event" (e.g., death, divorce, move) occurs. Assessment of separation anxiety should focus on early attachment history, patterns of caregiving behavior (specifically, inconsistent or unresponsive caregiving), and observation of parent­child interaction including reactions to separation (Lyman & Hembree­Kigin, 1994). Treatment typically will involve behavioral techniques such as gradual exposure to separation while engaged in an anxiety­reducing behavior (eating ice cream, watching cartoons, etc.) and reinforcement of good separation behavior (Lyman & Hembree­Kigin, 1994). Parent counseling and parent­child interaction training may also be included if the problem is related to attachment issues. Medication for separation anxiety in preschoolers is controversial because of potential EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 278 serious side effects and lack of adequate research (Last & Francis, 1988). Preschool Refusal Much has been written about school refusal or school phobia among older children, but there is little regarding preschoolers who refuse to go to preschool or day care. There is general agreement that preschool refusal is related to either separation anxiety, specific fears related to the preschool or day­care center, or part of a generalized pattern of conduct problems (Lyman & Hembree­Kigin, 1994). Children whose refusal to attend preschool is related to separation anxiety will typically have difficulty separating from parents in other contexts, whereas those who have a specific fear related to some aspect of the preschool environment will not. Children who resist going to preschool as part of a general pattern of negative behavior usually settle down and do well once the parent has left. Treatment of preschool refusal will obviously depend on which type the child manifests and may involve procedures described for specific fears and/or separation anxiety. If the fear is specific to the preschool or day care situation, the parent should investigate for possible problems in the setting. Children who have conduct­related problems can benefit from parent­training interventions. Negative Behavior One of the most frequent complaints from parents of preschool children is that of negative behavior or conduct problems. Negative behavior consists of a variety of aversive behaviors, including noncompliance, verbal and physical aggression, whining, temper tantrums, talking back, taunting and teasing, cursing, overactivity, destructive behavior, and deliberate cruelty. Although all preschool children engage in some of these negative behaviors at one time or another, most develop without difficulty. Some children, however, with severe conduct problems during the preschool years evidence behavior disorders, substance abuse, and legal problems later in childhood and adolescence (Campbell & Ewing, 1990; Pierce et al., 1999). Determining which children will continue to evidence conduct problems requires an understanding of the transactional nature of development and the many risk and protective factors that are both constitutional and environmental (Eyberg, Schuhmann, & Rey, 1998). Children who grow up in more adverse family circumstances, have more negative mother­child relationships, and demonstrate clusters of negative behaviors across multiple settings are particularly at risk for continuing conduct problems. Developmentally, negative behavior probably first appears as characteristics of difficult temperament (difficult to soothe, irritable, irregular, intense reactivity). In contrast, parents' earliest concerns about negative behavior revolve around overactivity, which is seen by 1 to 2 years (Loeber, Green, Lahey, Christ, & Frick, 1992). Stubbornness and noncompliance increase from age 2 and peak at about 3 years. This trend reflects the development of autonomy and independence and pressures of socialization. As language sophistication and social and emotional maturity develop, direct defiance (''No!") decreases and negotiation strategies increase (Kinzynski, Kochanska, Radke­Yarrow, & Girnius­Brown, 1987). Parent and sibling responses to and modeling of negative behavior give the child clear feedback about the efficacy of these behaviors, especially aggression, and serve to maintain or exacerbate the problem (Stormont­Spurgin & Zentall, 1995). Although preschool children are still strongly influenced by parenting style and environmental conditions, their peers also increasingly influence them. Recent research has found that preschool children are selective in their affiliation with peers who have a behavioral style and social competence level similar to themselves and that child behavior is subsequently shaped within those close affiliative relationships (Farver, 1996; Snyder, Horsch, & Childs, 1997). Snyder et al. found that aggressive preschool children appear to have more difficulty establishing affiliations, and they tend to select other aggressive children as strong peer affiliates. Further, the interactions of these aggressive children are characterized by frequent and lengthy conflict and by higher levels of escalation in aggressive behavior. Even relatively nonaggressive children became more aggressive as the amount of time they spent with aggressive peers increased. Treatment for aggression should thus go beyond the individual child and focus on the larger peer group (Farver, 1996). The teacher, for example, could change the composition of the children's "cliques" for particular activities to create opportunities for new friendships, peer alliances, and networks. The use of EBSCOhost - printed on 1/26/2025 1:43 PM via MCMASTER UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use  Page 279 cooperative versus competitive games in the classroom has also been shown to increase cooperative behaviors and decrease aggressive behaviors (Bay­Hinitz, Peterson, & Quilitch, 1994). Training children through videotapes and practice in dealing with interpersonal problems has also been found successful in reducing aggression and, when combined with parent training, gives even more significant improvements in child behavior at one­year follow­up (Webster­Stratton & Hammond, 1997). Parent management training and parent­child interaction training programs are the most frequent and successful treatments for preschool children with negative behavior problems (Brestan & Eyberg, 1998; Foote, Schuhmann, Jones, & Eyberg, 1998). Parent management training focuses on teaching parents basic principles of learning so that they can modify their child's behavior by targeting specific behaviors for reinforcement or punishment. In contrast, parent­child interaction training focuses on the relationship between parent and child using a two­step program that teaches parents positive interaction