richard and tantrums (answers)

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Richard is just over 2 1/2 years old, and his motherasks for your help because she finds his “temper tantrums”increasingly difficult to handle. His behaviour is now so troublesome, that theentire family is affected. For example, they can no longer go out together for ameal.

Richard was born at term by normal delivery and his neonatal course wasunremarkable. His mother says he was always a “difficult” baby: hissleep pattern was erratic, his predominant moods tended to be “grumpy”and he often winged and whined. He always did and still does display intense andextreme emotional reactions, both to novel situations or when he is thwarted. Hehas never been “cuddly”.

When going over his development, you notice a degree of speech delay: Richardonly has a vocabulary of at most half a dozen words, and these are difficult tounderstand. He is not putting any words together. Richard’s mother reports thathis non-verbal communication is good: he points at things when he wants them andbecomes very upset when his wishes are not gratified.

Richard has brought with him a set of Thomas the Tank-engine, and lies on thefloor pushing the engines backwards and forwards for 20 minutes withoutinterruption.

Case discussion: Behaviour difficulty with language delay

At the age of 2 1/2, children will normally havedeveloped the ability to engage in symbolic/pretend play and will explore thepossibilities of a toy methodically. They will begin to organise toys into gameswith theme and time sequence.

They can communicate verbally using two or three elements and non-verballyby pointing, gesture, bringing things, to parent etc. Beware difference betweenproto-declarative and proto-imperative pointing (pointing to indicate an objectof interest vs. pointing to attain a desired object).

Many children with pervasive developmental problems will show a reasonableattention span when manipulating an object which they like (or even have afixation with). It is important to observe them with a variety of toys. Flittingattention span, constant change from one toy to the next or fiddling with otherobjects in the room despite reprimands are worrying signs

A key factor in this child would be his social behaviour: how he respondsto parents/other familiar people/strangers? Does he come for comfort when hurtand will he appreciate hurt in other family members? Is he cuddly? Does he makeready eye-contact and will he take turns?

Pure language delay can be associated with behaviour and attentionproblems. The differential diagnosis also includes specific language problem andautism/autistic spectrum disorder.

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