The behavioral complaint:
Symptom of a psychiatric disorder or a matter of temperament?

By Stanley Turecki, MD

Don't immediately ask yourself "What's the diagnosis?" when parents bring a child with behavioral problems to you, a noted child psychiatrist urges in this essay. Instead, answer key questions about the extent of the problems and the settings in which they occur before you decide on the appropriate intervention.

As a psychiatrist who treats children, my approach to diagnosis is centrally linked to the concept of individuality and the understanding that any one child is different from all other children. "Different" is not the same as "abnormal," yet a range of individual differences have been categorized and labeled as "abnormalities" or "mental disorders."

I also recognize that there is a distinction between saying, on one hand, that a child, or his or her behavior, is "average" and, on the other hand, saying that he, or she, is "normal." "Average" is a statistical concept; a certain number of children fall in the average range and a number fall outside that average at one or the other end of the spectrum. A normal child is not necessarily an average child, and a child who is not average is not necessarily abnormal.

My point, then, before talking about the distinction between a difficult temperament and a psychiatric disorder, is this: We should, first, look at normal behavior as occupying a very wide range and, second, be careful when categorizing a child's behavior as in some way pathologic.

Approaches to diagnosis

How one makes a distinction between a difficult temperament and a psychiatric disorder in a child depends to some extent on the system of diagnosis that one uses. If you are using a categorical system—which says this is the illness, this is the etiology, these are the diagnostic criteria, and here are the special investigations that need to be done to confirm the diagnosis and justify specific treatment—you are taking the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) approach to diagnosis.

The other way of approaching diagnosis is to determine where the child's behavior, or problem, exists on a spectrum, or range, and to know that, somewhere along that spectrum, a decision is made that criteria have been met to make the diagnosis. The spectrum-oriented approach is less fixed, less rigid, more fluid, and more dependent on the context, or the setting, in which the behavior occurs.

I subscribe to the spectrum-oriented approach to diagnosis. One reason is that, when dealing with human behavior, particularly with regard to children, I believe that it is wrong to categorize too much. By the nature of childhood, children are constantly developing, and development dictates that symptoms and behaviors change over time—sometimes in just a few months.

What is "temperament"?

Simply, temperament is defined as an individual's nature—the part of his personality that is innate. Personality is formed by the interaction of those innate characteristics and the influences of the environment. The older a child is, the more of an impact the environment has—until, at last, a fully formed personality emerges. In younger children especially, temperamental characteristics are very important, and define the central question in any diagnostic undertaking: What kind of a person is this child?

Temperament can also be said to be the how of behavior—not the why or the what. It is, in other words, the individual's behavioral style. Consider three children approaching the task of homework; for argument's sake, make them similar in every way possible—age, gender, IQ, stable family environment:

• One child might accept the parent's instructions by listening carefully; she will sit, work consistently, finish on time, and move to the next activity. That is a very easy child, and they do exist (although if you have children of your own, you know that they always belong to someone else!).

• Another child is extremely resistant to the work at the beginning; she holds back and complains. But it's not that she cannot do the work. She will eventually get down to it, but the transition is difficult for her. Then, once she becomes engaged, she becomes very engaged and persistent. So when the time comes for her to move on to dinner, she struggles to make the transition away from the homework just as she did toward it. We would categorize that child as showing "initial withdrawal," and as being "poorly adaptable"—both temperamental characteristics.

• A third child listens very brightly to instructions. She is eager to begin, and upbeat, but she doesn't really hear all the instructions because her attention wanders. She easily sits down to the assignment, but within 10 minutes has lost her concentration: She's wandering around and has lost her focus. This child manifests a "high activity level" and "distractibility."

Without question, all three of these children are normal. But they are temperamentally different, and one needs to consider these differences in approaching, in this example, the task of homework.

Another way to define temperament is as the characteristics of a person that are evident early in life and that constitutionally determine part of his personality. Some characteristics of temperament are evident in infancy. You can see the differences among babies from the beginning: This one is a screamer, that one is quieter; one eagerly follows external stimuli, another turns away. Mostly, however, definition of an individual's temperament does not begin until toddler years. It is more evident at 3 years of age and fully so at 5 or 6 years. After that, the influence of environment becomes more pronounced and temperamental characteristics are somewhat diluted as they are acted on by outside forces.

Temperament can be broken down into as many as 10 categories, or characteristics. As one travels along that continuum of temperament, a child's behavior ranges from easy to deal with to very, very difficult to deal with. And so when we talk about the child with a difficult temperament, or, simply, a difficult child, we are talking about one whose temperamental characteristics tend to cluster more at the difficult end of the continuum of behavior.