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Behavior problems are among the most common presenting complaints that parents and caregivers have when seeking pediatric medical care, as up to 20% to 25% of the pediatric population may experience behavioral or emotional problems. Behavior problems can range from mild actions with minimal consequences to more significant behavior disorders with potentially severe outcomes. Evaluating behavior problems in children must take into account normal child development, temperament, parenting styles, and environmental circumstances.



Temperament refers to the inborn, biologically based behavioral style with which an individual interacts with his or her environment. Drs. Alexander Thomas (1914–2003) and Stella Chess (1914–2007), who were American child psychiatrists, expanded upon the pioneering work of American pediatrician Dr. Herbert Birch (1918–1973) in the study of child temperament and behavior. Thomas, Chess, and Birch conducted a longitudinal study of child behavior and temperament and proposed nine behavior characteristics (Table 85-1). These nine characteristics (activity, rhythmicity, approach/withdrawal, adaptability, threshold of sensory responsiveness, intensity of reaction, quality of mood, distractibility, and attention/persistence) combine into three temperamental categories: easy, difficult, and slow to warm up.

Children with an easy temperament (40% of children) are described as having regular biological rhythms (eg, eating, sleeping, toileting), adapt easily to change and new environments, and are in a generally pleasant mood. These children do not become extremely agitated when they do not get their own way or their expectations are not met.


Children with a slow-to-warm-up temperament (15% of children) are often described as being shy. These children tend to adapt slowly to new people and environments. They will watch a group of children play while staying close to their parents. When given time, they will gradually join the group of children playing once they feel comfortable.

Children with difficult temperaments (10% of children) may be challenging for their parents to manage. Their biological rhythms are unpredictable, and they may not sleep, eat, ...

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