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behaviorally inhibited temperament

Behaviours associated with an inhibited temperament

Image by Free-Photos from Pixabay

Now that we’ve seen a few tools in action (explanatory stories, brave stories, exposure ladders, routine chart), I am going to circle back around to talk about what motivated me to start investigating temperament and anxiety: my daughter’s behaviours in infancy. This ultimately led me to the brave tools that I am currently using.

From my daughter’s 3rd month of life, I knew her reactions to the environment were atypical. As time went on, I also knew she was not meeting social expectations/milestones for age-matched peers. There are plenty of books that advise parents not to worry about meeting milestones. Child development varies widely across children and a child who does not speak at two years might speak in full sentences by three without any intervention. On the other hand, delays in achieving milestones can indicate developmental issues that are best treated early or at least monitored by a healthcare professional. But how does a parent know when to wait and see and when to act? I started making a list of behaviours that were “different” when my daughter was around 18 months. There are too many behaviours to list all of them, but this is a representative sample. Each behaviour is not necessarily remarkable but taken together they paint a picture of a fearful child.

  • At 3 months Lisa was held by my friend. One week later, the same friend came over and upon seeing her, Lisa burst into tears; from that point forward, Lisa exhibited fear (crying) for all people other than mom and dad.
  • Lisa tracks/monitors every person in the room and is clearly concerned if someone “disappears” from view. Once she could make sounds, she called a person back when they left the room.
  • If a “stranger” (friend/acquaintance with child) comes into our house, Lisa sits in my lap, unable to do any activity.
  • At 5 months, Dad went on a five-day work trip. When he returned, Lisa cried and would not go to him. It took approximately 24-48 hours for her to warm to him again.
  • From 11-16 months, when we would walk down the street Lisa would fixedly stare at a stranger. After a couple minutes, she would burst into tears. She seemed paralyzed prior to crying.
  • At play gym if another child approaches or takes her toy, Lisa appears stunned and does not respond. If another child blocks her way out of an enclosed space or end of a tunnel, she will become afraid, panicky and eventually burst into tears.
  • Around 13-14 months, Lisa ran into the bathroom and saw the bathmat moved off the floor. She ran out of the room crying.
  • By 18 months, Lisa “freezes” and then bursts into tears if I talk to another mom at play gym or the park.
  • When Lisa is alone at the park, she makes sounds, sings, says words, and smiles; if another child approaches, she stops moving and making sounds. Her facial expression is blank. She stares at the child and is unable to continue with her activities.
  • Lisa stands off the sidewalk if she sees another person or dog walking, up to a block away (in either direction – behind or ahead of us). She waits for them to pass us (or turn a corner) before continuing.
  • By 21 months, Lisa smiles when she sees someone she likes arrive at a park (Grandpa, Gammie, Daddy), but when the person approaches, she shies away and hides behind my legs or indicates she wants to be held.
  • Lisa cried and hid when she observed Auntie letting out her hair from a ponytail.
  • At 2 years old, Lisa refused to get into the swimming pool when the music for aquacise was playing (although she was already in her bathing suit and showered). She said “no, stop” when the announcements played over the PA system at Science World and wanted to leave the Aquarium.
  • Lisa asks to sing songs outside music class and seems to express interest in going to class, but she will not participate in the class and “melts” into me if the teacher tries to touch her or speak to her directly.
  • Lisa is unable to go down the slide when another child is near the bottom or the side or is looking in her direction.
  • When staying at other places (grandparents’ house), Lisa reduces her food and liquid intake and appears distracted and unable to be calm.
  • Most recently, at almost 3 years old, Lisa reacted negatively upon seeing Daddy after he had trimmed his beard (no eye contact, avoidance). The next time Daddy trimmed his beard, we asked her to watch. After she watched and received a brave sticker, she was almost in tears and wanted to snuggle with Mommy.

If you met my 3-year-old daughter today, you would probably label her as shy and quiet. You might think she is timid and sedentary, and she may even seem a little dull! She probably wouldn’t speak to you and she might try to pull me away from you and eventually she might start crying from a seemingly miniscule event like falling down or eye contact! But she is a completely different child in her comfort zones at home, with select family members or outside alone. She sings, dances, runs, jumps, talks, builds, tells stories and moves constantly. This dual personality is typical of children with behaviorally inhibited temperaments [more info] and often only their parents and a few chosen people are privy to all the amazing parts of their personality. When my daughter was just under 2-years-old, I tried to record her different behaviours but unfortunately, she is also influenced by the camera such that she becomes more inhibited. I was not coordinated enough nor had the forethought to set up the camera unobtrusively. As a result, the differences that I captured are minimized on camera: the inhibited behaviour is more mild than typical because I couldn’t step back and film during extreme inhibition behaviours and she altered her behaviours, due to the camera, for the comfortable/uninhibited situations! Nevertheless, these videos provide a small glimpse into the range of behaviours exhibited by my behaviourally inhibited child.

My daughter exhibits inhibited behaviour. She is trying to tummy swing but focuses almost exclusively on another child and her mother playing on neighbouring equipment. The other child moves to the neighbouring swing and Lisa tracks the movement. Interestingly, at the time, I celebrated this behaviour because she was still able to push her feet against the ground. Typically, she would leave the swing and “melt” into me or hang completely limp on the swing. We were making progress!
My daughter is uninhibited while playing with the swings. She makes noises and is active. Daddy arrives and she starts tummy swinging and “cawing” like a crow, then says “sit” to indicate she wants help to sit on the swing. This video was recorded just 10 minutes after the “inhibited” video! Notice that she immediately changes tasks when she notices Daddy arrive. She does this even now. When someone arrives, she does not go to them nor hug them, and she barely acknowledges them. Instead, she will switch to a very active task. It is as if she gets a surge of adrenaline and needs to release it (my hypothesis is that this is the start of a “flight” response, but she is able to control it before completely succumbing to her amygdala).

As I tracked my daughter’s behaviours, I came across the description of a childhood anxiety disorder called selective mutism [more info]. When I read about the behaviours associated with selective mutism, it described my daughter perfectly. She was too young for us to determine if she was “mute” around other people, but everything else aligned well. I found a child psychologist in the city that specialized in childhood anxiety, selective mutism, and worked with very young children. While on the wait list, the psychologist recommended I start reading about the behaviourally inhibited temperament, since a 2-year-old would never be diagnosed with an anxiety disorder like selective mutism.

From what I have read, the behaviours of a child with either an anxiety disorder like selective mutism or a behaviourally inhibited temperament can be identical. Researchers have found that a behaviourally inhibited temperament in infancy is predictive of future social anxiety disorders, but not all people with an inhibited temperament will end up with an anxiety diagnosis (Kagan et al., 1992 and Degnan and Fox, 2007). Most children with anxiety disorders are diagnosed during school years, while temperaments can be detected by 3 months of age in infants. As I was writing this blog, I came across this article that proposes exactly what I have wondered: is an inhibited temperament different than an anxiety disorder or is it just an anxiety disorder that is observable in infants? The article does not answer the question as the research is not there yet. Ultimately, does it matter if your very young child (less than 3 years old) has an inhibited temperament or an anxiety disorder? If you’re looking at ways to help your child with behaviours and fears, then probably not; if you’re looking at how to understand your child and how to describe your child to other people, then it might make a big difference.

Mental health has a stigma associated with it. When someone hears that a young child has an anxiety disorder, they may have unhelpful thoughts:

  • the parent caused that (judgement)
  • the child is damaged (hopelessness)
  • the child should be fixed (judgement and power)
  • we need to make that child behave like this other “normal” child (control)

But if a person hears that a child has an inhibited temperament that is a stable part of personality, they will likely have different thoughts:

  • What is an inhibited temperament? (curiosity and learning)
  • I wonder what temperament I have and what I was like as a baby (curiosity and learning and possible recognition of genetic influence)
  • I guess that’s just who the child is (acceptance)
  • So that’s why that child is different than this one (understanding)
  • It looks like that child needs extra help with that task (empathy)

Many parents do not consider temperament when they have babies (and why should they? Not many people talk about it!), nor do they know how temperament is defined. Medical professionals do not educate new parents on this topic. Instead, they say the baby has “colic”, the toddler is “shy” or “slow to warm” (aka cold). Other parents can provide unhelpful advice such as expose the child and “socialize” them to fix their behaviours (aka cure them), leave the child to cry because this is the “real world” and the kid needs to adapt. But these words and ideas do not define temperament, they do not encourage respect of the child, nor do they validate that temperament is normal and stable. Children with different temperaments behave differently and that is okay.

One of my concerns as I read about behavioural inhibition, anxiety and treatments and prepared for my first appointment with the psychologist was that she would try to make me convert or change my daughter into the opposite of who she is. However, I was relieved when the psychologist confirmed that:

  1. Inhibited temperaments are stable through life.
  2. There is no cure for anxiety since the brain (amygdala) is designed to experience anxiety with fight/flight/freeze responses to threats.
  3. Bravery is not about eliminating fear but about accomplishing things that have meaning to us to lead a healthy and happy life, despite fear.

I often consider these points as I reflect on my daughter’s latest fears or most severe ongoing fears (talking and interacting socially). She is who she is. My job is to facilitate her interests and support her in finding contentment in her life. Hopefully, I will achieve this by providing a secure, loving foundation with tools she can wield to meet and overcome challenges. I want her to know that she can feel fear and still be brave and move forward towards her goals. She does not need to reach my potential or achieve my goals or become the person I am. Parents often talk about wanting their child to reach their full potential, but that is almost always code for wanting the child to reach the parent’s idea of potential. Ross Greene has a wonderful discussion in his book Raising Human Beings about accepting the cards you are dealt in life and moving forward together: parent and child. Will my daughter ever be the charismatic life of the party type? Probably not. Will she find a creative way to make her mark on the world? I think that is a very real possibility.

In my next post, I will describe seven useful strategies that we used to help our anxious daughter when she was less than 2 years old.

behaviorally inhibited temperament

The developmental psychologist Jerome Kagan studied temperament in infants and defined two temperaments: inhibited and uninhibited. Kagan described these temperament profiles as shy, timid, and fearful for the inhibited child and bold, sociable, and outgoing for the uninhibited child. Inhibited infants reacted more strongly to novel objects compared to uninhibited infants. Kagan and others also found that inhibited temperaments in infancy are associated with anxiety disorders in adolescence and adulthood. Researchers have suggested that parenting styles and cognitive behavioral strategies can positively affect an inhibited child’s response to novel stimuli, especially social situations, and reduce their fear response to prevent the onset of future anxiety disorders.

selective mutism

Selective Mutism is a childhood anxiety disorder characterized by a child’s fear of speaking in specific social situations (typically school). Children with selective mutism often have a genetic predisposition to anxiety and exhibit extremely inhibited temperaments as infants and toddlers. Like any anxiety disorder, the person’s brain has an over-active amygdala that is triggered into fight/flight/freeze by typically non-threatening events (like social situations). Many children with selective mutism also have sensory processing difficulties such that their brain may be over-reacting to smell, sight, touch, sound and/or taste stimuli causing inflexibility, frustration, and feelings of anxiety. A few typical behaviours include inability to speak in select social settings, blank facial expressions, lack of smiling, awkward body language, physical symptoms and negative behaviours prior to social activities.

Categories
explanatory story

COVID-19 story for young children

covid-19 virus drawing

A few weeks into isolation recommendations amidst the coronavirus pandemic I noticed some changes in my 2.5-year-old’s behaviour: more tantrums, constantly asking to eat, and more stuttering. I know her behaviourally inhibited (anxious) temperament causes her to have strong reactions to changes in routines, so I was not surprised. However, I thought the routine changes would reduce her social anxiety since she was no longer having to confront situations like music class, forest school or play gyms. I wasn’t too concerned with the changes, but I was having a hard time understanding her through the stutter and my husband was definitely worried. I made a virtual appointment with a child psychologist that specializes in anxiety. I had seen her weekly for a couple of months the previous autumn to get a better handle on behaviourally inhibited temperament, childhood anxiety and treatments. I wanted her to weigh in on whether my daughter’s “new” pandemic behaviours were normal. She made three recommendations: 1) stuttering is out of her wheelhouse and I should get referred to a speech and language pathologist (SLP), 2) make a simple routine chart showing our daily routine and meal times, and 3) talk to my daughter about COVID-19.

I diligently checked off the recommendations. We are on a waitlist for an SLP. I made a simple chart showing our daily activities including meal times and within a few days of posting it, my daughter stopped asking for food constantly. I felt uneasy about recommendation 3. I know it’s important to talk about the pandemic with children to help alleviate anxiety and I had already seen plenty of stories and articles about how to talk to your kids about COVID-19, but I hadn’t seen any stories appropriate for a 2 year old. The stories I read had a detailed description of COVID-19 and viruses and often described school being closed. The stories also seemed to assume the child had already heard words like pandemic, virus, coronavirus, COVID-19, etc. My daughter had never heard the word virus, let alone coronavirus, and did not relate to school closures. We don’t use screens, other than for video chats with extended family, so she wasn’t being exposed to information from the news. My husband was working fulltime from home and I was a busy mom and aunt; he and I did not discuss the pandemic in front of her. I assumed she didn’t have any idea what was going on. I was seriously thinking about ignoring recommendation 3. How could I explain this pandemic in a helpful way to my 2-year-old and how was talking about a virus really going to help with her tantrums? But, as a rule-follower, I find it hard to go against expert advice, so I gave it more thought and decided to write my ideas because I don’t do well trying to speak off the cuff (thank you, INTJ personality and behaviourally inhibited temperament!).

After some brainstorming, I concluded that the best format to deliver COVID-19 information would be a short, personalized story. Prior to this point, I had written a couple of Social Stories for a friend with an autistic child. I had written them in a rush and took some basic pointers from my friend about how they should be written. I decided to write a “social story” for my daughter about COVID-19. But I did not adhere to any specific principles of official Social Stories, per se. I focused on how to address anxiety for a very young child. For content ideas, I read articles from anxietycanada.com and Psychology Today. My goals for the story were as follows:

  1. The story is understandable
    1. Use age-appropriate (simple) language
    1. Use words that I know my child understands
  2. The story is relatable
    1. Use lots of personal pictures
    1. Describe the current unknown situation in relation to known situations
    1. Describe how we help
  3. The story is factual (not fearful)
    1. Highlight both positive and negative changes to my daughter’s routine
    1. Explicitly state positive and negative feelings

I wrote the story and was amazed at how much my daughter enjoyed it. Weeks after reading it she still talks about the “new cold” in relation to activities in our lives. If I say, “no” about something she will ask, “because of the new cold?” I was able to refer to the story when she resisted washing her hands after coming inside and avoided a few (not all!) meltdowns. The story provided us with a platform to talk about the changes we continue to notice when we go out for walks. It also provides my husband and I (and my parents and sister) the same language to consistently reinforce the story concepts.

Now that you have read the story, you might feel that it is not right for your family. That’s good! A story like this should not be right for anyone else’s family. It is critical to personalize these stories when you are using them for very young children. As children age, they gain life experience such that there is a greater chance that a generalized story is applicable to that child. However, for young children with very short memories and limited experience, it is important to adjust the story to fit the child such that it is understandable, relatable, and factual, from that specific child’s perspective.

I will review a few aspects of the story and how they relate to the three goals. Then, I will analyze some statements from a generalized COVID-19 Social Story to see why those statements are not useful in a story for my child and probably most 2-year-olds.

  • I call the coronavirus (COVID-19) the “New Cold” and people who have the new cold are referred to as “Sickly Sues”. This might seem like strange language to you, but I considered exactly what words I had used since my daughter’s birth to describe when we got sick (with anything – common cold, flu, food poisoning, headache, roseola, etc.). I most commonly used the words “cold” and “Sickly Sue” (That is a family thing – thanks, Mom!). Your family might use “Sniffles” or illness. The point is that I knew my daughter had feelings associated with those words. She used those words to describe herself when she was sick. Using this vocabulary supports goals one and two: understandable (language) and relatable (feeling of sickness).
  • I explain that some people wear masks like dentists and Mommy makes masks for our family and I have a photo of my daughter wearing her mask. Luckily, we had talked about masks prior to COVID-19 because of the dentist. We had already started our anxiety exposure ladder leading up to visiting the dentist and covered our faces with scarves while playing dentist. If you have not talked about the dentist in your family, try to think of another positive mask association that your child has. Maybe you have seen people cover their faces in the winter when skiing or playing in the snow. Maybe your child likes construction and they have seen a welder’s mask. Doctors, nurses, welders, carpenters, etc. The discussion of masks supports goals two and three: relatable (dentists wear masks) and factual (stating that masks are being worn without adding judgement or fear like relating the masks to robbers or “bad guys”).
  • I talk about “helpers” (i.e. doctors help, [Name] helps) because toddlers and young children love to be helpers! My daughter turns on the washing machine and dishwasher and we have talked about how to help someone who is hurt (ask if they are okay, get an adult). Being a helper is something she understands from other activities in life. So, instead of being burdened by having to wash hands, use sanitizer and give others space, it is empowering that this little person is helping with the “new cold”. Describing “helpers” supports goal two: relatable (helpers existed before the pandemic, exist during the pandemic and will exist after the pandemic).

Here are a few statements from a typical COVID-19 social story and why they don’t work for my daughter. Although I am reprinting statements from this story, most other stories had these same kinds of statements:

  1. The Coronavirus is a virus that can make people feel unwell. The coronavirus can also be called COVID-19. My daughter doesn’t know the word virus, Coronavirus or COVID-19. It’s too much detail and would have been superfluous to include a statement with synonyms of coronavirus.
  2. People who have the coronavirus may have fever, sore throat/dry cough, shortness of breath. This is too much detail for a young child; they likely won’t stay engaged for a long list of symptoms. I chose a single symptom (cough) in my story; I also selected a symptom that I knew my daughter understood (cough, not dry cough). I like the symptom “cough” because it is something we can easily play/pretend and she can see it (body tensing, hand/elbow covering face) and hear it.
  3. I know that I will be safe… I like the idea of stating that a child is safe, although I didn’t include that message in my story since there was no focus on the danger/threat/safety aspect of the pandemic; I didn’t discuss family members getting sick or dying because it was low risk for us. If I lived in a different place, that might be more relevant. Instead, I included a phrase from Daniel Tiger’s Neighborhood that we learned about in our Daniel Tiger Goes to the Dentist book, “When we do something new, let’s talk about what we’ll do.” I sing this phrase constantly for anything we do that is “new” and scary. Although the phrase is not correct for this situation, the feelings behind it are empowering to my daughter. This is one more personalized aspect of the story to keep my daughter engaged and feeling confident. I also included the phrase, “mommy, daddy and [Name] will always be a family.” This phrase is more powerful than the “safety” concept because even if mommy or daddy die, we are still a family. Relationships and family transcend death.
  4. …and I don’t have to feel afraid. I would not include this kind of statement in any story. No one has to feel afraid, but they do! I prefer to phrase feelings as simple statements like “I feel sad. I feel scared. I feel happy.” Negative commands are confusing and try to control how a child feels. Statements such as “I don’t have to feel happy. I don’t have to feel sad. I shouldn’t feel mad” may be confusing for a young child if they are experiencing a feeling that the story has told them not to feel. If you incorrectly guess a child’s feeling by writing, “I feel happy” when they actually feel sad, the child can say, “no” and then you can correct it. But if you write, “I don’t have to feel sad”, the child cannot easily respond “yes/no” because a statement written in the negative is more confusing for a young child to understand and then relate it back to what they are actually feeling.

It is June now and the city is starting to open up again, but I am resisting diving back into old patterns, as I expect a second wave of the virus and I’d rather try to hold steady instead of implementing more routine changes, suddenly. The story and routine chart helped to reduce some anxiety. In addition, enough time has passed such that our new isolation routine has now become our routine, and my daughter is surrounded by people with whom she feels comfortable and she isn’t having to confront anxiety-producing social situations. I believe my daughter’s stutter is caused by anxiety and her temperament and not by a developmental issue. Therefore, my hypothesis is that if we address the anxiety, improvement in stutter will follow. COVID-19 caused the elimination of most of my daughter’s anxiety sources. I’m not saying elimination (avoidance) is the best way to deal with anxiety (more info) and without COVID-19 I wouldn’t have self-selected this isolation just to see what happens, but now that it has happened, it’s amazing to see my daughter flourish! The stutter (more info) has improved to better than pre-COVID levels and tantrums are down. I hope that in this state of low anxiety, my daughter will be able to practice and solidify stutter-free speaking patterns. I am curious if, by eliminating most social situations and allowing her language to develop in a low anxiety COVID-19 isolation bubble, she will maintain that language and speech pattern when we eventually face new social situations. We may still need to employ exposure ladders for those social situations, but will her speech patterns be affected? Only time will tell! (And we have the SLP waitlist in our back pocket.)

Anxiety

Avoidance is precisely the wrong way to deal with anxiety because it does not help a person learn skills to cope with anxiety. It just pushes it out of the way until later. A person who avoids the fearful event/object will still experience anxiety when confronted with it in the future. Find out more about anxiety at anxietycanada.com. However, for extremely young children, there is also a developmental component to consider. Separation anxiety is normal in babies and toddlers and there is a large “normal” range of behaviour. As a scientist, I like to follow evidence-based parenting practices, which support non-avoidance exposure ladders for treating anxiety in children. However, most research is based on older children (school-age+) and adults with diagnosed anxiety disorders and it is often just assumed to work for young children (when it is still thought of as a temperament and not a disorder).

Stutter

My daughter has stuttered since she started talking at 2 years old. Usually I understood what she was saying through context and I even thought her stuttering was improving before the isolation rules came into effect. Prior to the pandemic, she exhibited whole word stuttering (5-20 times repetition of a word); for example, during snack time after music class she said, “got got got got got got got got got got got got… JAM!” which was an exclamation about the sandwich containing real jam instead of apple butter. During isolation, whole word stuttering continued as well as being “stuck” (no sound comes out and she was stuck on a word with her mouth open and muscles visibly straining to get the sound out) and sound holding, like “I want to go hoooooooooooooome”.

In the next post I will further discuss explanatory stories for young children with an example of coping with an autistic sibling.