Expert Are Your Child’s Emotional Milestones on Track?

In 2021, The American Academy of Paediatrics (AAP) declared mental health in children and adolescents a national emergency. Mental and emotional difficulties in childhood have risen to an unprecedented high and we, as healthcare providers and caregivers, have an important role to play in ensuring that children receive emotional, as well as physical care.

Parents generally understand the role of developmental check-ups, where their child’s physical health is examined to ensure milestones related to speech, gross motor and fine motor skills are being met. But emotional milestones are just as crucial. These are required for the transition from infant to toddler to child to adolescent and finally, to a well-balanced adult.

Healthy emotional development sets the stage for how your child will manage stress, regulate behaviour and socialise. Since their little brains are growing really fast, emotional experiences and how parents manage these shape a child’s ability to focus, adapt to difficult situations, manage anger and stress, while building self-confidence.

Sadly, one in 12 children younger than 10 years old experiences a mental disorder. These disorders include anxiety, depression and behavioural issues. Our role as healthcare providers and caregivers is to recognise what is normal for age and when we should be concerned, so that we can take steps to slow this tide.

From my own experience

The year my son turned four, the headmistress of his nursery school called all the parents to a meeting. She opened by saying that we were about to meet an entirely new being. We weren’t to wonder if the school was doing something wrong or if aliens had swapped our sweet child out for something else. We each received a two-page document on what to expect from our 4-year-olds emotionally. She wasn’t wrong. These guidelines proved incredibly useful and now, years later, I reflect on the wisdom of this. Not only did she guide us in terms of what to expect, but she also allowed us to anticipate new behaviours and to decide on the best way to handle our child to ensure healthy outcomes.

Let’s take a look at the four-year-old

Your child is past the toddler stage but still has limited access to the prefrontal cortex of the brain. This part of the brain manages executive functions like:

• Planning, problem solving and abstract reasoning
• Impulse control
• Consistent listening
• Working memory
• Fully understanding boundaries
• Making clear choices

Having said this, you can see why typical behaviours include:

• Spontaneous, sometimes dangerous activities, without predicting negative outcomes.
• Ignoring requests or doing exactly the opposite of what you ask. This may be due to their increased need for independence or because they are hyper-focused on their own activity. Even if they hear their name, they haven’t yet mastered pulling themselves away from play to process your verbal instructions immediately.
• A 4-year-old will keep pushing to test the boundary of a rule. The famous “no” to your request, or whining until they get their own way, is part of this boundary testing.
• I “do it myself”. They are eager to prove their capabilities and this results in them rebelling against constant instructions.
• Tantrums and big emotions. It is a time of intense feelings. They are learning empathy, sharing and conflict resolution. These skills are still developing, so at times they will cause big emotions if the child feels unjustly treated or overwhelmed.
• Vivid imaginations and fear. If you watch these little ones at play, you will see how remarkable their imaginations are. A stick can become a python; dinosaurs regularly roam around the garden and monsters often hide in the toilet and are bound to escape when they flush. Unfortunately, this can also lead to new anxieties and sudden fears.

How should a parent or caregiver respond?

• Provide opportunities for safe, free play. Your child needs to test physical boundaries and to develop new skills. Only interfere if the situation is dangerous.
• Choose appropriate times for instructions. If your child is engrossed in an activity, break the concentration before you give your instruction. You can do this by getting down to their level, touching them while you speak, or by removing the distraction. Allow time for them to process what you are saying.
• Ironically, 4-year-olds love boundaries and they like to understand rules. This helps the child to feel safe, secure and grounded. Bedtime routine is a good example of this.
• Encourage autonomy in areas such as dressing or choosing a healthy snack.
• Acknowledge that something is scary for your child, even if it is not real. Showing the child how a flushing toilet works might help to remove the monster fear.

A caregiver should seek assistance if they are concerned about:

• Physical aggression: 2- or 3-year-olds may express anger physically because they don’t have the verbal skills to express feelings. A 4-year-old should not consistently hurt themself or other children to express feelings or to solve problems.
• States of dysregulation: four-year-olds should be able to express certain emotions such as sadness, disappointment, fear and anger. If your child isn’t able to access these emotions, it may lead to states of dysregulation. Intense outbursts, extended recovery times or destructive behaviour may occur. On the other extreme, your child may become physically or emotionally withdrawn.
• Self-regulation: This is the ability to manage and control emotions and behaviours in different situations. A four-year-old is still learning and needs some help from caregivers to co-regulate. Caregivers do this by speaking in soft, calm voices, getting down to the child’s eye level and verbalising frustration over hitting. Self-regulation encourages sharing, cooperation and empathy in peer relationships. A child who can self-regulate experiences less anxiety and frustration and can filter out distractions to focus on the activity in front of them. If your child can’t wait for a turn, struggles to calm down when upset or lashes out when angry, this should be addressed.
• Fear and anxiety: four-year-olds are commonly afraid of the dark, imaginary creatures (like witches and monsters), loud noises or specific objects like clowns or large animals. Fear shouldn’t disrupt sleep, affect daily routines or inhibit normal childhood activities.

What about the other age groups?

I have spent a lot of time on the four-year-old to give an example of what to expect and when to be concerned. The other age groups deserve the same consideration, but that would require multiple blogs. To assist, I have taken some information from the paper produced by the AAP as a guideline.