pediatrics
Overview of Behavioral Problems in Children
Treatment of Behavioral Problems in Children
Early intervention Education and strategies for parents Once a behavioral problem has been identified and its etiology has been investigated, early intervention is desirable because behaviors are more difficult to change the longer they exist. The clinician reassures parents that the child is physically well (ie, that the child’s misbehavior is not a manifestation of physical illness). By identifying with parental frustrations and pointing out the prevalence of behavioral problems, the clinician often can allay parental guilt and facilitate exploration of possible sources and treatment of problems. For simple problems, parental education, reassurance, and a few specific suggestions often are sufficient. Parents should be reminded of the importance of spending at least 15 to 20 minutes/day in a pleasurable activity with the child and to calling attention to desirable behaviors when the child exhibits them (“catching the child being good”). Parents also can be encouraged to regularly spend time away from the child to help the child learn to be secure and also independent. For some behavioral problems, however, parents benefit from additional strategies for disciplining children and modifying behavior. Parents should identify triggers for the child's behavior and factors (eg, additional attention) that may inadvertently reinforce it. Desired and undesired behavior should be clearly defined. Parents should focus on the behavior itself and not equate it with the child (eg, "that was unacceptable behavior" vs "you're a bad person"). Consistent rules and limits should be established. Parents need to track compliance on an ongoing basis and provide appropriate rewards for success and consequences for inappropriate or undesired behavior. Parents should try to minimize anger when enforcing rules and maximize positive contact with the child. Positive reinforcement for appropriate behavior is a powerful tool with no adverse effects. Helping parents to understand that “discipline” implies structure and not just punishment allows them to provide the structure and clear expectations that children need. Ineffective discipline may result in inappropriate behavior. Scolding or physical punishment may briefly control a child’s behavior but eventually may decrease the child’s sense of security and self-esteem. Threats to leave or send the child away are damaging. Scolding, threats, and physical punishment also teach the child that these reprimands are appropriate responses to situations that the child does not like. A Time-Out Technique , in which the child must sit alone in a dull place (a corner or room [other than the child’s bedroom] that is not dark or scary and has no television or toys) for a brief period, is a good approach to altering unacceptable behavior. Time-outs are learning processes for the child and are best used for one inappropriate behavior or a few at one time. Physical restraint should be avoided. For children who escalate in the intensity of their reactions when put in time-out, parents may prefer to move more rapidly to redirection once they recognize the children have registered the reprimand for inappropriate behavior. This disciplinary technique is best used when children are aware that their actions are inappropriate or unacceptable and when they perceive withholding of attention as a punishment; typically this is not the case until 2 years of age. Care should be taken when this technique is used in group settings like day care because it can result in harmful humiliation. The technique can be applied when a child misbehaves in a way that is known to result in a time-out. Usually, verbal reprimands and reminders should precede the time-out. The misbehavior is explained to the child, who is told to sit in the time-out chair or is led there if necessary. The child should sit in the chair 1 minute for each year of age (maximum, 5 minutes). A child who gets up from the chair before the allotted time is returned to the chair, and the time-out is restarted. Talking and eye contact are avoided. When it is time for the child to get up, the caregiver asks the reason for the time-out without anger and nagging. A child who does not recall the correct reason is briefly reminded. The child does not need to express remorse for the inappropriate behavior as long as it is clear that the child understands the reason for the time-out. As soon as possible after the time-out, the caregiver should praise the child’s appropriate behavior, which may be easier to achieve if the child is redirected to a new activity far from the scene of the inappropriate behavior. The circular behavioral pattern may be interrupted if parents ignore behavior that does not disturb others (eg, refusal to eat) and use distraction or temporary isolation to limit behavior that cannot be ignored (eg, public Temper Tantrums ). A behavioral problem that does not change in 3 to 4 months should be re-evaluated; more intensive behavioral management coaching or mental health consultation may be indicated. 