Mental Health Blog

Managing challenging behaviors in children

• December 14, 2023
• The REACH Institute
• Assessment & screening, Parents, Patient communication

 

“There is a lot of research on programs to help parents manage their children’s behavior. It is not complex for clinicians to learn key evidence-based principles and share them with parents, even in brief office visits,” explains Elena Man, MD, a board-certified pediatrician and faculty member at The REACH Institute.

We asked Dr. Man to walk us through how clinicians can respond when parents come to them with concerns about their child’s behavior.

As a clinician, the first step is to get the details.

“Parents will often come in with generalities,” explains Dr. Man. “They are frustrated and overwhelmed by their children’s behavior, such as extended tantrums, hitting, and yelling. Their school or daycare may even be threatening to remove the child if their behavior doesn’t change.”

To get to the root of the problem, clinicians need to understand specifics, including the context of and response to the behavior. It is important for parents to realize that if a child is tired, hungry, mentally fatigued, sick, or in pain, behaving appropriately can be difficult. Dr. Man advises clinicians to also “consider the home structure, the parent’s mental health, and the overall psychosocial situation. For example, if there is abuse happening, acting out may be the child’s way of coping.”

Clinicians can start by asking parents for an example of the concerning behavior and using the COLDER approach to learn more:

Characteristics of behavior: Ask parents to describe the behavior in detail.

Onset: Are there specific situations that seem to trigger the behavior?

Length: For how long has the behavior been a concern?

Duration: When the behavior occurs, how long does it last?

Exacerbated by: What conditions or responses make the behavior worse?

Relieved by: What conditions or responses improve the behavior?

 

Clinicians should also keep an eye out for medical conditions that may require separate treatment, such as sensory overload, developmental delay, cognitive deficit, mental health conditions, or hearing difficulties.

During the conversation, be sure to empathize with parents and children.

Parents may feel shame or guilt about their child’s behavior, which can come off as defensiveness. The school or daycare may also blame the parent, adding to their frustration. Clinicians can empathize and explain that every child is unique and some children are more challenging than others.

Clinicians can then introduce parents to the basics of positive reinforcement

There are several programs that train parents to manage behavioral issues, but not all parents have the time and resources to participate in these. This is why The REACH Institute created our newest course, Practical Behavior Management in Pediatric Primary Care, which enables clinicians to deliver the most effective evidence-based strategies directly to parents.

Indeed, recent research reveals that when supporting parents and managing difficult behaviors, sticking with fewer but more effective interventions delivers better results.

Key strategies clinicians can share with parents are:

Praise the positive opposite. “Data shows that positive reinforcement is the most powerful tool for changing children’s behavior,” explains Dr. Man. Rather than catching their children misbehaving, parents should aim to “catch them being good.”

Parents can start by identifying what Dr. Alan E. Kazdin calls the “positive opposite” of a problematic behavior. For example, if a child is hitting their sibling, the positive opposite is treating each other gently. The parent should explain what it means to treat each other gently and let the child know they will be looking for this behavior during the different periods of the day. When the parent notices the positive behavior, they should praise the child with enthusiasm and specifics.

When parents consistently use praise this way, the positive behavior will recur and become a habit.

For example, in Dr. Man’s practice, the parents of a nine-year-old boy came to her because anytime their child became frustrated he started yelling and cursing. Dr. Man helped the parents identify the “positive opposite” of the undesirable behavior: using kind and respectful language.

The parents talked to their child about why kind and respectful language was important and empathized with how hard it can be to control language when you’re upset. Along with their child, the parents committed to managing themselves better too. They verbally praised their child’s positive behavior when it occurred and even set up a reward system where the child could earn stars for positive behavior during different segments of the day. Very quickly the cursing resolved.

Be intentional with attention. “Children do not distinguish between positive and negative attention,” explains Dr. Man. “So if parents are yelling at their child for misbehaving, they are still giving them attention.” Instead, parents should focus on praising positive behaviors and, when needed, using strategies like time outs effectively, which REACH covers in our course.

Prioritize behavioral changes. Clinicians should encourage parents to focus on one behavior at a time, instead of reacting to all behaviors. For example, if the most challenging behavior is hitting, parents should ignore smaller things like eye rolling or occasional door slamming while they work on the larger behavioral change.

Make sure the punishment fits. Parents should make sure that any punishment for their child’s behavior at home or in school is both appropriate and effective. Evidence shows that physical punishment or prolonged duration of punishment does not work.

Dr. Man shared a story of how punishment can go awry. A parent came to her because their child was acting out at school. When the child misbehaved, the school called the parent, who would leave work, take the child home, and return to work. The result? The child spent afternoons at home playing video games – a “punishment” that incentivized rather than deterred the behavior.

 

RESOURCES

• Behavior management training programs for parents include the Triple P – Positive Parenting Program, The Incredible Years, and the Kazdin Method of Parenting
• To learn more about why less is more when it comes to helping parents better manage challenging behaviors at home, check out Meta-Analyses: Key Parenting Program Components for Disruptive Child Behavior and Research Review: The Most Effective Parenting Program Content for Disruptive Child Behavior – A Network Meta-analysis.
• To sign up for The REACH Institute’s Practical Behavior Management in Pediatric Primary Care, clinicians can register online.