Behavioral Problems of Children
I. Prevention of behavioral problems
Family Physicians should anticipate and intervene in behavioral problems.
Factors that predispose children to behavioral problems include mismatch between parental and child temperaments (e.g., quiet, low-activity child with high-energy parent), parental mental health problems (including post-partum depression), poor parental self-esteem, attachment difficulties between parent and child, inconsistency of parental response to the child, unrealistic parental expectations regarding the child's behavior, and developmental delay, especially speech–language delay, which contributes to frustration for both parent and child.
Also, due to the conflict between the parents, the absence of a parent, and parental abuse of drugs or alcohol are risk factors for behavioral problems.
II. Stages of behavioral assessment and intervention.
Clarify parental concerns.
Assess parental knowledge regarding normal developmental stages. Many parental concerns about behavior stem from unrealistic expectations regarding their child's behavior relative to his or her developmental stage.
Assess for family stresses that may affect the child's behavior. Many behavioral problems stem from or are exacerbated by external stressors.
Prenatal alcohol and drug use, early childhood illnesses, and developmental delay can all lead to behavioral problems.
Counsel parents about possible interventions for behavioral problems.
III. Principles of behavioral intervention.
Children deserve and respond to respect from caregivers. Behavioral interventions will not be successful if parents treat the child disrespectfully.
Consistency of response is critical. Behavioral change only occurs in the context of consistent and predictable responses.
Positive reinforcement for desired behavior generally works better than negative reinforcement for undesirable behavior. Positive reinforcement includes active education of the child about expected behavior and its beneficial consequences rather than simply stating what the child should not do. When negative reinforcement is necessary, it should be age and behavior appropriate.
Reassure parents that children need and want parents to exert consistent, reasonable controls on their behavior. Children are frightened when boundaries of acceptable behavior are not well defined and will often accelerate the problem behavior in order to elicit a parental control response.
IV. Specific techniques for intervention
Many parents lack specific knowledge about acceptable, effective interventions to promote behavioral change. Too often, parents resort to punishments far more severe than the behavior warrants.
. Separate the child from desirable activities for a brief period (1–2 minutes for preschoolers, up to 15 minutes in school-aged children). “Grounding” adolescents for a day or two may help.
. Ignore the undesirable behavior, especially if it has previously elicited attention.
. Offer small rewards like inexpensive toys, increased time with one or both parents, increased privileges for positive behavioral change. For example, if the problem behavior relates to bedtime, reward the child for conflict-free completion of the bedtime routine.
Discussion of consequences of and alternatives to the behavior
. Respect for children includes teaching them the consequences of and alternatives to unacceptable behaviors. As children get older, reasoning plays an increasing role in behavior modification.
V. Major mental health concerns
Behavioral problems in children can generally be divided into three categories:
- (a) problems that are normal for the child's developmental stage and will resolve spontaneously as the child matures;
- (b) problems that began as a normal developmental phase, but have been exacerbated by external stresses and will require some level of intervention to resolve;
- (c) problems that indicate a more serious underlying mental health problem.
Depression in children is generally underdiagnosed.Criteria for depression in children are virtually identical to those in adults, with minor modifications relevant to usual daily activities. Five or more of the following criteria must be present for at least 2 weeks in order to diagnose depression: depressed mood, anhedonia, sleep disturbance (hypersomnolence or disruption of normal sleep pattern), change in weight or appetite (>5% change in body weight over 1 month and/or failure to make expected weight gains), psychomotor retardation or agitation, low energy, feelings of worthlessness or guilt, decreased concentration and increased indecisiveness, or recurrent thoughts of death or suicide. Children with depression may require medication, and this should generally be done in conjunction with a child mental health professional.
Virtually every child experiences some level of anxiety at various stages of life. Up to 50% of children may experience anxiety to the extent of true anxiety disorder that adversely affects their daily lives.
Anxiety disorders may present as multiple somatic complaints, a marked increase in nervous habits (e.g., nail biting or thumb sucking), or stereotyped behaviors (e.g., head banging or other repetitive behaviors).
Conduct disorder represents the extreme end of the spectrum of oppositional behavior.
It is defined as a persistent pattern of behavior (more than –6 months) that violates the basic rights of others, including acts of aggression against people or animals, property destruction, theft, repetitive lying or other deceptions, and serious violations of rules in multiple environments (e.g., home and school).
Children and adolescents with conduct disorder require prompt identification, aggressive intervention, and substantial support to their families.
VI. Common behavioral concerns seen in family practice.
Feeding problems are among the most common concerns.
Parents worry about adequate weight gain and spitting up (reflux) in infants, nutrition, food avoidance, and mealtime behaviors in preschoolers, and obesity in school-aged children.
It is important to remind parents that when food becomes a control issue between parent and child, this confrontation can lead to long-term unhealthy eating habits.
Parents should offer a diverse range of nutritious foods, supplement with a multivitamin if necessary, demonstrate healthy eating habits, and avoid using food as a reward for other behaviors.
Oral habits such as nail biting, digit sucking, and pacifier use, are common in preschool-aged children. Some authors hypothesize that these and other stereotyped behaviors are actually serving an important function in the child's development by serving as early coping mechanisms or self-calming techniques during stressful times or negative mood states. Increases in these behaviors often reflect new external stresses in a child's life.
Identifying and addressing stresses, combined with positive reinforcement of behavioral change and work with the child to develop alternate coping skills, is generally the most successful intervention for these behaviors.
This include trained night-waking, bedtime struggles, nightmares and night terrors, and sleepwalking .
Trained night-waking (i.e., the child awakens at a consistent time during the night) and bedtime struggles are best addressed by a consistent approach to bedtime that does not involve the parent staying with the child until the child falls asleep, and extinction (i.e., delayed response or no response at all to the child when he or she awakens during the night or protests at bedtime).
Nightmares occur in virtually all children and are generally indicative of developmental issues and fears.
Sleepwalking occurs in approximately 15% of children. It too has its onset in early childhood and generally resolves spontaneously in adolescence. Parents should provide a safe environment so that the child does not sustain injury during sleepwalking episodes.
Both night terrors and sleepwalking have strong familial histories, with 80%–95% of children with these disorders having a positive family history.
Stereotyped behaviors such as tics, head banging, body rocking, or other repetitive movements, can be disconcerting to parents.
Many toddlers and preschoolers display these behaviors, and stress, negative mood, and fatigue generally exacerbate them. These behaviors usually resolve spontaneously and rarely cause injury to the child.
Treatment involves reassurance of the parent, teaching other coping mechanisms to the child, and patience.
This begins as early as 12 months in many children and is completely normal.
Parents should use the behavior as an opportunity to begin discussion with the child about private behaviors and sexuality.
Anxiety including school phobia, occurs in many children at various stages of life.
Prevention includes giving the child accurate, age-appropriate information about expected separations and consistency in daily patterns of separation.
Treatment involves diminishing stress and establishing firm guidelines about appropriate reasons for missing school.
This occurs over a spectrum of behaviors, including various manifestations of limit testing, temper tantrums, oppositional defiant disorder, and conduct disorder. Early identification of and intervention for these problems is critical for prevention of long-term mental health problems .
Limit testing occurs at every stage of childhood and adolescence. Physicians should remind parents of the need to set and maintain firm, age-appropriate boundaries on behavior.
Temper tantrums are common (75%) in children aged 3–5, and their incidence tails off to 4% in children aged 9–12.
Children with this disorder frequently lose their tempers, argue with adults, defy rules, blame others for problems, and have poor social relationships due to anger, resentment, and spitefulness.
Treatment of ODD rests in the domain of behavior modification and often requires family and individual psychotherapy to assist with resolution.
Alcohol, tobacco, and other drug use should be screened for routinely during most visits with children over the age of 8 years.
Prevention is essential, and involves open discussion with parents and children about risk factors, including genetic predisposition (family history of drug misuse), peer pressure, low self-esteem, and poor resiliency to external change and stress.
Prevention also includes educating children in age-appropriate ways about the adverse effect of using tobacco, alcohol, and other drugs.