Helping Parents Manage Early Childhood Behavior Problems
October 14th, 2014
by Katrina Brooke
Child behavior problems are among the most common mental health disorders in childhood, with 7% to 25% prevalence, depending on the population surveyed.[1-3] According to a survey of primary care physicians in the Chicago area, 21% of children aged 2 to 5 years met criteria for a behavior disorder and 9% were rated as severe. The majority of these children may only have contact with a medical professional in a primary care setting. This review will help pediatricians to recognize cases that warrant referral and offer advice to parents who often feel ill equipped to manage their children’s behavioral problems.
The first challenge facing pediatricians is ascertaining when to refer a child for a mental health evaluation. All children experience behavioral problems sometimes, with certain transition periods (eg, “terrible twos,” adolescence) in which behavior problems tend to escalate. Typical 2-year-olds exhibit outright defiance, aggression, and anger tantrums that are developmentally appropriate as they are attempting to establish autonomy, test limits, and achieve mastery of their environment. Why do some children move beyond this developmental phase while others seem stuck in it? Variations in parental warmth, support, and appropriate control are important potential factors in determining a child’s ability to master this transition.
· Often loses his or her temper
· Often actively defies or refuses to comply with adult requests or rules
· Often blames others for his/her mistakes
· Often is angry or resentful
Most children will exhibit some of these behaviors occasionally. To establish a clinically significant problem, a clinician must look for a pattern or cluster of symptoms that has been troublesome for some time, is relatively severe, and is in some way impeding the child’s functioning (eg, child getting expelled from preschool).
There are numerous risk factors for the development of a behavior disorder. Some children are born with a difficult temperament and have always been fussy, irritable, and difficult to soothe, thus making them difficult to parent effectively. A child may present with other challenges, including attention deficit hyperactivity disorder (ADHD), learning disorder, speech and language delay, or autistic spectrum disorders.
Other risk factors include high levels of family stress (eg, poverty), single parenthood, neighborhood violence. Faulty parenting is certainly a risk factor that is most amenable to change. Parent training is the only empirically supported well-established treatment for children with a behavior disorder,  regardless of the etiology of the behavior disorder.
Other treatments may be necessary if the behavior disorder is concomitant with another mental health disorder, such as ADHD. The essential elements of parent training programs teach parents basic skills, including differential attention (ie, praising positive behavior, ignoring negative behavior), limit setting, use of consequences, time-out, and other discipline strategies.
One program in particular, the Incredible Years Parent Program,  targets parents of young children aged 3 to 8 years, and aims to strengthen parenting competence, emphasizing the use of nonviolent discipline approaches to decrease child behavior problems.
1. Developing a positive relationship through play Parents can remedy this situation by setting aside time every day or a few times per week to play with their child. Parent-child play is particularly important to children because it makes them feel loved and important, bolsters their self-esteem and feelings of competence, and fosters a secure base for children’s emotional development.
It is also a time when parents can model important social skills (ie, turn taking, asking, cooperation), help children develop skills such as vocabulary, and foster children’s use of imagination and problem solving. Studies have shown that children tend to be more creative, have increased self-confidence, and have fewer behavior problems if their parents engage in regular playtimes with them. It is important that parents allow the child to direct the play activity and not be overly concerned with rules or become overly involved in trying to teach or instruct the child during play. Playtime should be relaxed, enjoyable, and open-ended to maximize the amount of exploration for the child.
Parental attention is a powerful resource that parents often unwittingly misuse. By misbehaving, children receive negative attention such as yelling or scolding, but for many children, negative attention is better than no attention.
In this way, the negative attention is reinforcing the behavior, increasing the likelihood that it will happen again. Similarly, children can become so negative, that their parents may give in to a request, withdraw punishment, or placate the child, which further increases the chances that the negative behavior will recur. Parents should be encouraged to praise their children for everyday behaviors, and not reserve praise for big accomplishments.
Many parents feel that children are expected to behave well and should not need praise for everyday tasks, but this is unreasonable. Children have a need to feel appreciated just as adults do. Parents should “catch their children being good” by looking for positive behaviors.
See Table 1 for examples of behaviors that should be praised and suggestions on how parents can use praise most effectively.
Parents of children with behavior disorders need to work especially hard at finding positive behaviors to praise. Furthermore, parents of these children often have such a negative view of them that they do not notice the positive behavior exhibited by their children. The complement to praising positive behavior is to ignore negative attention-seeking behavior. Behaviors that are not harmful or dangerous are appropriate to ignore and include whining, tantrums, swearing, and arguing.
Many parents resist the use of ignoring because they feel that by ignoring misbehavior, they are allowing the misbehavior to continue. In a sense, that is true. However, if the behavior is attention-seeking and parents do not attend to it, there is no payoff for the child, and so the behavior will eventually disappear.
The use of ignoring, however, is far more difficult than it first appears. Ignoring consistently takes a great deal of effort and tenacity. In order to be effective, the target misbehavior must be ignored by all caregivers at every occurrence. Otherwise, if the misbehavior receives intermittent reinforcement, it actually makes it even more resistant to change. Parents should be advised to select a single behavior to ignore and to do so consistently. While ignoring the misbehavior, they should avoid eye contact and discussion, and possibly move away from the child.
A key to successfully ignoring misbehavior is to consistently praise the alternate positive behavior. For example, in the case of whining, the child should be frequently praised when he or she asks for things politely. Parents should especially look for opportunities to praise their child soon after they have ignored the negative behavior. Behavioral problems in young children may be part of a transient developmental phase or they may signal an emerging behavior disorder.
In determining whether a mental health referral is needed, pediatricians should keep in mind that it is not the presence of certain behaviors, but rather the frequency, intensity, chronicity, constellation, and social context that define a behavior disorder.
For all cases, techniques for managing children’s behavior problems by strengthening the parent-child bond and using differential attention can be relayed to parents during a brief office visit.
1. Campbell SB. Behavior problems in preschool children: A review of recent research. Journal of Child Psychology and Psychiatry & Allied Disciplines 1995;36:113-149. 3. Richman N, Stevenson L, Graham PJ. Pre-school to school: A behavioural study. London : Academic Press; 1982. 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington , DC : American Psychiatric Association; 1994. 7. Webster-Stratton C, Hancock L. Training for parents of young children with conduct problems: Content, methods, and therapeutic processes. In: Schaefer CE, Briesmeister JM, eds. Handbook of Parent Training. New York , NY : John Wiley & Sons; 1998:98-152. The Northwestern University Feinberg School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Northwestern University Feinberg School of Medicine designates this live activity for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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- 6. Brestan EV, Eyberg SM. Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. Journal of Clinical Child Psychology 1998;27:180-189.
- 4. Lavigne J, Gibbons R, Christoffel K, et al. Prevalence rates and correlates of psychiatric disorders among preschool children. Journal of the American Academy of Child & Adolescent Psychiatry 1996;35:204-214.
- 2. Landy S, Peters RD. Understanding and treating the hyperaggressive toddler. Zero to Three 1991;Feb:22-31.
- Parents must be prepared for an increase in intensity of the misbehavior. For example, if a child is used to getting his way by whining and the parent begins to ignore the whining, the child may escalate to yelling, then screaming, and perhaps even explode into a tantrum. If the parent gives in during this period of escalation, the parent has reinforced this higher level of misbehavior. On the other hand, if the parent can withstand this temporary increase in misbehavior, the long term result will be rewarding. It may take only a few times for a child to learn that the parent will not give in no matter how upset the child gets, and ultimately the child will stop whining altogether.
- Ignoring avoids a power struggle, giving children the ultimate control over whether or not to continue the misbehavior. Some parents welcome the use of ignoring, and in fact feel relieved that they have been given “permission” to ignore an annoying behavior, giving them a sense of relief from feeling the need to try to correct it, thus removing them from a power struggle.
- An additional benefit of praising children is the modeling of polite language. Children who are praised frequently are more likely to praise others, including their peers, which in turn improves their social relationships.
- Parents can drastically turn around and control this situation by making a concerted effort to attend to their child’s positive behavior and ignoring minor misbehavior. The use of praise is a way to deposit into a child’s bank. Praise encourages a child, and improves self-worth and feelings of accomplishment. Behavior that is praised is more likely to occur in the future.
- 2. Using the power of praise and ignoring
- Parents must overcome several barriers to play including limited amount of time and energy, or their own lack of desire to play. Many parents of children with behavior problems may not want to play with their children as their interactions are too stressful. These parents feel negative toward their children out of anger and frustration concerning their children’s misbehavior, and their children in turn are negative toward their parents. These are precisely the families in most need of some positive interactions and playtime can be a first step in breaking the negative cycle, promoting feelings of attachment and warmth between children and their parents.
- The Incredible Years Program emphasizes the need to improve the parent-child relationship before other parenting techniques are addressed. Many problems will desist simply because the child no longer needs to “act out” to get attention. Also, discipline strategies will be more effective when the parent-child bond is stronger. The program uses an analogy of a bank. A parent can deposit into their child’s bank by playing, giving positive attention, talking, and showing empathy. A parent can make a withdrawal (eg, setting a limit), as long as there is a positive balance in the bank account. Too many children are depleted, with little or nothing in their banks. Either the parent has not been making enough deposits (eg, busy schedules not permitting playtime), or they are making too many withdrawals (eg, incessant commands, high expectations).
- The dilemma facing most pediatricians is how to offer substantial parenting advice to distressed parents within a very limited time. Two main principles from the Incredible Years Program could be discussed with parents in a relatively short timeframe. Both are based on the premise that children seek parental attention by misbehaving. By offering their attention in both non-contingent and contingent ways, the parents are in a position to better manage their children’s behavior.
- Parent training during office visit
- Other diagnosable behavior disorders include disruptive behavior disorder not otherwise specified, which is typically used when full criteria for ODD is not met, yet the behaviors are impeding the child’s functioning. A child may have an adjustment disorder with disturbance of conduct when there is an identified stressor causing a temporary increase in misbehavior.
- · Often is spiteful or vindictive
- · Often is touchy or easily annoyed by others
- · Often deliberately annoys people
- · Often argues with adults
- Distinguishing a difficult, but transient phase from an emerging behavior disorder can be difficult. The Diagnostic and Statistical Manual of Mental Disorders  defines criteria for oppositional defiant disorder (ODD) as a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months for which at least 4 of the following behaviors are present:
- When is bad behavior a behavior disorder?
- CME credit