CHAPTER 7

Behavioral and emotional concerns are among the most common reasons that children are seen by primary pediatric health care professionals. Epidemiological studies show that 11% to 20% of children meet criteria for a behavioral or emotional disorder.1 Parents also raise concerns and seek intervention for problematic behaviors that do not reach the diagnostic threshold of a specific disorder but are nonetheless distressing to the child or family. To help these children and families, primary pediatric health care professionals must assess the nature and severity of the problem in order to decide whether to intervene in the office or to refer to a behavioral health specialist. Sometimes families only require reassurance and a sympathetic ear. Other times, contributing factors can be readily identified and remedied. This chapter presents a brief overview of why behavioral and emotional problems occur, how to assess the problem, and factors to consider in deciding to intervene or to refer to a behavioral health specialist. Principles of behavior management for primary pediatric health care professionals will then be outlined so that families can be given effective advice and appropriate behaviors can be proactively promoted. Finally, interventions for some common behavioral problems will be reviewed.

Assessment of Behavioral Problems in Children

Screening for Behavior Problems

Screening to ensure that a child’s physical and behavioral health support optimal growth and development is one of many goals of a pediatric health supervision visit. While some parents will directly raise concerns about their child’s behavior, others hesitate to do so, in part because they are not sure whether troublesome behaviors are within the range of normal, and in part because society often places responsibility for misbehavior on parental management. Medical professionals may hesitate to ask about behavioral concerns when they do not see such concerns as part of their scope of practice, if they lack the time, tools, or knowledge to screen and gather information efficiently, or if they lack the skill set to effectively intervene. When problems require referral to a behavioral health specialist, many communities have a dearth of effective resources, and many resources for less severe behavior problems are not covered by insurance.2 Thus, the US health care system does not reliably identify or treat behavioral and emotional concerns and disorders.¹

The use of standardized behavioral screening tools is one strategy to efficiently improve detection of behavioral and emotional problems in primary care. The Pediatric Symptom Checklist (PSC) is a 35-item parent-report scale that has been demonstrated to improve detection of behavioral and emotional problems in children from 4 to 15 years of age.³ It is available online at http://www.massgeneral.org/psychiatry/services/psc_online.aspx. Parents can complete the PSC in 5 to 10 minutes, and it can be scored in less than 5 minutes. Recently, an abbreviated 17-item version (PSC-17) has been reported to be an even more efficient behavioral screening measure, although it may miss children with anxiety disorders.⁴ For younger children, the Brief Infant-Toddler Social and Emotional Assessment (BITSEA)⁵ or Ages & Stages Questionnaires: Social-Emotional, 2nd Edition (ASQ:SE-2)⁶ are brief behavioral screening tools appropriate for use in primary care.

Defining the Problem

Once a behavioral concern is identified, the primary pediatric health care professional needs to obtain a description of what is happening, including the antecedents (what happens before the behavior), a description of the behavior, and the consequences (what happens after the behavior). This is often referred to as the ABCs of the behavior. Knowing the antecedents will help identify what triggers the behavior, such as whether it occurs only in certain settings (eg, school or home) or with certain caregivers. A complete description of the behavior will identify its intensity, duration, and frequency. This will allow the clinician to determine whether the behavior is outside the range of typical for a child of that age or developmental level and whether it potentially threatens the safety of the child or others. The consequences will include how parents (or others) respond to the behavior, which may help identify responses that are increasing the likelihood of the behavior continuing to occur (reinforcing the behavior). Primary pediatric health care professionals will also want to know when the behavior started and the impact the behavior is having on the child and family.

Behaviors that occur at high frequency, high intensity, and in the presence of multiple caretakers or in multiple environments are more suggestive of a behavioral or emotional disorder.⁷ Behaviors that are of new onset may represent a new stage in a child’s development, but they may be a result of pain or discomfort or a reaction to trauma, stress, or a change in family circumstances. All of this information will help clinicians determine whether a problem can be managed in primary care or needs referral for additional assessment and treatment. Families are more likely to listen to advice to pursue such resources when primary pediatric health care professionals express empathy for the challenges the child’s behaviors present and confidence that, with help, the behaviors can improve.

Understanding the Problem

Temperament: Children vary in how they approach and respond to different situations. Some children are not upset easily, while others have a low threshold for frustration, and relatively small triggers may result in large reactions. Some children go with the flow, transition well, and take changes in stride. Others have more difficulty shifting gears and need predictability in order to function well. Some children are able to pay attention and persevere in tasks until finished. Others get distracted by new projects and may need prodding to finish what they started. These differences in behavioral tendencies reflect variations in temperament. Temperament traits are in part inherited and in part born of experience.8 The different dimensions along which one sees variability in these behavioral tendencies is the subject of ongoing debate, but one frequently used model describes 9 dimensions along which these differences can be observed: adaptability, regularity, activity, intensity, persistence, approach/withdrawal (to new situations), sensitivity to sensory stimuli, mood, and distractibility.⁹ Certain temperament characteristics tend to be associated with an increased likelihood of difficult behaviors, particularly low adaptability, high intensity, low regularity, withdrawal in new situations, and negative mood. Helping parents to appreciate their child’s temperament and adjust their approach to better match the child’s temperament can minimize behavior problems and decrease parental tendency to feel like they are to blame for their child’s behaviors.⁹

Modeling and Learning: A key component of a child’s environment involves the child’s exposure to role models and teaching. Children learn through imitation of others. Imitation of simple motor movements starts in infancy. As children get older, they imitate more complex social and communicative behaviors. A child’s misbehavior may be due to lack of experience and/or opportunity to practice appropriate behavior. Another factor could be a child’s indiscriminate imitation of others (eg, a child imitating a parent’s adult language or imitating behavior from videos with inappropriate content). When inappropriate behavior results from inappropriate role models or skill deficits, interventions will need to provide exposure to appropriate role models and to teach the desired skill.

Consequences (Responses to Behavior): Before intervention, the primary pediatric health care professional must know how the parents understand the behavior, how the parents have been responding to the behavior, and what attempts they have made to change the behavior. The parents’ understanding of the behavior may be influenced by family, community, or cultural factors, all of which the clinician will need to consider when counseling the family. When a problem behavior occurs repeatedly, it is very likely that the response to the behavior reinforces it. Any response to a behavior (regardless of the intent of the response) that maintains or increases the frequency of the behavior is referred to as a reinforcer. The persistence of misbehavior often results from caregivers inadvertently reinforcing the problem behaviors. For example, when a child frequently tantrums when told “no,” it is likely that the parents are giving in frequently enough that the child is not sure whether no really means no. Parental attention, even negative attention such as yelling in response to the child’s misbehavior, is another common reinforcer of problem behaviors.

When to Refer: A parent’s gratitude for behavioral advice that works can be very rewarding to pediatric health care professionals, but some families will require more time and guidance than can be provided in a primary care visit. This may occur when the behavioral difficulty is a sign of child psychopathology and/or family stress or discord. Factors to consider when deciding whether to refer a child are included in Box 7.1. If these factors are present, the primary pediatric health care professional should consider referral to a behavioral therapist, developmental-behavioral pediatrician, child psychiatrist, psychologist, school guidance counselor, parenting class, or a community mental health agency. Primary pediatric health care professionals should provide families some guidance as to the services they should expect and follow up with the family to ask whether these services have been helpful.

Box 7.1. Factors That Make It More Difficult to Change Behavior

Behavior management starts with gaining an understanding of the behavior, which then guides the next step: changing behavior. The focus of behavioral change should be on encouraging the desired behavior, as well as discouraging the undesired behavior. Behavioral intervention occurs on several different levels, depending on the particular problem and situation (Table 7.1). Antecedent modification refers to changing the factors that trigger the problem in order to prevent the problem behavior from occurring. Giving instructions communicates how we want the child to behave. Finally, consequence modification refers to changing how the caregivers respond to both problem and desired behaviors.

Modifying Antecedents

One method for modifying antecedents is to alter the child’s physical environment. Childproofing, for example, removes access to hazards, decreasing the likelihood that the child might play with hazardous materials. Tantrums in a toy store can be reduced by limiting the time spent shopping or not going to a store when the child is tired or hungry. Aggressive behavior noted after the child plays fighting video games can be reduced by removing the child’s access to such games. Placing a high latch on a door decreases the likelihood of a young child escaping.

Antecedent modification may include teaching skills needed for alternative behaviors that accomplish the same goal. Misbehaviors that occur because of frustration often require these interventions. For example, teaching effective communication skills through sign language or picture exchange communication would be part of the behavioral plan for a child who gets frustrated because of difficulty with language. Similarly, if a child’s misbehavior is related to frustration with handwriting, obtain-ing occupational therapy and teaching computer keyboard skills might be useful interventions.

Another means of antecedent control is to ensure that appropriate behavior is modeled by the child’s peers and other adults. As discussed earlier, one of the most important ways that children learn behavior is through imitation.¹⁰ In order to use modeling to change behavior, parents need to be mindful of the behavior they want their child to display and to display such behavior themselves. For example, for a child who gets explosively angry, the appropriate behavior to model would be a calm response when upset and using words to relay the problem rather than behavior. Getting angry and yelling back at the child models the undesired behavior. For a child who is very anxious, a parent needs to model calm, confident reassurance.

A child’s behavior can be shaped through the instructions the child is given. Helping parents give instructions more effectively is an important part of behavioral counseling.11 Effective instruction starts with gaining the child’s attention. This sounds obvious, but too often parents try to engage their child when the child is doing something else. If a parent yells, “It’s time for dinner!” from the kitchen when the child is absorbed in a video game in the basement, it is likely that the child is selectively attending to the video game and not the parents’ instruction. Both the parent and child get rapidly exasperated if the parent sees the child as making an active decision to disobey. Such exasperation can be avoided if the parent first makes eye contact or receives verbal assurance that the child is listening before giving the instruction.

Instructions to alter or engage in a specific behavior need to be given in simple language that fits the comprehension abilities of the child. In general, the number of words used in the instruction should not be longer than the typical length of the child’s sentences. This does not mean that parents should always talk to the child in short sentences, but simplifying language when directing the child’s behavior helps the child understand what is expected. Instructions should also be given as firm statements and not as a question, unless the instruction is a choice (“It’s time to clean up.” versus “Can we clean up now?”). A “firm” voice (or “sergeant” voice) helps the child differentiate a parent’s directive from a choice.

Instructions that specify the desired behavior are more likely to be followed than general commands or “don’t” instructions. “Behave” is less likely to be successful than “Come sit by Mommy.” Saying “Walk.” is better than “Stop running.” Minimizing “don’t” instructions often requires parents to ignore minor misbehavior and redirect the child to what they want him or her to do.

Finally, successful instruction requires that the parent follow through with the instruction. Figure 7.1 illustrates a protocol to help parents follow through consistently with instructions to a child. After getting the child’s attention, the parent issues the instruction or directive followed by 5 to 10 seconds of silence. The period of silence is to allow the child to process the instruction. If the child listens, the parent could notice and sometimes provide a reinforcer (next section). If the child does not listen, the parent should reissue the instruction with a warning (“If you don’t put your shoes on now, the TV is getting turned off.”). If the child listens, the parent notices. If the child does not comply, the parent carries out the warning, and if the instruction was to complete a task, the parent reissues the directive. Children who do not comply unless the parent repeats the instruction multiple times or threatens them are likely playing the odds that a parent will drop the demand. From experience, they have learned that the likelihood a parent will follow through on a demand increases once a threat is issued, or once a parent’s voice reaches a certain angry pitch. Once a child learns that a parent is more consistent with follow through, warnings will not be needed as often in the future.

Figure 7.1. Giving instructions.

To be effective, reinforcing consequences need to have a positive value for the child and punishing consequences a negative value. They also need to be acceptable to the caregivers, affordable, and available. Attention (eg, praise) has a positive value for most children. Table 7.2 gives a list of suggested reinforcers. Withdrawal of attention (a time-out, discussed later in the chapter) has an aversive value to most children. The value of reinforcers is otherwise quite individual and will vary over time.

Both reinforcing and punishing consequences are most effective if they immediately follow the behavior. This is especially important for younger children and for children with developmental-behavioral disorders. For example, if a child repeatedly says Mom to no avail, and then kicks Mom, followed by Mom asking “What do you want?”, the behavior being reinforced is the kicking, not calling Mom’s name; eventually the child will preferentially kick to get attention. As children become older, reinforcers or punishments can be more delayed (eg, bedtime behavior rewarded with breakfast treat or school misbehavior punished by restriction of electronic games at home).

Punishment is a planned consequence to a behavior by the caregiver that decreases the frequency of that behavior. Punishment does not teach desired behaviors but may be a necessary component of behavior management plans for undesired behaviors that cannot be ignored, such as behaviors that are a danger to self or others, or the destruction of property. For more minor behaviors, warnings can be applied prior to the actual punishment. The success of punishment is defined as whether the behavior reduces in frequency over time, not by the child’s distress by the punishment itself. Children may appear nonchalant or even be insolent (“You’re not the boss of me!”). Parents need to ignore these distracting behaviors and calmly apply a punishment consistently across time before deciding whether it works or not.

Other punishment strategies are listed in Table 7.3. Although corporal or physical punishment (eg, spanking) continues to be commonly used, it is not recommended. Corporal punishment models behavior that would be inappropriate for the child to demonstrate with peers and adults, and it has been found to have negative effects on parent-child relationships, child development and behavior, and child and adult mental health across cultures.^12,13 Although most people in the United States would agree that not all forms of corporal punishment are child abuse, most child abuse starts as corporal punishment.¹³ For these reasons, practitioners should discourage parents from using corporal punishment and should emphasize the proactive and positive approaches described earlier in the chapter.

Behavior management counseling based on understanding the child factors, settings, expectations, and consequences that influence the behavior will often be successful. One-size-fits-all advice is generally neither rewarding nor successful.

The diagnosis of colic requires that the child be otherwise healthy and feeding well. Thus physical problems that can cause excessive crying must be excluded. Acute disorders that should be considered in a crying infant include conditions such as infections, corneal abrasion, glaucoma, skull or long-bone fracture, incarcerated hernia, supraventricular tachycardia, intussusception, midgut volvulus, and a hair tourniquet on a digit.14 A number of chronic conditions have been proposed to be the cause of infant colic, including cow’s milk allergy, lactose intolerance, constipation, and gastroesophageal reflux. Although in any one case, these problems are potential causes of crying, no well-designed study has suggested that these are common causes of excessive crying, and controlled studies using interventions targeting these problems in infants with colic have not been found to be effective for most infants.¹⁵ Recently, there have been studies of treatment with Lactobacillus-containing probiotics with mixed results.¹⁶

Infants with excessive crying have been found to have differences in temperament from those who cry less. Perhaps, not surprisingly, parents tend to rate these infants as more intense and more difficult to soothe (less easily distracted). However, these temperament characteristics of infants with excessive crying are also supported by independent observations. For example, independent observers of infants undergoing a physical examination rated infants with colic as crying more intensely and being more difficult to console.17 Infants with more persistent crying differ from those with less crying in that they have a higher crying-to-fussing ratio (suggesting greater intensity), and infants with colic have been found to be less likely to soothe in response to an orally administered sucrose solution than were infants without colic.¹⁸

Management of colic involves empathizing with parents about the stress and frustration colicky babies cause and reassuring them that their child is healthy. Helping parents to understand their infant’s temperament traits can allow them to better understand the infant’s crying and remain calm despite the crying. Parents should be counseled that crying is the infant’s way of communicating that there is something that the infant wants, but it is not necessarily a sign of pain or illness. Parents usually think of some things that an infant might want, such as to be played with, fed, or have a diaper changed. However, parents may not think of the crying as a sign of the need to be quietly held, the need for nonnutritive sucking, or the need to be left alone to sleep.¹⁹ Furthermore, parents need to understand that these infants are more difficult to soothe, and thus, even when the parent is providing what the infant wants, it may take many minutes before the infant stops crying. If parents rapidly change from one activity to another in futile attempts to soothe the infant, they may stop providing the infant with what he or she wants before the infant communicates to the parent that it is what he or she wants by stopping the crying.

Bedtime Resistance/Night Wakings

Sleep occurs in cycles that typically last about 60 minutes in babies, gradually increasing to 90 minutes in older children and adolescents. During the cycles, the child goes from light non-REM (rapid eye movement) sleep (described as Stage 1 and Stage 2 sleep) to deep non-REM sleep (Stage 3 and Stage 4 sleep) or into REM sleep. Most deep non-REM sleep occurs in the first third of the night, and most REM sleep occurs in the second half of the night.¹⁹ Individuals wake briefly between sleep cycles but tend not to be aware of this, as they rapidly go into the next sleep cycle. During the first year of life, average total daily sleep time decreases from about 16 hours a day in newborns to 13 hours a day at 1 year of age, with further decreases to about 9 to 10 hours per day during the elementary school–age years.²⁰

Falling asleep is facilitated by a calming and familiar environment and a consistent bedtime routine occurring at around the same time each night. Children need to learn to put themselves to sleep. Many associate different activities or objects with falling asleep (sleep associations). Younger children may have a favorite blanket or a stuffed animal or may fall asleep being rocked or nursed. Older children may have a favorite pillow or something they think about when they go to sleep. When these sleep associations are not available, initiating sleep may be more difficult for the child. In most children with night wakings, the problem is not actually the waking, but rather trouble falling back asleep because a sleep association is no longer present.22 For example, a parent lying down next to a child to get the child to fall asleep may be problematic because the parent is not present when the child wakes between sleep cycles during the night. In addition, infants should not have soft objects in the crib and should not sleep in the same bed as an adult due to the increased risk of sudden unexpected infant death.²¹ Other common problematic sleep associations include having an infant fall asleep while being rocked or nursed. Sometimes the parent is not part of the sleep association, but may be needed to help with a sleep association. For example, an infant may fall asleep sucking on a pacifier, but if the pacifier falls out of the child’s mouth, the child may need the parent to put the pacifier back in the mouth during the night. Night wakings can be managed by teaching the child to fall asleep without the problematic sleep association. This often results in bedtime resistance, which should be managed as described subsequently.

If a child is having trouble falling asleep, primary pediatric health care professionals should assess whether principles of good sleep hygiene are being maintained (Box 7.2). A regular morning wake-up time, consistent nap time and length, and a positive, calming bedtime routine followed by a consistent bedtime are particularly important. When unclear, it is helpful for parents to complete a 1- to 2-week sleep diary focusing on whether the expected time of sleep is con- sistent with the child’s physiological needs or tendencies. Trying to get a child to sleep when he or she is not tired or to sleep past the time the biological clock awakens the child is not likely to be suc- cessful. This may happen if parents do not understand the rapid decrease in the need for sleep during the infancy and toddler years or if the child has delayed sleep phase syndrome, which is characterized by a delay in initiation of sleep in relation to the desired sleep-wake times but an adequate total amount of sleep. In children with delayed sleep phase, one should slowly (in 10 to 15 minute increments) move the bedtime and morning wake-up times earlier. In addition, low doses of melatonin (1 to 5 mg/night) given 3 to 4 hours before the usual bedtime can be helpful.²³ Some children will resist going to bed at an appropriate bedtime because they have difficulty with parental limits or because they are being required to learn to fall asleep in the absence of an established sleep association. In this situation, parents often have to let children cry until they fall asleep.²⁴ After a few nights, most infants and toddlers will learn to fall asleep on their own, but the protests the first couple of nights can be dramatic and prolonged. Ignoring the tantrums is difficult for many parents, but if parents are going to check, they should briefly and calmly reassure the child that it is time for sleep and leave without touching the child. They should resist reintroducing the sleep association (eg, lying down with the child), as this would just teach the child that tantrums are effective in getting what he or she wants.

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