How Common Are Behavior Problems?

Nearly 25% of school-age patients are evaluated by physicians for behavioral concerns ranging from minor temper tantrums to severe behaviors that cause injury to self or others. The behaviors may occur with one person or many, at home, in school, or anywhere. Severe, pervasive behavioral concerns are discussed in Chapter 55.

Why Should I Worry about a Child’s Behavior?

Parents often seek assistance about behavioral problems from a child’s physician. Learning about behavior will assist you to master important clinical skills that will help you address these concerns. Primary prevention of problem behavior is aided when routine care includes:

How Does Behavior Relate to Child Development?

Knowledge of development helps you understand a child’s behavior and identify an approach to take with the parent. Many concerns about behaviors reflect typical child development. For example, impulsivity and the inability to stay with an activity for more than a few minutes are age-appropriate for a 2-year-old but suggest the need for further evaluation of a 7-year-old. Table 22-1 lists developmental highlights that relate to behavior.

Table 22-1 Highlights of Developmental Levels

Why Do Problem Behaviors Develop and Persist?

Behaviors persist when they are reinforced. We typically classify reinforcers into two categories based on the benefit to the child: gain (positive reinforcement) and escape (negative reinforcement). Problem behavior may gain a desired outcome, escape from an undesired outcome, or both. The events that initially cause a behavior problem may be completely different from the events that maintain or reinforce it. For example, a child may awaken at night crying during an acute illness and a parent may respond by comforting the child and providing medical treatment. The child’s behavior and the parent’s response are appropriate for the situation. Night waking and crying usually subside unless the parent continues to respond each time the child wakens or cries. The behavior may now persist because it is positively reinforced by parental attention. Or, parents may attempt a behavior management plan but give up when the child “tests the limits.” Thus the child learns to persist with the problem behavior to get what he or she wants.

What Is Attention Seeking?

Attention seeking commonly occurs when children are ignored until they misbehave. Problem behavior may offer the child the only way to get what he or she wants. Children learn to gain attention through their behavior. To them, even negative attention is better than no attention.

How Does Family Stress Affect Child Behavior?

Family stressors may cause or contribute to problem behaviors. For example, a parent who has depression may be unable to engage in positive interactions or preventive measures or carry out a management plan. Domestic violence provides poor role models for anger management and communication and creates an environment with unpredictable consequences for the child’s behavior.

What about Genetic, Medical, and School Influences?

Genetic or medical factors may contribute to the problem behavior. These include the child’s temperament, a genetic disorder, chronic illness, and the child’s cognitive skills or learning style. For example, fragile X syndrome is associated with repetitive behaviors, perseveration, and hyperactivity. The teaching approach in the school may trigger and reinforce problem behavior if it does not match the child’s learning style. A child who learns best from visual cues may become frustrated with verbal explanations and act out in an attempt to escape demands. A child who has a learning disability may demonstrate “hyperactive” behaviors in school that only diminish after the learning disorder has been identified and an educational management program instituted (see Chapter 55).

How Should I Begin an Evaluation of Behavior?

A good interview is important for gathering information.

How Do I Determine What Reinforces a Behavior?

Table 22-2 provides examples of questions and some answers that suggest possible reinforcers.

Table 22-2 How To Identify Reinforcers of Behavior

What Observations Will Help Me Assess Behavior?

Observe parent-child interactions in the clinic setting. Remember that interactions in clinic will not necessarily reflect what happens in other situations, but watch for general patterns. Observe the child’s response when you use one of the positive strategies in Table 22-3. If the child responds, try instructing the parent in these alternatives. If the child is unresponsive, and especially if similar behavior occurs in other situations, referral to a psychologist may be needed for further assessment and management.

Table 22-3 Parent-Child Interaction: Potential Problems and Positive Strategies