Behavioral Management: Theory and Practice
Edward R. Christophersen
Sarah S. Nyp
Traditional behavioral management techniques can be very useful to the primary care clinician. This chapter describes the concepts and techniques that parents can routinely use in interacting with their children.
I. Techniques to teach or improve behaviors.
A. Time-In and verbal praise.
1. Time-In refers to brief, nonverbal, physical contact provided to a child when a parent notices that the child is displaying appropriate or acceptable behavior. Examples include a pat on the back or a tussle of the hair. Time-In can be described to parents as a two-handed approach. One hand is on the child. The other hand is over the parent’s mouth. This description illustrates to parents the importance of providing physical contact as an encouragement to the child to continue the current behavior. The nonverbal nature of the communication decreases the chances of distracting the child from the behavior. If a child is sitting quietly while working on puzzles with her sibling and her mother “interrupts” the appropriate play and interaction by providing a verbal comment, even verbal praise, the child is less likely to continue the activity. The physical contact of Time-In provides the child with knowledge that the behavior was noticed, without distracting the child from the acceptable activity. Parents should be encouraged and educated to provide their children with Time-In whenever their children are engaging in acceptable behavior. They should not wait for “good behavior.”
2. Verbal praise is provided when a child has done something “good.” The best time to use verbal praise is during natural breaks in an activity. For example, when a child is engaged in a coloring activity, the parent should provide lots of brief, nonverbal, physical contact (time-in). Once the child has finished coloring or stops coloring to show it to a parent, verbal praise is appropriate.
Advantages. Time-in and verbal praise encourage children to continue to engage in acceptable behaviors. When applied correctly, these techniques take no additional parent time and do not distract children.
B. Incidental learning. Children learn behaviors by being around individuals who engage in those behaviors. This is called incidental learning. For example, if both parents smoke cigarettes, their child is significantly more likely to become a smoker than if neither parent smokes. A surprising number and variety of children’s behaviors appear to have been learned incidentally, including language, gestures, and anger management strategies.
Advantages and disadvantages. Incidental learning can be achieved without any additional effort on the part of the parents. They need only be aware that such learning occurs naturally and be cognizant of incidental learning during the time they spend with their children. The negative side is that children also learn behaviors the parents never intended for them to learn (e.g., swearing).
C. Modeling.
1. Two basic modeling techniques exist: live and video recordings. Most modeling procedures work best if the model is approximately the same age as the target child. For example, a 6-year-old boy who has previously had his teeth cleaned by a dentist and who behaved appropriately during the procedure could be observed live or on video recordings while being examined. A second child who observes the dental procedures being performed on this model can learn both what to expect of dental procedures and how to react to those procedures.
Advantages and disadvantages. Children are more likely to believe what they see a peer doing than what their parents tell them, particularly if the two messages are contradictory (e.g., one a verbal message that the child should relax, and the other the anxiety that a child feels in the dental chair). However, modeling can teach maladaptive behaviors as well as adaptive behaviors. For example, if a child is observing
a peer model in the dentist’s office and the peer model becomes very upset, the target child will probably have a more difficult time when it is his turn for the procedure.
D. Reinforcement. No other topic in the behavioral literature has been more misunderstood than reinforcement. An item or activity can be said to have reinforcing properties for an individual child if and only if that child has previously worked to obtain access to that item or activity.
1. Choosing rewards. Under the right circumstances, reinforcement, by definition, will work with virtually any age group and with many different behaviors. However, no item or activity can be accurately described as a reinforcer unless and until it has produced a change in behavior. For example, although candy is reinforcing for the vast majority of children, it cannot be referred to as a reinforcer until it has been demonstrated that the child will either work to obtain the candy or stop a behavior that prevents him from receiving it.
Principles of reinforcement, or the manner in which the reinforcer is made accessible to a child, are extremely important.
a. Small rewards offered frequently are better than large rewards offered infrequently. A physical hug offered several times during a household chore will usually be more effective than a big reward at the end of the chore. Small rewards during the chore and a reward at the end will also work nicely.
b. Repetition, with feedback, enhances a child’s learning. A child will learn more from performing the same task repeatedly, with help from his parent, than from performing it once. Although parents will often expect their child to perform a task correctly the first time, the child will actually learn the task better if he has many opportunities to practice. For example, a child who helps one of his parents to do the laundry several times each week for 2 years will probably be able to do the laundry for the rest of his life.
c. Making the choice to participate in acceptable behavior is a learning process. Children learn more quickly and retain the learning better if they are relaxed while they are learning. While helping children to acquire the skills to make appropriate choices can be very frustrating, the parent who becomes angry or impatient only exacerbates the situation. Similarly, an upset child does not learn as rapidly or as permanently as a calm child. Parents should be reminded that children learn a significant amount about what behaviors are “appropriate” by watching how their parents respond when presented with frustrating or otherwise challenging situations.
d. Warnings only make behavior worse. Although parents have a natural tendency to warn their children, it is far more effective to discipline the child (provide a consequence) for not performing the task after the first time the request is ignored and then give the child another opportunity to fulfill the command, rather than frequent warnings that the tasks must be done. In fact, children who receive warnings prior to consequences, often learn that they may continue to disobey their parents several times before they will either be forced to complete the request or receive a consequence. This “planned ignoring” on the part of the child often becomes increasingly frustrating to the parent.
e. A behavior must already be learned before it can be reinforced. If the child does not know how to perform the expected behavior, offering a reward, in lieu of teaching the child how to perform the behavior, is ineffective. For example, if a child has never tied his own shoes, offering him a new bicycle if he ties his shoes is not likely to be effective.
Advantages and disadvantages. Reinforcing items and activities frequently can become part of normal, everyday life without substantial planning on the parents’ part. Examples may include 10 minutes of one-on-one time playing catch with a parent or an extra story at bedtime. It should also be noted that reinforcing items and activities may sometimes be inadvertent. For example, when a parent waits until their child has been crying for several minutes in the morning, the parent may be reinforcing that child for crying. If the same parent had picked their child up BEFORE he started crying, however, he would be reinforcing the child for playing quietly in his crib instead of waiting until he was crying.
In addition, the child’s behavior may return to its prereinforcement level as soon as the reinforcers are no longer available. For example, in research on the use of reinforcers for automobile seat belt use, many children stopped wearing their seat belts as soon as the reinforcers were no longer available. Procedures that have been shown to be successful in maintaining desired behaviors after reinforcement ceases include gradually making the reinforcer available less often (e.g., on the
average, every second behavior is reinforced, then every third behavior, then every fourth behavior). Once a behavior becomes habitual, the individual will engage in it whether it is reinforced or not.
E. Conditioned reinforcers. Many items and activities that have no intrinsic reinforcing properties can take on reinforcing properties. Money, for example, is not usually a reinforcer to a small child. When the child learns what he can purchase with money, it begins to take on reinforcing properties. As another example, to a distressed child in the middle of the night, even the sound of the bedroom door opening can take on reinforcing properties, as the child associates the sound of the door opening with receiving attention from a caregiver.
Advantages. Conditioned reinforcers are usually more readily available than the actual reinforcer, and most children will work just as hard for a conditioned reinforcer as they will for the actual one. Conditioned reinforcers, such as money, also have the advantage that they can be traded for a wide variety of items or activities as the child’s tastes and preferences change.
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