A. Open-ended questions. The first requirement for addressing behavioral problems is their identification. This is not always easy because children rarely ask for help and the parents may not realize that the clinician has either the interest or the expertise to help. Discussing behavior and development at each visit, using screening questionnaires, and educating oneself to have practical advice will all encourage parents to discuss psychosocial concerns. Open-ended questions (ones that cannot be answered by one word), such as “How are things going?” allow the parent and child to express their own agenda for the visit. For children aged 3 years and older, an interview of the child first can convey their centrality to the visit and elicits their point of view before they have heard (and potentially clammed up from) parental complaints. In other families, the clinician may need to ask specifically about behavior at home, at school, or in day care. Another approach that broadens the agenda is to ask routinely, “What is the hardest part of taking care of an X-month-old?”

B. Observations in the office. Observations of behavior in the office and waiting room can be revealing. Toys in the examination room are an invaluable way to observe the child’s behavior and development (as well as to enhance the enjoyment of the visit). These observations can then be used to start the discussion (e.g., “I noticed that he is very active. How is that for you at home?”). Such comments should be asked in a nonjudgmental way so that the parents’ response can reveal if they view the behavior as problematic. The clinician’s own feelings and intuitions about the child and family should be compared with parental and child reports and used to raise questions or to formulate clinical hypotheses about the child’s behavior. Asking the child to draw a person and relate a story about that boy or girl or a Family Kinetic Drawing (“Everyone in your family doing something.”) can be very informative about the child’s perceptions as well as about their cognitive and fine motor skills.

C. Screening questionnaires. Questionnaires can be a valuable time saver and tool for identifying behavioral problems and adding to office documentation. Validated screening tools are now recommended as standard care as informal methods have low sensitivity (see Chapter 12).

D. Collecting additional information. The next task is to collect additional information by questions, observations, direct physical examination or testing, and usually requesting information from other sources such as notes from childcare or school report cards (see Chapter 67). Depending on the acuity of the problem and time available, this may be deferred to a scheduled follow-up visit.

A. Defining the problem and setting goals. The first step to successful problem resolution occurs during the initial discussion in defining the problem. After initial open-ended questions, it is crucial to elicit details about the onset and attempted solutions, as well as times when the problem was not present to look for relevant causal factors. A survey of the areas of daily functioning (including bedtime, meals, toileting, peer interaction, separation abilities, family relationships, and school adjustment) is all needed to detect patterns that suggest areas of weakness or dysfunctional management.

It is important for the clinician to summarize the parent’s (or his or her own if the parent has none) concerns to demonstrate that their worries have been heard. The clinician should formulate and explain his or her clinical hypotheses about the underlying child,
family, and environmental factors contributing to the child’s behavior. The problem should be discussed nonjudgmentally and reframed in a positive light and in terms of new specific desired behaviors rather than the ending of a behavior (e.g., “You would like him to listen to instructions [rather than to not act up]”).

The initial discussion should set the stage for treatment by clarifying the problem, setting a positive tone, engaging other family members by determining how it affects them, and not blaming or insulting the child (who may be listening).

The next step is to convey some hope and confidence that a solution is possible and collaboratively design an initial plan or “homework” that addresses relevant goals for behavior change. It is important to guide family members in selecting homework tasks that apply to the family dynamic that seems causative, include tasks for each family member that are doable and measurable, and are of a scope that is not overwhelming but also not trivial. Additional diagnostic information comes from seeing how the family acted on this advice when they come for a follow-up.

B. Levels of intervention in primary care. There are different levels of behavior management suitable for different practitioners depending on their amount of interest, skill, time available for this work, and acceptability as advisors to the family.