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Behavior Problems Among School-aged Children

Michael A. Davis, MD

Children's behavior is the result of the combination of temperament, inherited personality, and their experiences. It is possible to modify behavior by identifying and correcting adverse situations and by introducing appropriate interventions. Adverse situations may include child abuse or neglect, marital discord, or inappropriate class placement.

Identifying the Problems

The initial evaluation should determine what behaviors have been problematic and why, and it should determine under what circumstances the behaviors occur and how the parents deal with them. It is important to determine if there are other contributing factors at home or at school, such as family dysfunction or problems with peers.

More detailed information may be obtained through the use of behavior rating scales that are completed by parents and teachers. Behavior rating scales such as the Pediatric Symptom Checklist (for screening) or the Child Behavior Checklist (for more detailed information) will assess a broad range of behaviors.

Treatment

Behavior Modification

Primary intervention consists of helping parents to manage their child's behavior, generally in the form of behavior modification.

Principles of behavior modification. attempt to increase a child's appropriate behaviors by reinforcing the child for his appropriate behaviors and to decrease or eliminate inappropriate behaviors by ignoring or punishing the child for them.

Improving parenting skills has the goals of making parents: 1) more reinforcing and positive, 2) more consistent, and 3) more contingent.

It is surprising how infrequently most parents reinforce their children’s good behaviors or spend quality time with them. This usually is even more striking when the child is difficult.

An important element in any parent training intervention is to increase the parent's ability to be positive and reinforcing. Some parents may require role playing and practice with feedback to accomplish this task. They need to learn how to attend to (comment about and participate in) their child's activity. Their praise needs to be clear, focused on the desirable behavior, and appropriate to their child's developmental level.

Most behavior modification programs help the parents provide effective discipline. The consequences or punishments should be effective, constructive, and not unduly harsh.

Characteristics of Appropriate Discipline

• Rules and commands given to children must be clear and developmentally appropriate. • Commands should not be repeated more than once, and the child should be reminded of the consequence (repeated commands usually are not effective and frequently lead to anger). • The consequence must follow the infraction in a timely fashion. • The consequence should be administered before parents become angry. • The consequence must be appropriate to the child's level of development and sufficient to be considered negative without being unduly harsh. • The expectation should be that after the punishment the child will follow the rule or complete the command. • The parents always must praise the child when he or she behaves appropriately.

Behavior Modification Techniques

More complex activities, such as setting up a reward system using points or tokens, are also useful, particularly for older children.

Devise a chart. Charts give the child greater responsibility for his conduct. Prepare a checklist of responsibilities and place the youngster in charge of completing it. Points or special privileges can be awarded for a pre-determined numbers of "checks."

Revocation of privileges. Non-compliance with the rules of time-out usually leads to additional minutes being added, one at a time. However, an older child may be unswayed by extending his isolation. Instead, make a free-time privilege the price the youngster pays for not cooperating.

Assign penalty tasks. Assign the misbehaving child a five- or 10-minute chore. (Select something that is not part of the daily routine, such as vacuuming the car.) The child is told that a second job will be assigned if he doesn't comply, and that he'll be grounded until both chores are done.

Declare a parental time-out. The parent can reduce stress by taking a time-out and explaining tersely to the child that she needs to calm down before discussing the child's behavior.

Draw up a contract. Pinpoint a potential problem behavior, such as the child's failure to put away his playthings--and prepare a written statement spelling out the rule in question and the specific consequence of the child's breaking it. Confiscation of abandoned toys is a very effective deterrent to skipping clean-ups. For adolescents, written mutual agreements between parents and children are useful.

For more severe problems, group parent training programs that present information about appropriate interventions are required; for the most severe cases, individualized family therapy is necessary. For children who have severe and disturbed behavior, referral to a child psychiatrist, who may employ psychotropic medication, may be required.

Other Therapies

Dietary Interventions. No dietary intervention has been proven effective. Dietary interventions may result in inadequate intake of one or more nutrients. The diets can cause additional behavioral problems in making the children comply.

Exercise or Training Programs

Exercise interventions has been supported by well-controlled studies demonstrating their efficacy.

Some parents of children with autism have focused on facilitative communication, where a facilitator helps the child communicate by pointing to letters. Facilitative communication has been found to be of no benefit. §