Behavioral disorders and problems in children

Many behaviors in children or adolescents are of concern to parents or other caregivers. Disturbed behaviors or behaviors become clinically significant when they are frequent or persistent and inappropriate (e.g., interfere with emotional maturation or social or cognitive functioning). Severe behavioral disturbances may be classified as mental disorders (e.g., oppositional defiant disorder or conduct disorders). Prevalence may vary depending on how behavioral disturbances are defined and assessed.

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Diagnosis involves a multi-stage behavioral assessment. Problems that arise in children in the first years of life usually concern such functions as eating, defecating, sleeping, while in older children and adolescents, problems are mainly noted in the area of interpersonal communication and behavior (e.g., activity level, disobedience, aggression).

Identifying the disorder. The behavior disorder may appear suddenly as a single episode (e.g., arson, fighting at school). More often, the signs appear gradually and information must be collected over a period of time. It is best to evaluate the child's behavior in the context of his or her mental and intellectual development, overall health, temperament (e.g., difficult, carefree), and relationships with parents and others around the child.

Direct observation of the child-parent interaction during a visit to the physician provides valuable information, including the parents' reactions to the child's behavior. These observations are supplemented, when possible, by information from relatives, teachers, caregivers, and school nurses.

In a conversation with the parents or caregivers, the child's usual daily routine can be ascertained. Parents are asked to provide examples of events preceding and following certain actions or behaviors of the child. Parents are also asked about their interpretation of age-specific actions, expectations of the child, the level of parental interest in the child, the availability of support (e.g., social, emotional, financial) in their role as parents, and the nature of their relationships with other family members.

Interpretation of the problem. Some “problems” represent inappropriate parental expectations (e.g., that a 2-year-old will pick up toys without help). Parents misinterpret certain age-appropriate behaviors as problems (e.g., defiant behavior in a 2-year-old, i.e., the child refuses to follow rules or adult demands).

The child's history may include the presence of factors thought to increase the likelihood of behavior problems, such as exposure to toxins, complications during pregnancy, or serious illness in the family. Low levels of parent-child interaction (e.g., uncaring parents) predict subsequent behavior problems. Parental benevolent responses to a problem may make it worse (e.g., parents who are overprotective of a shy, clingy child or who give in to a manipulative child).

In young children, some problems develop through a vicious circle mechanism, whereby a parent's negative reaction to a child's behavior leads to a negative reaction from the child, which in turn leads to continued negative reactions from the parents. In this type of behavior mechanism, children are more likely to respond to stress and emotional discomfort with stubbornness, sharp objections, aggression, and outbursts of irritation, rather than crying. In the most common type of vicious circle behavior mechanism, parents respond to a child's aggressive and stubborn behavior by scolding, yelling, and possibly spanking the child; the child then further provokes the parents by doing the same things that caused the parents to react, and the parents react more strongly than they did initially.

In older children and adolescents, behavioral problems may be a manifestation of a desire for independence from parental rules and supervision. Such problems should be distinguished from occasional errors in judgment.

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Treatment of behavioral disorders and problems in children

Once the problem is identified and its etiology determined, early intervention is preferable, since the longer the problem exists, the more difficult it is to correct.

The physician should reassure the parents that there is nothing physically wrong with their child (e.g., that the behavioral problem is not a sign of a physical illness). By acknowledging the parents' frustration and pointing out the prevalence of various behavioral problems, the physician can often reduce the parents' feelings of guilt and facilitate the search for possible sources of the problem and ways to treat it. For simple problems, parental education, reassurance, and a few specific suggestions are often sufficient. Parents should also be reminded of the importance of spending at least 15 to 20 minutes a day in enjoyable interaction with the child. Parents should also be encouraged to regularly spend time away from the child. For some problems, however, additional methods for disciplining and modifying the child's behavior may be helpful.

The therapist may advise parents to limit the child's search for independence and his/her manipulative behavior, which allows for the restoration of mutual respect in the family. The desired and unacceptable behavior of the child should be clearly defined. It is necessary to establish permanent rules and restrictions, parents should constantly monitor their observance, providing appropriate rewards for successful implementation and consequences for inappropriate behavior. Positive reinforcement of rule-compliant behavior is a powerful tool that has no negative effects. Parents should try to minimize anger by insisting on compliance with the rules and increase positive contacts with the child ("praise the child when he/she is good").

Ineffective discipline can lead to behavioral problems. Yelling or physical punishment may control a child's behavior in the short term, but it can ultimately reduce the child's sense of security and self-esteem. Threats to abandon or send a child away are traumatic for the child.

A good way to address unacceptable behavior in a child is to use the "time-out" technique, which requires the child to sit for a short period of time alone in a quiet, boring place (a corner or room other than the child's bedroom that does not have a TV or toys, but which should not be dark or scary). "Time-outs" are a learning process for the child, and are best used for one or a small number of misbehaviors at a time.

The vicious circle mechanism can be broken if parents ignore the child's behavior that does not disturb others (for example, refusing to eat), and distract attention or temporarily isolate the child if his behavior cannot be ignored (public tantrums, outbursts of irritation).

If the behavior does not change within 3-4 months, the child should be re-evaluated to assess the problem; a mental health evaluation may be indicated.

"Time-out" method

This discipline method is best used when the child realizes that his or her behavior is wrong or unacceptable; it is not usually used with children under 2 years of age. It should be used with caution in a group setting, such as a daycare, as it may result in the child feeling humiliated.

This method is used when the child knows that his behavior leads to a “time-out,” but still does not correct it.

The child is explained the reasons for the punishment and told to go sit in the “time-out chair” or, if necessary, is taken there themselves.

A child should sit on a chair for 1 minute per year of life (maximum 5 minutes).

If the child gets up from the chair before the allotted time, he is returned to his place and the time is started again. If the child immediately gets up from the chair, it may be necessary to hold him (but not on your lap). In this case, avoid talking to the child and eye contact.

If the child remains sitting on the chair, but does not calm down for the entire allotted time, the time is started again.

When the time-out is over, the child is asked the reason for the punishment, avoiding anger and irritation. If the child cannot name it, he is briefly reminded of the correct reason.

Soon after the time-out, the child should be praised for good behavior, which is more easily achieved if the child is engaged in a different activity than the one for which he was punished.