The Doctor is in—

Questions and answers about behavioral and
emotional problems in children

D. RICHARD MARTINI, MD

aFall 1998

Positive reinforcement and consistency is the best approach to youngsters' problem behaviors

At the conclusion of a recent office visit, a mother complained that she was unable to control her 8-year-old son's behavior. He tended to be very oppositional and at times physically aggressive, particularly with his 6-year-old sister.

The parents have tried a variety of behavioral methods, including time outs and restriction of privileges. The mother was particularly upset at her husband's choice of corporal forms of punishment. She felt that these rarely worked, and that her son became more belligerent and almost provocative when faced with the threat of a spanking. She asked for any suggestions for her son. What would you suggest?

Dr. D. Richard Martini responds:

Positive reinforcement plans are much more likely to yield beneficial results than those based on criticism and confrontation. The goal is to focus on preferred behavior rather than on problems-to pay attention to positive rather than negative behaviors, which encourages children to improve. The parents should be supported as builders of self-image for their children, because no one plays a more important role. When criticism is necessary, parents should emphasize the behavior and not the children themselves. When they criticize their children, caregivers imply they don't like the youngsters, which leaves them feeling sad, hopeless and confused. Occasionally parents subtly criticize after praising their children, a tendency that should be avoided. For example, "You did a good job. Why can't you do that all of the time?"

Parental time is quite often the most positive and powerful of all reinforcers. The caregiver should make the time enjoyable and rewarding. Occasionally, parents get into the habit of using increased parental time as a form of punishment. For example, parents may respond to the children's poor grades by sitting with them and threatening to stay there all night until the homework gets done. Gradually these kinds of interactions cause children to dread contact with their parents.

Behavioral programming

Behavioral programming begins with a plan. The plan should be designed so that parents and their children see signs of success and are encouraged to continue working. In the same way that children are discouraged by failure, families and parents become disenchanted when their attempts at behavioral change are not productive. It is a good idea to begin with the parents and their children deciding together which problem they are working on and which reinforcer to use. The reinforcer must be a strong motivator. At times, the clinician may need to guide the parents to the most significant problem based on case history.

Along with the behavioral programming, it's important to assess the family's capabilities, including the parents' level of sophistication, and possible environmental factors. For example, families living in apartments where a screaming child is not well tolerated may be forced to act quickly.

Consistency also is crucial, especially when care must be coordinated among two or more family members. Individuals should share responsibilities and recognize that, although one caregiver may be more available than another, all should contribute. The skills that parents learn as they approach these problems are relevant to other situations and will last throughout youngsters' lives.

Parent management training can be seen as an attempt to wrestle control of children's behavior from the youngsters to the parents, and positive reinforcement makes this process easier and more effective. By being involved in the selection of target behaviors and reinforcers, children not only understand the program and who is participating but also own the process and are therefore more committed to its success.

Parents should let people know that their children are making good progress. This is the basis for the "star charts" that track youngsters' successes on a daily basis and are frequently stuck on refrigerators. Star charts occasionally draw the attention of other siblings, who may want to involve themselves in similar behavior programs to get similar rewards.

Consequences

There are always situations in which children's behavior (such as physical aggression) warrants consequences. As with the positive reinforcement plan, all caregivers in the family should agree on a plan in advance. Parents should not excessively punish a relatively small infraction with long-term consequences; the consequences should fit the infraction. For example, caregivers frequently ground children over extended periods of time for misbehavior. Unfortunately, it is then difficult to add consequences for infractions that occur while children are grounded, and the youngsters' behavior may deteriorate.

As with positive reinforcement programs, parents and caregivers must be consistent, should communicate, and should demonstrate that they are in agreement and in control of the situation. The clinician should identify a primary decision maker. Although many family members assist in child care and in some cases are the most important providers, most decisions should begin with the parents. Occasionally parents will relinquish control of behavioral decisions to another family member, and that decision should be clear early in the treatment process.

Consequences also should match the child's developmental level. For example, it is important that the consequences of problem behavior in younger children immediately follow their behavior so that the youngsters are more likely to make the connection between their action and what has happened. If the consequences are postponed until later in the day, the children are more likely to see them as arbitrary and punitive. After children are punished, the problem should not be mentioned again to avoid the appearance that they are being criticized a second time for a single infraction. This tends to occur in situations in which a daytime behavior is recounted when the other parent returns home.

Children often attempt to "divide and conquer" caregivers. They quickly recognize which of the two individuals is more likely to relent and will preferentially go to that caregiver with requests. Frequently, the other parent is completely unaware of the request or the response. The solution to these situations is active communication between parents, particularly in the presence of the child. Disagreements should wait until the adults are alone. As behavioral programs are constructed, particularly those that involve consequences, it is likely that the child's behavior will get worse before it gets better. Because the behavioral program is designed to wrestle control from the child to the parent, it is not surprising when youngsters are reluctant to cooperate and test their parents' mettle.

Time-out is a frequently used behavior consequence. The basis for the success of time-outs is the withdrawal of attention by the parent or caregiver to their children. Before using time-outs, parents should explain their purpose. The ideal time to do this is before a specific argument or problem is being addressed. For example, parents and their preschool children might sit together in the time-out room for three to five minutes with the timer going. Both get a sense of the discomfort and isolation that accompanies the intervention.

Time out is preceeded by a warning, giving the child an opportunity to change the behavior and avoid a consequence. Youngsters should not be getting time-outs in a room, like the living room, TV room, or kitchen, where there is heavy traffic and continued contact with parents and family members. Bedrooms are also not an appropriate place for time-outs, not only because a comfortable bed is available but also because a variety of games, reading materials, and audiovisual equipment are usually within easy access. Isolated rooms (such as a bathroom) with little available to entertain children are probably a much better place for time-outs.

Time-outs should be developmentally appropriate, particularly in length. The older the child is, the longer the time-outs can be. Preschool-aged children should not be in time-out longer than three to five minutes. If it is any longer, the consequence seems punitive, and the connection between the timeout and the inappropriate behavior is lost.

The doors of the time-out rooms may be open or closed depending upon the extent and severity of the problem. Children should be calm when leaving time-out even if that means taking advantage of brief moments when the youngsters become quiet.

An additional benefit of time-out is the separation of parents from their children after infractions. Frequently parents are upset after problematic behavior, and time-outs, even for a few minutes, allow them to collect their thoughts and respond appropriately.

Physical restraint should be avoided when using time-outs. Instead, parents may decide to punish children who refuse to comply with loss of privileges or possessions.

Corporal punishment

Corporal forms of punishment are a frequent topic of discussion in child psychiatry offices. It is generally agreed that physical forms of punishment work for short periods of time, usually through intimidation and fear. Sometimes families feel strongly about the likelihood of success, often because it has been a multi-generational practice. There are, however, basic problems with the use of corporal punishment. First, it models problem-solving behaviors that parents try to discourage, namely that in times of frustration or anger, physical aggression is the solution. Second, because of the anger and frustration in these situations, these feelings can inadvertently be expressed in ways that result in the injury of the child.

It is also difficult to corporally punish children in ways that match their infractions. Are parents, for example, always able to rationally choose to hit their children less for minor problems and more frequently or with more force when the rule breaking is serious? It seems a very arbitrary and dangerous process. In any case, parents have often complained that physical punishment loses its effect in a short period of time. Children scoff at their parents and may resort to the same forms of intimidation when they become old enough to resist physical overpowering.

Summary

Pediatricians should encourage behavior programming that emphasizes positive reinforcement and consistency when they attempt to treat youngsters with oppositional behaviors. If such behavioral programming is not successful, the case should be referred to a child and adolescent psychiatrist or psychologist.

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