A 5 year old girl named Sue is brought to the pediatrician's office with a chief complaint of temper tantrums. Her mother is frustrated and explains that Sue kicks and screams anytime she doesn't get her way. She sometimes swears and destroys things in her fits of rage. Two days ago she flailed her arms around while out of control and sustained a scratch on her forearm that bled. Her mother has tried yelling at Sue, spanking her on the buttocks, and embarrassing her in public. None of these techniques seem to work. In fact, her mother says that the harder she tries to control Sue, the worse she gets. This problem is causing difficulty especially between Sue's parents, as they don't agree on how to handle these tantrums. Sue's mother feels that they should take action immediately by confronting Sue and telling her that what she is doing is not acceptable. Sue's father would prefer to spank her several times on the buttocks and give her a lecture after sending her to her room for an hour or so. They openly disagree on how to discipline Sue, and Sue seems well aware of the difference in their parenting styles.

Exam: VS are normal. Height, weight and head circumference are at the 50th percentile. Sue is a well developed, well nourished attractive little girl in no acute distress. She comes in quietly with her mother and father and sits on the chair near her mother, looking up shyly at the examiner. No abnormalities can be identified on examination of HEENT, neck, heart, lungs, abdomen, and back. There is a healing 5 cm healing linear abrasion to her right forearm. There are multiple bruises to both anterior tibial surfaces at different stages of healing, with normal range of motion, no deformities and strength 5/5. Her neurological exam is intact.

Following this initial evaluation for temper tantrums, her mother and father return to the pediatrician weekly for the next eight weeks. They receive twenty minutes of instruction each time on behavioral problems, effective methods of discipline and child management. Her parents also keep a journal of specific instances when Sue becomes out of control and how they handle it. The tantrums become less and less frequent as time goes by and her parents become more relaxed and start to enjoy Sue again. By the end of the eight weeks, the tantrums have decreased from several times per day to once or twice per week. The tantrums are also less severe than they used to be and the recovery time is much shorter. Sue's mother and father are pleased with the results and are encouraged to return in the future if they need to discuss Sue's behavior again.

Some children seem to get through childhood without many problems at all and others seem to have an unusual amount of difficulty. Parents are often puzzled as to why their children do not behave or listen while their friend's children seem to be perfect angels. Some of the most common behavioral problems in children include temper tantrums, not following directions, whining, fighting with siblings or other children, breaking rules and talking back. Fortunately there is hope in dealing with everyday discipline problems using methods that are effective and easy to learn.

Parents have the ability to shape their children's behavior towards both good and bad results. All behaviors are shaped by rewards that are given to them. A common mistake that parents make is to accidentally reward their children's bad behavior. Four year old Jack gets to eat ice cream before dinner. He has been whining and begging for the ice cream long enough that his mother gives it to him so she can finish preparing dinner. Unfortunately, by rewarding bad behavior it is often strengthened. On the other hand behavior that is not rewarded, but instead punished, will often weaken and therefore decrease (1).

Developmentally, it is expected that young children will have a difficult time controlling their emotions, particularly if tired, hungry or stressed. Toddlers and preschoolers often lack the self-control necessary to express anger and other unpleasant emotions peacefully. When this happens it is important for the child's caregiver to be able to provide him or her with the support to deal with these difficult and uncomfortable feelings. Children learn a lot through their parents' modeling of behaviors and this is the main reason for parents needing to be most in control when their children are feeling out of control. If a father or mother joins the child in an uncontrollable emotional state, the situation will likely worsen because the child will feel less safe and more out of control (2).

Luckily for their parents, most children want to please their parents. Parents can therefore use this to their advantage when deciding how to discipline children. When a parent shows joy for a behavior that is good, the child will be positively reinforced for doing this behavior. On the other hand if a parent shows disapproval for a behavior, the child is less likely to repeat this behavior given the basic principle that children want to please their parents (3).

Discipline is the system in which parents guide and teach their children. This word is often confused with the term punishment. The purpose of discipline is to teach children the difference between right and wrong, to tolerate delayed gratification and to incorporate a sense of limits and appropriate behavior. Teaching discipline is a challenging task for parents and caregivers and not one that is taught overnight. It takes many years for most children to be able to achieve self-control. Also, as children grow and develop, so do the types of things that they must be taught. The method of discipline must grow and change with the child. Caregivers need to be flexible because of changes in children and their environment as children mature and grow (4).

Do's and Don'ts: Three Good Child-Rearing Rules to Keep in Mind

1) Reward good behavior and do it quickly and often. A child's good behavior will be positively reinforced and therefore strengthened when they receive a reward from a caregiver. Social rewards are the most effective rewards and include smiles, hugs, kisses, words or praise, eye contact and attention. Other rewards include activity rewards such as going to the park or helping to bake cookies and material rewards like ice cream, money or a compact disc. Social rewards are the most powerful, easiest to give and least expensive. The other types of rewards should be used less often. It is important for parents to remember that they are the most important reward for their children. It is very important to keep in mind that especially in younger children rewards need to immediately follow the behavior.

2) Avoid accidentally rewarding bad behavior. This will strengthen the bad behavior and is a very easy trap for parents to fall into. One example is when a child whines to get their parents attention. If a parent gives the child attention while they are whining, even if this attention is to yell at their child, it will act to reward the bad behavior of whining. Parents are very prone to making this mistake, especially if preoccupied with another activity like making dinner, talking on the phone or having a long day.

3) Punish some bad behavior by using mild punishment. Examples of mild punishment include time-out, scolding, natural consequences and logical consequences.

Time out is a very effective form of mild punishment. Time-out literally means time-out from all the things the child enjoys, for example - rewards, parent's attention, reinforcement, toys, music and all other interesting activities. Time-out has two major goals. The immediate goal is the stop the problem behavior as quickly as possible and the long-term goal is to help the child learn self-discipline. The good thing about time-out is that it does not emotionally harm the child and it models calm and good behavior on the parent's part. Time-out works best with children age two to twelve. This method should be considered with certain types of behaviors including impulsive, aggressive, hostile and emotional behaviors. Time-out does not work to get a child to begin doing a behavior, but it is very effective in stopping bad behaviors.

Time-out can be used initially with one or two target behaviors and once the parent and child get used to the technique it can be expanded to more problem behaviors. Getting started with time-out should occur after caregivers agree on this as a form of mild punishment. It should then be explained to the child before it is initially used so the child can understand what to expect the first time it is used. The child should immediately be placed in a very boring and safe predetermined location using up to ten words in less than ten seconds from the time the target behavior occurred. The child should be placed in time-out for one minute for every year of life (for example a five year old would sit in time out for five minutes) up to a maximum of about 10 minutes. A small portable timer should always be used to remind the child when the time-out is over. Once the timer rings the child will be asked why they went to time-out. Once they produce the answer the parent drops the issue and goes about their daily activities as usual. Time-out is not designed to make a child feel bad or humiliated.

Scolding is a common form of mild punishment used by parents. When scolding a child for bad behavior it is important to move close to the child, maintaining good eye contact, being stern, and expressing your feelings while naming the undesirable behavior. It is important to be brief and calm, showing disapproval for the behavior not the child. Another type of mild punishment is natural consequences. This is an event that would naturally occur after a child does a bad behavior. Some examples include not wearing an appropriate outfit to school and getting sent to the principal's office or being careless in not packing a lunch and being hungry at lunchtime. Logical consequences occur for behaviors that do not have natural consequences. Some examples include not eating all of your dinner and then not having any dessert; or riding the bicycle in the street and having the bike taken away for three days (1).

There are several ways in which parents can accidentally increase bad behaviors or decrease good behaviors. Once parents become aware of these common mistakes, avoiding them will be easier and promote a healthier parenting style. These errors include failing to reward good behavior, accidentally punishing good behavior, accidentally rewarding bad behavior and failing to punish bad behavior. A parent can fail to reward good behavior by not praising or recognizing that their child cleaned their room or brought home a great report card. Parents accidentally punish good behaviors by not being satisfied with a job well done and commenting that they could have done more or better. Some parents accidentally reward bad behavior by giving in to child who is whining and making unreasonable demands. Finally, parents can fail to punish bad behavior by ignoring it and saying something like "Oh well, boys will be boys" (1).

Common behavioral problems are challenges that all parents and caregivers face. Some caregivers have more difficulty than others in managing their children. Parents will often come to the pediatrician with questions about behavioral problems. It is important to listen to these parents, take them seriously and offer suggestions as to how some of these problems can be remedied. It is essential to praise the parents for the things that they are doing correctly and gently try to shape some of the less helpful things that they are doing in a positive way. Most children will show great improvements if the strategies in this chapter are followed. For those children with more serious behavioral problems, these strategies may not be enough and this is when the pediatrician may consider referral to a psychiatrist, psychologist or other behaviorally astute professional.

Questions

1. Which statement about solving child behavioral problems is FALSE:
. . . . a. Toddlers and preschoolers often lack the self-control necessary to express anger and other unpleasant emotions peacefully.
. . . . b. Children learn a lot through their parents' modeling of behaviors.
. . . . c. Most children want to please their parents.
. . . . d. Discipline is analogous to punishment.
. . . . e. It takes many years for most children to be able to achieve self-control.

2. What is a TRUE statement about time outs?
. . . . a. A good time out is when the parent praises the child outside of the child's playgroup.
. . . . b. A terrific place to have a time out is the child's room.
. . . . c. This method should be considered with certain types of behaviors including impulsive, aggressive, hostile and emotional behaviors.
. . . . d. Time-out works to get a child to begin doing a behavior.
. . . . e. A good rule of thumb is to use five minutes of time out per year of age (for example 25 minutes for a five year old).

3. Which of the following has as an example, not eating all of your dinner and then not having any dessert?
. . . . a. Time-out.
. . . . b. Triggering.
. . . . c. Scolding.
. . . . d. Natural consequences.
. . . . e. Logical consequences.

4. Which of the following is an error in parent behavior when disciplining a child?
. . . . a. Failing to reward good behavior.
. . . . b. Accidentally punishing good behavior.
. . . . c. Accidentally rewarding bad behavior.
. . . . d. Failing to punish bad behavior.
. . . . e. All are errors to avoid.

5. How could Sue's parent (case example) have better handled each error that they made?

6. Name three important child-rearing rules.

7. How does a parent successfully use time out? Name all the important steps?

8. What is the role of the pediatrician in helping parents with common behavioral problems?

9. When should a pediatrician refer a patient for more specialized evaluation of behavioral problems?

References

1. Clark L. SOS Help for Parents: A Practical Guide for Handling Common Everyday Behavior Problems. 1996, Bowling Green, KY: Parents Press.

2. Shelov SP, Hanneman RE. The American Academy of Pediatrics Complete and Authoritative Guide, Caring for your Baby and Young Child Birth to Age 5. 1998, New York: Bantam Books, pp. 507-518.

3. American Academy of Child and Adolescent Psychiatry, Facts for Families, No. 43 1995, Washington, DC: AACAP.

4. Pruitt DB. (The American Academy of Child and Adolescent Psychiatry). Your Child, What Every Parent Needs to Know About Childhood Development from Birth to Preadolescence. 1998, New York: HarperCollins, pp. 69-70.

Answers to questions

1.d, 2.c, 3.e, 4.e

5. Sue's parents could have used time-out to manage her bad behaviors. Since Sue is five she would have been placed in time-out for five minutes (one minute for each year of life). Spanking is chosen as a method of punishment by some parents and if this is the case it should only be one time on the buttocks and not intended to cause excess pain or injury. Parents should discuss their discipline styles behind closed doors and provide a united front with their children.

6. Reward good behavior and do it quickly and often. Avoid accidentally rewarding bad behavior. Punish some bad behavior by using mild punishment.

7. Time-out can be used initially with one or two targeted behaviors and once the parent and child get used to the technique, it can be expanded to more problem behaviors. Getting started with time-out should occur after caregivers agree on this as a form of mild punishment. It should then be explained to the child before it is initially used so the child can understand what to expect the first time it is used. The child should immediately be placed in a very boring and safe predetermined location using up to ten words in less than ten seconds from the time the target behavior occurred. The child should be placed in time-out for one minute for every year of life (for example a five year old would sit in time out for five minutes) up to a maximum of about 10 minutes. A small portable timer should always be used to remind the child when the time-out is over. Once the timer rings the child will be asked why they went to time-out. Once they produce the answer, the parent drops the issue and goes about their daily activities as usual. Time-out is not designed to make a child feel bad or humiliated.

8. Pediatricians should be available to offer counseling on routine visits with their patients. When the pediatrician observes bad behaviors in the office they should observe how the parent handles them and offer advice in a nonjudgmental way if they note errors. Pediatricians may also provide tips on effective parenting when the child is very young and be particularly sensitive to the needs of first time parents who may not know the correct way to discipline. One good way to find out how a parent is likely to discipline, is to ask them how they were disciplined as a child and the pediatrician can adjust their advice accordingly. It is very important to remain nonjudgmental and calm as you describe these techniques, as you don't want to add additional stress to a parent who is already taking on a very difficult task of raising a child. Be compassionate, listen and gently advise.

9. A pediatrician would likely want to advise a parent to see a specialist like a child psychiatrist or child psychologist if the problem seems to be more then they can handle. Some of these behaviors include extreme aggression and violence or if the child is engaging in dangerous behaviors. If the child is threatening or tying to hurt or kill themselves or others, this needs to be taken very seriously. The pediatrician will need to clinically assess the situation and decide if an emergency room visit is warranted. Threats of self-harm or harm to others should always be considered as a potential emergency.