Dr Max Davie | Dr Mark Butler

Emotional and behavioural problems in children and young people are complex. Specialist assessments and treatments are time-consuming and increasingly hard to obtain… and the vast majority of children with these problems get nowhere near a psychologist or psychiatrist. They are looked after as best they can by teachers, doctors, nurses, family support workers, and above all parents. But the training of this informal workforce is inconsistent, and often messages are mixed and contradictory.

Any system needs to be built on the foundation of everyone who works with families knowing the basics, and being able to communicate consistent messages.

This is a huge and potentially overwhelming topic, a post such as this can only scratch the surface. Behavioural issues in children are a huge source of concern to families and this may be the primary reason you are seeing a child, but we also very frequently encounter behavioural concerns where they intersect with other difficulties, particularly around feeding and toileting. It can be tempting as general paediatrician to narrowly focus on medical/biological treatments and to shy away from the ‘behavioural’ side of things. However, by taking a broader view of the situation and looking more closely at the context we are much more likely to intervene effectively, with better results for the child and their family. This brief overview is intended to give you a framework to better understand issues in children and some practical tips on management.

In order to give useful advice, you need to be able to understand the family’s story, and help them make sense of it. These are complex problems, but it is a myth that you need to be a specialist to understand them.

The Theory

It is helpful to think a little more deeply about how we think about behavioural issues, an awareness of how you, parents, the child themselves and other professionals think about behaviour. It makes it easier to talk about the issues and explain differing approaches.

The ‘biological approach’ essentially considers behaviour in terms of neuro-biological correlates and then focuses on modifying those, usually with medication. This is of course an oversimplification, and insufficient to adequately understand the situation. However it is an attractive explanation and medics have often been complicit in perpetuating this.

The ‘psychological approach’ considers behaviour to be a manifestation of the choices of an individual. It implies that children are essentially similar, and that if they exercised sufficient effort would be able to behave in the desired manner. This belief though often well-meaning is quite prevalent in the education system and can lead to significant conflict when children, for whatever reason, struggle compared to their peers.

Biopsychosocial model

In 1977, George Engel argued that medicine in general, and psychiatry in particular, ought to shift from a bio-medical perspective of disease to a biopsychosocial perspective on health. That we cannot adequately understand health and disease without putting them in a wider context. Most of us are aware of the concept, but rarely consciously apply it in our day to day work.  There are various criticisms of the concept and alternative proposals, but it gives us a straightforward and practical way to break down the complex issues that confront us when dealing with behavioural issues and can help us see a way forward.

What can help is learn to think in a particular way. Paediatricians are trained to think about symptoms and signs, find a cause, and apply a treatment; but these situations just aren’t like that, and you need to adopt approaches from other disciplines.

If you asked a historian why the first world war happened, and she simply said ‘Franz Ferdinand got shot’ then you probably would not think much of her skills. Instead we would expect her to tell a story, firstly outlining the predisposing factors which made 1914 so combustible, describing the chain of events which led to (precipitated) the declaration of war in September, and then explain the factors that perpetuated the conflict and made it so devastating. A good historian would range across economic, political and military aspects to really give the story explanatory power.

In the same way, professionals need to create a story with families about how the child was predisposed to difficulties, how the difficulties were precipitated, and how they are being perpetuated.

To generate a compelling story you need to range over biological aspects, psychology (that is the child’s own thoughts and emotions), and their social context and interactions, both within the family and outside. This sounds complex, but most of it falls out when you apply your curiosity and common sense to some of these questions.

• What is the problem?
• How does the problem affect the child and family?
• Who is in the family? Are there other problems in the family?
• Has the child themselves suffered any adversity?
• How did the current difficulties start?
• What else was happening at the time?

Doctors reading this may have switched off a bit. This is standard medical history stuff. You can wake up now.

• Next ask: how do people respond to the problem?
• What do you think about the problem? What does the child think?
• What worries everyone most?
• What are you doing about it already?
• Are there any times when it gets better?

These deceptively simple questions, if pursued with follow up enquiries, will allow you to populate, either in your head or on paper, something that looks a bit like this.

The 4P Framework:

	Biological/ developmental	Psychological	Social
Predisposing factors
Precipitating factors
Perpetuating factors
Protective factors

You can then use the information you have to agree a story with the family about what is happening.

What is the purpose of this? Out of this story will fall useful interventions, and adaptations to your generic advice. The problem with generic advice on its own is that it treats people as if one size fitted all, which of course it doesn’t. By combining your own on-the-ground understanding of this family’s predicament with the evidenced advice, you can make a huge difference to families.

Let’s take a short example of this process:

Ahmed, 4, has a tantrum every night at bedtime. His health visitor has advised his mother to shut the bedroom door and ignore him, but it’s not working. The table below shows her 4P framework.

	Biological/ developmental	Psychological	Social
Predisposing factors	Preterm birth	Maternal anxiety
Precipitating factors		Break-up of parents’ relationship	Domestic violence
Perpetuating factors	Screen use (TV) in bedroom up till bedtime	Anxiety of mother	Mother unavailable due to depression
Protective factors	Healthy, good communicator	Good relationship with mother during the day	Family well-supported by grandparents

This leads to some simple, hopefully helpful interventions. You cannot change what has gone before, the predisposing and precipitating factors, but you can tackle the perpetuating factors and try and support and enhance protective factors. Minimise blame and stigma and be positive about the way forward:

• Stop screen time before bedtime
• Mother to seek counselling/ treatment for depression.
• Grandparents asked to help with domestic tasks so mother can spend time with Ahmed
• Gradual withdrawal of mother from bedroom at bedtime, following good ‘wind-down’.
• Please see our upcoming post on sleep problems for more details!

We hope that you can see that by adopting this narrative approach and combining it with generic advice (and a flexible approach to finding sources of support!) then you can achieve an awful lot for children and families. Of course this approach won’t work for everyone, but it’s always a good starting point, from which other interventions and assessments can build.

The following broad categories encompass the majority of behavioural issues that we encounter in children.

• Tantrums
• Aggression and violence
• Defiance and oppositional behaviour
• Hyperactivity
• Feeding
• Toileting
• Sleeping

Rather than focus on individual areas or behaviours, this post will discuss common themes and approaches. Future posts will look at specific areas in more detail.

Talking about behaviour

When talking about behavioural issues, especially when a child is present it is extremely easy to slip into a litany of complaints that read like a charge sheet. “He does this, he never does this, he once…“ The parent or carer often has not had much chance to speak to a professional about this and is keen to make sure you understand their concerns, but to the child it appears accusatory and unfair.

A good way to approach this is to ask for a description of a normal day, this ‘grounds’ the problem in the actual behaviours and limits judgements. It affords the child an opportunity to challenge or qualify the description. “Describe what happens between getting up and going to school” is often an incredibly revealing question. Other situations that can reveal a lot about what is going on include mealtimes and bed time, another revealing question can be about going to the supermarket, do you take them with you? What would happen if you did?  (the look on a parent’s face at that last question can give you an insight into the scale of the issue). Even if they are not the focus of concern it is worth gathering basic information about the household routine, discipline, bedtimes, screen usage etc

It is worth mentioning here the importance of avoiding blame. This does not mean there is an abdication of responsibility, but blaming anyone, child, parent, carer, other professionals is unhelpful. It may be relevant, but blame puts up barriers and prevents engagement, which is needed to make progress. Everyone must accept responsibility from their actions from here, but what is done, is done.

Parenting

Parenting is an enormous topic, impossible to cover in depth in a moderately long book never mind a FOAMEd post. It’s quite often said children don’t come with a manual, though a quick search of a famous internet bookshop gives 131,649 titles on parenting. There is a huge amount of literature, research, advice, opinion, comment, from a range of sources. The following principles of positive behaviour management have a degree of consensus behind them and a quite robust evidence base. You are not going to be an expert, but you can help get things going in the right direction. These strategies work, but they are not a quick fix, it is hard!

Key principles

Positivity – In order for behavioural management to be effective, it needs to be based on a ‘good enough’ relationship. At some level, the child needs to care about the parent’s feelings, and also feel good about themselves, to cope with the changes the parent wants. Promoting the emotional security of the relationship through shared activities is useful, so any shared activity is worthwhile, but play is paramount for younger children. Play led by the child for a short (10 minute) period is advised, but any play where the adult attention is on the child is useful. It is easy to get out of the habit of doing things together that the child enjoys. This may require a bit of outreach from a parent, losing a few games on the playstation might help lay the groundwork for much more.

‘Catching them being good’ and noticing when they have made small positive steps is a powerful tool.  Praise should be targeted; vague, general praise (aren’t you a good boy) has been shown to be worse than none at all, whereas specific praise (I like how you did X) is beneficial.

Responsivity – Much attention is focused on children’s screen time, but it is perhaps more important that parents limit the time they are unavailable to their children due to phone conversations, Facebook etc. Unlike most household tasks, these cannot be combined with conversation with the child. Parents must learn to distinguish between listening to the child respectfully and granting the child’s every wish, as learning to tolerate a degree of frustration is an important step in emotional development.  A parent should demonstrate specific reactions to behaviour, positive and negative, at the time of the behaviour, and this should be clear to the child.  This might also involve explicitly communicating to a child why you are not going to do anything, but the communication is the response. They should understand why a particular sanction or reward has or has not occurred and how their behaviour caused this. A purely “transactional” approach is unhelpful but within a framework of structure and positivity rewards are helpful to engage and motivate change.

Planning – It’s really important to know what you are trying to do, what do you want to achieve? SMART objectives are helpful, and consider what is meaningful at the child’s level. Don’t be excessively ambitious, start with a limited number of objectives, with positive structured rewards. Sanctions should be thought out and you have to be able to carry out.

Structure – There need to be rules, binding upon the adults and children. These need to be simple, unambiguous, and (initially) few, perhaps 2 or 3. These rules should specifically target unwanted behaviours (eg don’t hit, rather than be good). In addition to a logical structure when thinking about rewards and sanctions life in general needs to be structured. This can be a big challenge for many families but a regular routine helps children feel secure, and without a clear understanding of what is expected, behaviour is likely to continue to be a problem despite the best of intentions.

Consistency – Closely linked to structure, rules and expectations need to be the same across carers, across time and place, this is particularly a problem where several carers share responsibility at different times, for example where parents have separated. Rules cannot be dependent on parents’ moods or energy levels. Occasional rule lapses act as ‘intermittent reinforcement’, shown to be the single most powerful way to ensure that the behaviour that is being targeted continues with a vengeance.

Patience – All of this takes time! Often behaviours can become more extreme when these strategies are put in place, things get worse not better initially, and it make take some time to see meaningful change. Being prepared for this makes it easier.

As a professional you can model these principles, you may find yourself doing so with the parent as well as the child. You should embody positivity and responsivity without judgement or blame. Don’t focus on negatives and de-escalate. A focus on what has been achieved – not on the final endpoint – will help maintain momentum. “Don’t be cross she has not eaten her vegetables, focus on praise for sitting at the table and eating her sausages”

Behaviour is complicated and many of us do not frequently see patients presenting explicitly with behavioural issues, but anyone working with children will benefit from considering how they think about it and being able to give some practical advice.

Though most of us are aware of the biopsychosocial model of health and disease, it is not often foremost in our mind when considering our diagnosis and intervention and we probably would do well to remember it more frequently in our practice.

Learning points

• Behaviour is complicated! Break issues down: Bio- psycho- social

• Predisposing, precipitating, perpetuating, protective factors

• Describe, don’t judge.

• Use specific and concrete examples to understand what is going on

• Positive parenting works, but it is not easy and things will get worse before they get better

• Model these principles in consultation

Dr Max Davie, consultant Community Paediatrician, and Dr Mark Butler, Paediatric registrar

Significant portions of this post first appeared on the Paediatric Mental Health Association website: http://pmha-uk.org which is an essential resource for anyone with a particular interest in paediatric mental health, but also has great stuff for anyone working with children and young people.