Pediatric Behavioral Mental Health: Outpatient Behavior
Management Counseling by: Daniel O’Meara, Beverly Aiyanyor,
Brenna Chase, and Katelin Blackburn. Outpatient behavior
management counseling. If you're viewing this video, you may have
just had an encounter where a patient's caretakers have asked
you what to do to help calm their child when they have out
of control behaviors at home or in the community, such as
tantrums, aggression, or defiant behaviors. By the end of this
video, you should be able to describe common challenging
behaviors that may be encountered at various stages of
childhood and adolescence. Create a safe space for
children, adolescents, and their caretakers to share their
thoughts and concerns regarding challenging behaviors that occur
at home or in the community. Describe a framework for why
behavioral dysregulation occurs and a model for how it can be
approached. And lastly, incorporate de-escalation and
behavior modification strategies into routine well-child visits
for teaching parents these skills. What are common
challenging behaviors that may be encountered during childhood?
Let's describe them by stage of development. In childhood, some
of these behaviors may include tantrums, impulsive behaviors,
lying, aggression, and defiance. In adolescence, some of these
behaviors may include delinquency, bullying,
disruptive behavior at school, aggressive or violent behaviors,
substance use, and school absenteeism. Some of these
behaviors may be manifestations of underlying issues and warrant
further investigation, such as disruptive school behavior as a
sign of ADHD and school absenteeism as a sign of
difficulties in the home. Challenging behaviors that are
encountered in childhood or adolescence sometimes have the
risk of resulting in significant personal, social, academic, or
legal consequences. They can also be a source of a lot of
distress for family and friends. When discussing these behaviors
with caretakers remember that this may be a distressful topic
as they reflect on their individual experiences. They may
feel helpless that their child may be carrying out such
behaviors. It is important that you as a provider create a safe
space for caretakers to share their thoughts and concerns.
We're going to now discuss one model for creating a safe space
for patient families to share about a child's behavior. First,
start with permission. Ask the caretaker if they would be
alright with sharing more information about the concerning
behavior, and also sharing with you about how they're feeling in
regards to the behavior. Allow for moments of silence.
Secondly, focus your attention on what the caretaker is
expressing to you. Pause note taking and look at them as they
speak. Encourage them and remind them their child's behavior is
not a reflection of their parenting. Remind them that you
as their child's provider will partner with them in finding
resolutions. Lastly, thank them for taking the time to bring
their concerns to your attention. These steps are
important and ensuring the caretakers view you as allies
along the journey to helping their child grow into their full
potential. During these discussions, it is important to
uphold a non-judgmental attitude as caretakers oftentimes feel
stigmatized by some of these behaviors, especially when they
occur in public settings. When treating adolescents, it is
important to invite the adolescent to share their
perspectives. Adolescents may choose to respond to their
caretakers concerns automatically, and sometimes
they may only share their perspectives upon prompting.
Occasionally, only upon building rapport and creating a safe
space during a confidential social history with a parent
outside of the exam room will the young person feel
comfortable enough sharing their perspectives, so it is important
to speak to adolescents privately at each visit.
Conversations with young people and their caretakers may uncover
challenging situations at home or school, mood disorder
symptoms, or traumas that the young person has endured, which
may be serving as antecedents to the concerning behaviors. When
eliciting behavior frequency and intensity continuing a
non-judgmental approach allows for collaboration and
pinpointing certain areas to focus on for next steps. One
such approach includes asking about the antecedent or what was
happening around the person before the behavior occurred,
followed by the behavior itself, and then the consequences of
that behavior, including social rewards, avoidance of unpleasant
situations, or feeling a sense of relief. Knowing the
antecedents and consequences of a behavior can help you as a
provider come up with a plan to help guide the family and
patient towards understanding why a behavior is happening, and
ultimately how to move towards behavior change. Let's now focus
on one particularly challenging behavior, tantrums.
Understanding the science behind tantrums can inform how we
discuss behavior management with families. A temper tantrum, and
more broadly behavior dysregulation, primarily
involves two parts of the brain, the amygdala and the
hypothalamus. The amygdala regulates emotions and behavior,
plays a role in evaluating environmental stimuli to
determine their importance, and contributes to the formation of
particularly meaningful memories. The hypothalamus, on
the other hand, is crucial in the maintenance of homeostasis,
as well as fight or flight reactions, feeding, and sleep.
When presented with a given conflict, the amygdala acts as
the brain's smoke detector and the hypothalamus as someone deciding
whether to put gasoline or water on the fire by way of hormones
such as adrenaline and cortisol. The actions of these hormones
contributes to tachycardia, bronchodilation and arousal, and
also suppresses the function of the prefrontal cortex, a highly
developed area of the brain essential to impulse control,
behavior regulation, and insight into one's own and others
reactions. With a bit of logical self reflection, adults can hit
the brakes on a stress response. A driver who cuts us off on the
highway often will not bring us to a rational action because we
can pause for a moment, decide not to react and move forward
with our day. However, the prefrontal cortex doesn't fully
develop until adulthood. Therefore, we must support
parents in their efforts to calm their children with the
knowledge in mind that children are working with different
machinery altogether. Now let's discuss a framework for managing
behaviors that we can communicate to families. The
framework of advice we can offer families involves three main
steps, namely controlling their own emotions, managing the
emotions of their children, and validating their children's
feelings. First, parents must manage their own emotions.
Parents can leave the room to take a few deep breaths or
confide in a partner, whatever they need to de escalate their
own frustration. This intentionally allows parents to
use their own calm state to calm their child. The efficacy of
this technique may stem from mirror neurons which fire in
response to one's own and other's behaviors. When parents
regulate their own emotions and dispositions they can directly
affect the manner in which their children respond to the same
situation by watching their example. After regulating their
own emotions, a parent must manage their child's reaction.
To do this, caretakers can provide warm and empathetic cues
with their body posture, tone of voice, facial expressions, and
word choice to calm a child, which can quell the stress
response experienced by the child and mitigate the effects
on their actions. Crouching down and making eye contact with the
children during a tantrum or behavioral outbursts shows
parents are listening and engaged. Parents can also
encourage their child to self-soothe with other types of
calming sensory inputs, such as breathing exercises and squeeze
balls. It is important for parents to introduce these
coping behaviors before a meltdown hits so that children
can manage a tantrum on their own once it happens. There are
some children for whom the simple coping skills we've mentioned
might not be enough to support the family and patient
in managing their perceived problematic behaviors, including
some children who have developmental disabilities, or
diagnosed mood or attention disorders. In these cases, it is
sometimes helpful to refer families to receive
multidisciplinary support, including parent training,
therapy, and consideration of pharmacotherapy in the case of
diagnosed mood disorders, attention disorders, or PTSD.
Finally, parents must validate their child's feelings. As much
as parents might want to try explaining to their child why
they should calm down, behavior correction rarely works when
stress is high. Once a child's partially developed prefrontal
cortex is back online, parents can take the opportunity to help
them form a story about the tantrum and validate how hard
the moment was, and repeating back what happened. Now that we
have outlined the three basic steps to convey to parents,
including regulating their own emotions, managing their child's
emotions, and validating their child's feelings, let's discuss
specific tips that you can offer families to prevent, limit, and
de-escalate tantrums and other problematic behaviors. These
tips can be broadly applicable to children of all ages. We
recommend to parents that they take as many opportunities as
possible to give attention to their child's good behaviors, in
turn, reinforcing the behaviors that they want their child to
engage in. You might say, one way you can help shape your
child's behavior is to catch them doing good often, and
ideally much more frequently than you catch them doing bad.
Your attention is a precious reward to your children and by
noticing your child engaging in desired behaviors, like politely
greeting someone, or sharing their emotions with words rather
than violence, this acts as positive reinforcement for these
behaviors. In your practice, model this for parents by
providing genuine and specific praise for the children you care
for when you notice them engaging in a desirable
behavior. You could say you did such a wonderful job sharing
your crayons with your little sister, I can tell you really
care for your family and want to help out mommy, which is really
awesome. Good job. We can also offer parents tips for what to
do when behavioral escalation is already occurring. Caretakers
can give children control over little things by offering small
directed choices with options rather than yes no questions.
Provide a distraction, move to a new room, offer a safer toy or
game, play music or sing a song. Choose battles and accommodate
when reasonable and safe. Know the child's limits in terms of
accomplishing tasks. Sometimes we don't get to finish the to-do
list. Engage in active ignoring of negative, attention seeking
behaviors. Ignoring requires consistency from all caregivers
and depends upon all caregivers recognizing ahead of time
behaviors may worsen in the short term in order to be
successful. The key to ignoring is making sure to give children
positive attention as soon as the bad behavior stops. Like
saying, you're quiet now it looks like you're ready to play.
Do not ignore behaviors like hitting, kicking, biting, or
throwing. Have a zero tolerance policy for these behaviors. Set
children up for success. If tantrums or outbursts peak when
the child is hungry have a healthy snack available when
leaving the house. If tantrums peak when the child is fatigued,
prioritize sleep and naptime even if it causes activities to
be missed. Take a break when needed. Take turns with another
caregiver or friend when frustration escalates. Children
often feel that they are the only ones who have to, use your
manners, share, and take turns. Therefore, when adults share
point it out to a child, for example, daddy is sharing his
drink with mommy. Good job sharing daddy. As stated in the
three general steps, model ways to calm down. Teach children how
to calm down when they're upset or frustrated and express actual
feelings. For example, if frustrated about sitting in
traffic, one might say, mommy is really frustrated right now.
Please help me calm down by taking 10 deep breaths with me.
This practice teaches children to say what they feel instead of
making critical or hurtful statements or engaging in
physically dangerous behavior. As we come to the end of our
video, let's recap what we've discussed. In summary, the best
way to improve behavior is to give children more attention
when they are doing something desired by caretakers and to
remove attention when they're doing something caretakers do
not want. Consistency from day to day is key in reducing the
level of frequency of tantrums. children's brains are still
under development and effective behavior management requires
persistence, teamwork, and patience from caregivers and
pediatricians alike. As pediatricians, we can empower
caretakers to manage tantrums and challenging behaviors and in
healthy and effective way, not only to reduce their length and
frequency, but also to promote mutual trust and respect for all
members of the family. We hope this video has been useful to
you in growing your capacity to counsel families dealing with
challenging behaviors. As providers, we must be alert to
behaviors outside the range of typical requiring us to consider
the presence of a neurodevelopmental disability or
mental health disorder. We must also monitor for and provide
support for caretaker mental health concerns or family
stressors, which can impact a child's behavior. If behaviors
are particularly challenging to manage providers can refer the
family for consultation with a social worker, psychologist, or
developmental and behavioral pediatrician to discuss behavior
management strategies. By partnering with families and
providing support, empathy, and practical advice you can connect
with caretakers and patients in a meaningful way and positively
impact the future of children in your practice. Thank you for
watching our video.