Many behaviors exhibited by children or adolescents concern parents or other adults. Behaviors or behavioral patterns become clinically significant if they are frequent or persistent and maladaptive (eg, interfere with emotional maturation or social and cognitive functioning). Severe behavioral problems may be classified as mental disorders (eg, oppositional defiant disorder [see Mental Disorders in Children and Adolescents: Oppositional Defiant Disorder], conduct disorder [see Mental Disorders in Children and Adolescents: Conduct Disorder]). Prevalence rates vary according to how behavioral problems are defined and measured.

Evaluation

Diagnosis consists of a multistep behavioral assessment. Concerns with infants and young children often involve bodily functions (eg, eating, eliminating, sleeping), whereas in older children and adolescents interpersonal behavioral concerns (eg, activity level, disobedience, aggression) predominate.

Problem identification

A behavioral problem may manifest alarmingly and abruptly as a single incident (eg, setting a fire, fighting at school). More often, problems manifest gradually, and identification involves gathering information over time. Behavior is best assessed in the context of the child's

• Physical and mental development
• General health
• Temperament (eg, difficult, easygoing)
• Relationships with parents and caregivers

Direct observation of parent-child interaction during an office visit provides valuable clues, including parental response to behaviors. These observations are supplemented, whenever possible, by information from others, including relatives, teachers, and school nurses.

Interviewing parents or caregivers provides a chronology of the child's activities during a typical day. Parents are asked to provide examples of events that precede and follow the specific behavior. Parents also are asked for their interpretation of

• Typical age-related behaviors
• Expectations for the child
• Their parenting style
• Support (eg, social, emotional, financial) for fulfilling their parenting role
• The child's relationship with the rest of the family

Problem interpretation

The child's history may include factors thought to increase the likelihood of developing behavioral problems, such as exposure to toxins, complications during pregnancy, or occurrence of a serious illness or death in the family.

Some problems may involve the parent-child relationship and can be interpreted in a number of ways:

• Unrealistic parental expectations: For example, some parents may expect that a 2-yr-old will pick up toys without help. Parents may misinterpret other normal, age-related behaviors, such as oppositional behavior (eg, refusal of a 2-yr old to follow an adult's request or rule) as problematic.
• Poor quality of parent-child interactions: For example, children of less attentive parents may have behavioral problems.
• Over-indulgent parenting: Well-meaning parental reactions to a problem may worsen it (eg, overprotecting a fearful, clinging child, giving in to a manipulative child).
• Circular behavioral pattern: In young children, some problems represent a circular behavioral pattern in which negative parental reaction to a child's behavior causes an adverse response from the child, which in turn leads to continued negative parental reaction. In this pattern, children often respond to stress and emotional discomfort with stubbornness, back talk, aggressiveness, and temper outbursts rather than with crying. Most commonly, a parent reacts to an aggressive and resistant child by scolding, yelling, and spanking; the child then escalates the behaviors that led to the parent's initial response, and the parent reacts more forcefully.

In older children and adolescents, behavioral problems may arise as independence is sought from parental rules and supervision. Such problems must be distinguished from occasional errors in judgment.

Treatment

Once a behavioral problem has been identified and its etiology has been investigated, early intervention is desirable because behaviors are more difficult to change the longer they exist.

The clinician reassures parents that the child is physically well (ie, that the child's misbehavior is not a manifestation of physical illness). By identifying with parental frustrations and pointing out the prevalence of behavioral problems, the clinician often can allay parental guilt and facilitate exploration of possible sources and treatment of problems. For simple problems, parental education, reassurance, and a few specific suggestions often are sufficient. Parents should be reminded of the importance of spending at least 15 to 20 min/day in a pleasurable activity with the child and to calling attention to desirable behaviors when the child exhibits them (“catching the child being good”). Parents also can be encouraged to regularly spend time away from the child.

For some problems, however, parents benefit from additional strategies for disciplining children and modifying behavior.

• Parents can limit the child's dependency-seeking and manipulative behavior so that mutual respect is reestablished.
• Desired and undesired behavior should be clearly defined.
• Consistent rules and limits should be established.
• Parents need to track compliance on an ongoing basis and provide appropriate rewards for success and consequences for inappropriate behavior.
• Parents should try to minimize anger when enforcing rules and increase positive contact with the child.

Pearls & Pitfalls Positive reinforcement for appropriate behavior is a powerful tool with no adverse effects.

Helping parents to understand that “discipline” implies structure and not just punishment allows them to provide the structure and clear expectations that children need. Ineffective discipline may result in inappropriate behavior. Scolding or physical punishment may briefly control a child's behavior but eventually may decrease the child's sense of security and self-esteem. Threats to leave or send the child away are damaging.

A time-out technique (see Table 1: Behavioral Concerns and Problems in Children: Time-Out Technique), in which the child must sit alone in a dull place (a corner or room [other than the child's bedroom] that is not dark or scary and has no television or toys) for a brief period, is a good approach to altering unacceptable behavior. Time-outs are learning processes for the child and are best used for one inappropriate behavior or a few at one time. Physical restraint should be avoided. For children who escalate in the intensity of their reactions when put in time-out, parents may prefer to move more rapidly to redirection once they recognize the children have registered the reprimand for inappropriate behavior.

Table 1
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Time-Out Technique This disciplinary technique is best used when children are aware that their actions are incorrect or unacceptable and when they perceive withholding of attention as a punishment; typically this is not the case until age 2 yr. Care should be taken when this technique is used in group settings like day care because it can result in harmful humiliation. The technique can be applied when a child misbehaves in a way that is known to result in a time-out. Usually, verbal reprimands and reminders should precede the time-out. The misbehavior is explained to the child, who is told to sit in the time-out chair or is led there if necessary. The child should sit in the chair 1 min for each year of age (maximum, 5 min). A child who gets up from the chair before the allotted time is returned to the chair, and the time-out is restarted. Talking and eye contact are avoided. When it is time for the child to get up, the caregiver asks the reason for the time-out without anger and nagging. A child who does not recall the correct reason is briefly reminded. The child does not need to express remorse for the inappropriate behavior as long as it is clear that the child understands the reason for the time-out. As soon as possible after the time-out, the caregiver should praise the child's good behavior, which may be easier to achieve if the child is redirected to a new activity far from the scene of the inappropriate behavior.

The circular behavioral pattern may be interrupted if parents ignore behavior that does not disturb others (eg, refusal to eat) and use distraction or temporary isolation to limit behavior that cannot be ignored (public tantrums).

A behavioral problem that does not change in 3 to 4 mo should be reevaluated; mental health consultation may be indicated.

Last full review/revision March 2013 by Stephen Brian Sulkes, MD