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Overview of Behavioral Problems in Children

By

Stephen Brian Sulkes

, MD, Golisano Children’s Hospital at Strong, University of Rochester School of Medicine and Dentistry

Last full review/revision Mar 2020| Content last modified Mar 2020
Click here for the Professional Version

Children acquire many skills as they grow. Some skills, such as controlling urine and stool, depend mainly on the level of maturity of the child's nerves and brain. Others, such as behaving appropriately at home and in school, are the result of a complicated interaction between the child's physical and intellectual (cognitive) development, health, temperament, and relationships with parents, teachers, and caregivers (see also Childhood Development). Other behaviors, such as thumb sucking, develop when children look for ways to help themselves cope with stress. Still other behaviors develop in response to parenting style.

Behavioral problems can become so troublesome that they threaten normal relationships between the child and others or interfere with emotional, social, and intellectual development. Some behavioral problems include

Many of these problems arise out of developmentally normal habits that children easily acquire.

Some behavioral problems, such as bed-wetting (see Urinary Incontinence in Children), can be mild and resolve quickly and spontaneously as part of normal development. Other behavioral problems, such as those that arise in children with attention-deficit/hyperactivity disorder (ADHD), can require ongoing treatment.

Stress-Related Behaviors in Children

Each child handles stress differently. Certain behaviors that help children deal with stress include thumb sucking, nail biting, and, sometimes, head banging.

Thumb sucking

Thumb sucking (or sucking a pacifier) is a normal part of early childhood, and most children stop by the time they are 1 or 2 years old, but some continue into their school-age years. Occasional thumb sucking is normal at times of stress, but habitual sucking past the age of about 5 can alter the shape of the roof of the mouth, cause misalignment of teeth, and lead to teasing from other children. Occasionally, persistent thumb sucking can be the sign of an underlying emotional disorder.

All children eventually stop thumb sucking. Parents should intervene only if their child’s dentist advises them to or if they feel their child’s thumb sucking is socially unhealthy. Parents need to gently encourage the child to understand why it would be good to stop. Once the child signals a willingness to stop, gentle verbal reminders are a good start. These can be followed by symbolic rewards put directly on the thumb, such as a colored bandage, fingernail polish, or a star drawn with a nontoxic colored marker. Additional measures, such as a plastic guard over the thumb, overnight elbow splinting to prevent a child from bending it, or painting the thumbnail with a bitter substance can be used. However, none of these measures should be used against the child’s will.

Nail biting

Nail biting is a common problem among young children. The habit usually disappears as the child gets older but is typically related to stress and anxiety. Children who are motivated to stop can be taught to substitute other habits (for example, twirling a pencil). A reward system in which the child keeps more rewards for avoiding the behavior reinforces desirable behavior. For instance, the child is given 10 pennies in the morning, and in the evening must return 1 penny for each nail that is bitten over the course of the day.

Head banging and rhythmic rocking

Head banging and rhythmic rocking are common among healthy toddlers. Although alarming to parents, the children do not seem to be in distress and actually seem to derive comfort from these behaviors.

Children usually outgrow rocking, rolling, and head banging between 18 months and 2 years of age, but repetitive actions sometimes still occur in older children and adolescents.

Children with autism and certain other developmental problems also may bang their head or make other repetitive movements. However, these children have additional symptoms that make their diagnosis apparent.

Although children almost never damage themselves by these behaviors, this possibility (and the noise) can be reduced by pulling the crib away from the wall, taking off the wheels or placing carpet protectors under them, and applying padding to the bars of the crib.

Behavioral Problems and Parenting Style

Praise and reward can reinforce good behavior. If parents are very busy, they may give their children attention only for negative behavior, which can backfire when that is the only attention the children receive. Because most children prefer attention for inappropriate behavior to no attention at all, parents should create special times each day for pleasant interactions with their children to avoid increases in inappropriate behavior.

A number of relatively minor problems of behavior may be due to parenting styles.

Child–parent interaction problems are difficulties in the relationship between children and their parents, which may begin during the first few months of life. The relationship may be strained because of

  • A difficult pregnancy or delivery

  • Postpartum depression affecting the mother

  • Inadequate support of the mother by the other parent, partner, relatives, or friends

  • Disinterested parents

Contributing to the strain of building a strong relationship are a baby’s unpredictable feeding and sleeping schedules. Most babies do not sleep through the night until 3 to 4 months of age. Poor relationships may slow development of mental and social skills and cause failure to thrive.

A doctor or nurse can discuss the temperament of an individual baby and offer the parents information on the development of babies and helpful tips for coping. The parents may then be able to develop more realistic expectations, accept their feelings of guilt and conflict as normal, and try to rebuild a healthy relationship. If the relationship is not repaired, the baby may continue to have problems later.

Unrealistic expectations contribute to the perception of behavioral problems. For example, parents who expect a 2-year-old child to pick up toys without help may mistakenly feel there is a behavioral problem. Parents may misinterpret other normal, age-related behaviors of a 2-year-old child, such as the refusal to follow an adult’s request or rule.

A self-perpetuating cycle is a cycle of negative (inappropriate) behavior by the child that causes a negative (angry) response from the parent or caregiver, followed by further negative behavior by the child, leading to a further negative response from the parent. Self-perpetuating cycles usually begin when a child is aggressive and resistant. The parents or caregivers respond by scolding, yelling, and spanking. Self-perpetuating cycles also may result when parents react to a fearful, clinging, or manipulative child with overprotection and overpermissiveness.

The self-perpetuating cycle may be broken if parents learn to ignore inappropriate behavior that does not negatively affect others, such as temper tantrums or refusals to eat. Redirecting the child's attention to interesting activities allows for the rewarding of good behavior, which makes the child and parents feel successful. For behavior that cannot be ignored, distraction or a time-out technique can be tried.

Discipline problems are inappropriate behaviors that develop when structure is ineffective. Discipline is more than just punishment. It is providing children with clear, structured, age-appropriate expectations that allow them to know what is expected. It is much easier and more satisfying to both parents and children to reward desirable behavior than to punish inappropriate behavior.

In older children and adolescents, behavioral problems may arise as children seek to free themselves from parental rules and supervision (see Behavioral Problems in Adolescents). Parents should learn how to distinguish such problems from occasional errors in judgment.

Treatment

  • Early intervention

  • Behavior-modifying strategies for parents

The goal of treatment is to change undesirable habits by getting children to want to change their behavior. This goal often takes persistent changes in actions by the parents, which in turn results in improved behaviors by the children.

Behavioral problems need to be addressed early because behaviors are harder to change the longer they exist. Sometimes, parents need only to be reassured that the particular behavior is normal or to hear a few simple suggestions. One simple suggestion is for parents to spend at least 15 to 20 minutes a day in a pleasurable activity with the child or to call attention to desirable behaviors (“catching the child being good”). Parents are also encouraged to regularly spend time away from the child.

Additional strategies for modifying behavior include the following:

  • Identifying triggers for the child's behavior and factors (such as additional attention) that may inadvertently reinforce it

  • Clearly defining for the child which behaviors are desired and which are undesired

  • Establishing consistent rules and limits

  • Tracking how well the rules and limits are followed

  • Providing appropriate rewards for success and consequences for inappropriate behavior

  • Minimizing anger when enforcing rules and increasing positive interactions with the child

Efforts to control a child’s behavior through scolding or physical punishments such as spanking may work briefly if used sparingly. However, these approaches generally tend not to alter the inappropriate behavior sufficiently and may reduce the child’s sense of security and self-esteem. Moreover, spanking can get out of hand when the parent is angry and may send the child the message that physical aggression is an acceptable way to deal with undesirable situations. A time-out procedure can be helpful. However, punishments become ineffective when overused or used inconsistently. Furthermore, threats that the parents will leave or send the child away can be psychologically damaging.

If a behavior problem does not change in 3 to 4 months, doctors may recommend a mental health evaluation.

The time-out technique

This disciplinary technique is best used when children are aware that their actions are incorrect or unacceptable and when they see withholding of attention as a punishment. Typically, children do not understand that withholding attention is a punishment linked to undesirable behavior until they are 2 years old. Care should be taken when this technique is used in group settings such as day care centers 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, the child should receive verbal statements and reminders before the time-out technique is used.

  • The inappropriate behavior 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 for 1 minute for each year of age (a maximum of 5 minutes). Physical restraints should be avoided.

  • 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 make an effort to identify good behavior and praise the child for it. Good behavior may be easier to achieve if the child is redirected to a new activity far from the scene of the inappropriate behavior.

Sometimes, a child's inappropriate behavior escalates when the child is in a time-out. In such cases, the caregiver may want to redirect the child to another activity before the full time has run out. Redirections should be done only after the child understands why the time-out had been given.

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