Topic Resources
Some behaviors exhibited by children or adolescents may concern parents or other adults. Behaviors or behavioral patterns become clinically significant if they are frequent or persistent and maladaptive, for example, they interfere with emotional maturation or social and cognitive functioning. Severe behavioral problems may meet criteria for diagnosis of psychiatric disorders (eg, oppositional defiant disorder, conduct disorder).
Prevalence rates vary according to how behavioral problems are defined and measured.
(See also Health Care Issues in Adolescents.)
Evaluation of Behavioral Problems in Children
The evaluation of behavioral problems in children involves a multistep behavioral assessment.
Concerns regarding 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) tend to predominate.
Problem identification
A behavioral problem may manifest abruptly as a single incident (eg, setting a fire, fighting at school). More often, problems manifest gradually, and identification and characterization of the problem involves gathering information over time. Behavior is best assessed in the context of the child’s:
Physical and mental development
General health
Temperament
Relationships with parents (or caregivers)
Parents are interviewed by the clinician assessing the behavioral problem; interviews are usually conducted with the parents alone and also with the parent and child together. Parents are asked to describe the behavior, to determine about when the behavior started, and to provide examples of events that preceded and followed the specific behavior. Parents can provide a chronology of the child’s activities during a typical day. They are also asked about the child's birth, developmental, and health histories and any current medical issues, medications, or other treatments. They are also asked about the child and family's living situation and support and any social, emotional, or financial stressors on the child or family.
Parents are asked for their interpretation of the following:
Typical age-related behaviors
Expectations for the child
Their parenting style
The child's relationship with parents, family members, school or community members (eg, teachers, coaches, childcare providers, clergy), and peers
Direct observation of parent–child interactions during an office visit provides valuable information, including parental response to behaviors. These observations are supplemented, whenever possible, by information from others, including relatives, teachers, and other school staff.
Problem interpretation
The child’s history may include factors associated with an increased risk of developing behavioral problems, such as complications during pregnancy or birth; medical issues or treatments; exposure to toxins (eg, lead); psychosocial or financial stressors in the child's family or social determinants of health; or problems with behavior or academic performance in school.
Some problems may involve the parent–child relationship and can be interpreted in a number of ways (1):
Unrealistic parental expectations: For example, some parents may expect that a 2-year-old will pick up toys without help, which is a behavior that is more likely to appear over a year later. Parents may misinterpret other normal, age-related behaviors, such as oppositional behavior (eg, refusal of a 2-year-old to follow an adult’s request or rule) as abnormal.
Poor quality of parent–child interactions: For example, children of less attentive parents may have behavioral problems.
Over-indulgent parenting: Parental responses intended to help with a behavioral problem can sometimes make the problem worse by unintentionally reinforcing the behavior (eg, overprotecting a fearful, clinging child; giving in to a manipulative child).
Circular behavioral patterns: In young children, some problems represent a circular behavioral pattern in which a negative parental reaction to a child’s behavior causes an adverse response from the child, which in turn leads to continued negative parental reactions. In this pattern, children often respond to stress and emotional discomfort with stubbornness, back talk, aggressiveness, and outbursts of temper rather than with crying. If a parent reacts to an aggressive and resistant child by scolding, yelling, and spanking, the child may escalate the behaviors that led to the parent’s initial response, resulting in the parent reacting more forcefully. Attention that children receive from a parent for their inappropriate behavior often reinforces it.
In older children and adolescents, behavioral problems may arise as independence is sought from parental rules and supervision (see Psychosocial Development in Adolescents). Behavioral problems must be distinguished from normal adolescent behavior, which may include occasional errors in judgment.
Evaluation reference
1. Sege RD, Siegel BS; COUNCIL ON CHILD ABUSE AND NEGLECT; COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH. Effective Discipline to Raise Healthy Children [published correction appears in Pediatrics. 2019 Feb;143(2):e20183609. doi: 10.1542/peds.2018-3609.]. Pediatrics. 2018;142(6):e20183112. doi:10.1542/peds.2018-3112
Treatment of Behavioral Problems in Children
Treatment of medical or psychological issues
Education and strategies for parents
Once a behavioral problem has been identified and its etiology has been identified, early intervention is desirable because behaviors become more difficult to change with longer duration.
If general medical issues have been excluded, the clinician can reassure the parents that the child is physically well (ie, that the child’s behavior is not a manifestation of a general medical illness). By listening to and validating parental frustrations and providing education about the prevalence of behavioral problems, the clinician can often provide the parents with a broader understanding of the behavior and reduce parental guilt and anxiety. The clinician counsels parents about the available management options.
For simple problems, parental education, reassurance, and a few specific suggestions are often sufficient. Parents should be reminded of the importance of spending at least 15 to 20 minutes/day in a pleasurable activity with the child and calling attention to desirable behaviors when the child exhibits them (“catching the child being good”). For some parents, it is helpful to encourage they regularly spend time away from the child to help the child learn to be secure and also independent.
For some behavioral problems, however, parents benefit from additional strategies for disciplining children and modifying behavior:
Parents should identify triggers for the child's behavior and factors (eg, additional attention) that may inadvertently reinforce it.
Desired and undesired behavior should be clearly defined.
Parents should focus on the behavior itself and not equate it with the child (eg, "that was unacceptable behavior" vs "you're a bad person").
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 or undesired behavior.
Parents should try to minimize their anger when enforcing rules and maximize positive contact with the child.
Pearls & Pitfalls
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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 may eventually decrease the child’s sense of security and self-esteem. Threats to leave or send the child away are damaging; fulfilling threats is potentially abusive, whereas leaving them unfulfilled sends a message that they are empty and can be ignored. Scolding, threats, and physical punishment also teach the child that these reprimands are appropriate responses to situations that the child does not like.
A time-out technique, in which the child must sit alone in a place with few sources of stimulation or distraction (a corner or room [other than the child’s bedroom] that is not dark or scary and has no television, digital devices, or toys) for a brief period, is one approach to altering unacceptable behavior (1). Time-outs should be 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 that children have registered the reprimand for inappropriate behavior. Although there has been some controversy over inappropriate use of this technique, it can be one effective behavioral tool.
Time-Out Technique
A time-out is having the child spend a few minutes alone in a location with few sources of stimulation or distraction (a corner or room [other than the child’s bedroom] that is not dark or scary and has no television, digital devices, or toys). This disciplinary technique is best used when children are aware that their actions are inappropriate or unacceptable and when they perceive withholding of attention as a punishment; typically this is not the case until 2 years of age. Care should be taken when this technique is used with an individual child who is in a group setting (eg, day care, school) 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.
As soon as possible after the time-out, the caregiver should praise the child for an appropriate behavior, which may be easier to achieve if the child is redirected to a new activity far from the scene of the inappropriate behavior. |
A 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 (eg, public tantrums).
A behavioral problem that does not change in 3 to 4 months should be re-evaluated; more intensive behavioral management coaching or mental health consultation may then be indicated.
Treatment reference
1. Enneking B. Child Development—The Time-Out Controversy: Effective or Harmful? Indiana University School of Medicine. 2020.
