21. Parenting tips: Helping preschoolers with Dr. Joyce Harrison

 Parenting young children with behavioral outbursts can be very challenging. Dr. Joyce Harrison, early childhood psychiatrist from Kennedy Krieger / Johns Hopkins shares practical parenting tips and referral resources for families of young children.

**What parenting tips could pediatric clinicians share with parents of preschool-aged children?

o   Stay calm

o   Positive instructions; tell what they SHOULD be doing; + instead of “stop”

o   Catch them doing something good/right thing; PRAISE

o   Ignore negative behaviors

o   Consequences in the moment – be consistent, avoid idle threats

o   Child centered time, money in the bank ($) = TIME IN

o   Practice Effective Time outs 

o   Parents need time outs, too

** Any resources that you could recommend for pediatricians to help them take care of preschool-aged kids w/ behavioral problems?

1. Statewide child psychiatry access phone hotlines/ Pediatric mental health case access programs can help you find resources for young children in your area
2. Local AAP chapter may also know about local resources
3. The national AAP offers Early Childhood ECHOs for education
4. The AAP sells their Toolkit for managing BEP in kids younger than 5

About Dr. Joyce Harrison: 

·       Associate Professor of Child and Adolescent Psychiatry at Johns Hopkins University School of Medicine and Faculty at the Kennedy Krieger Institute

·       Previous and first Medical director of Maryland Behavioral Health Integration in Pediatric Primary Care program (CPAP)

·       Project director for Kennedy Krieger Institute’s Early Childhood ECHO programs

·       Co-chair of AACAPs Infant and Preschool Committee

Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds

Transcript

Dr. Elise Fallucco: 0:21

Welcome back to psyched for paeds, the child mental health podcast for pediatric clinicians, helping you help kids. I'm your host, Dr. Elise Fallucco child psychiatrist and mom. Today, we're continuing the conversation with Dr. Joyce Harrison, who is an incredible clinician and child and adolescent psychiatrist who specializes in working with very young kids, infants, toddlers, and preschoolers with emotional and behavioral problems. Dr. Harrison works at the Kennedy Krieger Institute affiliated with Johns Hopkins. She brings her experiences as both a clinician and a parent to bear and giving advice about parenting. So we're going to be talking today about two main things. First Dr. Harrison is going to share some parenting tips for parents who are working with preschool aged kids. And honestly, I think a lot of these tips are helpful for kids of all ages. And after we talk about parenting we'll shift and talk about how pediatric clinicians can find referral resources for very young kids who need further evaluation and treatment. So jumping right back into it. Dr. Joyce Harrison, given your decades of experience in working with very young kids, what advice can you give pediatricians that they can share with parents about how to help kids who are having meltdowns and behavior problems?

Dr. Joyce Harrison: 1:36

The thing to always remember is just stay calm. Just modeling calmness is a really good thing for the parent because, you know, this, this child is setting everybody off and that just really escalates the situation. What's interesting is that parenting skills do not come naturally to some people and, I see this in my own family. I'm like, you said what? One of the things that I see all the time is that. You hear a parent say, stop that. Don't do that. That does not help a young child. What helps a young child is to tell them what they should be doing. So keep your hands to yourself. Sit calmly speak kindly, just to give the positive instruction. That's like a basic thing. And it's hard to get used to doing that when you have a child who's maybe hyperactive and you're just sitting.

Dr. Elise Fallucco: 2:20

Stop hitting your sister, hitting your sister, throwing the ball

Dr. Joyce Harrison: 2:24

around the room. Stop jumping on the couch. Yeah. Just stop it all right. Just giving the positive directions rather than the negative directions. If you say stop doing that kid can stop doing that and then they're like what am I supposed to do now? Let me find something else that I shouldn't be getting into. So telling them what they should do can be really helpful. And then I've worked a lot with the Chicago parent program, which is a really great thing, but we always talk about catching them doing the right thing. So one of the things we do know is that we pay huge amounts of attention to negative behaviors, right? So we will, we're doing our chores. They're fine. They're watching TV. They're on their tablet. They're playing nicely with their sibling. We ignore them, right? And then they start acting out So trying to pay attention to them when they're following directions and when they're doing the things and when they're behaving in the way you want them to do and praise them. I love the way you're, cause we just take that for granted. You know, We expect it, we take it for granted, but those basic things praising positive behaviors, ignoring negative behaviors when you can, when it's safe to do, telling children what they should do, not what you don't want them to do because they may not even hear the don't, depending on their communication style, right? Oh, you want me to jump on the couch?

Dr. Elise Fallucco: 3:35

Great. We are on the same page. Continue

Dr. Joyce Harrison: 3:38

the jumping. and then consequences, being really clear, consistent. And following through I always say pick your battles and be really consistent. Don't get distressed about something one day and not another. That's just, it gets confusing and it really perpetuates the behavior, but really. Figure out where your tolerance level is and stay there and be really consistent in your in your punishment. Idle threats. I see them and hear them all the time. You know, you're you're going to get it when we get home or you're going to, you know, it doesn't do anything in the moment. Having a direct consequence at the moment really helps kids manage their behavior.

Dr. Elise Fallucco: 4:14

This is great. And just to take a pause to summarize, it sounds like you're saying. Stay calm, give positive instructions for what you want them to do. Catch them doing something good and make sure to praise them. And if you have to give consequences, Make sure that they're immediate consequences and not idle threats

Dr. Joyce Harrison: 4:33

yeah The other thing, pediatricians can talk to their parents about is this whole idea of child centered time. We used to call it child centered play but it can be child centered time. I call it money in the bank, because Children behave because of their relationship, right? They care what the teacher thinks, they care what their mom thinks, they care what their dad thinks, most of the time, right? It's all about the relationship. So building a solid relationship that isn't just based on you always You know, telling them they're doing the wrong thing. Child centered time is a really interesting concept. And many parents have a hard time doing it, but I prescribed five minutes where you let the child be in control. Because they're never in control, right? We're always telling them, do this, don't do, so you let them determine the play, which I find really hard to do. And most parents do, because you want to play should be a teaching time, you want to ask them questions, you want to quiz them, but just let them have five minutes of your undivided attention, put away the phone, put away the tablets, put away everything. And it's amazing how many parents tell me that's really hard to do. But if you do that every day, you really build on the relationship and they begin to see you as somebody other than the enforcer. You're someone who cares enough about them to give your time to them. And so I think that's something that that can really be helpful in a parent child relationship when you have a child with a, with behavior, that's really frustrating you.

Dr. Elise Fallucco: 5:58

And I've, I've even told parents that like, you can even set the timer, sometimes when, when these kids are interested in things that are maybe not that interesting to parents, like little disclosure, I don't love trains.

Dr. Joyce Harrison: 6:12

I never loved knights and pirates either.

Dr. Elise Fallucco: 6:16

Knights and pirates and trains are not my thing. Um, But I, I. You know, Discreetly set the timer, put my phone away and just try to pay attention and act interested and kind of comment like, Oh, look at that train over there.

Dr. Joyce Harrison: 6:31

Yes. The commenting, we call it descriptive commenting, like sports casting also shows the child that you're really engaged and that you're paying attention and also helps with language

Dr. Elise Fallucco: 6:40

development. I love this. Something that pediatricians can also prescribe to the parents are just. Five minutes a day of child centered time or money in the bank. And just, don't ask questions. Don't ask demands, let them be in charge as long as they're safe. And it's amazing because I think sometimes as parents, we think it's going to require a lot more time. Like that we've just got to get down and play trains for eternity. And that doesn't seem fun. And so it's easy to avoid, but just five minutes, you can do this. Yes.

Dr. Joyce Harrison: 7:08

Yes. And it just slowly flips the script. So you begin to see your child as more fun. And your child begins to see you, as I said earlier, it's not the enforcer, but maybe the person who cares about me and will pay attention to me and for other things. And the other thing I did want to talk about is time out. Because child centered time, it's time in, it's I'm going to just pay attention to you, you're my focus and it's all about you, as opposed to time out which the theory is you just completely ignore that child, which, most children don't want to be ignored. They want attention and often they act in ways that we don't want them to because they're getting attention for it. I've asked parents to model a time out for me. And you see the parent is like constantly paying attention to the child, sit down. I told you to turn around, and it's like, you're defeating the point. There's lots of controversy about how you should do a timeout. And I think a minute per age is too long. I just think until the child settled, but making sure that whatever consequences or discipline is being instituted is, is done consistently and effectively.

8:11

Personally, I'm a big fan of timeouts for parents. I think it can be really helpful for us to take a little break when we recognize that we're getting a little. Stressed out or overwhelmed and ideally it sets a good example for our kids

Dr. Joyce Harrison: 8:24

That's a great point. That is the strategy we used to and say, it's okay for you to take a time out and tell your child. You know what? I'm taking time out. I've also seen kids say that give their parents a time out. You get you're getting a timeout mom. You said a bad word. So I agree. I think a parent timeout is a great strategy and it does it models like okay, I need quiet and calm and I need to calm myself because I'm getting upset, it's a nice way to model the coping strategy for your child.

Dr. Elise Fallucco: 8:49

These are incredibly helpful and very practical things time in of child center time and the time out and how to do a timeout. And I think a lot of pediatricians and parents already know about these, but it's probably helpful to refine them and to just be reminded that these are some of the tools in your toolbox. So switching gears, now that we've identified that a preschooler needs further evaluation and treatment for emotional and behavioral problems, how can we help these families find clinicians who can take care of their preschool aged kids with emotional and behavioral problems

Dr. Joyce Harrison: 9:21

yeah, so this is really one of the challenges, you know, we have this huge shortage in child psychiatrists in general. I'm sure that you know, a lot of people, who say, I can't find anyone who will treat somebody under five. What I was thinking about for resources the the child psychiatry access programs, which are now called pediatric mental health care access programs. I can't say it all PMHCAs but I still call them CPAPs. They're now in 43 states. But in our state, one of the functions we serve is to connect pediatricians to resources in their area. You can just call the access line and say, I need a therapist for a four year old with behavior problems. Who is in my area or where can you send me? So I think that's one good resource and In Maryland, we've worked to keep it really up to date, although it's hard to do, but I think that's one place. And the local AAP chapters often are a good place for resources. They know what's going on. The American Academy of Pediatrics has a dozen or 15 different ECHOs that they do, one of which is an early childhood ECHO.

Dr. Elise Fallucco: 10:22

And for any of our friends and colleagues who are listening and who are not familiar with ECHO, we've talked about it on some previous episodes, but basically. It's an innovative telementoring program where you create virtual communities of learners and you have subject matter experts like Joyce Harrison partnering with Clinicians in a larger community, to discuss cases and share educational presentations. And dr harrison is a huge fan of echo. I I love Echo because I really feel like it creates this community of practice where you support each other, where the, experts really share the evidence based practices, the best practices with the pediatricians. Each case that gets discussed can be, you know, transmitted to hundreds of other kids because you learn this one thing and then every then you see another child like that you say, Aha, I remember this is someone who works well with kids like that, or this is a strategy that will work well with the child like that.. I think it's a great way to expand what you can do and what you feel comfortable doing as a pediatrician. So you've shared about getting connected with their statewide pediatric mental health access program and calling that hotline to find out about early childhood resources. You've also shared about getting connected with the local AAP chapter. And then finally potentially enrolling in one of these early childhood echoes to help build your own skills in recognizing young kids with emotional and behavioral health problems. So where should pediatricians who were interested in participating in echo go to find out more information? So there's a website, and so you can go on the AAP website. You can also go on the ECHO website. The other resource was the toolkit for addressing mental health problems that the AAP, the publication that came out. Unfortunately, it's, you have to buy it, but it has a whole section On working with kids under the age of five, like the screening tools, assessing behavior, differential diagnosis, dysregulation and emotional or behavioral disturbance in kids younger than five when and how to refer. It's a really great toolkit. It's an AAP resource for yet for working with young kids for pediatricians. as we wrap up. What's one thing that you think you'd want all pediatricians to know. Or to be able to do so that they can help these families

Dr. Joyce Harrison: 12:37

When you're seeing a child in your office who's having, extreme and distressing behavior Think about, instead of saying what's wrong with that child, what happened to that child. What's going on with that child That's probably, my big take home and my big lesson is always look beyond the behavior to try to figure out how to help this child because Sometimes just addressing the behavior is not going to put the child on the right track. In fact, and sometimes it can make it worse because people get punitive and negative.

Dr. Elise Fallucco: 13:07

It's a great reminder That behavior is not always just behavior.

Dr. Joyce Harrison: 13:11

More often than not, many things underlying it in this age group.

Dr. Elise Fallucco: 13:15

Thank you so much, Dr. Joyce Harrison. It was a pleasure talking with you. And, we're so lucky because there, there really are very few people in the country who specialize in working with very young kids and really trying to understand their behavior. We are very honored to have you and thank you for joining us. It was wonderful talking with you today. Thank you again so much for having me. It was lovely. Wow. That was incredible. And for those of you who weren't taking copious notes, we're going to have some more information on our website, psyched, the number four paeds.com about some of the helpful tips that parents can use to help their kids with emotional behavior problems. And as always, if you have any questions about this episode or about anything else, feel free to message us on our website, through the chat function or email us at info at psyched the number four paeds.com. Thank you so much for listening. And if you liked this episode, please feel free to give us a five star review. And share it with a friend. Hope to see you next week.