56. Challenging Child Behaviors: Help Families Use Selective Attention

Join us as we talk about challenging child behaviors! We'll explore why these behaviors can be developmentally typical and introduce the selective attention strategy for handling them. Learn key techniques such as specific praise, time ins, and the stoplight approach to help parents manage green, yellow, and red behaviors. Additionally, discover important clinical questions to determine when children might need further evaluation and treatment. Join us for practical insights to support both parents and children through difficult behaviors.

00:00 Introduction to Challenging Child Behaviors

00:42 Understanding Challenging Behaviors

01:44 Reframing Behavioral Issues

03:26 Practical Strategies for Parents

04:00 Selective Attention Technique

05:15 Categorizing Behaviors: The Stoplight Approach

06:43 Reinforcing Positive Behaviors - GREEN

12:26 Managing Annoying but Safe Behaviors - YELLOW

15:35 Handling Unsafe Behaviors -RED

18:01 When to Seek Further Evaluation

19:03 Summary and Conclusion

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

Transcript

Dr. Elise Fallucco: 0:21

Welcome back to Child Mental Health for Pediatric clinicians, the podcast formerly known as Psyched for peds. I'm your host, Dr. Elise Lucco, child psychiatrist, and mom. Today we're gonna be talking about challenging behaviors in kids, and I say challenging behaviors instead of behavioral problems because we know a lot of these behaviors can be developmentally typical. and I'm gonna share with you a practical strategy that you can use in the office with families to help them. Learn a framework for managing these behavioral problems at home. Finally, we're gonna talk about the questions you need to ask clinically to figure out if a child with challenging behaviors might need further evaluation and treatment. So let's get started. So what do we mean when we say challenging child behaviors? So this is everything from defiance. The saying, no, I don't wanna do this, or more active emotional, verbal outbursts. Things that we would call temper tantrums, or when they're older, we might call them meltdowns. And a really important principle to make sure that parents know when we're talking about these behavioral issues is that behaviors are just a way of kids expressing an emotion We see these behavioral outbursts when kids are feeling frustrated or angry or overwhelmed or scared or hangry or tired or all of the above. And part of our job as parents is to try to figure out what the emotion is that they're experiencing. And then of course, we all know, the other reason that we see these behavioral outbursts is that a lot of times developmentally kids have not yet developed the. Ability to control their emotions, to self-regulate and to self-soothe, and that's usually when they get into trouble. But a positive thing to remember about. Behavioral outbursts is that they really come from a good place from the moment the kids first take their couple, few, couple of steps. They're seeking autonomy. They're trying to be independent individuals and parents of course, and pediatric clinicians as well. We all want them to become healthy, autonomous. Grown adults. So if we reframe some of these behavior problems as really a kid's way of seeking autonomy and trying to assert their independence, that can be a, a more positive take. It certainly doesn't take away the fact that they're incredibly frustrating from the perspective of a parent, but just something to keep in mind. Now, I'm sure you've had a lot of parents in your office say things like, you know, Timmy is a tyrant and I feel like, you know, my 2-year-old or my 4-year-old is running the show in our house and we don't like that very much. And when I hear that, I definitely reframe that as. It sounds like Timmy is really trying to assert his independence, and Timmy may have a really strong will, which is gonna serve him really well in life, but it makes it really hard as a parent. So one thing that parents can do at this stage is to offer Timmy choices, knowing that he wants to be autonomous, he wants to be able to have a say in his out of control world. And so let's say we're getting ready. For school in the morning, instead of just telling Timmy, put your clothes on, it's time to get ready for school. You can give him options like, okay, do we wanna wear the blue T-shirt, or do you wanna wear your fun red t-shirt? And then he gets a sense of choice and the parents can get the child to comply and move along with the morning routine. So let's get right into the practical strategies that we can share with parents to help them deal with common challenging behaviors in children. What I'm about to tell you is really based on a lot of evidence-based studying various parenting programs and parenting strategies, and is drawing from tried and true. Therapeutic modalities like parent-child interaction therapy, and this technique and this strategy has been shown to improve child behavior, reduce stress in the children, and most importantly, reduce stress in the parents. So let's go. So this strategy is called the strategy of selective Attention, and it's really based upon the idea that what we pay attention to in our children is the behavior that gets reinforced because children desire parent attention. They desire attention from trusted adults, and oftentimes the behaviors that they're using are their ways of trying to draw us towards them. And we know that as a parent, our instinct can be to pay attention to the naughty behaviors. So think about it. when the child has an outburst and decides that they don't wanna get dressed for school, or they don't wanna brush their teeth and they flail on the floor and they're kicking and screaming, of course the parent is paying attention to that. On the other hand, If a parent's trying to get dinner ready on the stove and her child is sitting on the floor and playing nicely. The parent's not gonna pay attention to that. They're gonna be relieved that they can get on with all the things that they need to do. All of that to say is that the parent instinct is often to give attention to the behaviors that we don't wanna see repeated or reinforced, and that we tend to ignore and not pay enough positive attention to the good behaviors that we wanna see repeated. Okay. So what I would tell parents is the first step in selective attention. Is to categorize child behavior in one of three categories, and I like to think of a stoplight. So the red behaviors on the stoplight are those behaviors that are unsafe, that are off limits that we want to stop. typically behaviors in this category would be things like aggression, you know, harming others, putting your hands on others. The next category is yellow. Proceed with caution. These are the behaviors that may be annoying to the parents, but they're not unsafe, and these are the behaviors that we're gonna teach the parents to ignore. And an example of a yellow behavior would be something like whining or interrupting or doing something similar that is disruptive or annoying, but not fully a red type of behavior. And then the third category of child behavior would be the green category on the stoplight. And these are the behaviors that you want to see. Again, you want them to be positively reinforced. So this would be the children playing nicely with their magnet tiles on the floor, or the child putting his sock on as part of getting ready for school in the morning. Okay, so now that you've categorized the behaviors into the stoplight, the red unsafe behaviors, the yellow safe behaviors that are just annoying that we're gonna ignore, and the green behaviors that are positive, let's talk about what we're doing with each of these three bins. In concert with the principle of selective attention, we wanna spend most of our time, energy, and effort on the green behaviors, the positive behaviors that we want to positively reinforce, and we want to give them positive attention. And there are a couple ways of doing this. One is to use specific praise to catch them doing something good. And to then. Describe exactly what you like about what they're doing. So this requires not only noticing when they're doing good behavior, but also calling it out in a specific way. So to give an example of specific praise, let's say it's mealtime and your child typically bops in and out of their seat or their chair multiple times. What you would do as a parent is to catch them actually sitting down quietly in between the jumping, um, in and out, and pay attention to that and say, I love how you're sitting, so still in your seat during dinner. And ideally then the child hears that, enjoys the positive praise, and then wants to continue that behavior to get some more. So in addition to specific praise, the other strategy for reinforcing positive behaviors or green behaviors is to try to connect with a time in. Time in or child-centered time or child directed play is something that parents can use to build a positive relationship with their child. And while that goal is good in and of itself, in addition to that, the positive relationship. We will pay dividends in the future as that will make the child more likely to want to follow directions and exhibit good behavior. So what is this time in? This time in, I like to prescribe five minutes a day where the parent lets the child direct the activity. So. As a parent, you would need to put down your cell phone. Any devices, sometimes sit on the floor with the child and say, you're the boss. What should we play now? And let the child choose the toys, the game, the activity, and you set your timer for five minutes and the child gets to be the boss, assuming they're not doing anything unsafe. And there are specific skills that we talk about in parent-child interaction therapy. That parents can use to make the most of these five minutes. So the general idea of what the parent should do in time in is to serve as a bit of a mirror to just reflect what the child is doing, repeat what the child is saying, and help the child feel seen and valued. So what does this look like? So let's say you're sitting down on the floor and the child is playing with trains, so you would want the parent to imitate. Imitation is one of the key skills. So if a child is sitting down and playing with trains, do you want the parent to literally grab a train and imitate what the child's doing with their trains to join in on the play? The next of the three time in skills is to describe, so you wanna be the parent, you want the parent to be a little bit of a sports commentator and say things like, oh wow, it looks like Red Train has gone up the hill very fast. Oh, and now Red Train is seeing Blue Train. Oh no, I think they're gonna collide. And so like a sportscaster, you narrate the play that the child is doing and. This typically delights the child, even though it feels a little counterintuitive and awkward for the parent. So after imitating and describing a third skill that you can use in time in is to literally reflect. So if your child is speaking or saying things like, let's say we're playing with dolls and they say, uh, little Sarah is hungry, time for lunch. As a parent, you could literally repeat what the child is saying, but I find it better to kind of rephrase like, oh look, Sarah is hungry. Good thing it's lunchtime. And this type of verbal reflection demonstrates active listening and it helps the child feel heard and understood. And as a side note, this technique is also good with kids and adults of all ages and is really important for people helping to feel understood and heard. And while I've given examples about time in that are really more appropriate for preschool aged children or kind of younger children, this type of time in is something that we should be doing with kids and teens of all ages. And so a time in with an older child might be something like, they get to pick the game and they decide that they're playing chess. And one of the things that we would do to try to be the mirror for them. Would be to do the sports commentary and say, Ooh, look how. You moved your queen in that position to block my rook, or, I actually don't know a lot about chess, but narrating something that has to do with the actual game and then a time in for a teenager might also look like going for a walk with them or throwing the football or doing something else that they choose that makes them feel comfortable. And before we move on from talking about addressing the green behaviors, I also wanna say for a lot of families it makes sense to only work on the green part of the stoplight for a week or a couple of weeks to give positive attention knowing that part of the reason why kids exhibit the yellow and red behaviors is that they're trying to get our attention. And so sometimes just investing in child-centered time or this type of time in for a while will naturally reduce some of the yellow and red behaviors. Alright, so to summarize, we've talked about how to positively reinforce. Good behaviors by using specific praise and then connecting during time ins and using the three skills of imitating, describing, or sportscasting and reflecting. So now very briefly, let's talk about the yellow behaviors. These are the annoying, but annoying, unwanted, but still safe behaviors. So what we do for these is we ignore them. So let's take an example. Let's say the parent is trying to be on a phone call or a Zoom call, and the child is interrupting and saying, mom, mom or Dad? Dad, pay attention. Pay attention. Now, what we would coach the parents to do would be to ignore these behaviors as much as possible, and the idea is that the child is. Doing this type of behavior in an effort to gain attention from the parents. But again, we don't wanna give them that attention'cause that will positively reinforce those behaviors. So it's our job as parents to try to ignore them and then try to catch them in the moments where they're not nagging or interrupting and where they're a little bit quieter. And then at that point. Because that's a positive green behavior. You'd reorient your intention to them and reengage with them and say, thank you so much for waiting patiently. I'm on a Zoom call right now, but I'd love to talk with you in a little bit. The important thing to note about this is that kids are very savvy and so while in theory, while in the long term, when you ignore behaviors, they tend to go away. The reality is. Um, that when kids are initially ignored, they will just continue the behavior, but just more loud, more loudly and more frequently in an effort to gain attention. And so behavior will get a little bit worse before it gets better. And in our mental health circles, we refer to this as extinction burst, which is just the idea that when we try to change behaviors, they get more intense and worse and almost sort of increase before eventually children learn. Okay, I'm not getting the. Positive reaction that I wanted from this, and they get better. And this part during the extinction burst is usually when most parents give up because you think, okay, I've applied this stoplight approach that my pediatric clinician told me about and it is not working. And in fact it seems like it's made things get worse. So it's really important to tell parents that the fact that the behaviors are getting worse is actually a sign that it is working and that we've just gotta hang on for a while and definitely let them know beforehand about this possibility so that they don't get dismayed and frustrated and give up. And in addition, while parents are tolerating this sort of yellow behavior, it's critical to be able to catch your child doing something good within that. Um, time period. And then of course afterwards, you know, if you have a specific behavior, let's say interrupting phone calls or interrupting conversations with other adults, that you wait until everyone is calmed down and then afterwards have a little conversation and say, I know you, you need to get my attention. Let's come up with a little signal that we can have if you need to get my attention, but in a way that doesn't interrupt these calls. So if you wanna put your hand on my leg and then I'll put my hand on top of your hand, that can be our secret signal that you need to get my attention and my way of telling you. I can be there, but you've gotta wait or you can come up with something creative on your own. And then finally, this is the part that I think everyone feels the most comfortable with. These are the red behaviors that are unsafe and absolutely off limits for which you can try things like time out or other types of consequences. So an example of a red unsafe behavior could be something like running out into the middle of the street, which you would obviously wanna give your immediate full attention or it could be something like hitting, kicking, doing something harmful to a sibling or to another person. obviously you wanna have clear expectations upfront with your kids about what are red off limits behavior and what the consequences are so that it's not a surprise when they exhibit that behavior and then have to meet those consequences. So you wanna make sure that the consequences for unsafe off limits behavior are safe and consistent and boring. And what do we mean by that? So. Consistent. Really what we mean by that is that almost every time they give that behavior or exhibit that behavior, you're responding with these consequences. Now onto the safe and boring part. remember the key for selective attention is that you don't want to give positive attention for negative behaviors. The hardest part for adults when we get to this point is that our tempers have increased and our frustrations have increased along with the kids. And so when we get to red behaviors, parents are often at the end of their rope as well. And so it's really important to coach parents to try to manage their own emotions. And to make sure that they're not inadvertently reinforcing these behaviors by their own anger. So what do we mean by that? Well, it may seem counterintuitive if a parent is screaming or getting red in the face and really dramatic and heated in delivering the consequences, even though that's negative attention, it still is attention and can inadvertently reinforce these behaviors. So important to coach parents to try to take their own time out if they need it, or time off, um, to take a break and compose themselves, and then to just say with a straight face in a really boring way. Because you did this off limits behavior, it's time for whatever the consequence is. I imagine many of you are already familiar with the concept of selective attention, but I hope this idea of the stoplight and what to do with the red, yellow, and green behaviors might be helpful for working with parents and families. Before we close, here's some questions that might be helpful in your clinical practice to determine whether the child needs further evaluation and treatment. So there are the obvious ones that have to deal with dysfunction. You know, is the child getting expelled from childcare or from preschool or from school? That would be a sign that. They would need further evaluation and potentially therapy or treatment. We also sometimes use a little bit of a time rule. Temper tantrums and behavioral outbursts should really just last a couple of minutes and the child should be able to self-soothe and calm down at the end of them. And. You're consistently finding that temper tantrums are very intense and lasting for say, 15 minutes or longer and seem to be occurring frequently that would also be a sign or a little bit of a red flag, and then always if you see major self harm or major aggression towards others. That is another sign of major emotional dysregulation that we would wanna take a further look at and potentially refer to one of our child mental health colleagues. All right, well, in summary, um, we talked about three major things. One. The importance of reminding parents that some of these challenging behaviors may be developmentally typical and that their child's way of expressing emotions and their child's way of desiring autonomy. The second thing we talked about is the principle of selective attention and using the stoplight approach to guide parents in understanding and managing behaviors in kids. The third part that maybe the most important part is encouraging parents to practice positive parenting. That's hard to say out loud. And build the relationship with their child through time, in and through using strategies like imitating and. Describing or doing sports commentary, and reflecting back during scheduled regular time in practices. Alright, that is it for a brief review of management of challenging child behaviors. Thank you for tuning in and look forward to seeing you next week.