Positive

Parenting

Lisa S. Spector MDChief, Division of Developmental and Behavioral Pediatrics – Nemours Children’s Hospital

Professor of Pediatrics - UCF

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Disclosure

I have nothing to disclose

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Objectives

How chronic stress effects brain development and child behavior

Effective behavior management strategies

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Brain on Trauma

THALAMUS

• Relay between subcortical &

cortex

• Translates senses into

language of the brain

• Regulating arousal,

awareness and activity

• Involved in memory

AMYGDALA• Emotional Computer and

Alarm System

• Responds to threat – Fight, Flight,

Freeze

• Formed at Birth

HYPOTHALAMUS• Link CNS to Endocrine System

• Send and receive hormones

• Activate Autonomic Nervous System

- Immediate

• Fight or Flight or Freeze

• Epi & Norepi

• Release hormones from Pituitary

- Slow

• HPA axis - cortisol from adrenals

HPA Axis

Excess Cortisol

Increased BP

Diabetes

Immune suppression

Infection

Atherosclerosis

Osteoporosis

Muscle atrophy

Cortisol

Metabolic & Cardiovascular

response to stress

Negative

Feedback

Loop

HIPPOCAMPUS

• Determine if Threat is Valid

• Links experience – sensations,

emotions, thoughts, facts &

reflections - into memories -

which we can recall and

describe

• Develops in first 5 years

PFC

• Make decisions about

cognitive and emotional

responses

• Abstract concepts - time

• Executive Functioning:

• Making, following & alt

plans

• Control & focus attention

• Inhibiting impulsive

behaviors

• Developing ability to hold

and incorporate new

information in decision

making

• Develops over 25 years

Studies of Trauma/Stress

Increase in Cortisol–

– increased levels of cortisol measured in 24 hr urine in children with PTSD

Hippocampus smaller

– adult veterans with PTSD;

– adults with childhood abuse related PTSD

Loss of neuronal Integrity in Prefrontal Cortex–

– reductions in N-acetyl aspartate (NAA) in PFC of children with new onset PTSD

Bremner, JD. Traumatic Stress: effects on the brain. Dialogues Clin Neurosci. Dec 2006;8(4):445-461

Summary - Always under Stress

Amygdala is Continuously Activated

– Increase in Cortisol – metabolic, immune and CV changes

Deficit in Hippocampal Structure and function

– Unable to classify and organize information properly

– Typical process for storing memories is altered and information remains perceptual (smells, sights, sounds) and not stored as verbal language

Deficit in PreFrontal Cortex Structure and Function

– Can not make meaning of what happened and grow and learn.

– Emotionally Reactive; easily triggered into a state of arousal –sensing threat in innocuous situation & may have no verbal language to describe it

The child…..

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How to Help

Help them feel - Safe

Focus on the positive to build – Self Esteem

Provide them - Predictability

Give them opportunities for - Control

Model and promote - Self Calming / Coping Strategies

Use Play to build skills – Emotion Regulation

Discipline = Guide and Teach!

Children learn how the world works by:

Watching what we do and say

Imitating what we do and say

Experiencing how we Respond!

We can change their behavior by changing what we do/say and how we respond!

Children….

Do well with Structure and Routine

Need some Prep Time

– We are going to leave in 5 min

– One more time down the slide

Learn through Repetition

– Especially kids with ADHD and traumatized children

Get better with Practice

Respond well when there is Consistency and Calmness

Monkey See, Monkey Do

They look up to us and they

watch & listen

even when we think they are not!

Be on our Best Behavior:

Use our Manners

Point out when we ‘share’ and ‘take turns’

Label our Feelings

– “You are driving me crazy!!” -> “Mommy is feeling frustrated”

– Helps kids label their feelings and know feelings are OK

Model Good Coping Skills

– “I need 10 big breaths to calm down. Lets do it together.”

– “Daddy needs a Time Out to calm down”

Be Proactive instead of Reactive Give lots of Attention for Good (desired) behavior

Remove Attention for ‘Bad’ (undesired) behavior

Build a Positive Relationship & Reinforce

Desired Behaviors

Attention O’meter

All Children Want Attention

All Children Seek Attention

Children don’t care what kind of Attention

..Attention is a POWERFUL TOOL

Behavior + Attention = More Behavior

+

+

=

=

3 ways to Positive Attention

Catch them being “good” or even just “OK”

Quality Play time, Time-In

Loving Touches 50-100 times a day

Catch them being ‘OK’

Praise behaviors you want to see again

– Manners, quiet, kind, helpful, following directions

– Makes children feel GOOD!

Don’t wait for perfection, ‘OK’ is good enough

– “Good job walking next to mommy”

– Makes children want to do it MORE!

Compliment an other child’s good behavior

– Stop there! – stay away from comparison/criticism

Catch them being ‘OK’ more often!

Goal:

Praise desired behaviors 5x more than disciplining undesired behaviors

Praise BEHAVIOR & EFFORT

Praise Behavior and Effort not ability

• working hard

• sticking with it

Not – “you are so smart”

If fail, will persist longer if effort was praised

Changing the Caregiver’s FOCUS

Actively work to Change the Focus

Runs around like an animal!

Never listens!

Constantly crying!

Lies all of the time!

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I….

am an animal!

never listen!

always cry!

always lie!

Instead Focus on the Positive Opposite

Sitting quietly

Listening the first time

Coping when things don’t go my way

Telling the truth

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I….

Sit quietly

Listen the first time

Cope when things don’t go my way

Tell the truth

Self Esteem

National Violent Death Reporting System (NVDRS) 03-12 for 17 states

Compared Suicide rates 5-11 yr and 12-14 yr

In the 5-11 yr old age group

– 85% were boys (70% in EA group)

– 60% relationship issue, 32% school problem, 38% recent crisis

– 30% disclosed intent

– 1/3 a current MH issue (same in EA group)

Of the 5-11 yr ADHD was the most common known mental health disorder in children who died of suicide

– 60% experienced ADHD and only 33% experienced depression/dysthymia (30% ADHD & 65% depression/dysthymia)

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Getting our PLAY ON!!

Let the child run the show – Decrease Demands:

Increase attentive responsiveness:

– Describing what they are doing

– Repeating what they say

– Catch them being “OK” – sitting still, using inside voice, sharing and taking turns

• Asking questions

• Telling what to do

• Criticizing (no, don’t, that’s not right)

Nurturing Touches 50-100x/day

Hugs, high-five, fist-bump!

Brief physical contact

– Head, back, shoulder

Attention without talking

Acknowledge good behavior without distracting

Therapeutic Massage

– Youtube Tina Allen -PMT

*Always ask for permission first

Give Good Instructions

Get their attention First!!

Be Calm, Neutral tone of voice

Tell them what you WANT THEM TO DO

– “Don’t climb the tree!!”

– “Put your feet on the ground”

Do not frame as a question unless they have a choice

– Be Polite by using “Please”

Give Good Instructions

Short, concise, and specific

How long is a reasonable time to wait for compliance?

– 6-10 seconds

Praise for compliance

Kids Learn through Play – So Teach them with Play

Social Emotional Skills

– Sharing, turn taking

– How to engage others in play

– Conflict resolution

Dolls take pressure off of the child

Window into their minds

Opportunity to reframe to provide a different perspective

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Good Ole Role Play

Help practice key skills

– Sharing

– Sitting in circle time

– Conflict resolution

Learn empathy and perspective taking

Ask What questions to engage them to set the stage

– What do if some does something you don’t like?

– What else can you do?

– Let them come up with answers and help if they need help

Okay lets pretend and you be ____

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Standing Rules

Engage them in creating the RULES

Modeling what rule-following looks like

Posting the rules in prominent place

Practice following the rules

– Using Descriptive Praise and Rewards

Use your inside voice

Predictability and Control

Preparation for changes/transitions– Talk about The Plan ahead of time– One more time down the slide– We are going to have to leave in 5 min,..

2 min,..1 min

Allow child to have control when appropriate – Try to find choices for child when appropriate

no matte how small– We have to go, do you want to put your shoes

on or do you want me to help you?

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Predictability and Control

Provide Visual Schedules

Calendar to mark down days – until visit/return

Most Behavior Charts

Geared towards kids with good behaviors

Doesn’t account for individuality - All kids do not start out at the same point

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Reward Charts

Need to get their buy in

– Engage them in creating it “We are going to work with you ___”

– Keep it simple (only 2 goals and 3 at the max)

– Make it easy for them to achieve the goal initially.

Need to make sure they understand what is desired

– What are some things you need to work on?

– Talk about each goal and what it looks like to exhibit that behavior

What does ‘Following Directions the First Time” mean (example)

Must focus on what you want them to do

– Have goals state the positive behavior

Keeping hands to self (vs not hitting others)

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Rewards

Don’t have to cost money (item or activity)

– Extra play time, pick the movie

Quick turn around time – almost immediate

– Pair with Descriptive PRAISE

Gradually increase the stakes over time

Motivators change day to day

Food Insecurity

Never use food as reward or punishment

Allow child to carry food if it provides comfort in secure container

Routine and visual schedule around meals and snacks (healthy foods)

Gradually teach child to wait between meals and snacks

Sleep Disturbance

Night Light

Positive Self Talk – I am brave

Transitional Object

Monster Spray (air duster)

Bedtime Pass

Reverse Baby Monitor

Change rooms

Flash Light

Bell to ring or walkietalkie

Sound Machine

Door Alarm (use with caution)

No TV/Electronics

Massage

Discourage Misbehavior

- The other side of the Attention Coin

Planned Ignoring and Time Out

Reactive

Proactive – IN Control

Ways we Get Sucked into the Tornado (tantrum)

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Talk /

Reason

Touch / Restrain

Eye Contact /

Facial Expressions

Planned Ignoring / Time-Out

Contingent use of Attention is very Powerful

Doesn’t work unless different that what usually occurs

Therefore, Need lots of Positive Attention

Self-Calming

Quiet Hands

Quiet Feet

Quiet Mouth

“Nice job calming down. It looks like you are ready to come out of time out”

*Nothing to do with age or other time limit

Specifics of TIME OUT

Location – where child can see you, see you are not angry, and see what he is missing

Boring – not around other toys or fun

Must be used Consistently

– Warning and Threats get you no where!

Planned Ignoring / Time Out

Respond Promptly

– Time Out ____ (hitting, kicking, not listening)

NO Contact

– No Eye Contact, No Touching, No Talking

Be Calm

– Keep your voice at a neutral tone or lower

Quickly catch them being “Good” or “Ok” and Promptly Respond

– “nice job calming down”

NO RECAP - what is done is done

Keys to Success

No arguing/debating, lectures or reasoning

Be consistent, do what you say

Don’t over react

Practice, Practice, Practice!!

Practice before you need to use it

Repetition – 10x TOs (1 min) over 1x TO for 10 min

Prepare when in new location (who and where)

Pit Falls

If not want to get out – say “time out starts again”

If concern to hurt others- pick up holding chest away from you and gently place in safe spot

If not sit in spot – planned ignore (walking TO), praise when calm, move toward sitting after calm

Prepare Parents

Worse before it gets better – Extinction Burst

– Temporary increase in Freq, Intensity, Duration

– Extinction induced aggression

– Extinction induced novel behavior

–

In one week will try it again to see if same rules apply

Cooper, John O.; Heron, Timothy E.; Heward, William L. Applied Behavior Analysis. Merril, Prentice Hall, 1987.

Miltenberger, R. G. "Behavioral Modification: Principles and Procedures". Thomson/Wadsworth, 2008.

Applied Behavior Analysis

To understand structure and function of behavior to teach effective alternative

A B C

Antecedent Behavior Consequence

What would I see if I was looking at a

video of the incident?

Antecedent- What happened before the behavior?

Precursors, contexts, developmentally appropriate instructions

Behavior- Tantrum, noncompliance, aggression, inattention

Frequency, Length, Intensity

What would I see if I was looking at a

video of the incident?

Consequence- What happens after the behavior? - EATS

Escape From Demand or Aversive event

access to Attention

access to Tangibles (e.g., activities, toys, edibles)

Sensory Stimulation or Removal

What behavior you do want to see?

Can’t just get rid of behavior and have desired behavior spontaneously appear

Is it developmentally realistic?

Has the child been taught the behavior?

ABC of Behavior Management

A B C

Avoid the

Antecedent

When practical

Desired

Behavior

Eliminate

Reinforcing

Consequences

Focus on Desired Behavior

Set them up for success

Giving good instructions

Be a good role-model

Reinforce toward compliance

Catch them being “ok”

Start small and work up

Rewards / Privileges

Ignore diversionary tactics/undesired behavior

Help adult cope with behavior

Any Questions?

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