Everyday Strategies for Child Behavior: Empowering Providers and Families and Facilitating Change with

a Realistic ApproachMatt Orr, PhD

Department of Family & Preventive MedicineUniversity of South Carolina School of Medicine

Matt.orr@uscmed.sc.eduCollaborative Family Healthcare Association 14th Annual Conference

October 4-6, 2012 Austin, Texas U.S.A.

Session # D2bOctober 5, 2012

Faculty Disclosure

I/We have not had any relevant financial relationships during the past 12 months.

Objectives• At the conclusion of this presentation, the participant will be

able to:

• Provide brief, yet rich, education on child development and behavior that engages and empowers parents in change process

• Integrate practical behavioral intervention strategies that are conducive to primary care-based office visits

• Identify and tailor brief interventions that fit the needs and abilities of the family and the child with disruptive behavior

Learning Assessment

A learning assessment is required for CE credit.

Attention Presenters:Please incorporate audience interaction through a

brief Question & Answer period during or at the conclusion of your presentation.

This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy

accreditation requirements.

5

Moral of the Story, Punch Line, and Bottom Line

If we want to understand how to help children regulate their

behavior, we must first understand what the behavior is

regulating

6

Over Time

Goal is long-term growth…

Skills that enable the child to adapt to the demands of everyday situations

Survival Skills

7

Nature of Behavior

Help parents know what they are seeing

Empower them with interventions that fit with family’s needs & abilities

Think Asthma or Allergies

8

Three Targets Over 1st Two Visits

1. Success: Identify in what situations the child does well & put him in them as often as possible

Promoting Task Completion & Productivity

2. Activities: Identify what extra-curriculars child is involved in

Promoting Development of a Sense of Competence

3. Play: Use Mother Nature (i.e. movement) to set the stage for success

Promoting Situational Self-Regulation

Anxious

TornadicHighly Active & Impulsive

Irritable & Cranky

Excessively Talkative Defiant &

Annoying

9

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What’s Out There Already

“Behavioral Treatment” usually means “Behavior Modification”

http://www.sccp.sc.edu/centers/SCORxE/protected/downloads/SCORxE%20Behavioral%20handout%203-1-12%20printing.pdf

Pertinent Brain & Behavior (in 2 slides) A

ROUSAL

REGULATION

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BEHAVIORAffectAttent

ion

Activity

Sensorium

Temperament

Internal Thermostat & Control System

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13

Temperament

Regulatory processes = developmental abilities

Tasks that must be mastered

Preferences & Quirks Goodness of Fit

Match between child & environment

Dimensions – Chess & Thomas Activity Level:

Low________Hyperactive

Regulation: Predictable__________Erratic

Initial Response: Approach_________Withdrawal

Adaptability: Flexible_____________Rigid

Intensity: Mild-Mannered______Forceful

Mood: Cheery____Serious____Irritable

Self-Control: Reflective______Impulsive

Concentration: Persistent______Distractible

Sensitivity: Unbothered________Reactive

Temperament in the Clinic16

Perception

Process

Response

Dennis MitchellThis superactive young upstart…is active, agile, tireless and hard to catch. He's also inquisitive, imaginative and of an experimental turn of mind, which frequently lands him in situations he can't always control. With his impish grin, he delivers sometimes blunt observations of the truth. While never malicious or mean, the irrepressible Dennis remains a threat to property, the pomposity of adults and quiet afternoons.

Adapted from www.kingfeatures.com (2009)

How was Dennis punished?

19Behavioral Strategies: Establishing Boundaries

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Behavioral Strategy #1

Grandma’s Rule aka Premack’s Principle

First broccoli, then cake

After shoes put away, then you can go outside

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Adaptation

“…and I will sit with you while you finish”

“Come on, I’ll walk with you to your room.”

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#2 Modify Time Outs

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#3 Pro-Social Consequences

For more serious offenses

Lying Stealing Harming others

Make them do “Community Service”

24Cognitive strategies: Teaching problem-solving

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Cognitive Strategy # 1

Turn Should’s into Could’s

Creates Options

Identifies alternatives & facilitates decision-making

Leaves option to “explode”

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Cognitive Strategy # 2

Replacements

Must replace undesirable behavior with a more desirable one

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Cognitive Strategy # 3

Rewind “Try that again…”

Modifies caregiver response

Gives child an opportunity to pause & choose more favorable response

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Everyday Survival Skills for Kids and Parents

Six Skills to Survive & Thrive

1. Modify Expectations

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Common Complaints

Children do well when they can

They do well in some situations but not others

“Cannot go into a store without asking for something”

“Cannot sit still for more than a minute” “Cannot play outside without getting

into an argument”

2. Identify Success

We Can Only Do What We Can Do

Put Kids in their Element

34

The Message in the Behavior

What’s the message here?

35

The Message in the Behavior

Take a

SNAPSHOT

!

What’s the Usual Outcome?

Adaptive Regulation View37

Behaviors are attempts to adapt to internal signals of discomfort or distress…to self-regulate o Stay awakeo Focuso Moveo Protecto Defend

38

Adaptive vs. Maladaptive

For children, environments (i.e. parents & teachers) determine whether a behavior is adaptive, not whether it helps the child pay attention, sit still, or be compliant

Maladaptive behaviors = “symptoms”

3. Get Moving

314 - Piano stairs - Rolighetsteorin.se - The fun theory.wmv

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Play – Pellegrini et al.

Physical activity positively affects classroom attention

More calm & relaxed

Best in short bursts (20 min. optimum)

Proprioception41

Sensory system involving stimulation to muscles, joints, & tendons

Calms & Organizes Considered queen of sensory systems Helps integrate the entire system

Includes Vestibular & Tactile senses

Proprioception42

Central role in governance of motor control and planning! (i.e. ADHD)

Regulates over- & understimulation Stimulation lasts for only 2-3 hours Recess anyone?!

43

Levels of Play

Vigorous Physical Activity – All out free play; sports; game provides the parameters

Moderate Physical Activity (think “Indoor”) Boundaries/rules allow for control Play wrestling; indoor trampoline

Fidgeting; Soothing Activities Playing with water Fidget toys

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Vigorous – Move & Soothe

Team sports (especially soccer) Individual sports (swimming, karate,

dance) Predictable after-school activity (play,

music)

Move & Soothe

Traction

Compression

Play Wrestling

Rough & Tumble Play

Move & Soothe

Bounce & Balance

4. Fidget to Focus

Fidgeting

Evidence that physical activity is related to central executive functioning – Working Memory

ADHD & Non-ADHD

We all fidget to focus

(Rapport et al., 2009)

49

Move & Soothe

Playfulness to Recalibrate

Try not to smile when a child is laughing…good luck!

5. Apply the Breaks

Chunk tasks into manageable doses with breaks in between

6. Background Sound

Taming the Wizard

Anxiety-Oriented Strategies

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Oppositional & Explosive Behavior

Playful (i.e. physical activity) interventions are essential for kids who are:

o Intenseo Irritableo Insatiable

Decisiveness

Coach parents to be DECISIVE Refrain from “We’ll see” Plan ahead If plans change, parents must prep the

team

Critical role in establishing emotionally secure atmosphere

55

Deflect-Reflect

Situation: Child/Teen is in a fit, riddled with anxious-speak; unhappy with some aspect of self or situation Whining Negative self-talk Complaining Blaming

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57

Deflect-Reflect

Maladaptive attempt to seek comfort from parent

Conflict ensues because parent cannot meet irrational demands

“You’re just saying that!” “You don’t understand!”

58

Deflect-Reflect

Deflection: “What do you think you are going to do about that?”

Reflection: Encourages child to think through/ name a solution

At least, sends message “I believe it’s possible for you to be competent”

“You can sort this out”

Sleep

Routine

Rhythm

Relax (Flexibility)

Ex: Sleep-Walk Technique

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Parent Sleep-Walk Strategy

Many parents report significant trouble with bedtime routine

Consider “sleep” time vs. bedtime Anxiety does not turn off at bedtime! Not a problem for parents to be part

of the bedtime routine; issue is with falling asleep

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Parent Sleep-Walk Strategy

Parents need a strategy that allows them to disengage at “sleep” time while still tending to child’s needs for comfort & security

Strategy allows parent to progressively disengage from the child when it is time to go to sleep Step-wise

61

Parent Sleep-Walk Strategy

Child is given a roadmap: After I read to you I am going to

Sit on the bed Lay on the floor Sit in the doorway

Begin with what child can handle and progress farther away each night or every few days/weeks

62

Basic Behavior Management

SOS Help for Parents by Lynn Clark, PhD

If you seek easy-to-read & do behavior mgmt training for parents

www.sosprograms.com

63

For Further Reading

Effective Parenting for the Hard-to-Manage Child: A Skills-Based Book by DeGangi and Kendall (2008)

More detailed exploration of some of these ideas and intervention 64

Play – Pellegrini et al.

Holmes, R., Pellegrini, A., & Schmidt, S. (2006, October). The effects of different recess timing regimens on preschoolers' classroom attention. Early Child Development and Care, 176(7), 735-743. Retrieved September 15, 2009, doi:10.1080/03004430500207179

Pellegrini, A., Dupuis, D., & Smith, P. (2007, June). Play in evolution and development. Developmental Review, 27(2), 261-276. Retrieved September 15, 2009, doi:10.1016/j.dr.2006.09.001

Pellegrini, A., & Holmes, R. (2006). The Role of Recess in Primary School. Play = learning: How play motivates and enhances children's cognitive and social-emotional growth (pp. 36-53). New York, NY US: Oxford University Press. Retrieved September 15, 2009, from PsycINFO database. 65

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!

Matt.orr@uscmed.sc.edu