This chapter reviews common childhood behavioral problems and suggests some management guidelines. Pediatric behavioral medicine cannot be easily disassociated from child development because many problematic childhood behaviors have developmental roots. Clinicians who work with children need to identify parents’ behavioral concerns, even if these are not brought up as problems by parents. Clinicians also need to develop strategies they are comfortable with to address childhood behavioral issues with parents, so that they can lead to resolution.

A child’s ability to understand and interact with the environment is constantly evolving. To learn more about the world, a child experiments with ways of interacting with it. Most often, children test the reactions of the people to whom they are closest, their parents. Colloquial phrases such as “the terrible twos,” “she’s going through a stage,” and “boys will be boys” indicate that undesirable childhood behaviors are commonly accepted as “normal.” But when an undesirable behavior is manifesting in your child, the normalcy can be difficult to accept. And even when the cause is well understood, many parents still need the knowledge and skills to respond to the problem behavior.

Extraordinary Stress

Behavioral problems associated with normal childhood development must be distinguished from problems with more complex causes. Aberrant childhood behaviors are often secondary to extraordinary life stresses. This applies to children who witness violence, are members of communities that have experienced a natural disaster or catastrophic event, are exposed to continuous marital discord, have a frequently absent parent (such as military deployment), have a chronic illness or a chronically ill sibling, or who do not feel wanted. Children living under any condition that seriously threatens healthy and successful transition through a developmental stage are likely to pose serious behavioral problems.

Children, like adults, may appear to be the dysfunctional member of an otherwise healthy family unit even though the problem actually stems from family issues. This is particularly the case with childhood behaviors, because children are dependent on adults in almost every way. Take, for instance, the child who refuses to attend school. Classically, this behavior occurs when one or both parents send subliminal messages to the child to remain home. Although the primary problem is parental anxiety about separation, it is the child who exhibits the apparent symptoms.

Stresses causing unwanted childhood behavior may be relatively more subtle than those described above. For example, children of immigrants often successfully acculturate to the prevalent culture. But when these children’s attitudes and behaviors are not culturally acceptable or understood by their parents, children can be perceived to be behavioral problems. Or, they may manifest true aberrant behaviors as a result of the stresses of this culture clash.

Inherent Disorders

In addition to childhood behavioral problems stemming from normal development and extraordinary life stresses, a third general category involves problems caused by disorders inherent to the child. Attention deficit disorders are the most common and well known, but conduct disorders, depression, autistic spectrum disorders, and other psychiatric diagnoses manifest during childhood. A complete history, observation, and response to treatment help the primary care clinician distinguish these from other causes of behavioral problems. The latest version of the Diagnostic and Statistical Manual of Mental Disorders is an excellent resource for primary care physicians trying to gauge a child’s behavior in relation to a psychiatric diagnosis.

Pediatric primary care providers must screen families for difficulties with undesirable childhood behaviors, sort out probable causes for the behaviors, recognize when a mental health referral is appropriate, and manage those problems that are likely to respond to simple environmental changes or to elementary behavioral management techniques.

Practitioner concern versus time constraints. Many parents do not know where to seek help for behavioral problems such as their baby’s night awakenings, their toddler’s tantrums, or their fourth grader’s class clown behavior. They do not realize that their child’s clinician can assist them. To overcome these barriers, health care providers should take every opportunity to talk about behavioral issues, although time constraints may limit the practitioner’s ability to listen to extensive histories. Therefore, clinicians need to screen for behavioral information in ways that are expedient and that leave time to reflect on issues that can be discussed more fully at another time.

Trigger questions and questionnaires. One way to elicit information from parents is to ask a preset list of key questions, specific to each age group. Use of a screening questionnaire that is mailed home in advance or that parents can answer electronically is a reliable way to elicit history. Numerous such questionnaires have been available since the 1990s. Despite their availability, they are rarely used by primary care clinicians. Some feel these questionnaires merely confirm what a clinician would suspect anyhow once the patient and family are in the office for a clinical evaluation. In addition, these screens have not yet been shown to be cost-effective. Nevertheless, brief screening tools, such as the 17-item Pediatric Symptom Checklist should be considered by clinicians prior to the child’s visit or even while the family is waiting to be led to a clinical interview or examination room. These tools help clinicians gather history and distinguish between disorders and problem behaviors.

To effectively screen for childhood behavioral problems, practitioners need to develop their skills of observation and to learn to apply their natural intuitions. Parent–child interaction in the office can be an excellent indicator of problems occurring at home. When reported childhood behavior problems are combined with a clinician’s suspicion that there is aberrant pattern of attachment between parent and child, this is a warning sign. Incidents in the office that induce parents to discipline their child are opportunities for clinicians to better understand the parent–child relationship and to bring behavioral management issues into discussion. Experienced clinicians have learned to become aware of subtle signs in the office that are indicative of a family’s dynamics, such as how a mother holds her baby. A mother who seems uncomfortable feeding her baby, a pattern of noncompliance, or suspicion about the levels of interest mother or father show are all indicative of issues that should register concern with the clinician. Involvement of grandparents and other extended family, references parents make about their own upbringing, and other family characteristics are also worth noting. Positive impressions that clinicians form about families also provide clinically useful information.

Television, movies, video games, texting, smartphones, and computer networks have assumed central roles in our children’s daily lives. It is still unclear what effect this has on children’s general mood and associated behavior. There are probably both negative and positive consequences to this growing phenomenon. Excessive screen time should be a concern if it appears to be associated with the emergence of behavior problems. It is certainly worthwhile to take a history of how “wired” a child is when confronted with a history of problem behaviors.

Interviewing young children. Primary care providers can find themselves in a quandary when they try to elicit information directly from the child. Most children by age 2½ to 3 years are capable of communicating certain thoughts and feelings to an inquiring health provider. But children do not typically divulge such information to clinicians when questioned directly. Children freely offer their honest opinions on just about any topic, sensitive or banal, but they often do so when it is unsolicited. Parents themselves are often surprised when their children first reveal their feelings about a delicate personal issue to an adult with whom they are not ostensibly very close (a preschool teacher, a friend’s mother in their car pool, and so on).

Primary care providers should, therefore, use tools that help children more freely and predictably disclose what’s on their minds. One way is to ask children old enough to understand and comply to draw a picture, for example, to draw “anything they want,” “something scary,” “their family,” or “the worst day at school.” The position of the characters in the drawings, facial expressions, and choice of colors can yield important information about what they are thinking and may be indicative of how they are feeling and can be used as a starting point for discussion. Children often find it easier to speak about themselves when the conversation is in the third person, such as “Why would that little girl in the picture want to hit her mommy?”

To avoid alienating parents, you may go through a few such questions when both parent and child are in the room. But many children, and most of those older than age 4 years, respond differently when their parents are in the room. Explain to parents that you would like to interview the child in the same way without them. The general nature of children’s responses can be discussed later with parents. Parents should be notified that this will occur, but the interviewer need not feel compelled to reveal children’s specific responses to each interview item, particularly if information may be hurtful and not of therapeutic value at that time. Parents and children should know that too.

Other oblique ways of eliciting information from children are to ask open-ended questions using questions that children like to respond to: “Pretend a magical genie in a bottle wanted to grant you three wishes, what would they be?” And “If you could magically turn into any animal you wanted, what would it be?” To their response to the last question, then ask, “Well that’s wonderful! And why would you be happy as that animal?”

Sentence completion games are also useful. The clinician begins the first few words of a sentence and asks the child to complete the sentence by making something up. Examples of some are given in Table 12-1. These (and clinicians can improvise on others like them) can be typed onto colorful cards so that children can choose one at a time and perceive it as a game, not a real interview. Allow the child to be imaginative with responses, and indicate that their responses can be the truth but do not have to be.

Toddlers and school-age children are often aware of the clinician’s actual intent when these interviewing techniques are used. Despite this, children seem to enjoy going along with this format of questioning and appreciate having an easy way to express themselves. Children respond best when they are comfortable with the clinician. Arranging a number of office visits can help to establish that relationship.

When using drawings, questions in the third person, or questions evoking the child’s imagination, it is important not to read too deeply into children’s responses. Children have active imaginations: they play around with frightening ideas and with wishful thinking. Sometimes they are merely obsessed with speaking about what they have recently seen on television. To be taken seriously, responses of young children should fit into a general pattern of what the clinician suspects from parent interview and symptoms. One or two worrisome responses should not stand on their own as proof for the etiology to a problem.

Beyond the physician–child–parent triad. Many toddlers are placed in the care of a day care provider, babysitter, or relative. Virtually all children older than age 5 years of age spend a large portion of their waking hours in school. Yet despite this, clinicians traditionally rely almost exclusively on parents (and the children themselves) to gather a behavioral history. Some clinicians send questionnaires to school staff to elicit information, or they ask parents about their children’s progress at school or day care. It is rare, however, for clinicians to routinely engage in direct telephone contact with child care providers and teachers. Yet these people occupy many, and occasionally most, of children’s waking hours. The value of attaining parental permission to speak directly with educational professionals in a child’s life cannot be overstated. Teachers and child care providers can provide valuable insight. Many have numerous years of experience with all types of children, and their observations rarely include the emotional biases that sometimes confound a parent’s interpretation and recollection of details. Once a behavior plan has been recommended, a relationship with daytime caretakers may extend the plan’s implementation to that setting and render it more effective.

Knowledge about stages of normal childhood development can assist a clinician with understanding the etiology of a maladaptive behavior. It can allow the clinician, and in turn the parent, to attribute an undesirable behavior to a developmental stage of childhood. An understanding of child development can guide parents to respond to a child problem behavior using a strategy that is consistent with that child’s stage of development. For example, it is often appropriate to just give a firm “no” to a child’s behavior without any supportive reason when they are very young, but that response would be insufficient for an older child who has developed skills of reasoning.

Sigmund Freud’s psychoanalytic theories emphasized unconscious and conscious mental processes that children go through. Each stage, which is several years long, is a decisive turning point where a child can become vulnerable or strong for a certain characteristic. For example, according to this theory, in the anal stage at 1½ to 3 years of age, children are personally focused on elimination and interpersonally focused on “rebellion versus compliance” with parental demands. At this stage, they may fear loss of parental love. Erik Erickson’s stages are an expanded version of psychoanalytic theory, and his teachings can help clinicians and parents understand children’s psychosocial development. Infants develop trust or mistrust through their experiences up to about age 18 months. In the next stage (ending around age 3 years), children develop autonomy versus doubt in themselves. And in preschool (up to age 6 years), children learn to either take initiative, or feel inhibited to do so. Through school age, children can acquire the psychological skills to feel competent in work, versus repeated frustration and feelings of inferiority. No one stage is ever really resolved completely forever, but the experience of those critical years are present in some way as the person moves throughout life.

Jean Piaget described stages of cognitive development. Though his theories have since been proven to underestimate children’s abilities, they are still very useful guides. For example, until around age 7 years, children are what Piaget termed as “preoperational.” They engage in make believe, and parents should not misconstrue this as lying. Complex concepts, such as cause and effect, are not yet developed. Parents must not get frustrated by trying to rationalize with them by using logic. Once well into elementary school, they are at the “concrete operational” stage, meaning they are less egocentric and understand how events outside of their own actions can lead to concrete changes. Hence, parental explanations for behavior are important for children at this age. Adolescence is marked by the increasing ability to work with abstract concepts. They test out these new skills by how they interact with their peers. They can begin to moralize about their own and others’ behaviors.