When you assess and address a child or an adolescent’s mental and behavioral health problems, you often direct caregivers to resources or interventions that they will deliver themselves. After all, most care for persons is delivered at home—where children are welcomed, fed, cleaned, taught, and nurtured. Motivated caregivers can implement evidence-supported care strategies that they learn from you or from handouts, books, Web sites, or videos you recommend. As noted in Chapter 2, “Addressing Behavioral and Mental Problems in Community Settings,” such bibliotherapy has shown clinical effectiveness in some situations. Pediatric primary care practitioners tend to be particularly skilled in the realm of offering psychosocial intervention advice, because a key part of that professional role is offering parenting advice and anticipatory guidance.
This chapter contains selected highlights from among the psychosocial intervention strategies and tips we often describe for caregivers. Their inspiration comes from many different sources, including lessons from different lines of clinical research, general professional consensus, and personal experience (Chorpita and Daleiden 2009; Hilt 2014; Jellinek et al. 2002). This is not meant to be an exhaustive list of psychosocial strategies but rather a few we think you may find useful. These may be either sufficient on their own to resolve a mild concern or used to supplement specialist-delivered services.
Time-out is a strategy by which caregivers shape a young child’s behavior through selective and temporary removal of that child’s access to desired attention, activities, or other reinforcements following a behavioral transgression. This strategy works only for a child who experiences regular positive 258praise and attention from his caregiver because the child feels motivated to maintain that positive regard. The temporary removal of desired attention from a time-out can happen anywhere, not just via physically placing a child into a designated time-out area.
It is often said that the length of a time-out should be about 1 minute for each year of age, but adjustments need to be made on the basis of developmental level—for instance, time-outs for a developmentally delayed child should have shorter durations.
Although time-outs may be simple in concept, they are often difficult to implement. The following is a list of parent tips for time-out.
• To avoid confusion, set consistent limits.
• Focus on changing the priority misbehaviors rather than everything at once.
• After announcing time-out, decline further verbal engagement until “time-in.”
• Ensure that time-outs occur immediately after misbehavior instead of being delayed.
• Follow through if using warnings (e.g., I’m going to count to three...).
• Minimize reinforcement of misbehavior with calm, quiet limit-setting.
• State when the time-out is over (the child does not determine this). Setting a timer may help.
• When the time-out finishes, simply “resume business as usual” or congratulate the child on regaining personal control. Then look for the next positive behavior to praise.
• For time-outs to help, give children far more positive attention than negative attention.
Special time is a way for a caregiver and young child to reestablish the enjoyment of each other’s company. Sometimes this reestablishment of positive caregiver-child interactions alone will be able to resolve a chronic behavior problem. Special time also can be referred to as child-directed play because it emphasizes that parents spend that time following their child’s lead and attending to what the child can do. The following is a list of parent tips for successful use of special time.
259• Commit to setting aside a regular time to try this with your child. Daily is best, but two to three times a week consistently also works.
• Select time of day, labeling it as something like our play time or our special time.
• Choose a time short enough that it can happen reliably, usually 15–30 minutes.
• Once this one-on-one time is planned, ensure that it happens no matter how good or bad the day was.
• Allow child to pick the together activity, which must be something you do not actively dislike and that does not involve spending money or completing a chore.
• Follow the child’s lead during play, resisting urges to tell him or her what to do.
• End on time; a timer may help. Remind the child when the next special time will be.
• If the child refuses at first, explain that you will just sit with him for his special time.
• Expect greater success if you as a caregiver get your own special or nurturing times too.
Functional analysis is a general strategy for resolving a recurrent problem behavior. Functional analysis is most often cited as a treatment for a child with developmental impairments or a limited verbal capacity, but its principles apply to any child. The objective is to first identify why a behavior keeps recurring and then intelligently devise a plan to prevent future repetitions.
For instance, imagine a young child throws tantrums during trips to stores. When a health care practitioner helps to analyze the behavior’s function, the child’s caregiver realizes he has been giving the child candy to halt the tantrums, which for the child functionally serves to reward the behavior and encourage it to happen again. If the caregiver chooses to stop delivering these unintentional rewards, the tantrum behavior would be theorized to decrease, although usually after a temporary increase in the behavior while the child tests out the new rules (an extinction burst). Alternatively, a caregiver may focus on avoiding reexposing the child to a recognized behavior trigger, such as no longer bringing the child into a store’s candy aisle. The following is a list of tips 260for performing a functional analysis of behavior (Hanley et al. 2003; Hilt 2014).
1. Identify the behavior.
• Determine the character, timing (especially what happens before and after), frequency, and duration of the behavior.
2. Analyze and hypothesize about the behavior’s function.
• Achieve a goal. This might include escaping an undesired situation, avoiding a transition, acquiring attention, or getting access to desired things.
• Communicate. Maladaptive behavior may communicate physical or emotional discomfort.
• If no function is clear, other causes such as medical or psychiatric disorders, medication side effects, and sleep deprivation become more likely.
3. Make a change, usually changing something in the environment.
• Remove future reinforcements for the maladaptive behavior (attention or other gains).
• Avoid known behavioral triggers.
• Modify task demands to be appropriate for developmental stage and language ability.
• Reinforce positive behaviors with attention and praise.
• Enhance communication (e.g., helping a nonverbal child use pictures to communicate).
• Clarify any unclear expectations—show or follow a daily schedule; prepare a child for transitions.
• Allow child access to escapes when overwhelmed (time limited in a calm, quiet place).
4. Analyze if the interventions worked, and if not, repeat the process.
• Look for improvements in the behavior’s timing, character, frequency, and duration.
Behavioral activation is a way to help a young person reengage with other people. When a young person is sad or worried, he is less likely to engage in the activities he typically enjoys, and this 261withdrawal from otherwise pleasurable activities deepens his isolation and lowers mood. Therefore, despite other areas of difference, most cognitive-behavioral therapies for depression and anxiety will seek behavioral activation. After all, the path to recovery from depression and anxiety does not begin with spending all your time alone in a darkened room.
In behavioral activation, a person pushes himself to more regularly do things that he finds pleasurable or that serve his goals. If he can accomplish this behavioral activation, his symptoms usually will improve. The challenge is to create the necessary motivation when feeling depressed or anxious. The following is a list of tips for succeeding with behavioral activation.
• Identify activities that you (not others) would find motivating or rewarding. Work on developing a variety of options because repetitively doing the same thing can get boring.
• Refine the list to things that can be measured as completed rather than relatively vague goals that you cannot determine whether they are completed.
• Rank the activities in order from those that would be easier to those that would be more difficult to complete.
• Start by selecting something easy to accomplish to get started and work your way up the list from there.
• Let others know your plans to increase your activities and enlist their help in motivating you further.
For years, it has been recognized that bullying is both common and harmful for both the victim and the perpetrator. If you notice a relatively sudden change in a child’s mood, behavior, sleep, or body symptoms or any sudden change in social or academic functioning, then you should consider the possibility he is being bullied.
If bullying is discovered, it is often challenging for an adult to know how to respond. The following is a list of tips for how to respond to bullying (Buxton et al. 2013; Hilt 2014).
1. Detect
• Ask the child: “I know kids sometimes get picked on or bullied. Have you ever seen this happen? Has this ever happened to you?”
262• If the child says no, but you still suspect bullying, have caregivers ask teachers about bullying and/or review the child’s social media accounts.
2. Educate
• Let children know that bullying is unacceptable and that if they encounter bullying, you will help them respond.
3. Plan
• Coach the child to avoid places where bullying happens.
• Teach the child to walk away when bullying occurs and tell a trusted adult who can be accessed quickly.
• Instruct the child to stay near adults—most bullying happens when no adults are around.
• If a child feels that he can confront the bully, teach him to say, in a calm, clear voice, to stop the behavior, that “bullying is not OK.”
• Note that if a child is comfortable with deflating situations with humor, he may use humor to challenge the bullying.
• Encourage a child to ask his peers for their support and ideas.
• Ensure that caregivers communicate the problem to a child’s school and other families, jointly devising solutions.
4. Support
• Tell caregivers to encourage participation in prosocial activities to build peer networks, enhance social skills, and gain confidence. Additional information is available on Web sites such as www.stopbullying.gov.
Sleep hygiene is a good idea for anyone, but especially for young people. Insomnia is a common problem among children and adolescents. Most sleep problems can be resolved by changing habits and routines that affect sleep, what practitioners call good sleep hygiene. The following is a list of parent tips for how to improve sleep hygiene (Hilt 2014; Mindell and Owens 2009).
263• Maintain consistent bedtimes and wake times every day of the week.
• Maintain a routine of presleep activities (e.g., read a book, brush teeth).
• Avoid spending nonsleep time in or on one’s bed (i.e., “beds are for sleep”).
• Ensure that the bedroom is cool and quiet.
• Avoid high-stimulation activities just before bed or during awakenings (television, video games, texting friends, or exercise).
• Do not keep video games, televisions, computers, or phones in a child’s bedroom.
• Do physical exercise earlier in the day to help with sleep hours later.
• Avoid caffeine in the afternoons and evenings, which can cause shallow sleep or frequent awakenings.
• If awake in bed and unable to sleep, get out of bed for a low-stimulation activity, (e.g., reading), then return 20–30 minutes later. This keeps the bed from becoming associated with sleeplessness.
• Encourage children and adolescents to discuss any worries with a caregiver before bed rather than ruminating later.
• Ensure that children go to bed drowsy but still awake. Falling asleep in other places forms habits that are difficult to break.
• Use security objects at bedtime for a young child who needs a transitional object with which to feel safe and secure when his caregiver is not present.
• When checking on a young child at night, aim to only briefly reassure the child that you are present and that he is OK.
• Avoid afternoon naps for all but the very young because they often interfere with nighttime sleep.
• If a child or an adolescent is still having difficulties, keep a sleep diary to help you track his naps, sleep times, and activities to identify patterns.
From time to time, major crisis events happen with young people. This might involve a major argument, an emotional trauma, or a child threatening to hurt himself. The first steps 264are to address any acute safety concerns and obtain any necessary professional assistance. Afterward, it can be helpful to develop a prevention plan for future crises. The following is a list of parent tips for postcrisis planning in the home.
1. In the home environment, maintain a “low-key” atmosphere and keep up regular routines.
2. Follow typical house rules, but pick your battles; for example:
• If a child engages in aggressive or dangerous behaviors, intervene immediately.
• If a child is using oppositional words, you may be able to ignore those words.
3. Provide appropriate supervision until the crisis is resolved (i.e., always have an adult around).
4. Make a specific crisis prevention plan:
• Identify likely triggers for a crisis (such as an argument).
• Plan with the child what to do the next time the triggers occur (e.g., remove self from the situation until feeling calm again, call a friend, engage in a distracting activity).
5. Encourage your child to attend school, unless otherwise directed by a practitioner.
6. Attend the next scheduled appointment with your practitioner.
7. Administer medications as directed by the child’s medical or psychiatric practitioner.
8. Enter into each day and evening with a plan for how time will be spent—this should help prevent boredom and arguments in the moment.
9. If there are self-harm risks, secure and lock up all medications and objects a child or an adolescent could use to hurt himself, including
• Sharp objects such as knives and razors
• Materials that can be used for strangulation attempts, such as belts, cords, ropes, and sheets
• Firearms and ammunition (locked and kept in separate locations from each other)
• Medications of all family members, including all over-the-counter medicines
26510. In the event of another crisis,
• Contact your health care provider.
• Call 911 to have your child transported to the nearest emergency department if you believe that he, yourself, or another person is no longer safe as a result of his behavior.
• Consider using local and national crisis and suicide hotlines.266