Social Interaction

1. Key Points of Social Interaction
2. Definitions of Social Interaction
3. Differential Diagnosis of Social Interaction
4. Management of Social Interaction
5. Interpersonal intelligence
   1. Key Points of Interpersonal Intelligence
6. Negative Emotional Behaviors
   1. Key Points of Negative Emotional Behaviors
   2. Definitions of Negative Emotional Behaviors
   3. Clinical Guides for Negative Emotional Behaviors(See Clinical Guide Algorithm)
   4. Differential Diagnosis of Negative Emotional Behaviors
   5. Management of Negative Emotional Behaviors
   6. Co-Morbid Conditions of Negative Emotional Behaviors
7. Aggression/Oppositionality
   1. Key Points of Aggression/Oppositionality
   2. Definitions of Aggression/Oppositionality
   3. Clinical Guide for Aggression/Oppositionality (See: Clinical Guide Algorithm)
   4. Differential Diagnosis of Aggression/Oppositionality (algorithm)
   5. Management of Aggression/Oppositionality
   6. Comorbid Conditions of Aggression/Oppositionality
8. Secretive Antisocial Behavior
   1. Key Points of Secretive Antisocial behavior
   2. Definitions of Secretive Antisocial behavior
   3. Clinical Guides for Secretive Antisocial Behaviors (See Clinical Guide Algorithm)
   4. Differential Diagnosis of Secretive Antisocial Behaviors
   5. Management of Secretive Antisocial Behaviors
   6. Comorbid Conditions of Secretive Antisocial behavior
9. Tools
10. Exposure to Violence Screening Measure
11. Citations
12. Resources for Parents

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• Overview of Infant Social Development: 1)In infancy, psychosocial development occurs almost entirely in the context of the family and other close caregivers. From birth to 12 months, it is through responsive interactions with parents and a few other special caregivers that infants develop a sense of a safe, interesting, and orderly world. Learning that they can depend on being cared for and being kept safe helps infants build both a sense of trust in their ability to communicate their needs and wants and a sense of security that influences their inclination to explore. 2) Exploration takes center stage as infants become more mobile. It is important for parents to remember that infants at this stage practice independence but very much need trusted adults as a secure base of support. During the first year, children make use of new physical, cognitive, social, and emotional abilities and the connections among them to discriminate between familiar and unfamiliar people. Almost all infants during this period show stranger anxiety toward unfamiliar people. 3) The period from 12-36 months is filled with exploration, discovery, and determination to find meaning and relationships in events, objects, and words. At about 18 months of age, the focus shifts to issues of identity, autonomy, power, and control. 4) As part of their social development, toddlers begin to move away from their parents, but they also learn now to maintain and reestablish the relationship by coming back. Toddlers know that if they run away, parents, will come and swoop them up. But as children get father away from their secure base, or if parents or caregivers are not available for refueling, the child will engage in what Margaret Mahler refers to as "wooing." In cases in which toddlers are not sure that their parents will be there, they use up all their energy "wooing" instead of exploring new territory. 5) By two years of age, the task of forming an attachment to a primary caregiver is largely accomplished, and the toddler's task is to draw on that attachment to function independently. The average 3-year-old can separate easily from parents and go to known adults; however, there is great variability, related largely to temperament. Children with difficult attachment histories may react to separation with either clinginess and fear or indiscriminate sociability.
  1)In infancy, psychosocial development occurs almost entirely in the context of the family and other close caregivers. From birth to 12 months, it is through responsive interactions with parents and a few other special caregivers that infants develop a sense of a safe, interesting, and orderly world. Learning that they can depend on being cared for and being kept safe helps infants build both a sense of trust in their ability to communicate their needs and wants and a sense of security that influences their inclination to explore. 2) Exploration takes center stage as infants become more mobile. It is important for parents to remember that infants at this stage practice independence but very much need trusted adults as a secure base of support. During the first year, children make use of new physical, cognitive, social, and emotional abilities and the connections among them to discriminate between familiar and unfamiliar people. Almost all infants during this period show stranger anxiety toward unfamiliar people. 3) The period from 12-36 months is filled with exploration, discovery, and determination to find meaning and relationships in events, objects, and words. At about 18 months of age, the focus shifts to issues of identity, autonomy, power, and control. 4) As part of their social development, toddlers begin to move away from their parents, but they also learn now to maintain and reestablish the relationship by coming back. Toddlers know that if they run away, parents, will come and swoop them up. But as children get father away from their secure base, or if parents or caregivers are not available for refueling, the child will engage in what Margaret Mahler refers to as "wooing." In cases in which toddlers are not sure that their parents will be there, they use up all their energy "wooing" instead of exploring new territory. 5) By two years of age, the task of forming an attachment to a primary caregiver is largely accomplished, and the toddler's task is to draw on that attachment to function independently. The average 3-year-old can separate easily from parents and go to known adults; however, there is great variability, related largely to temperament. Children with difficult attachment histories may react to separation with either clinginess and fear or indiscriminate sociability.
• Trigger Questions: 1) How does _____ act around family members? 2) How does she/he react to strangers? 3) How is child care (preschool, kindergarten) going? (as related to separation) 4) How do you deal with temper tantrums? 5) What do you and your partner enjoy most about _____? 6) What seems to be most difficult?
  1) How does _____ act around family members? 2) How does she/he react to strangers? 3) How is child care (preschool, kindergarten) going? (as related to separation) 4) How do you deal with temper tantrums? 5) What do you and your partner enjoy most about _____? 6) What seems to be most difficult?
• Normative Social Milestones Through Age 3: Adapted from Healthy Steps Interactive Multimedia Training and Resource Kit (2000). Independent Production Fund; Toby Levine Communications, Inc.; and the Boston University School of Medicine, Department of Pediatrics
  Adapted from Healthy Steps Interactive Multimedia Training and Resource Kit (2000). Independent Production Fund; Toby Levine Communications, Inc.; and the Boston University School of Medicine, Department of Pediatrics
• Perspective taking: Selman Stages of Perspective Taking
  Selman Stages of Perspective Taking
• Self-Awareness: Identifying one's thoughts, feelings, and strengths, and recognizing how they influence one's choices and actions.
  Identifying one's thoughts, feelings, and strengths, and recognizing how they influence one's choices and actions.
• Social Awareness: Identifying and understanding the thoughts and feelings of others, respecting their rights, and appreciating diversity.
  Identifying and understanding the thoughts and feelings of others, respecting their rights, and appreciating diversity.
• Self-Management: Establishing and working toward short- and long-term goals, and handling emotions so that they facilitate rather than interfere with the task at hand.
  Establishing and working toward short- and long-term goals, and handling emotions so that they facilitate rather than interfere with the task at hand.
• Responsible Decision Making: Generating, implementing, and evaluating positive and informed solutions to problems, and assuming responsibility for personal decisions and behaviors.
  Generating, implementing, and evaluating positive and informed solutions to problems, and assuming responsibility for personal decisions and behaviors.
• Relationship Skills: Communication, listening, and negotiation skills to establish and maintain healthy and rewarding connections with individuals and groups.
  Communication, listening, and negotiation skills to establish and maintain healthy and rewarding connections with individuals and groups.
• Key Points: Acquiring self-care skills is a major area of mastery which symbolizes growing independence and self control to the child.
  Acquiring self-care skills is a major area of mastery which symbolizes growing independence and self control to the child.
• Management: 1) Advise parents to begin predictable fun routines such as brushing teeth and hand washing at a young age, to reduce resistance, facilitate learning, and teach the ability to tolerate necessary discomfort. 2) Encourage parents to use self-care as an opportunity for the child to make choices (within those acceptable to the family) and to act independently, e.g., choosing clothing, bathing themselves. Remind parents that children need extra time and chances to make mistakes during this learning process. Small steps towards success should be praised. 3) Anticipate regressions in self care at times of stress or transition and encourage the family to accept these and to assist the child rather than criticizing her. 4) Consider that temper tantrums during self-care may point to a weakness in skills that needs to be evaluated or suggest too much pressure or restriction by parents. 5) For children with fine-motor delays or deficits: Suggest accommodations such as loose-fitting clothing, angled spoons, or other adaptive equipment so that children can maximally care for themselves. Occupational therapists can advise on specific equipment and provide teaching. 6) Parents who are having trouble allowing their child to mature may be underestimating their child's abilities. Parenting groups or classes, Mothers Morning Out, and other opportunities to talk with parents of similar age children can help with developing realistic goals. Discuss the risk of oppositional behavior resulting from parental interference in self-care. 7) Discuss self-care routines as "transitions"
  1) Advise parents to begin predictable fun routines such as brushing teeth and hand washing at a young age, to reduce resistance, facilitate learning, and teach the ability to tolerate necessary discomfort. 2) Encourage parents to use self-care as an opportunity for the child to make choices (within those acceptable to the family) and to act independently, e.g., choosing clothing, bathing themselves. Remind parents that children need extra time and chances to make mistakes during this learning process. Small steps towards success should be praised. 3) Anticipate regressions in self care at times of stress or transition and encourage the family to accept these and to assist the child rather than criticizing her. 4) Consider that temper tantrums during self-care may point to a weakness in skills that needs to be evaluated or suggest too much pressure or restriction by parents. 5) For children with fine-motor delays or deficits: Suggest accommodations such as loose-fitting clothing, angled spoons, or other adaptive equipment so that children can maximally care for themselves. Occupational therapists can advise on specific equipment and provide teaching. 6) Parents who are having trouble allowing their child to mature may be underestimating their child's abilities. Parenting groups or classes, Mothers Morning Out, and other opportunities to talk with parents of similar age children can help with developing realistic goals. Discuss the risk of oppositional behavior resulting from parental interference in self-care. 7) Discuss self-care routines as "transitions"
• Helping toddlers get dressed without a battle: 1) Choose clothing that is easy to put on (Sweatpants and leggings, clothing with large arm and neck holes and few fasteners, Velcro) 2) Give toddlers limited choices (two or three acceptable outfits chosen by parent) This gives children some control and may prevent battles. 3) Allow extra time 4) Prepare the toddler in advance 5) Use distraction (singing, talking, etc.) or make dressing a game 6) Praise for compliance 7) Discuss "getting dressed" as a transition
  1) Choose clothing that is easy to put on (Sweatpants and leggings, clothing with large arm and neck holes and few fasteners, Velcro) 2) Give toddlers limited choices (two or three acceptable outfits chosen by parent) This gives children some control and may prevent battles. 3) Allow extra time 4) Prepare the toddler in advance 5) Use distraction (singing, talking, etc.) or make dressing a game 6) Praise for compliance 7) Discuss "getting dressed" as a transition
• smooth transitions: Definition of transitions: the time periods in which a parent moves the child's focus from playing to what the parent needs him or her to do 1) Ask the parent which are the hardest transitions for the parent and child. 2) Some of the hardest transitions may include: a) Starting the day after awakening b) Getting him or her dressed c) Sitting down for mealtime d) Getting the child into the car e) Starting bath time f) Getting the child into bed at nap or night 3) Suggest ways to the parent to better manage transitions: a) Give the child enough control so that the child feels as if she or he can do it herself or himself. b) Prepare the child and anticipate concerns so that she or he will know what to expect. c) Give the child extra time and slow down. When the child senses that he or she is being rushed, the child may resist the change and transition. d) Give the child choices so the child feels as if he or she has more control of the situation. e) Make it a game and playful in order to peak the child's interest. A related song during the transition can be both entertaining and enticing. f) Daily routines make it easier for the child to anticipate what is next. g) Rewards for a smooth transition are positive reinforcers and can be as simple as several extra minutes of the parent reading a bedtime story. h) Discourage threats (including those of separation) and punishment.
  Definition of transitions: the time periods in which a parent moves the child's focus from playing to what the parent needs him or her to do 1) Ask the parent which are the hardest transitions for the parent and child. 2) Some of the hardest transitions may include: a) Starting the day after awakening b) Getting him or her dressed c) Sitting down for mealtime d) Getting the child into the car e) Starting bath time f) Getting the child into bed at nap or night 3) Suggest ways to the parent to better manage transitions: a) Give the child enough control so that the child feels as if she or he can do it herself or himself. b) Prepare the child and anticipate concerns so that she or he will know what to expect. c) Give the child extra time and slow down. When the child senses that he or she is being rushed, the child may resist the change and transition. d) Give the child choices so the child feels as if he or she has more control of the situation. e) Make it a game and playful in order to peak the child's interest. A related song during the transition can be both entertaining and enticing. f) Daily routines make it easier for the child to anticipate what is next. g) Rewards for a smooth transition are positive reinforcers and can be as simple as several extra minutes of the parent reading a bedtime story. h) Discourage threats (including those of separation) and punishment.
• Shyness and introversion: Shy individuals avoid social contact and sometimes fear it; introverts simply prefer being alone over social activities and do not have trouble interacting and socializing with others as many shy people experience.
  Shy individuals avoid social contact and sometimes fear it; introverts simply prefer being alone over social activities and do not have trouble interacting and socializing with others as many shy people experience.
• shy: Shyness, or "behavioral inhibition to the unfamiliar", evidences significant heritablity. Research has shown that having an inhibited behavioral style as early as age 2 years may predispose one to social anxiety in adolescence. Also inhibition has been shown to manifest as early as 4-months of age and to be moderately stable over the course of development. 1) Shyness may be associated with low threshold for arousal in forebrain limbic areas. 2) Among adults about 40% describe themselves as shy to such a degree that it interferes with daily life. Symptoms of shyness may include, but are not limited to, self-consciousness, embarrassment interacting with others, avoidance of social situations, dry mouth, racing heart, and speech idiosyncrasies or dysfluencies, usually all when presented with the possibility or reality of social interaction. More serious symptoms may indicate an anxiety disorder.
  Shyness, or "behavioral inhibition to the unfamiliar", evidences significant heritablity. Research has shown that having an inhibited behavioral style as early as age 2 years may predispose one to social anxiety in adolescence. Also inhibition has been shown to manifest as early as 4-months of age and to be moderately stable over the course of development. 1) Shyness may be associated with low threshold for arousal in forebrain limbic areas. 2) Among adults about 40% describe themselves as shy to such a degree that it interferes with daily life. Symptoms of shyness may include, but are not limited to, self-consciousness, embarrassment interacting with others, avoidance of social situations, dry mouth, racing heart, and speech idiosyncrasies or dysfluencies, usually all when presented with the possibility or reality of social interaction. More serious symptoms may indicate an anxiety disorder.
• seek ways to overcome: Given the value modern society places on being out-going, treatments geared primarily for adolescents and adults are available for "shyness". Treatment modalities include but are not limited to social skills training, flooding, in-vivo exposure, assertiveness training, self-concept restructuring.
  Given the value modern society places on being out-going, treatments geared primarily for adolescents and adults are available for "shyness". Treatment modalities include but are not limited to social skills training, flooding, in-vivo exposure, assertiveness training, self-concept restructuring.
• fostering healthy peer relations: Children who are rejected by peers have more academic and behavioral problems while children who are neglected by peers appear to actually quite well academically. For children who are already "at-risk", healthy peer relations and the social support they imbue may serve as a protective buffer that shields the child from the otherwise damaging effects of poverty, violence, family mental illness and other environmental or familial risk factors.
  Children who are rejected by peers have more academic and behavioral problems while children who are neglected by peers appear to actually quite well academically. For children who are already "at-risk", healthy peer relations and the social support they imbue may serve as a protective buffer that shields the child from the otherwise damaging effects of poverty, violence, family mental illness and other environmental or familial risk factors.
• Guide child through social conflicts: Usually by age 4 children are able to do some problem solving on their own (at least partially). With guidance they will become more skilled.
  Usually by age 4 children are able to do some problem solving on their own (at least partially). With guidance they will become more skilled.
• Capacity for intrapersonal intelligence is localized in the frontal lobes.: Damage to this area can result in severe or acute impairment of intrapersonal and/or interpersonal knowledge and functioning. Yet even with severe brain injury in the frontal lobes, other forms of intelligence may remain intact. The effect is similar in some developmental disorders, such as autism spectrum disorders, where the capacity for making and maintaining interpersonal relationships is severely impaired, but other intelligences are functional or even enhanced.
  Damage to this area can result in severe or acute impairment of intrapersonal and/or interpersonal knowledge and functioning. Yet even with severe brain injury in the frontal lobes, other forms of intelligence may remain intact. The effect is similar in some developmental disorders, such as autism spectrum disorders, where the capacity for making and maintaining interpersonal relationships is severely impaired, but other intelligences are functional or even enhanced.
• Trigger questions: 1)How does s/he seem to feel when acting badly? When punished? 2) How much time do you have with him/her alone each day? How about your partner? 3) (To child) Would you say you are a good boy or a bad boy? 4) (To child) What do your parents do when you do something bad? What do you think they should do? 5) (To child) Do you get enough time alone with your mom? Dad?
  1)How does s/he seem to feel when acting badly? When punished? 2) How much time do you have with him/her alone each day? How about your partner? 3) (To child) Would you say you are a good boy or a bad boy? 4) (To child) What do your parents do when you do something bad? What do you think they should do? 5) (To child) Do you get enough time alone with your mom? Dad?
• Temperament: Ask parents who the child "takes after" to elicit a description of temperament and parental projections. Check the child adjective checklist to get a sense of the parent's perception of the child's temperament or have the parents fill out a standard temperament questionnaire.
  Ask parents who the child "takes after" to elicit a description of temperament and parental projections. Check the child adjective checklist to get a sense of the parent's perception of the child's temperament or have the parents fill out a standard temperament questionnaire.
• give caregiver book to read: Understanding Your Child's Temperament, by William B. Carey, Martha M. Jablow, C. Everett Koop, 1997, Macmillan General Reference.
  Understanding Your Child's Temperament, by William B. Carey, Martha M. Jablow, C. Everett Koop, 1997, Macmillan General Reference.
• lack of sleep: makes children vulnerable to aggressive behaviors due to the fact that they are often tired, hungry, or stressed by irregular, unusual demands.
  makes children vulnerable to aggressive behaviors due to the fact that they are often tired, hungry, or stressed by irregular, unusual demands.
• inadequate attention: Children will do anything to engage caregivers including the opposite of what is asked.
  Children will do anything to engage caregivers including the opposite of what is asked.
• witness to violence: Children viewing violence may model after it. Children with a traumatic experience may feel guilty and act up to elicit punishment. Family members experiencing trauma may change their parenting. Trigger questions to ask if Age = Early Childhood 1) Have you ever been worried that someone was going to hurt your child? 2) Has your child ever been abused? 3) Do you feel safe in your neighborhood? Trigger questions to ask if age = Middle childhood 1) Have you ever been worried that someone was going to hurt your child? 2) Has your child ever been abused? 3) (To child) Has anyone tried to harm you physically? 4) (To child)Has anyone touched you in a way you didn't like? 5) Do you feel safe in your neighborhood? Does Johnny feel safe? Adapted from: Jellinek MS. Bright Futures in Practice, Mental Health (2002). Georgetown University: National Center for Education in Maternal and Child Health.
  Children viewing violence may model after it. Children with a traumatic experience may feel guilty and act up to elicit punishment. Family members experiencing trauma may change their parenting. Trigger questions to ask if Age = Early Childhood 1) Have you ever been worried that someone was going to hurt your child? 2) Has your child ever been abused? 3) Do you feel safe in your neighborhood? Trigger questions to ask if age = Middle childhood 1) Have you ever been worried that someone was going to hurt your child? 2) Has your child ever been abused? 3) (To child) Has anyone tried to harm you physically? 4) (To child)Has anyone touched you in a way you didn't like? 5) Do you feel safe in your neighborhood? Does Johnny feel safe? Adapted from: Jellinek MS. Bright Futures in Practice, Mental Health (2002). Georgetown University: National Center for Education in Maternal and Child Health.
• tense family atmosphere: Trigger Questions: 1) How are things going in your family? 2) How are things with your marriage? 3) How are things sexually? 4) (To child)How do people get along at your house? Adapted from: Jellinek MS. Bright Futures in Practice, Mental Health (2002). Georgetown University: National Center for Education in Maternal and Child Health.
  Trigger Questions: 1) How are things going in your family? 2) How are things with your marriage? 3) How are things sexually? 4) (To child)How do people get along at your house? Adapted from: Jellinek MS. Bright Futures in Practice, Mental Health (2002). Georgetown University: National Center for Education in Maternal and Child Health.
• depressed or stressed caregiver.: Caregivers who are depressed, overburdened or under stress may have a low threshold for reacting to negative emotions in their children or may react irritably to normal behavior. Consider a questionnaire about perceived family stressors and their impact on family functioning.
  Caregivers who are depressed, overburdened or under stress may have a low threshold for reacting to negative emotions in their children or may react irritably to normal behavior. Consider a questionnaire about perceived family stressors and their impact on family functioning.
• insecure attachment: Securely attached children have more cooperative behavior and better peer relationships. Insecure attachment predisposes to suspicion of others and preemptive aggression.
  Securely attached children have more cooperative behavior and better peer relationships. Insecure attachment predisposes to suspicion of others and preemptive aggression.
• Aggression can be a part of normal development.: "Observational studies (Holmberg, 1977) indicate that approximately 50% of the social interchanges between children 12-18 months of age in a nursery school setting can be viewed as disruptive or conflictual. By age 2.5 years, the proportion of conflicted social interchanges decreases to 20%.".
  "Observational studies (Holmberg, 1977) indicate that approximately 50% of the social interchanges between children 12-18 months of age in a nursery school setting can be viewed as disruptive or conflictual. By age 2.5 years, the proportion of conflicted social interchanges decreases to 20%.".
• Rates: DSM-IV, American Psychiatric Association, 1994.
  DSM-IV, American Psychiatric Association, 1994.
• Combination of genetic, child, familial and environmental factors.: 1) Some evidence for heritability exists although these traits are by no means immutable. 2) Family factors such as inconsistent schedules, emotionally conflicted relationships and poor parenting may contribute. A learned pattern of coercive aggression among children whose parents are dismissive, overly hostile, negative and inconsistent is now widely accepted. In essence, the child who acts aggressively does so because it is the one way he has learned to get attention from parents who otherwise ignore or are hostile with him. The child's aggressive behavior escalates when reinforced. Parents can reinforce by giving in with attention, even if negative, overly harsh punishment, or by yielding to the child's demands. 3) Other factors contributing to the development and stability of aggression in childhood are rejection by peers early in grade school, media violence, and social skills deficits.
  1) Some evidence for heritability exists although these traits are by no means immutable. 2) Family factors such as inconsistent schedules, emotionally conflicted relationships and poor parenting may contribute. A learned pattern of coercive aggression among children whose parents are dismissive, overly hostile, negative and inconsistent is now widely accepted. In essence, the child who acts aggressively does so because it is the one way he has learned to get attention from parents who otherwise ignore or are hostile with him. The child's aggressive behavior escalates when reinforced. Parents can reinforce by giving in with attention, even if negative, overly harsh punishment, or by yielding to the child's demands. 3) Other factors contributing to the development and stability of aggression in childhood are rejection by peers early in grade school, media violence, and social skills deficits.
• Can be a precursor of Conduct Disorder in adolescence.: Two developmental pathways have been proposed: the early starter and late starter. Early starters develop Oppositional Defiant Disorder early in the preschool years and steadily progress to more serious antisocial behavior in adolescence. Late starters have normal early childhoods and engage in antisocial behavior beginning in adolescence. The prognosis is much more favorable for late starters.
  Two developmental pathways have been proposed: the early starter and late starter. Early starters develop Oppositional Defiant Disorder early in the preschool years and steadily progress to more serious antisocial behavior in adolescence. Late starters have normal early childhoods and engage in antisocial behavior beginning in adolescence. The prognosis is much more favorable for late starters.
• ADHD: Up to 60% of children with oppositional behavior may have ADHD.
  Up to 60% of children with oppositional behavior may have ADHD.
• self-destructive, suicidal: Suicide accounts for 12% of mortality among adolescents in the US. Older adolescents (15-19 years) have a rate of suicide that is 8 times higher than younger adolescents (10-14 years).
  Suicide accounts for 12% of mortality among adolescents in the US. Older adolescents (15-19 years) have a rate of suicide that is 8 times higher than younger adolescents (10-14 years).
• substance misuse evaluation: 1.Perform a physical examination looking for signs of drug abuse. 2. Consider screening urine or blood for substances. 3. See the Substance Abuse section.
  1.Perform a physical examination looking for signs of drug abuse. 2. Consider screening urine or blood for substances. 3. See the Substance Abuse section.
• symptoms: (1)often loses temper (2) often argues with adults (3) often actively defies or refuses to comply with adults' requests or rules (4) often deliberately annoys people (5) often blames others for his or her mistakes or misbehavior (6) is often touchy or easily annoyed by others (7) is often angry and resentful (8) is often spiteful or vindictive
  (1)often loses temper (2) often argues with adults (3) often actively defies or refuses to comply with adults' requests or rules (4) often deliberately annoys people (5) often blames others for his or her mistakes or misbehavior (6) is often touchy or easily annoyed by others (7) is often angry and resentful (8) is often spiteful or vindictive
• Elicit specific examples of misbehavior: Examples will help determine parent management, which may be appropriate or may promote the problem. Trigger questions: 1) Can you recall a recent example -what did you do about it? 20 What have you done so far to correct the problem?
  Examples will help determine parent management, which may be appropriate or may promote the problem. Trigger questions: 1) Can you recall a recent example -what did you do about it? 20 What have you done so far to correct the problem?
• Assess intensity: Trigger Question: How bad goes it get?
  Trigger Question: How bad goes it get?
• Assess interference with family functioning.: Trigger Questions: 1) What is it like for you at home? 2) Has this behavior problem changed your daily life?
  Trigger Questions: 1) What is it like for you at home? 2) Has this behavior problem changed your daily life?
• cognitive delay: Check the results of the START developmental screening or perform an academic screen. 1) Refer for developmental evaluation if you can't rule out delay 2) Child Find evaluation (early intervention age 3-5) 3) Psychoeducational testing at school
  Check the results of the START developmental screening or perform an academic screen. 1) Refer for developmental evaluation if you can't rule out delay 2) Child Find evaluation (early intervention age 3-5) 3) Psychoeducational testing at school
• adjust parenting strategies appropriately for mental age: 1) Consider whether expectations are appropriate for the child's abilities. 2) Determine if oppositional only in situations which stress their abilities 3) Consider transfer to a less demanding setting. 4) Appropriate special education 5) Coach parents about expectations for the child's mental age. 6) Suggest that parents observe other children of that mental age (e.g., on playground) or read about normal skills for that mental age (see Gesell) to set new expectations.
  1) Consider whether expectations are appropriate for the child's abilities. 2) Determine if oppositional only in situations which stress their abilities 3) Consider transfer to a less demanding setting. 4) Appropriate special education 5) Coach parents about expectations for the child's mental age. 6) Suggest that parents observe other children of that mental age (e.g., on playground) or read about normal skills for that mental age (see Gesell) to set new expectations.
• sleep debt: Fatigued children are often irritable. School aged children need 9.5 or more good quality sleep. If sleep is disrupted or inadequate, treat that. 1) Explain the need for structure and consistency 2) Children who are overtired or overstressed have a hard time controlling their emotions. 3) Assess total sleep and sleep quality 4) Choose one particularly problematic area and work out a schedule 5) See the family back within a week or two to make adjustments as necessary. 6) Refer to the handouts on sleep routine, toilet training challenges, helping your child master self care, and eating as appropriate
  Fatigued children are often irritable. School aged children need 9.5 or more good quality sleep. If sleep is disrupted or inadequate, treat that. 1) Explain the need for structure and consistency 2) Children who are overtired or overstressed have a hard time controlling their emotions. 3) Assess total sleep and sleep quality 4) Choose one particularly problematic area and work out a schedule 5) See the family back within a week or two to make adjustments as necessary. 6) Refer to the handouts on sleep routine, toilet training challenges, helping your child master self care, and eating as appropriate
• mood disorders: 1) Assess suicidality 2) Make prompt mental health referral. 3) Continue intermittent visits to monitor progress/compliance and serve as a support person/ care coordinator.
  1) Assess suicidality 2) Make prompt mental health referral. 3) Continue intermittent visits to monitor progress/compliance and serve as a support person/ care coordinator.
• Asperger's disorder, Autism or Child Disintegrative Disorder: These Pervasive Developmental Disorders are typically, but not exclusively, diagnosed by the preschool years.
  These Pervasive Developmental Disorders are typically, but not exclusively, diagnosed by the preschool years.
• infant biting: Biting in infancy can be simply another way for babies to experiment with putting things in their mouths. Help parents to understand this, and to manage infant biting by: 1) Staying calm but giving a clear and strong message of disapproval followed by a 15 second "time out" in which the baby is put down 2) Clarifying those times when infants are biting due to hunger or teething 3) Making sure parents are not teaching infants not to bite by biting back. 4) Monitoring to make sure that the child is not being hurt by another child or caregiver 5) Monitoring for tension in the home, which may increase infant biting
  Biting in infancy can be simply another way for babies to experiment with putting things in their mouths. Help parents to understand this, and to manage infant biting by: 1) Staying calm but giving a clear and strong message of disapproval followed by a 15 second "time out" in which the baby is put down 2) Clarifying those times when infants are biting due to hunger or teething 3) Making sure parents are not teaching infants not to bite by biting back. 4) Monitoring to make sure that the child is not being hurt by another child or caregiver 5) Monitoring for tension in the home, which may increase infant biting
• Biting: Biting and other forms of aggression can be common during the toddler years, but are upsetting to parents, children, and victims. Toddler aggression can result from frustration at lack of verbal means of expression, lack of understanding of social rules, curiosity, boredom, anxiety, or teething. Help parents to determine the reason their child is being aggressive (e.g. excitement, anger, stress, imitating another child). The following can help to decrease toddler aggression: 1) Remaining calm, but separating biter and victim. Offer comfort to the victim to minimize attention to the biter. 2) Giving a clear and strong message of disapproval, offering an explanation of how the child's aggression hurts another child 3) Time out 4) Helping the child develop the words to express his feelings of anger or frustration 5) Helping the child develop other ways to vent anger or frustration (e.g. pounding a pillow) 6) Offer praise for cooperation 7) Make sure parents are not biting back to teach the child what it feels like 8) Monitor for cognitive/language delays that may increase frustration and therefore aggression 9) Monitor for cases in which the child is being hurt by other children or caregivers 10) Ask about daycare and whether caregivers give "positive attention" for good behavior and self-control 11) Monitor for excessive tension/yelling in the home, which may increase toddler aggression. 12) Ask about the amount of time the toddler spends with more advanced children. Too much time with more advanced children may overwhelm the child and increase his or her aggression.
  Biting and other forms of aggression can be common during the toddler years, but are upsetting to parents, children, and victims. Toddler aggression can result from frustration at lack of verbal means of expression, lack of understanding of social rules, curiosity, boredom, anxiety, or teething. Help parents to determine the reason their child is being aggressive (e.g. excitement, anger, stress, imitating another child). The following can help to decrease toddler aggression: 1) Remaining calm, but separating biter and victim. Offer comfort to the victim to minimize attention to the biter. 2) Giving a clear and strong message of disapproval, offering an explanation of how the child's aggression hurts another child 3) Time out 4) Helping the child develop the words to express his feelings of anger or frustration 5) Helping the child develop other ways to vent anger or frustration (e.g. pounding a pillow) 6) Offer praise for cooperation 7) Make sure parents are not biting back to teach the child what it feels like 8) Monitor for cognitive/language delays that may increase frustration and therefore aggression 9) Monitor for cases in which the child is being hurt by other children or caregivers 10) Ask about daycare and whether caregivers give "positive attention" for good behavior and self-control 11) Monitor for excessive tension/yelling in the home, which may increase toddler aggression. 12) Ask about the amount of time the toddler spends with more advanced children. Too much time with more advanced children may overwhelm the child and increase his or her aggression.
• unreasonable expectations: Ask parents about their child's level of self care (i.e. toileting, eating, dressing, homework) and at what age they expect a child to perform these tasks independently. Trigger questions to ask: 1) How is Johnny's doing with independence in toileting, dressing, eating, homework, etc....? 2) At what age do you expect him to be independent at these tasks?
  Ask parents about their child's level of self care (i.e. toileting, eating, dressing, homework) and at what age they expect a child to perform these tasks independently. Trigger questions to ask: 1) How is Johnny's doing with independence in toileting, dressing, eating, homework, etc....? 2) At what age do you expect him to be independent at these tasks?
• tantrums: 1) Tantrums represent the child's emotions going beyond their control. 2) Tantrums or "falling out" spells are nearly universal during toddlerhood and preschool. Children unable to tantrum may be insecure in their relationships although children of easy temperament may not tantrum. 3) Tantrums may start as early as 9 months but peak between 15-36 months with another peak at age 6 years. 4) Developmental gaps predispose to tantrums through frustration. Expressive language delay and fine motor delays are the most common precipitants. 5) Tantrums are often viewed as manipulative by parents even when they don't start out to be. However, tantrums often result in caregivers giving the child what they wanted quickly resulting in a manipulative habit (reinforcement). 6) Tantrums are more likely when the child is sleep deprived, at a tired time, hungry, needing attention or stressed. This can be helped by routines and adequate sleep. 7) Temperamentally intense or "difficult" children have more tantrums than "easy" children. 8) Some parents are better at easing children through transitions than others thus avoiding tantrums. Other parents seem to gain satisfaction on an unconscious level by frustrating their child. This is likely to be related to their own parents having done this to them during child rearing (See Social History) or a negative perception of this child (see adjective checklist results). Some caregivers covertly reinforce tantrums by giving extra attention or by punishing the child in the context of relatively low attention otherwise. 9) Inconsistency among caregivers can confuse and frustrate the child increasing tantrums. Consistency within the practices of an individual caregiver is more important, however, and inter-caregivers disputes are more damaging than inconsistency from the child's point of view. 10) Children with very severe tantrums may have a mental health disorder, especially Attention Deficit Hyperactivity Disorder or a Mood Disorder.
  1) Tantrums represent the child's emotions going beyond their control. 2) Tantrums or "falling out" spells are nearly universal during toddlerhood and preschool. Children unable to tantrum may be insecure in their relationships although children of easy temperament may not tantrum. 3) Tantrums may start as early as 9 months but peak between 15-36 months with another peak at age 6 years. 4) Developmental gaps predispose to tantrums through frustration. Expressive language delay and fine motor delays are the most common precipitants. 5) Tantrums are often viewed as manipulative by parents even when they don't start out to be. However, tantrums often result in caregivers giving the child what they wanted quickly resulting in a manipulative habit (reinforcement). 6) Tantrums are more likely when the child is sleep deprived, at a tired time, hungry, needing attention or stressed. This can be helped by routines and adequate sleep. 7) Temperamentally intense or "difficult" children have more tantrums than "easy" children. 8) Some parents are better at easing children through transitions than others thus avoiding tantrums. Other parents seem to gain satisfaction on an unconscious level by frustrating their child. This is likely to be related to their own parents having done this to them during child rearing (See Social History) or a negative perception of this child (see adjective checklist results). Some caregivers covertly reinforce tantrums by giving extra attention or by punishing the child in the context of relatively low attention otherwise. 9) Inconsistency among caregivers can confuse and frustrate the child increasing tantrums. Consistency within the practices of an individual caregiver is more important, however, and inter-caregivers disputes are more damaging than inconsistency from the child's point of view. 10) Children with very severe tantrums may have a mental health disorder, especially Attention Deficit Hyperactivity Disorder or a Mood Disorder.
• Trigger questions: 1)"How are tantrums?" 2) "What do you do when s/he has a tantrum?" 3) "What does his/her father (other caregivers) do about tantrums?" 4) "How bad does it get?" 5) "How does that make you feel?" 6) "When have you felt that way before sometime in your life?" 7) "What do you think it means when s/he has a tantrum?" 8) "Give me an example of a tantrum s/he has had recently." 9) "Who does s/he take after?"
  1)"How are tantrums?" 2) "What do you do when s/he has a tantrum?" 3) "What does his/her father (other caregivers) do about tantrums?" 4) "How bad does it get?" 5) "How does that make you feel?" 6) "When have you felt that way before sometime in your life?" 7) "What do you think it means when s/he has a tantrum?" 8) "Give me an example of a tantrum s/he has had recently." 9) "Who does s/he take after?"
• Normal tantrums: Anticipate the onset of tantrums by 12 months and check parental philosophy to avoid punishment but also avoid reinforcement through giving in. 1) Tantrums resulting in aggression should be managed for the aggression i.e. time out. 2) Educate parents about the importance of gradually gaining ability to tolerate frustration in little doses during toddlerhood for future adult functioning. 3) Caregivers can avoid tantrums by facilitating the child getting what they want but need to do this quickly before a tantrum starts to avoid reinforcement. Have them decide quickly what is acceptable for the child to have or do and provide it promptly.
  Anticipate the onset of tantrums by 12 months and check parental philosophy to avoid punishment but also avoid reinforcement through giving in. 1) Tantrums resulting in aggression should be managed for the aggression i.e. time out. 2) Educate parents about the importance of gradually gaining ability to tolerate frustration in little doses during toddlerhood for future adult functioning. 3) Caregivers can avoid tantrums by facilitating the child getting what they want but need to do this quickly before a tantrum starts to avoid reinforcement. Have them decide quickly what is acceptable for the child to have or do and provide it promptly.
• Severe tantrums: 1) Elicit a specific example of a tantrum and what the parent did about it. Look for the "A"ntecedants (circumstances, preceding actions by others)- "B"ehavior (what the child did) and "C"onsequences (what the caregiver did, or the result for the child) to analyze potential reinforcers. If reinforcement seems to be the source- coach on giving adequate attention when the child is doing well and distracting or ignoring when tantrums start. 2) Assure adequate sleep, food, and routines 3) Check developmental skills for gaps (See developmental items of Babybook). Perform a developmental assessment especially for fine motor and language skills and refer for habilitation if needed. 4) If parents have trouble tolerating their child's frustration, examine the reasons usually stemming from the parent's past, marital discord over child management, or vulnerable child syndrome. 5) If parents are overtly frustrating the child- ask about their own parents' child rearing and their perception of this child. 6) Coach on consistency within the practices of an individual caregiver and avoiding interference between caregivers. Tell them to practice "Whoever starts, finishes". 7) Check on quality of other childcare for sources of upset or frustration e.g. discipline, overwhelmed by older peers, neglect. If this is a major factor, suggest changing daycare. Consider a smaller family day care setting with a larger range in ages of children. Consider mental health disorders e.g. ADHD, mood disorders if the child is not functioning well, the family is very distressed, or there are other symptoms suggestive.
  1) Elicit a specific example of a tantrum and what the parent did about it. Look for the "A"ntecedants (circumstances, preceding actions by others)- "B"ehavior (what the child did) and "C"onsequences (what the caregiver did, or the result for the child) to analyze potential reinforcers. If reinforcement seems to be the source- coach on giving adequate attention when the child is doing well and distracting or ignoring when tantrums start. 2) Assure adequate sleep, food, and routines 3) Check developmental skills for gaps (See developmental items of Babybook). Perform a developmental assessment especially for fine motor and language skills and refer for habilitation if needed. 4) If parents have trouble tolerating their child's frustration, examine the reasons usually stemming from the parent's past, marital discord over child management, or vulnerable child syndrome. 5) If parents are overtly frustrating the child- ask about their own parents' child rearing and their perception of this child. 6) Coach on consistency within the practices of an individual caregiver and avoiding interference between caregivers. Tell them to practice "Whoever starts, finishes". 7) Check on quality of other childcare for sources of upset or frustration e.g. discipline, overwhelmed by older peers, neglect. If this is a major factor, suggest changing daycare. Consider a smaller family day care setting with a larger range in ages of children. Consider mental health disorders e.g. ADHD, mood disorders if the child is not functioning well, the family is very distressed, or there are other symptoms suggestive.
• Encourage Strengths: 1) Community service is source of skill building for child and families (e.g., Habitat for Humanity, soup kitchens, Candy Stripers, Salvation Army, church group activities). 2) Encourage extra curricular activities even when not doing well academically to help them to bond to the school or other social structure, stay motivated, and develop self esteem. 3) In some cases, the child should be required to participate. 4) Refer children to mentors for talents they have or interest areas even if their abilities are unknown. See resources by activity area. 5) Community service is source of skill building for child and families (e.g., Habitat for Humanity, soup kitchens, Candy Stripers, Salvation Army, church group activities).
  1) Community service is source of skill building for child and families (e.g., Habitat for Humanity, soup kitchens, Candy Stripers, Salvation Army, church group activities). 2) Encourage extra curricular activities even when not doing well academically to help them to bond to the school or other social structure, stay motivated, and develop self esteem. 3) In some cases, the child should be required to participate. 4) Refer children to mentors for talents they have or interest areas even if their abilities are unknown. See resources by activity area. 5) Community service is source of skill building for child and families (e.g., Habitat for Humanity, soup kitchens, Candy Stripers, Salvation Army, church group activities).
• social skills training intervention: This type of program will train children to improve social skills (empathy, listening, ascribing attributions) and problem-solving (resolving conflict, communication, understanding consequences). Comprehensive social skills programs that involve parents, are specifically geared for the age of the child, and focus on reducing aggression will be most effective.
  This type of program will train children to improve social skills (empathy, listening, ascribing attributions) and problem-solving (resolving conflict, communication, understanding consequences). Comprehensive social skills programs that involve parents, are specifically geared for the age of the child, and focus on reducing aggression will be most effective.
• If childcare or school setting is deficient: 1) Encourage parents to drop in at the day care to observe the quality of care 2) If attention to their child is inadequate, they may try to coach day care to do better 3) If nothing improves in 3 weeks or if family is dissatisfied, recommend new quality child care or school
  1) Encourage parents to drop in at the day care to observe the quality of care 2) If attention to their child is inadequate, they may try to coach day care to do better 3) If nothing improves in 3 weeks or if family is dissatisfied, recommend new quality child care or school
• If child is reacting to family event such as divorce, death or marital discord, have parents assure children it is not their fault: Some children feel that their bad behavior has lead to divorce, family strife, or other poor outcome. Directly tell child "It is not your fault" and coach child to tell themselves that it is not his/her fault. Tell parents this may be the case and that they should also reassure child.
  Some children feel that their bad behavior has lead to divorce, family strife, or other poor outcome. Directly tell child "It is not your fault" and coach child to tell themselves that it is not his/her fault. Tell parents this may be the case and that they should also reassure child.
• exposure to violence: Discuss the importance of limiting the child's exposure to violence via TV and video games. By the age of 18 most kids have been exposed to hundreds of thousands of acts of violence on television. Also a recent study found that all children's animated movies made from 1936 through 1999 contained violent acts.
  Discuss the importance of limiting the child's exposure to violence via TV and video games. By the age of 18 most kids have been exposed to hundreds of thousands of acts of violence on television. Also a recent study found that all children's animated movies made from 1936 through 1999 contained violent acts.
• Too lax: 1) Encourage avoiding rescuing child too quickly from difficulties to build competence. 2) Praise child for strength and resilience to accept failures and mistakes gracefully and continuing to try. 3) Adults model tolerance for their own mistakes. 4) Advise parental noninterference to allow children to solve interactional problems 5) Role play with child generating solutions and likely outcomes, especially possible impacts upon relationships. 6) Help parent detect a difference between the current situation and the past one (trigger) to remind to react differently. 7) Consider "nchor" (e.g., touch, thought, or phrase to remind that they and child are safe now). 8) Parents unable to make progress need mental health referral.
  1) Encourage avoiding rescuing child too quickly from difficulties to build competence. 2) Praise child for strength and resilience to accept failures and mistakes gracefully and continuing to try. 3) Adults model tolerance for their own mistakes. 4) Advise parental noninterference to allow children to solve interactional problems 5) Role play with child generating solutions and likely outcomes, especially possible impacts upon relationships. 6) Help parent detect a difference between the current situation and the past one (trigger) to remind to react differently. 7) Consider "nchor" (e.g., touch, thought, or phrase to remind that they and child are safe now). 8) Parents unable to make progress need mental health referral.
• Too strict limits: 1) Determine discipline philosophy and strategies for different child behaviors. 2) Ask child (3 and over): What happens when you do __? What do your parents do? What do you think about that? 3) Interpret pleasure in breaking rules as learning not criminality but that explanation and consequences are still needed. 4) Teach to explain rules calmly, require a consequence, and increase monitoring. 5) Educate in smaller consequences along with reasons. 6) Handout: Principles of limit setting 7) Advise to respond to aggression promptly, calmly and not excessively from an early age, showing appropriate facial disapproval (e.g., time out, remove an object) 8) Assure that negative behavior is not the main way of getting attention. 9) Educate that misbehaviors are usually repeated even when appropriate consequences are being given. 11) Handout: Time out 12) Explore how parents interact around managing the child's behavior looking for interference or undermining. This usually works best when all principal caregivers are included in the discussions 13) Explore caregivers' own experiences as children (How would your parents have handled this?) and how they developed their limits (What did you decide about that?). 14) Work with them to understand the relationship between their parenting practices and the child's behavior and to find a middle ground 15) Pick one behavioral scenario to do differently and come to agreement on each parents' actions for it. Signing a contract may be needed. 16) Schedule a follow up in 2-3 weeks by phone or in person. 17) Handout: Principles of Limit Setting handout.
  1) Determine discipline philosophy and strategies for different child behaviors. 2) Ask child (3 and over): What happens when you do __? What do your parents do? What do you think about that? 3) Interpret pleasure in breaking rules as learning not criminality but that explanation and consequences are still needed. 4) Teach to explain rules calmly, require a consequence, and increase monitoring. 5) Educate in smaller consequences along with reasons. 6) Handout: Principles of limit setting 7) Advise to respond to aggression promptly, calmly and not excessively from an early age, showing appropriate facial disapproval (e.g., time out, remove an object) 8) Assure that negative behavior is not the main way of getting attention. 9) Educate that misbehaviors are usually repeated even when appropriate consequences are being given. 11) Handout: Time out 12) Explore how parents interact around managing the child's behavior looking for interference or undermining. This usually works best when all principal caregivers are included in the discussions 13) Explore caregivers' own experiences as children (How would your parents have handled this?) and how they developed their limits (What did you decide about that?). 14) Work with them to understand the relationship between their parenting practices and the child's behavior and to find a middle ground 15) Pick one behavioral scenario to do differently and come to agreement on each parents' actions for it. Signing a contract may be needed. 16) Schedule a follow up in 2-3 weeks by phone or in person. 17) Handout: Principles of Limit Setting handout.
• Inconsistent management: Inconsistency is confusing and tends to make testing by the child worse. Advise parents to pick a few key behaviors, decide on the way they want to handle these, and stick to the plan for at least 3 weeks. They should notice, after an initial period of increased testing, a decreased struggle around these. This will motivate them to try a few more. If parents disagree, at least have them stick to their own ideas and not interfere or comment openly about the way the other parent handles things. A good rule is "Whoever starts (to handle the situation), finishes". If one parent spanks and the other doesn't approve, see management of spanking section.
  Inconsistency is confusing and tends to make testing by the child worse. Advise parents to pick a few key behaviors, decide on the way they want to handle these, and stick to the plan for at least 3 weeks. They should notice, after an initial period of increased testing, a decreased struggle around these. This will motivate them to try a few more. If parents disagree, at least have them stick to their own ideas and not interfere or comment openly about the way the other parent handles things. A good rule is "Whoever starts (to handle the situation), finishes". If one parent spanks and the other doesn't approve, see management of spanking section.
• Inappropriate expectations: 1) Ask at what age they expect a child to perform these tasks. 2) Consider Vineland Test of Adaptive Functioning. 3) Suggest parenting groups, Mothers Morning Out 4) Discuss the disadvantages of oppositional or passive behavior that may result. 5) Consider factors predisposing to the Vulnerable Child Syndrome. 6) Help parents differentiate high expectations from damaging pressure 7) Explain the risks of: child feeling like a failure; futile efforts to please being replaced by resistance, resentment, and damaged self esteem. 8) Help design at least one appropriate expectation 9) Help identify a strength on which to build. See strengths questionnaire, adjective questionnaire. 10) Assure challenges in the major developmental domains (e.g., chores for responsibility; independence for social development; tasks requiring some effort for motor and cognitive abilities; talking and being listening to at family meals for language skills). 11) Consider a developmental screen (e.g., DDST-R) to point to lack of opportunity or challenge to develop.
  1) Ask at what age they expect a child to perform these tasks. 2) Consider Vineland Test of Adaptive Functioning. 3) Suggest parenting groups, Mothers Morning Out 4) Discuss the disadvantages of oppositional or passive behavior that may result. 5) Consider factors predisposing to the Vulnerable Child Syndrome. 6) Help parents differentiate high expectations from damaging pressure 7) Explain the risks of: child feeling like a failure; futile efforts to please being replaced by resistance, resentment, and damaged self esteem. 8) Help design at least one appropriate expectation 9) Help identify a strength on which to build. See strengths questionnaire, adjective questionnaire. 10) Assure challenges in the major developmental domains (e.g., chores for responsibility; independence for social development; tasks requiring some effort for motor and cognitive abilities; talking and being listening to at family meals for language skills). 11) Consider a developmental screen (e.g., DDST-R) to point to lack of opportunity or challenge to develop.
• Overt or covert reinforcement of misbehavior: 1) Elicit examples of response to tantrum or aggressive behaviors 2) Determine if parents view misbehavior as vigor or means to solving problems. 3) Explain the connection of passive reactions to persist opposition/aggression. 4) Obtain agreement for noninterference: "Whoever starts, finishes" 5) Discuss what each parent "gets out of" the way they handle the behavior and the "costs" 6) Ask how they would like things to be 6 months from now. 7) Prescribe private parental debriefing" daily to review and renegotiate. 8) Teach "one request and then move" and use of Time out. See Principles of limit setting 9) Refer parents with a lot of anger to parent groups provided by Protective Services, Parents Anonymous, Children with Hyperactivity and Attention Deficit Disorder (CHADD), Alcoholics Anonymous or Alanon, or mental health providers. See Resource list. 10) Refer parents who can't agree on discipline for further counseling.
  1) Elicit examples of response to tantrum or aggressive behaviors 2) Determine if parents view misbehavior as vigor or means to solving problems. 3) Explain the connection of passive reactions to persist opposition/aggression. 4) Obtain agreement for noninterference: "Whoever starts, finishes" 5) Discuss what each parent "gets out of" the way they handle the behavior and the "costs" 6) Ask how they would like things to be 6 months from now. 7) Prescribe private parental debriefing" daily to review and renegotiate. 8) Teach "one request and then move" and use of Time out. See Principles of limit setting 9) Refer parents with a lot of anger to parent groups provided by Protective Services, Parents Anonymous, Children with Hyperactivity and Attention Deficit Disorder (CHADD), Alcoholics Anonymous or Alanon, or mental health providers. See Resource list. 10) Refer parents who can't agree on discipline for further counseling.
• Parental Depression: 1) Emphasize that parents take care of themselves for the child's sake. Refer to appropriate services. 2) Take a history of family health and treatments to determine if they are appropriate. 3) Recommend quality child care or school if the parents can't provide a safe and stimulating environment. 4) Get written permission and communicate with health, mental health and childcare providers so that services can be coordinated. 5) Prescribe "50 touches per day" to increase indications of positive regard. 6) Prescribe Special Time
  1) Emphasize that parents take care of themselves for the child's sake. Refer to appropriate services. 2) Take a history of family health and treatments to determine if they are appropriate. 3) Recommend quality child care or school if the parents can't provide a safe and stimulating environment. 4) Get written permission and communicate with health, mental health and childcare providers so that services can be coordinated. 5) Prescribe "50 touches per day" to increase indications of positive regard. 6) Prescribe Special Time
• work stress: 1) Recommend parent groups, babysitting cooperatives, Mothers Morning Out, Tot Gymnastics as ways to meet potential social supports. 2) Encourage church or synagogue or temple membership. 3) Suggest cheap young sitter so parent can have "alone time" in the house. 4) Encourage regular dates for the parents to relieve stress. 5) Suggest a few extra minutes for themselves before picking up from day care. 6) Suggest the sitters at spa or gym to simultaneously exercise and get a break. 7) If family discord is preventing relatives from being supportive, suggest family counseling. 8) Refer to pastoral counseling as an alternative
  1) Recommend parent groups, babysitting cooperatives, Mothers Morning Out, Tot Gymnastics as ways to meet potential social supports. 2) Encourage church or synagogue or temple membership. 3) Suggest cheap young sitter so parent can have "alone time" in the house. 4) Encourage regular dates for the parents to relieve stress. 5) Suggest a few extra minutes for themselves before picking up from day care. 6) Suggest the sitters at spa or gym to simultaneously exercise and get a break. 7) If family discord is preventing relatives from being supportive, suggest family counseling. 8) Refer to pastoral counseling as an alternative
• Domestic violence: 1) Prevalence: Approximately 4 million American women experience a serious assault by an intimate partner during any single year, exposing an estimated 3.3 million children to family violence annually. Few clinicians identify domestic violence, although they may be the only professionals seeing the affected families. 2) Effects on children: Children exposed to domestic conflict suffer the psychological trauma of witnessing battering, which can lead to learning difficulties and problems in social relationships. Witnessing violence affects the way children view the world and their place in it. They come to see the world as a dangerous and unpredictable place. This fear may limit their exploration of their environment, which is the key to learning in childhood. They also may suffer psychological trauma and develop multiple problems including aggressive b ehavior as well as depression, low self-esteem and posttraumatic stress disorder.
  1) Prevalence: Approximately 4 million American women experience a serious assault by an intimate partner during any single year, exposing an estimated 3.3 million children to family violence annually. Few clinicians identify domestic violence, although they may be the only professionals seeing the affected families. 2) Effects on children: Children exposed to domestic conflict suffer the psychological trauma of witnessing battering, which can lead to learning difficulties and problems in social relationships. Witnessing violence affects the way children view the world and their place in it. They come to see the world as a dangerous and unpredictable place. This fear may limit their exploration of their environment, which is the key to learning in childhood. They also may suffer psychological trauma and develop multiple problems including aggressive b ehavior as well as depression, low self-esteem and posttraumatic stress disorder.
• Corporal punishment: Educate in the use of non-corporal punishment to avoid the side effects of fostering and modeling aggression.
  Educate in the use of non-corporal punishment to avoid the side effects of fostering and modeling aggression.
• Marital discord: 1) Refer for marital counseling or mediation 2) Emphasize to avoid arguments in front of children 3) Teach active listening skills to encourage verbalization of emotions 4) Encourage modeling expression of affection, concern, caring 5) Prescribe "50 touches a day" to aid conveying positive regard 6) Prescribe Special Time 7) Model and teach having children self evaluate strengths and successes 8) Refer to parent groups provided by Protective Services, Parents Anonymous, Alcoholics Anonymous or Alanon, or mental health providers.
  1) Refer for marital counseling or mediation 2) Emphasize to avoid arguments in front of children 3) Teach active listening skills to encourage verbalization of emotions 4) Encourage modeling expression of affection, concern, caring 5) Prescribe "50 touches a day" to aid conveying positive regard 6) Prescribe Special Time 7) Model and teach having children self evaluate strengths and successes 8) Refer to parent groups provided by Protective Services, Parents Anonymous, Alcoholics Anonymous or Alanon, or mental health providers.
• Insecure attachment: 1) Discuss that a child who feels adults believe in her will begin to believe in herself. 2) Help parents understand that higher self esteem is positively related to closeness with parents and negatively related to parental punitiveness and control 3) Encourage parents to allow their child to make decisions 4) Discuss that parents need to guide children to show them what is wrong, dangerous, unacceptable, or in poor taste. 5) When children make mistakes parents need to correct in a loving way, not personally attack, and avoid scolding or embarrassing a child in front of friends. 6) Encourage parents to support their child's relationships with other adults-extended family members, neighbors, teachers, religious leaders, and coaches.
  1) Discuss that a child who feels adults believe in her will begin to believe in herself. 2) Help parents understand that higher self esteem is positively related to closeness with parents and negatively related to parental punitiveness and control 3) Encourage parents to allow their child to make decisions 4) Discuss that parents need to guide children to show them what is wrong, dangerous, unacceptable, or in poor taste. 5) When children make mistakes parents need to correct in a loving way, not personally attack, and avoid scolding or embarrassing a child in front of friends. 6) Encourage parents to support their child's relationships with other adults-extended family members, neighbors, teachers, religious leaders, and coaches.
• History of receiving poor parenting: 1) Help parent detect a difference between the current situation and the past one (trigger) to remind to react differently. 2) Consider "anchor" (e.g., touch, thought, or phrase to remind that they and child are safe now) 3) Congratulate on overcoming and clarify that parenting reflexes are based on past 4) Have parents notice and thank themselves when they stop maladaptive responses earlier 5) Consider a "trigger" to remind themselves of how they want to act 6) Create nonverbal signal for couples to use if one is losing control for other to take over 7) Teach time out early explaining that they "will never have to spank" 8) Teach to explain rules calmly, require a consequence, and increase monitoring. 9) Educate in smaller consequences along with reasons. 10) Advise to respond to aggression promptly, calmly and not excessively from an early age, showing appropriate facial disapproval (e.g., time out, remove an object) 11) Assure that negative behavior is not the main way of getting attention. 12) Parents unable to make progress need mental health referral.
  1) Help parent detect a difference between the current situation and the past one (trigger) to remind to react differently. 2) Consider "anchor" (e.g., touch, thought, or phrase to remind that they and child are safe now) 3) Congratulate on overcoming and clarify that parenting reflexes are based on past 4) Have parents notice and thank themselves when they stop maladaptive responses earlier 5) Consider a "trigger" to remind themselves of how they want to act 6) Create nonverbal signal for couples to use if one is losing control for other to take over 7) Teach time out early explaining that they "will never have to spank" 8) Teach to explain rules calmly, require a consequence, and increase monitoring. 9) Educate in smaller consequences along with reasons. 10) Advise to respond to aggression promptly, calmly and not excessively from an early age, showing appropriate facial disapproval (e.g., time out, remove an object) 11) Assure that negative behavior is not the main way of getting attention. 12) Parents unable to make progress need mental health referral.
• Prejudiced against this child: 1) Have the parent keep a diary of incidents and exactly what thoughts and feelings they had just before and just after each incident 2) Have the parent pretend they are someone else when they begin with the inappropriate pattern. 3) Encourage parents to resolve past conflicted relationships either in reality or just in their minds so that "it no longer has power over their parenting". 4) Refer for mental health counseling of the parent or the child if these strategies do not change the pattern.
  1) Have the parent keep a diary of incidents and exactly what thoughts and feelings they had just before and just after each incident 2) Have the parent pretend they are someone else when they begin with the inappropriate pattern. 3) Encourage parents to resolve past conflicted relationships either in reality or just in their minds so that "it no longer has power over their parenting". 4) Refer for mental health counseling of the parent or the child if these strategies do not change the pattern.
• risk taking: 1) If self destructive, refer immediately for mental health services. 2) Reframe such behavior as an emergency for the parent since their lack of concern is likely to have been part of the escalation of the child's actions. 3) If mainly group risk taking, end or limit. This reason should be made explicit so child will know it is done out of caring. 4) See Six Rules for Decision Making parent text 5) A child who does not understand risk may have Mental Retardation, Asperger's Syndrome, or Attention Deficit Hyperactivity Disorder.
  1) If self destructive, refer immediately for mental health services. 2) Reframe such behavior as an emergency for the parent since their lack of concern is likely to have been part of the escalation of the child's actions. 3) If mainly group risk taking, end or limit. This reason should be made explicit so child will know it is done out of caring. 4) See Six Rules for Decision Making parent text 5) A child who does not understand risk may have Mental Retardation, Asperger's Syndrome, or Attention Deficit Hyperactivity Disorder.
• Other general Acute Medical Conditions: Any acute illness requiring hospitalization (Any severe injury, Sickle cell disease, esp. during crises, Cystic fibrosis, Diabetes Mellitus, Celiac Disease). Parental expectations for behavior of ill children are often inconsistent. Child may also be more irritable due to discomfort, fatigue, medications, frustration, etc.
  Any acute illness requiring hospitalization (Any severe injury, Sickle cell disease, esp. during crises, Cystic fibrosis, Diabetes Mellitus, Celiac Disease). Parental expectations for behavior of ill children are often inconsistent. Child may also be more irritable due to discomfort, fatigue, medications, frustration, etc.
• ADHD: Up to 60% of children with oppositional behavior may have ADHD. Consider using a standard screening questionnaire, such as the Connors Rating Scale.
  Up to 60% of children with oppositional behavior may have ADHD. Consider using a standard screening questionnaire, such as the Connors Rating Scale.
• Impaired language comprehension: Even mildly hearing impaired children may cover up their lack of comprehension by general opposition. Because they are often frustrated by their inability to express their needs, children with developmental delay, especially speech delay, are prone to negative emotional behaviors.
  Even mildly hearing impaired children may cover up their lack of comprehension by general opposition. Because they are often frustrated by their inability to express their needs, children with developmental delay, especially speech delay, are prone to negative emotional behaviors.
• Mood disorder: When aggressive behaviors are persistent and associated with symptoms of sadness, this suggests a mood disorder. Young children may not necessarily report sadness. Depression may present as hyperactivity or irritability in this age group.
  When aggressive behaviors are persistent and associated with symptoms of sadness, this suggests a mood disorder. Young children may not necessarily report sadness. Depression may present as hyperactivity or irritability in this age group.
• Asperger's disorder, Autism or Child Disintegrative Disorder: These disorders are typically, but not exclusively, discovered and diagnosed during the preschool years.
  These disorders are typically, but not exclusively, discovered and diagnosed during the preschool years.
• Low self esteem: Children with low self esteem and/or low school affiliation are more likely to act out aggressively than those with talents and good self esteem.
  Children with low self esteem and/or low school affiliation are more likely to act out aggressively than those with talents and good self esteem.
• social deficits: Children who don't know how to act appropriately may instead be aggressive to engage others.
  Children who don't know how to act appropriately may instead be aggressive to engage others.
• temperament: Ask parents who the child "takes after" to elicit a description of temperament and parental projections. Check the child adjective checklist to get a sense of the parent's perception of the child's temperament or have the parents fill out a standard temperament questionnaire.
  Ask parents who the child "takes after" to elicit a description of temperament and parental projections. Check the child adjective checklist to get a sense of the parent's perception of the child's temperament or have the parents fill out a standard temperament questionnaire.
• book: Understanding Your Child's Temperament, by William B. Carey, Martha M. Jablow, C. Everett Koop, 1997, Macmillan General Reference.
  Understanding Your Child's Temperament, by William B. Carey, Martha M. Jablow, C. Everett Koop, 1997, Macmillan General Reference.
• Sleep debt: Makes children vulnerable to aggressive behaviors due to the fact that they are often tired, hungry, or stressed by irregular, unusual demands.
  Makes children vulnerable to aggressive behaviors due to the fact that they are often tired, hungry, or stressed by irregular, unusual demands.
• peer problems) all play an important role along with environmental exposure to violence through peers, parents, media and neighborhood influences.: Being rejected by peers early in grade school may predispose children towards aggressive behavior and later towards conduct disorder.
  Being rejected by peers early in grade school may predispose children towards aggressive behavior and later towards conduct disorder.
• suicidal or homicidal ideations/behavior. Refer immediately for mental health services if child is judged to be immediate threat to self or others. Children who are prone to "risk taking" may incur harm to themselves or others even when not intending it. : Suicide accounts for 12% of mortality among adolescents in the US. Older adolescents (15-19 years) have a rate of suicide that is 8 times higher than younger adolescents (10-14 years).
  Suicide accounts for 12% of mortality among adolescents in the US. Older adolescents (15-19 years) have a rate of suicide that is 8 times higher than younger adolescents (10-14 years).
• Antisocial Personality Disorder: This diagnosis cannot be given to individuals under the age of 18 years.
  This diagnosis cannot be given to individuals under the age of 18 years.
• Narcissistic Personality Disorder: This diagnosis cannot be given to individuals under the age of 18 years.
  This diagnosis cannot be given to individuals under the age of 18 years.
• Borderline Personality Disorder: This diagnosis cannot be given to individuals under the age of 18 years.
  This diagnosis cannot be given to individuals under the age of 18 years.
• Trigger questions: 1) What do you make of this behavior? What does your spouse make of it? 2) What is it like for you when you have to discipline ________? 3) What was it like for you when you were disciplined growing up? 4) What is it like for you when ________ is upset or frustrated? 5) What do you do when he/she does something he's not supposed to do? 6) How bad does it get? 7) Give me an example of ________'s "bad" behavior? How do you respond to the behavior? How does your partner respond?
  1) What do you make of this behavior? What does your spouse make of it? 2) What is it like for you when you have to discipline ________? 3) What was it like for you when you were disciplined growing up? 4) What is it like for you when ________ is upset or frustrated? 5) What do you do when he/she does something he's not supposed to do? 6) How bad does it get? 7) Give me an example of ________'s "bad" behavior? How do you respond to the behavior? How does your partner respond?
• risk-taking behaviors: 1) If self destructive, refer immediately for mental health services. 2) Reframe such behavior as an emergency for the parent since their lack of concern is likely to have been part of the escalation of the child's actions. 3) If mainly group risk taking, end or limit. This reason should be made explicit so child will know it is done out of caring. 4) A child who does not understand risk should be evaluated for Mental Retardation, Asperger's Syndrome, or Attention Deficit Hyperactivity Disorder.
  1) If self destructive, refer immediately for mental health services. 2) Reframe such behavior as an emergency for the parent since their lack of concern is likely to have been part of the escalation of the child's actions. 3) If mainly group risk taking, end or limit. This reason should be made explicit so child will know it is done out of caring. 4) A child who does not understand risk should be evaluated for Mental Retardation, Asperger's Syndrome, or Attention Deficit Hyperactivity Disorder.
• social skills deficits, or below average cognitive functioning (see : Improving social skills (empathy, listening, ascribing attributions) and problem-solving (resolving conflict, communication, understanding consequences) can be done effectively through group and/or individual social skills training interventions. Comprehensive social skills programs that involve parents, are specifically geared for the age of the child, and focus on reducing aggression are most effective. For teenagers with serious conduct or antisocial problems social skills training should be conducted in conjunction with individual, family or group therapy.
  Improving social skills (empathy, listening, ascribing attributions) and problem-solving (resolving conflict, communication, understanding consequences) can be done effectively through group and/or individual social skills training interventions. Comprehensive social skills programs that involve parents, are specifically geared for the age of the child, and focus on reducing aggression are most effective. For teenagers with serious conduct or antisocial problems social skills training should be conducted in conjunction with individual, family or group therapy.
• sexual activity: Query about consensual sex with peers and adults as well as possible sexual abuse -- where patient may be either victim or perpetrator or both.
  Query about consensual sex with peers and adults as well as possible sexual abuse -- where patient may be either victim or perpetrator or both.
• variety of reasons.: 1. This is more common in parents who were exposed to severe punishment or violence as children, which they do not want to repeat. They may give in for a while, then have outbursts of excessive reaction which stimulate fearfulness, preemptive misbehavior, low self esteem, or aggressive behavior in their children. 2. Parents who disagree in their discipline style encourage tantrums by displaying inconsistent methods of discipline. 3. Parents may be too busy, tired or unavailable to think up or maintain consistency. 4. Parents may view their child as special and vulnerable and be uncomfortable seeing their child upset. This is most likely to occur with children who have been seriously ill, if the parents had trouble conceiving the child or if there is a history of prior abortions. The parents' inability to tolerate the child's upset and keep rules leads to the child using angry or aggressive behavior to get what they want. Some children treated as vulnerable are oppositional in order to achieve any freedom from the over protective parent. 5. One parent may feel the other is too strict and therefore be more lax than is appropriate in an attempt to counterbalance the other's discipline. 6. Parents may inappropriately under control or over control children when they react to them as though they were someone else eg a despised ex spouse or disliked aspect of themselves.
  1. This is more common in parents who were exposed to severe punishment or violence as children, which they do not want to repeat. They may give in for a while, then have outbursts of excessive reaction which stimulate fearfulness, preemptive misbehavior, low self esteem, or aggressive behavior in their children. 2. Parents who disagree in their discipline style encourage tantrums by displaying inconsistent methods of discipline. 3. Parents may be too busy, tired or unavailable to think up or maintain consistency. 4. Parents may view their child as special and vulnerable and be uncomfortable seeing their child upset. This is most likely to occur with children who have been seriously ill, if the parents had trouble conceiving the child or if there is a history of prior abortions. The parents' inability to tolerate the child's upset and keep rules leads to the child using angry or aggressive behavior to get what they want. Some children treated as vulnerable are oppositional in order to achieve any freedom from the over protective parent. 5. One parent may feel the other is too strict and therefore be more lax than is appropriate in an attempt to counterbalance the other's discipline. 6. Parents may inappropriately under control or over control children when they react to them as though they were someone else eg a despised ex spouse or disliked aspect of themselves.
• excessive punishment: Ask for an example of the child's bad behavior and how the caregiver responded. Children who are given excessively harsh punishment or who are constantly "being yelled at" for even minor behavior issues are likely to continue the behavior when they are given no reinforcement for good behavior or as pay back to their apparently "mean" parent. Spanking or other physical punishment fosters aggression in children by modeling aggressive behavior and also by inducing pain, especially in families lacking warmth in relationships. Low self esteem from harsh punishment can also elicit aggression.
  Ask for an example of the child's bad behavior and how the caregiver responded. Children who are given excessively harsh punishment or who are constantly "being yelled at" for even minor behavior issues are likely to continue the behavior when they are given no reinforcement for good behavior or as pay back to their apparently "mean" parent. Spanking or other physical punishment fosters aggression in children by modeling aggressive behavior and also by inducing pain, especially in families lacking warmth in relationships. Low self esteem from harsh punishment can also elicit aggression.
• prejudiced parent syndrome: Parents may under control or over control children when they react to them as though they were someone else (e.g., a despised ex spouse or disliked aspect of themselves.
  Parents may under control or over control children when they react to them as though they were someone else (e.g., a despised ex spouse or disliked aspect of themselves.
• inadequate attention: Children will do anything to engage caregivers including the opposite of what is asked.
  Children will do anything to engage caregivers including the opposite of what is asked.
• Pharmacological treatment alone: Antidepressants, lithium carbonate, carbamazepine, and propranolol are sometimes used to treat Conduct Disorder, but empirical studies proving their efficacy have not been done.
  Antidepressants, lithium carbonate, carbamazepine, and propranolol are sometimes used to treat Conduct Disorder, but empirical studies proving their efficacy have not been done.
• ADHD: This is the most common co-morbid condition with Conduct Disorder. Consider using a screening questionnaire such as the Connors Rating Scale.
  This is the most common co-morbid condition with Conduct Disorder. Consider using a screening questionnaire such as the Connors Rating Scale.