Behavioral Issues in Children

Behavioral problems (e.g., noncompliance, tantrums, and aggression) are the most common concerns mentioned to pediatricians by parents during pediatric exams. While it is normative for young children to exhibit mild forms of disruptive behaviors, these concerns should improve as a result of socialization. Parents who use effective parenting strategies are most likely to observe improvements in their child’s behavior; however, a subset of children with significant emotional dysregulation will continue to exhibit behavioral issues without appropriate intervention. When disruptive behaviors persist, its places a child at increased risk of developing a behavioral disorder and associated negative life outcomes.

• The Centers for Disease Control and Prevention (CDC) has reported that behavioral issues are the most commonly diagnosed mental health concerns in the United States.
  • 9.4% of children and adolescents have received an ADHD diagnosis.
  • 7.4% of children and adolescents have received a disruptive behavior diagnosis, such as Oppositional Defiant Disorder.
• Children with a behavioral disorder are a chronically underserved population. Approximately half (47.5%) of children with a behavioral disorder do not receive mental health treatment and even fewer are receiving treatment that is empirically supported.
• Children with behavioral difficulties are at risk of a variety of negative life outcomes including comorbid psychiatric difficulties (e.g., depression, anxiety), educational difficulties, poorer physical health, legal problems and social concerns.

Pediatric behavioral health screening

Timely identification of children with behavioral issues needing mental health services is critical. Unfortunately, many pediatric patients with mental health disorders are not identified. Pediatric providers that rely solely on clinical judgment to identify patients with mental health issues will positively identify only about 30% of clinical patients, whereas 70% of these patients are accurately identified when using a validated screening measure. Providers can use a number of screening measures when they suspect the presence of ADHD or other behavioral concerns. These measures include:

• Vanderbilt ADHD Rating Scales
• Behavior Concerns: Strengths and Difficulties Questionnaire (SDQ)

If a patient is positively identified on a screening measure, it is critical that pediatric providers discuss mental health in a destigmatizing manner. Mental health stigma is one of the biggest barriers to families seeking treatment. This is particularly true for families raising a child with behavioral difficulties, as parents often are concerned that they will be blamed for their child’s behavior. Providers should emphasize that behavioral difficulties in children are common and that seeking support for these concerns is a positive step toward promoting their child’s overall health and well-being.

Treatment for behavioral issues in children

Some well-established psychotherapy treatments for behavioral issues are very effective in reducing concerns. This is particularly true when treatment can be provided in a timely fashion, because early intervention can change problematic parent-child dynamics and shift the child’s overall emotional and behavioral developmental trajectory.

The intervention that has the strongest empirical support is behavioral parenting programs. This intervention aims to coach parents in effectively using a variety of behavior management and parenting techniques that promote a child’s engagement in prosocial behaviors and discourage engagement in disruptive behaviors. Recent meta-analyses have identified key parenting practices responsible for the most significant positive treatment gains. These practices include use of positive reinforcement and nonviolent discipline techniques (e.g., timeout, ignoring and logical consequences).

If providers are concerned about a patient and would like to make a referral for psychiatric evaluation and treatment, they can refer families to the following:

• Children’s Hospital Colorado Pediatric Mental Health Institute provides evidence-based, family-focused comprehensive mental health services. For more information, providers can call 720-777-6200 or visit the website.
  • The Colorado Department of Human Services also has a lot of great resources on its website.

Additional resources for pediatric behavioral concerns

Websites:

• Society of Clinical Child & Adolescent Psychology
• Consortium for Science-based Information on Children, Youth, and Families
• American Academy of Child & Adolescent Psychiatry
• CDC Positive Parenting Tips

Books:

• “Parenting the Strong-Willed Child” (Long & Forehand)
• “The Kazdin Method for Parenting the Defiant Child” (Kazdin)
• “The Explosive Child” (Greene)