Chapter 87. Difficult Behavior

Disruptive behaviors in childhood are a part of growing up. An adult’s perception of the behavior, their tolerance, emotional response, and social expectations often determine whether a child’s behavior comes to the attention of a pediatrician. Disruptive behaviors become a part of pediatric encounters under 3 circumstances: (1) when the behavior is overwhelming to parents or teachers and is interfering with social interactions, (2) when a pediatrician systematically surveys family function and childhood behavior as part of a periodic health supervision visit, or (3) when a disruptive behavior occurs during an office visit.

Disruptive behaviors in children include temper tantrums, angry outbursts that may be physical or verbal, hitting, biting, pushing, as well as more serious antisocial behaviors such as stealing, setting fires, truancy from school, destruction of property, animal cruelty, and physical confrontations with other people. An understanding of a disruptive behavior begins with an exploration of the nature of the behavior in the context of a child’s developmental stage, the environmental factors that may trigger the behavior, and the adult’s response to the episodes. Each of these elements is critical in addressing the following questions:

• Is the behavior a normal variation at a particular stage of development?

• Infants are characteristically more irritable in late afternoon and early evening.
• Strangers may initiate a fear response in some infants at the end of the first year of life and during the second year.
• All toddlers experience temper tantrums during moments of frustration when their journey toward psychological autonomy is threatened.
• Separation experiences from parents are commonly associated with emotional outbursts, crying, and sleep disturbances at this age.

These examples reflect the importance of the developmental tasks of attachment during the first year of life and autonomy in the second year. Exploring disruptive behaviors at this time of life in the context of the continuum from attachment and trust to autonomy and independence provides a clinical framework for insight as well as guidance.1

What characteristics of the child’s family, peer, and school environments contribute to or modify the behavior? The social context in which behaviors unfold may trigger, exacerbate, or ameliorate behaviors. Emotional responses in younger children may be modified by verbal and nonverbal responses of parents and other caretakers. School-aged children and adolescents are influenced by peers and teachers. The media, the neighborhood, and the expectations generated from school are additional potent environmental influences on the behavior of children.

How have the parents (and other providers of childcare) responded to the disruptions? Parent responses to disruptive behaviors in their children span a broad continuum, from active intervention to withdrawal. Parent response reflects their own temperament, understanding of developmental expectations, economic or psychological stress in the family, and their experiences growing up and memories of past parent-child encounters. An exploration of these factors often yields insights into the interventions and responses that parents experience as they attempt to alter disruptive behaviors. In addition, the information provides a basis for the clinician to tailor pediatric guidance to the needs of a particular family and child.

The spectrum of disruptive behaviors in childhood is broad and, to a large extent, depends on developmental stage. Episodic crying of less than 3 cumulative hours each day occurs in all infants in the first 3 months after birth. Approximately 15% of young infants experience longer periods of fussiness at this stage. These “colicky” babies are typically calmer as they enter the fourth month (see Chapter 83). Temper tantrums are reported by parents in as many as 80% of 2- to 4-year-old children. Tantrums occur at least once each day in about 20% of 2-year-old children and 10% of 4-year-old children. Moderate to severe tantrums are reported in 5% of 3-year-old children.

Some infants and children hold their breath during a temper tantrum. Breath-holding usually occurs at the initiation of a tantrum when fear, anger, or frustration is triggered by an environmental event.2 At least one breath-holding spell occurs in 5% of children. Family pedigree analysis of children with severe breath-holding spells suggests an autosomal dominant trait with reduced penetrance. A positive family history for breath-holding or fainting is common. These behaviors usually appear in the second year of life and may continue until 5 years of age; they also may occur in some infants after 6 months of age. Two physiological types have been described: (1) a cyanotic form in which the face turns blue until breathing resumes and (2) a pallid type in which the face is pale secondary to vasovagal syncope. In both forms, the child ceases breathing following a period of intense crying. Syncope occasionally develops at the moment the child begins to cry; this may be seen with the pallid spells and be associated with a rigid, arching posture. Breathlessness is brief and followed by spontaneous respiration and normal behavior. A minority of these children will have symmetric tonic-clonic movements before awakening. Although benign, breath-holding spells are dramatic and frightening to many parents. With a family history of breath-holding spells, some parents may be less concerned as a result of awareness of their benign nature. They do not cause irreversible hypoxic brain injury or epilepsy, and subsequent cognitive development and behavior are normal. There is some evidence that iron therapy is effective in reducing the frequency of recurrent breath-holding spells in children with and without biochemical evidence of iron deficiency. The mechanism for this response is unknown.3

The multiple factors that underlie socially disruptive behavior can be framed in the context of developmental expectations and temperament patterns of the child and family; expectations and responses of caretakers to disruptive behaviors; family patterns including interpersonal relationships, socioeconomic class, and educational levels; and a biological predisposition for specific patterns of psychological dysfunction.

Development and Temperament

Frustration, anger, and aggressive outbursts are experienced during all stages of the life cycle, with a predictable decline in frequency and intensity through time. Age-specific developmental tasks account for some of these behaviors. For example, the toddler’s struggle for emotional independence as she separates from an infantile attachment to parents frequently manifests with tantrums or nightmares; these behaviors reflect the child’s struggle with the “push-pull” process of emotional separation and individuation. In a similar fashion, adolescent defiance directed to parents, verbal and physical outbursts of anger, and isolated acts of social defiance may reflect the requisite quest for autonomy from family while searching for a personal identity.

Behaviors that are outside of the expected developmental range may result from individual temperament styles. Temperament refers to stable biopsychological traits that describe self-regulation and an individual’s reactive style and are under some degree of genetic control. Easily excitable infants, excessively clinging 1-year-old children, often frustrated and tantrum-prone toddlers, and physically intrusive preschoolers represent particular, specific temperament-regulated patterns of behavior that manifest at different developmental stages.

Temperament may play an even larger role in the etiology of a disruptive behavior when temperament is not in harmony with that of an adult authority. Coping strategies in response to developmentally appropriate disruptive behaviors require parental composure, reflection, and recognition of the need for a cooling-off period, which may not be a natural response for some temperamentally highly reactive parents. An inhibited toddler may be at greater risk for disruptive behaviors with a temperament mismatch between child and parent.4

Expectations and Responses

The expectations of adult caretakers and teachers may mediate the intensity, frequency, and outcome of disruptive behaviors in children. Childhood behaviors are transactional phenomena. A behavior does not stand alone. Its quality and quantity is influenced by other persons in the immediate environment (eg, peers, parents, and teachers).

A behavioral dialog is an emotional conversation between two individuals, each influencing the other by verbal and nonverbal responses. In this transactional model, the expectations of parents and teachers will modify the behavior of a child. When a school-aged child repeatedly refuses to clean his or her room, parental expectations of personal responsibilities for tidiness and the youngster’s desire to please the parent will interact and guide their response. The parent may make a reasoned request, an angry demand, or may physically punish the child; a reward system or series of punishments may follow. The adult response to a disruptive behavior is mediated by both the adult’s expectations and the effect the behavior evokes in the adult.

Family Patterns

The quality of early attachment experiences influences subsequent behavior, especially in response to frustration. The emotional security and nutritional adequacy that are required for healthy infant-maternal attachment during the first year yields a sense of trust in oneself and others as the infant enters the second year. The development and maintenance of psychological attachment to a parent or other family member over time provides the emotional foundation to manage and make sense out of moments of ambiguity and uncertainty that become prominent after the child’s first birthday.5 Children who experience family disruptions, serious physical or emotional illness in a parent, family violence that is directed toward the child or parent, or major economic hardship are at risk for disruptive behaviors. Social, economic, or psychological stressors within the family may be a primary cause of the behavior or act as secondary triggers for a child or family where a biologic predisposition exists.

A disruptive behavior pattern in a child may reflect pathology in the social or psychological makeup of the family system. At times, a family may appear to be functionally and socially intact, while a child’s externalizing behavior presents as the problem. Drug or alcohol abuse in a parent, marital disharmony, and chronic sexual abuse are examples of family dynamics that may influence disruptive behavior in children.

Biologic Factors

Genetic endowment appears to play a role in the etiology of disruptive behaviors. Infant temperament appears to persist through development. For example, a vigilant, alert baby with smooth state transitions tends to be a less irritable infant and more uninhibited as a toddler and school-aged child. The risk for oppositional behavior and conduct disorder is considerably less than that in an irritable infant who develops an inhibited toddler temperament. A genetic component for aggressive and antisocial behavior has been demonstrated in studies that show a concordance for criminality among monozygotic twins. In addition, children of male and female criminals who are raised in adoptive homes demonstrate more antisocial behaviors than do adopted children of noncriminal parents.

Brain injuries are associated with disruptive social behaviors. Temporal lobe epilepsy is an example of a focal abnormality that may be associated with episodic disruptive behaviors. Central nervous system tumors and encephalitis may be associated with behavioral outbursts or mood lability. Chromosome disorders (eg, XYY and 5p deletion), progressive encephalopathies (eg, Rett syndrome), inborn errors of metabolism (eg, Lesch-Nyhan syndrome and Wilson disease), and toxic encephalopathy (eg, lead, mercury, alcohol, cocaine, methamphetamine, hallucinogen poisoning) are biologic disorders that may be associated with disruptive behaviors. Although the precise anatomic and neurochemical abnormality remains uncertain, it does appear that function in the amygdala portion of the limbic system may be altered in these disorders.

A genetic component for aggressive and antisocial behavior has been demonstrated in studies that show a concordance for criminality among monozygotic twins. In addition, children of male and female criminals who are raised in adoptive homes demonstrate more antisocial behaviors than do adopted children of noncriminal parents.

Symptoms of disruptive behaviors are specific to each developmental stage. The pattern of expressed behavior reflects a child’s verbal, motor, and affective developmental capacities. Boundaries for behavior set by adults also determine the characteristics of the behavior. The challenge for clinicians is to separate those behaviors that are normal developmental variations from those that represent an emotional disorder or are symptoms of a specific disease process. Prognosis and intervention strategies are guided by this distinction. When distinguishing developmental variation from a disorder, the evaluation process begins with assessment of duration, intensity, and effect on family function, school performance, and socialization skills.

Oppositional Defiant Disorder

Frequent temper tantrums occur in some children with an intensity, frequency, and duration that disrupts the family, school, or neighborhood. These children often experience frequent loss of temper in response to minimal frustrations. They may express a pattern of behavior that is argumentative, negativistic, and hostile. Lability of mood, limited tolerance to frustrating events, and low esteem may be associated with the disruptive behavior in these children. Oppositional defiant disorder (ODD) describes these children in whom a specified pattern of behavior lasting at least 6 months can be documented (see eTable 87.1). Importantly, these behaviors occur in normal children at the school-aged and adolescent stages of development. When they present frequently and with a greater-than-expected intensity, an oppositional defiant disorder should be considered.6

Conduct Disorder

Disruptive behaviors that are repetitive, persistent (at least 6 months), and violate the rights of other people or their property suggest a behavior pattern consistent with a conduct disorder (see eTable 87.2). Children who have a conduct disorder do not respond with guilt or remorse when confronted with their misconduct. These quarrelsome school-aged and adolescent children are typically seen by pediatricians after recurrent episodes of stealing, lying, fighting, setting fires, perpetration of sexual abuse, or drug abuse. Both oppositional defiant disorder and conduct disorder are seen with greater frequency in children and adolescents with attention deficit hyperactivity disorder, academic underachievement, learning disabilities, depression, and anxiety.

Two distinct groups of children and adolescents with a conduct disorder have been identified. The undersocialized demonstrate an impairment in interpersonal relationships that manifests as unpopularity, lack of any close friendships, and generalized social isolation. These children may lack empathy for peers and are hostile and argumentative toward adults. This form of aggressive and undersocialized behavior is pervasive, typically occurring at school, at home, and in the community. Children with the socialized pattern of conduct disorder participate in antisocial behaviors (eg, criminal acts, school truancy) in the context of a peer group. Interpersonal attachments are strong and binding, but relationships with adults are inconsistent and characterized by confrontation with authority.6

The diagnostic assessment process has 4 major goals:

1. 1. To describe the child’s or adolescent’s behavior in detail, with attention to triggering events and environmental setting.

   2. To define psychological, economic, and social stressors within the family or community that may affect the behavior.

   3. To delineate the content and style of parental responses to the behavior.

   4. To explore the strengths that exist within the child as well as the family and the community environment that may be protective factors.

It is important to prevent premature diagnostic impressions. A comprehensive, developmentally based personal and family history will assure the primary care clinician that important data are included.7 Clinicians who follow children longitudinally for developmental surveillance and comprehensive health supervision have the advantage of previous knowledge about the child’s development and the family’s level of functioning and will be positioned to recognize and assess disruptive behaviors at an early stage.

A request should be made to the parent or school for past psychoeducational evaluations, disciplinary reports, and report cards. A brief narrative from the teacher, addressing classroom and playground behaviors, learning style and output, and perceived strengths, is helpful. During the initial interview, observation of the child’s and parent’s affective state and the parent-child interactions should be recorded in the medical record. Assessment of independent and interactive play in a pediatric office is possible when toys are available. Some pediatricians find it useful to supplement the initial interview with a brief behavioral screening test. A pediatric assessment for a behavioral problem is not complete without a physical examination. Parents can be interviewed alone and with the child; adolescents should be given an opportunity to tell their story without the presence of a parent. When possible, a family interview, including parents and siblings, may add important information about interpersonal dynamics. Focused questions delineate important details about the behaviors and contributing factors:

• Describe your child’s tantrum (or troubling behavior) as you experience it.
• Do you know what brings on these behaviors?
• In what settings does the behavior occur?
• What is your response to the behavior? Your spouse’s and other children’s response?
• Have you tried different responses in the past? Describe them.
• Who manages most disruptive behaviors in your home?
• Describe some of your child’s strengths. When does your child make you happy or proud?
• Does your child have friends? A best friend? What activities do they participate in together?
• Can you recall how tantrums and other difficult child behaviors were managed during your childhood? Tell me about those experiences.

Asking these questions begins the treatment process. Questions should be asked without conveying a hurried atmosphere. Recognition of effective parent interventions will go far in the development of a therapeutic alliance.8 Inquire about anger outbursts, physical or verbal violence, and specific encounters with a mental health professional by other members of the immediate and extended family. A family history of related problems such as dropping out of school, truancy, job dissatisfaction or chronic unemployment, and alcohol or drug abuse may be helpful in formulating a diagnosis. Some pediatricians may resist exploring the family dynamics in areas of marital discord, sexual dissatisfaction, and childhood experiences of parents. However, this information informs the diagnostic process, especially during an evaluation for disruptive childhood behaviors.

Inquire about social forces that influence childhood behaviors. Does violence permeate the neighborhood? Are guns available in the home? How much television does the child watch each day? What kinds of programs are watched? Are violent shows or those with overt sexual messages monitored? Do the parents discuss violent themes or socially controversial topics on television with the child? This line of questioning is also appropriate for movie-watching behavior.

The final step in the diagnostic formulation is to decide which behaviors are developmentally appropriate, which reflect a moderate variation from a predictable norm, and which patterns of behavior represent a disruptive behavior disorder.9 This formulation may not be apparent after the initial interview; at other times, the pattern of behavior may not fit into a single category. The assessment process for disruptive behaviors may not require a specific pediatric diagnosis but rather the development of insight about the place on the continuum from normal variation to psychopathology at which this child’s and family’s behavior fits. Further “diagnostic tuning” may occur at future office visits or in association with a referring mental health professional.

The approach to management of disruptive childhood behaviors depends on the intensity, frequency, and number of settings in which the behavior occurs, as well as the pediatrician’s willingness to spend a modest amount of time with the family. For most parents, a setting to explore the troublesome behavior with a pediatric clinician is therapeutic in itself. An empathic clinician listens carefully and actively while asking focused questions about the child’s temperament; social interactions with peers, parents, siblings, and teachers; and the responses of parents and other caretakers. A clear demonstration of respect for different parenting styles encourages a therapeutic bond between parent and clinician. This bond can be used to explore family values about child rearing and specific responses to disruptive behavior. Focused questions directed to the parent may clarify the nature of discipline: What are you trying to teach? Why is it important to you? How are you trying to teach it? What is your child learning?

In some situations, a parent may be reassured about the range of normal developmental expectations and a statement that an isolated disruptive behavior may reflect an adaptive response and a strength in development. The clinician may point out that the behavior is an expression of autonomy and a quest for emotional independence in a healthy, affirmative way. In other cases, an assessment will suggest that the behaviors are outside the expected developmental range and require intervention.1 Pediatricians can manage most children with toddler tantrums, episodic breath-holding spells, and mild forms of oppositional defiant disorder. School-aged children and adolescents with a conduct disorder generally require a more extensive intervention program managed by a mental health specialist.

A common pitfall in the treatment of disruptive behaviors is to limit the intervention to a plan for behavior modification. While a therapeutically powerful and useful treatment, a management plan that is limited to behavioral techniques risks inattention to coexisting conditions such as parental depression, disorders of attention, learning disabilities, and child or spousal abuse.

One of the most challenging and frequent inquiries for pediatricians in the area of behavioral pediatrics is discipline. Parents often find it useful to learn that the Latin verb disciplinare (to teach or to instruct) is the root of the English word discipline. A parent’s ability to discipline and to teach is central to raising emotionally healthy children who can learn societal rules; live, play, and eventually work with others; develop a positive sense of self; and discern right from wrong. Modeling positive behaviors by means of language and actions remains the most effective “discipline” tool for parents. Punishments for unwanted and disruptive behaviors should be consistent (over time and among family members), logical, and reasonably immediate. Loss of privileges (eg, television, cell phone, a sleepover with a friend) usually gives a strong message that the disruptive behavior will not be tolerated.

Physical punishment in the form of spanking is a common practice in American families. The initial rapid suppression of a disruptive behavior after physical punishment is attractive to many parents. Many well-meaning and effective parents occasionally use physical punishment to teach acceptable behavior; in some cultures and ethnic groups, physical punishment toward children is more acceptable than in others.

The argument against physical punishment focuses on 2 issues. First, there are other effective methods for managing disruptive behaviors10-13 that teach children self-regulation, provide alternatives to uncontrolled anger, and assist in the attainment of self-esteem (Table 87-1). Second, physical punishment models an adult method of conflict resolution that children should not be taught to use. It is a form of behavior modification that cannot be internalized as a young child is learning to regulate emotions and conflicts. In fact, it may be experienced as a form of resolving unpleasant situations that is counterproductive to their emerging sense of self-worth. Child-oriented advocacy that focuses on anticipatory guidance, behavior modification, improved parent-child communication skills, and effective limit-setting is more appropriate for pediatric counseling.14,15