DEVELOPMENT AND BEHAVIOR
From Masters of Pediatrics 2007 Leadership Conferences, presented by the University of Miami, Leonard M. Miller
School of Medicine, Department of Pediatrics, and Department of Dermatology and Cutaneous Surgery, Miami, FL
Barbara J. Howard, MD, Assistant Professor of Pediatrics, The Johns Hopkins University School of Medicine,
Baltimore, MD
| DISCIPLINE IN EARLY CHILDHOOD
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| Definition: systems of teaching, learning, and nurturing that encourage appropriate behavior and deter misbehavior;
goals—competence; self-control; self-direction; caring; components—positive relationships between parents and
child; positive reinforcement for desired behaviors; consequences for undesired behaviors
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| Child factors: difficult temperaments, developmental disabilities, and mental health problems may make discipline
more challenging; disciplinary techniques should reflect mental age of children with developmental disabilities (eg,
mental retardation); attention-deficit/hyperactivity disorder (ADHD) common contributing factor; children with
higher IQs and better language skills have fewer problems; children with expressive language delay display 4 times
as much aggressive behavior as those with normal language development
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| Parent factors: social support key; marital discord and multiple life stressors (especially poverty) increase risk for
behavioral problems in children; parents with low levels of education, although more likely to have children with
behavioral problems, do as well as other parents in parent-education programs; history of psychiatric disorders (especially
depression, antisocial personality disorder, and substance use disorder) increases risk; social support especially
important for teenaged parents; family history (how parents were raised, eg, history of abuse) influential
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| Factors that promote positive parent-child relationships: positive emotional tone (playful, warm, affectionate);
parental satisfaction with marriage and job; high parental involvement; consistency and rhythmicity (absence
of consistency associated with maternal mental health problems); flexibility (especially with older children); positive
role models (most protective factor for 30-yr outcomes); positive attention
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| Age-appropriate attention: infants need parents to understand and appropriately respond to their cues and to
quickly and gently respond to their needs; preschool children need frequent short bouts of attention; parents of
school-aged children should make themselves regularly available, attend child’s events, and learn about child’s interests;
brief attention immediately—watch for child’s first bid for attention; make eye contact and touch child;
briefly comment on child’s activities; special time—daily period reserved for parent-child interaction; symbol of
unconditional positive regard (therefore, never taken away as punishment); child’s choice of interactive activity for
10 to 15 min without interruptions and ended on time (consider using timer)
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| Echoing: active listening, reflecting content and emotions; tips—match body posture, tone, and speed; avoid adding
information or comments
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| Modification of mood: using humor to lighten mood provides behavioral model (instructive for children who have
not yet mastered self-control) and conveys liking and tolerance
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| Positive reinforcement: appropriate use increases desired behaviors; tracking changes in behavior provides feedback
(recommended for anxious parents or for monitoring behaviors with low frequency); rewards and consequences
should be consistent, moderate in strength, and delivered in calm manner; positive reinforcement must
never have embedded criticism
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 | Simple tracking: “marks” technique appropriate for children 18 mo to 6 yr of age; parent marks child’s hand for desired
behaviors (or abstinence from undesired behaviors), aiming for 6 to 10 marks/hr; child rewarded every day
for having marks (not based on number of marks)
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| Tips: keeping reinforcement short, simple, and specific also allows for instruction and avoids sibling rivalry;
verbal and written (ie, visual) acknowledgment of success recommended; praise should outnumber corrections
by 10 to 1; parents should avoid generalizations and comparisons
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| Consequences: ignoring, with or without explanation (explanation improves noncompliant behavior); verbal or
nonverbal disapproval with consequences; time out; natural— occur naturally, as result of child’s behavior; some
lessons too big to allow natural consequences; logical—meaningfully related to behavior and dosed appropriately
(shorter recommended); emotional congruence important (no mixed messages); delivered promptly (exception if
consultation required) and privately; in some cases, older children may help decide parameters of consequence;
threats—vague; do not provide instruction; raise tension; impair problem solving; divert child from task; suggest
parental desperation; damage parent-child relationship; may place power in hands of one parent; excessive
consequences—generally given when parent out of control; often not enforceable; may elicit opposition by other
parent; damage parent-child relationship
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| Limits: setting limits important role of parent; reasons adults may avoid setting limits —to avoid placing hardship
on child; negatively react to limits placed on them; to balance limits placed on child by other parent; to avoid angering
child
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| Enforcement: one request then move—give simple instruction once; if no response in 10 sec, move child to task and
supervise; praise cooperation; “1-2-3 Magic”—count to 3, waiting 10 sec between each number; give time out or
other consequence if no response; time out—time away from reinforcement and attention, usually accompanied
by disapproval, loss of freedom, and loss of interesting things to do; technique reserved for 2 or 3 behaviors; explanation
of process and consequences should occur before first use; no warnings for aggressive behaviors; child
briefly informed of offense then put in uninteresting place and ignored (up to 1 min for each year of age); after
time out, parents should reinforce first positive or neutral behavior; any discussion of offense should wait until
parents and child calm; technique effective in children 9 mo to 12 yr of age; physical punishment—may be as
effective as time out, but associated with many adverse outcomes
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| Preventive approach: parents model and teach praise, positive attention, distraction, safeguarding, and removal;
discipline starts early (eg, time out by 12 mo of age); mental health—discipline problems sometimes indicative of
larger issues, eg, 60% of children with oppositional defiant disorder have ADHD
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| COMMON PRESCHOOL-AGE BEHAVIOR PROBLEMS
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| State regulation: awake vs asleep and upset vs calm (different states of consciousness and different states of
arousal); aided by presence of routines (eg, sleep and eat at regular times), sufficient sleep (behavior problems inversely
related to amount of sleep), and consistent parental response (positive and negative reinforcements);
overstimulation—reduce stimuli (eg, television), especially for children who have trouble with state regulation
(including those with brain damage or prenatal substance exposure)
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| Whining: effective method for getting parents’ attention; children who receive appropriate attention on regular basis
less likely to whine; frequency tends to increase with sleepiness, hunger, and boredom; response—ignore
with explanation; respond even to slight improvement in tone of voice; reserve time outs for other offenses (unless
whining primary concern)
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| Temper tantrums: frequency tends to peak between 12 and 36 mo of age, with second peak at ≈6 yr of age (child responding
to increased demands in first grade); response to issues of autonomy and environmental demands; emotions
exceed child’s ability to control (ie, behavior not willful or intentionally manipulative); reducing
tantrums—reduce stresses in child’s life as much as possible; allow child to make choices, when appropriate;
pay attention to child when behaving well; echo child’s frustrations (this can give words to their feelings); responding
to tantrums—stay calm; remove child from danger; stand nearby or hold child silently without giving
in to reason for tantrum; comfort and distract child; avoid discussion until child completely calm
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| Breath-holding: exhibited by 5% of children <8 yr of age; tends to run in families (23%); types—blue spells tend
to occur when child upset; child starts to cry, stops breathing, turns blue, goes limp, loses consciousness, and
may become stiff; white spells often occur in response to pain; child may start to cry, become pale, stop breathing,
may become asystolic or have seizure; outcomes—spells stop by 6 yr of age in 90% of children; no harmful
effects, even if child has seizure; response—prevent breath-holding by managing tantrum; avoid giving secondary
gain when child awakens; consider 6-wk trial of therapeutic iron (decreases spells in 85% of children)
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| Head-banging: may accompany tantrum; also may occur as child falls asleep or in response to pain in head; typically
involves banging frontal or parietal parts of head against hard surface; incidence and duration—sessions
typically last <15 min (but may last hours); most children stop by ≈3 yr of age; regular pattern, often 60 to 80
“beats” per minute; behavior occurs in 3% to 15% of children (more common in boys), and associated with
sleep-walking, encopresis, and family history of dyslexia; concerns—autism or other developmental problem;
severely retarded children may bang with sufficient intensity and frequency to dislocate lenses or develop cataracts
(refer to specialized behavioral psychologist); differential diagnosis—pain (eg, otitis media, serous otitis);
sensory deprivation (including neglect); disorder of central nervous system that causes pain in head; abuse;
response—increase rhythmic activities (eg, dancing, jumping on trampoline); reduce stress; increase frequency
of holding, especially at night; bolt crib to wall to reduce rocking and vibrations; manage tantrums (if related);
medications—hydroxyzine (eg, Atarax) and imipramine (Tofranil) used off-label, reduce incidence, but nonmedical
interventions typically sufficient
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| Thumb-sucking: state-regulatory activity often begun in womb; children suck thumb for stress reduction; behavior
peaks between 18 and 21 mo of age; thumb-sucking does not affect dentition unless it continues after 6 yr of age;
response—reduce stress; distract child; limit pacifier or thumb-sucking to certain times or places; provide incentive
to stop sucking (but, child must be motivated); use thumb guard at night for habitual sucking during
sleep; consider topical product to deter sucking (consistent use essential); praise child for not sucking thumb
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| Mastery: parents should offer children opportunities to try new things without overwhelming them with responsibility;
children struggling to master certain tasks may require assessment of developmental skills (eg, fine motor,
language)
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| Eating: advise parents to avoid turning feeding into power struggle; parents’ responsibility—to provide nutritious
food at regular intervals; response to gorging or refusing food—tray with variety of nutritious foods, made
readily available; child chooses what and when to eat; parent does not comment on child’s selection or eating
habits; technique typically resolves feeding problem after 4 to 7 days; picky eaters—less likely to develop obesity;
more likely to eat something after repeated exposures or after seeing peers or heroes eat it; tips —pleasant
mealtimes improve feeding behavior; provide at least one food item child will eat at each meal; response to disruptive
behavior—dismiss child from table; remove child’s chair from table; wrap up food; refuse child food for
1 hr; offer nutritious food to child after 1 hr
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| Managing negative affect: response to angry child—lighten mood; distract child; model anger-resolution; acknowledge
and help child verbalize feelings; response to explosive child—make fewer demands (in general); target
limited number of behaviors; avoid backing down when child explodes (promotes coercive cycle of
interaction); parental mental health—psychiatric disorders (eg, depression) may impair parent’s ability to deal
with child; tips—teach child acceptable outlets for anger (eg, punching bags, teething rings)
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| Developing prosocial behavior and empathy: teaching and modeling behaviors (eg, sharing, taking turns, seeing
others’ points of view) inherent in parenting; transmission of prosocial behavior more challenging in single-
parent households, large families (\>4 children), and those with low income
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| Aggressive behavior: direct attention to victims (eg, tending to their needs) rather than to aggressive child (eg, to
give time out)
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| Toilet training: in control struggle over toileting, child always wins; if struggle begins, put child back in diapers
then work on behavior; issues—young children may regress after birth of new sibling; sleeping or bathing with
parents may create anxiety about genitalia; children anxious about getting dirty may use toilet but refuse to wipe
(recommend “pudding painting” for child and parents); constipation may interfere (consider polyethylene glycol
solution [MiraLax]); anxiety (eg, about anatomic differences between girls and boys) may contribute to refusal to
toilet; room-restriction method—work on discipline first; establish pattern; inform child of plan; move child to
designated room 30 min before expected bowel movement; restrict electronics, but allow play; keep child in designated
room until he or she uses toilet; avoid celebration (only when using this technique)
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Suggested Reading
Barkin S et al: Determinants of parental discipline practices: a national sample from primary care practices. Clin
Pediatr (Phila) 46:64, 2007; Bauer NS, Webster-Stratton C: Prevention of behavioral disorders in primary care.
Curr Opin Pediatr 18:654, 2006; Davidov M, Gursec JE: Multiple pathways to compliance: mothers’ willingness
to cooperate and knowledge of their children’s reactions to discipline. J Fam Psychol 20:705, 2006; Faber A, Mazlish
E: How to talk so kids will listen and listen so kids will talk. New York, NY: Avon, 1982; Galloway AT et
al: Parental pressure, dietary patterns, and weight status among girls who are “picky eaters.” J Am Diet Assoc
105:541, 2005; Greene RW: The Explosive Child, 2nd ed. New York, NY: Quill, 2001; Hudaoglu O et al: Parental
attitude of mothers, iron deficiency anemia, and breath-holding spells. Pediatr Neurol 35:18, 2006; Kahn R
et al: Randomized controlled trial of bottle weaning intervention: a pilot study. Clin Pediatr (Phila) 46:163, 2007;
Kochanska G, Aksan N: Children’s conscience and self-regulation. J Pers 74:1587, 2006; Macias MM et al:
Toileting concerns, parenting stress, and behavior problems in children with special health care needs. Clin Pediatr
(Phila) 45:415, 2006; Morawska A, Sanders MR: Self-administered behavioral family intervention for parents of
toddlers: Part I, Efficacy. J Consult Clin Psychol 74:10, 2006; Overbeek G et al: Parent-child relationships, partner
relationships, and emotional adjustment: a birth-to-maturity prospective study. Dev Psychol 43:429, 2007;
Phelan TW: 1-2-3 Magic. 3rd ed. Glen Ellyn, IL: ParentMagic, Inc., 2003; Robson WL, Leung AK: An approach
to daytime wetting in children. Adv Pediatr 53:323, 2006; Stang J: Improving the eating patterns of infants
and toddlers. J Am Diet Assoc 106(Suppl 1):S7, 2006.
Educational Objectives
| The goal of this program is to provide clinicians with tools for advising parents about discipline and behavior problems
in young children. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Identify parent and child factors that promote behavioral problems.
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| 2. Educate parents about factors that promote positive parent-child relationships.
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| 3. Describe effective methods of providing positive reinforcement for desired behaviors and administering consequences
for undesired behaviors in young children.
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| 4. List several common behavioral problems related to state regulation and describe effective responses for each.
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| 5. Provide evidence-based information in response to parents’ questions about common behavioral problems in
preschool-aged children.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the following has been disclosed: Dr. Howard is a consultant
for Total Child Health, Inc. and Learning through Entertainment, Inc.
Acknowledgements
Dr. Howard was recorded at Masters of Pediatrics Leadership Conferences, presented by the University of Miami,
Leonard M. Miller School of Medicine, Department of Pediatrics and Department of Dermatology and Cutaneous
Surgery, and held February 21-26, 2007, in Miami Beach, FL. The Audio-Digest Foundation thanks Dr. Howard and
the University of Miami Leonard M. Miller School of Medicine for their cooperation in the production of this program.
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