Behaviour Problems in Young Children: Assessment and Management

Behaviour problems in young children: Assessment and management

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This time interval typically results in positive sensations in anticipation of food without the physical discomfort of extreme hunger. To encourage the intake of a broad range of foods, only a small amount of a preferred food should be offered at the scheduled feeding time, at least until after nonpreferred foods have been consumed [ 33 ].

Generally, clinicians suggest that the duration of mealtimes for children be between min or up to 45 min for children with physical impairments affecting eating [ 16 ].

Shorter meals have been associated with undernutrition and long mealtimes have been associated with behavioral feeding problems; however, problems with meal duration are likely to be symptoms of an underlying behavioral problem [ 29 ]. Interventions to reduce excessive meal length include use of a timer or marking the hands of a clock as a visual reminder of when mealtimes will be over [ 33 ].

Caregivers should avoid using timers and clocks which are digital as the units of time of these devices may be difficult for the child to interpret. Rather, wind-up timers or sand timers are particularly useful with young children. Once the meal is ended, it is important not to provide the child with food or beverages other than water for a period of at least 2 h, in order to establish a clear discrimination between eating and noneating occasions and to promote greater hunger before the next scheduled feeding period.

Behavioral Management of Feeding Disorders of Childhood

Meal setting characteristics or environmental control can exert facilitative or detrimental effects on children's behavior. Typically, clinicians will evaluate attributes of the feeding setting including physical surroundings, feeding position and body support, and activities preceding and following eating. Generally, a solitary location devoid of visual or auditory distractions e. This also helps children to focus on their parents as a source of feedback, facilitating a caregiver's ability to manage the meal. Caregivers are advised to serve meals in a consistent eating area, to restrict the people present to those who are eating, and to prohibit toys or activities as they typically disrupt eating.

It may also be advisable to limit the number of feeders to one or two people who are trained in the feeding procedure, especially early in intervention. Body positioning may also have significant effects on a child's eating habits. A secure, well-balanced posture during meals is recommended as it typically enhances a child's motor coordination and attention to feeding.

As part of the intervention, parents are often told to seat children securely for meals e. Children with physical disabilities may need additional modifications in feeding positions to provide for optimal alignment of head, neck, and trunk and may benefit from evaluation by a pediatric occupational therapist. Many caregivers report that mealtime transitions are among the most difficult aspects of feeding their child. The type of activity immediately preceding meals may have direct effects on the transition and perhaps on the entire meal, particularly when the child perceives the preceding activity as enjoyable in contrast with the child's perceptions regarding the challenges of mealtime.

Clinicians should advise families to engage in quiet activities preceding meals and encourage families to establish a routine to facilitate the transition into the meal e.

Similarly, families should select an activity that the child looks forward to at the completion of the meal, contingent upon reaching mealtime objectives. Families should avoid offering a strongly preferred activity after the meal without a clear exit criterion [ 10 ] as this may result in a child attempting to hasten the meal resulting in poor intake. Exit criterions make use of the Premack principle [ 39 ] in which individuals will perform less desirable activities to earn a more desirable activity e.

Similarly to environmental interventions, strategies to increase desirable feeding behaviors are generally easy to understand and to implement for caregivers in the home environment. However, these strategies typically require parent training and ongoing consultation with a pediatric psychologist to ensure success table 2. Positive reinforcement is the delivery of a reward e.

Typically, attention from an adult caregiver is the most common method of reinforcement, as attention is easily delivered and highly sought after by children. For older children, the use of tangible reinforcement such as a sticker chart or point system in which points can be accumulated to earn prizes or privileges may be more motivating [ 40 ]. For these techniques to be effective, the reward must be motivating enough to change feeding behavior, and the caregivers and the child must understand and follow the reinforcement schedule. Negative reinforcement involves terminating or withholding an aversive stimulus contingent on performance of a desired behavior, with the result that it strengthens the probability that the desired behavior will occur in the future.

As negative reinforcement involves the use of aversive stimuli, these techniques are typically only used in more intensive therapeutic settings e.

Perhaps the most commonly used form of negative reinforcement is the use of physical guidance also called contingency contacting or chin or jaw prompting to induce a child to accept or swallow a bite of food [ 41 , 42 , 43 , 44 ]. In practice, a child is offered a bite of food, if he or she refuses the food the feeder physically guides the food to the child's lips or into the child's mouth and holds the jaw until the bite is accepted and swallowed. Termination of the physical guidance the aversive stimulus occurs when the child accepts the food the desired behavior.

With continued use of this technique, the child learns to avoid the use of physical guidance by accepting the food at the first presentation. Discrimination training , also known as differential reinforcement , teaches the child that targeted desirable feeding behaviors e. Modeling demonstration of a desired feeding behavior and then praising when the behavior is exhibited by the child and shaping and fading reinforcing successive approximations of a more complex or higher-order behavior are commonly used in discrimination training [ 46 ].

Texture fading, a procedure in which food textures are systematically increased [ 47 ], and graduated guidance for self-feeding [ 48 ] and least to most prompts for self-feeding [ 49 ], methods to help children progress to age-appropriate self-feeding, are techniques which rely on discrimination training methods. Unlike environmental strategies and strategies to increase desirable feeding behavior, strategies to decrease undesirable feeding behaviors may be more difficult for caregivers to implement. These strategies typically require parent training and ongoing consultation with a pediatric psychologist to ensure success table 3.

Extinction is the systematic withholding of a reward following a problem feeding behavior which has been targeted for elimination.

Behavioural and emotional disorders in childhood: A brief overview for paediatricians

The most common example of extinction, in a feeding disorder treatment context, is to ignore undesired child behaviors such as refusals or tantrums [ 32 , 50 ]. Often, extinction techniques are difficult for parents to implement, and learning these techniques may require in vivo training for caregivers which might include modeling, behavior reversal, and practice to refine caregivers' skills and to provide emotional support during intervention.

Punishment is the delivery of an aversive stimulus or the removal of a rewarding stimulus that weakens the probability that the response will occur. Punishment procedures involving highly aversive stimuli are recommended only when less intrusive procedures are not successful, the target behavior is damaging to the child or others, and when carefully monitored by trained personnel.

Perhaps the most commonly used punishment technique is timeout from positive reinforcement [ 51 ].

In a feeding context, the child may be turned or moved away from the table to eliminate any reinforcement from the child's refusals. Timeout at the table is commonly used because it is safe and highly effective.

INTRODUCTION

In some cases, negative verbal attention may, in fact, serve as a positive reinforcer and, therefore, it is essential to monitor the effects of delivering the punishment to determine whether the technique is actually effectively decreasing the target behavior. Response-contingent withdrawal of positive reinforcement [ 52 ] and response cost for refusal [ 53 ] are other forms of punishment.

Typically, these techniques involve the withdrawal of toys or other preferred stimuli during a meal or at the end of a meal as a consequence of misbehavior. To be most effective, the child should have the opportunity to regain access to the preferred stimuli by engaging in cooperative behavior either at the meal or at a subsequent meal. Finally, overcorrection , a procedure in which the child is physically directed through a series of repetitive, presumably unpleasant acts, has also been used as another form of punishment [ 54 ].

This technique is frequently used for children who intentionally throw foods or spit up during meals. Some behavioral interventions may be too aversive for parents to implement or may inadvertently increase the frequency and severity of behavioral problems if implemented incorrectly, such as swallow induction [ 55 ], which elicits a swallow by stimulating the back of the throat. Also, avoidance conditioning has been effectively applied as a punishment technique to reduce a problem behavior e.

However, careful consideration of the use of these techniques should be made with a feeding specialist prior to use as there is a relatively high risk of increasing aversion if the techniques are used improperly. Occasionally, a child will have a history of aversive feeding events which underlies the negative feeding behaviors, which become the target of treatment e. To reverse the effects of aversive conditioning, desensitization procedures are often used [ 56 ].

Desensitization is the repeated pairing of the conditioned aversion with the absence of the aversive event, generally with the additional delivery of a positive reinforcement as an alternative, adaptive response. Generally, desensitization includes graduated exposure to the stimuli in nonthreatening conditions.

Behavioral problems in children

Within a feeding context, a hierarchy of exposure may be developed to gradually shape the child's acceptance of new or nonpreferred foods. Parents typically learn interventions from providers and ultimately implement these recommendations in the home environment fig.

References

To enhance the likelihood of a successful treatment outcome, parents need to be educated about the basic theory and applications of behavioral techniques [ 13 ]. Frequently, parent training includes education on how adaptive and maladaptive behaviors develop and become reinforced, how to assess antecedents and consequences as they affect behavior, and how to use basic behavioral interventions to effect change.

Parent training often includes: 1 the provision of written information including descriptions of intervention techniques to be used; 2 a therapist modeling intervention techniques during a simulated meal; 3 in vivo coaching - directly with the child in the room or through remote coaching e. Methods in white are suitable for families to implement at home with education and ongoing consultation.

Methods in grey are suitable for families to implement at home with regular contact with the treatment team. Methods in black may not be suitable for home use and require close contact with the treatment team for any use. Feeding problems are common and represent a cluster of symptoms which are often of significant concern to families and pediatricians alike.

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