This chapter reviews some important concepts in child behavior and the primary care provider’s role in assessing and providing guidance on common behavioral challenges. Pediatric behavioral medicine is closely linked to child development because many problematic childhood behaviors are developmentally normal. Clinicians who work with children need to identify parents’ behavioral concerns, even if parents do not initially volunteer this information at the visit. Clinicians also need to become comfortable with principles to address behavioral challenges in order to help parents learn skills to manage these behaviors. The second half of this chapter includes case illustrations of some common behavioral concerns in pediatric primary care such as aggression, oppositional behaviors, and infant sleep patterns.
UNDESIRABLE BEHAVIOR: PART OF NORMAL CHILDHOOD DEVELOPMENT
A child’s ability to understand and interact with the environment is constantly evolving. To learn more about the world, a child experiments with ways of interacting with it. Most often, children test the reactions of the people, such as parents, to whom they are closest. Colloquial phrases such as “the terrible twos” and “she’s going through a stage” indicate that some undesirable childhood behaviors are commonly accepted as “normal.” But when a child is demonstrating an undesirable behavior, parents can have a hard time accepting the behavior, and many parents need guidance. The clinician’s goal in these cases is to educate parents about normal child development, provide reassurance and advice, and emphasize the positive aspects of a child’s behavior and development in order to maintain a warm and supportive relationship between parent and child.
Behavioral challenges associated with normal childhood development must be distinguished from behavioral disorders, such as attention deficit hyperactivity disorder (ADHD), which are not the focus of this chapter. Disorders are diagnosed in children when problems are not related to normal development, symptoms meet the threshold set out by the Diagnostic and Statistical Manual of Mental Disorders or related criteria, and the behaviors cause distress or impairment for the child. The diagnostic requirement for distress or impairment is critical because behaviors or mental states such as anxiety, sadness, and inattention occur in healthy children and do not necessarily reflect pathology.
Aberrant childhood behaviors can be secondary to life stresses. This applies to children who witness violence, are members of communities that have experienced a natural disaster or catastrophic event, are exposed to continuous marital discord, have a frequently absent parent (such as military deployment), have a chronic illness or a chronically ill sibling, or who do not feel wanted. Children living under any condition that seriously threatens healthy and successful transition through a developmental stage are at risk for behavioral problems.
Children, like adults, may appear to be the dysfunctional member of an otherwise healthy family unit even though the problem actually stems from family ...