This chapter reviews common childhood behavioral problems and suggests some management guidelines. Pediatric behavioral medicine cannot be easily disassociated from child development because many problematic childhood behaviors have developmental roots.
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 to whom they are closest, their parents. Colloquial phrases such as "the terrible twos," "she's going through a stage," and "boys will be boys" indicate that undesirable childhood behaviors are commonly accepted as "normal." But when an undesirable behavior is manifesting in your child, the normalcy can be difficult to accept. And even when the cause is well understood, many parents still need the knowledge and skills to respond to the problem behavior.
Behavioral problems associated with normal childhood development must be distinguished from problems with more complex causes. Aberrant childhood behaviors are often secondary to extraordinary life stresses. This applies to children who witness violence, are members of communities that have experienced a catastrophic event, are exposed to continuous marital discord, have a chronic illness or a chronically ill sibling, or who don't feel wanted. Children living under any condition that seriously threatens healthy and successful transition through a developmental stage are likely to pose serious 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 issues. This is particularly the case with childhood behaviors, because children are dependent on adults in almost every way. Take, for instance, the child who refuses to attend school. Classically, this behavior occurs when one or both parents send subliminal messages to the child to remain home. Although the primary problem is parental anxiety about separation, it is the child who exhibits the apparent symptoms.
In addition to childhood behavioral problems stemming from normal development and extraordinary life stresses, a third general category involves problems caused by disorders inherent to the child. Attention deficit disorders are the most common and well known, but conduct disorders, depression, pervasive developmental disorders, and other psychiatric diagnoses may manifest during childhood. A complete history, observation, and response to treatment help the primary care clinician distinguish these from other causes of behavioral problems.
Pediatric primary care providers must screen families for difficulties with undesirable childhood behaviors, sort out probable causes for the behaviors, recognize when a mental health referral is appropriate, and manage those problems that are likely to respond to simple environmental changes or to elementary behavioral management techniques.
Practitioner Concern versus Time Constraints
Many parents do not know where to seek help for behavioral problems such as their baby's night awakenings, their toddler's tantrums, or their fourth grader's class-clown behavior. They do not realize that their child's clinician ...