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Management of Disruptive
Behavior53
in Young Children
Disruptive behavior tends to worsen with time, but it can be treated effectively. Parent-child interaction
therapy (PCIT), an evidence-based treatment for preschoolers with disruptive behavior and their parents,
focuses on changing ineffective parent-child interaction patterns. The first phase, focusing on child-directed
interaction, strengthens the parent-child relationship, builds the childs self-esteem, and reinforces the childs
prosocial behaviors. The second phase, focusing on parent-directed interaction, introduces parent management training. Treatment is guided by assessment and continues until parents master interaction skills and
child behavior problems fall within the normal range. Emerging evidence suggests that treatment gains are
maintained for several years posttreatment. Key words: aggressive behavior, behavior problems, child,
disruptive behavior, oppositional, parent-child interaction, preschoolers
Erin M. Neary, BS
Graduate Student
Sheila M. Eyberg, PhD, ABPP
Professor
Department of Clinical and Health Psychology
University of Florida
Gainesville, Florida
S PART OF their normal development, preschool-age children are highly active, often
moody, and aggressive. Moreover, typical
preschoolers disobey 25% to 50% of their parents
commands.1 With such frequent negative behavior
typical of young children, how can parents decide
if the bad behavior they are seeing in their preschooler signifies a significant concern or is within
normal limits? Disruptive behavior refers to a wide
range of conduct problems, such as oppositional,
stubborn, aggressive, and impulsive behaviors, that
cluster together and occur at higher rates than usual
for preschoolers of the same age. Normal children
show many of the problem behaviors seen in
children with diagnosed disruptive behavior, but
their behavior problems are fewer and occur less
frequently.2 Disruptive behavior occurs at the same
rate in chronically ill as healthy children, and
although children with developmental disabilities
have a higher rate of disruptive behavior than
others, their scores on measures of disruptive
behavior remain within normal limits on average.2
PREVALENCE AND STABILITY OF
DISRUPTIVE BEHAVIOR
Disruptive behavior in preschool-age children is
more common than previously thought.3 Richman
and Graham4 found 15% of 3- and 4-year-old
Inf Young Children 2002; 14(4): 5367
2002 Aspen Publishers, Inc.
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INFANTS
AND
problems to adulthood, but early disruptive behavior is the single most substantial risk factor for
adolescent delinquency and adult criminal behavior.3538 Young children with disruptive behavior
also have an elevated risk of psychiatric problems
in adulthood, including a higher suicide rate.39 All
told, early disruptive behavior results in enormous
societal costs.19,40
IMPORTANCE OF EARLY INTERVENTION
A younger age of onset is associated with greater
severity of disruptive behavior throughout its
course,19 and disruptive behavior can be reliably
identified in children as young as age 3.32,41 Evidence also suggests that intervention is more
effective at the preschool age than when children
are older.4244 Effective treatment of disruptive behavior prior to school entry may prevent the
associated problems with academic performance
and peer relationships that require multiple interventions only a few years later.4547
Primary care physicians are often the only professionals to see young children before school
entry48 and are thus critical to early identification.
Studies4951 have found that at least 20% of the 2- to
5-year-olds seen in primary care settings have
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)52 disorders, yet
young children with significant psychopathology
are frequently not referred for treatment.53 Identification of child psychopathology is difficult.
Costello et al49 found that pediatricians were able to
correctly identify only 17% of children with mental
health problems. With increasing use of the Diagnostic and Statistical Manual for Primary Care
(DSM-PC),54 recognition of the problems that require referral to mental health providers is likely to
improve. Further, due to their effectiveness in
screening, behavior rating scales have been recommended for use in primary care settings.2 The use
of rating scales has been shown to improve pediatrician recognition and referral of children who
need mental health treatment.55 In the authors
experience, pediatricians are the primary referral
55
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zation of the child and environmental factors contributing to the development and maintenance of the
childs disruptive behavior. Assessment methods
include clinical interviews, parent and teacher rating
scales, behavior observations, and measures of parent functioning and satisfaction with treatment (see
Table 1 for a summary of measures developed
specifically for use with PCIT).
The intake assessment begins with a semistructured interview with the childs parents. As the
first contact between therapist and parents, the dual
goals of the interview are to establish a strong
therapeutic alliance and to gather information. The
therapist also attempts to build positive expectations
for treatment outcome. At the same time, the
therapist describes the realistic demands of treatment and helps parents consider potential barriers
Assesses
Semistructured interview98
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PRIDE rules
Reason
Examples
Praise appropriate
behavior.
Reflect appropriate
talk.
Imitate appropriate
play.
Describe appropriate
behavior.
Be Enthusiastic.
Fig 1. PRIDE skills. Source: This is a prepublication version of material from a forthcoming work tentatively titled
Comprehensive Handbook of Psychotherapy, Volume 2, edited by T Patterson and F Kaslow to be published in Spring
2002. Copyright 2001, John Wiley & Sons, Inc. All rights reserved.
59
Reason
Examples
1. Commands should be
direct rather than
indirect.
2. Commands should be
positively stated.
3. Commands should be
given one at a time.
4. Commands should be
specific rather than
vague.
5. Commands should be
age appropriate.
6. Commands should be
given politely and
respectfully.
7. Commands should be
explained before they
are given or after they
are obeyed.
continues
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Table 2. Continued
Rule
Reason
Examples
8. Commands should be
used only when
necessary.
Source: This is a prepublication version of material from a forthcoming work tentatively titled Comprehensive Handbook of Psychotherapy,
Volume 2, edited by T Patterson and F Kaslow to be published in Spring 2002. Copyright 2001, John Wiley & Sons, Inc. All rights reserved.
61
COMMAND
Disobey
Obey
WARNING
(CHAIR)
LABELED PRAISE
Disobey
Obey
CHAIR
LABELED PRAISE
Gets off
Stays on
WARNING
(TIME-OUT
ROOM)
RETURN TO
TASK
TIME-OUT
ROOM AND
CHAIR
ACKNOWLEDGE
Gets off
RETURN TO
TASK
TIME-OUT
ROOM AND
CHAIR
Stays on
etc.
ACKNOWLEDGE
Gets off
Stays on
Example: Fine
Go to the chair and say: Are
you ready to come back and
put the car in the toy box?
Fig 2. Parent-directed interaction algorithm. Source: Adapted from Handbook of Parent Training: Parents as CoTherapists for Childrens Behavior Problems (2nd ed.) by JM Briesmeister and CE Schaefer. Copyright 1998, John Wiley
& Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.
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