MODIFYING

BEHAVIORS
JORDAN KONCINSKY, MD

PGY2 TRIPLE BOARD RESIDENT

PEDIATRIC MORNING REPORT

You are seeing a 5-year-old boy, Arnold, for his well-child check-up. The
parents are stressed, stating that their child “never listens” to them. They
have a new baby in the family and the mother just went back to work. What
is the most appropriate next step for counseling this family?

• a) Refer the family for parent-child interaction therapy

• b) Give the family parent and teacher Vanderbilt’s and have them return in
one month

• c) Recommend sending the boy for a weekend visit with his grandmother

• d) Obtain more information about the child’s behavior at school and at

home
You are seeing a 5-year-old boy, Arnold, for his well-child check-up. The
parents are stressed, stating that their child “never listens” to them. They
have a new baby in the family and the mother just went back to work. What
is the most appropriate next step for counseling this family?

• a) Refer the family for parent-child interaction therapy

• b) Give the family parent and teacher Vanderbilt’s and have them return in
one month

• c) Recommend sending the boy for a weekend visit with his grandmother

• d) Obtain more information about the child’s behavior at school and at

home
UNDERSTANDING BEHAVIORS

• Collect ABCs of behavior

• Antecedents of behavior
• Behavior itself
• Consequences of behavior
ABCS

• Carlos presents with his mother,

Ms. Sanchez for his 6-year-old
check-up. Ms. Sanchez states
Carlos is doing well at school, but
is difficult to control at home. He
refuses to go to bed at night,
falling asleep on the couch in
front of the TV. He is not overly
aggressive with his younger
siblings, but refuses to complete
his chores and “talks back” to his
mother.
ABCS
• Carlos presents with his mother,
Ms. Sanchez for his 6-year-old
check-up. Ms. Sanchez states
Carlos is doing well at school, but
is difficult to control at home. He
refuses to go to bed at night,
falling asleep on the couch in
front of the TV. He is not overly
aggressive with his younger
siblings, but refuses to complete
his chores and “talks back” to his
mother.
• Your ABC history reveals that
Carlos begins to act out right after
he is told to go to bed. He refuses
to turn off the TV or leave the
couch, he yells, screams, and “goes
limp” if his mother tries to
physically move him or turn off
the TV. He will not stop until he is
allowed to remain on the couch
with the TV on. Ms Sanchez tries
to punish him by telling him he
cannot watch TV before bed the
next day, but his grandmother
watches him in the afternoon and
evening. When Ms Sanchez arrives
home from work the TV is always
on.
DISCIPLINE AND POSITIVE PARENTING
WITH LIFE ADJUSTMENTS
• New stressors or changes can incite behavioral changes in
children. These behavior changes are generally transient, especially if a
previously established routine and secure attachment with the
caregiver was in place prior to a change (eg. new sibling).
• Children who experience divorce, separation, extreme poverty,
substance abuse, and parental mental illness may be at greater risk for
persistent behavior disorders
• Pediatrician counseling should focus on maintaining consistent
routines in the during specific periods of adjustment to ensure a safe,
warm environment for the child.
Rachel is a 28-month-old female who has tantrums when told “no”, pushes
other children when she wants a toy, and hits when physically restrained.
Which of the following is the best approach?
a. Give a hug during the tantrum, model sharing with other children, and
spanking for hitting other children
b. Restrain during tantrum, model sharing with other children, and 5-
minute time out for hitting
c. Ignore the tantrum, model sharing with other children, 2 minute time
out
d. Ignore the tantrum, model sharing with other children, explaining that
hitting is inappropriate
e. Talk to Rachel during the tantrum, remove Rachel from other children
when not sharing, 2 minute time out.
Rachel is a 28-month-old female who has tantrums when told “no”, pushes
other children when she wants a toy, and hits when physically restrained.
Which of the following is the best approach?
a. Give a hug during the tantrum, model sharing with other children, and
spanking for hitting other children
b. Restrain during tantrum, model sharing with other children, and 5-
minute time out for hitting
c. Ignore the tantrum, model sharing with other children, 2 minute time
out
d. Ignore the tantrum, model sharing with other children, explaining that
hitting is inappropriate
e. Talk to Rachel during the tantrum, remove Rachel from other children
when not sharing, 2 minute time out.
DISCIPLINE-”TO TEACH”

• Goal: help child attain self-control, self-direction, and

emotional competence
• 3 components:
• Positive, supportive, loving relationship
• Positive reinforcement to increase desired behaviors
• Remove reinforcement or apply punishment to reduce/eliminate
undesired behaviors
 POSITIVE PARENTING

• 1. safe and engaging environment: interactive play time

https://www.youtube.com/watch?v=mEqaNDwaKfk&list=PLgp6bXecNYCBZxJpnFfTu
RV3FMSNw-e5l
• 2. Positive learning environment: Role of parents as child’s first teacher. Encourage
positive response to child-initiated interactions.
• 3. Assertive discipline: Ground rules for specific situations in clear, calm manner. Give
age-appropriate instructions and logical consequences
• 4. Realistic expectations: explore with parents and help choose developmentally
appropriate goals.
• 5. Parental self-care: Parenting as part of a larger context of personal self-care,
resourcefulness, and well-being.
 BEHAVIOR STRATEGIES

Strategy Age Example

Redirect Child’s Focus Late infancy-Toddler Exchange breakable object for

age appropriate toy

Give Good Directions Toddler “We will get ready for bed in 5
minutes. First we do X, then we
do Y. I will warn you in 3
minutes”

Time In Toddler-school age Time in: spend time together to

cultivate positive relationships

Time Out Toddler-school age 3 year old hits his brother. Walk
child to wall for 3 minutes.
 BEHAVIOR STRATEGIES CONT.

Strategies Age Example

Enforce limits and Toddlers- 6 yo turns on TV after being told to do HW. Parent
rules Adolescence reminds child of rule. Consequence of canceled play date.

Insist on an apology School Age 8 yo took siblings toy and broke it. Parent requires an
apology and way to fix or replace toy.

Act like a coach School age 9 yo has a new toy that her brother grabs away, she
begins to yell. Parent says “I know you’re frustrated but
stop and take a breath. How can we communicate
without yelling?”

Offer rewards School age Use star chart or token system with reward after earning
a specified amount.
Reggie missed his 30 month WCC but is coming in at 3 years old. You have taught
Mr. and Mrs. Smith several discipline techniques including effective use of time
outs, ignoring bad behavior and using consequences as negative
reinforcement. They are happy to have learned to avoid corporal punishment but
feel as though their relationship with their son is too negative. What can you add
to their discipline portfolio to help?

• a) At this age, positive reinforcements are too confusing to be effective. They should
plan to initiate a star/sticker chart when the child is in pre-school.

• b) A simple star/sticker chart would allow them to encourage and celebrate good
behavior with their son

• c) Children at this developmental stage respond best to verbal instructions so use

positive reinforcement for fun, but not as a discipline technique

• d) Their anxiety about the negativity implies that the discipline techniques are
overused. They should be directed to employ only positive reinforcement for a few
months.
STAR CHARTS-DOS AND DON’TS

• 1. make it clear what behaviors you are working to change

• 2. Identify prize ahead of time (let kids choose between options so
you can choose $ limit)
• 3. Identify how many stickers are needed for prize
• 4. Make prize achievable
• 5. Use meaningful rewards that the child wants
• 6. Be consistent
• 7. Connect sticker to targeted behavior
• 8. Think of as a reward, not bribe
TOKEN SYSTEM

• Choose a negative behavior that you want to change and a

positive behavior that you would like to see start or
continue.
• Set up a Home Token Economy to implement your behavior
management plan.
• Have daily, weekly, and big rewards. Change up rewards.
RESOURCES TO RECOMMEND

• 1-2-3 Magic: Effective Discipline for Children 2-12 by Thomas W. Phelan Ph.D.
• Positive Discipline A-Z: 1001 Solutions to Everyday Parenting Problems (Positive
Discipline Library) by Jane Neslon, Ed.D.
• Authoritative Parenting: Synthesizing Nurturance and Discipline for Optimal Child
Development by Robert E. Larzelere
• The Whole-Brain Child: 12 Revolutionary Strategies to Nurture Your
Child’s Developing Mind, Survive Everyday Parenting Struggles, and Help
Your Family Thrive by Daniel J. Siegel, MD and Tina Payne Bryson, Ph.D.
• No-Drama Discipline: The Whole-Brain Way to Calm the Chaos and
Nurture Your Child’s Developing Mind by Daniel J Siegel, MD and Tina
Payne Bryson, Ph.D.
• https://www.cdc.gov/parents/essentials/videos/index.html
• http://www.smarterparenting.com/specific-lesson/
The next patient on your schedule is John, a 4-year-old with chief
complaint of “behavior problems”. The medical student you are
working with will see the family first. You discuss the “ABC”
approach to a behavioral history. What are the components of the
“ABCs” of behavior?
• a) Assess parental capacity; Be objective; Clarify confusion

• b) Approach non-judgementally; Behavior Modification; Child

discovery
• c) Antecedents of Behavior; Behavior itself; Consequences of
Behavior
• d) Allow parental discussion; Behavior itself; Congratulate parents
on efforts
The next patient on your schedule is John, a 4-year-old with chief
complaint of “behavior problems”. The medical student you are
working with will see the family first. You discuss the “ABC”
approach to a behavioral history. What are the components of the
“ABCs” of behavior?
• a) Assess parental capacity; Be objective; Clarify confusion

• b) Approach non-judgementally; Behavior Modification; Child

discovery
• c) Antecedents of Behavior; Behavior itself; Consequences of
Behavior
• d) Allow parental discussion; Behavior itself; Congratulate parents
on efforts
A twenty-five-month old girl is brought to your office for persistent
tantrums. Mom states that tantrums occur at least five times a
day. Responses from mom so far have been to give her candy which
stops the tantrum briefly but does not decrease the overall
frequency. The most appropriate next step is:
• a) Refer her to a behavior specialist

• b) Provide reassurance that distraction is an appropriate

technique and reassure her that the tantrums will improve.
• c) Encourage the mother to engage the child in a discussion to
figure out what is wrong when she has a tantrum.
• d) Advise the mother to ignore the child when she is exhibiting
tantrum behaviors.
A twenty-five-month old girl is brought to your office for persistent
tantrums. Mom states that tantrums occur at least five times a
day. Responses from mom so far have been to give her candy which
stops the tantrum briefly but does not decrease the overall
frequency. The most appropriate next step is:
• a) Refer her to a behavior specialist

• b) Provide reassurance that distraction is an appropriate

technique and reassure her that the tantrums will improve.
• c) Encourage the mother to engage the child in a discussion to
figure out what is wrong when she has a tantrum.
• d) Advise the mother to ignore the child when she is exhibiting
tantrum behaviors.
Parents of a 7-year-old boy are seeking advice about methods of
disciplining him as he was involved in a physical fight at school today.
What is the best technique to recommend to respond to this issue?
• a) Apply an immediate consequence and seek an apology and
restitution for harm inflicted on the other child

• b) Wait a few days until everyone is calm and apply a

consequence for fighting
• c) Apply an immediate consequence but do not force him to
apologize if he doesn’t want to.
• d) Do not apply a consequence because the fight was started by
the other child.
Parents of a 7-year-old boy are seeking advice about methods of
disciplining him as he was involved in a physical fight at school today.
What is the best technique to recommend to respond to this issue?
• a) Apply an immediate consequence and seek an apology and
restitution for harm inflicted on the other child

• b) Wait a few days until everyone is calm and apply a

consequence for fighting
• c) Apply an immediate consequence but do not force him to
apologize if he doesn’t want to.
• d) Do not apply a consequence because the fight was started by
the other child.
ONLINE REFERENCES

• https://www.empoweringparents.com/free-downloadable-
charts/behavior-chart-preschool-kids/
• https://www.psychologytoday.com/us/blog/dont-worry-
mom/201408/the-dos-and-donts-the-sticker-chart
• https://ped.peaconline.org/
• https://www.cdc.gov/parents/essentials/videos/index.html
• http://www.smarterparenting.com/specific-lesson/
• https://depts.washington.edu/hcsats/PDF/TF-
%20CBT/pages/combined/CBT+-Home-Token-Economy-
Guide.pdf
THANKS!