BHIPP Bulletin
Volume 7, Issue 5
November 2021
Disruptive Behavior in Childhood
This months' BHIPP Bulletin is a contribution from Carisa Parrish, PhD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine, Director of Pediatric Health Psychology, Johns Hopkins Children's Center and BHIPP Consultant. Additionally, this month's BHIPP Resilience Break focused on "Disruptive Behavior and DMDD" and was presented by Robert Paine, DO, Child and Adolescent Psychiatrist and BHIPP Consultant. To view the full session recording, slides, and related resources: click here!

Disruptive behavior problems are a common source of parent and teacher frustration. Behavior problems at home and at school rank in the top 5 concerns seen by providers who call the BHIPP consultation line. Despite being a typical part of child behavior, noncompliant and disruptive behavior can create significant stress for caregivers, and responding effectively can be challenging! Behavior problems can manifest in a variety of ways, including not following directions, not completing a task, delaying starting on a task, arguing, irritating others, whining, complaining, talking back, and breaking minor to major rules. We will briefly review evidence-based strategies for supporting parents in taming unruly and uncooperative behavior.
The Society of Clinical Child and Adolescent Psychology (Division 53 of the American Psychological Association) sponsors a website dedicated to evidence-based approaches to child and adolescent mental health. The section on rule-breaking and disruptive behavior provides a list of excellent resources for providers. The section dedicated to disruptive behavior disorders provides a summary of evidence-based treatment approaches for children and adolescents. Parent behavior therapy is one of the top treatment options, so let’s review this option, and how it could be implemented in a primary care setting.
Theoretical Model: Operant conditioning and behavioral reinforcement model
           Gerald Patterson, a child psychologist who co-founded the Oregon Social Learning Center, dedicated his career to understanding patterns of parent-child interaction that explain and predict children’s oppositional defiance and later conduct problems. The diagram below (Patterson, 1982) depicts how a normal parent-child exchange (e.g., a parent tells a child to do something, like "brush your teeth") can escalate into a coercive exchange between child and parent that can inadvertently reinforce negative behavioral patterns from both children and their caregivers. This dyadic framework is complex and highlights that children who display disruptive behavior shape and reinforce (or punish) their parents’ behavior as much as parents are influencing and managing children’s behavior. This dyadic model places the parent-child interaction at the center of the therapeutic frame, rather than the individual child.
           Dr. Patterson’s contributions likely influenced decades of behavioral research as well as numerous clinical treatment approaches based on his empirical model. The major umbrella term for these approaches are “behavioral parent training” or “parent management training.” These terms are synonymous and refer to treatments that focus on equipping parents with positive, effective strategies for influencing parent-child interactions to promote healthy attachment relationships and emotionally rewarding exchanges between parents and their children. Ideally, parents begin to recognize maladaptive interaction patterns that occur with their children and interrupt these habits with more positive exchanges.

Figure reproduced from Patterson (1982). 
Mindful parenting
           Remembering all the behavioral terminology in behavior therapy can be daunting! Although most of us can try to stretch back to a college course that introduced the ideas of reinforcement and punishment, keeping the technical aspects may feel, well, overly technical. While the behavioral technology is very evidence-based, the fast-paced setting of primary care may not lend itself to a didactic discussion of the differences between negative reinforcement and positive punishment, and how a savvy parent can avoid one and minimize the other. One explanatory model that may be easier to explain is the idea of automatic habits. We can understand that there are things that make the mindless habit more likely to stay a habit, as well as things that help us create new habits. Old habits can be hard to break, and many of us could probably use help (or at least some cheerleading!) as we try to change long-standing habits. So here are a few take-aways from brief parent training:
1.    Increase value and frequency of parental attention for good behavior
Think of your favorite supervisor or coach. Contrast with your least favorite. Ted Lasso is a recent popular example of a fictional coach who provides strategic positive attention to maintain focus, attention, motivation, and cooperation. The aim of this behavioral strategy is to help parents develop a positive interactional style in part by increasing the frequency of positive parent-child interactions. Here are two specific techniques: (a) encourage parents to provide specific labeled praise when children display prosocial, cooperative behavior (“Thank you for putting your dishes away!”), also called “catch ‘em being good”, and (b) one-on-one special play time, 5+ minutes per day, every day (for a brief description, check out this CDC website).
Accentuate the positive
Reinforcement highlights what we want children TO do!
2.    Decrease reliance on punishment
Think of your least favorite coach or supervisor again. How often did you feel like errors and shortcomings were front and center, while incremental improvements and efforts were overlooked? Excessive reliance on punishment can be a sign of parental stress, frustration, or time pressures. The goal of punishment is to terminate a behavior. In a moment of danger (yelling to stop your 5-year-old from running into the street), verbal punishment may be appropriate. In less dire moments, punishment may not yield the desired decrease in negative behavior, and may instead produce resentment and defiance from a strong-willed child. Helping parents recognize patterns of ineffective punishment (whether harsh, inconsistent, or unpredictable) may minimize a flood of maladaptive parent-child interactions. A kind, encouraging coach is focused on practicing positive habits, not berating someone who is learning from their mistakes. Help parents develop a mindful approach consistent with their goals.
Eliminate the negative
Remember, punishment only teaches children what NOT to do.
3.    Reduce reinforcement for noncompliance
Ooops, I let my child keep watching TV instead of help me set the table for dinner. I gave an instruction (“Help me set the table”), and my child tuned me out and kept watching TV (noncompliance). This is an example of reinforcing noncompliance. Many factors can contribute to noncompliance, so help parents make sure that they have their child’s attention, provide an age-appropriate command, and follow through to monitor for compliance. Ideally, follow compliance with a specific labeled praise (accentuate the positive!). If compliance does not occur with first command, maybe there is a way to improve command delivery (e.g., positive tone, reducing distractions before delivering command, cheerleading at the first sign of compliance, celebrating success when completed).
Don’t mess with Mr. In-between
Try not to reward disruptive behavior. Warning: this strategy is more difficult than it sounds.
In summary, positive behavioral parenting is a helpful, effective approach to reducing noncompliant and disruptive behavior in children. Prominent organizations including the AAP, psychology (APA Division 53), AACAP, CDC, and UNICEF all recognize the importance of positive parenting approaches for managing childhood behavioral challenges. Encourage parents to be mindful in their parenting approach and provide support for reflecting on parents’ goals and potential barriers to goals. Embody compassion for parents who are learning how to take care of their child. Humility and humor can go a long way in manifesting compassion for parents learning and unlearning habits related to managing disruptive behavior! Your BHIPP colleagues are eager to assist you with learning more about all these intervention approaches, so please send your questions our way!

Table reproduced from Dumas (1995)

Dumas, J. E. (2005). Mindfulness-based parent training: Strategies to lessen the grip of automaticity in families with disruptive children. Journal of Clinical Child and Adolescent Psychology34(4), 779–791.

Patterson, G. R. (1982). Coercive family processes. Eugene, OR: Castalia.

Thomas E.A. (2011) Coercion Theory. In: Goldstein S., Naglieri J.A. (eds) Encyclopedia of Child Behavior and Development. Springer, Boston, MA.

Resources Playful Parenting Tip Sheets APA child psychology website
Parenting the Strong-Willed Child: The Clinically Proven Five-Week Program for Parents of Two- to Six-Year-Olds, Third Edition Paperback – July 13, 2010 by Rex Forehand PhD (Author), Nicholas Long PhD (Author)
Your Defiant Child, Second Edition: Eight Steps to Better Behavior, Second Edition, by Russell A. Barkley PhD (Author), Christine M. Benton (Author)

As always, if you have questions about behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.
BHIPP Announcements
BHIPP in Your Neighborhood
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  • BHIPP Resilience Break presented by Shauna Reinblatt, MD
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  • Interested in organizing a (virtual) training event? Need more information? Message our team!
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Please note that the telephone consultation line will be closed on the following upcoming holiday(s):

  • Friday, December 24
  • Friday, December 31
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BHIPP is supported by funding from the Maryland Department of Health, Behavioral Health Administration and operates as a collaboration between the University of Maryland School of Medicine, the Johns Hopkins University School of Medicine, Salisbury University and Morgan State University.

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