Nov SE Breakfast - by Jean Mercer

PA-AIMH 11/6/15
A large and enthusiastic audience welcomed the infant mental health breakfast seminar presentation by Dr. Nathan Blum on Nov. 6, 2015. Dr. Blum is Chief of the Division of Developmental and Behavioral Pediatrics at Children’s Hospital of Philadelphia. He spoke on behavioral management of children’s oppositional behavior.
A basic theme of Dr. Blum’s presentation was that oppositional behavior has generally been learned in the course of a child’s interactions with parents, and if the nature of the interactions is changed, more compliant behavior can be learned and can take the place of opposition. To accomplish this, parents need to understand the role of reward/reinforcement of desirable behavior and the withholding of rewards for unwanted oppositional behavior (for example, by the use of time-outs).
Children who become oppositional may lack flexibility and adaptability to begin with, but a problematic social environment operates to bring about consistent noncompliance. Dr. Blum mentioned as features of this environment the following: unclear rules; inappropriate expectations about behavior; lack of parental attention for desirable behavior; parental failure to recognize a child’s efforts when they do not have a perfect outcome; the child’s experience of escaping from demands by inappropriate behavior; “bribing” by allowing the child a reward following undesirable behavior; and the existence of excessive environmental stressors.
As children become more oppositional, parent-child interactions move toward a more coercive pattern, said Dr. Blum. The child learns not to listen; the parent learns to repeat commands; the parent learns that only the statement of a threat will bring compliance; and the child learns that it is not necessary to listen until the threat appears. Parents who have learned to use threats begin to threaten or yell at the slightest problem event, and the child learns to engage the parents’ attention in this way.
Dr. Blum mentioned a number of evidence-based treatments (EBTs) designed to correct oppositional behavior. These all share certain components that are taught to parents: the use of praise, time-outs that withhold attention and rewards following unwanted behavior, the use of tangible rewards, the use of clear commands, problem-solving to eliminate obstacles like stress, and the use of differential reinforcement with high contrast between reinforcing and non-reinforcing conditions. Dr. Blum also recommended the “1, 2, 3, magic” approach, in which clear, brief, and precise commands – statements, not questions—are not followed by parent commentary or discussion; the parent counts to 3 instead of continuing to talk.
Dr. Blum suggested that when a new behavior is to be learned, its difficulty should be managed so that the child can be successful and be reinforced on 7 or 8 occasions out of every 10 attempts. When the behavior has become well established, reinforcement can become intermittent, but frequent reinforcement is needed early on. If this reward system does not seem to be working, there may be one or more of several problems that need to be corrected. The behavior being demanded may be too difficult for the child at this point in development. The reward chosen may be wrong--  not of interest or value to the child. (Parental attention is often the most valuable reward.) Or, high levels of stress in the environment and the parent-child relationship may interfere with the child’s ability to comply.
Some problems with which parents may need help are inconsistency and the wish to try to change too many behaviors at the same time. Rules and commands need to be limited. Parents need to be counseled to ignore behaviors that are simply mildly to moderately annoying, and to select 2 or 3 positive behaviors that can be worked on consistently and attentively; once these are established, 2 or 3 more may be chosen. Dangerous behaviors should always be punished by methods like time-out.  In answer to an audience question, Dr. Blum suggested that parents who are unduly concerned with “defiance” and triggered emotionally by child opposition may need more basic work before they are able to use behavior management methods.