This information sheet has been written by Dr Ian Frampton who is a Clinical Psychologist and former member of the Brain and Behaviour team at the Maudsley Hospital.
This article is based on HemiHelp workshops on behavioural problems in children with hemiplegia. As well as summarising my talks, I hope to reflect the thought-provoking and fascinating discussion contributed by parents at the workshops. It is important to acknowledge that when ‘experts’ start to speak, it is often clear that they have spent too long in their ivory research towers and need a good dose of reality to bring them back to earth. However, research has taught us a great deal about what works, and it can be helpful to think about turning these ideas into reality.
When is a problem a 'problem'?
All children behave badly - this is a natural part of growing up and learning about the world. The two year old starting to scribble with fat crayons can be forgiven for getting carried away and decorating the table, but the nine year old producing graffiti art on the new wallpaper is probably pretty aware of the consequences of their action! In other words, what makes behaviour a problem can depend on lots of things like the age of the child and where the behaviour is happening. On the other hand, sometimes what makes behaviour a problem is extremely simple. Running into the road without looking, for example, will always be a problem for all children at all ages.
Traffic light system
It can be helpful for parents to have in mind rough-and-ready rules for what is acceptable and what is not. One helpful way is to code behaviour using a traffic light system.
• Green behaviour would be the angelic things you’d love them to do more of the time (being polite to guests, helping around the house, getting on with brothers and sisters...)
• Amber behaviour would be things that are OK but could end up in a problem (running round the house with a drink in their hand, getting tired and whiny)
• Red behaviour would be things that are unacceptable and have to stop NOW (like hitting the baby or throwing things around).
One of the advantages of thinking about behaviour like this is that you can decide at what point you need to do something about it. This can help to avoid the situation where you end up having to tell your child off almost all the time for everything they do (or don’t do) - which gets boring for everyone involved.
Problem behaviour, not problem child!
This sounds a bit like a platitude from an American chat show to ‘love the child and hate the behaviour’. Nevertheless, it can be helpful to remember (through gritted teeth if necessary) that it is the behaviour that is the problem, not the child. This can make it easier to think about how to banish bad behaviour, and even to get your child involved in thinking about changing their behaviour.
Why children with hemiplegia
We know from research that children with hemiplegia are more likely than their classmates to be irritable. This means that they tend to run on a short fuse, and small upsets or hassles can provoke tantrums and outbursts that are completely over the top, especially when they are tired (which is why after school can be a high risk period).
It is likely that the same damage to the brain that caused their hemiplegia is also leading them to be rather ‘prickly’ in this way. So this is a good example of problem behaviour which is not the child’s fault, although they will need to develop skills to manage their irritability in ways that are acceptable to others as they get older.
Like lots of sensible behavioural advice, good ideas about responding to tantrums are exactly those that your grandmother would have given you, but dressed-up in more modern jargon.
The most important elements are:
• ignore the tantrum if you can (not providing an audience and going out of the room to make a cup of tea can sometimes help)
• modify the environment if you can’t (this is a jargon way of saying remove the best china and get the TV out of range so a bad situation doesn’t degenerate into a terrible one)
• if neither of the above work, consider removing the child (see time-out)
The meaning of problem behaviour
Children act out and do bad things for lots of reasons: sometimes just to get a reaction; sometimes to find out where the limits are; sometimes to express feelings that they cannot put into words and sometimes just to be plain naughty. Especially with younger children, it’s often not that helpful to have a prolonged ‘post-mortem’ after an outburst to try to get to the bottom of what’s behind the behaviour. On many occasions the outburst may have occurred precisely because the child can’t put into words the mixed-up angry and cross feelings they have, so trying to get them to talk about it is doubly hard.
It’s usually better to move on to the next thing as soon as everyone feels calm enough, making sure that you don’t inadvertently reward the bad behaviour (if you were on the way to McDonald’s anyway then that’s probably OK, but going there specially is guaranteed to ‘positively reinforce’ it, as we say in the jargon).
At bedtime you might want to ask your child to think back to the outburst and perhaps talk about it, while stressing that it is all over now (unless, of course, pocket money needs to be withheld as a contribution towards window repairs).
Responding to problem behaviour
There have been loads of books published about parenting, and if it really were as easy as most of them suggest, then none of us would have any problems at all (and we psychologists would be out of a job!).
Although they do oversimplify complex problems and may miss the point, one common theme does emerge which is supported by research. When all is said and done, there are only two ways to change problem behaviour:
• get the child to do less of what you don’t want them to do
• get the child to do more of what you do want them to do.
Accentuate the positive
This again sounds just like what your grandmother would have said, but it can be helpful to think through problem behaviour by working out the alternative positive good behaviour you want from your child.
Planning in advance
Sometimes children behave badly because they don’t know what is expected of them in a particular situation. If you have friends coming over for the evening it’s helpful to negotiate with your children in advance and agree that they will be allowed to have two fizzy drinks, will go upstairs to watch the TV at 8.30 and bed will be 9.00. Having a plan in advance can avoid an embarrassing confrontation and tantrum in front of others.
Deciding together with your child exactly what you want them to do is an important first step. This needs to be as specific as possible (so “you are not allowed to come out of your room after 9.00pm” rather than something general like “be good at bedtime”) so that both you and your child know whether or not this has been accomplished.
Motivation and rewards
The second step is to give the child a reason for good behaviour that makes sense to them. Although we as adults can see why sitting on the toilet and trying when you come home after nursery at 4.00pm is a good idea for a three year old (not least because it can prevent damp knickers and recriminations at 5.00pm), young children just do not think that way.
Making it their responsibility also makes it their fault if things go wrong, and you can end up feeling like they’re trying to get at you through the problem behaviour of refusing to go to the toilet. In this case, increasing their motivation might include establishing a routine of always going to the toilet as soon as they come in “because that’s what big girls or boys do” (which is rewarding them for being grown-up with praise - a powerful reinforcer), or maybe having a sticker they can put on their chart after sitting and trying for two minutes (note that the reward here is for trying rather than performing).
With older children, rewards can be more tangible (like pocket money). We had some interesting discussion at parent workshops about the rights and wrongs of rewarding children for doing things they should just do; however, a show of hands of who would go to work if they didn’t get paid for it seemed to seal the debate.
Rewards do need to be carefully chosen (in jargon it’s called the Goldilocks Principle: not too much and not too little) and need to be updated if they’re not working any more. Small things like being allowed to have breakfast in front of the TV can be better than elaborate presents. Praise for good behaviour can be a powerful reinforcer for many children (although, as some people in workshops have noted, some children can be praise-phobic, in which case an alternative is needed).
Dealing with negative behaviour
Of course, it’s not always possible to encourage good behaviour and ignore bad. Families have their own rules for what is acceptable and what is not, and children learn best when these rules are kept as simple and clear as possible (even though you might sometimes feel that you need a Philosophy degree to explain why it’s OK to behave like this in one situation but not in another; understanding such ambiguity is the very stuff of growing up).
Natural consequences are a suitable negative ‘reward’ for some bad behaviour (if you have a paddy and throw your drink on the floor then you haven’t got a drink any more).
Time-out has been advocated by many childcare ‘experts’ and although it is clear from discussion in the workshops that it doesn’t always work as planned, a brief time (3-5 minutes) sitting on the bottom step of the stairs until calm or being sent to your room for 5 minutes makes clear what is unacceptable behaviour.
Loss of privileges like TV had also been found quite helpful by workshop participants, although it is important to try to limit consequences to a single day so that your child has another chance to start afresh tomorrow.
Older children sometimes like contracts, where they agree with parents a ‘deal’ that both sides can keep (“I won’t swear at my sister if you don’t hassle me about homework”), with rewards if each side keeps its bargain (“I’ll drive you to the disco on Friday”) and sanctions for transgressions (“No football magazine”). Negotiating and brokering such contracts can be a helpful way to include your child in making decisions about their behaviour, and you might be surprised at their prowess at haggling!
Looking after yourself
If bringing up children were an Olympic sport, we’d all be gold medallists. Having time for yourselves once the children are in bed or for the odd weekend is crucial to recharge the batteries.
Some young people with hemiplegia tend to be rather clingy and don’t like the thought of staying away from home without you; however, they might be brought round to the idea of Grandma coming over to look after them in your house while you’re away overnight, especially if the idea is introduced gradually and centres on a premiere of the latest Disney DVD!
Finally, we know from talking to parents that dealing with problem behaviour can be a difficult and challenging business. As with all problems, sharing can make them easier to bear, and sometimes having another point of view can bring a fresh perspective and new ideas. There are many books on the market that offer advice - my personal preference is for books by Dr. Christopher Green like Toddler Taming and Now I Know Why Tigers Eat Their Young, which combine sensible advice with a humorous approach to problems that sometimes can feel anything but funny.
For younger children, Health Visitors and GPs can provide helpful advice; alternatively your GP can refer you to your local Child and Family Therapy Service to someone who is trained in advising on problem behaviour in children.
See also HemiHelp’s information sheet Emotional and Behavioural Difficulties