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Editorials for Clinical Practice

CHADIS Co-Director and President, Dr. Barbara Howard is a regular contributor to the Behavioral Consult column of Pediatric News and an Assistant Professor of Pediatrics at The Johns Hopkins University School of Medicine.


Dr. Howard is a developmental-behavioral pediatrician trained by Dr. T. Berry Brazelton at Harvard University. She is a national speaker on child behavior problems and is a past president of the Society for Developmental and Behavioral Pediatrics. She was a contributing author for Bright Futures™, Diagnostic and Statistical Manual for Primary Care (DSM-PC) and Bright Futures in Practice: Mental Health and has served on national committees of the American Academy of Pediatrics.

We already tried that ... Refining your behavior management plans

Barbara Howard, MD

It is the rare family of a child with behavior problems that has not already tried a plan from a book or advice from friends or relatives. They may even have done what their parents did to them, whether it worked or not! The first message you hear in the visit may be "We already tried the star chart thing."


Can you really provide any better advice for changing behavior than what they have already heard?


Unlike casual sources, you know the family well and are a trusted counselor. You may guess meanings the behavior has such as avoiding upset for their "delicate" preemie by not enforcing limits.


But the main way you can provide more effective advice is by knowing the scientific basis for behavior change methods. First, understand the W’s – What is the specific current behavior and What is the desired behavior?; Who is present, When and Where is the behavior most often happening? What does the presence of this behavior mean to the child and family?


You need a thorough understanding of the behavior to advise ways to prevent it by avoiding or reducing demands that the child cannot meet. Reframe the issue as the child lacking skills needed to act appropriately and suggest ways to build them.


The use of rewards or consequences can then be targeted to encouraging skill building or reducing established behavior patterns. In general, positive reinforcement or rewards are more effective than consequences. Why reward? Changing behavior is hard work for the child (and parent), and positive reinforcement helps both initiate and maintain a behavior.


The most effective positive reinforcers are things that are valued by the child, are available infrequently otherwise, are novel, are given contingent on the desired behavior, are related to the desired action, are dosed appropriately; can be delivered immediately and consistently after the desired behavior occurs, and are acceptable to the parent.


Bigger rewards may be needed to start new behaviors (a Barbie got our shy daughter onto the soccer field the first time), but smaller rewards have advantages. Parents will more cheerfully and consistently deliver a 25-cent Pokemon card every time the child cooperates with homework than a $25 video game. Smaller reinforcers also mean less is needed to maintain the behavior.


Children are smart – if it takes the promise of Disneyland to sleep in their own bed then it must be pretty bad! Larger rewards also result in less self-satisfaction; the child justifies going along with the plan to get the reward rather than because it was a good idea.


With the ultimate goal of behaving for their own sake, rewards (and later even praise) should be used sparingly and phased out quickly. As children mature, they can be encouraged to self-evaluate, such as asking, "How do you think you handled that?"


Food rewards should be avoided as they can promote emotional attachment to unhealthy snacks, although for children with autism or intellectual disabilities it may be the only effective reinforcement.


All new behaviors are learned better when the reason for the change is explained; the child participates in choosing the new behavior and its reward; the desired behavior is named, modeled, and then practiced; and the reinforcement is accompanied by verbal praise. So-called "differential reinforcement" works best when incompatible behavior is rewarded, for example spitting toothpaste in the sink is incompatible with spitting on a sibling.


All inadvertent positive reinforcement for the undesired behavior must be avoided. The subterfuge may be subtle, for example biting may be reinforced if one adult rushes to the child, giving special attention even to scold. Even seemingly aversive things may be positive reinforcers if they result in increasing rather than decreasing a behavior.


Of course, for most children no reward is needed to gain cooperation – just ask! For tougher situations, the optimal frequency of reward comes from a "schedule of reinforcement." At first, reinforcement is likely needed every time and for little pieces of the ultimately desired action ("shaping"). For example, cleaning up toys has to start with the parent picking up 99 and the child 1 (with praise!).


Once the child is doing the new behavior fairly consistently with reinforcement, start "fading" the prompts and rewards. This increases "acting well" spontaneously and helps generalization. You hardly need to teach a parent to fade rewards as they naturally tend to forget, delay, or give fewer prompts. Rewards also can be decreased in amount, delayed, or reserved for increasingly elaborated positive behaviors – all helping solidify the new behavior.


Consequences are mainly needed for younger children and as back up to reinforcement. Similar principles apply to consequences. Consequences are most effective when used infrequently but consistently for the same behavior, unwanted by the child, done immediately after the unwanted behavior, related to the nature of the misbehavior and dosed appropriately (smaller is better!), and acceptable to the parents. The child should have a "clean slate" after the consequence to help restore the relationship. Painful, harsh, scary, or injurious consequences are neither acceptable nor effective.


Two methods of behavior modification I find easy to teach and implement are marks and points.

Marks make reinforcing behavior easy and fun for children 2-7 years old. The adult marks with a pen on the child’s hand along with verbal praise for each behavior "just a little bit better than usual," such as tantrums lasting 1 minute instead of 2, aiming for 6-10 marks per hour. High frequency helps adults notice more and smaller "okay" behaviors, often a deficit. At the end of the marking period each day, give a small reward (such as extra playtime, grab bag prize, pennies) for having a "bunch" to confer value to the marks. Give bonus marks for outstanding or spontaneous behaviors (Hey, they’re free!). Marks are faded out when the behavior has improved and parents are noticing and praising good behavior. While the removal of marks for inappropriate behavior can be used, I do not recommend it as parents are often in a punitive cycle in that case and need to refocus on the positive.


For older children, a "token economy" (star chart) using points, stars, or poker chips is an evidence-based method for behavior change when done correctly. Optimal implementation includes outlining the plan with parent and child together so that the desired behaviors, rewards, and costs are clear and relevant. Together they set the "price" for behaviors (such as 5 earned for 30 minutes of TV without fighting or 10 lost for a squabble). While token economies work for chore compliance, the focus here is on behavior. A key component motivating participation is charging for things taken for granted such as TV, computer, outside playtime. Give "bonus points" for initiating, extra acts of kindness, etc. "Purchases" for basics or privileges are deducted from the total kept on a card or a subset of freedoms can be allowed based on a minimum total "in the bank."


Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at

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