Anticipatory guidance for behaviour concerns: School age children

Abstract

Parenting powerfully influences children’s cognitive and social-emotional development. Parents often have behaviour concerns and seek advice from their clinician. This paper is an evidence-based clinic tool to empower clinicians to promote pro-social behaviour through developmentally-targeted strategies that parents can use to decrease problem behaviour. Typical scenarios are provided for noncompliance, aggression, attention, and bedtime worries.

Parenting principles

Authoritative parenting is essential for healthy outcomes. It combines warmth and structure to foster emotional regulation, attachment, and perspective-taking and problem-solving skills.

A framework for developmentally-targeted parenting strategies

We present a framework for parenting strategies which integrates The Incredible Years Parenting Pyramid® and Antecedent-Behaviour-Consequence model, to guide parents on prevention of problem behaviour. The framework emphasizes daily relationship time and using empathy to the child to help him/her calm, become aware of his/her own emotions, and be receptive to the parent’s instructions. It also teaches skills to replace the behaviour, providing physical needs, and explaining reasons for rules. When parents focus most of their time on the foundational skills of the pyramid, problem behaviour decreases, and consequences are rarely needed.

Managing behaviour concerns

Managing behaviour concerns also requires screening for developmental and behavioural disorders, and following up to determine whether referrals are needed.

Conclusion

Anticipatory guidance for behaviour concerns prioritizes children’s rights to respect and dignity.

Anticipatory guidance teaches parents about child development (1). Parents want and need physician guidance on parenting that helps children develop social and cognitive competence and decreases negative behaviours (1–4). Problem behaviours are common (5), yet physicians feel unprepared to address them (6). We have synthesized an evidence-based approach to addressing common behaviour concerns in children (1) by teaching prevention, and have applied this to case scenarios. This tool helps clinicians know when to use which strategy (7–25). It adds to previous work (26–29) by providing a framework of parenting principles for school age typically-developing children, developmentally-based guidance for each concern and tips on when to refer.

PARENTING PRINCIPLES

Behaviour management is primarily about teaching the child and fostering development, not about punishment (3). Overarching parenting principles essential to healthy cognitive and social-emotional growth include: 1) attachment, 2) regulation and 3) authoritative parenting (3). Using these principles early through anticipatory guidance helps prevent many problem behaviours. Table 1 defines these principles and other related concepts which constitute building blocks for behaviour management strategies. Parenting fosters development when children demonstrate temperament dimensions that make it harder for them to self-regulate, give empathy or pay attention. Although temperament has a physiologic and genetic basis, it may be shaped by the prenatal environment and subsequently by childhood experiences for positive outcomes (30).

Table 1.

‘How to’ definitions and other related concepts for parenting strategies

Strategy	‘How to’ definition
WARMTH	Relationship time, empathy, reflective listening, circles of communication, comforting when hurt or afraid, giving affectionate greetings and goodbyes, showing interest and love even when the child has done something wrong, paying attention to positive behaviours (7,12,14,15)
Relationship time	Daily one-on-one time wherein the parent focuses solely on showing interest in child’s interests and following child’s lead; this time can be preset or (9+ years) as it arises when child is enjoying play alone; even five minutes of uninterrupted time can let child know that parent cares (9,13–15)
Giving empathy	Asking and understanding child’s perspective, even when one doesn’t like their feeling, and mirroring that through facial expression, tone of voice, and reflective listening (4,8,14,25)
Reflective listening	Using words to show one has heard or seen child’s feelings and thoughts (“You’re feeling tired, that sounds frustrating, seems like you’re sad”). This teaches child to use emotion words (16)
Circles of communication	Communication child → partner→ child created by exchange of actions, body language, words, and thoughts; let child (not parent) break the circle (8,14)
Paying attention to positive behaviours	Praising child for the socially-expected behaviour which you want to see replace the problem behaviour; praise should specifically describe the behaviour to help child understand exactly what it is that he/she has done well (“You played what your friend wanted – that’s caring”) (13)
STRUCTURE	Basic physical needs, i.e., safe environment (food, shelter, healthy parents, childcare), predictable routine (awake-, meal-, and bedtimes), nutrition (Canada Food Guide), sufficient sleep (wakens in morning acting rested) and exercise (60 min daily play that increases heart rate); skills teaching to replace problem behaviours, coping statements to internalize for self-talk (“He didn’t do it on purpose; it was an accident”), clear expectations and reasons (“house rules”), and consistently enforced limits to feel calm and safe (12,37)
Coaching self-regulation	Using a calm voice, help child recognize early body signs of dysregulation (warning signals), then stop trigger, help child name feeling and, if necessary, give additional measures to calm (take a break, change tasks, do sensorimotor or cognitive activity) (4,8,10,24)
Coaching empathy	Give empathy, point out other person’s body language and facial expressions, ask child what other person is feeling and why, if this happened to child what would make him/her feel better (4)
Perspective-taking	Understanding other person’s thoughts and feelings (3)
Problem-solving conversations	At calm times, repeatedly help child anticipate difficult situations and plan ahead how his/her behaviour will meet his/her values. Discuss or role play causal event for problem behaviour, child’s feelings, body language and perspective of other person, natural consequences of behaviour and plan desired response. Eventually, problem-solving conversations will help child pause to think in the moment instead of giving an immediate aggressive response (4,14)
Tangible reward system	For a difficult-to-learn expected behaviour, immediate sticker or poker chip (4-7 years), points (8+ years), traded in for reward prechosen by child; phased out when automatic habit (9,13)
Family meeting	When family is calm, a specific time set aside to make house rules and review rules for clarity, child helps decide consequences so that he/she knows he/she is responsible for his/her behaviour choice and won’t feel resentful, assess how solutions are working, and plan daily schedule; discussion and consequence need to be respectful, not degrading or painful (13,15)
Ignoring	Ignore child while staying nearby to monitor safety, turn attention to child as soon as he/she stops, then redirect to something else to think about or do, praise the expected behaviour that is the opposite of the one you are ignoring (13)
Time-out (>10 years may prefer other term, e.g., time to ‘chill’)	Time by him/herself to calm down and reflect on better decisions, in a predetermined quiet place, with parent nearby to support child in his/her stress; 1–5 min (<10 years), 2–15 min (older) are usually enough; some children may need parent with them in time-out, to help calm (8,13,15,24)
Natural consequence	For recurring problems, a natural consequence is one that would result from child’s action if there were no adult intervention (13)
Logical consequence	For recurring problems, a logical consequence is designed by parents as a negative consequence; if possible, it is inherently related to the misbehaviour (13)
Processing the event	Immediately after the problem behaviour, once child is calm, process the event by giving empathy and coach problem-solving to prevent recurrence; when mutual conflict, help child problem- solve with the person he hurt. If needed (time-out with parent or for more serious aggression), assign predetermined consequence after time-out (4,13,15).
Coaching problem-solving	See child’s perspective (help verbalize emotion and what event caused the feeling), help brainstorm better solutions and their outcomes to prevent behaviour next time, help choose the best one to try, and later review what worked. When helping resolve conflict, have both children problem- solve together (7,13,15).
Restitution	Child makes it up to person hurt by problem behaviour, to self-heal and repair the relationship; restitution should be relevant to the situation where possible (rebuild project, act of kindness) (4,11)
‘EAT’ reinforcers	Behaviour may be inadvertently reinforced if the following occur: Escape from work (command not repeated after time out), attention from parent (instead of proactive one-on-one time), tangible reward (getting purchase from tantrum) (32)

Attachment is the emotional relationship the child forms with the caregiver (7); it is most influenced by a caregiver’s sensitive response to child cues (4). This relationship is paramount in fostering mastery of developmental milestones and emotional self-regulation. The website www.circleofsecurity.net offers 2 to 4-minute free animations for parents describing aspects of attachment. Parent–child relationship time provides a sense of being loved and respected; it encourages development of compassion, flexibility and a desire to follow rules (8,9,13–15).

Regulation is the ability to stay calm and alert, and to return to that state from a stress response; being calm is necessary for paying attention and clear thinking. Regulation is impacted by, and affects, sleep, eating, elimination and emotions. Development of self-regulation is influenced by biology (temperament) and environment (relationships). Co-regulation (being soothed by another person) occurs before self-soothing (8).

Authoritative parenting combines warmth (support) and structure (information) for the healthiest outcomes (3,7,12,18,30). Warmth fosters attachment and self-regulation, which encourage short-term compliance, and teach long-term values (12). Empathy, a necessary component of warmth, helps a child see him/herself through another’s eyes, recognize his/her own feelings, and use emotion words to express them. This fosters recovery to a calm state; the child feels understood and can collaborate on solutions (4,7,8,10,14,25). Empathy connects parent and child, and models compassionate relationships. Structure helps children feel secure, learn rules, understand and fix their mistakes, and eventually solve problems when parents aren’t there (12,15). Permissive or neglectful parenting styles do not provide enough structure; authoritarian parenting is over-controlling and lacks warmth. Authoritative parenting is ‘connecting and coaching’, which reflects the child’s need for empathy in order to feel understood and calm as a pre-requisite to being receptive to instruction (Box 1) (4,8). This parenting principle parallels the cognitive process a child must go through to change behaviour: the child names the feeling and its causal event, which allows sufficient calming for perspective-taking, problem-solving and skill building.

Box 1. Key point

Authoritative parenting combines warmth and structure to ‘connect and coach’.

A FRAMEWORK FOR DEVELOPMENTALLY-TARGETED PARENTING STRATEGIES

The Incredible Years Parenting Pyramid® IYPP is well-cited in parenting literature (13). This schematic is used here as a model to guide developmentally-targeted parenting strategies for school age children. Starting from the bottom, the five levels of the pyramid depict a general approach to behaviour, with the majority of parenting time at the wider part of the pyramid (foundational skills). Levels 4 and 5 represent increasing, predictable parental response to specific undesired behaviours, including consequences, implemented as behaviour severity increases. The ABC model (Antecedents, Behaviour, Consequences) is a traditional tool commonly used to change behaviours by teaching the desired skill to replace the undesired behaviour and by modifying antecedents and consequences (21,31). We have integrated these two approaches (level 1 bottom of the pyramid, Figure 1, Table 2). When anticipatory guidance and parenting focus on levels 1 to 3 of the pyramid, parents are providing the warmth and structure which prevent problem behaviours and decrease the need for consequences.

Figure 1.

The Incredible Years Parenting Pyramid®, adapted with permission from ©The Incredible Years (8). Levels 1–3 are the parent’s main focus to prevent problem behaviours, with levels 1 and 2 implemented liberally across a variety of environments. Level 1, the bottom, promotes child resiliency development and creation of strong parent–child relationship; always consider seeking supports to foster parent resilience because parents need to maintain their own mental and physical health to get to the bottom of the pyramid. At level 3, limit-setting is the goal, begun as soon as limits are tested, preferably starting in late infancy and evolving as the child’s development progresses. Levels 4 and 5 are used more selectively, to respond to specific undesired behaviours.

Table 2.

Framework for behaviour guidance, integrating ABC with The Incredible Years Parenting Pyramid® for ‘connecting and coaching’

Framework Level	ABC (31,33)	Parenting Pyramid® (8)
LEVEL 1 - PREVENTION – ‘CONNECT’ Create strong parent–child attachment and self-regulation (13,15) - Ensure basic needs (12) - Keep relationship time (13,14) - Develop child’s coping skills and positive behaviours (give empathy, reflective listening, comfort when sick or upset; show interest) (8,13,15,16) - Give opportunities for positive experiences (humour, fun games, hang out together, time with friends, recess, activities he/she succeeds at, attend his/her special events, respect need for autonomy where child is capable) (15) - Create social conscience (volunteer, donate food) (3,15) - Model how you would like child to act respectfully (3,12)	Antecedents Recognize situations at risk for behavioural break-down: - Immediate trigger (hunger, jealousy) - Situational precipitants (new sibling, chronic illness, lack of skill)	Initiate level 1 pyramid parenting skills and strategies: - Consider child’s needs and positive relationship building strategies - Provide one-one-one relationship time, empathy, reflective listening, play, problem-solving Benefits for child: - Attachment, self-esteem, cooperation, problem-solving - When parents focus more time on levels 1 and 2 than focusing on negative behaviours, there is less need for levels 4 and 5 and discipline goes more smoothly - Even children with frequent noncompliance usually show high levels of improvement using levels 1–4
LEVEL 2 - PREVENTION – ‘CONNECT AND COACH’ Teach skills, use reinforcement to increase positive behaviours (13,21) - Coach self-regulation and empathy (4,8,10,24) - Coach helping, manners, steps for self-care tasks and chores, remind child to use skills (13,21) - Have problem-solving conversations (4,14) - Praise specific desired behaviour, child’s effort to improve behaviour and to connect (“I feel good when you…”) (13,15)	Antecedents Recognize pattern: - Identify antecedents of problem behaviour - Modify where possible, to prevent undesired behaviour	Continue level 1 pyramid parenting Start level 2 pyramid parenting: - Praise, tangible reward system, coach, encourage appropriate behaviours Benefits for child: - Motivation, thinking skills, social skills
LEVEL 3 – PREVENTION – ‘CONNECT AND COACH’ Give clear rules, taught before needed and consistently used (13) - Discuss rules with child, have family meeting, ensure child clearly knows the rules regarding which behaviours are inappropriate (13,15) - Decide consequences together ahead of time and when they will be applied (13,15) - Be prepared for levels 4 and 5 response, with a well-learned approach to the specific behaviour, as it is often hard to act appropriately in the heat of the moment - Make sure all the child’s caregivers use the same approach (13) - Recognize that undesired behaviours can require interventions over a period of time before resolving (15)	Antecedents - Modify, where possible, to prevent undesired behaviour	Continue levels 1 and 2 pyramid parenting Establish pyramid parenting level 3: - Set routines - Have clear limits - Discuss rules so that consequences will be predictable - Be consistent with follow-through Benefits for child: - Obedience, predictability, responsibility
LEVEL 4 - IN THE MOMENT – ‘CONNECT AND COACH’ Modify intervention according to the child’s specific undesired behaviour - When coaching and assigning consequence, speak calmly, at or below eye level, respectful of child’s emotional needs and dignity (15) (1)Immediate supportive response: Ignore annoying behaviour (protests, complaints, rude remarks, disrespectful replies, interrupting) (13,15,16) When child clearly knows the rule - Give empathy when you foresee behaviour: “I’m sorry, but there is no screen time at meals” - If dysregulation, calmly give empathy “I can see you’re frustrated; I understand,” coach self-regulation to prevent escalation - Ignore after (“Why do we have to have this dumb rule? I hate you”) When rule not clear, young child - Give empathy, if needed coach self-regulation - Prompt once before ignoring “I know it’s frustrating. I’m uncomfortable with that language. Please say…” The prompt redirects to a positive opposite behaviour to support his/her decision-making. If child responds to the coaching, praise and re-engage “Thank you. My answer is…” - Bypass prompt when child always escalates from it (2)Immediate limiting response: Consequence (13,15) - Time-out for annoying behaviour when escalates to very strong emotional dysregulation, or extreme teasing, that does not stop from a couple of supportive prompts “(calm tone) It looks like it’s hard for you to think right now. Please go chill on the couch and then I’ll check back” - Time-out for more serious misbehaviour (physical aggression, throwing objects, property destruction, threatening, bullying, severe noncompliance) to let child know that his/her action is not acceptable “(supportive volume) No wrecking allowed. Please cool off for a few minutes and then we’ll talk” - Loss of privilege, or natural or logical consequence, for forgetting chores, stealing, lying, or refusal to go to time-out despite warnings “(respectfully) It’s not easy to remember to do your laundry when you’re excited to play your video game. I’m sorry you’ll need to forego the game today and do your laundry”	Behaviour - Identify undesired behaviour and its message (what does child need help with?) - Teach skill in advance to replace behaviour (prevention)	Continue level 1 pyramid parenting Institute level 4 pyramid parenting: - Ignore, distract, redirect Benefits for child: - Decreased annoying behaviours
LEVEL 5 - IMMEDIATELY AFTER – ‘RE-CONNECT AND COACH’ Process after level 4 consequence has been given and child is calm - Process the event; stay calm, respectful (4,13,15) - Restitution as needed (4,11) - Forgive child, rebuild your relationship as soon as consequence is given, start over with levels 1 and 2 (13,15) - To prevent inadvertent reinforcement after consequence, do not give in to what child wanted from the undesired behaviour; for noncompliance, repeat the command and follow through (13) - Level 5 may be hard for some parents—seek parent coaching from mental health therapist if needed	Consequences - Choose reinforcers to increase expected behaviour and to decrease undesired behaviour - Consequence may also be antecedent for the next behaviour	Continue level 1 pyramid parenting Initiate level 5 pyramid parenting: - Time-out, loss of privilege, natural and logical consequences - Time-out is only effective if used infrequently, in combination with frequent positive parental attention and reinforcement (levels 1 and 2) -Start by using levels 1-4 well - Reserve time-out for aggression, severe dysregulation, or residual severe noncompliance (disobeying the majority of parent commands in general); give time-out for a specific disobeyed command, before working on compliance to another command once the first has resolved) - Use time-out for only one misbehaviour, for a few weeks until less frequent, and then add time out for another misbehaviour Benefits for child: - Decreased aggression

Of note, negative behaviours may be inadvertently increased (reinforced) when a child gets what s/he wants from the behaviour. These behaviours may be remembered by the acronym EAT: Escape from work or chores, Attention from parent, Tangible reward or purchase after a tantrum (32).

ADVICE FOR PARENTING STRATEGIES

Following are a series of common parent–child scenarios for which targeted developmentally appropriate strategies are provided. The ABC model and the progressive approaches of The Incredible Years Parenting Pyramid® are synthesized in these examples. While using the specific strategies outlined below, it is important to remember the overarching principle of parent giving one-on-one relationship time to their child, which applies to all scenarios.

Eight-year-old with frequent noncompliance

Cooper keeps doing what I tell him not to do. He never does what I tell him! Eight-year olds tend to quarrel with parents, but can be reasoned with (33). Noncompliance and defiance occur a minority of the time by 6 years (3,13), when children have developed a conscience of right versus wrong (3) and understand natural consequences (13). Between 7 and 10 years, children gain increasing independence from parents; with minimal scaffolding they can initiate and complete chores (3,20). If chronic, Cooper’s noncompliance may represent temperament characteristics (30).

Prevention.

Challenging behaviour requires more warmth and structure, because we are asking more of the child (14); thus, parenting requires more energy and supports. Teach (coach) skills (steps to tidying) (21), empower independence (picture on toy box shows what goes where) (7) and modify antecedents (tidy up after snack, when he won’t be hungry or tired) (21). Recognize his efforts (12) through praising compliance (13) (“You put away your toys – that’s responsible!”) (16). Have family meeting; review rules (“Toys belongs in box”) (13,16). Temporarily reduce commands to essentials (prioritize safety, respect), ensuring parent follow through to insist child obey all commands (13,25). For essential commands, tell, don’t ask (“Put away toys now”) (9,13).

In the moment.

Keep a calm, friendly attitude (12,13). Give empathy (“You feel disappointed you can’t splash in the puddle, and it looks like fun”) (16). Give natural consequence (he will have to wear wet shoes) (13). If he disobeys the majority of the time, give time-out (discussed prior in family meeting) after repeat command with warning (“If you don’t put boots on vent to dry now, you’ll need to go to time-out”) (13) or after counting to three to reduce parental frustration (23).

Immediately after. Follow through by repeating command after time-out and praise “Great! You put your boots on the vent”) (13).

Twelve-year old with noncompliance when consequences don’t work

Tyler won’t do any jobs to help around the house. He acts annoyed when told to help. He has intense emotions and is slow to adapt. At 11 to 13 years, emotions may be intense, and up and down; children are still self-focused and, wishing more freedom, may often be angry toward parents and temporarily push them away (3). Limit-testing is common (33), but many are capable of preparing meals (10 to 13 years), babysitting younger sibling and working outside the home for pay (11 to 13 years) (3). If chronic, Tyler’s noncompliance may stem from temperament characteristics and trouble developing flexible problem-solving. A positive aspect of noncompliance is persistence; he needs to hear that we value his decisiveness and are working together as a team to problem-solve (24).

Prevention.

Tyler needs more warmth and structure. Teach the skill (how to set table). Give support if he has not mastered the skill (picture of table setting, coach at each step). Change antecedents (give warning to set table, allowing transition from play). Give information (‘table needs setting’) instead of imperative command (‘Set table now’). Choose consequences together ahead of time (reward effort with time together) (13,14,16,21,24,25).

In the moment.

Give empathy (“You’re annoyed right now because you’d rather keep playing”). If the command is non-negotiable, remind him of the rule and reward/consequence (“If you don’t wear your helmet, you are not allowed to ride your bike”). If the command is negotiable, teach flexibility by helping him problem-solve (“It feels hard to start a chore when I’m in the middle of drawing,” “Set table in 5 minutes or when I’ve finished drawing”) (13,14,24,25).

Immediately after.

Praise problem-solving (“You did a nice job working this out”) (25). Consequences should rarely be needed when using prevention and problem-solving (13,24).

Nine-year old with aggression when consequences don’t work

Brigita slams the door, yells, and pulls her sister’s hair. Consequences upset her even more. She has always been very sensitive; she assumes the negative thing and feels left out. Nine-year olds tease and insult each other, but feel genuine regret and get very upset when criticized or unfairly blamed (33). Seven- to ten-year olds see others’ perspectives and want to be accepted by their peer group, but won’t be better at understanding others and expressing their own perspective until 10 to 13 years (3). Brigita’s temperament characteristics make her more easily emotionally dysregulated (30). Using positive labels (such as referring to her as caring) helps parent and child see herself more positively and then act differently (7).

Prevention.

Brigita needs more warmth and structure. Emphasize relationship time and empathy to create closeness, while keeping firm limits (14,16). Ensure opportunities for pleasure (friend time) to help regulation (10,15). Chores, volunteering and extracurricular activities capitalizing on strengths foster a sense of competence (3,7). Coach self-regulation and give empathy to prevent escalation to aggression (separate her from her sister, “You look upset; let’s go take a walk”) (24). Eventually, naming her feelings will calm her (4,10). Help her read body language more accurately (4). Teach a replacement skill for the aggression (ask what the other person is thinking, “Dad, we haven’t played together for a while. Do you like my sister better?”). Praise (“Good checking out your Dad’s feelings”) (13). During problem-solving conversations, help her to imagine her own feelings were her sister to act aggressively toward her (14).

In the moment.

Stay with Brigita during a time-out to help her calm (read book together). Mirror her feelings when she starts to calm (“You sounded very mad. Were you feeling left out?”) (8,24). For most children, time-out by themselves for aggression serves both to calm and consequence (13). However, since Brigita’s time-out was for calming only, she will need a logical consequence, such as giving sister her space this afternoon (24).

Immediately after.

Process the event (15). Ask what the other person feels or sees from their perspective (4). If her sister does not want restitution, Brigita could give parent an act of kindness instead (11).

Six-year old with short attention

Joshua doesn’t stick to anything for more than a few minutes. He doesn’t listen when we speak to him. By 6 years, children use private speech to help them concentrate (3); they are able to complete simple chores (7). However, 6 year olds get easily distracted, leave tasks unfinished, and are in constant motion (33); feelings are easily hurt, and they need lots of reassurance of being loved (33). At 7 to 10 years, they will work harder to perfect tasks (3).

Prevention.

Predictable routines and physical health (regular food intake, sleep, exercise) help Joshua stay calm to pay attention (10). Play one-on-one in relationship time (7). Offer a few toys at a time, coach during chores (21). Help him learn mindfulness to increase present moment awareness, which might strengthen his attention (34).

In the moment.

To lengthen attention, set a timer for a couple minutes longer than his base rate (21). To increase motivation, give him something to look forward to (‘play after work’) (21). To ensure listening, minimize distractions, make eye contact or touch him first before speaking, give one short instruction at a time and have him repeat it to ensure he has remembered (3).

Immediately after.

Praise persistence and task completion (‘Great finishing the puzzle!’), to maintain self-esteem (7).

Seven-year old with bedtime worrying

Amata can’t fall asleep because she is worrying and has a tummy ache. “I’m not taking swimming ever again!” Seven-year olds hate making mistakes, and this age is typical for such worries to delay sleep onset (33). Worries at school age are about real life issues (relationships, news events) (19).

Prevention.

Rule out medical disorder (sleep apnea) (19). Reflective listening and empathy for her emotions allow her to feel heard and understood (16). Retelling her story several times (or drawing, writing) and making a plan will decrease fears (4); do this at another time of day, not at bedtime (19) (“Let’s try to remember what happened at your last lesson. . . .That must have been scary. . . . remember your teacher helped you. . . .let’s plan how you could feel comfortable when you start swimming again”) (4).

In the moment.

Keep limits on consistent bedtime without screens. End a calming bedtime routine with relaxation (deep breathing, progressive muscle relaxation, visual imagery of place where she feels calm and peaceful) (19).

Immediately after.

Reassure you will check-in on her, on a predictable schedule (19).

MANAGING BEHAVIOUR CONCERNS

Clinicians give anticipatory guidance through verbal suggestions and handouts, in ‘teachable moments’ when parents express concerns, or when the clinician observes behaviour. Developmental surveillance (through standardized screening instruments or informal questions) allows parents to express concerns. More than 25% of children with behaviour concerns at 4+ years have mental health conditions (attention deficit hyperactivity disorder, anxiety, depression) (35). Assess such concerns with a standardized behaviour screen (NICHQ Vanderbilt Assessment Scales (6 to 12 years) http://www.nichq.org/childrens-health/adhd/resources or Pictorial Pediatric Symptom Checklist – 17 (4-18 years) http://www.pedstest.com/TheBook/Chapter9) and history and physical exam (Table 3) (36). Follow-up after guidance is necessary; if concerns persist, referral may be needed for group parenting programs, individual mental health therapy, or specialist evaluation (35). Aggression in children 9+ years usually has multiple underlying etiologies and is best referred (3). The website www.parentsmatter.ca offers free evidence-based parenting handouts in multiple languages and downloadable Canadian-authored book ‘Positive Discipline in Everyday Parenting’, published by Save The Children Sweden, which helps parents teach children self-discipline while advocating for children’s rights to protection against violence (12). Parenting books cited in this article are described in Box 2.

Table 3.

When to refer for treatment and specialist* diagnostic evaluation for developmental or behavioural disorder (35,36)

Scenario-based parent concern	Features of concern
All scenario topics	Concerns on behaviour screen Limited progress at follow up with appropriate strategies Academic difficulty Developmental delay Family stress Suspected abuse
Noncompliance	‘Red flags’ (frequent and chronic arguing and noncompliance to reasonable requests, annoying others on purpose)
Aggression	‘Red flag’ behaviours (frequent and chronic aggression, fights with peers, swearing in inappropriate settings, aggression toward self, disruption to family routines or school, negative responses from peers or teachers)
Short attention	‘Red flags’ (problems completing play, chores, self-care tasks, and schoolwork, easily distracted, difficulty listening, misses social cues, often forgetful, cannot sit still, makes disruptive noises, frequently interrupts)
Bedtime worrying	Child significantly distressed, daytime functional impairment, persistent fears

*Decision to refer versus performing the evaluation oneself depends on clinician scope of practice and experience.

Box 2. Parenting books cited in references

Parenting book	Topics of guidance
Positive Discipline in Everyday Parenting	Warmth and structure, parent–child relationship, empathy, problem-solving, compliance, fears, normal development, temperament for all ages. Downloadable from www.parentsmatter.ca
The Incredible Years	Parent–child relationship, compliance, aggression, problem-solving, emotional regulation
The Whole-Brain Child	Parent–child relationship, empathy, emotional regulation, cognitive behavioural therapy, fears, perspective-taking
How To Talk So Kids Will Listen and Listen So Kids Will Talk	Empathy, communication, compliance
Siblings Without Rivalry	Sibling rivalry
Kids Are Worth it!	Empathy, compliance, aggression
Take Charge of Your Child’s Sleep	Sleep
Children Who Do Too Little	Chores
Smart but Scattered	Inattention, disorganization
Growing up Mindful	Coping with stress through awareness, concentration, compassion for self and others
1-2-3 Magic	Compliance, aggression
The Challenging Child	Parenting child with temperament individual differences
Raising Your Spirited Child	Parenting child with temperament individual differences
The Explosive Child	Empathy, compliance, aggression, problem-solving, for children with temperament individual differences or developmental/behavioural disorders
No Such Thing As a Bad Kid	Parenting child with behavioural disorder

CONCLUSION

Anticipatory guidance for behaviour concerns focuses on preventing problem behaviours. Parents often seek help from clinicians for guidance in managing behaviour concerns about school age children and these parenting skills and strategies significantly impact a child’s social-emotional development. This article provides a series of scenarios which illustrate guidance within a developmentally-targeted framework for clinicians to use with parents for these concerns. The framework, designed for a range of problem behaviours among typically-developing children, synthesizes an evidence-based approach to provide the warmth and structure of authoritative parenting, ‘connecting and coaching’. As always, behaviour concerns require screening, evaluation and follow-up, with referrals to local specialty consultants, agencies or resources for persistent, severe or escalating problems.

Notes

Area of specialization: Developmental paediatrics