Matt Orr, PhD Department of Family & Preventive Medicine

1. Session # D2b October 5, 2012 Everyday Strategies for Child Behavior: Empowering Providers and Families and Facilitating Change with a Realistic Approach Matt Orr, PhD Department of Family & Preventive Medicine University of South Carolina School of Medicine Matt.orr@uscmed.sc.edu Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A.

2. Faculty Disclosure I/We have not had any relevant financial relationships during the past 12 months.

3. Objectives • At the conclusion of this presentation, the participant will be able to: • Provide brief, yet rich, education on child development and behavior that engages and empowers parents in change process • Integrate practical behavioral intervention strategies that are conducive to primary care-based office visits • Identify and tailor brief interventions that fit the needs and abilities of the family and the child with disruptive behavior

4. Learning Assessment A learning assessment is required for CE credit. Attention Presenters: Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation. This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.

5. Moral of the Story, Punch Line, and Bottom Line If we want to understand how to help children regulate their behavior, we must first understand what the behavior is regulating

6. Over Time • Goal is long-term growth… • Skills that enable the child to adapt to the demands of everyday situations • Survival Skills

7. Nature of Behavior • Help parents know what they are seeing • Empower them with interventions that fit with family’s needs & abilities • Think Asthma or Allergies

8. Three Targets Over 1st Two Visits • Success: Identify in what situations the child does well & put him in them as often as possible • Promoting Task Completion & Productivity • Activities: Identify what extra-curriculars child is involved in • Promoting Development of a Sense of Competence • Play: Use Mother Nature (i.e. movement) to set the stage for success • Promoting Situational Self-Regulation

9. Excessively Talkative Defiant & Annoying Anxious Highly Active & Impulsive Tornadic Irritable & Cranky

10. What’s Out There Already • “Behavioral Treatment” usually means “Behavior Modification” • http://www.sccp.sc.edu/centers/SCORxE/protected/downloads/SCORxE%20Behavioral%20handout%203-1-12%20printing.pdf

11. REGULATION Pertinent Brain & Behavior (in 2 slides) AROUSAL

12. Temperament Attention Sensorium BEHAVIOR Affect Activity Internal Thermostat & Control System

13. Temperament • Regulatory processes = developmental abilities • Tasks that must be mastered • Preferences & Quirks • Goodness of Fit • Match between child & environment

14. Dimensions – Chess & Thomas • Activity Level: • Low________Hyperactive • Regulation: • Predictable__________Erratic • Initial Response: • Approach_________Withdrawal • Adaptability: • Flexible_____________Rigid

15. Intensity: • Mild-Mannered______Forceful • Mood: • Cheery____Serious____Irritable • Self-Control: • Reflective______Impulsive • Concentration: • Persistent______Distractible • Sensitivity: • Unbothered________Reactive

16. Temperament in the Clinic

17. Dennis MitchellThis superactive young upstart…is active, agile, tireless and hard to catch. He's also inquisitive, imaginative and of an experimental turn of mind, which frequently lands him in situations he can't always control. With his impish grin, he delivers sometimes blunt observations of the truth. While never malicious or mean, the irrepressible Dennis remains a threat to property, the pomposity of adults and quiet afternoons. Adapted from www.kingfeatures.com (2009)

18. How was Dennis punished?

19. Behavioral Strategies: Establishing Boundaries

20. Behavioral Strategy #1 • Grandma’s Rule • aka Premack’s Principle • First broccoli, then cake • After shoes put away, then you can go outside

21. Adaptation • “…and I will sit with you while you finish” • “Come on, I’ll walk with you to your room.”

22. #2 Modify Time Outs

23. #3 Pro-Social Consequences For more serious offenses • Lying • Stealing • Harming others • Make them do “Community Service”

24. Cognitive strategies: Teaching problem-solving

25. Cognitive Strategy # 1 • Turn Should’s into Could’s • Creates Options • Identifies alternatives & facilitates decision-making • Leaves option to “explode”

26. Cognitive Strategy # 2 • Replacements • Must replace undesirable behavior with a more desirable one

27. Cognitive Strategy # 3 • Rewind • “Try that again…” • Modifies caregiver response • Gives child an opportunity to pause & choose more favorable response

28. Six Skills to Survive & Thrive Everyday Survival Skills for Kids and Parents

29. 1. Modify Expectations

30. Common Complaints • Children do well when they can • They do well in some situations but not others • “Cannot go into a store without asking for something” • “Cannot sit still for more than a minute” • “Cannot play outside without getting into an argument”

31. 2. Identify Success

32. We Can Only Do What We Can Do

33. Put Kids in their Element

34. The Message in the Behavior • What’s the message here?

35. The Message in the Behavior Take a SNAPSHOT!

36. What’s the Usual Outcome?

37. Adaptive Regulation View • Behaviors are attempts to adapt to internal signals of discomfort or distress…to self-regulate • Stay awake • Focus • Move • Protect • Defend

38. Adaptive vs. Maladaptive • For children, environments (i.e. parents & teachers) determine whether a behavior is adaptive, not whether it helps the child pay attention, sit still, or be compliant • Maladaptive behaviors = “symptoms”

39. 3. Get Moving 314 - Piano stairs - Rolighetsteorin.se - The fun theory.wmv

40. Play – Pellegrini et al. • Physical activity positively affects classroom attention • More calm & relaxed • Best in short bursts (20 min. optimum)

41. Proprioception • Sensory system involving stimulation to muscles, joints, & tendons • Calms & Organizes • Considered queen of sensory systems • Helps integrate the entire system • Includes Vestibular & Tactile senses

42. Proprioception • Central role in governance of motor control and planning! (i.e. ADHD) • Regulates over- & understimulation • Stimulation lasts for only 2-3 hours • Recess anyone?!

43. Levels of Play • Vigorous Physical Activity – All out free play; sports; game provides the parameters • Moderate Physical Activity (think “Indoor”) • Boundaries/rules allow for control • Play wrestling; indoor trampoline • Fidgeting; Soothing Activities • Playing with water • Fidget toys

44. Vigorous – Move & Soothe • Team sports (especially soccer) • Individual sports (swimming, karate, dance) • Predictable after-school activity (play, music)

45. Move & Soothe • Traction • Compression • Play Wrestling • Rough & Tumble Play

46. Move & Soothe Bounce & Balance

47. 4. Fidget to Focus

48. Fidgeting • Evidence that physical activity is related to central executive functioning – Working Memory • ADHD & Non-ADHD • We all fidget to focus (Rapport et al., 2009)

49. Move & Soothe

50. Playfulness to Recalibrate Try not to smile when a child is laughing…good luck!