Yves Talbot

Behavior Problems in Children: A Family

Approach to Assessment and Management
SUMMARY
When parents bring a child with a behavior
problem to the family physician, he should
obtain from them a brief developmental
history of the child, a relevant family history,
a precise description of.the child's behavioral
problem and the parents' attempts to solve it.
The physician should recognize the different
family styles susceptible to maintaining a
behavior problem. The physician can help the
family anticpate changes in behavior
appropriate for the child's age. He can help
the parents to agree on what the problem is
and how to solve it; to reinforce good
behavior by rewarding it; to avoid paying
attention to negative behavior and to indude
the child in discussions about his behavior
problem. The physician can also help them to
taclde easy problems first so they become
confident enough to handle more difficult
ones, and advise them to give adolescents
responsibility for solving some of their own
problems without 'bailing them out' if they
fail to do so. Sometimes the family physician
will have to refer families with complex
problems for more intensive or expert
guidance. Parents can also be referred to
community parenting groups that will help
them cope. (Can Fam Physician 1983;
29:1889-1895).
SOMMAIRE
Lorsque les parents consultent un medecin de
famille pour un enfant ayant un probleme de
comportement, le medecin devrait obtenir d'eux une
breve histoire du developpement de l'enfant, une
histoire familiale pertinente, une description pr6cise
du probleme de comportement de l'enfant et les
efforts des parents pour le r6soudre. Le medecin
devrait aussi evaluer le milieu familial, le
temperament de l'enfant et son niveau de
developpement. Le medecin peut alors anticiper les
problemes susceptibles de survenir lorsque l'enfant
atteindra un certain age, et aider les parents a
consulter pour les r6soudre. Par exemple, il peut
enseigner aux parents a s'entendre sur la nature du
probleme et comment le resoudre; susciter un bon
comportement par un incitatif de recompense; eviter
de porter attention au comportement negatif et
inclure l'enfant dans les discussions concernant son
probleme de comportement. Le m6decin peut aussi
aider les parents a s'attaquer d'abord a des
problemes faciles de faqon a devenir suffisamment
confiants pour s'occuper ensuite de problemes plus
difficiles, et leur conseiller de donner aux
adolescents la responsabilite de resoudre certains de
leurs problemes sans les abandonner s'ils echouent.
Parfois, le medecin de famille devra referer les
familles aux prises avec des problemes complexes
pour des conseils plus approfondis ou obtenir une
expertise. Les parents peuvent aussi etre referes a
des groupes parentaux communautaires qui les
aideront a faire face a leur situation.

I M-- M 1-

Dr. Talbot is an associate
professor of family medicine and
pediatrics, and family physician in
chief at the Mount Sinai Hospital,
Toronto. Reprint requests to:
Mount Sinai Hospital, 600
University Ave., Toronto, ON.
M5G 1X5.
CAN. FAM. PHYSICIAN Vol. 29: OCTOBER 1983
THE PRIMARY CARE clinician illness to the forefront of the day-to-
who deals with children and their day care of children. 1-3
families is likely to encounter prob- Behavior labelled as 'problem' be-
lems that physicians seldom saw a few havior by the parent is often part of
decades ago. Changes in infant mortal- normal child development (e.g., cry-
ity and a marked decrease in infectious ing, temper tantrums). On the other
diseases have brought child develop- hand, a child with a constitutional vul-
ment, behavior problems and chronic nerability (e.g., asthma, enuresis, re-
1889
current abdominal pain) may cause mate age when they oceur. This is to the understanding of behavior prob-
family concern or conflict. clearly not a normative chart; some be- lems. First, these investigators stress
The family may also help prolong haviors are more common and more the innate differences between chil-
the child's behavior and prevent his 'normal' than others. References are dren in activity level, biological regu-
continuing development. For example, given in brackets for readers who are larity (sleep and appetite), sensory
a five-year-old who continues to have interested in more detailed descrip- thresholds, mood, approach to a new
temper tantrums may get everything he tions about behavior problems. The situation, adaptability, intensity of re-
wants from his parents and siblings Shepherd and Oppenheim (1971) and sponse, how easily they are distracted
and be prevented from acquiring social the Achenback and Edelbroock (1981) and attention span. How newborns be-
skills like sharing, cooperation or even studies provide the clinician with a fre- have helps explain why they behave in
classroom learning. A child with re- quency distribution of these behaviors a particular way later on. Secondly,
current abdominal pain due to relative from age four to 16 years.2-4 these authors highlight the interaction
lactose intolerance may maintain his between a particular child and a partic-
symptomatic behavior when he be- ular set of parents. A docile child, for
comes subconsciously aware that the Assessment example, may be less acceptable to en-
symptoms can be used to prevent his When parents seek help for a child ergetic, active parents than an active,
parents from fighting, or can help him with problem behavior, it is usually aggressive child, who might be la-
avoid school. because the behavior is a cause for belled 'hyperactive' by quieter
concern or conflict to the entire family parents.
In any child there is constant in- This approach benefits the parent-
teraction between constitutional and rather than to just one member. It is
therefore very important in assessing child relationship when the clinician
developmental factors with environ- indicates to parents the particular per-
mental factors. Therefore, in ap- such a problem to see all involved
family members, not only to help them sonality of the child. This often lessens
proaching a behavioral problem, the guilt feelings that they have failed or
family physician will have to assess understand the problem better, but to been inadequate. A typical example,
the role of heredity, personality and increase the possibility of effective described by Chess and Thomas,6 is
development as well as the role of management. The clinician must ob- the slow-to-warm-up child, who tends
parenting and the environment. tain a brief developmental history of to be timid and adapts very gradually
the child and a relevant family history, to any new situation (e.g., eating new
Table 1 lists common behaviors and and a precise description of the behav-
behavioral problems and the approxi- ioral problem and of the parents' at- food, meeting new people). Such a
tempted solutions. He must also evalu- child may create anxiety in parents
ate the child's temperament. eager to see their child develop and
they may feel that they are doing
something wrong as parents. By point-
Developmental history ing out the child's particular 'style',
A review of the child's principle the clinician can prevent problems
TABLE 1 from escalating and help the family
'Problem' Behavior in Children stages of development and his current find alternative ways to manage. For
abilities will establish how he has de- example, an abnormally active child in
Approx. Age veloped and the appropriateness of his a family used to quieter children may
Behavior of Presentation current behavior. For example, re- be labelled 'hyperactive', and the situ-
tarded sphincter control can explain ation may be made worse in a nursery
Crying10' 12 0-6 months parents' frustration in some cases of
Problems feeding13 14 6 months enuresis or encopresis. A family his- school with little space for activity,
Rocking, head banging
tory of late development in the same where for practical reasons teachers
(rythmic movement)15 9-15 months favor quieter pursuits and quieter per-
Temper area can often be elicited. sonalities. A nursery school encourag-
tantrums11 12,15 10-36 months Important family events in the re- ing more activity and with more space
Toilet training12 16,17 21/2 yrs. cent or remote past may have a bearing may prevent frustration in child,
Resistance to bed time7 3 yrs. on behavior. For example, it is well parents and teacher. The slow-to-
Fears12 3-5 yrs. known that a move or the arrival of a
Problems with sibling12 2'/2 yrs. new sibling will produce regression in warm-up child will be helped by grad-
Pavor Nocturnus18 3-6 yrs. older children and the return of temper ual introduction to new situations, and
Nightmares18 3 yrs. tantrums or enuresis. If a problem limited contact with visitors.
Sleepwalking'8 3 yrs. recurs after a period of normalcy or
Thumb sucking2 3 yrs. greater development, the most impor-
Soiling19 31/2yrs.
Bedwetting18' 20, 21 6 yrs. tant question to ask is what happened Description of the problem
Fighting7, 22 5 yrs. to the child or family immediately be- If the physician receives a full de-
Stealing15 5 yrs. fore the recurrence. scription of the problem and recog-
Shyness5' 6 5 yrs. nizes who defines it as a problem, he
School phobia23 5-6 yrs. can often clarify why it developed and
Lying15 22 5 yrs. Temperament formulate a management strategy.
Behavior problem The important work of Chess and Such data gathering begins during the
at school15 22 7 yrs. Thomas5 in the area of child tempera- first telephone call or a visit and
Abdominal pain25' 26 7 yrs. ment has made two main contributions should continue at an interview in

1890 CAN. FAM. PHYSICIAN Vol. 29: OCTOBER 1983

which all involved family members are contributes to its maintenance. Try to case, fortunately for enuresis or enco-
present. discover the sequence of behavior, presis. If it does happen, however, it is
who does what and when. Ask what important for the clinician to allow it
Who defines the problem? happens first? What happens next? to continue because it is an important
It is important to identify for whom What then? By identifying the se- source of information about how the
the behavior is a problem. This will quence of behavior, one can see how a family handles the problem.
allow the physician to better decide behavior is reinforced. For example, a
who should be present at the initial in- classic sequence between parent and Family Styles
terview. For example, if a grand- child before a temper tantrum is: Certain family styles help maintain
mother believes a two-month-old 1. the parent asks the child to do some- behavior problems. Almond, Buch-
baby's crying results from a lack of thing (e.g., pick up his toys) man and Goffman7 have identified five
food or is abnormal because her chil- 2. the child resists family types: the uproars, the reason-
dren never cried, she should be in- 3. the parent insists and may use ables, the silent, the blamers, and the
cluded in the discussion. If behavior is threats, sometimes unrealistic ones intellectualizers. Each family will be
defined as 'problem' by one parent and (e.g., you will go to your room for the briefly described.
not by the other, this may indicate lack rest of the day)
of support or undermining by the sec- 4. the child resists The uproarfamily
ond parent, or a plea for help with a 5. the mother insists
larger family problem by the first 6. the child resists This family is characterized by dis-
parent. 7. the mother takes the child to his organization. Often repeated phone
room calls are required for scheduling their
Exact description of the problem 8. the tantrum occurs. first visit. On entry to the office, chil-
Vague expressions such as 'my Depending on the child and his behav- dren are out of control, running around
child is nervous, hyperactive, anxious' ior, he is asked out of the room or or playing with medical equipment.
often mean different things for the cli- stays in the room until he becomes Everyone talks at once and the clini-
nician than for the parent. Specific de- calm. He then comes out but is not cian may feel he is on a battlefield.
scriptions of what happens and when, asked to pick up his toys. In any event, The situation is best dealt with by poli-
its intensity and frequency are neces- the child ends up winning. tely establishing the rules of office be-
havior and by asking parents to ensure
sary. For example, a two-month-old A different sequence may occur they are observed. This allows the
child who cries for twenty minutes when father is home. After two at- physician to observe how they comply
every evening after supper is not ab- tempts from mother, he may inter- with the request and their ability to
normal. This is usually the time when vene, get the child to pick up the toys, perform as a team.
crying occurs. Questions should be and prevent him from having a temper
specific. For example, if an older child trantrum. This makes the mother feel The reasonable family
demonstrates problem behavior at bed- incompetent and even less able to deal
time, it is important to ask parents with the problem the next day when This family often presents as a
what time bedtime commences and she is alone with the child. The child model of togetherness, always finding
when the child finally goes to bed, will continue to misbehave when his a way to keep the peace. They avoid
rather than whether they have diffi- father is not home. talking to anybody, but will talk about
culty with this task. Behavior sequence can be obtained everybody. This sense of togetherness
by taking a history during the family may lead the physician to erroneously
Are there any other problems? interview and by getting parents to see them as a family without prob-
It is important to know, for prog- keep a daily record of their interven- lems, but parents will say that the child
nosis and management, whether the tions before and after the child's be- 'does not listen' to them. Because it
child has only one behavior problem havior occurs. This record, like any avoids conflict, the reasonable family
and whether other children show the record used in behavioral therapy, can often is full of inconsistencies and
same behavior or other problems. help chart progress, predict when be- parents undermine each other. After
Some behavior problems tend to clus- haviors will occur, and reveal asso- seeking the clinician's advice this fam-
ter, indicating more general problems ciated events and sequence. The physi- ily often does not act upon it and gives
or difficulty parenting. It is also im- cian can also observe directly during good reasons for not doing do. The
portant for the family to specify, when the interview the way the behavioral best strategy is to teach better com-
many behaviors are creating concern, problem is expressed and dealt with. munication skills. Insist that members
which one specifically they want to This is termed 'enactment'. talk to each other, not about each
deal with. When one problem is suc- We have found the daily record and other, encourage use of the pronoun 'I'
cessfully solved, increased self-confi- direct observation particularly useful and not 'we', and support any expres-
dence may allow parents to solve because they take little time. Observa- sion of discord. This encourages indi-
others. tion rarely takes more than five min- vidual opinions and statements. Avoid
utes during a regular examination. We giving early advice in favor of encour-
What is the context and have found that the same behavior for aging decision-making by the family.
sequence of the behavior? which the parents consult often occurs
The silent family
This line of questioning is aimed at during the interview. For example,
eliciting the family's solution or adap- temper tantrums are almost automatic This is the monosyllabic family.
tation to the behavior, which often or very easy to provoke. This is not the Heavy silence often makes it very dif-
CAN. FAM. PHYSICIAN Vol. 29: OCTOBER 1983 1891
ficult to initiate the interview. The be- mine each other and have inconsistent had died. In this case, discussing the
havior problem is often maintained by ideas about the child's problem. The problem with the mother alone would
lack of communication. The clini- clinician's task is to make a crack in simply cause communication problems
cian's first task is to deal with the fam- this intellectural barrier to enable the between her and her husband.
ily's silence and sense of discomfort. family to express how they feel about If a child's misbehavior is a result of
To challenge the silence leads to even the situation. If a child is having problems between parents, it may need
more withdrawal; it is better to deal temper tantrums they need to describe to be relabelled a marital problem.
with their expectations of the sessions their own feelings of helplessness or However, it is judgmental and unhelp-
and to decrease their anxiety by stating anger when they are unable to control ful to do so before helping the couple
that most families find it difficult to him. The tantrums may be his way of with the problem as they see it. By fo-
come to a professional's office to dis- expressing the bottled-up family emo- cussing on parenting skills as a way to
cuss a problem as a family. Asking 'Is tion. If a trusting relationship has been help solve the behavior problem, the
your family as private as mine?', or by developed with the clinician, the sug- couple will either improve as a team,
suggesting that the children draw a gestion that the child plays such a role which may benefit the marriage, or
family picture or describe a picture of and that he may stop having tantrums recognize that conflicts about parent-
a family may help to warm up the dis- if other family members express emo- ing represent more serious marital con-
cussion. Joining with every member of tion may act-as a catalyst for change. It flicts.
the family at the beginning of the inter- may also encourage the parents to act As in other areas of health care,
view is particularly essential for this as a team in controlling the child's out- simple explanations or diagnoses
type of family. The clinician must con- burst. should be made first, and simple, short
vey the impression that everyone's solutions should be suggested.
opinion and perspective is important Why is The
and needed. As family members be- Behavior a Problem? Solutions Attempted
come more comfortable with the pro-
fessional, they may begin to discuss A behavioral problem is a symptom What solutions has the family tried
concerns that have never been men- that may disappear when the family is in order to solve the problem? Assess-
tioned at home. educated and supported. Parents suffer ing how the family has approached the
from a lack of training and role problem gives information on their
modelling in good parenting. They are consistency, flexibility and ingenuity,
The blaming family also unsure which of many experts to and on the parents' ability to work to-
These families argue almost from follow. Guidance by the clinician over gether. For a problem of any duration,
the moment they enter the office, or one to three sessions may be neces- the family's typical solution will often,
the moment you enter their home. sary. in fact, be the mechanism for its main-
Problems are always someone else's The child's behavior may also be tenance. For example, the parent may
fault; one family member is always the tip of an iceberg of family conflicts reward the child when he stops under-
under attack and this person is an ex- and dysfunction which require refer- sired behavior; the child quickly learns
pert at defending himself; family ral. The underlying reason for the that if he wants the rewards he must
members do not listen to one another. problem must be elicited. It is impor- present the behavior; a candy for stop-
The escalation of blame may make tant to hear the family's explanation ping a temper tantrum will clearly in-
them similar to an uproar family. It is for the child's behavior. For example, crease the incidence of tantrums. A
very difficult to establish a relationship a child may suffer recurrent abdominal parent who utilizes coersion or vio-
with such families without siding with pain in a family who worries a great lence in order to stop coersion or vio-
one member in the discussion. But, for deal about cancer or gastrointestinal lence doubly reinforces the behavior.
the family to communicate effectively disease. Folkloric or cultural explana- For example, a child hits his sister in
and manage a behavior problem, they tions may be the key to effective com- order to stop her doing something he
need to learn to talk without explaining munication and if they are not elicited, dislikes. Then he is hit by the parent.
and defending. A neutral outsider who the family may seek help elsewhere. Not only is his behavior reinforced be-
refuses to judge can help point out how Lack of experience of normal child de- cause his sister stops doing what he
blame lets family members avoid re- velopment together with fear of in- dislikes, but by the parent's role
sponsibility and change, and prevents herited illness may produce marked modelling. The parent who makes
problem solving. anxiety in parents. For example, a threats which are never carried out
family with a history of mental retar- teaches a child never to take parental
dation may. panic if a child is slow to demands seriously and reinforces bad
The intellectualizing family achieve first year milestones compared behavior. The instruction 'say 'no'
This family will keep the physician to the neighbor's child, or if he pur- three times a day but mean it' helps
or nurse up-to-date on journals and posely bangs his head or rocks at five some of these parents, as does the
childcase books. They wage an intel- to 15 months. guiding phrase 'firm but friendly'.
lectual battle to stay away from feel- In one family the mother realized Finally, there are parents who
ings. They limit themselves to the suppertime crying was normal in her would like a professional to be a sub-
facts, as if they are involved in a pro- firstborn child. However, the husband stitute parent and in effect ask him or
fessional case discussion; they sound found this crying intolerable because her to 'please fix our child'. Here the
as though they are talking about a child he remembered as a young child listen- solution is up to the professional. If
from someone else's family. As in a ing to a neighbor's baby cry contin- this bait is accepted, the prognosis is
reasonable family, parents may under- uously. He later learned that the baby poor. When children are misbehaving,
1892 CAN. FAM. PHYSICIAN Vol. 29: OCTOBER 1983
it is often tempting for the professional
to step in and 'role model' proper dis-
cipline. This has some benefits if done
sparingly, but has the danger of mak-
ing parents feel incompetent and sug-
gesting that the professional is willing
to take over from them.
Management
In managing families who have a
child with behavior problems, the role
of the family physician is threefold.
He or she can provide information and
anticipatory guidance, facilitate prob-
lem solving by making specific sug-
gestions to the family about how to
control a behavior or to improve com-
munication, or refer families in need
of more intensive family therapy or
some practical assistance (e.g., baby-
sitting, daycare) to handle their child's
behavior problem.
Education and anticipatory guidance
The goal of educational counselling
is to explain to parents their child's be-
havior in its developmental context.
The clinician can also play a preven-
tive role by anticipating problems be-
fore they occur, and making sugges-
tions to ensure parents don't encourage
problem behavior. For example, when
a mother leaves hospital with her new-
born, the clinician can mention the
typical pattern of bedtime crying in a
six-to 12-week-old infant. This may
persist longer through no fault of the
parents if the child is more excitable
than usual or is sensitive to environ-
mental stimuli; this is a normal phe-
nomenon in North American babies.
Crying infants often reflect tension
in the mother or family by crying or
having difficulties feeding. Maternal
anxiety or lack of milk if the mother is
breast feeding, the demands of other
children and of in-laws and work pres-
sures affect both parents and child. For
example:
Mr. and Mrs. P. came to see
their family physician because of
their new baby's constant crying.
There were two other preschool
children in the house. The mother
described this baby as more irrita-
ble and a light sleeper who
reacted more actively to noise.
He seemed not to be as cuddly as
the older two had been and when
held would sometimes arch his
back. During feeding he would
often swallow greedily and then
choke and stop feeding, and
CAN. FAM. PHYSICIAN Vol. 29: OCTOBER 1983
would be hungry again two hours
later. As soon as the two toddlers
were settled the baby woke up.
The cycle would repeat, leaving
the mother exhausted. The father
was a hard worker, who had re-
cently been promoted, and was
trying to make the mortgage pay-
ments on the new house. He was
not very supportive when he
came home in the evening. They
had recently moved to a new
community near Mrs. P.'s
parents but the parents were
rarely available. The family knew
no neighbors and had no other re-
sources. The family's ability to
cope was now stretched to the
breaking point by the crying
baby.
During the interview, the clini-
cian noted that the child was very
calm and relaxed. He enquired
whether he could also be relaxed
at home. The mother admitted
that the baby nursed perfectly
when everyone else was asleep
and they were both relaxed. The
clinician recognized that the
child's temperament made him
highly reactive to his environ-
ment which, in this case, was a
very stimulating one. The crying
was part of a chain of events for
this family, and an immediate so-
lution was needed. The grand-
mother had accompanied Mr. and
Mrs. P. to the interview. The cli-
nician asked them if they thought
she could look after the other
children part of the day. They felt
this would be a good idea and the
grandmother agreed to their re-
quest.
A week after the interview a
phone call revealed that the baby
was feeding well and was more
relaxed. The parents had in-
creased the time between feeding
and when the two other children
returned for supper, the mother
and father spent time with them.
The mother had also resumed
some community activities be-
cause more time was available
between feedings. Thus the clini-
cian had helped dispel the
parents' feeling of inadequacy
that resulted from a crying child,
had put the child's behavior in the
context of his own temperament
and of the family, and had helped
the family to make use of avail-
able resources to solve their prob-
lem.
Anticipatory guidance can easily be
incorporated in the child's regular
visits for immunization and physical
examination. Changes such as the in-
fant's decreased appetite around age
one, the development of temper tan-
trums at 18 months, toilet training at
two and a half years, and sibling ri-
valry after the birth of an infant-
which is greatest over age 18 months
when there is increased indepen-
dence-are all part of normal develop-
ment.
The usual sequence of sphincter
control, dry by day and then dry by
night, is established in most children
by age three, but 15% of four- and
five-year-olds still wet the bed. It is
important for parents to avoid paying
too much attention to this, as it will en-
courage persistent enuresis and lower
the child's self-esteem. Temper tan-
trums, although normal, require firm-
ness and consistency to prevent their
continuation as a way for the child to
control the environment.
Entry into school-particularly for
the first child-can be traumatic for
both child and family. It indicates that
the family's boundaries have widened
to include more contact with the out-
side world. Much earlier suggestions
by the clinician that the mother not cut
herself off from friends and interest
groups, and that the gradual introduc-
tion to play groups or a nursery school
may prepare the child, can be impor-
tant. School phobia can be a serious
problem. If it does occur, it is impor-
tant not to allow it to continue for
long, but to treat it as an emergency.
The family must gain the support of
teachers, and the clinician must help
the mother who is anxious both for the
child and for herself. At this stressful
time, the clinician can expand his pre-
ventive role by suggesting that couples
increase their time together alone, and
by recognizing warning signs or
stresses such as the father spending.
more time at work.
School problems tend to present
again during adolescence, as the fol-
lowing case history shows:
Mr. and Mrs. T. brought their
14-year-old son Jack to the family
physician. Jack had been sus-
pended from school because he
had been missing classes.
Jack was the youngest in a
family of three boys in which the
older two were currently doing
1893
 well in school. The father, a
member of the school board, was
a self-made man and very active
in his community. Mrs. T. felt
desperate about this son's poor
school achievement.
The family physician enquired
about the problem, eliciting the
sequence that typically occurred,
and kept the discussion to a very
factual level. He rapidly discov-
ered that when Jack decided not
to go to school he slept in until 11
a.m., watched television during
the day and went out with his
friends in the evening. Apart
from the school problem he was a
cooperative boy and when asked
what he wanted to do instead of
school he said he wanted to work.
The physician took this opportu-
nity to suggest that the father,
who had also learned to work at
an early age, plan with his son a
regular day of work with pay if
Jack elected to stay home. Jack's
parents decided what had to be
done, Jack had to get up at 6:30
a.m. After breakfast he worked
all day with a brief break in the
mid-morning and at lunch. This
lasted two days.
Jack has now been attending
school all day and his father has a
built-in check with the school to
confirm this. As a reward, father
and son have planned a trip to-
gether for the summer.
Although there are many reasons
why a child may wish to avoid school,
something must be happening to allow
him to do so. An investigation of the
sequence of events usually gives a
very good picture of why the child is
able to miss school. By recognizing
that this boy was repeating the father's
own adolescent history, and by mak-
ing simple suggestions to the family,
the physician helped the parents to
work as a team and to facilitate a rapid
solution. Had the couple been unable
to function as a team, and conflict be-
tween them surfaced as the reason for
the truancy, the clinician would have
had to steer them towards counselling
for themselves.
Often adolescents need discipline
and established limits. The clinician's
awareness of how much autonomy is
appropriate can help him educate
parents. Parents need to gradually in-
crease autonomy as the adolescent gets
older, but at the same time must in-
crease their expectations and the ado-
1894
lescent's responsibility. The mother
who has been preoccupied with 'child
watching', needs to be nudged to de-
velop her own autonomy. Such
mothers may otherwise undermine
children's attempts at independence,
and be overly affected by adolescents'
mood swings and derogatory com-
ments about their parents' abilities.
Specific suggestions
In the case of both the 'T' family
and the 'P' family, the clinician
prompted the family to devise a man-
agement plan. The clinician should act
as a coach and give occasional specific
suggestions when parents are at a loss,
These suggestions should be based on
several practical principles:
Positive enfrcement: Parents often
Positiveenforcmet
unwittingly reinforce negative behav-
ior. For example, some parents pay at-
tention to their children only when
they fight. Such parents would do well
to note when children are happily play-
ing together and either comment on it
or non-verbally reward them; it is
more appropriate to give children can-
dies at this time than after they have
been naughty. Children may fight
more if their parents pay attention to
the fighting. Also, children may fight
with each other when they are angry at
their parents.
Shared information: The child
should be included in discussions
about his behavior problems and about
possible solutions. This helps parents
learn that negotiation, particularly
once the child has reached adoles-
cence, is a sound basis for effective
communication.
Parental agreement: Parents must
agree on the problem and how to solve
it. Persistent disagreement will effec-
tively block problem solving and may
indicate the need for family therapy.
Avoiding paying attention to nega-
tive behavior: By visiting a health pro-
fessional, the family focuses on the
'problem child'. As soon as possible
the parents should regain control and
treat the child no differently than his
siblings. Parents must learn to turn
their attention to positive behaviors.
The principles ofprogressive desen-
sitization: These can be applied to
fears and phobias. Mild fears are dealt
with first, and the parents' resultant
sense of mastery and decreased anxi-
ety will give them the confidence and
competence to handle more difficult
problems.
The adolescent as problem solver:
Some problems are more appropriately
dealt with by the child than by the
parent, particularly if the child is an
adolescent. Over involvement and
child-watching, beyond the age where
it might be appropriate, can produce
problems. The child may complete his
homework poorly, get failing grades,
or have difficulty with peers. When
parents give the impression that it is
for their sake that the child must get
good grades, eat a hearty meal, have a
certain number or type of friends, or
wear a sweater, they invite rebellion.
Once parents perceive that their efforts
are counterproductive, the child's own
desire to succeed (or his own physio-
logical needs in the case of eating),
and his fear of the consequences of
poor school work will take over. For
example, a child should be responsible
for getting to school on time in the
morning; he can be given an alarm
clock and should not be 'bailed out' by
a drive if he gets up too late to walk or
take the bus. Teachers' cooperation
will often facilitate giving the adoles-
centincraed tesoibility.
cent increased responsibility.
Christopherson7-8 has described in-
tervention models for certain very
common behavior problems. These
suggestions can be used by the family
clinician; compliance with the 'pre-
scnption is increased if instructions
are written. A telephone follow up or
clinician availability if the parents'
first attempts do not succeed will mar-
kedly decrease the incidence of fail-
ure.
Behavior charting, reporting when
the child's negative behavior occurs
and what the parents' reactions are,
records progress and indicates if
parents are helping the child maintain
his problem behavior. The clinician
should budget for two to three meet-
ings with the family before change
occurs and can be maintained. Meet-
ings can be scheduled for half an hour
at two to three week intervals. After
the first visit, parents should be
warned that behavior will worsen be-
fore it improves. The classic punish-
ment of isolating the child for a short
period of time has to be applied consis-
tently to children aged four to six. For
older children, rewards or punish-
ments have to be set depending on the
individual's preferences or dislikes.
Referral
There are certain situations when re-
CAN. FAM. PHYSICIAN Vol. 29: OCTOBER 1983
ferral for more intensive or expert
guidance is indicated. If parents need
more support and ongoing discussion
than time permits, parenting groups in
the community are often extremely
helpful. If problems are more complex
or of long duration, as many problems
during adolescence are, or if one or
two sessions reveal parental conflict or
that the family is maintaining the prob-
lem for other reasons, then referral is a
service to the whole family. A dys-
functional family, such as one where
conflict between the parents is de-
toured through a child's delinquent be-
havior, is difficult even for a family
therapist to treat.
The primary care clinician's job is
to reframe the child's problem as a
family problem. This may take a long
time and can often be done only by a
trusted clinician who has ongoing con-
tact with the family. Too abrupt a re-
statement of the problem will simply
prompt disbelief, and the family will
seek individual therapy for the child,
or 'doctor shop'.
The primary care clinician should
monitor a family that has been referred
without interfering in the relationship
between family and therapist. If the
therapist is in the same practice loca-
tion, communication is particularly
easy, and awareness of the consul-
tant's goals will allow the clinician to
support intervention. (*)
References
1. Chamberlain R: Behavioral problems in
pre-school age children, in Haggerty RJ:
Child Health and the Community. New
York, John Wiley and Son, 1975.
2. Sheperd M, Oppenhein B, Mitchel J:
Childhood Behavior and Mental Health.
London, Grune and Stratton, 1971.
3. Rogers DE, Blendon RJ, Hearn RP:
Some observations on pediatrics: Its past,
present and future. Pediatrics 1981; 67
(suppl):775-784.
4. Achenback T, Edelbroock C: Behavior
Problems and Competencies, Reported by
Parents of Normal and Disturbed Children
Aged Four Through Sixteen. Monograph of
Society for Research in Child Develop-
CAN. FAM. PHYSICIAN Vol. 29: OCTOBER 1983
ment. Chicago, University of Chicago
Press, 1981.
5. Chess S, Thomas, A, Birch H, et al: Be-
havior Individuality in Early Childhood.
New York, New York University Press,
1963.
6. Chess S, Thomas A: Your Child is a Per-
son: A Psychological Approach to Parent-
hood Without Guilt. New York, The Viking
Press, 1972.
7. Allmond B, Buckman W, Gofman H:
The Family is the Patient. St. Louis, MO.,
The C. V. Mosby Company, 1979.
8. Christophersen E, Barnard J: Preven-
tion, detection and treatment of commonly
encountered pediatric behavior problems.
Read before the Ambulatory Pediatric As-
sociation workshop, Washington, DC.,
Sept 1976.
9. Christopherson E: Behavioral pediat-
rics. Am Fam Physician 1978; 17:3.
10. Brazelton TB: Crying in infancy. Pedi-
atrics 1962; 29:579-584.
11. Brazelton TB: Anticipatory guidance.
Pediatr Clin North Am 1975; 22:533-544.
12. Brazelton TB: Doctor and Child. New
York, Seymour Lawrence, 1979.
13. Green M: A developmental approach
to symptoms based on age groups. Pediatr
Clin North Am 1975; 22:571-581.
14. Schwartz A: Eating problems. Pediatr
Clin North Am 1958; 5:595.
15. Sallusto J: Body rocking, head bang-
ing, head rolling in normal children.
J Pediatr 1978; 193:704-709.
16. Brazelton T: Toilet training. Pediatrics
1962; 129:121.
17. Stehbens JA: Toilet training. Pediat-
rics 1974; 54:493.
18. Guille Minault C, Anders T: Sleep dis-
orders in children. Part II. Adv Pediatr
1976; 22:151-174.
19. Levine M: Children with encopresis-A
descriptive analysis. Pediatrics 1975;
156:545-560.
20. Cohen M: Eneuresis. Pediatr Clin
North Am 1975; 22:412-416.
21. Kovlin I, MacKeith R, Meadows R:
Bladder Control and Enuresis. Philadel-
phia, J. B. Lippincott Co., 1975.
22. Reid JB: A Social Learning Approach
to Family Intervention. Eugene, OR., Cas-
talia Publishing Co., 1975, vol 1.
23. Schmitt B: School phobia-The great
imitator-A pediatrician's viewpoint. Pe-
diatrics 1971; 48:433-443.
24. Berger H: Somatic pain and school
avoidance. Clin Pediatr 1974; 13:819-
826.
25. Apley J: The Child with Abdominal
Pains. Oxford, Blackwell Scientific Publi-
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26. Barr RE: Recurrent abdominal pain in
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Engl J Med 1978; 300:1449-1452.
INDICATIONS
PARAFON FORTE tablets provide symp-
tomatic relief of pain, stiffness and lim-
itation of motion associated with most
musculoskeletal disorders through
(a) relaxation of muscle spasm by chlor-
zoxazone, an effective and well-tolerated
centrally-acting agent, and
(b) analgesia by acetaminophen, a non-
salicylate analgesic useful in skeletal
muscle pain.
CONTRAINDICATIONS
PARAFON FORTE tablets are con-
traindicated in patients sensitive to either
component.
WARNINGS
Usage in Pregnancy
The safe use of PARAFON FORTE tablets
has not been established with respect to
the possible adverse effects upon fetal de-
velopment. Therefore, it should be used
in women of childbearing potential only
when, in the judgment of the physician,
the potential benefits outweigh the possi-
ble risks.
PRECAUTIONS
PARAFON FORTE tablets should be used
with caution in patients with known al-
lergies or with a history of allergic reac-
tions to drugs. If a sensitivity reaction oc-
curs such as urticaria, redness, or itching
of the skin, the drug should be stopped.
If any signs or symptoms suggestive of
liver dysfunction are observed, the drug
should be discontinued.
ADVERSE EFFECTS
Chlorzoxazone
Occasionally, mild gastrointestinal dis-
turbances or central nervous system ef-
fects such as drowsiness, dizziness, light-
headedness, malaise or overstimulation.
Rarely, allergic-type skin rashes, pete-
chiae or ecchymoses. Angioneurotic
edema or anaphylactic reactions are ex-
tremely rare. Rarely, a clinical picture
compatible with either a viral hepatitis or
drug-induced hepatitis has developed
during treatment.
Acetaminophen
The incidence of gastrointestinal upset is
less than after salicylate administration.
ADULT DOSAGE
Two tablets four times daily.
SUPPLIED
Each light green tablet imprinted "McNEIL"
contains 250mg chlorzoxazone and
300mg acetaminophen. Available in
bottles of 50.
Complete product information available
upon request.
CC'tPPI
NkNEIL
PHARMACEUTICAL (CANADA) LTD.
600
MAIN STREET WEST STOUFFVILLE ONTARIO OH 'LO (416) 6406982
1895