Parenting Lisa S. Spector MD Chief, Division of Developmental and - - PowerPoint PPT Presentation

Positive Parenting

Lisa S. Spector MD

Chief, Division of Developmental and Behavioral Pediatrics – Nemours Children’s Hospital Professor of Pediatrics - UCF

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Disclosure

• I have nothing to disclose

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Objectives

• How chronic stress effects brain development and child behavior
• Effective behavior management strategies

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Brain on Trauma

THALAMUS

• Relay between subcortical &

cortex

• Translates senses into

language of the brain

• Regulating arousal,

awareness and activity

• Involved in memory

AMYGDALA

• Emotional Computer and

Alarm System

• Responds to threat – Fight, Flight,

Freeze

• Formed at Birth

HYPOTHALAMUS

• Link CNS to Endocrine System
• Send and receive hormones
• Activate Autonomic Nervous System
• Immediate
• Fight or Flight or Freeze
• Epi & Norepi
• Release hormones from Pituitary
• Slow
• HPA axis - cortisol from adrenals

HPA Axis

Excess Cortisol

• Increased BP
• Diabetes
• Immune suppression
• Infection
• Atherosclerosis
• Osteoporosis
• Muscle atrophy

Cortisol

Metabolic & Cardiovascular response to stress

Negative Feedback Loop

HIPPOCAMPUS

• Determine if Threat is Valid
• Links experience – sensations,

emotions, thoughts, facts & reflections - into memories - which we can recall and describe

• Develops in first 5 years

PFC

• Make decisions about

cognitive and emotional responses

• Abstract concepts - time
• Executive Functioning:
• Making, following & alt

plans

• Control & focus attention
• Inhibiting impulsive

behaviors

• Developing ability to hold

and incorporate new information in decision making

• Develops over 25 years

Studies of Trauma/Stress

• Increase in Cortisol–

– increased levels of cortisol measured in 24 hr urine in children with PTSD

• Hippocampus smaller

– adult veterans with PTSD; – adults with childhood abuse related PTSD

• Loss of neuronal Integrity in Prefrontal Cortex–

– reductions in N-acetyl aspartate (NAA) in PFC of children with new onset PTSD

Bremner, JD. Traumatic Stress: effects on the brain. Dialogues Clin Neurosci. Dec 2006;8(4):445-461

Summary - Always under Stress

• Amygdala is Continuously Activated

– Increase in Cortisol – metabolic, immune and CV changes

• Deficit in Hippocampal Structure and function

– Unable to classify and organize information properly – Typical process for storing memories is altered and information remains perceptual (smells, sights, sounds) and not stored as verbal language

• Deficit in PreFrontal Cortex Structure and Function

– Can not make meaning of what happened and grow and learn. – Emotionally Reactive; easily triggered into a state of arousal – sensing threat in innocuous situation & may have no verbal language to describe it

The child…..

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How to Help

• Help them feel - Safe
• Focus on the positive to build – Self Esteem
• Provide them - Predictability
• Give them opportunities for - Control
• Model and promote - Self Calming / Coping Strategies
• Use Play to build skills – Emotion Regulation

Discipline = Guide and Teach!

Children learn how the world works by:

• Watching what we do and say
• Imitating what we do and say
• Experiencing how we Respond!

We can change their behavior by changing what we do/say and how we respond!

Children….

• Do well with Structure and Routine
• Need some Prep Time

– We are going to leave in 5 min – One more time down the slide

• Learn through Repetition

– Especially kids with ADHD and traumatized children

• Get better with Practice
• Respond well when there is Consistency and Calmness

Monkey See, Monkey Do

They look up to us and they watch & listen even when we think they are not!

Be on our Best Behavior:

• Use our Manners
• Point out when we ‘share’ and ‘take turns’
• Label our Feelings

– “You are driving me crazy!!” -> “Mommy is feeling frustrated” – Helps kids label their feelings and know feelings are OK

• Model Good Coping Skills

– “I need 10 big breaths to calm down. Lets do it together.” – “Daddy needs a Time Out to calm down”

Be Proactive instead of Reactive

• Give lots of Attention for Good (desired) behavior
• Remove Attention for ‘Bad’ (undesired) behavior

Build a Positive Relationship & Reinforce Desired Behaviors

Attention O’meter

• All Children Want Attention
• All Children Seek Attention
• Children don’t care what kind of Attention

..Attention is a POWERFUL TOOL

Behavior + Attention = More Behavior

+ +

= =

3 ways to Positive Attention

• Catch them being “good” or even just “OK”
• Quality Play time, Time-In
• Loving Touches 50-100 times a day

Catch them being ‘OK’

• Praise behaviors you want to see again

– Manners, quiet, kind, helpful, following directions – Makes children feel GOOD!

• Don’t wait for perfection, ‘OK’ is good enough

– “Good job walking next to mommy” – Makes children want to do it MORE!

• Compliment an other child’s good behavior

– Stop there! – stay away from comparison/criticism

Catch them being ‘OK’ more often!

Goal: Praise desired behaviors 5x more than disciplining undesired behaviors

Praise BEHAVIOR & EFFORT

• Praise Behavior and Effort not ability
• working hard
• sticking with it

Not – “you are so smart” If fail, will persist longer if effort was praised

Changing the Caregiver’s FOCUS

Actively work to Change the Focus

• Runs around like an

animal!

• Never listens!
• Constantly crying!
• Lies all of the time!

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I….

• am an animal!
• never listen!
• always cry!
• always lie!

Instead Focus on the Positive Opposite

• Sitting quietly
• Listening the first time
• Coping when things don’t go my way
• Telling the truth

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I….

• Sit quietly
• Listen the first time
• Cope when things don’t go my way
• Tell the truth

Self Esteem

National Violent Death Reporting System (NVDRS) 03-12 for 17 states

• Compared Suicide rates 5-11 yr and 12-14 yr
• In the 5-11 yr old age group

– 85% were boys (70% in EA group) – 60% relationship issue, 32% school problem, 38% recent crisis – 30% disclosed intent – 1/3 a current MH issue (same in EA group)

• Of the 5-11 yr ADHD was the most common known mental

health disorder in children who died of suicide

– 60% experienced ADHD and only 33% experienced depression/dysthymia (30% ADHD & 65% depression/dysthymia)

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Getting our PLAY ON!!

• Let the child run the show – Decrease Demands:
• Increase attentive responsiveness:

– Describing what they are doing – Repeating what they say – Catch them being “OK” – sitting still, using inside voice, sharing and taking turns

• Asking questions
• Telling what to do
• Criticizing (no, don’t, that’s not right)

Nurturing Touches 50-100x/day

• Hugs, high-five, fist-bump!
• Brief physical contact

– Head, back, shoulder

• Attention without talking
• Acknowledge good behavior without distracting
• Therapeutic Massage

– Youtube Tina Allen -PMT

*Always ask for permission first

Give Good Instructions

• Get their attention First!!
• Be Calm, Neutral tone of voice
• Tell them what you WANT THEM TO DO

– “Don’t climb the tree!!” – “Put your feet on the ground”

• Do not frame as a question unless they have a choice

– Be Polite by using “Please”

Give Good Instructions

• Short, concise, and specific
• How long is a reasonable time to wait for compliance?

– 6-10 seconds

• Praise for compliance

Kids Learn through Play – So Teach them with Play

• Social Emotional Skills

– Sharing, turn taking – How to engage others in play – Conflict resolution

• Dolls take pressure off of the child
• Window into their minds
• Opportunity to reframe to provide a different perspective

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Good Ole Role Play

• Help practice key skills

– Sharing – Sitting in circle time – Conflict resolution

• Learn empathy and perspective taking
• Ask What questions to engage them to set the stage

– What do if some does something you don’t like? – What else can you do? – Let them come up with answers and help if they need help

• Okay lets pretend and you be ____

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Standing Rules

• Engage them in creating the RULES
• Modeling what rule-following looks like
• Posting the rules in prominent place
• Practice following the rules

– Using Descriptive Praise and Rewards

Use your inside voice

Predictability and Control

• Preparation for changes/transitions

– Talk about The Plan ahead of time – One more time down the slide – We are going to have to leave in 5 min,.. 2 min,..1 min

• Allow child to have control when appropriate

– Try to find choices for child when appropriate no matte how small – We have to go, do you want to put your shoes

• n or do you want me to help you?

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Predictability and Control

• Provide Visual Schedules
• Calendar to mark down days – until visit/return

Most Behavior Charts

• Geared towards kids

with good behaviors

• Doesn’t account for

individuality - All kids do not start out at the same point

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Reward Charts

• Need to get their buy in

– Engage them in creating it “We are going to work with you ___” – Keep it simple (only 2 goals and 3 at the max) – Make it easy for them to achieve the goal initially.

• Need to make sure they understand what is desired

– What are some things you need to work on? – Talk about each goal and what it looks like to exhibit that behavior

• What does ‘Following Directions the First Time” mean (example)
• Must focus on what you want them to do

– Have goals state the positive behavior

• Keeping hands to self (vs not hitting others)

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Rewards

• Don’t have to cost money (item or activity)

– Extra play time, pick the movie

• Quick turn around time – almost immediate

– Pair with Descriptive PRAISE

• Gradually increase the stakes over time
• Motivators change day to day

Food Insecurity

• Never use food as reward or punishment
• Allow child to carry food if it provides comfort in secure

container

• Routine and visual schedule around meals and snacks

(healthy foods)

• Gradually teach child to wait between meals and snacks

Sleep Disturbance

• Night Light
• Positive Self Talk – I

am brave

• Transitional Object
• Monster Spray (air

duster)

• Bedtime Pass
• Reverse Baby Monitor
• Change rooms
• Flash Light
• Bell to ring or walkie

talkie

• Sound Machine
• Door Alarm (use with

caution)

• No TV/Electronics
• Massage

Discourage Misbehavior

• The other side of the Attention Coin
• Planned Ignoring and Time Out

Reactive

Proactive – IN Control

Ways we Get Sucked into the Tornado (tantrum)

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Talk / Reason Touch / Restrain Eye Contact / Facial Expressions

Planned Ignoring / Time-Out

Contingent use of Attention is very Powerful

• Doesn’t work unless different that what usually occurs
• Therefore, Need lots of Positive Attention

Self-Calming

• Quiet Hands
• Quiet Feet
• Quiet Mouth

“Nice job calming down. It looks like you are ready to come out of time out”

*Nothing to do with age or other time limit

Specifics of TIME OUT

• Location – where child can see you, see you are not

angry, and see what he is missing

• Boring – not around other toys or fun
• Must be used Consistently

– Warning and Threats get you no where!

Planned Ignoring / Time Out

• Respond Promptly

– Time Out ____ (hitting, kicking, not listening)

• NO Contact

– No Eye Contact, No Touching, No Talking

• Be Calm

– Keep your voice at a neutral tone or lower

• Quickly catch them being “Good” or “Ok” and

Promptly Respond

– “nice job calming down”

• NO RECAP - what is done is done

Keys to Success

• No arguing/debating, lectures or reasoning
• Be consistent, do what you say
• Don’t over react

Practice, Practice, Practice!!

• Practice before you need to use it
• Repetition – 10x TOs (1 min) over 1x TO for 10 min
• Prepare when in new location (who and where)

Pit Falls

• If not want to get out – say “time out starts again”
• If concern to hurt others- pick up holding chest away from you

and gently place in safe spot

• If not sit in spot – planned ignore (walking TO), praise when

calm, move toward sitting after calm

Prepare Parents

• Worse before it gets better – Extinction Burst

– Temporary increase in Freq, Intensity, Duration – Extinction induced aggression – Extinction induced novel behavior –

• In one week will try it again to see if same rules apply

Cooper, John O.; Heron, Timothy E.; Heward, William L. Applied Behavior Analysis. Merril, Prentice Hall, 1987. Miltenberger, R. G. "Behavioral Modification: Principles and Procedures". Thomson/Wadsworth, 2008.

Applied Behavior Analysis

• To understand structure and function of behavior to teach

effective alternative

A B C

Antecedent Behavior Consequence

What would I see if I was looking at a video of the incident?

Antecedent- What happened before the behavior?

• Precursors, contexts, developmentally appropriate instructions

Behavior- Tantrum, noncompliance, aggression, inattention

• Frequency, Length, Intensity

What would I see if I was looking at a video of the incident?

Consequence- What happens after the behavior? - EATS

• Escape From Demand or Aversive event
• access to Attention
• access to Tangibles (e.g., activities, toys, edibles)
• Sensory Stimulation or Removal

What behavior you do want to see?

Can’t just get rid of behavior and have desired behavior spontaneously appear

Is it developmentally realistic? Has the child been taught the behavior?

ABC of Behavior Management

A B C

Avoid the Antecedent When practical

Desired Behavior

Eliminate Reinforcing Consequences

Focus on Desired Behavior

Set them up for success

• Giving good instructions
• Be a good role-model

Reinforce toward compliance

• Catch them being “ok”
• Start small and work up
• Rewards / Privileges

Ignore diversionary tactics/undesired behavior Help adult cope with behavior

Any Questions?

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