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Positive
Parenting
Lisa S. Spector MDChief, 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
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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
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HPA Axis
Excess Cortisol
Increased BP
Diabetes
Immune suppression
Infection
Atherosclerosis
Osteoporosis
Muscle atrophy
Cortisol
Metabolic & Cardiovascular
response to stress
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Negative
Feedback
Loop
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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
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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
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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
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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
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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!
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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
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Monkey See, Monkey Do
They look up to us and they
watch & listen
even when we think they are not!
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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”
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Be Proactive instead of Reactive Give lots of Attention for Good (desired) behavior
Remove Attention for ‘Bad’ (undesired) behavior
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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
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Behavior + Attention = More Behavior
+
+
=
=
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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
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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
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Catch them being ‘OK’ more often!
Goal:
Praise desired behaviors 5x more than disciplining undesired behaviors
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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
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Changing the Caregiver’s FOCUS
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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!
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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
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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)
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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
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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”
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Give Good Instructions
Short, concise, and specific
How long is a reasonable time to wait for compliance?
– 6-10 seconds
Praise for compliance
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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
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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
on 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
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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
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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
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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 walkietalkie
Sound Machine
Door Alarm (use with caution)
No TV/Electronics
Massage
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Discourage Misbehavior
- The other side of the Attention Coin
Planned Ignoring and Time Out
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Reactive
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Proactive – IN Control
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Ways we Get Sucked into the Tornado (tantrum)
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Talk /
Reason
Touch / Restrain
Eye Contact /
Facial Expressions
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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
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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
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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!
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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
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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)
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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
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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.
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Applied Behavior Analysis
To understand structure and function of behavior to teach effective alternative
A B C
Antecedent Behavior Consequence
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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
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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
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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?
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ABC of Behavior Management
A B C
Avoid the
Antecedent
When practical
Desired
Behavior
Eliminate
Reinforcing
Consequences
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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
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Any Questions?
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