Chapters Transcript Video Meltdowns to Cooldowns: Effective Strategies for Assessing and Treating Disruptive Behaviors Our presentation today is on meltdowns, uh, to cooldowns, effective strategies for assessing and treating disruptive behaviors with Doctor Josiah Cox. Um, he is a child and adolescent psychiatrist in the division of Mental Health and Child Development at UCSF Benioff Children's Hospital Oakland and the division of Child and Adolescent Psychiatry at the UCSF Department of Psychiatry and Behavioral Sciences. Um, he provides consultation for CAP and clinical care in outpatient psychiatry clinics at UCSF Beach Children's Hospital Oakland. Um, Doctor Cox recently completed training in pediatrics, psychiatry, and child and adolescent psychiatry at Tulane University in New Orleans, um, after completing medical school in the physician scientist training program at the University of Kansas School of Medicine. His primary interests are in integrating behavioral health and primary care pediatrics and early childhood trauma, and we are thrilled to have him with us today um for the morning. So please join me in welcoming Dr. Josiah Cox. Hey, thanks Sarah. Hi everyone. Thanks for the introduction, and it's really honored to be speaking to you all today. Grand rounds. I hate that I can't see you, um, but it's OK. I'm just going to imagine that you're all there, and I have to say, you all look fantastic today. So thanks for being here. And also as someone as Sarah mentioned, um coming to California by way of New Orleans, I also have to say happy Mardi Gras to everybody. Happy Fat Tuesday. And as they say, laisse les boon to roulet, that's the good times roll. Let's get started. So, um. Today I wanna talk to you all about. Um, first of all, I have to say no relevant financial relationships, commercial interests disclose, but today I wanna talk to you all about disruptive behaviors, and that's a really broad category, and if anything broad it can feel overwhelming. So I hope to break it down a little bit, um, make it feel more manageable, and we'll start with what we mean when we say disruptive behaviors, and then go into how to evaluate, assess. Um, in frequent conditions that present with disruptive behaviors and different types of approaches including behavioral and pharmacological approaches to help with them. So, Let's talk about the language, the words that we use, um, to, to, to describe kids' behavior. Um, parents, teachers, you all as medical providers, people in the medical professions, we have a lot going on, a lot of responsibilities, lots of stressors in our lives. So when kids are compliant, Um, when they sit quietly at their desk, they're doing work, and they don't scream and wriggle where we're trying to look in their ears for a well child visit, when they get ready to go to school in the morning quickly and to go to bed at night quickly, it makes our lives easier. And less stressful. So naturally, we want compliance for our kids, and disruptive behaviors on the other hand, interrupting class by being loud, not sitting still, screaming bloody murder at the side of the stethoscope as we walk into the exam room, uh, taking forever to get ready to go to bed at night or transition to bedtime, it adds stress to our lives. So, These words, though, we use when we're describing their behavior, like disruptive, defiant, and as kids get older, sometimes delinquent, they often represent the feelings we have about their behavior, and honestly, how we feel about them sometimes too. And kids, they pick up on this. They hear how we talk about their behavior. And they feel how we feel about them, and that's how they learn to feel about themselves. And the reason I'm bringing all this up and I talk about behavior is because how we feel about kids, how kids feel about themselves, has an enormous impact on how they behave. And so, you know, how we feel about kids. Influences their behavior, but it can also be influenced their behavior can also be influenced and how we feel about them can be influenced by how they look, by the language they speak, the color of their skin. So, we know that um black, Hispanic and Latino, and indigenous youth are more likely to be diagnosed with oppositional find disorder than ADHD versus their white peers who have the same symptoms. Black kids, in fact, are uh are 69% less likely to receive a diagnosis of ADHD than their white peers with the same symptoms, and black children with autism on average don't get diagnosed with autism until 3 years after parents voice concern, and that's about 1.5 years longer than their white peers. And The reason for all of this is because our unconscious and for some folks, unfortunately, conscious biases and these differences in diagnoses. Not only reflect how reflect how we see kids and in fact how kids see themselves and influence their behavior, but the treatments and the interventions and the support they receive are different, which of course then all leads to different outcomes, and I hate the word outcomes, it's, it's their lives, it's what happens in their individual lives and where they end up, who they become. So, it's, it's, it's important that we're aware that we all have at least unconscious biases that affect how we see kids, and the words we use to describe them and their behavior, and even the diagnoses we give. So, now let's talk about how we can evaluate behavior concerns in a thorough and structured way that helps us better understand the behaviors and how to affect those concerns effectively. And the, the way to start, the first thing to start with is Asking the question, what lies beneath the surface of the behavior. We think about it like an iceberg, you know, the behaviors on top, you see things like hitting, eloping, um, all kinds of different sorts of disruptive behaviors, but whatever you want up there, and underneath the surface can be all kinds of different reasons for your drivers of the factors involved in that behavior. Behaviors largely serve a function and often become a form of communication for kids. And what we're trying to do when we're trying to help with it is this first time is what lies underneath that, what's bringing that behavior to the surface? What is it trying to communicate? So, the first steps in asking that question is what lies beneath behavior is one gathering information about behavior. To, doing a thorough mental and physical health assessment, and after you have that data, putting that together, um, and coming up with hypotheses about the function, and from there, you know, letting that drive how you intervene and what kinds of things you can do to support. But one quick side note about how we ask the questions and how we listen, communication, even just the process of evaluating behaviors and asking these questions, how we communicate really matters, can have a huge therapeutic effect. So I really like the the AP's help mnemonic, um, this is like common factors from all a different evidence-based types of therapy, um, things that they have in common. And that we can use in any kind of setting, even in a 15 minute well child check or in your in your specialty care visit and have a really big therapeutic impact on the kids and their family. So age for hope, you know, your emotions in the visit, how you're how you're interacting with the kids and families is infectious. So expressing hope will help them feel hope. And that will help them continue on and and be resilient and and um in the face of adversity. And then E for empathy. Validating and holding space for caregivers' feelings is is super therapeutic in itself. Um, language, L for language, reflecting their words shows that you're listening, and when people feel heard, that's also therapeutic and, and it helps you connect with them and and make a plan together. Second L for loyalty, um, you know, knowing that they're not alone and that you're in it with them can be really, uh, a really big boost. And then the first P for partnership. Asking what they think is the cost, asking what they've tried, or they haven't tried, what they plan to try. These are all great places to start using that shared decision making kind of process, um, empowers people, empowers families to do things and, and again, again feel supported and, and, um, not alone. And then the second P for permission, um, just asking if they want any guidance or help, if You know, if they're not asking for it and we're trying to give it, I think that's showing that we're not listening, and that's that can harm the the the relationship with the with their families and um and and and um just rough kind of our ability to help them going forward. And then this the the third P for plan. We'll get into plan, but just having a plan is, is really therapeutic as well as whatever it is, having some kind of way forward, um, it, it feels it feels good and it helps people keep moving. And this is all a parallel process, so we're doing this with our kids and with the families that we're working with and We're hopefully helping them feel supported and listened to, and the parents then are caregivers can then share that process with their child. So we're kind of role modeling these types of behaviors we want want them to use as well. So then we get into gathering information and sometimes you may hear the term like functional behavior analysis. Um, this is like a a method for gathering information about behaviors and it has three main components, and they are the antecedents that comes with before behaviors themselves, and then the consequences what comes after. And I'll talk more about about that in the next slide. This is, this is really what it looks like. So the B for behavior, getting information about the character, what what what did they do? So, you know, sometimes you just hear. You know, they've they've been their behavior's been really, you know, difficult. So what actually is difficult and kind of narrowing down what actually happened and getting the main concerning ones, focusing on the main concerning ones first, um, and then getting information and more information about that specific behavior, what came, what came before it. So antecedents are actions. That activate behavior or conditions that make an environment that activate a behavior. Um, so things like for the kids it could be things like they're feeling hungry, or they're feeling tired, or they're feeling sick. Um, for parents, it could be the same thing, um, maybe the tone of voice they use or the body language they use. Just where that, where it happens, you know, is it happening in the store? is it happening at school, is it happening at home, um, and, and, and what time of day is it happening and what is the sensory stimuli in the environment. These are all can be all clues and help us figure out what is underneath the behavior. And then going on to what comes after as well. So these are the consequences, the responses of people involved or around the situation when the behavior occurs. So it could be from caregivers, from um people at school, from uh people in public, and it can be all kinds of stuff like. You know, praise for good behavior if we're talking about good behaviors we want to encourage, or could be selective attention, ignoring time outs. Some families use different kinds of different kinds of discipline, corporal punishment, um, or maybe, you know, um, sometimes, you know, you know, giving the child what they want in that situation. So trying trying to trying to reduce the behavior quickly in that way. So getting information about what came before, what was the environment like, what came after. And then also, um, to get a sense of the severity can help to know how often it's it's happening, how often these behaviors are happening, so a number of times per day, number of times per week, how long they last, 30 minutes versus 30 seconds, a really big difference there. And we're asking the caregivers, usually this is what, you know, most of us are starting with asking the caregivers this information, and, and they may have, you know, usually they have a lot, you know, can answer most of these questions, but sometimes maybe the the behavior is happening at school, um, or maybe, you know, the caregivers are well overwhelmed and having a hard time track what's happening, what the environment's like, so getting additional information from collateral sources if possible, can be really, really helpful, um, in particular in the school. Um, talking with teachers, um, um, uh, any school staff, other therapists, other caregivers sometimes, um, can, can provide an additional perspective on things and help us understand behaviors better. So this is kind of how we go about gathering information. Somebody comes in, probably you start asking these questions, and it's OK to say, right, we don't know all this information now, but this is information that will help us figure out what's going on. Here's the things I'd like you to track, you know, if we can. What came before, what came after, how many times it happened in a week, if anybody else, you know, if we don't know some of the information, can we ask anybody else and get that information so we can start to get a picture. And then for the step too as we as we said before, um, the next step is doing a thorough mental and physical health assessment. So it's in the middle here we have disruptive behavior and all around the outside with so many different things can contribute to disruptive behavior kind of like we showed in that iceberg slide. Um, you know, we start with environmental factors, you know, what's going on in the kids' lives, you know, is there any stressful new stressful events and we had to move. Um, is there any community violence they're experiencing? Is there, you know, disruptions in caregiving? Is there bullying at school? Asking about things going on in kids' lives can, can, is definitely important and can be, uh, those factors can be a big, um, can be a big contributor to disruptive behavior. Um, trauma, especially traumatic experiences definitely present with this proper favor, especially in younger kids. Um, so it's really important we're asking about traumatic experiences, and then from there traumatic, um, trauma related symptoms. And doing a medical and um dental evaluation as well, especially important for non-verbal patients, um, doing a full body physical exam, looking for sources of pain, potentially, anything going on in their bodies that maybe they're trying to communicate with us but don't have the words to say. So that's, this is really important as well, you know, we're considering things like medication side effects, you know, things like neur neurological conditions. Um, definitely want to be considering that as a possibility of, of a contributor to disruptive behavior. Um, for kids who are, um, who have neurodevelopmental disorders like autism and ADHD and intellectual delay, um, these, you know, often have, um, kids that have, you know, are more commonly have disruptive behavior problems related to how their brains work, um, whether it's executive function or if it's rigidity, difficulty with transition or trouble um with social communication. A lot of these things can contribute to disruptive behavior, and we have, um, you know, particular approaches to address those concerns. Um, so asking about symptoms of autism, symptoms of ADHD, asking about school function to try to get a sense of cognitive function, maybe, maybe, you know, maybe needing to do, um, if there's a concern, maybe needing to do um a a neuropsychological evaluation to get some information. Anxiety can definitely present with the disruptive behavior. The kids are special again I go back to especially young kids when they're when they're nervous or anxious or scared. Um, you know, contribute that fight or flight response, and some kids it's more of the fight than the flight, and even the flight can be really disruptive at times, like through elopement. So definitely something you want to look into and you have behavioral symptoms, depression as well, and we don't often think about it in terms of disruptive behavior as we usually think about withdrawal and and and and just sadness, but it can also present with irritability. And um anger and and and and and avoidance and things like that. So it's, it's also important one to consider. Substance use can be part of the disruptive behavior itself, but it can also contribute to disruptive behavior if it's actively going on. Sleep issues, man, sleep definitely something we have to think about, um, you know, could be part of all these other things, trauma, anxiety, depression, but it can be a problem in itself, you know, uh, you know, asking about snoring, asking about nightmares, are we getting a good quality sleep as well as quantity? Um, temperament attachment, that's where we're thinking about how kids, how, what's their personality like, but also what their parent, this is the category where parent-child relationship falls under, and that could go back to that 1st, 1st part I was talking about how how parents or caregivers and other people in their lives are seeing the kids, what their relationship is like, it's a huge effect on how kids see themselves and on their behavior. So this is almost always part of disruptive behavior, something we have to consider. And then this last category is something I'll talk about for a second. It's, um, you know, a few different acronyms, oppositional defiant disorder, conduct disorder, intermittent expulsive disorder, so. These are, you know, technically diagnoses that are in the DSM 5, and, and the argument, you know, for including them as diagnoses, I think that most people use is, is that we can help us maybe communicate, you know, as medical providers, maybe help us communicate with other people in the medical field. Those are people who look at their chart, look at their problem list, what kinds of behaviors we're seeing in their life, what kinds of problems they're dealing with, and um that's Good, you know, it's helpful that we communicate with each other. We know what's going on, but the, the problem is that I think people misunderstand that, think that these diagnoses are the cause of the behavior, um, but really what they represent is just a description of the behaviors. They don't explain what the behavior, what the reasons why the kids are having them. Um, there's always something else going on underneath. So, um, So I, I tend to, I very, very rarely use these diagnoses on people's, um, problem lists in their charts and things like that, because there's a lot of um negative connotation related to them, stigma, and again it can reflect how we're seeing kids and how influence how other people are seeing kids, and then that, again, going back to how kids see themselves and and not affecting their behavior, so. Um, so that's just stepped down from my soapbox about that, but that's just a, a little bit how I feel about um those diagnoses. Um, but yeah, these, these are all, all things that can contribute. So if you get information from the carvers, you're kind of getting information about these things as well, but you, but first you're starting with the specific behaviors, information about behaviors, but now you're thinking, OK, more, more thoroughly, more kind of what's going on in their lives and all different kinds of things that that could be contributing. OK, and just, yeah, last, I wanted to make sure um Highlight again, kids and families will sometimes show up and say, I've had this traumatic experience, you know, I need help with it, but sometimes they don't tell us. So it's really important that we're asking and asking about traumatic experiences and if if they've had them in the in the, you know, recent or or distant past, asking about trauma related symptoms and then asking about safety. Safety can sometimes, you know, suicidal behaviors or self harm can be part of the disruptive behaviors, but it can also just not be related, but something related to other the underlying causes like depression and anxiety. So always want to make sure we're asking about trauma and asking about safety. Um, again that and also the from the safety side of things, kids are experiencing abuse or neglect, of course, that's an environmental factor that can contribute to behavior and we have to be addressing that safety part first. OK, so the next part is we have information, we've gather information about what the behaviors are themselves, you know, starting with the main concerns, and then doing a thorough mental and physical health assessment to gather more information about the setting that everything the factors that could be underlying it. And now we have this data where we want to hypothesize about the function. We'll come up with some ideas what, you know, we, we don't have like a blood test to say this is what this is what's causing this, but we're using the data we have to come up with some ideas and then from there. Um, um. figuring out how we can help families. So, you know, so possible categories about function, what could be, as I mentioned before, a lot of times it's communicating something, especially for young children or kids with neurodevelopmental disorders, um, or non-verbal patients. It could be communicating pain or communicating feelings that they have. Um, another possible thing is, is the, uh, a function of the behavior is achieving a goal, so escaping or avoiding non-preferred activities or objects, um, you know, achieving more attention from caregivers or from other other other people in their lives, getting access to preferred objects or preferred activities. These can be, um, are really common um kind of functions of of disruptive behaviors. And then there's a whole host of other things including, as I mentioned before, like medication, side effects, medical conditions, psychiatric conditions, all kinds of different um possible causes, but just to give you some examples of how we come up, OK, I think this is part of the function and, and that's and then not leading into the next step of how we help. So, that gets to the changing behavior part, um. And there are a couple ways, you know, for a lot of disruptive behaviors, behavioral approaches are the most effective way. We have pharmacological approaches, sometimes, tools that can be helpful for some kids, and I'll talk about those at the end, but for most kids, it's gonna be starting with trying to modify the behavior by modifying the antecedents and the consequences, the provoking and the reinforcing factors, becoming good behaviorists. So, talking a little bit about this. Um, You know, so, for instance, if it's, if the uh if the function of behavior is for communication, Maybe we're helping kids name what they can see or help them learn to use their words. If kids are nonverbal, we can use communication assisted devices sometimes. Um, you know, if it's a struggle around transition, if that's the, the part of the function of the behavior is, is, is to get out of a certain kind of transition, providing structure, helping caregivers and and school provides structure, prepare kids for routines for for transitions and and using a really rigid schedule can be really helpful, um, helpful to uh uh something you can modify to help reduce um disruptive behaviors. If the function of behavior is achieving a specific goal, Maybe, maybe it's it's avoidance um of, of non preferred activities, maybe taking breaks sometimes to to avoid becoming overwhelmed and avoid, you know, elopement or other escape behaviors later on, um, you know, working on the consequences of, of, of the behaviors, so avoid reinforcing um behaviors that we don't want to see with attention, and then reinforcing behaviors we do want to see with praises. These are things that we can do. Um, and then, you know, for other things too, sometimes simplifying commands. Sometimes, you know, uh, adjusting commands so that there are demands that they're appropriate for developmental level and um addressing any underlying underlying other underlying issues. So this is like, this is an overview of how we generally try to address disruptive behavior concerns, but it can be hard to address behavior concerns as medical providers, some of you, some of you all out there, um, are maybe behavioral providers and, and are doing this sort of thing, but a lot of us are more in, and as medical providers and they'll see kids maybe every week or um even maybe maybe even every month. So even me, I, I see kids, you know, probably more frequently and for longer visits than most of you. And I often need help um with this step with addressing and changing the behaviors. I can counsel and counsel and counsel once a month, but it's hard to make changes at home, um without without more direct help sometimes. So it's OK to, um, and, and often we need to get help for ourselves and for families through lots of different sources through school, through different types of therapy, etc. we'll go over some of these, these sources of help we can ask for. But these are just, just a few highlights of things we can do, um, and I'll talk about a few slides coming up to some pearls. I I wish I could share, you know, a lot of all the things I, I, uh, all the education I, I do with families, but just share a few highlights of things that we can do as medical providers to address different kinds of behavior problems, um, and then, and then talk more about the, the types of help we can see for families. So one of the things I share with families is, is about what to expect. So some good old anticipatory guidance, you know, um, help them prepare for them that help them prepare that. Sometimes as we're trying to make these changes, the behaviors may get worse before they get better. Um, there's, there's, there's sometimes there's a honeymoon period after we start to make changes, but then there's often something called an extinction burst where it actually The behavior gets escalated, you know, um, and it makes sense. The kids are trying to see if, well, maybe more of this behavior, it was giving me what I wanted before, maybe more of this behavior will then reach that goal. Um, so it sometimes that's where this kind of plan can fall apart which is help parents and other the caregivers prepare that that may happen and to stick with the plan and over time behaviors do get better. There's sometimes there's spikes depending on other factors like stressors in their lives. But um over time they're really, really effective. So helping parents understand the process, what to expect. We're really after. It's, it's impossible to have the help the kids change their behaviors without the parents, often without having the parents change their behaviors as well. So if they're, they've always responded to a certain type of behavior before and in one way. Um, and, and we figure out that that's contributing to or reinforcing the behavior itself, they have to change their behavior, um, before the kids can change theirs. So we're retraining really caregivers, not to reinforce negative behaviors, behaviors we don't want, and, and then also to, um, you know, to and also to praise behaviors that we do want, and, and that's in turn then retraining the the kids to have those behaviors that they desire that we desire. Another thing I talked to families about is, is, um, just general positive parenting strategies. So, you know, three main parts to this. One that I can't emphasize enough is the positive foundation, you know, If we're just focusing on correction and and and consequences and um changing behaviors that negative things that that kids are doing, then again it goes back to that very first thing I was talking about. It's gonna affect how kids see themselves and it's gonna negatively affect their behaviors. So it really helps to have a positive connection, relationship, bearing child relationship as a foundation. And to do that, I could talk a little bit more in the next slides about how we can do that, but it's really it's about getting close to spending time with, you know, sharing, uh, you know, having mutual enjoyment and different activities they do together. Um, it's just, it's so crucial. I mean, we've all had times where we've had jobs and, and you had a boss that You know, that you had a really good connection with and you felt like treated you with respect and and was, you know, not micromanaging you and you wanted to do everything you could for that in that job, in that position. You've got other uh we've had other other bosses where, you know, really harsh or critical and and not uplifting and it's, it definitely affects, affects how you do in those position is the same thing between a parent and child. Um, another part of, like, of positive parenting, it's important to remember is that, that, you know, we want to educate caregivers on what is normal development. You know, parents feel like, OK, this is, I can expect this, this is part of growing up for, for a lot of kids. It can help them cope with it and help them remain calm when it's happening and help them kind of continue to chip away at that as, as kids develop. Um, so helping parents set realistic expectations. Um, for, for behavior and demands that they're putting on kids. And also, you know, how to ignore unwanted or but safe behaviors, and then, you know, types of types of consequences, types of um of of reactions that are um not harmful, you know, things that don't work, um, you wanna make sure that that we talked to parents about those things like corporal punishment, uh, and then the structure too is another super important crucial part of this, um. Kids feel when kids feel safe and secure, They're much more likely to be able to have emotion regulation, to be able to behave in ways that that are that are helpful and and compliant. When kids feel unsafe, when kids don't know what to expect, when things are, you know, they're getting different responses from different caregivers, it's, it can be like make things much more difficult. So setting clear limits is really important. Planning ahead, um, and being predictable, and, and, and being structured can be really helpful, um, a part of changing behaviors. You know, and sometimes we hear positive parenting we just tell parents that this isn't letting kids do whatever they want to do or having no rules. Um, it's what it is, is helping kids develop self control over time. So yes, it's OK to use rewards and and positive reinforcement at the start, but with structure and developing appropriate demands. Um, kids are going to internalize their motivation to to do the things that we're asking them to do. They're gonna start doing things based on their values rather than just getting rewards. Um, you know, it's communicating clearly with kids so that, you know, in a, in a developing appropriate way, it's having that positive foundation, respecting kids and earning their respect. And, and teaching them to do make good decisions or teaching them to respect other people's feelings. So these are some some general kind of overview of parenting approach, positive parenting approaches I could talk with families about that can be helpful, especially addressing that parent-child relationship component that's a big part of the, the function of the underlying behavior. And a little bit more about creating structure, you know, for for families when that's a particularly big problem, you know, being consistent and understanding and confident and respectful, um, but just these kinds of things again, I can't emphasize enough how, how much that sense of safety and security can really have a positive effect on kids' behavior. So setting reasonable, achievable expectations, sometimes creating a visual reminder, especially for challenging multi-step routines, such as getting ready for bed, getting ready to go in the morning, doing things at the same time, in the same order every day as much as possible, see acknowledging that that's not always possible, but doing as much as you can. Really can help um reduce the uncertainty for kids and and make it make it much more smooth and much easier for them to follow each step and get through to the end. And then, yeah, especially at the beginning, pairing kinds of behavior we want, we want them to do the structure when they when they are in the routine, pairing it with praise and sometimes with rewards as well, but over time, doing less of that as it becomes kind of ingrained and easier for them to to to get through on their own. And as I said before, that positive foundation, just a little bit more about that. Sometimes, you know, there's some different types of therapy I'll I'll show in a in a few minutes, use this term called special time, and it really is just a method of, of trying to build up that positive foundation. So it's something for, for kids, you know, we have caregivers, some we all see caregivers, ones who have are really great with that positive foundation, you know, really close and warm and connected with their kids, but they struggle more with the. and, and routine and setting clear and, and, and, and firm limits. And so we may, we help them more with that part. The other, other caregivers and other other situations, they're having a harder time with that positive foundation part. They're really structured, really routine, setting clear expectations. But they don't have that, you know, warm close connection with their kids. So for those families, you're, you're, you may think about talking to them about having special time together and what, what that is in in the different types of therapies and, and it can, you know, it doesn't have to look exactly like this, but the what what it looks like is is having a one on one time between a caregiver and a child, and That time being child led, so just having the caregiver follow what the kid is doing, engage in imaginatory play. And engaging in the kids' rules, what they set up, you know, um, reflecting what they're saying, you know, being enthusiastic, describing what they're doing, and this kind of play is, is just such a boost to kids and their attention, what they're getting with their caregiver in that time. It really helps that connection with them, and, and even it could just be like 5 minutes out of the day, um, really. Quality over quantity here I 5 minutes each day can have a huge effect on the parent-child relationship and then that downstream effect on kids' behaviors. So that's something we can talk with with caregivers about. Um, and then just a note about, you know, or saying what we can't do, you know, we have to set clear members, but what am I supposed to do when what's it, what's something I can do when, um, you know, when, when kids aren't following directions and I need to keep them safe and I want to try to, um, you know, provide some negative reinforcement. Timeouts is something I sometimes talk with families about. Um, what timeout is is when a behavior happens, you spend a specific amount of time away after that. And, you know, sometimes that time away doesn't have to actually be physical time away, say you're in the car, it could be 5 minutes and no talking in the car after uh, uh, you know, a particular behavior. And a lot of times the general rule of thumb is people like to use is one minute for every year of one minute of time out for every year of age, but adjusting that for based on developmental level, of course. And then, you know, a lot of times I talk with parents about timeouts and say, well, I tried that, it doesn't work. First question I ask is, well, what happened? What was the goal? Was it that, you know, well they, they kicked and they screamed during the timeout and and and it didn't change their behavior. And then I go back to what is the what is the responsibility that we have as parents? It goes back to those positive parenting things. So setting the clear structure and having a positive foundation being developmentally appropriate. So, Your job is to set, set the expectations, so to have, say, if this happens, this is the this is what's gonna happen or can have a time out. And the kid is allowed to have whatever feelings they have about that kind of expectation. You can't control that as the caregiver. If they didn't have a, you know, they, if they didn't respond in a in a, you know, sort of, um. In a way that that was the that was like fighting against it, then they probably wouldn't need the time out in the first place. So I guess, you know, just reset the expectation that this doesn't mean that they're gonna, you know, go to time out or that it's gonna change right away, but you're this is part of how we work on behaviors is setting clear expectations and and and consequences sometimes after certain behaviors. Some tips for success with timeouts using consistent limits, no inconsistency. You know, doing it one time and not doing it again, um, another time leads to more limit testing from kids. Focus on one or two behaviors at a time. If you're doing multiple timeouts and, you know, several timeouts each day, it's we're probably doing something wrong. We need to change either our expectations or or focus in on one or one or two behaviors, um, because if you're having again too much of that negative reinforcement, it, it's, it has that um negative impact on how kids are seeing themselves. And then, don't continue with verbal engagement, so many times. Parents trying to talk to kids, help them understand why they're why they're in trouble. Um, and, and in these states, a lot of times the kids are are upset and so it's not really helpful to then get into a verbal engagement. So I just tell parents, say once, this is what happened, so this is the consequence. I'm not gonna respond to any questions after that, we're just gonna follow through with this. And they can say it and talk to you and try to engage as much as you want, but you can't, can't respond. You know, it's like. It's like playing ping pong with someone, and the person keeps hitting the ball at you, and you keep hitting it back. You keep, OK, well I'm just gonna hit it back to them and they just keep smacking it right at you. So just you have to just let the ball lie and stop hitting it back to them, and um that can help, help calm things down. You want to follow through when you say something's gonna happen, if you give a warning, you wanna follow through so that kids learn to respect what you're saying and expect, you know, when mom and dad say something. I know that they're gonna do it. As much as possible, try to keep your cool, we're modeling that behavior with them. Um, if you need to take a break or rely on other other caregivers can be really helpful. And then as soon as the timeout is over, return to business as usual. So, you know, look for the next thing that you can praise, you know, don't go into a lecture or continue on, I'm I'm mad at you, just go right back to what we're into our regular routine and um and and look for the next thing you can praise in their behavior. All right, so then, um, when we're asking for help, these are some different types of therapy, evidence-based therapies for youth with disrupt behavior disorders, and they're, they have slightly, you know, some differences and depending on Um, what you're exactly trying to target. So parent management training and parent-child interaction therapy, this is a type of parent coaching for, um, parents of young kids with disruptive behavior, often, you know, for ADHD and things like that, it can be really helpful. And really it's again it's kind of what we've been talking about focusing on that positive foundation for the first half of things. And their relationship and then going into how do we set realistic expectations, give appropriate commands, how do we communicate effectively and and use use effective discipline strategies. Cognitive behavioral therapy you probably heard of, you know, if there's something going on with depression or anxiety, this can be really helpful for the for the kids themselves in particular, um. Behavioral therapy, so, you know, ADA, there's lots of variations that um they focus on reinforcing positive behaviors and decreasing problematic behaviors through structure reward systems and can be really, really effective. Particularly helpful for kids with neurodevelopmental disorders, um, so that's, that's oftentimes, um, really the most kind of potent um behavioral strategy that we have. Dialectical behavioral therapy for adolescents, if, um, if there's a lot of mood instability, if there's, um, you know, chronic suicidal ideation or self-harming, um, it can work on emotional regulation, distress tolerance, interpersonal effectiveness and communication. Um, can be really helpful for kids with those kinds of things going on, underlying their behavior. Multisystemic therapy and functional family therapy, these are for kids usually with um really severe disruptive behaviors and usually teenagers, and there's either involved in juvenile justice system or involved in the in um a child protective system and helping with their full environment, so their families is going into the home. Um, and so it's, it's pretty intensive, it can be really effective in reducing, losing really problematic, um, destructive behaviors. And then there's uh there's some other problem solving skills training incredible Years program helping for address specific problems that we're seeing, whether it's social communication and incredible Years is is like a a group-based parent-child program again working mostly on that positive foundation to help kids um with social emotional uh regulation. And some other quick note about um resources in our community, the the Calho programs, so these, these are funded by Department of Child Health Services of California, Bright Life Kids is a mental health coaching resource for parents of kids ages 0 to 12. It's free. Um, there's an app you can get like video coaching or you can weekly sessions or I think even more frequently than that with a coach to work on behavioral strategies. Um, so for kids who have more like Mild to moderate types of behavior problems and there's a big parent-child interaction problem, and it's hard, maybe it's hard time maybe you don't, don't need to do for the full kind of parent management training or or PCIT but want to give some support. This is a really good option to tell families about. So Luna is is a um is a mental health coaching resource. A platform for teens and young adults. So this is for our teenagers who are having anxiety and depression and other kinds of things going on that's underlying their behaviors. This is gonna be a really helpful resource for them. Um, to work on those in addition to sometimes, um, sometimes I needing more than that, needing therapy. And then also in the Callow programs, I have to make a plug for you. My background here is for CalMap. Um, this is a free consultation program for primary care providers in California, throughout the state of California. We, you know, you can. You know, if you can call me on, on, I'm on Wednesdays, you can call and talk to me for free and and we talk about faithful strategies, medications, um, it's basically like a curbside consultation with a with a child psychiatrist Monday through Friday. We also have some great child psychologists that specialize in areas like eating disorders, early childhood, autism, um, substance abuse, and, and you can also consult with them about different strategies for For for these kids and then resource navigation. So I know I put up that slide about the different types of therapy and you're, I'm sure you're thinking like, yeah, well, how are we gonna access that? Like the the people we work with, you know, the families we work with may not have the resources to find that, maybe it's not available in our community. Um, so if you're having trouble connecting your kids, you know what they want, you know what you want for them, or you're, you're figuring that out, but you're having trouble connecting, getting support in school, getting support from therapy. Please don't hesitate to use our resource navigation or care coordination team. So you can ask for that directly. You don't have to go through a psychiatrist or psychologist. You can ask for care coordination directly at CalMap. And the care coordinator will reach out to you, figure out what's going on, and then they can reach out directly to the families and help them navigate system to, to get connected to care. And then of course we have lots of training and education stuff, our website CalMap.org. I think actually one of our psychiatrists giving a talk on disruptive behaviors later this week, so you can, you can take a look at that and compare and, and, and see, see which one you preferred. I'll be joining in that too to learn to myself. Um, so I have to make a plug about that. And then finally, wrapping it up with medications, you know, a child psychiatrist, I haven't talked about medication yet, what's going on. Um, there are medication treatments that we use to address disruptive behaviors, not directly though. We used to address them more, more depending on what's going on underneath. So this goes back to the importance of What is the function, what's underlying these behaviors that we're seeing and figuring that out with gathering information, doing mental and physical health assessment. And so if we're seeing, and we think that, you know, we hypothesize about the function, what's going on, we think that part of it is related to ADHD. This is a diagnosis that in particular is really um responsive to medication. The symptoms can be really responsive to medication, so stimulants are first line therapy even before behavioral interventions for ADHD for kids over 6. And um and, and if you're comfortable describing symptoms, that's great. If you, if you need help again, feel free to reach out or or ask for help um for those of your medical providers. Alpha agonists is another group of class of medications we sometimes use for kids with ADHD um as an adjunct to address insomnia or to address some um irritability sometimes if that's part of the ADHD symptoms for depression and anxiety, oftentimes we're thinking about SSRIs, SNRIs as well, in addition to things like cognitive behavioral therapy, um, or dialect and behavioral therapy sometimes. And we use some other medications off label, mostly, again, these are things that you may not be comfortable using yourself or want to be asking questions about, but just so you're aware that there are things that we, tools that we sometimes use in these situations. For autism. You know, if they have other comorbid problems like anxiety, depression, ADHD, we're using these medications, but it, we don't have medications that address core symptoms of autism. However, for severe irritability related in in situations where with a with a kid with autism or other neuro development disability, we do have two medications that are FDA approved, risperidone and aripiprazole. And, and sometimes those can be really helpful, but they have a lot of side effects, they have a lot of things you have to monitor, so it's something I know a lot of folks are not comfortable with and that's OK to ask for help, but just knowing that there are options out there to help address those in these types of situations and for for for kids with bipolar disorder also use mood stabilizers and really important um that medications are are part of, are part of the treatment. So, yeah, so it's 8:49. I don't know that we have time for full case discussions. I wanna make sure we leave time for um for uh for questions at the end, but just to kind of summarize it. Um, you know, start with a place of curiosity, you know, before we label, before we jump to conclusions, before we kind of let those, um, unconscious biases, you know, affect how we see kids, be curious, ask questions, what's underlying this behavior, be kind of a detective, you know, get information. Um, and while you're doing that, be validating, use those good communication skills like that help mnemonic, you know, because that in itself can be really, really therapeutic for families. just a process of evaluating and assessing can be therapeutic, um, and, and start simple, uh, you know. Trying to address the kids who have a lot of different disruptive behaviors. It's overwhelming for you, for for families. So start with one and come up with a plan for that and follow up frequently and chip away at it. And as you address one behavior, it often has downstream effects on the other behaviors as well. So it's OK to just to really narrow it down and start simple, gathering information, coming up with a function, um, hypothesis around the function, and then. What kinds of interventions could be helpful, and it's OK to consult, it's OK to refer when needed. A lot of, a lot of times we need extra help when when addressing behaviors. OK. Thank you all so much. I really appreciate your attention and um yeah, happy to answer any questions they have. Also, I'll just say that like I'm in my office here at 5275, you can always come by here and see me. You can send me an email, um, love to chat about these topics or anything, um, be here to help. Thanks. Thank you so much for that wonderful presentation. Um, we do have some questions in the chat, and while I go through them, would you mind going back to the intro slides so people can scan the QR code and complete the evaluation? Yeah, I think sir. Perfect. Thank you. Um, OK, so one of the first questions that we have is, um, with regards to, um, inappropriate behaviors or disruptive behaviors, when is it appropriate to ignore those behaviors like based on their age, what type of behavior, if you can speak more to that? Yeah, yeah. Yeah, I kind of, I don't know that I put it on the slide, but if, if the behavior is safe, generally it's OK to ignore it, and it can be helpful at any age, um, and, and, and not, you know, I think sometimes, yeah, you have to like read the situation, kind of use your, your parent intuition or caregiver or provider intuition, like, um. Is this what's the function, I can give it back to what is the function of behavior. This is a kid that kind of, you know, desperately needs some kind of co-regulation or help regulating their emotions in this moment, and they're just not, you know, old enough to do it and, and, and I need to give them some scaffolding. I need to kind of assist them in this. It's OK to then do that, maybe you're ignoring the behavior, but maybe you're just providing some comfort, some physical touch, um. Something like that. It's, it's OK to do that. So you kind of have to read the situation if it's if the function of the behavior is more kind of for for attention in particular or to as a way of communicating, uh, achieving the goal, it's OK to then oftentimes try to ignoring that that behavior. Again, these are hypotheses about the function and so, you know, as you try different things, so you try ignoring the behavior and and and, you know, maybe it escalates and that that could be part of an extinction burst. But it's OK to look back and go, is this working? Is this something that, am I, do I have the function right or am I missing something? And that's where it's really helpful to have, you know, someone to talk to about these things, to bounce ideas off of, and not just be alone as caregivers in this, and that's, you know, why we're helping, um, and think about these things. So it, it's a little bit nuanced, it's not a simple answer, but, um, you know, it's it's OK to ignore really at any age, but it depends on what, what's the function underlying the the behavior. No, definitely. Thank you. And um we have another question too um about where physically is the best place to execute a successful timeout. Yeah, yeah, I mean, places where you're most familiar with the environment and you have kind of the most control over it, it's obviously a little tougher in public spaces, you know, as I mentioned, um that, you know, you can do it anywhere because it can be, you know, it can be really more of a removal of attention like a timeout from attention. Um, so it can be like, you know, if this happens in the store in the car, we're gonna have 5 minutes of quiet time where, you know, I'm not gonna be talking, we're not gonna be interact, you know, talk, I'm not gonna be talking anymore, um, and that's and and that's OK to do it in that way, but it's, you know. In terms of having a physical space where we kind of go to be by ourselves, it can be helpful to, you know, you have control of that space and at home, and it's it's something that's that's kind of um difficult to do at school and then again in public spaces because of sometimes the like. You know, we, we gotta think about, you know, we don't want to be publicly shaming kids and have other people looking at kids and, and that affecting how they see themselves. I think it's, it's most helpful if it's something that's kind of done one on one private and and not having a lot of attention from from bystanders if possible. So, um, so yeah, there are times where like, but, but it is also you want to be doing it right away. So if you're not able to do it in that moment. Don't really know then like, you know, 2 hours later when we get home, you're gonna have this time out. It it's not really effective at that time, so you're just gonna have to kind of come back to it later I come up with some different kinds of strategies um for reducing it, um, if you're not able to do it in the environment that you're in. Excellent, thank you. And then we have another question which I suspect the answer might be the CalMap website, so feel free to plug it again if that's the case, but there's a question of are there any listings of local by county and by city resources for referrals for families, including for therapists, neuropsych evaluation, psychiatrists, parenting coaches, other than the news app or psychologyToday.com. Yeah. Yeah, I, I, you know, there isn't a good comprehensive source like our care care coordination team through CalMap, has their own kind of um Uh, really big Excel sheet with resources by county, and so, but they haven't published that. I think it would be great. I think at some point it takes a lot of updating it's constantly changing, so that's why it's not sort of on the website, but that is also a really good source. Again, I will make a plug for asking for care coordination support, even if it's just. Phone call with Careoin and they're like, OK, my family lives in this county, we're looking for this kind of resource. What can you tell me about that? In an, in an email, in a phone call. I do that myself oftentimes. So I, cause I'm still getting familiar with, and I'll reach out to our care coordination team and, and, um, and, and get some advice about that. But yeah, it's, uh, there aren't, isn't like something great up to date and, and, um, and. Publicly accessible, you know, you listed some of the things that we do look at like psychology today, um, using word of mouth, asking, asking people, you know, who are in the mental health field, but um, yeah, so that that's my plug, yeah, we'll plug C map again with that. Perfect, thank you. And I, I don't know how long your cases are. We're having many, um, uh, requests to go through one of the cases if there's time and really quick I'll, I'll do that kind of skip to the end. So one I, I kind of like just to demonstrate what it can look like, um. We'll kind of take one that has a little more information. So we could do this seven year old, so a seven year old comes and and the parents, the chief complaint is they're just their behavior, they they they don't behave well. And so you're getting a little bit more information, I mean you can get a lot more than this, but this is a little bit of information that caregivers give you. It's it's really intensely hyperactive in the morning and in the evening. Also in the morning, OK, so what's happening? Let's just narrow down what's happening in the morning. Well, he's he can yell and scream and kick, but it's really in particular after his sister comes too close to him, like if he's around his sister, that's when it's happening. OK, OK. Now, um, you know, get some more information about the afternoon, yelling and screaming at peers or adults if the limit is set. Sometimes angry, really angry and throw and kick the cats, you know, so we really can be aggressive with animals, and you, you know, you're getting some information, you're doing mental and physical health assessment, part of that, you're getting some information about medications. You know that you found out that his current treatment is, he's on Adderall XR 10 mg in the morning, and he's uh on clonidine 0.1 mg in the afternoon. So the parents tell you he has a history of ADHD and then again you're getting more information about the background and you find out he's adopted at 3 years old with his bio younger sister. There's no major medical problems. He did have some in ute exposure to substances and it's very stressful pregnancy. He's doing well in school, like behavior wise and academically, but and then at night he is having some trouble falling asleep, so. So we're using that step by process they talked about. First is gathering more information. I think we need a lot more information here, but let's focus in on, you know, focusing on one time. So if you're thinking, look what's happening in the morning, let's focusing on that. So, you know, part of it, he's jumping around, he's really hyperactive, he's impulsive, but what's going on with this sister and asking more um questions about, you know, that is it only happens is there's other people. Um, and then, you know, any other information around anxiety, depression, other symptoms that you could, you'd ask about. So you have that information and then you're, you're, you're kind of developing a hypothesis. So one could be like, you know, is there trauma related symptoms, you know, when he was adopted with his sister, his sister comes close to him, is she triggering? You know, trauma related symptoms, the hyperarousal, avoidance, things like that, um, and when, when, because he's around this is that's something we need to consider? Are there other trauma related symptoms that he's having? Do we need to address that specifically, um, with a certain type of therapy, other intervention? And then the hyperactivity, you know, is that the bigger part of it, is that bigger part of the morning problems. There are medication strategies sometimes we use, there's a certain Journay is is a stimulant medication you can take at night, but then it's effective in the morning. So sometimes we're using medications, but other times it's a behavioral approaches that we're using in the morning, like having a really good routine, really good structure, visual schedule, what kids know what to expect can really help with those transitions that happen oftentimes multi-step kind of transitions in the morning. So that's kind of OK, you come with the hypothesis about the function, you develop a sort of plan based on that, and that can be kind of what it looks like. And then again you can ask for more help there like, oh OK, it's really, really it's a lot of trauma related symptoms. We need to address this, helping processes, there's there's trauma specific types of therapy evidence-based treatments for therapy for for trauma in kids, um, or if it's more around ADHD, you know, helping it with those symptoms or both. That's an example, a quick, really quick 3 minute kind of overview of what it can look like to to address behaviors with the strategies and we're talking about. No, that was wonderful. Thank you so much for going through that and thank you for this presentation. I think it's about time to wrap up, but we're very grateful to have you, um, chat with us this morning and again another plug for using the CalMA website, which is excellent and giving um Doctor Josiah Cox and his colleagues a call. Thanks, Sarah. Thanks everyone. Created by
