How Can I Discipline How Can I Discipline My Child Who is My Child Who is

Already Suffering?Already Suffering?Positive Behavioral Strategies Positive Behavioral Strategies

for Children with Medical for Children with Medical Conditions and their SiblingsConditions and their Siblings

Stephanie P. Farrell, Stephanie P. Farrell, Ph.D.Ph.D.

American Family Children’s HospitalAmerican Family Children’s HospitalApril 15, 2008April 15, 2008

Discipline• Not punishment• Instead think of as an opportunity to teach

– Right from wrong– How to respect & care for others– Which behaviors are acceptable – Responsibility

• With the goal of helping your child – Feel secure, loved, & confidant – Learn self control & frustration tolerance with the

normal stresses of everyday life

Effective Discipline • Proactive• Rules help keep a child safe• Strengthens parent-child

relationship, as well as promotes positive social relationships in future

• Advances development

Guiding Principles• Predictability, Consistency, &

Stability– Provide structured, predictable

routines (eating, sleeping, meds, etc.)– Consistency across caregivers– Rules

• Choose your battles

Guiding Principles cont.• Ignore low level annoying behaviors

– Children give up behaviors that get no attention• Catch a child “doing good”

– Give attention to that behavior which you want repeated

• Provide frequent praise– Most powerful reinforcer of learning

• Eye contact• Smile• “I” messages – “I like it when you……”• Deliver positive messages immediately

Guiding Principles cont.• Provide choices when feasible

– To increase child’s sense of control • Provide safe, loving environment

– Be creative in how you organize, enhance, sooth, redirect and safe proof to promote a child’s sense of security & self-control

• Be a good role model– Children learn more by watching adults

Guiding Principles cont.• State limits clearly and simply

– Children test limits frequently to find out where their boundaries are

– Children need to know what the limits are & that they stay the same each time

• Be specific about the behavior you do not like – Intervene early so that negative behavior does not

escalate– Give fair warning (e.g., “If you don’t stop that by the time I

count to 3…”), then Follow- through

Guiding Principles cont.• Use humor • Allow for negotiation & flexibility

– Particularly, with older children & teens– Helps build your child’s social & problem

solving skills– Reduces noncompliance with parental

expectations– Involving child in decision making has been

associated with long term enhancement of moral judgment

But my Child is Sick………

• Or hospitalized or undergoing horrible treatments/procedures……..

• Importance of continued limit setting• Routine + Structure + Consistency + Limits +

Boundaries = Sense of Security & Safety for Children

• Consider alternate messages we may give child if suddenly anything goes – “Hmm, I must really be sick if they’re letting me get away with this.”

But my Child is Sick cont.

• Need rules & expectations to help them learn appropriate behavior

• Develop sense of self-discipline which leads to positive self-esteem

• Ensures our little ones grow up to be respectful, caring & well-behaved adults

But my child is sick, cont.

• Resort back to guiding principle #2 – Choose your battles– Is it really critical that my child uses

please & thank you when he/she is nauseated & has a fever? Certainly not.

– What is important in your family?• For many, it is gentleness towards one

another (No hitting, kicking, swearing, etc.)

Sick children may……….

• Lash out, especially if they feel out of control, helpless & scared – & be prepared, because often it is the one

closest to them that is on the receiving end– Toddlers in particular or early pre-verbal

children as they have limited coping skills & moreover lack effective ways to verbally communicate their distress

– It is still appropriate to give the clear message that “We don’t hit. Hitting hurts.”

Then……….• Help the child label their feelings

– “I wonder if you are mad about not getting what you wanted.

– “I bet it is scary having to get pokes”• Provide support & reassurance• Re-direct/distract• Remove child from situation & substitute with

safe, less messy or less destructive alternative• Teach coping skills

Understand/Appreciate Triggers

What sets most children off– Tired– Sick– Hungry– Overstimulated– Bored

• Now, think of how often your hospitalized child or child in treatment feels these– Tired - not resting as well, secondary to illness or treatments,

beeping IVs or vitals during night, etc.– Sick – chemo, infections, etc.– Hungry – NPO for procedures, loss of appetite from

illness/treatments– Overstimulated – new environment, new people, medical

equipment, unfamiliar sounds

Know your own Limits too!

• It is challenging to remain calm, be creative and maintain energy when …..– You too are sleep deprived– Not eating well– Not maintaining your exercise routine– Juggling family roles

• Be gentle with yourself– We all make mistakes – use them as

opportunities to model problem solving

Examine your Expectations

• Be realistic• Have appropriate expectations given

child’s developmental age– Parents should not expect reasoning or verbal

commands to manage behavior of infants & toddlers

– Preschoolers begin to develop an understanding of rules & their behavior is guided by these rules and the consequences associated with them

Expectations cont.• Similarly, examine your

expectations of siblings• Remember, they are just kids too!• Don’t expect your children to be

perfect – allow for mistakes and help your children learn from them

Behavioral Strategies & Techniques

• Reward Systems– Sticker charts

• Small & simple• 1 behavior at a time

– Token economy– Tangible rewards

• Small gestures of approval– Privileges

Behavioral Strategies & Techniques cont.

• Time outs– Not a punishment, but rather a time to calm down & collect

oneself– Used to interrupt unacceptable behavior– Remove child from situation that brought about loss of

control– Should be short enough so child has chance to go back to

original situation & be successful with acceptable behavior– Be consistent on when a time out is given, for what

purpose, how long & where – only for actions you have previously warned are not acceptable, not for first time offenses

– Use sparingly– Not appropriate for all children

Behavioral Strategies & Techniques cont.

• Consequences– Allow your child to experience the natural consequences

of his/her behavior• (e.g., if child throws toy and breaks it, can no longer play with it)

– Logical consequences for misbehavior helps them learn that they are accountable for their actions, without damaging their self esteem

– When possible, should be delivered immediately, should relate to rule broken & be short enough so that you can move on again to emphasize the positives.

• Withholding privileges

A Word (or 2) about Temper Tantrums

• Developmentally appropriate– Need to release frustration, given strong drives for

mastery & autonomy being continually stymied either by adults or own limitations

• Need to express their feelings – To them, a tantrum speaks louder than words

• Need to assert themselves– “I am important. What I want counts.”

• Lack of control over their lives– With adults always telling them what to do & what not to

do, a tantrum is often the only way to say “Enough. This is my life!”

Temper Tantrums cont.• Encourage better outlets &

anticipate frustration• Reduce need to say “no”• Get down to child’s physical level

– Kneeling to ensure eye contact– Reduces power differential

Caveats• Not all discipline approaches work with all

children• Need to consider temperament factors• Need to modify based on developmental age• Sometimes when trying new behavioral

techniques, behaviors may get worse, before they get better – “Hmm, this used to elicit this response…..I

better take it up a notch”

What to Avoid• Avoid yelling, as this models loss of control when you

don’t get your way• Sarcasm• Guilt trips• Criticism

– Instead, provide unconditional love, helping your child understand that it is the misbehavior you are unhappy with

• Physical punishment– Spanking is not effective and teaches kids it’s okay to hit when

they are angry• Nagging• Unrealistic threats

– Be prepared to follow through

What if my child’s behavior is really out of control? What if all else fails?• Parent time-outs• Psychological consultation

Parenting Truly is the Most Challenging Job!

• Gentleness, patience & firmness are required over and over

• Research shows that effective parents raise well-adjusted children who are more self-reliant, self-controlled and positively curious than children raised by parents who are punitive, overly strict or permissive.

References• American Academy of Child & Adolescent

Psychiatry• American Academy of Pediatrics• Child Welfare League of America• Guidance for Effective Discipline – Committee

on Psychosocial Aspects of Child & Family Health

• National Network for Child Care• Parent Center - The Discipline Tool Kit:

Successful strategies for every age