Addressing Challenging Behaviors in Children: A New Approach for Parents

by | Jul 30, 2019 | 4ABHN

Becky Scott

Becky Scott

Every year, the Hogg Foundation gives the Frances Fowler Wallace Memorial Award for Mental Health Dissertation Research to eligible doctoral candidates at institutions of higher education in Texas. Awardees receive a $1,500 scholarship to help cover research-related expenses.

Becky Scott, who completed her dissertation at Garland School of Social Work at Baylor University, received the award in 2018.We recently talked with Scott about the aims, methods and contexts of her research:

Hogg Foundation: Your study is titled, “Feasibility of an Adaption of Child Adult Relationship Enhancement (CARE) Model in Integrated Behavioral Health Care – A Brief Parent Training Model.” What led you to take a professional interest in this topic?

Becky Scott: The Texas community that I live in is collectively asking the following questions:

  • How do we best help parents and children with difficult behaviors?
  • How do we make sure that school staff are not the only ones addressing these behaviors?
  • What are the programs for children with difficult behaviors that really work, and how do we increase access to these programs for all children in our community?

A significant part of answering these questions, I believe, is equipping primary care doctors and their offices with the knowledge and skills needed to respond to parents’ concerns about their children’s behavior.

It is common for parents to wonder “Am I doing this right?” at many points of their parenting journey. This is especially true when their child begins to demonstrate resistant or difficult behavior—even when it is a challenging behavior that is age-appropriate. Most frequently, parents confronted with difficult behavior look to their child’s physician for guidance on how to respond. Therefore, increasing the ability of primary care physician (family medicine doctors and/or pediatricians) teams to provide evidence-informed brief screening and intervention in the exam room during a child’s doctor’s appointment means more children and parents will have increased access to effective care. This population-level approach can decrease the negative effects of challenging behaviors in children.

Hogg Foundation: What questions were you trying to answer with this research?

Scott: This study, in response to parents who have concerns about their children’s behavior, attempted to determine the use of the highly accessible Child Adult Relationship Enhancement (CARE) model (Gurwitch, Messer, Masse, Olafson, Boat & Putnam) in primary care. CARE has several “ingredients” that are similar to the kind of therapy that is the most effective for children with difficult and challenging behaviors. We especially wanted to measure the effectiveness of CARE in a primary care clinic that has at least one team-member focusing on behavior and mental health.

We also wanted to know if parents and the primary care team would like the 3-4 brief session in-exam room intervention, and if it would lead to increased access for parents and children that may not get these types of services otherwise. For this, we wanted more specifically to see if this intervention, in 30 minutes or less, could be delivered in the exam-room—with or without the doctor present, and with child and parent present—and provide a foundation for the next level of care (specialty mental health) if a referral was indicated.

Finally, and importantly, we wanted to see if the intervention seemed to reduce the difficult behaviors indicated on the Eyberg Childhood Behavioral Inventory (ECBI). However, this final question needs to be better evaluated in a fully controlled study.

Hogg Foundation: How do you think your research methods and approach helped you answer the questions you’re posing?

Scott: We used a multi stepped process to begin to answer these questions.  First, we interviewed parents at our research site—a community health clinic that serves almost a third of our local population—to ask them if they wanted more and/or different kinds of support from their child’s primary care treatment team regarding their child’s difficult behaviors. Then we implemented our study to determine if the CARE model, when adapted for primary care (i.e. IntegratedCARE or I-CARE), might be the type of intervention our primary care team and parents were looking for. We included parents and behavioral health professionals in the studies that were experiencing these problems in real life.

We care if this intervention works, but that is irrelevant if it only works for a small group of people with a lot of resources. Therefore, we made sure that our study was set up in a way that we could see if this intervention would work for parents and children no matter their insurance status, ethnicity, access to transportation or mental health status. Throughout the study we maintained a real-world implementation approach. In other words, we made sure that the way we delivered I-CARE in the study was the way we would deliver it every day in the clinic whether we were evaluating the program or not. In fact, even though the study has ended, all the behavioral health professionals that participated in the study are still providing this intervention in our clinic. 

Hogg Foundation: What, from your perspective, is the biggest area of need—or the greatest opportunity—related to this topic? In other words, how could we really move the needle on this front?

Scott: Our greatest opportunity to maximize the extremely promising model of behavioral health integrated into primary care for the children of Texas is to identify financially sustainable, evidence-based interventions that address parenting and child behavior concerns in the medical exam room.

Often young children who engage in difficult or defiant behavior do not have a diagnosable problem. These children (and their parents) benefit from an early childhood parenting intervention that, in many cases, will prevent the development of behavior that meets the criteria of a clinical psychological diagnosis in later childhood. For children that do have a diagnosis from a younger age, such as ADHD or Autism, these parents also benefit from additional skill-building and support from their child’s medical home. However, these parents and children will also benefit from engaging evidence-based interventions from a trained professional—such as Parent Child Interaction Therapy or Applied Behavioral Analysis.

When parents have the skills—and when they believe in their ability to apply the skills—they remain their child’s best teacher and guide. Equipping parents to shape their child’s behaviors positively can lead to improvement in their ability to control their emotions, obey, and interact well with others. Skills such as these are importation in social settings such as schools.

With all that physicians must address in the care of their patients, it makes sense to give children’s primary care providers more support in addressing parenting and behavior concerns via well-equipped behavioral health professionals. The I-CARE model appears to be a way to do so.

Scott recommends the following resources:

Websites

Books