What to Consider before Starting Childhood Behavioral Therapy

Aly’s sleep problems were becoming so challenging that now her parents were losing sleep. For years, the five-year-old had woken up several times nightly. When a pediatrician’s advice failed to alleviate the problem, her parents sought help from an agency that offered their daughter sleep training using a behavioral approach. After just three weeks, Aly was sleeping through the night.

Or so her parents thought.
After the girl repeatedly dozed off during kindergarten class, the parents installed a video monitor in her bedroom to monitor her at night. Their surprising discovery: Aly spent most of each night awake, staying in bed in order to earn her reward, but repeatedly looking at her clock until daylight came.

Aly’s story illustrates the potential limitations of certain behavioral therapies—techniques that focus solely on altering an individual’s behaviors—on young children. And while seeking early help for children’s challenges is important, many parents are unaware of the widely differing treatment methods available. In my opinion, all therapies for young children should prioritize the child’s feelings of safety in relationships as the foundation of treatment, while being considerate of each child’s unique and individual needs.

As Aly’s story illustrates, when we ask children to do things that exceed their developmental capacity, we risk causing new problems, such as an increased stress load.

We need to shift our thinking about behavioral challenges to look beneath behaviors for triggers and causes such as:

  • Immature social-emotional development. Many professionals don’t use a roadmap of social-emotional development to determine the type of treatment a child needs. To truly understand behavioral consequences, a child must first have adequate emotional and physiological regulation (ability to calm one’s mind and body), the ability to engage in relationships, and the capacity for verbal and/or non-verbal back-and-forth communication. These abilities are core, “bottom-up” processes, leading children to develop social problem-solving skills and—eventually—executive functioning.
  • Past experience of developmental or environmental stress or trauma. Developmental anxiety and hypervigilance can stem from a wide variety of causes, including how the brain is wired, as in the autism spectrum. For instance, some professionals utilize rewards/consequences to treat instinctual sensory or motor responses. We should be cautious in introducing behavioral therapies, as they may cause additional stress for the child. The neuroscientist Stephen Porges emphasizes that it’s important to understand that “adaptive physiological reactions may result in maladaptive behaviors.” It’s not developmentally appropriate to punish or issue a negative consequence for a child’s subconscious survival mechanisms.
  • Sensory-processing challenges or disorders. Children with sensory-processing challenges (under- or over-reactivity in how they experience the world through their sensory systems) often exhibit “fight-or-flight” behaviors. Providers then attempt to use behavioral techniques to change this behavior. No amount of consequences or reinforcers will truly help a child whose sensory system is wired in such a way that the world feels like a threatening place.
  • Compromises in volitional motor control. These include apraxia of speech or motor planning challenges; autism spectrum disorder; and other motor difficulties that affect an individual’s communication channels. Professionals often recommend behavioral therapies as initial treatment for autism spectrum disorders. But as one researcher, Anne Donnelan, points out, it’s overly simplistic and not appropriate to use behavioral techniques that rely on punishment (including planned ignoring and time outs) for individuals who have compromised volitional movement control.

There are plenty of options to help children with developmental, behavioral and mental health challenges, including:

  • Work with professionals who prioritize the child’s level of social and emotional development when planning all treatment strategies. Organizations such as the Profectum Foundation offer free online webcasts about social-emotional development for parents and professionals.  I also describe an easy way to measure the child’s level in my book on social-emotional development.
  • Figure out whether a child is experiencing developmental or environmental stress. If so, make it a top priority to help the child experience the feeling of safety in relationships as the top priority across all therapies. As Dr. Stephen Porges says, “treatment is safety and safety is treatment”.
  • Determine the child’s capacity to take in the world around her and respond to it from a sensory standpoint. A large portion of toddlers I see experience undetected sensory challenges that contribute to their confusing behaviors. Most childhood providers, including pediatricians, know little about sensory or motor processing, even though it is a significant contributor to behavioral difficulties. An occupational therapist trained in sensory processing and integration can assist in determining the child’s individual differences in this area.
  • Try to assess, understand, and compassionately learn more about individuals with limited control over their physical movement, including apraxia, dyspraxia and autistic persons who are non-speaking. Find experts who can help the child/teen access technology and facilitated/augmented communication. These experts are often progressive speech and language pathologists. It’s not appropriate to use behavioral techniques dependent on a functional motor system for individuals who do not have adequate movement control.

If we pay attention to the precursors of healthy social-development, then, ultimately, we will not need to employ stand-alone behavioral techniques reliant on negative consequences such as ignoring certain behaviors. Instead, we can use organic interactions—such as hugs, smiles, and reassuring nods—that naturally promote a sense of cooperation and well-being. These keys to mental health are hallmarks of supportive relationships and crucial factors in helping all children to develop resilience and a sense of well-being.

Stay in touch! Sign up for my email list for resources and updates on my upcoming book about behavioral challenges.

My  book describes how we can all embrace principles of social-emotional health across disciplines.

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Trying to fix sleep problems with behavioural therapy is ridiculous. It assumes a level of control that just isn’t there. A five year old isn’t deciding to wake up at 3am. What five year old could decide that and follow through? That kind of thing is evidence of a SLEEP DISORDER. It’s probably fixable with low dose melatonin, like many of the sleep disorders common among autistic people. JFC please will people stop assuming everything is “behavioural”. I had sleep problems for fucking years, no amount of desperately trying to sleep actually worked, medication did.

Thank you for this article. Unfortunately you forgot to mention the essential role of the speech-language pathologist. The SLP is the professional with the appropriate training in communication and social skills, and the only person who should be assessing, making recommendations, and treating these areas… not to mention feeding and swallowing disorders.

HI Shelly, Thanks for commenting. I will amend to mention SLP’s in particular. However, in the many teams I work on, sometimes it’s not the SLP that insists on AAC and FC, but me or the parents. As you know, there’s a controversy here in the US about FC. Unfortunately, for many of my patients, I have been the one to advocate for it with IEPs, sometimes with limited success depending on the openness and willingness of districts and their “policies”. But to me, seeing is believing I feel that we must provide the correct supports for each child and not withhold the support until the child is ready to prove it works.

Thank you. But FC? I hope you don’t mean facilitated communication.

I am lucky enough to work with a few sophisticated SLPs and teachers who do actually look at supported typing / FC as one possible tool in the AAC tool box. Though they well understand the controversy and ASHA’s guidelines – and some are exclusively AAC specialists – they have found that some of their children have been able to move to through the supported typing into independent typing. Some of these individuals with Autism are now becoming independent advocate voices for very disconnected bodies, with higher level minds. They are helping us all, as professionals, think about and tease out which questions to ask, which forms of treatment may be helpful for which profiles… and which modalities are in desperate need of further research.

Thank you for sharing your thoughts. As a pediatric occupational therapist and an educational psychologist, I am so happy when other professionals understand the interplay between behavior, cognition, and sensory processing. I really like the way you’ve differentiated this in your blog.

I did want to mention, as well, that folks should be concerned if sleep problems, separation anxiety, sensory processing problems, or behavioral regression occur suddenly, especially if the child has been ill – as those can be signs of a post-infectious autoimmune response known as PANDAS or PANS. Such children should receive a medical evaluation from a practitioner familiar with the disorder. PANDAS network. org is a great resource for more information. ( http://www.pandasnetwork.org) as is PANDAS Physician’s Network (https://www.pandasppn.org) and NIMH (https://www.nimh.nih.gov/labs-at-nimh/research-areas/clinics-and-labs/pdnb/web.shtml)

Jan Tona, PhD, OTR

Yes, good point Jan. Thanks for commenting.

Another resource that I would suggest consulting when it comes to addressing medical causes of behavioral issues is Neuroimmune Foundation: neuroimmune.org. Neuroimmune Foundation advocates on behalf of individuals with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Syndrome Associated with Streptococcal Infections (PANDAS), as well as infectious, post-infectious, and autoimmune encephalitis. They have extensive free resources for both clinicians and patients/families alike.