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Disruptive Behaviors

Disruptive Behaviors Program Transcript

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NARRATOR: Disruptive behaviors vary from child to adolescent. Their causes are just as varied. Doctors John Sommers-Flanagan and Eliana Gil discuss disruptive behaviors and therapeutic approaches that can be utilized.

ELIANA GIL: I think of disruptive behaviors as the child's action language. And I'm always happy when they can do that, because it is a way that they're showing the world that I need something, and I need something to happen soon. And they kind of escalate if they're not given the attention or the help that they need.

The most disruptive behaviors that we get are kids who are basically dis- regulated in school. So they get up and down from their chairs. They don't listen. They won't follow the directions of the teachers. They go into recess, and they're completely aggressive with other children. They're pushing children down.

So they are kids that become real control issues for those that are trying to maintain the control in the classroom; so the aggressive behaviors, definitely, the kicking, and punching, and biting, and those kinds of things. And then again, the kids who just don't pay attention, and cannot be re-directed, those kids get a lot of attention as well. So those are the referrals we most typically get.

JOHN SOMMERS-FLANAGAN: So what you're saying is that the behavior is communicating something important. Do you have some examples that you can think of that might be related to a child you worked with or an adolescent you worked with who was behaving in a disruptive way, and that it was communicating something in particular?

ELIANA GIL: I think that one of the things that I find most frequently is that the kids need more limits, that they need more structure, and that they aren't being given that—usually in their home or their family environment. And then they go into a school setting, where these are now people that are unknown to them, unfamiliar to them, who begin to try to set that structure and that foundation. But because it hasn't been provided earlier, then the kids really don't know how to follow directives, don't know how to use their internal controls.

I think for all of us as parents, when we're working with our littlest kids—our children, grandchildren, whatever it may be—we're really trying to teach them how to regulate themselves and their emotions. So the earliest thing we see in little kids is temper tantrums.

Disruptive Behaviors

And those are really the kids' way of saying, you know, I have feelings. And they're big feelings. And I don't know what to do with them anymore.

So I think that what they're looking for is their parents to really co-regulate them, and to say to them, you're really tired right now. You haven't eaten. You're going to feel better later. You probably need to go to sleep. You need to take a little nap right now.

And so the parent kind of co-regulates, and explains, and helps the kids, and holds them close to them. And eventually the kids calm down.

This foundation is really important, not only because it shows the child that they can trust someone, but also it teaches internal controls, so that eventually as the kids grow older, they know, “When I feel this big feeling, now I understand that sometimes I can make it smaller, that sometimes going to my mom will make it smaller.”

If that isn't set early on, the kids just kind of are all over the place. And that's what happens in the schools. They get in there, and they cannot be contained.

There's just a dis-regulation that is not working for them. And there's no way for them to reach out to others or to go inside. And so I think what it's communicating is, I need someone to help me regulate myself. I need someone to show me what to do with these big emotions. And that's pretty classic.

We had a case recently where there's a little six-year-old child. And the parents are leaning towards a very permissive approach to the child, partly because they're new at parenting. It's an adopted child.

And the child is saying pretty clearly, I'm going to go urinate on the floor whenever you tell me I can't do something. And the child says it, and says, “No I don't want to do that. I'm going to go pee.” And the parents say nothing. And the child does it. And then they clean it up.

So what's going on there? It's a very disruptive behavior. But the child is needing something from them. And I think what he needs is more structure, someone who says, “No, that's not OK for you to do that,” someone who, if the child does it, says, “Now you need to clean that up.” So you're beginning to teach the internal controls.

So I think there's a disconnect there, that sometimes these communications that are done through action are not addressed properly. And a little aggressive child, sometimes they go and they bang into someone. And it may be that they want to be friends with them. And it may be that they want to somehow get the attention from them, and they don't have any ways to do it.

Disruptive Behaviors

So I'm always thinking that these are children who need something, and that my job is to figure out exactly what that is, and to engage the people who can provide that for them. And that may be the parents.

And it might also be talking to the teachers and saying, “You know your response to this particular disruptive behavior actually escalates it sometimes.” So if they get into an altercation with the child, where the child yells and they yell back. And the child yells back more, and so forth and so on.

That isn't going to help. But I also understand that for teachers, to have a child who is present daily with these kinds of provocative behaviors can also really wear you down.

JOHN SOMMERS-FLANAGAN: So it really may be a call for co-regulation or limits that the child needs, which reminds me of Diana Baumrind's old model of the permissive parents and the authoritarian parent on both extremes, and your example of the permissive parents, who maybe doesn't set those limits, and then maybe the authoritarian teacher, who just gets in a yelling match, you know, it's my way or the highway.

And I think it's so hard for parents and teachers to operate from the middle. I've done a fair amount of parent education. And one of the lessons that I try to get through is, it's OK to set a limit and show empathy at the same time, to say, “I know you really want that second piece of cotton candy, but you can't.” It's hard though. I know it's hard.

And then the child, of course, will roll around in the sawdust at the fair grounds, and throw a tantrum. And yet there still needs to be that firm limit with empathy at same time.

ELIANA GIL: Exactly. And I think that, again, systemically what ends up happening, is that often the parents are doing the best they can. But they may not have the tools. And they may have a history behind them that hasn't really allowed them to develop those tools. So we really can't work with these issues in isolation from the families and those primary caretakers who need to do whatever they can, I think, to assist the children.

There's a wonderful model called circle of security, which is an attachment-based model. And I've found that some of the basic principles that they communicate are very helpful to parents.

But one is, when do you step in, and when do you take control, and when do you follow the child's lead? And those are two different things. And getting parents to really begin to recognize, and also recognize what is developmentally appropriate in children, so they don't begin to take a disruptive behavior as some

Disruptive Behaviors

kind of sign that the child doesn't like them or—Parents' perceptions of that can be pretty critical, in terms of what they're then able to provide to the child.

JOHN SOMMERS-FLANAGAN: I have heard of the circle of security model. And I think it does provide parents with this nice practical foundation for how to intervene and when not to intervene. I also know, as we speak diagnostically for just a couple of minutes, that the disruptive behavior disorders that we're talking about probably include ADHD and its variants, as well as oppositional defiant disorder, and conduct disorder.

And one of the things that my impression about the research is, that there's a little bit of a developmental trajectory if a child with maybe some challenging temperamental qualities, parents have trouble setting limits, and maybe there's a little bit of a difficult family process that reinforces misbehavior. And then you see this evolution of behavior moving out of the attention deficit sort of behaviors, into oppositional behaviors, and then maybe into more serious misconduct, where there's a systematic violation of interpersonal rules, and legal boundaries, and those kinds of things.

And I’m wondering, in your practice I know you do a fair amount of play therapy, I'm wondering if you've seen that more extensive misbehavior that you might associate with conduct disorder, and how that gets manifest in your experience?

ELIANA GIL: Yes, we definitely get a lot of kids along that continuum that you just described with conduct disorders, ADHD—at least the question of ADHD, because I think that that sometimes gets a little bit over-diagnosed—impulse control problems. And these kids are very difficult to contain in a therapy setting.

The play therapy that we do is a combination of the non-directive play therapies. But I think in this particular instance, with any of the behavioral problems, we need to bring in more of the cognitive behavioral play therapy. We need to bring in much more attention, with the kids, to assessing their own affective state.

So for example, we have a little piece of paper that we give kids when they come in. And we say to them, point to the feeling you feel right now. And so we give them choices. But they also get to draw one in.

And then once they point to it, we go to a second page that has the smaller little face, and then growing all the way to a big one. So it's kind of like a Likert Scale. But it's very visible. And then we say, “What size is that feeling for you right now?”

So we're really teaching kids to look at the difference, in terms of being able to scale how big that feeling can get, and what it feels like when it's this big. And how do we make it just a little less big? How do you bring it down?

Disruptive Behaviors

So that already begins to really work on the cognitive behavioral piece, where you're looking at the relationship between what they think, what they feel, and what they do. So we spend a little bit more time doing that and being more directive when kids have behavioral problems, particularly that are getting them identified for negative attention from others, that that's affecting their own self esteem, where they're beginning to say very negative things to themselves like, “I can't do anything right, and nobody likes me,” and those kinds of things.

I think the integrated approach there becomes much more beneficial. The non- directive play therapy alone, I think has its limitations sometimes, with these very dis-regulated disruptive behaviors.

So I always use a little bit of that, just to kind of assess the child's ability to regulate self. But they can come in, and pretty much destroy your office, or try to throw things out the window, or break things just to break them.

They have to have limits. And after that, thinking a little bit more about, “So what was going on right before you took that and broke it,” and having those kind of discussions about the behavior when the kids calm down.

I mean I've gotten to the point with some disruptive behaviors where I have to stop the session. And the child just isn't able to really respond to a container.

I've started trying not to use the word resistant. I'm trying to say to myself, they're ambivalent or they're hesitant. And somehow that makes a little bit of a difference to me, because there's less of an emotional charge to just saying the child is resistant to you.

But I notice that they're very ambivalent about being in a contained place or having the structure in anything that they do. And of course that manifests itself in the therapy situation.

With the older kids, it's interesting. Sometimes they just come in, and they say, “I'm not talking to you. I don't want to be here. Forget about it.” And that's an interesting thing for me, because as a non-directive play therapist, or as someone who's trained in that, I can say to them, “That's OK. You don't have to talk.“

And then I say something like, “But go find something”—and I give them a whole bunch of miniatures—“that shows kind of what's on your mind today. And you don't have to talk to me about it. Just find something.”

And sometimes the kids will do that. And then I say to them, “OK, now find something that might be something that might help with that right now.” And suddenly they have a miniature and a whole bunch of other little miniatures.

Disruptive Behaviors

And I don't push them to say anything. And sometimes even slightly paradoxical interventions where, I don't really want to hear about it. It's just what you're getting from that. And that's what's important.

But sometimes that takes away this power and control differential that sometimes kids feel, especially the older kids, because I think they're getting a lot of that from their environments, whether it's at school or at home. And so I try to create a different kind of a space for them. And sometimes that can work as well.

JOHN SOMMERS-FLANAGAN: Yeah, I'm hearing kind of a combination of some non-directive play therapy, maybe that's a little more expressive, as well as some focus in cognitive behavioral realm of skill building. How do we really build up these skills?

ELIANA GIL: Exactly. And the combination is, I think, what's really the best, because sometimes engaging kids can be best done through some of the expressive therapies. So I've started, for example, doing drama therapy techniques. Art therapy is wonderful, sometimes music therapy.

All of these are designed to kind of move something in a different direction, take away the expectations that kids have of therapy—that they're going to come in and get a Q&A from the therapist or the counselor—and their hesitancy about that.

And so inviting them to do other things, and taking away that expectation that this is going to be really horrible for me, that's the engagement process. Now once they're engaged, then we go back to, OK, let's figure out what's going on.

How are you going to monitor that particular reaction that you have, and how you make it smaller, what the alternatives are to that behavior. So what can you do instead of that? And so then we really begin to do some of the work.

And again systemically, I always come back to that, because the kids are always in an environment that's really necessary to become involved with.

JOHN SOMMERS-FLANAGAN: Sure, and so if they're not engaged, obviously, you can't even do any productive work. And now you just mentioned the systems issue. And I want to just get to that before we stop this segment. And that is, how do you decide whether to intervene individually with a child or adolescent versus family counseling?

ELIANA GIL: To me, it's never an either or. It's always I will do both. And I know that from the outset. The only distinction for me is when to do what.

JOHN SOMMERS-FLANAGAN: Which one.

Disruptive Behaviors

ELIANA GIL: Exactly. And so it's looking at I meet with the family at the beginning, and I advise them of that. I usually call myself a family play therapist, because it's the combination of those two major theories. And I say, “So there's going to be times I'll invite all of you in. Sometimes I'll invite some of you in together, dyads together. Sometimes I'll invite you to do some play activities or some expressive activities. And other times we'll be doing conversations.”

And then it's a question of what suits that child best, and also what needs that child has immediately from their system. It may be that this child needs to know directly from the parent, immediately, “I don't want you to die. I love you. I don't want to have you gone from my life. I need you to be safe.”

And that sounds really like an intuitive, automatic kind of thing. But sometimes the parents have obstacles to actually expressing that directly. Or they'll say things like, “Oh you know he doesn't mean that stuff,” or “He knows we love him.” And that's not enough.

And so getting them immediately to do that in that situation would be, I need you guys, the parents, in here. And I need you in here today. And this is what I need you to say. And make that to the extent that they can talk with me, about making that as genuine as they can. That's the important thing to do.

And there may be another case where I really need to build rapport with the child. And that might take precedence until I feel like we're OK and we are engaged, and then bring the family system in. So it's a little bit of an assessment, in terms of when you do it. And from my point of view, it depends on the family. And I need to take my cues from them, but not hesitate to do either.

And so I meet, over my training experiences, lots of people who are purists, so the play therapists who never work with the parents, and the family therapists who don't include children. And both of those just amaze me, because they need to be, obviously, combined.

And some people have very rigid—maybe that's too strong a word—but very structured approaches, where they say, “We always do this. And then we always follow it with this.”

And I just really like to meet the family that I'm working with, and the person of the child, and really think relationships are important. So my best way sometimes to help the whole family is to have a positive relationship with the child, and build on that. If I can do it with the parents and the entire family there, that's great. But if I can't, then I do it differently.

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Disruptive Behaviors

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