Pediatricians are likely to see at least one family a day with complaints about the child's lying, stealing,1,2 refusing to go to school,3'4 setting fires,5,6 or getting into fights with other children.7,8 Traditional clinicians, responses have ranged from comments that minimize the complaint - such as "He'll outgrow it," "You're only young once," or "Many kids go through a stage like this" - to explanations and advice, such as "You've got to be more strict" or "You should spend more time with him," or possibly recommending referral to a psychiatrist or child-guidance clinic. There is an approach9 to parental complaints about child misbehavior that offers the pediatrician an opportunity to deal more directly with the complaint and to offer the parents, in one or a few family sessions, a constructive solution to their problem. Optimally the whole family should participate in these sessions, but frequently it is expethent to work with one parent and one child.
In 1949 Adelaide Johnson1 mentioned "orders" and "insistence" in describing the communication of "mature" mothers with their nonproblem children. She then contrasted this with the communication of mothers with children who lied, stole, were truant, set fires, were assaultive, ran away from home, and acted out sexually. In her description of the latter she demonstrated that the parents had an interest, usually unconscious, in the problem behavior and obtained vicarious gratification from that behavior in their child. She pointed out that the parents often had an unconscious interest in punishing or complaining about the child and that their communication with the child revealed their interest and their ambivalence about getting the child to stop.
In describing her efforts to apply these observations to her work with families, Johnson noted the difficulty in avoiding engendering so much defensiveness on the part of parents that they would leave therapy. Subsequent investigations9,10 have revealed a focus of parentchild communication that can be discussed with parents without eliciting such a defensive response. This approach succeeds, partly because the emphasis is not on what parents have done to encourage problem behavior but on what they have not done to get it to stop and partly because it avoids the accusation that parents want their children to misbehave.
Johnson observed that parents with adopted children almost always see problem behavior as inherited. It is now apparent that all parents of children who persistently misbehave see their children as unable or limited in their ability to behave in the way the parents would like. Also, such parents often see themselves as having an obligation to allow or tolerate the misbehavior. The pediatrician can demonstrate this in his office by asking the parents what ideas they have about what has led to their child's problem behavior. It will quickly become apparent that the parents believe it is unreasonable for them to firmly and persistently demand that their child change his behavior. The pediatrician can also demonstrate that the parents have not been making relevant demands of their child by asking them what kinds of things they have said and done to get the child to change his behavior.
The goal of this approach to problem behavior is not to get the parents to be demanding but, rather, to change their view of the child - to change their view of the child as "disabled" or having a right to misbehave, which results in their feeling obligated to tolerate and be patient with the misbehavior. What we say reveals what we think, and our ideas fashion what we say. When a parent's ideas about a child change, the parent's communication with that child will also change.
Why would parents so universally see children with problem behavior as disabled (limited in their ability and capacity to behave)? Part of the answer lies in the way we deal with anger. If we perceive a person as unable to avoid a behavior we do not like or as unable to do what we would like, his behavior will not appear deliberate. We avoid feeling helpless by seeing him as helpless. Thus we avoid anger or diminish our anger. Many people think that it is dangerous to get or be angry. To be angry means to them to be in danger of losing control and doing something they would not choose to do. Parents might be fearful, for example, of hurting their child. And parents will sometimes reveal this concern when the pediatrician points out that their saying "Stop lying or I'll punish you" is an ambiguous demand because the child is offered two alternatives from which to choose. The parents may then express their concern about what they will do if they do not have an alternative plan.
Expressing anger is not the only alternative to denying or avoiding anger, and it is not necessarily productive. The solution to anger is changing what one is angry about. If a parent avoids being angry at his child by seeing him as "disabled," the parent has also eliminated the solution. When, however, a parent gets the child to behave, there is nothing to be angry about.
The ideas that parents have about what has led to the problem behavior in their child are not new to physicians. They include:
1. "He doesn't know how to behave" -implying that mental retardation or lack of understanding is the cause of the problem.
2. "He was born that way" - implying that heredity is the reason for the child's sensitivity, shyness, temper, stubbornness, or tendency to be easily led.
3. "He was brain damaged" - implying that an organic brain lesion is the cause of the problem behavior or abnormal development.
4. "He was spoiled by ..." - implying that abuse, emotional deprivation, oversolicitude, or "bad example" is the root of the problem behavior.
Many of these views may be reasonable and have an element of validity. However, they need not be seen as limiting current capability. Explaining how you got to Detroit does not mean that you cannot go to Toledo or that what was done in Detroit has to be undone. In the common clinical explanations of behavior - which take into account antecedent events, such as physical disfigurement - it is not so much the events themselves that are agents but the views taken of them by the participants.11 However, if the pediatrician who is seeing a family limits his views to such antecedent or underlying phenomena, he will see little to be gained from anything more than a supportive approach ("You'll have to learn to live with it") or a referral to a child psychiatrist or psychologist ("You'll have to consult someone who can change or modify the child's behavior"). Certainly the pediatrician who agrees with the family's reasoning will have difficulty undermining or eliminating that point of view.
Given any family, however, that comes to the physician with complaints about behavior, it can be demonstrated from material presented by family members that the views expressed are usually insufficient to account for the problem. For example, parents and child may agree that the child hits without thinking when he gets angry. It should not take much investigation to find some examples of situations where the child has been angry and has not been assaultive. One little girl agreed, for example, that she had been angry with her father. When asked why she had not hit him, she observed with surprise that he was "too big." If it can be demonstrated that the child can make a choice in his behavior, the parent will see the deliberate nature of the behavior and will have difficulty avoiding anger with the child. It will then be much easier for the parent to be appropriately demanding about the problem behavior, especially if the pediatrician has clearly delineated the ways in which the parent has not been sufficiently forceful.
A demand, in this context, is meant to describe a very limited phenomenon of communication - an unambiguously imperative sentence that begins with a verb and cannot be construed as a question. Examples are "Sit down," "Close the door," and "Begin your homework now and have it done by eight o'clock." Whenever parents have complaints about a child's behavior, it can be demonstrated that they have not been persistently and unambiguously demanding about that behavior.
Although a few parents readily admit that they have not been insistent, either as a matter of principle or because they see the child as "disabled," most parents believe that they have been demanding when they have actually used a variety of other communications, such as threats, questions, explanations, or even demands that fall short of including what the parent really wants. All the other kinds of communications have in common the fact that they would not be unreasonable if they saw the child as limited in ability to perform at an age- and situation-appropriate level.
An alternative may be offered, either a punishment or a reward, that then converts what might have been a demand into a proposition. "Mow the lawn and I'll give you a dollar" may clearly be said to a neighbor's child as easily as to one's own, and it can readily be construed as a business deal. Similarly, "If you don't get home on time tonight, you won't got out for a week" offers the child a choice, which he might in fact verbalize: "Well, since this is the big game tonight, it's worth it."
Rhetorical questions from parents are more likely to reveal their view of the child as disabled than to be heard as a demand. "Why can't you behave?" "Why can't you remember to hang up your clothes?"
Explanations may clearly reveal what a parent wants a child to do but may also suggest that the parent does not think the child previously knew what was wanted - a kind of disability.
Parents will complain, of course, that words do not mean much, that their child knows what they mean. One can agree that words are not everything. Words are not accidental, however, and as long as the parents see their child as limited in his ability to behave, it is logical to assume that they would perceive a demand, order, or command as unreasonable.
The pediatrician is in a good position to help parents understand how effective they really can be in communicating with the child with a behavioral problem. He will probably be in the best position to do this if he can contrast the parents' nondemanding communication about some problem behavior with demands the parents make in other behavioral areas - or with demands they make on children who do not have behavioral problems. A stepfather, for example, described his 10year-old boy as out of control when surrounding excitement reached a certain level of intensity. Questions about a particular day revealed that he said, "Go to your room and stay there until you calm down." The boy did what the father demanded^ but the father had not demanded what he really wanted (that his son calm down then and there), obviously because he did not think his son could do it. Parents who think of themselves as never demanding are suprised to find that in trivial matters about which they are not concerned they are effectively demanding - e.g., in the clinician's office, when they say to their child, "Take your feet off the table" or "Put the comb in your pocket."
The point of this approach, as mentioned earlier, is not to get parents to be demanding but to eliminate their views and the child's view of the child as "disabled." The exploration of events and communication is a productive area for this endeavor. If the boy who went to his room, for example, was "out of control," how did his father get him to go there? Note also that the child who shares his parents' view of himself as "disabled" will not see the opportunity of choosing to behave differently.
The following is offered as a way of organizing the pediatrician's approach to a family.
ELICITING PARENTS' BEHAVIORAL GOALS
Usually the parents' complaints about a child's behavior are obvious, but when asked about their interest in getting the child to do or not do what would seem to be the obvious preferred alternative to the complaint, parents may be unsure. When asked, for example, if she would like to get her eight-year-old boy to "pay attention" in school, a mother said she did not know. When this reservation was explored further, she said that she thought he was creative and artistic and she was concerned that if she got him to daydream less she might thwart his creativity.
Sometimes the parents' goal is conspicuously something other than changing the behavior. They may verbalize an interest in "understanding" the problem behavior. This is really an interest in being provided with an explanation of the behavior that will lessen their anger and make the behavior more tolerable. Parents may also believe there is something that must be understood as a first step toward changing the behavior.
Presenting goals other than the changing of behavior does not mean that the parents are content with the behavior. More likely it reflects their feelings of hopelessness about change, based on their view of the child as "disabled." The mother of a 12-year-old girl, for example, after hearing yet another account of her daughter's habitual stealing, said she wished her daughter did not always do it in such a way as to get caught. When it was pointed out that the comment might suggest to her daughter that stealing would be acceptable if she did not get caught, she said, "You're right. I hope she does get caught when she steals." Her words dramatize the difficulty she had in thinking of her daughter in any way but as a thief. Her options were limited to confronting the stealing instead of stopping it.
Sometimes parents are reluctant to complain about a child in his presence. Of course, if they have difficulty mentioning his stealing or calling what he does stealing in his hearing, it is obvious that they will have difficulty demanding that he stop.
Sometimes what the parents describe as a complaint or problem is so vague or generalized that it is not clear what they would alternatively like the child to do. They may complain of immaturity or not caring, for example. Such complaints are often, in fact, their view of what is wrong with the child and what leads to the behavior they do not like.
Parents ordinarily have more than one complaint about their child. This gives the pediatrician an opportunity to be selective about the area to be discussed. Some behaviors are less immediately productive for discussion. Lying, for example, is a frequent complaint of parents. Almost always, however, children lie to avoid adults' finding out about some other misbehavior. This results in the peculiar circumstance that if parents pursue getting the child to be truthful, they are pursuing his being truthful about the other behavior - e.g., stealing. But the child cannot be truthful in the future about stealing unless he has some future stealing about which to be truthful. Thus, for the parents to be successful in getting their child to be truthful about stealing, they are indirectly requiring that the stealing be continued. Alternatively, if they get the child to stop stealing, there will be nothing to lie about - a presumably acceptable goal. One set of parents said that they were more concerned about the lying than what their 12-year-old boy lied about. They were, in fact, upset by his being able to lie successfully. They saw this as providing a potential ability to commit a variety of crimes. Inquiry revealed that both parents saw themselves as unable to lie and believed that this disability saved them from a variety of misbehaviors.
It is generally more productive to talk about a behavior that occurs with sufficient frequency so that parents are aware of success when they become successful in effecting changes in their child's behavior. Setting fires, for example, usually occurs with periods of months intervening. If the parents of a child who sets fires do become effectively demand* ing, they are not likely to be convinced for six months if that is the only behavior discussed.
The mother of an eight-year-old boy who was hospitalized for psychiatric study after causing considerable property damage with fires related in one session that the patient's younger brother had burned the drapes in his bedroom. Exploration revealed that she considered it an accident resulting from using candles throughout the house when the electricity was turned off. On another occasion, the mother described herself as having thoughts of burning the house down when she was depressed. Other behaviors of the child, such as lying and stealing, were discussed. This allowed her to "see results" - which, in turn, lessened her helplessness, anger, and depression. The youngster's behavior improved, and he did not set more fires even though little time was devoted to her efforts to get him to stop that particular behavior.* Without accusing his mother of wanting him to set fires or enjoying the behavior, we could observe that if she sometimes felt like burning something and could "understand" his inclination, it might be difficult for her to be as insistent about his not setting fires.
ELICITING PARENTAL IDEAS OF CAUSATION
Asking parents what ideas they have had about what led to the problem behavior usually results in some of the ideas of disability previously described. If parents say they do not know why their child behaves the way he does, the pediatrician can point out that he was only interested in ideas they have had about it as opposed to the "real reason." Parents will sometimes deny any ideas, but questions about what they have done will reveal ideas. For example, if they say they have tried to spend more time with their child, there is an implied relationship between the behavior and the amount of time they spend with him.
ELICITING INFORMATION ABOUT PREVIOUS PARENTAL EFFORTS TO CHANGE THE CHILD'S BEHAVIOR
Initial responses to the question "What have you tried?" may include such broad categories as talking to a counselor, changing schools, or "We've tried everything." More personal efforts will include restrictions, punishments, and rewards. We are most interested in what the parents have said to the child - and in the same words, as in a quotation. Do not ask them if they have told him to stop the problem behavior. They will always say Yes because they see the other kinds of communication, described above, as demands.
CONFRONTING PARENTS WITH THEIR FAILURE TO DEMAND
When the parents' recollection of what they have said to the child to get him to change seems exhausted, summarize for them what they have done. Recount in some generalized way what they have said to the child, point out that they have not included appropriate or sufficiently forceful demands among their comments, and observe that this is reasonable in view of their ideas about the child. Some clarification of what you mean by demands as opposed to what they have said is usually necessary.
INTERPRETING FOR PARENTS WHAT IS MEANT BY DISABILITY" AFFECTING ANGER
Point out to the parents that seeing their child as "disabled" prevents them from being as angry as they would otherwise be. If the parents give any indication of agreement with this idea, pursue their concern about getting angry. This concern usually amounts to a fear of losing control - a kind of disability. This view can be attacked or undermined just as one undermines their view of the child as "disabled."
One mother, seen because she had been sleepless and anxious for a week, traced her symptoms to getting "so angry" at her children one morning that she had thrown furniture around the room. She viewed herself as having "lost control," and the idea that this could happen led to her symptoms. A reconstruction of events, however, revealed she had considered a number of alternatives, including hitting her children. She then secluded herself from the children before throwing the furniture and managed to do that without causing any damage. If you can demonstrate deliberation, you have demonstrated that the behavior is deliberate - and, therefore, not out of control. This woman's symptoms disappeared when she viewed herself as having chosen the behavior. Many parents have similar episodes that they consider as evidence that getting angry may be dangerous.
ATTACKING PARENTAL MISCONCEPTIONS
Merely contradicting the parents' view of their child or themselves in terms of disability is usually not successful. The goal of eliminating their views is best achieved by further eliciting from them the evidence on which the views are based and contrasting the views with observed or reported behavior that contradicts the views. For example, if the little girl has time to note that her father is too big to hit, why does she not have time to think before hitting her smaller peers?
Arguing between parents about how to deal with the children is not limited, of course, to those with more serious behavior problems. An ail-American example is the boy who will not take out the garbage. His mother says it is because his father does not take any interest in the house or his son. His rather says his son does not take the garbage out because his mother nags him. Since both parents hold the other accountable, not their son, neither is persistently demanding with the boy. Note that if each were not complaining on behalf of the son, the father might complain about his wife's nagging and the mother might complain about her husband's not paying enough attention to her. Typically, each parent will agree with the other's complaints; they will see themselves as unable to behave differently and will agree with each other about this too. If the pediatrician confronts them with their ability to get the hoy to do what they want, using the approach described in this article, he may deprive them of the opportunity of using their son in the battle between them. The parents are then more likely to be hopeful about dealing with their conflicts.
It is not surprising that parents who believe that there is something wrong with themselves anticipate problems with their children and feel helpless with the first "evidence." When they present their children for help, they are indirectly presenting themselves. They do not say or admit this, of course. They may, in fact, feel so worthless and hopeless about themselves or so defensive about what they suspect about themselves that asking for help is untenable. About their children they are more hopeful, and getting help for them appears to these parents, who feel personally worthless, to be more unselfish.
Pediatricians have successfully used this method for dealing with parents' complaints about children's behavior with any number of family members, but only one parent and child are required and they are routinely available. The approach can be launched without fanfare or explanation whenever complaints are presented. It uses parent-child communication as an avenue toward ridding the parents and child of their views that the child is unable to behave appropriately and that the parents are unable to influence the child's behavior. It offers parents hope for a solution and resolution of their anger. It offers children enhancement of their self-image and the prospect of a more rewarding future.
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1 1 . Watson, E. J., and Johnson, S. M. The emotional significance of acquired physical disfigurement in children. Am. J. Orthopsychiatry 28 (1958), 85.