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Working with Children with Behavioral Difficulties During Therapy Sessions - Q&A December 2009

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Working with Children with Behavioral Difficulties During Therapy Sessions, Q&A

By: Susan Giurleo, PhD in Counseling Psychology

Children with special needs are often frustrated, confused and overwhelmed. The following are possible reasons for behavioral acting out.
  • The child has sensory issues that are not identified. Often children do not have the language ability to let adults know that they are physically uncomfortable, feel like they are about to fall, or are afraid to do an activity you are offering them. When they feel uncomfortable or scared, they act out their feelings rather than use words to express themselves.
  • The child does not understand what is expected of him. Many children with autism, ADHD or other learning disabilities have a hard time processing language. While you may think your directions are clear, the child may not understand what you have said and may do something you do not expect or act up because of the anxiety of not knowing what to do next.
  • They can’t do a task (or think they can’t do it) and misbehave to avoid the activity. Sometimes, as we evaluate or treat a child, we hit on a task that they find very difficult. Sometimes our expectations don’t match what the child feels she is capable of doing. This discrepancy between what we expect and what they can do often can lead to behavioral acting out.
  • The child has been “pushed” to do uncomfortable activities in the past. Children have good memories and often kids with developmental delays have been in many doctors and therapists office over the years. Somewhere along the line, someone may have pushed too hard, or inadvertently hurt them. The child doesn’t want to experience those feelings again, so we misbehave to get out of your office as soon as they can.
  • You are not addressing the child’s needs. Kids with developmental delays are complex. All of us, no matter how experienced, sometimes miss a diagnostic element that leads us off track. If a child is acting out over and over again in your office, it is time to reassess your treatment approach.
  • The child has learned that poor behavior gets her what she wants. Often parents, caregivers, teachers and therapists unconsciously

What is the best way to assess children with behavioral difficulties?

Children with ongoing behavioral difficulties benefit from a comprehensive developmental evaluation that includes physical exam, neuropsychological assessment, OT and Speech Language components.

Poor behavior can be linked to a medical problem, learning/perceptual difficulties, sensory integration weaknesses, or speech and language deficits.

A team approach is best because difficulties with behavior and regulation are typically not symptoms of just one weakness or diagnosis.

When a child is acting out during a therapy session, what is the best way to help them calm down?

If a parent is also in the room, I often follow their lead in terms of supporting the child. However, some parents are overwhelmed by their child’s behavior and looking to you as a child development expert to help manage behaviors.

The first step is to clearly understand that a child who misbehaves is in distress. He is not engaging in inappropriate behavior “just because.” Using a framework of compassion helps us to be calm and constructive in our treatment.

Next, it is best to be clear with the child about the rules during your session. I often will say to a child who is standing on furniture or touching things he shouldn’t, “It is a rule in my office that we don’t stand on the couch.” Or “It is a rule in my office that no one sits at my desk, except me.” You decide on the rules, but make sure they are concrete and clear.

Have a small number of toys or fun do-dads that kids find interesting to look at. Distraction is a great behavioral intervention.

Don’t give too much power to poor behavior. Ignore as much of it as you can. Often kids are looking to get a reaction and when you are calm and non-reactive, many will give up.

How should I handle tantrums, screaming and crying?

Sometimes kids just “lose it.” It can be distressing to the child, parent and you. The best way to handle these is to stay calm, tell the child you understand her distress and you will wait until she calms down.

Stop talking. (We often want to use logic and verbal means to calm kids down. Resist the urge. It only adds more information to their already overwhelmed sensory system.)

Be calm. If you become anxious, the child will sense that you are not helpful, making the child feel more out of control.

Wait. Sometimes it can take a few minutes for the storm to pass. But if we are calm and supportive with our presence (rather than our words) a child will eventually relax and calm down.

If a child is inconsolable it makes sense to stop all treatment for the day and let them leave.

How should therapists handle poor behavior when it appears the parent is overwhelmed or cannot address the problems appropriately?

As therapists part of our role is to model for parents how to respond to symptoms of their child’s disorder. It can be very helpful to model staying calm, getting down to the child’s level to speak to him, using diversion or distraction, problem solving and having realistic expectations for behavior.

How can behavioral acting out be prevented?

Knowing a child’s triggers or sensitivities can help therapists and parents prevent some behavioral difficulties. If possible, avoid activities that are upsetting. If those activities must be pursued, prepare the child ahead of time and allow plenty of time for transitioning from one activity to the next.

I work with a child whose behavior is fine with me, but she acts out with her parents. Why is there a difference?

It is quite common for children to display different behavior at home and at school or out in public. Often children know what behavior is acceptable in front of their peers or adults they do not know well. Some kids manage to “hold it together” in school or the community, but fall apart once home. Finally, special needs children are often difficult to parents and mom/dad may have more difficulty being consistent in their expectations and discipline than we can in a school or clinic setting.

The discrepancy between public and home behavior is often very distressing to families. Parents can feel overwhelmed, misunderstood and judged when therapists report, “His behavior is fine with me.” It is important for us to be aware that parents are doing their best, but they may need help with parenting skills.

How can I help parents who find their children’s behavior overwhelming or out of control?

Parents are often aware that they need support in their parenting skills and are open to constructive advice and support. It is best to give parents written lists of strategies or coping skills to practice at home with their child. Often what is told to them at the end of a therapy session or shared by phone is forgotten or not clearly understood. Sending brief, useful information home on a consistent basis will be much appreciated by busy parents.

Should children receive consequences for poor behavior?

In most cases children act out because they are distressed, however, they do need to learn how to manage their emotions in appropriate ways. While I would not advise punishment for a child who is acting out, natural consequences after the fact are necessary to teach the concept of cause and effect, as well as to reinforce the development of adaptive coping strategies. Natural consequences can include, picking up messes made, replacing things that have been broken, apologizing to those who have been hurt emotionally or physically. Consequences such as losing a favorite toy, missing recess or being “grounded” often do not result in any long-term behavior change.

When should a child be referred to a psychologist or other mental health professional for treatment of a behavioral disorder?

If a child’s behavioral difficulties are ongoing and do not seem to fluctuate or respond to interventions it is best to refer the family for more intensive professional support.


This Month's Featured Author: Susan Giurleo, PhD

We thank Dr. Giurleo for providing us with this months Q&A.

Susan Giurleo is a licensed psychologist and coach to families living with children diagnosed with ADHD, autism spectrum and/or learning disorders. She founded Child Development Partners as a means to share accurate, specific, useful information about these disorders, as well as to provide a forum for parents to learn skills and tools to support their children and the family as a whole.

She has a PhD in Counseling Psychology and extensive experience counseling and coaching children, adolescents and families on issues of behavioral and emotional control, organization, and academic success. Susan has also worked for several years as a school psychologist and understands the realities of what it means to live with attentional, social, and learning disorders in the school setting.

Susan sees and appreciates the special gifts of children with "quirky" social, emotional and learning styles. She sees each child as unique, with strengths and weaknesses. Her coaching philosophy is to develop everyone's strengths as a means to support those areas that need improvement. Children with ADHD, autism spectrum and learning disorders are not seen as mentally ill, unstable, or in need a being "fixed." Through her newsletter, workshops, tele-seminars and coaching programs Susan provides families the information, tools, skills, and support they need to bring peace, calm, organization, and joy to living with children who are unique in the ways they perceive and communicate.

Susan lives in suburban Boston, Massachusetts, with her husband and 6 year old son.

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