Keywords

Origin of Behavior Problems

Disruptive behaviors including aggression, property destruction, hyperactivity, defiance, and self-injury are the most common reasons prompting a young child’s referral to mental health services (Kazdin, 2008). These children may receive a diagnosis of oppositional defiant disorder (ODD), characterized by angry and irritable mood, argumentative and defiant behavior, and vindictiveness, or conduct disorder (CD) , characterized by a disregard for the rights of others including aggression, destruction of property, deceitfulness or theft, and violations of rules (American Psychiatric Association, 2013). In the United States, 4.6% of children aged 3–17 years received a diagnosis of ODD or CD , with a higher prevalence among boys (6.2%) than girls (3.0%) (US Department of Health and Human Services, Centers for Disease Control and Prevention [CDC], 2013). Among Latino children, approximately 4% had received a diagnosis of a behavior problem (CDC, 2013). While relatively few preschool-aged children are diagnosed with a psychiatric disorder, researchers have estimated 13–21% of 1–5-year-old children consistently exhibit high levels of disruptive behaviors that pose significant challenges to their caretakers (Carbonneau, Boivin, Brendgen, Nagin, & Tremblay, 2015). Estimates of children living in urban environments who exhibit moderate to clinically significant emotional and behavioral problems may even range as high as 30% (Barbarin, 2007). The typical onset of these disruptive behaviors begins very early in life and, if left untreated, may lead to mental health and social adjustment problems as the child matures into adolescence and even adulthood, including academic impairment, peer rejection, and unemployment (Carbonneau et al., 2015; Odgers et al. 2007).

Many factors influence the development of behavior problems in early childhood, including the parental use of verbal (Berlin et al., 2009) and physical punishment (Gershoff & Grogan-Kaylor 2016), parent marital status and cohabitation (Fomby & Estacion, 2011), maternal mental health (Goodman et al., 2011), child temperament (Rubin, Burgess, Dwyer, & Hastings, 2003), attachment style (Fearon, Bakermans-Kranenburg, Van IJzendoorn, Lapsley, & Roisman, 2010), parental expectations (Mattek, Harris, & Fox, 2016; Solis-Camara & Fox, 1996), and a myriad of stressors endemic to poverty (Santiago & Wadsworth, 2011; Wadsworth et al., 2008). Latino children, especially those in immigrant families, may be exposed to additional risk factors due to acculturation stress, low English language competency, overcrowded housing, and being disproportionately affected by poverty (Leidy et al, 2012). In 2014, Latino children accounted for the highest proportion of children living in poverty (36%), relative to Caucasian (30%), African American (26%), and Asian (3.31%) children (US Census Bureau, 2015). Similarly, researchers have suggested that poverty affects children indirectly through their parents as poverty leads to an increase in parental stress (Wadsworth et al., 2008). Researchers also have demonstrated that Latina mothers of children referred to clinical services for their child’s behaviors showed more frequent use of verbal and physical punishment and less nurturing than in non-referred mothers (McCabe & Yeh, 2009; Perez & Fox, 2008).

Latino Cultural Factors

While a similar presentation of early behavior problems appears across cultures (Crijnen, Achenbach, & Verhulst, 1997), cultural values unique to the Latino population may impact the course of such behaviors as well as inform best treatment methods. These Latino values include familismo, machismo, marianismo, respeto, personalismo, and simpatía (Arcia, Reyes-Blanes, & Vazquez-Montilla, 2000; Barker, Cook, & Borrego, 2010; Calzada, Fernandez, & Cortes, 2010; Castillo, Perez, Castillo, & Ghosheh, 2010). Adherence to and identification with these constructs vary greatly between and within families. However, a general understanding of these cultural constructs as well as their influence on family functioning will aid the clinician responsible for delivering culturally sensitive mental health services. Clinicians should be sure to have a conversation with the caregivers regarding their cultural beliefs and values and how they play out in daily family life.

Considered the foundational value of Latino culture, familismo is generally defined as the emphasis on family unity and collectivism (Ayón, Marsiglia, & Bermudez-Parsai, 2010). It encompasses many values such as loyalty and support, as well as the expectation that each family member respects, participates in, and places family responsibilities above individual desires (Santisteban, Muir-Malcolm, Mitrani, & Szapocznik, 2002). It also should be noted that familismo extends to non-blood members of the family, such as close family friends (compadres) and godparents (padrinos). Another expectation of familismo is keeping problems private and within the family, which has been shown to decrease mental health service utilization (Villatoro, Morales, & Mays, 2014).

Like familismo, respeto also encompasses a diverse array of values, including obedience, respect for elders, upholding family honor through appropriate manners and behavior , and adherence to traditional gender roles. It also functions in the hierarchical understanding of social relationships within Latino culture (Antshel, 2002). Machismo and marianismo are the culturally prescribed roles of men and women, respectively (Castillo et al., 2010; Glass & Owen, 2010). Although machismo often connotes male domination, holding power over women, and hypermasculinity, it also may include more family responsibility, a positive work ethic, and respect for women and the family (sometimes viewed as caballerismo). Marianismo encompasses the qualities and expectations derived from the Virgin Mary that Latina mothers are expected to embrace, such as virtue, chastity, humility, self-sacrifice, and spirituality, with women considered as the primary caregivers and nurturers within the home (Rocha-Sanchez & Diaz-Loving, 2005).

Definitions of personalismo and simpatía tend to overlap and generally refer to a dislike of competition and confrontation and a desire for warm, trusting relationships and social politeness (Antshel, 2002). These two constructs are especially important to consider in creating the therapeutic relationship, as they tend to include expectations for mutual self-disclosure of personal experiences over less impersonal information and warm interpersonal interactions (Donlan, 2011). Developing a warm, interpersonal relationship between the family and therapist will aid clinicians working with Latino families to achieve better outcomes and client satisfaction (Parish, Magana, Rose, Timberlake, & Swaine, 2012).

Gold Standard Treatment for Behavior Problems

Research on the effectiveness of treatment programs for behavior problems in young Latino children has recommended they should be family oriented and culturally adapted and delivered by Spanish-speaking facilitators (Bandy & Moore 2011). However, there are relatively few evidence-based programs available for very young children with behavior problems in general and even fewer for children from diverse families living in poverty, including Latino children (Fung & Fox, 2014). Early Pathways (EP) , a home-based mental health program for young children with behavior problems, was initially developed to serve children 5 years of age and younger, primarily from a diverse population of families living in poverty (Fox & Holtz 2009). EP has since been culturally adapted to serve young Latino children and their families and has undergone rigorous efficacy testing with very positive outcomes and large effect sizes (Fung & Fox, 2014; Fung, Fox, & Harris, 2014).

EP also has been recognized as a highly effective, evidence-based treatment program for addressing behavior problems in young children by the Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices (NREPP) . EP’s theoretical foundation includes a strong developmental perspective and a primary emphasis on the central importance and quality of the parent-child relationship, along with the use of cognitive behavioral strategies for both the caregiver and child. As such, EP initially requires the development of a trusting relationship between the clinician and caregiver(s), and most parent worksheets are designed to facilitate the therapeutic process as well as achieve positive outcomes for the child and family. EP was designed for use by qualified professionals who when working with Latino families in their homes should have the following: (1) cultural sensitivity and supervised experience working with Latino families; (2) either speak Spanish or have a translator available (which makes therapy a much more arduous process); (3) comfortable in conducting therapy in the child’s home; (4) a solid foundation in early childhood development and its myriad of contributing factors; and (5) ability to tailor cognitive behavioral strategies to the unique circumstances of each family.

Treatment Plan

In general, the program requires 8 consecutive weeks of 1 h weekly sessions to complete, depending on how quickly the caregiver can learn and implement the strategies as well as manage the unique referral concerns presented by the child. The subject of each session plan may change in response to the individual needs of the caregiver and child, the goals of treatment, and the potential gaps in parenting knowledge. So, the EP therapist needs to be very flexible, “think on their feet,” and be prepared to intervene with any strategy in the program that is warranted. As a general rule, the child’s safety trumps everything else. Typically, clinicians have found it helpful to introduce a developmentally appropriate discipline strategy (e.g., time-out) much earlier if the child’s challenging behavior poses a threat to their safety or the safety of others and if the parent becomes easily frustrated and has a history of using frequent verbal and physical punishment. Consequently, the following treatment schedule should be used only as a general guide.

Session 1: Establishing Rapport and Conducting Assessment

The first session should be used to develop initial rapport with the caregiver and child, as well as gain a clear understanding of the child’s challenging behaviors by conducting an extensive intake interview. The intake typically includes an assessment of the child’s challenging and positive behaviors (Worksheet 1a), a caregiver interview, and therapist observation, during which the therapist and caregiver identify one to two challenging behaviors and one positive behavior as the foci of treatment. The therapist should assess the frequency, intensity, and duration of the child’s behavior to determine whether it is typical or clinical and if it occurs across home and community settings; determine the degree to which a young child’s behavior affects the child’s and family’s daily functioning; and identify potentially contributing risk factors relevant to a young child’s behavior (e.g., mom’s age and experience, how many children are in the home, caregiver support system, etc.). This is important to ensure appropriate, effective treatment is given and to prevent therapists from treating nonbehavior problems (i.e., medical problems) with psychological interventions. If there is a possibility of an underlying medical condition (e.g., ear infection), the child should have a thorough physical examination before starting EP. The intake information should be recorded and used to create treatment goals, which are then discussed, agreed upon, and written on the treatment plan (Worksheet 1b). It is important to introduce the EP treatment program and give the caregiver a concrete idea of their expected level of involvement and the daily effort it requires. Any advocacy needs of the family (e.g., housing, food, medical care) should be addressed and resources should be provided.

Session 2: Introduce the EP Treatment Program and Behavior Plan

The therapist and caregiver should begin by reviewing the treatment plan. The majority of the session should be used to establish positive family foundations by teaching, demonstrating, and practicing child-led play (Worksheet 2a). During child-led play, the child is allowed to select what they would like to play with as the caregiver takes a nondirective approach and comments positively on what the child is doing. Therapists should explain the caregiver’s role as being “like a sports commentator,” positively commenting on what is happening in play without questioning, criticizing, or telling the child what to do next. The therapist should also introduce praise and rewards as ways to improve the caregiver-child relationship and reinforce prosocial behaviors (Worksheet 2b). If the child does something the caregiver wants, such as cleaning up their toys following play, the caregiver can tell them “good job picking up your toys!” or give a reward (e.g., small prize or a sticker). The therapist should help caregivers identify positive nurturing activities, like child-led play or reading together, that the child and caregiver enjoy and can engage in together. At the end of the session, the therapist and caregiver should complete the behavior plan (Worksheet 2c). The behavior plan specifies what the caregiver should do to implement the treatment plan during the coming week and to track the caregiver’s progress with treatment strategies. A new behavior plan is created each week to fit the treatment material covered in that particular week and includes both challenging and positive behaviors with their corresponding treatment strategies. The therapist may include reminders for areas that the caregiver may be struggling with and use the space provided for caregivers to track their implementation of treatment strategies through the week. The therapist may also use the treatment report to track progress (Worksheet 2d). The therapist should continue to address any advocacy needs of the family at each session.

Session 3: Psychoeducation : Cognitive Behavioral Strategies

The therapist should begin each session by reviewing the behavior plan from the previous week and allowing time for child-led play. The focus of session 3 is psychoeducation about developmentally appropriate expectations and cognitive behavioral strategies for understanding behaviors. The clinician may begin this conversation by introducing what a behavior is and help the caregiver identify differences between behavior and the child’s personality/temperament (Worksheet 3a). The therapist should explain that children often behave in ways to get their needs met, and so they have learned a behavior because at some point in time it was effective. Behaviors are therefore not about the child being “good” or “bad” but about the child performing an action to get a desired response. An easy way to describe behaviors is “anything you see or hear your child doing,” while a label is a description of a child as an individual. Labeling a child as “bad” can hamper the child’s self-concept development. Once this distinction has been made, the therapist can illustrate what contributes to behavior by identifying components of behavior cycles (Worksheet 3b). Behavior cycles are a way of describing how a caregiver and child interact in both positive and negative ways. It includes the child’s behavior, the caregiver’s thoughts and feelings, the caregiver’s reaction to the behavior, and what the child learns from the interaction. The therapist and caregiver should use one of the target behaviors and go through the behavior cycle being sure to incorporate how the caregiver’s thoughts and feelings contribute to their child’s behavior. The therapist should then practice this strategy in session with the caregiver when applicable, fill out a new behavior plan with the caregiver, and complete the therapist treatment report.

Session 4: Psychoeducation : Promoting Positive Behaviors Through Thoughtful Responses

The therapist should collect the behavior plan from the caregiver and allow time to practice child-led play in session. The therapist should then review and build upon behavior cycles by introducing PARE y PIENSE (STOP and THINK) (Worksheet 4a). Following a behavior, caregivers should “PARE” (“STOP”) before responding to give them time to calm down. Offering anger management suggestions may be appropriate if the caregiver has difficulty calming down. The second step is “PIENSE” (“THINK”) to allow the caregiver to reflect on their thoughts and feelings (e.g., “My child is just like his father,” anger, embarrassed). They should then think about their expectations for the child and examine if they are appropriate before engaging in a thoughtful response to the behavior. The therapist may add this component using “PREGUNTE” (“ASK”) if it is easier for the caregiver to remember this very important step by using an additional “P” word. This strategy will help the caregiver begin to understand how they can alter behavior cycles by examining their reactions to their child’s behavior. Their responses should discourage negative behaviors and encourage positive behaviors. For example, if the child has taken a toy away from a playmate, the response might be to have the child practice sharing a toy, instead of just reprimanding the child for the bad behavior. By offering the child what they should do instead, the caregiver has given the child a new, positive behavior to replace the old, negative behavior when the situation occurs in the future. The therapist should also use a prosocial behavior and explain how the caregiver can use PARE y PIENSE to reward good behaviors and encourage their future use (see Worksheet 2b for examples of rewards and praise).

Session 5: Improving Communication: Giving Effective Requests

The therapist should collect the behavior plan from the caregiver and allow time to practice child-led play in session. The therapist should then discuss giving effective requests with the caregiver. Very young children only comply with about 50% of parental requests, so giving effective requests that are necessary, clear, and simple is important in achieving optimal compliance. The caregiver can use PARE y PIENSE to consider if their request is developmentally appropriate. Similarly, instructions for tasks requiring several actions, such as getting ready for bed, should be broken down into small steps, such as “Time to brush teeth” and then “Now it’s time to put on our pajamas.” Preparing children for transitions between activities, especially if the child is involved in play or finishing a drawing, can help compliance. Using natural breaks, such as after dinner, can also be helpful for children who usually do not understand time concepts. Along with considering the timing of their requests, caregivers should pay attention to how they give the request, being sure to establish eye contact, and use very simple statements. The request should only be repeated once, and then assist the child with completing the task. Offering the child a choice (“either you can put on your pajamas or I can help you”) sometimes persuades them to be independent and complete the task on their own. The therapist should stress that following through on the request is important to show the child that the caregiver means what they say. The therapist can demonstrate following through during session, for example, by gently using a “hand-over-hand” technique if a child refuses to pick up toys where the therapist places his/her hand over the child’s and gently helps him/her pick up a toy and put it away. Once the child complies with a request, even after using hand-over-hand technique, the caregiver should praise the child with direct feedback, “Thank you for picking up the toys!” The therapist can give the caregiver the “escuchando” (“listening”) worksheet to practice giving good requests and rewarding compliance during the session (Worksheet 5a). The therapist and caregiver should also check in on goals and strategies used when filling out the behavior plan (Worksheet 2c) and therapist treatment report (2d).

Session 6: Establishing Home Routines, Supervision, and Planning Ahead

As young children do best when their world is predictable, the therapist should help the caregiver establish a daily home routine, taking into consideration the amount of close supervision a young child requires. To facilitate this discussion, the therapist should ask the caregiver to describe a typical day in the life of their child, from waking until bedtime. Using the “routina diaria” (daily routines) worksheets (6a, 6b) may be helpful to establish a daily routine of activities, with the therapist making suggestions to improve the routine, if needed. For example, establishing a standard bedtime is a good start. The therapist can also help the caregiver identify steps they can take to help the child with a disruption in the regular routine or with a transition. This may involve telling the child what they can expect well before the disruption will take place. For example, if the child must go to a doctor’s appointment, the caregiver can tell the child the day before and remind him/her in the morning of the day’s plans. The caregiver can also prepare to bring toys or other necessary things to help the child with the transition and at the appointment.

Session 7: Discipline Strategies

The therapist can begin the discussion of discipline with the caregiver by stating that the word discipline (both in English and Spanish, la disciplina) literally means to teach, and it should not be viewed as punishment. Discipline involves setting reasonable limits for children’s challenging behaviors to teach them what behaviors are expected and what behaviors are not acceptable. Discipline helps young children gradually develop self-control and does not include teasing, name-calling, belittling, harassing, or physically hurting children. Research shows corporal punishment has an opposite effect than caregivers expect; that is, the more a caregiver uses physical punishment, the more problematic behaviors a child demonstrates (Gershoff & Grogan-Kaylor 2016). However, this is a sensitive topic that often is fully integrated into a caregiver’s belief system about child-rearing. The therapist may find it helpful to have the caregiver describe their own experiences with verbal and physical punishment, listing the negative and positive aspects from their perspective. The therapist may introduce the EP discipline strategies as alternatives to punishment that have been proven to reduce challenging behaviors through years of research.

The first discipline strategy is redirection , to distract or redirect the child to more appropriate behavior before the challenging behavior can occur. For example, if a child is told he cannot have a toy, which normally results in a tantrum, redirecting his attention to another activity may prevent the tantrum. Taking precautions, such as “baby proofing” the house by locking cabinets and putting dangerous objects and substances out of reach, may prevent naturally curious children from getting into harm’s way. Similarly, if a child is caught drawing on a wall, a caregiver can redirect the drawing to an appropriate piece of paper. The second technique, ignoring (Worksheet 7a), is useful for children who act out for attention. By not giving the child the attention they seek, the caregiver is not reinforcing the acting-out behavior. For example, if a child screams to get her caregiver’s attention, the caregiver can ignore this behavior, wait until the child stops screaming, and then calmly redirect the child to a more appropriate way of getting the caregiver’s attention. After ensuring the child is safe, a caregiver can also use ignoring during tantrums. The third technique, natural consequences (Worksheet 7b), teaches children their actions have consequences. The consequence should not be fun or harmful to the child and should logically follow from what the child did. For example, if a child throws a toy, the natural consequence of throwing the toy is not getting to play with it. Similarly, if a child spills milk, the caregiver should have the child help clean it up. The last discipline technique, time-out, should be used after trying redirection, ignoring, and natural consequences, or if they are not practical given the behavior. It is recommended that aggressive behaviors such as hitting, kicking, or biting be given a time-out. The therapist should use the time-out worksheet (7c) with the caregiver and go through the time-out procedure, demonstrated during session when possible. As a general rule, the child should be in time-out 1 min for each year of age (age 2, 2 min time-out), and the time-out location should be neutral (chair in the corner of room), not scary (dark closet).

Session 8: Behavior Maintenance and Treatment Evaluation

The final session should be used to review the strategies, check in on goals, and conduct posttreatment assessment to compare progress with pretreatment assessment scores (Worksheet 1a). This time should also be used to problem-solve issues that arose in implementing the treatment plan. It is recommended that the therapist fill out a behavior plan (Worksheet 2c) with the caregiver as an “ongoing behavior plan” to help maintain treatment gains. The therapist should address any further advocacy needs and make appropriate referrals if necessary. Therapists may also choose to do a “closing activity” to congratulate the family on their progress and reflect on their time spent together. For some parents, additional sessions will be needed to reach the treatment goals.

Treatment Plan Summary

This treatment plan summary has been adapted from Early Pathways.

Component

Session plan/goals

Worksheet

Establishing rapport, conducting intake assessment, and creating a treatment plan

Complete an intake evaluation (1a)

Introduce EP

Develop initial treatment goals

Develop initial treatment plan (integrate with intake assessment findings) (1b)

Address advocacy needs of child/family

1a, 1b

Review treatment plan,

establish positive family foundations,

introduce behavior plan

Review treatment plan with caregiver (1a)

Describe and implement child-led play (2a)

Introduce praise and rewards, and identify ways for parents to effectively praise their children (2b)

Introduce nurturing and identify positive nurturing activities

Introduce behavior plan (2c)

Complete therapist treatment report (2d)

Address advocacy needs of child/family

2a, 2b, 2c, 2d

Psychoeducation, cognitive behavioral strategies

Collect behavior plan from parent

Practice child-led play

Introduce behavior, identify differences between behavior and personality/temperament, and discuss what contributes to behavior (3a)

Identify components of behavior cycles (3b)

Revise treatment plan (if need be)

Complete behavior plan and treatment report (2c, 2d)

Address advocacy needs of child/family

3a, 3b, 2c, 2d

Psychoeducation,

promoting positive behaviors through thoughtful responses

Collect behavior plan from parent

Practice child-led play

Identify main components of STOP and THINK (PARE y PIENSE) cognitive strategy (4a)

Identify positive situations when using PARE y PIENSE is appropriate

Identify appropriate developmental expectations

Identify appropriate strategies to improve child’s listening

Identify how to teach families to develop household routines

Complete treatment report

Address advocacy needs of child/family

4a

Improving communication, giving effective requests

Collect behavior plan from parent

Practice child-led play

Review and practice child-led play and PARE y PIENSE

Identify how to give effective requests using simple, goal-oriented language (5a)

Discuss the use of positive reinforcement to promote listening

Complete behavior plan and treatment report (2c, 2d)

Address advocacy needs of child/family

5a

Establishing home routines, supervision, planning ahead

Collect behavior plan from parent

Practice child-led play

Complete treatment report

Collect behavior plan from parent

Practice child-led play

Review and practice child-led play and PARE y PIENSE

Help caregiver establish a daily home routine, taking into consideration the amount of supervision a child requires Identify steps caregiver can take to help child with a disruption in the regular routine or with a transition

Address advocacy needs of child/family

6a, 6b

Discipline strategies

Complete treatment report

Collect behavior plan from parent

Practice child-led play

Review and practice child-led play

Review STAR parenting model

Identify developmentally appropriate responses (discipline strategies) for a child’s challenging behaviors

Address advocacy needs of child/family

7a, 7b, 7c

Behavior maintenance and treatment evaluation

Complete treatment report

Collect behavior plan from parent

Practice child-led play

Problem-solve issues that arose in implementing treatment plan

Discuss maintenance of treatment gains with caregiver

Review and practice child-led play

Review STAR parenting model

Review discipline strategies and their implementation

Review overall treatment progress

Address advocacy needs of child/family