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Children & Problem Behaviour - The Clinical Difficulties
By James Keightley of giggleberries
Few children grow up without problems and deciding what behaviour is normal or abnormal can be problematic, as it is widely accepted that it follows from social norms and is socially constructed. Variations between cultures and societies as to how problems are measured and perceived generate inherent difficulties in being able to develop a clinical formulation and there can be no wholly objective measure of what constitutes problem behaviour. Therefore, any approach to arrive at a suitable formulation needs to adopt a holistic and constructive understanding of the contexts in which problem behaviours manifest. I therefore intend to discuss the social construction of problem behaviour and how this and the varying perspectives of behaviour create problems in developing a clinical formulation. Herbert (1991) explained that problems are manifestations of emotional, behavioural and social responses common to all children and become a problem when it is abnormally intense, inappropriate, lacking or highly frequent. However, there is no prescriptive measure for what is abnormally intense, inappropriate or what should be present that is lacking and how frequent or infrequent behaviour should be. Children with problem behaviour rarely refer themselves for treatment and it is inevitably reported by a significant adult, usually the parent or perhaps a teacher. Consequently, judgements can be very subjective and influenced by the beliefs and values of the individual and that raises questions as to ‘who’s problem it is, the adults or the child’s? What might be viewed as inappropriate behaviour by one may not be inappropriate for another. Crying, tantrums, clinginess, sulking and being withdrawn are all developmentally normal behaviours, but the context in which they are considered appropriate varies from person to person, in different societies and cultures. We only have to look at Whiting & Whiting’s (1975, p.10) ‘Six Cultures Project’ to see how developmental expectations can vary between cultures to realize that not all cultures regard behaviour to be a problem in the same way as others. They discovered that it is the varying agendas that each culture has of children, which influence the developmental expectations of not only their capacities and nature, but also their behaviour. For example agricultural and less complex cultures place higher expectations on independence, which Bronfenbrenner (1979, p. 51) stated is valued by some cultures as having ‘ecological adaptiveness’ and yet, which others describe as disobedient. It might be argued that it is the extent to which a child achieves a ‘goodness of fit’ to the demands and expectations of its own cultural and social norms that determines if others perceive behaviour as problematic. This is extended by Achenbach et al (1987, p. 50) who claims that a child’s ‘goodness of fit’ to its social demands and expectations may not transcend and are context embedded, as different contexts offer different opportunities and place different demands on children. The standard of behaviour expected from children may vary or the relationship patterns with children may differ and those making the judgements may vary in the expectations of children’s behaviour. This is supported by Achenbach demonstrating from ‘Meta Analysis’ that there was only a very modest agreement between parents and teachers as to what they considered was problem behaviour, illustrating the variations that exist in judgement. The contexts found within family dynamics is a powerful example in which problem behaviour can manifest itself. This is illustrated by Haley (1976, p.283) who explains that a child’s behavioural problems can be the consequence of them trying to deal with the demands and influences faced within the context of the family environment. These can include them behaving in away to achieve what she describes as ‘conflict detouring’, ‘enmeshment’ or ‘distortion of reality’. These are all intended to allow the child to gain a sense of control and ability to cope and can result in the behaviour of the child becoming passive or active adaptations of the parents direct behaviour.
These circumstances illustrate the importance of being able to understand exactly the contexts experienced by a child in order to gain an insight in to the cause of its behaviour and to develop a clinical formulation. Consequently, the development of any clinical formulation requires not only a holistic approach, but also the development of a constructive relationship with a child based on sympathy and empathy in a way that Rogers (1955) termed as ‘Non Evaluative Warmth’. Kelly (1955) also postulated the significance of adopting a ‘Reflexive Position’ where one is able to have curiosity and question the extent to how the child’s experiences are similar or different to our own. Thus, psychological concepts to therapy seek to develop clinical formulations that are based on a rational and empirical approach, grounded in scientific theory and method. Adopting a ‘cultural line’, they consider children as social beings connected with others and recognizes the social factors that are important in the development of behaviour. The emphasis is on treating the cause and not the symptoms. This is in contrast to a more prescriptive medical approach, which has a danger of labelling problems in a way that can be a device for avoiding further thought and serve to create a gulf between a maladjusted child and those considered better adjusted. Clinical formulations of therapies can usually be differentiated along two dimensions; problems located within the child vs. problem in the child’s environment and therapies focusing on current behaviour vs. therapies focus on past behaviour (Kazdin 1988, p. 284). Consequently, it is not only important for clinical formulations to take a holistic approach but also to consider the transactional nature of both personal and situational influences on behaviour. Therefore, few involve only one method, but usually include common variants of techniques from several methods so that clinical formulations are tailored to the individual needs of the child. There are broadly three types of psychotherapy; behavioural therapies, talking therapies and group therapies. They each have their own advantages and disadvantages and highlight the difficulties of developing psychological therapies. Behavioural therapy sees the modification of learning, unlearning or re-learning behaviour and is understood by focusing on current behaviour, causation and future outcomes. It works on the premises that normal and abnormal behaviour share the same hypothetical laws and principles of learning and unlearning. This clinical approach views children as machine like; reacting to external influences in a predictable manner and adopts a behaviourist perspective advocated by Skinner (1904 – 1990, p. 22) that sees the child as relatively passive and whose behaviour is capable of being shaped by direct input from the therapist. It considers that problem behaviour can be unlearnt in the same way that that it was learnt, by reinforcing desired changes through ‘classical’, ‘operant’ and ‘social’ conditioning. This behaviourist approach acknowledges the power of social influences on children’s behaviour and has a number of advantages in allowing an appropriate clinical formulation to problem behaviour to be developed. The ecological usefulness of this type of therapy is extended by behaviour therapy allowing others, such as parents and teachers, to take part in the treatment and that can be implemented in a number of settings, which facilitates the ease of a constructive relationship between the therapist and child. It also relies on observable behaviour and so subjectiveness is minimized and treatment is also easy to demystify, making the child more motivated without demanding high levels of verbal ability. However, criticisms have been levelled at the imbalances in the power relationship between child and therapist known as ‘Pindown Regimes’ (Levey & Kahan 1991) resulting in a child possibly finding it difficult to articulate anxieties. On this analysis it has also been argued that such imbalances can allow therapists to pursue an ego trip, which is counter productive to developing a clinical formulation. Also, the context in which therapies takes place are not always reflective of the contexts in which problem behaviours manifest and due to a lack of ecological validity, any behavioural improvements may lack permanency. Therefore, treatment may be required to be more reflective of real life contexts and conditioning, and offer a more even keel on which children are able to express anxieties. The clinical formulation offered by talking therapies addresses some of theses concerns and are underpinned by Freudian perspectives. They focus on conversations to understand the source of difficulties that exist in a person’s unconscious coping mechanisms and that manifest themselves in maladaptive behaviour, which therapists seek to unravel in order to adjust behaviour. This is a popular approach as it facilitates a strong constructive relationship with the child and overcomes issues of empowerment, an important feature of understanding the child’s problems. However, it is not without criticisms as it is considered that children are less able to make use of the verbal insights offered by the therapists. Additionally, Freudian approaches usually seek to expose underlying motivations that are sexual in nature. These were also supported by Melanine Klien, a strong proponent of such perspectives and who subscribed to views that advocated unwavering certainty about the psychosexual nature of children’s problems. Consequently, it has been considered that people who may have been able to contribute to therapeutic approaches are uneasy about the roots of such therapeutic origins and are put off, and makes a holistic approach more difficult to achieve. However, group therapies are a further alternative approach to developing a clinical formulation as they consider that as we live, experience and define ourselves in relation to groups, they are an equally important holistic approach to therapy. Groups are used as a medium for ameliorating difficulties and offer the benefits of using group dynamics to shape behaviour through positive and negative feedback, without the unwanted stigma attached to other forms of therapy. This type of therapy uses the dynamics of a group to gain the greatest holistic approach that individuals within the group can offer in terms of acting as prompters and reinforces to the insights being gained. However, this type of therapy does have its limitations as it is generally only considered appropriate for older children and adolescents due to the peer social pressure that can be encountered. Whilst behavioural therapies do acknowledge some social learning, they still view the child as relatively passive, acting and being able to be treated in predictable ways that share common laws, and capable of being influenced purely by environmental influences. In this sense the approach to behaviour and therapies seems relatively fixed and prescriptive and less holistic in its approach, adopting an empiricist view that dismisses internal influences over the development or unlearning of problem behaviour. In contrast, talking and group therapies adopt a more social constructivist perspective to clinical formulations. They see the child as much more active in both the ability to develop and change their behaviour and not just as solitary thinkers. These work on the premise that children are able to internalise information from social interactions to bring about qualitative changes and that a transactional process exists between child and environment. On reflection it can be seen that social contexts play a significant part in the construction of problem behaviour, which are context embedded. The variation between societies and cultures results in differing perspectives on behaviour, to the extent that there is never a single objective measure. In stead judgements are subjective and make developing a clinical formulation difficult. However, it can be argued that a holistic and constructive understanding makes locating the cause and formulating treatment better. Behavioural, talking and group therapies are evidence of some of these formulations, that adopt various methods and illustrate to varying extents that wider holistic perspectives and deeper understanding of the social and cultural demands or issues faced by a child improves clinical formulations. Consequently, it can be argued that a child can not be treated in isolation to any one method, that relationships between child and therapist are crucial and that a multi method and holistic approach provides for a more creative formulation to individual therapeutic solutions for problem behaviour.
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Thanks for nice topic.
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This intel was contributed by Jimbob
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February, 2012
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