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Deep Dive

Managing Challenging Behaviors

Ages 3 - 17

All children sometimes act in ways that are difficult to manage. However, some children display challenging behaviors more often than others.These tips should help you to understand these behaviors within the context of your child’s development, and use strategies to help manage them.  It can help to remember that behavior is communication, and adults respond best when they understand what and why the child is communicating.

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Managing challenging behaviors

Children often behave in ways that are challenging to adults.  In many cases, these behaviors are a normal and healthy part of development. Children often behave in challenging ways because they: 

  • Are becoming more independent 

  • Know what they want, and what they do not want 

  • Have trouble waiting 

  • Do not understand other people well yet 

  • Do not understand the consequences of their actions 

  • May not have the language to say what they want or need 

  • Have big emotions, and get easily overwhelmed 

  • Do not have the skills to manage big feelings 

Luckily, simple strategies can usually help parents to guide their children through challenging moments. Everyone in a family can feel calmer knowing that children are usually able to behave in a way that feels safe and expected. 

Build a solid foundation with play

Just like adults, young children need to feel relaxed and safe in order to control their feelings and behaviors. Children feel best when they have a positive relationship with at least one primary caregiver.  Caregivers can help build (or re-build!) a strong foundation by setting aside special child-led playtime every day.  

Child-led play can be as short as five minutes.  Shorter is often better, so that caregivers can really focus on the child.   As caregivers get more comfortable, they may want to do it more often, or for longer. During child-led play, caregivers should: 

  • Let the child choose what to do 

    • Do not offer suggestions! This can be very hard for adults who are used to leading. 

  • Give specific praise about what the child is doing (Example: “You did such a nice job balancing that block!”) 

  • Listen to what a child says, and repeat it or paraphrase it (Example: “Yes, the plane is taking off!”) 

  • Imitate how your child is playing (Example: Sit at a table next to where the child is coloring, and color as well.) 

  • Describe what the child is doing. (Example: “You are tucking the baby into bed.”) 

  • Enjoy the time, and show the child that you are enjoying it with smiles, laughter, affection, and words. (Example: “Dancing with you is so much fun!”) 

Over time, child-led play sessions can lead to a more positive parent-child relationship, which is the foundation of adaptive behavior. 

Set children up for success

Like all people, children want to do well.  They want to feel success, mastery, love, and approval.  However, children often do not know what to do, or how to do it.  They might insist on doing things their own way, and do not understand when their way does not work.  They become easily overwhelmed, and do not have mature strategies to handle big feelings.  Adults can help to shape a child’s environment so that they are better able to: 

  • Understand what is happening 

  • Know what is expected 

  • Prepare for challenges 

  • Use strategies to calm down 

  • Feel seen and respected 

Make success more likely

Setting children up for success can mean: 

  • Having a daily routine 

    • A clear visual schedule helps children to understand the routine 

  • Making sure children get enough sleep, food, and drink 

  • Setting rules that make sense 

    • Are important 

    • Can be explained to the child 

    • Are consistent 

    • Are something the child can reasonably do 

  • Giving the child choices when possible 

  • Previewing new experiences or changes to routine 

    • Practicing what will happen 

    • Looking at pictures of what will happen 

  • Staying consistent with routine, behavior expectations, and consequences 

  • Taking a break or offering comfort when a child starts to have big feelings 

Children do well when they: 

  • Know what to do and how to do it 

  • Feel loved, safe, and seen 

  • Feel a sense of agency and control 

  • Feel comfortable physically and emotionally 

Find skill gaps

Adults are often confused about children’s behaviors.  They may wonder why a child "refuses" to do something that seems reasonable, or insists on doing something that seems unreasonable.   

Children’s behavior is easier to understand when adults think about what skills are required to complete a task.  In many cases, children may not have the skills they need to be successful in what adults expect. When a child is not doing something adults want them to do, the adults can ask: 

  • What skills are involved in this task? 

  • Which skills might be hard for the child? 

  • Could a gap in skills explain the child’s behavior? 


"Children may not have the skills they need to be successful in what adults expect."

Types of skill gaps

All children have gaps in skills.  They are new to the world, and are still learning just about everything.  Children with heart defects often learn in a different way from other children, and may have more skill gaps, larger skill gaps, or uncommon skill gaps.  Children often have gaps in: 

  • Understanding or remembering the steps of a task 

  • Language (both expressing themselves, and understanding what others say)

  • Physical strength, coordination, and endurance

  • Attention and focus 

  • Controlling their feelings and body 

  • Social skills 

  • Being flexible 

  • Managing sights, smells, sounds, tastes, and feelings 

  • Controlling impulses 

Examples of skill gaps and behavior

Skill gaps can explain many challenging behaviors. For example: 

  • Not sitting at the table could come from a gap in attention 

  • Hitting a yelling sibling could come from a gap in managing loud noises 

  • Not finishing homework could come from a gap in sustained attention

  • Running into a parking lot could come from a gap in impulse control 

  • Not following directions could come from a gap in language understanding 

  • Saying something mean could come from a gap in social skills 

  • Having a messy room could come from a gap in visual spatial skills

Respond to skill gaps

When adults realize that skill gaps are leading to challenging behaviors, then they can use this understanding to help the child. After identifying a skill gap, adults can: 

  • Teach the lagging skill 

  • Make the task easier, so that the child can be successful 

  • Feel compassion and understanding, rather than frustration or confusion 

Through this process, children eventually learn the skills they need to master more and more daily tasks.   

Work together to understand and solve problems

As they grow older and learn language, most children start to understand their own feelings and behavior.  From this point on, adults can work with children to solve behavior problems together.  

FIrst: listen to the child

The first part of the process is to understand the child’s perspective.   

The adult can follow these steps: 

  • Wait until the child is calm 

  • Calmly describe what they have noticed (Example:“I’ve noticed that you’ve had a hard time getting out of car at preschool.”) 

  • Calmly and neutrally ask the child what is going on (Example: “What’s up with that? Why do you think that’s happening?”)  

  • LISTEN to the child, remain open-minded, and try hard to understand their perspective. 

    This step takes a lot of patience! It is very important to hear and understand what the child says.  

  • Repeat back what the child said, and check that everyone understands each other. (Example: “So, you are saying that you do not like naptime since it is hard to lie still, and you do not want to get out of the car because you are worried about naptime? Is that right?”) 

Then: develop a plan together

The next part of the process is to figure out a solution together: The adult can follow these steps: 

  • Calmly say why the behavior has been a problem. (Example: “When you do not get out of the car at preschool, then I am late for work. I need to be on time for work since that is my job.”) 

  • Ask the child to help think of solutions to the problem.   

  • This step takes patience again! It is very important to hear the child’s ideas. Caregivers should be careful not to jump in with their own ideas, and instead let the child work on the process collaboratively. 

  • Suggest a solution that both the adult and the child agree on. Make sure the solution includes the child’s ideas.  (Example: “So, I will talk to your teacher, and see if you can use the swing and your fidgets during naptime instead of lying still.  And you are going to work on getting out of the car quickly. Does that sound right?” 

  • Agree to check in after a short period of time to see how well the solution is working. 

This problem-solving process is hard for many child.  It can also be hard for parents!

However, by starting to use this process early on, children learn important skills in self-regulation, self-understanding, communication, and problem-solving.   When families use these strategies regularly, they get easier for everyone.

Increase wanted behaviors

Caregivers can often identify behaviors that they wish a child would do more often.  For example, they might want the child to: 

  • Stay in their bed at night 

  • Sit during a meal 

  • Keep their shoes and coat on outside 

  • Take turns with a toy 

  • Complete their homework

  • Say hello when they see someone 

  • Hold hands in a parking lot 

One adults have identified a wanted behavior, the first step is to make sure the child CAN do the behavior.  If the child has a lagging skill, they may not be able to do what the adult is asking.   If the child cannot do the behavior, then it does not make sense to ask them to do it.  Once an adult is sure that the child has the skills to do the behavior, then they can help the child to do the behavior more often.  

How to encourage behaviors

Adults can encourage behaviors by: 

  • Associating the behavior with something positive (Example: putting a new nightlight and gentle music in the bedroom to encourage the child to stay in bed at night) 

  • Clearly telling and showing the child what behavior is expected, and what will happen if they do the behavior 

  • Praising the child (“Wow! You did a great job holding my hand to cross the street!”) 

  • Showing the natural positive consequence for the behavior (“Look, you shared your toy, and now your friend wants to keep playing with you!”) 

  • Giving an earned activity reward such as going on a swing, running a race, playing a game, using a device, or watching a show 

  • Giving an earned physical reward such as a sticker, token, treat, or other small prize (“You sat in the chair for a whole five minutes, so I’m putting this sticker on your chart!”) 

Decrease unwanted behaviors

Caregivers often can identify behaviors that they wish their child would NOT do.  For example, they might want their child not to: 

  • Run into the street 

  • Hit a sibling 

  • Pull out a feeding tube 

  • Scream in public buildings 

  • Color on the walls 

  • Jump off furniture 

Caregivers can use these six steps to help their child to reduce behaviors that are dangerous, maladaptive, or interfering: 


It can help to remember that behavior is communication, and adults respond best when they understand what and why a child is communicating."

1. Understand the behavior’s purpose

Try to understand the purpose of the behavior.  Ask and observe: 

  • When does the behavior happen? 

  • What happens before the behavior? 

  • What happens after the behavior? 

  • What does the child get from the behavior? 

    • Attention? 

    • Avoiding something they do not like? 

    • Doing something fun, satisfying, or soothing?  

    • An object, experience, or person they like? 

  • What could the child be communicating with the behavior? 

    • Feeling bored, sad, scared, or frustrated? 

    • Wanting a person, object, or experience? 

    • Feeling sick, tired, hungry, or thirsty, or uncomfortable? 

    • Being overwhelmed or confused? 

    • Wanting control or agency? 

    • Seeking a physical sensation? 

2. Reduce triggers

Try to reduce or eliminate the situations that lead to the behavior. Examples: 

  • If the child hits when people are too loud, give the child sound-protecting headphones. 

  • If the child refuses bedtime if they are not done with their game, then save long games for the morning or early afternoon. 

  • If the child yells and cries when they go somewhere new, preview new places by looking at pictures and talking through what will happen. 

3. Notice natural consequences

Many unwanted behaviors naturally result in something that a child does not like. Help the child to notice natural consequences for maladaptive behaviors.  When children understand that a behavior results in something they do not want, then they will often reduce the behavior. For example, tell and show the child: 

  • When you hit your friend, she walks away and does not want to play 

  • When you slam your truck, then it breaks and you cannot use it anymore 

  • When you pull out your feeding tube, then we need to put it back in 

  • When you do not keep your shoes on, your feet get wet and cold 

4. Set clear if/then consequences

Identify the most important interfering behaviors that are possible to change.  Agree on clear, consistent, and reasonable consequences for these behaviors.  Make sure all adults will use the consequences in the same way.  If the child is able to understand, tell and show the child which behavior will lead to which consequence.  

Examples of clear if/then consequences: 

  • If the child runs in a parking lot, then they need to hold hands.

  • If a child throws a tablet, then they lose the tablet for rest of the day. 

  • If a child shoves a peer, then they need to take a 5-minute break from playing. 

When a child does something that results in a consequence, adults should be calm and neutral.  They should avoid showing anger or criticizing the child. 

5. Reward positive behavior

Catch the child being good, and praise them for good choices.  The child needs to learn that they get more attention for making good choices than bad choices.  Examples: 

  • “I love how nicely you are using those blocks! You are being so safe with them and building such a great tower!” 

  • “Great job staying in your bed! You’re doing an amazing job controlling your body.” 

  • “I love the calm way you are waiting for your turn on the slide.” 

6. Offer replacement behaviors

Teach the child adaptive behaviors that could take the place of unwanted behaviors. Offer them these choices when they are likely to use an unwanted behavior. Examples: 

  • Hang a whiteboard, and encourage the child to draw on the whiteboard instead of the wall 

  • Buy a fun handle, and encourage the child to hold the handle when crossing a parking lot 

  • Provide a wiggle seat and allow the child to move around on the seat during a meal 

  • Teach the child to punch a pillow when they feel like hitting a person  

While working to reduce unwanted behaviors, caregivers should always remember that young children are changing quickly.  They are naturally learning new skills, practicing independence, and gaining control over their feelings and bodies. With patience and support, young children can become better and better at behaving in adaptive ways. 

Understanding behavior in context

When a child acts in a challenging way, it can help to remember that behavior is a form of communication. It is always embedded within a child's developmental stage, and within a relationship. When we try to understand what and how a child is communicating through their behavior, we can better anticipate, comprehend, and improve child behaviors.

This content was reviewed by a psychologist at Boston Children's Hospital.

Developmental care is best when it is local. Families local to Boston can receive care from the Cardiac Neurodevelopmental Program (CNP). Families from other regions can use the link below to find their local care team.

Behavior Analysis Certification Boardhttps://www.bacb.com/about-behavior-analysis/
Clancy, T., Jordan, B., de Weerth, C., & Muscara, F. (2020). Early emotional, behavioural and social development of infants and young children with congenital heart disease: a systematic review. Journal of Clinical Psychology in Medical Settings, 27, 686-703.https://link.springer.com/article/10.1007/s10880-019-09651-1
Dahlawi, N., Milnes, L. J., & Swallow, V. (2020). Behaviour and emotions of children and young people with congenital heart disease: A literature review. Journal of Child Health Care, 24(2), 317-332.https://researchoutput.csu.edu.au/ws/portalfiles/portal/51078874/34921076_Published_article.pdf
Parent-Child Interaction Therapyhttps://www.pcit.org/what-is-pcit.html
Think: Kidshttps://thinkkids.org/
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