Managing Challenging Behaviors

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. 

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. 

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 

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 

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

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.  

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.

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.  

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!”) 

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? 

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. 

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 

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.