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WHAT WE CALL IT MAY MATTER
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One of the most frequent questions I get from school personnel is "How do I know if this is a symptom or a behavior?" My usual reply is "Why do you want to know? Is it because if you think it's a behavior, you might use negative consequences, whereas if it's a symptom, you might handle it differently?"
If you were to think of a particular behavior as a "symptom," do you think it might change your reaction to the behavior or your strategy for handling it? Or what if you still called it "behavior," but called it an "involuntary" or "unvoluntary" behavior? Do you think it would change your approach? When someone asks "Is this intentional behavior or involuntary?" there are four implications to the question:
- That behavior is either one or the other
- That it is possible for us to know whether the behavior is voluntary or whether it is involuntary
- That if it's voluntary behavior, then it is "intentional" and the person has somehow chosen to engage in the behavior (on the assumption that we have "free will"), and
- That if it's a "symptom," it's involuntary (or unvoluntary)
This type of thinking often interferes with developing effective strategies. In my opinion, asking whether a particular behavior is "voluntary" or a "symptom" may be as unhelpful as posing the old "Is it Nature or is it Nurture?" question because -- with the exception of reflexes (like knee jerks) -- most behaviors involve higher-order cortical inputs from the brain and are modifiable on some level. For example, breathing is involuntary in the sense that we usually don't have to think about it, but it is also true that people can learn to regulate or modify their breathing (within limits). Does that mean that breathing is "voluntary?" Of course not.
The same type of thinking applies when we talk about neurological "symptoms." Some symptoms may be involuntary, while other symptoms may be primarily involuntary but be modifiable or have a voluntary component to them. Does that mean that they are all "voluntary" behaviors? Of course not.
If we were to change our language system, for the moment, so that what we were calling "symptoms" we now think of as "characteristic or probable behaviors under particular conditions," then how might that change our thinking? Does taking the behavior out of a medical (i.e., "symptom") model and into a psychological framework help us and the child? In my opinion, it does, as the "why" of the behavior may not be as helpful as determining "how" and "under what conditions" the behavior occurs, but it may be hard for parents to let go of the medical model, so let's deal with the reason that parents may get too vested in the medical model.
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PARENTAL FEARS AND GUILT
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For many parents, learning that the child has a condition or "medical problem" was both a relief and a source of fear, grief, and guilt. Relief to have a name and an explanation for why the child is acting the way they do and relief that their misbehavior isn't a reflection on their parenting skills, fear for their child's future, and grief over the loss of the perfect child. For many parents, there is also a strong component of guilt as parents berate themselves for all the times they may have scolded the child or punished them for behaviors that they now understand are part of the "diagnosis" or "disorder."
Having discovered that the child has a [disease, illness, condition], parents may become even more protective of the young child. The need for protectiveness is obvious to anyone who's parented such children, as they are often ridiculed for their symptoms, or asked to suppress symptoms that may currently be impossible for them to suppress.
"Don't ask Joey to do [x] because he can't." As a consequence of accepting the notion that the child's behavior is a symptom of a medical illness, the parent may often land up spending a lot of their time explaining to others why their child can't do what every other child is doing or why their child shouldn't be punished for doing what other children might be punished for.
Parents who try to explain to the child's school that these "behaviors" are really neurologic symptoms are generally doing so because of a fear that the child will be blamed for something that the parent has reason to believe that the child can't help or can't manage easily. They are instinctively trying to protect their child from a system that tends to punish departures from a fairly rigid set of expectations for how children should behave.
Just as some parents may "medicalize" or "overmedicalize" behaviors, some teachers attribute too much voluntary intention to the behavior. One of the most frequent examples I see of this in my work is teachers who, describing a child's tics or compulsions, characterize them as "attention-seeking" behaviors. In some cases, then, parents and teachers are polarized in their understanding or explanation of the child's behavior. In my experience, disagreements over the cause or voluntary nature of the child's behavior is one of the biggest sources of conflict and disputes between parents of children with neurobehavioral conditions and school personnel.
All too often, I think that what eventually happens is that the parent comes to believe that the child can't control very much of their behavior and the parent accepts too much as they stop trying to discipline the child at all for fear that the child's "symptoms" will become worse. Sometimes the notion of "accepting the child" gets taken to the extreme of not trying to help the child improve that which they need to improve.
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DISCIPLINE MEANS "TRAINING"
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Recognizing that we don't want to be harsh or punitive about something that the child really can't control, but that there are some behaviors that really are problematic, what would happen if we take punishment off the table? Would parents be more inclined to acknowledge that something needs to be addressed? Would parents and teachers find it easier to come up with an appropriate plan to help the student self-manage? My experience suggests that they would, but both parents and teachers need to share the goal of helping the child learn to self-regulate. If the teacher is stuck in the noncreative "He has to be taught a lesson for this by punishing him" mode, this won't work. The teacher is right on one level: the child does need to be taught something. But what you teach the child and how you teach the child will make a tremendous difference in whether the child learns to self-manage.
When a child is struggling behaviorally, I take a "no fault" approach to understanding and trying to change things. I start from the premise that for whatever reason, the child or adolescent is predisposed to have particular behaviors, and that in light of those strong predisposing factors, we need to carefully consider what kind of environmental supports the child needs if they are to modulate this behavior. I do not assume, however, that just because the parents and teachers may not like something that it makes it a target for intervention. As you shall see, there are certain "tests" a behavior has to pass before I would attempt any intervention that involved consequences to the child.
And the very first thing I change or try to change is not the child or adolescent, but what the parents and teachers do before anything happens.
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LIMITS OF BEHAVIOR MODIFICATION
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In my article "Reflections of a Former Rat-Runner," I describe a bit of my professional and personal history using behavior modification and explain that I do not think it appropriate or effective for some of the most problematic behaviors we see in children with neurobehavioral conditions (that article presents an alternative way to approach working with children). A few examples will suffice here, I hope, to show that not all behaviors are amenable to what is loosely referred to as "behavior modification."
Assume that a child has grand mal seizures. During the seizures, the child's arms and legs may flail. Suppose that in the course of one such seizure, someone standing by the child got kicked or hit. Would we then say that we should try to modify the child's arm-flailing by behavior modification? Probably not. Similarly, if a child has seasonal allergies and sneezes, would we try to modify their sneezing by consequences? For the most part, no, but:
We might try to teach the children in the above examples to take steps to reduce the problem or its impact on others. For example, a child who has some awareness that they are about to have a seizure can be taught to get themselves down or into a safer position to protect themselves; peers and teachers can be taught what to do and what not to do before and during the seizure. The child who is sneezing excessively can be taught to use a handkerchief and to turn their head so that they are not sneezing in others' faces; others can be taught not to make a big deal out of their peer's sneezing.
Makes sense, right? But how do we apply that same kind of rational approach to other behaviors? All too often, schools and parents jump to behavior modification plans that predictably fail. Why do they fail? Well, partly because most nonpsychologists do not have a sophisticated appreciation of how to do behavior modification properly. In the article "Pitfalls in Behavior Modification", you can find a description of some of the common problems that I've observed over the years.
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ACKNOWLEDGE THE NEED FOR CHANGE
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If a child or adolescent's behavior is causing problems for them, then it needs to be addressed. In contrast to the parents who throw up the "But it's a symptom" barrier or explanation, I'm suggesting that we all take a somewhat more temperate and what I think is a more realistic approach: that we recognize that even if something is a symptom, if it's problematic, it's problematic, and it needs to be addressed. Parents and school personnel should not waste time arguing over whether something is a 'voluntary behavior' or a 'symptom.' Instead, what they can (and should) do is see if they agree that the behavior is not in the child's best interest, and if they agree it's not, begin to put their heads together on what is the most effective way to approach the problem.
As suggested above, assuming that parents and school personnel agree that something is problematic, it does not necessarily follow that a behavior modification plan is the appropriate way to approach the problem. See if the behavior can pass "The Acid Test."
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