SUBJECT: Behavioral Issues and Behavior Plan Considerations

QUESTION: I am a developmental pediatrician seeking direction regarding my patient's difficulty cooperating, even after making choices, his poor compliance with medication, bedtime and car seats, and his need for one-on-one attention at home due to misbehavior related to impulsive hurting his dog, flushing his cat and objects down the toilet, pinching, biting, etc.

Are you aware of effective ways to break this cycle in an effort to develop more self-control for the long run? My thoughts include:

1. Giving him daily playtime with each parent in which he is in control and they are having fun together as a kind of reserve or bank of good times that will motivate him to be more cooperative.
2. Parent training with a behaviorialist as to ways to help child understand the expectations for his behavior, including preparation for transitions using picture schedules, regular predictable routines, rewards, and natural consequences.
3. Psychological counseling for the family on how to negotiate without force or anger, and helping child feel understood (since he can't communicate well at all).
4. Augmentative communication evaluation to help the child develop more effective communication strategies.
5. Occupational therapy for help developing improved self-regulatory mechanisms when he gets over-stimulated and upset, as well as ways to prepare him for transitions, so he is more tolerant.
6. Possible medications. Do you have experience with medications for these children and their effectiveness?

RESPONSE: Although children with CdLS can have behavior problems, it is not a forgone conclusion. Nor is it the case that behaviors always get worse over time. Problematic behaviors can occur, and both behavioral interventions and medications have been used in children with CdLS.

Your suggestions are excellent. Referring this family to a behavioralist or psychologist is critical, as they can analyze the specific behavior problems and come up with a behavioral plan. Professionals who have experience in Autism are often very helpful, as the two groups of children often have shared behavioral and communication issues. Working on the communication issue is also very important. A lot of "behavior problems" can stem from the frustration of not communicating one's thoughts or needs. Consultation for an augmentative communication device would be great. As you mentioned, using picture cards and having a predictable schedule are very important as well. The picture cards facilitate communication and the schedule may do much to ease anxiety (and ensuing behavior problems that result from not knowing what will happen next).

I would suggest trying all of the strategies that you outlined to help extinguish undesirable behaviors and to promote communication. These kinds of interventions can make a huge difference in terms of behavior. Medications could be considered if behavioral interventions do not work, but there has been inconsistent response to psychotropic medications.

My suggestion would be to exhaust the non-medication interventions first (they are often effective, and would result in less risk for the patient).

EA 5/02