This article was originally published in The Notebook. In August 2020, The Notebook became Chalkbeat Philadelphia.
Why do children of a certain age wait until the shopping cart is full and then proceed to throw an ear-splitting, face-reddening temper tantrum that is so loud and so embarrassing that a parent’s most fervent wish is for the floor to open and swallow the child, the shopping cart, the parent, and, yes, even the orange cheese puffs, twice denied, that started the whole screaming fiasco?
Maybe pediatrician Joanne N. Wood, director of research at Safe Place: Center for Child Protection and Health at The Children’s Hospital of Philadelphia, asked herself that question when her daughter, then age 2½, freaked out at high volume over cheese puffs at Costco.
Possible responses: yelling, threatening to take away SpongeBob for life, or perhaps, in desperation, just giving up and handing over the cheese puffs, all three pounds of them. Or maybe just abandon the cart and walk out the door. With or without the child.
Instead, Wood, 41, followed the advice given weekly to members of a successful program that she and her team developed to train parents and caregivers to avert behavioral problems among 2- to 6-year-olds.
So how did Wood deal with her daughter, who is now 10, on that dreadful day in Costco?
She ignored her.
“We teach ignoring mild misbehaviors,” Wood said. “But you feel judged, and that’s hard in a public place.”
It didn’t take long (although it seemed an eternity at the time) before her child calmed down, minus the cheese puffs.
Children’s Hospital offered its first PriCARE class to parents and caregivers (such as grandparents and foster parents) in May 2014. About eight to 12 parents or caregivers per class attend six weeks of sessions at Children’s Hospital’s primary care clinics in South and West Philadelphia, where they learn “positive parenting” methods and stress-reduction techniques.
Perhaps, with training, parents can nip issues in the bud at an early age, before behavior problems affect the children’s education in school, setting off a course of difficult consequences.
During the sessions, babysitters watch over the children in another room and adults take turns pretending to be toddlers. Role-playing, they practice new ways of interacting with their children.
They learn about child development and receive encouragement and acknowledgment that parenting can be difficult, challenging, and sometimes lonely. They support each other, and the trainers give them tips on ways to reduce their own stress.
Leigh Wilson, project manager for PriCARE and a trainer for the program, said: “Anytime we can offer support to the parent, it is a huge gift to the child. When parents and caregivers do better, children do better. I really believe in that philosophy..
“Children don’t live in a vacuum. They live in a family.”
‘A patient I never met’
What makes the program unique is that the classes take place in their pediatricians’ offices, “considered a trusted, safe place by parents,” said Wood, who developed the program with her team at the hospital’s PolicyLab.
“I was drawn into the multidisciplinary approach with families, social workers, and organizations outside the hospital, not just focusing on a medical problem, but also on the social and emotional needs of children,” she said.
What piqued her interest in behavioral health, child abuse, and child maltreatment was the case of “a patient I never met,” she said.
While in medical school, she helped a colleague preparing to testify in a legal case about the patient, a little boy who had suffered so much abuse at the hands of his mother’s boyfriend that he died.
“I was young and a medical student and I wanted to fix things,” she said. She later became a specialist in trauma, child abuse, child maltreatment, and harsh parenting.
Her work connected her with children in foster care, many of whom had suffered a lot of trauma in their young lives. Nearly all went through more trauma as they were removed from their parents’ care.
Their foster parents “voiced that they didn’t have the tools they needed” to cope with the behavioral problems that often came with their young charges, Wood said.
Behavior health disorders
Research indicates that 11 to 20 percent of U.S. children could be diagnosed with a behavioral health disorder at any time.
Children who have behavioral problems start school at a disadvantage, with lower language, motor, social and school readiness skills.Behavioral problems are also linked with other issues – anxiety disorders, attention-deficit/ hyperactivity disorder and suicide.
“You can develop the cycle of increasing attention to negative behaviors, which in turn leads to more of those behaviors,” Wood said.
Children with behavioral problems are more at risk for abuse and harsh parenting, including corporal punishment and mean, belittling talk.
Many of the behaviors are common to most children – tantrums, hitting, spitting, maybe cursing. What’s different with children who have behavioral issues is the intensity, frequency, and duration.
Trying to work out how to change those behaviors led Wood to an existing intervention that’s called Child- Adult Relationship Enhancement, or CARE.
The idea is to, as much as possible, specifically praise and reinforce positive behavior, ignore mild negative behavior, and spend at least three to five minutes per day with each child in non-instructional play activities where the child sets the tone and calls the shots.
“We sort of fell in love with the intervention,” Wood said. “These are core skills that any parent could use. And as a parent, they were helpful to me.”
Wood and her colleagues at both Safe Place and the department of psychiatry and behavioral sciences at Children’s Hospital modified the CARE program for use at primary care centers – hence the name PriCARE.
They also did testing. They enrolled 120 families, placing some in the program and putting others on a waiting list. They compared answers to well-known screening questions that
answers given by parents in the PriCARE program, who were surveyed before and after the class.
The research, published in the January-February 2017 issue of the journal called Academic Pediatrics, demonstrated that PriCARE graduates had developed more empathy toward their children and were less likely to rely on corporal punishment.
“A lot of parents value the empathy they get from the other parents in the group,” said clinical research coordinator Devon Kratchman. “It’s recognizing that other parents are in the same situation.”
25 groups trained
Groups 24 and 25 finished their sessions at the end of February, and groups 26 and 27 began in early March. So far, about 190 caregivers have taken the course. Of these, nearly four in 10 are eligible for Medicaid.
Over time, the staff has learned the importance of providing child care, a modest meal of pizza and salad, and bus fare. When parents drop out, it’s often because of family emergencies.
The class costs the Policy Lab $300 to $400 per caregiver, plus additional staff time. The Pew Charitable Trusts, Oscar G. & Elsa S. Mayer Family Foundation, the Annie E. Casey Foundation and a private donor have supported the development, implementation, expansion, and evaluation of the PriCARE program.
Referrals come from doctors at Children’s Hospital, who are prompted by a reminder in the hospital’s computerized medical records whenever they enter any information about a patient’s behavioral issues.
Currently PriCARE is only offered to patients within the CHOP primary care network. Parents can connect with PriCARE directly via phone 267-318-1707 or email to firstname.lastname@example.org.
Screeners talk to parents about their stress levels and depression and also refer serious behavioral problems to clinicians who can provide the necessary individual care.
Staffers at the center are working on expanding the training to include caregivers and educators at early childhood centers. And because the PolicyLab’s mission is to find ways to expand proven programs through policy, staffers are also researching how more widespread funding can be made available to more parents.
One goal of the training, Wood said, is to normalize children’s behaviors and adults’ reactions that seem, in the heat of the moment, overwhelming.
“We recognize and acknowledge the stress,” she said. “We talk to parents about what they can do to manage their own stress. And kids do know how to push your buttons.
“But it’s not a personal attack. It’s a normal childhood reaction. We’re helping parents frame these incidents.”
Participants learn to be able to view the child with more understanding of her situation. Sometimes, Wood said, a tantrum happens.
“It doesn’t mean that she’s a bad child,” Wood said. “She’s tired. She’s an overtired child, who has had a long day.
“And then she sees the cheese puffs.”
Jane M. Von Bergen is a freelance writer and former Philadelphia Inquirer reporter who regularly contributes to the Notebook.