Dealing with children with behavioral problems.

angelalala · May 2, 2012

I'm not a psych nurse (yet); I'm a student nurse who has a MA in psychology and have worked in wrap-around services with children like those you've described (and children on the spectrum).

One of my first concerns about the scenario you described is the lack of a core staff: without that consistency I don't forsee the situation on that floor getting much better. Kids with behavioral problems absolutely need consistency, consistency, consistency (with staff, routine, schedule, etc). Is their day well scheduled/managed?

You didn't mention how old these kiddos are, so it's hard to really give specific advice regarding interventions. You're already doing a good job by rewarding good behavior (depending on age I've used the things you've mentioned, stickers, books, magazines, etc). Some kids (especially younger, especially on the spectrum) may need to work on communication skills to circumvent behavioral outbursts. Are these kids on any kind of behavioral plan?

I'm sorry, I know it's hard, especially when they throw a bunch of kids together in one place without one-on-one staff.

elkpark · May 2, 2012

I've worked in child psych for many years in a variety of settings; your original post sounds like you are being left to your own devices for milieu management. Any decent unit should have a schedule of groups/activities during the day/evening, and a general plan/program of how the unit is to operate and the kids are to be managed so that everyone is using a consistent approach. In most of the inpatient units I've known, the attending child psychiatrist, nursing leadership, and staff members from other disciplines (SW, psychology) have been been v. involved and proactive in developing a positive, structured environment and the rules/expectations of the unit and what the consequences are if those rules & expectations are not met. It sounds insane to me that your facility is trying to operate a child psych inpatient unit without a core, dedicated nursing staff, and where are these other figures (the physician(s), nursing leadership/management, therapists, etc.)? In my experience, nothing any one nurse does is going to make much difference if these other elements aren't in place.

jenmesh · May 8, 2012

I'm not a psych nurse (yet); I'm a student nurse who has a MA in psychology and have worked in wrap-around services with children like those you've described (and children on the spectrum).
One of my first concerns about the scenario you described is the lack of a core staff: without that consistency I don't forsee the situation on that floor getting much better. Kids with behavioral problems absolutely need consistency, consistency, consistency (with staff, routine, schedule, etc). Is their day well scheduled/managed?
You didn't mention how old these kiddos are, so it's hard to really give specific advice regarding interventions. You're already doing a good job by rewarding good behavior (depending on age I've used the things you've mentioned, stickers, books, magazines, etc). Some kids (especially younger, especially on the spectrum) may need to work on communication skills to circumvent behavioral outbursts. Are these kids on any kind of behavioral plan?
I'm sorry, I know it's hard, especially when they throw a bunch of kids together in one place without one-on-one staff.

The problem with the hospital is that since the program is not really that consistent, they put people in the unit, and once they see how bad the kids can get, they don't want to be in that unit anymore, so they try to put in a new one and the cycle goes on.. I guess it burns them out as well. I'm new, 3 months into the job, and I feel bad if I complain, because I'm technically a new hire. I've been trying to be pro-active by researching and asking people who have the same experience as mine.

The kids are from 6-12 years old, which is also another problem. I've heard one time that a 7 year old mother complained because her daughter said that a 12 year old told her about "rape". However, these are things beyond our control because you can't really hear everything these kids talk about.

I've seen that separating boys from girls work at times, and it's quieter. However, I am still trying to figure out ways how to keep them busy.

elkpark · May 11, 2012

This sounds like a larger, "systems" issue to me. Also a "chicken and egg" issue -- if the child unit had good leadership and a decent program/milieu in place, people wouldn't get burned out or object so much to working there, and they would be able to keep a consistent staff (which, IMO (and experience) is vital to operating a decent kids' unit). That's not going to just happen on its own -- the administration/leadership of the facility need to put those things (strong, experienced, competent leadership and some good programming and specialized staff orientation/education) in place, and then the staffing thing will work itself out.

Inpatient child psych is definitely a whole different ballgame than adult inpatient psych, and most people who like working in adult psych don't like working in child psych (and vice versa). IMO (and experience), you can't have a decent child psych unit without having a dedicated nursing staff, some specialized education/orientation for them, a decent milieu program, and some committed, competent nursing and medical leadership. Does the facility even have any "real" (trained and credentialed in the subspecialty) child psych people?

Purple_Scrubs, BSN, RN · May 11, 2012

It blows my mind that these kids are there mainly due to behavioral issues, and yet there are not set policies on behavioral management and discipline! This is a recipe for disaster. If every employee is left to their own devices to manage behaviors, there is no consistency and the kids never know what to expect, which leads to fear, which leads to acting out.

I understand that you are in the position of working within this crazy, broken system, however and need strategies. For minor things I would try re-dos. Basically, you interrupt a behavior and ask the child to re-do the behavior correctly. Example, a child takes something that belongs to another child, then when asked to give it back he throws it. I would say something like "Uh-oh, that wasn't the best way to give her the toy back. Let's try that again, more gently." Once the child gets it right, praise the heck out of it. This way you are ending the interaction on a positive note, and the child gets the muscle memory of doing something correctly.

For second offenses or higher level misbehaviors, I would give choices. Say the same child takes the toy away again, and pushes the girl in the process. Go to the child, kneel down to their level and get eye contact from them. Hold up two fingers. "You have two choices here. One, you can find another toy to play with and leave Suzy alone. Two, you can ask Suzy to play with the toy with her and play nicely together. You may NOT take Suzy's toy and you may not put your hands on her. That behavior is unacceptable". Once the child chooses, praise the choice and send them on their way. If the child refuses to choose, do not let them drag it out. Give them a few seconds then say "If you cannot choose, I will choose for you. What is your choice". Throughout your interaction, keep your tone serious, but low. Do not raise your voice, and keep your body lowered to their level unless they are acting out aggressively (in which case you will need to escalate the methods anyway).

For higher offenses, you can do time-ins or time-outs. We know what time-outs are, but I like time-ins better because you keep the child closer to you to monitor their behavior. Let's say the child above chooses to pick another toy to play with, but as soon as you turn around he throws it at Suzy. Go to him and get on his level, "It is not ok to throw toys and to hurt people. You are going to come sit here by me. When you are ready to talk about what went wrong and how you can fix it, let me know by saying Ready". Stay close to the child but do not pay too much attention to them. Once they say "Ready" you can prompt them to say what they did wrong, and how they can make it right. If they are struggling you can make suggestions, like an apology to Suzy. It is a good idea to walk them through a re-do once they are calm.

I fully realize these situations are over-simplified and it becomes a different ballgame when you are dealing with a group of kids, but I think they are good tools to use when you can. If you are interested, these techniques are mainly from a book called The Connected Child by Dr. Karen Purvis, and are intended for "children from hard places" such as foster kids or kids adopted from orphanages. However, as a school nurse I have used them on "typical" kids and find they work wonders. They have started using them with the kids in a foster group home for kids with serious behavioral issues, and they noticed a decrease in restraints within days. It would be great if there was consistency with the techniques, but I think you will find they are useful for you as well. You can google her name for some online resources as well.

Good luck, let us know how it goes!