Managing challenging behaviour is not easy. You need to let yourself to enter a frame of mind that allows you to use many different strategies and look from many different viewpoints, but most importantly, see what role you are playing in the behaviour that you are finding challenging.
The process of behaviour guidance starts with identifying any health problems the child may have and working with families to address them.
Sometime health issues cause behaviour problems and some health problems are hard to identify with children.
Abraham Maslow (1908 – 1970) is famous for “Maslow’s Hierarchy” which explains the needs people have and the order in which they need to be realised. The diagram explains the types of needs children have and the order in which they must be met. For example, children’s need for food, sleep, shelter and human touch must come before any other need can be met.
Many of a child’s health care needs fall into this level as well. Children cannot learn if they are tired, hungry, ill, fearful or in pain caused by illness.
Remember – children are wholly or partly dependent on adults to provide their basic needs.
Thinking about “Maslow’s Hierarchy, is there an underlying health issue that could be causing the behaviour problems? Health issues can cause pain, and when a child is in pain, they act out in ways we could mistake as a behaviour issue.
Let’s look at health issues from two different perspectives before we start looking at it from a child’s perspective. First, some parents might not tell you about health issues with their child, not that they don’t want to, they just might not see it as important.
Now from our perspective. We need to dig a little deeper because when we don’t, we could come across looking silly.
I’ll give you an example. Tara, Charlies mum was contacted by her centre because Charlies wasn’t himself. The educators said he wasn’t eating and didn’t have his usual sleep. Tara had explained he was tongue tied and just had a recent operation to fix the problem, but his mouth would be sore, and he would find it difficult to chew.
Another example, A nominated supervisor was approached by a mother asking if she had a spot at her preschool because she needed to leave the centre she was currently at. The Nominated Supervisors asked, “what was the problem at the other service”,
The mother said the educators had told her, her son wasn’t poorly behaved and didn’t listen.
The mother said to the educator, had you ever wondered what that thing was attached to my son’s head? It’s a cochlear ear plant as he is deaf….
Now we are going to look at children’s behaviour from their perspective when they might be ill or have other health issues.
Let’s start with ears. Ears and hearing – can the child hear properly, are child’s ears infected, inflamed, blocked.
When a child’s ears are healthy, they can:
- learn language and talking;
- listen to stories;
- listen to music;
- talk with family, friends; and educators
- feel good about themselves;
However, we know that continuous ear infections (one of which is called Otis Media – middle ear infection) hinder a child’s language development and their ability to read and write in the future. We learn how to read and write by identifying small sounds called phonemes. Phonemes become syllables, and syllables become words. We need the ability to identify these small sections of sounds to learn how to put words together and write them. When you have an ear infection it becomes harder to identify phonemes.
Also, hearing loss may limit a child’s capacity to develop socially and emotionally and can lead to behaviour issues.
The symptoms of a middle ear infection in children can include a cold, runny ear, pain, fever, pulling at ears, not eating, diarrhoea or vomiting and not hearing properly.
Sometimes middle ear infections show no symptoms.
Children should have their ears checked regularly by a health worker, nurse, or doctor.
Prompt treatment can avoid permanent damage.
If you think a child in your class may have an ear infection or hearing loss, talk to their parent or carer. If appropriate, you can encourage the parent or carer to take their child to see the health worker, nurse or doctor to have their ears checked. Or, you could invite your local health worker, nurse or doctor to your class to talk about ear health.
An ear infection is a good example because some children can cover up the typical sore ear or sometimes we don’t see them pulling at the ear which could indicate an infection.
Case Study – Ryan the loud one.
Ryan aged 4 has started to display the following behaviour. He gets loud when he talks, and educators say he isn’t listening. He has angry outbursts. There are group time disturbances and he often doesn’t want to join in with the group. He doesn’t pay attention and there are delayed responses when he does answer.
Let’s use the Learning Outcome Indicators in our curriculum to see if they can identify these issues.
For example, the Learning Outcome- Children feel safe, secure, and supported has these indicators.
‘Child initiates interactions and conversations with educators’ and ‘Child maintains relationships with other children and educators’.
If we can’t see Ryan meeting these indicators we need to look a little further. We need to ask questions too.
Ryan knew he couldn’t cope with the group, but why? He didn’t express it by talking to the educator. He expressed it through actions. He wanted to rest over in the corner by himself.
When looking at Learning Outcome – Children develop their emerging autonomy, inter-dependence, resilience and sense of agency – we see another indicator that is not being met –
‘Child demonstrates an increasing capacity for self-regulation’. Educators have noticed Ryan is having angry outbursts and these are progressively getting worse.
Educators did ask Ryan if he had a sore ear because they thought he wasn’t himself, but like I said at the beginning, children can be very good at hiding problems.
Ryan of course said no, his ear wasn’t sore. On a physical inspection, his ear appeared okay. His ear wasn’t red, and he wasn’t pulling at it.
The good news is educators spoke to the parents.
The educators were able to show the parents how Ryan wasn’t meeting the curriculum indicators and that is why they started to worry and why they suggested to the parents this needs further investigation.
The educators also if they had seen similar things at home. It turns out they had but just thought he was a little naughty and might grow out of it at school next year.
Ryan was booked in to see the doctor, where they discovered he needed grommets and had a very bad inner ear infection.
Ryan’s parents were not neglecting Ryan. They just didn’t know.
The really important point here is to remember that the curriculum can help identify when a child has an issue that needs further investigating.
Sometimes children need a little more rest than they have needed before. The first thing you need do is look for out of the ordinary explanations, like illness for example a cold, or a new baby at home, grandparents visiting etc. If these events are short episodes, we shouldn’t have concerns.
But, if you remain concerned, look at the child and ask, can they breathe properly, are sinuses infected or inflamed. Breathing can be related to sleep. If they can’t get enough oxygen because of a blocked nose or sinus they may need more sleep, they may also be irritable, lose concentration, or hit out at other children because they haven’t received enough sleep. So let’s look a little further.
Sinusitis means infection or inflammation of the sinuses. The sinuses are air-filled spaces within the bones of the face. They are located in the cheeks, forehead and around the eye. The sinuses are linked together, and connected to the nose, throat, and ears.
One function of the sinuses is to warm and moisten inhaled air before it reaches the lungs. The sinuses are also lined with cells that help prevent infection by producing mucus to trap particles of dirt and other pollutants that are breathed in.
Causes of sinusitis
Sinusitis is caused by too much mucus, or a swelling of the lining of the sinuses and nose, which can block the narrow channels. This can occur during a cold, or may be due to allergy (for example, hayfever) or irritation of the linings of the sinuses (for example, from chlorine in a swimming pool).
Bacteria (germs) then grow inside the sinuses, causing pain, headache and sometimes fever. Mucus from infected sinuses can be yellow or green. Some people get sinusitis with most colds, while others rarely get it
Common symptoms of sinusitis include:
- Blocked nose
- Feeling of pressure inside the face
- Facial pain, particularly when leaning forward
- Aching teeth in the upper jaw
- Yellow or green-coloured mucus from the nose
- Swelling of the face
- Loss of the senses of smell and taste
- Persistent cough
- Generally feeling unwell.
Again, if you think a child in your class may have a sinus infection or constant blocked nose, talk to their parent or carer. If appropriate, you can encourage the parent or carer to take their child to see the health worker, nurse or doctor to have their nose checked.
The key point here is one thing effects another then another which may reveal itself as inappropriate behaviour, that is why we need to know our families and dig a little deeper.
The ears, nose and throat are interlinked. That’s why we have specialist doctors that just work on ears, noses and throat. They are usually called ENT specialist.
Here’s when you should call the parents about a child’s sore throat so they can seek medical attention
- if they are having any trouble breathing, or if their breathing just seems different to you
- if they are having trouble swallowing, especially if they are drooling
- if they have a stiff neck
- if they have high fever
- if they are refusing to drink or is drinking much less than normal
- if the pain is severe
- if they are so sleepy that they are hard to wake or keep awake
- if they have a rash, headache, stomachache, or vomiting, to be checked for strep throat (or other infections). If your child has been around someone with strep, any sore throat warrants an appointment to get checked.
Mouth, Teeth and tongue – Another interesting set of body parts that are totally interrelated.
Let’s start with the mouth and Mouth ulcers, they are a type of sore inside the mouth. They can have several causes.
Traumatic ulcers are a common type of mouth ulcer that results from injury to the mouth; for example, after biting the cheek. Then there is the other type of painful type of ulcer that tends to come back again and again as one or many sores a few millimetres in size.
Mouth ulcers usually heal on their own in a week or two. If any ulcer does not heal after two weeks, it is important to see a doctor or oral health professional. Some can be related to more serious issues, diets, or allergies.
A child aged two was irritable and was hitting out at other children. Her physical appearance had changed as she was dribbling. On inspection her mouth, gums and inside lips were very red. When the educators talked to mum she said they had recently moved house and there was a lot of dust in the new house, as well as their diet had changed to more junk food during the days they were moving as the kitchen was in boxes. Both parents and educators monitored the child as well as seeking medical support and in no time the child returned to her normal self.
Are the child’s teeth well cared for, are there holes in them or infections causing pain? Again, this is something that is not always easy to detect with children and their behaviour change may indicate this.
If left untreated, decayed teeth can cause pain and make it difficult to chew and eat.
Also, baby teeth serve as “space savers” for adult teeth. If baby teeth are damaged or destroyed, they can’t help guide permanent teeth into their proper position, possibly resulting in crowded or crooked permanent teeth. Badly decayed baby teeth could lead to an abscessed tooth, with the possibility of infection spreading elsewhere in the body.
Now, tongues, they are interesting, a speech pathologist will always have a great interest in a tongue. And so should we as they can indicate issues that need further assistance from professionals.
For example, Tongue Thrust
A tongue thrust is when the tongue pushes against or between the teeth while your child is at rest, swallowing, or talking. The child does not use the muscles of the mouth, lips, jaw, or face correctly.
Tongue thrust, can cause dental and speech problems. Speech problems usually create what we might identify as a behaviour problem.
Most infants push their tongues forward to swallow. Most children change to a normal swallow by age six. If this change does not happen, the tongue continues to push against the teeth as the child swallows.
This tongue thrust can carry over into speech and resting. Because it is almost constant, having the tongue push against the teeth while the mouth is at rest may have the worst impact on the development of the child’s mouth. The habit of tongue thrusting is hard to change without help from a professional.
This is why we need to identify this type of issues. With a tongue thrust disorder, the child’s tongue sticks out between their teeth during one or more of these times:
A child with a tongue thrust disorder, may have one or more of these:
- High palate (high roof of the mouth)
- Speech problems
- Tongue rests in the wrong position
- Open lips when in a resting position
- Prolonged sucking habit
- Food chewing problem
- Having or needing orthodontic treatment
If a child is older than age 4 and having trouble swallowing or speaking, they may need to see a specialist for treatment. The front teeth of older children with tongue thrust may grow at an angle. This can lead to feeling self-conscious about their looks. They will probably develop speech problems, adding to their self-consciousness.
Bowel – is child constipated – this can cause pain and fear of going to the toilet, especially with our children with autism. Some helpful advice from a nurse that specializes in this is to ensure you tell parents that all forms of laxatives should be taken with water only, not juice. The juice has the opposite effect and doesn’t always allow the laxative to work properly.
What I’m about to describe to use is a case study where an educator started a lesson plan and when implementing it discovered a concern. Here we go.
To continue with our sewing and making our own juggling bean bags Miss Tamara set up a planned physical exercise activity. The children needed to balance on the beam while holding their juggling bean bags. The activity progressively became harder with the final move including hopping over the beam with the juggling bean bag on the child’s head. This is where Miss Tamara became concerned about one of the twins Ada. Normally she wouldn’t have a problem completing this activity. She stopped doing it and said she didn’t feel good and her tummy hurts.
Miss Tamara thought, this is not right, this is impacting on Ada’s health. She contacted Ada’s mum again and described the situation and held a meeting later that day. Ada was taken to the doctor and it was discovered she was constipated and had faecal impaction of the colon. She was prescribed a laxative. Which the mother administered that night.
The following day there was still no movement and educators reflected on this situation to try and assist Ada’s and ensure they were meeting her health outcomes. They started a discussion with other educators (confidentially of course). Mel, asked, what did Ada take the laxative with?
Miss Tamara said fruit juice because of the taste and Mel said that could be a problem because the laxative packaging said it should only be taken with water. When it was time to administer another dose the other children were taken outside for so Ada could have some privacy while using the toilet.
Mel suggested they give Ada a balloon to blow up while sitting on the toilet. Soon there was success. Tamara passed her knowledge and technique on to the parent later that day and Aria started to feel better immediately.
Eczema is another health issues that can cause behaviours that can be seen as an issue. At this point, let’s think about a time when a mosquito has bitten you, and it causes us to scratch and scratch, but imagine if that itch was all over us, how would you feel? Could you concentrate, would you be able to listen, sit still, stay at an activity and complete it if you always wanted to scratch yourself?
You need to look further and from the perspective of the child and ask, how would you feel?
We have talked about some major problems. The next lot of issues are just as important, but I’m not going to go into as much detail.
- Eyes – can child see properly, is there conjunctivitis etc
- Bottom-does child need medical attention for nappy rash
- Colic – does baby need medical help for painful colic
- Scratching – does child have nits/lice, allergies which need treating
- Asthma – are there breathing issues causing stress for the child
Arrange a meeting with the families to discuss the physical or medical issues first before launching into a behaviour diagnosis.
Second consider environmental issues eg
- Diet – what is child eating, is there too much sugar, is at served at the wrong times, is it contributing to child’s allergies, is child eating enough, has child had breakfast
- Sleep – is child sleeping at night, is child being forced to sleep at service instead of rest/quiet activities