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Breaking the Tantrum Cycle
When your kid whines, screams, hits, kicks, and bites—relax. Child psychologist Alan Kazdin can help you find your inner parent.
by Carlo Rotella ’94PhD
September/October 2005
Carlo Rotella ’94PhD is the author of Cut Time: An Education at the Fights.
When I told my wife I was writing a story about an illustrious child psychologist, she said, half-jokingly, “See if you can pick up anything useful.” We both knew what she meant: anything that might prove useful in handling our older daughter, a four-year-old spitfire whose virtuosity on the monkey bars and heroic self-reliance are matched only by her gift for busting our chops.
My daughter’s no more than a high-spirited handful, but matching wills with her has given me new sympathy for the parents of kids—usually boys—with serious conduct problems. What do you do when misconduct isn’t throwing sand or talking back but stealing, slugging teachers, or setting fires? I’ve had enough of a taste of preschool tantrums to be able to imagine grade-school escalations: the ingrained defiance and lamp-smashing rages, the despair surging through a household in chaos, and, of course, the worries. What if he never learns to behave? Is there something wrong with him, a disorder that’s going to ruin his life? Or am I just an incompetent parent who’s going to ruin it for him?
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“You can get rid of a behavior by rewarding behaviors that are incompatible with it.” |
You tell your kid not to do something; he looks you right in the eye and does it. You’re on his case all the time, issuing warnings, threats, reprimands, punishments, updates on policy. He must hate the sound of your angry, frustrated voice. You hate the sound of it. Every once in a while, in the brief interval of clarity between being provoked and blowing up, you realize that this dispiritingly familiar drama is a shared habit, one you could change. The thought floats tantalizingly for a moment; you feel yourself teetering at the brink of a well-worn behavioral groove into which you could, in theory, refuse to plunge. Then he throws a toy at his little sister’s face, and you’re hauling him off by the arm with a violence that frightens all of you. Suddenly everybody’s yelling, red-faced, at wit’s end. Having tipped headlong into the groove without consciously choosing to, you’re rocketing along, out of control again.
You love your child, but you really, truly hate this.
“You can get rid of just about any behavior by rewarding behaviors that are incompatible with it,” says Alan Kazdin, John M. Musser Professor of Psychology and Child Psychiatry, director and chair of the Child Study Center at the Yale School of Medicine, and director of the Yale Parenting Center and Child Conduct Clinic. “This is nothing interesting,” he adds, which means that it’s a reliable conclusion backed up by empirical research. Children receive all response—shouting and hitting as well as kind words and hugs—as affirmation of the behavior that elicits it, so you can best shape the result you want not primarily with negative interventions like punishing misconduct but by using praise and other rewards to reinforce behavior that replaces it.
This may come as interesting and even thrilling news to beleaguered parents all over, but it’s not fresh science, so there’s nothing surprising in it for Kazdin. “Almost everybody responds to reinforcement, but there are conditions. It has to be frequent, dependent on the behavior, immediate, multimodal—verbal praise, touch—and so on. Let’s say, for example, controlling tantrums.”
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Kazdin treats families with hostile, aggressive, antisocial, or oppositional children. |
Kazdin gets up from his chair and comes around his desk to demonstrate. A youthful 60-year-old, slightly gaunt in his suit, he has a mobile, expressive face that’s pleasantly smile-crinkled around the edges. We’re in his office in a rambling old house on Prospect Street that the Parenting Center and Child Conduct Clinic shares with the Yale Review and the university’s fire marshal. At the clinic, he and his staff treat families with hostile, aggressive, antisocial, or oppositional children up to the age of 14. Down Prospect in the direction of campus is Science, up Prospect the other way is Faith (the Divinity School); east and west, downhill, in the Dixwell and Orange Street neighborhoods, lies Real Life, family life. Kazdin spends about three hours most weekday afternoons at this particular crossroads of theory and practice, coming over from his office at the medical school, where he administers a much larger research and teaching operation.
“This is practice,” he says to an imaginary kid seated in an empty chair facing his desk. “I’m going to say No to you, just for practice, and if you can sit quietly and don’t yell and scream when I say No, you’ll earn a bubble.” A bubble is a token that can be cashed in for a treat—a special food, activity, or other privilege the kid would be eager to accrue enough tokens to pay for. When the imaginary kid finally manages to take No without losing it, Kazdin praises him and steps close to mime giving him a high five, all the while smiling warmly and sustaining eye contact. Then he checks outside the doorway to see if the coast is clear, leans back in, and says, conspiratorially, “I’m not supposed to do this, but let’s see if we can get you another bubble. I bet you can’t do that again.”
Kazdin’s manner changes when he talks to the imaginary kid. His shoulders loosen and he bends at the knees like a vaudevillian trouper. He bobs in and out, now muting his voice, coming close, and crouching down low to a seated child’s level, now moving back and standing up straighter, filling the room with his beaming presence. His face lights up with enthusiasm, eyes opening extra-wide to accentuate his smile, catching and holding the kid’s gaze. His ears seem to grow bigger.
It’s almost disturbing to see how well he’s clicking with this nonexistent kid. Just the spillover from the connection feels so potent that I find myself wanting to show Kazdin that I can sit quietly and not have a tantrum. I could use a bubble, too. And yet, beneath the practiced charm of an adult who works with children, Kazdin’s clinical reserve and intellectual command are evident, the hard-boiled knowingness of a professional who has made a career out of breaking down even the most passionately out-of-control human behavior into component elements that can be reassembled in desired form. For more than 20 years, he has devoted himself to research that has resulted in a high degree of confidence in the efficacy of his approach to treating children’s conduct disorders.
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“You can shape what goes on during a tantrum.” |
“You can shape the behavior you want,” Kazdin says, now talking to me, and I believe him. He may be one of the foremost child psychologists in the world today—“In the scientific part of the field, he’s the industry standard,” says John Weisz, an eminent colleague at Harvard—but what a lobbyist or police interrogator Kazdin would have made. He continues, “And you can shape what goes on during a tantrum. First, say, no hitting, and you reward that, reinforce that, even if he’s throwing things and yelling, as long as he’s not hitting. Then no throwing things, you work on that, then no yelling, no bad words. You can model, practice, break down the behavior into steps. We already know all this. This is boring.”
He doesn’t mean that he’s bored; he means that research has proven the point to his satisfaction. It’s not an opinion, it’s a fact.
A monitor in Kazdin’s office allows him to watch what’s going on in the clinic’s five session rooms, each equipped with a video camera. There’s a family drama on every channel.
On the monitor now, for instance, a young female therapist takes an almost-as-young mother through a role-playing situation. The round, sweet-faced mom tells her son, played by the therapist, to clean up his toys. She gives the initial command properly, but when the therapist-as-son doesn’t comply, the mom says, “Don’t you want to get a bubble for picking up your toys?” in a wheedling singsong, giving him too many chances. The therapist departs the character of the son to interrupt her. “You can just go ahead and prompt him once,” she says, now in character as the therapist, unflinchingly perky. “With a statement, not a question. ‘You have a chance to earn a bubble. Show me you can pick up your toys.’ Then, if he doesn’t do it, you go straight to ‘You didn’t do it, so no bubble. We’ll try again later.’” Like a boxing trainer ingraining a basic move into her charge, the therapist won’t let the mother do it wrong even once. That’s the point of interrupting. When the mom finally gets it right, eliminating sequence-muddying questions and reiterations, the therapist multimodally reinforces the result with a smile, a touch on the shoulder, and praise: “You said it just once, nice and clear, and you went straight to the bubble! Good prompting!”
“It’s the un-American way,” says Kazdin, looking at the monitor. “Practice, practice, practice.”
At staff meetings with his therapists, Kazdin will toss out a challenge like, “Okay, three ways to stop a child of five from breaking things around the house, without punishing.” Every parent must have fantasized at some point about the existence of such a Mission: Impossible team of child-wranglers. But, really, they’re parent-wranglers. “There’s a gentle deception in what we do,” says Kazdin. “The parents think they’re here to fix the child, but we’re training the parents.” The ambiguous name of the principal therapy he has designed, Parent Management Training (PMT), suggests the nature of the gentle deception. Parents come to the office, at first not even accompanied by their child, for a series of 12 sessions in which they use role-playing and other simulations to refine techniques to use at home.
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Ignoring a behavior can eliminate it, like starving a fire of oxygen. |
None of these techniques, all by itself, will strike a parent as a miraculous gimmick for getting kids to behave. The power of PMT lies in the systematic arrangement into a resonant whole of largely unexceptional details and the principles that animate them. To begin with, parents must stay calm and not manhandle or hit their child—not because it’s wrong, but because negative interventions don’t work as well as positive reinforcement and have harmful side effects, such as increased aggression. Parents first assess and define their child’s problem behaviors, then learn how to manage the process of altering them. They practice shaping and reinforcing desired behavior, building it up in a chain of manageable steps, and they learn how to employ the most effective forms of praise, reprimands, and the token economy (bubbles, for instance, or stickers, or points) used to keep track of rewards. They also learn to strategically employ extinction—ignoring a behavior to eliminate it, like starving a fire of oxygen—in concert with positive reinforcement.
As they consistently link behaviors to their consequences, parents present their child with a path to good conduct that’s clearly signposted as the best route to what the kid himself wants. Because they’re less often at wit’s end, now that they have a system to follow, and because they’re concentrating on rewarding the positive opposites of misconduct, they can largely abandon the role of livid enforcer. You don’t realize how much opposition and anger there might be in your household until the level of it drops.
Although much of PMT seems commonsensical, parents do have trouble adjusting to some aspects of it. Introducing the token economy into your household can seem like a defeat, an admission that neither love nor Because I said so generates enough leverage for your authority. Also, it can feel spinelessly counterintuitive to reward good conduct in the middle of bad conduct—to give your son a bubble, say, for going calmly to the time-out chair after he hits his sister. Then there’s all the gushing. The emphasis on positive reinforcement entails a great deal of enthusiasm and praise, which can make you feel like you’re trying to sell a used car to your skeptical kid. “You have to be effusive, because it makes a difference,” says Kazdin. “If a funerary response would do it, we'd use that.”
Whatever their misgivings, PMT gives parents a sense of purpose, of working toward a better family life. Sharon, who came to Kazdin’s clinic because her five-year-old son had begun having tantrums and breaking things to get attention, says, “I felt like instead of winging it all the way, just flailing around, I was following a program. I had a goal.” She confesses to backsliding, though. “I was all gung ho at first, but you get into the thick of the situation at home and you fall into old habits. It definitely helped, but I think that if I could stick to it more, it would be even better. We do what we can.”
They do what they can. PMT does not produce perfection. Results can be complicated by variations in parents' availability, health, attitudes (toward sparing the rod, for instance), and relationship to each other. Some children with conduct disorders also have other disorders that respond better to different treatments, like attention-deficit/hyperactivity disorder, for which medication is the treatment of choice. Sometimes, when the parents can’t be counted on, PMT has to be augmented or even replaced with another therapy, Problem-Solving Skills, aimed directly at the child.
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“Even the best-behaved child only does what he’s told about 80% of the time.” |
But it’s still scientifically accurate to say that PMT usually works. “Seventy-eight percent of the time the children get much better,” says Kazdin. When you stop to consider that the typical referral to his clinic comes after suspension from school or a visit to the emergency room, “much better” can be the difference between entry into the juvenile justice system and what society calls a normal childhood. PMT does not grow a halo on your kid—Kazdin notes that “even the best-behaved child only does what he’s told about 80 percent of the time”—but when a household stands down from a constant state of red alert, the release of pressure can make the difference between misery and happiness.
Okay, full disclosure. Although he doesn’t know it, Alan Kazdin took a thorn out of my paw. He maintains that families confronting mild conduct problems that fall well below the clinical threshold can also benefit from PMT, and he’s right.
Growing impatient with the intermittent trickle of information coming from me, my wife stole my copy of Kazdin’s most recent book, Parent Management Training: Treatment for Oppositional, Aggressive, and Antisocial Behavior in Children and Adolescents, a manual for therapists. She read it late into the night, and the next morning she was furiously pounding away at her laptop, boiling down the book’s main points to a series of outlines which she printed out and taped to the kitchen cabinets. “This guy’s a genius,” she informed me.
Or maybe we just needed a little help. Either way, even our partial, do-it-yourself application of his principles effected an instant and (so far) lasting improvement in our household. It turns out This is a chance to earn a star really does work better than Do it now, or your bear goes Up High On The Shelf, and a useful reprimand really does consist of three components (what to stop, why to stop it, what to do instead). When my wife and I decline to flail around in the usual minefield of blowup options sown by our daughter, we exchange a look: Nicely done, fellow Kazdinite. Then comes a follow-up look: Boy, were we bad at this before.
There’s deep satisfaction in doing something right that you’ve been doing wrong, especially when your loved ones benefit from the change. When you give your child a way to choose good conduct and she chooses it, when you head off chaos by short-circuiting an overfamiliar sequence of mutual provocation, you bring the pleasure of competence to family life, a relatively rare convergence for most Americans. Usually, we seek the pleasures of competence at work, in sports, in getting and spending. When it comes to raising kids, we usually just muddle through. We watch Supernanny not because she’s so adept at getting kids to behave but because the hapless parents' well-intentioned incompetence reassures us of our own normalcy.
But the parental craving for competence runs deep enough that it might inspire you to try something new, maybe even to rethink a bias. As a member of the arts-and-humanities tribe, I’ve never accorded any special authority to the truth claims of science. I’ve never put much stock in arguments that begin “Studies show …” Kazdin’s book has made me more open-minded on that score. It’s rare to read anything about raising children that’s founded in fact rather than floated on a cloud of opinion. The author never allows himself to speculate or philosophize about human nature or childhood; he just explains what we think we know, and shows how to take advantage of it. It’s a thick book, but its content is arrestingly lean.
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“Practice changes the brain.” |
The roots of PMT, Kazdin’s compendium of field-tested knowledge backed up by scientifically rigorous research (his own and others'), lie in the work of B. F. Skinner and other founding behaviorists. As befits a therapy based on principles first established by animal studies, PMT does not try to help a child achieve an understanding of his own inner life, nor does it seek the root causes of misbehavior. “People like me don’t care what the unexplained part comes from,” says Kazdin. “We come to this from the evidence. You work on the actions. Often, the insight into yourself is epiphenomenal.” Insight can follow from action, as well as the reverse. “Reinforced practice is really critical. Practice changes the brain. There are studies showing that violinists' brains actually change from years of practice.” He mimes playing a violin. Change behavior and you change the brain’s function and structure, and also, perhaps, what Freudians regard as underlying conflicts or other root causes.
Kazdin’s methods do not resemble play therapy or the many pediatric versions of the talking cure that still dominate treatments currently employed for kids. “The model for that therapy is this very special relationship,” he says. “By me understanding you, you’ll feel better. That works for some things, like low self-esteem.” And, he adds, cognitively based therapies work best in the treatment of anxiety, depression, shyness, or withdrawal. “But PMT is the treatment of choice for aggression and oppositional disorders. Therapies that focus on talk, play, insights, or explanations of why a child is aggressive do not have the evidence that they make a difference. The old model—get this out of one’s system, bring this to the surface—does not apply here.”
Making his discipline more accountable to scientific standards may be Kazdin’s deepest commitment. “There are over 550 therapies out there for children and adolescents,” he says, “and over 90 percent of them haven’t been tested. We don’t know if they work or don’t work. There’s no public outcry of ‘What’s the basis for this?’ There are no hoops to get a therapy in the market”—no equivalent of the FDA’s approval process for a new drug—“so what’s out there might work, but it’s often being used in place of things that are known to work.” Certain widely accepted treatments have actually been proven to hurt. “Group therapy for antisocial children, like Scared Straight, has been demonstrated many times to make children worse. When you put the children together, they bond with peers, they talk about antisocial behavior, then they follow up by doing it.”
Kazdin betrays a scientist’s impatience with the loose attitude toward empirical evidence that prevails in clinical work, an attitude that strikes him as irresponsible, given the high social stakes. “Conduct disorder is the most expensive mental health problem in this country,” he says. When the usual treatment doesn’t work, a conduct disorder child takes off like a pinball. “He bounces around all of the different obstacles, and as he hits them, points are accumulated—so many dollars for calling the police, for special social work service at school, placement in a classroom for socially and emotionally disturbed children, treatment with a therapist, treatment at another clinic with another therapist, and so on.” The ball tends to keep bouncing and ringing up social costs; unsuccessfully treated childhood conduct problems often continue in different form in adolescence and adulthood.
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“Discovery is my job, and I love it, but now we have to get the word out.” |
Kazdin came to working on children’s mental health not because he felt some special calling to help kids but because it was important, understudied, and even more unscientific in its practices than other aspects of psychology. A clear-eyed guy with an unsentimental outlook, he offers up no pious rationales on the order of I just love kids or I feel a special bond with them. “I’m interested in children and their disorders, and that’s a kind of career move,” he freely admits. “That said, the seriousness of this makes it a mission for me.”
“Discovery is my job, and I love it,” says Kazdin, “but now we have to get the word out.” At this point, PMT qualifies as “a technology,” like a surgical procedure, proven to work on both serious and mild cases. There’s still vital research to be done—what about that 22 percent of children who don’t get a lot better after treatment?—but now he has to think beyond research. “We want to disseminate what we’ve got, we want to find a way to give this technology away. One of the frustrations of Jonas Salk, when he died, was that people were still dying of polio, even though there was a cure.”
Parent Management Training is the 40th book Kazdin has authored, co-authored, or edited. He has garnered copious honors and respect from his colleagues, including those who disagree with him; he enjoys as much prominence in his field as any sane person could wish for. And yet, his approach to treating children and his emphasis on scientific standards still have the underdog status of an insurgency, only gradually gaining ground against the continuing dominance of therapies with no scientific support for their efficacy. Making up this lag in the field will entail changing the disciplinary culture of psychology. He can get kids and parents to change their ways, but what about mental health professionals?
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PMT catches conduct disorders before they begin racking up major social costs. |
John Weisz, president of the Judge Baker Children’s Center at Harvard and an expert on the dissemination of psychotherapies for children, believes that “people in the field would like to be using evidence-based procedures, but changing to such practices is difficult. There’s no one arbiter, no FDA, to come up with a single accepted list of which psychotherapies are evidence-based. Also, the best way that treatments get disseminated is through making a profit, and that model works well for a new drug, where a drug company has a stake in its success and works with doctors to make sure of it, but for psychotherapy there’s no comparable financial engine.” That goes double for PMT, which catches conduct disorders early, before they begin racking up major social costs. “Alan’s program is terrific, and it has unusual potential for dissemination because there’s such strong evidence showing how well it works, but there’s less immediate cost benefit, even if there’s great benefit in the future.” And it takes a lot of work to convert clinicians to a treatment like PMT. “Evidence-based psychotherapies tend to be rather complicated, guided by detailed manuals and requiring extensive training—much more training than that required to properly prescribe a new medication.”
So how might Kazdin go about spreading the word? By way of the market, says Weisz, who points out that the dissemination of evidence-based treatments for children has worked best “when the treatment’s cheaper than prison and you can show that the kids are clearly going to be in the juvenile justice system if it doesn’t work.” One avenue would be through government agencies and foundations that invest in best-tested therapies. Then there’s the more dramatic gambit, an end-run through popular culture to build broad demand for PMT, which would put pressure on providers, thereby activating the crucial profit motive.
I asked Weisz if he could picture Kazdin taking the latter route, via popular books, radio, 20/20, and the like. Weisz said, “If he had the interest and the time, he'd be way better than Doctor Phil.” But it’s a rare serious researcher who crosses over. David H. Barlow, of Boston University, was the only one Weisz could think of. When I asked Barlow how Kazdin would fare on the pop-culture route, he said, “There are scientists and there are popularizers, and you don’t find too many people who do both. But Alan could do both.”
I can picture it. Kazdin uses self-deprecating humor and plain speech to take the edge off a potentially intimidating intelligence, and he’s smooth without seeming like he’s trying to put one over on you. He’s not a scold, either—as opposed to, say, Dr. Laura, the moral physiologist. When asked about raising his own children, Kazdin ruefully admits to having been as confounded and exasperated as the next parent. He does not base his authority in his own putative brilliance or in the rhetoric of values; rather, he presents himself as a bearer of what science has discovered about rearing children. And, as a democratic Mr. Fix-It rather than a technocratic scaremonger, he wants to show you how to apply that knowledge. “Most parents do fine most of the time,” he likes to say, but, hey, most parents could use a little help, and some could use a lot of help.
“I realize that I have to do some media,” Kazdin says. “Otherwise it’s like being a meteorologist and knowing the weather and staying in your room and not telling anybody.” After a school shooting, for instance, news organizations press him into service as a talking head. But building wider support for his approach to treating children will take more than the token hour a week he tries to set aside for doing media. It will require turning the main strength of his intellectual firepower to the task. If he does commit himself to it, Oprah, Katie Couric, and other such gatekeepers—and their audiences—should be putty in his behavior-shaping hands.
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PMT is not fast, it’s not easy, but it works. |
I’d be lying if I portrayed my household as having entered into some blissed-out pax Kazdiniana. There is still plenty of confusion, noise, and ill-considered behavior by young and old. I—and, more rarely, my wife—still backslide into Because I said so or furiously garnisheeing the bear. (As I write this paragraph, I can hear my wife saying, on cue, “Hey! Hey! No! Absolutely not!” Then the thunder of small feet fleeing justice, then generalized wailing.)
But life in my household remains measurably better than it was before the outlines went up on the kitchen cabinets. The change is palpable. Lots more minding. Better manners. Fewer, shorter, and less acute meltdowns, and quicker recovery times. Fewer lost tempers. More consideration. Most important, my older daughter has changed her default setting from You and What Army? to All for One and One for All, which has dialed down the level of conflict to a setting between tolerable and pleasant.
PMT works. Bear that in mind when you consider Alan Kazdin’s prospects for using popular culture to put pressure on his slow-changing field. Sure, it may not be the ideal treatment to bring directly to the people. It’s not fast, it’s not easy, and, as a systematic approach, it needs to be set out at length, not reduced to sound bites. But in other ways PMT seems well suited to the cultural moment, not least because it proposes an affirmative breed of authority—featuring positive reinforcement, rather than the Naughty Chair or Value-Driven Spanking—that will appeal to parents trying to make a way between well-intentioned weakness and the pathological exercise of strength. Finally, don’t underestimate Kazdin’s remarkable persuasiveness. If he can just figure out a way to get physically close to the American people, make eye contact, and touch each of them on the shoulder, they’ll behave.  |
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