By Rachel Rosenholtz, LCSW

*Names and circumstances have been altered to protect client privacy

He’s out of control.

David is constantly fighting with kids in his class and taking things from them, often unprovoked. He has been this way since he entered preschool a year ago. He is defiant at school and aggressive at home.    

Leah has a difficult time focusing and following instructions. She often appears distracted and has to constantly be redirected. She is socially awkward and misses social cues that other children seem to have picked up long ago. 

Sara avoids reading out loud. She insists that she knows the work being taught in class but consistently underperforms and often avoids doing work all together. Sara spaces out in class, is defiant, and engages in attention seeking behavior, which teachers find to be extremely disruptive. All remedial attempts to help her are met with resistance.

In all three situations, there is no underlying trauma or major issues in the home.

When behavioral issues are identified, our immediate reaction is to take steps to rectify the problematic behaviors. This usually takes the form of a combination of behavior charts, disciplining, and/or various behavior modification modalities designed to reign in undesired behaviors. With socially awkward children, we teach social skills and expect them to model the taught behaviors.

In all three of these actual cases, various behavioral systems were implemented yet yielded no meaningful results. The parents were frustrated. They could not understand or identify where the behavioral issues were coming from. The teachers were frustrated. They genuinely wanted to help these children but no matter what they tried, nothing seemed to really help.

All three children were referred for counseling and their parents were strongly encouraged by laypeople to medicate. In all three situations, medication would have been a mistake.

Some of the classic diagnoses given to such children include ADHD, ODD, and Conduct Disorder, which speaks to a common issue that is all too prevalent.  Affirmation bias. Diagnosis and treatment is based on behaviors that are seen and what those behaviors are believed to represent. There is a tendency to treat the symptoms instead of the underlying problem. Unfortunately, this is all too often the playbook for the treatment of children exhibiting behavioral symptoms.

    The amount of medical issues that can affect a child’s behavior are numerous. I will focus on three common medical problems that are often overlooked when assessing a child for emotional issues. They are perfectly suited to serve as examples of conditions that can significantly impact the way a child experiences and interacts with their surroundings.

Leah suffers from chronic congestion.

I have found that breathing difficulties play a big role in a child’s inability to function and adapt to their surroundings. This problem often manifests in, what appears to be, focusing issues as well as an inability to properly read and react to social cues.

Chronically congested children breathe through their mouths. Try spending a whole day breathing only through your mouth. Maybe you experienced this when you had a cold. What does that feel like? Imagine what  children who are chronically congested have to deal with.

Breathing through the mouth is a louder form of breathing, which creates additional noise. Children may have trouble hearing what people are trying to tell them or have greater difficulty focusing during social interactions. This also impacts the ability to focus in school and process information. Difficulty breathing is also associated with lightheadedness, which makes it much harder to focus and tune into social cues. “Clogged ears” is another common feature in these scenarios which can do a good job of throwing off a child's equilibrium. Feeling off balance can make them appear to be in their own world or all over the place. Their mouth may be uncomfortably dry as well. Another problem I have often found is that such children will sometimes play around in their mouth with their tongue as a way of coping with this condition. This is yet another diversion from paying attention to what is going on in their environment. 

Chronic breathing issues can also cause difficulty sleeping, leaving the child tired and unable to focus.  

Not surprisingly, children tend to be the most congested during the winter months, the bulk of the school year when they most have to focus and concentrate.

Parents become so used to their child's breathing "style" that it is not recognized as an issue that must be treated. In fact, this is the first, and very possibly the most important, step in treatment for improving focus and sociability. 

Another major issue is an undiagnosed vision problem. I am not referring to a child with less than 20/20 vision who needs glasses.   

A child may have 20/20 vision but there are other issues that impact upon a child's ability to visually focus, such as tracking problems and lazy eye. Let’s take a look at Sara. One thing I noticed while working with her was that whenever she would shift from looking down to looking up, her eye drifted slightly. I referred her to a vision specialist who diagnosed her with multiple visual perception issues. The ophthalmologist stated that she had no idea how Sara had made it so far academically given her visual perception impairments.  

While she was able to compensate for the deficiency enough to passably read to herself, reading out loud was torture. It also affected her ability to focus in general.   Sara is an extremely intelligent and sensitive girl. She avoided school work because she knew she could never keep up with her peers academically. She chose to act out and not try, rather than experience the embarrassment of not being able to succeed. For this reason, she was also resistant to any other remedial interventions or tutoring. None of these interventions addressed the real problem. They only served to exacerbate her feeling of ineptitude. Her resistance to all the support the school was trying to give her left the school staff frustrated with her. They wanted to help, but Sara became so distrusting and rebellious that she had pushed everyone away. She felt misunderstood and her lack of trust and anger at the school led to serious behavioral problems.  

After months of vision therapy to correct her visual perception problems and counseling to help her work through the emotional issues she developed, she agreed to tutoring to help her make up the material in which she fell behind. With her improved ability to focus alongside having worked through some of the hurt, resentment, and mistrust she had developed towards adults, her grades and overall behavior improved dramatically! She was even chosen to be part of the student council.

David suffers from chronic ear infections and has fluid in his ears.

How does being in pain affect a child's behavior? Every child has a unique temperament and will react to pain, stress, and frustration differently but these can be significant behavioral levers. Just think of how much pain can affect an adult’s behavior.

Children often lack the capacity to understand and articulate their pain, especially when it is chronic. In scenarios such as this, one child may take out their anger on classmates and family members while another may become sad and withdrawn.

David had a very difficult time coping with the pain from his ear problems and as a result, he acted out aggressively.

Children like David are generally punished for such behaviors. This, however, makes the situation even more painful and difficult for the child and as a result, a vicious cycle is often created.

Fluid in the ears can also cause difficulty hearing. It can be like being underwater.   Imagine swimming in a pool and while your head is submerged, you try to listen in on a conversation going on above the surface. Pretty difficult to understand. Children who hear this way can seem socially inept, or be incapable of following instructions in class and at home because they never adequately receive them.

When we don’t feel good physically and something upsets us we tend to overreact.   This is true for adults. How much more so for children?

Bad behavior driven by a physical issue is, in reality, an outlet for the stress, pain, and frustration that the physical issue is causing. Disciplining the behavior while neglecting to address the underlying physical issue will only cause more problems. A child who is already not feeling well and is yelled at or punished is more likely to overreact and exhibit behavioral issues.

Behavioral interventions don’t achieve the desired results because either the child is too irritated or uncomfortable to care, or the physical problem prevents them from being able to follow through for the promised rewards. Instead of seeing an improvement we will often see just the opposite. 

As soon as any behavioral issues are observed a full health assessment is an absolute must, regardless of the child’s age. If detected, any underlying medical issue can be treated. If there are significant medical issues that go undiagnosed for too long, bona fide emotional and behavioral problems can manifest as a result.   

Children who are suffering from physiological issues may have lost out on integral developmental stages as well. Their social skills may have been compromised and they may have fallen behind academically. They may have developed learned behaviors that are maladaptive and now have to be rectified. In such instances, professional therapeutic intervention will likely be necessary.

The long winter months lie ahead. Take the time to carefully assess your child and their situation. The well-being of our children depends on our asking the right questions and addressing the right problems. Every day that goes by with unasked questions or incorrect assumptions is precious time lost.

Let this be the year your child thrives and shines in school, with friends, and at home.

Rachel Rosenholtz, LCSW is certified in TF-CBT, a child centered therapy that focuses on helping children overcome traumatic experiences. She has a private practice located in the Five Towns and specializes in treating anxiety, trauma, and behavioral related issues in people of all ages. Rachel can be reached at (347) 673-1953 and Rachel@InvestInTherapy.com. To find out more, visit her website - InvestInTherapy.com