Behavioral Pediatrics: The Top ThreeJodi Polaha, Ph.D.

Assistant Professor, Pediatrics

Munroe-Meyer Institute

Behavioral Health Clinics

Why Primary Care? Physicians as gate keepers for mental health

services

Why Primary Care? Physicians as gate keepers for mental health

services Increased continuity of care

Why Primary Care? Physicians as gate keepers for mental health

services Increased continuity of care De-stigmatizes mental health treatment

Top Three Problems Behavior-based problems (58%) Otitis Media (48%) URI (41%)

Arndorfer, R. E., Allen, K. D., Aljazireh, L. (1999). Behavioral health needs in pediatric medicine and the acceptability of behavioral solutions: Implications for behavioral psychologists. Behavior Therapy, 30,137-148.

Top Three Behavior Problems Oppositional behavior Sleep/bedtime problems ADHD

Arndorfer, R. E., Allen, K. D., Aljazireh, L. (1999). Behavioral health needs in pediatric medicine and the acceptability of behavioral solutions: Implications for behavioral psychologists. Behavior Therapy, 30,137-148.

Case #1 5 y.o. boy at well-child check

Mom’s main concern is sleep Notes he is aggressive at school

Questions What concerns should be assessed? What screening measures should be used? What diagnoses should be considered? What recommendations should be made?

Oppositional Behavior Core issue is typically noncompliance

How many of 10 instructions would s/he do the first time asked?

Mealtimes? Bedtime? Public outings?

Oppositional Behavior Significant problems will not dissipate with

age

Oppositional Behavior Oppositional Defiant Disorder (DSM-IV)

6 month pattern of negative, hostile, defiant behavior with 4 of the following: Loses temper Argues with adults Blames others Etc.

Causes Impairment Not psychosis Not Conduct Disorder

Oppositional Behavior Use behavioral screening such as the Eyberg

Child Behavior Checklist (ECBI) For those who exceed cutoff, consider referral to

behavioral health specialist. For those who do not, but have concerns, provide

handouts, brief verbal guidance based on empirically supported findings.

Oppositional Behavior Talking with parents:

“teaching a behavioral skill” Following instructions Coping with anger Persisting on a task Self-quieting

Oppositional Behavior Talking with parents:

“teaching a behavioral skill” Following instructions Coping with anger Persisting on a task Self-quieting

Must use two-part approach Encourage skills you want to see more often. Discourage behaviors you want to see less.

Oppositional behavior Time-In: Encouraging use of new skill

Frequent, intermittent “bursts” of attention to average behavior

BIG reaction for demonstrating skill

Oppositional Behavior Time-Out: Discouraging Problem Behavior

Misconceptions: Child must be quiet Child must sit still Child must be sorry Child must understand

Oppositional Behavior Time-Out: Discouraging Problem Behavior

What it IS: Brief, unpleasant consequence during which there is

no access to attention or anything fun

Oppositional Behavior Time-Out: Discouraging Problem Behavior

Procedure Adult-sized chair Area easy to covertly monitor 2-3 minutes Parent ends the time-out Child completes task after time-out is over

Sleep/Bedtime Problems Most common:

Difficulty settling and night time awakenings

Sleep/Bedtime Problems Basic Intervention:

Improved sleep hygiene Systematic ignoring Faded bedtime procedure Reward program

Sleep/Bedtime Problems Basic Intervention:

Improved sleep hygiene Systematic ignoring

Unmodified (“cold turkey”) With parental presence Quick check Graduated (Ferber)

Sleep/Bedtime Problems Basic Intervention:

Improved sleep hygiene Systematic ignoring Faded bedtime procedure

Establish time of sleep onset Set “window” of sleep Gradually increase time

Sleep/Bedtime Problems Basic Intervention:

Improved sleep hygiene Systematic ignoring Faded bedtime procedure Reward Program

Case #2 8 y.o. female with “difficulty sleeping”

Noncompliant at bedtime Three hour latency to sleep Co-sleeping

Questions: How much sleep is the child lacking? How would you set up the faded procedure? What other procedures might you employ?

ADHD “Attentional problems” greatest increase of all

mental health problems in PC since 1979 ADHD diagnosis a 2.3-fold increase in the

population-adjusted rate from 1990-1995 Children with ADHD use primary care more,

cost more

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion A:

Six or more symptoms from one or both of these lists:

• Inattentive Type• Hyperactive/Impulsive Type

…have been present for at least 6 months.

Symptom ListsInattentive Type• fails to attend to details, makes

careless mistakes• difficulty sustaining attention in

play or work• does not listen when spoken to• does not follow through• difficulty organizing tasks• avoids task requiring sustained

mental effort• loses things needed• distracted by extraneous stimuli• often forgetful

Hyper/Impulsive Type• often fidgets hands/feet or squirms• often leaves seat when sitting is

expected• runs about or climbs excessively• difficulty playing or engaging in

leisure activities quietly• often “on the go”/ “driven by

motor”• talks excessively• blurts out answers before questions

completed• difficulty awaiting turn• interrupts or intrudes on others

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion B:

Some of the symptoms were present before the age of seven years.

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion C:

Some impairment from the symptoms is present in two or more settings (e.g., home, and school or work).

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion D:

There is evidence of clinically significant impairment in social, academic, or occupational functioning.

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion E:

The identified symptoms are not better accounted for by another mental disorder.

ADHD: Assessment Information gained by qualified clinician

From family From school Observation

ADHD: Assessment Well-regarded rating scales:

Conners (Parent and Teacher) ADHD Checklist (DSM-IV)

ADHD: Treatment What we KNOW works:

Drug Therapy Hundreds of studies (N > 5,000)

Behavior Therapy 48 classroom studies (N > 900) 80 parent/home studies (N > 5,000)

Combined Behavioral/Drug 10 classroom studies (N > 800)

ADHD: TreatmentThe AAP Guidelines:

1. Establish management program

2. Specify target outcomes in cooperation

3. Use medications/behavior therapy

4. Re-evaluate

5. Follow-up systematically

ADHD Other information

NIH Consensus Statement AAP Clinical Practice Guidelines (Pediatrics,

2000) AACAP Practice Parameters for the Assessment

and Treatment of Children, Adolescents, and Adults with ADHD