Transcript Behavioral Pediatrics: The Top Three

Behavioral Pediatrics:
The Top Three
Jodi Polaha, Ph.D.
Assistant Professor, Pediatrics
Munroe-Meyer Institute
Behavioral Health Clinics
Why Primary Care?
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Physicians as gate keepers for mental health
services
Why Primary Care?
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Physicians as gate keepers for mental health
services
Increased continuity of care
Why Primary Care?
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Physicians as gate keepers for mental health
services
Increased continuity of care
De-stigmatizes mental health treatment
Top Three Problems
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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
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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
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5 y.o. boy at well-child check
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Mom’s main concern is sleep
Notes he is aggressive at school
Questions
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What concerns should be assessed?
What screening measures should be used?
What diagnoses should be considered?
What recommendations should be made?
Oppositional Behavior
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Core issue is typically noncompliance
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How many of 10 instructions would s/he do the
first time asked?
Mealtimes?
Bedtime?
Public outings?
Oppositional Behavior
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Significant problems will not dissipate with
age
Oppositional Behavior
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Oppositional Defiant Disorder (DSM-IV)
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6 month pattern of negative, hostile, defiant behavior with
4 of the following:
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Loses temper
Argues with adults
Blames others
Etc.
Causes Impairment
Not psychosis
Not Conduct Disorder
Oppositional Behavior
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Use behavioral screening such as the Eyberg
Child Behavior Checklist (ECBI)
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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
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Talking with parents:
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“teaching a behavioral skill”
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Following instructions
Coping with anger
Persisting on a task
Self-quieting
Oppositional Behavior
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Talking with parents:
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“teaching a behavioral skill”
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Following instructions
Coping with anger
Persisting on a task
Self-quieting
Must use two-part approach
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Encourage skills you want to see more often.
Discourage behaviors you want to see less.
Oppositional behavior
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Time-In: Encouraging use of new skill
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Frequent, intermittent “bursts” of attention to
average behavior
BIG reaction for demonstrating skill
Oppositional Behavior
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Time-Out: Discouraging Problem Behavior
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Misconceptions:
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Child must be quiet
Child must sit still
Child must be sorry
Child must understand
Oppositional Behavior
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Time-Out: Discouraging Problem Behavior
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What it IS:
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Brief, unpleasant consequence during which there is
no access to attention or anything fun
Oppositional Behavior
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Time-Out: Discouraging Problem Behavior
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Procedure
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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
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Most common:
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Difficulty settling and night time awakenings
Sleep/Bedtime Problems
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Basic Intervention:
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Improved sleep hygiene
Systematic ignoring
Faded bedtime procedure
Reward program
Sleep/Bedtime Problems
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Basic Intervention:
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Improved sleep hygiene
Systematic ignoring
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Unmodified (“cold turkey”)
With parental presence
Quick check
Graduated (Ferber)
Sleep/Bedtime Problems
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Basic Intervention:
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Improved sleep hygiene
Systematic ignoring
Faded bedtime procedure
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Establish time of sleep onset
Set “window” of sleep
Gradually increase time
Sleep/Bedtime Problems
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Basic Intervention:
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Improved sleep hygiene
Systematic ignoring
Faded bedtime procedure
Reward Program
Case #2
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8 y.o. female with “difficulty sleeping”
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Noncompliant at bedtime
Three hour latency to sleep
Co-sleeping
Questions:
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How much sleep is the child lacking?
How would you set up the faded procedure?
What other procedures might you employ?
ADHD
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“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 Criteria
DSM-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 Lists
Inattentive Type
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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
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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 Criteria
DSM-IV, 1994
Criterion B:
Some of the symptoms were present before the
age of seven years.
Formal Diagnostic Criteria
DSM-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 Criteria
DSM-IV, 1994
Criterion D:
There is evidence of clinically significant
impairment in social, academic, or
occupational functioning.
Formal Diagnostic Criteria
DSM-IV, 1994
Criterion E:
The identified symptoms are not better
accounted for by another mental disorder.
ADHD: Assessment
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Information gained by qualified clinician
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From family
From school
Observation
ADHD: Assessment
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Well-regarded rating scales:
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Conners (Parent and Teacher)
ADHD Checklist (DSM-IV)
ADHD: Treatment
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What we KNOW works:
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Drug Therapy
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Behavior Therapy
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Hundreds of studies (N > 5,000)
48 classroom studies (N > 900)
80 parent/home studies (N > 5,000)
Combined Behavioral/Drug
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10 classroom studies (N > 800)
ADHD: Treatment
The 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
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Other information
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NIH Consensus Statement
AAP Clinical Practice Guidelines (Pediatrics,
2000)
AACAP Practice Parameters for the Assessment
and Treatment of Children, Adolescents, and
Adults with ADHD