Transcript Behavioral Pediatrics: The Top Three

Munroe-Meyer Institute
Department of Psychology
Holly Roberts, Ph.D.
Munroe-Meyer Institute
University of Nebraska Medical Center
Munroe-Meyer Institute Psychology
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Provide clinical services and training for a
wide variety of infant, child, and adolescent
concerns
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Behavioral
Social-emotional
Physical
Medical
Cognitive Abilities
Munroe-Meyer Institute Psychology
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Services are provided
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Hospitals
Schools
Community-based clinics throughout Nebraska
Munroe-Meyer Institute Psychology
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Education
Training
Research
Clinical Services
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MMI
Outreach clinics
Home and school visits
Typical Child Concerns
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academic/school problems
adjustment (death/divorce)
anxiety/fears
attention & behavior problems
feeding/eating problems
habits (e.g., thumb-sucking)
sleep problems
toileting
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.
Behavioral Approach
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ABC’s
Functional Assessment informs treatment
Empirically supported treatments
Oppositional Behavior
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Core issue is typically noncompliance
“KEYSTONE BEHAVIOR”
 How many of 10 instructions would s/he do the
first time asked?
 Mealtimes?
 Bedtime and morning routines?
 Public outings?
Oppositional Behavior
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Significant problems will not dissipate with
age
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5% of 3-year olds. 68% @ 8 years
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—Part of Spectrum
Oppositional Behavior
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Most parents rely on repeated:
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Lecturing
Reasoning
Explaining
Warning
Threatening
Yelling
Oppositional Behavior
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Children learn best from…
Immediate feedback from their environment
--i.e., “hands on” not by lecture
by doing not from hearing
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
Parent training only supported treatment!
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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REPETITION X CONTRAST=
BEHAVIOR CHANGE
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High contrast= quick (often 1 trial)
learning, requires less reps
Oppositional behavior
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Time-In: Encouraging use of new skill
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Frequent, intermittent “bursts” of attention for
average behavior
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Keep attention tank full
BIG reaction for demonstrating skill
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Enthusiasm, Touch, Praise
Oppositional Behavior
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Time-Out: Discouraging Problem Behavior
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Misconceptions:
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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
Consistent use for every occurrence of target behavior
No reprimand on release
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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20-25% of 1-5 year olds
Parasomnias & Dyssomnias
Most common:
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Difficulty settling and night time awakenings
 Very persistent problem: 84% still have
problems after 3 years
Behavioral Formula for Establishing
Pediatric Sleep Disturbance
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Repeatedly attend to child’s continuous
calling out, crying, and “curtain calls”
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Allow child to fall asleep in living area, then
transfer him/her to bed once asleep
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When child awakens at night, stay with
him/her or admit them to parents’ bed until
they fall back to sleep
Sleep/Bedtime Problems
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Basic Intervention:
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Improved sleep hygiene
 Routines
 Consistent bed and wake times throughout the
week
 The Bedroom
 Teach independent sleep onset skills (drowsy
but awake)—i.e.,being alone, self-calming
Sleep/Bedtime Problems
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Basic Intervention:
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Improved sleep hygiene
Systematic ignoring---(EXTINCTION BURST)
 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
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
Top 10 Myths of ADHD
10. ADHD and ADD are different disorders
9. Girls aren’t hyperactive
8. ADHD is outgrown in adolescence
7. ADHD is caused by poor parenting
6. ADHD is caused by diet (sugar, food additives)
Top 10 Myths cont.
5. There is a “cure” for ADHD
4. Taking medications for ADHD leads to drug abuse
3. Children who improve with stimulant medication
(Ritalin) must have ADHD
2. If the child fails to display ADHD behaviors in the
doctor’s office, then the child doesn’t have ADHD
1. It is a “medical diagnosis”
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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Behavior ratings from family
Behavior ratings from the school
Observation (clinic or in vivo)
Treatment Unproven/Disproven
ADHD is a disorder of performance, not of skill
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problem is not with “knowing what do”
problem is with “doing what you know”
To be effective, treatments must be in place at the
“point of performance”
 outpatient psychotherapy alone
 play therapy
 group classes (e.g., social skills training)
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)
No Support for Antidepressants and Clonidine for
young children
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 Home Programs
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Parent training in behavior management
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Positive attending
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reinforcement, “time-in”
Anticipating and preventing problems
Compliance training
Discipline strategies
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time-out
job card grounding
token systems
Job Card Grounding
Primarily for older children (9 and up)
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create 25 to 50 job cards (15 to 30 min each)
assign jobs for breaking rules
child/teen is grounded until jobs completed
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no TV
no Telephone
no allowance
no going outside
no contact with friends
no playing with toys
School Interventions
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Token programs
Home School Notes
Classroom Accommodations
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e.g., preferential seating, adjustments in testing
and classwork (extra time, reading directions
aloud to students)
Token Systems
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Program in which child (or group of
children)….
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Earn tokens for engaging in a variety of
desired behaviors and,
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Later exchange the tokens for things they
want
Daily Home-School Note
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Basic components
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Specific behaviors are identified & defined
A school note is created
Divides day into shorter segments
Lists identified behaviors
Daily Home-School Note
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Basic components
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Teacher marks note, gives feedback at end of
each period
Rewards/consequences provided at home for
performance at school
Student is responsible for getting note from place
to place
10 Management Principles for
Children w/ ADHD
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Greater immediacy/frequency of consequences
Use of more salient (noticeable) consequences
More frequent change in rewards
“Act, don’t yack”
Use rewards before punishment
Anticipate problems; Have a plan
Keep a disability perspective
Prioritize
Don’t personalize the child’s problem
Practice forgiveness!