1. Behavioral Pediatrics: The Top Three
Jodi Polaha, Ph.D.
Assistant Professor, Pediatrics
Munroe-Meyer Institute

2. Behavioral Health Clinics

3. Why Primary Care?
Physicians as gate keepers for mental health services

4. Why Primary Care?
Physicians as gate keepers for mental health services
Increased continuity of care

5. Why Primary Care?
Physicians as gate keepers for mental health services
Increased continuity of care
De-stigmatizes mental health treatment

6. 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,

7. 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,

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

9. Oppositional Behavior
Core issue is typically noncompliance
How many of 10 instructions would s/he do the first time asked?
Mealtimes?
Bedtime?
Public outings?

10. Oppositional Behavior
Significant problems will not dissipate with age

11. 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

12. 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.

14. Oppositional Behavior
Talking with parents:
“teaching a behavioral skill”
Following instructions
Coping with anger
Persisting on a task
Self-quieting

15. 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.

16. Oppositional behavior
Time-In: Encouraging use of new skill
Frequent, intermittent “bursts” of attention to average behavior
BIG reaction for demonstrating skill

17. Oppositional Behavior
Time-Out: Discouraging Problem Behavior
Misconceptions:
Child must be quiet
Child must sit still
Child must be sorry
Child must understand

18. Oppositional Behavior
Time-Out: Discouraging Problem Behavior
What it IS:
Brief, unpleasant consequence during which there is no access to attention or anything fun

19. 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

20. Sleep/Bedtime Problems
Most common:
Difficulty settling and night time awakenings

21. Sleep/Bedtime Problems
Basic Intervention:
Improved sleep hygiene
Systematic ignoring
Faded bedtime procedure
Reward program

22. Sleep/Bedtime Problems
Basic Intervention:
Improved sleep hygiene
Systematic ignoring
Unmodified (“cold turkey”)
With parental presence
Quick check
Graduated (Ferber)

23. 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

24. Sleep/Bedtime Problems
Basic Intervention:
Improved sleep hygiene
Systematic ignoring
Faded bedtime procedure
Reward Program

25. Case #2 8 y.o. female with “difficulty sleeping” Questions:
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?

26. 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
Children with ADHD use primary care more, cost more

27. 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.

28. Symptom Lists Hyper/Impulsive Type Inattentive 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
Inattentive 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

29. Formal Diagnostic Criteria DSM-IV, 1994
Criterion B:
Some of the symptoms were present before the age of seven years.

30. 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).

31. Formal Diagnostic Criteria DSM-IV, 1994
Criterion D:
There is evidence of clinically significant impairment in social, academic, or occupational functioning.

32. Formal Diagnostic Criteria DSM-IV, 1994
Criterion E:
The identified symptoms are not better accounted for by another mental disorder.

33. ADHD: Assessment Information gained by qualified clinician From family
From school
Observation

34. ADHD: Assessment Well-regarded rating scales:
Conners (Parent and Teacher)
ADHD Checklist (DSM-IV)

38. ADHD: Treatment What we KNOW works: Drug Therapy Behavior 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)

39. ADHD: Treatment The AAP Guidelines: Establish management program
Specify target outcomes in cooperation
Use medications/behavior therapy
Re-evaluate
Follow-up systematically

40. 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