Behavioral Pediatrics: The Top Three Jodi 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 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?

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” 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?

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 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 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

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 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 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)

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