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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