1. No category

Congreso del Centenario
de la
Sociedad Argentina de Pediatria
13 al 16 de septiembre de 2011
How to Incorporate the Concepts of
Development and Behavior
into the Practice of Pediatrics
Martin T. Stein, MD
Professor of Pediatrics
Division of Child Development and Community Health
University of California San Diego
Rady Children’s Hospital San Diego
Disclosure
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„
„
Neither I nor any member of my immediate family
has a financial relationship or interest with any
proprietary entity producing health care goods
or services related to the content of this CME
activity.
My content will not include discussion/
reference of any commercial products or services.
I do not intend to discuss an unapproved/
investigative use of commercial products/devices.
Rethinking Well Child Care
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Historical legacy and current practices
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Why change now?
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Research to define current practices and
promote change
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Innovations and the future
History of Guidelines for Pediatric
Well Child Care
First AAP WCC guidelines (1974)
14 visits recommended
Revised 2-3 times each decade
American Academy of Pediatrics
Bright Future: Guidelines for Health Supervision of
Infants, Children, & Adolescents (2008)
31 visits between birth and 21 years
12 visits between 0 and 3 years of age
Drowning in a sea of advice: pediatricians and
AAP policy statements.
Belamarich PF et al. Pediatrics 2006:118:e964-e978.
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344 AAP policy statements
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57 health advice directive policies
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192 discrete health advice
directives
185 (96%) created from 1993-2002
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Safety advice 67%
Media use 12%
Substance abuse 5%
Environmental health 4%
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Development/behavior 4%
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Sexuality/pregnancy 3%
Nutrition 2%
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International Trends in WCC
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US: only country where board certified
pediatricians deliver WCC
Australia, UK, Sweden: nurses w/ PH training;
home visits
Netherlands: WCC MD’s (no internship or
residency; 3-wk training in WCC)
Group Well Child Care: Japan and Denmark
Kuo. A: Rethinking Well-Child Care in the United States: An
International Comparison
Pediatrics (2006) 118:1692-1702.
Reason for Visit to Pediatrician
37 %
32 %
15 %
Preventive
Visit
Sick Visit
Follow-up
Visit
8%
8%
Psychosocial
Problem
Other
Average Length of Preventive Care
Total Time in Office (Minutes)
Min.
50
W aitin g Tim e
Co ntact Time
40
30
20
10
0
0 -2 yr
AAP, PS#43, 2000
3 -5 yr
6-11 y r
12- 17 yr
Average waiting time = 19.5 minutes
18+ y r
Pediatricians Always Counseling
for Children 2-5 Years
71 %
34 %
41 %
48 %
49 %
Car Seat
Healthy
Weight
15 %
Firearm
Safety
Tobacco
Use
Physical
Activity
Diet &
Nutrition
Galuska, et al. Pediatrics, 2002;109(5)e83
Parent Health Asked About by
Child’s Health Care Providers
70 %
58 %
50 %
8.5 %
Domestic
Violence
Depression
Bethell et al. Commonwealth Fund, Sept. 2002
Ericson et al, Pediatrics 2001
Alcohol or Drug
Use
Social Support
Parents Want More information On:
%
54 %
42 %
41 %
30 %
23 %
How to Help
How to
Learn
Discipline
Toilet
Training
Sleep
Patterns
Crying-What
to Do
Continuity of Care
„
Primary care: first contact, integration of
services, continuity, family focus
Alpert JJ, Charney E. HSR #73, 1974; Alpert JJ et al. Pediatrics
57:917,1976
„ Therapeutic alliance:
a trusting
relationship developed over time
Green, M: Guidelines to Health Supervision Visits III. AAP:3-9,
2002
Continuity of Care
„ Improved parent satisfaction
Pediatrics, 109: 2002
„ Reduced
emergency room utilization
Pediatrics (Supplement) 113:1917;1985 (2004)
Contemporary trend: Only 46% of
parents report that their child saw the
same pediatric clinician for well child
visits up to 3 years of age (NSECH)
Pediatrics (Supplement)113:1917 (2004)
Limited Evidence-base: the Challenge
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Promoting optimal nutrition after infancy:
prevention of obesity and eating disorders
Safety: bicycle safety (helmets), guns in homes,
preventing burns and motor vehicle injuries
Substance abuse: education/prevention
Early recognition of school-related problems:
ADHD, learning disabilities, social
relationships
Early detection and diagnosis of behavioral
conditions: Autistic Spectrum Disorder,
ODD, Anxiety, Depression, PTSD
Use of developmental theories
in clinical practice
A language and “frame” for understanding behavior
in children and youth
„ Use in talking to parents (and children)
„ Practical theories in pediatrics
Psychosocial stages (tasks): Erikson
Attachment: Bolby
Separation-Individuation: Mahler
Cognitive Development: Piaget
Ref: Dixon SD, Stein MT. Encounters with Children: Pediatric Behavior
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and Development (4th ed) Elsevier-Mosby, 2006.
Innovations in WCC in
Promotion of
Development/Behavior
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Systematic screening:
standardized tests
Theme for each visit
Risk categories
Co-locating
Healthy Steps model
Family drawings
Attention to parent’s
mental health
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Group discussions
Group WCC
Reach Out and Read
Limit PE’s to increase
time for dev-behavior
screening/counseling
Computers/DVDs
Links w/ community
Innovations in WCC
Developmental-Behavioral Pediatrics
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SYSTEMATIC STANDARDIZED
SCREENING
DEVELOPMENTALLY FOCUSED WCC
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GROUP WELL CHILD CARE
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REACH OUT and READ
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FAMILY DRAWINGS
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Pediatricians Reporting Screening Young
Children for Developmental Problems
96 %
71 %
15 %
Any Screening
Always Only Clinical
Assessment
Sometimes Only
Clinical
Assessment
23 %
Standardized
Instrument
AAP Periodic Survey #53, 20
AAP: Recent Policy for
Developmental Surveillance and
Screening (0-3 years)
„ Developmental
Surveillance: all well
child preventive visits
„ Developmental screening: standardized
developmental screening test at:
9, 18 and 30 month WCC visits
AAP: Identifying infants and young children with developmental disorders
in the medical home: an algorithm for developmental surveillance and
screening (2006) Pediatrics 118:405-420.
PEDS
Parents’ Evaluation of Developmental Status
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Organized method to focus on parent’s agenda for
developmental assessment
Language used to ask questions is critical
“CONCERNS”
“List any concerns about your child’s learning,
development and behavior.”
Sensitivity/Specificity: 70-80%
Glascoe FP. Collaborating with Parents: Using PEDS to Detect and Address
Developmental and Behavioral Problems. Nashville, TN: Ellsworth VandeMeer
Press, 1998 (4405 Scenic Drive, Nashville, TN 37204)
PEDS
Parents’ Evaluation of Developmental Status
Do you have any concerns about how
your child
talks and makes speech sounds?
„ understands what you say?
„ uses his or her hands and fingers to do things?
„ uses his or her arms and legs?
„ behaves?
„ gets along with others?
„ is learning to do things for himself/herself?
„ is learning preschool or school skills?
Please list any other concerns
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Behavioral Screening
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Pediatric Symptom Checklist (4-16 yr)
J Pediatr 112:201, 1988
http://psc.partners.org/
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Family Psychosocial Screening
http://www.pedstest.com/links/resources.html
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M-CHAT (18-24 mo. screen for autism)
J of Autism and Develop Disorders. 31: 131-144 (2001)
Challenge to Pediatricians:
Suspect and Refer by 18-24 months
MCHAT: Modified Checklist for Autism in
Toddlers.
Robins D, et al J Autism Develop Dis (2001) 31: 131-144.
www.dbpeds.org (Search MCHAT)
MCHAT
18-24 month Autism Screen
23-question parent form
6 Critical Questions:
1. Does your child take an interest in other children?
2. Does your child ever use his/her index finger to point,
to indicate interest in something?
3. Does your child ever bring objects over to you to show
you something?
4. Does your child imitate you?
5. Does your child respond to his/her name?
6. If you point to a toy across the room, does your child
look at it?
Earliest Diagnosis of Autism
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By age 12 months: a loss of social and language
skills in 75% of infants with ASD
Most parents did not report regression in
development retrospectively.
Behaviors in infants and young toddlers--frequency of gaze to faces
shared smiles
directed vocalizations
Ozonoff S et al. J Am Acad Child Adolesc Psychiatry 2010 Mar
Developmentally Focused
Well Child Care Visits
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Major developmental theme for each visit
Parents’ agenda
Relate counseling to developmental
observations
Communicating with children and parents
Spectrum of normal development
Dixon SD, Stein MT. Encounters with Children: Pediatric Behavior and
Development (4th ed) Elsevier-Mosby, 2006.
Developmentally Focused Well Child
Care Visit: Newborn
“Innate readiness for interaction with the
environment”
Neonatal vision and hearing
State variations
Intersensory coordination
Primitive reflexes
Motor behaviors
Dixon SD, Stein MT. Encounters with Children: Pediatric Behavior and
Development (4th ed) Elsevier-Mosby, 2006.
Developmentally Focused Well
Child Care visit: 18-months
“Asserting oneself---a push-pull process”
Autonomy vs. dependence/attachment
Self-determination
Predictable regression
Discipline
Transition object
Behavior Modification
Dixon SD, Stein MT. Encounters with Children: Pediatric Behavior and
Development (4th ed) Elsevier-Mosby, 2006.
Group Well Child Care
First published description in a pediatric practice
Stein M. Clin Pediatr 16: 825, 1977
•
Improved attendance at WCC, less calls between visits, more time
for personal issues, more open-ended questions
Osborn L et al. Pediatrics 67:701, 1981
•
More WCC topics discussed (safety, nutrition, behav/devel, sleep,
parenting)
M Dodds et al. Pediatrics, 91: 668, 1993
•
Pre and post tests similar on maternal knowledge, providing social
support, and decreasing maternal depressive symptoms
Rice et al Clin Pediatr 36:685,1997.
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High-risk families: child devel status, mat-child interactions, home
environment, provider time---no differences. Lower show rate in
group WCC. Similar measures of parental competence, social
isolation, social support and reports to CPS
Taylor et al Pediatrics 99:e9, 1997
Taylor et al Arch Pediar Adolesc Med 152:579,1998
Reach Out and Read
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Significant association between early reading
aloud and later academic outcomes
Developmentally appropriate book at all
WCC visits (6 months to 5 years)
Demonstrate reading to child during visit
Bus AG et al. Joint book reading…a meta-analysis on intergenerational
transmission of literacy. Review of Educational Research (1995) 65:1-21.
Reach Out and Read
(controlled trials)
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Increased reading aloud at home
Increase in expressive and receptive
language at 2 years
Reading aloud as a favorite parenting activity
Reading aloud at bedtime
Reading aloud >3 days/ week
Ownership of >10 picture books
Needlman R et al. J Develp Behav Pediar (2004) 25:352-363.
Needlman R et al. Ambul Pediatr. (2005) 5:209-15.
Kinetic Family Drawing
“Draw a picture of everyone in
your family----all doing something”
Stein MT. The use of family drawings by children in pediatric
practice. J Dev Behav Pediatr (1997)18: 334.
Themes from Focus Groups
with Pediatricians
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Therapeutic alliance (“trust”)
Major focus on parents’ concerns
Use of screening tests wisely; not a
substitute for clinical interview
Evidence-based when applicable
Beyond children: family pediatrics
Innovations in practice of well child care
Biopsychosocial perspective
3 components of all behavior presentations:
Biology (genetic endowment)
Psychology (internal mental processes;
monitor and expression of emotions)
Social (contextual: family, peers, school
and community)
Engel GL: The need for a new medical model: a challenge for
biomedicine. Science 1977:106:129-136.
6 yo boy: prolonged crying every
morning before school
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Awakens with crying that persists through
breakfast and often until he is taken to school
1st grade, new school; did well in kindergarten
Family moved to new city 2 months prior to
onset of crying. He left 2 close friends. Father
busy with new job while mom is caring for 2
younger children and establishing family in new
home without her own social supports
Insidious behavioral changes in
some neurological disorders
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Personality change
Irritability
Disruptive outbursts
Sadness
Social withdrawal
Drop in school performance
Neurological conditions with
early behavior change
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Brain tumor
Metabolic disorders
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Toxic encephalopathy
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CNS infections
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Degenerative disorders
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Wilson’s disease
Thyroid dysfunction
Lead
Carbon monoxide
TB meningitis
HIV encephalopathy
Adrenoleukodystrophy
Subacute sclerosing
panencephaliltis
Brainstem glioma: 2 phases of
behavioral alterations
1st phase: Withdrawal, apathy, lethargy
Cries easily
Decline in school performance
2nd phase: Hyperactivity
Aggression
Nightmares
Lassman LP et al. Lancet (1967) 1:913-15.
Pathologic Laughter and
Crying
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PLC due to damage of pathways arising in motor
areas of cerebral cortex and descent to brainstem
to inhibit a putative center for laughter and crying
Disinhibition (or release) of the laughter and
crying center
PLC lesions occur in the cerebro-pontinecerebellar pathways
Cerebellum modulates laughter or crying in
context of situational and cognitive events.
Parvize J et al. Brain (2001) 124:1709-1709.
Innovations in WCC in
Promotion of
Development/Behavior
„
„
„
„
„
„
„
Systematic screening:
standardized tests
Theme for each visit
Risk categories
Co-locating
Healthy Steps model
Family drawings
Attention to parent’s
mental health
„
„
„
„
„
„
Group discussions
Group WCC
Reach Out and Read
Limit PE’s to increase
time for dev-behavior
screening/counseling
Computers/DVDs
Links w/ community
There is always one moment in
childhood when the door opens
and lets the future in
Graham Greene (1940)
The Power and the Glory
Martin T. Stein, MD
[email protected]