Guiding Parents through Behavioral Issues Affecting Their Childs Health

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Guiding Parents through Behavioral Issues
Affecting Their Childs Health

• The Primary Care Providers Role
• David A. Levine, MD

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Learning Objectives

• Participants will identify opportunities in well
  child care to assist families in identifying and
  discuss key behavior issues in anticipatory
  guidance.
• Participants will understand the value of
  developmental screening over commonly practiced
  developmental surveillance.
• Participants will understand and select the
  varied developmental and behavioral screening
  tests available for primary care specialists in
  clinical practice with infants and children.
• Participants will describe the types of
  interventions available for infants and children
  for addressing behavioral or developmental
  challenges.

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The Issue

• Every day, on average, 6-7 youths are murdered in
  this country each day
• Our prison system is overwhelmed by continued
  infusion of new offenders
• There is evidence that demonstrates that early
  childhood interventions may reduce both of these
  factors.
• Source Child and Adolescent Violence Research
  At the National Institute of Mental Health. Fact
  Sheet. April 2000.

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From the NIMH Fact Sheet

• Such forces such as weak bonding, ineffective
  parenting (poor monitoring, ineffective,
  excessively harsh, or inconsistent discipline,
  inadequate supervision), exposure to violence in
  the home.puts children at risk for being violent
  later in life. This is particularly so for youth
  with problem behavior such as early conduct and
  attention problems, depression, anxiety
  disorders, lower cognitive and verbal abilities

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So What About Solutions?

• NIMH funded project, The Nurse Home Visitation
  Program
• Nurses visit mothers from pregnancy to childs
  second birthday
• Currently in NY, CO, and TN
• Long-term follow up indicated that by age 15
• Fewer behavioral problems
• Less substance abuse
• Fewer arrests
• Fewer sexual partners when adolescents

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So How do We Identify These Families?

• We must identify risk factors that lead to poor
  parenting examples are
• Unplanned pregnancies
• Adolescent parents (without proper guidance)
• Poor bonding and attachment noted in the hospital
  nursery or at the initial office visit.
• We must be vigilant for behavioral and
  developmental issues in early childhood

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So How Do We Identify these Families?

• Observation of the interaction developmental
  and behavioral surveillance
• Role of developmental-behavioral screening
• Targeted behavioral issues relevant to specific
  developmental stages

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Developmental Surveillance

• The classic method when pediatricians, experts in
  child behavior and development, observe the child
  and/or parent-child interaction and determines if
  this is normal or not
• This is done on every patient and parent
  encounter
• The problem is, however, what is your gold
  standard ?

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What is the Problem with Developmental
Surveillance?

• Surveillance works well in office visits for
  illness or chronic care
• We can spot check development and behavior and
  offer targeted advice
• But consider a 15 month old infant at the time of
  a health check (EPSDT visit)

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With this 15 month old toddler, you find out she
is

• Just waving bye-bye, not drinking from a cup
• Bangs 2 cubes, but does not scribble
• Says mama and dada to the right folks, but no
  other words
• Just taking a few steps, not walking well
• What do you think of the development?

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Limitation of Surveillance

• It is fairly clear that that infant has a delay
  and needs referral
• But what about the 15 month old infant that is
• Waving bye-bye and drinking from a cup
• Scribbling, but unable to stack items
• Says one word, other than mama and dada
• How much delay is abnormal? We need a standard!

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What is Happening at Child Health Provider
offices?

• Source Sices, F et al, How do Primary Care
  Physicians Identify Young Children with
  Developmental Delays? Developmental and
  Behavioral Pediatrics. 24 (6)409-17, December
  2003.

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Developmental Screening

• While the developers continue to duke it out in
  the literature, they agree that surveillance is
  not enough, especially
• William Frankenburg, MD, MSPH, U Colorado,
  developer of the Denver Developmental Screening
  Test
• Frances Glascoe, PhD, Vanderbilt U, developer of
  Parents Evaluation of Developmental Status
• Both with scathing, albeit amusing, editorials
  about each other
• Source Glascoe, FP and then Frankenburg, W,
  (Letters). Pediatrics 109(6) 1181-1183, June
  2002.

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Which Test to Use in a Busy Practice?

• The Goals of a good developmental test for
  clinical practice
• Easy to store and use
• Easy to administer by ancillary health
  professionals
• High sensitivity and specificity
• Easy to interpret quickly by providers
• Low cost

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Whats Out There

• Three most suggested tests
• Denver Developmental Screening Test II (DDSTII)
• Ages and Stages
• Parents Evaluation of Developmental Status (PEDS)
• Other available tests, generally considered
  beyond the scope of generalist practice and not
  discussed
• Child Development Inventories
• Bayley Infant Neurodevelopmental Screener

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The Traditional Test

• DDST II been around a while, with recent
  revisions
• Confusing information in the literature about how
  well the test performs
• Attempt to make it more office friendly with use
  of the Parents Developmental Questionnaire II
  (PDQ II)
• If PDQ II abnormal, then do a DDST II
• This strategy has not been evaluated well

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DDST II

• Pros
• Teaches milestones
• Easy to interpret in busy office
• Inexpensive
• Fun to do with a cooperative child
• Serves as a recorded, developmental growth chart

• Cons
• Requires cooperation of infant or toddler
• Have to use the DDST II kit to do test
• Not all tasks are culturally appropriate for all
  kids (blocks stacking not always with blocks at
  home!)
• Significant time to use

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Ages and Stages

• Attempt by the test to be milestone driven still,
  but with a questionnaire structure
• Parent completed developmental questionnaire with
  data specific by age
• Separate packet for ages 4 months to age 5 years
  2 month intervals to age 2 years, then 3 month
  to age 3, then every 6 months to age 5

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Ages and Stages

• Pros
• Most detailed for parents who are motivated
• Teaches parents (and learners) milestones
  expected
• Provided as a CD to print forms

• Cons
• Developmental ages do not always match with AAP
  periodicity14 month standard at 15 month
• Storage and confusion for staff
• Significant parent time to complete may mean
  fewer answered comprehensively

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Parents Evaluation of Developmental Status

• Predicated on two assumptions
• Parents know their children the best
• Parents are naturally inclined to compare their
  children with other kids of the same age
• Simple 10 item questionnaire that is the same for
  ages birth to 8 years.

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PEDS

• Pros
• Very easy to administer
• Elicits behavioral concerns even if not part of
  surveillance
• Simple forms for the chart
• Performs as well as others, even if simple!

• Cons
• Feels different when use itnot milestone
  driven, so still do some surveillance with it
• Dependent on English Language or foreign language
  forms validated version wording specific
• May seem to recommend over-referral

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Targeting Age-Appropriate Problems

• Parents may not be aware that their child health
  provider can assist with developmental or
  behavioral issues
• Discussing high yield issues at each age health
  check is appropriate to prevent know problems and
  open the door about minor issues
• The most comprehensive reference on this is
  Bright Futures (http//www.brightfutures.org/).

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Bright Futures

• Begun in 1990 funded by the Health Resources and
  Services Administration, Maternal and Child
  Health Bureau
• Developed health supervision guidelines with the
  collaboration of four interdisciplinary panels of
  experts in infant, child, and adolescent health
• Was reviewed by nearly 1,000 health
  professionals, educators, and child health
  advocates throughout the United States
• Published originally in 1994, guidelines updated
  and revised in 2000.

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So What are the Highest Yield Issues?

• Initial office visit (1-2 weeks)
• Discuss fussy crying coming
• Prevent shaken baby syndrome
• Two and Four month visit rarely with behavioral
  concerns
• Use this time for safety and nutrition
• Six months start of separation and stranger
  anxiety, should sleep through night

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Highest Yield Issues

• Nine months preparing for exploration
• Review Injury prevention in the house
• Twelve months beginning of tantrums
• Set limits, reward wanted behaviors
• Expected appetite drop and finicky eating
• Limit the rules and be consistent
• Fifteen months Emerging independence
• Use discipline to teach, not punish, review time
  out vs. corporal punishment

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Highest Yield Issues

• Eighteen months
• Allow assertiveness within limits
• Expect nightmares
• Toilet training approaches
• Two years The TERRIBLE Twos
• Beginning toilet training when ready
• Anticipate the broad range of behavior issues
• Independent play together dont expect
  sharing of toys

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Highest Yield Issues final

• After the third birthday, behavior issues calm
  downin many ways until adolescence!
• Encourage Head Start (or Pre-K, if not available)
  if able to easily separate from parents

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How to Get More Help

• Once you have determined that there is a
  behavioral or developmental issue
• Is this a global issue or a focused behavioral
  problem?
• Is there a validated behavioral approach that
  you, as a primary care provider, can attempt in
  the office?

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Targeted Behavioral Approaches

• Many of the issues that are raised as concerns on
  either discussion or Developmental Screening are
  age appropriate or minor problems
• The two-year-old that says NO to everything
• Infants that are trained night criers
• While beyond the scope of this presentation,
  there are validated responses to a variety of
  these kind of problems.

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But What About Infants That Have More Significant
Issues

• If you are concerned that there is an underlying
  cause to the developmental or behavioral issue
  (e.g. autism spectrum disorder)
• Developmental-Behavioral Pediatricians
• Child Psychology
• Child Psychiatry

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Referring Children

• If you have done a history and physical and do
  not see evidence of a disorder with a
  recognizable pattern (e.g. isolated speech delay,
  but the remainder of development is normal)
• Early Intervention (In GA, Babies Cant Wait to
  age 3, School Districts after age 3)
• Direct referrals to Oro-motor/Speech,
  Occupational Therapy, or Physical Therapy

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Cross-over to These Strategies

• If one of the doctorate level specialists agrees
  with the developmental delay, they will likely
  work with the same therapists or refer to early
  intervention
• If one of the specialists in early intervention
  performs a developmental assessment, they often
  find other issues, which may necessitate a
  referral to a doctorate level professional

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Summary

• We MUST detect, intervene and unravel early
  childhood behavioral and developmental problems
• The next person that asks you for spare change
  (or worse) may have had their developmental
  issues missed by our last generation of
  Pediatricians.