Introduction to Behavioral Pediatrics

Jodi Polaha, Ph.D.Assistant Professor, PediatricsMunroe-Meyer InstituteUniversity of Nebraska Medical Center

Overview of this class

• Goals• Use of class time• Expectations• Questions

Overview of today

• Behavioral pediatrics • Definition• History• Models

• The theory behind a behavioral approach • Definition• “Three essentials” for teaching

behavioral skills• Assessment of function

What is Behavioral Pediatrics?

What is Behavioral Pediatrics?

• Field of psychology representing interface between behavioral health care and pediatric primary care.

BehavioralHealth

Medical Health

PediatricPsychology&Behavioral Pediatrics

What is Behavioral Pediatrics?

• Pediatrics• Emerged in late 1800s.

• Concerned with infection, mortality.

• Grew to identified specialty in 1930s.• Focus on public policy for children.

What is Behavioral Pediatrics?

• Clinical Psychology• First clinic in 1899.• First documented collaboration

with pediatrics in 1930.• First call to collaboration in 1965.

What is Behavioral Pediatrics?

• Developmental and Behavioral Pediatrics• 1967, 1975 incorporate child

development training into pediatric practice.

• 1968 Society of Pediatric Psychology

• 1980s Society for Developmental and Behavioral Pediatrics

Collaboration with Primary Care

Collaboration withPrimary Care

Why primary care?• Physicians are “de facto”

mental health service providers (deGruy, 1997)

Collaboration withPrimary Care

Why primary care?• Physicians are “de facto”

mental health service providers (deGruy, 1997)

• #1 presenting problem in PC: behavior problems

Collaboration withPrimary Care

Why primary care?• Physicians are “de facto”

mental health service providers (deGruy, 1997)

• #1 presenting problem in PC: behavior problems

• Increased continuity of care

Collaboration withPrimary Care

Why primary care?• Physicians are “de facto”

mental health service providers (deGruy, 1997)

• #1 presenting problem in PC: behavior problems

• Increased continuity of care• De-stigmatizes mental health

services

Collaboration withPrimary Care

Why primary care?• Physicians are “de facto” mental

health service providers (deGruy, 1997)

• #1 presenting problem in PC: behavior problems

• Increased continuity of care• De-stigmatizes mental health

services• Increased confidentiality

Collaboration with Primary Care

Models (Drotar, 1995)• Independent Functions

Collaboration with Primary Care

Models (Drotar, 1995)• Independent Functions• Indirect Consultation

Collaboration with Primary Care

Models (Drotar, 1995)• Independent Functions• Indirect Consultation• Collaborative Team

Collaboration with Primary Care

Models of Collaboration (Drotar, 1995)

• Independent Functions• Indirect Consultation• Collaborative Team• Systems Approach

The Theory Behind a Behavioral Approach

• The Behavioral Approach Defined

• “Three Essentials” for Teaching Behavioral Skills

• Assessment of Problem Behavior: Looking at Function

The Behavioral Approach Defined

The Behavioral Approach Defined

Three Important Underlying Concepts:

1. Behavior is driven by the environment in which it occurs.

The Behavioral Approach Defined

Three Important Underlying Concepts:

1. Behavior is driven by the environment in which it occurs.

2. Increasing appropriate behavior is as important as decreasing problem behavior.

The Behavioral Approach Defined

Three Important Underlying Concepts:

1. Behavior is driven by the environment in which it occurs.

2. Increasing appropriate behavior is as important as decreasing problem behavior.

3. Focus is on observable, measurable outcomes.

Teaching Behavioral Skills

Teaching Behavioral Skills

• What are behavioral skills?• Behaviors that society expects.

Teaching Behavioral Skills

• What are behavioral skills?• Behaviors that society expects.• Behaviors that facilitate good

relationships.

Teaching Behavioral Skills

• What are behavioral skills?• Behaviors meeting societal

expectations• Behaviors facilitating good

relationships• Prerequisites for learning any

other skill

Teaching Behavioral Skills

• Birth through toddler years:• Independent sleep• Self-quieting• Independent play

Teaching Behavioral Skills

• Preschool Years:• Beginning anger management• Following one-step instructions• Following simple long-term and

short-term rules• Waiting one’s turn• Sharing and parallel play

Teaching Behavioral Skills

• Elementary Years:• Advanced anger management• Following increasingly complex

instructions• Following multiple and complex

long-term and short-term rules• Cooperation in group activities

Teaching Behavioral Skills

• Adolescence• Persistence in working toward

long-term objectives• Problem-solving• Increased emotional

management• Negotiating

Teaching Behavioral Skills

The Three Essentials:1. Predictability

Teaching Behavioral Skills

The Three Essentials:1. Predictability

• In your daily structure• In the consequences you

provide

Teaching Behavioral Skills

The Three Essentials:1. Predictability2. Practice

Teaching Behavioral Skills

The Three Essentials:1. Predictability2. Practice

• Break the new skill down • Give lots of opportunities to try it • Provide predictable feedback

Teaching Behavioral Skills

The Three Essentials:1. Predictability2. Practice3. “Big Difference”

Teaching Behavioral Skills

Creating a “Big Difference”

Your consequence for demonstrating a skill

appropriately should be VERY DIFFERENT

than your consequence for demonstrating a problem

behavior.

Teaching Behavioral Skills

0

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Quiet Gagging

BABY LEARNS TO GAG

Mom

’s R

eact

ion

none

HUGE!

Teaching Behavioral Skills

0

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1

Quiet Gagging

IGNORING:BABY LEARNS NOTHING

Mom

’s R

eact

ion

none

HUGE!

Teaching Behavioral Skills

0

20

40

60

80

100

Quiet Gagging

BABY LEARNS TO QUIET

Mom

’s R

eact

ion

none

HUGE!

Teaching Behavioral Skills

• Generating an “effect” in the environment can be very reinforcing.

Teaching Behavioral Skills

• Generating an “effect” in the environment can be very reinforcing.

Touch, Talk, and Look are all effects.

Teaching Behavioral Skills

• Problem #1:• Not enough of a reaction for

using the skill appropriately.

Teaching Behavioral Skills

• Problem #1:• Not enough of a reaction for

using the skill appropriately.

Teaching Behavioral Skills

0

0.2

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0.8

1

Quiet Gagging

NO LEARNING

Teaching Behavioral Skills

WHAT ARE YOU DOING WHEN YOU SEE THE SKILL?

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SKILL! Problem Behavior

You

r R

eact

ion

Teaching Behavioral Skills

1. Frequent, brief, “bursts” of attention for AVERAGE behavior.

Teaching Behavioral Skills

1. Frequent, brief, “bursts” of attention for AVERAGE behavior.

2. BIG REACTION for demonstrating the skill.

Teaching Behavioral Skills

1. Frequent, brief, “bursts” of attention for AVERAGE behavior.

2. BIG REACTION for demonstrating the skill.

3. Play the Child’s Game

Teaching Behavioral Skills

• The Child’s Game:A relationship-building activity that

makes children want to earn your POSITIVE attention.

Teaching Behavioral Skills

• DO• Describe• Praise• Touch

• DON’T• Command• Reprimand• Question

Teaching Behavioral Skills

• Problem #1:• Not enough of a reaction for

using the skill appropriately.• Problem #2:

• Too much reaction for problem behaviors.

Teaching Behavioral Skills

0

20

40

60

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SKILL! Problem Behavior

NO LEARNING

Teaching Behavioral Skills

• Solution:• Use Less Talk!

Teaching Behavioral Skills

• Why not talk?• Child may not understand.

Teaching Behavioral Skills

• Why not talk?• Child may not understand.• Understanding doesn’t mean the

child will change behavior, anyway.

Teaching Behavioral Skills

• Why not talk?• Child may not understand.• Understanding doesn’t mean the

child will change behavior.• Experience is a better teacher.

Teaching Behavioral Skills

• Why not talk?• Child may not understand.• Understanding doesn’t mean the

child will change behavior.• Experience is a better teacher.• Child needs to learn to perform

the skill independently.

Teaching Behavioral Skills

• Why not talk?• Child may not understand.• Understanding doesn’t mean the

child will change behavior.• Experience is a better teacher.• Child needs to learn to perform

the skill independently.• Leads to arguing.

Teaching Behavioral Skills

• Why not talk?• Child may not understand.• Understanding doesn’t mean the child

will change behavior.• Experience is a better teacher.• Child needs to learn to perform the skill

independently.• Leads to arguing.• Talking creates a motivating “effect.”

Teaching Behavioral Skills

• The Three Essentials:1. Consistency2. Repetition3. High Contrast

Teaching Behavioral Skills

• The Three Essentials:1. Consistency2. Repetition3. High Contrast

….well, sort of…

Assessment of Problem Behavior: Looking at Function

Three Functions:1. To Get Something

Assessment of Problem Behavior: Looking at Function

Three Functions:1. To Get Something2. To Get Out of Something

(Escape)

Assessment of Problem Behavior: Looking at Function

Three Functions:1. To Get Something2. To Get Out of Something

(Escape)3. Self-Stimulation