introduction to behavioral pediatrics

Introduction to Behavioral PediatricsJodi Polaha, Ph.D.Assistant Professor, PediatricsMunroe-Meyer InstituteUniversity of Nebraska Medical Center

Overview

Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)BackgroundAssessmentTreatment

ODD

Enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures.

ODD

Enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures.

Does not involve major antisocial violations.

ODD

Enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures.

Does not involve major antisocial violations.

Frequently confused with ADHD.

ODD

DSM-IV Criteria Loses temper Argues with adults Actively defiant or refuses to comply Deliberately annoys people Blames others for own mistakes Touchy or easily annoyed Angry or resentful Spiteful or vindictive

ODD

Enduring pattern. Early behavioral intervention

very successful. No medication treatment.

ODD

Coercive Family Processes (Patterson)

ODD

Coercive Family Processes (Patterson)

Child escalatesgets his way

Parent gives inGets peace and quiet

Pattern of two-way negative reinforcement

ODD

AssessmentOf 10 commands…?

ODD

AssessmentOf 10 commands…?Routines: eating, sleeping, public.

ODD

AssessmentOf 10 commands…?Routines: eating, sleeping, public.Eyberg Child Behavior Inventory

ODD

ODD

AssessmentOf 10 commands…?Routines: eating, sleeping, public.Eyberg Child Behavior InventoryIn-clinic observation

• Formal• Informal

ODD

What behavioral skills?

ODD

What behavioral skills?Self-quietingAnger managementFollowing instructions, rulesIndependent playSocial skills

ODD

What behavioral skills?Self-quietingAnger managementFollowing instructions, rulesIndependent playSocial skills

ODD

Thinking time question #1:How to improve skill of self-

quieting?

ODD

Self-quietingPredictablilityRepetition/PracticeHigh contrast or “big difference”

ODD

Parent-Child Interaction TherapySheila Eyberg (1990s)Forehand & McMahon (1980s)Hanf (1960s)

ODD

Part 1.Child’s Game“CDI”

Part 2.Parent’s Game“PDI”

ODD

Part 1.Child’s Game“CDI”

To establish the parent’s positive attention as a reinforcer.

Part 2.Parent’s Game“PDI”

ODD

CDI

Do: Don’t:Describe CommandPraise ReprimandTouch Question

ODD

CDI

5-10 min. per day. Bug in the ear. Work to criteria. Feedback in subsequent

sessions.

ODD

Part 1.Child’s Game“CDI”

GOALTo establish the

parent’s positive attention as a reinforcer.

Part 2.Parent’s Game“PDI”

ODD

Part 1.Child’s Game“CDI”

GOALTo establish the

parent’s positive attention as a reinforcer.

Part 2.Parent’s Game“PDI”

GOALTo establish

“instructional control”

ODD

PDI

Do: Don’t:Good commands Nag, etc.Consistent response Vascillate

ODD

PDI

Compliance trainingTime-Out

ODD

Time-Out (my version)

Misconceptions: Must be quiet/still Must be sorry Must understand why Length

ODD

Time-Out (my version)

Definition:

ODD

Time-Out (my version)

Definition: no access to attention or anything fun

ODD

Time-Out (my version)

1-3 min in chair Noncompliance and aggression Daily reward

ODD

Time-Out (my version)

IMPORTANT TOPICS: Extinction burst/training time-out

chair Pick your battles

ODD

Job Card Grounding

ODD

Job Card Grounding Rules Odd Jobs (Job Cards) Incentives

ODD

Three types of consequences:

Natural

ODD

Three types of consequences:

Natural Related

ODD

Three types of consequences:

Natural Related Unrelated

ODD

Thinking time question #2:

How to get child to stay in car seat?

ODD

Thinking time question #3:

How to decrease disruptive behavior in church?

ODD

Thinking time question #4:

How to get family to keep their “things” out of main areas of house?

CD

Persistent pattern of behavior that is not socially acceptable

May violate rights of others.

CD

DSM IVAggression to people and animals

• Often bullies threatens or intimidates• Often initiates physical fights• Has used a weapon/can cause harm• Has been physically cruel• Has stolen with confrontation• Has forced someone into sexual

activity

CD

DSM IVAggression to people and animalsDestruction of property

• Has deliberately engaged in fire-setting to cause damage

• Has deliberately destroyed others’ property

CD

DSM IVAggression to people and animalsDestruction of propertyDeceitfulness or theft

• Has broken into someone else’s house, building or car

• Often lies to obtain goods/avoid obligation

• Has stolen items of nontrivial value w/o confrontation

CD

DSM IV Aggression to people and animals Destruction of property Deceitfulness or theft Serious violation of the rules

• Often stays out at night despite parental prohibitions before age 13

• Has run away from home overnight at least twice.

• Often truant from school before age 13.

CD

Treatment OptionsJob Card GroundingProblem-Solving/NegotiatingResidential Treatment