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Behavioral Pediatrics

Description of the Strategy

Behavioral pediatrics (BP) is a branch of pediatrics that integrates behavioral and pediatric sciences to promote the health of children. A unique aspect of BP is that competencies for practice can be met by physicians or psychologists, and thus its practitioners include both. Most typically, however, the physician and psychologist work in partnership whether the task at hand involves a particular case or a promising area of research. Another unique aspect is that BP plays a significant role across the three levels of care in medicine: primary (e.g., routine, preventive), secondary (e.g., therapeutic, curative), and tertiary (e.g., rehabilitative, palliative). Historically, there have been three general areas of inquiry and application in BP: (1) common behavior problems that present in outpatient pediatric medical settings (e.g., bedtime problems), (2) behavior problems with significant biological components (e.g., soiling), and (3) biological (i.e., medical) problems with a significant behavioral component (e.g., enuresis). More recently, a fourth general area of BP has emerged, one that more strongly emphasizes the interaction between biological and behavioral factors (e.g., attention-deficit/hyperactivity disorder—ADHD). In addition, there are two general forms of treatment supplied in BP: (1) supportive counseling, usually involving the delivery of health education (e.g., extended crying is normal in early infancy) but no specific action and (2) prescriptive behavioral treatment, usually involving the provision of specific procedures for remediation of presenting problems to caregivers (e.g., motivational programs). This entry will primarily emphasize the latter. Recognition of the high prevalence of behavioral problems that initially and often only present in pediatric settings as well as the reciprocal nature of interactions between medical and behavioral factors in child health has led to dramatic growth in BP over the past 30 years. In addition, the range of behavioral treatments that have been shown to eliminate or at least reduce the severity of problems seen by BP practitioners has also expanded greatly. This entry elaborates on the four general areas of BP, includes examples of problems representative of each, and, where relevant, describes methods that have been utilized for successful treatment.

Behavior Problems Presenting in Pediatric Settings

Twenty to 30% of children seen in primary care exhibit behaviors that meet criteria for a behavioral or emotional disorder, and another 40% or more exhibit behaviors or emotions that cause their parents concern and/or cause some functional impairment for the child but do not meet criteria for a disorder. The types of concerns commonly seen in pediatric settings vary with the age of the child. Parents of infants are most often concerned about excessive crying and sleep problems, parents of preschool children mostly worry about oppositional behaviors, toileting, attentional problems, selective eating, and fears, and parents of school-aged children are mostly concerned about academic, school behavior, and peer relationship problems.

Minor behavior problems will often resolve without the direct intervention of a professional. Thus, pediatric advice about behavior problems is frequently limited to recommending that parents let their child “grow out of it.” However, this “tincture of time” approach ignores the substantial stress that child behavior problems can place on a family, a fact highlighted by the increased risk of child abuse that occurs in association with many problem behaviors (e.g., crying and incontinence are leading causes of abuse). In addition, not all children grow out of their behavior problems, and currently there is no reliable means of determining those who will from those who will not. Poorly managed oppositional behaviors can devolve into much more serious problem behaviors that require extraordinary therapeutic interventions for remission (e.g., conduct disorder, delinquency). Unresolved toileting problems can lead to serious medical problems (e.g., megacolon, urinary tract infection). Untreated sleep problems can lead to habitually disrupted sleep patterns, family discord, and child maltreatment. Unsolved school problems can lead to incomplete education and school failure that, in turn, set the stage for drug use, delinquency, and crimes against others. There are many other examples. The upshot is that children with routine behavior problems and their families can benefit substantively from the provision of brief, problem-specific, prescriptive advice. The range of problems initially presenting in primary care settings for which such advice can ultimately be beneficial is broad, and complete coverage is well beyond the scope of this entry. By way of illustration, a very common pediatric complaint, sleep disturbance, and five problem specific interventions that have been used for treatment in pediatric settings will be described.

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