Introduction to
Behavioral Pediatrics
Jodi Polaha, Ph.D.
Assistant Professor, Pediatrics
Munroe-Meyer Institute
University 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.
Behavioral
Health
Pediatric
Psychology
&
Behavioral
Pediatrics
Medical
Health
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 with
Primary Care
Why primary care?
• Physicians are “de facto” mental
health service providers (deGruy,
1997)
Collaboration with
Primary Care
Why primary care?
• Physicians are “de facto” mental
health service providers (deGruy,
1997)
• #1 presenting problem in PC:
behavior problems
Collaboration with
Primary 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 with
Primary 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 with
Primary 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.
2.
3.
Behavior is driven by the environment
in which it occurs.
Increasing appropriate behavior is as
important as decreasing problem
behavior.
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 shortterm 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 longterm and short-term rules
• Cooperation in group activities
Teaching Behavioral Skills
• Adolescence
• Persistence in working toward longterm 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. Predictability
2. Practice
Teaching Behavioral Skills
The Three Essentials:
1. Predictability
2. Practice
•
•
•
Break the new skill down
Give lots of opportunities to try it
Provide predictable feedback
Teaching Behavioral Skills
The Three Essentials:
1. Predictability
2. Practice
3. “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
HUGE!
Mom’s Reaction
100
80
60
40
20
none
0
Quiet
Gagging
BABY LEARNS TO GAG
Teaching Behavioral Skills
HUGE!
Mom’s Reaction
1
0.8
0.6
0.4
0.2
none
0
Quiet
Gagging
IGNORING:BABY LEARNS NOTHING
Teaching Behavioral Skills
HUGE!
Mom’s Reaction
100
80
60
40
20
none
0
Quiet
Gagging
BABY LEARNS TO QUIET
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
1
0.8
0.6
0.4
0.2
0
Quiet
NO LEARNING
Gagging
Teaching Behavioral Skills
Your Reaction
100
80
60
40
20
0
SKILL!
Problem Behavior
WHAT ARE YOU DOING WHEN YOU SEE THE SKILL?
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
100
80
60
40
20
0
SKILL!
NO LEARNING
Problem Behavior
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. Consistency
2. Repetition
3. High Contrast
Teaching Behavioral Skills
•
The Three Essentials:
1. Consistency
2. Repetition
3. 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 Something
2. To Get Out of Something (Escape)
Assessment of Problem Behavior:
Looking at Function
Three Functions:
1. To Get Something
2. To Get Out of Something (Escape)
3. Self-Stimulation