Introduction to Behavioral Pediatrics

1. Introduction to Behavioral Pediatrics Jodi Polaha, Ph.D. Assistant Professor, Pediatrics Munroe-Meyer Institute University of Nebraska Medical Center

2. Overview • Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) • Background • Assessment • Treatment

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

4. ODD • Enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures. • Does not involve major antisocial violations.

5. ODD • Enduring pattern of uncooperative, defiant, and hostile behavior toward authority figures. • Does not involve major antisocial violations. • Frequently confused with ADHD.

6. 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

7. ODD • Enduring pattern. • Early behavioral intervention very successful. • No medication treatment.

8. ODD Coercive Family Processes (Patterson)

9. ODD Coercive Family Processes (Patterson) Child escalates gets his way Pattern of two-way negative reinforcement Parent gives in Gets peace and quiet

10. ODD • Assessment • Of 10 commands…?

11. ODD • Assessment • Of 10 commands…? • Routines: eating, sleeping, public.

12. ODD • Assessment • Of 10 commands…? • Routines: eating, sleeping, public. • Eyberg Child Behavior Inventory

13. ODD

14. ODD • Assessment • Of 10 commands…? • Routines: eating, sleeping, public. • Eyberg Child Behavior Inventory • In-clinic observation • Formal • Informal

15. ODD • What behavioral skills?

16. ODD • What behavioral skills? • Self-quieting • Anger management • Following instructions, rules • Independent play • Social skills

17. ODD • What behavioral skills? • Self-quieting • Anger management • Following instructions, rules • Independent play • Social skills

18. ODD • Thinking time question #1: • How to improve skill of self-quieting?

19. ODD • Self-quieting • Predictablility • Repetition/Practice • High contrast or “big difference”

20. ODD • Parent-Child Interaction Therapy • Sheila Eyberg (1990s) • Forehand & McMahon (1980s) • Hanf (1960s)

21. Part 1. Child’s Game “CDI” Part 2. Parent’s Game “PDI” ODD

22. Part 1. Child’s Game “CDI” To establish the parent’s positive attention as a reinforcer. Part 2. Parent’s Game “PDI” ODD

23. ODD CDI Do:Don’t: Describe Command Praise Reprimand Touch Question

24. ODD CDI • 5-10 min. per day. • Bug in the ear. • Work to criteria. • Feedback in subsequent sessions.

25. Part 1. Child’s Game “CDI” GOAL To establish the parent’s positive attention as a reinforcer. Part 2. Parent’s Game “PDI” ODD

26. Part 1. Child’s Game “CDI” GOAL To establish the parent’s positive attention as a reinforcer. Part 2. Parent’s Game “PDI” GOAL To establish “instructional control” ODD

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

28. ODD PDI Compliance training Time-Out

29. ODD Time-Out (my version) Misconceptions: • Must be quiet/still • Must be sorry • Must understand why • Length

30. ODD Time-Out (my version) Definition:

31. ODD Time-Out (my version) Definition: no access to attention or anything fun

32. ODD Time-Out (my version) • 1-3 min in chair • Noncompliance and aggression • Daily reward

33. ODD Time-Out (my version) IMPORTANT TOPICS: • Extinction burst/training time-out chair • Pick your battles

34. ODD Job Card Grounding

35. ODD Job Card Grounding • Rules • Odd Jobs (Job Cards) • Incentives

36. ODD Three types of consequences: • Natural

37. ODD Three types of consequences: • Natural • Related

38. ODD Three types of consequences: • Natural • Related • Unrelated

39. ODD Thinking time question #2: • How to get child to stay in car seat?

40. ODD Thinking time question #3: • How to decrease disruptive behavior in church?

41. ODD Thinking time question #4: • How to get family to keep their “things” out of main areas of house?

42. CD • Persistent pattern of behavior that is not socially acceptable • May violate rights of others.

43. CD • DSM IV • Aggression 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

44. CD • DSM IV • Aggression to people and animals • Destruction of property • Has deliberately engaged in fire-setting to cause damage • Has deliberately destroyed others’ property

45. CD • DSM IV • Aggression to people and animals • Destruction of property • Deceitfulness 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

46. 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.

47. CD • Treatment Options • Job Card Grounding • Problem-Solving/Negotiating • Residential Treatment