Strategies to Enhance Developmental and Behavioral Services in Primary Care

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CHAPTER 27 Strategies to Enhance Developmental and Behavioral Services in Primary Care

The foundation of pediatric practice is child development. Knowledge and application of the principles of biological development and the interaction between biology and experience are concepts used by pediatricians each day in office and hospital practice. The momentum and focus of a comprehensive pediatric practice is captured in the term biopsychosocial medicine, in which biology, psychology, and social interactions mediate emerging developmental components of childhood, adolescence, and family life.¹

Development, in the context of child and adolescent health, refers to the predictable emergence of specific milestones of growth. Pediatricians view these milestones from the perspective of predictable neuromaturational processes during fetal and postnatal brain growth. The interaction between genetic endowment and environmental experience mediates neuromaturation.²

Behavior refers to the way a person acts; it is conduct as experienced by others who interact with a person. Behavior is also influenced by neuromaturation in the brain during child and adolescent development, as well as by interpersonal experience with parents, other family members, peers, teachers and coaches. Behaviors are dependent on (1) temperament; (2) attainment of motor, language, social, and cognitive skills; and (3) the experience acquired from self-exploration and social interactions with others.

Development and behavior are shaped by transactions between genetic endowment and environmental influences. The interplay between the maturation of the developing brain and behavioral experiences is dynamic and present at each stage of child and adolescent development. The practice of biopsychosocial pediatrics during each well-child visit is ensured when the clinician’s observations, questions, assessment, and management plan are based on a model that incorporates an understanding of neurological development and the spectrum of behavioral change.

The challenge for pediatricians is to adapt the principles of developmental and behavioral pediatrics to the practice of primary care. They strive to learn about the unique developmental pathway of each child and family, provide anticipatory guidance, and recognize early clues to developmental delays and behavioral problems. The conscientious practice of developmentally and behaviorally sophisticated primary care pediatrics supplies the fuel that sustains an intellectual interest in pediatric medicine.

Several innovative strategies to enhance the quality of developmental and behavioral practices have been described. The use of a group format for well-child care, collaborative care with a mental health professional or a child development specialist located in the office, and creating methods to encourage parents to model reading to young children are among a few of these new formats. Other innovations have involved new ways to screen for delays in development and behavior problems through more efficient and effective screening questionnaires, and the use of new information technologies. In this chapter, these strategies are explored and how they may enhance primary care practice is discussed.

WHY CHANGE AT THIS TIME?

More than half of the parents with children younger than 5 years old report that common developmental and behavioral topics were not discussed during well-child visits. Parents report that they would like more information and support about infant crying (23%), toilet training (41%), discipline (42%), sleep issues (30%), and ways to encourage a child to learn (54%).³ Screening for developmental and behavioral conditions is highly variable, as reported by pediatricians. When asked about office screening practices in an American Academy of Pediatrics (AAP) Periodic Survey, 96% of pediatricians responded that they screen for these conditions, but only 71% reported using a structured clinical assessment, and only 23% reported using any standardized screening instrument.⁴ Expanded screening that includes family issues is also variable. Ascertainment of parents’ health by pediatricians is limited in areas of domestic violence, social support, depression, and alcohol or drug abuse.

Developmental and behavioral aspects of primary care practices have been affected by a change in the ecology of many office and clinic practices. For example, only 46% of parents reported that their child had seen the same pediatric clinician for well-child visits up to 3 years of age.⁵ Continuity of care by one person, a fundamental principle of primary care, has been replaced by continuity within one clinic or office.⁶ Many children do not even have the benefit of the number of well-child visits recommended by the AAP; nationally, only half of the well-child visits recommended by the AAP are completed in the first 2 years of life.⁷

At the same time, stress on families continues to grow. Poverty, lack of health insurance, unemployment, marital conflicts and divorce, community and family violence, and parental depression are among the many contemporary factors that potentially challenge a child’s development. Many families are now without extended family supports. These social factors interact with biological vulnerabilities and may account for the growing number of children who display adverse effects in neurodevelopment and social interactions.

Two traditional roles of pediatric practice have been to focus on all aspects of growth and development and to provide scientifically sound primary prevention. The early assessment of maternal depression, school failure, substance abuse, and family violence is as important as an early diagnosis of short stature or the assurance of complete immunizations. This type of pediatric practice can be achieved by discovering effective methods to emphasize child development, behavior, and family functioning on an equal footing with biological aspects of pediatric care.

HISTORICAL PERSPECTIVE

Pediatrics has a long history of attention to preventive aspects of child health care. Nineteenth century pioneers of pediatrics in Europe and America focused on descriptions of childhood diseases, but they soon recognized the value and importance of prevention. Abraham Jacobi, one the founders of pediatrics as a specialty for children, devoted his work to the elimination of the deadly summer diarrhea epidemics in New York City by emphasizing prevention through hygiene in the preparation of milk and other foods for young children.⁸ At the opening of the 20th century, periodic and frequent weight determinations in infants and young children in public health clinics was a way to monitor children’s general health and well-being. As a part of America’s Progressive Movement from 1900 to 1920, the U.S. Children’s Bureau proposed that monitoring the weight of young children should be the central activity for the National Year of the Child in 1918 in order to diagnose malnutrition.⁹

Nurses, social workers, and lay reformers planned and implemented these screening programs as a part of the child welfare movement in cities and small communities throughout the country. Eventually, physicians who cared for children adopted routine weight and height measurements in their offices and clinics as a part of overall supervision of a child’s health. A major force that led to the establishment of the AAP in 1930 was a recognition that pediatric care would improve significantly when pediatricians adopted a prevention-oriented strategy and collaborated with the leaders of the child welfare movement. In 1933, the president of the AAP made the radical (for that time) proposition that pediatricians should begin to offer periodic health examinations. This may have marked the beginning of primary care pediatrics and standard well-child visits. In 1910, there were approximately 100 physicians who limited their practice to children. By 1930, there were several thousand; it is estimated that a third of their visits were for well-child care.⁹ In 2000, the AAP had almost 60,000 members.

Developmental and behavioral health care for children in the context of pediatric practice was an outgrowth of these early events. Leaders in pediatrics wrote about the importance of attention to the social and psychological development of children during pediatric encounters. Significant contributions to the practice of well child care were made by many pioneers, including Anderson Aldrich, Edith Jackson, Morris Wessel, Milton Senn, Helen Goffman, and Benjamin Spock.¹⁰ They increased the attention of pediatricians to motor, language, and social skill development of young children; the importance of assessing mother-child attachment and educational achievement; and the development of a therapeutic alliance in optimizing all aspects of pediatric care.

These historical trends are antecedents to the schedule of well-child visits used in contemporary pediatrics. The so-called periodicity schedule was established in the 1960s by a group of pediatricians working with the AAP. It was based on the best clinical judgment available at the time and guided by the immunization schedule. Since the 1950s, multiple additional topics for assessment and anticipatory guidance have been added to the initial template.¹¹ Unfortunately, developmental themes and psychosocial tasks among children and families that are unique to each age group have not led to specific recommendations and guidance about optimal structuring of well-child visits or to their increased frequency or duration.

WELL-CHILD VISITS: WHAT DO WE DO THAT IS EVIDENCE-BASED?

Medical care, including preventive medicine, strives for a foundation of evidence-based studies to support clinical practice. There are some areas of well-child care that are supported by strong evidence from randomized controlled studies. Examples of these practices include standard immunizations,¹² promoting good nutrition during infancy,¹³ encouraging parents to put their infants to sleep on their backs,¹⁴ and the judicious use of antibiotics for respiratory infections.¹⁵

Other components of well-child care practices that focus on the development and behavior of children have not been studied with large randomized trials. A careful review of published studies reveals support for some practices, suggestions for new directions, and opportunities for further research. Regalado and Halfon ¹⁶ reviewed published studies on evaluations of four areas of developmental and behavioral pediatric practice in children from birth to 3 years of age. These studies reflect the potential for current clinical practices. Regalado and Halfon’s conclusions were the following:

1. Structured and systematic approaches to eliciting concerns of parents during well-child visits improve communication between parents and clinicians and are helpful in detecting developmental and behavioral problems.^17,^17a

2. Current developmental and behavioral screening in pediatric practice is not routinely performed, and as a result, children with mild and moderate conditions are not identified effectively during these years.

3. The use of a standardized questionnaire in conjunction with clinical observations and impressions is more effective in identifying psychosocial risk factors than simply clinical impressions alone. Parental risk factors such as depression, substance abuse, poor self-esteem, domestic violence, and abuse of a parent during childhood are all areas of relevance that can be identified with a questionnaire.

4. Only one study has supported the overall effectiveness of anticipatory guidance by showing that pediatricians may affect a child’s development through positive effects on the mother-child relationship.^17a However, evidence does exist for the effectiveness of selected parts of the health supervision agenda:

A. Discussions or a videotape about infant social development during the postpartum period and during early well-child visits resulted in more favorable interactive behavior with infants, less reported maternal stress, and enhanced mother-infant interactions during feeding.

B. Parents report that a discussion of their infant’s temperament during well-child visits is an effective method to inform them about approaches to child rearing.

C. Preventive counseling directed to parents of infants to inform them about caregiving practices that improve infant sleep habits has been demonstrated to be effective. Behavioral approaches include extinction (ignoring the child’s crying for attention at bedtime), reinforcement, shaping (adjustments of the bedtime period), and cueing (institution of a bedtime routine).

D. Behavioral interventions and counseling that provide specific advice and strategies to parents to prevent and manage excessive crying have been demonstrated to be effective in comparison with empathic listening alone or no intervention.

Many components of well-child care need improvement in order to determine and maximize their effectiveness. Evidence-based studies of the effectiveness of pediatric well-child visits are insufficient with regard to the following:

Promoting optimal nutrition after infancy: prevention of obesity and eating disorders.

Safety issues: bicycle safety and helmets, accessible guns in homes, preventing burns and motor vehicle injuries.

Substance abuse: education/prevention.

Counseling parents about behavioral concerns: oppositional behaviors, feeding problems, bullying.

Early detection and diagnosis of behavioral conditions: Autistic Spectrum Disorder, Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, Anxiety, Depression, Post-traumatic Stress Disorder, learning disabilities, and social dysfunction.

CLINICAL INTERVIEW AND THERAPEUTIC RELATIONSHIP

As in most areas of medical practice, clinicians rely on the medical interview to determine patients’ (and parents’) concerns. A detailed and focused medical history, including psychosocial and biological factors in an individual and family, suggests a diagnosis. The mutual trust that is the outcome of a therapeutic alliance between patient (parent and child) and clinician is the core of clinical practice.

In the early 1980s, a major shift occurred in the way pediatricians think about health care delivery. Before that time, models of care—especially primary care—were based largely on the relationship between a pediatrician and the parents and children in her or his practice. The pediatrician was given responsibility for all aspects of care: diagnostic, prescriptive, and preventive. The quality of the doctor-patient (and doctor-staff) relationship was the core ingredient of quality care.

After 1980, organized systems of health care delivery became prominent. Initially a public health concept, systems-based medicine attracted the leaders of clinical medicine: both inpatient and outpatient, both specialist and general care. Systems were created for screening for disease; monitoring chronic medical and psychological conditions; and maintaining efficiency, output, and patient satisfaction. Systems were also developed for guiding clinical practice patterns in developmental-behavioral pediatrics. This trend had a profound effect on the development of a multitude of time-saving techniques to increase the efficiency of well-child visits, including questionnaires (for parents, older children and adolescents, and teachers) to assess and monitor problems in child development and behavior.

Pediatricians in training have always been encouraged to develop interpersonal clinical skills that nurture the doctor-patient relationship. From that relationship, in the best of circumstances, a “therapeutic alliance” takes shape. Morris Green defined the therapeutic alliance as

When pediatricians succeed in engaging parents and children as partners in health care.… The powerful therapeutic potential of the interactions of pediatricians with families is not always sufficiently realized. In order to achieve the most effective working relationship (i.e., therapeutic alliance) with parents, pediatricians must be responsive consistently to contributions of children and parents while being aware of their own resources and limitations.

—Morris Green,¹⁸ p 3

Clinical strategies that enhance the therapeutic relationship include the following:

1. Communication of trust and respect; sensitive awareness of patients’ needs, expectations, and concerns, as well as their resources and limitations.

2. Long-term comprehensive, personalized, family-centered care (see Chapter 8B).

3. Realistic recognition of limitations in self, patient, time, and environment.

4. Effectively planned use of time.

5. Respect for patients’ agendas and solutions.

An effective therapeutic alliance is dependent on an informed communication process between child/parent and clinician/office staff that is developed over time. Clinicians should strive to be as careful with their use of words as in their prescription of medicine. When an office visit is viewed as an opportunity to teach parenting skills and convey knowledge that will promote health, the importance of both verbal and nonverbal components of communication is emphasized. Nonverbal information refers to observations about the style, timing, affect, and flow of information and even what is not said. The quality and tone of speech, facial expressions, posture, and body movements of parents and children often provide clues to critical aspects of a child’s life and family. A few examples of nonverbal communication providing important clinical information follow:

Entering the examination room, the pediatrician observes that the mother of a toddler appears sad and pale; eye contact with the pediatrician is minimal and difficult to encourage. The child plays in a corner of the room without mother-child interchange. There is not enough information to suggest a diagnosis, but the initial impression is maternal depression. An empathic introductory comment, “You appear sad today” often opens a dialogue. If the mother does not respond, suggest, “Is there something you’d like to talk about—about your child or something in the family?”

A mother, father, and 5-year old come to the office for a 2-week well-child visit for the new addition to the family. Mother’s facial appearance and minimal body movements suggest sleep deprivation. The father, in contrast, is ebullient about his new son. The 5-year old draws a picture of his family that reveals these nonverbal communications (Fig. 27-1).

An 8-year-old girl sits in the chair biting her nails with slightly flexed truck and neck. She fidgets and responds to questions in short phrases. Inquiries about school and friends are followed by splotchy areas of erythema on her neck and face. Nonverbal body language suggests an anxiety state and an opportunity to gently probe her concerns. If she remains silent, spending time with her parent alone while the child is asked to draw a picture of her family may be a good strategy to encourage communication.

A 4-year-old monitored since birth with a slow-to-warm-up temperament refuses to speak to the pediatrician. Her mother notes that she thinks his behavior is appropriate for a younger child; language acquisition continues to be delayed. A neuromaturational developmental screening test suggests global delay. Mild or moderate cognitive delay may be missed when an attractive, nondysmorphic child with minimal social responsiveness is assumed to be shy and temperamentally slow to warm up.

FIGURE 27-1 Enhancing the communication process between pediatrician and parents during a well child visit (see text).

There are many opportunities to fine-tune a clinical interview with children and parents (Table 27-1). These methods have been studied and used by experienced clinicians who recognize the value of the clinical interview as a means of acquiring information and counseling children and families.¹⁹ In addition, the physical proximity between the pediatrician, child, and family members may orchestrate the interview. Physical barriers to communication should be avoided (Table 27-2).

TABLE 27-1 Fine-Tuning the Clinical Interview

Open- and Closed-Ended Questions

Open-ended questions (“How is your baby doing?” or “What do you like about your baby?”) encourage spontaneous, less structured responses than do closed-ended questions. They allow parents to express their concerns and an “explanatory model” of a problem or illness. Too many closed-ended questions, especially early in an interview, inhibit spontaneity and assessment of the parent’s agenda for the visit.

Pauses and Silent Periods

Such periods provides time for a parent or child to collect thoughts and express feelings at moments when stressful or sad feelings emerge during an interview. They convey the message that the clinician cares enough to take the extra time.

Repetition of Important Phrases

Repeating or interpreting a statement made by the patient often encourages further clarification and exploration.

Active Listening

Most interviewing mistakes are caused by too much talking by the clinician. Active listening is the process of giving undivided attention to a patient’s words and body language. The empathic clinician practices active listening through his or her facial expressions, posture, hand movements, and head nodding. It is a skill that can be learned.

Transference

On some occasions, a parent (or older child) may experience the pediatrician as someone who is symbolically and psychologically identified with another important person in his or her life. The symbolic attachment (to a mother, father, other relative, or person) is experienced by a parent or child at a time of deep emotional expression (joy, relief, anger, grief, or disappointment). Recognition of the transference process guides a clinician’s insight and responses.

TABLE 27-2 Positioning the Participants during a Pediatric Interview to Enhance Observations and Communications

The clinician and parent should be positioned at the same level to ensure eye contact and to prevent a subservient positioning effect. Both sit down or both stand up.

For a new patient or a new problem that requires an extensive history, sitting down with the parent and child may encourage greater information exchange, as well as allow the clinician to pay more attention to nonverbal cues.

For an established patient with an acute illness, the history may be taken while the parent and clinician are standing.

A young child who is ill may remain in the arms of the parent or with close physical contact.

The placement of chairs in an examination room and the proximity of clinician and patient influence the style and content of the interview.

A desk between a practitioner and the parent and child can be a barrier to optimal communication.

Picking up a chair and moving it closer to a parent may facilitate the exchange of information; the act itself may enhance a therapeutic relationship.

When interviewing a child or a teen, apply the same principles of spacing and eye contact.

A cautionary note on the use of the electronic medical record during an interview: Remember that you are interviewing the parent and child, not the computer screen. Frequently turn to the parent and child, make effective eye contact, and send a visual message that they are important. Or take notes and convert it to the electronic record later.

From Stein MT: Developmentally based office: Setting the stage for enhanced practice. In Dixon SD, Stein MT, eds: Encounters with Children: Pediatric Behavior and Development, 4th ed. Philadelphia: Elsevier, 2006, p 78.

SCREENING FOR DEVELOPMENTAL AND BEHAVIORAL CONDITIONS WITH CHECKLISTS AND QUESTIONNAIRES

Developmental milestones (in the motor, language, and social domains according to the neuromaturational theory of child development) and behavior problems are assessed informally during a clinical interview and/or by use of an abbreviated checklist format. An individual clinician or practice group may develop these checklists by developing questions about selective developmental milestones and behaviors described in screening instruments. Monitoring development and behavior through a clinical interview or an informal checklist is dependent on the experience and skill of the clinician.

In contrast to informal screening, the advantage of a systematic screening questionnaire used in the course of a well-child visit is that predictable areas are assessed at each visit by asking a parent about specific neurodevelopmental achievements and behaviors. Many standardized questionnaires and observational tools have been developed for use in primary care pediatric practices ^17a (see Chapter 7B).

One innovation to incorporate developmental and behavioral issues into primary care is the Child Health and Development Interactive System (CHADIS). Parents complete questionnaires and computerized interviews online through an electronic decision support system, before a well-child care visit. The questionnaires are scored by the computer, which generates a list of prioritized parent concerns and scored questionnaires. These results provide evidence of behavioral and developmental concerns consistent with formats in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV),^19a and the Diagnostic and Statistical Manual for Primary Care (DSM-PC): Child and Adolescent Version.^19b The results are also linked to resources, including parent handouts, national level organizations, books, and videos, and local resources such as mental health clinicians, support groups, mentors, agencies, and activities.²⁰

Screening questionnaires should be viewed as a supplemental aid to the clinical interview. When they are available before the interview, screening instruments may guide the clinician’s area of inquiry, focus the visit on a particular topic that emerges from the questionnaire, or provide an opportunity for the parent or child to clarify a response on the questionnaire. They should not be used as a substitute for clinical observations, and interviewing must be tailored to the needs of each child and family. Patients and children need to “tell their own story”²¹—a process that is enhanced by the trust that develops through a therapeutic relationship based on sensitive interpersonal communication with children and parents (Table 27-3).

TABLE 27-3 Screening Checklists as Aids to Interview: Benefits and Risks

Selected screening checklists may supplement or focus the clinical interview. These tests, when administered before a child is seen, can trigger questions, raise issues, and prevent omissions in data collection. Most formal screening tests have been evaluated for validity, reliability, and predictive value. Be aware that a screening test is not diagnostic. Rather, it suggests a problem that must then be evaluated further through a comprehensive and focused interview by a primary care clinician. A referral for a developmental assessment or a mental health consultation may follow, depending on the clinician’s interpretation of the screening test and clinical interview. Perrin and Stancin ^17a observed that “screening instruments are clinical tools that are useful to help identify and quantify parent’s concerns and worrisome child behavior or feelings efficiently … as long as their limitations are recognized.” Rating scales for behavioral conditions (e.g., depression) cannot take the place of a careful clinical interview. They are often helpful in the assessment of severity of symptoms and monitoring progress over time.

It is important to be informed about the advantages and limitations of these instruments. They provide a standardized database that serves to organize a health supervision visit. Screening tests prevent omissions that may occur during an interview alone. They provide potential educational value as a parent or older child answers questions that raise a concern that may not have been considered previously. They may help parents become better observers of their child’s developmental changes and behaviors. Maintaining copies of the screening checklist in the medical record leads to quality assurance. A potential disadvantage of using a checklist alone is missing a parent’s agenda for the visit by not permitting an individualized focus for the visit. A checklist without a therapeutic interview encourages an emphasis on content at the expense of process and a false sense of completeness.

When a screening test is used, it is the clinician’s responsibility to interpret the results accurately and convey the information to the parents and/or child clearly. Screening for developmental and behavioral conditions should always be done with current knowledge about available referral sources in the community. Screening programs, whether for a biological, developmental, or behavioral condition, should be associated with a referral source for further evaluation and treatment when a positive test occurs. It is unethical to screen for a treatable condition without accurate interpretation, parent/child education, and an appropriate source for a more comprehensive assessment.⁴⁸

Each opportunity to screen for developmental and behavioral problems is an interaction between the examiner and the child. The state, temperament, and availability of the child, as well as the training, ease, skill, and style of the examiner, influence it. The results of screening tests must always be interpreted with these factors in mind. They should never be a substitute for face-to-face clinical encounters in primary care practice.

Modified from Dixon SD, Stein MT: Encounters with Children: Pediatric Behavior and Development, 4th ed. Philadelphia: Elsevier, 2006, p 727.

INNOVATIONS TO ENHANCE QUALITY AND BREADTH OF ATTENTION TO DEVELOPMENT AND BEHAVIOR IN OFFICE PRACTICE

In an effort to increase the efficient and effective delivery of developmentally sophisticated primary care, a number of innovative strategies have been considered and tried, with variable success.

Group Office Visits

The usual organization of medical practice is built on a model that attends to individual medical and psychological concerns. In an alternative model, the group process is used as a way to improve practice efficiency, get messages across to a larger number of patients, and encourage dialogue and support among patients with similar concerns or conditions.

PARENT GROUP DISCUSSIONS

Groups have been used to bring together individuals with similar problems. Parents of children with a chronic physical health condition, Down syndrome, attention-deficit/hyperactivity disorder, learning disabilities, mental retardation, cerebral palsy, and other conditions have been assembled for educational programs that enhance knowledge and skills in these specific areas. Parents who are negotiating similar life transitions (e.g., divorce, adoption, caring for aging parents) have also found group discussions helpful. These parent groups may be condition specific, especially those in specialty practices and children’s hospitals, but more general groups have been successful in community practices. The clinician may be more or less directive in running these groups, taking the role of a teacher or a facilitator. As teacher, the leader of the group provides information that may be supplemented with written or audiovisual material. As facilitator, the leader encourages more dialogue among participants as a way to raise both individual and shared concerns and to provide an opportunity for parents to receive support and feedback from other parents who are (or who have children) in a similar circumstance.

In some primary care pediatric practices, the group discussion model has been adapted to address preventive topics. The focus can be on a developmental stage (e.g., in toddlers, school-aged children, adolescents), a particular topic (e.g., nutrition, tantrums and discipline, home safety, school underachievement, substance abuse), or a condition (e.g., asthma/allergies, recurrent ear infections, attention deficit/hyperactivity disorder, eating disorders, divorce). Some pediatricians have found the well-child visit before kindergarten entry especially suitable for this format. Some practices are beginning to experiment with the notion of providing actual behavioral guidance to selected parents in groups.^21a

GROUP WELL-CHILD CARE

An innovative use of the group process in pediatric practice has been the group well-child model.²² In this model, children and their parents are seen for health supervision visits in the first few years of life, not individually but in small groups of parents and infants. Beginning usually with the first well-child visit after the child’s birth, a group of infants and parents meet (usually 45 minutes) to discuss issues of general interest. The clinician is in the roles of both an educator and facilitator. Parent concerns guide the discussion. Because their children are of similar age, parents typically have similar concerns, and they learn from each other as well as from the clinician-facilitator. After the group discussion, each child is examined; the physical and developmental assessment can occur within the group or individually. Group well-child care was developed in an effort to find a method of delivering well-child care that includes more attention to development and behavior; is also cost effective, efficient, and satisfying to parents; and includes all the substantive content found in traditional individual care. It has the added advantage of creating a mutually supportive group of parents who can share their parenting experiences while observing a range of developmental and behavioral characteristics.

Studies comparing group and traditional well-child care visits document several assets but also suggest limitations of the group process. A study of typically developing children in group well-child care found improved attendance at well-child visits, fewer calls between visits, more time for personal issues, and more open-ended questions.²³ In another study, more well-child care topics were discussed, including safety, nutrition, behavior, development, sleep, and parenting.²⁴ Parents’ child care knowledge, social support, and maternal depressive symptoms were compared between groups and traditional models and found to be surprisingly similar.²⁵ Group well-child visits have been studied among high-risk families, for which higher no-show rates were found with group well-child care but no differences were seen in child development status, maternal-child interactions, home environment, provider time spent at visits, parental competence, social isolation, social support, and reports to child protective service.^26,²⁷

Teachable Moments

“Teachable moments” are opportunities for a clinician to comment about or demonstrate a response to a child’s behavior or to communicate information during the physical, developmental, and behavioral examinations. They are unplanned opportunities to provide information, promote discussion, and support parents. Observation of a difficult temperament, a child’s refusal to cooperate during a physical examination, and concern about maternal depression are examples of teachable moments. They occur frequently during both well-child and illness-related visits. In a busy practice, not every observed event that the clinician would like to comment on can be used as a teachable moment. Conscious vigilance for these opportunities and a commitment to responding to them several times each day enhance quality of care, satisfaction with the practice, and intellectual stimulation of the pediatrician (Table 27-4).

TABLE 27-4 Teachable Moments

Jake has been a healthy child before his health supervision visit at 18 months old. As you enter the examination room, you observe Jake playing on the floor with a plastic toy that has several movable parts. He appears engaged and intent on mastering the toy. You also notice that his fine motor skills are mature for his age when you observe Jake drawing. Jake appears not to notice you when you enter. Shortly after you begin to gather information from his mother, Jake’s activity level and focus change dramatically. He starts hitting the toy, screams “bad … bad,” and throws the toy into a wall. He starts to cry, resists his mother’s attempt to hold him while she provides reassuring words, and hits her with his hand several times. His mother begins to cry and says, “He was such a good baby. In the last few months, he’s a different child—selfish, angry, and always throwing a tantrum.” You are faced with several options at this point:

1. Quickly perform a physical examination, check the growth chart, and order immunizations (and a blood lead and hematocrit if appropriate).

2. Talk to Jake’s mother about tantrums and the need for discipline. Provide a handout on toddler development and discipline.

3. Attempt to engage Jake with words and a toy (i.e., sit down on the floor and play with the toy and say something like: “Gee, this is a great toy. I can make the door open so the boy can go inside.”). Alternatively, address Jake and say, “It’s real hard to come to the doctor!” or, “You are real upset at the doctor’s office.” Follow these words with silence and wait patiently for Jake’s response.

The first option brings closure to the office visit but does not address Jake’s behavior. The second option demonstrates recognition of a problem and expands the mother’s knowledge about toddler behaviors and approaches to discipline. The third option illustrates immediate recognition of a “teachable moment.” The pediatric clinician chooses to model an age-appropriate response to a tantrum through action and language. Engaging the child formulates the scene to the child’s reality. The pediatrician’s language is direct and brief; she tries to mirror the child’s feelings with a few words and waits for a response. This technique, known as “active listening,” encourages Jake’s mother to learn that she can interact with her son at these difficult moments by feeding back to him the feelings he is experiencing. The clinician’s modeling of the behavior can be followed by the information exchange illustrated in the second option.

Teachable moments involve using experiences and questions that occur in the context of the visit to provide an opportunity for discussion, the exploration of parental feelings, modeling positive interactions, reframing negative parental attributions about their child, and providing specific information. A teachable moment capitalizes on the parent’s immediate issues and concerns, when there is an increased desire to learn, rather than a preset list of anticipatory guidance issues, which may or may not coincide with parental priorities. Many teachable moments occur in response to a parent’s questions but can also be found in the child’s office behavior or in responses to written materials such as prompt sheets. Teachable moments provide a clinically effective and efficient approach to anticipatory guidance so that parents can prevent problems.

—Zuckerman et al,²⁸ p 822

“Reach Out and Read”

This creative, office-based intervention was developed by a group of pediatricians to promote literacy, language skills, and a close parent-child attachment through reading to children at an early age. The rationale for the Reach Out and Read (ROR) program is that poor reading skill among many children in elementary school is associated with limited exposure to reading aloud during preschool years. A meta-analysis of 29 studies revealed a significant association between early reading aloud and later academic outcomes.²⁹

The ROR program offers a developmentally appropriate book to a family at each well-child visit from 6 months to 5 years old. In some programs, a volunteer reads to children in the waiting room as a way to model reading aloud for parents. Clinicians are encouraged to demonstrate reading a book during an office visit. ROR has been used extensively in more than 2000 pediatric offices and clinics, especially (but not limited to) those serving underserved populations.

A number of studies have evaluated some form of the ROR program in pediatric settings; three of the studies are prospective controlled trials. Results of 12 studies support an association between ROR and increased reading aloud at home; four studies revealed that children in the program show increases in expressive and receptive language at 2 years of age in comparison with children in control groups.³⁰ In a large study including 730 parents who participated in ROR in 19 clinical sites in 10 states, and 917 parents from the same clinics who did not participate in the program, significant associations were found between exposure to ROR and reading aloud as a favorite parenting activity, reading aloud at bedtime, reading aloud 3 or more days per week, and ownership of 10 or more picture books.³¹

Co-location of Mental Health Clinicians

Effective professional relationships between pediatric clinicians and mental health professionals have been difficult to maintain because of very different training experiences, pacing, and different clinical languages. Traditional referrals to mental health clinicians have been successful only about half the time. Barriers such as stigma, financial constraints, and time limitations limit the effectiveness of the traditional referral procedure.

One solution that has been proposed to address this dilemma is to co-locate a mental health consultant in the pediatric office.^31a A referral can be made more efficiently to “my colleague in the office” rather than to someone in another office building. Communication between the primary care clinician and the consultant, and common recordkeeping, are facilitated. For some families, the location of the mental health clinician in the pediatrician’s office reduces the stigma associated with a mental health referral. Billing for mental health services may be done synchronously or independently, depending largely on the structure of health insurance plans in the community. In large staff-model health maintenance organizations and in some multispecialty community clinics, mental health services may be seamlessly included; however, the office of the mental health professional is still often physically distant from the primary care clinician, and some of the potential benefits of the collegial relationship are sacrificed.

Co-locating clinical care facilitates active communication through which referral history, psychopharmacological and psychotherapeutic treatments, and plans for follow-up are discussed in person. Joint care of some patients is facilitated: for example, when mental health professionals refer children to the pediatrician when they recognize the need for an updated or comprehensive medical assessment. The care of children with a chronic health or developmental condition is especially amenable to this form of teamwork.

Healthy Steps

An innovative form of co-locating care is the Healthy Steps model. The goal of this system of care is to increase a clinician’s ability to address behavioral, emotional, and cognitive development in early childhood. To achieve this goal and create a strong bond between clinicians and parents, a specialist in child development—trained in pediatric nursing, early childhood education, or social work—is added to the practice staff to provide enhanced well-child care.³² In this model, the child development specialist is an additional staff member whose role supplements those of the pediatrician and the office nurse. Her or his activities may include the following:

Making home visits to the family, starting in the child’s neonatal period.

Focusing on promotion of children’s development, including strategies to improve “the goodness of fit” between parent and child; paying closer attention to parental questions and concerns.

Meeting with parents before, during, and after well-child visit to discuss behavioral and developmental concerns.

Performing standardized developmental and behavioral screening tests.

Providing written materials.

Being accessible for questions and concerns through a child development telephone information line.

Providing links to community resources.

Initiating and managing parent groups to discuss common concerns.

Coordinating early detection of substance abuse and domestic violence.

An evaluation of Healthy Steps included 5565 children and their parents at 15 sites.²⁸ Research demonstrated that parents in the program acquired more knowledge about child development and behavior and were better able to use community resources than control parents, who used traditional pediatric care. Families involved in the Healthy Steps program received significantly more preventive and developmental services than did families in the control group. They were more likely than nonparticipating families to

Discuss with someone in the practice the importance to children of routines, discipline, language development, temperament, and sleeping patterns.

Have greater adherence to visits, nutritional guidelines, developmental stimulation, and use of appropriate discipline techniques.

Be highly satisfied with their care.

Ensure that infants slept on their backs, to help reduce the risk of sudden infant death syndrome.

Receive timely well-child visits and vaccinations.

Be more sensitive to their child’s signals during play and more likely to match their interactions to their child’s developmental level, interests, and capabilities.

The positive effects of the program were identified for all parents regardless of their income, parity, or maternal age. On the other hand, other measured outcomes showed no significant differences between the groups; these outcomes included initiation or duration of breastfeeding, child development knowledge, sense of competence, self-report of nurturing behavior and expectation of children, reports of children’s language development at 2 years of age, and safety practices.²⁸

Collaborative Office Rounds

Programs known as collaborative office rounds have been initiated in many communities to develop and support effective relationships between pediatricians and mental health professionals.³³ These group meetings consist of 8 to 12 pediatricians and one or two mental health clinicians who meet once or twice a month to discuss clinical cases that are challenging and engaging to the participants. Some of these groups also include a specific topic for discussion at some of the sessions. Supplementary readings, audio recording of office interviews with children and parents, invited experts from the community, and families invited to contribute to the discussion have been additional components. These ongoing group meetings have been evaluated and appear to provide

Enhanced understanding of psychosocial aspects of pediatrics.

Greater facility in dealing with developmental crises.

A more comprehensive approach to health supervision.

Fuller appreciation of psychosocial implications of chronic illness and disability.

Increased ability to advocate for families.

Expanded power to discriminate between tran-sient disturbances and more serious psychiatric disorders.

More highly developed interviewing and counseling skills.

Heightened awareness of the scope of one’s competency in the area of psychiatric disorders.

Increased effectiveness in making referrals to mental health colleagues.³⁴

Building Consensus with Staff

A pediatric office or clinic is, in many ways, like a family. The individuals who work in a child health care setting bring a wide variety of personal, educational, and professional experiences to the work setting each day. Individually and collectively, they each affect quality of care. To achieve a developmental-behavioral focus in the office, it is crucial that the entire staff understand concepts of child development and behavioral interactions that are adaptive to pediatric practice.

In an office or clinic with more than one clinician, different opinions and perspectives on practice style and emphasis should be discussed. Formative pediatric training, prior practice experience, and temperament often shape a practice style. This is especially true in the area of development and behavior. Goals for developmental and behavioral monitoring should be outlined with enough specificity so that each clinician has a clear understanding of the group consensus. Each member of the staff should be given an opportunity to express her or his point of view and concerns. Research into alternative practice patterns and consultation with local experts should be encouraged. Pediatricians in some communities have found it valuable to meet periodically with colleagues from other offices to discuss practice patterns and strategies to improve care.

During meetings with the nurses and nonprofessional office staff and through selective printed material and videotapes, the clinic staff can receive education about major themes of development at each age group, developmental milestones, and common problems in development and behavior at specific ages. The goal of this educational process should be to empower the office staff to be sensitive “observers” of social interactions throughout the office visit and to prevent missed opportunities for important observations: when making an appointment by phone, at the time a parent and child check in with the office receptionist, when weighing and measuring a child, and when asking about a parent’s concerns for the visit. These moments are opportunities to observe parent-child interactions in a context that may not be available to the pediatrician in the examination room. The office staff should be encouraged to communicate their observations to the child’s clinician (Table 27-5). Periodic discussions during staff meetings with case examples from the office serve to reinforce the importance of staff observations.

TABLE 27-5 Notes from Medical Assistants Who Make an Important Observation while Preparing a Child or Youth for an Office Visit

2-Month-old’s well-child visit: “Mom seems tired or depressed … few words and awkward when handling the baby.”

5-Year-old’s well-child visit: “I know this child … she is usually shy but cooperative. Today she resists weighing, blood pressure, and vision test. She won’t talk to me.”

12-year-old girl with a sore throat: “Very rude to her mom when checking in.”

COMMUNITY-BASED NEEDS ASSESSMENT

Pediatric practices might consider borrowing a public health method to assess the needs of a community with regard to behavioral and developmental concerns of parents who bring their children to the practice. Socioeconomic, educational, and ethnic differences create different concerns. Environmental hazards, child care opportunities, and school curriculum and health services are among a few examples of community differences. An example of community-based needs assessment is evidenced in primary care family practice in Cuba, where a doctor and nurse are responsible for about 180 families surrounding the office neighborhood. An initial and ongoing assessment of health and psychosocial needs is the responsibility of the physician and nurse. Preventive programs and health education are formulated from the results of the assessments.³⁵

COORDINATION OF CARE AND LINKAGES WITH COMMUNITY RESOURCES

A primary care pediatric office should serve as the coordinator of care for the medical, educational, and psychosocial needs of children. These activities are a major component of the medical home (see Chapter 8B). An individual provider of care (or a single office) cannot fulfill all the needs of all children and families. Coordinated care with community resources is crucial for effective developmental and behavioral services for children and adolescents. Coordinated services for children with disabilities have been organized in some communities through a network whereby initial referrals and monitoring of referrals are organized by a central agency that works closely with each pediatric practice in the community to ensure access to appropriate services. An extensive outreach program links at-risk children and their families to programs and services.³⁶

To achieve coordinated care for children with chronic physical and developmental conditions, pediatricians (and other office personnel) must be up to date on services available in a variety of areas, including the following: