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.