DEVELOPMENT AND BEHAVIOR
From the 50th Annual Pediatrics Symposium, presented by Kaiser Permanente
Martin T. Stein, MD, Professor of Pediatrics, University of California, San Diego, School of Medicine, and Pediatrician,
University of California, San Diego, Medical Center
Educational Objectives
| The goals of this program are to improve the effectiveness of well child care (WCC) visits and review important recently
published research in pediatrics. After hearing and assimilating this program, the clinician will be better able
to:
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 | 1. List reasons for rethinking content of WCC visits.
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| 2. Describe the evidence base for and limitations of current clinical practice in WCC visits.
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| 3. Review the effectiveness of systematic screening and standardized tests.
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| 4. Discuss the merits of several suggestions for improving WCC visits, including group visits and visits structured
around a developmental theme.
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| 5. Describe recent research findings in child development and behavior.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning
committee reported nothing to disclose.
Acknowledgments
Dr. Stein was recorded at the 50th Annual Pediatrics Symposium, presented October 31 to November 2, 2008, in Palm
Springs, CA, by Kaiser Permanente. The Audio-Digest Foundation thanks Dr. Stein and Kaiser Permanente for their
cooperation in the production of this program.
Rethinking Well Child Care Visits
Overview of Current Well Child Care (WCC)
| Guidelines: Guidelines for Health Supervision Visits III (2002) from American Academy of Pediatrics (AAP); Bright Futures:
Guidelines for Health Supervision of Infants, Children and Adolescents (2002, revised 2008)
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| International trends: United States—only country where board-certified pediatricians deliver majority of WCC; Australia,
United Kingdom, and Sweden—nurses with public health training provide all WCC in first 3 to 5 yr; Netherlands—well
child physicians receive 3 wk training; Japan and Denmark—group WCC common; care given in small groups of 4 or 5
parent-child dyads during first 2 yr of life
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Reasons to Rethink WCC
| WCC epidemiology: prominent part (33%) of visits to pediatricians; 20 min patient contact time (adequate for introducing
changes); 16 to 18 visits through childhood and adolescence
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| Role of parents’ mental health: important in concept of “family pediatrics”; 58% of pediatricians ask parents about social
support; 70% about alcohol and drug use; 50% about depression; 8.5% about domestic violence; variability in how pediatricians
address parents’ mental health; parents want information—54% of parents want to learn more about how to help
children learn; 42% how to discipline; 41% toilet training; 30% sleep problems; 23% what to do about crying
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| Attendance: parents bring children to half of planned WCC visits; in surveys, many parents perceived purpose of WCC
limited to immunizations and satisfying school requirements
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| Continuity of care (COC): crucial to building trust over time (“therapeutic alliance”); primary care COC—means first contact,
integration of services, and family focus; evidence base—COC results in improved parent satisfaction, which leads to
better outcomes; reduces visits to emergency department (ED); yet only 46% of young children see same pediatrician for
WCC up to 3 yr of age
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| Evidence for benefit from WCC practice: best evidence—immunization; good evidence—promoting optimal nutrition
during infancy, with advice on breast-feeding and introduction of solid food; limited evidence—promoting optimal nutrition
after infancy; preventing obesity and eating disorders; bicycle safety (WCC reasonably effective if information exchange
high); gun control in home; burn prevention; prevention of motor vehicle injuries and substance abuse; early
recognition of school-related problems; early detection and diagnosis of behavioral conditions
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| Importance of environment on development: after birth, formation of new synapses (ie, synaptogenesis) continues
throughout brain; arborization present at birth; by 6 yr of age, large increase in synaptic connections; synaptic pruning of
unused neurons occurs concomitantly; synaptogenesis and pruning occur throughout childhood and adolescence, so brain
constantly changing; environment and learning influence brain development
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| Contributions of child development theorists: John Bowlby—primary attachment early in life; Margaret Mahler—period
of separation-individuation from ≈9 mo to 3 yr of age; Donald Winnicott—importance of transitional object (ie, security
blanket) in separation-individuation period; Sigmund Freud—“grandfather” of many theories; Erik Erikson—added social
context to Freudian psychology; author of Childhood and Society (1950); highly recommended for stages of child development;
psychosocial tasks from infancy through adolescence (ie, trust, autonomy, initiative, industry, and identity); if
identity not established by mid-adolescence, role confusion may result
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| Overview of 13 WCC innovations: 1) systematic screening and standardized tests—more popular in last 15 yr; 2) themes for
each visit—guide questions, observations, and anticipatory guidance; 3) risk categories—common in obstetrics but not in
WCC; categorizing family risk could improve effectiveness of WCC visit; 4) co-locating—having other practitioners
nearby (eg, nutritionists, psychologists) to whom physician can refer family immediately; 5) Healthy Steps model—
experimental model; child health specialists (within pediatric practices) perform developmental and behavioral screening
and first-line counseling; keeps directory of community resources for referrals and coordinates with pediatricians and staff;
6) family drawings; 7) parents’ mental health—evidence in past decade that postpartum depression affects children’s social
development, learning, and motor skills; 8) group discussions—group gatherings on weekends or evenings that relate to
particular developmental stage or problem (eg, feeding in infants and toddlers, obesity prevention) 9) group WCC; 10)
reach out and read; 11) limit physical examinations (PEs)—increase time for developmental-behavioral screening with
counseling; PE low-yield except in newborns; consider doing only 1 to 2 PEs during first 3 yr; not recommended by AAP;
12) computers and DVDs—use for screening, developmental, behavioral, safety, and nutrition issues at home or in waiting
area; 13) community links—keep community resource directories up to date
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Focus on 5 of 13 WCC Innovations
| Systematic screening (SS) and standardized tests (ST): SS—good psychometrics sensitivity, specificity, validity, and
predictive value; one-quarter of surveyed AAP fellows report using SS (most screen for developmental delay, not behavior);
yields better detection of developmental delays; AAP 2006 SS recommendations—developmental surveillance (DS)
during all preventive visits; DS involves talking to and making observations about child’s behavior and development;
subjective; AAP recommends standardized developmental screening at 9, 18, and 30 mo of age; good reasoning for chosen
times but no evidence base; 9-mo stage—infants able to pull themselves up; pincer grasp (complex motor perceptual
skill); bilateral pincer grasp; begin babbling; 18-mo stage—earliest age at which ST available (for autism spectrum disorders
[ASD]); 30-mo stage—added because at 24 mo, 15% to 20% of children late in developing expressive language
(mostly familial); child has normal motor and social skills and receptive language, but only 3 to 5 words, possibly 10;
>50% of these have normal expressive language at 30 mo of age; ST for development—most involve language, social,
and motor skills; most ask parents questions about motor, social adaptive, and language development skills; questions involving
word “concern” evoke most accurate and detailed information from parents on child’s development, behavior,
and learning; Parents’ Evaluation of Developmental Status (PEDS)—concerns about how child 1) talks and makes speech
sounds (expressive language and articulation); 2) understands what you say (receptive language); 3) uses his or her hands
and fingers to do things (fine motor); 4) uses his or her arms and legs; 5) behaves; 6) gets along with others; 7) learning to
do things for himself/herself; 8) learning preschool or school skills; other concerns (key word for getting accurate information);
PEDS outcomes—nearly half of children >8 yr of age at low risk (no major concerns); 20% low risk but may
need behavioral counseling; for moderate risk, one concern warrants additional developmental screening; 11% with >1
concern, usually warranting referral (mostly developmental delays or behavior); ST for behavioral development—few
available; Pediatric Symptoms Checklist—appropriate for low, middle, and upper-middle income families; free; available
in English and Spanish; google “pediatric symptom checklist”; for children 4 to 16 yr of age; 17 questions; no diagnosis
for behavioral problems, but clusters that suggest, eg, anxiety, depression; Family Psychosocial Screen—not commonly
used; SS for parental alcoholism, substance abuse, domestic violence, and others; Modified Checklist for Autism in Toddlers
(M-CHAT)—best psychometric screen for early detection of autism in primary care pediatrics
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| Developmental theme: for each visit, pick developmental, behavioral, or family-focused theme most prominent in child’s
life; pay attention to parental agenda; observations and anticipatory guidance related to theme, giving organization to
WCC visit; example of newborn—teach parents innate readiness of baby for environmental interactions; vision and hearing
capacity; quiet alert state (present in 15% of waking hours in first few weeks; best time to interact); meaning of primitive
reflexes; all developmental elements that equip children for environmental interaction; 18-mo visit—“asserting
oneself—a push-pull process” (period between emerging autonomy compared to dependent state of first year); importance
of self-determination in predicting certain regressions or tantrum patterns; role of discipline framed in developmental
theme; transitional objects; behavior modification
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| Group WCC: visit at 2 wk or 2 mo of age; 4 to 5 parent-infant dyads; shared concerns and issues; involves first-time parents
and some experienced parents; comprises two 45-min sessions; first 45 min—parent discussion; clinician covers agenda and
interests and concerns of parents; second 45-min period—physical and developmental examination, including growth measurements
(can be done before meeting starts); positive outcomes—improve attendance at WCC; fewer calls between visits;
more time for personal issues; more topics discussed; neutral outcomes—children show no difference in skills or knowledge;
no improvement in child developmental status, maternal-child interactions, home environment, or provider time
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| Reach Out and Read (ROR): good evidence base and link to later academic performance; give children developmentally
appropriate book at each WCC visit (6 mo to 5 yr of age); observe parent reading to child; encourage reading at home; evidence
of benefit—increase in home reading in ROR families; increase expressive and receptive language at 2 yr of age;
reading aloud favorite parenting activity; reading aloud at bedtime more likely; reading aloud families read >3 days/wk
and own >10 picture books
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| Kinetic family drawings: ask child to draw picture of family members, each performing activity; some skills easy to observe
(eg, fine motor, visual-perceptual skills, attention span); also learn about child and family relationships; do not
overinterpret drawings (ask parent or older children to interpret drawings after examination); provides opportunity to talk
about topics not raised in usual WCC visit
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| Making WCC effective for development and behavior
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| Therapeutic alliance: in pediatrician focus groups, identified as crucial; social scientists not able to quantify benefit
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Top Recent Articles in Developmental and Behavioral Pediatrics
Temper Tantrums (TT) in Preschool Children
| Background/ methods: normal variation in TT in children; average preschooler has 1 TT per day for median duration of 3
min; two-thirds of TT range from 1.5 to 5 min; questionnaire completed by caregivers of 279 urban children (3-6 yr of
age); evaluated TT characteristics predicting depression or disruptive behavior disorders (ie, oppositional defiant disorder
or attention deficit/hyperactivity disorder [ADHD]) or both
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| Behaviors in preschoolers linked to disruptive behavior and/or depression: 1) aggressive destructive behaviors (eg,
kicking, breaking objects); 2) self-injurious behavior; 3) excessive TT frequency (eg, 10-20 days/mo or >5 episodes/day);
4) extended duration of TTs (>25 min); 5) inability to calm down without assistance
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Guanfacine for ADHD
| Background: 3 United States Food and Drug Administration (FDA)-approved drugs to treat ADHD in children, including
stimulants (eg, methylphenidate) and atomoxetine (Strattera); 15% of children do not tolerate or respond; 75% have significant
increase in core ADHD symptoms
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| Methods: manufacturer-sponsored; randomized 345 patients (6-17 yr of age, mean age 10.5 yr) with ADHD; randomized
to extended-release guanfacine or placebo; 1 mg starting dose, increased by 1 mg/wk incrementally to assigned dose (≤4
mg/day); after 5 wk, medication tapered over 3-wk period
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| Guanfacine outcomes: reduction of core ADHD behaviors; best results at 4 mg/day; parent and teacher scores included;
reduction in hyperactive and impulsive symptoms but not inattentiveness (unlike other FDA-approved drugs); children
demonstrated greater response, compared to adolescents (unlike previous drugs)
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Early Identification and Evaluation of Children with ASD
| Importance of early identification: allows early intervention, investigation of potential etiologies, and counseling for parents
about recurrence risk for subsequent children (5%-6%); many studies show early recognition followed by behavioral
intervention improves development, functional outcome, and quality of life
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| ASD core features: 1) deficits in inherent drive to connect with others and share feelings; 2) restricted, repetitive, and stereotyped
patterns of behavior, interests, and activities; 3) speech and language delay (except in Asperger syndrome, in
which early language milestones normal)
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| Red flags for ASD in children <2 yr of age: 1) no babbling, pointing, or other gesturing by 12 mo of age; 2) no single
words by 16 mo of age (most express 30-50 words); 3) no 2-word spontaneous phrases by 24 mo of age; 4) loss of language
or social skills; 25% of children with ASD have regressive type (develop language and social skills by 15-16 mo of
age but then regress)
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| Modified Checklist for Autism in Toddlers: SS used ≥18 mo of age; 23 development questions including 6 critical ones;
incorporate questions into interviews of children; critical questions—does child 1) take interest in other children? 2)
point (preverbal communication)? 3) bring objects over to you to show you something? 4) imitate you? 5) respond to
name? and 6) look at toy if parent points to it, then look at parent (“joint attention”; critical aspect of development)?
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ADHD: Delay in Brain Maturation or Deviation in Brain Development?
| Background: in last 50 yr, emerging evidence for biologic basis of ADHD symptoms; in normal development, cortical
thickness increases in predictable pattern and rate, and thins during adolescence
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| Methods: brain scans of 223 children with ADHD (mean age 10 yr) and 223 age-matched controls over several years; most
had combined-type ADHD; National Institutes of Health (NIH)-sponsored study
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| Results: for both groups, no difference observed in sequence of cortical maturation and thickness; median age by which
50% of cortical points reach peak thickness 10.5 yr in ADHD group vs 7.5 yr in controls; delayed brain maturation
most prominent in prefrontal region, where executive function centered
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Can Live Music Reduce Procedural Distress and Pain?
| Background and methods: repeated painful experiences (eg, injections, venipunctures) internalized into child’s thought
processes and feelings; may last into adulthood; 108 Italian children (4-13 yr of age) undergoing venipuncture for routine
blood tests; randomized to group receiving standard medical care or music group in which children and parents interacted
with musician who played instrument, sang, and interacted with child and parent
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| Results for music group: distress significantly lower; perceived pain reduced; effects similar in boys and girls; recent study
showed oral sucrose reduced pain experience in immunizations
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Suggested Reading
Adler LA et al: Double-blind, placebo-controlled study of the efficacy and safety of lisdexamph etamine dimesylate in
adults with attention-deficit/hyperactivity disorder. J Clin Psychiatry Nov 17, 2008 [Epub ahead of print]; Beauchaine TP et
al: Ten good reasons to consider biological processes in prevention and intervention research. Dev Psychopathol 20:745,
2008; Belden AC et al: Temper tantrums in healthy versus depressed and disruptive preschoolers: defining tantrum behaviors
associated with clinical problems. J Pediatr 2008 152:117, 2008; Brothers KB et al: PEDS: developmental milestones-
-an accurate brief tool for surveillance and screening. Clin Pediatr (Phila) 47:271, 2008; Caprilli S et al: Interactive music as
a treatment for pain and stress in children during venipuncture: a randomized prospective study. J Dev Behav Pediatr 28:399,
2007; Dixon SD, Stein MT: Encounters with Children: Pediatric Behavior and Development (4th ed) Elsevier-Mosby, 2006;
Galuska DA et al: Pediatrician counseling about preventive health topics: results from the Physicians' Practices Survey,
1998-1999. Pediatrics 109:E83-3, 2002; Johnson CP et al: Identification and evaluation of children with autism spectrum
disorders. Pediatrics 120:1183, 2007; Kuo AA et al: Rethinking well-child care in the United States: an international comparison.
Pediatrics 118:1692, 2006; Shaw P et al: Attention-deficit/hyperactivity disorder is characterized by a delay in cortical
maturation. Proc Natl Acad Sci U S A 104:19649, 2007; Willis E: Early literacy interventions: reach out and read.
Pediatr Clin North Am 54:625 viii, 2007.
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