Developmental Concerns

From Masters of Pediatrics 2009 Leadership Conferences, presented by the University of Miami Miller School of Medicine

Barbara J. Howard, MD, Assistant Professor of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD

Educational Objectives

The goal of this program is to improve communication with children of different ages and the management of chil­dren with oppositional defiant disorder (ODD). After hearing and assimilating this program, the clinician will be bet­ter able to:

1.   Utilize methods for interacting with children of different ages to obtain information.

2.   Educate parents on how to interact with their child appropriately.

3.   Recognize ODD, based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

4.   Differentiate other similar or underlying conditions (eg, attention-deficit/hyperactivity disorder) from ODD.

5.   Describe the importance of recognizing ODD in childhood and the outcomes of aggressive behavior.

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 following has been disclosed: Dr. How­ard is a consultant for Total Child Health, Inc and is the creator of Child Health and Development Interactive System. In addition, Dr. Howard presents information in this lecture that is related to off-label use of a medication. The planning committee reported nothing to disclose.  

Acknowledgements

Dr. Howard was recorded at Masters of Pediatrics 2009 Leadership Conferences, held January 28 to February 2, 2009, in Miami Beach, FL, and sponsored by the University of Miami Miller School of Medicine, Department of Pe­diatrics and Department of Dermatology and Cutaneous Surgery. The Audio-Digest Foundation thanks Dr. Howard and the University of Miami Miller School of Medicine for their cooperation in the production of this program.

Communicating with Children of Different Ages 

Introduction: in pediatric visits, common for pediatrician to never directly address child or make special effort to en­hance interaction or quality of information obtained from child; talking to child during visits enables physician to  — establish rapport with child, so child feels safe and comfortable; send message to child that visit for him or her (which makes examination easier for pediatrician); obtain accurate picture of chief complaint and acquire informa­tion about child’s developmental abilities; physician misses »50% of children with developmental delays if he or she bases diagnosis solely on informal clinical information (one of fallacies of developmental surveillance); chil­dren may provide information that parents have no wish to share; children ruthlessly honest about events occurring at home; talking directly to children models for parents how to talk directly to children and how to give information to, and obtain information from, children; issues to consider  —  children have different language abilities at differ­ent ages, with social and emotional stages that make certain interactions effective at different ages (also true for cognitive abilities); direct interaction with child often elicits information about child’s temperament (temperament affects how much information obtained)

Infants 0 to 8 mo of age: physician’s interaction with infant can teach parents how to be gentle and confident in han­dling baby; social stage between parent and child initially similar to symbiosis (ie, baby still part of mother psycho­logically); examining child while in mother’s lap and child looking up to check with parent whether acceptable to interact with physician example of social referencing; also, teachable moment for parents, to show them impor­tance of their reaction to child; teaching parent to control his or her face helps prevent transmission of anxiety from parent to child; nodding, smiling, and waiting for child to take his or her turn elicits verbalization (and models turn-taking principle to parents); handing tongue blade to infant and watching what infant does effective method of de­termining infant’s motor abilities

Infants 9 to 12 mo of age: greater sense of self; at 8 mo of age, “hatching” occurs (infant coming into his or her own); valuable to model act of giving infant space; while examining infant on parent’s lap, look at infant’s shoes and give compliment on shoes first; if removing shoes, put them back on immediately (makes infant feel safe); when examining infant, placing stethoscope on mother’s arm before placing it on infant assures infant of safety in physician’s presence; to determine language skills, ask infant where his or her mother is; physician can model adult talking to infant in regular language and with honesty; to determine whether infant has cognitive ability to store >1 thing, hand infant 2 or 3 tongue blades; note, object permanence develops at 8 to 10 mo of age

Infants 12 to 24 mo of age: important to model sense of humor; when examining child on parent’s lap, lifting child’s clothes and putting them back on makes child feel safe; may ask child “what’s this?” with funny look on your face and then ask them location of ear; looking at ear when child points out ear facilitates examination; determine fine motor abilities; by 12 mo, child able to poke pen at paper and notice marks made; by 24 mo, child able to make scribbling circular movements and already interested in causality

Children 2 yr of age through preschool: 2 to 3 yr of age  —help parents understand that child regarded as valuable informant; determine how child’s autonomy developing; neglected or abused children tend to passively agree to what adults say; for verbal interview, start by asking child’s name and age; try to guess wrong age and play game of misunderstanding them (puts physician in role of play-partner and child more likely to respond); always inform child what will be performed next (eg, “now I’m going to listen to your heart”) and ask them, eg, to pull up shirt first to determine receptive language ability; at this age, children engaging in pretend play and interested in choices; beginning of animism; ³3 yr of age  —  speaker obtains majority of history from child; always asks whether child knows why he or she at clinic (if child does not know, opportunity to tell them what will be done that day); most children able to identify area of problem; development and confirmation of gender identity occurs at this age, along with understanding of need for privacy; physician should offer child privacy for dressing; to determine fine motor skills, gazelle figures used (simple test of fine motor control and cognitive ability; also helpful to have figures as baseline for children to draw); at 4 yr of age have child draw person, make up story about person, and explain how story ends (standardized examination and predictive of emotional indicators); to obtain cognitive information, ask child to sing letters of alphabet or let child initiate next letter; have child count; preschool children  —concept of ill­ness unclear; children at this age unable to judge size well, and do not understand concept of time, permanence, and which things can transform to others; ask child what they think made them sick; tell them “germ” made them sick and not anything they did; give child “band-aid” (band-aid has magical connotations); allow child to cry if upset (gives child permission to have emotions)

School-aged children (6-11 yr of age): mastery and sense of privacy important; oriented towards peer group; ask child if they want parents in room with them; school life  —  ask about school, teachers, trouble at school, report card, and best and worst subjects; if child asked whether he or she wants to stay home or go to school, normal re­sponse “go to school” (child wants to master school); with child who prefers to stay home, suspect learning disabil­ity, emotional difficulties, or separation difficulties; social life  —  to obtain peer history, ask for name of best friend; useful to learn what child able to manage socially; also ask whether friends have been to house and what activities they do; if child only has friends several years younger, social skills suspect; ask child whether he or she has enough friends or if he or she is being bullied or bullying somebody else; have child tell you what he or she excels in; home life  —  ask who lives at home; cognitively impaired child may name neighbors; go through each member of family, starting with siblings; ask about chores, allowance, and consequences of misbehaving (to determine disci­pline history from child’s viewpoint); what do parents do if child gets in fight? how much time does child spend with either parent alone and is time adequate? enough privacy in house? how do people in household behave when upset? asking directly about depression not helpful (instead, ask how many days per week child feels sad and how bad days are); ask young patients whether they have tried to hurt themselves, what they are afraid of, and how peo­ple show love for each other in family; projective tests  —  have child draw picture of everyone in family doing something and explain what each person doing; giving choices gives sense of self-esteem; “3 wishes” classic pro­jective question and gives idea of how severely child suffering; with younger children, use squiggle drawing to ex­pound on feelings

Adolescents: interested in comparison to peers; important to talk about confidentiality agreement, especially relating to sexuality and substance abuse; one of most difficult questions about homosexual feelings; by late adolescence, ask about future and relationship with parents

Conclusion: physician needs to tell truth but allowed to reframe it; use open-ended questions; write down details to let child know you care about what they are saying; involve young patients in planning, priorities, and time-frame of any intervention

The Oppositional Child

Oppositionality: commonly seen in practice; oppositional defiant disorder (ODD) affects 2% to 16% of children; presents as child not listening, not minding parent, doing opposite of what parent says, and having to be told several times; typical compliance of preschoolers 60% (with noncompliant children, 30%); definition  —  aggressive-oppo­sitional variation (behavior seen several times per week, and has minimal impact on family life [considered within normal range]); aggressive-oppositional problem (behavior has moderate effect on child or family life); if worse, considered ODD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV] diagnosis)

DSM-IV criteria for ODD: hostile defiant behavior of ³6 mo duration; developmentally inappropriate and signifi­cantly impairing; characteristics include often losing temper, arguing with adults, and actively defying or refusing to comply with adults’ requests or rules; deliberately annoying people; blaming others for one’s own mistakes; touchy or easily annoyed by others; angry and resentful; spiteful and vindictive; in psychiatric community, not clear whether ODD true psychiatric disorder or behavior due to underlying problem (eg, parenting problem, regulatory disorder, attention-deficit/hyperactivity disorder [ADHD], post-traumatic stress disorder [PTSD]); behavior has meaning to child and to family and may be initiated or maintained by family interaction

History: aggression possibly part of normal development, particularly at 18 to 36 mo of age; elicit specific example of misbehavior and its management; assess frequency, intensity, and extent to which behavior interferes in life to determine whether condition variation, problem, or disorder; behavior may begin at home and only later affects other settings; elicit activities of daily living (ADLs) and family and social history; ABCs of behavior  —  antecedent (events occurring before behavior occurred); behavior (what child did exactly); consequence (what resulted for child and for parent, including reinforcement and feelings); in eliciting ADLs, ask about mealtimes; in obtaining family and social history, ask about health, and emotional or learning problems; include substance abuse and edu­cational or vocational attainments to look for ADHD, mood disorder, juvenile delinquency, or learning disability; also ask about who lives at home and who child takes after (parent’s projection of meaning onto child; parent may react to child in way that makes it self-fulfilling prophecy)

Management: clarify meaning of behavior; educate child and parent about origin of behavior; treat underlying condi­tion(s); provide bypass strategies; utilize behavior modification for dysfunctional patterns; refer if behavior en­trenched

Meaning of problem to child: child may act badly to elicit negative responses, due to inadequate attention or feeling guilty about some real or imagined offense (eg, separation or divorce, death); child may misbehave selectively in certain emotionally conflicted relationships; child may misinterpret or react inflexibly or explosively to normal situations; recommendations  —  if child feels guilt or like “bad person,” child should be told directly that condi­tion not their fault; inattentive parents or those who punish excessively should be educated and counseled on dis­cipline strategies; if child behaves poorly only with selected people, investigate relationship and work to improve it; use marks with pen each time child does something with greater flexibility or acts in desirable manner; if child has problem with certain triggers or tasks, attempt to avoid

Meaning of problem to parent: ask parent’s opinion about situation to help determine severity of problem; asking what things will be like in 10 yr good question

Underlying condition(s): most common include inappropriate expectations and management by parent; child has difficult temperament or temperament mismatch between parent and child; sleep deprivation; ADHD; stressful environment; less common causes include hearing problem, trauma, mood disorder, receptive-expressive lan­guage disorder (children with receptive-expressive language disorder 4 times more likely to exhibit aggressive and oppositional behavior), low cognitive functioning, learning disability, pervasive developmental disorder (As­perger’s syndrome), and regulatory/sensory integration problem; health conditions, eg, chronic pain, anemia, ce­liac disease (irritability one of hallmarks; highly underdiagnosed), hypoxemia, sleep disorders; sleep debt  —  destabilizes frontal lobe; worsens all mood disorders; parent with sleep debt more irritable; obtain sleep diary; consider sleep apnea; work on sleep first or simultaneously

Attention-deficit/hyperactivity disorder: £60% of children with ODD have ADHD; consider screening for ADHD in children with oppositional behavior as chief complaint; manage ADHD first or simultaneously for better re­sults; children with ADHD have problem with timing (planning, transitioning, and completing tasks); tend to have aggressive response and give impulsive answers; dislike admitting mistakes and deny to cover up; caregiv­ers may not accept style and become angry or rejecting

Reaction to stressful environment: irregular schedule or inconsistent parenting makes children vulnerable to aggressive behaviors because child hungry, tired, or stressed; violence predisposes to aggressive behavior; mood disorders  —  in children, irritability and hyperactivity possible primary symptoms; if mood swings rapid, consider bipolar disorder; family history may help; cognitive behavioral therapy (CBT) first-line treatment; if child has developmental disorder, adjust expectations; screen for developmental delay, low cognitive functioning, or learn­ing disability in speech or language, or social learning problems

Regulatory differences: children overly sensitive or undersensitive to touch, taste, or smell; may overreact, with­draw, or explode if unable to handle stimulation; may benefit from occupational or physical therapy (desensitiza­tion); parent, child, and sometimes teacher may need education

Behavior modification: basic compliance training  —  first, teach parents how to give positive feedback to child (by, eg, simple praise, tokens); when giving instructions, reduce distractions (eg, television) first; give instructions in ef­fective manner; avoid contaminating instructions with other verbiage (“act, don’t yack”); one request then move on; parents should make requests only when ready to act; pen marks or tokens for compliance as reward; “compliance hour” (practice period); time out for noncompliance; whoever starts handling situation should finish it, without comment by other parent or partner; should not be practiced in public until effective at home

Outcomes of aggressive behavior: 15% to 30% of preschoolers have significant behavior problems which usually include aggression; 25% to 40% of boys 2 to 5 yr of age have moderate to high aggression (incidence 10%-28% in girls); aggression peaks at <3 yr of age (if seen at >3 yr of age, severe problem); 40% of adults with severe adult ag­gression first began acting aggressively at <8 yr of age; early aggression correlates 0.68 with later behavior disor­ders, including antisocial disorder as adult

Suggested Reading

Cao M et al: Sleep difficulties and behavioral outcomes in children. Arch Pediatr Adolesc Med 162:385, 2008; Clark NM et al: The clinician-patient partnership paradigm: outcomes associated with physician communication behavior. Clin Pe­diatr 47:49, 2008; Farley SE et al: Clinical inquiries. What are effective treatments for oppositional and defiant behaviors in preadolescents? J Fam Pract 54:162, 2005; Hamilton SS et al: Oppositional defiant disorder. Am Fam Physician. 78:861, 2008; Herpertz SC et al: Response to emotional stimuli in boys with conduct disorder. Am J Psychiatry 162:1100, 2005; Kotch JB et al: Importance of early neglect for childhood aggression. Pediatrics. 121:725, 2008; Leve­town M: American Academy of Pediatrics Committee on Bioethics. Communicating with children and families: from ev­eryday interactions to skill in conveying distressing information. Pediatrics 121:e1441, 2008; Strasburger V: Gaps in pediatricians' advice to parents regarding early childhood aggression. Clin Pediatr 46:189, 2007; Williams J et al: Diag­nosis and treatment of behavioral health disorders in pediatric practice. Pediatrics 114:601, 2004; Williams J et al: Refer­ral by pediatricians of children with behavioral health disorders. Clin Pediatr 44:343, 2005.