Pediatric Primary Care (128 page)

J.  Plan.

1.  Assess family's readiness to make changes.

a.  Motivational interviewing–patient-centered method for enhancing intrinsic motivation.

b.  Elicit patients' and families' motivation to change.

c.  Encourage patients to take responsibility for their behavior.

d.  Ambivalence needs to be resolved for change to occur.

2.  Goal setting.

a.  Set measurable and achievable goals.

b.  Use small steps and gradual change.

c.  Aim for long-term healthy behaviors/lifestyle change with slow weight loss (1-2 pounds per week).

d.  Focus on success, what has worked in the past.

e.  Expect periods of relapse and be ready to help guide patient and family and troubleshoot situations and support return to plan in nonjudgmental way.

3.  Logging of food intake.

a.  Provide a journal to log the diet, with beverages, meal time, food and portion size, snacks on a daily basis. This will increase awareness of intake and has proven to show weight loss if done consistently.

4.  Nutritional goals.

a.  Promote three meals daily, not meal skipping, and emphasize that breakfast provides energy for the day.

b.   Increase fruit and vegetable intake; daily fruit recommendations from
http://www.choosemyplate.gov/
.

c.   Water and low-fat milk as main beverages; eliminate high-calorie, sugar-sweetened beverages; limit 100% fruit juice.

d.   Avoid distractions during meal time; eat as a family and not alone. This will promote good nutrition practices, increase awareness, and slow down mealtime.

e.   Provide age-appropriate information on portion size.

f.   Limit fast foods.

g.   Limit refined sugars, high-fat foods.

h.   Aim for reasonable daily target for calorie reduction and weight loss (1-2 pounds per week).

5.   Physical activity goals.

a.   Assess present activity level, both individual and family.

b.   Promote increasing activity on a daily basis, such as increased outside activity–goal is 60 minutes or more daily.

c.   Gradually increase vigorous aerobic activity as tolerated.

d.   Limit total screen time to 2 hours or less per day (TV, computer, texting, video games).

e.   Remove TV from the bedroom; keep sleeping area free of distractions.

f.   Provide free pedometers with age-appropriate goals for steps; parents may also enjoy walking with children to encourage family activity.

g.  Provide information on community gyms, centers, after-school activity centers that promote increased physical activity. Look for scholarship opportunities or discounts based on family income in these centers. Promote activities provided by schools, sports, clubs, and year-round athletic activities.

6.   Subspecialist referral for comorbidities.

a.  Provide referrals to orthopedics, physical therapy, or podiatrist for hip/knee pain or flat feet.

b.  Promote adequate sleep, early bedtime, and waking at the same time each morning; refer for a polysomnography if snoring, unrefreshed sleep, headaches, or daytime sleepiness.

c.  Refer to neurology for headaches, pseudotumor cerebri.

d.  Pediatric endocrinology for type 2 diabetes, metabolic syndrome, polycystic ovarian syndrome.

e.  Pediatric gastroenterology for progressive elevated ALT and AST levels and persistent stomach pain.

f.  Pediatric pulmonary for sleep study and asthma.

g.  Pediatric psychology for depression, anxiety, and low self-esteem, family dysfunction.

h.  Medical genetics for chromosome abnormalities, Prader-Willi syndrome, fragile X, developmental delay.

7.  Follow up.

a.  Patients will set and reach healthy weight goals pertaining to physical fitness, activity level, and weight.

b.  Patients will develop individualized health plans to encourage increased activity and decreased caloric intake.

c.  Patients will participate in individual sessions, behavioral modification, and group activity sessions.

d.  Patients will be responsible for keeping a food log, wearing pedometer for 24 hours, and keeping activity log.

e.  BMI will be tracked at all clinical visits.

f.  Incentives will be offered to encourage program compliance.

BIBLIOGRAPHY

American Academy of Pediatrics
Pediatric Obesity Clinical Decision Support Chart
5201; 2008.

Barlow SE, & Dietz WH. Obesity Evaluation and Treatment: Expert Committee Recommendations.
Pediatrics
, 2007;102:S164.

Daniels SR, Arnett DK, & Eckel RH. Overweight in children and adolescents: Pathophysiology, consequences, prevention, and treatment.
American Heart Association: Scientific Statement.
2005;111:1999-2012.

Fennoy I. Metabolic and Respiratory Co morbidities of Childhood Obesity.
Pediatric Annuals.
2010;39: 140-145.

Parks E. Practical application of the nutrition recommendations for the prevention and treatment of obesity in pediatric primary care.
Pediatric Annuals.
2010;39:147-153.

Riley POWER Program Tool Kit: A comprehensive weight management program designed to improve health of obese children (ages 2-18) Riley Children's Hospital, A Clarian Health Partner. NICHQ National Initiative for Children's healthcare Quality.

Schwartz RP. Motivational Interviewing (Patient-Centered Counseling) to Address Childhood Obesity.
Annuals.
39:154 -158.

CHAPTER 34

Behavioral Disorders

Donna Hallas

I.  BEHAVIORAL ASSESSMENT INSTRUMENTS

A.  Various instruments are available for assessment of children with behavioral and emotional disorders in primary care settings. Based on the results of these assessments, referral to a psychiatrist, psychologist, or social worker for completion of additional assessment tools may be indicated. Data from these evaluations will assist in understanding dynamics of family functioning and behavioral management plan
(
Boxes 34-1
,
34-2
,
34-3
).

Box 34-1
Behavioral Assessment Rating Scales

Achenbach Child Behavior Checklist System (CBCL)

•  Parent Form (CBCL)

•  Teacher Report Form (TRF)

Attention Deficit Disorders Evaluation Scales (ADDES)

•  Home Version

•  School Version

Behavior Assessment System for Children (BASC)

•  Parent Rating Scale (PRS)

•  Teacher Rating Scale (TRS)

Connor's Parent/Teacher Rating Scale

Personality Inventory for Children-Revised (PIC–R)

Social Skills Rating Scale (SSRS)

Walker Problem Behavior Identification Checklist (WPBIC)

Box 34-2
Behavioral Assessment: Self-Report Rating Scales

Achenbach Child Behavior Checklist System (CBCL)

Youth Self-Report

Behavior Assessment System for Children (BASC)

Self-Report of Personality

Child Anxiety Scale

Children's Personality Questionnaire (CPQ)

Early School Personality Questionnaire (ESPQ)

High School Personality Questionnaire (HSPQ)

Revised Children's Manifest Anxiety Scale (RCMAS)

Social Skills Rating System (SSRS)-Student Form

Box 34-3
Behavioral Assessment: Protective Measures

Draw a Person: Screening Procedure for Emotional Disturbance (DAP: SPED) Minnesota Multiphasic Personality Inventory–A (MMPI-A) Tell Me a Story (TEMAS)

II.  ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

A.  ADHD is one of the most common chronic conditions of childhood and the most common neurobehavioral disorder in child health. ADHD is characterized by the children presenting with three core behavioral symptoms: hyperactivity, impulsive behaviors, and inattentive behaviors outside the normal parameters of the psychosocial development for child's age. Symptoms are displayed by the child before 7 years of age even though diagnosis may not be established until child enters the school setting. Three subtypes of ADHD are now recognized: (1) hyperactive/impulsive (ADHD-HI), (2) inattentive (ADHD-IA), and (3) combined (ADHD-CT).

B.  ADHD-not otherwise specified: for children who present with symptoms predominantly of inattentive type but do not meet the full criteria.

C.  The American Academy of Pediatrics (AAP) evidence-based guidelines for diagnosis and management of ADHD are limited to children 6 to 12 years of age with any coexisting conditions.