Behavioral-medical treatment of pediatric toileting refusal.

Behavioral and medical treatments for toileting refusal (TR) were investigated using two additive treatments in a multiple-baseline design with 11 preschool-aged children. After Pretreatment A, Treatment B increased high-fiber foods and liquids, initiated mineral-oil therapy, and added positive reinforcement for appropriate toileting. After bowel clean-out, Treatment C induced daily bowel movements with suppositories and applied negative behavioral consequences for inappropriate toileting. Behaviors measured were appropriate and inappropriate bowel movements. Treatment B alone eliminated TR in three boys in 27 to 36 days and reduced the TR of one girl in 40 days. When indicated, Treatment B + C eliminated TR in two boys and four girls in 37 to 79 days and reduced the TR of one boy in 92 days. All 11 of the children were accident free and having at least one bowel movement every 2 days during 5 consecutive days of follow-up conducted 3 to 4 months after treatment. Parents reported general satisfaction with the treatment.

Disciplining young children: the role of verbal instructions and reasoning.

Pediatricians are often asked to advise parents who are having difficulty managing the oppositional behaviors of their toddlers and preschool-age children. A large number of articles provide advice to pediatricians and parents on effective disciplinary strategies. However, despite the fact that verbal explanations, reasoning, and instructions are commonly used by parents, few articles directly address the use of these strategies to affect children's behavior. In this paper, we review studies that explicitly investigate the ability of adults' verbal explanations or instructions to alter the behavior of young children. These studies suggest that under most circumstances, verbal explanations and instructions are not effective in changing young children's problem behaviors. We then discuss how theories in developmental and behavioral psychology help explain the limitations of using verbal reasoning and instructions to change young children's problem behaviors. Finally, we provide some recommendations for parents on the use of verbal explanations and instructions in disciplining young children.

Society of Pediatric Psychology Task Force Report: pediatric psychology and injury control.

Injuries are the major causes of death for children. Pediatric psychology offers significant contributions to the multidisciplinary efforts necessary to prevent injuries and reduce harm to children. This Task Force Report reviews epidemiological data, characteristics of children's injuries, passive and active interventions for reducing injuries, and research, policy, and evaluation issues for individual and community injury control efforts. Directions for future pediatric psychology efforts are identified and placed in a context of collaborative efforts required to advance the control of children's injuries.

An appointment-keeping improvement package for outpatient pediatrics: systematic replication and component analysis.

Child health-care appointments that are not kept are an important pediatric problem. Previous research has shown that reducing effort (with a parking pass) and reminding patients (with mailed and telephone reminders) significantly improved appointment keeping for first-time and patient-scheduled appointments. This study, using a posttest-only group design, evaluated the effects of various combinations of that intervention applied to clinic-scheduled follow-up appointments. All combinations of the intervention significantly increased cancellations, but none increased appointments kept or decreased appointments not kept significantly. Log linear analyses showed that the lag time between scheduling and the appointment significantly influenced appointment keeping. The results suggest that if clinics want to increase cancellations, a mailed reminder and effort reduction are sufficient. To increase appointment keeping, other interventions, such as reduced lag time, may be necessary.

The overestimation of adherence to pediatric medical regimens.

We evaluated the accuracy of primary health care providers' predictions of parents' adherence to their children's short-term antibiotic regimen and a scheduled follow-up appointment. Adherence predictions were compared with objective measures of the parents' adherence. Providers were poor predictors of nonadherence, greatly overestimating the percentage of parents who would be adherent. Nonadherence is typically addressed by applying adherence improvement strategies to all patients. Recent pediatric research, however, suggests that applying contingency-based interventions for adherent patients can result in later nonadherence if the strategies are withdrawn. Inaccurate predictions of adherence will result in many nonadherent patients not receiving a needed intervention. The results indicate the need for strong behavioral predictors that result in more accurate identification of patient nonadherence to guide further applications of adherence improvement strategies.

Discipline.

Discipline is one topic that virtually every ambulatory care pediatrician is frequently asked about. Although there is a tendency to provide parents with short, glib answers to questions about discipline, the literature on time-in, self-quieting skills, and independent play skills has rarely been addressed in the pediatric literature. It is, rather, covered in the research literature--a literature that is not exactly easily accessed by the pediatrician.

Pediatric feeding disorders.

Feeding problems occur in children who have normal development, who have failure to thrive, and who have developmental disabilities. This article focuses on the latter two groups. The characteristics and developmental concerns include family characteristics, parent-child interactions, cognitive development, and oral-motor development. The evaluation process for children with feeding problems should include an interdisciplinary approach with a medical, nutritional, occupational therapy, and behavioral evaluation. The behavioral treatments include the Premack principle, time-out plus reinforcement, and negative reinforcement. Future research should focus on the parent-child interaction process in both mealtime and nonmealtime situations, along with demonstrating parents' and teachers' ability to implement mealtime treatment protocols.

Oppositional behavior in children.

Early intervention for children's oppositional behaviors is likely to be more effective than later treatment. The term oppositional includes a variety of noncompliant and aggressive behaviors that can be assessed with clinical interviews, rating scales, direct observation, and self-report measures. Treatment of children's oppositional behaviors is best approached from a parent training perspective. Parent training approaches have produced significant improvements in children's behavior, although far more research has been devoted to discipline than to identifying the more salient features of time-in. Recent advances in assessment and treatment are notable, but continued efforts are needed to determine the optimal treatments that produce the best social and psychological outcomes for children and adolescents.

Does SleepTight work? A behavioral analysis of the effectiveness of SleepTight for the management of infant colic.

We evaluated the effectiveness of SleepTight in the management of infant colic. SleepTight is a device that vibrates the infant's crib to simulate the action of a car traveling at 55 mph. A multiple baseline design across 6 infants was used. Data were collected on infant crying, parental use of SleepTight, and parental satisfaction. The application of SleepTight was associated with reduction in crying in 4 of the 6 infants. These outcome data notwithstanding, consideration of reported nonrecording of severe episodes and mixed reports of satisfaction suggests that SleepTight may not be a viable means of managing infant colic.

Injury control.

Injuries are now the cause of more deaths in children than the next six most frequent causes combined. It is estimated that 8.7 million injuries occur each year. Together with noninjury motor vehicle accidents and fires, these accidents cost the nation an estimated $107.3 billion. The major approaches to injury control have involved legislation, health education, and behavioral strategies. In this article, the research evidence on the effectiveness of these strategies is reviewed, and suggestions for additional research are proposed.

Do encopretic children have clinically significant behavior problems?

Pediatricians are increasingly recognized as the providers of choice for children with functional encopresis. The presence of clinically significant behavior problems could interfere with pediatric regimens for encopresis, however. To study the extent to which encopretic children exhibit behavior problems, we compared the scores on a standardized behavioral checklist for three randomly selected samples: a sample group of children with encopresis, a sample group of children with behavior problems, and a sample group of children without encopresis or behavior problems. All three samples were matched for age and gender. An analysis of variance showed that the scores of children with encopresis did not differ from the normative sample but were significantly lower than the scores from the behavior problem sample (P less than .00001). The results support the appropriateness of the trend toward expanding the primary pediatrician's role in the treatment of encopresis.