Behavioral Pediatrics PDF

CHAP TER 24 Behavioral Pediatrics Integrating Applied Behavior Analysis with Pediatric Medicine Patrick C. Friman Few children in the United States have a men- of pediatrics that focuses on the relation between tal health care provider, but all have a medical behavior and pediatr...

CHAP TER 24 Behavioral Pediatrics Integrating Applied Behavior Analysis with Pediatric Medicine Patrick C. Friman Few children in the United States have a men- tal health care provider, but all have a medical health care provider. The medical care provided falls under the general rubric of pediatric primary care, and a pediatric primary care provider is the first professional a caregiver concerned about his or her child’s behavior problems contacts. About one-fourth of the children seen in primary care have symptoms that meet criteria for a behav- ioral or emotional disorder (Costello, Edelbrock, et al., 1988; Horwitz, Leaf, Leventhal, Forsyth, & Speechley, 1992), and another 40% or more may exhibit subclinical behaviors or emotions that cause their caregivers concern (Costello & Shugart, 1992). These proportions are found in urban (e.g., Costello, Edelbrock, et al., 1988) and rural (Polaha, Dalton, & Allen, 2011) settings. As a result, researchers have referred to pediatricians as “gatekeepers” for child mental health services (Dulcan et al., 1990; Costello, Burns, et al., 1988), and to the locus of their practices as “de facto mental health settings” (Green et al., 2017; Jens- sen, Buttenheim, & Fiks, 2019; Regier, Goldberg, & Taube, 1978; cf. Polaha et al., 2011). Applied behavior analysis (ABA) is a powerful science that specializes in behavior, its analysis, and the devel- opment of methods for influencing it in socially adaptive ways. Behavioral pediatrics is the branch 408 RELATIONSHIP BETWEEN PEDIATRICS AND ABA As indicated above, primary care providers (sever- al subspecialties provide primary care for children but the most common by far is pediatrics; hereafter, I use the term pediatrician to refer to the providers and pediatrics to the settings) are the profession- als who are most likely to provide initial inter- ventions for children’s behavioral or emotional problems (Christophersen, 1982; Costello, Burns, et al., 1988; Costello, Edelbrock, 1988; Dulcan et al., 1990). They are most likely to use supportive counseling, prescriptive behavioral treatment, or referral (Blum & Friman, 2000; Friman 2003; Friman, 2005a, 2008). ABA has contributed substantially to the development, implementa- tion, and evaluation of pediatric interventions, especially prescriptive behavioral treatment, for many of the behavior problems children present initially in primary care (Christophersen, 1982; Friman, 2005a, 2008; Friman & Blum, 2003). The cardinal principle informing these interven- tions—that behavior is influenced by its current and historical circumstances—is familiar to and accepted by most pediatricians. Thus primary care pediatricians have incorporated many of these in- terventions into practice, including interventions for child discipline, incontinence, sleep disorders, habit disorders, and symptoms of attention-deficit/ hyperactivity disorder (e.g., Blum & Friman, 2000; Blum, Williams, Friman, & Christophersen, 1995; Christophersen & Friman, 2010; Christophersen & Mortweet, 2013; Friman, 2002; Friman & Schmitt, 1989). In this chapter, I discuss four problems havior analysts treat, study, or treat and study, one representing each of the four primary domains of behavioral pediatrics: (1) bedtime struggles, repre- senting routine behavior problems; (2) constipa- tion and retentive encopresis, representing physi- ological influences on behavior; (3) nocturnal enuresis, representing behavioral influences on medical problems, and (4) adherence to medical regimens, representing contextual variables cen- tral to problems in the first three domains. ROUTINE BEHAVIOR PROBLEMS The pediatrician is one of the most trusted profes- sionals in the United States. Almost all families have pediatric care providers for their children— and, contrary to the stigma that results from contacting a mental health care provider about a 410 S U B S P E C I A LT IE S I N Schnoes, 2020). This response usually motivates the caregiver to intervene either by further sooth- ing or by disciplining the child—both of which, unfortunately, usually worsen the problem. Sooth- ing responses to crying can reinforce it, disciplin- ary responses to crying often provoke more crying, and both caregiver responses interfere with the child’s learning to self-quiet (Blampied & Bootzin, 2013; Friman, 2005b; Friman & Schnoes, 2020; Lozoff et al., 1985; Schnoes & Reimers, surprisingly, after failed attempts to solve the prob- lem themselves, caregivers whose children exhibit bedtime problems often ask their pediatricians for advice. I have described the four procedures pro- fessionals are most likely to prescribe below, which were all ABA-derived. Extinction. The extinction approach to bed- time problems involves no visits by the caregiver to the child’s bedroom after the child has gone to bed. In effect, the child is left to cry it out. Gen- erally, extinction works more rapidly than other approaches, but it presents problems that mitigate its overall effectiveness: (1) Crying can be highly aversive to caregivers, especially during the first nights of treatment; (2) crying and screaming can draw attention from the neighbors, with predict- ably problematic consequences; and (3) extended crying and screaming differentially affects care- givers, which can cause marital/couple discord (Adams & Rickert, 1989; Edwards & Christo- phersen, 1994; Rickert & Johnson, 1988). Thus extinction is a straightforward behavioral ap- proach to child bedtime problems that has limited social validity. To improve social validity, sleep researchers have developed other multicomponent methods that employ extinction but include other procedures to decrease its intensity and aversive- ness for caregivers. Graduated Extinction. Graduated extinction involves advising caregivers to ignore bedtime problem behavior for specific time intervals that gradually increase, usually beginning with a 5-minute interval at the first episode, 10 minutes at the second, and 15 minutes for subsequent epi- sodes on Night 1 (e.g., Adams & Rickert, 1989). These intervals increase over the course of a week, ending with 35 minutes for the first episode on Night 7, 40 minutes for the second, and 45 minutes for all subsequent episodes and nights. Although children can have tantrums for longer than 45 minutes at night, research (Adams & Rickert, 1989; see also Edwards & Christophersen, 1994) eliminated the high rates of crying out, calling out, and coming out of the bedroom after bedtime that two children (ages 3 and 10 years) exhibited. Ad- ditionally, caregivers achieved these successful sults without an accompanying “extinction during initial intervention periods, and a large group of sample caregivers rated the intervention as more acceptable than extinction alone (Friman et al., 1999). Investigators replicated bedtime pass program in a single-subject analysis of four 3-year-old children (Freeman, 2006) and a randomized trial involving 19 children ages 3–6 years (Moore, Fruzetti, & Friman, 2007). The bed- time pass may achieve its effectiveness through differential reinforcement of alternative behavior (Vollmer & Iwata, 1992), in which the request and surrender of the pass allow the child to access po- tent bedtime reinforcers, and the caregiver places bedtime problems on extinction. This brief discussion of child bedtime problems and their treatment is by no means complete. It merely involves four ABA-derived interventions that professionals use most frequently and have the most empirical support (for other interven- tions, see Burke, Kuhn, & Peterson, 2004; Fri- man, 2005b; Friman & Schnoes, 2020; Honaker & Meltzer, 2014). INFLUENCE OF PHYSIOLOGICAL VARIABLES ON CHILD BEHAVIOR PROBLEMS The fundamental assumption of ABA is that be- havior occurs as a function of environmental cir- cumstances, but this position does not exclude influence of physiological variables. Rather, many physiological variables may be causal but are the results of environmental contingencies that oc- curred in a phylogenetic context (Skinner, 1966). Physiological variables often play an initiating role in behavior problems that present in pediat- rics. For example, child stomach pain caused by physiological variables (e.g., a flu virus) can lead to missing school. While home from school, reinforc- ers such as avoidance of schoolwork and contact with sympathetic responses from caregivers influ- ence the child’s behavior. These influences can in turn result in complaints of stomach pain that do not involve physiological variables, a condition sometimes referred to as recurrent abdominal pain (Finney, Lemanek, Cataldo, Katz, & Fuqua, 1989). There are many other examples, but the one I want to discuss here is constipation—a physio- 412 S U B S P E C I A LT IE S I through the colon; various external events (e.g., a meal, moving about) stimulate these movements. The colon absorbs moisture from the waste that moves through it, creating semisolid feces. The rectum, a hollow receptacle at the distal end of the colon, usually contains little or no feces until muscular contractions in the colonic wall propel feces into it, which produces distension. Distension stimulates sensory receptors in the rec- tal mucosa and in the muscles of the pelvic floor, resulting in relaxation of the internal sphincter, which facilitates defecation. This process is invol- untary, but a child can constrict the anal canal and inhibit defecation by contracting the external anal sphincter and the functionally related pu- borectalis muscle. When the child suppresses the urge to defecate, the rectum accommodates the retained stool through the adaptive pliance of its structure and terminates the reflex relaxation of the internal sphincter. The urge gradually decays, and some of the fecal matter in the rectum returns to the descending colon by retroperistalsis. Etiology Physicians can trace between 80 and 95% of en- copresis cases to a primary causal variable, con- stipation (Hatch, 1988; Levine, 1982). Although definitions for constipation vary, children who frequently go 2 or more days without a bowel movement are probably prone to constipation. Caregivers of children with encopresis common- ly complain that the children deliberately soil their clothing, but this attribution is usually false (Levine, 1982). The primary cause of soiling is fecal retention (constipation), which is generally not caused by characterological or psychopatho- logical problems (Friman, 2002; Friman, Mathews, Finney, & Christophersen, 1988; Gabel, Hegedus, Wald, Chandra, & Chaponis, 1986). Retention is usually the result of a constellation of factors, many of which are beyond a child’s immediate control (Levine, 1982). These factors include a constitutional predisposition (i.e., slow gastroin- testinal transit time); diet; insufficient leverage for passage of hard stools; and occasional or frequent painful passage of hard stools, resulting in negative reinforcement for holding stools. In rare cases, re- tention may be related to sexual abuse. Some chil- dren—especially those with extreme constipation, treatment failure, or both—have an increased threshold of awareness of rectal distension, a possi- bly weak internal sphincter, a tendency to contract the external sphincter during the act of defeca- Encopresis is not well understood outside the medical community, and characterological and psychopathological interpretations prevalent in Western culture are likely to influence a caregiver’s interpretation of the condition, which may influ- ence how the child views the problem. The behav- ior analyst can begin encopresis treatment during the evaluation by providing accurate information that “demystifies” the problem. Lastly, the evalua- tion should include questions about diet and tim- ing of meals. Low-fiber diets and irregular meals can contribute to encopresis (Koppen et al., 2016). Treatment During the past 40 years, several descriptive and controlled experimental studies have supported a multicomponent approach to treatment of chronic retentive encopresis, partly derived from the pio- neering work of Davidson (1958), Christophersen and Rainey (1976), Levine (1982), and Wright (1975). The behavior analyst can address the first component during the evaluation by demystifying the entire elimination process and its disordered manifestations. Generally, this means providing information about bowel dynamics and the rela- tion of the problem to constipation. Second, the caregiver should remove fecal impaction with enemas, laxatives, or both under the direction of the pediatrician. Third, the child should sit on the toilet for about 5 minutes once or twice a day. Fourth, the caregivers should promote proper toi- leting with encouragement and not with coercion. Additionally, they should not reserve their praise and affection for proper elimination; caregivers should provide praise for just sitting on the toi- let. Fifth, caregivers should give the child a stool softener like mineral oil or MiraLAXTM under the pediatrician’s direction, to ease the passage of hard stools. Sixth, the caregiver should increase the child’s dietary fiber. Seventh, the caregiver should arrange for and encourage the child to increase his or her activity level and fluid intake, to increase and maintain colon motility. Eighth, the child’s feet should be on a flat surface during toileting episodes. Foot placement is crucial to the Valsalva maneuver, which is the grunting push necessary to produce a bowel movement. Ninth, the caregiver should reward the child for bowel movements in the toilet. See Christophersen and Friman (2010) and Friman (2019) for reviews discussing these recommendations in greater depth. The literature on this approach or variations thereof has progressed sufficiently to lead to group 414 S U B S P E C I A LT IE S I N the discussion of adherence below). Therefore, this domain of behavioral pediatrics provides many op- portunities for applied behavior analysts interested in working in pediatric health care settings. INFLUENCE OF BEHAVIORAL VARIABLES ON CHILD MEDICAL PROBLEMS In this section, I discuss the influence ior on physiological variables, with emphasis on the behavioral treatment of physiologically based behavior problems that pediatricians frequently see. For decades, health-based sciences have dem- onstrated relations between child behavior and health. As examples, eating nutritious food and engaging in modest exercise can improve chil- dren’s cardiovascular health; obtaining sufficient sleep can improve children’s emotional resiliency and adaptability; and maintaining adequate per- sonal hygiene can decrease children’s susceptibil- ity to infectious disease. Historically, ABA has demonstrated a variety of healthful outcomes from behavior changes (e.g., Friman & Christo- phersen, 1986; Finney et al., 1993; Irwin, Cataldo, Matheny, & Peterson, 1992; Stark et al., 1993). An updated review of this literature is beyond the scope of this chapter. Here I merely focus on bio- feedback, a treatment involving the manipulation of behavioral variables to improve health, and use treatment of nocturnal enuresis as the primary ex- ample. Biofeedback involves the use of electrical or elec- tromechanical equipment to measure and increase the salience of stimuli associated with pertinent physiological processes and training patients to discriminate and control them to improve their own health. The penultimate goal of biofeedback is to train patients to alter the physiological pro- cesses in healthful directions, and the ultimate goal is to train them to do so without biofeedback (Culbert, Kajander, & Reaney, 1996). Most bio- feedback treatments (e.g., anorectal manometry combined with electromyography for treatment of fecal incontinence) require sophisticated instru- mentation and specialized training to use them; thus pediatricians may not incorporate them into primary care practices readily. However, nocturnal enuresis, a physiologically based behavior prob- lem that is one of the most frequent presenting behavioral complaints in primary care pediatrics, is highly responsive to urine alarm treatment—a minimally technical, uncomplicated form of bio- partial contraction, which maintains the bladder neck in an elevated and closed position (Vincent, 1974). Even after initiation of urination contraction of the pelvic-floor muscles can raise the bladder neck abruptly and terminate urina- tion. These urinary inhibitory responses not present or sporadic for children with enuresis (Christophersen & Friman, 2010; 2017, 2019; also see Houts, 1991). Etiology Although nocturnal enuresis has a strong genetic basis, its exact cause is unknown. For decades, researchers attempted to link it to causal psycho- pathology, but contemporary research (Friman, Handwerk, Swearer, McGinnis, & Warzak, 1998) and several reviews of older research (Christo- phersen & Friman, 2010; Friman, 2017, 2019) sug- gest that most children with enuresis do not ex- hibit clinically significant psychopathology, and psychopathology is more likely to be an outcome than a cause of nocturnal enuresis when they do. Physiologically oriented studies of nocturnal enuresis suggest that some affected children may have difficulty concentrating their urine during the night and produce more urine nocturnally than their nonenuretic peers (Lackgren, Neveus, & Stenberg, 1997; Rittig, Knudsen, Norgaard, Ped- ersen, & Djurhuus, 1989). The overall importance of this factor, however, is controversial, because the proportion of children with enuresis who have urine concentration problems may be small (Eg- gert & Kuhn, 1995). Nocturnal enuresis is usu- ally most productively viewed as a deficit in the skills necessary to prevent urination while asleep (Christophersen & Friman, 2010; Friman, 2017, 2019; Houts, 1991). Evaluation As for a child with encopresis, the behavior ana- lyst should refer a child with nocturnal enuresis to a pediatrician for a medical evaluation before initiation of treatment. Although pathophysi- ological causes of nocturnal enuresis are very rare, they are real and should be ruled out. There are several other elements necessary for a complete evaluation of nocturnal enuresis, but these are well documented in other sources. I refer the reader to them because the intention of this section is mere- ly to describe alarm-based treatment (e.g., Christo- phersen & Friman, 2010; Friman, 2017, 2019). 416 S U B S P E C I A LT IE S I N a skill that would be difficult to teach without the sensory feedback the alarm provides. The enuresis alarm produces cures slowly, and during the first few weeks of alarm use, waking occurs only after a complete voiding if it occurs at all. One study using the size of the urine stain on the soiled sheets as the dependent measure showed that before accident-free nights, the stain grew increasingly smaller on successive nights, suggesting a gradual process of continence attain- ment (Ruckstuhl & Friman, 2003). In other words, the feedback properties of the alarm gradually but inexorably strengthened the skills necessary to avoid it. The core skill involves contraction of the pelvic-floor muscles, causing sustained elevation of the bladder neck, which stops or prevents urina- tion. Increased sensory awareness of urinary need and waking to urinate are possible outcomes, but are less likely and actually inferior to sustained, accident-free sleep throughout the night. Increasing sensory awareness of urinary need before daytime accidents, however, is a nent in the most empirically supported treatment for diurnal enuresis. Only two studies are avail- able, as researchers have studied diurnal enuresis minimally, and the first used a much simpler con- ceptualization (Halliday, Meadow, & Berg, 1987). Specifically, this early study merely suggested that the alarm served as a reminder for urination. A colleague and I (Friman & Vollmer, 1995) con- ducted a subsequent study using the biofeedback conceptualization with a young girl who was ini- tially unresponsive to urinary urge and onset, but who rapidly became responsive with use of the alarm. The decreasing latency between alarm onset and appropriate response was characteristic of learning curves during alarm-based treatment for nocturnal enuresis and biofeedback treatments in general. Most biofeedback treatments are much more technically complex than the urine alarm, and clinicians use them for a broad range of physi- ologically based behavioral concerns that often initially present in pediatric settings. physiological processes that we can monitor are muscle tension, skin temperature, respiratory rate, blood pressure, and skin moisture (perspiration) (Friman, 2009). Researchers and clinicians have used biofeedback devices sensitive to these pro- cesses in treating a variety of disorders, including headaches, other varieties of chronic pain, asth- ma, bruxism, anxiety disorders, sleep disorders, and dysfunction of the autonomic nervous system because it begins with adhering to the pediatric appointment itself. Treatment effectiveness is a moot issue if families do not keep appointments or do not follow prescribed treatments. Estimated rates of nonadherence hover around 50% for both psychological (Kazdin, 1996) and medical (Rapoff, 2010) services. Although treatment adherence is problematic across clinical populations, it is par- ticularly challenging with children and adoles- cents, because there are usually at least two sourc- es of nonadherence: the children/adolescents and their caregivers (Watson, Foster, & Friman, 2006). Thus establishing acceptable levels of adherence requires examining child and caregiver variables that either facilitate or impede it. The relevant literature highlights three salient terms: adherence, compliance, and integrity. Com- pliance and adherence are basically synonymous, but adherence has gained favor in recent years (see Rapoff, 2010), and I use it here. Adherence and integrity, however, are not synonymous, because treatment integrity refers to the fidelity with which a clinician delivers treatment. Adherence refers to the extent to which patients keep appointments and accurately and consistently follow the steps of prescribed treatments. For example, a routine prescription for functional retentive encopresis in- cludes increases in fluid, fiber, scheduled toilet sits, stool softeners, and incentives, as well as decreases in dairy products, processed foods, coercion, pun- ishment, and irregular or extended toilet sits. As- sessing treatment adherence involves determining the number of prescribed steps actually followed (accuracy) and the regularity of applications (con- sistency). Although patient nonadherence has always been the primary focus in treatment adherence re- search, clinicians and researchers alike now realize that treatment integrity among clinicians should also be a target. Clinician communication about treatment has a significant effect on the probabil- ity of adherence, and accuracy and consistency are dimensions of the communication. Additional variables include clinician training and experi- ence, interpersonal skill, capacity to manifest au- thority without instigating resistance, and sense of timing. Other not so self-evident and possibly more manipulable variables include the specificity of treatment recommendations; the standardiza- tion of treatment protocols; and the provision of supportive instructional aids like handouts, audio and video recordings, and e-mail or web-based communications. For example, as described above, incontinence is a problem that frequently pres- 418 S U B S P E C I A LT IE S I N The next issue involves who does the assessing and who is assessed—questions particularly im- portant in pediatrics, because although children are the targets of treatment, their caregivers are usually the recipients of the regimen and are al- ways partly and often fully responsible for carry- ing it out. Thus both a child and a caregiver can often be the focus of assessment. Additionally, as is typical in most branches of medicine, there are multiple sources of information, including physi- cians, nurses, therapists, and support staff. For ex- ample, in our early appointment-keeping research, the staff at the outpatient check-in desk supplied critical assessment data (Friman, Finney, Rapoff, & Christophersen, 1985). The final issue involves how to assess adher- ence, and the literature describes multiple strate- gies. Here, I briefly discuss only the most common. However, this dimension of adherence assessment would seem to be limited only by the resources, ingenuity, and creativity of investigators. In short, how best to assess adherence presents a growth potential for behavior analysts. The types I list here include drug assays, direct observation, elec- tronic monitoring, pill counts, provider estimates, and patient and caregiver reports (Rapoff, 2010). There are advantages and disadvantages to each. I then discuss functional assessment of adherence and some general concerns about procedures. Drug Assays. Drug assays range in sophistica- tion from observing a bioavailable marker that is either part of or added to a drug to various of testing, ranging from determining simple blood sugar levels (something the patient or patient’s caregivers do) to testing for various metabolites (something that only a lab technician can do). However, proper interpretation of a drug assay virtually always involves some basic knowledge of clinical pharmacology, especially as it pertains to absorption, distribution, and elimination of medi- cations in (or not in) the body. The advantages of assays include objective quantification, clinical utility, and information on dose–response rela- tions. Their disadvantages include abbreviated time horizons, expense, invasiveness, need for ex- pert readings, and variability of readings due to various causes (e.g., enteric coatings, contents of the stomach, presence of other drugs, age, gender, habits). Observation. Although direct observation is considered a sine qua non for behavior-analytic research, it is actually limited in research on ad- penser, and may dispense mist from an inhaler into the air rather than inhale it into the lungs. Thus, independent of other measures indicating that the patient ingested the medicine, the behav- ior analyst is likely to consider electronic monitor- ing only as a supplementary measure. Pill Counts. The long-standing tradition of using pill counts as a measure of adherence began to fade with the advent of electronic monitoring. Their use is simple: The researcher merely counts the pills remaining in the medication container and compares it against the prescribed regimen. Obviously, this is a primitive method, compared to the real-time data available from electronic moni- toring. Thus, although pill counts are a measure of adherence behavior and any measure is better than no measure, they share none of the advan- tages of electronic monitoring and all their disad- vantages. Provider Estimates. Obtaining provider esti- mates typically involves asking medical provid- ers to complete scales that assess adherence. The most common involve Likert-type scales whose items pertain to judgments about the likelihood adherence has occurred and its extent. In a more primitive form, providers merely answer yes or no when asked whether they believe a patient has or will follow a regimen. The primary advantage of provider estimates is feasibility. They require little effort or expense. A small amount of evidence suggests that they are more accurate than global ratings from patients and their caregivers. The disadvantages will be obvious to behavior ana- lysts. Provider estimates merely involve asking for providers’ opinions, and opinions, even from well- established experts, are subject to bias and other well-known threats to validity (Rapoff, 2010). Moreover, outside of some forms of social valid- ity, opinions are wholly unsatisfactory as a primary measure for behavior analysts. Patient and Caregiver Reports. Patient and care- giver reports are merely variations on self-reports— a method fundamental to research in mainstream psychology, psychiatry, some related social sci- ences, and clinical medical research. Yet, outside of social validity, behavior analysts virtually never use them as a primary source of assessment data. The reasons are immediately evident to behavior analysts: Behavior is the subject under consider- ation, and reports of behavior are only considered as behavior, not as measures of behavior. Although 420 S U B S P E C I A LT IE S I N consumed. Direct measures, when possible and feasible, are always preferred over indirect mea- sures, because they more completely and accurate- ly capture the essence of adherence. For example, directly observing a patient walking into a clinic is superior to asking a caregiver whether his or her child kept his or her appointment. Standards of measurement, especially reliability and validity, are essential considerations in all measurement systems, and assessment of adherence is no excep- tion. Interpretation is important, because the data do not speak for themselves. Learning that a pa- tient took a pill means little without information about the importance, meaning, and relevance (to the regimen) of that pill. Adherence to a medical regimen is a clinical activity, and its assessment data should have demonstrable clinical utility. As a counterexample, much of the information solic- ited in the packets that patients receive in medical settings has little or no bearing on their medical condition or its treatment. Improving Adherence Health Education. There are two forms of in- tervention in behavioral pediatrics, and health education is one of them (prescriptive treatment is the other). Some amount of health education accompanies all treatment prescribed in pediatrics (e.g., see the discussions of bedtime problems, en- copresis, and enuresis above), and a major portion of it pertains to the importance of following the treatment regimen. As one example, health educa- tion messages about the importance of completing the regimen are now a standard part of prescribed antibiotic regimens. This was not always the case. Patients often discontinued the regimen as soon as their symptoms receded. Premature discontinua- tion, however, can lead to symptom recurrence and treatment resistance. In pediatric studies evaluat- ing the use of health education to increase adher- ence, among the most typical targets are antibiotic regimens for otitis media; the results are mixed, with only about half of available studies showing a significant benefit (Rapoff, 2010). However, this 50% failure rate may be more a reflection of edu- cational methods than of health education itself. For example, a test of three educational methods to promote adherence to a regimen for reducing dangerous infant behavior showed that an educa- tional video with modeling was as effective as an in-home demonstration, and more effective than educational materials supplied by the American Academy of Pediatrics (Linnerooth et al., 2002). how professionals address nonadherence in medi- cal settings. That influence extends far beyond appointment keeping. Some form of prompting could potentially improve adherence to any medi- cal regimen to be followed outside a clinic setting. As just one example of potential research in this area, research on smartphone-based prompting applications to improve adherence is limited. But the ubiquity of smartphones coupled with their al- most limitless capacity for applications presents an opportunity for enterprising behavior analysts to assess their potential for increasing adherence to appointments and medical regimens. Incentives. Presumably the most powerful in- centive for adhering to a medical regimen involves negative reinforcement in the form of rapid relief from symptoms. However, not all appointments re- sult in treatment, and not all treatment results in rapid relief. As just one example of the latter, the regimen for juvenile diabetes requires multiple be- haviors that are effortful (e.g., dietary restrictions, foot care), painful (e.g., insulin shots, blood sugar tests), or both, but that do not provide immedi- ate symptom relief. Thus the addition of positive reinforcement in the form of tangible incentives can be helpful. One example involves token sys- tems to promote adherence to regimens in juve- nile rheumatoid arthritis. The basic form involves four primary components: (1) task-analyzing the regimen into readily executable steps, (2) supply- ing tokens contingent upon completion of steps, (3) withdrawing tokens contingent upon failure to complete steps, and (4) arranging for regular ex- change of tokens for agreed-upon rewards. One of the most difficult regimens to follow involves ab- staining from addictive substances, and incentive programs have been more effective than virtually any other method for accomplishing this outcome (e.g., Higgins, Heil, & Sigmon, 2013). Despite this extraordinary range of documented effective ap- plications, ranging from performing simple steps in a juvenile rheumatoid arthritis regimen to com- plying with prescribed abstinence from the most addictive substances known to humankind, incen- tive programs for improving adherence to medical regimens has received only modest attention from researchers in general and even less from analysts in particular. Miscellaneous Approaches. There are various other approaches to promoting adherence in pe- diatric populations, although research directly evaluating them is scant. Disciplinary interven- 422 S U B S P E C I A LT IE S I N 2010; Stuart, 1982). Although the section ends this chapter on behavioral pediatrics, it should probably have been the introductory section (as noted earlier), because the treatments discussed in the first three dimensions of behavioral pediatrics are moot if patients do not keep appointments or follow regimens. One of the major concerns of be- havior analysts in the 21st century is how to bring our field more into the mainstream of everyday life. Almost all U.S. children have a primary care physician. Thus any research or intervention that targets pediatrics in general, as adherence does, is by definition, mainstream. Enterprising behavior analysts might consider taking that route. CONCLUSIONS Behavioral pediatrics is a diverse field that in- cludes research and treatment of common child behavior problems, research on the interactions between physiology and behavior that affect child health, and treatments derived from the findings of that research. ABA is a science that conducts research on interactions between environmental and behavioral variables and evaluates interven- tions for socially significant problems that have been derived from that research. The integration of behavioral pediatrics and ABA not only benefits both fields, but actually extends the effectiveness of pediatricians—the primary guardians of child health in this country—and thereby contributes to the health of children. I have confined my dis- cussion to four problem areas, each representing one domain of behavioral pediatrics. This repre- sents a much-abbreviated review of behavioral pe- diatrics and the potential role of ABA, and there are many aspects of behavioral pediatrics that I have not addressed (e.g., infant colic, oppositional behaviors, habit disorders, anxiety and depressive disorders, chronic illnesses, and pain). For a broad- er sample, please refer to various source documents (e.g., Allen, Barone, & Kuhn, 1993; Blum & Fri- man, 2000; Christophersen, 1982; Friman, 2005a, 2008; Friman & Blum, 2003). Despite its many contributions to behavioral pediatrics, ABA is still not widely available and accepted in the pediatric medical community. Remedying the problem of limited availability is a primary purpose of this chapter; I hope to increase the number of applied behavior analysts interested in behavioral pediatrics. Remedying the problem of limited acceptance is an important concern, REFERENCES Adams, L. A., & Rickert, V. I. (1989). 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Washington, DC: American Psychological Association. Blum, N., & Friman, P. C. (2000). Behavioral pediat- rics: The confluence of applied behavior analysis and pediatric medicine. In J. Carr & J. Austin (Eds.), Handbook of applied behavior analysis (pp. 161–186). Reno, NV: Context Press. Blum, N., Williams, G., Friman, P. C., & Christophers- en, E. R. (1995). Disciplining young children: The role of verbal instructions and reason. Pediatrics, 96, 336–341. Burke, R. V., Kuhn, B. R., & Peterson, J. L. (2004). A “storybook” ending to children’s bedtime problems: The use of a rewarding social story to reduce bedtime resistance and frequent night waking. Journal of Pedi- atric Psychology, 29, 389–396. Christophersen, E. R. (1982). Incorporating behavioral pediatrics into primary care. Pediatric Clinics of North America, 29, 261–295. Christophersen, E. R., & Friman, P. C. (2010). Elimina- tion disorders. Cambridge, MA: Hogrefe. Christophersen, E. R., & Mortweet, S. M. (2013). Treat- ments that work with children (2nd ed.). Washington, DC: American Psychological Association. Christophersen, E. R., & Rainey, S. K. (1976). Manage- ment of encopresis through a pediatric outpatient clinic. Journal of Pediatric Psychology, 4, 38–41. Costello, E. J., Burns, B. J., Costello, Dulcan, M., & Brent, D. (1988). Service utilization and psychiatric diagnosis in pediatric primary care: The role of the gatekeeper. Pediatrics, 82, 435–441. Costello, E. J., Edelbrock, C., Costello, A. J., Dulcan, M., Burns, B. J., & Brent, D. (1988). Psychopathology in pediatric primary care: The new hidden morbidity. Pediatrics, 82, 415–424. 424 S U B S P E C I A LT IE S I N and therapy (Vol. 2, pp. 731–739). Thousand Oaks, CA: SAGE. Friman, P. C. (2005b). Good night, we love you, we will miss you, now go to bed and go to sleep: Managing bed- time problems in young children. Boys Town, NE: Girls and Boys Town Press. Friman, P. C. (2008). Primary care behavioral pediat- rics. In M. Hersen & A. Gross (Eds.), Handbook of clinical psychology (Vol. 2, pp. 728–758). Hoboken, NJ: Wiley. Friman, P. C. (2009). Behavioral assessment. In M. Hersen, D. Barlow, & M. Nock (Eds.), Single case experimental designs (3rd ed., pp. 91–143). Boston: Allyn & Bacon. Friman, P. C. (2010). Come on in, the water is fine: Achieving mainstream relevance through integra- tion with primary medical care. Behavior Analyst, 33, 19–36. Friman, P. C. (2017). Incontinence. In A. Wetzel (Ed.), The SAGE encyclopedia of abnormal and clinical psy- chology (pp. 1296–1298). Thousand Oaks, CA: SAGE. Friman, P. C. (2019). Incontinence in the child: A biobehavi of pediatrics that focuses on the relation between behavior and pediatric health care (Blum & Fri- man, 2000; Christophersen, 1982; Friman, 2005a, 2008; Friman & Blum, 2003). The central mes- sage of this chapter is that integrating ABA and behavioral pediatrics extends the scope of ABA, expands effective practice, and improves pediatric health care for children. Behavioral pediatrics is a broad field that in- cludes four primary domains of research and prac- tice: (1) the evaluation and treatment of high- frequency, low-intensity (routine) child behavior problems presenting in primary health care set- tings; (2) the influence of physiological variables on child behavior problems; (3) the influence of behavioral variables on child medical problems; and (4) contextual variables that are central to the first three domains. The high prevalence of be- havioral problems presenting in pediatric settings, and the increasing recognition of the reciprocal relationship between medical concerns and child behavior problems, have led to dramatic growth in behavioral pediatrics over the past 40 years. ABA has made significant contributions over that time, and these, coupled with the continuing growth of behavioral pediatrics, provide multiple opportuni- ties for applied behavior analysts to work in child health care settings. Behavioral Pediatrics 409 child’s problem, stigma results from not contacting a pediatric care provider about a child’s problem. Therefore, the pediatrician is almost always the first professional to learn of child behavior prob- lems. Most of these are low-intensity, high-fre- quency problems that are not necessarily represen- tative of true pathology. But by caregivers’ reports, they are often disruptive to families and difficult to solve (Christophersen, 1982; Earls, 1980; Friman, 2005a, 2008). Additionally, a significant percent- age of them will deteriorate into more serious con- ditions if left unsolved. A classic example involves bedtime problems. & Blum, Bedtime Problems Teaching children to go to bed, go to sleep, and stay asleep throughout the night is difficult for many families in mainstream North American culture, in that at least 30% of families contend with sleep problems three or more nights a week (Friman & Schnoes, 2020; Lozoff, Wolf, & Davis, 1985). The difficulties caregivers report include bedtime struggles like resistance to going to bed; fussing and crying while in bed; and night waking with fussing, crying, and unauthorized departures from the bedroom. Pediatricians often address these problems by prescribing soporific drugs, but these medications produce side effects, and treat- ment gains are often lost when the medication is withdrawn (Christophersen & Mortweet, 2013; Edwards & Christophersen, 1994). Behavioral Treatment for Bedtime Problems that be- The primary component of the most effective behavioral interventions for bedtime problems involves one of the first documented and most fre- quently used ABA-informed procedures: extinc- tion. As children develop sleep habits, they often learn to associate specific environmental factors with self-quieting and the induction of sleep. Mis- informed caregiver efforts to help children sleep (e.g., soothe, cuddle, or lie down with the child until sleep onset occurs) often result in problem- atic sleep associations that mitigate the process of falling asleep. Unfortunately, when such a care- giver is absent at bedtime, the child is left with- out the stimulus that is most powerfully associated with sleep. The child’s response to the caregiver’s absence typically involves prolonged and intensive crying that resembles an extinction burst (Blamp- ied & Bootzin, 2013; Edwards & Christophersen, 1994; Ferber, 2006; Friman, 2005b; Friman & A P P L IE D B E H AV I O R A N A LY S I S and a large amount of clinical experience that Ferber (2006) has described suggest that very few do. Although the mechanism responsible for the effectiveness of graduated extinction is unknown, one possible explanation is that increasing the re- sponse requirement to 45 minutes of crying may lean the schedule so much that the reinforcing ef- fects of sleep supersede the reinforcing effects of caregiver visitation. 2009). Not Positive Routines. The positive-routines proce- dure involves a hybrid of extinction and a reinforc- ing bedtime ritual. In this procedure, a caregiver decides on a preferred bedtime for the child and establishes the time at which the child typically falls asleep. Beginning shortly before the time the child typically falls asleep, the caregiver engages the child in several quiet activities lasting no lon- ger than 20 minutes total. During the activities, the caregiver issues easily followed instructions and richly supplies reinforcement for compliance. These are followed by the terminal instruction “Now get in bed and go to sleep,” or something equivalent—a procedure consistent with the high- probability instructional sequence in research on behavioral momentum (Mace et al., 1988). If the child leaves the bed at any time after the comple- tion of the routines and the terminal instruction, the caregiver places him or her back in bed, telling the child that the routine is over and it is time for bed. The caregiver ignores crying or verbal- izations. At specified intervals (e.g., 1 week), the caregiver moves the positive routine back in time 5–10 minutes. This backward movement continues until the caregiver arrives at the preferred bedtime for the child, which can take 6–8 weeks or more. Experimental comparison of the positive-routines procedure with scheduled extinction showed that both improved bedtime behavior for children, but the caregivers using positive routines reported sig- nificantly improved marital relations, suggesting a more socially valid procedure (Adams & Rickert, 1989). The Bedtime Pass. The bedtime pass program involves (1) requiring the child to get into bed; (3) providing the child with a small object (e.g., a laminated note card) exchangeable for one “free” trip out of the bedroom or one visit by the care- giver after being put to bed to satisfy an accept- able request (e.g., for a drink, hug, or visit to the bathroom); (3) having the child surrender the pass after using it; and (4) using extinction thereafter (Schnoes, 2011). In the initial study, the program Behavioral Pediatrics 411 logical variable that can cause toileting problems, ranging from resistance to a bona fide diagnostic category known as retentive encopresis. re- burst” Retentive Encopresis Definition Functional encopresis, a common presenting results of the complaint in pediatrics (representing 3–5% of referrals), is a disorder in which children either voluntarily or involuntarily pass feces into or onto an inappropriate location, usually their clothing (Christophersen & Friman, 2010; Friman, 2017, 2019). Encopresis is not diagnosed if the problem is exclusively due to an anatomical or neurologi- cal abnormality that prevents continence. The current criteria from the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM- 5; American Psychiatric Association, 2013) are as follows: (1) inappropriate passage of feces at least once a month for at least 3 months; (2) chrono- logical or developmentally equivalent age of at least 4 years; and (3) not due exclusively to the direct physiological effects of a substance (e.g., a laxative) or a general medical condition, except through a mechanism involving constipation. DSM-5 distinguishes two subtypes of encopresis: one with constipation and overflow incontinence, and one without these symptoms. I focus on en- copresis with constipation and overflow, because this subtype has a physiological cause (i.e., consti- pation). The etiology of encopresis without con- stipation remains unknown (Beaudry-Bellefeuille, Booth, & Lane, 2017). the Relevant Physiology The large intestine or colon is the distal end of the alimentary tract, which is composed sequen- tially of the esophagus, stomach, small intestine, and colon. I provide a rudimentary description of the system here, because behavior analysts should understand the physiology that supplies the logic of effective treatment (for more thorough reviews, see Weinstock & Clouse, 1987; Whitehead & Schuster, 1985). The colon is a tube-shaped organ with a muscular wall. It connects the small intes- tine to the rectum and anus. It has three primary functions: fluid absorption, storage, and evacua- tion. Extended storage and planned evacuation are the defining features of fecal continence. Muscu- lar contractions of the colon walls, called peristal- sis, produce a wave-like motion that moves waste N A P P L IE D B E H AV I O R A N A LY S I S tion, or a combination of these factors (Meunier, Marechal, & De Beaujeu, 1979; Wald, Chandra, Chiponis, & Gabel, 1986). The combined effects of these factors are a lowered probability of volun- tary stool passage and a heightened probability of fecal retention. Chronic fecal retention causes fecal impaction, which enlarges the colon, produces decreased mo- tility of the bowel system, and occasionally results in involuntary passage of large stools and soiling due to seepage of soft fecal matter. Physicians often refer to the seepage as paradoxical diarrhea, because the children retain large masses of stool and are functionally constipated, but their colon allows passage of soft stool around the mass, which results in diarrhea (Levine, 1982). The relation of fecal impaction to encopresis is well established, and 80% of patients show fecal impaction accom- panying fecal incontinence at the first clinic visit via clinical exam and 90% on X-ray of the lower abdomen (Davidson, 1958; Levine, 1982). Evaluation Either before or directly after the initial visit, the behavior analyst should refer a child with encopre- sis to the pediatrician for a medical examination; this usually includes a routine check of history, abdominal palpation, rectal examination, and sometimes an X-ray of the abdomen to determine the extent of fecal impaction. A barium enema is rarely necessary unless features of the exam suggest Hirschsprung’s disease. Rare anatomical and neurological problems can cause fecal reten- tion and soiling; neurological problems include Hirschsprung’s disease, and anatomical defects in- clude a variety of malformations and locations of the anus that a physical exam can detect and that require medical management (Hatch, 1988). In addition to routine behavior assessments, the behavioral interview for encopresis should include questions related to constipation. These include asking whether (1) there is ever a long period be- tween bowel movements; (2) bowel movements are atypically large (e.g., stop up the toilet); (3) fecal matter ever has an unusually foul odor; (4) fecal matter is ever hard, difficult, or painful to pass; (5) the child ever complains of not being able to feel the movement or make it to the toilet on time; and (6) the child ever hides soiled underwear. An af- firmative answer to one or more of these questions is highly suggestive of retentive encopresis, and hiding underwear suggests a history that includes some form of punishment. Behavioral Pediatrics 413 trials (e.g., Stark et al., 1997). For example, in a study of 58 children with encopresis, 60% were completely continent after 5 months, and those who did not achieve full continence averaged a 90% decrease in accidents (Lowery, Srour, White- head, & Schuster, 1985). However, not all children succeed with the conventional approach, and re- searchers have developed augmentative methods for these children. In a manner typical of ABA, developing these augmentative methods began with the study of behaviors associated with treat- ment failure (Stark, Spirito, Lewis, & Hart, 1990). Incorporating behavior management methods rel- evant to the behaviors, teaching caregivers to use them, and delivering treatment in a group format produced an 83% decrease in accidents in 18 treat- ment-resistant children with encopresis, and the children maintained decreased accidents or even improved at a 6-month follow-up (Stark, Owens- Stively, Spirito, Lewis, & Guevremont, 1990). The general premise of this section—that phys- iological variables can influence or cause behavior problems—is not controversial even within ABA, a science dedicated to environmental variables. Constipation is one such variable, and there are many others (e.g., anorexia due to gastroesophage- al reflux, restricted activities due to pain). Because of the physiological component of these problems, serious health consequences of unsuccessful treat- ment often compound the behavioral components that contribute to the problem. For example, ex- treme fecal retention can be life-threatening, and even routine cases can seriously decrease social standing and increase social isolation in affected children. Because of the behavioral components of these problems, a solely medical intervention is insufficient for effective treatment. A method that delivers or aids the delivery of the medical compo- nents of treatment while addressing the behavioral components is needed, and thus behavioral pedi- atrics is an ideal context. Additionally, although many types of behavior problems stem from physi- ological influences, the most frequently occurring problem is some form of noncompliance with a treatment regimen for the physiological dimen- sions. As an example, cooperation with prescribed treatment for encopresis is so necessary for success that instructional control training is frequently a component of treatment (Christophersen & Fri- man, 2010; Friman, 2017, 2019). Furthermore, al- though researchers have made progress in improv- ing pediatric compliance, it remains one of the most chronic problems in pediatric medicine (see A P P L IE D B E H AV I O R A N A LY S I S feedback that is used readily in primary care set- tings (Christophersen & Friman, 2010; Friman, 2017, 2019). Below I briefly review nocturnal en- uresis, its relevant physiology, and its alarm-based treatment. Nocturnal Enuresis Definition of behav- The current criteria for nocturnal and diurnal en- uresis from DSM-5 (American Psychiatric Associ- ation, 2013) are as follows: (1) repeated urination into bed or clothing; (2) at least two occurrences per week for at least 3 months, or a sufficient num- ber of occurrences to cause clinically significant impairment or distress; (3) chronological age of 5 years, or for children with developmental delays, a mental age of at least 5; and (4) not due exclusively to the direct effects of a substance (e.g., diuretics) or a general medical condition (e.g., diabetes). There are three subtypes of enuresis—nocturnal only, diurnal only, and mixed nocturnal and di- urnal. There are two courses: The primary course includes children who have never established con- tinence, and the secondary course involves chil- dren who resume having accidents after establish- ing continence. Here I primarily discuss nocturnal enuresis, which researchers estimate occurs in as many as 20% of first-grade children (Christophers- en & Friman, 2010; Friman, 2017, 2019). Relevant Physiology The bladder is an elastic, hollow organ with a wall consisting of detrusor muscle. Its shape resem- bles an upside-down balloon with a long narrow neck; it has two primarily mechanical functions, storage and release of urine (Vincent, 1974). Ex- tended storage and volitional release are the defin- ing properties of urinary continence. In infancy, distension of the bladder leads to contraction of the bladder and automatic (nonvolitional) urine evacuation. As children mature, the capacity of the central nervous system to inhibit bladder con- traction increases, which typically coincides with the development of continence in early childhood (Berk & Friman, 1990; Koff, 1995). The components of the urogenital system that are under volitional control to establish conti- nence are the muscles of the pelvic floor. Ex- cept during imminent or actual urination, these muscles remain in a state of tonus or involuntary Behavioral Pediatrics 415 Treatment The most common treatments for nocturnal en- has begun, uresis are the urine alarm and the two medications, desmopressin acetate (DDAVP) and imipramine. These medications can provide symptomatic re- are either lief (approximately 25–40% of children will be nocturnal dry most nights when taking them); however, the Friman, enuresis usually returns when the medications are stopped (Moffatt, 1997). More importantly, both medications have been associated with adverse side effects. For imipramine, just the common side effects give one pause, as they range across systems from extrapyramidal symptoms in the central nervous system to urticaria and pruritus of the skin (Skidmore-Roth, 2010). For DDAVP, the most serious side effects are hyponatremia, seizures, and death; the occurrence of these has led the U.S. Food and Drug Administration to rule against use of the most widely used DDAVP formula (nasal spray) for treatment of enuresis (Hatti, 2007). The urine alarm is a moisture-sensitive switch- ing system that sounds when the child urinates. Researchers have reported that repeated pairing of awakening by the alarm with episodes of wetting is the single most effective treatment for enuresis (Christophersen & Friman, 2010; Friman, 2017, 2019). Its success rate is higher (approximately 75%) and its relapse rate lower (approximately 41%) than those for any other drug or skill-based treatment (Shepard, Poler, & Grabman, 2017). The urine alarm is a simple form of biofeedback treatment, because its primary function is to pro- vide feedback for a physiological event (urination) that occurs beneath awareness. The feedback, the alarm ringing, increases the salience of urination and aids the child to ultimately establish urinary self-control. The mechanism by which the alarm improves enuresis, however, is still unknown. Changes in secretion of hormones that affect the ability to concentrate urine or alterations in the brain’s inhibition of bladder contraction are at least theoretically possible, but have not been investigated. The current prevailing account in- volves a combination of classical conditioning of pelvic-floor muscles and operant conditioning of volitional behaviors related to continence via avoidance of the alarm (Christophersen & Fri- man, 2010; Friman, 2017, 2019; Houts, 1991). In this account, children are not necessarily trained to awaken to the alarm, merely to engage their uri- nation-inhibiting system even if they are asleep— A P P L IE D B E H AV I O R A N A LY S I S (Culbert et al., 1996). Additionally, evidence that biofeedback can generate operant responses that lead to control over physiological processes long thought to be outside volition, like skin tempera- ture and blood pressure, is mounting. For example, researchers have used verbally based awareness en- hancement methods to alter the level of mediators of the immune system in saliva (Olness, Culbert, & Uden, 1989) and to decrease the recurrence of chronic mouth ulcers (Andrews & Hall, 1990). Collectively, the large body of research document- ing the effectiveness of the urine alarm, and the even larger literature on the effectiveness of bio- feedback treatment for a broad range of medical conditions, underscore the research and clinical potential represented by the influence of behav- ioral variables on physiology. This potential, in turn, represents an excellent opportunity for ap- plied behavior analysts interested in working in pediatric settings. key compo- CONTEXTUAL VARIABLES A broad range of contextual variables influence the effectiveness of health care and its delivery. These variables are not specific to any particular problem that presents in a health care delivery sys- tem, but they have the capacity to influence all of them. For example, doctor communication is cen- tral, but not specific, to care for problems treated in health care settings, although its role can vary depending on the problem at hand. For example, effective communication may be less critical for treatments like “the tincture of time” (e.g., “Let’s just watch this for a while and see if the child grows out of it”) than it would be for a complex medical intervention. A directly related contextual vari- able is patient communication. For example, if patients incompletely report symptoms or do not ask critical questions, the care they receive may be inadequate (e.g., Finney et al., 1990). I have chosen treatment adherence for this chapter as the exem- plar of a contextual variable that affects care. Among the Treatment Adherence Definition Treatment adherence is so central to pediatric medicine that this chapter probably should have begun with it. True, routine behavior problems are very frequently concerns in pediatric medi- cine, but treatment adherence is always a concern Behavioral Pediatrics 417 ents in pediatrics, and there are empirically sup- ported treatment protocols for its most commonly presenting forms (enuresis and encopresis). These treatments include information on relevant physi- ology, diet, toileting schedules, behavioral contin- gencies, activity levels, and caregiver involvement. To maximize integrity, a clinician would verbally deliver information covering these details and sup- plement the delivery with supportive instructional aids. Other examples include regimens for chronic diseases and empirically supported treatment pro- tocols for behavior disorders. Assessment of Adherence Adherence is an observable and measurable be- havior, and thus well suited to behavioral as- sessment. The primordial adherence behavior is appointment keeping, and its assessment is straightforward: Did the patient keep the appoint- ment? The other adherence behaviors to be as- sessed are determined by the nature of the problem to be treated. For acute problems like otitis media or strep throat, the behaviors of primary concern are relatively simple; they typically involve rest and taking prescribed medication for an abbrevi- ated time. For chronic diseases, the behaviors of concern are usually more complex. They typically involve multiple timelines and classes of behavior. The vast literature on behavioral assessment of- fers some guidance on selection of target behav- iors that can readily inform how and what to as- sess when adherence to a complex regimen for a chronic condition is the focus (e.g., Friman, 2009). A complete review of assessment is far beyond the scope of this chapter. I merely provide a cur- sory description. There are at least four options for selecting target regimen behaviors. The first is the most straightforward, but probably the most difficult, and this is to measure all behaviors that are relevant to regimen adherence. The second involves targeting only those behaviors that are most problematic or aversive to others. For exam- ple, children with enuresis are often less bothered by soiled bedding than their caregivers are. The third involves targeting behaviors that are the most immediately crucial to a patient’s health and well-being. For example, compliance with daily insulin injections is more immediately critical to health maintenance in diabetes than foot care is. The fourth involves targeting those behaviors that are easiest to change; the rationale here is to build up momentum for larger changes (cf. Mace et al., 1988). A P P L IE D B E H AV I O R A N A LY S I S herence. Most measures are indirect, like assays (see above) or pill counts (see below). But the lim- ited use of direct observation is not so much an obstacle as it is an opportunity. The indirect mea- sures are likely to dominate the field, but direct observation can supplement them when this is fea- sible. However, expanding assessment to include direct observation will usually require observers other than those on the research team, because although treatments are prescribed in clinical set- tings, they are usually carried out elsewhere (e.g., home, school). The most likely candidates are family members or school personnel, but there are other possibilities. For example, a study on dietary compliance used camp counselors as observers (Lorenz, Christensen, & Pitchert, 1985). Validity is the primary advantage of direct observations. They are direct measures of adherence, and they accrue all the scientific advantages that behavior analysts have touted for decades (e.g., Johnston & Pennypacker, 2009; Rapoff, 2010). Their disadvan- tages primarily involve access. As indicated above, little of the typical treatment regimen is carried out in the clinic setting. Regimen requirements are distributed temporally across the patients’ days and nights, and situationally across the settings of their lives. The cost of resources necessary to carry out representative direct observations of ad- herence behaviors necessary for most regimens is prohibitive. Nonetheless, when accessibility is not a significant concern, behavior analysts should in- clude direct observation in adherence assessment. kinds Electronic Monitors. The revolution in elec- tronic technology that has occurred over the past few decades has significantly expanded assessment options for adherence researchers. For example, researchers can now monitor whether a patient retrieves pills or liquids from medication bottles or an inhalant from an inhaler, and researchers can store the obtained data electronically and retrieve it later for analysis. The research on electronic monitoring is so extensive that a pediatric psy- chology task force has identified it as a well-estab- lished measure (Quittner, Modi, Lemanek, Levers- Landis, & Rapoff, 2008). The primary advantage of electronic monitoring is that it can provide ob- jective measures of a broad spectrum of adherence behaviors continuously (if necessary) in real time. No other method has this advantage. The primary disadvantage is that data from electronic monitor- ing provide only an indirect measure of adherence behavior. A patient may not take pills retrieved from a bottle, may not swallow liquid from a dis- Behavioral Pediatrics 419 some well-respected behavior analysts have ac- knowledged the potential utility of self-reports and have suggested methods for increasing their rigor (e.g., reducing bias, heightening validity; Critch- field, Tucker, & Vuchinich, 1998), behavior-ana- lytic researchers remain skeptical of their use as a source of data. Non-behavior-analytic researchers studying adherence are much less skeptical, and they have developed multiple self-report methods, including global rating scales, structured inter- views, and daily diaries. As just one example, sleep diaries are a staple of clinical and scientific ap- proaches to pediatric sleep problems (e.g., Ferber & Kryger, 1995). The behavior analyst contemplat- ing research that involves assessment of adherence should consider coupling self-report measures with the more objective measures favored in behavior analysis. Doing so could expand the scope of the research and the possibility of having behavior- analytically oriented adherence research accepted in mainstream medical journals. Although the re- search (or at least a portion of it) could strain the credulity of behavior analysts, the advantage of exporting the behavior-analytic dimension of the research into mainstream medicine could—and would, in my opinion—be worth the cost. Functional Assessment. There is little mention of function in the adherence literature. Once again, behavior analysts should see this as an op- portunity rather than as a reason to avoid this important area of investigation. Although what follows is elementary to behavior analysts, it bears mentioning nonetheless: Determining the func- tion of a behavior, whether it involves self-injury or nonadherence, is a well-established method for designing treatments that are informed by the identified functions. General Concerns about Procedures. There are multiple issues to address in the pursuit of adher- ence research that I only briefly mention here, but the brevity of my remarks is inversely related to their importance. Beyond limited space, the rea- son for brief mention of these concerns is that they are central to all methods deployed to mea- sure human behavior. The first is reactivity. All measurement systems are reactive, and the portion of data resulting from the reactivity is not reflec- tive of the behavior being measured. Second, the measures employed must be representative of that behavior (in this instance, adherence). For exam- ple, pills missing from a pill container are not nec- essarily an accurate representation of medication A P P L IE D B E H AV I O R A N A LY S I S The point for behavior analysts is that health education is a primordial component of pediatric medicine, and that one of its central purposes is to promote adherence. The extent to which it does so in its currently employed forms, the extent to which those forms could be improved, and the de- velopment of new behaviorally informed methods are all rich opportunities for behavior-analytic re- search. Monitoring. Monitoring, whether its target is subatomic dynamics (Heisenberg, 1958/1999) or human behavior (Friman, 2009), affects the be- havior of the object monitored. The direction of the change in human behavior is determined by its social valence: Socially acceptable behaviors tend to increase in frequency, and socially unac- ceptable behaviors tend to decrease in frequency (Nelson, 1977). As a thought experiment, imag- ine the amount and direction of behavior change that would result from pointing a video camera at a group. In pediatric medicine, the primary moni- tor is almost always a caregiver. Researchers have used monitoring to enhance adherence across a broad range of programs, from functional encopre- sis (O’Brien, Ross, & Christophersen, 1986) to diet and exercise (Rapoff, 2010). Prompts and Reminders. Although prompts and reminders can play a role across virtually all medi- cal regimens, professionals use them more for ap- pointment keeping than for any other dimension of pediatric medicine. Reminder phone calls are now a basic part of virtually all medical subspecial- ties that involve prescriptive treatment, although this was not always the case. For example, Outpa- tient Pediatrics at the University of Kansas School of Medicine routinely reported high no-show rates for pediatric visits. The department had not used prompts or reminders. Our research group imple- mented an intervention involving mailed and telephoned reminders, and it resulted in approxi- mately a 20% increase in appointments kept and a 20% decrease in appointments not kept (cancel- lations were not included in the database). These improvements in appointment keeping were ac- companied by substantial cost savings (Friman et al., 1985). We replicated these results in a training clinic staffed by pediatric residents (Friman, Glass- cock, Finney, & Christophersen, 1987). Studies like these have led to the virtually universal use of reminder systems in modern medicine and stand as evidence that behaviorally based research on prompting can exert a significant influence on Behavioral Pediatrics 421 tion is one example. The literature showing that behaviorally based disciplinary interventions (e.g., time out, time in) can improve compliance is so well established that it need not be cited here. Nonadherence to a medical regimen is a form of noncompliance, and child resistance is frequently a factor. The extent to which disciplinary strate- gies can improve adherence is a subject worthy of behavior-analytic investigation. Rule governance is another aspect of behavior that almost certainly plays a significant role in adherence. Skinner (1969) described rules as con- tingency-specifying stimuli, and Hayes (1989) has characterized rule-governed behavior as behavior under the control of verbal stimuli. When cogni- tively oriented investigators refer to self-manage- ment for promoting adherence (cf. Rapoff, 2010), they are really referring to rule-governed behavior. However, the cognitive account places emphasis on the self as agent and deemphasizes the role of the environment (i.e., verbal community). This may explain why there is so little research show- ing that self-management can improve adherence. Why there is no behavior-analytic research exam- ining the role rule governance plays in adherence awaits an explanation. A final option involves various forms of psycho- therapy. From a cognitive perspective, mental ill- ness involves some combination of cognitive dis- tortion and neurotransmitter levels. Despite being highly theoretical at this stage of its development, this perspective appears to operate at the level of dogma in mainstream psychology and psychiatry. From a behavioral perspective, mental illness in- volves maladaptive verbal behavior and environ- mental contingencies. Regardless of perspective, the so-called illness can interfere with adherence when present. Conventional approaches (e.g., cog- nitive) employ some combination of medication and direct psychotherapy to resolve the illness and increase compliance. Behavioral approaches em- ploy health education to correct the problematic rule governance (e.g., vaccines do not cause autism spectrum disorder) and contingency management to improve behaviors related to adherence. Testing these approaches to improving adherence against each other could be interesting. behavior This section on adherence is cursory. Nonad- herence to medical regimens is the single greatest threat to the health and well-being of children in the United States. This problem is so well recog- nized that it typically receives book-length treat- ment (e.g., O’Donohue & Levensky, 2006; Rapoff, A P P L IE D B E H AV I O R A N A LY S I S but a subsidiary one in this chapter. Nonetheless, I suggest a few tactics that could help. For example, applied behavior analysts interested in collabo- rating with pediatricians at a local level should attend and present at pediatric conferences and lectures. They should also attend case manage- ment discussions in pediatric settings and offer to help physicians implement behavioral assessments and treatments. If these contacts result in a refer- ral, promptly sending data-based feedback on the effects of the ABA interventions to the referring pediatrician for inclusion in the patient’s medical chart not only mirrors standard practice between physicians in all domains of medicine; it is also likely to lead to more referrals. Additionally, the increasing demands by third-party payers for docu- mentation of treatment and its effects can make data-based feedback necessary for continued reim- bursement for costs accruing from needed ongoing treatment. This fact, coupled with the value ABA places on ongoing data collection, makes applied behavior analysts increasingly attractive as col- laborators in pediatric medicine. Applied behavior analysts could also become more involved in medi- cal professional organizations and thereby provide a community resource for questions pertaining to behavior. More systemically, incorporating the clinical phenomena referred to by hypothetical constructs like depression, anxiety, or tempera- ment into behavior-analytic theories, and making those phenomena the focus of ABA assessments and interventions, could advance the field and in- crease its acceptance (e.g., Friman, Hayes, & Wil- son, 1998; see also Friman, 2010). Lastly, and con- sistent with the primary purpose of this chapter, designing and testing treatments for problems that frequently present in pediatric settings contributes to the recognition of ABA as a resource and ac- ceptance of it by pediatricians as a valuable sci- ence (Riley & Freeman, 2019). Perhaps more than any other subspecialty in medicine, pediatrics is a pragmatic specialty, and effective and efficient treatments readily trump ideological differences. In conclusion, the large and mounting body of evidence documenting the many ways ABA has been found to influence behavior, coupled with the mutually determinative role played by behav- ior and physiology, suggests that a partnership be- tween applied behavior analysts and pediatricians would benefit the health of children in the United States. I have argued in this chapter that behav- ioral pediatrics is the ideal locus for this partner- ship. Behavioral Pediatrics 423 Costello, E. J., & Shugart, M. A. (1992). 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