TABLE 1

Overall Goals for Developmental-Behavioral Promotion Across Well Visits

• Preventing, detecting, and intervening with developmental delays
 Many developmental deficits, subsequent school failure, and concomitant behavior problems arise in families with psychosocial risk factors. Risk factors include parents with less than a high school education; who are single and lack social support; who are impoverished; who have housing, food, and employment instability; who do not speak English well; who have mental health problems including depression; and, most especially, who have parenting styles that fail to build skills needed for school success.69 So, a critical goal in preventing problems is to teach resilience, meaning positive parent-child interactions that promote development (eg, encouraging parents to talk about children’s interests, share books, and engage infants in vocal play).1013
 Providers should: identify and intervene with psychosocial risk factors; explain the value of language stimulation; show parents various ways to verbalize with their young children; monitor parents’ response to suggestions and children’s developmental-behavioral status; refer to more intensive parent-training and other social services if parents are unable to benefit from in-office advice; assess and intervene with parental depression; and ensure that children are promptly enrolled in early intervention when delays are found.9,1416
• Preventing behavior problems and injuries
 Various committees of the American Academy of Pediatrics advise providers to use well-child care as a platform for averting conduct problems and thus accidental injuries. During well visits clinicians should offer anticipatory guidance (eg, explaining that emerging motor skills can increase risk of injury such as when infants learn to crawl, hidden choking hazards may be discovered under furniture). Providers should also teach preventive disciplinary techniques to assist children in acquiring behavioral self-control (eg, bedtime hassles can be prevented by putting infants to bed while still awake to promote independent sleeping skills).1719
• Demystifying/reframing behavior challenges and teaching appropriate disciplinary techniques
  Because behavioral issues are a particularly common complaint, parents almost always need guidance on this issue (eg, learning that “disobedience” is often a healthy striving for autonomy and that children are social creatures who seek attention in almost any manner offered). Clinicians should help parents focus on positive behaviors, that is, “time-in” in which children are praised for complying, and to use “time-out” less often than time-in.17,18 Parents may not realize that punishment is rarely effective and simply “drives problem behavior underground.” Discipline, in contrast, teaches children better ways to behave.1719
 The contingent use of praise for prosocial behavior increases the occurrence of desirable conduct. The use of severe or loud reprimands dramatically actually increases disruptive behavior.17,18 Developmentally, this makes sense because children are pre–abstract thinkers: they do not process words quickly, readily generalize to new situations, and lack the skills in planning and foresight required to change future behavior. Even compliant children typically require 6–9 seconds to understand instructions and act on them, but are often peppered with the same instructions without sufficient time to obey.1720 Too often, parents give commands that are actually choices. A question such as “Can you pick up your toys please?” does not convey what is meant, that is, “It is time to pick up your toys now.”
 Providers should help parents understand that developmental status affects behavioral self-control. Acting out is often caused by difficulties with self-expression, whether children’s language skills are age-appropriate but inherently limited, or because of age-inappropriate deficits in understanding and talking. An intervention example is having parents model short phrases so that children learn to use words instead of tantrums to express feelings and needs.711,1720
 Before embarking on developmental-behavioral interventions, it is absolutely imperative to make sure children are healthy, hear and see well, and that untreated developmental deficits are not contributors to acting out (the most common parental complaint). Many noncompliant children are those who cannot hear their parents’ requests; do not understand what is being said to them; lack the motor, memory, or attentional skills to execute commands; or who are frustrated by difficulties communicating. Health/sensory plus broadband developmental-behavioral screening should be a first step in deciding on types of needed interventions.