Maria: stubborn, willful, and always full of energy.

CASE “Maria is stubborn, willful and always full of energy. For the past 2 months, I [haven’t been able to] leave her for a moment without her grabbing me and crying. She refuses to sit on the potty seat. Yesterday, she threw herself on the floor, yelling and kicking after I suggested she use the potty seat. Tantrums occur every day—sometimes in response to a simple request.” Maria’s mother offered this vivid description of her child’s behavior at a 2-year health supervision visit in response to the pediatrician’s question, “Tell me how Maria has been recently.” Maria had been followed since birth by her pediatrician. Maria was born to a single mother who works part-time and is enrolled in two college courses, and the gestation and perinatal periods were uncomplicated. A review of the medical record reveals that she was an especially active infant, experienced mild to moderate colicky behavior in the first 3 months, and achieved all of her motor, language, and social milestones at appropriate times. After it was established that the frequent tantrums, clinging behaviors, and “stubbornness” had escalated considerably during the past 2 months, the medical history was directed toward any recent changes in the family, caretakers, or living situation. The combination of job and school had been a major focus of her mother’s life for the past year. Recently, school work was more demanding and, after a change in supervisors, her work in a clothing store was less satisfying. Finances were marginal, but she was making ends meet with medical assistance from Medicaid and with discounted child care at her college. Maria’s mother had always been a single parent, and her pediatrician was impressed with this mother’s resiliency, flexibility, and ability to continue her education while raising a young child. Sitting in her mother’s lap throughout the visit, Maria played with a toy, snuggling close to her mother. She refused both eye contact and a play interaction with the pediatrician. (Her mother stated that this behavior was a typical response to people who Maria was not familiar with.) Verbal interchange was unsuccessful although it was noted that Maria responded to her mother’s requests. Growth measurement, physical examination, and a screening developmental assessment were normal. Dr. Martin T. Stein The recognition, interpretation, and management of common behavioral problems in children and adolescents have developed into an important component of primary care pediatrics. Textbooks, review articles, and parenting guides are plentiful and available to pediatricians. However, the challenge for the active pediatric clinician with a characteristically busy practice is to discover strategies that address biological and psychosocial issues and problems within a time frame adaptable to contemporary medical practice. Even before the recent dramatic changes brought about by managed care, general pediatric practice was fast-paced. All too often, the agenda for office visits is limited to the chief complaint; health supervision visits are notably packed with a long list of “things-to-do.” As health care services to children become more efficiencyand outcome-sensitive, the challenge to create new models and strategies for effective delivery of services must be met. Child and adolescent development behaviors are especially vulnerable to current political and economic changes in health care delivery. The following case study, a description of a mother’s concern about specific behaviors in her 2-year-old daughter, illustrates the knowledge base, openness to discovery, and use of historical information that are outgrowths of continuity of care and a mature pediatric clinician. How many pediatricians hesitate to ask an openended question, such as, “Tell me how Maria has been recently,” for fear that the answer will prolong the visit, redirect the clinician’s agenda, or raise issues for which immediate solutions are not forthcoming? How can we guide primary care pediatricians so that this kind of discovery is encouraged and begin the diagnostic and therapeutic process in a limited time frame? For the specialist in behavioral pediatrics, the case of Maria raises similar and contrasting questions. Managed care medical practice has put time limits on the diagnostic interview and length of therapy. As the medical field becomes more organized into “care units,” how can the behavioral specialist work effectively with primary care clinicians to (1) screen for behavioral problems routinely, (2) address those problems in a step-wise fashion that respects practice limitations, and (3) discover new strategies for collaborative work among generalists and specialists who care for the same group of patients? Subspecialty pediatricians who treat patients with asthma and neonatal jaundice have developed guidelines that address these questions. Specialists who treat adults with a variety of chronic illnesses in a managed care environment have developed elaborate al* Originally published in J Dev Behav Pediatr. 1996;17(4) PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Academy of Pediatrics and Lippincott Williams & Wilkins.