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ISSN: 2375-4273
Health Care : Current Reviews
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Emotional/Educational, Behavioral & Developmental [EBD] Problems in Children - Nursing Opportunities

Anjan Bhattacharya*

Department of Paediatrics, Apollo Gleneagles Hospital, Kolkata, India

Corresponding Author:
Anjan Bhattacharya
Department of Paediatrics
Apollo Gleneagles Hospital
Kolkata, India
Tel: 9874797726
E-mail: [email protected]

Received date: June 26, 2014; Accepted date: June 06, 2015; Published date: June 15, 2015

Citation: Bhattacharya A (2015) Emotional/Educational, Behavioral & Developmental [EBD] Problems in Children - Nursing Opportunities. Health Care Current Reviews 3:132. doi:10.4172/2375-4273.1000132

Copyright: © 2015 Bhattacharya A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Biopsychosocial Model of multifactorial causation of diseases are increasingly understood by the care providers for children (Figure 1 adopted from Nelsons Textbook of Pediatrics [1,2] below).


Figure 1: Physically manifested disease.

Global burden of Emotional/Educational, Behavioral and Developmental [EBD] problems are said to be in the order of 1 in 4 to 1 in 5 children (prevalence rate) [3].

75% of all such children present in Primary Care Setting and accounts for 50% of all Pediatric consultations. Despite being in the privileged gatekeeping position, Primary Care Physicians were found to be only less than 20% efficient in identifying such problems [3].

Opportunity must be similarly missed by other healthcare providers both in the community setting as well as hospital in-patients and outpatient departments.

Neuro-developmental problems like Autism, ADHD (Attention Deficit Hyperactivity Disorder), DCD (Developmental Coordination Disorders), Dyslexia and Emotional and Psychosocial Disorders like Low Mood, Low Self Esteem, Frozen Watchfulness, Inappropriate Affect need to be spotted and reported early (Early Detection) and addressed expertly promptly (Early Intervention) as we know that delay leads to downward spiral with lasting morbidity through adolescence and adulthood [3].

We know that the School Nurses are better at such a role [4]. But there are disheartening reports on identification and effective prevention for conditions like obesity despite of their involvements [5].

Missed opportunities of reporting EBD concerns must be one of the important determinants of such morbidity. Opportunities may be missed due to –

• Lack of awareness of their existence

• Inadequate learning to aid spotting them

• Inter-observer variations, bias, prejudices

• Brushing off subtle concerns as “may be, I am being silly”

• Lack of trained supervision and vetting skills in health professionals

• Acknowledging that this is a concern and yet not knowing how to go about it

There is enough science for all healthcare providers to take up leadership role in their day to day practices to try to halt the menacing march of these ballooning biopsychosocial problems, should there be clear cut guidelines to act for them.

Planners and Policy Makers have the daunting task of balancing the act of rationing healthcare [6] vis a vis address public health hazards.

Notwithstanding their dilemma, the cost-effectiveness [7] must be justifiable, when measured not only in the terms of an individual but also in cost reduction through family’s health and lost work, if not that of the society at large in the long run.

Hence, Early “Red Flag” Signs must be identified and acted up on. Nurses in all walks of their profession, are in similar privileged role of a “gatekeeper” to pick up ‘subclinical’ and ‘sub threshold’ early features and help them nip it in the bud. The basic issues to remember are as follows:

Try to follow standardized and validated Screening Tools wherever possible (see below: a combination of Pediatric Symptom Checklist of Bright Futures (PSC) and M-CHAT of Diana Robins has the potential to be user friendly and good yield in healthcare set ups) (Figure 2a and 2b).


Figure 2a: The proposed combined Screening Tool of PSC and M-CHAT.


Figure 2b: The proposed combined Screening Tool of PSC and M-CHAT.

• ‘Breaking News’ skills [8-10] must be mandatory skill development for all healthcare professionals. I propose OSCE styled competency based learning modules for all healthcare professionals worldwide

• Avoid ‘Anticipatory Decision Regret’ [11] in care givers through such skill development

• Prompt (same day) referral to Child Development Centre or Early Start Centre [IDEA in the States]

Developmental Pediatricians are appropriate resources to Care Coordinate EBD problems, including prompting a CAMHS (Child and Adolescent Mental Health Services) referral. Care Coordination involving Health, Education and Social Services is an expert domain of a Developmental Pediatrician. Child Development Centers are Resourced Centers for these problems. At the community level a multitude of Early Start Centre under expert professional contribution with overall overview of the Child Development Centre of the catering locality can help prevent snow balling of this health and social menace to the monster that it purports to be.

Care Pathway

A Universal Care Pathway for “Red Flag” Sub-syndromic and Subthreshhold [12] signs and symptoms of Pediatric EBD problems is proposed as follows:

1. Healthcare professionals receiving training in “Red Flag” signs

2. Suspects or observes any “Red Flag” signs in healthcare setting or community

3. Approaches the accompanying adult and establishes identity and carer responsibility, introducing oneself in a competent and professional ease

4. Applies “Breaking News” principles to broach upon the subject without provoking alarm

5. Competently achieves permission for appropriate referral; alternatively hands over information leaflet (which needs to be universally designed that says about why a healthcare professional might approach carer in such a manner and what they are supposed to do once they have “thought about it”, informing them that soon somebody will make a follow up call in a week or two) for parents/carers to ponder about

6. A system of follow-up call is in-built (ideally the same professional, if possible)

7. A failure to take up three such reminders should qualify for a Social Service referral under, perhaps ‘unintentional neglect’!

8. Finally, the child is provided appropriate Early Intervention, nipping the ugly and hydra headed monster of downward spiral of such ‘missed opportunity’ through proactive and decisive prevention

9. Planners and Policy makers to ensure that such easy but robust preventative tool is put in place

10. Save ‘Social Capital’ before it sours off!

Such Universal Care Pathway for Preventing “Missed Opportunities” for Early Detection and Early Intervention is now long overdue!


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