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Behavioral Determinants of Health: Time for a New Basic Science?

Steven Merahn, MD FAAP

Abstract

Public health authorities attribute almost half of an individual’s quality of health to behavioral
determinants.1 However, outside of psychiatry, mainstream medicine does not have a true basic
science foundation upon which to rest a rational and integrated approach to understanding and
managing primary behavioral conditions, nor other health-related behaviors. Applied Behavior
Analysis has a 50-year history of disciplined research across a wide range of neuropsychological
conditions (such as Autism, or anxiety) and health-related behaviors (such as smoking, or
safety). Considering behavior analysis as a basic science akin to microbiology, biochemistry and
genetics could be a critical success factor in our capacity to achieve genuine behavioral health
integration in both our mental models for care and our clinical armamentarium.

Introduction

The growing prevalence of healthcare revenue models based on measures of quality and
outcomes has thrust the determinants of health beyond pharmacotherapies and surgery to the
forefront of consideration. Variously called ‘social’ or ‘non-medical’ determinants, their
influence is well-validated 2, although there is debate as to the extent to which the healthcare
community should be held responsible for their role in patient’s quality of health.3
However, among the social determinants of health, there is little debate as to the prominent
effect of behavioral conditions and health-related behaviors on health status. Behavioral
health has a history of being ‘carved out’ from traditional medical care, but with upwards of
40% of health status attributed to individual behavior (vs 10% of medical care),4 healthcare
providers and managed care systems are now working to acquire the capabilities to both
manage behavioral health conditions, and effectively and efficiently assess and modify health-
related behaviors among their patients and members.5

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Discussion

Efforts to integrate behavioral health into mainstream clinical operations fall into two
categories: managing neuropsychological conditions that have behavioral symptoms (such as
depression and anxiety), and crafting interventions to address behavior as a determinant of
health status in both those, and otherwise neurotypical, patients. Competencies in both areas
are increasingly core to the successful practice of medicine across the lifespan.

While the former remains largely managed with pharmacotherapy, there is increasing interest
in how social factors – housing, food insecurity -- effect health resource utilization and common
morbidities associated with mental health conditions. This has resulted in partnerships with
community agencies to add social services to the clinical armamentarium.6 Current approaches
to managing health-related behavioral determinants have focused on incorporating techniques
such as motivational interviewing, positive psychology, and cognitive-behavior therapies,7 and
tools such as the mobile apps, smart watches and other monitors.8 While all these efforts have
demonstrated directional progress, they do not provide a framework for an integrated model of
care.

However, there is a well-established and evidence-based framework for understanding and

managing behavior that can support efforts towards care delivery redesign to achieve
ambitious goals for both behavioral health and health-related behaviors: Applied Behavior
Analysis (ABA).

Despite over 50 years of research, ABA is not a common therapeutic modality in the medical
literature9; as some behavior analysts have noted: “Indeed, deciding where to publish studies
addressing physical health conditions can pose a significant challenge for applied behavior
analysts. To publish in the Journal of Applied Behavior Analysis (JABA), which values the
methodological and conceptual systems of behavior analysis but is not widely read by the

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medical community, is to risk being ignored by the very audience most interested in the
problems being studied”.10

Applied behavior analysis (ABA) is a scientific discipline that uses the principles of behavior and
learning theory to meaningfully effect positive and productive behavior change and
demonstrate that the procedures used were directly attributable to the new behavior.11 ABA is
not a single therapeutic approach, but disciplined framework of highly individualized
assessment and intervention strategies using continuous measurement, data-driven feedback
and procedure optimization. Behavior analysis relies on functional analysis and direct
observation of treatment effects and addresses both antecedents and reinforcers as well as
motivating operations or context of the behaviors being addressed.

ABA is sometimes criticized for a lack of large scale clinical trials, but we need to be careful not
to apply standards from pharmaceuticals to behavioral interventions, which better evaluated
based on single subject design,12 a model more aligned with the n-of-1 study model associated
with personalized medicine.13 Single subject designs can be pressure-tested with reversals to
and from baseline, multiple baselines and successive addition or removal of components of
treatment. The individual focus of single-subject trials permits true assessment of treatment
effect and identification of characteristics that may alter treatment progress and outcomes.
While there is a limited corpus of systematic large-scale replications of ABA studies, it is the
body of evidence in toto that signifies the rigor and conduct of ABA in clinical practice across a
wide range of conditions; this has been especially true for behavioral health.

One such body of widely accepted research relates to the success of ABA as evidence-based
treatment for disabilities associated with Autism Spectrum Disorder (ASD).14,15 The resultant
insurance reform in 46 states mandating access to ABA for children with ASD has created a
narrow perception of the indications for ABA.16 Nevertheless, the foundations of the discipline
of behavior analysis, and its applications, are much broader17, including, but not limited to, the
documented capacity to address primary behavioral health conditions (ADHD, anxiety,

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depression, obsessive-compulsive disorder, feeding, and eating disorders) well as severe

behavior topographies such as self-injurious behavior, aggression, and both inborn and
acquired brain disorders, such as Prader-Willi Syndrome, dementia, and traumatic brain injury.
There are additional bodies of evidence demonstrating the potential of ABA to support positive,
productive changes in health-related behaviors, including diet and nutrition, physical activity,
sleep, substance abuse, safety, and medication adherence, as well as behavioral management
of specific conditions such as asthma, high blood pressure, and diabetes. The principles of
behavior analysis can also be used to define pinpoint behavioral targets for therapeutic
intervention, and more accurately measure the effectiveness and associated outcomes, of
pharmacotherapies, surgery and rehabilitation services.

Conclusions
When we refer to therapeutic modalities that target behavior as ‘non-medical’, we only sustain
the conceptual body-mind duality that has fragmented our capacity to delivery truly integrated
care. The purview of medicine must be the whole person; limiting our modalities to molecular,
cellular and anatomic systems to the exclusion of a person’s experience, behavior, community
and society puts unnecessary restrictions on our capacity to positively influence their quality of
health.

The discipline of behavior analysis constitutes a ‘new’ basic science to serve as a foundation for
the development of a rational approach to behavioral examination, diagnostics and
therapeutics, just as germ theory was for the management of infectious disease. Partnering
with behavior analysts in the same way we partner with microbiologists, biochemists and
physiologists could be a critical success factor in our capacity to achieve the true value of
behavioral integration in the evolution of healthcare’s clinical operating model.
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Contact the author: Steven Merahn, MD smerahn@mac.com 917-689-8954
REFERENCES

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