1. Introduction to Pediatric Psychology Laura Williams, M.S. November 15, 2005 PSY 4930

2. What is Pediatric Psychology? Concerned with physical health and illness of children and the relationship between psychological/behavioral factors and health, illness, and disease. “Pediatric Psychology” first coined in 1967 by Logan Wright, “dealing primarily with children in a medical setting which is nonpsychiatric in nature” (p. 323)

3. Roots of Pediatric Psychology

4. Clinical Activities: Settings Inpatient medical units – Consultation/liaison services – Medical units such as hem/onc, burn, PICU Medical outpatient clinics – Private pediatric practices – Clinics such as craniofacial, endocrinology Outpatient psychology clinics

5. Clinical Activities: Settings Specialty clinics – Physical rehabilitation centers, Child study centers Camps or groups – Camps for children with chronic illness

6. Types of Issues Problems related to pediatric conditions – Adjustment to disease – Adherence – Coping with procedural pain Mental health problems arising in medical units – Behavior problems while hospitalized – Bereavement – Reintegration into school after hospitalization

7. Types of Issues General mental health concerns Programs for health promotion and early intervention – Programs to increase physical activity – Early intervention with high-risk infants Mental retardation and developmental disabilities – Assess, train, and educate parents and professionals Education/consultation for physicians Public health and public policy

8. Peds Psych Cases Example One: The boy who couldn’t stop crying Example Two: The girl who was starving herself Example Three: The case of Renal Rickets and Mom’s Jell-O Example Four: Oppositional behavior on the Bone Marrow Unit

9. It Looks Physical, But is it? The pediatric psychologist is often called on by physicians to determine whether psychological factors are contributing to or causing a child problems DSM-IV diagnostic categories of: – Somatization Disorders – Conversion Disorders – Psychological Factors Affecting Medical Condition

10. Somatization Disorder History of many physical complaints that occur over a period of years and result in treatment being sought or significant impairment in functioning. Following symptoms have been displayed – Four pain symptoms – Two GI symptoms – One sexual symptom – One psuedoneurological symptom Symptoms cannot be fully explained by known medical condition or substance use. If medical condition is present, symptoms are beyond that expected for condition.

11. Conversion Disorder One or more symptoms or deficits affecting voluntary, motor or sensory functions that suggest a neurological or other general medical condition (and causes distress or impairment). Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptoms or deficit is preceded by conflicts or other stressors. Symptom not fully explained by a general medical condition or substance or culture.

12. Psychological Factor Affecting Medical Condition A general medical condition is present. Psychological factors adversely affect the medical condition in one of the following ways: – The factors have influenced the course of the medical condition - as shown by a close temporal relationship between psychological factors and the development or exacerbation, or delayed recovery from the condition.

13. Psychological Factors Affecting Medical Condition – The factors interfere with the treatment of medical condition – The factors cause additional health risks – Stress-related physiological responses precipitate or exacerbate symptoms of the general medical condition – Example: Depression and diabetes Needle phobia and diabetes

14. Considerations in Psychological/Medical Links With some medical disorders it is difficult to assess and find the real cause of the symptoms you are being consulted about. The fact that psychological factors are found to exist does not necessarily mean that they are causally related to an existing medical symptoms There is a difference between correlation and causation

15. Things to Look For Do psychologically relevant factors (eg., trauma, stress, life disruptions, etc.) precede onset. Do these factors exacerbate “medical” symptoms. Is it possible to find evidence for secondary gain resulting from the “medical symptom” or “disorder”. Be cautions of “as yet undiagnosed” medical conditions that may really account for symptoms. Cases referred for evaluation often turn out to have some sort of physical problem. The Case of Dr. X’s Patient

16. Psych Problems Due to Medical Conditions Depression, anxiety or other psychological issues can result from dealing with chronic illnesses or stressful medical conditions – coping with disorders such as cancer, cystic fibrosis, craniofacial disorders – having to undergo painful treatments such as burn patients These child may often benefit from therapy Parents of these children may also need help in coping with these types of conditions in their children

17. Examples of Peds Psych. Practice Transplant Evaluations Diabetes Clinic Craniofacial Clinic

18. Transplantation Evaluations Pediatric psychologists work with children being considered for transplantation – bone marrow transplants, heart transplants, lung transplants, kidney transplants Determining whether the child/family is a good candidate for a transplant – Assessment of medical and psychosocial issues that contribute to the overall decision making process

19. Issues to Consider in Pre- Transplant Evaluation Presence of major psychological issues in child or parent that could compromise maintenance of the transplant Knowledge of what is involved in the transplant process Motivation for transplantation Barriers to adherence—past behavior best predicts future behavior Stress and coping Social support Example of Issues: – 5 Year Old (bone marrow)

20. Pediatric Endocrinology Clinic Outpatient tertiary care clinic Psychologist serves as a consultant in a multidisciplinary team – Pediatric endocrinologist – Nurses, nurse practitioners – Diabetes educators – Nutritionists – Residents, fellows

21. Pediatric Endocrinology Clinic Most patients have type 1 diabetes (but also type 2 and other endocrine disorders) Physician refers patients for: – Adjustment difficulties – Poor functioning (academic, behavioral, family, emotional) – Poor adherence/diabetes control

22. Pediatric Endocrinology Clinic Psychologist conducts brief assessments (15-30 minutes) and provides feedback to the family and physician Family feedback – Referrals – Behavioral recommendations – Problem solving Physician feedback – Referrals – Prognosis – Treatment regimen change?

23. Peds Endo Consult Information collected about: – Diabetes care – Emotional functioning – Academic functioning – Behavioral functioning – Social functioning

24. Pediatric Endocrinology Consult: Typical Issues Poor adherence – Inappropriate level of responsibility for child – Overbearing parent – Arguing about the diabetes regimen – Poor understanding of diabetes regimen – Stressors/life events impact adherence Emotional, Academic, Social, Behavioral functioning – Poor functioning related to diabetes care or other issues

25. Craniofacial Clinic Clinic for children with genetic craniofacial abnormalities – Cleft lip and/or palate, craniosynostosis, hemifacial microsomia Psychologist is a member of an interdisciplinary team including: – Physicians, general surgeons, plastic surgeons, dentists, oral surgeons, nurse, social worker, insurance representative, orthodontists

26. Craniofacial Clinic Psychologist conducts a brief assessment of every patient Issues assessed: – Medical issues – Social functioning – Development – Academic, psychological, and behavioral functioning

27. Major Developments in Pediatric Psychology APA Division Status – 2001: The Society of Pediatric Psychology became Division 54 in APA – http://apa.org/divisions/div54/ http://apa.org/divisions/div54/ – Differentiated from clinical child, clinical, and health psychology – Made the field more recognized and viable – Led to collaborations with the American Academy of Pediatrics

28. Major Developments Managed Care and Reimbursement – Has negatively affected delivery of services – Many peds psych services are not covered by insurance: Pain management Interventions to increase adherence Work on multidisciplinary teams

29. Response to Managed Care Medical Cost Offset Research – “The cost of pediatric psychology services would be ‘offset’ by savings in medical expedenditures” (Roberts, Mitchell, & McNeal, 2003, p. 14) This research is somewhat controversial

30. Major Developments Primary Care – Pediatric psychologists are moving away from university-based hospitals – Focusing more on primary care intervention and prevention activities

31. Major Developments Empirically supported treatments – Disciplines of medicine and psychology are placing more emphasis on ESTs – Journal of Pediatric Psychology EST reviews: Regimen adherence Nocturnal enuresis Feeding problems Pain

32. EST criteria Reports detailed info about participants Randomized or single-case design Detailed description of treatment approach (usually with a treatment manual) Replication by independent researchers Goal: the determine the most effective treatment for specific mental disorders

33. Child Health Conference 2006 http://www.childhealthpsychology.com/... provides a national forum for sharing current research findings in the area of Child Health/Pediatric Psychology. Additional objectives include facilitating advances in clinical practice and in the training of Pediatric Psychologists. The conference is designed for psychologists, physicians, nurses, physical therapists, occupational therapists, social workers, and other professionals involved in children's health care.