1. Introduction to Pediatric Psychology Gregg Selke, Ph.D. November 14, 2006 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. Defining Features 1. Promotion of healthy behaviors 2. Prevention of problematic health effects (e.g., unhealthy lifestyles, behavioral patterns….overeating) Goal: Target behaviors early in life or early in the onset of a chronic medical condition

5. 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

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

7. 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 (e.g., noncompliance) – Bereavement (Death and Dying issues) – Reintegration into school after hospitalization

8. 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

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 – Feeding and Eating Disorders of Infancy or Early Childhood Pica, Rumination Disorder, Feeding Disorder of Infancy and Early Childhood

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. Diagnostic Criteria for 307.59 Feeding Disorder of Infancy or Early Childhood A. Feeding disturbance as manifested by persistent failure to eat adequately with significant failure to gain weight or significant loss of weight over at least 1 month. B. The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux). C. The disturbance is not better accounted for by another mental disorder (e.g., Rumination Disorder) or by lack of available food. D. The onset is before age 6 years.

15. 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

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. 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.

18. Case Examples 1. Adolescent who had nauseau, dizziness, and collapsing “spells” 2. The girl who refused to eat

19. Case Examples Role of Pediatric Psychologist – Systematic Assessment of Antecedents and Consequences (Reinforcement Contingencies – Determine effective/noneffective strategies of treatment team and family – Strategies: Contingent or differential social attention, shaping and fading procedures, positive reinforcement (verbal and tangible rewards) – Liaison between PT, OT, Speech, and family

20. Examples of Pediatric Psychologists on UF Clinic Teams Transplant Evaluations Diabetes Clinic Craniofacial Clinic

21. 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 – Contraindicating Factors?

22. 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

23. 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

24. 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

25. 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?

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

27. 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

28. Craniofacial Clinic Clinic for children with genetic craniofacial abnormalities – Cleft lip and/or palate – Craniosynostosis Premature fusion of the sutures of the skull – H emifacial microsomia Malformation of the jaw, cheek and ear associated with vertebral defects, with deformity of the external ear and abnormal smallness of that half of the face. Psychologist is a member of an interdisciplinary team including: – Physicians, general surgeons, plastic surgeons, dentists, oral surgeons, nurse, social worker, insurance representative, orthodontists

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

30. Recent 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

31. Current trends 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

32. 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

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