PrefaceMany years ago, when symptoms of most psychological disorders were justb eginning to be identified, the prevailing belief was that these symptoms were theresult of deeply embedded psychogenic conflicts that required psychoanalysis towork through. Over the past five decades, however, a plethora of research revealedthat many individuals with these disorders exhibit structural and functional differ-ences in their brains. Since brain changes are likely to be reflected in feelings andbehaviors, psychopharmacological approaches were developed to try to addresssome of the biological factors that may be responsible, at least in part, for the symp-toms. Indeed, many of these have proven effective in reducing (and, sometimes,eliminating) the symptoms of some psychological disorders, and intervening phar-macologically may be beneficial (and in some cases is indispensable) since withoutmedications some symptoms (for example, psychosis) are not likely to resolve. When treating disorders with known biological etiology, many nonmedicalm ental health professionals seek to minimize pharmacological approaches andinitially try psychosocial treatment. This is a reasonable approach, especially withchildren. However, many factors may contribute to the decision to utilize pharma-cological approaches, in conjunction with or instead of psychotherapy.The Use of Medications to Treat Mental Health DisordersSeverity of the symptoms often influences the decision of whether or not treatmentwith medications is needed. For example, milder forms of depression, impulsivity,anxiety, or agitation may respond well to psychotherapy. However, severe variantsof these symptoms may be difficult to treat with talk therapies, and intense symp-toms are likely to require psychopharmacological treatment. For example, it maybe very difficult to communicate with a severely depressed or agitated patient, anda severely anxious patient may have difficulties coming in for psychotherapy. Thus,most clinicians find that symptoms that are very impairing usually require anapproach that includes pharmacological treatment. When psychotherapy is effective, progression of improvement is gradual andrequires several sessions to become evident. Even those variants that are called v
vi Preface“brief therapy” generally require 8–15 sessions before significant improvement isexpected. When the patient is very uncomfortable, and when the symptoms debilitatethe patient and significantly interfere with normal functioning, waiting this long forimprovement may not be prudent. Conversely, many pharmacological treatmentsproduce at least some improvement within days of the onset of treatment, althougha few weeks (in some cases, 4–6) may be needed for more comprehensive response.Still, this is usually faster than psychotherapy, and the amount of improvement seenwith medications may be greater than the improvement seen with psychotherapyover the same period of time. In order for psychotherapy to be effective, patients need to attend sessions regu-larly. If rapid progress is needed, sessions need to be scheduled at least weekly.However, driving to the therapist’s office once per week, and spending an hour inthe office, may be difficult for some patients (or families) with significant timeobligations. When the patient is a child or adolescent, psychotherapy must be doneoutside of school hours, since missing school 1 day/week to attend psychotherapyis neither practical for the family nor beneficial to the student. The cost of weekly psychotherapy is also likely to constitute a significantexpense for many families, and few are able to cover such costs out of pocket.In the United States, most children and adolescents who have healthcare coverageare covered by private plans, usually purchased through the parent’s employer.The quality of this coverage varies widely. Unfortunately, mental health care isoften considered to be the “step-child” of the healthcare industry, and levels ofcoverage for mental health treatment are often much lower than they are for medicalcare. Although laws on the federal and state levels have been passed to close thatgap, many exclusions exist and the disparity between medical and mental healthcoverage continues. Limiting the patient’s access to care is one common method of containinghealthcare costs. Many individuals with managed healthcare coverage have benefitsthat primarily are evident “on paper” and virtually disappear when the insuredseeks treatment. Gatekeepers are assigned who review the need for care, and thesereviews delay sessions and interrupt the continuity of care. Usually, four to sixsessions may initially be authorized, and additional reviews are needed for eachsubsequent block. It is up to the discretion of the gatekeeper to authorize furthertreatment, and when the gatekeeper feels that sufficient progress was attained, orthat sufficient progress is not evident, further authorization may not be issued.Although every insurer has appeals procedures that may be utilized, these appealsare internal to the insurer, and usually no external review exists that may be invokedif the insurer continues to refuse to authorize care. To make matters worse, appealsoften take months, and meanwhile, the patient is getting no care. In addition, millions of children and adolescents in the US have no healthcarecoverage. While federal and state authorities are striving to close this gap, therecontinues to be a significant portion of our society that cannot afford mental healthcare and has no insurance coverage. Various agencies exist that may service theseindividuals, including networks of community mental health centers (CMHCs) thatprovide care to those who need it, sometimes without (or with minimal) cost.
Preface viiHowever, in many states, CMHCs are overextended and long wait times aren ecessary (in some cases, up to 8 weeks) before the agency is able to provide care.Meanwhile, patients are suffering and are receiving no treatment. In addition, inrural states, the nearest CMHC may be quite a distance away. For all of the reasons reviewed above, patients and/or their families may needto utilize psychopharmacological treatment either instead of, or in addition to,psychosocial interventions.Availability of Medical Mental Health ProfessionalsWhen the decision is made that a patient needs to be treated with medications,patients must have access to necessary medical care to obtain the prescription.Traditionally, psychiatrists have been considered as the providers of choice todispense prescriptions for psychotropic medications. However, this is changingrapidly, especially in the US, where 96% of counties do not have enough psychia-trists (or related mental health prescribers) to meet the needs in the community(Thomas, Ellis, Konrad, Holzer, & Morrissey, 2009). This shortage of psychiatristsis worsening, since the number of physicians pursuing a residency in psychiatrycontinues to decline (Rao, 2003). This is especially evident in the treatment ofchildren and adolescents. According to the US Bureau of Health ProfessionsNational Center for Health Work Force Information and Analysis, at least 12,500pediatric psychiatrists are currently needed to match the level of service providedin 1995, but only 8,300 are available (Kim, 2003). Others have suggested that theshortage may be even greater (Brauer, 2010). In addition, most mental health problems initially come to the attention of thegeneral physician which, for children and adolescents, is the pediatrician.Pediatricians encounter a wide variety of medical problems and must make a deci-sion about which will be treated “in-house” and which will be referred to specialists.At one time, patients needing psychiatric mental health care were immediatelyreferred to psychiatrists. However, this is changing and pediatricians now often findit necessary to treat many mental health disorders in their offices.Pediatricians as Provides of Mental Health CareMany factors influence the pediatrician’s decision to eschew a referral to a psychiatristand treat a mental health problem within the pediatrician’s office. For one, managedhealthcare plans severely curtail the primary physician’s referrals to specialists,thus forcing a shift of mental health care onto primary care physicians. Since familydoctors must weigh whether to use up a precious referral to address psychologicalsymptoms (like ADHD or depression) or a potentially life-threatening medicaldisorder (like a heart problem), most physicians opt to address many sychological pproblems in-house.
viii Preface This trend is especially evident among pediatricians (Koppelman, 2004), whoface additional pressures because of the shortage of pediatric psychiatrists. Thus,referring patients to pediatric psychiatrists does not necessarily lead to the deliveryof needed mental health services because psychiatrists often refuse new patientsand require several months’ wait time for the initial appointment. Not surprisingly,it is evident that most psychotropic medications are now prescribed to children bytheir pediatricians (Olfson, Marcus, Weissman, & Jensen, 2002). Although highly knowledgeable about medicine and medications in general,most physicians complete only 6 weeks of exposure to psychiatry during medicaltraining (Serby, Schmeidler, & Smith, 2002) and receive no further required trainingin psychiatry during pediatric residency (Kersten, Randis, & Giardino, 2003).Thus, pediatricians are caught in a double bind – they are compelled to treat mentalhealth disorders “in house,” but they lack the training (and the time) to deliver thistreatment competently and comfortably.Psychology and PsychopharmacologyPsychology has recognized this shortage of mental health prescribers for some threedecades, when a task force report to the American Psychological Association (APA)Board of Professional Affairs proposed that psychologists should become moreinvolved in the provision of physical and biological interventions for mental disorders(APA Board of Professional Affairs, 1981). By 1989, the APA Board of ProfessionalAffairs endorsed advanced training in psychopharmacology for psychologists. As psychologists began to show more interest in being involved in psychophar-macological treatment, it became important to determine what role was appropriatefor pharmacologically trained psychologists to take. Eventually, APA came torecognize three levels of psychopharmacology training for psychologists. Level 1 refers to the amount of training that all psychologists involved in healthcare should receive. Because psychotropic medications are increasingly prescribed topatients seen by all psychologists, all psychologists should have at least a rudimentaryunderstanding of psychotropic medications and their desired and adverse effects. Level 2 denotes a level of training that prepares psychologists for active collabo-ration with primary care physicians (for example, pediatricians) about treatmentwith medications. This level of training allows psychologists to gain enough knowledgeabout psychotropic medications to participate in the decision making (for example,selection of medications and monitoring of response and side effects). Psychologistswho complete this level of training are prepared to consult with pediatricians aboutthe use of medications to treat their patients. Level 3 describes training that prepares psychologists for the independentauthority to prescribe psychotropic medications, and efforts have continued to passlegislation allowing psychologists with Level 3 training to prescribe. In 1999, theUS Territory of Guam approved prescriptive authority to appropriately trainedp sychologists (Guam Public Law 24-329), and in 2002, the state of New Mexicoenacted prescriptive authority for psychologists (New Mexico Administrative Code
Preface ix16.22.20-16.22.29), followed in 2004 by Louisiana (Louisiana Revised Statutes37:1360.51-1360.72). The fight for prescriptive authority continues in many otherstates, although opposition from psychiatry is fierce and thus far many other legis-lative efforts have been defeated. Despite legislative struggles, to date some 1,500 psychologists have completedpostdoctoral training in psychopharmacology (Ax, Fagan, & Resnick, 2009), and itis expected that many of them have significant expertise in working with childrenand adolescents. Thus, even in states where psychologists do not prescribe, phar-macologically trained psychologists are available to consult with pediatricians andcan play an important role in addressing the shortage of appropriate medicationmanagement for pediatric patients.Pediatrician/Psychologist CollaborationBecause of their busy schedules, pediatricians spend a limited amount of time witheach patient and cannot perform in-depth reviews of personal, family, developmental,health, and social history necessary for proper diagnosis of most psychologicaldisorders. Conversely, psychologists are specifically trained in the diagnosis andtreatment of mental disorders and traditionally see patients for 1-h appointments,usually weekly or biweekly. Thus, pediatricians can benefit from collaborativerelationships with clinical child psychologists. After accurate diagnosis, treatment options must be considered. Often, the ques-tion of whether or not to use medications must first be considered. Where psycho-logical treatment is likely to be effective and the use of medications is notnecessarily indicated, psychologists can make such a recommendation to the pedia-trician and the patient’s family. If the family is receptive to this recommendation,the psychologist then may be able to deliver this treatment. When this option isutilized, the psychologist needs to provide the pediatrician with periodic updatesabout the patient’s progress. When a decision is made to treat a patient with medications, pediatricians whohave developed an active collaborative relationship with a pharmacologicallytrained psychologist may choose to write the prescriptions, especially when thedisorder is one with which they have some familiarity and the level of severity doesnot appear unusually high. When medications are used, the patients’ progress andside effects must be monitored. Many pediatricians, however, may not be conversantwith dose–response profiles and side effects of psychotropics. In addition, pediatri-cians may not be able to see their patients frequently enough, and long enoughduring each visit, to accurately screen these issues. Psychologists with pharmaco-logical training can perform medication monitoring and track the patient’s progressand adverse effects. When medication changes are warranted, sychologists with pRxP training can have input into the nature of the adjustments. In providing thisservice, psychologists can offer relief to busy pediatricians who, instead of spendingoffice visits troubleshooting psychotropic medications, will be able to devote theseappointment times to the care of patients with medical problems. In this way,
x Prefacee fficiency of the use of the pediatricians’ time is greatly improved. Consequently,clinical child psychologists with extensive, formal training in psychopharmacologycan be an invaluable resource to pediatricians.Definition of TermsAs psychology continues to expand its scope into the area of psychopharmacology,it is necessary to differentiate those psychologists who completed Level 2 or 3 trainingin psychopharmacology from other practicing psychologists. Two competing termsare now in use. In New Mexico, psychologists with authority to prescribe medica-tions are referred to as “prescribing psychologists.” In Louisiana, however, psycholo-gists with authority to prescribe are referred to as “medical psychologists.” While some may dismiss these differences as a matter of semantics, both termshave their proponents and critics. The term “medical psychologist” has sometimesbeen used by health psychologists who treat medical (not mental health) disorders(for example, diabetes). Thus, some argue that the use of “medical psychologist” asdescribed in Louisiana legislation is confusing because the terms have been used bynonpharmacologically trained health psychologists. Conversely, proponents of theterm argue that it is more descriptive of the depth and breadth of medical trainingthat must be completed in order to obtain prescriptive authority, and that prescribinga medication is a medical service. While this dispute is far from over, both terms are used throughout this volume.It is important for the reader to remember that for the purposes of this book, theterms “pharmacologically trained,” “medical,” and “RxP-trained” psychologist areused interchangeably and refer to the same level of training (at least Level 2). It is also important for readers to remember that this book primarily focuses oncollaborating with pediatricians. Since the vast majority of the US has not yetenacted prescriptive authority for psychologists, the book aims to help psycholo-gists with Level 2 or Level 3 training develop collaborative relationships withpediatricians practicing in a state that does not allow psychologists to prescribemedications. Of course, the contents of this book are also applicable to statesthat have enacted prescriptive authority for psychologists (RxP), and in thosestates, psychologists consulting with pediatricians will be able to take on a moreautonomous role.Organization of This VolumeThis book is organized into four sections. Part I summarizes the basic principlesand professional issues involved in collaborative relationships with pediatricians.Muse, Brown, and Cothran-Ross describe a model that helps readers conceptualizewhen patients are usually treated by pediatricians in-house or referred to outside
Preface xiprofessionals. The algorithm developed by the authors can help both medical andpsychological professionals make this important decision. In the next chapter,McGrath outlines the history of the RxP movement and its applicability to the pedi-atric patient population. McGrath outlines important professional, ethical, and legalissues that should be reviewed by all who aspire to venture into this practice area. Part II reviews the various practice settings where pediatricians and pharmaco-logically trained psychologists are likely to collaborate. Kozak and Kozak Millerdiscuss collaboration that takes place between pediatricians and RxP-trainedpsychologists in states that have not enacted prescriptive authority for psychologists.Since this encompasses the vast majority of the US, the information provided in thischapter is likely to be highly relevant to most readers. To balance the contents,Nemeth, Franz, Kruger, and Schexnayder discuss collaboration in an RxP state,primarily based on their experiences while practicing in Louisiana. Readers cancompare these two chapters to contrast methods of collaboration in non-RxP vs.an RxP state. Part II also includes chapters that review specific situations that affect collabora-tive relationships. Alford describes methods of collaboration in rural settings,outlining the unique challenges that these locations pose to professionals and patientsalike. Tilus and colleagues describe emerging efforts to meet the mental healthneeds of the American Indian population, and how RxP training allows psycholo-gists to make a meaningful contribution within portions of the country that experi-ence especially difficult conditions. Finally, Courtney describes his account of apractice within a medical children’s hospital in a state that permits prescriptiveauthority for psychologists. Part III reviews specific disorder categories that are excellent candidates forcollaborative care. Kapalka reviews the treatment of disruptive and mood disorders,Evers discusses the treatment of anxiety disorders, and Sanzone reviews the treat-ment of eating disorders. Collectively, these constitute the vast majority of disor-ders for which children and adolescents receive psychological care, and many ofthese patients are treated with medications, usually prescribed by pediatricians.Psychologists working with children are likely to find much relevant informationwithin these three chapters. Part III also contains chapters that focus on collaborative treatment of medicaldisorders. Kotkin discusses the treatment of diabetes, a common medical disorderthat often presents significant psychological complications. The section is roundedout by Clendaniel, Hymanand, and Courtney who discuss collaborative treatmentof gastrointestinal disorders in children and adolescents. Collectively, Part III ofthis volume covers many disorders that psychologists are likely to encounter intheir practice. Part IV outlines the future directions of pharmacological consultations andcollaboration with pediatricians. Alvarez discusses the use of brain markers to assistin diagnosis and treatment planning, an emerging area that offers exciting opportu-nities for greater precision in developing treatments to address individual needs ofthe patients. Chapters by Raggi and Olivier review important training aspects,pre- and postdoctoral, to make sure that psychologists who wish to expand into the area
xii Prefaceof psychopharmacology attain a solid base of knowledge during their professionaldevelopment. The volume concludes with a chapter by Lopez-Williams whod iscusses ways in which pharmacological training informs the practice of supervisionof nonpharmacologically trained mental health professionals. This emerging areahas not yet received much attention in the professional literature, and therefore,Lopez-Williams’ chapter makes an important contribution in this area. In addition, to a wide diversity of topics, this book also outlines a wide varietyof styles utilized by RxP-trained psychologists who regularly collaborate withpediatricians. Some chapters present a formal approach, based on scientificevidence and findings of relevant literature. Other chapters provide a more personalaccount, filled with practical information that one acquires through years of prac-tice and extensive “on the ground” experience. It is hoped that the wide variety oftopics and styles provides a good overview of the practice of collaboration withpediatricians, and that the chapters within this book are representative of the widebreadth of approaches and activities that such collaboration traditionally entails.June 30, 2010 George M. Kapalka Monmouth UniversityReferencesAmerican Psychological Association Board of Professional Affairs. (1981). Task force report: Psychologists’ use of physical interventions. Washington, DC: American Psychological Association.Ax, R. K., Fagan, T. J., Resnick, R. J. (2009). Predoctoral prescriptive authority training: The rationale and a combined model. Psychological Services, 6, 85–95.Brauer, D. (2010, June 4). Pilot program aims to combat shortage of child and adolescent psychia- trists. Medscape Medical News. Retrieved June 21, 2010, from http://www.medscape.com/ viewarticle/722981Kersten, H., Randis, T., Giardino, A. (2003). Evidence-based medicine in pediatric residency programs: Where are we now? Ambulatory Pediatrics, 5, 302–305.Kim, W. J. (2003). Child and adolescent psychiatry workforce: A critical shortage and national challenge. Academic Psychiatry, 27, 277–282.Koppelman, J. (2004). The provider system for children’s mental health: Workforce capacity and effective treatment. National Health Policy Forum Issue Brief No. 801. Washington, DC: George Washington University.Olfson, M., Marcus, S. C., Weissman, M. M., Jensen, P. S. (2002). National trends in the use of psychotropic medications by children. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 514–521.Rao, N. R. (2003). Recent trends in psychiatry residency workforce with special reference to international medical graduates. Academic Psychiatry, 27, 269–276.Serby, M., Schmeidler, J., Smith, J. (2002). Length of psychiatry clerkships: Recent changes and the relationship to recruitment. Academic Psychiatry, 26, 102–104.Thomas, K. C., Ellis, A. R., Konrad, T. R., Holzer, C. E., Morrissey, J. P. (2009). County-level estimates of mental health professional shortage in the United States. Psychiatric Services, 60, 1323–1328.
About the EditorGeorge M. Kapalka earned his PhD in Clinical Psychology from Fairleigh DickinsonUniversity and holds board certifications in several areas of practice, including clinicalpsychology, psychopharmacology, child and adolescent psychology, learningdisabilities, and forensic psychology. He is an associate professor (tenured, graduatefaculty appointment) at Monmouth University where he currently serves as theInterim Chair of the Department of Psychological Counseling. Dr. Kapalka previ-ously taught at several universities, including Fairleigh Dickinson University (withinthe PhD program in Clinical Psychology) and the New York Institute of Technology(where he served as the Director of Counselor Education). Dr. Kapalka is licensed to practice psychology in NJ, NY, PA, and NM and hasbeen in practice for over 20 years. He maintains a private practice that primarilyfocuses on the treatment of children and adolescents with learning and emotionaldisorders. Dr. Kapalka completed Level 3 psychopharmacology training throughthe Prescribing Psychologists’ Register, and in his practice, he frequently consultswith pediatricians about the use of medications in the treatment of children andadolescents. For over a decade, he has been a member of medical staff at MeridianHealth, Brick Hospital Division, a primary care hospital. In addition, Dr. Kapalkais school-certified in New Jersey and heads a state-accredited Independent ChildStudy Team. Dr. Kapalka’s research program has focused on the education and treatment ofyouth with disruptive disorders, as well as the use of nutritional and herbal supple-ments in the treatment of children and adolescents. He is the author of four booksand dozens of professional publications and presentations. Dr. Kapalka is active inprofessional and community education and has held dozens of workshops form edical and mental health professionals, teachers, and parents. Dr. Kapalka hasbeen interviewed in newspapers, Internet publications, and on television. xiii
ContentsPart I Foundations of Collaborative Care 1 Psychology, Psychopharmacotherapy, and Pediatrics: When to Treat and When to Refer......................................................... 3 Mark Muse, Syd Brown, and Tanya Cothran-Ross 2 Collaboration Between Pharmacologically Trained Psychologists and Pediatricians: History and Professional Issues............................................................................ 17 Robert E. McGrathPart II Collaboration with Pediatricians in Specific Settings 3 The Clinical Experience of RxP-Trained Psychologists Working in Non-RxP States..................................................................... 37 Thomas M. Kozak and Andrea Kozak Miller 4 The Practice of Medical Psychology in an RxP State: New Opportunities for Comprehensive Pediatric Care....................... . 49 Darlyne G. Nemeth, Sandra Franz, Emma Kruger, and Maydel M. Schexnayder 5 Integrated Care in Rural Settings.......................................................... 67 Nancy Boylan Alford 6 Collaborative Practice with Pediatricians Within the Indian Health Service: Taking Care of Frontier Children................................................................................ . 95 Michael R. Tilus, Kevin M. McGuinness, Mimi Sa, Earl Sutherland, Bret A. Moore, Vincen Barnes, Johna C. Hartnell, and Anthony Tranchita xv
xvi Contents 7 The Practice of Medical Psychology in a Pediatric Hospital Setting: A Personal Account from an RxP State..................................................................................... 119 John C. CourtneyPart III Collaboration with Pediatricians in Treatment of Specific Disorders 8 Collaborative Treatment of Disruptive and Mood Disorders................................................................................ 135 George M. Kapalka 9 Collaboration Between Pediatricians and Pharmacologically Trained Psychologists in the Treatment of Anxiety Disorders in Pediatric Patients............................................................... 153 Sean R. Evers10 Collaborative Treatment of Eating Disorders....................................... 167 Marla M. Sanzone11 Collaborative Treatment of Medical Disorders: The Management of Diabetes................................................................. 183 Lawrence R. Kotkin12 Collaborating with Pediatricians and Gastroenterologists: A Biopsychosocial Approach to Treatment of Gastrointestinal Disorders.................................................................. 199 Lindsay D. Clendaniel, Paul E. Hyman, and John C. CourtneyPart IV Future Directions in Pharmacological Collaboration13 Brain Markers: An Emerging Technology with Potential to Enhance Collaboration Between Pediatricians and Pharmacologically Trained Psychologists...................................... 233 Margaret B. Alvarez14 Internship and Fellowship Experiences: Preparing Psychology Trainees for Effective Collaboration with Primary Care Physicians................................................................ 249 Veronica L. Raggi15 The New Face of Psychology Predoctoral Training: Psychopharmacology and Collaborative Care...................................... 271 Traci Wimberly Olivier
Contents xvii16 RxP Training Informs the Practice of Supervision of Nonpharmacologically Trained Mental Health Practitioners................................................................................. 285 Andy Lopez-WilliamsIndex.................................................................................................................. 301
ContributorsNancy Boylan Alford, PsyD, is a clinical psychologist who is board certified inpsychopharmacology (ABMD). She is a member of a group private practice in ruralNorth Carolina where she treats children and adults and works part-time for aPediatric Service at the Rural Health Group in Roanoke Rapids, a subsidized medicalcare facility in North Carolina. Dr. Alford is a founding member of the AmericanSociety for the Advancement of Pharmacotherapy, Division 55 of the AmericanPsychological Association.Margaret B. Alvarez, PsyD, MS, is a child clinical school psychologist and amedical psychologist. She also completed a postdoctoral respecialization inneuropsychology and recently completed the coursework for a degree as a medicaldoctor (MD). She a member of the editorial board of The American Journal ofIntegrated Mental Health Care and has published in the field of health psychology(about childhood obesity), primary prevention, and neuropsychological sequelae incardiac bypass surgery with differential blood profusion. She is an AssociateProfessor of Psychology at Touro College in Manhattan and maintains a privatepractice in Pomona, NY.Vincen Barnes, PsyD, is a clinical psychologist with the Public Health Service.He completed two tours of service on two different reservations in North Dakota.He served as a staff psychologist on the Turtle Mountain reservation and as themental health director on the Standing Rock reservation. Dr. Barnes has beendeployed to three reservations experiencing suicide epidemics. During the deploy-ments he provided treatment and conducted community assessments to helpdevelop suicide prevention strategic plans.Syd Brown, PhD, is a child and adolescent clinical/neuropsychologist who isboard certified in clinical neuropsychology (FACPN). Dr. Brown maintains a privatepractice in Bethesda, MD.Lindsay D. Clendaniel, PhD, is a pediatric psychologist at Children’s Hospital,New Orleans. She specializes in treating children coping with gastrointestinaldisorders and pain-related illness. Her research focuses include pain assessment,acute and chronic pain management, and management of functional gastrointestinaldisease. Dr. Clendaniel has presented her research at the International Pediatric xix
xx ContributorsPain Symposium and Society of Pediatric Psychology conferences. Her publishedresearch has focused on coping with chronic illness and acute pain assessment andmanagement.Tanya Cothran-Ross, MD, is a board certified pediatrician (FAAP).Dr. Cothran-Ross works as a pediatrician in Gaithersburg, MD.John C. Courtney, PsyD, is a medical psychologist and a board certified neurop-sychologist. He is the director of the department of psychology at Children’sHospital of New Orleans, LA. Dr. Courtney is also an Associate Clinical Professorof Neurology, Psychiatry and Pediatrics at Louisiana State University HealthSciences Center in New Orleans.Sean R. Evers, PhD, MS, is a clinical psychologist who maintains a private prac-tice in Manasquan, NJ. He treats children and adolescents and supervises otherprofessionals. Dr. Evers is a frequent presenter on Posttraumatic Stress Disorderand its impact on children and the family. Dr. Evers is a consultant to the NewJersey Department of Military and Veterans Affairs and the Veteran’s AdministrationCenter’s program that focuses on addressing the needs of veterans and theirfamilies.Sandra A. Franz, MD, is a board certified (FAAP) pediatrician. For the past10 years, Dr. Franz has been a member of a private group practice. In addition, sheteaches medical students and residents through the Our Lady of the Lake RegionalMedical Center’s Pediatric Residency Program.Johna C. Hartnell, PhD, MS, is a medical psychologist recently employed withthe Indian Health Service at Fort Thompson, SD. Dr. Hartnell is completing herpreceptorship toward the Conditional Prescribing License in New Mexico. Prior tojoining the Indian Health Service, she worked in a private practice in Madison, WI.She works with all age populations, including children, adolescents, and adults.Paul E. Hyman, MD, is Professor of Pediatrics at Louisiana State University andChief of Pediatric Gastroenterology at Children’s Hospital, New Orleans.Dr. Hyman’s research focuses on pediatric gastrointestinal motility disorders andchronic visceral pain. In 1999, Dr. Hyman chaired the Pediatric ROME II WorkingTeam, charged with developing the first symptom-based criteria for the diagnosisof childhood functional gastrointestinal orders. Dr. Hyman has made contributionsto the training of several pediatric motility researchers. In 2002, Dr. Hymanreceived an Award for Outstanding Achievement in Clinical Gastroenterology fromthe American Gastroenterological Association.Lawrence R. Kotkin, PhD, MS, is a medical and school psychologist whocurrently focuses on the treatment of chronic illnesses, especially diabetes. He holds aboard certification in diabetes education, and the Professional Section of theAmerican Diabetes Association placed him in the Who’s Who in DiabetesTreatment, Education, and Research. He is a member of a Diabetes EducationCenter team at the Einstein College of Medicine’s Diabetes Research and Training
Contributors xxiCenter and is a supervising psychologist of the Geriatrics Division at New York’sCreedmoor Psychiatric Center. He maintains a private practice and consults withhospitals and schools about psychological aspects of managing diabetes. He alsoteaches as an adjunct at St. Joseph’s College in New York.Thomas M. Kozak, PhD, is a psychologist who practices in The Woodlands, TX.He is Co-Chair of the Texas-Oklahoma Prescribing Psychologists’ Register and wasformer Legislative Chair of the Texas Psychological Association. He currentlyworks collaboratively with physicians in establishing and monitoring patientm edication regimes. Dr. Kozak has previously authored articles on managed care,family therapy, and RxP legislative action.Andrea Kozak Miller, PhD, is a psychologist in Atlanta, GA. She is a facultymember at Walden University in Minneapolis, MN. In the past, Dr. Miller servedas a site supervisor for a nonprofit clinic in New York City that provided consumersa combination of psychological and medical services. She currently works as apartner in a data analysis company as well as teaches online. Dr. Miller is theauthor of the column, “From Research to Practice,” a regular feature in TheIndependent Practitioner, a publication of Division 42 of the AmericanPsychological Association.Emma Kruger, MD, is a physician and founder of the Metabolic Anti-AgingCenter, LLC, in Baton Rouge, LA, where she practices metabolic and functionalmedicine.Andy Lopez-Williams, PhD, is the President and Clinical Director of ADHDand Autism Psychological Services and Advocacy in Utica and Oneida, NY.He is also a founding member and Chief Executive Officer of Central New YorkQuest, a not-for-profit agency focused on services, education, advocacy, andpolicy for persons with special needs. Dr. Lopez-Williams has coauthored numerousarticles on the assessment and treatment of children and adolescents with mentalhealth disorders. He has developed individualized assessment protocols designedto evaluate the effectiveness of psychotropic medications in children and adoles-cents and currently trains and supervises mental health therapists to utilize thesepsychopharmacological assessment protocols in collaboration with primary carephysicians.Robert E. McGrath, PhD, is a clinical psychologist and Professor of Psychologyat Fairleigh Dickinson University in Teaneck, NJ. He is also the Director of boththe Ph.D. Program in Clinical Psychology and the M.S. Program in ClinicalPsychopharmacology at the University. He is the author of over 150 publicationsand presentations in the areas of professional issues in pharmacotherapy andpsychological assessment. He is a recipient of the American Society for theAdvancement of Pharmacotherapy Award for Outstanding Contribution toPrescriptive Authority on the National Level and three-time winner of the MartinMayman Award from the Society for Personality Assessment for distinguishedcontributions to the literature in personality assessment.
xxii ContributorsKevin M. McGuinness, PhD, is a clinical psychologist, clinical health psychologist,and medical psychologist who is board certified in clinical health psychology(ABPP). He is a senior commissioned officer of the U.S. Public Health Service.Dr. McGuinness is licensed in Louisiana as a medical (prescribing) psychologistand is a conditional prescribing psychologist in New Mexico. Dr. McGuinness iscurrently assigned to a community health center in rural New Mexico and main-tains a private practice in Las Cruces, NM. He is the founding Vice President of theJoshua Foundation, Inc., which strives to educate and safeguard the public regardingthe delivery of health care in the State of New Mexico. Dr. McGuinness hasauthored numerous professional publications.Bret A. Moore, PsyD, is a board-certified clinical psychologist (ABPP) and aconditional prescribing psychologist in New Mexico. He is the author or editor offive books including Pharmacotherapy for Psychologists: Prescribing andCollaborative Roles. He is a Fellow of the American Psychological Association andSecretary-Treasurer of Division 18 (Psychologists in Public Service). He maintainsa private practice in San Antonio, TX.Mark Muse, EdD, PhD, is a prescribing medical psychologist in Louisiana. Healso maintains a practice in Maryland, where he consults about medication issues.Dr. Muse’s most recent publication, The Handbook of Medical Psychology andClinical Psychopharmacology, is in press with John Wiley Sons.Darlyne G. Nemeth, PhD, is a clinical, medical, and neuropsychologist who isboard certified in clinical psychopharmacology (ABMP). She is the founder ofThe Neuropsychology Center of Louisiana, LLC. Dr. Nemeth is a prescribingpsychologist in Baton Rouge, LA, where she has maintained a private practice forover 30 years. Dr. Nemeth is the recipient of the 2010 Distinguished PsychologistAward by the Louisiana Psychological Association. Dr. Nemeth coauthored thebook, Helping Your Angry Child, which promotes healthy family interactions.Traci Wimberly Olivier, BS, is a doctoral student at Nova Southeastern University’sCenter for Psychological Studies doctoral program in clinical psychology. She com-pleted a 2-year clinical and research externship at the Neuropsychology Center ofLouisiana (NCLA). After receiving her doctorate, Mrs. Olivier intends to obtain apostdoctoral master’s degree in clinical psychopharmacology and plans to seekprescriptive authority.Veronica L. Raggi, PhD, is a clinical child psychologist who earned her doctoratein clinical psychology from the University of Maryland, College Park. She com-pleted internship training at Children’s National Medical Center in Washington,D.C. and postdoctoral training at the New York University Child Study Center. Dr.Raggi currently provides clinical services at Alvord, Baker, and Associates, LLC,a group private practice located in Silver Spring, MD. She has published in numer-ous scholarly journals on topics related to academics, homework and school func-tioning, parenting skills, and the treatment of ADHD and other disruptive behaviordisorders.
Contributors xxiiiMimi Sa, PhD, MS, is a clinical and medical psychologist who gained prescriptiveauthority in New Mexico in 2009. She has worked in Indian country for 10 years bothin urban and tribal settings and is currently stationed at the Mescalero Service Unitin southern New Mexico. Her experience includes working with indigenous elders inCosta Rica and Brazil, as well as with the Ojibwe and Lakota elders in Minneapolis.In addition, Dr. Sa has participated in Native American workshops and Native radioshows with a panel of medicine men. She was recently awarded by the IndianHealth Service for her participation in a state of emergency at Mescalero due to asuicide cluster.Marla M. Sanzone, PhD, is a clinical psychologist with a postdoctoral Master’sof Science in psychopharmacology. She is in independent practice in Annapolis,MD, where she specializes in the treatment of eating disorders and related mood,anxiety, and compulsive conditions. Dr. Sanzone works closely with pediatricians,internists, endocrinologists, and other primary care providers toward integratingpharmacotherapies with cognitive–behavioral, interpersonal, and systems treat-ment approaches. She also presents at state and national conferences on the treatment ofeating disorders and psychopharmacology and is adjunct faculty at Loyola Collegeof Maryland.Maydel M. Schexnayder, MS, CRC, holds a Master of Science in RehabilitationCounseling and is a Certified Rehabilitation Counselor. She has been working forthe Louisiana Rehabilitation Services program for 8 years and is currently theVocational Rehabilitation District Supervisor. Ms. Schexnayder coauthored thebook, Helping Your Angry Child, which promotes healthy family interactions.Earl Sutherland, PhD, MS, is a school/child clinical psychologist and a medicalpsychologist. Currently, he is a Supervisory Psychologist and chair of the RxP TaskForce with the Indian Health Service and director of CARE center, the first fullyfederal child advocacy center. He is a member of the Board of Directors of NativeAmerican Children’s Alliance and a member of Board of Directors of MontanaChildren’s Alliance. He is as a Member at Large of Division 55 of the AmericanPsychological Association and the Prescription Privileging Chair with the MontanaPsychological Association. In 2007, he received the Indian Health Service NationalDirector’s Award.Michael R. Tilus, PsyD, is a licensed clinical psychologist, marriage and familytherapist, and board-certified pastoral counselor. He is on active duty with the U.S.Public Health Service (Commander) and is the Director of Behavioral Health atSpirit Lake Health Center at Ft. Totten, ND. Dr. Tilus has a Conditional PrescribingPsychologist license from New Mexico and provides a wide range of psychologicaland psychopharmacological services to American Indians and Alaska Natives inisolate, remote, medically underserved communities within an integrated, behav-ioral health and primary care setting.Anthony Tranchita, PhD, is a staff psychologist and chief of the Alcohol andDrug Abuse Prevention and Treatment (ADAPT) program at the Grand Forks Air
xxiv ContributorsForce Base in North Dakota. He is currently completing psychopharmacologytraining at Alliant International University in San Francisco. Dr. Tranchita previ-ously worked as a staff psychologist at a residential treatment center for NativeAmerican youth with substance abuse issues and an Air Force treatment center inOklahoma.
4 M. Muse et al.increases the possibility of fragmented rather than integrated care. This is especiallytrue when the collaborating specialist is less than fully available for coordinatedclinical intervention with the pediatrician. In this regard, having the psychologist onthe premises with the primary care provider, or linked through open channels ofcommunication as in the HMO model, is a distinct advantage. Short of this, a referralto a psychologist would require additional need for specialist attention to offset thedisadvantage inherent in referring to an outside agency or provider. What, then, are the behavioral health conditions which might best be handleddirectly by the pediatrician, and which conditions warrant a referral to a child andadolescent psychologist? One way to approach this question is to look at conditions and to offer a pre-ferred ordering of first-line provider specialists in the diagnosis of the variousmental health concerns that present in the pediatric population. A second approachis to consider the treatments involved in the management of such conditions and todetermine which treatments are best managed by whom. A third option is to com-bine the first two approaches in order to determine the optimal integration ofp sychology and pediatrics, according to the behavioral/pharmacological manage-ment prescribed for a given condition.ConditionsMental health conditions can be divided into three broad categories:1 . Cognitive concerns, including mental retardation, pervasive developmental disorders, autism spectrum, and academic concerns such as learning disabilities and attention deficit hyperactivity disorder (ADHD) (especially the variant with predominantly inattentive symptoms), as well as thought disorders.2 . Emotional concerns, including anxieties such as specific phobias, social/separa- tion anxieties, obsessive-compulsive disorder (OCD), and generalized anxiety, as well as depression in all its forms (adjustment reaction, dysthymia, major depression, and bipolar disorder).3 . Behavioral concerns, including oppositional defiant disorders, disruptive behaviors and ADHD (especially the variant with predominantly hyperactive/impulsive symptoms), impulse control disorders (anger), and conduct disorders. Of these conditions, some are more challenging to diagnose and require extensiveinterviewing of the child and significant others as well as the use of psychometrics.A differential diagnosis is the basis of efficacious treatment, and time and expertisespent at the conceptualization stage of treatment will pay off in the long-term man-agement of complex conditions. Such complex conditions, requiring extensive psychodiagnostics, include thefollowing:1 . Mental retardation/autism and organic brain syndromes.2 . Confounded academic conditions involving a combination of factors such as learning disabilities with ADHD, overlaid with emotional, behavioral, and/or social concerns.
1 Psychology, Psychopharmacotherapy, and Pediatrics 53 . Thought disorders and other psychoses.4 . Anxieties not of a transient nature, as well as depressions not of a transient and/ or mild intensity.5 . Behavioral concerns that are not secondary to transient issues and which are not believed to be resolved with the passing of a temporary trigger; e.g., ADHD, oppositional-defiant disorder (ODD), conduct disorder, and pernicious impulse disorders. A simple way of approaching the question “which mental health conditionsshould a pediatrician treat without referring to a psychologist?” is to identifystraightforward, uncomplicated conditions, such as unadulterated ADHD. A condi-tion such as ADHD, however, can easily become enmeshed in comorbid conditionssuch as ODD, substance abuse, and impulse control problems. In such cases, areferral to a psychologist is warranted. In the case of “simple ADHD,” however, theproblem lies in separating it from other mimicking conditions such as anxiety dis-orders, and making sure that it is a bona fide case of ADHD and not simply apseudo-condition created by a frustrated parent or teacher who assigns too muchemphasis to distractibility or impulsive tendencies in a given child. Here is where amere description of symptom constellations taken from the Diagnostic andStatistical Manual of Mental Disorders (DSM-IV), or the use of a non-normedscale, is insufficiently powerful to weed out the false positives. The unmitigatedcase of manifest ADHD notwithstanding, the question has to be asked, in differen-tiating the diagnosis of ADHD from mere ADHD-like behaviors, if the combina-tion of symptoms is not only attributable solely to ADHD, but the magnitude of thesymptoms, according to the child’s age and gender, is also of such severity that thecondition truly stands out from that of the rest of the children who also show onedegree or another of distraction and impulsivity? ADHD scales based on normeddata that include the child’s age and gender, such as the Conners (2008) or DuPaul,Power, Anastopoulos, and Reid (1998) ADHD scales, are far more robust instru-ments in this sense than a simple interview with the parents and the child, or the useof descriptive, non-normed instruments. Another factor to consider is that ADHD, predominantly inattentive type, can bedifficult to diagnose, as one does not see the obvious hyperactive and impulsivebehaviors of ADHD, combined type. With the inattentive subtype of ADHD, onemay observe a child or adolescent “space out,” etc., but this could be ADHD, inat-tentive type, or it could be absence seizures, or both; it should be noted thatapproximately one-third of children with childhood absence epilepsy also meet thecriteria for ADHD, predominantly inattentive type (Hermann et al., 2007). If the seizure disorder can be ruled out, one must consider other ways of diag-nosing the inattention; behavioral inventories may not provide adequate data, but acareful clinician should not just rule it out because adults do not “see” the disorder.At this point, one needs to know when to order neuropsychological testing to lookfor evidence of inattention which reaches a clinical level, warranting a diagnosisand treatment. If ADHD poses certain difficulties in its accurate diagnosis, many other condi-tions pose even greater challenge and require the discerning eye of the specialist
6 M. Muse et al.and the time required to perform a thorough evaluation which may necessitate formalpsychometrics. With the exception of patently transient conditions such as mild tomoderate anxiety reactions after an identifiable trigger, the rest of the conditionscomposing the three categories of cognitive, affective, and behavioral disorders arebest diagnosed after a thorough psychological evaluation.TreatmentsIt has been a longstanding tradition for pediatricians to refer behavioral treatmentsto psychologists. This does not exclude the pediatrician from developing a thera-peutic rapport with the patient, encouraging healthy interactions between patientand parents, and instructing parents on basic reinforcement strategies for promotinghealthy compliance on the patient’s part, but it recognizes that the design and appli-cation of a systematic behavioral plan require therapeutic input and follow-up of amore extensive nature than that afforded by the standard pediatric visit. Medication management of mental health concerns through the years hasevolved into a collaborative relationship between psychologists and pediatricians.Both professions have benefitted from two-way communication in which diagnosticimpressions and treatment strategies, including medication, are openly discussed.Pediatricians have become increasingly comfortable with consultations with psy-chologists on such medication issues as whether pharmacotherapy is indicated andwould compliment other prescribed behavioral approaches, and which class ofmedication best fits the diagnosis and therapeutic needs of the patient. The role ofmedication consultation for pharmacologically trained psychologists is contem-plated in the rulings of many state psychology licensing boards which find medica-tion consultation by pharmacologically trained psychologists with primary care andpediatric physicians to be within the purview of the psychologists’ license to prac-tice psychology according to their competency in specialty areas such as clinicalpsychopharmacology. The advent of the specialty of “medical psychologist,”1r ecognized by the Drug Enforcement Agency (DEA) in the granting of the controlsubstance registration number to prescribing psychologists, has expanded this role The term medical psychologist, as adopted by Division 55 of the American Psychological1 Association, is used in this paper to mean a pharmacologically-trained psychologist, regardless ofwhether the jurisdiction in which the psychologist resides allows for full prescriptive authority atthis time. A medical psychologist, or pharmacologically-trained psychologist, as these two termsare used interchangeably in this chapter, holds a doctorate degree in psychology and a license topractice psychology in his or her respective state, as well as having completed postdoctoral trainingrequirements outlined by the American Psychological Association to demonstrate competency inthe specialty area of pharmacotherapy. It is specifically recognized that such a psychologist is quali-fied to advise physicians on medication in those states whose boards of psychology have renderedan opinion that allows for such, and it is assumed that equivalently trained psychologists residingand working in states without a formal opinion from the board are equally competent to advisephysicians on medication, just as the same medical psychologist is qualified to write a prescriptionin those states and federal jurisdictions that allow for prescriptive authority (McGrath, 2010).
1 Psychology, Psychopharmacotherapy, and Pediatrics 7and has redefined the psychologist as the primary prescriber of psychotropicmedications where current legislation provides for such prescriptive authority. Thisraises the question of to what extent psychologists, in general, and pharmacologi-cally trained psychologists, in particular, should play a role in the behavioral medi-cation management of their patients. It should be stated that a collaborativerelationship with the patient’s pediatrician with regard to medication issues fromthe onset is, for the psychologist, not only a best-practice imperative, but also alegal one where prescriptive authority for psychologists has been enacted. While the interplay of condition with treatment/medication is specifically addressedin the coming section on the integration of medical psychology with general pediatrics,the extent of the psychologist’s involvement in medication issues is addressed here. Evidenced-based clinical intervention has demonstrated that certain psychologicalconditions respond better to different treatments. While empirically based selectionof treatments is far from established for the majority of conditions, there is reasonto believe that future research efforts to identify first-line approaches for the arrayof mental disorders will progressively offer greater specificity as to which treatmentis more likely to provide positive results for a particular condition. This does notobviate the argument of the “dodo-bird effect,” which refers to the observation thatall credible psychotherapies result in significant therapeutic improvement just as allantidepressant medications result is similar therapeutic effects, an argument whichmaintains that it is unlikely that precise behavioral intervention/medication-specificalgorithms will ever be definitively developed.2 Psychopharmacology trained psychologists’ involvement in pharmacotherapywith the pediatric population ranges from full responsibility for prescribing andmonitoring psychotropic medications to making recommendations to the prescribingphysician on the class of medication most indicated for the treatment of the presentingdiagnosis or symptom constellation. At the upper end of involvement are child andadolescent medical psychologists who have been issued the DEA controlleds ubstance certificate to prescribe within a territorial jurisdiction (either state/territoryor, in the case of federal agencies, federal installations) and who are consultants orprimary therapists for the patients’ mental health needs. In every case, it is incumbent Still, evidence to date indicates that combined, medication/psychotherapy, treatment is likely to2 be optimum for bipolar (Sachs, 1996), some forms of depression (Thase et al., 1997) smokingcessation (Hatsukami Mooney, 1999), schizophrenia (Rosenheck et al., 1998; Spalding,Johnson, Coursey, 2003), panic disorder (Bruce, Spiegel, Hegel, 1999) and substance abuse(Carol, 1997), while the use of pharmacotherapy and, more specifically, benzodiazepine is notgenerally indicated in the treatment of phobias, as medication effects tend to confound exposure-based treatments (Sammons Schmidt, 2003). In general, pharmacotherapy is less effective as asingle modality approach than psychotherapy when treating chronic depression with an Axis IIdisorder (Sammons Schmidt, 2003). In the treatment of OCD, research indicates that singletreatment modality (behavioral therapy) is more effective than combination treatment modalitywhen symptoms are primarily compulsive, whereas combined treatment modality (medication-behavioral therapy) is more effective than single treatment modality when symptoms are primarilyobsessive (Hohagen et al., 1998). In many other disorders, not enough evidence has accumulatedto be able to discern treatment superiority; for such conditions, single-modality treatments shouldbe attempted before combined treatments are implemented, opting for the treatment with less sideeffects (usually psychotherapy) when treatment specificity is ambiguous (Muse, 2010).
8 M. Muse et al.upon the psychologist to collaborate with the patient’s pediatrician to coordinatethe prescription, and subsequent adjustment, of any psychoactive medicationaccording to the patient’s medical status, keeping especially in mind any contrain-dication for medications due to a preexisting medical condition or interaction withother drugs currently taken by the patient. A recent study (Rae, Jensen-Doss,Bowden, Mendoza, Banda, 2008) suggests that pediatric psychologists havegreater positive views of prescriptive authority than pediatricians, although themajority of pediatricians indicated that collaborating with child medical psycholo-gists would not be negatively influenced by the new role as prescriber.Integration of Medical Psychology with PediatricsNot every case of mental retardation requires a psychologist’s intervention, just asnot every case of ADHD is manageable by pediatrics alone. Some cases, such asmajor depression, generally require interventions by both specialties. In cases wherebehavioral medications are prescribed, coordination between the two specialtieswould appear to be especially indicated. If the nature of the various conditions aswell as their respective first-line interventions is considered, one might construct analgorithm combining these two dimensions to project the discipline, pediatrics orpsychology, as well as the subspecialty within psychology that might best managecertain behavioral health syndromes. Figure 1.1 presents such an algorithm. In Fig. 1.1, it is essential NOT to make a distinction between medical psycholo-gists practicing where prescriptive authority currently exists, and pharmacologi-cally trained psychologists practicing in jurisdictions where their ability to consulton medication can be effective in the management of the patient’s pharmacotherapyneeds without directly writing the medication script. The pediatrician would bedirectly involved in pharmacotherapy in either case, either reviewing the recom-mendations of the script-writing medical psychologist or, alternatively, writingthe script based on the recommendations of the consulting medical psychologist.In either case, the pediatrician benefits from the expertise of the pharmacologicallytrained psychologist, while the medical psychologist benefits from the close collabo-ration and coordination of care with the pediatrician. The fully qualified medicalpsychologist is competent in all psychotropic medications used in the treatment ofmental health disorders, and collaboration of the pharmacologically trained psycholo-gist with the patient’s pediatrician allows for the patient’s medication needs to bemet fully. As is true with all specialties, referral to another professional would beindicated if the medical psychologist were to require the opinion or intervention ofanother prescribing professional (a medical psychologist or psychiatrist) in specialcases that warrant further consultation. As such, the algorithm in Fig. 1.1 assumesthat the collaboration between a pediatrician and a pharmacologically trainedpsychologist will cover all conditions and treatments contained within the algo-rithm. While the algorithm indicates that certain conditions that may benefit frompharmacotherapy be initially referred to a pharmacologically trained psychologist,
1 Psychology, Psychopharmacotherapy, and Pediatrics 9 Presenting Problem Cognitive Affective Behavioral Developmental Academic Thought Anxiety Impulse Impulse Depression Disorders Disorders Disorders Dyscontrol Dysfunction 1,4,2 Attention 2 Adjustment 2 Conduct 3,2 4,2 2 Tourettes, Deficit/Hyper- Psychoses Disorder, Adjustment 2 Oppositional Disorder Organic Brain activity Generalized Disorder, Defiant Syndromes, Anxiety Dysthymia Disorder, Mental 3,2 Disorder, Explosive Anger 4,2 Retardation; Learning Addiction Disabilities Phobias 4,2 *Pervasive Major Developmental Depression, 4,2 Disorders, Autism Posttraumatic Bipolar Spectrum Stress Disorder, Disorder Obsessive Compulsive Disorder, Panic DisorderKey::Preferred Provider: fe ide :1 Pediatrician e i ri an2 Clinical, Counseling, or School Psychologist l ic g, o h o h o3 Neuropsychologist or Psychodiagnostician e ro yc o gis r gn t4 Medical Psychologist i al l st*Often in conjunction with Developmental Pediatrics e nc n n to h e lo m n Pe iat icFig. 1.1 Algorithm for pediatrics interface with psychology (Muse, Brown, Cothran-Ross, 2010)this does not imply that a clinical, counseling, or school psychologist withoutexpertise in clinical psychopharmacology would not be able to make the diagnosisor provide the indicated behavioral treatment based on the diagnosis, but simplyacknowledges that where there is the possibility of medication management, thepharmacologically trained psychologist might be considered first line. However,this certainly does not imply that all patients with suspected diagnoses that mightrequire medication be initially referred to the medical psychologist. Quite to thecontrary, the majority of such patients are traditionally referred to a clinical, counseling,or school psychologist, who might then request a consult with a medical psychologist,should medication recommendations be sought. Along this same line, referral to a neuropsychologist or psychodiagnostician3 maybe initiated at anytime that a precise differential diagnosis is sought on conditions The term psychodiagnostician is used here to identify clinical, counseling and school psycholo-3 gists who have specialized in diagnosing disorders and providing differential diagnoses throughthe use of psychological testing and investigative interviewing. The neuropsychologist performsessentially the same service, having specifically developed an expertise in neuropsychologyinstruments that rule in/rule out organic syndromes.
10 M. Muse et al.that may require in-depth study in the formulation of treatment recommendations.The algorithm in Fig. 1.1 not only indicates which of these conditions might warrantan initial referral by the pediatrician, but also assumes that in many cases these condi-tions will be managed by a clinical, counseling, or school psychologist and referredfor psychological testing when the managing psychologist believes it indicated. Figure 1.1 depicts different pathways in which the patient presenting to thepediatrician with behavioral health concerns might be triaged according to the typeof concern – cognitive, affective, or behavioral – as well as the particular condition.According to the algorithm proposed by the current authors, the pediatrician wouldtreat simple, manifest ADHD with medication when the disorder has no othercomorbid condition and when a differential diagnosis is not required to separateADHD from other confounding symptoms. The pediatrician might also treat, wheretime permits, transient conditions such as circumscribed anxieties that respond tostraight forward reassurance. The remaining mental health conditions may be referred to a psychologist foreither further workup and differential diagnosing, or for psychotherapy, pharmaco-therapy, or a combination of both. In the case of developmental and academicdisorders other than ADHD, referral to a neuropsychologist or psychodiagnostician(clinical, counseling, or school psychologist specializing in psychometrics) iswarranted if the condition has not previously been diagnosed. For conditions thatstand to benefit from medication or a combination of medication and psychosocialinterventions [(e.g., psychoses, OCD, panic disorder, posttraumatic stress disorder(PTSD), major depression, bipolar disorder, and addictions)], a referral to thepharmacologically trained psychologist is particularly indicated. With conditionswhere medication is not a first-line intervention, which is the case with majority ofcognitive, affective, and behavioral conditions, a direct referral to a clinical, coun-seling, or school psychologist for psychosocial treatment is the appropriate path. A final advantage to integrating condition with treatment is the interplay ofmedication management with other behavioral techniques. Medication can be con-ceived of as a behavioral approach and, as such, conforms to the laws of respondentand operant conditioning (Muse, 1984, 2008; Muse McFarland, 1994). Integratingpharmacotherapy into behavioral treatment paradigms, giving full weight to thereinforcing qualities of medication, can be a powerful alternative to prescribingmedication as a univectorial intervention, expected to impact on symptoms in alineal fashion. Pharmacologically trained psychologists, due to their training in thescience of psychology in addition to their training in mental health issues, are in aunique position to assess the role of medication in the therapeutic alliance, and theimpact that medication has on the patient’s self-perception. Moreover, the pharma-cologically trained psychologist is cognizant of the various reinforcement contin-gencies that tend to keep different conditions in a state of perpetual balance, and themedical psychologist can bring medications to bear in a way that breaks up thestatus quo of a condition and promotes new learning through new reinforcementstrategies. A case in point is the reinforcing qualities of phobic avoidant behavior.By avoiding the phobic stimulus, the patient receives negative reinforcement, whichis a powerful motivator for maintaining the avoidant behavior. The use of a selectiveserotonin reuptake inhibitor (SSRI) may apparently reduce a phobia by reducing
1 Psychology, Psychopharmacotherapy, and Pediatrics 11anxiety but, in doing so, it acts in much the same way as the avoidant behavior:It allows the patient to escape feelings of anxiety. What is being learned, however,is that medication must be ingested to avoid anxiety and, not surprisingly, manyphobias return when medication is stopped (Prasko et al., 2006), with an estimated50% of social phobias returning when SSRI medication is iscontinued (Veale, d2003). The medical psychologist is far less inclined to use an anxiolytic in treatinga phobia, but would rely primarily on relaxation techniques and gradual hierarchi-cal exposure techniques in order to teach the patient that he or she can withstandsome anxiety while in the presence of the feared stimulus, thereby short circuitingavoidance patterns. This sets the stage for new learning and the subsequent reduc-tion of anxiety, as habituation to the trigger stimulus occurs. Such learning is moredurable and easily generalized to other fears that the patient might have in the pres-ent or future (Dadds, Spence, Holland, 1997).Case Study VignettesThe following section highlights pediatric referrals made to medical psychology.The short case summaries are meant to illustrate the utility of the preferential referralto a psychologist with psychopharmacology training, with or without prescriptiveauthority, for the management of certain types of conditions that warrant the use ofpharmacotherapy, usually in combination with psychotherapy.Attention DeficitThe patient was a 15-year-old Hispanic boy who had been failing eighth grade andhad been held back twice in the past. His mother, who spoke little English, com-plained to the pediatrician that the patient is violent in the house and has attackedthe father on more than one occasion. On the last such incident, the police intervenedand a subsequent investigation by Child Protection Services resulted in the recom-mendation that the patient seek medical/psychological evaluation. The patientstated to the pediatrician that he does not wish to cooperate with the evaluation andavoided answering her questions. The pediatrician referred the case to a psycholo-gist because of the difficulty in arriving at a differential diagnosis in the limitedtime allowed within the medical consultation. The psychological evaluation, which required multiple extended visits to engagethe youth and to collect information from his family and teachers, confirmed ADHDfrom early childhood. The condition had gone undiagnosed and the school failureresulted in increased acting out until a true ODD had formed. The patient was placedon Adderall by the medical psychologist, who resided in a state where prescriptiveauthority exists, and the patient and his family were seen in family therapy conductedin Spanish. The patient’s opposition to treatment dissolved into a collaborative effort.His self-esteem improved as did his grades. His oppositional behavior was mitigatedand the beginnings of learned helplessness and depression were averted. The medical
12 M. Muse et al.psychologist kept the pediatrician informed on treatment milestones and the patientwas discharged back to his pediatrician at the end of 9 months; the pediatricianassumed medication management of the ADHD once the ODD was resolved.PsychosisAn 18-year-old girl was treated for depression for years with SSRIs with little suc-cess before transferring to the care of a new pediatrician, who referred the patient toa medical psychologist for evaluation. The patient’s medication was left unchangedwhile psychotherapy was initiated. In the course of therapy, the patient slowlyrevealed a well-developed belief in her ability to communicate with the dead, whichentailed auditory and visual hallucinations of specters. The psychologist consultedwith the pediatrician and the patient was started on aripiprazole, 10 mg qd, whichprovided the patient sufficient distancing from her psychosis to begin to address, ininsight-oriented psychotherapy, the biochemical nature of her experience. Shegradually gained an understanding and awareness of her condition, which eventuallyled to self-acceptance and a mitigation of her depression, at which time the SSRIwas discontinued on the advice of the pharmacologically trained psychologist.Panic DisorderA 13-year-old girl was referred by her pediatrician for school phobia. She had notgone to school in the last 3 weeks. The medical psychologist discerned the moregeneralized condition of agoraphobia after the child’s narrative of her first panicattack outside of the house several months earlier. She had suffered a total of threepanic attacks in rapid succession, one on her way to the market with her mother andtwo on her way to school. She was now unwilling to leave the house unless accom-panied by a parent. She refused to be separated from the parent and, hence, refusedto attend school. Paroxetine was prescribed at 10 mg qd, and the patient wasinstructed on anxiety tolerance and graded exposure to her fears. The use of anSSRI helped reduce the incident of panic, while behavioral therapy addressed anxi-ety and its phobic avoidance component. The patient was able to recover her fullmobility and to attend school, and paroxetine was gradually reduced 6 months laterwithout any recurrence of panic.Bipolar/Major DepressionThe patient was a 17-year-old boy who was newly transferred to the pediatricianfrom a previous provider; the patient was on Depakote 125 mg bid for a diagnosisof bipolar disorder with anger outbursts. The pediatrician referred the patient to a
1 Psychology, Psychopharmacotherapy, and Pediatrics 13child medical psychologist for the assessment and treatment of mental healthconcerns, and the psychologist subsequently developed rapport with the patient andover the course of interviews and psychometrics, diagnosed ADHD with ODD, aswell as the beginnings of significant depression. The patient was taken off Depakotefor, although mood stabilizers are sometimes prescribed to reduce anger outbursts,there is little evidence to support their use in the treatment of anger dyscontrol notassociated with bipolar disorder (Fleminger, Greenwood, Oliver, 2006); whiledepakote might be useful in mitigating anger or other impulsive outbursts in bipolarpatients, its use is best justified in the treatment of bipolar disorder, with any benefitin anger control being secondary to the management of the mood swing. In thepresent case, the diagnosis of bipolar disorder was not substantiated and the newdifferential diagnosis argued for a behavioral approach for treating the anger as anoutgrowth of ODD and depression. Furthermore, no medication was prescribed forthe depressive symptoms as it was decided to wait and see how they developed asthe newly diagnosed condition of ADHD was treated. The patient was placed onAdderall ER 10 mg, and behavioral therapy was begun to increase study habits anddevelop academic mastery. The patient began to experience success and his depres-sive symptoms remitted. His ODD condition, including anger outbursts, was treatedwith family therapy in which parents and patient were taught conflict resolution andanger management techniques. The patient’s anger outbursts lessened with treat-ment and his ODD condition was eventually resolved. The patient was referredback to the pediatrician 12 months later, where his Adderall was managed throughpediatric services; a recommendation for periodic behavioral reassessment with themedical psychologist ensured that gains would be maintained as the adolescenttransitioned to adulthood.AddictionsThe patient was a 16-year-old boy who was brought in by his parents for academicfailure and alcohol abuse. The patient’s family was made up of high achievers, withtwo professional parents and an older brother attending an Ivy League university.The patient was of high average to superior intelligence and had been a straight Astudent until his first year of high school, when he began to abuse alcohol. At thetime of the consultation, he had been caught at school with a fifth of hard liquor andconfessed to drinking between a fifth and a quart of vodka daily in between classes.He also occasionally smoked marijuana. A psychological evaluation, includingclinical interviews with the patient and his parents, and positive findings on perti-nent standardized, normed psychometrics [(e.g., Continuous Performance Test II:CPT II (Conners Staff, 2000); ADHD Rating Scale-IV (DuPaul et al., 1998); andBehavior Assessment System for Children – Second Edition: BASC II (Reynolds Kamphaus, 2004))] revealed ADHD, hyperactive type, with poor executive func-tioning. Teachers had hinted at hyperactivity through the years to the parents, butthe mother did not “believe” in the ADHD label.
14 M. Muse et al. Normally, the use of psychoactive medication where there is an addictivep otential is an argument against starting stimulant medication, but in this case,Concerta 36 mg q am provided an immediate relief from the “ants running upand down my nerves.” Psychosocial therapy was begun to address family issueswith the high-pressure, perfectionist expectations of the parents, and drug/alcoholc ounseling with weekly drug testing was also instituted. The patient’s grades rap-idly returned to straight A’s, and he did not abuse alcohol or drugs during a 2-yearfollow-up. He stated in retrospect that he had been self-medicating his hyperactivitywith alcohol and marijuana, which was experienced as egodystonic nervousness.Once the ADHD was mitigated with pharmacotherapy, he no longer felt the needfor illicit drugs, and all subsequent drug screens were negative. After familydynamics had been addressed, the patient was allowed to choose an academic paththat interested him and he applied his cognitive abilities toward a goal that provedself-motivating. In this case, the medical psychologist resided in a state withoutprescriptive authority but where the board of psychologists has affirmed that con-sulting on medication with patients and prescribing professionals is within thecompetencies of a pharmacologically trained psychologist. The psychologist con-sulted with the treating pediatrician and medication was managed through periodiccommunication between the two treating professionals.ConclusionThe majority of mental health concerns do not require the use of psychotropicmedication, and even less so in the pediatric population.4 For conditions that do,however, there is an advantage in the coordination of care when the referring physi-cian is able to consult with the treating psychologist on all aspects of therapy,including pharmacotherapy. This interface between medicine and psychology is less than standard practice,but it is more likely to occur between pediatrics and child/adolescent psychologybecause of the long history of collaboration between these two disciplines. The adventof pharmacologically trained psychologists extends this tradition of collaborationto incorporate pharmacotherapy within established psychosocial approaches formanaging mental health issues. The degree of the psychologist’s involvement indirect prescribing is dictated by the jurisdiction in which the patient is treated;nonetheless, even in the jurisdiction where medical psychologists do not write theprescription, pediatricians can effectively manage the psychotropic medicationneeds of their patients and safely prescribe all classes of medications for the treat-ment of ADHD, major depressive disorder, bipolar disorder, anxiety disorders,PTSD, psychoses, and addictions when they consult with pharmacologically trained It is the very rare case, apart from pharmacotherapy of ADHD, which requires medication in the4 preteen population. Thus, our case studies include teenagers, exclusively.
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