Psychotherapy in Youth with Chronic Illness


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  • My presentation today is on psychotherapy and evidence-based treatments in youth with chronic illnesses, better known as the field of pediatric psychology.
  • I’m going to begin with a brief overview of pediatric psychology, some background regarding it’s definition, it’s history, and it’s research designs. Then I’ll talk a bit about typical psychosocial effects of chronic illness in children adolescents to further articulate the rationale behind and need for further research in this area. Then I’ll review a few articles – one focusing on anxiety related to needles in young patients with cystic fibrosis, one evaluating cognitive-behavioral therapy for youth with inflammatory bowel disease, and a third addressing cultural competency in evidence-based treatments in the field. Finally, I’ll draw some conclusions from the research and my own personal experience, and I have a brief discussion question for the group as well.
  • Pediatric psychology is defined in the Handbook of Pediatric Psychology as…The field was developed initially to address unmet needs of psychological services in pediatric settings, and is extremely interdisciplinary involving the medical field, psychiatry, social work, nursing, and even occupational or physical therapy.
  • Read slides, elaborate on current state of the field…
  • Similar to what we’ve learned about research on EBTs, pediatric psychologists study the relationships between variables, what factors influence the magnitude of change, mechanisms, and differences between groups. The field also utilizes RCTs to test the effectiveness of behavioral interventions, however as we know, these are not without their flaws. Quasi-experimental designs are used when random assignment is not possible. And the field also uses observational research designs like cohort and case-control studies. Single-participant designs or case studies are also used with the participant themselves serving as their own control. Lastly, the field uses meta-analyses, one of which I’ll present to you today.
  • Being diagnosed with a chronic illness at a young age is very difficult for young patients, and as a result of growing up with a medicalized childhood or adolescents, many young people struggle with psychological and psychosocial issues – the two most common of which are anxiety and depression. Fear and anxiety is often related to medical procedures, but can also stem from a number of other sources. Depression is often found to be related to a child having a low locus of control. When diagnosed with a difficult illness – often children and especially adolescents feel like everything is happening to them, they might feel at fault or simply out of control of their lives. They have doctors and caregivers making all their decisions for them, and that can result in hopelessness and a depressed mood.Youth also tend to develop low self-esteem or self-efficacy in part due to this low locus of control, or even due to changes in their appearance and everyday lives that cause their self-esteem, self-efficacy, and and issues with social development. Time spent in the hospital can result in missed school which has been shown to affect academic achievement and social development.
  • Read slide and elaborate on complex treatments…
  • Before we develop an intervention to be tested, we need to ensure that we fully understand the problem. This article attempts to do just that through qualitative, semi-structured interviews with children with CF and their parents. CF involves regular needle procedures that may be associated with distress, behavioral difficulties, and lack of adherence to treatment.
  • Conclusions from the interviews indicated that children with CF experience needle-related distress with associated physiological and behavioral reactions due to previous negative experiences, pain, and anticipatory anxiety. Coping strategies usually increase the child’s control over the situation (choosing where the needle be placed, counting 3,2,1, etc.), parental support, and familiar staff and trust. Interestingly, none of the children or parents mentioned distractions – which is an evidence-based treatment for reducing needle-related anxiety and medical procedure-related anxiety.
  • Read objective. Participants were recruited from both BCH and CHP and were screened in two steps – CDI child and parent-report, and then K-SADS-PL. Major depression and dysthymic disorders were excluded as were depression requiring repeated hospitalizations, antidepressant medication within the two weeks prior to assessment, substance abuse/dependence issues only because those randomly assigned to the control condition would not have therapist contact.Besides the CDI, CDI-P, and K-SADS-PL, investigators measured cognitive processing with The Perceived Control Scale for Children (PCSC) and The Children’s Global Assessment Scale (CGAS).
  • PASCET-PI consisted of 9 modules via phone or face-to-face sessions – focused on targeting depression and teaching skills to improve cognitions and behaviors related to IBD. Trained therapists delivered the interventions.Results indicated to significant differences between groups at baseline, but significant treatment effects were observed in all four measures – the child depression index parent and child reported, the measure for affective disorders and schizophrenia and school-aged children, the generalized anxiety scale, and the perceived control scale for children.
  • Read objective. The article gave a great background on common Middle Eastern cultural values, specifically beliefs pertaining to mental health care, medical care, and the family structure and hierarchies. Authors illustrated this with a few case vignettes, and I’d like to read one today for you. Names have been changed.Faisal – father did not buy into mental healthcare, so Faisal reported dissatisfaction with the therapy, Faisal’s parents thought his fear was medical, not mental and taught them about anxiety, difficulty coping with refugee status  Faisal not being able to cope with needlesNadia – prayer required her to move a lot, get down on the ground, considered exercise and worked with family to accept prayer without physical exertion for her healthSalma – collectivist family structure, more permissive parenting styles when addressing Salma’s refusal to take her medicine, therapist worked with family on this to encourage her behavioral management
  • Read conclusions…
  • Read conclusions and bring back to this week’s readings…
  • Read slide and give examples…
  • Psychotherapy in Youth with Chronic Illness

    1. 1. J I L L P L E V I N S K YA P R I L 1 5 , 2 0 1 3Psychotherapy in Youth withChronic Illness
    2. 2. Outline A brief overview of pediatric psychology Psychosocial effects of chronic illness in youth Treatment research on psychotherapy in childrenand adolescents with chronic illness Conclusions and ideas for future research
    3. 3. Definition of Pediatric Psychology “A multi-facted and integrated field of both scientificresearch and clinical practice that focuses onaddressing a wide range of physical andpsychological issues related to promoting the healthand development of children, adolescents, and theirfamilies, with an emphasis on evidence-basedmethods” (Roberts & Steele, 2009, p. 3).Roberts & Steele (2009)
    4. 4. Founders of Pediatric Psychology• Aaron Gesell was one of the firstclinical psychologists to also earn hisMD, and suggested that the need forclinical psychologists to address thepsychological issues of children inmedical settings (Gesell, 1919).• J.E. Anderson (1930) also made a presentation to theAmerican Medical Association stating the potential benefitsof the collaboration between pediatricians and clinicalpsychology.Roberts & Steele (2009)
    5. 5. Research Questions and Design in PediatricPsychology Relationships between variables and differences betweengroups Experimental and treatment outcome designs (RCTs) Quasi-experimental designs Observational research designs Case studies Meta-analysesRoberts & Steele (2009)
    6. 6. Psychosocial Effects of Chronic Illness Anxiety Depression Low self-esteem/self-efficacy Low quality of life Disrupted social development
    7. 7. Treatment Research in Pediatric Psychology Common chronic conditions evaluated tend toinclude those with complicated treatments andmanagement Asthma Cancer Cystic fibrosis Inflammatory bowel disease (IBD) Juvenile diabetes (Type I) Juvenile rheumatoid arthritis (JRA)
    8. 8. Understanding Needle Anxiety Objective: To explore the nature and management ofneedle-related distress in children and adolescents withcystic fibrosis. 14 parent-child dyads Diagnosed for at least 12 months and at least 7 years old Themes identified Perceived causes of needle-related distress Reactions to needles Coping strategies Management of needle anxiety Parents’ role during needles Staff influencesAyers et. al, 2011
    9. 9. Understanding Needle Anxiety Conclusions Children with CF experience needle-related distress withassociated physiological and behavioral reactions Coping usually increases the child’s control, parental support,familiar staff, and trust No one mentioned distractions, which has been previouslyshown as effective for reducing needle-related anxiety (Blountet al., 2006)Ayers et. al, 2011
    10. 10. Cognitive Behavioral Therapy for Adolescentswith IBD and Subsyndromal Depression Objective: To examine the feasibility and efficacy of a manual-basedcognitive-behavioral therapy in reducing depressive symptomologyin adolescents with inflammatory bowel disease. n = 41 Children’s Depression Inventory (CDI and CDI-P) Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL) Assessments at baseline and within two weeks of post-treatment Randomization was stratified according to severity of depression Other variables measured: cognitive processing, global functioning,and IBD severitySzigethy et al., 2007
    11. 11. Cognitive Behavioral Therapy for Adolescentswith IBD and Subsyndromal Depression Intervention procedures Comparison group received treatment as usual (TAU) Primary and Secondary Control Enhancement Training –Physical Illness (PASCET-PI) (Weisz et al., 1997) Results No significant differences between groups at baseline Treatment effect in all four measures was significant PASCET-PI group showed significant reduction in scores on CDI-CP, K-SADS, CGAS, and PCSC compared with the comparisongroupSzigethy et al., 2007
    12. 12. Cultural Adaptations of EBTs in PediatricPsychology Objective: To address the need for more research oncultural adaptations of EBTs, particularly with thosefrom the Middle East. Case vignettes “Faisal,” addressing needle phobia with systemicdesensitization and in vivo exposure “Nadia,” addressing anorexia using prescribed intake, limitedexercise, contigency management, and family therapy “Salma,” addressing poor treatment adherence to cancertreatment with parent behavior management training,establishing routines, and developing a behavioral planHilliard et al., 2012
    13. 13. Cultural Adaptations of EBTs in PediatricPsychology Conclusions There’s clearly a need for more research in this area Pediatric psychology’s biopsychosocial approach is needed todo so Healthcare teams should perceive cultural factors asopportunities for enhanced, personalized treatment, notbarriers Treatment adaptations can be beneficial in many casesHilliard et al., 2012
    14. 14. Pediatric Psychology, EBTs, and CulturalCompetency Overall conclusions Pediatric psychology needs more EBTs for children andadolescents battling severe chronic illnesses, and theseinterventions need to consider perceptions of treatments on anindividual level and a cultural level Limitations Small sample sizes Limited resources Many confounding variables (very difficult to isolatemechanisms of change)
    15. 15. Future Directions Behavioral EBTs utilizing technology Group-based therapy vs. individual therapy Interventions delivered via Skype, or web-basedmodules More multi-disciplinary approaches involvingphysicians, nurses, and psychologists workingtogether
    16. 16. Discussion Given what we know about diverse populations fromthis week’s readings, if you were to conduct an RCTfor an intervention to promote mental health amongyouth with chronic illnesses, would you design thestudy to be illness-specific? Why/why not?
    17. 17. References Ayers, S., Muller, I., Mahoney, L., & Seddon, P. (2011). Understanding needle-relateddistress in children with cystic fibrosis. British Journal of Health Psychology. 16. 329-343. Blount, R.L., Piira, T., Cohen, L.L., & Cheng, P.S. (2006). Pediatric procedural pain.Behavior Modification. 30. 24-49. Hilliard, M.E., Ernst, M.M., Gray, W.N., Saeed, S.A., & Cortina, S. (2012). Adaptingpediatric psychology interventions: Lessons learned in treating families from the MiddleEast. Journal of Pediatric Psychology. 37(8). 882-892. Roberts, M.C. & Steele, R.G. (2009). Handbook of pediatric psychology. New York: TheGuilford Press. Szigethy, E. Kenney, E., Carpenter, J., Hardy, D.M., Fairclough, D., Bousvaros, A., Keljo,D., Weisz, J., Beardslee, W.R., Noll, R. & DeMaso, D.R. (2007). Cognitive-behavioraltherapy for adolescents with inflammatory bowel disease and subsyndromal depression.Journal of the American Academy of Child and Adolescent Psychiatry. 46(10). 1290-1298. Weisz, J., Thurber, C.A., Sweeney, L., Proffitt, V.D., & LeGagnoux, G.I. (1997). Brieftreatment of mild-to-moderate child depression using primary and secondary controlenhancement training. Journal of Consulting and Clinical Psychology. 65. 703-707.