This document discusses psychotherapy for youth with chronic illnesses. It begins with an overview of pediatric psychology and the psychosocial effects of chronic illness in youth. It then reviews treatment research on psychotherapy for children and adolescents with chronic conditions like asthma, cancer, cystic fibrosis, and juvenile diabetes. Two studies are discussed in depth: one on cognitive behavioral therapy to reduce needle anxiety in youth with cystic fibrosis, and another on CBT for adolescents with inflammatory bowel disease and subsyndromal depression. The document concludes by calling for more culturally-competent evidence-based treatments and future research directions in pediatric psychology.

1. J I L L P L E V I N S K Y
A P R I L 1 5 , 2 0 1 3
Psychotherapy in Youth with
Chronic Illness

2. Outline
 A brief overview of pediatric psychology
 Psychosocial effects of chronic illness in youth
 Treatment research on psychotherapy in children
and adolescents with chronic illness
 Conclusions and ideas for future research

3. Definition of Pediatric Psychology
 “A multi-facted and integrated field of both scientific
research and clinical practice that focuses on
addressing a wide range of physical and
psychological issues related to promoting the health
and development of children, adolescents, and their
families, with an emphasis on evidence-based
methods” (Roberts & Steele, 2009, p. 3).
Roberts & Steele (2009)

4. Founders of Pediatric Psychology
• Aaron Gesell was one of the first
clinical psychologists to also earn his
MD, and suggested that the need for
clinical psychologists to address the
psychological issues of children in
medical settings (Gesell, 1919).
• J.E. Anderson (1930) also made a presentation to the
American Medical Association stating the potential benefits
of the collaboration between pediatricians and clinical
psychology.
Roberts & Steele (2009)

5. Research Questions and Design in Pediatric
Psychology
 Relationships between variables and differences between
groups
 Experimental and treatment outcome designs (RCTs)
 Quasi-experimental designs
 Observational research designs
 Case studies
 Meta-analyses
Roberts & Steele (2009)

6. Psychosocial Effects of Chronic Illness
 Anxiety
 Depression
 Low self-esteem/self-efficacy
 Low quality of life
 Disrupted social development

7. Treatment Research in Pediatric Psychology
 Common chronic conditions evaluated tend to
include those with complicated treatments and
management
 Asthma
 Cancer
 Cystic fibrosis
 Inflammatory bowel disease (IBD)
 Juvenile diabetes (Type I)
 Juvenile rheumatoid arthritis (JRA)

8. Understanding Needle Anxiety
 Objective: To explore the nature and management of
needle-related distress in children and adolescents with
cystic 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 influences
Ayers et. al, 2011

9. Understanding Needle Anxiety
 Conclusions
 Children with CF experience needle-related distress with
associated physiological and behavioral reactions
 Coping usually increases the child’s control, parental support,
familiar staff, and trust
 No one mentioned distractions, which has been previously
shown as effective for reducing needle-related anxiety (Blount
et al., 2006)
Ayers et. al, 2011

10. Cognitive Behavioral Therapy for Adolescents
with IBD and Subsyndromal Depression
 Objective: To examine the feasibility and efficacy of a manual-based
cognitive-behavioral therapy in reducing depressive symptomology
in 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 severity
Szigethy et al., 2007

11. Cognitive Behavioral Therapy for Adolescents
with 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 comparison
group
Szigethy et al., 2007

12. Cultural Adaptations of EBTs in Pediatric
Psychology
 Objective: To address the need for more research on
cultural adaptations of EBTs, particularly with those
from the Middle East.
 Case vignettes
 “Faisal,” addressing needle phobia with systemic
desensitization and in vivo exposure
 “Nadia,” addressing anorexia using prescribed intake, limited
exercise, contigency management, and family therapy
 “Salma,” addressing poor treatment adherence to cancer
treatment with parent behavior management training,
establishing routines, and developing a behavioral plan
Hilliard et al., 2012

13. Cultural Adaptations of EBTs in Pediatric
Psychology
 Conclusions
 There’s clearly a need for more research in this area
 Pediatric psychology’s biopsychosocial approach is needed to
do so
 Healthcare teams should perceive cultural factors as
opportunities for enhanced, personalized treatment, not
barriers
 Treatment adaptations can be beneficial in many cases
Hilliard et al., 2012

14. Pediatric Psychology, EBTs, and Cultural
Competency
 Overall conclusions
 Pediatric psychology needs more EBTs for children and
adolescents battling severe chronic illnesses, and these
interventions need to consider perceptions of treatments on an
individual level and a cultural level
 Limitations
 Small sample sizes
 Limited resources
 Many confounding variables (very difficult to isolate
mechanisms of change)

15. Future Directions
 Behavioral EBTs utilizing technology
 Group-based therapy vs. individual therapy
 Interventions delivered via Skype, or web-based
modules
 More multi-disciplinary approaches involving
physicians, nurses, and psychologists working
together

16. Discussion
 Given what we know about diverse populations from
this week’s readings, if you were to conduct an RCT
for an intervention to promote mental health among
youth with chronic illnesses, would you design the
study to be illness-specific? Why/why not?

17. References
 Ayers, S., Muller, I., Mahoney, L., & Seddon, P. (2011). Understanding needle-related
distress 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). Adapting
pediatric psychology interventions: Lessons learned in treating families from the Middle
East. Journal of Pediatric Psychology. 37(8). 882-892.
 Roberts, M.C. & Steele, R.G. (2009). Handbook of pediatric psychology. New York: The
Guilford 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-behavioral
therapy 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). Brief
treatment of mild-to-moderate child depression using primary and secondary control
enhancement training. Journal of Consulting and Clinical Psychology. 65. 703-707.