CCIntroduction to Pediatric Psychology.ppt


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CCIntroduction to Pediatric Psychology.ppt

  1. 1. Introduction to Pediatric Psychology Gregg Selke, Ph.D. November 14, 2006 PSY 4930
  2. 2. What is Pediatric Psychology? <ul><li>Concerned with physical health and illness of children and the relationship between psychological/behavioral factors and health, illness, and disease. </li></ul><ul><li>“ Pediatric Psychology” first coined in 1967 by Logan Wright, “dealing primarily with children in a medical setting which is nonpsychiatric in nature” (p. 323) </li></ul>
  3. 3. Roots of Pediatric Psychology
  4. 4. Defining Features <ul><li>Promotion of healthy behaviors </li></ul><ul><li>Prevention of problematic health effects (e.g., unhealthy lifestyles, behavioral patterns….overeating) </li></ul><ul><li>Goal: Target behaviors early in life or early in the onset of a chronic medical condition </li></ul>
  5. 5. Clinical Activities: Settings <ul><li>Inpatient medical units </li></ul><ul><ul><li>Consultation/liaison services </li></ul></ul><ul><ul><li>Medical units such as hem/onc, burn, PICU </li></ul></ul><ul><li>Medical outpatient clinics </li></ul><ul><ul><li>Private pediatric practices </li></ul></ul><ul><ul><li>Clinics such as craniofacial, endocrinology </li></ul></ul><ul><li>Outpatient psychology clinics </li></ul>
  6. 6. Clinical Activities: Settings <ul><li>Specialty clinics </li></ul><ul><ul><li>Physical rehabilitation centers, Child study centers </li></ul></ul><ul><li>Camps or groups </li></ul><ul><ul><li>Camps for children with chronic illness </li></ul></ul>
  7. 7. Types of Issues <ul><li>Problems related to pediatric conditions </li></ul><ul><ul><li>Adjustment to disease </li></ul></ul><ul><ul><li>Adherence </li></ul></ul><ul><ul><li>Coping with procedural pain </li></ul></ul><ul><li>Mental health problems arising in medical units </li></ul><ul><ul><li>Behavior problems while hospitalized (e.g., noncompliance) </li></ul></ul><ul><ul><li>Bereavement (Death and Dying issues) </li></ul></ul><ul><ul><li>Reintegration into school after hospitalization </li></ul></ul>
  8. 8. Types of Issues <ul><li>General mental health concerns </li></ul><ul><li>Programs for health promotion and early intervention </li></ul><ul><ul><li>Programs to increase physical activity </li></ul></ul><ul><ul><li>Early intervention with high-risk infants </li></ul></ul><ul><li>Mental retardation and developmental disabilities </li></ul><ul><ul><li>Assess, train, and educate parents and professionals </li></ul></ul><ul><li>Education/consultation for physicians </li></ul><ul><li>Public health and public policy </li></ul>
  9. 9. It Looks Physical, But is it? <ul><li>The pediatric psychologist is often called on by physicians to determine whether psychological factors are contributing to or causing a child problems </li></ul><ul><li>DSM-IV diagnostic categories of: </li></ul><ul><ul><li>Somatization Disorders </li></ul></ul><ul><ul><li>Conversion Disorders </li></ul></ul><ul><ul><li>Psychological Factors Affecting Medical Condition </li></ul></ul><ul><ul><li>Feeding and Eating Disorders of Infancy or Early Childhood </li></ul></ul><ul><ul><ul><li>Pica, Rumination Disorder, Feeding Disorder of Infancy and Early Childhood </li></ul></ul></ul>
  10. 10. Somatization Disorder <ul><li>History of many physical complaints that occur over a period of years and result in treatment being sought or significant impairment in functioning. </li></ul><ul><li>Following symptoms have been displayed </li></ul><ul><ul><li>Four pain symptoms </li></ul></ul><ul><ul><li>Two GI symptoms </li></ul></ul><ul><ul><li>One sexual symptom </li></ul></ul><ul><ul><li>One psuedoneurological symptom </li></ul></ul><ul><li>Symptoms cannot be fully explained by known medical condition or substance use. </li></ul><ul><li>If medical condition is present, symptoms are beyond that expected for condition. </li></ul>
  11. 11. Conversion Disorder <ul><li>One or more symptoms or deficits affecting voluntary, motor or sensory functions that suggest a neurological or other general medical condition ( and causes distress or impairment). </li></ul><ul><li>Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptoms or deficit is preceded by conflicts or other stressors. </li></ul><ul><li>Symptom not fully explained by a general medical condition or substance or culture. </li></ul>
  12. 12. Psychological Factor Affecting Medical Condition <ul><li>A general medical condition is present. </li></ul><ul><li>Psychological factors adversely affect the medical condition in one of the following ways: </li></ul><ul><ul><li>The factors have influenced the course of the medical condition - as shown by a close temporal relationship between psychological factors and the development or exacerbation, or delayed recovery from the condition. </li></ul></ul>
  13. 13. Psychological Factors Affecting Medical Condition <ul><ul><li>The factors interfere with the treatment of medical condition </li></ul></ul><ul><ul><li>The factors cause additional health risks </li></ul></ul><ul><ul><li>Stress-related physiological responses precipitate or exacerbate symptoms of the general medical condition </li></ul></ul><ul><ul><li>Example: </li></ul></ul><ul><ul><ul><li>Depression and diabetes </li></ul></ul></ul><ul><ul><ul><li>Needle phobia and diabetes </li></ul></ul></ul>
  14. 14. Diagnostic Criteria for 307.59 Feeding Disorder of Infancy or Early Childhood <ul><li>A. Feeding disturbance as manifested by persistent failure to eat adequately with significant failure to gain weight or significant loss of weight over at least 1 month. </li></ul><ul><li>B. The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux). </li></ul><ul><li>C. The disturbance is not better accounted for by another mental disorder (e.g., Rumination Disorder) or by lack of available food. </li></ul><ul><li>D. The onset is before age 6 years. </li></ul>
  15. 15. Considerations in Psychological/Medical Links <ul><li>With some medical disorders it is difficult to assess and find the real cause of the symptoms you are being consulted about. </li></ul><ul><li>The fact that psychological factors are found to exist does not necessarily mean that they are causally related to an existing medical symptoms </li></ul><ul><li>There is a difference between correlation and causation </li></ul>
  16. 16. Psych Problems Due to Medical Conditions <ul><li>Depression, anxiety or other psychological issues can result from dealing with chronic illnesses or stressful medical conditions </li></ul><ul><ul><li>coping with disorders such as cancer, cystic fibrosis, craniofacial disorders </li></ul></ul><ul><ul><li>having to undergo painful treatments such as burn patients </li></ul></ul><ul><li>These child may often benefit from therapy </li></ul><ul><li>Parents of these children may also need help in coping with these types of conditions in their children </li></ul>
  17. 17. Things to Look For <ul><li>Do psychologically relevant factors (eg., trauma, stress, life disruptions, etc.) precede onset. </li></ul><ul><li>Do these factors exacerbate “medical” symptoms. </li></ul><ul><li>Is it possible to find evidence for secondary gain resulting from the “medical symptom” or “disorder”. </li></ul><ul><li>Be cautions of “as yet undiagnosed” medical conditions that may really account for symptoms . </li></ul><ul><li>Cases referred for evaluation often turn out to have some sort of physical problem. </li></ul>
  18. 18. Case Examples <ul><li>Adolescent who had nauseau, dizziness, and collapsing “spells” </li></ul><ul><li>The girl who refused to eat </li></ul>
  19. 19. Case Examples <ul><li>Role of Pediatric Psychologist </li></ul><ul><ul><li>Systematic Assessment of Antecedents and Consequences (Reinforcement Contingencies </li></ul></ul><ul><ul><li>Determine effective/noneffective strategies of treatment team and family </li></ul></ul><ul><ul><li>Strategies: Contingent or differential social attention, shaping and fading procedures, positive reinforcement (verbal and tangible rewards) </li></ul></ul><ul><ul><li>Liaison between PT, OT, Speech, and family </li></ul></ul>
  20. 20. Examples of Pediatric Psychologists on UF Clinic Teams <ul><li>Transplant Evaluations </li></ul><ul><li>Diabetes Clinic </li></ul><ul><li>Craniofacial Clinic </li></ul>
  21. 21. Transplantation Evaluations <ul><li>Pediatric psychologists work with children being considered for transplantation </li></ul><ul><ul><li>bone marrow transplants, heart transplants, lung transplants, kidney transplants </li></ul></ul><ul><li>Determining whether the child/family is a good candidate for a transplant </li></ul><ul><ul><li>Assessment of medical and psychosocial issues that contribute to the overall decision making process </li></ul></ul><ul><ul><li>Contraindicating Factors? </li></ul></ul>
  22. 22. Issues to Consider in Pre-Transplant Evaluation <ul><li>Presence of major psychological issues in child or parent that could compromise maintenance of the transplant </li></ul><ul><li>Knowledge of what is involved in the transplant process </li></ul><ul><li>Motivation for transplantation </li></ul><ul><li>Barriers to adherence—past behavior best predicts future behavior </li></ul><ul><li>Stress and coping </li></ul><ul><li>Social support </li></ul>
  23. 23. Pediatric Endocrinology Clinic <ul><li>Outpatient tertiary care clinic </li></ul><ul><li>Psychologist serves as a consultant in a multidisciplinary team </li></ul><ul><ul><li>Pediatric endocrinologist </li></ul></ul><ul><ul><li>Nurses, nurse practitioners </li></ul></ul><ul><ul><li>Diabetes educators </li></ul></ul><ul><ul><li>Nutritionists </li></ul></ul><ul><ul><li>Residents, fellows </li></ul></ul>
  24. 24. Pediatric Endocrinology Clinic <ul><li>Most patients have type 1 diabetes (but also type 2 and other endocrine disorders) </li></ul><ul><li>Physician refers patients for: </li></ul><ul><ul><li>Adjustment difficulties </li></ul></ul><ul><ul><li>Poor functioning (academic, behavioral, family, emotional) </li></ul></ul><ul><ul><li>Poor adherence/diabetes control </li></ul></ul>
  25. 25. Pediatric Endocrinology Clinic <ul><li>Psychologist conducts brief assessments (15-30 minutes) and provides feedback to the family and physician </li></ul><ul><li>Family feedback </li></ul><ul><ul><li>Referrals </li></ul></ul><ul><ul><li>Behavioral recommendations </li></ul></ul><ul><ul><li>Problem solving </li></ul></ul><ul><li>Physician feedback </li></ul><ul><ul><li>Referrals </li></ul></ul><ul><ul><li>Prognosis </li></ul></ul><ul><ul><li>Treatment regimen change? </li></ul></ul>
  26. 26. Peds Endo Consult <ul><li>Information collected about: </li></ul><ul><ul><li>Diabetes care </li></ul></ul><ul><ul><li>Emotional functioning </li></ul></ul><ul><ul><li>Academic functioning </li></ul></ul><ul><ul><li>Behavioral functioning </li></ul></ul><ul><ul><li>Social functioning </li></ul></ul>
  27. 27. Pediatric Endocrinology Consult: Typical Issues <ul><li>Poor adherence </li></ul><ul><ul><li>Inappropriate level of responsibility for child </li></ul></ul><ul><ul><li>Overbearing parent </li></ul></ul><ul><ul><li>Arguing about the diabetes regimen </li></ul></ul><ul><ul><li>Poor understanding of diabetes regimen </li></ul></ul><ul><ul><li>Stressors/life events impact adherence </li></ul></ul><ul><li>Emotional, Academic, Social, Behavioral functioning </li></ul><ul><ul><li>Poor functioning related to diabetes care or other issues </li></ul></ul>
  28. 28. Craniofacial Clinic <ul><li>Clinic for children with genetic craniofacial abnormalities </li></ul><ul><ul><li>Cleft lip and/or palate </li></ul></ul><ul><ul><li>Craniosynostosis </li></ul></ul><ul><ul><ul><li>Premature fusion of the sutures of the skull </li></ul></ul></ul><ul><ul><li>H emifacial microsomia </li></ul></ul><ul><ul><ul><li>Malformation of the jaw, cheek and ear associated with vertebral defects, with deformity of the external ear and abnormal smallness of that half of the face. </li></ul></ul></ul><ul><li>Psychologist is a member of an interdisciplinary team including: </li></ul><ul><ul><li>Physicians, general surgeons, plastic surgeons, dentists, oral surgeons, nurse, social worker, insurance representative, orthodontists </li></ul></ul>
  29. 29. Craniofacial Clinic <ul><li>Psychologist conducts a brief assessment of every patient </li></ul><ul><li>Issues assessed: </li></ul><ul><ul><li>Medical issues </li></ul></ul><ul><ul><li>Social functioning </li></ul></ul><ul><ul><li>Development </li></ul></ul><ul><ul><li>Academic, psychological, and behavioral functioning </li></ul></ul>
  30. 30. Recent Developments in Pediatric Psychology <ul><li>APA Division Status </li></ul><ul><ul><li>2001: The Society of Pediatric Psychology became Division 54 in APA </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>Differentiated from clinical child, clinical, and health psychology </li></ul></ul><ul><ul><li>Made the field more recognized and viable </li></ul></ul><ul><ul><li>Led to collaborations with the American Academy of Pediatrics </li></ul></ul>
  31. 31. Current trends <ul><li>Managed Care and Reimbursement </li></ul><ul><ul><li>Has negatively affected delivery of services </li></ul></ul><ul><ul><li>Many peds psych services are not covered by insurance: </li></ul></ul><ul><ul><ul><li>Pain management </li></ul></ul></ul><ul><ul><ul><li>Interventions to increase adherence </li></ul></ul></ul><ul><ul><ul><li>Work on multidisciplinary teams </li></ul></ul></ul>
  32. 32. Response to Managed Care <ul><li>Medical Cost Offset Research </li></ul><ul><ul><li>“ The cost of pediatric psychology services would be ‘offset’ by savings in medical expedenditures” (Roberts, Mitchell, & McNeal, 2003, p. 14) </li></ul></ul><ul><li>This research is somewhat controversial </li></ul>
  33. 33. Major Developments Place of Employment <ul><li>Primary Care </li></ul><ul><ul><li>Pediatric psychologists are moving away from university-based hospitals </li></ul></ul><ul><ul><li>Focusing more on primary care intervention and prevention activities </li></ul></ul>