Introduction to Pediatric Introduction to Pediatric PsychologyPsychology

Gregg Selke, Ph.D.

November 14, 2006

PSY 4930

What is Pediatric Psychology?What is Pediatric Psychology?

Concerned with physical health and illness of children and the relationship between psychological/behavioral factors and health, illness, and disease.

“Pediatric Psychology” first coined in 1967 by Logan Wright, “dealing primarily with children in a medical setting which is nonpsychiatric in nature” (p. 323)

Roots of Pediatric PsychologyRoots of Pediatric Psychology

C lin ica l C h ild P sych o lo gyD e ve lo p m e n ta l C o ns id e ra tio ns

Im p ortan ce o f the fam ily

H e a lth P sych o lo gyIn te ra ctio n b e tw ee n h e a lth a nd

p sycho lo g ica l fu n c tio n ing

P e d ia tric P sych o lo gy

Defining FeaturesDefining Features

1. Promotion of healthy behaviors

2. Prevention of problematic health effects (e.g., unhealthy lifestyles, behavioral patterns….overeating)

Goal: Target behaviors early in life or early in the onset of a chronic medical condition

Clinical Activities: SettingsClinical Activities: Settings

Inpatient medical units– Consultation/liaison services– Medical units such as hem/onc, burn, PICU

Medical outpatient clinics– Private pediatric practices– Clinics such as craniofacial, endocrinology

Outpatient psychology clinics

Clinical Activities: SettingsClinical Activities: Settings

Specialty clinics– Physical rehabilitation centers, Child study

centersCamps or groups

– Camps for children with chronic illness

Types of Issues Types of Issues

Problems related to pediatric conditions– Adjustment to disease– Adherence– Coping with procedural pain

Mental health problems arising in medical units– Behavior problems while hospitalized (e.g.,

noncompliance)– Bereavement (Death and Dying issues)– Reintegration into school after hospitalization

Types of IssuesTypes of Issues General mental health concerns Programs for health promotion and early

intervention– Programs to increase physical activity– Early intervention with high-risk infants

Mental retardation and developmental disabilities– Assess, train, and educate parents and

professionals Education/consultation for physicians Public health and public policy

It Looks Physical, But is it?It Looks Physical, But is it? The pediatric psychologist is often called

on by physicians to determine whether psychological factors are contributing to or causing a child problems

DSM-IV diagnostic categories of:– Somatization Disorders – Conversion Disorders– Psychological Factors Affecting Medical

Condition– Feeding and Eating Disorders of Infancy or

Early Childhood Pica, Rumination Disorder, Feeding Disorder of

Infancy and Early Childhood

Somatization DisorderSomatization Disorder History of many physical complaints that occur

over a period of years and result in treatment being sought or significant impairment in functioning.

Following symptoms have been displayed– Four pain symptoms– Two GI symptoms– One sexual symptom– One psuedoneurological symptom

Symptoms cannot be fully explained by known medical condition or substance use.

If medical condition is present, symptoms are beyond that expected for condition.

Conversion DisorderConversion Disorder One or more symptoms or deficits affecting

voluntary, motor or sensory functions that suggest a neurological or other general medical condition (and causes distress or impairment).

Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptoms or deficit is preceded by conflicts or other stressors.

Symptom not fully explained by a general medical condition or substance or culture.

Psychological Factor Affecting Psychological Factor Affecting Medical Condition Medical Condition

A general medical condition is present.Psychological factors adversely affect the

medical condition in one of the following ways:– The factors have influenced the course of the

medical condition - as shown by a close temporal relationship between psychological factors and the development or exacerbation, or delayed recovery from the condition.

Psychological Factors Psychological Factors Affecting Medical ConditionAffecting Medical Condition

– The factors interfere with the treatment of medical condition

– The factors cause additional health risks– Stress-related physiological responses

precipitate or exacerbate symptoms of the general medical condition

– Example:Depression and diabetesNeedle phobia and diabetes

Diagnostic Criteria for 307.59 Feeding Diagnostic Criteria for 307.59 Feeding Disorder of Infancy or Early ChildhoodDisorder of Infancy or Early Childhood

A. Feeding disturbance as manifested by persistent failure to eat adequately with significant failure to gain weight or significant loss of weight over at least 1 month.

B. The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux).

C. The disturbance is not better accounted for by another mental disorder (e.g., Rumination Disorder) or by lack of available food.

D. The onset is before age 6 years.

Considerations in Considerations in Psychological/Medical LinksPsychological/Medical Links

With some medical disorders it is difficult to assess and find the real cause of the symptoms you are being consulted about.

The fact that psychological factors are found to exist does not necessarily mean that they are causally related to an existing medical symptoms

There is a difference between correlation and causation

Psych Problems Due to Medical Psych Problems Due to Medical ConditionsConditions

Depression, anxiety or other psychological issues can result from dealing with chronic illnesses or stressful medical conditions– coping with disorders such as cancer, cystic fibrosis,

craniofacial disorders– having to undergo painful treatments such as burn

patients These child may often benefit from therapy Parents of these children may also need help in

coping with these types of conditions in their children

Things to Look ForThings to Look For Do psychologically relevant factors (eg.,

trauma, stress, life disruptions, etc.) precede onset.

Do these factors exacerbate “medical” symptoms.

Is it possible to find evidence for secondary gain resulting from the “medical symptom” or “disorder”.

Be cautions of “as yet undiagnosed” medical conditions that may really account for symptoms.

Cases referred for evaluation often turn out to have some sort of physical problem.

Case ExamplesCase Examples

1. Adolescent who had nauseau, dizziness, and collapsing “spells”

2. The girl who refused to eat

Case ExamplesCase ExamplesRole of Pediatric Psychologist

– Systematic Assessment of Antecedents and Consequences (Reinforcement Contingencies

– Determine effective/noneffective strategies of treatment team and family

– Strategies: Contingent or differential social attention, shaping and fading procedures, positive reinforcement (verbal and tangible rewards)

– Liaison between PT, OT, Speech, and family

Examples of Pediatric Examples of Pediatric Psychologists on UF Clinic Psychologists on UF Clinic

TeamsTeamsTransplant EvaluationsDiabetes ClinicCraniofacial Clinic

Transplantation EvaluationsTransplantation EvaluationsPediatric psychologists work with children

being considered for transplantation– bone marrow transplants, heart transplants,

lung transplants, kidney transplantsDetermining whether the child/family is a

good candidate for a transplant– Assessment of medical and psychosocial

issues that contribute to the overall decision making process

– Contraindicating Factors?

Issues to Consider in Pre-Issues to Consider in Pre-Transplant EvaluationTransplant Evaluation

Presence of major psychological issues in child or parent that could compromise maintenance of the transplant

Knowledge of what is involved in the transplant process

Motivation for transplantation Barriers to adherence—past behavior best

predicts future behavior Stress and coping Social support

Pediatric Endocrinology ClinicPediatric Endocrinology Clinic

Outpatient tertiary care clinicPsychologist serves as a consultant in a

multidisciplinary team– Pediatric endocrinologist– Nurses, nurse practitioners– Diabetes educators– Nutritionists– Residents, fellows

Pediatric Endocrinology ClinicPediatric Endocrinology Clinic

Most patients have type 1 diabetes (but also type 2 and other endocrine disorders)

Physician refers patients for:– Adjustment difficulties– Poor functioning (academic, behavioral,

family, emotional)– Poor adherence/diabetes control

Pediatric Endocrinology ClinicPediatric Endocrinology Clinic Psychologist conducts brief assessments (15-

30 minutes) and provides feedback to the family and physician

Family feedback– Referrals– Behavioral recommendations– Problem solving

Physician feedback– Referrals– Prognosis– Treatment regimen change?

Peds Endo ConsultPeds Endo Consult

Information collected about:– Diabetes care– Emotional functioning– Academic functioning– Behavioral functioning– Social functioning

Pediatric Endocrinology Pediatric Endocrinology Consult: Typical IssuesConsult: Typical Issues

Poor adherence– Inappropriate level of responsibility for child– Overbearing parent– Arguing about the diabetes regimen– Poor understanding of diabetes regimen– Stressors/life events impact adherence

Emotional, Academic, Social, Behavioral functioning– Poor functioning related to diabetes care or

other issues

Craniofacial ClinicCraniofacial Clinic Clinic for children with genetic craniofacial

abnormalities– Cleft lip and/or palate– Craniosynostosis

Premature fusion of the sutures of the skull

– Hemifacial microsomia Malformation of the jaw, cheek and ear associated with

vertebral defects, with deformity of the external ear and abnormal smallness of that half of the face.

Psychologist is a member of an interdisciplinary team including:– Physicians, general surgeons, plastic surgeons,

dentists, oral surgeons, nurse, social worker, insurance representative, orthodontists

Craniofacial ClinicCraniofacial Clinic

Psychologist conducts a brief assessment of every patient

Issues assessed:– Medical issues– Social functioning– Development– Academic, psychological, and behavioral

functioning

Recent Developments in Recent Developments in Pediatric PsychologyPediatric Psychology

APA Division Status– 2001: The Society of Pediatric Psychology

became Division 54 in APA– http://apa.org/divisions/div54/– Differentiated from clinical child, clinical,

and health psychology– Made the field more recognized and viable– Led to collaborations with the American

Academy of Pediatrics

Current trendsCurrent trendsManaged Care and Reimbursement

– Has negatively affected delivery of services

– Many peds psych services are not covered by insurance:Pain managementInterventions to increase

adherenceWork on multidisciplinary teams

Response to Managed CareResponse to Managed Care

Medical Cost Offset Research– “The cost of pediatric psychology

services would be ‘offset’ by savings in medical expedenditures” (Roberts, Mitchell, & McNeal, 2003, p. 14)

This research is somewhat controversial

Major DevelopmentsMajor DevelopmentsPlace of EmploymentPlace of Employment

Primary Care– Pediatric psychologists are moving

away from university-based hospitals– Focusing more on primary care

intervention and prevention activities