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Introduction to Pediatric Psychology


									Introduction to Pediatric

   Gregg Selke, Ph.D.
   November 14, 2006
       PSY 4930
    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 Psychology

                    Pediatric Psychology

  Clinical Child Psychology          Health Psychology
Developmental Considerations   Interaction between health and
  Importance of the family        psychological functioning
           Defining 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
    Clinical 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: Settings
   Specialty clinics
    – Physical rehabilitation centers, Child study
   Camps or groups
    – Camps for children with chronic illness
             Types of Issues
   Problems related to pediatric conditions
    – Adjustment to disease
    – Adherence
    – Coping with procedural pain
   Mental health problems arising in medical
    – Behavior problems while hospitalized (e.g.,
    – Bereavement (Death and Dying issues)
    – Reintegration into school after hospitalization
             Types of Issues
 General mental health concerns
 Programs for health promotion and early
    – Programs to increase physical activity
    – Early intervention with high-risk infants
   Mental retardation and developmental
    – Assess, train, and educate parents and
 Education/consultation for physicians
 Public health and public policy
    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
    – Feeding and Eating Disorders of Infancy or
      Early Childhood
          Pica, Rumination Disorder, Feeding Disorder of
           Infancy and Early Childhood
             Somatization Disorder
 History of many physical complaints that occur
  over a period of years and result in treatment
  being sought or significant impairment in
 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 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
 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
         Medical Condition
 A general medical condition is present.
 Psychological factors adversely affect the
  medical condition in one of the following
    – 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
Affecting 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 diabetes

    Needle phobia and diabetes
  Diagnostic Criteria for 307.59 Feeding
  Disorder 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
    Psychological/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
 Psych Problems Due to Medical
   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
 These child may often benefit from therapy
 Parents of these children may also need help in
  coping with these types of conditions in their
            Things to Look For
   Do psychologically relevant factors (eg.,
    trauma, stress, life disruptions, etc.) precede
   Do these factors exacerbate ―medical‖
   Is it possible to find evidence for secondary
    gain resulting from the ―medical symptom‖ or
   Be cautions of ―as yet undiagnosed‖ medical
    conditions that may really account for
   Cases referred for evaluation often turn out to
    have some sort of physical problem.
           Case Examples
1.   Adolescent who had nauseau,
     dizziness, and collapsing ―spells‖

2.   The girl who refused to eat
             Case Examples
   Role of Pediatric Psychologist
    – Systematic Assessment of Antecedents
      and Consequences (Reinforcement
    – Determine effective/noneffective strategies
      of treatment team and family
    – Strategies: Contingent or differential social
      attention, shaping and fading procedures,
      positive reinforcement (verbal and tangible
    – Liaison between PT, OT, Speech, and
  Examples of Pediatric
Psychologists on UF Clinic
 Transplant Evaluations
 Diabetes Clinic
 Craniofacial Clinic
    Transplantation Evaluations
   Pediatric psychologists work with children
    being considered for transplantation
    – bone marrow transplants, heart transplants,
      lung transplants, kidney transplants
   Determining 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-
      Transplant 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 Clinic
 Outpatient tertiary care clinic
 Psychologist serves as a consultant in a
  multidisciplinary team
    –   Pediatric endocrinologist
    –   Nurses, nurse practitioners
    –   Diabetes educators
    –   Nutritionists
    –   Residents, fellows
Pediatric Endocrinology Clinic
 Most patients have type 1 diabetes (but
  also type 2 and other endocrine
 Physician refers patients for:
    – Adjustment difficulties
    – Poor functioning (academic, behavioral,
      family, emotional)
    – Poor adherence/diabetes control
Pediatric 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 Consult
   Information collected about:
    – Diabetes care
    – Emotional functioning
    – Academic functioning
    – Behavioral functioning
    – Social functioning
        Pediatric Endocrinology
        Consult: 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 Clinic
   Clinic for children with genetic craniofacial
    – 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 Clinic
 Psychologist conducts a brief
  assessment of every patient
 Issues assessed:
    –   Medical issues
    –   Social functioning
    –   Development
    –   Academic, psychological, and behavioral
        Recent Developments in
         Pediatric Psychology
   APA Division Status
    – 2001: The Society of Pediatric Psychology
        became Division 54 in APA
    –   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 trends
   Managed Care and Reimbursement
    – Has negatively affected delivery of
    – Many peds psych services are not
      covered by insurance:
        Pain management

        Interventions to increase

        Work on multidisciplinary teams
    Response 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 Developments
        Place of Employment

   Primary Care
    – Pediatric psychologists are moving
      away from university-based hospitals
    – Focusing more on primary care
      intervention and prevention activities

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