Pediatric Psychology Training models and content Palermo, Sicily January 2017 Michael C. Roberts, PhD, ABPP Clinical Child Psychology Program University of Kansas

Logan Wright’s “Role Model” Paper (1967) 1. Establish an identity through a formal organization 2. Construct new knowledge through applied research 3. Focus on professional training in the specialty

Logan Wright’s “Role Model” Paper (1967) 1. Establish an identity through a formal organization 2. Construct new knowledge through applied research 3. Focus on professional training in the specialty

SPP mission and vision statements ”SPP aims to promote the health and psychological well-being of children, youth and their families through science and an evidence-based approach to practice, education, training, advocacy, and consultation.” (2012) sani bambini, giovani e famiglie

pediatric psychologists provide: Psychosocial services for issues related to pediatric health conditions Psychological services for mental health problems appearing in medical settings along with a pediatric problem Assessment and treatment for psychological problems presenting in a medical setting without a concomitant medical condition Roberts, Aylward, & Wu (2014)

pediatric psychologists provide: Programs for health promotion, disease, and injury prevention, and early intervention Advocacy for public policy supporting children and families and promoting public health advancements Roberts, Aylward, & Wu (2014)

Pediatric psychology Training 1987: “No single path to becoming a pediatric psychologist” (La Greca et al.) 2017: Training now more developed and formal Didactic coursework Research Experience Clinical Practicum

Domains OF TRAINING In Pediatric psychology Lifespan developmental psychology and psychopathology Child, adolescent, and family assessment Intervention strategies Research methods and systems evaluations Professional, ethical, and legal issues Diversity considerations Spirito et al. (2003)

Domains OF TRAINING In Pediatric psychology Role of multiple disciplines in service delivery systems Prevention, family support, and health promotion Social issues affecting children, adolescents, and families Consultation and liaison roles Disease process and medical management Spirito et al. (2003)

Competency initiatives in professional psychology

Competency initiatives in professional psychology

Competencies in pediatric psychology Values and understands foundation underlying the practice of pediatric psychology Builds on strong foundation in clinical child psychology Has knowledge of biological, cognitive, social, affective, sociocultural, and lifespan developmental influences on children’s health and illness Palermo et al. (2015)

Competencies in pediatric psychology Understands pediatric acute and chronic illness, injury conditions, and medical management from the medical literature Has knowledge of the role and effect of families on children’s health and of health, of illness, and medical management on family functioning Has knowledge of the effect of socioeconomic factors on health and illness Palermo et al. (2015)

Competencies in pediatric psychology Understands how other systems affect pediatric health and illness and a child’s adaptation to illness Understands the roles of other disciplines in health service delivery systems Palermo et al. (2015)

Competencies in pediatric psychology Appreciates the function of health information technology in children’s healthcare Has knowledge of the transition of pediatric patients to adulthood and adult oriented health care Palermo et al. (2015)

Common presenting concerns and settings

presenting problems Unintentional injury Infants born prematurely or at biological risk Pain from medical procedures Pain from pediatric conditions Sleep disorders Juvenile idiopathic arthritis Pediatric HIV Asthma Diabetes Obesity Cancer Seizure disorders/epilepsy

presenting problems End of life issues Cystic fibrosis Sickle cell disease Pediatric organ Transplantation Feeding disorders Elimination disorders: enuresis and encopresis Traumatic brain injury Spina bifida Cardiovascular disease Pediatric burns Gastrointestinal disorders Autism spectrum disorder Attention deficit/hyperactive disorder Sexual development disorders and differences End of life issues

Outpatient setting interventions: hospital-based clinics Making broad and targeted assessments of functioning Teaching and facilitating use of problem-solving strategies Providing psychoeducation on relevant topics

Outpatient setting interventions: hospital-based clinics Facilitating communication between medical team and patient and family Implementing brief cognitive-behavioral or other therapeutic techniques to address referral question Referring to more intensive services if needed

Outpatient setting interventions: specialized care Providing psychoeducation on the rationale for recommended interventions Teaching families behavioral strategies (e.g., reinforcement, planned ignoring) to address noncompliance and aggression Using cognitive-behavioral or other therapeutic strategies to address mood or coping concerns

Outpatient setting interventions: Primary care Making brief assessment of referral concern Providing psychoeducation on child development and/or the referral problem Using behavioral strategies, such as for toileting or to address behavior problems

Outpatient setting interventions: Primary care Initiating problem-solving interventions Serving as an advocate for children Making referrals for extended evaluations or services

Outpatient setting interventions: Private practice Using various assessment and intervention strategies Treating more frequently in private practice than by primary care physicians or in hospital-based clinics Implementing over a longer period of time, modifying treatments as patient’s needs change

inpatient setting interventions: consultation-liaison Implementing cognitive-behavioral techniques (e.g., relaxation training) Providing problem-solving strategies for coping with hospitalization and medical treatment Using behavioral strategies for increasing adherence and/or meeting goals of hospitalization Facilitating communication between medical team and patient and family

inpatient setting interventions: consultation-liaison Assisting medical team in implementing interventions Educating medical team about development, adherence barriers, behavioral strategies Facilitating disposition planning and transitions

inpatient setting interventions: Emergency room Using relaxation training and other cognitive-behavioral techniques for acute stabilization Providing psychoeducation for families and staff on behavioral techniques to use with disruptive youth Using problem-solving strategies to address presenting problem Assisting medical team with disposition planning

inpatient setting interventions: Specialized care Implementing cognitive-behavioral techniques to manage mood and anxiety concerns Educating children about parental illness Educating parents and family members on typical childhood reactions to parental illness

inpatient setting interventions: Specialized care Using behavioral strategies in supporting children during a parent’s illness Providing problem-solving and educational strategies to help parents transition to parenthood or to learn to care for a medically fragile infant and cope with a child’s hospitalization

Emerging & Cross-cutting issues

Pediatric medical home “Medical care of infants, children, and adolescents ideally should be accessible, continuous, comprehensive, family-centered, coordinated, and compassionate” --American Academy of Pediatrics Integrated health care movement

Primary care Historically, only a few pediatric psychologists have worked in primary care settings Developed effective models for assessment, treatment, and consultation for behavioral concerns Provide services in numerous areas including prevention, screening and early intervention, health promotion and prevention, developmental disorders, and family-centered treatments

Traumatic medical stress “A set of psychological and physiological responses…to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences” “These responses may include symptoms of arousal, re-experiencing, and/or avoidance” --National Child Traumatic Stress Network

Traumatic medical stress May include diagnosable disorders as well as stress symptoms Preventive and therapeutic interventions to address

School and home reintegration Reestablishing regular school attendance, maintaining school performance, and coping with effects of illness or medical treatment on academic and cognitive functioning Potential psychosocial adjustment difficulties Collaboration between pediatric psychologist, medical team, and school staff

Treatment regimen adherence Adherence to treatment regimen---medication, health procedures (e.g., respiratory therapy, blood glucose monitoring), and lifestyle changes Numerous factors related to nonadherence including cognitive abilities, adjustment and coping values and attitudes toward regimen family resources

Treatment regimen adherence Variety of interventions for nonadherence including: problem-solving approaches educational behavioral motivational interviewing

Patient and family Diversity Patients and families who are diverse in numerous ways, including: cultural ethnic socioeconomic geographic sexual orientation

Patient and family Diversity Incorporate unique diverse characteristics into case conceptualization and into choice of intervention Fewer clinical strategies are validated for use with diverse populations

Adjustment to chronic illness Impact of illness can be associated with experience of illness itself developmental period of the child, psychosocial difficulties resulting from interaction between illness symptoms, the child, and the child’s immediate environment

Adjustment to chronic illness Factors on an adjustment continuum— some are protective (e.g., family support) others are potentially negative (e.g., ignoring medical care as a way of coping with “bad” news)

Outcome measurement & Evaluation Demonstrate effectiveness of clinical services using objective measures Quality Improvement Examine outcomes over time Provide feedback at point of care and monitor treatment progress Use scale-up methods to implement clinical improvements to other patients or settings PLAN  DO  STUDY  ACT

Evidence-based Practice Evidence-based practice (EBP): “Integration of best available research with clinical expertise in context of patient characteristics, culture, and preferences” American Psychological Association 2006

Collaboration and consultation Conceptual models for collaboration and consultation: Independent Function Model: services without extensive interaction with pediatrician Indirect Consultation Model: provide information to referral but not interact directly with the patient Collaborative Team Model: multiple disciplines work together with joint responsibility Systems-Based Consultation: systematic change on medical units and consult on procedural/structural changes in health care Roberts & Wright/Mullins

Collaboration and consultation 5 C’s of pediatric consultation-liaison services: Crisis Coping Compliance (Adherence) Communication Collaboration Carter et al. (2017)

Maturation of Pediatric Psychology …growth of the field can be traced to the value attributed to the concepts and psychological applications in meeting the multiple needs of children in the medical setting with a set of complex problems requiring interdisciplinary collaborations. Roberts, Aylward, & Wu (2014)

Maturation of Pediatric Psychology …growth has been propelled by the well-received effectiveness of pediatric psychologists as individual practitioners interacting with patients and medical personnel and of pediatric psychology as an integrative field collectively demonstrating the worth of its practitioners’ knowledge and skills. Roberts, Aylward, & Wu (2014)

Maturation of Pediatric Psychology Development of: Sophisticated scientific and professional scholarship Specialized assessment & measurement approaches Empirically supported treatments for a wide range of clinical problems [now  evidence-based practice] Drotar (2007) Roberts (2017)

Maturation of Pediatric Psychology Development of: Informational resources for clinical care, research, and training Professional roles and specialization in multiple settings Pediatric psychology specialty training programs Drotar (2007) Roberts (2017)

Maturation of Pediatric Psychology Development of: Specialized research methodologies Prospective research methods Advanced statistical methods Multisite studies to enhance sample size for generalizability Drotar (2007) Roberts (2017)

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