Behavioral Health Issues and Pediatric Hospitalizations Stephen R. Gillaspy, PhD 11/05/09 Reaching Out To Oklahoma III Annual Pediatric Interdisciplinary Conference

Objectives Discuss common behavioral health issues Discuss common behavioral health issues Discuss identification and assessment of behavioral health issues during pediatric hospitalizations Discuss identification and assessment of behavioral health issues during pediatric hospitalizations Discuss management and treatment of behavioral health issues during pediatric hospitalizations Discuss management and treatment of behavioral health issues during pediatric hospitalizations

Inpatient Pediatric Services Inpatient Pediatric Services Why is this needed? Why is this needed? –Response to the psychosocial needs of children with medical problems and their families (Carter et al., 2003). What does it affect? What does it affect? –Outcomes Short-term Short-term Long-term Long-term

Inpatient Pediatric Services Pediatric Inpatient C&L Service Pediatric Inpatient C&L Service –Providers Psychology, Psychiatry Psychology, Psychiatry Behavioral Health Service Behavioral Health Service –Process Referral from physician / medical team Referral from physician / medical team Assessment conducted Assessment conducted Advises physician / medical team about finding and management of patient and family (Drotar et al., 2003). Advises physician / medical team about finding and management of patient and family (Drotar et al., 2003).

Common Inpatient BH Issues Different ways to categorize issues Different ways to categorize issues –Acute versus chronic illness –Medical versus mental health issues Pros and cons of categorizing Pros and cons of categorizing –Staff –Patient and families

Common Inpatient BH Issues What are some common issues? What are some common issues? –Patients –Parents and Families –Acute Illness –Chronic Illness –Mental Health Issues –Medical Issues

Common Inpatient BH Issues Traditional Mental Health Traditional Mental Health –Depression –Anxiety –Somatization and Organic versus Psychogenic –Suicide –Substance Abuse –Behavioral Problems

Common Inpatient BH Issues Traditional Mental Health Traditional Mental Health –Trauma –Developmental –Cognitive –Eating Disorders –Bereavement

Common Inpatient BH Issues Parents and Families Parents and Families –Coping and Adjustment –Mental Health Issues –“The Problem Family” –Communication –Medical Compliance

Common Inpatient BH Issues More Traditional Medical More Traditional Medical –Sleep –Feeding –Pill Swallowing –Medical Compliance –Pain Management –Adjustment to hospitalization and illness –Procedures

Common Inpatient BH Issues Olson et al., 1988 Olson et al., 1988 –749 inpatient referrals over 5 years Depression or suicide attempt Depression or suicide attempt Adjustment problems to chronic illness Adjustment problems to chronic illness Behavior problems Behavior problems –Health care professionals generally satisfied with services and expressed a high likelihood of future referrals

Common Inpatient BH Issues Rodrique et al., 1995 Rodrique et al., 1995 –448 inpatient referrals Cognitive and neuropsychological functioning Cognitive and neuropsychological functioning Behavior problems Behavior problems Presurgery and pretransplant evaluations Presurgery and pretransplant evaluations Adjustment to chronic illness Adjustment to chronic illness –Health care professionals generally high overall satisfaction with service quality.

Common Inpatient BH Issues Carter et al., 2003 Carter et al., 2003 –104 inpatient referrals Coping with physical illness/injury Coping with physical illness/injury Improving treatment adherence Improving treatment adherence Assessing and treating depression and anxiety Assessing and treating depression and anxiety Teaching pain management techniques Teaching pain management techniques Assistance with parent coping Assistance with parent coping Adjustment to new diagnosis Adjustment to new diagnosis Resolving family conflict Resolving family conflict

Common Inpatient BH Issues Carter et al., 2003 Carter et al., 2003 –88 referring physicians Goal attainment - mean of 4.34 (1-5 scale) Goal attainment - mean of 4.34 (1-5 scale) Overall helpfulness (1-5 scale) Overall helpfulness (1-5 scale) –88 parents/guardians Helpful to the child – 3.45 (1-4 scale) Helpful to the child – 3.45 (1-4 scale) Helpful to the parent – 3.20 (1-4 scale) Helpful to the parent – 3.20 (1-4 scale) Did consultation aid in child’s recovery in the hospitalization – 85% yes Did consultation aid in child’s recovery in the hospitalization – 85% yes

Common Inpatient BH Issues Biopsychosocial Perspective Biopsychosocial Perspective –Medical –Behavioral –Emotional –Developmental –Social –Family System –Environmental

Common Inpatient BH Issues When to consult When to consult –Does it interfere with current medical treatment –Does it decrease quality of life –Does patient and/or family recognize it as an area of concern –Does it affect overall health outcome

Identification and Assessment Who typically identifies the issue? Who typically identifies the issue? –Attending Physicians –Nursing –Social Work –Child Life –Physical Therapy –Occupational Therapy –Nutrition

Identification and Assessment Who typically identifies the issue? Who typically identifies the issue? –Consulting Specialists –Nutrition –Patient –Family

Identification and Assessment Process Process –Multiple clinical interviews Child and family Child and family –Consultation with medical staff –Behavioral observations –Rating scales –Occasionally formal psychological testing

Identification and Assessment Goals Goals –Specific –Problem-focused –Designed to be met within a specific time frame.

Identification and Assessment Assessment is ongoing Assessment is ongoing Regular feedback to the medical team Regular feedback to the medical team A good referral question always helps! A good referral question always helps!

Identification and Assessment Pediatric Inpatient Behavior Scale (PIBS, Kronenberger, et al., 1997) Pediatric Inpatient Behavior Scale (PIBS, Kronenberger, et al., 1997) –Designed to be completed by a pediatric nurse who has worked closely with the child for at least one shift –Completed as part of routine evaluation and treatment planning for the child

Identification and Assessment Two forms Two forms –PIBS-47 –PIBS-25 Developed as a shorter more practical version Developed as a shorter more practical version

Identification and Assessment Seven Subscales Seven Subscales –Oppositional – Noncompliant –Positive – Sociability –Withdrawal –Conduct Problems –Distress –Anxiety –Overactivity

Intervention Role of the consultant Role of the consultant Management versus Treatment Management versus Treatment Problem-Focused Problem-Focused Limited Timeframe Limited Timeframe Not your typical mental health setting and relationship Not your typical mental health setting and relationship

Intervention – Five C’s Crisis Crisis –Initial diagnosis with severe illness or injury –Patient and family in disbelief and shock –Difficulty coping or understanding details and decisions. –Families in need of intervention that provides a sense of understanding and control. –Normalize emotional distress. –Facilitate improved coping

Intervention – Five C’s Coping Coping –Procedures –Lengthy hospitalizations –Chronic illness –Mental health issues –Distress

Intervention – Five C’s Compliance Compliance –Patient and family –Typical interventions Education Education Skills development Skills development Behavioral contracting Behavioral contracting Removing barriers Removing barriers Self-monitoring Self-monitoring

Intervention – Five C’s Compliance Compliance –Typical interventions Altering family interactions Altering family interactions Altering healthcare system interactions Altering healthcare system interactions Altering expectations Altering expectations Altering lifestyle and daily behaviors Altering lifestyle and daily behaviors

Intervention – Five C’s Communication Communication –Miscommunication Medical staff Medical staff Patient Patient Family Family –Length of hospitalization –Diagnoses –Decision making –Procedures

Intervention – Five C’s Collaboration Collaboration –Shared goal Patient Patient Family Family Medical staff Medical staff –Physicians –Nursing –Child Life –Other services

Intervention Problem-focused Problem-focused Family-systems approach Family-systems approach Evidence-based Evidence-based –Cognitive Behavioral Therapy –Motivational Interviewing Appropriate Referrals Appropriate Referrals

Thanks You! Stephen R. Gillaspy, Ph.D. Assistant Professor Section of General & Community Pediatrics Department of Pediatrics The University of Oklahoma Health Sciences Center