Clinical Practice in Pediatric Psychology

Objective: Psychosocial stress contributes to asthma disparities for low-socioeconomic status (SES) Latinx children, but primary and secondary control coping by children and parents is associated with better psychosocial and asthma outcomes. Therefore, we developed and pilot tested Adapt 2 Asthma (A2A), a family based coping and asthma self-management intervention for low-SES Latinx families. Method: Children, parents, and primary care providers (N = 16) participated in five focus groups to refine A2A’s content and delivery. Subsequently, families of children ages 9–12 with asthma (N = 24) were recruited from primary care clinics and randomly assigned to receive A2A or enhanced usual care (EUC). Results: Based on focus groups, A2A was refined to address feasibility, Latinx-specific cultural factors, and provider-family gaps. Results of the pilot randomized controlled trial (RCT) showed that 92% of families completed all sessions of A2A, and there were high levels of satisfaction with and fidelity to A2A. There were no statistically significant differences between the A2A and EUC groups at three-month follow-up, although there were small, nonsignificant effects favoring A2A on parent-reported asthma control, parent secondary control coping, and emergency department visits. Conclusions: We found evidence of acceptability, feasibility, and potential benefits of A2A for low-SES Latinx families. Findings provide guidance for future implementation in primary care.

Objective: Parents and young children in low-income communities have compounding risk factors for their health and mental health, and integrated primary care has been identified as an effective approach for embedding needed auxiliary supports. Less is known about how primary care clinicians—who are key organizational drivers for integrated primary care—perceive the impact of this support on themselves and their clinics. Method: This study used a qualitative approach to gather clinicians’ perceptions of how HealthySteps (one approach to integrated care for young families) impacted their functioning and their clinic in an urban low-income community. Results: Thematic analysis of clinician interviews resulted in four themes. Clinicians opined that HealthySteps reduced their stress, eased their workload, and supported their job satisfaction in a setting where most families had significant psychosocial risk factors. They highlighted components of HealthySteps perceived to be the most impactful (e.g., tangible supports for families, connection to community services) and highlighted its role in improving relationships with families and case conceptualization. Conclusions: Recommendations are provided to leverage clinician voices to advocate for integrated primary care.

Objectives: Hypermobile Ehlers-Danlos Syndrome (hEDS) is a heritable connective tissue disorder that results in physical symptoms, psychosocial challenges, and functional disability. Children with hEDS and their caregivers face challenges in managing the symptoms and associated impacts of the syndrome. Method: Mixed methods were utilized to allow children with hEDS and their caregivers to share challenges faced, effective coping strategies, and their readiness to engage in a self-management approach to treatment. As caregivers are frequently proxy reporters for their child’s experience, concordance between caregiver and child was assessed for each variable. Additionally, child outcomes were assessed in relation to caregiver–child concordance on readiness to engage in self-management. Results: Results suggest moderate concordance across dyads, with many dyads agreeing on the challenges presented by the physical consequences of hEDS but differing on beliefs regarding coping. There were small effect sizes indicating better child psychosocial functioning when dyads were concordant on readiness to engage in self-management. Conclusion: When making treatment recommendations, practitioners should consider differences and similarities between caregivers and children’s reported experiences with and beliefs about hEDS. Further, practitioner facilitation of family concordance on beliefs about hEDS may result in better outcomes for the child.

Objective: The extent to which tailored executive functioning (EF) interventions lead to improvements in other areas of functioning in adolescents with epilepsy is unknown. The types of problems that youth select to practice EF skills during tailored interventions has not been documented. This study aimed to systematically evaluate (a) the EF problems and strategies selected during a tailored EF intervention for youth with epilepsy, and (b) the impact of a tailored intervention on specific problems for subgroups who choose to practice EF skills in those areas. Method: We conducted secondary data analyses of a proof-of-concept clinical trial of a tailored Web based EF intervention for youth with epilepsy. Baseline and two-months postintervention questionnaire data were included. A coding system was developed to identify the problem domains that adolescents targeted during treatment. Descriptive statistics and paired sample t-tests were used to examine whether adolescents who identified specific EF problems improved on specific domains. Results: Coding revealed 8 domains: Academics, Activities of Daily Living, Family, Social, Adherence, Healthy Habits/Self-care, Sleep, and Emotion/Stress. Significant improvements were noted on “Academics,” “Emotion/Stress,” and “Sleep” domains for those who applied EF skills to those domains. Conclusions: Tailored EF interventions such as Epilepsy Journey are related not only to improvements in broad EF skills, but also to improvements across areas of functioning that adolescents identify as important. Clinically, EF skills may be more effectively learned when adolescents directly apply EF skills to the problems they identify as most salient.

Objective: Psychosocial concerns are common among youth with Type I diabetes; psychosocial screening and integrated care models can address these concerns. Medical providers are key stakeholders, but their perspectives on the role of mental health within pediatric diabetes care represent a gap in the literature. This study aimed to describe pediatric diabetes care providers’ views on the relationship between psychosocial stress and diabetes, their experiences with psychosocial screening and psychological consultation within their clinic, and their suggestions for mental health professionals working with youth who have diabetes. Method: All endocrinologists, fellows, and diabetes educators involved with psychosocial screening and psychology consultations (N = 7; 71.4% female, 42.9% Hispanic/Latinx White, 28.6% Non-Hispanic/Latinx White, 28.6% Asian) at a single outpatient pediatric diabetes clinic participated in semistructured interviews. Qualitative data were analyzed via thematic content analysis. Results: Providers described a bidirectional relationship between psychosocial stress and diabetes management. They expressed positive views of psychosocial screening and the clinic’s integrated psychology team, which allow them to focus on the medical aspect of care and gain comfort with mental health. Providers offered suggestions to improve coordination and communication with mental health professionals. Conclusions: Pediatric diabetes care providers valued psychosocial screening and benefited from collaboration with the clinic psychology team. Clinics without access to mental health professionals may struggle to sustain screening practices. Eliciting medical providers’ opinions and using other implementation science strategies are important for incorporating psychosocial screening and intervention within pediatric diabetes clinics, especially for clinics with unique models for psychological services.

Objective: Research identifying effective treatments for functional nonretentive fecal incontinence (FNRFI) is limited, making the establishment of empirical evidence-based practice parameters difficult. The purpose of the current study is to add to the literature by examining the effects of a comprehensive behavioral treatment for three children with FNRFI. Method: A comprehensive behavioral treatment involving education about FNRFI, regularly scheduled brief toilet sits, a reward system contingent on successful bowel movements in the toilet, and a cleanup procedure for fecal accidents was implemented at home and at school with three children (age range = 9–12 years), experiencing chronic fecal incontinence with no history of constipation or stool retention and concurrent behavior problems related to toileting. A nonconcurrent multiple baseline design across participants was used to evaluate the effects of the treatment on participants’ frequency of soiling, frequency of successful bowel movements in the toilet, and percentage of self-initiated successful bowel movements in the toilet. Results: The treatment resulted in improvements in all three participants’ fecal incontinence. Specifically, participants achieved full fecal continence after at least 7 weeks of treatment and maintained gains following the withdraw of the treatment. Conclusion: Results indicate that a comprehensive behavioral intervention implemented across settings can have a profound positive impact on children’s FNRFI.

Objective: Despite strong evidence supporting the efficacy of family-based behavioral treatment (FBBT) for pediatric obesity, programs rarely achieve optimal effectiveness for all youth. Understanding treatment response among racially/ethnically diverse youth and the role of psychological concerns in obesity treatment response will better inform pediatric psychologists' treatment recommendations in pediatric obesity populations. The current study aimed to evaluate (a) FBBT effectiveness in a racially/ethnically diverse population and (b) the rates, and possible impact, of psychological comorbidities at baseline on treatment outcomes. Method: Participants included 351 youth who had obesity and their families who participated in 12 weeks of group FBBT. Parent-reported psychological concerns were measured at baseline using the Pediatric Symptom Checklist-17, and anthropometric data were collected at baseline and treatment end. Paired-samples t-tests and mixed-effects repeated-measures analysis of covariance were utilized to examine psychological predictors of changes in body mass index percent of the 95th percentile (%95thpercentile) during treatment. Results: No differences in FBBT response based on race or ethnicity were identified. Findings indicated that a higher baseline %95thpercentile was associated with more internalizing, externalizing, and total psychological concerns. While youth in the intervention experienced a significant reduction in %95thpercentile from baseline to treatment end overall, youth with elevated baseline externalizing concerns did not exhibit significant decreases in %95thpercentile. Conclusions: FBBT was demonstrated to be equally effective across racial/ethnic groups, while significant differences were observed based on psychological concerns reported at baseline. This study highlights the utility of preliminary psychological screening to promote individualized care within pediatric obesity treatment.

Objective: Treatment plans for youth with chronic illness are often solely focused on illness symptomatology, resulting in missed opportunities to address other components of the chronic illness experience. Because yoga incorporates physical activity and meditation, this practice has the potential to improve physical and psychosocial health while improving overall quality of life. Thus, this topical review (a) briefly summarizes preliminary evidence for the impact of yoga on quality of life in pediatric populations with chronic medical conditions, (b) evaluates the current feasibility and acceptability of yoga interventions, (c) describes limitations of current research, and (d) provides an agenda for future research and clinical directions. Method: Topical review. Results: The current literature on yoga interventions in pediatric populations with chronic medical conditions is limited by methodological issues, impacting the interpretability of findings. While more rigorous methodology is needed, preliminary findings suggest promise for the feasibility and acceptability of yoga interventions. Further, the current data indicates practicing yoga may positively impact quality of life outcomes in pediatric populations with chronic illness. Conclusion: Yoga interventions may have the potential to improve quality of life in youth with chronic medical conditions. However, further research is warranted to advance the literature and determine whether yoga is an efficacious and effective treatment for pediatric populations with chronic illness.

Objective: Inpatient neuropsychological screening represents a promising direction for addressing consultation questions directed to pediatric psychiatry consultation/liaison (C/L) providers. Despite the potential of such a service, few studies have directly examined the role of targeted neuropsychological screening on a pediatric psychiatry C/L team. Thus, the primary goals of this paper were to explore the feasibility and utility of brief neuropsychological assessment in the context of a C/L service. Method: We review the literature related to neuropsychological consultation in pediatric medical settings. We provide a clinical case example to illustrate our experience incorporating targeted neuropsychological screening on our pediatric psychiatry C/L service. Results: Targeted screening as part of a psychiatry consultation service has the potential to be informative in patient care. Several existing preventive pediatric care models that include brief assessment are already being used in other pediatric medical settings. Conclusions: Inpatient neuropsychological screening can play a role in integrated care teams when both its strengths and limitations are understood. The incorporation of brief neuropsychological assessment into clinical practice within C/L services represents an important and potentially impactful future direction in both research and clinical care.

Objective: This review aims to provide a brief introduction of clinical decision support systems (CDSSs) and discuss the role of psychology for the integration of CDSSs for child mental health into pediatric subspecialty care. Methods: A review of literature regarding CDSSs used for physical and mental health services was conducted to lay the foundation for our recommendations. Results: Children with chronic physical illness are twice as likely to suffer from mental illness as compared to healthy controls. These mental health problems are often discovered in pediatric subspecialty care. Yet their mental health needs are often unaddressed when the sections of pediatric subspecialty care and mental health are not well coordinated. CDSSs could help subspecialty providers with evidence-based decision-making regarding mental health screening and referrals. That is, CDSSs could enhance the access to most effective mental health treatment for children. However, the implementation of CDSSs in pediatric subspecialty care is very limited. Conclusions: Psychologists could assist subspecialty providers with advocating CDSSs to administrative and information technology staff, as well as build, customize, evaluate, and update CDSSs.

Objective: The purpose of the current project was to distill guidance for psychology researchers regarding ethical challenges that may arise in the conduct of qualitative research aimed to improve pediatric clinical care. Method: 6 pediatric psychologists with relevant research experience participated in semistructured interviews. Data were analyzed using inductive methods of general thematic analysis and then emerging ethical issues were interpreted within the framework of the American Psychological Association (APA) Ethics Code. Results: 6 broad areas of ethical considerations were derived: Establish competence and ensure research rigor; clearly distinguish research and clinical roles; consider the potential for sample selection bias and demand characteristics; protect research participants, especially minors; attend to common and unique privacy and confidentiality concerns; and respect provider stakeholders and the clinical setting. Researchers consistently identified proactive, rather than reactive approaches, in addressing potential ethical concerns. Some of the themes and subthemes represent typical considerations of psychology research while others speak to the unique elements of qualitative methodologies, pediatric populations, and clinical care improvement. Conclusions: Researchers’ identified ethical considerations aligned with the APA Ethics Code, specifically sections 2 (competence), 3 (human relations), 4 (privacy and confidentiality), and 8 (research and publication). Recommendations were derived to aid in study planning and reflect the importance of considering competencies within the research team, dual relationships, privacy and confidentiality, and the context of clinical qualitative research. Overwhelmingly, researchers encouraged others to conduct qualitative pediatric clinical care research and emphasized the invaluable nature of the rich, in-depth information gained from such research.