Clinical Practice in Pediatric Psychology

Behavioral pain management treatments are typically provided after a multidisciplinary assessment determining whether the nature of pain is expected to be short-term (i.e., acute) or whether the pain is persistent (i.e., chronic). However, many of the standard ways clinicians approach pain management are challenged by the presentation of co-occurring acute and chronic pain experiences, such as can be the case in sickle cell disease (SCD), headache management (migraines and daily persisting headaches), chronic musculoskeletal pain with reinjury, and juvenile idiopathic arthritis, among others. Such overlapping pain presentations can involve conflicting treatment approaches for pain management. Currently, there is burgeoning, yet still limited, understanding of the complexity of co-occurring acute and chronic pain presentations.

Given the unique pain presentation common in SCD, among other conditions, we review how behavioral pain management strategies can utilize complementary approaches to address the experience of co-occurring acute and chronic pain.

This commentary provides a brief historical review of the evolution of our understanding of pain perception and psychological treatments for pain. We propose an innovative clinical framework for behavioral pain management of co-occurring acute and chronic pain.

We hope to enhance the current dialogue around pain perception and pain burden to address the unique needs of co-occurring acute and chronic pain presentations. Ongoing areas for research and clinical considerations are also discussed.

There is increasing awareness of the heterogeneity of pain conditions involving both acute and chronic pain. This commentary proposes a new care model for behavioral pain management for individuals experiencing co-occurring acute and chronic pain. Behavioral pain management strategies should consider complementary and flexible approaches that address the cumulative experience of both acute and chronic pain.

The purpose of this study is to describe the implementation of the Novel Interventions in Children’s Healthcare (NICH) program for youth with inflammatory bowel disease (IBD) and high social risk.

This study examined the implementation of NICH with four adolescents of racial and ethnic diversity with high social risk and IBD, using a retrospective pretest–posttest design. Chart reviews captured descriptions of the course of treatment and healthcare utilization data for one year prior to and one year post NICH service initiation, including the presence and frequency of hospital admissions, ED visits, and the number of days spent in the hospital. Demographic information and medical appointment attendance data were also collected.

EHR records indicated that NICH services were tailored to account for factors specific to IBD as well as youth and family culture. All four youths demonstrated improvements in health, and most youths evidenced reductions in acute care use and associated costs, increased engagement in recommended preventative care, and improved disease management.

NICH is a promising intervention for youth with IBD who are experiencing disease management difficulties due to social factors and represents an alternative approach to care for this population.

This case series examines how an alternative program to office-based services (Novel Interventions in Children’s Healthcare: NICH) could be feasibly used for youth with IBD and high social risk. Youth generally evidenced fewer acute complications and improved outpatient medical attendance, reported improved quality of life, and demonstrated reduced healthcare costs one year following NICH enrollment. Findings indicated NICH is a promising service for youth with IBD and specifically for youth with IBD from underserved and underrepresented populations.

Inflammatory bowel disease (IBD) is characterized by inflammation in the gastrointestinal tract with painful and distressing symptoms periods of exacerbations and remissions. Youth with IBD are at increased risk of experiencing challenges across psychosocial functioning. Mental health concerns (i.e., anxiety, depression) are commonly assessed in youth with IBD, but measures used to assess psychopathology may not fully capture emotional distress unique to living with IBD. There remains no well-validated measure of IBD-specific distress in pediatrics.

The Crohn’s and Colitis Distress Scale (CCDS), a newly developed measure of pediatric IBD-distress, was completed by 120 youth with IBD during routine care. The psychometric properties of the measure were examined.

The Cronbach’s alpha for the full scale was .94 and subscale internal consistency ranged from .66 to .90. Longer time since diagnosis and longer time since last flare was associated with lower IBD-distress. Further, greater IBD-distress was reported in girls with a diagnosis of ulcerative colitis, currently symptomatic, or currently flaring respective to their counterparts. Though moderately to largely correlated (.30 < r < .73), IBD-distress was found to be a distinct construct from global anxiety and depression.

Data support the use of an instrument specific to IBD-distress, such as the CCDS, to allow for more accurate detection of risk for emotional distress in IBD. Further assessment of the reliability and validity of the measure within larger, more diverse samples is warranted. Such investigation should include assessment of the associations between IBD-distress and treatment engagement and health outcomes.

Mental health concerns (e.g., anxiety, depression) are commonly assessed in youth with Inflammatory Bowel Disease (IBD), but the measures used do not fully capture emotional distress that is unique to living with IBD. The Crohn’s and Colitis Distress Scale (CCDS) is a newly developed measure assessing IBD-related emotional distress in youth. Our study found initial evidence for validating the CCDS, we identified 5 factors of IBD-distress, and we found that IBD-distress as a distinct construct from more global anxiety and depression.

Developmental screening is a critical component of care for children with sickle cell disease (SCD), who are at elevated risk for neurodevelopmental disorders. This report describes the implementation of two related developmental screening programs implemented in different SCD specialty care settings with the purpose of describing screening protocols, outcomes, and lessons learned.

Program 1 reviewed medical records for 201 children with SCD screened at ages 2 and 4 years. Program 2 reviewed program tracking and visit notes for 155 screenings across 67 children screened between 9 and 66 months of age. Key outcomes included characteristics of children screened, screening results, concordance between parent concerns and screening outcomes, and access to evaluation and intervention services.

Each program identified a substantial number of children with developmental concerns, including 42% of screenings in Program 1 and 36% of unique children screened in Program 2. Program 1 resulted in 56% of identified children receiving follow-up developmental services and 62% receiving developmental monitoring. Program 2 resulted in 58% of identified children receiving further evaluation following developmental screening, with 67–75% of children with neurodevelopmental diagnoses receiving intervention services following evaluation. While parent concerns were related to screening outcomes, screening instruments detected many children whose parents did not express developmental concerns.

Routine developmental screening is a feasible, acceptable, and effective method for identifying concerns in children with SCD in specialty care. Flexible and collaborative care and sustainability are key considerations for effective programming, with pediatric psychologists uniquely positioned to provide optimal integrated care.

Children with sickle cell disease are at high risk for neurodevelopmental disorders and benefit from early, high-quality identification and support for these concerns. Routine developmental screening delivered by a psychologist in specialty sickle cell disease care is a feasible, acceptable, and sustainable approach for meeting these important needs.

This article describes a pediatric quality improvement (QI) initiative designed to improve access to behavioral health (BH) care across pediatric specialty clinics. Mental health concerns and chronic health conditions are undertreated in American youth. By implementing a robust biopsychosocial model of care, behavioral health integration (BHI) across pediatric specialty clinics provides opportunities to address mental health concerns, reduce access barriers to mental health care, decrease mental health stigma, improve care continuity, and increase effectiveness of medical care provided.

The Survey Needs Assessment in Ambulatory Pediatric Specialties (SNAAPS) was developed and implemented within the pediatric QI initiative following the Plan, Do, Study, Act (PDSA) cycle. The SNAAPS was used to assess medical provider identification of challenging mental health concerns and perceived need for BHI.

Results were shared with department stakeholders to inform new integration efforts. Providers reported highest demand for BHI to address issues of depression, anxiety, distress regarding medical diagnosis and treatment, and treatment adherence. Providers reported several BH concerns created barriers to effective medical care and providers only sometimes felt successful in overcoming these barriers to conducting medical care.

Demand for BHI was clear across many specialties. Using the SNAAPS as part of the PDSA cycle was a useful process to inform new BHI efforts and therefore facilitate improved effectiveness and quality of health care.

This study provides an organizational model and needs assessment survey that can be used to improve access to behavioral health care across pediatric specialty clinics. Results demonstrated that pediatric specialty providers identified several behavioral health concerns that created barriers to their patients’ medical care, which could be addressed by integrating behavioral health services directly into pediatric specialty clinics. Further, using the SNAAPS within the quality improvement context (following the PDSA cycle) was a useful strategy to increase access to behavioral health care in an evidence-based, resource-sensitive way.

Intervention in the earliest period of parenthood can make a strong, positive impact on parenting, yet engaging parents of newborns in parenting interventions can be difficult. Technological adaptation of important interventions can improve early engagement. This study reports the initial feasibility of the Creating Connections intervention, a technology-based intervention developed to support mothers of newborns, and feasibility of evaluating the intervention through a randomized clinical trial in pediatric primary care. The intervention includes: (a) a brief tablet-based intervention delivered during a newborn well-child pediatric check-up, and (b) tailored text messages delivered thereafter to boost intervention content. Intervention content includes empirically-supported aspects of parenting behaviors known to positively influence children’s social-emotional development.

Project recruitment took place in an ambulatory care pediatric clinic in a large Midwestern city. Mothers received information about infant soothing, book sharing, or both.

One-hundred and three parents learned about the program and 72 participated. Mothers were primarily Black/African American with incomes at or below $30,000. Only 50% of mothers that received text messages through the program completed follow-up, but these mothers gave overall positive ratings of text messages.

Program engagement and ratings of parents support feasibility, but retention rates need improvement. Based on barriers and successes of this investigation, lessons learned about feasibility and acceptability are discussed.

This brief report describes a unique approach to using technology as part of a pediatric visit to deliver information to mothers of newborns aimed at promoting bonding.

Parental stress can have an impact on health outcomes of chronically ill children (Cousino & Hazen, 2013). Pediatric psychologists are well suited to address these issues with understanding of empirically supported treatments, impact of mental health on medical care behaviors, and parent–child interactions (Ernst et al., 2015). Use of empirically supported treatments, such as graduated exposure therapy (ET), within an uncontrolled environment such as an inpatient setting can be challenging. This case study illustrates adaptation of ET in an inpatient setting to address parental mastery of medical care.

ET was implemented with a mother of an infant with a newly placed tracheostomy to reduce her severe anxiety that was preventing her from interacting with her infant or engaging in medical care necessary for hospital discharge.

Through 31 exposure sessions, the patient’s mother met all four treatment targets: daily tracheostomy care, stoma desensitization, tracheostomy tube changes, and suctioning. Self-reported distress data were presented for each exposure.

Use of ET with a clear treatment plan and coordinated multidisciplinary inpatient team efforts can successfully reduce severe parental anxiety that is impeding medical care, hindering parent–child interaction, and interfering with parental ability to care for a child with complex medical needs. This article discusses multiple factors that are unique to the inpatient setting and the target behaviors for consideration.

This case highlights the use of empirically supported treatments to target complex parent behaviors in a pediatric inpatient setting. Reducing barriers to discharge, such as inability to demonstrate adequate medical care, promotes better patient and family outcomes.

Acute lymphoblastic leukemia (ALL) treatment mandates 2 to 3 years of maintenance therapy that includes daily oral 6-mercaptopurine (6-MP). Unfortunately, 6-MP nonadherence is linked with progressive relapse risk. This study evaluated feasibility, acceptability, and fidelity of a motivational interviewing (MI) intervention targeting 6-MP adherence during pediatric ALL maintenance therapy.

We randomized 80 caregivers to receive a single MI session and 42 to an education-only control condition. Participants completed self-report measures about demographics, 6-MP adherence, and intervention acceptability. MI sessions were delivered during a routine clinic visit and were fidelity-coded using Motivational Interviewing Treatment Integrity 4.2.1 coding.

Findings confirmed MI feasibility and acceptability during routine outpatient clinic visits. In the MI condition, 92.5% of caregivers completed the MI session and 96.20% reported strong MI acceptability. We found no differences in enrollment, completion, or MI acceptability by cultural group. All Spanish-delivered MI sessions addressed social contextual stressors and/or culture-specific values.

MI may represent a “no-risk” approach to improving adherence and potentially enhancing cure. This study demonstrates feasibility and acceptability of MI during routine clinic visits, providing the basis for a larger randomized trial.

This study evaluated MI feasibility and acceptability to promote oral chemotherapy adherence during pediatric acute lymphoblastic leukemia treatment. We found strong evidence for feasibility and acceptability among majority and ethnic minority participants. Additional study is needed to evaluate intervention effectiveness. MI may present a new way to enhance oral chemotherapy adherence.

This report describes data regarding the acceptability of delivering a family-based behavioral lifestyle intervention for adolescent obesity in a brief, intensive onsite program (initial 3 sequential days + 1 follow-up day) combined with telephonic wellness coaching (WC).

Four cohorts consisting of 7 adolescents aged 15–17 years (self-identifying as 4 male, 2 female, 1 transgender male; 6 White, 1 African American and White) and thirteen parents participated in a new clinical intervention consisting of 3 days onsite programming, 3-months telephonic wellness coaching, and 1 day onsite follow up. Enrollment, attendance, and retention were recorded. Participants provided quantitative and qualitative feedback regarding acceptability of the program during postintervention interviews.

Of 11 families invited, 8 enrolled. Seven families participated, with 1 family lost to follow up. Adolescents completed an average 5.6/9 planned WC sessions. Adolescents rated the program positively overall and liked experiential sessions best. However, participants reported the onsite program was too long, they encountered barriers to sustained engagement during wellness coaching follow up, and parents desired greater guidance and structure for their involvement.

Combining in-person sessions with telephonic wellness coaching was acceptable to participants, but intervention refinement is needed. Future program development and research investigating hybrid models should consist of briefer in-person sessions, emphasize skill practice, and include ongoing guidance to parents to provide developmentally appropriate support.

This new clinical program evaluation found that extending onsite family-based behavioral lifestyle intervention for adolescent obesity with telephonic wellness coaching was acceptable to participants, but that program refinement is needed. Feedback highlighted the importance of keeping onsite sessions brief, engaging adolescents with hands-on skill practice, and providing ongoing guidance to parents to support sustained adolescent engagement in behavior change.

Most of the transition literature has examined adolescents and young adults with special health care needs, though many youth will eventually transition to adult health care providers, regardless of medical complexity. This study addressed this gap by examining transition needs and experiences specifically within a college student sample of emerging adults without complex medical needs.

One hundred eight college students (M_age = 20.93 years, SD = 1.14) completed interviews and questionnaires regarding transition. The most difficult and easiest aspects of health care self-management were thematically coded. Differences in questionnaires were assessed across sources of transition education.

Fifty-two percent of college students reported receiving education about managing health care from medical providers versus 95% from caregivers. Notably, 57% desired more support. Those receiving medical provider education reported higher responsibility. Students reported most difficulty managing health insurance. Results were similar across racial and ethnic groups and genders.

Gaps in transition preparation include low rates of medical provider education and support regarding health insurance. College students receiving education from medical providers reported greater health care responsibility. Provider-led transition education is needed for college students without complex medical needs.

This study suggests that college students without complex medical conditions experience gaps in transition preparation. Although half reported talking to their medical provider about transitioning to adult care, many desired more support, with the greatest difficulty reported in learning to manage health insurance.

The COVID-19 pandemic has caused a decline in well-being for many adolescents. However, the impact of COVID-19 on mental health outcomes among adolescents remains understudied. The current study qualitatively examined the impact of COVID-19 restrictions on adolescents with mental health concerns prior to the pandemic.

We enrolled 20 adolescents who were engaged in care through an Adolescent Health Specialty Clinic prior to COVID-19. Participants were 12- to 19 years old who experienced mental health concerns prior to COVID-19 and experienced declining mental health (e.g., new mental health diagnosis or increased severity of previous mental health diagnosis reported during clinical visit or documented in medical chart) during the pandemic. In-depth interviews were conducted, and inductive coding was applied to transcripts to identify emergent themes.

Five key themes were identified: manifestations of declining mental health, loss of motivation, changes to social relationships, use of social media, and coping mechanisms. Adverse mental health outcomes were provoked by experiences of loneliness and social isolation, especially due to school closures which disrupted routines, access to educational and social support, and key cultural milestones. The increased uses of social media and illicit substances were notable coping strategies.

Findings from this study strengthen our understanding of the key factors influencing the psychosocial well-being of adolescents during the pandemic. Our results may help inform researchers, clinicians, and policymakers to develop guidelines and community-based strategies for mitigating the potentially negative effects of future pandemic-related disruptions to mental health among adolescents.

The current study examined the impact of COVID-19 restrictions on adolescents with mental health concerns prior to the pandemic. Results emphasize the importance of obtaining first-hand perspectives from adolescents to optimize their care. Providers should prioritize mental health and substance use screening given the impact of the pandemic.

The COVID-19 pandemic is the deadliest pandemic in American history. This study aims to assess the differences in youth reported traumatic stress among those with and without chronic illness, and how those reports are impacted by parental level of concern regarding the COVID-19 pandemic.

Using convenience sampling, parents and their children completed a series of questionnaires focused on demographic information including questions about medical conditions, parental level of concern about COVID-19, and youth-report of posttraumatic stress symptoms.

Results of the anonymous survey (n = 164) found that parental reported level of concern of COVID-19 significantly predicted youth report of posttraumatic stress symptoms (F(4, 159) = 2.607, p = .038). There was no significant difference in youth-report of posttraumatic stress symptoms between youth with and without chronic medical conditions (F(1, 162) = .438, p = .509).

Children often look to their parents for guidance during stressful life events, as confirmed by our findings. Parental emotional and behavioral responses may influence how youth make sense of highly stressful events and should be considered when determining intervention strategies in the COVID-19 era.

This study found that youth with and without chronic health conditions did not differ in their report of posttraumatic stress 6 months after the onset of the COVID-19 pandemic. However, youth report of traumatic stress symptoms was predicted by their parents’ level of concern regarding the impact of COVID-19 on their families, suggesting the need for targeted parent-based intervention. Clinical interventions to prevent chronic posttraumatic stress responses in youth regardless of medical comorbidity are discussed.

The aim of this article is to illustrate and discuss ethical dilemmas that might occur in the context of pediatric end-of-life care using case examples. The cases highlight ethical principles and are distilled by a multidisciplinary group of pediatric providers (i.e., psychologists, medical student, psychiatrist, bone marrow transplant physician), offering a unique perspective and insight. Familiarity with the principles discussed is important for pediatric psychologists working in medical settings, who might be uniquely suited to help patients, families, and medical teams navigate these challenges.

Two composite case examples are presented that focus on commonly encountered ethical dilemmas including: disclosing poor prognoses to patients; disagreements between families and medical teams; differing opinions on plans of care between medical team members. Important cultural considerations are also highlighted. Core ethical dilemmas are discussed and potential ways in which pediatric psychologists can offer expertise and intervention.

Recognition and collaboration around ethical dilemmas is essential to managing complex situations in pediatric palliative care. Moreover, it is imperative to consider the cultural factors of a family, which could provide additional insight into their preferences and values.

Ethical challenges are prevalent in the field of pediatric palliative care. As the medical field continues to advance, pediatric psychologists are likely to encounter a range of clinical dilemmas. They should be prepared to consider the complex systemic, interpersonal, family, and cultural factors that might arise in their work.

This article discusses ethical challenges pediatric psychologists might encounter when treating patients at the end of life. It is written by a group of multidisciplinary providers, thus offering a unique perspective. Two composite case examples are presented which demonstrate the complex ethical dilemmas that often arise when working with critically ill youth, including those with poor prognosis. Pediatric psychologists involved in pediatric palliative care might benefit from being familiar with ethical principles in order to navigate challenging and complex situations.