Clinical Practice in Pediatric Psychology

Research on the experience of parents caring for a child with chronic pain indicates that high levels of parental role stress, feelings of frustration over an inability to help, and psychological distress are common. Moreover, parental distress adversely influences child adjustment to chronic pain. Therefore, intervening with parents of youth with chronic pain may, in turn, result in positive outcomes for children in their ability to engage in positive coping strategies, reduce their own distress, and to function competently in their normal daily lives. Our aim was to adapt an intervention, problem-solving skills training, previously proven effective in reducing parental distress in other pediatric illness conditions to the population of caregivers of youth with chronic pain. In the first phase, the intervention was adapted based on expert review of the literature and review of parent responses on a measure of pain-related family impact. In the second phase, the intervention was tested in a small group of parents to evaluate feasibility, determined by response to treatment content, ratings of acceptability, and ability to enroll and deliver the treatment visits. This phase included piloting the PSST intervention and all outcome measures at pretreatment and immediately posttreatment. In an exploratory manner we examined change in parent distress and child physical function and depression from pre- to posttreatment. Findings from this feasibility study suggest that PSST can be implemented with parents of youth with chronic pain, and they find the treatment acceptable.

Needle procedures are a painful and distressing experience for many children. There is a strong evidence base that demonstrates the efficacy of psychological interventions for reducing pain and distress during needle procedures. However, actual implementation of these strategies before, during, and after a needle procedure is affected by multiple factors that increase the complexity of delivery of these interventions in clinical settings. These challenges include application of evidence-based strategies to diverse populations that tend to be excluded from the research literature (e.g., children with developmental delays, children with needle anxiety or phobia), environmental barriers (e.g., providing pain management strategies for needle procedures in different settings), and practical or logistical issues (e.g., inadequate preparation time). We discuss these issues, provide practical suggestions for increasing access to evidence-based pain management strategies, and present three illustrative case examples. Pediatric psychologists may face challenges in implementing evidence-based strategies for needle pain and distress, but important opportunities for educating families and health professionals about the management of procedural pain from needles are available.

The purpose of this case study is to describe the application and challenges of utilizing a manualized behavioral parent group intervention to address pediatric obesity in a community-based rural setting. Treatment included 21 group sessions, which focused on nutritional and physical activity education, gradual changes to healthy lifestyle behaviors, and implementation of behavioral and parenting strategies, over a 1-year period. Barriers to treatment effectiveness included the comorbidity of behavioral and emotional disorders, complex family dynamics and inconsistent parenting with multiple caregivers, limited access to mental health care and economic resources due to rurality, and limited readiness to actively engage in treatment. Despite these barriers, the child’s Body Mass Index z score remained stable and clinically significant reductions in disordered eating attitudes and behaviors were observed after treatment. This case study demonstrates the challenges of conducting a manualized group intervention for pediatric obesity with fidelity and flexibility in the context of co-occurring emotional and behavioral difficulties, complex family dynamics, and rurality. Implications for pediatric obesity clinical practice in underserved settings and with complex cases are discussed.

Unintentional injury is the leading killer of children in the United States. Children under the age of 5 are at particularly high risk for death from injury. The evidence base for prevention programs in the area of unintentional injury is limited by a lack of rigorous research, inclusion of low-risk participants, and interventions that do not include behavioral skills training. The article presented here will discuss promising injury prevention programs for children below age 5 and will highlight program strengths and weaknesses. Interventions that prevent the leading causes of death among young children will be discussed, including car seat use, safe infant sleep, home hazard reduction, and caregiver supervision.

The prevalence of impairments in attention, working memory and executive functions associated with traumatic brain injury and developmental childhood diagnoses has resulted in increased research to identify effective treatments. The use of a broad based approach that combines both strategy training (domain specific training) and repetitive drill practice (domain general training), has been investigated in the acquired brain injury population with some promising initial findings although methodological issues and demonstration of transfer of training is challenging. This paper describes a pilot study, evaluating an integrated intervention, Attention Improvement Management (AIM) in eleven participants with cognitive processing impairments due to traumatic brain injury. The paper explores the therapy components that appear to be critical to achieving meaningful improvements in attention, working memory and executive functions using this hybrid approach. The results of the pilot study are analyzed to identify the clinical decisions and behaviors required by clinicians implementing even a highly proceduralized computer intervention such as AIM, in hopes of guiding current practice and improving future research investigations.

Parent and family interventions have a long, demonstrated history of utilization in pediatric psychology settings. The current article will first briefly overview and describe the predominant parent and family intervention approaches used in pediatric psychology, including traditional family therapy approaches, cognitive–behavioral family therapy, behavioral family systems therapy, multisystemic therapy, and problem-solving therapy approaches. Broad strategies for the practical implementation of these interventions are discussed, including working with multiple subsystems, collaboration with interdisciplinary teams, developing shared conceptual models with family and medical team members, and exercising both flexibility and clinical judgment with complex cases. Obstacles and barriers to successful implementation of these treatments will next be reviewed, including parent/caregiver characteristics, patient characteristics, economic challenges, medical setting characteristics, and communication barriers, as well as recommendations for overcoming these barriers. A case study is presented that illustrates a typical family intervention approach. Future directions are reviewed including continued empirical evaluation of family interventions, conducting dismantling studies, targeting of resiliency variables, and evaluation of electronically delivered treatments.

Fecal incontinence is a common childhood condition that causes significant disruption and impairment to children and families. Recent reviews have found that the treatment literature remains disjointed and difficult to interpret. Fecal incontinence should be conceptualized within a biopsychosocial model and treatment often occurs within some collaborative practice models with medical providers. We conducted an informal survey of pediatric psychologists nationwide who specialize in this issue to gather information about their clinical practice. A medical–behavioral approach to treatment is well supported and includes clean-out and maintenance treatment of constipation, education to the child and family about the condition, and behavioral interventions focused on improvements in toileting. Specific behavioral components supported by recent reviews and our survey of providers includes incentive programs based on operant conditioning and enhanced toilet training as successful treatments beyond what may be considered medical management. However, many other behavioral treatment components have been studied in small sample designs and case studies and are used clinically. The goal of this article is to present clinical application of evidence-based treatment strategies in the treatment of fecal incontinence. We present our clinical approach using treatment algorithms for basic management and advanced behavioral treatments for this clinical issue. The treatment of fecal incontinence can occur in diverse practice settings with collaboration with medical providers and implementation of evidence-based behavioral treatments.

Pediatric feeding disorders are complex and require specialized intervention approaches. A recent review of the literature suggests positive effects of psychological interventions for pediatric feeding disorders as part of an interdisciplinary intervention approach. In considering the application of evidence-based interventions for pediatric feeding, multiple factors affect the desired outcome and therapists are challenged to meet the long-term needs of these patients. This article describes the application of the literature review to an interdisciplinary treatment approach. A case illustration is provided to highlight the outcomes from a patient treated in an intensive feeding program. Challenges to successful implementation of an interdisciplinary treatment program and strategic implications are provided.

With advances in medical care, youths with chronic illness have the potential for higher quality of life; however, these treatments often come with cost (i.e., burden, financial) that can result in nonadherence. Pediatric nonadherence, on average, is approximately 50% across chronic health conditions. Research has identified effective, evidence-based assessment measures and intervention strategies to promote regimen adherence in youths. Yet, these measures and strategies typically are designed for clinical trials and thus may not be feasible or practical in typical clinic settings. As the field of adherence assessment and intervention expands, it will be important to devise evidence-based tools that are pragmatic and can be translated easily into practice. To guide this future direction, the goals of this paper are to review evidence-based adherence assessment and intervention strategies that can be used with youths and families in clinical practice, to illustrate the complexities of addressing adherence concerns in routine practice, and to discuss the challenges of disseminating and implementing evidence-based strategies in the real world.

Pediatric sleep disorders are common and are associated with significant behavioral and medical morbidity. Pediatric insomnia is the most prevalent pediatric sleep disorder and a frequent complaint in primary care settings. The recognized need for early detection and treatment of pediatric insomnia has prompted a proliferation of research supporting the efficacy of behavioral sleep treatments. However, there are few large-scale studies that have examined insomnia evaluation and treatment in real-world settings. Recently published treatment protocols provide increased clarity about the clinical delivery of evidenced based treatments. Despite advances in the field, there remain gaps in the translation of research findings to practice settings that have practical implications for clinical care. An overarching objective of this article is to demonstrate the feasibility of providing evidence based evaluation and treatment to children clinically referred for insomnia. We report a comprehensive data-driven analysis of the practice patterns and treatment outcomes from a well-established pediatric sleep medicine clinic. These findings expand the limited literature demonstrating the clinical effectiveness (vs. efficacy) of behavioral and cognitive behavior therapy for pediatric insomnia. Implications for practice and clinical effectiveness research are made based on the study findings.

This article is a program description addressing program implementation process and feasibility and initial data on implementation and efficacy. It describes the implementation of a school-wide system-level health promotion initiative, Make School a Moving Experience (MSAME), which was designed to promote physical activity in 74 Delaware elementary schools from 2009 to 2012. By working with the schools to create environments supportive of physical activity (PA), the project goal was to provide students with the opportunity to participate in recommended levels of PA for at least 150 min per week during school hours. Evaluation data was presented in terms of school engagement, school-level PA plans and program implementation, student-level PA and fitness. Findings from the program evaluation illustrate a promising approach for generating system-level changes designed to influence children’s health behaviors.