Clinical Practice in Pediatric Psychology

There is a high prevalence of pain-related somatic symptoms among children with internalizing disorders. Despite the documented comorbidity between somatic and internalizing symptoms in youth, there are limited empirically supported interventions that simultaneously target these issues. In light of this, the current pilot study investigated the feasibility and preliminary efficacy of a novel 12-week manualized group-based CBT-yoga protocol, which aimed to target co-occurring physical and internalizing symptoms in a sample of youth. Twenty-eight children between the ages of 10 and 12 years old who had clinically relevant internalizing symptoms and pain-related somatic symptoms were enrolled in the 12-week intervention protocol. Attendance rates and parent and child responses on social validity scales provided measures of feasibility. Preliminary efficacy was examined through a series of paired sample t tests, measuring changes in internalizing and somatic symptoms, and pain-related coping following the intervention. Results suggest strong levels of child- and parent-rated feasibility. Preliminary data also reveal improvements in internalizing and somatic symptoms following the intervention, in addition to improvements in pain-related coping. These findings provide initial support for the feasibility and acceptance of an integrative group-based intervention combining cognitive–behavioral strategies with yogic practices.

The purpose of this study was to develop and pilot test a program to meet the needs of mothers of adolescents with Type 1 diabetes (T1D) and to improve outcomes in adolescents with T1D. We conducted focus groups with mothers of adolescents to identify needs and develop a cognitive–behavioral intervention aimed at reducing maternal distress, improving parenting practices, and reducing family conflict. This intervention was pilot tested in a randomized trial; mothers were randomized to either the Coping & Communication (N = 15) intervention or Usual Care (N = 15). Mothers and adolescents completed questionnaires measuring distress, parenting, and family conflict pre- and postintervention, and HbA1c values were obtained from adolescents’ medical records pre- and postintervention. Intervention materials (Communication & Coping) received high scores on health literacy and engagement. There was a significant Time × Group interaction for maternal diabetes distress, family conflict (as reported by both mothers and adolescents), and adolescent quality of life. Mothers and adolescents randomized to the intervention group reported significant improvements on these factors as compared with those randomized to usual care. The Communication & Coping program was developed by adapting existing interventions proven to reduce depressive symptoms and improve parenting practices to address the specific needs of mothers of adolescents with T1D. The program shows promise for not only reducing distress in mothers, but also for improving adolescent outcomes, possibly through reductions in family conflict.

Chronic constipation is a common and challenging childhood problem. Effective treatment for chronic constipation and fecal incontinence includes a combination of medical and behavioral treatments. This study evaluates the outcomes associated with providing these treatments in a specialty outpatient clinic consisting of a nurse practitioner and behavioral psychologist. Fifty-seven patients were followed up for initial and follow-up appointments in this multidisciplinary chronic constipation clinic. In addition, 65% of the patients did not return after the initial visit; from this cohort, 21 patients (20%) were randomly selected and outcomes were derived by phone interview. Results showed a reduction in bowel accident frequency, abdominal pain, use of diapers, and perceptions of having constipation. In most cases, these outcomes were achieved after a single visit; however, a more extended treatment was required to achieve optimal benefits for patients who initially presented with frequent bowel accidents. These results suggest that a multidisciplinary clinic comprised of a nurse practitioner and behavioral psychologist provides an effective and efficient way to provide a combined treatment protocol for constipation in children. Future research should evaluate long-term effects of this intervention on constipation symptoms and overall health care utilization.

Pediatric psychologists are frequently consulted for inpatient concerns regarding disruptive behaviors (e.g., verbal and physical tantrum, defiance) that impact medical care. The purpose of this case study is to describe the implementation of a behavioral protocol for a young child in an inpatient medical setting. This study describes the application and challenges of utilizing a behavioral management plan to address tantrum behaviors associated with medical care in an Arabic-speaking 4-year-old child from the Middle East hospitalized for a chronic medical condition. Treatment included 32 contacts over the course of a 2-month hospitalization. The focus of these contacts included implementation of behavioral and parenting strategies to decrease tantrum behaviors during routine medical care. Challenges in implementing a behavior plan within a large medical setting are discussed, including issues associated with fidelity to behavioral interventions, psychoeducation about behavioral principles, and cultural factors and barriers relevant to this patient. These factors are highlighted to better examine their impact on the implementation of behavioral interventions for international patients in a tertiary care pediatric hospital. Further research is necessary to better understand cultural differences influencing behavioral management of patients with chronic medical conditions during prolonged medical stays.

Integrated care is increasingly recognized as an ideal treatment model for a variety of medical conditions, including pediatric gastroenterology. The current study aims to better understand the impact of psychology integration into a subspecialty gastroenterology clinic on referral patterns and psychology utilization. A retrospective chart review evaluated 504 unique referrals over a period of two years, including the 12-month period immediately pre and post integration of psychology services. The impact of integrated psychology and medical services included a large increase in the overall number of referrals placed, a significant increase in the rate of follow-through of these referrals, and a significant decrease in elapsed time from the referral to initial psychology appointment for referrals placed following the integration of psychology services. Utilization was not significantly affected by demographic characteristics (i.e., age, gender, distance from the hospital, insurance type). Referral characteristics, including referring physician and presenting problem, had varying impacts on patient follow-through depending on the time period studied, highlighting the complexity of integrated care’s impact on referral patterns and psychology utilization. Results add to existing literature on the benefits of integrated care and accentuate the need for better understanding and ultimately reducing the barriers to utilization of psychology services.

Children and adolescents are increasingly being prescribed psychotropic medications to address mental health needs. With the difficulty in accessing child and adolescent psychiatrists, primary care providers are often tasked with initiating and managing these medication regimens. The standard of care around psychotropic prescribing in primary care often falls short of practice parameters and prescribing guidelines due to a number of factors including lack of training, time, and payment reimbursement for these services. Pediatric psychologists embedded in the primary care medical home are well positioned to undertake collaborative medication-related roles as part of the standard of care in these settings. This commentary highlights the rationale for pediatric psychologists to undertake collaborative roles in medication management, outlines what collaborative roles may look like in practice, and discusses implications for training and research. A case example is also included to highlight a collaborative consultation around medication management in primary care.

Growing numbers of transgender and gender-nonconforming (TGNC) youth are presenting for medical and mental health care, and increasingly, pediatric psychologists are being called upon to serve as critical members of interdisciplinary care teams. In this commentary, we present information on TGNC youth in three distinct developmental cohorts: prepubescent TGNC children, peripubertal TGNC youth, and pubertal TGNC adolescents. First, we describe the social, medical, and/or surgical treatments available to each cohort of youth. Next, we address the state of the science related to these treatments. Then, we highlight some of the ongoing controversies related to social, medical and/or surgical interventions that are most relevant to pediatric psychologists and the role they play in gender-affirming care. Finally, we conclude with a call for papers for an upcoming special issue of Clinical Practice in Pediatric Psychology focused on advancing the practice of pediatric psychology in transgender health care.

Transgender adolescents and young adults may wish to use cross-sex hormones as a means to achieve identity goals. However, these hormones may impair future reproductive functioning. This case explores the complexities related to clinical decision making concerning fertility and the use of cross-sex hormones in adolescent and young adult transgender populations.

Increasing numbers of transgender adolescents are presenting for transition-related medical care, including gender-affirming estrogen and testosterone. The decision to transition with hormones has long-term implications, including possible irreversible impairment of future reproductive functioning. The commentary by Hudson, Nahata, Dietz, and Quinn (2018) outlines the importance of fertility counseling for transgender adolescents and young adults as ethical, interdisciplinary practice. Key considerations raised include implementing shared decision-making strategies that account for youths’ maturity and individual decisional capacity, evaluating co-occurring psychiatric conditions that could interfere with future-oriented decision-making, and considering benefits and harms of fertility preservation (FP) in the context of a youth’s values, identity, and comfort. This report includes two case illustrations of transmasculine youth which highlight how ethical considerations emerge in clinical practice and underscore the nuance and complexity of fertility-related decision-making among transgender adolescents.