Clinical Practice in Pediatric Psychology

Objective: Through the use of quality improvement methodology, we aimed to increase the percent of eligible patients seen for developmental testing at our institution from 2.6% to 25% within a 36-month timeframe. Method: The Model for Improvement (Langley et al., 2009) was utilized as a framework to develop and implement an interdisciplinary, hospital-based early intervention program that included comprehensive developmental assessments intended to inform intervention services. A kaizen event was used to map current processes, identify desired future state, and identify potential interventions. Outcomes were demonstrated through use of an annotated run chat and calculation of the percent of eligible patients seen. Descriptive feedback was solicited by e-mail from interdisciplinary team members. Results: The percent of eligible patients seen for clinical comprehensive developmental assessments and provided in-house early intervention services increased to 35.5% (N = 155). Multidisciplinary team members reported that collaboration has improved, leading to enhanced developmental service delivery. Conclusions: This quality improvement initiative resulted in a program that filled a substantial clinical need at our institution. Pediatric psychologists could utilize the model for improvement to similarly enhance the quality of care for very young patients with cancer in their hospital settings. In doing so, professionals who work at hospitals dependent upon clinical revenues may consider utilization of Medicaid’s early and periodic screening, diagnostic, and treatment benefit.

Objective: Adolescent depression is a serious behavioral health concern often seen in primary care clinics. The purpose of this study was to examine the relationship between successful implementation of integrated behavioral health (IBH) services in primary care settings and clinics’ rates of screening adolescents for depression. Method: We examined clinic-level data, with screening rates obtained from a statewide reporting agency and IBH data obtained through an implementation collaborative. Using the Site Self-Assessment, we first examined global IBH integration using a simple regression, then examined specific components of integration using 2 multiple regressions. Results: While an overall level of behavioral health integration was not significantly related to screening rates, several specific components were. These included positive relationships of adolescent depression screening rates with evidence-based practice and provider/staff integrated care training; and negative relationships of adolescent depression screening rates with funding access and integration, organizational leadership for integrated care, and linking to community resources. Conclusions: Clinical implications include the importance of training providers and staff in behavioral health care and regular use and reinforcement of evidence-based practices to facilitate adolescent depression screening. In addition, clinic personnel may perceive less support for IBH implementation from organizational leadership and less financial integration between behavioral and medical services, when clinics have high screening rates. While more research is needed to examine this unexpected finding, it may be that in clinics with high screening rates a culture of valuing behavioral health care leads to a desire for more organizational support for IBH.

Objective: Given the costs of diabetes care, finances may be a source of stress for parents of youth with type 1 diabetes. The purpose of this study was to characterize the perspectives of parents of youth with type 1 diabetes about diabetes-related expenses and any potential relationship with quality of life. Methods: Parents (n = 23, 96% mothers) of youth with type 1 diabetes (aged 5–17 years; 35% female, mean HbA1c = 8.7%) each completed a semistructured qualitative interview. Verbatim transcripts were coded using thematic analysis to derive central themes related to diabetes-related finances. Results: Two primary themes emerged: (a) sacrifices and hardships—Parents described making decisions about household finances to accommodate diabetes-related expenses and employment choices based on salary and benefits; many described prioritizing spending for diabetes supplies, healthy foods, and medical bills and forgoing spending related to family vacations, recreation, and personal needs; and (b) gratitude—Parents discussed feeling thankful for employment and insurance coverage, which help reduce diabetes-related financial stressors or hardships. Conclusions: Care of families of youth with type 1 diabetes should consider parents’ financial experiences and effects on family. Routinely asking about diabetes-specific financial issues in relation to family stress and coping may help inform behavioral and medical care and can facilitate referrals to social work.

Objective: Research has established associations between parental self-efficacy (SE) related to managing their child’s food allergy (FA) and parent quality of life, but there has been limited examination of how parent variables predict child social outcomes. This study examined whether parental SE related to managing their child’s FA moderates the association between parental worry and activity limitation of the child. Methods: Parents of 218 children with parent-reported FA completed an online survey, which included measures of demographics, child FA characteristics, parental SE, parental worry, and social activity limitation. Participants were recruited locally and nationally through social media, e-mail listservs, and paper flyers in pediatricians’ and allergists’ offices in the region. Results: Linear regression results indicated that parental SE moderated the association between parental worry and limitation of child’s social activities, R ² = .14, F(3, 213) = 8.35, p < .001. Parents with higher SE were less likely to limit their child’s social activities, regardless of worry level, whereas parents with lower SE were more likely to limit child social activities as their reported worry increased. Conclusions: Findings suggest that SE may act as a protective factor against child’s activity limitation and impairment of social quality of life when parents report high levels of worry, suggesting treatment targets for anxious parents of children with parent-reported FA.

Objective: To describe the barriers and facilitators to integrating behavioral health services and pediatric primary care in federally qualified health centers (FQHCs) during the early stages of implementation. Method: We conducted 34 semistructured interviews with primary care providers (n = 11), behavioral health clinicians (n = 12), community health workers, and other pediatric staff (n = 11) at 3 FQHCs. Themes were identified inductively using methods informed by grounded theory; inductively identified themes were then deductively organized within the Consolidated Framework for Implementation Research. Results: Interviewees perceived that the adoption and sustainability of behavioral health integration (BHI) in the pediatric practices of FQHCs were most dependent on barriers and facilitators in the outer setting (the health system context, including financing, partnerships with community organizations and providers, local supply of specialty behavioral health providers, and characteristics of their patient population) and internal clinic structures (resources to support protected provider/staff time, colocation, professional development, and adequate staffing). In turn, adequate clinic structure was perceived as a foundational component in facilitating the process, relational, and individual changes required for BHI implementation, including improving provider and staff collaboration and communication, reducing staff stigma, improving provider compassion, and supporting provider and staff well-being. Conclusions: The successful adoption and sustainability of BHI in the pediatric primary care practices of urban FQHCs may depend highly on the health system context and internal clinic structures. Implications for implementing pediatric BHI interventions in FQHCs are discussed.

Objective: Fertility-related health care and decision-making needs for youth with differences of sex development (DSD) are complex and vary by condition and the values and preferences of each individual and their partner and/or family. Discussing fertility implications can be a challenging aspect of clinician and family communication about a DSD diagnosis. This qualitative study assesses fertility-related communication experiences of adolescents and young adults (AYA) with DSD. Method: Participants included 97 AYA with DSD ages 12–26 years (M = 18.5, SD = 3.9) who completed questionnaires on demographic and medical information and patient–clinician communication. A subsample of 33 AYA also completed semistructured interviews about experiences with fertility discussions. Results: Two major themes, each with subthemes, were identified: (1) understanding of fertility related to (1a) one’s own fertility status, (1b) reproductive and parenting options, and (1c) emotional reactions to one’s own fertility status and (2) conversations about fertility related to (2a) reflections on conversations, (2b) barriers, and (2c) advice. Conclusions: AYA perspectives in this study provide important information about how youth with DSD learn about their fertility status, the impact their fertility status has on them, and the fertility-related conversations they have with their providers and families. Specific recommendations for providers and parents or caregivers include the following: inform youth of their fertility status as early as possible; be direct but patient in delivering information; begin by giving basic information and provide more detail as the conversation unfolds; revisit the conversation over time to allow for further discussion or information-seeking; offer additional information or resources, including behavioral health resources.

Objective: Pediatric obesity and pain are 2 of the more prevalent chronic health conditions in childhood. Recent research suggests a strong correlation between these conditions; however, more research is needed to clarify the nature of this relationship. Method: Youth (N = 103) between the ages of 7 and 19 who were undergoing evaluation in a pediatric obesity program were assessed for prevalence, location, and burden of pain. In addition, for those endorsing pain, its relationships to age, body mass index (BMI), BMI z score, mood, and eating behaviors were evaluated. Finally, the utility of a pain measure, The Pain Burden Interview, in a sample with obesity was examined. Results: Almost 75% of youth reported pain on entry into the obesity program with the most common areas of pain being headache, back pain, and knee pain. Almost 44% of these youth reported pain in more than one location. Pain burden over the previous month was similar to that seen in those youth with other pain conditions. There was no relationship seen between pain and age, BMI, or BMI z score. However, for those endorsing pain, increased pain burden scores were correlated with increased depressive symptoms, food addiction, and inattention scores. The Pain Burden Interview demonstrated evidence validity in this sample in identifying a population with unique needs that require further attention. Conclusions: Pain is a common comorbidity of youth with obesity. Providers should be assessing and tailoring interventions to manage these two conditions. Future research should evaluate treatment interventions for youth with obesity and pain.

Objectives: The appropriateness and relevance of somatic symptom disorder and conversion disorder (American Psychiatric Association, 2013) diagnoses are in question as they relate to pediatric chronic pain. This survey-based study on pediatric chronic pain explores how these psychiatric diagnoses are made and perceived and how treatment of patients is approached by Canadian health care professionals working in pediatric chronic pain clinics. Method: Health care professionals (N = 50) completed the survey, which contained both qualitative and quantitative items. Results: Of participants, 88% reported moderate/advanced training in pain, whereas only 26% reported moderate/advanced training in somatic symptom disorder and conversion disorder. Somatic symptom disorder and conversion disorder were reportedly diagnosed in approximately 17% and 5% of young people with chronic pain, respectively; however, overall, the participants were not confident or only slightly confident when diagnosing these disorders. There were no major differences in the reported interventions used to treat pain, somatic symptom disorder, or conversion disorder. Conclusions: These results highlight the need for standardized training in pain and psychiatric assessment, diagnosis, and treatment; diagnostic guidelines; and how to best provide this training to health care staff who work with young people with chronic pain.

Objective: As the landscape of health care continues to shift, providing mental health and pain management services via telehealth is becoming an ideal option to increase accessibility of care. Research demonstrates the benefit of biofeedback-assisted relaxation training (BART) for children. During the COVID-19 pandemic, clinicians required to use telehealth needed an alternative to provide ongoing services. This commentary seeks to illustrate the benefits of offering BART virtually with discussing considerations and future directions. Method: An existing BART protocol was modified for telehealth delivery. Variations to the approach included increased psychoeducation, more parental engagement, and a greater focus on mobile applications (apps) in treatment. Mobile apps were used to introduce relaxation strategies, encourage practice outside of session, and obtain physiological measurements pre- and postpractice of relaxation strategies. Results: Clinicians quickly pivoted their approach and provided services without interruption. Protocol changes illustrated the need for more thorough description of treatment sessions, increased focus on privacy and ethical considerations, and age-related factors. Conclusions: As the uncertainty of the pandemic continues, it is important for clinicians to innovate to provide effective remote clinical interventions for patients and families. Future research studies examining the provision of BART via telehealth and its impact on pain and overall functioning are warranted.

Objective: The objective of this paper is to address ethical and training considerations with behavioral health (BH) services practicing within rural, integrated primary care (IPC) sites through the conceptual framework of an ethical acculturation model. Method: Relevant articles are presented along with a description of how the acculturation model can be implemented to address ethical dilemmas. Results: Recommendations are provided regarding practice considerations when using the acculturation model and the utility of the model for both established BH practitioners and trainees. Conclusions: Psychologists integrated into rural IPC teams may be able to enhance their ethical practice and improve outcomes for patients and families through the use of the acculturation model. Psychologists serving as supervisors can utilize the acculturation model to provide valuable experiences to trainees in addressing ethical dilemmas when competing ethical principles are present.