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BRIEFING PAPER:
Child Clinical Psychologists working with children with
medical conditions
Produced for the Faculty for Children & Young People by the following working party:
Diane Melvin (Chair) Clinical Health Psychology Service at St Mary’s Hospital,
London (providing psychology service to a specialist HIV team ) & Gt Ormond
Street Hospital for Children (paediatric psychology and psychosocial services at
specialist children’s hospital)
Deborah Curson/ Annette Lawson Diana Birmingham Children’s Hospital
(representing wider group including child neuro-psychologists)
Sue Dolby Paediatric Renal Unit, Bristol Royal Hospital for Children & Jessie May
Trust (Charity providing respite & palliative care services for children with life
limiting illnesses)
Michele Puckey Chelsea & Westminster Hospital & Brompton Hospital, London (
providing paediatric services in a general and a specialist hospital)
Lindsey Williams The Lifetime Service, Avon & Wiltshire Partnership NHS Trust
(representing group of psychologists in Community based service)
This working group represents a wide range of experiences from Child Clinical
Psychologists working within different teams providing for the psychological needs
of children with medical conditions.
Thanks also go to Mike Berger and Judith Houghton for their invaluable comments on this paper
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INDEX
Page No.
AIMS of paper
3
INTRODUCTION & BACKGROUND
3
EPIDEMIOLOGY & EVIDENCE of PSYCHOLOGICAL NEED 4
PART 1
WHO WE ARE,
WHERE WE WORK
WHAT WE DO
PART 2
EVIDENCE & OUTCOMES
5
6
8
9-11
PART 3
SERVICE PROVISION/PROFESSIONAL ISSUES
12-14
Workforce planning
12
Consent, Confidentiality & Information sharing
13
Record keeping, accountability, clinical supervision, CPD
14
PART 4
DEVELOPING FUTURE CLINICAL PSYCHOLOGY
SERVICES TO PAEDIATRICS
15-16
………………………………………………………………………………………..
REFERENCES - Professional
17
REFERENCES – Clinical
18-19
APPENDIX 1: Common Problems referred to
Child Clinical Psychologists in Paediatrics
20-21
APPENDIX 2: Staff Consultation examples from
clinical practice
22-23
APPENDIX 3 Record Keeping
24
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AIMS of the Briefing Paper
The primary aims of this paper have been agreed as:
 To inform other Clinical Psychologists about work in paediatric settings
 An aid to service planning in this area and it’s evaluation
 To help inform those professionals/services/interested parties with whom
clinical psychologists work ( including Paediatricians and Purchasers)
 To suggest ideas for future working in this area.
This paper uses the following working definition of a ‘paediatric’ clinical
psychologist:
‘ any Child Clinical Psychologist whose role includes working with children with a
physical illness and/or physical symptoms, their families and or carers ( including
staff.’
This Briefing Paper describes how these clinical psychologists, both as part of child
health teams and as individual practitioners, can support children, families and fellow
healthcare staff and provide a range of services to meet their needs.
Introduction & Background
Physical illness and/or symptoms, of varying cause and severity, affect a great
number of children and young people. These conditions often have consequences
for personal, emotional and social development and general functioning of the child
or young person. They also affect families and others involved in the child’s care
and in service provision.
It is now increasingly recognised that psychological factors have an impact on the
outcome and quality, actual and perceived, of healthcare. Much of the application
of psychology in child health settings already comes from doctors, nurses and other
health care professionals, using their experience, common sense and knowledge of
psychologically-orientated care. There are however circumstances – increasingly
common – where it is recognised that a more focused expertise is needed because
of the nature of the problems, the cost benefits of specialist psychological
intervention or other relevant factors. It is in such circumstances that the
contribution of clinical child psychologists with special experience of child health
services can be realised. This contribution may be achieved by a combination of
direct work with children and families but often also by consultation and liaison
with others involved at different levels within the system caring for the child.
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Epidemiology and evidence of psychological need
Around 10% of children (under 19 years) are admitted to hospital each year, with
more young children (under 5s) admitted than older children (DoH 1993). It is
respiratory difficulties which have a particularly high prevalence in this figure.
Estimates of prevalence of chronic illness in children (under 16 years) vary between
10 and 30% (Eiser, 1995).
Prevalence of Psychological Difficulties:
(i)
(ii)
(iii)
(iv)
(v)
(vi)
Estimates of prevalence of psychological difficulties in the general
paediatric population range from 10-37% (Kush & Campo, 1998)
15% of children with life threatening illness have significant emotional /
behavioural difficulties (DoH, 2000).
Chronic illness is associated with a three-fold risk of emotional /
behavioural problems compared with the general population especially
internalising problems such as anxiety and depression. Also reported: 25%
of children and adolescents with chronic illness have significant functional
problems (i.e. 1-3% of general population) (Garrison & McQuiston 1989)
Neurological involvement increases the risk of emotional / behavioural
difficulty (e.g. 40% of children with Cerebral Palsy have significant
emotional / behavioural problems; epilepsy increases the risk of four-fold
compared with the general population)
Medical progress, often involving complex and demanding treatments, is
leading to longer survival of children with chronic and life threatening
conditions. It is likely this will result in an increase in numbers presenting
with psychological need.
Further studies have acknowledged that when paediatricians have been
provided with extra training they have been able to identify psychological
concerns earlier and this results in more effective interventions. Such
evidence has resulted in the project ‘The Child in Mind’ being set up (this
is an initiative by the Royal Colleges of Psychiatry and Paediatrics and
Child health together with the Faculty for Children & Young People)
This may lead to an increase in referrals to psychologists from
paediatricians.
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Part 1. Who we are, where we work and what we do
This paper recognises the particular expertise and knowledge that a Clinical
Psychologist can bring to working with children with medical conditions through their
training and knowledge and professional structures.
1.1 Who we are
 All clinical psychologists are trained to apply psychological knowledge and
approaches to a formulation about the nature of a presenting difficulty upon
which further assessment or intervention can be based. Formulation implies a
broad – based assessment, drawing on one or several theoretical models; an
understanding of the relationship between the identified difficulties, their
aetiology, and maintaining factors; and an intervention devised in recognition
of the limitations and opportunities presented by the individual circumstances.
One example of this is identifying and understanding the different, and
interacting, influences that cause and maintain chronic pain in children.
 Further, clinical psychologists have a generic training with an emphasis on
understanding normal development and behaviour as well as difficulties and
problems, so they have competencies in understanding developmental and
systemic influences across the age range (from birth to old age). Examples
include: i) providing explanations about health and illness depending on age,
maturity and circumstances and ii) understanding how parental behaviours,
mental health etc. can effect a child’s recovery and well-being.
 Clinical psychology training provides a broad based knowledge of different
interventions from systemic understanding to cognitive, behavioural and
narrative approaches as well as those based on more psychodynamic ideas.
 Clinical psychologists have a key place in meeting the goals of a modern
N.H.S. with a background training in the science and methods of psychology,
a specialist training in applied psychology within health care settings and an
accredited practitioner status. As a profession, clinical psychologists
incorporate principles of Clinical Governance into their roles (see later
references to Professional Practice Guidelines and Guidelines for Clinical
Psychology Services) and a commitment to applying evidence based practice.
 Those working with this population also have an interest in and some
knowledge about the interface between physical and emotional health and
health care systems and the effects of disability on social & emotional
development. They will also be aware how to access literature and knowledge
from appropriate research such as Health Psychology.
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Whilst this paper focuses on Clinical Psychology, there is recognition of the
important role of other psychologists who may also work within Paediatric
settings e.g. Neuro psychologists, Health and Research Psychologists
psychologists, and particularly those working in child development teams in the
community or hospital etc. Establishing partnerships both with these
psychology services and with other psycho-social professions such as
psychotherapy, play therapy, social work etc. forms an essential part of a
knowledgeable, multidisciplinary and needs led service.
1.2 Where we work
Clinical Psychologists working with children and young people with medical
conditions may work in primary, secondary, tertiary or quadertiary services and can
be funded from a range of sources (e.g. acute and primary health care trusts, research
or charities etc). The following lists some of the settings in which clinical
psychologists in this area at present work:







Primary care teams
General paediatric inpatients/outpatients.
Child and Adolescent Mental Health or Neuropsychology Services
Child Development Services
Clinical Health Psychology Service
Medical units e.g. Accident & Emergency, Neonatal Intensive Care, Paediatric
Intensive Care.
Specialist Medical Services for conditions such as cystic fibrosis, oncology,
HIV, diabetes, renal, cardiac, rheumatology, orthopaedics etc. and also for the
effects of trauma or illness such as burns, head injury, acute and chronic pain
management etc
The paediatric psychology service to any of the above can be delivered in a range of
ways but broadly there appear to be three basic categories:
A. Dedicated Paediatric posts (usually situated in a hospital or community
paediatric setting). Service will include input to children and families,
input to specific medical teams/units and input to the organisation such as
strategic planning.
B. Psychology posts with dedicated paediatric time (posts often based within
a CAMHS team). Likely to be offering any one of roles above but not all
three.
C. Psychology posts without dedicated paediatric time but where some
paediatric referrals are accepted. (Psychologist not usually a member of a
paediatric team so does not offer consultation to team or organisation).
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Multidisciplinary team approaches have also been seen as the key to successful
paediatric services. Working with medical conditions the psychologist is often faced
with a number of different teams with which they are expected to link or to be
involved and accountable. Models of service delivery and professional relationships
within these teams not only differ from those present in CAMHS or Child
Development teams but may vary across the teams. The following diagram illustrates
some of the teams a Paediatric Psychologist may be involved in:
Management Team(s)
Peer Team
(Psychology/non-psychology)
Line manager
Supervisor/professional
manager
Other psychologists
e.g. child dev., adult
clinical, health, neuro. etc
,neuro.psychologist etc.
Clinical Psychologists
Paediatric Team(s)
Psychosocial Team
Others involved in emotional and
Community &/or Acute Hospital Services e.g., paediatrician,
nurses
psychological
care
physiotherapist,
e.g. social worker, play specialist
dietician etc.
counsellor, psychiatrist, CNS, teacher,
.
chaplain, etc.
Child development services
Sometimes the needs and working practices of different teams are not always
compatible and may exist in different physical locations or managerial systems.
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1.3 What we do
Clinical Psychologists in paediatrics share psychological knowledge in both direct
and indirect ways.
Appendix 1 describes some of the common referral questions leading to direct work
with children, their families and siblings and staff.
Further as well as referral based work there may be planned proactive/protocol
driven work based on preventing or reducing possible long term sequelae of illness
and treatment plans as well as monitoring outcomes and effects. For example in
transplants and elective surgery psychological involvement may be at times of
decision making and adjustment during the pre and post transplant times. And in
chronic illness systematic assessment of psychological well being may help in
determining present or future treatment decisions. Further there is also often a need
for psychological input when palliative care is being planned and implemented for
terminally ill children.
Some examples of the range of proactive and consultation work to the wider health
system are highlighted in Appendix 2.
The following are examples of consultation around children and families needs:
 Involvement in psychosocial ward meetings where reviews/plans made
for inpatients.
 Facilitating group experiences for parents or siblings when there has
been a bereavement or when coping with significant change in child’s
health or functioning.
 Liasing both within hospital or health services and with other agencies
in community e.g. schools, local CAMHS
 Consultation with colleagues or families over consent or coping issues
 Running joint clinics with medical colleagues over complex adherence
and adjustment cases.
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Part 2 : Evidence and Outcomes
This section considers what evidence of effectiveness there is for psychological input
in paediatric settings.
2.1 Context
(i) There is an emerging evidence base for the effectiveness of psychological
approaches but further research and reporting of clinical cases is needed.
(ii) The focus has shifted from assessing psychological problems to recognising that
many children and families cope well , prompting investigation into the attributes
which predict coping and resilience.
(iii) Risk factors include severity, visibility and unpredictability of the condition, a
remitting-relenting course , age of onset, duration, pattern of medical care, male
gender and the presence of CNS involvement
(iv) Interventions focus on physical outcomes (e.g. better treatment adherence) and/or
psychological adjustment.
(v) There are many methodological issues including small sample size, inadequate
outcome measures, and timing of measurements. Qualitative methodology is
advocated by some researchers (Morse & Eiser 1996).
(vi) Research has focussed on cognitive and behavioural approaches with less
investigation of psychodynamic or systemic interventions.
(vii) Monitoring progress over time including developmental functioning can also
provide useful evidence of adjustment and the effectiveness of psychological support
as well as treatments.
2.2 Effective interventions
Documented evidence comes from both child mental and physical health conditions,
with a number of published summaries of the evidence available so far (Fonagy et al
2002, Wolpert et al 2002). There have also been an excellent series of special articles
in the Journal of Paediatric Psychology ( April 99- July 01) covering empirically
supported treatments in paediatric psychology including adherence to treatment
regimes ( July 2001), disease related symptoms in asthma, diabetes and cancer ( Aug
1999), and procedure and disease related pain ( April 1999).
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The following paediatric areas have particularly been reported on:
(i) Preparation for hospitalisation, painful procedures and surgery
For example:
 Parents can be trained to help children cope with procedures
 Education, distraction, cognitive techniques and coping skills training
shown to be effective
 Hypnosis may be effective during lumbar punctures and Bone Marrow
aspirates
(ii) Chronic illness
 Psychological interventions have been found to be effective in improving
physical outcome in asthma, diabetes, JRA and other chronic illnesses by means
of multi-component approaches encompassing education, relaxation, trigger
recognition, problem solving skills and stress reduction
 Education , organisational and behavioural strategies can be effective in managing
adherence (Leman et al 2001)
 Family Therapy and Psychoanalytic Psychotherapy may be effective in asthma
and diabetes
 Relaxation and biofeedback techniques are effective in headaches and migraine
(iii) Pain Management
For example cognitive and behavioural interventions (relaxation, guided imagery
etc.) are effective in managing pain from various sources including musculoskeletal pain and cancer pain in combination with pain relieving medication
(iv) Physical Symptoms with no known cause
For example cognitive behavioural techniques ( including relaxation, positive
self statements by children, contingency management by parents) have been
found to be effective in Recurrent Abdominal Pain
(v) Other kinds of relevant evidence
Examples exist from related areas of knowledge e.g. child development, risk and
resilience, stress and coping which may guide practice and interventions.
Two examples are:
 Evidence of openness and honesty about hospitalisation and illness generally
reduces anxiety for many children (Rushforth 1999).
 Evidence from stress management and reflective practice as effective
interventions with staff groups (Firth-Cozens & Payne 1999)
Appendix 2 also gives some examples from ongoing clinical practice.
(vi) Future practice.
There is much scope for more research especially on prevention/amelioration of
adverse psychological consequences of illness as there is for clinicians to report
on effectiveness from individual or group clinical casework.
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2.3 Outcome Measures
There are issues around the definition of an outcome in ‘physical health’ and around
how psychological outcomes should be measured. The following reflect some
factors to be considered when planning outcome research (see also reviews by Drotar
1997, Carr 2001)
 Audit and Service evaluation can be a very helpful part of measuring
effectiveness. Measures include the number of cases referred, time of
referral , kinds of difficulties seen etc.
 Outcomes for interventions with the team or organisation are often less
well monitored. Qualitative and anecdotal measures may be most
useful e.g. changes in kinds of referral questions asked.
 Identifying which psychological factors/attributes are protective and
give resilience and which increase vulnerability to distress,
emotional/behavioural difficulties etc. can help in decisions about
appropriate outcome measures (Eiser 1995). Background models of
psychological understanding may help to drive hypotheses and can
indicate appropriate outcomes to monitor. Such models include
disability models (e.g.Varni & Wallender), systemic models (e.g Carter
& McGoldrick ) or social or ethnographic models (e.g. Blubond
Langer ).
 Developmental and educational outcomes often provide a core
outcome. Longitudinal research or follow up can both provide
outcome data and help plan later service provision.
 In paediatrics interest is both in ‘quantity’ ( life expectancy etc) and
‘quality’ of life. Outcome measures of effectiveness of treatments on
quality of life often centre around presence or absence of problems (in
development, growth, illnesses, hospital admissions etc.) It is not clear
whether quality of life can be standardised across ages and diagnoses.
(see Eiser & Morse’s critical overview of measures). Self esteem and
body image measures are also important in this context.
 Some rating scales and questionnaires have been used to measure
specific symptoms or behavioural changes. These are generally self
report measures and have often been used to measure changes e.g.
pain or adherence scales but can also measure frequency and severity
of headaches, anxiety attacks etc. It is difficult to know whether
other measures used in research or mental health situations, are useful
measures in this area of clinical practice e.g. Goodman SDQ, Spence
Anxiety Scale.
There are a number of methodological difficulties in measuring effectiveness
including concerns around the large number of interactive factors, the reliability and
validity of measures e.g. the low correlation between professionals and parents rating
of a young child’s pain. Measures standardised on healthy populations or developed
for mental health settings may not be appropriate. It can also be hard to identify
suitable comparison groups.
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Part 3. SERVICE PROVISION
3.1 Workforce Planning
At present significant variation exists in the provision of clinical psychology services
for children with medical conditions (Houghton 2002). Adequate formulae with
which to calculate appropriate levels of input to meet the needs of children and
families within particular settings or health care systems are not available. It may be
that such formulae will only be able to provide a baseline estimate as there will be
considerable variation in population needs as well as the availability of different
medical specialisms in different areas. For example an urban area with a children’s
hospital and/or specialist units (for asthma, cystic fibrosis etc) will have differing
needs than a rural area with a District General Hospital. Combining local variations
with general population needs as suggested in BPS documents (D.C.P., 2001) need to
guide service development within emerging governmental initiatives which are aimed
at ensuring equality of access to services nationally (NSF Frameworks for Children )
There are a number of other factors to be taken into account when identifying
appropriate provision including :

What other psychological and related resources and skills are already
available (e.g. health psychologists, counsellors, nurse specialists).

Whether the demand is for a generic or specialist paediatric post.

The population to be served (in terms of numbers, geographical spread and
availability and complexities of existing clinical networks). Ethnic mix and
cultural diversity within the population may be crucial factors too as these
may influence readiness to access certain services due to differing health
beliefs or previous experiences.

The demand generated by existing protocols (e.g. pre-transplant assessments)

The need to increase psychological skills and competencies within the team
through education, joint working, supervison etc.
It is suggested that in order for a clinical psychologist to provide an effective, safe,
evidence based service to a multidisciplinary paediatric medical team the following
elements are regarded as essential minimum requirements when commissioning the
service :
 Sufficient clinical sessions for direct work with children and families
 Space to interview children and families which ensures privacy
 Time for consultation to and liaison with the health and social care systems
around the child
 Time and funding for activities relating to clinical governance ( e.g. appraisals,
C.P.D., clinical supervision, audit, research )
 Access to administrative and I.T. resources
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3.2 Guidelines for good practice
The current guidelines available on professional practice (D.C.P., 1995), clinical
psychology services (D.C.P., 1998), case notes (D.C.P., 2000), C.P.D. (D.C.P., 2001),
consent (S.I.G., 2001, D.O.H., 2001) and evidence based practice (Faculty for
Children and Young People, 2002) provide the foundation for developing operational
policies and good practice guidelines for clinical psychology services for children and
young people with medical conditions. However a number of issues specific to
providing such services within paediatric healthcare systems may require more
precise guidance. Examples of these include:
i) Consent
When a clinical psychologist is an integral member of the multi-disciplinary medical
specialty team the process for obtaining specific consent for psychological assessment
and treatment still needs to be negotiated with the team and made explicit for the
child, young person and their carers. ( SIG Practice Guidance on Consent 2001)
The clinical psychologist may also find they have a primary role in situations of
helping clarify a child or young person’s competence to consent to medical treatments
etc. where there are situations when parental permission is unavailable or conflicts
arise so familiarity with these procedures is also a necessary part of knowledge for
practice (DOH 2001)
ii) Confidentiality and information sharing
Clarification will need to occur with a child and his/her family and also within the
multidisciplinary paediatric team about what levels of information sharing of
psychological information is appropriate. Other members of the team may have
different expectations and understanding of what level of personal information needs
to be shared in different settings. (e.g. ward rounds, clinical meetings, psycho-social
meetings). Achieving an appropriate balance between enabling the child and
family’s psychological needs to be understood and respecting their confidentiality has
to be attempted. Clear explanations about what information the clinical psychologist
will share, with whom, how and for what purpose need to be given to children and
their families, and their permission sought. There can be an assumption that there is
open sharing of all information particularly if the clinical psychologist is seen as an
integral part of the service of the paediatric team (e.g. within the paediatrician’s
clinic, joint sessions with play specialists or nurse specialists, ward rounds). The
psychologist needs to clarify with both families and staff their commitment to
preserving the confidentiality of psychological information and being open about
what will and will not be shared more widely. There must always be a clear
understanding that the child’s well being is paramount and that any child protection
concerns will have to be acted upon (Children’s Act 1989 )
Guidance on the dissemination of written information pertaining to the child and
family also needs to be agreed and explicit. For example decisions about what other
services e.g. GP’s, the child’s school will be forwarded copies of psychological
reports.
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iii) Record keeping
There should be agreed procedures by the clinical psychologists within a service with
respect to where information is recorded (medical notes, joint psycho-social notes,
psychology notes) as well as guidance on what information it is appropriate to record
in each file particularly with respect to confidentiality and access to information by
other professionals. The child and family should be aware of where information is
located should they require access to these. Providing some written guidance on
recording in particular notes (e.g. medical notes) helps with effective communication
about psychologists involvement to other staff and also helps ensure consistency and
informs trainees and new members of staff ( See Appendix 3 for an example).
iv) Accountability
The varied funding for posts in paediatric settings may lead to clinical psychologists
being line managed outside an existing clinical psychology service structure. This
raises the need to establish a professional management structure which encompasses
such posts.
v) Clinical supervision
In view of the relatively small numbers of clinical psychologists working in specialist
paediatric posts, clinical supervision may need to be accessed from a range of other
sources such as colleagues within C.A.M.H.S., Health Psychology Services or similar
specialist services in other Trusts. This needs to be recognised and resourced
appropriately in order to help reduce isolated practice and enhance quality and
professional development.
vi) Continuing Professional Development
C.P.D. for clinical psychologists working with children and young people with
medical conditions should include access to training and information on generic child
and family psychology, health psychology as well as on specialist paediatric practice.
There is currently an annual meeting of clinical psychologists working in paediatrics
and plans for a U.K. paediatric clinical journal. Balancing the need to maintain up to
date clinical practice across these different domains has to be considered within
appraisal systems.
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Part 4. Developing Future Clinical Psychology services to Paediatrics
How is Clinical Psychology in Medical Settings Different?
The paediatric physical health system differs from the child and adolescent mental
health services and this variance prompts differences in the delivery of Clinical
Psychology. The concerns raised are often to do with reactions to adverse situations
or coping with stress and distress rather than with mental health diagnoses or severe
psychological disturbances. Clinical Psychologists in Paediatrics need to offer
planned positive input rather than referral-based work. Clinical Psychologists in
Paediatrics are likely to provide consultancy and liaison to several Multi-disciplinary
teams. Other areas of psychology practice have as much to contribute to this
developing field as has that of child mental health, for example from those working
in child disability or health psychology services.
Where should we develop Clinical Psychology Further?
As well as current areas of research and practice, it is likely that Clinical Psychology
will focus increasingly on:
 Coping with treatments
 Transition to adult services
 Areas where long term effects on appearance and functioning.
 Working within a range of clinical networks (e.g. primary, secondary, tertiary
levels; care pathways)
 Developing models of service structure (different models work in different
settings and with different populations)
 Theoretical models appropriate to Paediatric settings
Factors Likely to Influence Future Developments Include:
1.) Initiatives from the wider system e.g NSF plan
Commissioning of services by PCTs
Developing role of other healthcare professionals including other Applied
Psychologists
Policy within other agencies (notably Education and Social Services e.g. SEN
code of practice; quality protects)
2.) Initiatives within the Professional System
Children and Young Person’s Faculty future position papers
Developments in training of Psychologists to work in Paediatric settings, both on
training courses and CPD for qualified Clinicians Development of practitioner
networks
On-going research into effectiveness, outcome measures etc.
3.) Initiatives within the local services
Skill mix initiatives
Joint statutory and voluntary sector funding of posts
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In conclusion at a time of rapidly expanding medical progress, not only in the
identification of but also in treating diseases and conditions affecting children’s
present and future health , there is a need for an increasing proactive approach to the
development of services aimed at managing the functional, emotional, behavioural
and social consequences for children and young people living with these conditions.
Evidence is already available which shows that effective management of any child or
young person in need happens by supporting the family and other care systems which
surround that child as well as by providing direct input to the individual. Further
early and easy access to appropriate support services not only helps manage any
existing distress, concerns or psychological consequences due to the physical
symptoms or ill health but also aims to enhance the existing adjustment and coping
strategies and resources of the child and family. Such input has both immediate and
future benefits for the child and their family and can help prevent or reduce any
future psychological consequences which may be more difficult and more costly to
manage.
This paper has proposed that Clinical psychologists, because of their training and
knowledge and professional structures, have a pivotal role in the development of
services for children and young people with physical conditions or symptoms. It has
also proposed that Clinical Psychologists have much to contribute along the multidisciplinary care pathways exiting in both community and hospital settings that enable
these children and their families to lead as healthy and normal a life as possible.
Ideas for the further development of psychology services with this population have
also been provided.
We hope that the original aims of the paper have been met and that this document
forms part of the overall goal of achieving:
Access to an equitable and quality Clinical Psychology
service for children with medical conditions and for
their families and carers.
Page 17
Professional References
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Clinical Psychology Information Leaflet No.4. British Psychological Society
Øvretveit, J., Brunning, H. & Huffington, C. (1992). Adapt or Decay: why clinical
psychologists must develop the consulting role. Clinical Psychology Forum (46)
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Psychological Society
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Psychological Society
Page 18
Clinical References
Blubond Langer (1996) In the shadow of illness: parents & siblings of the chronically
ill child. Princeton NJ. Princeton University Press
Carr (2001) ‘What works with children & Adolescents’ Routledge London
Carter & McGoldrick (1991) in Walsh & McGoldrick (Eds) Living beyond loss: death
in the family. New York. Norton
Child in Mind Project 2002: Audit Commission
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Eiser (1995) Growing up with a chronic Disease . Jessica Kingsley London
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commissioners and providers. Institute of Psychiatry. London
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Practitioner Review
Page 19
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Paediatric Psychology NY. Guilford
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Page 20
Appendix 1.
Common problems referred to Child Clinical Psychologists in Paediatrics – these
may be met by both direct and indirect ways of working
CHILD
(i)
helping child co-operate with prescribed treatments and/or
procedures e.g. needle anxieties, nebulisers, oral medicines
thinking about choices about treatments and/or life changes e.g.
cessation of treatment, changing to special needs school
behaviour and/or emotional difficulties which may or may not be
associated with physical illness/symptoms e.g. enuresis, feeding or
sleep problems, low mood, school difficulties
consideration of effects of physical illness/symptoms on child at
present and in future and providing opportunities for open discussion
e.g. infertility, change to physical appearance and body image,
headaches, life limiting implications, adjustment to diagnosis and
treatment regimes, informed consent and participation, end of life
concerns
Assessment of cognitive, learning and specific functions e.g. to
assess impact and progression of illness, to assess levels of
functioning to inform future care and treatments including self
medication in e.g. diabetes
Supporting child through transitions e.g. child to adolescence to adult
services, hospital to home, specialist to local services
(ii)
(iii)
(iv)
(v)
(vi)
SIBLINGS
(i)
Understanding the nature of the physical illness and/or
symptoms and
(ii)
a consideration of implications for them e.g. whether they
have/will have the same condition, how to explain the illness to
others if they are asked, changes to family life including parental
absence due to hospitalisation
(iii)
Coping with own thoughts and feelings about siblings’ illness in
confidential way
(iv)
Helping in management of other difficulties which may/may not
be experienced by their siblings’ physical illness/symptoms e.g.
bullying, low mood, anxiety
(v)
Helping in preparation and support if they are directly involved
in sibling’s treatment e.g. sibling donors in bone marrow
transplant
N.B Siblings can often be the ‘neglected/ marginalised’ group within the hospital
service and often not high priority for local CAMHS, or other support services in
community
Page 21
FAMILY/CARERS
coping with own thoughts and feelings about their child’s illness and/or
physical symptoms. Awareness of impact of own emotional well being on
child’s illness
(ii)
how to answer questions put by child with physical illness and those of
friends, family
(iii)
preparing and supporting child for future treatment/changes in life style
etc.
(iv)
negotiating role as a parent of a sick child at home, outside home and in
medical settings
(v)
balancing parenting sick child with other aspects of family need and
functioning & meeting needs of other family members
(vi) dealing with transition especially to adolescence e.g. how to give
child/young person greater independence
(i)
Page 22
Appendix 2.
Examples of practice related to staff and system input from Clinical Psychology
in Paediatrics
 Consulting to paediatric teams on ways of screening for psychological difficulties
in children and families.
 Attending a regular ward round/psychosocial meeting to consider family and
systemic perspectives
 Teaching staff about children’s development and emotional/behavioural needs in
hospital
 Contributing to the development of protocols or guidelines for pain management,
treatment plans, palliative care, transitional services, or care pathway guidelines.
 Providing reflective practice opportunities for staff over difficult ward situations
 Involvement in debriefing or support opportunities for all staff when a child’s
death occurs, or when terminal care is being planned
 Facilitating group discussions in high stress units e.g. paediatric accident &
emergency and intensive care units
 Working with others ( e.g. senior nurses, play specialists etc) to develop policies
for childrens care. e.g. preparation for procedures
One example here is an initiative set up in East Kent where a clinical psychologist
with limited dedicated paediatric time has helped for a Preparation for Procedures
working group called PITSTOP aimed at both providing information to children
about procedures and trying to influence environments. They are forming links with
other services e.g. radiology and departments across the area.
 Involvement in decisions to help recruit to the existing psychosocial team or in
planning future developments in this area.
 Contributing to clinic, team or service documents emphasising the psychological
needs of children in hospital or coping with medical conditions
Page 23
Appendix 3
Record Keeping
Example from one trust on Guidance for record keeping, given here as an example:
WRITING IN A PATIENT’S MEDICAL NOTES
If an inpatient is seen on the ward, writing in the notes should be done within 24
hours.
Say who you are at the beginning, for example, ‘seen by A. Person, Clinical
Psychologist’.
Write the date, and if appropriate, the time.
Write a short summary of the interview you have had. It is important to include who
referred and why, who was present at the interview, the main (salient) topics
discussed, the plan for future work (including any suggestions and when or if you see
the child and/or his/her family next), especially concerning the identified problems
that the referrer made.
Discriminate between fact and opinion. For example, ‘in my opinion, he/she is not
clinically depressed at present’.
Sign the report at the end, including a contact number – bleep, and/or telephone
number.
Do not use abbreviations and/or jargon that other professionals may misinterpret or
not understand. For example, CBT or .