Introduction to Pediatric
Psychology
Gregg Selke, Ph.D.
November 14, 2006
PSY 4930
What is Pediatric Psychology?
Concerned with physical health and illness
of children and the relationship between
psychological/behavioral factors and
health, illness, and disease.
 “Pediatric Psychology” first coined in 1967
by Logan Wright, “dealing primarily with
children in a medical setting which is
nonpsychiatric in nature” (p. 323)

Roots of Pediatric Psychology
Pediatric Psychology
Clinical Child Psychology
Developmental Considerations
Importance of the family
Health Psychology
Interaction between health and
psychological functioning
Defining Features
1.
2.

Promotion of healthy behaviors
Prevention of problematic health
effects (e.g., unhealthy lifestyles,
behavioral patterns….overeating)
Goal: Target behaviors early in life or
early in the onset of a chronic medical
condition
Clinical Activities: Settings

Inpatient medical units
– Consultation/liaison services
– Medical units such as hem/onc, burn, PICU

Medical outpatient clinics
– Private pediatric practices
– Clinics such as craniofacial, endocrinology

Outpatient psychology clinics
Clinical Activities: Settings

Specialty clinics
– Physical rehabilitation centers, Child study
centers

Camps or groups
– Camps for children with chronic illness
Types of Issues

Problems related to pediatric conditions
– Adjustment to disease
– Adherence
– Coping with procedural pain

Mental health problems arising in medical
units
– Behavior problems while hospitalized (e.g.,
noncompliance)
– Bereavement (Death and Dying issues)
– Reintegration into school after hospitalization
Types of Issues

General mental health concerns
 Programs for health promotion and early
intervention
– Programs to increase physical activity
– Early intervention with high-risk infants

Mental retardation and developmental
disabilities
– Assess, train, and educate parents and
professionals

Education/consultation for physicians
 Public health and public policy
It Looks Physical, But is it?

The pediatric psychologist is often called
on by physicians to determine whether
psychological factors are contributing to or
causing a child problems
 DSM-IV diagnostic categories of:
– Somatization Disorders
– Conversion Disorders
– Psychological Factors Affecting Medical
Condition
– Feeding and Eating Disorders of Infancy or
Early Childhood

Pica, Rumination Disorder, Feeding Disorder of
Infancy and Early Childhood
Somatization Disorder

History of many physical complaints that occur
over a period of years and result in treatment
being sought or significant impairment in
functioning.
 Following symptoms have been displayed
–
–
–
–

Four pain symptoms
Two GI symptoms
One sexual symptom
One psuedoneurological symptom
Symptoms cannot be fully explained by known
medical condition or substance use.
 If medical condition is present, symptoms are
beyond that expected for condition.
Conversion Disorder

One or more symptoms or deficits affecting
voluntary, motor or sensory functions that
suggest a neurological or other general
medical condition (and causes distress or
impairment).
 Psychological factors are judged to be associated
with the symptom or deficit because the initiation
or exacerbation of the symptoms or deficit is
preceded by conflicts or other stressors.
 Symptom not fully explained by a general medical
condition or substance or culture.
Psychological Factor Affecting
Medical Condition
A general medical condition is present.
 Psychological factors adversely affect the
medical condition in one of the following
ways:

– The factors have influenced the course of the
medical condition - as shown by a close
temporal relationship between psychological
factors and the development or exacerbation,
or delayed recovery from the condition.
Psychological Factors
Affecting Medical Condition
– The factors interfere with the treatment of
medical condition
– The factors cause additional health risks
– Stress-related physiological responses
precipitate or exacerbate symptoms of the
general medical condition
– Example:
 Depression and diabetes
 Needle phobia and diabetes
Diagnostic Criteria for 307.59 Feeding
Disorder of Infancy or Early Childhood
A. Feeding disturbance as manifested by
persistent failure to eat adequately with
significant failure to gain weight or significant
loss of weight over at least 1 month.
B. The disturbance is not due to an associated
gastrointestinal or other general medical
condition (e.g., esophageal reflux).
C. The disturbance is not better accounted for by
another mental disorder (e.g., Rumination
Disorder) or by lack of available food.
D. The onset is before age 6 years.
Considerations in
Psychological/Medical Links

With some medical disorders it is difficult to
assess and find the real cause of the
symptoms you are being consulted about.

The fact that psychological factors are
found to exist does not necessarily
mean that they are causally related to
an existing medical symptoms

There is a difference between correlation and
causation
Psych Problems Due to Medical
Conditions

Depression, anxiety or other psychological
issues can result from dealing with chronic
illnesses or stressful medical conditions
– coping with disorders such as cancer, cystic fibrosis,
craniofacial disorders
– having to undergo painful treatments such as burn
patients

These child may often benefit from therapy
 Parents of these children may also need help in
coping with these types of conditions in their
children
Things to Look For





Do psychologically relevant factors (eg.,
trauma, stress, life disruptions, etc.) precede
onset.
Do these factors exacerbate “medical”
symptoms.
Is it possible to find evidence for secondary
gain resulting from the “medical symptom” or
“disorder”.
Be cautions of “as yet undiagnosed” medical
conditions that may really account for
symptoms.
Cases referred for evaluation often turn out to
have some sort of physical problem.
Case Examples
1.
Adolescent who had nauseau,
dizziness, and collapsing “spells”
2.
The girl who refused to eat
Case Examples

Role of Pediatric Psychologist
– Systematic Assessment of Antecedents
and Consequences (Reinforcement
Contingencies
– Determine effective/noneffective strategies
of treatment team and family
– Strategies: Contingent or differential social
attention, shaping and fading procedures,
positive reinforcement (verbal and tangible
rewards)
– Liaison between PT, OT, Speech, and
family
Examples of Pediatric
Psychologists on UF Clinic
Teams
 Transplant
Evaluations
 Diabetes Clinic
 Craniofacial Clinic
Transplantation Evaluations

Pediatric psychologists work with children
being considered for transplantation
– bone marrow transplants, heart transplants,
lung transplants, kidney transplants

Determining whether the child/family is a
good candidate for a transplant
– Assessment of medical and psychosocial
issues that contribute to the overall decision
making process
– Contraindicating Factors?
Issues to Consider in PreTransplant Evaluation






Presence of major psychological issues in
child or parent that could compromise
maintenance of the transplant
Knowledge of what is involved in the
transplant process
Motivation for transplantation
Barriers to adherence—past behavior best
predicts future behavior
Stress and coping
Social support
Pediatric Endocrinology Clinic
Outpatient tertiary care clinic
 Psychologist serves as a consultant in a
multidisciplinary team

–
–
–
–
–
Pediatric endocrinologist
Nurses, nurse practitioners
Diabetes educators
Nutritionists
Residents, fellows
Pediatric Endocrinology Clinic
Most patients have type 1 diabetes (but
also type 2 and other endocrine
disorders)
 Physician refers patients for:

– Adjustment difficulties
– Poor functioning (academic, behavioral,
family, emotional)
– Poor adherence/diabetes control
Pediatric Endocrinology Clinic

Psychologist conducts brief assessments (1530 minutes) and provides feedback to the
family and physician
 Family feedback
– Referrals
– Behavioral recommendations
– Problem solving

Physician feedback
– Referrals
– Prognosis
– Treatment regimen change?
Peds Endo Consult

Information collected about:
– Diabetes care
– Emotional functioning
– Academic functioning
– Behavioral functioning
– Social functioning
Pediatric Endocrinology
Consult: Typical Issues

Poor adherence
–
–
–
–
–

Inappropriate level of responsibility for child
Overbearing parent
Arguing about the diabetes regimen
Poor understanding of diabetes regimen
Stressors/life events impact adherence
Emotional, Academic, Social,
Behavioral functioning
– Poor functioning related to diabetes care or
other issues
Craniofacial Clinic

Clinic for children with genetic craniofacial
abnormalities
– Cleft lip and/or palate
– Craniosynostosis

Premature fusion of the sutures of the skull
– Hemifacial


microsomia
Malformation of the jaw, cheek and ear associated with
vertebral defects, with deformity of the external ear and
abnormal smallness of that half of the face.
Psychologist is a member of an
interdisciplinary team including:
– Physicians, general surgeons, plastic surgeons,
dentists, oral surgeons, nurse, social worker,
insurance representative, orthodontists
Craniofacial Clinic
Psychologist conducts a brief
assessment of every patient
 Issues assessed:

–
–
–
–
Medical issues
Social functioning
Development
Academic, psychological, and behavioral
functioning
Recent Developments in
Pediatric Psychology

APA Division Status
– 2001: The Society of Pediatric Psychology
–
–
–
–
became Division 54 in APA
http://apa.org/divisions/div54/
Differentiated from clinical child, clinical,
and health psychology
Made the field more recognized and viable
Led to collaborations with the American
Academy of Pediatrics
Current trends

Managed Care and Reimbursement
– Has negatively affected delivery of
services
– Many peds psych services are not
covered by insurance:
 Pain management
 Interventions to increase
adherence
 Work on multidisciplinary teams
Response to Managed Care
Medical Cost Offset Research
– “The cost of pediatric psychology
services would be ‘offset’ by savings
in medical expedenditures” (Roberts,
Mitchell, & McNeal, 2003, p. 14)
 This research is somewhat controversial

Major Developments
Place of Employment

Primary Care
– Pediatric psychologists are moving
away from university-based hospitals
– Focusing more on primary care
intervention and prevention activities