вторник, 18 сентября 2012 г.

Consultation and Collaboration in the Care of Children and Families: The Role of the Pediatric Psychologist - Journal for Specialists in Pediatric Nursing

Collaborative Practice provides a forum for healthcare professionals to share expertise and enhance communication.

When children are seen for medical care, whether in an outpatient primary care setting, or in an inpatient facility for a serious illness, psychological factors invariably intersect with medical ones. The idea that the mind and body are interconnected is not new, and research has consistently shown that physical and psychological health systems invariably impact each other. Therefore, when treating a child, whether for a medical condition or an annual well-child visit, attention to biological as well as psychosocial factors is critical. The field of pediatric psychology, defined and formalized almost 40 years ago (Roberts, Mitchell, & McNeal, 2003; Routh, Schroeder, & Koocher, 1983), was born, in part, out of the recognition that neither mental nor physical disorders could be treated in a vacuum. Pediatric psychologists provide a variety of services to children and families, as well as to nursing and medical practitioners who may be the first to come in contact with children facing serious mental health issues.

From consultation, assessment, and treatment, to primary prevention, research, and advocacy, pediatric psychologists play a number of roles in promoting positive physical, emotional, and psychosocial development and in eliminating or reducing the impact of negative outcomes. The purpose of this brief article is to describe the interplay between physical and psychological factors in both typically developing as well as chronically ill children, and how pediatric psychologists may work effectively with nursing and medical practitioners to provide psychological care to these individuals and their families within a collaborative practice framework.

Psychological Issues in Primary Care

In primary care settings, parents regularly turn to their child's pediatrician, nurse practitioner, or registered nurse for information/advice about a host of physical health issues, as well as for counseling regarding significant behavioral or developmental concerns (Gardner et al., 2000; Lavigne et al., 1993; Routh et al., 1983). As many as 50% of visits to the pediatrician's office include a presenting problem of a behavioral, emotional, or academic nature (Cassidy & Jellinek, 1998); and as many as 90% of mothers of toddlers and preschoolers report some behavioral concerns (Howard, 2005).

In recent years, the American Academy of Pediatrics (AAP) has highlighted the importance of emotional, behavioral, and social factors on the physical and cognitive development of young children and has consistently called for medical providers to be especially aware of psychosocial issues in their practices (AAP, Committee on Psychosocial Aspects of Child and Family Health, 1982, 1993). Additionally, the AAP encouraged practitioners to improve their knowledge of behavioral and mental health issues, basic counseling skills, and referral resources in order to identify those at increased risk for negative psychological outcomes. The primary care setting offers a unique opportunity for collaboration among nurses, medical practitioners, psychologists, and other disciplines. In particular, because prevention of health-related negative outcomes has been embraced as a primary goal in pediatric care (Fuemmeler, 2004; Shonkoff, 2006), pediatric psychologists are well situated to provide these services directly and to assist nursing and medical providers with the development of their own behavioral pediatric knowledge base and skills.

Several studies have indicated that primary care pediatricians may underdiagnose significant behavioral problems in children (Costello et al., 1988; Lavigne et al., 1993); may feel knowledgeable about and comfortable assessing only a select number of prevalent mental health concerns (Williams, Klinepeter, Palmes, Pulley, & Meschan Foy, 2004); and may identify a number of barriers to assessment and treatment within their practices, such as time limitations and lack of training (Horwitz et al., 2007). Psychologists working directly in primary care clinics, or indirectly as a referral source, may provide families with general education about important developmental milestones, health promotion, and screenings for behavioral problems or developmental delay.

When potential problems are identified, psychologists are then able to conduct comprehensive assessments and provide interventions in a timely fashion. An integrated, coordinated approach to managing the mental and physical health of children in primary care is highly desirable because it reduces stress among families and providers, and it facilitates identification of needs and access to resources. Thus, some of the most common barriers to care may be prevented (Chung & Shuster, 2004). For example, one recent survey of children and their caregivers who obtained psychological services through their primary care clinics found that the majority of patients referred actually followed through with services; most families were very pleased with the care provided; and the behavioral functioning of the patients improved significantly (Sobel, Roberts, Rayfield, Barnard, & Rapoff, 2001).

Psychological Issues in Chronic/Life-Threatening Illnesses

Children with chronic or life-threatening conditions face numerous psychological factors that may have significant implications for their physical health and recovery. How well a child adapts to and copes with stressful situations, adheres to a medication regimen, or has access to viable support systems in the family or community may substantially impact disease progression or outcome. Applied research on numerous chronic illnesses affecting children, such as sickle cell disease, diabetes, and asthma, have all identified psychological issues related to management and coping with these diseases (Drotar, Spirito, & Stancin, 2003; HarbeckWeber, Fisher, & Dittner, 2003). Conversely, a specific disease process or treatment may have profound and negative consequences for overall psychological well-being, family stability, or neurocognitive functioning. For example, research on the late effects of treatment for childhood cancer has identified significant risk for frank neurocognitive declines (Dickerman, 2007; Armstrong & Briery, 2003), posttraumatic stress and behavioral problems in the child (Vannatta & Gerhardt, 2003), and adjustment problems in the parents and siblings (Vannatta & Gerhardt).

Pediatric psychologists working in specialty outpatient clinics or inpatient units typically serve as consultants/liaisons to the entire multidisciplinary team. The primary role is to identify and treat psychological factors impacting medical care and to work with care providers to develop the most appropriate treatment plan in light of both physical and psychosocial needs of a child. Psychologists in these settings are often called upon to evaluate those protective factors that might aid a child and his or her family during treatment and identify those risk factors or the evident psychopathology that might interfere with treatment issues and disease management.

Subsequent interventions that are provided are designed to be focused and brief, particularly in inpatient settings, so as not to delay the discharge process. For example, children with sickle cell disease may experience frequent pain episodes requiring hospitalization. Pediatric psychologists, working in conjunction with the collaborative care team, may augment the use of medication-based pain management through noninvasive techniques (e.g., relaxation, guided imagery, hypnosis) to reduce the child's subjective experience of pain. Such techniques, when practiced regularly, may also improve a child's overall coping ability and reduce subsequent pain-related hospitalizations (Lemanek, Ranalli, Green, Biega, & Lupa, 2003).

Children with chronic conditions, such as diabetes, sickle cell disease, asthma, or HIV infection, may be required to adhere to strict medication regimens; yet doing so often proves to be quite difficult (La Greca & Bearman, 2001). Pediatric psychologists may assist care providers in the care and management of such children through assessment of barriers to adherence and in the development of specific intervention strategies designed to minimize the impact of those barriers and improve adherence.

Other chronic or life-threatening conditions, such as acute lymphoblastic leukemia, place children at substantial risk for serious neurocognitive consequences (Armstrong & Briery, 2003). Illness-associated developmental delay or cognitive declines have significant implications for children's adaptation to disease treatment, management, psychosocial adjustment, and academic achievement. Many pediatric psychologists have expertise in the assessment of children who have experienced or who are at risk for neurocognitive deficits and can provide needed recommendations and interventions for children and their families.


Pediatric psychologists have an important role to play in both primary and specialty medical settings. In concert with the collaborative care team, psychologists offer a range of services to aid in the care of both healthy and medically ill children and their families. Direct intervention with children and families, coupled with consultation to care providers regarding the interplay between biological and psychological factors in the developing child, are designed to meet several important goals. The role of the pediatric psychologist is to enhance pediatric practice by insuring that those in need of psychological services are readily identified and treated and by generally reducing the impact of psychopathology on physical health outcomes through education and primary intervention.


Search terms: Collaboration, joint practice, pediatric care, psychologists



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[Author Affiliation]

Elizabeth Willen, PhD

Assistant Professor of Clinical Pediatrics

Director, Developmental Services Program

Mailman Center for Child Development

University of Miami, Miller School of Medicine

Miami, FL

Author contact: ewillen@med.miami.edu, with a copy to the Editor: roxie.foster@uchsc.edu