Handbook of Pediatric Psychology in School Settings

Ronald T. Brown

• Publisher: Routledge
• Year: 2003
• eBook ISBN: 9781135645694
• Topic: Education
• Subtopic: Education Counseling

In recent years the escalating costs of health care have caused managed care programs to shift the delivery of pediatric psychological services away from specialized medical centers and into primary care and school settings. One result has been a radical expansion of school psychology into issues of clinical intervention, health promotion, and the assessment of psychotropic medications. School psychologists are now expected to either deliver or (more likely) to provide consultation regarding a wide variety of pediatric psychological services. Because this is a recent phenomenon, very few school-based psychologists or allied health practitioners (school counselors and social workers) have received training in pediatric psychology. The mission of this book is to provide them with a comprehensive and authoritative guide to their newly acquired responsibilities in such areas as psychotherapy, psychopharmacology, health promotion, and prevention of disease.

This book is appropriate for anyone concerned with issues of pediatric psychology in school settings: school psychologists, pediatric psychologists, clinical child psychologists, as well as pediatricians and child psychiatrists.

1
Introduction: Changes in the Provision of Health Care to Children and Adolescents

Ronald T. Brown

Medical University of South Carolina

The focus of this handbook is the delivery of pediatric psychological services in schools, but in this introduction the focus is on the broader context of pediatric psychology and health care. To understand changes in the provision of health care to children and adolescents, it is helpful first to understand the several natures of childhood illness. These aspects are both physical and psychological. Chronic illnesses are conditions involving a protracted course of treatment. Chronic illnesses can result in compromised mental, cognitive, and physical functioning and are frequently characterized by acute complications that may result in hospitalizations or other forms of intensive treatment (Thompson & Gustafson, 1996). Included in chronic illnesses are such conditions of childhood as developmental illnesses like mental retardation and diseases like cystic fibrosis. A condition that persists for more than 3 months within 1 year and necessitates ongoing care from a health care provider is considered to be chronic.

By the age of 18 years, 10% to 15% of children have experienced one or more chronic medical conditions (Tarnowski & Brown, 2000). Approximately 1 million children in this country have a chronic illness that may impair their daily functioning, and an additional 10 million children have a less serious form of chronic conditions (Thompson & Gustafson, 1996). Prevalence of chronic conditions in children has nearly doubled over the past several decades. This increased prevalence has been attributed to several factors, including advances in health care reflecting improved early diagnosis and treatment, the survival of infants of extreme prematurity or low birth weight, and new diseases like prenatal drug exposure and AIDS.

During the past two decades, the importance of psychological variables in understanding health and illness has become well established (for review, see Brown et al., 2002; Tarnowski & Brown, 2000). With medical advances and improvements in living conditions, contemporary medicine has focused on psychological determinants and sequelae of disease. In fact, the United States Public Health Service has reported that lifestyle and behavioral factors comprise seven of the leading health-risk factors in the United States (VandenBos, DeLeon, & Belar, 1991). As serious pediatric disorders (e.g., acute lymphocytic leukemia) have yielded to improved medical treatments and as some infectious diseases have been eradicated, greater attention has focused on the role of psychosocial factors. These factors mediate and moderate response to illness and are important in the prevention and management of, and adaptation to, illness. Behavioral factors can be major contributors to disease and injury onset and maintenance (e.g., smoking, lack of exercise, diet, treatment nonadherence, substance abuse) (Brannon & Feist, 1997; Brown et al., 2002).

Brown and DuPaul (1999) delineated variables that predict adaptation to illness and injury and promote health. These variables include developmental issues, socioemotional development, and environmental problems. Recent focus has been on increasing the knowledge of health-related developmental variables, including children’s developmental level as it influences their conceptualization of health, injury, and illness. A child’s capacity to comprehend health-related communications is critical. In addition, a child’s capacity to cope with the myriad of challenges posed by chronic illness or injury may be significantly taxed by such environmental stressors as extended hospitalizations; separation from parents, siblings, and peers; and frequent painful medical procedures. Likewise, the child’s illness may affect family functioning and psychological and financial resources. The environmental context in which attention to health care and management of illness or injury occurs is especially important. Family functioning and support can provide an important buffer from the short- and long-term stressors associated with hospitalization (Kazak, Segal-Andrews, & Johnson, 1995). Basic resources (e.g., access to health care, transportation, finances to secure appropriate treatment) and psychological resources (e.g., family support, coping skills) are essential ingredients in a successful formula against the challenges of a chronic illness.

CHANGES IN HEALTH CARE

Change permeates the delivery of health care services in the United States. The cost of health care has risen dramatically, in part from improved technology that better enables us to manage diseases, enhance quality of life, and reduce mortality. Third-party payers (e.g., Medicaid, private health maintenance organizations, third-party insurers) systematically attempt to limit spending and evaluate care so that services, including mental health services, are provided in the most cost-effective manner. Health care has become expensive, and efforts to contain and reduce these costs continue. If children are to receive adequate mental health care, it is important that pediatric psychologists respond appropriately. In the following sections, the areas of change are described, and arguments are made for increasing the presence of appropriately trained psychologists in schools and in primary care centers.

Focus on the Primary Care Setting

One way to contain health care costs is to limit services provided by psychologists, psychiatrists, and other mental health specialists in health care settings (e.g., hospital psychologists) or private practice. By placing the initial point of service in the primary care system and limiting referrals to specialty care providers, costs are contained (American Academy of Pediatrics, 2000), but the availability of mental health services for children and adolescents has decreased. The decrease is attributed to insurance packages that limit mental health services. Before managed care, pediatricians routinely referred their patients with emotional or behavioral disturbances or those with adjustment difficulties associated with the stressor of a chronic condition or illness to mental health providers. This made it more likely that caregivers and school personnel would have direct access to mental health professionals. Decreased availability of these services has resulted in a growing trend to fulfill mental health service needs in the primary care setting (Brown et al., 2002) or schools (Power, Shapiro, & DuPaul, 2003). This has occurred in the midst of increased evidence on the efficacy of specific mental health services (Kazdin, Bass, Ayers, & Rodgers, 1990). Primary care providers can adequately perform some of the basic services of specialists (e.g., pharmacotherapy for the management of attention deficit hyperactivity disorder) (American Academy of Pediatrics, 2000). However, this clearly detracts from the critical needs of managing serious physical illnesses and conditions. Primary health care providers have the added burden of continuing education in disorders for which they have not been trained.

Efforts to drive down the costs of health care run concurrently with increasing mental health needs of children and adolescents and decreasing access to services (American Academy of Pediatrics, 2000). Lavigne and associates (1999) found that the percentage of emotional disorders in children has increased in recent years, particularly among preschool children. In addition, compelling evidence has emerged on psychological consequences of physical illness in children and adolescents (Cadman, Boyle, Szatmari, & Offord, 1987; Gortmaker, Walker, Weitzman, & Sobol, 1990).

Access to services for many youth in rural and disadvantaged communities is sometimes exceedingly difficult because of a shortage of mental health providers (American Academy of Pediatrics, 2000). In some locations, access to mental health care from providers other than primary care physicians or pediatricians is almost nonexistent. Data from the first wave of the Great Smoky Mountains Study of Youth, an epidemiologic investigation of psychopathology and mental health service utilization among regional children, suggest that the major system providing mental health services to children is the educational system, with 70% to 80% of children receiving services in school (Burns, Costello, Angold, Tweed, & Stangl, 1995). For most of these children, their school was the only provider of mental health services. In this study, fewer than 15% of children received mental health services in a general medical setting. Although the investigators recommended research to replicate their findings, schools clearly represent a critical venue for addressing emotional and behavioral needs of children.

There are also difficulties associated with the identification of mental health problems in the primary care setting. First, there are data to suggest that primary care providers underidentify psychological problems in pediatric populations (Brown et al., 2002). Several factors may contribute to this underidentification, including the fact that caregivers may not spontaneously report concerns of a psychological nature, because of reluctance to disclose such concerns to a primary care provider. In a survey of more than 200 mothers, 70% of the mothers had fundamental concerns about emotional and behavioral issues but fewer than one third discussed these concerns with their child’s pediatrician (Hickson, Altemeir, & O’Conner, 1983). Nondisclosure of emotional and behavioral concerns is also evident in more recent surveys. Although 40% to 80% of parents have questions or concerns about their children’s behavioral and emotional development, many do not raise these concerns with their pediatricians or primary care provider (Lynch, Wildman, & Smucker, 1997; Richardson, Keller, Selby-Harrington, & Parrish, 1996; Young, Davis, Schoen, & Parker, 1998).

Perrin (1999) suggested other limitations related to the identification of psychological problems in the primary care setting. First, primary care pediatricians are not generally informed about their patients’ developmental and psychosocial problems. This has been attributed in part to the hesitancy of pediatricians to inquire about children’s behavior, development, or family functioning. Perhaps as a result, approximately 50% of caregivers seen for well-child visits report having psychosocial concerns that go unaddressed (Sharpe, Pantell, Murphy, & Lewis, 1992).

Clearly there have been changes in the structure of health care in our country. Pediatricians and other primary care providers are now gatekeepers for subsequent mental health services; and, more important, they may underidentify psychosocial dysfunction (Costello et al., 1988). It is a serious concern when children and adolescents go without needed mental health services.

Brown et al. (2002) identified a number of factors that play a significant role in impeding the assessment and management of emotional and behavioral disturbances in primary care settings. These barriers include training programs that do not provide pediatricians with specific education, knowledge, training, and skills to address psychosocial disturbances in their patients. Pediatricians may be undertrained in recognizing the complex problems associated with mental health issues and also may lack the necessary expertise to care for children who evidence psychopathology. With the constraints associated with managed care, physicians are often faced with time and financial pressures that restrict their ability to devote sufficient efforts toward assessment and management of their patients’ psychological functioning (American Academy of Pediatrics, 2000; Perrin, 1999). The average office visit in a pediatric practice for both well- and sick-child visits is less than 15 minutes (Ferris et al., 1998), barely sufficient time to assess and manage physical needs.

Primary care physicians also may be faced with inadequate resources to manage emotional disturbances in their patients. For example, they may practice in a community where services that address emotional disturbances in children and families are inadequate (Drotar, 1995). Also, primary care providers may face cumbersome impediments when referring patients to other specialty providers (American Academy of Pediatrics, 2000). Even in the case where a child is identified by the primary care physician and referred to a mental health specialist for further evaluation and treatment, families may be reluctant for a number of reasons to follow through with recommended services. Reasons may include financial limitations, long waiting lists, and the stigma associated with labeling and receiving services at a psychiatric or mental health clinic (Armstrong, Glanville, Bailey, O’Keefe 1990). Perrin and Ireys (1984) observed that this stigma may diminish when these services are provided in pediatric offices. This would also facilitate access to mental health services.

Armstrong et al., (1990) also delineated barriers to mental health care. A general unfamiliarity with the nature and benefits of psychological services by children and their caregivers and health care providers hinders use of services. So do environmental barriers like limited office space and schedules that overlap medical appointments. Other barriers may include resources for travel and increased time demands from multiple appointments.

Another factor that may play a role in the underidentification and management of psychosocial problems in primary care settings is the extent to which the primary care provider views physical health and mental health as distinct entities. For some, the incorporation of mental health issues into one’s scope of practice may require a paradigm shift. McLennan, Jansen-Williams, Comer, Gardner, and Kelleher (1999) found that psychosocial orientation was associated with a primary care provider’s practice of identifying and managing emotional and behavioral disturbances. Beliefs about their inability to manage psychosocial problems and perceptions that patients would resist having psychosocial issues addressed in the primary care setting were associated with primary care providers’ practice methods.

There has been some interest in determining the degree to which pediatricians regard specific treatments as acceptable and whether they actually follow treatment guidelines (Tarnowski, Kelly, & Mendlowitz, 1987). Interventions applied to severe behavioral problems (e.g., suicidal concerns) were rated as more acceptable than those interventions applied to more minor behavioral problems (e.g., temper tantrums). The severity of a child’s medical condition did not contribute to the outcome of acceptability ratings. Although these findings are important in understanding the acceptability of psychological treatments among pediatric primary care providers, much more research in this area is necessary before formulating any definitive conclusions.

These issues underscore an increasing need for collaboration between psychologists and primary care pediatricians as a result of the shifts in the priority of the health care system from specialty care to primary care (Rabasca, 1999). As Roberts (1986) observed over a decade ago, roles for psychologists in primary care settings may increase. For example, many innercity parents value working with health care providers to enhance their own knowledge of developmental and behavioral issues (Schultz & Vaughn, 1999). Only 8% of the caregivers in the Schultz and Vaughn study were in need of medical information, but nearly one half wanted specific information about developmental and behavioral issues. Other important steps in meeting the mental health needs of children include improving the detection of emotional and behavioral disturbances in primary care settings and building more integrated settings in which psychologists work alongside pediatricians and family physicians in children’s primary medical homes.

Changing and Expanding the Role of Psychology in Health Care Delivery

With the growth of behavioral medicine and pediatric psychology, psychologists have had increasing numbers of opportunities to collaborate with other health care disciplines in addressing important health issues for children and adolescents. Over the years, we have witnessed the application of behavioral principles to a broad range of medical problems (for review, see Beutler, 1992). Collaborative endeavors between psychology and pediatric medicine have been important in improving health outcomes, preventing disease and injury, enhancing adaptation to illness, and reducing mortality from disease.

Traditional medicine focused largely on the treatment of disease, but recent concerns about the rising cost of health care and the cost-effectiveness of treatments may help shift the focus of health care toward preventive efforts. Psychologists are well positioned to contribute in this area. Our nation’s recent emphasis on health promotion highlights the importance of psychologists’ work toward the prevention of specific disorders and diseases as well as general health promotion. With the advent of evidence-based medicine, psychologists have had unique opportunities to contribute to the empirical basis of health care. Psychologists’ expertise in research and evaluation have added to physical and psychological empirically based treatments. With these changes, there have been immense opportunities for psychologists to expand beyond traditional practice opportunities to exciting new domains in the delivery of health care. There are already abundant signs that psychology’s influence is being felt in the medical community. For example, in primary care settings, medical utilization and costs can be reduced with psychological interventions (Sobel, 1995).

Over the years, psychologists have made significant contributions to pediatric health care (for review, see Brown et al., 2002). Dimensions include a range of disease states, diverse service activities, and psychologists’ contributions to primary through tertiary prevention.

Within the range of disease entities, psychiatric or mental health disorders are conceptualized as health conditions of equivalent import to other disease categories. Psychologists have been involved in virtually all of these disease categories through research and clinical practice. For many of the diseases, interventions grounded in psychological theory are used to prevent, manage, or ameliorate the symptoms or sequelae of the disease. To participate in the management of these disorders, psychologists have developed a broad range of treatments. Empirically supported interventions ranging from weight control programs to cognitive behavior therapy and a host of other interventions improve health and well-being significantly.

As previously discussed, traditional psychological practice has emphasized a tertiary care role in the mental health arena. However, psychologists have played an integral role in public health initiatives, with researchers, service providers, and policymakers calling for the inclusions of prevention efforts in public health policy (e.g., Lorion, Myers, & Bartels, 1994). Calls for change in the delivery of health care support psychology’s contributions in the areas of primary and secondary prevention activities and across a broader range of health conditions.

Primary prevention refers to efforts aimed at decreasing the prevalence of a disease or disorder by reducing its occurrence (Caplan, 1964). Thus, primary prevention addresses risk and protective factors that may influence the onset of a disease. The goals of primary prevention are to prevent specific disorders and diseases and to foster general health enhancement through education. Primary prevention has become a priority in health policy initiatives (e.g., Kaplan, 2000) and is reflected in the growth and development of programs to promote health and reduce risk factors associated with illness. Programs to promote healthy diet and exercise habits for children and adolescents in an effort to prevent or delay the onset of disease are examples of primary prevention.

Secondary prevention is aimed at reducing the prevalence or severity of a disorder through early identification and treatment (Caplan, 1964). Prevention at this level encompasses work with at-risk populations, the assessment of early disease states, and the implementation of interventions to prevent the exacerbation of symptoms. Targets for secondary prevention efforts might include individuals at high risk for adverse health outcomes due to biologic (e.g., genetic disorders), environmental (familial and sociologic risk factors), and ethnic or cultural (e.g., some diseases are more prevalent among specific ethnic groups) risk factors. Psychologists have successfully applied secondary prevention efforts with premature and low-birth-weight infants at risk for health problems and developmental and cognitive delays.

Tertiary prevention refers to efforts to minimize the sequelae of established disorders or diseases through rehabilitation. Psychologists frequently apply tertiary prevention efforts to alleviate suffering and to reduce problems that are residual to the illness or the disord...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Preface
• Contributors
• 1: Introduction: Changes in the Provision of Health Care to Children and Adolescents
• Part I: Background
• Part II: Prevention and Health Promotion
• Part III: Diseases Encountered in School Settings
• Part IV: Developmental Disorders and Conditions
• Part V: Health Issues Related to Development
• Part VI: Interventions Within School Settings
• Part VII: Special Topics
• Part VIII: Professional Issues