Title: Developing Competence in Pediatric Psychology within a General Child Internship
1Developing Competence in Pediatric Psychology
within a General Child Internship
- Jennifer C. West, PhD.
- University of Rochester Medical Center
- Departments of Psychiatry and Pediatrics
- April 17, 2009
2 Objectives
- Describe an elective rotation designed to
promote emerging competence in pediatric
psychology - Describe the challenges associated with
integrating a specialized elective experience
within a generalist internship program - Highlight outcomes of the elective experience
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4University of Rochester Medical Center Internship
Child and Adolescent Track
- 4 interns
- 12 months outpatient (10-12 weekly patient
contacts, groups) - 6 months acute psychiatry (testing/consultation/tr
eatment) - 6 months elective with higher outpatient caseload
- 8 hours Pediatric Psychology
- 8 hours Research
- 4 hours Pediatric Psychology/ 4 hours Research
- Seminars Psychotherapy, Diagnostic Clinic, Group
Therapy, Multicultural (1/xmo), Teaching/Case
Conference (1x/mo), Professional Development
(1x/mo)
5Pediatric Psychology Elective
- Development of the elective was guided by 2003
Society of Pediatric Psychology Task Force Report
on Training of Pediatric Psychologists (Spirito
et al) - Also informed by training experiences of faculty
supervisors - What was positive about their training
experiences and what they would have changed
6Taskforce Recommendations (Spirito et al, 2003)
- Training in a variety of skills direct service,
research, consultation, program development and
evaluation - Focused training in 1-2 areas of interest with
goal of developing specialization - Practice in primary care
- Interdisciplinary training
- Mentoring
7Domains of Training (Spirito et al., 2003)
- Life-span Developmental Psychology and
Psychopathology - Child, Adolescent and Family Assessment
- Intervention Strategies
- Research Methods and Systems Evaluation
- Professional, Ethical and Legal Issues Pertaining
to Children, Adolescents, and Families
- Issues of Diversity
- Role of Multiple Disciplines in Service Delivery
Systems - Prevention, Family Support, and Health Promotion
- Social Issues Affecting Children, Adolescents,
and Families - Consultation and Liaison Roles
- Disease Process and Medical Management
8Pediatric Psychology Elective
- Supervisors Psychology Faculty and Psychology
Fellows - Provide consultation, assessment, and short-term
treatment in the following ambulatory clinics at
the Golisano Childrens Hospital at Strong - General Pediatrics
- Pediatric Diabetes Clinic
- Pediatric Gastroenterology Clinic
- Pediatric Pulmonology Clinic
- Provide psychological treatment to patients with
chronic illness in the outpatient psychiatry
clinic
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10Pediatric Psychology Elective
- Aims to promote development of foundational and
core competencies that are integral to the
internship, within a specialized context (Kaslow,
2004) - And, development of specialty competencies
- Developmental model of competence
- Interns arrive with varying levels of experience
and different training goals - Minimum threshold of competence, yet tailor to
the individual training/ professional development
goals - Training that combines didactic, experiential,
and mentoring components
11Internship Competencies
- Professional Skills and Competencies
- Diagnostic and Assessment Skills
- Treatment, Consultation and Administrative Skills
- Professional Standards and Behavior
- Ethical Understanding and Behavior
- Professional Development and Demeanor
- Academic Competencies
- Teaching and Supervision
- Scholarship
12Pediatric Clinical Experiences Goals and Domains
of Training
- Training in a variety of skills direct service,
consultation - Some opportunities for program evaluation and
development - Fewer opportunities for research
- Training in 1-2 specific areas of interest
- Interdisciplinary training
- Interdisciplinary settings (medicine, nursing,
social work, nutrition, education-liaison, Child
Life) - Some joint training opportunities with pediatric
residents - Mentors
- Paired with faculty, postdoctoral fellows
- Developmental process
13Clinical Experiences Goals and Domains of
Training
- Emphasis on primary care
- Provide consultation and service in general
pediatric clinic - Involved in mental health screening initiative to
enhance detection of behavioral/emotional health
concerns - Provide evaluation/treatment to patients/families
who are at-risk - Educate primary care providers re psychosocial
treatments - Consultation, didactic lectures
- Provide psychoeducation, anticipatory guidance to
prevent mental illness - Identify/refer patients who need ongoing mental
health treatment
14Clinical Experiences Goals and Domains of
Training
- Lifespan Developmental Psychology
- Supervised clinical cases across the lifespan
that focus on issues related to chronic illness
(e.g. adherence, procedure-related anxiety,
illness management at transition to college) - Area for improvement Infancy
- Lifespan Developmental Psychopathology
- Participation in routine mental health screening
initiative to identify youth at risk for mental
illness - Observe and conduct supervised clinical
activities with patients presenting with range of
psychopathology - Area for improvement acute medical illness
15Clinical Experiences Goals and Domains of
Training
- Child, Adolescent and Family Assessment
- Multiple opportunities for assessment related to
adherence, quality of life, coping, pain, weight
control, health beliefs - Assessment of family functioning strengths,
vulnerabilities - Area for improvement Increased use of
empirically based assessment tools - Intervention Strategies
- Opportunities to observe supervisors conduct
interventions - Opportunities to deliver interventions with
children with chronic medical and behavioral
health conditions (e.g., encopresis, recurrent
abdominal pain, procedure-related anxiety,
adjustment issues, adherence to medical regimens) - Fewer opportunities for bereavement counseling,
group interventions
16Clinical Experiences Goals and Domains of
Training
- Research Methods and Systems Evaluation
- No current formal opportunities
- Professional, Ethical, and Legal Issues
Pertaining to Children, Adolescents, and Families - Multiple experiences focused on developing
appropriate communication in healthcare settings
(progress notes, evaluation summaries,
interdisciplinary team meetings) - Issues of Diversity
- Multiple opportunities for supervised service
delivery to patients of diverse ethnic and
cultural backgrounds, sexual orientations and to
conduct evaluations using interpreter services - Area for improvement Currently only in one
setting (ambulatory)
17Clinical Experiences Goals and Domains of
Training
- Role of Multiple Disciplines in Service Delivery
- Participate in multidisciplinary staffings
- Lectures to medical students and residents,
observed visits - Area for improvement participation in regular
team mtngs - Prevention, Family Support, and Health Promotion
- Supervised experience in promoting healthy
lifestyles, especially related to physical
activity, diet, sleep hygiene, family violence,
effective discipline
18Clinical Experiences Goals and Domains of
Training
- Social Issues Affecting Children, Adolescents,
and Families - Service in primary care aimed at reducing
barriers to accessing mental health care - Consultation and Liaison Roles
- Multiple opportunities to observe and provide
consultation to medical providers (primary care
and subspecialty), as well as to educators - Area for development no current involvement on
inpatient C-L team - Disease Process and Medical Management
- Clinics provide multiple opportunities to gain
knowledge of disease process and treatment
19Pediatric Supervision Group
- Meets weekly for one hour
- Participants All trainees (interns, fellows)
providing service in the Pediatrics Department - Case discussions weekly (30 min)
- Weekly didactic presentations (30 min)
- 1st week of month Guest Lecturer
- 2nd week of month Treatment presentation
- 3rd week of month Journal article review
- 4th week of month Multicultural presentation
20Pediatric Supervision Group
- Case discussions
- Provide additional opportunities for trainees to
gain knowledge about chronic illness and related
psychosocial factors beyond clinics where they
are providing service - Case-based learning focus on assessment
strategies, differential diagnoses, treatment
planning, interventions, ethical issues, issues
related to diversity, systems issues - Role modeling by supervisors
- Role plays
- Discussion of community resources
21Pediatric Supervision Group
- Directed readings focused on domains of training
(Spirito et al, 2003) - Handbook of Pediatric Psychology (Ed. Roberts)
- Binder of articles general issues,
illness-specific - Web-based resources Bright Futures toolkit,
American Academy of Pediatrics, community
resources - Journal of Pediatric Psychology series of
review articles on EBTs, current volumes - Attendance at Pediatric Grand Rounds
- Additional instructional techniques could include
videotapes, demonstrations with standardized pts,
virtual-reality based peds psych interactive
training materials
22Guest Lecturer Topics
- Psychological Consultation in Medical Settings
- Psychosocial Aspects of Chronic Illness
- Neuropsychological Sequellae of Chronic Illness
- Child Life Services
- Education Liaison Services in the Medical Center
- Sickle Cell Disease
- Eating Disorders
- Understanding Behaviors of Families in Poverty
- Motivational Interviewing
- Nutrition and Pediatric Diabetes
23Treatment Presentation
- Emphasis on empirically validated treatments of
common behavioral health conditions - Topics have included
- Encopresis Procedure-related anxiety
- Recurrent abdominal pain Enuresis
- Pica Adherence
- Vocal cord dysfunction Habit cough
- Feeding Difficulties Sleep Problems
- Adjustment to Illness Weight management
24Multicultural Topics
- Multicultural Factors Related to Engagement and
Attrition - Working with Amish Families
- Jehovahs Witnesses and Medical Procedures
- Working with Refugee Families
- Working with Families of Greek Heritage
- Culture of the Single Father
- Cultural Issues Related to the Use of Physical
Punishment - Working with Families of Latino Heritage
25Assessment of Competence
- Interns receive oral and written feedback after
each patient contact, at mid-way point of the
elective, and at the conclusion of the elective
experience - Formative and summative feedback
- Development and periodic review of learning plans
- Attempt to incorporate self-assessment informally
- Additional assessment tools
- Portfolios
- 360-degree evaluations
- Standardized patients
26Formative Assessment of Competence
Date Supervisor Supervisor Trainee Trainee
Child (1st init) Child (1st init) Activity Activity Clinic
Strengths Strengths Strengths Strengths Strengths
Goals/Areas for Continued Development Goals/Areas for Continued Development Goals/Areas for Continued Development Goals/Areas for Continued Development Goals/Areas for Continued Development
27Feedback
- Interns provide written feedback on the elective,
(clinics, supervision group, supervisors)
bi-annually - Feedback is solicited by supervisors and during
monthly meetings with the Training Director - All training faculty and interns have a bi-annual
retreat during which trainees can provide
feedback about all aspects of the training
program, including the pediatric elective
experience
28Challenges
- Funding
- Competing demands (for interns and faculty)
- Scheduling constraints interns may not be able
to participate in some clinics - Range of prior experience among interns
- Requires high degree of individualizing to ensure
that each trainees goals for the experience are
met
29Challenges
- Meeting intern expectations
- Importance of truth in advertising
- May require modifying some goals (some may become
a focus of postdoctoral training) - High no-show rates in some clinics
- Mental health stigma (patients and medical
providers) - Continuing need to re-educate medical providers
about training of interns and role of
psychologists - Mentorship of faculty
30Future Directions
- Inclusion of inpatient and community settings
- Clinical experiences with neonatal populations
- Research experiences
- Group therapy experiences with children with
medical illness - Increased opportunities for program development
and evaluation - Obtain funding for the elective
- Increase networking with other training programs
31Outcomes
- Popular elective
- 2000-2008 26 interns have participated (74)
- 10 did a blended elective
- Interns give highly positive evaluations of
supervisors, supervision group, practica settings - Evaluations of interns indicate that they attain
or exceed expected level of competence
32Outcomes
- 14 interns obtained fellowships with a pediatric
psychology focus - 7 former interns work in settings that include a
pediatric psychology focus - 4 trainees obtained faculty psychologist
positions at medical centers - 2 have psychologist positions within a
school-based health clinic - 1 has a psychologist position within a pediatric
practice