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Title: Developing Competence in Pediatric Psychology within a General Child Internship


1
Developing 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

3
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4
University 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)

5
Pediatric 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

6
Taskforce 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

7
Domains 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

8
Pediatric 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

9
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10
Pediatric 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

11
Internship 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

12
Pediatric 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

13
Clinical 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

14
Clinical 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

15
Clinical 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

16
Clinical 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)

17
Clinical 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

18
Clinical 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

19
Pediatric 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

20
Pediatric 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

21
Pediatric 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

22
Guest 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

23
Treatment 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

24
Multicultural 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

25
Assessment 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

26
Formative 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
27
Feedback
  • 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

28
Challenges
  • 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

29
Challenges
  • 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

30
Future 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

31
Outcomes
  • 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

32
Outcomes
  • 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
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