Developing Competence in Pediatric Psychology within a

General Child InternshipJennifer C. West, PhD.

University of Rochester Medical Center

Departments of Psychiatry and Pediatrics

April 17, 2009

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

University of Rochester Medical Center Internship – Child and Adolescent Track

4 interns12 months outpatient (10-12 weekly patient contacts,

groups)6 months acute psychiatry

(testing/consultation/treatment)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)

Pediatric Psychology ElectiveDevelopment 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

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 trainingMentoring

Domains of Training (Spirito et al., 2003)Life-span Developmental

Psychology and Psychopathology

Child, Adolescent and Family Assessment

Intervention StrategiesResearch Methods and

Systems EvaluationProfessional, Ethical and

Legal Issues Pertaining to Children, Adolescents, and Families

Issues of DiversityRole 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

Pediatric Psychology ElectiveSupervisors: Psychology Faculty and Psychology

FellowsProvide consultation, assessment, and short-term

treatment in the following ambulatory clinics at the Golisano Children’s Hospital at Strong:General Pediatrics Pediatric Diabetes ClinicPediatric Gastroenterology ClinicPediatric Pulmonology Clinic

Provide psychological treatment to patients with chronic illness in the outpatient psychiatry clinic

Pediatric Psychology ElectiveAims 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 competenceInterns arrive with varying levels of experience and

different training goalsMinimum threshold of competence, yet tailor to the

individual training/ professional development goalsTraining that combines didactic, experiential, and

mentoring components

Internship CompetenciesProfessional Skills and Competencies

Diagnostic and Assessment SkillsTreatment, Consultation and Administrative

SkillsProfessional Standards and Behavior

Ethical Understanding and BehaviorProfessional Development and Demeanor

Academic CompetenciesTeaching and SupervisionScholarship

Pediatric Clinical Experiences: Goals and Domains of Training

Training in a variety of skills: direct service, consultationSome opportunities for program evaluation and

development Fewer opportunities for research

Training in 1-2 specific areas of interestInterdisciplinary training

Interdisciplinary settings (medicine, nursing, social work, nutrition, education-liaison, Child Life)

Some joint training opportunities with pediatric residentsMentors

Paired with faculty, postdoctoral fellowsDevelopmental process

Clinical Experiences: Goals and Domains of Training

Emphasis on primary careProvide consultation and service in general pediatric clinicInvolved in mental health screening initiative to enhance

detection of behavioral/emotional health concernsProvide evaluation/treatment to patients/families who are

at-riskEducate 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

Clinical Experiences: Goals and Domains of Training

Lifespan Developmental PsychologySupervised 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 PsychopathologyParticipation in routine mental health screening

initiative to identify youth at risk for mental illnessObserve and conduct supervised clinical activities with

patients presenting with range of psychopathologyArea for improvement: acute medical illness

Clinical Experiences: Goals and Domains of Training

Child, Adolescent and Family AssessmentMultiple opportunities for assessment related to adherence,

quality of life, coping, pain, weight control, health beliefsAssessment of family functioning – strengths, vulnerabilitiesArea for improvement: Increased use of empirically based

assessment toolsIntervention Strategies

Opportunities to observe supervisors conduct interventionsOpportunities 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

Clinical Experiences: Goals and Domains of Training

Research Methods and Systems EvaluationNo current formal opportunities

Professional, Ethical, and Legal Issues Pertaining to Children, Adolescents, and FamiliesMultiple experiences focused on developing appropriate

communication in healthcare settings (progress notes, evaluation summaries, interdisciplinary team meetings)

Issues of DiversityMultiple 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)

Clinical Experiences: Goals and Domains of Training

Role of Multiple Disciplines in Service Delivery Participate in multidisciplinary staffingsLectures to medical students and residents,

observed visits Area for improvement: participation in regular team

mtngs

Prevention, Family Support, and Health PromotionSupervised experience in promoting healthy

lifestyles, especially related to physical activity, diet, sleep hygiene, family violence, effective discipline

Clinical Experiences: Goals and Domains of Training

Social Issues Affecting Children, Adolescents, and FamiliesService in primary care aimed at reducing barriers to

accessing mental health careConsultation 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 teamDisease Process and Medical Management

Clinics provide multiple opportunities to gain knowledge of disease process and treatment

Pediatric Supervision Group

Meets weekly for one hourParticipants: 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 Lecturer2nd week of month: Treatment presentation3rd week of month: Journal article review4th week of month: Multicultural presentation

Pediatric Supervision GroupCase 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

Pediatric Supervision GroupDirected readings focused on domains of training

(Spirito et al, 2003)Handbook of Pediatric Psychology (Ed. Roberts)Binder of articles – general issues, illness-specificWeb-based resources –Bright Futures toolkit, American

Academy of Pediatrics, community resourcesJournal of Pediatric Psychology – series of review articles

on EBTs, current volumesAttendance at Pediatric Grand RoundsAdditional instructional techniques could include

videotapes, demonstrations with standardized pts, virtual-reality based peds psych interactive training materials

Guest Lecturer TopicsPsychological

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 DiseaseEating DisordersUnderstanding

Behaviors of Families in Poverty

Motivational Interviewing

Nutrition and Pediatric Diabetes

Treatment PresentationEmphasis on empirically validated treatments

of common behavioral health conditionsTopics have included:

Encopresis Procedure-related anxietyRecurrent abdominal pain EnuresisPica AdherenceVocal cord dysfunction Habit coughFeeding Difficulties Sleep ProblemsAdjustment to Illness Weight management

Multicultural Topics

Multicultural Factors Related to Engagement and Attrition

Working with Amish Families

Jehovah’s 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

Assessment of CompetenceInterns receive oral and written feedback after

each patient contact, at mid-way point of the elective, and at the conclusion of the elective experienceFormative and summative feedbackDevelopment and periodic review of learning plansAttempt to incorporate self-assessment informally

Additional assessment toolsPortfolios360-degree evaluationsStandardized patients

Formative Assessment of CompetenceDate: Supervisor: Trainee:

Child (1st init):

Activity: Clinic:

Strengths:

Goals/Areas for Continued Development:

FeedbackInterns 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

Challenges

FundingCompeting 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 trainee’s goals for the experience are met

Challenges

Meeting intern expectationsImportance of truth in advertisingMay require modifying some goals (some may

become a focus of postdoctoral training)High no-show rates in some clinicsMental health stigma (patients and medical

providers)Continuing need to re-educate medical

providers about training of interns and role of psychologists

Mentorship of faculty

Future Directions

Inclusion of inpatient and community settingsClinical experiences with neonatal

populationsResearch experiencesGroup therapy experiences with children with

medical illnessIncreased opportunities for program

development and evaluationObtain funding for the electiveIncrease networking with other training

programs

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

Outcomes14 interns obtained fellowships with a

pediatric psychology focus7 former interns work in settings that

include a pediatric psychology focus4 trainees obtained faculty psychologist

positions at medical centers 2 have psychologist positions within a school-

based health clinic1 has a psychologist position within a

pediatric practice