Michelle M. Ernst

Using Quality Improvement Science to Implement a Multidisciplinary Behavioral Intervention Targeting Pediatric Inpatient Airway Clearance

OBJECTIVE The objective of this study was to use quality improvement science methodology to develop a multidisciplinary intervention improving occurrence of best-practice airway clearance therapy (ACT) in inpatient adolescents with cystic fibrosis during routine clinical care. METHODS The model for improvement was used to develop and implement interventions. Primary outcomes were quality of ACT (% ACT meeting criteria for best practice) and quantity of ACT (% of hospital days patients received ACT four times/day). Annotated control charts were used to document the impact of the interventions. RESULTS Quality of ACT significantly improved from 21% best practice ACT at baseline to 73%. Quantity of ACT significantly improved from 41% days with ACT four times/day at baseline to 64%. CONCLUSIONS A multidisciplinary, evidence-based intervention was effective for improving occurrence of best-practice ACT. Pediatric psychology can make valuable contributions to improving the quality of care provided in the medical setting.

Adapting Pediatric Psychology Interventions: Lessons Learned in Treating Families From the Middle East

OBJECTIVE Pediatric psychologists are increasingly called upon to treat children from non-Western countries, whose cultures may contrast with a Western medical setting. Research on cultural adaptations of evidence-based treatments (EBTs), particularly for individuals from the Middle East, is sparse. To address this need, we discuss clinical issues encountered when working with patients from the Middle East. METHODS Synthesis of the literature regarding culturally adapted EBTs and common themes in Middle Eastern culture. Case vignettes illustrate possible EBT adaptations. RESULTS Integrating cultural values in treatment is an opportunity to join with patients and families to optimize care. Expectations for medical and psychological treatment vary, and collaborations with cultural liaisons are beneficial. CONCLUSIONS Critical next steps include systematic development, testing, and training in culturally adapting EBTs in pediatric medical settings. Increased dialogue between clinicians, researchers, and cultural liaisons is needed to share knowledge and experiences to enhance patient care.

Developmental and Psychosocial Issues in Cystic Fibrosis

Cystic fibrosis (CF) is a multisystemic life-limiting genetic disorder, primarily affecting respiratory functioning. Most patients with CF are diagnosed by 2 years of age, and the current median predicted survival rate is 37.4 years old, with 95% of patients dying from complications related to pulmonary infection. Given the chronic, progressive, and disabling nature of CF, multiple treatments are prescribed, most on a daily basis. Thus, this illness requires children, with the aid of their families, to adopt multiple health-related behaviors in addition to managing more typical developmental demands. The morbidity and mortality factors pose cognitive, emotional, and behavioral challenges for many children with CF and their families. This article applies a developmental perspective to describing the psychosocial factors affecting psychological adjustment and health-related behaviors relevant to infants, preschool and school-age children, and adolescents with CF. Topics particularly pertinent to developmental periods and medical milestones are noted, with clinical implications highlighted.

Similarities and Differences Between Migraine in Children and Adults: Presentation, Disability, and Response to Treatment

Purpose of ReviewThis review presents findings from investigations of migraine in children and adults. Similarities and differences in the presentation, related consequences, and treatments between children and adults are reviewed.Recent FindingsSignificant similarities exist in the presentation, disability, and treatments for migraine between children and adults. Despite such similarities, many adult migraine treatments adapted for use in children are not rigorously tested prior to becoming a part of routine care in youth. Existing research suggests that not all approaches are equally effective across age groups. Specifically, psychological treatments are shown to be somewhat less effective in adults than in children. Pharmacological interventions found to be statistically significant relative to placebo in adults may not be as effective in children and have the potential to present more risk than benefit when used in youth. The placebo effect in both children and adults is robust and is need of further study. Better understanding of treatment mechanisms for all interventions across the age spectrum is needed.SummaryAlthough migraine treatments determined to be effective for adults are frequently adapted for use in children with little evaluation prior to implementation, existing research suggests that this approach may not be the best practice. Adaptation of adult pharmacological treatment for use in youth may present a particular risk in comparison to benefits gained. Because of the known efficacy of psychological treatments, such as cognitive behavioral therapy, more universal use of these interventions should be considered, either as first-line treatment or in combination with pill-based therapies.

The Hospital-Based Consultation and Liaison Service

Psychosocial factors have a broad and substantial impact on patient presentation in the inpatient medical setting. Research clearly demonstrates that psychosocial factors play a crucial role in the etiology, pathophysiology, treatment, and clinical outcomes of numerous chronic and comorbid diseases as well as postsurgical outcomes and recovery. Given that psychiatric and behavioral symptoms can have a significant influence on chronic and acute illness, it is not surprising that inpatient medical settings have reported significant psychiatric issues in approximately 35 % of all inpatients. These psychiatric comorbidities can have negative consequences on medical outcomes as well as fiscal outcomes (e.g., increased length of stay and repeated readmission). Beyond clinical psychiatric diagnosis, the multiple stressors of the hospitalization can negatively impact the quality of life for even high-functioning patients. Unfortunately, these psychosocial factors are often poorly recognized and managed within the hospital setting. For example, less than 5 % of admissions across the hospital appear to receive a mental health consult, far less than the one third of patients estimated to have psychiatric comorbidity.

CBT for Pediatric Migraine: A Qualitative Study of Patient and Parent Experience

The goal of this study was to determine which cognitive behavioral therapy (CBT‐HA) treatment components pediatric headache patient stakeholders would report to be most helpful and essential to reducing headache frequency and related disability to develop a streamlined, less burdensome treatment package that would be more accessible to patients and families.

Headache, Burden, and Quality of Life

Headache is a frequent health complaint during childhood, with increasing prevalence in adolescence, high likelihood of persisting into adulthood, and rising incidence over the past decades [1, 2]. Given the significant frequency of pediatric headache, it is important to understand the influence of headache on the functioning of children and adolescents because childhood is a time during which important developmental milestones occur via engagement in social and academic settings. This impact can be examined in terms of the specific burden that it creates for children and families as well as in terms of the effect it has on a more holistic view of quality of life (QoL).

Acceptance and Commitment Therapy (ACT) to Foster Resilience in Pediatric Chronic Illness

Children with chronic illness face numerous stressors related to their condition such as coping with illness-related procedures, managing tremendous illness burden, dealing with aversive physical symptoms, and attempting to minimize the impact of their illness on their quality of life. Despite these challenges, children with chronic illnesses and their families demonstrate resilience in that the majority are able to demonstrate relatively typical levels of emotional and behavioral functioning. Psychological flexibility is a psychological construct that reflects many of the factors associated with resilience and positive coping, such as active engagement in the stressors, emotion regulation, and maintenance of developmentally expected activities. Acceptance and Commitment Therapy (ACT) has been shown to promote psychological flexibility in chronic illness populations. This chapter highlights the overlap between psychological flexibility and resilience, and identifies the application of Acceptance and Commitment Therapy to promoting those factors thought to be critical for resilience. Relevant literature is reviewed, and case vignettes are used to highlight key clinical features of ACT.

Working in Pediatrics

Nowhere does the interface between clinical psychology and the medical experience pose as many interesting challenges and opportunities as in the field of pediatric psychology. Here, factors such as developmental level and the particularly strong influence of systems on children need to be considered in addition to other behavioral medicine variables. This chapter will review a variety of behavioral health issues in both acute and chronic medical experiences that children commonly encounter, and present evidence-based interventions designed to assist children and their families in managing these situations with an emphasis on both developmental and systems perspective.