Clinical Practice in Pediatric Psychology

The Diversity, Equity, and Inclusion Supervisor Self-Assessment Tool (DEI-SST) was developed to help psychology supervisors reflect on their supervisory practices regarding diversity, equity, and inclusion. The Society of Pediatric Psychology’s Anti-racism Workgroup, Training Subgroup, adapted a preexisting psychology course syllabus evaluation tool for self-assessment in supervision to include aspects of clinical training, the APA multicultural guidelines, and the domains from the APA Guidelines for Clinical Supervision in Health Service Psychology. Following an expert review of the modified tool, the tool was administered in three settings, and qualitative themes were extracted from participant feedback. All participants (N = 38) endorsed that the DEI-SST helped them reflect on their supervisory practice. No participants provided feedback on the wording of the tool. All participants identified at least one area of supervision they had not considered previously. Suggested improvements to the tool included reducing the length of the tool, expanding the examples provided within each developmental stage, and including resources to enhance supervision. The DEI-SST shows promise to help supervisors incorporate aspects of DEI into their supervision that they may not have previously done. It provides a starting point for further growth needed to improve their practice. Future directions include investigating best practices for tool administration and a continued review of tool content to reflect advances in equitable and inclusive supervisory practices.

Pediatric psychologists face unique ethical challenges in medical settings, especially in oncology, where psychological, social, and medical factors intersect. This case report explores the application of psychological and medical ethical principles in the care of a psychiatrically complex pregnant adolescent newly diagnosed with cancer. We present a case study of a 15-year-old pregnant female, “Jane,” with newly diagnosed high-grade osteosarcoma, posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder. A multidisciplinary team collaborated to guide decision-making during an acute stage of treatment. Psychological and medical ethical frameworks informed treatment planning. Ethical tensions included balancing maternal and fetal health, aligning conflicting goals of care, and navigating barriers to effective communication. Additionally, conflicting legal and ethical obligations are addressed. Oncology treatment decisions were supported through multidisciplinary collaboration, ethics and legal consultation, and psychological conceptualization and recommendations. Psychology played a critical role in assessing and supporting psychological coping, facilitating family communication, and mitigating psychological harm during an acute and distressing phase of care. This case underscores the need for integrated psychological care in pediatric oncology, particularly when ethical dilemmas arise with complex patients. Pediatric psychologists are uniquely positioned to inform ethical decision-making by contextualizing psychological history, assessing risk, and facilitating communication.

Objective: Inequities in accessing waitlisting for liver and kidney transplantation among pediatric and adult populations are well-documented, with disparities related to race, ethnicity, and socioeconomic status consistently present in both settings. Historically, studies examining barriers to transplant waitlisting have focused mainly on patient and family demographics. However, due to the complexity and subjectivity of pretransplant evaluations, other factors (e.g., provider biases) likely influence waitlisting decisions. This topical review brings awareness to how provider biases toward race, ethnicity, and socioeconomic status may impact access to pediatric liver and kidney transplant waitlisting. Methods: Searches using keywords such as ethnic and racial minorities, waiting lists, transplantation, poverty, and pediatrics were conducted in https://inPubMed.gov, CINAHL Complete (EBSCO), PsychINFO (EBSCO), https://Embase.com, https://Scopus.com, and Web of Science databases with no relevant findings including provider bias in pediatric liver or kidney transplant. A second search in only PubMed with no limit by age produced four relevant articles between 2004 and 2023. Results: Provider biases within the pretransplantation evaluation and waitlisting processes have been explored in adult populations and are starting to be explored in some pediatric subspecialties, though gaps remain in pediatric liver and kidney transplantation. Conclusions: Pediatric kidney and liver transplant waitlisting may be impacted by provider biases throughout the evaluation process. More research is needed to determine areas of susceptibility and how to reduce bias throughout the subjective processes of transplant evaluation. We provide recommendations for how pediatric psychologists can use their skillsets to decrease bias and advance equity in pediatric liver and kidney transplantation settings.

Objective: Fecal incontinence affects up to 7.8% of youth and can impact psychological and physiological well-being, including increased risk for loss of rectal nerve functioning, high family stress, and mental health disorders. Behavioral approaches can be combined with medical management, but have limited research support. This article describes the development, acceptability, and feasibility of a group-based, telehealth, caregiver-only behavioral intervention for pediatric fecal incontinence. Methods: Caregivers of children with fecal incontinence were referred by gastroenterology providers. Participants completed four virtual group sessions focused on psychoeducation and implementing strategies for shaping child behaviors related to medication adherence, toileting, and clean-up. Feasibility was assessed via recruitment and uptake, participant retention, and implementation within routine clinical operations. Acceptability was assessed via caregiver satisfaction. Caregivers stress, frequency of accidents, clean-up behaviors, and intervention satisfaction were assessed. Results: Mean child age was 5.80 (SD = 1.80) with 51.4% male. Of the 72 caregivers who began the intervention, 88.9% (n = 64) completed all 4 sessions. Most (98%; n = 52) respondents completing post-program questionnaires would recommend it. The majority thought the number (60%; n = 32) and length of sessions (79%; n = 42) were “just right.” Child responsibility for cleaning increased (X ² (1, N = 131) = 3.90, p = .04) and there were significant reductions in caregiver stress levels on all subscales of the POOP-C (p < .05–p < .01). Conclusion: Results support the initial acceptability and feasibility of a caregiver-only group behavioral intervention for pediatric fecal incontinence. Future research includes evaluation of program adjustments and clinical efficacy.

Pediatric burn injuries are a global health concern that significantly impacts children’s well-being. Few cost-effective psychosocial interventions currently exist that focus on bolstering resilience in pediatric burn survivors and their surrounding support systems, specifically in resource-constrained contexts. Therefore, this study sought to explore caregivers’ perceptions of an existing resilience-themed multimedia psychosocial intervention aimed at child burn survivors. This qualitative study’s design was exploratory and utilized face-to-face, semistructured interviews. The caregivers of 13 child burn survivors were recruited from the Red Cross War Memorial Children’s Hospital, South Africa. Thematic analysis yielded four themes revealing some key caregiver perceptions of the burn recovery video: (1) acceptance of burn injury promotes psychological recovery; (2) hope matters; (3) emotional support matters in all contexts; and (4) resilience matters, but… The themes echoed the resilience literature and emphasized the importance of support from all systems, including professional, and peer and familial groups, in postburn recovery. They also identified areas not usually foregrounded, such as the social contexts which may mitigate against resilience. Caregivers distilled some key aspects of resilience from the multimedia intervention and through this felt encouraged about the recovery process. The findings highlight the importance and utility of resilience-orientated multimedia and complementary interventions in pediatric postburn care.

The study’s findings highlight the importance of incorporating resilience strengthening into postburn recovery as well as the need for complementary interventions to support pediatric burn care. Importantly, the study findings caution against social contexts which may undermine resilience and postburn recovery.

Objective: The pediatric mental and behavioral health (MBH) health crisis is a public health imperative. Identification and management of MBH crosses primary care, community mental health centers (CMHCs), and hospital systems. To deliver the best outcomes, active collaboration and coordination of care is required. However, coordinated approaches are hampered by data silos resulting from lack of parity between physical and MBH, overly restrictive privacy policies, and technical barriers arising from disparate electronic health records (EHRs) across systems. This proof-of-concept provides information on the development and initial implementation of one model as a blueprint for other systems seeking to improve continuity of care. Methods: With cross-system collaborators, the population behavioral health leadership team at a large pediatric hospital advanced solutions to break down data silos via a MBH patient attribution strategy. Elements of this build included developing the value proposition, navigating legal requirements, identifying a technical solution, and onboarding practices. Results: This strategy ultimately produced real-time, population-level visibility of community-delivered MBH services within the hospital EHR, democratized community-based providers’ access to clinically actionable data housed within the hospital EHR, and is advancing MBH integration to enhance whole-child outcomes. Conclusions: MBH attribution has allowed for the creation of population-level dashboards that aggregate and share critical health information to external partner organizations and will serve as the backbone for additional clinical information exchange moving forward.

Objective: Pediatric primary care providers are increasingly asked to care for their patients’ behavioral health needs, but few models of behavioral health integration emphasize practical strategies that are widely applicable to practices regardless of resources or size. A pilot cohort of pediatric primary care practices participated in a regional quality improvement (QI) project focused on improving each practice’s levels of behavioral health integration using the Comprehensive Healthcare Integration (CHI) Framework (National Council for Mental Wellbeing, 2022) as a guiding framework. Method: Five practices joined the 10-month QI project pilot cohort. Each practice chose one subdomain from the CHI Framework’s Multidisciplinary Teamwork domain as their project’s focus. Participants attended monthly meetings and educational sessions, completed QI deliverables while implementing their identified interventions, and completed surveys and interviews pre- and post-project. Results: Four of the five practices (80%) reported increasing their behavioral health integration by at least one level on a subdomain of Multidisciplinary Teamwork CHI Framework domain. All practices (100%) reported increased satisfaction with their practice’s level of behavioral health integration, with an average 60% increase from pre- to post-project. Conclusions: Practices made notable improvements to their behavioral health integration during the project. The CHI Framework was useful in structuring practices’ behavioral health goals and assessing improvements. Elements of the QI project process, such as having access to content experts, the cohort format, and accountability provided by the project, appeared valuable to participants. Insights are shared for organizations aiming to support pediatric primary care providers in their behavioral health integration efforts.

Five pediatric primary care practices made notable improvements to how they integrate behavioral health concepts into their work during their participation in a new quality improvement project. Supportive efforts like this project could help pediatric primary care practices make positive changes so they can better care for their patients’ behavioral health needs within the primary care setting.

Adolescents have experienced negative psychological and physiological effects during the COVID-19 pandemic, including sleep disturbances. Previous research has demonstrated a reciprocal relationship between sleep quality and psychological resilience, but there is a lack of evidence on their association. This study addresses this gap by examining the relationship between sleep quality and psychological resilience among adolescents using cross-sectional (Study 1) and longitudinal (Study 2) designs. The results revealed that poor sleep quality at the initial assessment point (T1) negatively correlated with psychological resilience at both T1 and the second assessment point (T2). Furthermore, the initial level of psychological resilience predicted better sleep quality and increased resilience at T2, suggesting a unidirectional influence of resilience on sleep quality over time. These findings imply that resilience can foster better sleep outcomes. These results suggest that schools and mental health professionals should consider integrating sleep hygiene practices and resilience-building exercises into their intervention programs.

High levels of stress are frequently observed in children during hospitalization. Among available stress management tools, virtual reality (VR) represents a promising option due to its immersive, engaging qualities. While many VR platforms exist, most rely on passive distraction; few incorporate guided breathing exercises. Objective: This pilot study aimed to develop and assess the feasibility and acceptability of two immersive virtual environments (VEs) designed to promote relaxation in children through nature-inspired landscapes and guided diaphragmatic breathing. Before conducting randomized trials in clinical settings, a preliminary evaluation of the key design elements, essential for developing effective VR experiences in health care, is necessary. Methods: A total of 105 healthy children aged 6 to 15 years experienced both VEs. Feasibility and acceptability were assessed through perceived usefulness, satisfaction, cybersickness symptoms, and sense of presence. Anxiety levels before and after immersion were also measured. Results: Findings showed high satisfaction and a strong sense of presence for both environments, with minimal cybersickness reported. Preliminary data suggest a potential reduction in postimmersion anxiety. Age and gender effects on these outcomes are also discussed. Conclusions: This study provides initial evidence supporting the acceptability and feasibility of these nature-based VEs incorporating breathing exercises. It represents a fundamental step within a broader iterative process of design, evaluation, and optimization. The findings offer valuable insights to guide the refinement of future iterations of these environments, while also raising considerations for their potential clinical implementation.

Maternal depression negatively impacts parenting practices and child development. Many mothers of young children screen positive for depression in our clinics. The objective of this quality improvement initiative was to use the SQUIRE 2.0 framework to evaluate a quality improvement initiative that focused on the integration of a brief parenting intervention in two family medicine clinic’s routine depression screening. Patients who were caregivers of young children and who screened positive for depressive symptoms but did not endorse suicidality were invited to receive parenting tips via automated text, a few learning materials (e.g., books, blocks), and monthly support phone calls over a 5-month period. Though initially intended to include caregivers regardless of sex or identified gender, only caregivers who self-identified as females participated. Outcome measures included the Patient Health Questionnaire-2 and -9 (depression symptoms) and portions of the Family Map Inventories (parenting-practices). Sixty-two percent of participating patients completed pre- and postintervention surveys. Following intervention participation, patients’ depression symptoms significantly decreased and their self-reported positive parenting practices (e.g., use of routines, parent–child play, positive guidance) significantly increased. Leveraging technology to improve parenting practices and mental health among parents of young children expanded access to support services and was effective in our setting.

Objective: Many children with autism experience unmet needs, emphasizing the importance of research on service access. Methods: We surveyed English-speaking caregivers of children diagnosed with autism in 2018 at a tertiary Midwestern children’s hospital. The survey assessed satisfaction with accessing services and included open-ended questions. Results: A total of 189 caregivers participated. Most accessed speech (86.2%), occupational (90.0%), and educational services (93.7%). Fewer received behavior therapy (35.6%), applied behavior analysis (23.8%), or group therapy (15.1%). While overall satisfaction was high, families who expressed dissatisfaction noted barriers such as difficulty navigating the system, limited availability, long waitlists, and high costs. Families cited advocacy and service navigation as key facilitators. Low uptake of certain services and persistent barriers underscore the need for systemic changes. Conclusions: We outline potential solutions, including expanding Medicaid and insurance coverage, redesigning service pathways, and implementing family navigation to improve access and outcomes.

At a well-resourced hospital, most children with autism received speech, occupational, and educational services, but far fewer accessed behavior therapy, ABA, or group therapy. Families described barriers such as high costs, long waitlists, and difficulty navigating complex systems. These findings highlight the need for changes in service pathways, insurance coverage, and family navigation supports to ensure that all children can benefit from the therapies they need.

Objectives: Youth spend the majority of their time in school, making school-based health centers (SBHCs) an accessible and innovative health care delivery system. SBHCs initially targeted preventative medical needs of youth, while some now offer more comprehensive care including mental health services. Experts view SBHCs as one of the most effective ways to identify and treat youth with mental health difficulties, since over 6.3 million students in the United States have access to some form of school-based healthcare. There are approximately 3,900 SBHCs in the United States and the majority of these centers treat the underserved and uninsured at no out of pocket expense to students. Pediatric psychologists can leverage their expertise as advocates to inform public health policy and payment models in favor of SBHCs, thereby dismantling systems of racism, bias and oppression in schools and communities. This review summarizes the benefits of integrating a pediatric psychologist into existing models of SBHCs, and proposes future avenues. Methods: Review existing literature and multiple existing SBHC programs that have an embedded pediatric psychologist. Results: The vision of expanding access to culturally responsive behavioral health care, informed by clinical, research and outreach initiatives on a broad scale will be discussed. SBHCs that include a pediatric psychologist decrease health disparities among marginalized youth, particularly for those identifying as Hispanic or Black and with low socioeconomic status. Conclusions: Integrating pediatric psychologists provides another layer of mental health support for at-risk youth and this is particularly salient when providers practice cultural humility.

Integrating pediatric psychologist in school health centers can improve behavioral healthcare systems and subsequent access for at-risk youth. Existing programs targeted toward improving BIPOC youth social emotional outcomes are examined.