Competencies for Psychology Practice in Pediatric Palliative Care.

OBJECTIVE: Pediatric psychologists have unique expertise to contribute to the care of youth with serious illnesses yet are not routinely integrated into pediatric palliative care (PPC) teams. To better define the role and unique skillset of psychologists practicing in PPC, support their systematic inclusion as part of PPC teams, and advance trainee knowledge of PPC principles and skills, the PPC Psychology Working Group sought to develop core competencies for psychologists in this subspecialty. METHODS: A Working Group of pediatric psychologists with expertise in PPC met monthly to review literature and existing competencies in pediatrics, pediatric and subspecialty psychology, adult palliative care, and PPC subspecialties. Using the modified competency cube framework, the Working Group drafted core competencies for PPC psychologists. Interdisciplinary review was conducted by a diverse group of PPC professionals and parent advocates, and competencies were revised accordingly. RESULTS: The six competency clusters include Science, Application, Education, Interpersonal, Professionalism, and Systems. Each cluster includes essential competencies (i.e., knowledge, skills, attitudes, roles) and behavioral anchors (i.e., examples of concrete application). Reviewer feedback highlighted clarity and thoroughness of competencies and suggested additional consideration of siblings and caregivers, spirituality, and psychologists' own positionality. CONCLUSIONS: Newly developed competencies for PPC psychologists highlight unique contributions to PPC patient care and research and provide a framework for highlighting psychology's value in this emerging subspecialty. Competencies help to advocate for inclusion of psychologists as routine members of PPC teams, standardize best practices among the PPC workforce, and provide optimal care for youth with serious illness and their families.

The effects of coping style on virtual reality enhanced videogame distraction in children undergoing cold pressor pain.

This study sought to evaluate the effectiveness of virtual reality (VR) enhanced interactive videogame distraction for children undergoing experimentally induced cold pressor pain and examined the role of avoidant and approach coping style as a moderator of VR distraction effectiveness. Sixty-two children (6-13 years old) underwent a baseline cold pressor trial followed by two cold pressor trials in which interactive videogame distraction was delivered both with and without a VR helmet in counterbalanced order. As predicted, children demonstrated significant improvement in pain tolerance during both interactive videogame distraction conditions. However, a differential response to videogame distraction with or without the enhancement of VR technology was not found. Children's coping style did not moderate their response to distraction. Rather, interactive videogame distraction with and without VR technology was equally effective for children who utilized avoidant or approach coping styles.

Interactive versus passive distraction for acute pain management in young children: the role of selective attention and development.

OBJECTIVE: To examine whether age and developmental differences in selective attention influence young children's differential responses to interactive and passive distraction. METHODS: 65 3- to 6-year-old children underwent three cold-pressor trials while receiving no intervention, playing a video game (interactive distraction), or watching a video game (passive distraction). In addition, children completed a test of selective attention, and parents completed ratings of attention. RESULTS: Consistent with neurocognitive models of pain, children benefited more from interactive distraction than from passive distraction. Although older children demonstrated superior pain tolerance overall, age and selective attention skills did not moderate children's responses to the distraction intervention. CONCLUSIONS: These findings suggest that younger preschoolers can benefit from interactive distraction to manage acute pain, provided that the distraction activity is developmentally appropriate. Research is needed to determine whether developmental issues are more important moderators of children's responses to distraction when faced with more challenging task demands.

The effects of interactive and passive distraction on cold pressor pain in preschool-aged children.

OBJECTIVE: Using a mixed model design, this study examined the effects of interactive versus passive distraction on healthy preschool-aged children's cold pressor pain tolerance. METHODS: Sixty-one children aged 3-5 years were randomly assigned to one of the following: interactive distraction, passive distraction, or no distraction control. Participants underwent a baseline cold pressor trial followed by interactive distraction trial, passive distraction trial, or second baseline trial. One or two additional trials followed. Children originally assigned to distraction received the alternate distraction intervention. Controls participated in both interactive and passive distraction trials in counterbalanced order. RESULTS: Participants showed significantly higher pain tolerance during both interactive and passive distraction relative to baseline. The two distraction conditions did not differ. CONCLUSIONS: Interactive and passive video game distraction appear to be effective for preschool-aged children during laboratory pain exposure. Future studies should examine whether more extensive training would enhance effects of interactive video game distraction.

Videogame distraction using virtual reality technology for children experiencing cold pressor pain: the role of cognitive processing.

OBJECTIVE: This study examined whether increasing the demand for central cognitive processing involved in a distraction task, by involving the child in ongoing, effortful interaction with the distraction stimulus, would increase children's tolerance for cold pressor pain. METHODS: Seventy-nine children ages 6-15 years underwent a baseline cold pressor trial followed by two cold pressor trials in which they received interactive distraction (i.e., used voice commands to play a videogame) or passive distraction (in which they merely watched the output from the same videogame segment) in counterbalanced order. Both distraction conditions were presented via a virtual reality-type helmet. RESULTS: As expected, children demonstrated significant improvement in pain tolerance during distraction relative to baseline. Children showed the greatest improvement during the interactive distraction task. CONCLUSION: The effects of distraction on children's cold pressor pain tolerance are significantly enhanced when the distraction task also includes greater demands for central cognitive processing.

Predictors of quality of life in type 2 diabetes patients with schizophrenia, major mood disorder, and without mental illness.

PURPOSE: The aim of the current study is to compare the predictors of health-related quality of life in individuals with schizophrenia, major mood disorder, and no mental illness, all with type 2 diabetes. METHODS: A total of 100 individuals with schizophrenia, 101 with a major mood disorder, and 99 without mental illness, all with type 2 diabetes, rated their health-related quality of life on the Medical Outcomes Survey, Short Form-12; physical and mental composite scores (PCS and MCS) were calculated. We performed a hierarchical multiple regression on PCS and MCS in each sample starting with a basic set of predictors and then adding diabetes-related variables. We compared the regression weights and incremental variance explained within each group. RESULTS: The number of co-occurring medical conditions was significantly associated with lower PCS in all three groups and with lower MCS in the no mental illness group. Diabetes-related variables added significant incremental variance to the prediction of PCS in the no mental illness group but not in either psychiatric group. CONCLUSIONS: For persons with diabetes and mental illness, as well as with no mental illness, additional medical conditions exert a strong effect on physical well-being. The impact on quality of life of diabetes-related factors may be lower in persons with diabetes and serious mental illness compared to those with diabetes and no mental illness.

Effects of videogame distraction and a virtual reality type head-mounted display helmet on cold pressor pain in young elementary school-aged children.

OBJECTIVE: This study examined the effects of videogame distraction and a virtual reality (VR) type head-mounted display helmet for children undergoing cold pressor pain. METHODS: Fifty children between the ages of 6 and 10 years underwent a baseline cold pressor trial followed by two cold pressor trials in which interactive videogame distraction was delivered via a VR helmet or without a VR helmet in counterbalanced order. RESULTS: As expected, children demonstrated significant improvements in pain threshold and pain tolerance during both distraction conditions. However, the two distraction conditions did not differ in effectiveness. CONCLUSIONS: Using the VR helmet did not result in improved pain tolerance over and above the effects of interactive videogame distraction without VR technology. Clinical implications and possible developmental differences in elementary school-aged children's ability to use VR technology are discussed.

Quality of diabetes care among adults with serious mental illness.

OBJECTIVE: The study compared the quality of care for type 2 diabetes delivered to two groups with type 2 diabetes--adults with serious mental illness and those with no serious mental illness--in a range of community-based clinic settings. METHODS: Cross-sectional analyses of medical chart data from 300 patients (201 with serious mental illness and 99 without serious mental illness) were used to examine indicators of the quality of care established by the Diabetes Quality Improvement Project. Recommended services assessed included glycosylated hemoglobin examination, eye and foot examinations, blood pressure check, and urine and lipid profiles. Self-report data were used to compare receipt of provider-delivered diabetes education and receipt of cues regarding self-management of diabetes for the two study groups. RESULTS: Evidence of lower quality of diabetes care was found for persons with serious mental illness as reflected by their receipt of fewer recommended services and less education about diabetes, compared with those without serious mental illness. Although participants with serious mental illness were less likely to receive cues from providers regarding the need for glucose self-monitoring, they were as likely as those without serious mental illness to receive cues regarding diet and medication adherence. CONCLUSIONS: Although participants with serious mental illness received some services that are indicated in quality-of-care standards for diabetes, they were less likely to receive the full complement of recommended services and care support, suggesting that more effort may be required to provide optimal diabetes care to these vulnerable patients.

Health status of individuals with serious mental illness.

We examined indices of the health of persons with serious mental illness. A sample of 100 adults with schizophrenia and 100 with major mood disorder were recruited from randomly selected outpatients who were receiving community-based psychiatric treatment. Participants were surveyed about health indicators using items from the National Health and Nutrition Examination Study III and the National Health Interview Survey. Their responses were compared with those of matched samples from the general population surveys. A total of 1% of persons with serious mental illness, compared with 10% from the general population sample, met criteria for all 5 of selected health indicators: nonsmoker, exercise that meets recommended standards, good dentition, absence of obesity, and absence of serious medical co-occurring illness. Within the mentally ill group, educational level, but not a diagnosis of schizophrenia versus mood disorder, was independently associated with a composite measure of health behaviors. We conclude that an examination of multiple health indicators may be used to measure overall health status in persons with serious mental illness.

Religiosity, psychosocial adjustment, and subjective burden of persons who care for those with mental illness.

OBJECTIVE: The purpose of this study was to characterize the nature of religious and spiritual support received by family caregivers of persons with serious mental illness and to test hypotheses that religiosity would be associated with caregiver adjustment. METHODS: Eighty-three caregivers who participated in a study of the Family to Family Education Program of the National Alliance on Mental Illness were assessed at baseline in terms of their religiosity and receipt of spiritual support in coping. They also completed measures of depression, self-esteem, mastery, self-care, and subjective burden. Hierarchical regression was used to test hypotheses that religiosity would be associated with better adjustment, with confounding variables controlled for. RESULTS: Thirty-seven percent of participants reported that they had received spiritual support in coping with their relative's illness in the previous three months. When age, race, education, and gender were controlled for, religiosity was associated with less depression and better self-esteem and self-care. Personal religiosity was a stronger predictor of adjustment than religious service attendance. CONCLUSIONS: Family caregivers of persons with serious mental illness often turn to spirituality for support, and religiosity may be an important contributor to caregiver adjustment. Collaborative partnerships between mental health professionals and religious and spiritual communities represent a powerful and culturally sensitive resource for meeting the support needs of family members of persons with serious mental illness.

Use of emergency department services for somatic reasons by people with serious mental illness.

OBJECTIVE: This study identified factors associated with use of the emergency department for medical reasons among individuals with serious mental illness. METHODS: A total of 200 randomly selected outpatients who were receiving community-based psychiatric care were recruited for the study and interviewed with items from the National Health Interview Survey and other national health surveys. RESULTS: Emergency department use (37 percent of the sample) was negatively associated with older age and positively associated with the number of co-occurring medical conditions, smoking, recent injury, and recent change in health care provider. CONCLUSIONS: The relatively high rate of emergency department use may be suggestive of inappropriate use or may reflect perceived barriers to care. Future work should identify specific reasons for seeking care in the emergency department and develop interventions to optimize appropriate emergency department use.

A comparison of type 2 diabetes outcomes among persons with and without severe mental illnesses.

OBJECTIVE: Type 2 diabetes is an important comorbid medical condition associated with schizophrenia. The objective of this study was to compare glycosylated hemoglobin (HbA(1c)) levels of patients who had type 2 diabetes and schizophrenia with those of patients who had type 2 diabetes and major mood disorders and those who had type 2 diabetes but who did not have severe mental illness. METHODS: A sample of 300 patients with type 2 diabetes was recruited from community mental health centers in the greater Baltimore region and nearby primary care clinics. Of these, 100 had schizophrenia, 101 had a major mood disorder, and 99 had no identified severe mental illness. HbA(1c), the main outcome measure, was compared between the group with schizophrenia and the other two groups. RESULTS: All three groups had HbA(1c) values above recommended levels. HbA(1c) levels were significantly lower among patients with schizophrenia than among patients who did not have severe mental illness but were not significantly different from those of patients who had major mood disorders. Patients for whom olanzapine was prescribed had higher HbA(1c) levels than those for whom other antipsychotic agents were prescribed. CONCLUSIONS: All three groups of patients require improved diabetes treatment to achieve acceptable HbA(1c) levels. There may be previously unrecognized benefits for diabetes management among persons with severe mental illnesses who are receiving regular mental heath care, but these individuals may also have risk factors that can influence diabetes outcomes and HbA(1c) levels.

Quality of life in individuals with serious mental illness and type 2 diabetes.

Diabetes is a pervasive metabolic disease that disproportionately affects persons with serious mental illness. The authors studied the effect of diabetes on quality of life in a sample of 369 adult outpatients with schizophrenia or major mood disorder, 201 of whom had type 2 diabetes. Patients with diabetes reported greater impairment in both physical and mental-health quality of life than those without diabetes. The diabetes patients also reported less satisfaction with health but not with other life domains. Medical providers need to be attentive to the burden of disease experienced by patients with both serious mental illness and diabetes.

Correlates of religious service attendance and contact with religious leaders among persons with co-occurring serious mental illness and type 2 diabetes.

The purpose of this study was to examine the prevalence and correlates of religious participation among persons with co-occurring serious mental illness and type 2 diabetes. Among 201 outpatients, 53% attended religious services, 36% had regular contact with a religious leader, and 15% received assistance from a religious leader. Persons with schizophrenia and African Americans were more likely to attend services and have contact with religious leaders. Both attendance at religious services and regular contact with a religious leader were linked to higher quality of life in selected domains, but not associated with global health ratings or glycosylated hemoglobin (HbA1c) levels. Results indicate that there are important diagnostic and racial differences in religious participation, and that religious participation may be a resilience factor that supports enhanced quality of life for persons with serious mental illness and diabetes.

Consumer satisfaction with inpatient psychiatric treatment among persons with severe mental illness.

Consumer satisfaction with inpatient care is an important component of quality of care and a recovery-oriented system of care. This study assessed association of patient, demographic and process of care variables with inpatient satisfaction focusing on modifiable service delivery factors. Participants were 136 people with psychotic or affective disorders recruited from VA inpatient units who were interviewed with an extensive assessment. Staff teaching efforts regarding medication, illness management, substance abuse, outpatient treatment and living skills were significantly associated with greater levels of satisfaction with care, controlling for demographic and clinical variables. This may reflect value consumers place on staff time, attention and communication. Teaching may enhance self-efficacy and hope thereby facilitating recovery.

Correlates of severity of smoking among persons with severe mental illness.

Individuals with schizophrenia and severe mental illness smoke cigarettes at rates that well exceed the general population. Little is known about the correlates and sequelae of increased smoking severity on persons with severe mental illness. A total of 304 smokers from six community mental health centers were assessed for smoking history, psychiatric symptoms, co-occurring disorders, subjective quality of life, and expired carbon monoxide (CO). Statistical analyses identified correlates of smoking severity, as assessed by number of cigarettes smoked per week. The average number of cigarettes smoked per week was 136+/-83. Increased smoking was associated with higher levels of expired CO and being Caucasian, and with a greater likelihood of a current diagnosis of hypertension and oral/gum disease. Greater smoking severity was also associated with greater perceived stress, poorer overall subjective quality of life, and lower satisfaction with finances, health, leisure activities, and social relationships. This study confirms high rates of heavy smoking among persons with severe mental illness. The association of increased quantity of cigarettes smoked with being Caucasian is consistent with previous reports in mentally ill and non-mentally ill populations. The linkage of heavy smoking with poorer quality of life and co-occurring medical disorders suggests the importance of smoking reduction and cessation strategies to reduce smoking and decrease patients' total pack years of smoking.

Extent and management of cardiovascular risk factors in patients with type 2 diabetes and serious mental illness.

Cardiovascular disease is the leading cause of death in Type 2 diabetes, which commonly occurs in patients with serious mental illnesses (SMIs). We determined the extent to which patients with diabetes and SMI, relative to diabetes patients without SMI, met American Diabetes Association goals for cholesterol and blood pressure, met criteria for the metabolic syndrome, and were prescribed medications known to reduce cardiovascular events. We found that less than half of diabetes patients, both with and without SMI, met recommended goals for cholesterol levels; even fewer had adequate blood pressure control. In addition, a substantial proportion of all diabetes patients met metabolic syndrome criteria. However, diabetes patients with SMI were less likely to be prescribed cholesterol-lowering statin medications, angiotensin-converting enzyme inhibitors, and angiotensin receptor blocking agents than diabetes patients without SMI. Patients with both diabetes and SMI are treated less aggressively for high cardiovascular risk than diabetes patients without mental disorders.

Predictors of HIV and hepatitis testing and related service utilization among individuals with serious mental illness.

Two hundred mentally ill adults receiving community-based outpatient psychiatric services were surveyed. Although 59% received an HIV test, only 41% received a hepatitis test. Clinic location and reports of unprotected sex were associated with receipt of an HIV test. Although no behavioral risk factors were associated with hepatitis testing, those with a comorbid medical condition were more likely to be tested. Only 15% of the sample was immunized against hepatitis B. Medical hospitalization was the only factor related to immunization. These results indicate an urgent need to improve access to HIV and hepatitis testing and related treatment.

Physical activity patterns in adults with severe mental illness.

Although physical inactivity is a leading cause of death and the Surgeon General recommends regular moderate physical activity, many Americans are inactive. Because of their increased burden of obesity and diabetes, people with severe mental illness (SMI) especially may benefit from physical activity, yet little is known about the prevalence and types of physical activity in people with SMI. We surveyed outpatients with schizophrenia and affective disorders at two psychiatric centers in Maryland and compared physical activity patterns to an age-gender-race-matched national sample (National Health and Nutrition Examination Survey III) of the general population. We found that people with SMI are overall less physically active than the general population, although the proportion with recommended physical activity levels was equal. The participants with SMI were more likely to walk as their sole form of physical activity. Within the SMI group, those without regular social contact and women had higher odds of being inactive.