Pediatric Consultation-Liaison Psychology: Insights and Lessons Learned During the COVID-19 Pandemic.

COVID-19 has presented a variety of challenges to the provision of psychology services. In the first month of the pandemic, pediatric consultation-liaison (CL) psychologists reported significant changes in methodology of service delivery (Steinberg et al. in Clin Pract Pediatr Psychol 9:1, 2020). To better understand how and if these changes persisted, as well as other emerging trends, a follow-up study examined changes and challenges six months into the pandemic. An anonymous questionnaire assessed topics related to pediatric CL psychology including practice changes, perception of changes, and institutional support. The questionnaire was sent to the APA Society of Pediatric Society's special interest group listservs. Thirty responses were analyzed. Quantitative results showed participants' beliefs that telemedicine is equally efficacious to in-person services for outpatient psychological care, but less effective for inpatient care. Participants reported their perception of how institutions supported their safety, psychology trainee safety and training goals, and patient care. Qualitative results demonstrated that most psychologists experienced changes related to their dynamics with medical teams, which included changes in team efficiency, workload, transition, and team collaboration.

A Review of the Impact of Sociodemographic Factors on the Assessment and Management of Pediatric Somatic Symptom and Related Disorders.

BACKGROUND: While factors such as race, sex, gender identity, and socioeconomic status impact the diagnosis and treatment of a variety of conditions, there are few studies examining their influence on somatic symptom and related disorders (SSRDs), particularly in the pediatric population. OBJECTIVE: In this review, we outline the existing literature on how sociodemographic characteristics influence the overall care of pediatric SSRDs. Throughout this literature review, we highlight opportunities for further research, including potential disparities in evaluation, management, and outcomes along several sociodemographic domains. METHODS: We conducted a thorough review of the evidence for potential impact of race, sex, gender identity, and socioeconomic status on the presentation, diagnosis, management, and outcomes of pediatric somatization and SSRDs. RESULTS: Recent studies evaluating the impact of race on SSRD care suggest the potential for provider bias in the evaluation and management of this population based on racial differences in diagnostic evaluations. Somatization may present differently based on a patient's race and potential cross-cultural status. Among studies of cisgender patients, there is evidence of provider bias in the assessment of somatic symptoms such that female patients are more likely to be diagnosed with an SSRD than male patients. However, there is little research among youth identifying as LGBTQ. The literature also indicates that low socioeconomic status and associated stressors are linked with the development of SSRDs, although it is unclear whether these factors are subject to bias by providers. CONCLUSIONS: While the literature is sparse, there is evidence that sociodemographic factors contribute to differences in diagnosis, evaluation, and management of pediatric SSRDs. These factors, particularly race and sex, may also be subject to provider bias, although further studies are necessary. Provider bias can directly impact patients' perception of care, including feelings of dismissal, and may have downstream influences on symptom manifestation, patient-provider engagement, diagnostic evaluation, and management practices.

Increased prevalence and severity of psychiatric illness in hospitalized youth during COVID-19.

BACKGROUND AND OBJECTIVES: Previous studies have demonstrated an increase in mental health emergencies among youth seen in ambulatory and emergency room settings during the COVID-19 pandemic. This study investigates rates of mental health-related consultation and markers of illness severity since the start of the pandemic. METHODS: We evaluated all pediatric patients admitted to a single children's hospital from March 2019 to March 2021 who received psychiatry and/or psychology consults. We report the absolute number of these patients, as well as the proportion of all study site admissions who received such consults. Severity of psychiatric illness was described in terms of LOS, disposition, and use of restraints and psychotropic medications. RESULTS: The number and proportion of pediatric patients receiving psychiatry and/or psychology consults rose during the pandemic. Participants also became proportionally more female and older. The study population had higher odds of requiring restraints and antipsychotics during the pandemic. CONCLUSIONS: More pediatric inpatients at the study site have required psychiatric care during the pandemic. The severity of mental illness in this population appears to have worsened based on increased utilization of as-needed psychotropic medications and restraints. These findings highlight the changes experienced by patients and providers during the pandemic and merit further study.

Standardizing Pediatric Somatic Symptom and Related Disorders Care: Clinical Pathway Reduces Health Care Cost and Use.

BACKGROUND: Pediatric somatic symptom and related disorders (SSRDs) are common with high health care costs and use because of lack of standardized, evidence-based practice. Our hospital implemented a clinical pathway (CP) for SSRD evaluation and management. Our study objective was to evaluate health care cost and use associated with the organization's SSRD CP in the emergency department (ED) and inpatient settings hypothesizing lower cost and use in the CP group relative to controls. METHODS: We conducted a retrospective analysis of costs and use before and after implementation of the SSRD CP. Data were collected from the hospital's electronic health record and the Pediatric Health Information System database. Participants included pediatric patients on the CP ("P" group) and control groups with an SSRD diagnosis and mental health consultation either the year before the CP ("C" group) or during the CP study period ("T" group). Primary outcomes included costs, length of stay, diagnostic testing, imaging, subspecialty consultation, and readmission rates. RESULTS: The ED P group had more lower-cost imaging, whereas the inpatient T group greater higher-cost imaging than other groups. The inpatient P group had significantly shorter length of stay, fewer subspecialty consults, and lower costs. There were no significant group differences in readmission rates. The CP reduced median total costs per patient encounter by $51 433 for the inpatient group and $6075 for the ED group. CONCLUSIONS: The CP group showed significant reductions in health care cost and use after implementation of a CP for SSRD care. In future work, researchers should explore patient and practitioner experience with the SSRD CP and long-term outcomes.

Taking the Pain out of Somatization: Development and Implementation of a Hospital-Based Clinical Practice Guideline to Address Pediatric Somatic Symptom and Related Disorders.

OBJECTIVES: The diagnostic category of somatic symptom and related disorders (SSRDs), although common, is often poorly recognized and suboptimally managed in inpatient pediatric care. Little literature exists to address SSRDs in the inpatient pediatric setting. The purpose of the study was to characterize current SSRD practice, identify problem areas in workflow, and develop a standardized approach to inpatient evaluation and management at a tertiary care academic children's hospital. METHODS: A multidisciplinary group identified patients with SSRD admitted between May 2012 and October 2014. A retrospective chart review on a convenience sample was performed to identify population characteristics and current practice. Lean methodology was used to define current state practice and future state intervention. These methods were used to guide identification of problem areas, which informed protocol, a clinical practice guideline, and resource development. RESULTS: Thirty-six patients aged 8 to 17 years met inclusion criteria for chart review. Most patients presented with either neurologic or pain-related complaints. The mean length of stay was 5.44 days (SD = 6.3), with few patients receiving a mental health consultation within 24 hours of hospitalization. Patients averaged 5.8 medical and/or psychiatric diagnoses on discharge (SD = 5.2), and two-thirds did not have an SSRD diagnosis. Half of patients had comorbid psychiatric diagnoses, whereas one-quarter were discharged with no mental health follow-up. CONCLUSIONS: In this study, we describe the process and content development of a single-site institutional protocol, clinical practice guideline, and resources for the evaluation and management of pediatric SSRDs. This study may serve as a model for similar standardization of SSRD care in other inpatient pediatric medical settings.

Functional Impairment Predicts Outcome of Youth With Headache in the Emergency Department.

Headache is a common presenting complaint in emergency departments (EDs), with the goal of improving acute pain. However, youth with chronic headaches may demonstrate broad functional impairment in their lives due to headaches. Our objective was to determine if degree of functional impairment predicts ED course for patients with headache as part of a clinical protocol. One hundred and thirty-seven pediatric patients presenting to an ED with headache were included. Patients and parents were administered the Functional Disability Index (FDI) and ED charts were reviewed to evaluate outcomes. Higher child-reported FDI scores were associated with more medications, longer ED stay, and admission. High parent-proxy FDI score was associated with longer ED stay. Both pain score and parent-proxy FDI score were associated with imaging. The FDI was a more useful predictor of visit resources than pain score. FDI scores could be used to help anticipate patients who may require greater time and resources.

It's Not Just a Needlestick: Exploring Phlebotomists' Knowledge, Training, and Use of Comfort Measures in Pediatric Care to Improve the Patient Experience.

BACKGROUND: Blood draws are a routine element of the pediatric patient experience. They are also associated with the greatest fear and pain for a child. Because of the limited literature regarding phlebotomists' knowledge, experience, training, or stress related to their use of comfort techniques during pediatric blood draws, this study explored current practices and training methods. Phlebotomist training tends to focus on clinical technique rather than pediatric or patient comfort support. The study includes aims to develop a measurement for phlebotomists' use of comfort techniques for pediatric blood draws. METHOD: Focus groups of parent advocates (n = 24) and pediatric phlebotomists (n = 11) reviewed the survey questionnaire, and it was revised before being e-mailed to hospital system phlebotomists (n = 128). RESULTS: Almost half of the sample group lacked training in child development. The most frequently used comfort measures were words of explanation and reassurance, positioning of the child, and distraction. Requesting child life specialist support and using pain management devices or topical anesthetics were used less often. Primary challenges to performing pediatric blood draws were anxious patients and parents. CONCLUSION: Phlebotomists' use of available comfort measures occurs infrequently. Including child development and comfort techniques in training programs is essential to providing pediatric patients with a more satisfactory experience.

Understanding the Unique Needs of Hospitalized Adolescents and Young Adults Referred for Psychology Consults.

Hospitalized children and adolescents/young adults (AYA) frequently have mental health concerns that may be addressed by consulting psychology. We examined demographic, medical, referral, intervention, and disposition differences between children (≤11 years) and AYA referred for a psychology consult at a pediatric hospital (N = 1091). Referred AYA were more likely to be female, have shorter lengths of stay, and repeat psychology consults. Children were more likely to be referred for anxiety or feeding; AYA were more often referred for depression, pain, somatic complaints, or maladjustment. AYA were more often the target of intervention, receiving cognitive behavioral or problem-focused coping interventions, and more often recommended for psychological follow-up. AYA present unique medical and psychological challenges when hospitalized. Understanding these challenges will help providers improve the care and treatment of AYA. Academic training and future research recommendations are provided.

Pediatric Somatic Symptom and Related Disorders: Primary Care Provider Perspectives.

Somatization, or physical symptoms that are inconsistent with a physiological cause that may or may not involve an identified stressor, is common in outpatient pediatrics. When these symptoms persist, they can impair function and progress to a somatic symptom and related disorder (SSRD), resulting in increased health care use and increased demands on primary care providers (PCPs). We performed a needs assessment among PCPs to better understand how best to support providers caring for children with SSRDs. Pediatric PCPs (n = 77) were surveyed to better understand their training, experience, perceptions, and practices of SSRD care. Findings indicate that PCPs have limited training in SSRD care but express interest in learning more. Many barriers to effective care were reported. We hope to use these findings to develop training materials and support services for pediatric PCPs managing SSRDs.

Using an interactive water bottle to target fluid adherence in pediatric kidney transplant recipients: a pilot study.

Hydration is important post-renal transplant to maintain adequate renal perfusion and graft function. Adherence to fluid recommendations is challenging given barriers to staying hydrated. There are no studies of adherence to fluid intake recommendations following pediatric renal transplant. Through this pilot study, we sought to determine whether the use of a commercially available interactive water bottle would lead to better adherence to recommended fluid intake and improved kidney functioning post-transplant relative to standard of care. Participants included 32 youth ages 7-19 ≥1 month post-kidney transplant randomized to the intervention (HydraCoach(®) water bottle) or standard education control group. Laboratory records were reviewed for serum chemistries (Na, BUN, creatinine) at baseline and one-month follow-up, and participants recorded daily fluid intake for 28 days. Those in the intervention group were significantly more likely to meet or exceed their fluid target, but this did not translate into better kidney functioning. Participants in the intervention group largely reported satisfaction with the water bottle and were likely to continue its use. While an interactive water bottle providing real-time feedback may be a promising intervention to help pediatric kidney transplant patients meet fluid goals, it did not appear to impact kidney function.

Measuring family management of transplant tasks: the transplant responsibility questionnaire.

Little is known about how parents and youth perceive their roles in post-transplant management and how this relates to post-transplant adherence. The goals of this study are to (1) describe a new measure, the TRQ, (2) to describe parent and child performance on the TRQ, and to (3) determine the relationship between the TRQ and adherence. We hypothesized that older youth would describe higher post-transplant self-care behaviors, parents would underestimate youth self-care, and greater parent involvement would be associated with better adherence. Participants included 59 parent-child dyads. Inclusion criteria included: (i) youth aged 7-18 yr and (ii) at least three months post-kidney or post-liver transplant. Parents and youth completed the TRQ, and adherence was measured by s.d. of sequential immunosuppressant blood levels. Youth perceived greater levels of self-care than their parents perceived. Older youth reportedly engaged in more self-care than younger youth. Less than 25% of the sample was non-adherent, and non-adherence was unrelated to performance on the TRQ. The TRQ may have utility as a clinical tool to address areas for improvement in youth self-care. The high degree of parental involvement likely explains the high degree of adherence in this sample.