A Biopsychosocial Approach to Complex Regional Pain Syndrome in a Pediatric Inflammatory Bowel Disease Patient.

Pediatric chronic pain is typically framed as a purely biomedical problem requiring exclusively biomedical solutions. However, research indicates that pain is biopsychosocial, produced and reduced by a combination of biological, psychological, sociological, and environmental factors, and that treatment must therefore also be biopsychosocial, incorporating interventions such as pain psychology and physical therapy. We report a case of a 16-year-old patient with Crohn disease and complex regional pain syndrome, and the multidisciplinary approach to care that was crucial for his return to function.

Integrative pediatric pain management: Impact & implications of a novel interdisciplinary curriculum.

OBJECTIVES: Objectives of this paper are to: 1) Describe a novel interdisciplinary, integrative pain curriculum for pediatric residents. 2) Describe changes in residents' understanding of pain epidemiology, physiology, and management; application of the biopsychosocial model in pain management; and understanding and application of non-pharmacologic approaches to pain management. DESIGN, SETTING: This study was done in a pediatric residency program within an urban pediatric teaching hospital. It employed both anonymous, Likert-scale surveys administered via Qualtrics, as well as open-ended, free response questions. INTERVENTIONS: We provided a multidisciplinary pain education curriculum to pediatric residents with a focus on pain neuroscience, a history of pain management, the biopsychosocial model of care, and exposure to non-pharmacologic interventions to pain management over six hours of instruction conducted in two blocks of three hours each. OUTCOME MEASURES: Self-identified changes via survey measuring resident physician knowledge, comfort, approach, and management of pediatric pain through an interdisciplinary pain curriculum. RESULTS: Prior to this training, many residents were not confident in their understanding of pain neuroscience, the biopsychosocial model of care, and non-pharmacologic interventions. At completion of training, residents indicated positive changes in knowledge of, and comfort with, all of the domains taught. Ninety percent of residents indicated that the curriculum changed the way they conceptualized, approached, and/or managed pain, and reported thinking more holistically about pain management. Nearly all residents indicated they would like to have more training (98 %, N = 57) in integrative modalities. CONCLUSIONS: Pediatric resident physicians are receptive to training in an interdisciplinary, integrative, pediatric pain management education intervention, and subsequently show positive changes in knowledge and comfort levels. There is a need and desire for additional pain education in resident training programs.

Review of the Management of Pediatric Post-Concussion Syndrome-a Multi-Disciplinary, Individualized Approach.

PURPOSE OF REVIEW: Post-concussion syndrome (PCS), when the patient's concussion symptoms last longer than 4-6 weeks, affects 10-30% of concussion patients. PCS presents a significant source of morbidity to patients and a management challenge to providers. In this review, we present the current evidence and best management approaches for pediatric PCS. RECENT FINDINGS: There is limited high-quality evidence in pediatric PCS. There is some evidence supporting pharmaceutical management of post-traumatic headaches, cognitive symptoms, and emotional symptoms. Vestibular-ocular dysfunction should be evaluated and managed appropriately. Neuropsychological recovery is expected, but requires appropriate attention to Return to Learn. Emotional symptoms are common in PCS and the evidence supports treatment with cognitive behavioral therapy. PCS presents a unique therapeutic challenge affecting multiple domains for patients-physical, sleep, cognitive, and emotional. Successful management of PCS requires a multi-disciplinary and individualized approach. There remains a significant need for further research, specifically looking into the outcomes and effective interventions in pediatric PCS.

Mental health care for children with disruptive behavior problems: a view inside therapists' offices.

OBJECTIVES: In the United States, more money is spent on treatment for children's mental health problems than for any other childhood medical condition, yet little is known about usual care treatment for children. Objectives of this study were to characterize usual care outpatient psychotherapy for children with disruptive behavior problems and to identify consistencies and inconsistencies between usual care and common elements of evidence-based practices in order to inform efforts to implement evidence-based practices in usual care. METHODS: Participants included 96 psychotherapists and 191 children aged four to 13 who were presenting for treatment for disruptive behavior to one of six usual care clinics. An adapted version of the Therapy Process Observational Coding System for Child Psychotherapy-Strategies scale (TPOCS-S) was used to assess psychotherapy processes in 1,215 randomly selected (out of 3,241 collected) videotaped treatment sessions; treatment sessions were recorded for up to 16 months. RESULTS: Most children received a large amount of treatment (mean number of sessions=22, plus children received other auxiliary services), and there was great variability in the amount and type of care received. Therapists employed a wide array of treatment strategies directed toward children and parents within and across sessions, but on average all strategies were delivered at a low intensity. Several strategies that were conceptually consistent with evidence-based practices were observed frequently (for example, affect education and using positive reinforcement); however, others were observed rarely (for example, assigning or reviewing homework and role-playing). CONCLUSIONS: Usual care treatment for these youths reflected great breadth but not depth. The results highlight specific discrepancies between evidence-based care and usual care, thus identifying potentially potent targets for improving the effectiveness of usual care.

Factors associated with use of evidence-based practice strategies in usual care youth psychotherapy.

The purpose of this study was to gain an understanding of how therapists providing usual care (UC) psychotherapy are using elements of treatment common to evidence-based practices (EBPs) for children with disruptive behavior disorders (DBPs) and to identify client and therapist characteristics that may be associated with EBP strategies directed toward children and those directed to their caregivers. Results indicate that certain child, family, and therapist characteristics are associated with use of EBP strategies; however, much of the variability in practice was not explained by the variables examined. These findings highlight the complexity of UC psychotherapy and provide directions for future research on implementation of EBPs in UC.

Case Management as a Significant Component of Usual Care Psychotherapy for Youth with Disruptive Behavior Problems.

Youth with disruptive behavior problems (DBPs) represent the majority of youth served in usual care (UC) psychotherapy, and are at high risk for maladaptive outcomes. Little is known about UC psychotherapeutic strategies utilized with this population. Researchers and clinicians suggest that case management (CM) is a major activity occurring in usual care. CM includes coordinating care with service providers and individuals, including schools, psychiatrists, and community-based services. This study assesses the prevalence and predictors of clinician use of CM in usual care. Results from this study suggest that CM is frequently used in UC psychotherapy with youth with DBPs. The extent of use of CM in UC may have implications for implementation of evidence-based practices in usual care psychotherapy.

Therapists' attitudes towards psychotherapeutic strategies in community-based psychotherapy with children with disruptive behavior problems.

Little is known about what individual treatment strategies therapists providing usual care psychotherapy consider the most valuable to their practice. The Therapeutic Strategies Survey (TSS) assesses therapists' attitudes about the value of 27 individual treatment strategies in their practice with children with disruptive behavior problems in community-based outpatient psychotherapy. Findings indicate that therapists from multiple professional disciplines highly value many individual psychotherapeutic strategies, and consider strategies common to a majority of evidence-based practices (EBPs) for this population at least as important as strategies not emphasized in EBPs. Implications for developing therapist training and implementation of EBPs are discussed.

Effectiveness of a children's home and community-based services waiver program.

OBJECTIVE: Limited alternatives exist to residential treatment or hospitalization for children with the most serious emotional disturbances. Community-based interventions are intended to offer less restrictive and expensive options than traditional treatment. One such program is New York State's Home and Community-Based Services (HCBS) Waiver Program. METHODS: From 1996 to 2002, 169 children were enrolled in the Manhattan HCBS. All spent at least one month on the wait list prior to admission to the waiver program. We used our wait list as a control group (WLC), allowing for comparison of the HCBS intervention. RESULTS: Sample consisted of 169 children between the ages of five and eighteen. The ethnic composition was 46.8% Hispanic (N = 79), 47.9% African-American (N = 81), and 5.3% Caucasian (N = 9). Average stay was 12 months in the HCBS program and 3.5 months for the WLC. Only 30% of children in the WLC were maintained in the community, while 81% of children in the HCBS were similarly maintained (P < 0.001). Also, the rate of hospitalization for the HCBS group was significantly lower (3 versus 41%; P < 0.001). There was also a trend for the WLC group to have had substantially higher rates of removal by the Administration for Children's Services (New York City's protective service agency) (8.3 versus 1.8%) and to more frequently require residential treatment (13.0 versus 8.9%). CONCLUSIONS: It would seem that the HCBS program appears to be a clinically and cost-effective method of maintaining children in their community.