behavioral health issues and pediatric hospitalizations stephen r. gillaspy, phd 11/05/09 reaching...

Behavioral Health Issues and Behavioral Health Issues and Pediatric HospitalizationsPediatric Hospitalizations

Stephen R. Gillaspy, PhDStephen R. Gillaspy, PhD

11/05/0911/05/09

Reaching Out To Oklahoma Reaching Out To Oklahoma III Annual Pediatric Interdisciplinary III Annual Pediatric Interdisciplinary

ConferenceConference

ObjectivesObjectives

• Discuss common behavioral health Discuss common behavioral health issuesissues

• Discuss identification and assessment Discuss identification and assessment of behavioral health issues during of behavioral health issues during pediatric hospitalizationspediatric hospitalizations

• Discuss management and treatment Discuss management and treatment of behavioral health issues during of behavioral health issues during pediatric hospitalizationspediatric hospitalizations

•Inpatient Pediatric ServicesInpatient Pediatric Services

• Why is this needed?Why is this needed?– Response to the psychosocial needs of Response to the psychosocial needs of

childrenchildren with medical problems and with medical problems and their their familiesfamilies (Carter et al., 2003). (Carter et al., 2003).

• What does it affect?What does it affect?– OutcomesOutcomes

•Short-termShort-term

•Long-termLong-term

Inpatient Pediatric ServicesInpatient Pediatric Services

• Pediatric Inpatient C&L ServicePediatric Inpatient C&L Service– ProvidersProviders

•Psychology, PsychiatryPsychology, Psychiatry

•Behavioral Health ServiceBehavioral Health Service

– ProcessProcess•Referral from physician / medical teamReferral from physician / medical team

•Assessment conductedAssessment conducted

•Advises physician / medical team about finding Advises physician / medical team about finding and management of patient and family (Drotar and management of patient and family (Drotar et al., 2003).et al., 2003).

Common Inpatient BH Common Inpatient BH IssuesIssues

• Different ways to categorize issuesDifferent ways to categorize issues– Acute versus chronic illnessAcute versus chronic illness– Medical versus mental health issuesMedical versus mental health issues

• Pros and cons of categorizingPros and cons of categorizing– StaffStaff– Patient and familiesPatient and families

Common Inpatient BH Common Inpatient BH IssuesIssues

• What are some common issues?What are some common issues?– PatientsPatients– Parents and FamiliesParents and Families– Acute IllnessAcute Illness– Chronic IllnessChronic Illness– Mental Health IssuesMental Health Issues– Medical IssuesMedical Issues

Common Inpatient BH Common Inpatient BH IssuesIssues

• Traditional Mental HealthTraditional Mental Health– Depression Depression – AnxietyAnxiety– Somatization and Organic versus Somatization and Organic versus

PsychogenicPsychogenic– Suicide Suicide – Substance AbuseSubstance Abuse– Behavioral ProblemsBehavioral Problems

Common Inpatient BH Common Inpatient BH IssuesIssues

• Traditional Mental HealthTraditional Mental Health– TraumaTrauma– DevelopmentalDevelopmental– Cognitive Cognitive – Eating DisordersEating Disorders– BereavementBereavement

Common Inpatient BH Common Inpatient BH IssuesIssues

• Parents and FamiliesParents and Families– Coping and AdjustmentCoping and Adjustment– Mental Health IssuesMental Health Issues– ““The Problem Family”The Problem Family”– CommunicationCommunication– Medical ComplianceMedical Compliance

Common Inpatient BH Common Inpatient BH IssuesIssues

• More Traditional MedicalMore Traditional Medical– SleepSleep– FeedingFeeding– Pill SwallowingPill Swallowing– Medical ComplianceMedical Compliance– Pain ManagementPain Management– Adjustment to hospitalization and illnessAdjustment to hospitalization and illness– ProceduresProcedures

Common Inpatient BH Common Inpatient BH IssuesIssues

• Olson et al., 1988Olson et al., 1988– 749 inpatient referrals over 5 years 749 inpatient referrals over 5 years

•Depression or suicide attemptDepression or suicide attempt

•Adjustment problems to chronic illnessAdjustment problems to chronic illness

•Behavior problemsBehavior problems

– Health care professionals generally Health care professionals generally satisfied with services and expressed a satisfied with services and expressed a high likelihood of future referralshigh likelihood of future referrals

Common Inpatient BH Common Inpatient BH IssuesIssues

• Rodrique et al., 1995Rodrique et al., 1995– 448 inpatient referrals 448 inpatient referrals

•Cognitive and neuropsychological Cognitive and neuropsychological functioningfunctioning

•Behavior problemsBehavior problems

•Presurgery and pretransplant evaluationsPresurgery and pretransplant evaluations

•Adjustment to chronic illnessAdjustment to chronic illness

– Health care professionals generally high Health care professionals generally high overall satisfaction with service quality. overall satisfaction with service quality.

Common Inpatient BH Common Inpatient BH IssuesIssues• Carter et al., 2003Carter et al., 2003

– 104 inpatient referrals104 inpatient referrals•Coping with physical illness/injuryCoping with physical illness/injury

• Improving treatment adherenceImproving treatment adherence

•Assessing and treating depression and anxietyAssessing and treating depression and anxiety

•Teaching pain management techniquesTeaching pain management techniques

•Assistance with parent copingAssistance with parent coping

•Adjustment to new diagnosisAdjustment to new diagnosis

•Resolving family conflictResolving family conflict

Common Inpatient BH Common Inpatient BH IssuesIssues

• Carter et al., 2003Carter et al., 2003– 88 referring physicians88 referring physicians

•Goal attainment - mean of 4.34 (1-5 scale)Goal attainment - mean of 4.34 (1-5 scale)

•Overall helpfulness - 4.64 (1-5 scale)Overall helpfulness - 4.64 (1-5 scale)

– 88 parents/guardians88 parents/guardians•Helpful to the child – 3.45 (1-4 scale)Helpful to the child – 3.45 (1-4 scale)

•Helpful to the parent – 3.20 (1-4 scale)Helpful to the parent – 3.20 (1-4 scale)

•Did consultation aid in child’s recovery in Did consultation aid in child’s recovery in the hospitalization – 85% yes the hospitalization – 85% yes

Common Inpatient BH Common Inpatient BH IssuesIssues

• Biopsychosocial PerspectiveBiopsychosocial Perspective– MedicalMedical– Behavioral Behavioral – Emotional Emotional – DevelopmentalDevelopmental– SocialSocial– Family SystemFamily System– EnvironmentalEnvironmental

Common Inpatient BH Common Inpatient BH IssuesIssues

• When to consultWhen to consult– Does it interfere with current medical Does it interfere with current medical

treatmenttreatment– Does it decrease quality of lifeDoes it decrease quality of life– Does patient and/or family recognize it Does patient and/or family recognize it

as an area of concernas an area of concern– Does it affect overall health outcomeDoes it affect overall health outcome

Identification and Identification and AssessmentAssessment

• Who typically identifies the issue?Who typically identifies the issue?– Attending PhysiciansAttending Physicians– NursingNursing– Social WorkSocial Work– Child LifeChild Life– Physical TherapyPhysical Therapy– Occupational TherapyOccupational Therapy– NutritionNutrition

Identification and Identification and AssessmentAssessment

• Who typically identifies the issue?Who typically identifies the issue?– Consulting SpecialistsConsulting Specialists– NutritionNutrition– PatientPatient– FamilyFamily

Identification and Identification and AssessmentAssessment

• ProcessProcess– Multiple clinical interviewsMultiple clinical interviews

•Child and family Child and family

– Consultation with medical staffConsultation with medical staff– Behavioral observationsBehavioral observations– Rating scalesRating scales– Occasionally formal psychological Occasionally formal psychological

testingtesting

Identification and Identification and AssessmentAssessment

• GoalsGoals– SpecificSpecific– Problem-focusedProblem-focused– Designed to be met within a specific Designed to be met within a specific

time frame.time frame.

Identification and Identification and AssessmentAssessment

• Assessment is ongoingAssessment is ongoing

• Regular feedback to the medical Regular feedback to the medical teamteam

• A good referral question always A good referral question always helps!helps!

Identification and Identification and AssessmentAssessment

• Pediatric Inpatient Behavior Scale Pediatric Inpatient Behavior Scale (PIBS, Kronenberger, et al., 1997)(PIBS, Kronenberger, et al., 1997)– Designed to be completed by a pediatric Designed to be completed by a pediatric

nurse who has worked closely with the nurse who has worked closely with the child for at least one shiftchild for at least one shift

– Completed as part of routine evaluation Completed as part of routine evaluation and treatment planning for the childand treatment planning for the child

Identification and Identification and AssessmentAssessment

• Two formsTwo forms– PIBS-47 PIBS-47

– PIBS-25PIBS-25•Developed as a shorter more practical Developed as a shorter more practical

versionversion

Identification and Identification and AssessmentAssessment

• Seven SubscalesSeven Subscales– Oppositional – NoncompliantOppositional – Noncompliant– Positive – SociabilityPositive – Sociability– WithdrawalWithdrawal– Conduct ProblemsConduct Problems– DistressDistress– AnxietyAnxiety– OveractivityOveractivity

InterventionIntervention

• Role of the consultantRole of the consultant

• Management versus TreatmentManagement versus Treatment

• Problem-FocusedProblem-Focused

• Limited TimeframeLimited Timeframe

• Not your typical mental health Not your typical mental health setting and relationshipsetting and relationship

Intervention – Five C’sIntervention – Five C’s

• CrisisCrisis– Initial diagnosis with severe illness or injuryInitial diagnosis with severe illness or injury– Patient and family in disbelief and shockPatient and family in disbelief and shock– Difficulty coping or understanding details and Difficulty coping or understanding details and

decisions.decisions.– Families in need of intervention that provides Families in need of intervention that provides

a sense of understanding and control.a sense of understanding and control.– Normalize emotional distress.Normalize emotional distress.– Facilitate improved copingFacilitate improved coping

Intervention – Five C’sIntervention – Five C’s

• CopingCoping– ProceduresProcedures– Lengthy hospitalizationsLengthy hospitalizations– Chronic illnessChronic illness– Mental health issuesMental health issues– DistressDistress

Intervention – Five C’sIntervention – Five C’s

• ComplianceCompliance– Patient and familyPatient and family– Typical interventionsTypical interventions

•EducationEducation

•Skills developmentSkills development

•Behavioral contractingBehavioral contracting

•Removing barriersRemoving barriers

•Self-monitoringSelf-monitoring

Intervention – Five C’sIntervention – Five C’s

• ComplianceCompliance– Typical interventionsTypical interventions

•Altering family interactionsAltering family interactions

•Altering healthcare system interactionsAltering healthcare system interactions

•Altering expectationsAltering expectations

•Altering lifestyle and daily behaviorsAltering lifestyle and daily behaviors

Intervention – Five C’sIntervention – Five C’s

• CommunicationCommunication– MiscommunicationMiscommunication

•Medical staffMedical staff

•PatientPatient

•FamilyFamily

– Length of hospitalizationLength of hospitalization– DiagnosesDiagnoses– Decision makingDecision making– ProceduresProcedures

Intervention – Five C’sIntervention – Five C’s

• CollaborationCollaboration– Shared goalShared goal

•PatientPatient

•FamilyFamily

•Medical staffMedical staff– PhysiciansPhysicians– NursingNursing– Child LifeChild Life– Other servicesOther services

InterventionIntervention

• Problem-focusedProblem-focused

• Family-systems approachFamily-systems approach

• Evidence-based Evidence-based – Cognitive Behavioral TherapyCognitive Behavioral Therapy– Motivational InterviewingMotivational Interviewing

• Appropriate ReferralsAppropriate Referrals

Thanks You!Thanks You!

Stephen R. Gillaspy, Ph.D.Stephen R. Gillaspy, Ph.D.

Assistant ProfessorAssistant Professor

Section of General & Community PediatricsSection of General & Community Pediatrics

Department of Pediatrics Department of Pediatrics

The University of Oklahoma Health Sciences CenterThe University of Oklahoma Health Sciences Center

Stephen-Gillaspy@ouhsc.eduStephen-Gillaspy@ouhsc.edu