Pediatricians and Pharmacologically Trained Psychologists: Practitioner's Guide to Collaborative Treatment

Pediatricians and Pharmacologically Trained Psychologists

George M. Kapalka Editor

Pediatricians and Pharmacologically Trained Psychologists Practitioner’s Guide to Collaborative Treatment

Editor George M. Kapalka Department of Psychological Counseling Monmouth University West Long Branch, NJ USA [email protected]

ISBN 978-1-4419-7779-3 e-ISBN 978-1-4419-7780-9 DOI 10.1007/978-1-4419-7780-9 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2011920690 © Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Preface

Many years ago, when symptoms of most psychological disorders were just ­beginning to be identified, the prevailing belief was that these symptoms were the result of deeply embedded psychogenic conflicts that required psychoanalysis to work through. Over the past five decades, however, a plethora of research revealed that many individuals with these disorders exhibit structural and functional differences in their brains. Since brain changes are likely to be reflected in feelings and behaviors, psychopharmacological approaches were developed to try to address some of the biological factors that may be responsible, at least in part, for the symptoms. Indeed, many of these have proven effective in reducing (and, sometimes, eliminating) the symptoms of some psychological disorders, and intervening pharmacologically may be beneficial (and in some cases is indispensable) since without medications some symptoms (for example, psychosis) are not likely to resolve. When treating disorders with known biological etiology, many nonmedical ­mental health professionals seek to minimize pharmacological approaches and initially try psychosocial treatment. This is a reasonable approach, especially with children. However, many factors may contribute to the decision to utilize pharmacological approaches, in conjunction with or instead of psychotherapy.

The Use of Medications to Treat Mental Health Disorders Severity of the symptoms often influences the decision of whether or not treatment with medications is needed. For example, milder forms of depression, impulsivity, anxiety, or agitation may respond well to psychotherapy. However, severe variants of these symptoms may be difficult to treat with talk therapies, and intense symptoms are likely to require psychopharmacological treatment. For example, it may be very difficult to communicate with a severely depressed or agitated patient, and a severely anxious patient may have difficulties coming in for psychotherapy. Thus, most clinicians find that symptoms that are very impairing usually require an approach that includes pharmacological treatment. When psychotherapy is effective, progression of improvement is gradual and requires several sessions to become evident. Even those variants that are called v

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“brief therapy” generally require 8–15 sessions before significant improvement is expected. When the patient is very uncomfortable, and when the symptoms debilitate the patient and significantly interfere with normal functioning, waiting this long for improvement may not be prudent. Conversely, many pharmacological treatments produce at least some improvement within days of the onset of treatment, although a few weeks (in some cases, 4–6) may be needed for more comprehensive response. Still, this is usually faster than psychotherapy, and the amount of improvement seen with medications may be greater than the improvement seen with psychotherapy over the same period of time. In order for psychotherapy to be effective, patients need to attend sessions regularly. If rapid progress is needed, sessions need to be scheduled at least weekly. However, driving to the therapist’s office once per week, and spending an hour in the office, may be difficult for some patients (or families) with significant time obligations. When the patient is a child or adolescent, psychotherapy must be done outside of school hours, since missing school 1 day/week to attend psychotherapy is neither practical for the family nor beneficial to the student. The cost of weekly psychotherapy is also likely to constitute a significant expense for many families, and few are able to cover such costs out of pocket. In the United States, most children and adolescents who have healthcare coverage are covered by private plans, usually purchased through the parent’s employer. The quality of this coverage varies widely. Unfortunately, mental health care is often considered to be the “step-child” of the healthcare industry, and levels of coverage for mental health treatment are often much lower than they are for medical care. Although laws on the federal and state levels have been passed to close that gap, many exclusions exist and the disparity between medical and mental health coverage continues. Limiting the patient’s access to care is one common method of containing healthcare costs. Many individuals with managed healthcare coverage have benefits that primarily are evident “on paper” and virtually disappear when the insured seeks treatment. Gatekeepers are assigned who review the need for care, and these reviews delay sessions and interrupt the continuity of care. Usually, four to six sessions may initially be authorized, and additional reviews are needed for each subsequent block. It is up to the discretion of the gatekeeper to authorize further treatment, and when the gatekeeper feels that sufficient progress was attained, or that sufficient progress is not evident, further authorization may not be issued. Although every insurer has appeals procedures that may be utilized, these appeals are internal to the insurer, and usually no external review exists that may be invoked if the insurer continues to refuse to authorize care. To make matters worse, appeals often take months, and meanwhile, the patient is getting no care. In addition, millions of children and adolescents in the US have no healthcare coverage. While federal and state authorities are striving to close this gap, there continues to be a significant portion of our society that cannot afford mental health care and has no insurance coverage. Various agencies exist that may service these individuals, including networks of community mental health centers (CMHCs) that provide care to those who need it, sometimes without (or with minimal) cost.

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However, in many states, CMHCs are overextended and long wait times are ­necessary (in some cases, up to 8 weeks) before the agency is able to provide care. Meanwhile, patients are suffering and are receiving no treatment. In addition, in rural states, the nearest CMHC may be quite a distance away. For all of the reasons reviewed above, patients and/or their families may need to utilize psychopharmacological treatment either instead of, or in addition to, psychosocial interventions.

Availability of Medical Mental Health Professionals When the decision is made that a patient needs to be treated with medications, patients must have access to necessary medical care to obtain the prescription. Traditionally, psychiatrists have been considered as the providers of choice to dispense prescriptions for psychotropic medications. However, this is changing rapidly, especially in the US, where 96% of counties do not have enough psychiatrists (or related mental health prescribers) to meet the needs in the community (Thomas, Ellis, Konrad, Holzer, & Morrissey, 2009). This shortage of psychiatrists is worsening, since the number of physicians pursuing a residency in psychiatry continues to decline (Rao, 2003). This is especially evident in the treatment of children and adolescents. According to the US Bureau of Health Professions National Center for Health Work Force Information and Analysis, at least 12,500 pediatric psychiatrists are currently needed to match the level of service provided in 1995, but only 8,300 are available (Kim, 2003). Others have suggested that the shortage may be even greater (Brauer, 2010). In addition, most mental health problems initially come to the attention of the general physician which, for children and adolescents, is the pediatrician. Pediatricians encounter a wide variety of medical problems and must make a decision about which will be treated “in-house” and which will be referred to specialists. At one time, patients needing psychiatric mental health care were immediately referred to psychiatrists. However, this is changing and pediatricians now often find it necessary to treat many mental health disorders in their offices.

Pediatricians as Provides of Mental Health Care Many factors influence the pediatrician’s decision to eschew a referral to a psychiatrist and treat a mental health problem within the pediatrician’s office. For one, managed healthcare plans severely curtail the primary physician’s referrals to specialists, thus forcing a shift of mental health care onto primary care physicians. Since family doctors must weigh whether to use up a precious referral to address psychological symptoms (like ADHD or depression) or a potentially life-threatening medical disorder (like a heart problem), most physicians opt to address many ­psychological problems in-house.

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This trend is especially evident among pediatricians (Koppelman, 2004), who face additional pressures because of the shortage of pediatric psychiatrists. Thus, referring patients to pediatric psychiatrists does not necessarily lead to the delivery of needed mental health services because psychiatrists often refuse new patients and require several months’ wait time for the initial appointment. Not surprisingly, it is evident that most psychotropic medications are now prescribed to children by their pediatricians (Olfson, Marcus, Weissman, & Jensen, 2002). Although highly knowledgeable about medicine and medications in general, most physicians complete only 6 weeks of exposure to psychiatry during medical training (Serby, Schmeidler, & Smith, 2002) and receive no further required training in psychiatry during pediatric residency (Kersten, Randis, & Giardino, 2003). Thus, pediatricians are caught in a double bind – they are compelled to treat mental health disorders “in house,” but they lack the training (and the time) to deliver this treatment competently and comfortably.

Psychology and Psychopharmacology Psychology has recognized this shortage of mental health prescribers for some three decades, when a task force report to the American Psychological Association (APA) Board of Professional Affairs proposed that psychologists should become more involved in the provision of physical and biological interventions for mental disorders (APA Board of Professional Affairs, 1981). By 1989, the APA Board of Professional Affairs endorsed advanced training in psychopharmacology for psychologists. As psychologists began to show more interest in being involved in psychopharmacological treatment, it became important to determine what role was appropriate for pharmacologically trained psychologists to take. Eventually, APA came to recognize three levels of psychopharmacology training for psychologists. Level 1 refers to the amount of training that all psychologists involved in health care should receive. Because psychotropic medications are increasingly prescribed to patients seen by all psychologists, all psychologists should have at least a rudimentary understanding of psychotropic medications and their desired and adverse effects. Level 2 denotes a level of training that prepares psychologists for active collaboration with primary care physicians (for example, pediatricians) about treatment with medications. This level of training allows psychologists to gain enough knowledge about psychotropic medications to participate in the decision making (for example, selection of medications and monitoring of response and side effects). Psychologists who complete this level of training are prepared to consult with pediatricians about the use of medications to treat their patients. Level 3 describes training that prepares psychologists for the independent authority to prescribe psychotropic medications, and efforts have continued to pass legislation allowing psychologists with Level 3 training to prescribe. In 1999, the US Territory of Guam approved prescriptive authority to appropriately trained ­psychologists (Guam Public Law 24-329), and in 2002, the state of New Mexico enacted prescriptive authority for psychologists (New Mexico Administrative Code

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16.22.20-16.22.29), followed in 2004 by Louisiana (Louisiana Revised Statutes 37:1360.51-1360.72). The fight for prescriptive authority continues in many other states, although opposition from psychiatry is fierce and thus far many other legislative efforts have been defeated. Despite legislative struggles, to date some 1,500 psychologists have completed postdoctoral training in psychopharmacology (Ax, Fagan, & Resnick, 2009), and it is expected that many of them have significant expertise in working with children and adolescents. Thus, even in states where psychologists do not prescribe, pharmacologically trained psychologists are available to consult with pediatricians and can play an important role in addressing the shortage of appropriate medication management for pediatric patients.

Pediatrician/Psychologist Collaboration Because of their busy schedules, pediatricians spend a limited amount of time with each patient and cannot perform in-depth reviews of personal, family, developmental, health, and social history necessary for proper diagnosis of most psychological disorders. Conversely, psychologists are specifically trained in the diagnosis and treatment of mental disorders and traditionally see patients for 1-h appointments, usually weekly or biweekly. Thus, pediatricians can benefit from collaborative relationships with clinical child psychologists. After accurate diagnosis, treatment options must be considered. Often, the question of whether or not to use medications must first be considered. Where psychological treatment is likely to be effective and the use of medications is not necessarily indicated, psychologists can make such a recommendation to the pediatrician and the patient’s family. If the family is receptive to this recommendation, the psychologist then may be able to deliver this treatment. When this option is utilized, the psychologist needs to provide the pediatrician with periodic updates about the patient’s progress. When a decision is made to treat a patient with medications, pediatricians who have developed an active collaborative relationship with a pharmacologically trained psychologist may choose to write the prescriptions, especially when the disorder is one with which they have some familiarity and the level of severity does not appear unusually high. When medications are used, the patients’ progress and side effects must be monitored. Many pediatricians, however, may not be conversant with dose–response profiles and side effects of psychotropics. In addition, pediatricians may not be able to see their patients frequently enough, and long enough during each visit, to accurately screen these issues. Psychologists with pharmacological training can perform medication monitoring and track the patient’s progress and adverse effects. When medication changes are warranted, ­psychologists with RxP training can have input into the nature of the adjustments. In providing this service, psychologists can offer relief to busy pediatricians who, instead of spending office visits troubleshooting psychotropic medications, will be able to devote these appointment times to the care of patients with medical problems. In this way,

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e­ fficiency of the use of the pediatricians’ time is greatly improved. Consequently, clinical child psychologists with extensive, formal training in psychopharmacology can be an invaluable resource to pediatricians.

Definition of Terms As psychology continues to expand its scope into the area of psychopharmacology, it is necessary to differentiate those psychologists who completed Level 2 or 3 training in psychopharmacology from other practicing psychologists. Two competing terms are now in use. In New Mexico, psychologists with authority to prescribe medications are referred to as “prescribing psychologists.” In Louisiana, however, psychologists with authority to prescribe are referred to as “medical psychologists.” While some may dismiss these differences as a matter of semantics, both terms have their proponents and critics. The term “medical psychologist” has sometimes been used by health psychologists who treat medical (not mental health) disorders (for example, diabetes). Thus, some argue that the use of “medical psychologist” as described in Louisiana legislation is confusing because the terms have been used by nonpharmacologically trained health psychologists. Conversely, proponents of the term argue that it is more descriptive of the depth and breadth of medical training that must be completed in order to obtain prescriptive authority, and that prescribing a medication is a medical service. While this dispute is far from over, both terms are used throughout this volume. It is important for the reader to remember that for the purposes of this book, the terms “pharmacologically trained,” “medical,” and “RxP-trained” psychologist are used interchangeably and refer to the same level of training (at least Level 2). It is also important for readers to remember that this book primarily focuses on collaborating with pediatricians. Since the vast majority of the US has not yet enacted prescriptive authority for psychologists, the book aims to help psychologists with Level 2 or Level 3 training develop collaborative relationships with pediatricians practicing in a state that does not allow psychologists to prescribe medications. Of course, the contents of this book are also applicable to states that have enacted prescriptive authority for psychologists (RxP), and in those states, psychologists consulting with pediatricians will be able to take on a more autonomous role.

Organization of This Volume This book is organized into four sections. Part I summarizes the basic principles and professional issues involved in collaborative relationships with pediatricians. Muse, Brown, and Cothran-Ross describe a model that helps readers conceptualize when patients are usually treated by pediatricians in-house or referred to outside

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professionals. The algorithm developed by the authors can help both medical and psychological professionals make this important decision. In the next chapter, McGrath outlines the history of the RxP movement and its applicability to the pediatric patient population. McGrath outlines important professional, ethical, and legal issues that should be reviewed by all who aspire to venture into this practice area. Part II reviews the various practice settings where pediatricians and pharmacologically trained psychologists are likely to collaborate. Kozak and Kozak Miller discuss collaboration that takes place between pediatricians and RxP-trained psychologists in states that have not enacted prescriptive authority for psychologists. Since this encompasses the vast majority of the US, the information provided in this chapter is likely to be highly relevant to most readers. To balance the contents, Nemeth, Franz, Kruger, and Schexnayder discuss collaboration in an RxP state, primarily based on their experiences while practicing in Louisiana. Readers can compare these two chapters to contrast methods of collaboration in non-RxP vs. an RxP state. Part II also includes chapters that review specific situations that affect collaborative relationships. Alford describes methods of collaboration in rural settings, outlining the unique challenges that these locations pose to professionals and patients alike. Tilus and colleagues describe emerging efforts to meet the mental health needs of the American Indian population, and how RxP training allows psychologists to make a meaningful contribution within portions of the country that experience especially difficult conditions. Finally, Courtney describes his account of a practice within a medical children’s hospital in a state that permits prescriptive authority for psychologists. Part III reviews specific disorder categories that are excellent candidates for collaborative care. Kapalka reviews the treatment of disruptive and mood disorders, Evers discusses the treatment of anxiety disorders, and Sanzone reviews the treatment of eating disorders. Collectively, these constitute the vast majority of disorders for which children and adolescents receive psychological care, and many of these patients are treated with medications, usually prescribed by pediatricians. Psychologists working with children are likely to find much relevant information within these three chapters. Part III also contains chapters that focus on collaborative treatment of medical disorders. Kotkin discusses the treatment of diabetes, a common medical disorder that often presents significant psychological complications. The section is rounded out by Clendaniel, Hymanand, and Courtney who discuss collaborative treatment of gastrointestinal disorders in children and adolescents. Collectively, Part III of this volume covers many disorders that psychologists are likely to encounter in their practice. Part IV outlines the future directions of pharmacological consultations and collaboration with pediatricians. Alvarez discusses the use of brain markers to assist in diagnosis and treatment planning, an emerging area that offers exciting opportunities for greater precision in developing treatments to address individual needs of the patients. Chapters by Raggi and Olivier review important training aspects, pre- and postdoctoral, to make sure that psychologists who wish to expand into the area

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of psychopharmacology attain a solid base of knowledge during their professional development. The volume concludes with a chapter by Lopez-Williams who ­discusses ways in which pharmacological training informs the practice of supervision of nonpharmacologically trained mental health professionals. This emerging area has not yet received much attention in the professional literature, and therefore, Lopez-Williams’ chapter makes an important contribution in this area. In addition, to a wide diversity of topics, this book also outlines a wide variety of styles utilized by RxP-trained psychologists who regularly collaborate with pediatricians. Some chapters present a formal approach, based on scientific evidence and findings of relevant literature. Other chapters provide a more personal account, filled with practical information that one acquires through years of practice and extensive “on the ground” experience. It is hoped that the wide variety of topics and styles provides a good overview of the practice of collaboration with pediatricians, and that the chapters within this book are representative of the wide breadth of approaches and activities that such collaboration traditionally entails. June 30, 2010 

George M. Kapalka Monmouth University

References American Psychological Association Board of Professional Affairs. (1981). Task force report: Psychologists’ use of physical interventions. Washington, DC: American Psychological Association. Ax, R. K., Fagan, T. J., & Resnick, R. J. (2009). Predoctoral prescriptive authority training: The rationale and a combined model. Psychological Services, 6, 85–95. Brauer, D. (2010, June 4). Pilot program aims to combat shortage of child and adolescent psychiatrists. Medscape Medical News. Retrieved June 21, 2010, from http://www.medscape.com/ viewarticle/722981 Kersten, H., Randis, T., & Giardino, A. (2003). Evidence-based medicine in pediatric residency programs: Where are we now? Ambulatory Pediatrics, 5, 302–305. Kim, W. J. (2003). Child and adolescent psychiatry workforce: A critical shortage and national challenge. Academic Psychiatry, 27, 277–282. Koppelman, J. (2004). The provider system for children’s mental health: Workforce capacity and effective treatment. National Health Policy Forum Issue Brief No. 801. Washington, DC: George Washington University. Olfson, M., Marcus, S. C., Weissman, M. M., & Jensen, P. S. (2002). National trends in the use of psychotropic medications by children. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 514–521. Rao, N. R. (2003). Recent trends in psychiatry residency workforce with special reference to international medical graduates. Academic Psychiatry, 27, 269–276. Serby, M., Schmeidler, J., & Smith, J. (2002). Length of psychiatry clerkships: Recent changes and the relationship to recruitment. Academic Psychiatry, 26, 102–104. Thomas, K. C., Ellis, A. R., Konrad, T. R., Holzer, C. E., & Morrissey, J. P. (2009). County-level estimates of mental health professional shortage in the United States. Psychiatric Services, 60, 1323–1328.

About the Editor

George M. Kapalka earned his PhD in Clinical Psychology from Fairleigh Dickinson University and holds board certifications in several areas of practice, including clinical psychology, psychopharmacology, child and adolescent psychology, learning disabilities, and forensic psychology. He is an associate professor (tenured, graduate faculty appointment) at Monmouth University where he currently serves as the Interim Chair of the Department of Psychological Counseling. Dr. Kapalka previously taught at several universities, including Fairleigh Dickinson University (within the PhD program in Clinical Psychology) and the New York Institute of Technology (where he served as the Director of Counselor Education). Dr. Kapalka is licensed to practice psychology in NJ, NY, PA, and NM and has been in practice for over 20 years. He maintains a private practice that primarily focuses on the treatment of children and adolescents with learning and emotional disorders. Dr. Kapalka completed Level 3 psychopharmacology training through the Prescribing Psychologists’ Register, and in his practice, he frequently consults with pediatricians about the use of medications in the treatment of children and adolescents. For over a decade, he has been a member of medical staff at Meridian Health, Brick Hospital Division, a primary care hospital. In addition, Dr. Kapalka is school-certified in New Jersey and heads a state-accredited Independent Child Study Team. Dr. Kapalka’s research program has focused on the education and treatment of youth with disruptive disorders, as well as the use of nutritional and herbal supplements in the treatment of children and adolescents. He is the author of four books and dozens of professional publications and presentations. Dr. Kapalka is active in professional and community education and has held dozens of workshops for ­medical and mental health professionals, teachers, and parents. Dr. Kapalka has been interviewed in newspapers, Internet publications, and on television.

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Contents

Part I  Foundations of Collaborative Care   1 Psychology, Psychopharmacotherapy, and Pediatrics: When to Treat and When to Refer......................................................... Mark Muse, Syd Brown, and Tanya Cothran-Ross   2 Collaboration Between Pharmacologically Trained Psychologists and Pediatricians: History and Professional Issues............................................................................ Robert E. McGrath

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Part II  Collaboration with Pediatricians in Specific Settings   3 The Clinical Experience of RxP-Trained Psychologists Working in Non-RxP States..................................................................... Thomas M. Kozak and Andrea Kozak Miller   4 The Practice of Medical Psychology in an RxP State: New Opportunities for Comprehensive Pediatric Care........................ Darlyne G. Nemeth, Sandra Franz, Emma Kruger, and Maydel M. Schexnayder   5 Integrated Care in Rural Settings.......................................................... Nancy Boylan Alford   6 Collaborative Practice with Pediatricians Within the Indian Health Service: Taking Care of Frontier Children................................................................................. Michael R. Tilus, Kevin M. McGuinness, Mimi Sa, Earl Sutherland, Bret A. Moore, Vincen Barnes, Johna C. Hartnell, and Anthony Tranchita

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  7 The Practice of Medical Psychology in a Pediatric Hospital Setting: A Personal Account from an RxP State..................................................................................... 119 John C. Courtney Part III Collaboration with Pediatricians in Treatment of Specific Disorders   8 Collaborative Treatment of Disruptive and Mood Disorders................................................................................ 135 George M. Kapalka   9 Collaboration Between Pediatricians and Pharmacologically Trained Psychologists in the Treatment of Anxiety Disorders in Pediatric Patients............................................................... 153 Sean R. Evers 10 Collaborative Treatment of Eating Disorders....................................... 167 Marla M. Sanzone 11 Collaborative Treatment of Medical Disorders: The Management of Diabetes................................................................. 183 Lawrence R. Kotkin 12 Collaborating with Pediatricians and Gastroenterologists: A Biopsychosocial Approach to Treatment of Gastrointestinal Disorders.................................................................. 199 Lindsay D. Clendaniel, Paul E. Hyman, and John C. Courtney Part IV  Future Directions in Pharmacological Collaboration 13 Brain Markers: An Emerging Technology with Potential to Enhance Collaboration Between Pediatricians and Pharmacologically Trained Psychologists...................................... 233 Margaret B. Alvarez 14 Internship and Fellowship Experiences: Preparing Psychology Trainees for Effective Collaboration with Primary Care Physicians................................................................ 249 Veronica L. Raggi 15 The New Face of Psychology Predoctoral Training: Psychopharmacology and Collaborative Care...................................... 271 Traci Wimberly Olivier

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16 RxP Training Informs the Practice of Supervision of Nonpharmacologically Trained Mental Health Practitioners................................................................................. 285 Andy Lopez-Williams Index.................................................................................................................. 301

Contributors

Nancy Boylan Alford, PsyD, is a clinical psychologist who is board certified in psychopharmacology (ABMD). She is a member of a group private practice in rural North Carolina where she treats children and adults and works part-time for a Pediatric Service at the Rural Health Group in Roanoke Rapids, a subsidized medical care facility in North Carolina. Dr. Alford is a founding member of the American Society for the Advancement of Pharmacotherapy, Division 55 of the American Psychological Association. Margaret B. Alvarez, PsyD, MS, is a child clinical school psychologist and a medical psychologist. She also completed a postdoctoral respecialization in neuropsychology and recently completed the coursework for a degree as a medical doctor (MD). She a member of the editorial board of The American Journal of Integrated Mental Health Care and has published in the field of health psychology (about childhood obesity), primary prevention, and neuropsychological sequelae in cardiac bypass surgery with differential blood profusion. She is an Associate Professor of Psychology at Touro College in Manhattan and maintains a private practice in Pomona, NY. Vincen Barnes, PsyD, is a clinical psychologist with the Public Health Service. He completed two tours of service on two different reservations in North Dakota. He served as a staff psychologist on the Turtle Mountain reservation and as the mental health director on the Standing Rock reservation. Dr. Barnes has been deployed to three reservations experiencing suicide epidemics. During the deployments he provided treatment and conducted community assessments to help develop suicide prevention strategic plans. Syd Brown, PhD, is a child and adolescent clinical/neuropsychologist who is board certified in clinical neuropsychology (FACPN). Dr. Brown maintains a private practice in Bethesda, MD. Lindsay D. Clendaniel, PhD, is a pediatric psychologist at Children’s Hospital, New Orleans. She specializes in treating children coping with gastrointestinal disorders and pain-related illness. Her research focuses include pain assessment, acute and chronic pain management, and management of functional gastrointestinal disease. Dr. Clendaniel has presented her research at the International Pediatric xix

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Pain Symposium and Society of Pediatric Psychology conferences. Her published research has focused on coping with chronic illness and acute pain assessment and management. Tanya Cothran-Ross, MD, is a board certified pediatrician (FAAP). Dr. Cothran-Ross works as a pediatrician in Gaithersburg, MD. John C. Courtney, PsyD, is a medical psychologist and a board certified neuropsychologist. He is the director of the department of psychology at Children’s Hospital of New Orleans, LA. Dr. Courtney is also an Associate Clinical Professor of Neurology, Psychiatry and Pediatrics at Louisiana State University Health Sciences Center in New Orleans. Sean R. Evers, PhD, MS, is a clinical psychologist who maintains a private practice in Manasquan, NJ. He treats children and adolescents and supervises other professionals. Dr. Evers is a frequent presenter on Posttraumatic Stress Disorder and its impact on children and the family. Dr. Evers is a consultant to the New Jersey Department of Military and Veterans Affairs and the Veteran’s Administration Center’s program that focuses on addressing the needs of veterans and their families. Sandra A. Franz, MD, is a board certified (FAAP) pediatrician. For the past 10 years, Dr. Franz has been a member of a private group practice. In addition, she teaches medical students and residents through the Our Lady of the Lake Regional Medical Center’s Pediatric Residency Program. Johna C. Hartnell, PhD, MS, is a medical psychologist recently employed with the Indian Health Service at Fort Thompson, SD. Dr. Hartnell is completing her preceptorship toward the Conditional Prescribing License in New Mexico. Prior to joining the Indian Health Service, she worked in a private practice in Madison, WI. She works with all age populations, including children, adolescents, and adults. Paul E. Hyman, MD, is Professor of Pediatrics at Louisiana State University and Chief of Pediatric Gastroenterology at Children’s Hospital, New Orleans. Dr. Hyman’s research focuses on pediatric gastrointestinal motility disorders and chronic visceral pain. In 1999, Dr. Hyman chaired the Pediatric ROME II Working Team, charged with developing the first symptom-based criteria for the diagnosis of childhood functional gastrointestinal orders. Dr. Hyman has made contributions to the training of several pediatric motility researchers. In 2002, Dr. Hyman received an Award for Outstanding Achievement in Clinical Gastroenterology from the American Gastroenterological Association. Lawrence R. Kotkin, PhD, MS, is a medical and school psychologist who currently focuses on the treatment of chronic illnesses, especially diabetes. He holds a board certification in diabetes education, and the Professional Section of the American Diabetes Association placed him in the Who’s Who in Diabetes Treatment, Education, and Research. He is a member of a Diabetes Education Center team at the Einstein College of Medicine’s Diabetes Research and Training

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Center and is a supervising psychologist of the Geriatrics Division at New York’s Creedmoor Psychiatric Center. He maintains a private practice and consults with hospitals and schools about psychological aspects of managing diabetes. He also teaches as an adjunct at St. Joseph’s College in New York. Thomas M. Kozak, PhD, is a psychologist who practices in The Woodlands, TX. He is Co-Chair of the Texas-Oklahoma Prescribing Psychologists’ Register and was former Legislative Chair of the Texas Psychological Association. He currently works collaboratively with physicians in establishing and monitoring patient ­medication regimes. Dr. Kozak has previously authored articles on managed care, family therapy, and RxP legislative action. Andrea Kozak Miller, PhD, is a psychologist in Atlanta, GA. She is a faculty member at Walden University in Minneapolis, MN. In the past, Dr. Miller served as a site supervisor for a nonprofit clinic in New York City that provided consumers a combination of psychological and medical services. She currently works as a partner in a data analysis company as well as teaches online. Dr. Miller is the author of the column, “From Research to Practice,” a regular feature in The Independent Practitioner, a publication of Division 42 of the American Psychological Association. Emma Kruger, MD, is a physician and founder of the Metabolic Anti-Aging Center, LLC, in Baton Rouge, LA, where she practices metabolic and functional medicine. Andy Lopez-Williams, PhD, is the President and Clinical Director of ADHD and Autism Psychological Services and Advocacy in Utica and Oneida, NY. He is also a founding member and Chief Executive Officer of Central New York Quest, a not-for-profit agency focused on services, education, advocacy, and policy for persons with special needs. Dr. Lopez-Williams has coauthored numerous articles on the assessment and treatment of children and adolescents with mental health disorders. He has developed individualized assessment protocols designed to evaluate the effectiveness of psychotropic medications in children and adolescents and currently trains and supervises mental health therapists to utilize these psychopharmacological assessment protocols in collaboration with primary care physicians. Robert E. McGrath, PhD, is a clinical psychologist and Professor of Psychology at Fairleigh Dickinson University in Teaneck, NJ. He is also the Director of both the Ph.D. Program in Clinical Psychology and the M.S. Program in Clinical Psychopharmacology at the University. He is the author of over 150 publications and presentations in the areas of professional issues in pharmacotherapy and psychological assessment. He is a recipient of the American Society for the Advancement of Pharmacotherapy Award for Outstanding Contribution to Prescriptive Authority on the National Level and three-time winner of the Martin Mayman Award from the Society for Personality Assessment for distinguished contributions to the literature in personality assessment.

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Kevin M. McGuinness, PhD, is a clinical psychologist, clinical health psychologist, and medical psychologist who is board certified in clinical health psychology (ABPP). He is a senior commissioned officer of the U.S. Public Health Service. Dr. McGuinness is licensed in Louisiana as a medical (prescribing) psychologist and is a conditional prescribing psychologist in New Mexico. Dr. McGuinness is currently assigned to a community health center in rural New Mexico and maintains a private practice in Las Cruces, NM. He is the founding Vice President of the Joshua Foundation, Inc., which strives to educate and safeguard the public regarding the delivery of health care in the State of New Mexico. Dr. McGuinness has authored numerous professional publications. Bret A. Moore, PsyD, is a board-certified clinical psychologist (ABPP) and a conditional prescribing psychologist in New Mexico. He is the author or editor of five books including Pharmacotherapy for Psychologists: Prescribing and Collaborative Roles. He is a Fellow of the American Psychological Association and Secretary-Treasurer of Division 18 (Psychologists in Public Service). He maintains a private practice in San Antonio, TX. Mark Muse, EdD, PhD, is a prescribing medical psychologist in Louisiana. He also maintains a practice in Maryland, where he consults about medication issues. Dr. Muse’s most recent publication, The Handbook of Medical Psychology and Clinical Psychopharmacology, is in press with John Wiley & Sons. Darlyne G. Nemeth, PhD, is a clinical, medical, and neuropsychologist who is board certified in clinical psychopharmacology (ABMP). She is the founder of The Neuropsychology Center of Louisiana, LLC. Dr. Nemeth is a prescribing psychologist in Baton Rouge, LA, where she has maintained a private practice for over 30 years. Dr. Nemeth is the recipient of the 2010 Distinguished Psychologist Award by the Louisiana Psychological Association. Dr. Nemeth coauthored the book, Helping Your Angry Child, which promotes healthy family interactions. Traci Wimberly Olivier, BS, is a doctoral student at Nova Southeastern University’s Center for Psychological Studies doctoral program in clinical psychology. She completed a 2-year clinical and research externship at the Neuropsychology Center of Louisiana (NCLA). After receiving her doctorate, Mrs. Olivier intends to obtain a postdoctoral master’s degree in clinical psychopharmacology and plans to seek prescriptive authority. Veronica L. Raggi, PhD, is a clinical child psychologist who earned her doctorate in clinical psychology from the University of Maryland, College Park. She completed internship training at Children’s National Medical Center in Washington, D.C. and postdoctoral training at the New York University Child Study Center. Dr. Raggi currently provides clinical services at Alvord, Baker, and Associates, LLC, a group private practice located in Silver Spring, MD. She has published in numerous scholarly journals on topics related to academics, homework and school functioning, parenting skills, and the treatment of ADHD and other disruptive behavior disorders.

Contributors

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Mimi Sa, PhD, MS, is a clinical and medical psychologist who gained prescriptive authority in New Mexico in 2009. She has worked in Indian country for 10 years both in urban and tribal settings and is currently stationed at the Mescalero Service Unit in southern New Mexico. Her experience includes working with indigenous elders in Costa Rica and Brazil, as well as with the Ojibwe and Lakota elders in Minneapolis. In addition, Dr. Sa has participated in Native American workshops and Native radio shows with a panel of medicine men. She was recently awarded by the Indian Health Service for her participation in a state of emergency at Mescalero due to a suicide cluster. Marla M. Sanzone, PhD, is a clinical psychologist with a postdoctoral Master’s of Science in psychopharmacology. She is in independent practice in Annapolis, MD, where she specializes in the treatment of eating disorders and related mood, anxiety, and compulsive conditions. Dr. Sanzone works closely with pediatricians, internists, endocrinologists, and other primary care providers toward integrating pharmacotherapies with cognitive–behavioral, interpersonal, and systems treatment approaches. She also presents at state and national conferences on the treatment of eating disorders and psychopharmacology and is adjunct faculty at Loyola College of Maryland. Maydel M. Schexnayder, MS, CRC, holds a Master of Science in Rehabilitation Counseling and is a Certified Rehabilitation Counselor. She has been working for the Louisiana Rehabilitation Services program for 8 years and is currently the Vocational Rehabilitation District Supervisor. Ms. Schexnayder coauthored the book, Helping Your Angry Child, which promotes healthy family interactions. Earl Sutherland, PhD, MS, is a school/child clinical psychologist and a medical psychologist. Currently, he is a Supervisory Psychologist and chair of the RxP Task Force with the Indian Health Service and director of CARE center, the first fully federal child advocacy center. He is a member of the Board of Directors of Native American Children’s Alliance and a member of Board of Directors of Montana Children’s Alliance. He is as a Member at Large of Division 55 of the American Psychological Association and the Prescription Privileging Chair with the Montana Psychological Association. In 2007, he received the Indian Health Service National Director’s Award. Michael R. Tilus, PsyD, is a licensed clinical psychologist, marriage and family therapist, and board-certified pastoral counselor. He is on active duty with the U.S. Public Health Service (Commander) and is the Director of Behavioral Health at Spirit Lake Health Center at Ft. Totten, ND. Dr. Tilus has a Conditional Prescribing Psychologist license from New Mexico and provides a wide range of psychological and psychopharmacological services to American Indians and Alaska Natives in isolate, remote, medically underserved communities within an integrated, behavioral health and primary care setting. Anthony Tranchita, PhD, is a staff psychologist and chief of the Alcohol and Drug Abuse Prevention and Treatment (ADAPT) program at the Grand Forks Air

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Contributors

Force Base in North Dakota. He is currently completing psychopharmacology training at Alliant International University in San Francisco. Dr. Tranchita previously worked as a staff psychologist at a residential treatment center for Native American youth with substance abuse issues and an Air Force treatment center in Oklahoma.

Part I

Foundations of Collaborative Care

Chapter 1

Psychology, Psychopharmacotherapy, and Pediatrics: When to Treat and When to Refer Mark Muse, Syd Brown, and Tanya Cothran-Ross

Psychologists and pediatricians have a longstanding history of collaborative effort in the treatment of behavioral health issues with patients 18 years of age  and younger. The majority of patients with psychological concerns in this age group initially present to the pediatrician, and the pediatrician either manages the mental health concern directly or manages it through a referral to a child and adolescent psychologist. The purpose of this chapter is to spell out when a referral to a psychologist is most indicated and to address specifically the proper ­collaborative effort between a psychologist and a pediatrician when medication  management forms a part of the treatment of emotional or behavioral symptoms. Ideally, every complaint of a specific nature would be evaluated and treated by a specialist whose training is specific to the complaint. That being said, most ­complaints are presented to primary care where they are triaged and subsequently resolved by the generalist, or are referred for further study by a specialist. It is important not to lose sight of the entire person, and the patient’s primary care provider is in the best position to integrate and coordinate all aspects of the patient’s health concerns. Although pediatrics is a specialty in its own right, it is by its very nature a primary care specialty that seeks to coordinate all aspects of the patient’s health. In pediatrics, health concerns include, in addition to physical issues, the emotional, mental, and behavioral well-being of the patient. In deciding whether or not to refer to a psychologist, the pediatrician weighs many factors, among them the severity and complexity of the condition, as well as the cost of treatment and the benefits vs. inconveniences of referring to a second provider. It might well be argued that if the condition’s diagnosis and treatment are relatively straight forward, there is an advantage to having the pediatrician maintain exclusive responsibility for the management of the condition inasmuch as a referral

M. Muse (*) Muse Psychological Associates, Rockville, MD, USA e-mail: [email protected]

G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_1, © Springer Science+Business Media, LLC 2011

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increases the possibility of fragmented rather than integrated care. This is especially true when the collaborating specialist is less than fully available for coordinated clinical intervention with the pediatrician. In this regard, having the psychologist on the premises with the primary care provider, or linked through open channels of communication as in the HMO model, is a distinct advantage. Short of this, a referral to a psychologist would require additional need for specialist attention to offset the disadvantage inherent in referring to an outside agency or provider. What, then, are the behavioral health conditions which might best be handled directly by the pediatrician, and which conditions warrant a referral to a child and adolescent psychologist? One way to approach this question is to look at conditions and to offer a preferred ordering of first-line provider specialists in the diagnosis of the various mental health concerns that present in the pediatric population. A second approach is to consider the treatments involved in the management of such conditions and to determine which treatments are best managed by whom. A third option is to combine the first two approaches in order to determine the optimal integration of ­psychology and pediatrics, according to the behavioral/pharmacological management prescribed for a given condition.

Conditions Mental health conditions can be divided into three broad categories: 1. Cognitive concerns, including mental retardation, pervasive developmental disorders, autism spectrum, and academic concerns such as learning disabilities and attention deficit hyperactivity disorder (ADHD) (especially the variant with predominantly inattentive symptoms), as well as thought disorders. 2. Emotional concerns, including anxieties such as specific phobias, social/separation anxieties, obsessive-compulsive disorder (OCD), and generalized anxiety, as well as depression in all its forms (adjustment reaction, dysthymia, major depression, and bipolar disorder). 3. Behavioral concerns, including oppositional defiant disorders, disruptive behaviors and ADHD (especially the variant with predominantly hyperactive/impulsive symptoms), impulse control disorders (anger), and conduct disorders. Of these conditions, some are more challenging to diagnose and require extensive interviewing of the child and significant others as well as the use of psychometrics. A differential diagnosis is the basis of efficacious treatment, and time and expertise spent at the conceptualization stage of treatment will pay off in the long-term management of complex conditions. Such complex conditions, requiring extensive psychodiagnostics, include the following: 1 . Mental retardation/autism and organic brain syndromes. 2. Confounded academic conditions involving a combination of factors such as learning disabilities with ADHD, overlaid with emotional, behavioral, and/or social concerns.

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3 . Thought disorders and other psychoses. 4. Anxieties not of a transient nature, as well as depressions not of a transient and/ or mild intensity. 5. Behavioral concerns that are not secondary to transient issues and which are not believed to be resolved with the passing of a temporary trigger; e.g., ADHD, oppositional-defiant disorder (ODD), conduct disorder, and pernicious impulse disorders. A simple way of approaching the question “which mental health conditions should a pediatrician treat without referring to a psychologist?” is to identify straightforward, uncomplicated conditions, such as unadulterated ADHD. A condition such as ADHD, however, can easily become enmeshed in comorbid conditions such as ODD, substance abuse, and impulse control problems. In such cases, a referral to a psychologist is warranted. In the case of “simple ADHD,” however, the problem lies in separating it from other mimicking conditions such as anxiety disorders, and making sure that it is a bona fide case of ADHD and not simply a pseudo-condition created by a frustrated parent or teacher who assigns too much emphasis to distractibility or impulsive tendencies in a given child. Here is where a mere description of symptom constellations taken from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), or the use of a non-normed scale, is insufficiently powerful to weed out the false positives. The unmitigated case of manifest ADHD notwithstanding, the question has to be asked, in differentiating the diagnosis of ADHD from mere ADHD-like behaviors, if the combination of symptoms is not only attributable solely to ADHD, but the magnitude of the symptoms, according to the child’s age and gender, is also of such severity that the condition truly stands out from that of the rest of the children who also show one degree or another of distraction and impulsivity? ADHD scales based on normed data that include the child’s age and gender, such as the Conners (2008) or DuPaul, Power, Anastopoulos, and Reid (1998) ADHD scales, are far more robust instruments in this sense than a simple interview with the parents and the child, or the use of descriptive, non-normed instruments. Another factor to consider is that ADHD, predominantly inattentive type, can be difficult to diagnose, as one does not see the obvious hyperactive and impulsive behaviors of ADHD, combined type. With the inattentive subtype of ADHD, one may observe a child or adolescent “space out,” etc., but this could be ADHD, inattentive type, or it could be absence seizures, or both; it should be noted that approximately one-third of children with childhood absence epilepsy also meet the criteria for ADHD, predominantly inattentive type (Hermann et al., 2007). If the seizure disorder can be ruled out, one must consider other ways of diagnosing the inattention; behavioral inventories may not provide adequate data, but a careful clinician should not just rule it out because adults do not “see” the disorder. At this point, one needs to know when to order neuropsychological testing to look for evidence of inattention which reaches a clinical level, warranting a diagnosis and treatment. If ADHD poses certain difficulties in its accurate diagnosis, many other conditions pose even greater challenge and require the discerning eye of the specialist

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and the time required to perform a thorough evaluation which may necessitate formal psychometrics. With the exception of patently transient conditions such as mild to moderate anxiety reactions after an identifiable trigger, the rest of the conditions composing the three categories of cognitive, affective, and behavioral disorders are best diagnosed after a thorough psychological evaluation.

Treatments It has been a longstanding tradition for pediatricians to refer behavioral treatments to psychologists. This does not exclude the pediatrician from developing a therapeutic rapport with the patient, encouraging healthy interactions between patient and parents, and instructing parents on basic reinforcement strategies for promoting healthy compliance on the patient’s part, but it recognizes that the design and application of a systematic behavioral plan require therapeutic input and follow-up of a more extensive nature than that afforded by the standard pediatric visit. Medication management of mental health concerns through the years has evolved into a collaborative relationship between psychologists and pediatricians. Both professions have benefitted from two-way communication in which diagnostic impressions and treatment strategies, including medication, are openly discussed. Pediatricians have become increasingly comfortable with consultations with psychologists on such medication issues as whether pharmacotherapy is indicated and would compliment other prescribed behavioral approaches, and which class of medication best fits the diagnosis and therapeutic needs of the patient. The role of medication consultation for pharmacologically trained psychologists is contemplated in the rulings of many state psychology licensing boards which find medication consultation by pharmacologically trained psychologists with primary care and pediatric physicians to be within the purview of the psychologists’ license to practice psychology according to their competency in specialty areas such as clinical psychopharmacology. The advent of the specialty of “medical psychologist,”1 ­recognized by the Drug Enforcement Agency (DEA) in the granting of the control substance registration number to prescribing psychologists, has expanded this role

1  The term medical psychologist, as adopted by Division 55 of the American Psychological Association, is used in this paper to mean a pharmacologically-trained psychologist, regardless of whether the jurisdiction in which the psychologist resides allows for full prescriptive authority at this time. A medical psychologist, or pharmacologically-trained psychologist, as these two terms are used interchangeably in this chapter, holds a doctorate degree in psychology and a license to practice psychology in his or her respective state, as well as having completed postdoctoral training requirements outlined by the American Psychological Association to demonstrate competency in the specialty area of pharmacotherapy. It is specifically recognized that such a psychologist is qualified to advise physicians on medication in those states whose boards of psychology have rendered an opinion that allows for such, and it is assumed that equivalently trained psychologists residing and working in states without a formal opinion from the board are equally competent to advise physicians on medication, just as the same medical psychologist is qualified to write a prescription in those states and federal jurisdictions that allow for prescriptive authority (McGrath, 2010).

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and has redefined the psychologist as the primary prescriber of psychotropic medications where current legislation provides for such prescriptive authority. This raises the question of to what extent psychologists, in general, and pharmacologically trained psychologists, in particular, should play a role in the behavioral medication management of their patients. It should be stated that a collaborative relationship with the patient’s pediatrician with regard to medication issues from the onset is, for the psychologist, not only a best-practice imperative, but also a legal one where prescriptive authority for psychologists has been enacted. While the interplay of condition with treatment/medication is specifically addressed in the coming section on the integration of medical psychology with general pediatrics, the extent of the psychologist’s involvement in medication issues is addressed here. Evidenced-based clinical intervention has demonstrated that certain psychological conditions respond better to different treatments. While empirically based selection of treatments is far from established for the majority of conditions, there is reason to believe that future research efforts to identify first-line approaches for the array of mental disorders will progressively offer greater specificity as to which treatment is more likely to provide positive results for a particular condition. This does not obviate the argument of the “dodo-bird effect,” which refers to the observation that all credible psychotherapies result in significant therapeutic improvement just as all antidepressant medications result is similar therapeutic effects, an argument which maintains that it is unlikely that precise behavioral intervention/medication-specific algorithms will ever be definitively developed.2 Psychopharmacology trained psychologists’ involvement in pharmacotherapy with the pediatric population ranges from full responsibility for prescribing and monitoring psychotropic medications to making recommendations to the prescribing physician on the class of medication most indicated for the treatment of the presenting diagnosis or symptom constellation. At the upper end of involvement are child and adolescent medical psychologists who have been issued the DEA controlled ­substance certificate to prescribe within a territorial jurisdiction (either state/territory or, in the case of federal agencies, federal installations) and who are consultants or primary therapists for the patients’ mental health needs. In every case, it is incumbent Still, evidence to date indicates that combined, medication/psychotherapy, treatment is likely to be optimum for bipolar (Sachs, 1996), some forms of depression (Thase et  al., 1997) smoking cessation (Hatsukami & Mooney, 1999), schizophrenia (Rosenheck et  al., 1998; Spalding, Johnson, & Coursey, 2003), panic disorder (Bruce, Spiegel, & Hegel, 1999) and substance abuse (Carol, 1997), while the use of pharmacotherapy and, more specifically, benzodiazepine is not generally indicated in the treatment of phobias, as medication effects tend to confound exposurebased treatments (Sammons & Schmidt, 2003). In general, pharmacotherapy is less effective as a single modality approach than psychotherapy when treating chronic depression with an Axis II disorder (Sammons & Schmidt, 2003). In the treatment of OCD, research indicates that single treatment modality (behavioral therapy) is more effective than combination treatment modality when symptoms are primarily compulsive, whereas combined treatment modality (medicationbehavioral therapy) is more effective than single treatment modality when symptoms are primarily obsessive (Hohagen et al., 1998). In many other disorders, not enough evidence has accumulated to be able to discern treatment superiority; for such conditions, single-modality treatments should be attempted before combined treatments are implemented, opting for the treatment with less side effects (usually psychotherapy) when treatment specificity is ambiguous (Muse, 2010).

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upon the psychologist to collaborate with the patient’s pediatrician to coordinate the prescription, and subsequent adjustment, of any psychoactive medication according to the patient’s medical status, keeping especially in mind any contraindication for medications due to a preexisting medical condition or interaction with other drugs currently taken by the patient. A recent study (Rae, Jensen-Doss, Bowden, Mendoza, & Banda, 2008) suggests that pediatric psychologists have greater positive views of prescriptive authority than pediatricians, although the majority of pediatricians indicated that collaborating with child medical psychologists would not be negatively influenced by the new role as prescriber.

Integration of Medical Psychology with Pediatrics Not every case of mental retardation requires a psychologist’s intervention, just as not every case of ADHD is manageable by pediatrics alone. Some cases, such as major depression, generally require interventions by both specialties. In cases where behavioral medications are prescribed, coordination between the two specialties would appear to be especially indicated. If the nature of the various conditions as well as their respective first-line interventions is considered, one might construct an algorithm combining these two dimensions to project the discipline, pediatrics or psychology, as well as the subspecialty within psychology that might best manage certain behavioral health syndromes. Figure 1.1 presents such an algorithm. In Fig. 1.1, it is essential NOT to make a distinction between medical psychologists practicing where prescriptive authority currently exists, and pharmacologically trained psychologists practicing in jurisdictions where their ability to consult on medication can be effective in the management of the patient’s pharmacotherapy needs without directly writing the medication script. The pediatrician would be directly involved in pharmacotherapy in either case, either reviewing the recommendations of the script-writing medical psychologist or, alternatively, writing the script based on the recommendations of the consulting medical psychologist. In either case, the pediatrician benefits from the expertise of the pharmacologically trained psychologist, while the medical psychologist benefits from the close collaboration and coordination of care with the pediatrician. The fully qualified medical psychologist is competent in all psychotropic medications used in the treatment of mental health disorders, and collaboration of the pharmacologically trained psychologist with the patient’s pediatrician allows for the patient’s medication needs to be met fully. As is true with all specialties, referral to another professional would be indicated if the medical psychologist were to require the opinion or intervention of another prescribing professional (a medical psychologist or psychiatrist) in special cases that warrant further consultation. As such, the algorithm in Fig. 1.1 assumes that the collaboration between a pediatrician and a pharmacologically trained psychologist will cover all conditions and treatments contained within the algorithm. While the algorithm indicates that certain conditions that may benefit from pharmacotherapy be initially referred to a pharmacologically trained psychologist,

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Presenting Problem

Cognitive Developmental Disorders 3,2

Tourette's, Organic Brain Syndromes, Mental Retardation; *Pervasive Developmental Disorders, Autism Spectrum

Academic Disorders 1,4,2 Attention Deficit/Hyperactivity

3,2

Learning Disabilities

Affective Thought Disorders

Anxiety 2

4,2

Psychoses

Adjustment Disorder, Generalized Anxiety Disorder, Phobias

4,2 Posttraumatic Stress Disorder, Obsessive Compulsive Disorder, Panic Disorder

Depression

Behavioral Impulse Dyscontrol

Impulse Dysfunction 2

2

Adjustment Disorder, Dysthymia

2

Oppositional Defiant Disorder, Explosive Anger

Conduct Disorder

4,2

Addiction

4,2

Major Depression, Bipolar Disorder

Key:: Preferred Provider: fe ide : 1 Pediatrician e i ri an 2 Clinical, l ic Counseling, g, or o School h o Psychologist h o 3 Neuropsychologist or Psychodiagnostician e ro yc o gis r gn t 4 Medical i al Psychologist l st *Often e in n conjunction c n n t o with h Developmental e lo m n Pediatrics Pe iat ic

Fig. 1.1  Algorithm for pediatrics interface with psychology (Muse, Brown, & Cothran-Ross, 2010)

this does not imply that a clinical, counseling, or school psychologist without expertise in clinical psychopharmacology would not be able to make the diagnosis or provide the indicated behavioral treatment based on the diagnosis, but simply acknowledges that where there is the possibility of medication management, the pharmacologically trained psychologist might be considered first line. However, this certainly does not imply that all patients with suspected diagnoses that might require medication be initially referred to the medical psychologist. Quite to the contrary, the majority of such patients are traditionally referred to a clinical, counseling, or school psychologist, who might then request a consult with a medical psychologist, should medication recommendations be sought. Along this same line, referral to a neuropsychologist or psychodiagnostician3 may be initiated at anytime that a precise differential diagnosis is sought on conditions The term psychodiagnostician is used here to identify clinical, counseling and school psychologists who have specialized in diagnosing disorders and providing differential diagnoses through the use of psychological testing and investigative interviewing. The neuropsychologist performs essentially the same service, having specifically developed an expertise in neuropsychology instruments that rule in/rule out organic syndromes.

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that may require in-depth study in the formulation of treatment recommendations. The algorithm in Fig. 1.1 not only indicates which of these conditions might warrant an initial referral by the pediatrician, but also assumes that in many cases these conditions will be managed by a clinical, counseling, or school psychologist and referred for psychological testing when the managing psychologist believes it indicated. Figure  1.1 depicts different pathways in which the patient presenting to the pediatrician with behavioral health concerns might be triaged according to the type of concern – cognitive, affective, or behavioral – as well as the particular condition. According to the algorithm proposed by the current authors, the pediatrician would treat simple, manifest ADHD with medication when the disorder has no other comorbid condition and when a differential diagnosis is not required to separate ADHD from other confounding symptoms. The pediatrician might also treat, where time permits, transient conditions such as circumscribed anxieties that respond to straight forward reassurance. The remaining mental health conditions may be referred to a psychologist for either further workup and differential diagnosing, or for psychotherapy, pharmacotherapy, or a combination of both. In the case of developmental and academic disorders other than ADHD, referral to a neuropsychologist or psychodiagnostician (clinical, counseling, or school psychologist specializing in psychometrics) is warranted if the condition has not previously been diagnosed. For conditions that stand to benefit from medication or a combination of medication and psychosocial interventions [(e.g., psychoses, OCD, panic disorder, posttraumatic stress disorder (PTSD), major depression, bipolar disorder, and addictions)], a referral to the pharmacologically trained psychologist is particularly indicated. With conditions where medication is not a first-line intervention, which is the case with majority of cognitive, affective, and behavioral conditions, a direct referral to a clinical, counseling, or school psychologist for psychosocial treatment is the appropriate path. A final advantage to integrating condition with treatment is the interplay of medication management with other behavioral techniques. Medication can be conceived of as a behavioral approach and, as such, conforms to the laws of respondent and operant conditioning (Muse, 1984, 2008; Muse & McFarland, 1994). Integrating pharmacotherapy into behavioral treatment paradigms, giving full weight to the reinforcing qualities of medication, can be a powerful alternative to prescribing medication as a univectorial intervention, expected to impact on symptoms in a lineal fashion. Pharmacologically trained psychologists, due to their training in the science of psychology in addition to their training in mental health issues, are in a unique position to assess the role of medication in the therapeutic alliance, and the impact that medication has on the patient’s self-perception. Moreover, the pharmacologically trained psychologist is cognizant of the various reinforcement contingencies that tend to keep different conditions in a state of perpetual balance, and the medical psychologist can bring medications to bear in a way that breaks up the status quo of a condition and promotes new learning through new reinforcement strategies. A case in point is the reinforcing qualities of phobic avoidant behavior. By avoiding the phobic stimulus, the patient receives negative reinforcement, which is a powerful motivator for maintaining the avoidant behavior. The use of a selective serotonin reuptake inhibitor (SSRI) may apparently reduce a phobia by reducing

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anxiety but, in doing so, it acts in much the same way as the avoidant behavior: It allows the patient to escape feelings of anxiety. What is being learned, however, is that medication must be ingested to avoid anxiety and, not surprisingly, many phobias return when medication is stopped (Prasko et al., 2006), with an estimated 50% of social phobias returning when SSRI medication is ­discontinued (Veale, 2003). The medical psychologist is far less inclined to use an anxiolytic in treating a phobia, but would rely primarily on relaxation techniques and gradual hierarchical exposure techniques in order to teach the patient that he or she can withstand some anxiety while in the presence of the feared stimulus, thereby short circuiting avoidance patterns. This sets the stage for new learning and the subsequent reduction of anxiety, as habituation to the trigger stimulus occurs. Such learning is more durable and easily generalized to other fears that the patient might have in the present or future (Dadds, Spence, & Holland, 1997).

Case Study Vignettes The following section highlights pediatric referrals made to medical psychology. The short case summaries are meant to illustrate the utility of the preferential referral to a psychologist with psychopharmacology training, with or without prescriptive authority, for the management of certain types of conditions that warrant the use of pharmacotherapy, usually in combination with psychotherapy.

Attention Deficit The patient was a 15-year-old Hispanic boy who had been failing eighth grade and had been held back twice in the past. His mother, who spoke little English, complained to the pediatrician that the patient is violent in the house and has attacked the father on more than one occasion. On the last such incident, the police intervened and a subsequent investigation by Child Protection Services resulted in the recommendation that the patient seek medical/psychological evaluation. The patient stated to the pediatrician that he does not wish to cooperate with the evaluation and avoided answering her questions. The pediatrician referred the case to a psychologist because of the difficulty in arriving at a differential diagnosis in the limited time allowed within the medical consultation. The psychological evaluation, which required multiple extended visits to engage the youth and to collect information from his family and teachers, confirmed ADHD from early childhood. The condition had gone undiagnosed and the school failure resulted in increased acting out until a true ODD had formed. The patient was placed on Adderall by the medical psychologist, who resided in a state where prescriptive authority exists, and the patient and his family were seen in family therapy conducted in Spanish. The patient’s opposition to treatment dissolved into a collaborative effort. His self-esteem improved as did his grades. His oppositional behavior was mitigated and the beginnings of learned helplessness and depression were averted. The medical

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psychologist kept the pediatrician informed on treatment milestones and the patient was discharged back to his pediatrician at the end of 9 months; the pediatrician assumed medication management of the ADHD once the ODD was resolved.

Psychosis An 18-year-old girl was treated for depression for years with SSRIs with little success before transferring to the care of a new pediatrician, who referred the patient to a medical psychologist for evaluation. The patient’s medication was left unchanged while psychotherapy was initiated. In the course of therapy, the patient slowly revealed a well-developed belief in her ability to communicate with the dead, which entailed auditory and visual hallucinations of specters. The psychologist consulted with the pediatrician and the patient was started on aripiprazole, 10 mg qd, which provided the patient sufficient distancing from her psychosis to begin to address, in insight-oriented psychotherapy, the biochemical nature of her experience. She gradually gained an understanding and awareness of her condition, which eventually led to self-acceptance and a mitigation of her depression, at which time the SSRI was discontinued on the advice of the pharmacologically trained psychologist.

Panic Disorder A 13-year-old girl was referred by her pediatrician for school phobia. She had not gone to school in the last 3 weeks. The medical psychologist discerned the more generalized condition of agoraphobia after the child’s narrative of her first panic attack outside of the house several months earlier. She had suffered a total of three panic attacks in rapid succession, one on her way to the market with her mother and two on her way to school. She was now unwilling to leave the house unless accompanied by a parent. She refused to be separated from the parent and, hence, refused to attend school. Paroxetine was prescribed at 10  mg qd, and the patient was instructed on anxiety tolerance and graded exposure to her fears. The use of an SSRI helped reduce the incident of panic, while behavioral therapy addressed anxiety and its phobic avoidance component. The patient was able to recover her full mobility and to attend school, and paroxetine was gradually reduced 6 months later without any recurrence of panic.

Bipolar/Major Depression The patient was a 17-year-old boy who was newly transferred to the pediatrician from a previous provider; the patient was on Depakote 125 mg bid for a diagnosis of bipolar disorder with anger outbursts. The pediatrician referred the patient to a

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child medical psychologist for the assessment and treatment of mental health concerns, and the psychologist subsequently developed rapport with the patient and over the course of interviews and psychometrics, diagnosed ADHD with ODD, as well as the beginnings of significant depression. The patient was taken off Depakote for, although mood stabilizers are sometimes prescribed to reduce anger outbursts, there is little evidence to support their use in the treatment of anger dyscontrol not associated with bipolar disorder (Fleminger, Greenwood, & Oliver, 2006); while depakote might be useful in mitigating anger or other impulsive outbursts in bipolar patients, its use is best justified in the treatment of bipolar disorder, with any benefit in anger control being secondary to the management of the mood swing. In the present case, the diagnosis of bipolar disorder was not substantiated and the new differential diagnosis argued for a behavioral approach for treating the anger as an outgrowth of ODD and depression. Furthermore, no medication was prescribed for the depressive symptoms as it was decided to wait and see how they developed as the newly diagnosed condition of ADHD was treated. The patient was placed on Adderall ER 10 mg, and behavioral therapy was begun to increase study habits and develop academic mastery. The patient began to experience success and his depressive symptoms remitted. His ODD condition, including anger outbursts, was treated with family therapy in which parents and patient were taught conflict resolution and anger management techniques. The patient’s anger outbursts lessened with treatment and his ODD condition was eventually resolved. The patient was referred back to the pediatrician 12 months later, where his Adderall was managed through pediatric services; a recommendation for periodic behavioral reassessment with the medical psychologist ensured that gains would be maintained as the adolescent transitioned to adulthood.

Addictions The patient was a 16-year-old boy who was brought in by his parents for academic failure and alcohol abuse. The patient’s family was made up of high achievers, with two professional parents and an older brother attending an Ivy League university. The patient was of high average to superior intelligence and had been a straight A student until his first year of high school, when he began to abuse alcohol. At the time of the consultation, he had been caught at school with a fifth of hard liquor and confessed to drinking between a fifth and a quart of vodka daily in between classes. He also occasionally smoked marijuana. A psychological evaluation, including clinical interviews with the patient and his parents, and positive findings on pertinent standardized, normed psychometrics [(e.g., Continuous Performance Test II: CPT II (Conners & Staff, 2000); ADHD Rating Scale-IV (DuPaul et al., 1998); and Behavior Assessment System for Children – Second Edition: BASC II (Reynolds & Kamphaus, 2004))] revealed ADHD, hyperactive type, with poor executive functioning. Teachers had hinted at hyperactivity through the years to the parents, but the mother did not “believe” in the ADHD label.

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Normally, the use of psychoactive medication where there is an addictive p­ otential is an argument against starting stimulant medication, but in this case, Concerta 36  mg q am provided an immediate relief from the “ants running up and down my nerves.” Psychosocial therapy was begun to address family issues with the high-pressure, perfectionist expectations of the parents, and drug/alcohol ­counseling with weekly drug testing was also instituted. The patient’s grades rapidly returned to straight A’s, and he did not abuse alcohol or drugs during a 2-year follow-up. He stated in retrospect that he had been self-medicating his hyperactivity with alcohol and marijuana, which was experienced as egodystonic nervousness. Once the ADHD was mitigated with pharmacotherapy, he no longer felt the need for illicit drugs, and all subsequent drug screens were negative. After family dynamics had been addressed, the patient was allowed to choose an academic path that interested him and he applied his cognitive abilities toward a goal that proved self-motivating. In this case, the medical psychologist resided in a state without prescriptive authority but where the board of psychologists has affirmed that consulting on medication with patients and prescribing professionals is within the competencies of a pharmacologically trained psychologist. The psychologist consulted with the treating pediatrician and medication was managed through periodic communication between the two treating professionals.

Conclusion The majority of mental health concerns do not require the use of psychotropic medication, and even less so in the pediatric population.4 For conditions that do, however, there is an advantage in the coordination of care when the referring physician is able to consult with the treating psychologist on all aspects of therapy, including pharmacotherapy. This interface between medicine and psychology is less than standard practice, but it is more likely to occur between pediatrics and child/adolescent psychology because of the long history of collaboration between these two disciplines. The advent of pharmacologically trained psychologists extends this tradition of collaboration to incorporate pharmacotherapy within established psychosocial approaches for managing mental health issues. The degree of the psychologist’s involvement in direct prescribing is dictated by the jurisdiction in which the patient is treated; nonetheless, even in the jurisdiction where medical psychologists do not write the prescription, pediatricians can effectively manage the psychotropic medication needs of their patients and safely prescribe all classes of medications for the treatment of ADHD, major depressive disorder, bipolar disorder, anxiety disorders, PTSD, psychoses, and addictions when they consult with pharmacologically trained

It is the very rare case, apart from pharmacotherapy of ADHD, which requires medication in the preteen population. Thus, our case studies include teenagers, exclusively.

4 

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psychologists who can assist them with medication selection, dose adjustment, and the monitoring of response and adverse effects, while integrating pharmacotherapy with psychosocial therapeutic interventions. Where psychoactive medication is concerned, both the psychologist and pediatrician should always maintain a collaborative relationship, no matter who the primary prescriber is.

References Bruce, T. J., Spiegel, D. A., & Hegel, M. T. (1999). Cognitive-behavioral therapy helps prevent relapse and recurrence of panic disorder following alprazolam discontinuation: A long term follow up of the Peoria and Dartmouth studies. Journal of Consulting and Clinical Psychology, 67, 151–156. Carol, K. M. (1997). Integrating psychotherapy and pharmacotherapy to improve drug abuse outcomes. Journal of Addictive Behaviors, 22, 233–245. Conners, C. K. (2008). Conners 3rd edition: Manual. North Tonawanda: Multi-Health Systems. Conners, C. K., & Staff, M. H. S. (Eds.). (2000). Conners’ continuous performance test II: Computer program for windows technical guide and software manual. North Tonwanda: Mutli-Health Systems. Dadds, M., Spence, S., & Holland, D. (1997). Prevention and early intervention for anxiety disorders: A controlled trial. Journal of Consulting Clinical Psychology, 65, 627–635. DuPaul, G. J., Power, T. J., Anastopoulos, A. D., & Reid, R. (1998). ADHD rating scale-IV: Checklists, norms, and clinical interpretation. New York: The Guilford Press. Fleminger, S., Greenwood, R. R. J., & Oliver, D. L. (2006). Pharmacological management of agitation and aggression in people with acquired brain injury. Cochrane Database of Systematic Reviews, 4, CD003299. Hatsukami, D. K., & Mooney, M. E. B. (1999). Pharmacological and behavioral strategies for smoking cessation. Journal of Clinical Psychology in Medical Settings, 6, 11–38. Hermann, B., Jones, J., Dabbs, K., Allen, C. A., Sheth, R., Fine, J., et al. (2007). The frequency, complications, and etiology of ADHD in new onset pediatric epilepsy. Brain, 130, 3135–3148. Hohagen, F., Winkelmann, G., Rasche-Rauchle, H., Hand, I., Honig, A., Manchau, N., et al. (1998). Combination of behavior therapy with Fluvoxamine in comparison with behaviour therapy and placebo: Results of a multicenter study. British Journal of Psychiatry, 173, 71–78. McGrath, R. E. (2010). Prescriptive authority for psychologists. Annual Review of Clinical Psychology, 6, 21–47. Muse, M. (1984). Narcosynthesis in the treatment of posttraumatic chronic pain. Rehabilitation Psychology, 29, 113–118. Muse, M. (2008). Convergencia de psicoterapia y psicofamacología: El uso de regímenes conductistas en el manejo de medicamentos psicoactivos. Revista de Psicoterapia, 69, 5–10. Muse, M. (2010). Combining therapies in medical psychology: When to medicate and when not. Archives of Medical Psychology, 1, 19–27. Muse, M., Brown, S., & Cothran-Ross, T. (2010). Psychology, psychopharmacotherapy and pediatrics: When to treat and when to refer. In G. Kapalka (Ed.), Collaboration between pediatricians and pharmacologically-trained psychologists. New York: Springer. Muse, M., & McFarland, D. (1994). The convergence of psychology & psychiatry: The use of behaviorally prescribed medications. Lyon: Second International Congress of Eclectic Psychotherapy. Prasko, J., Dockery, C., Horacek, J., Houbova, P., Kosova, J., & Klaschka, J. (2006). Moclobemide and cognitive behavioral therapy in the treatment of social phobia. A six-month controlled study and 24 months follow up. Neuroendocrinology Letters, 27, 473–481.

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Rae, W., Jensen-Doss, A., Bowden, R., Mendoza, M., & Banda, T. (2008). Prescription privileges for psychologists: Opinions of pediatric psychologists and pediatricians. Journal of Pediatric Psychology, 33, 176–184. Reynolds, C. R., & Kamphaus, R. W. (2004). Behavior assessment system for children – second edition manual. Circle Pines: American Guidance Service Publishing. Rosenheck, R., Tekell, J., Peter, J., Crammer, J., Fontanan, A., Xu, W., et  al. (1998). Does participation in psychosocial treatment augment the benefit of Clozapine? Archives of General Psychiatry, 55, 618–625. Sachs, G. S. (1996). Bipolar mood disorder: Practical treatment strategies for acute and maintenance phase treatment. Journal of Clinical Psychopharmacology, 16, 32S–40S. Sammons, M., & Schmidt, N. (2003). Combined treatments for mental disorders: A guide to psychological and pharmacological interventions. Washington: American Psychological Association. Spalding, W. D., Johnson, D. L., & Coursey, R. D. (2003). Combining treatments and rehabilitation of schizophrenia. In M. Sammons & N. Schmidt (Eds.), Combined treatments for mental disorders: A guide to psychological and pharmacological interventions. Washington: American Psychological Association. Thase, M. E., Greenhouse, J. B., Frank, E., Reynolds, C. F., Pilkonis, P. A., Hurley, K., et al. (1997). Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapy combinations. Archives of General Psychiatry, 54, 1009–1015. Veale, D. (2003). Treatment of social phobia. Advances in psychiatric treatment, 9, 258–264.

Chapter 2

Collaboration Between Pharmacologically Trained Psychologists and Pediatricians: History and Professional Issues Robert E. McGrath

Research demonstrates a substantial shortage in the availability of mental health ­prescribers. Thomas, Ellis, Konrad, Holzer, and Morrissey (2009) estimated that 96% of US counties do not have enough prescribers with specialty training in mental disorders to meet the need. The shortage of psychiatrists in the USA is only likely to worsen in the coming years given declines in the number of physicians pursuing a residency in psychiatry (Rao, 2003). Nowhere is the shortage of mental health prescribers more evident than in the treatment of children and adolescents. Various estimates of the shortage are available. The U.S. Bureau of Health Professions National Center for Health Work Force Information and Analysis concluded that more than 12,500 psychiatrists with specialized training in the treatment of children and adolescents would be needed by 2010 even to match the level of service provided in 1995, but only 8,300 will be available (Kim, 2003). To put this disparity in context, the Bureau of Labor Statistics indicates that there are only about 34,000 psychiatrists in the entire country, so 10% of the entire psychiatric work force would have to shift their specialization to children and adolescents just to meet the need. Others have suggested that the shortage may be far greater than that (Brauer, 2010). It is estimated that approximately 1,500 psychologists across the country have completed postdoctoral training in psychopharmacology (Ax, Fagan, & Resnick, 2009) even though, in the absence of authorization to prescribe, there is little financial incentive for doing so. No information is available on how many of those psychologists specialize in the treatment of children, but given clinical opportunities in psychology one would expect a fair number have had extensive experience working with children. If more states pass prescriptive authority, the number of psychologists who have completed training may start to increase dramatically. Pharmacologically trained psychologists (PTPs) can play an important role in addressing the shortage of appropriate medication management for children and adolescents, whether as independent prescribers or as collaborators with pediatricians on medication decision-making. R.E. McGrath (*) School of Psychology, Fairleigh Dickinson University, Teaneck, NJ 07666, USA e-mail: [email protected] G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_2, © Springer Science+Business Media, LLC 2011

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This chapter addresses several issues relevant to the discussion of collaboration between PTPs and pediatricians. The first section provides a brief outline of the history of the movement to train psychologists in pharmacotherapy. This information is included to provide a context for the subsequent discussion, and also as a resource for readers who are potentially interested in pursuing postdoctoral training in pharmacotherapy. The second section makes the case for using PTPs in the medication management of mental disorders, particularly for children and adolescents. The final section addresses professional issues that are likely to prove prominent in collaborative relationships between PTPs and pediatricians.

A Brief History of a Movement The movement to train psychologists in pharmacotherapy has its origins in a 1981 task force report to the American Psychological Association (APA) Board of Professional Affairs that proposed psychologists should become more involved in the provision of physical and biological interventions for mental disorders. The report concluded that the scope of practice of psychology included physical ­interventions appropriate to healthcare practice and within the practitioner’s scope of competence (APA Board of Professional Affairs, 1981). The report received little attention at the time. Few seem to have recognized that it signaled an important turning point in how the association conceptualized the scope of clinical practice. Where the practice of psychology was traditionally based on whether or not an intervention emerged primarily out of psychosocial theory, the task force report suggested that the scope of practice could be defined in terms of the service needs of the patient. It also reflected the perception that psychologists should be trained to provide healthcare services in the context of the broader biopsychosocial model that was beginning to influence all aspects of the medical system (Engel, 1977). In a 1984 presentation to the Hawaii Psychological Association, Senator Daniel Inouye noted the coming shortfall in the number of mental health prescribers and challenged psychologists to begin the quest to acquire prescriptive authority. By 1989, his challenge was being discussed at the highest levels within APA. The APA Board of Professional Affairs decided to endorse advanced training in psychopharmacology for psychologists. In 1995, the APA Council of Representatives adopted prescriptive authority as one of the association’s goals (Fox, 2003). In 1990, APA organized a task force specifically to discuss psychologists’ involvement and training in pharmacotherapy. The report of this task force (Smyer et al., 1993) had a profound influence on the movement that was to follow. It described three levels of education and training for involvement in pharmacotherapy. Level 1 referred to the level of training that all psychologists involved in health care should receive. Given that a substantial number of individuals whom psychologists see for treatment are using medications (VandenBos & Williams, 2000), even psychologists providing psychotherapy should have some minimal understanding of psychotropic medications, their likely course of action, and common side effects.

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The members of the task force intended Level 1 training to begin during doctoral training, with continuing education afterward. To date, only Georgia has mandated continuing education in psychopharmacology for all licensed psychologists. Level 2 referred to training in preparation for active collaboration with pediatricians and other primary care physicians (PCPs) on medication decision-making, but without actual prescriptive authority. Level 3 referred to training in preparation for the independent authority to prescribe. Levels 2 and 3 required more intensive training and were therefore expected to be offered at the postdoctoral level. APA subsequently sponsored the development of a model curriculum for each of the three levels. The Level 1 curriculum was meant to be covered in a single graduatelevel course (Kilbey et al., 1995). The Level 2 curriculum represented more intensive didactic training in various aspects of psychopharmacology (APA Board of Educational Affairs Working Group on Psychopharmacology Education and Training, 1997), while the Level 3 model curriculum required both didactic and supervised clinical experiences (APA Council of Representatives, 1996). A parallel set of developments was emerging having to do with the founding of training opportunities in pharmacotherapy specifically geared to psychologists. The first was a pilot program funded by the US Congress in 1989 to train Department of Defense psychologists to prescribe. Opposition to the program from physicians slowed its implementation so that the first cohort of the Psychopharmacology Demonstration Project (PDP) did not begin training until 1991. Sammons and Brown (1997) have outlined the evolution of the PDP’s curriculum. The most consistent theme was a gradual reduction in the demands of the program, from one that essentially matched the training of a physician’s assistant or the first 2 years of medical school to one that involved half as many contact hours. Opposition to the program continued unabated, resulting in four independent evaluations (Newman, Phelps, Sammons, Dunivin, & Cullen, 2000), and despite very positive conclusions about the outcomes of the program it was discontinued in 1997. In the private sector, the first training program was offered by the Prescribing Psychologists Register in 1993. Once APA established the Level 3 model curriculum, however, additional programs began to emerge. Other programs currently in operation include those at Alliant International University (starting in 1998), Nova Southeastern University (1999), Southwestern Institute for the Advancement of Psychotherapy and New Mexico State University (1999), Argosy UniversityHawaii Campus (2000), and Fairleigh Dickinson University (2000). At least five other programs were founded but have since either ceased operation or seem to be indefinitely suspended. The APA College of Professional Psychology also began offering the Psychopharmacology Examination for Psychologists (PEP) in 2000 as a competency examination in psychopharmacology for psychologists. These programs were all intended to offer Level 3 training, training in preparation for independent practice as a prescriber. No program has emerged specifically to offer Level 2 training. Instead, the de facto path to preparation for collaboration has become completion of the Level 3 didactic coursework through one of the available programs without participation in a supervised clinical experience.

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As the number of psychologists pursuing Level 3 training increased, a variety of inconsistencies and impracticalities became evident in the model curriculum, particularly concerning the clinical experiences needed to complete the training. As a result, no program was able to comply with the guidelines completely, and another task force was impaneled to revise the model curriculum. The report of that task force has now been adopted as APA policy (APA Council of Representatives, 2009b). One of the recommendations made by the task force was the development of a system for evaluating programs for consistency with the new model. This system was expected to be more demanding than that used for sponsors of continuing education, which are referred to as “approved,” but less demanding than that used for clinical doctoral programs, which are referred to as “accredited.” Accordingly, such programs are to be referred to as “designated,” to avoid confusion with existing levels of program review. Guidelines for designation have now been adopted (APA Council of Representatives, 2009a), and program review began in the summer of 2010. A third thread of developments in the movement to involve psychologists in medication decision-making has to do with enactment of legislation authorizing prescriptive authority in civilian settings. In 1993, the licensing law for psychologists was amended to allow prescriptive authority for psychologists participating in a “federal government sponsored training or treatment program” (Indiana Code 25–33-1–2(c)). To my knowledge, however, no psychologist has yet taken advantage of this authority. In 1999, the U.S. Territory of Guam was the first jurisdiction to award prescriptive authority to any appropriately trained psychologist (Guam Public Law 24-329). Subsequent political struggles over the regulations governing professions in the territory delayed the implementation of the statute for many years. Those issues have finally been resolved, and psychologists from Guam are now completing their training in preparation for becoming prescribers. Guam was followed in 2002 by New Mexico (New Mexico Administrative Code 16.22.2016.22.29) and in 2004 by Louisiana (Louisiana Revised Statutes 37:1360.511360.72). The New Mexico and Louisiana laws were much more detailed than the Guam law, and are similar in terms of their implications for didactic training. The primary difference is that the Louisiana licensing law requires the psychologist to receive a master’s degree in psychopharmacology. Most training programs that remain operational now provide a degree upon completion, though a few still offer a certificate. The New Mexico bill also stipulates a program of at least 450 contact hours, but all current programs are consistent with that requirement. The two state laws differ most in their expectations for supervised clinical experience. Upon completion of the didactic training and passage of a competency examination, usually fulfilled via the PEP, Louisiana psychologists are immediately eligible for licensure as “medical psychologists.” The law does not require a supervised clinical experience. Instead, the psychologist can only prescribe or change a prescription with the concurrence of the patient’s PCP. This represents an unusual relationship: the PCP is not the psychologist’s supervisor, the physician involved may be different for every patient, and the psychologist maintains primary responsibility for psychotropic medication decisions. However, the psychologist cannot act without the agreement of a physician involved in the patient’s care. The law was

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modified in 2009 so that after three incident-free years of prescribing the psychologist can apply for a certificate of advanced practice. This certificate permits the psychologist to prescribe with complete independence. In contrast, after the completion of coursework and the PEP, the New Mexico legislation requires the psychologist to complete an 80-h practicum in clinical assessment and pathophysiology and a 400-h/100-patient practicum under the supervision of a physician. The psychologist is then eligible for a conditional prescribing ­certificate. This is followed by two more years under the supervision of a physician. The psychologist can then apply for a certificate that allows independent prescribing, though there is still a requirement of on-going consultation with the patient’s PCP.

The Case for PTPs in Pediatric Care Prescriptive authority for psychologists has been a topic of extensive debate for almost 20 years. I have provided a lengthy review of the arguments for and against prescriptive authority elsewhere (McGrath, 2010). For the present purposes, I will focus specifically on the question of whether PTPs can and should play a central role in addressing the shortfall in the availability of appropriate medical resources for children and adolescents with mental disorders. The medical community is aware of the shortage of child/adolescent psychiatrists. Physicians have suggested three strategies for improving access to care. Not surprisingly, all three focus primarily on using physicians to fill the gap. Unfortunately, by doing so all three proposals fall short of addressing the real issue. The first proposed solution is telepsychiatry, in which interactions between professionals and patients occur at distance. The most basic vehicle for telepsychiatric consultation is the telephone, though various organizations have been successfully experimenting with videoconferencing via the Internet. The popularity of telepsychiatry is growing, particularly as a means of providing services to children and adolescents without easy access to transportation to mental health facilities (Myers et al., 2010). Physicians have enthusiastically pursued telemedicine in various forms to expand their reach beyond the medical office, and several journals are now devoted exclusively to the discussion of telemedicine. Despite this enthusiasm, telepsychiatry remains a relatively rare phenomenon (Hailey, Ohinmaa, & Roine, 2009). Concerns about reimbursement, the ethical and legal issues associated with distance care (such as communications that cross state lines, and threats to the security of transmissions over the Internet), and the technological obstacles involved in maintaining a teleconferencing system have all hampered the growth of distributed medicine. More specific to the field of psychiatry, service provision at distance may make it easier to treat patients with limited access, but does nothing to offset the shortage of providers. The other two approaches focus on improving PCPs’ ability to identify and treat mental disorders. Most of these efforts involve short-term training programs on the nature and treatment of common mental disorders. In those few cases where

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effectiveness has been evaluated, results have not been promising (Tiemens et al., 1999; Vicente et  al., 2007), perhaps because of limited interest among PCPs in becoming more involved in the provision of mental health care. In response to the limitations of brief training programs, the American Academy of Child and Adolescent Psychiatry has initiated the Post-Pediatric Portal Project, which abbreviates the traditional residency training in psychiatry from 4 to 3 years for pediatric physicians (Brauer, 2010). A recent review of the program indicated that in its first 3 years the program has attracted perhaps a dozen participants, and not all slots have been filled (Brauer). Though the Academy intends to recruit participants more aggressively, it is questionable how many active pediatricians will be willing to commit themselves to a second, if abbreviated, residency in psychiatry. Furthermore, solutions that rely heavily on PCPs providing more mental health care are unlikely to succeed given a growing shortage in PCPs (Lloyd, 2009). Nursing is similarly unlikely to be able to meet the shortfall given that Manderscheid and Henderson (2004) estimated that there were only 18,269 psychiatric nurses in the entire country in 2002. Solutions that rely on PCPs and nurses are probably doomed to fail unless the financial rewards for doing so become substantially greater than the reimbursement system will permit. PCPs provide primary care for individuals with mental disorders primarily because they are unable to access mental health specialty care (Cunningham, 2009). It is not even a role for which they are well-trained, since PCPs often receive no formal training in pharmacotherapy let alone psychopharmacotherapy (Bazaldua et al., 2005). Individuals who are interested in working with individuals with mental disorders pursue training as a psychologist, social worker, or counselor. Of those, psychologists are the only doctoral-level providers, and, therefore, are most likely to be acceptable to PCPs as collaborators in the medication decision-making process. With over 100,000 psychologists involved in health care nationally, the PTP potentially offers the number of practitioners needed to meet the need. Of course, the case for involving PTPs in pediatrics is still weak if the quality of advice (for collaborating PTPs) or direct service (for prescribing PTPs) is poor. Rigorous evidence on the treatment effectiveness of PTPs still needs to be collected. However, it is noteworthy that: 1. Psychologists have now been prescribing in the military for 15 years without a single complaint lodged in their service records. One psychologist, Alan Hopewell, was awarded the Bronze Star in part because of his work prescribing to soldiers with mental disorders. Based on their experiences with graduates of the PDP and the occasional psychologist who pursued training elsewhere and was privileged to prescribe, the Army, Navy, and Air Force have now all adopted regulations allowing for the privileging of prescribing psychologists. 2. Psychologists in New Mexico and Louisiana have written hundreds of thousands of prescriptions without a single complaint or malpractice claim. 3. The change to the Louisiana licensing law allowing for the certificate of advanced practice, prescribing without the approval of a physician, was instituted without opposition from physicians in the state. The lack of evidence of substandard care from prescribing psychologists, despite close scrutiny by physicians, belies any claim that psychologists’ training in

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p­ harmacotherapy is inadequate. Another source of evidence for this conclusion comes from analyses of the training experience psychologists receive. A direct comparison of training hours for programs in medicine, psychology, and psychiatric nursing suggested that psychologists receive far more training in most areas directly relevant to the medication management of mental disorders than members of the other two professions (Muse & McGrath, 2010). A comparison of civilian training programs with the PDP suggested that they are roughly equivalent in most areas (McGrath, 2010). Both analyses suggested civilian Level 3 training programs were comparable or superior to other training models in all content areas except clinical medicine. However, it is important to remember that the psychologist is expected to refer all medical issues to a PCP, so it is unclear whether additional training in clinical medicine would translate into improved patient safety. In fact, there is evidence suggesting that psychiatrists also tend to depend on collaborative ­relationships with PCPs for general medical care. Surveys of psychiatrists indicate that they rarely perform physical examinations, and more than half admitted they either did not feel competent to conduct a general health examination or did not have the facilities for such an examination (Krummel & Kathol, 1987; Patterson, 1978). Still, the large majority of individuals who have completed Level 3 didactic training cannot prescribe; and so at present they are only eligible to collaborate with a prescriber. It is difficult to argue against the value of collaborative relationships between PTPs and pediatricians. In this situation, the physician maintains the ultimate responsibility for medication decision-making, and can accept or reject the advice of the PTP. Theoretically, the outcome of decision-making should be no worse than that of the physician alone, though in reality that would only be the case if humans consistently optimized their decision-making.

Professional Issues in Collaborating with Pediatricians Three distinct contexts have evolved in which psychologists tend to collaborate with PCPs. The first is that in which the psychologist provides psychosocial services for mental disorders while the PCP maintains complete responsibility for all physical and biological interventions. These types of interactions between therapy providers and PCPs have been occurring for years, and Pace, Chaney, Mullins, and Olson (1995) provided a good introduction to the professional issues associated with that context. Another context for psychologist–PCP interactions occurs when the psychologist with expertise in behavioral medicine provides psychosocial services for physical disorders while the physician maintains complete responsibility for parallel physical interventions. A more recent variant of this context involves psychologists working in integrated primary care settings, where a multidisciplinary team led by the PCP offers combined physical and psychosocial services to primary care patients. A number of publications in recent years have discussed the nature of professional relationships in these integrated care settings (Gunn & Blount, 2009; McDaniel & Fogarty, 2009). Collaborations between PCPs and PTPs represent an even more recent ­development in professional relationships between the two disciplines. This context

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occurs when the PTP plays a role in biological interventions for mental disorders, whether as prescribers or collaborators. This section will focus on issues specific to this last context, specifically involving psychologists with advanced training in clinical psychopharmacology. The following comments are presented in light of practice guidelines that have been developed (APA Council of Representatives, 2009c; see Table 2.1) to outline the implications of the APA Ethical Principles of Psychologists and Code of Conduct for psychologists’ involvement in the process of pharmacotherapy. These guidelines were intended to inform the behavior of any psychologist who plays any role in the process of pharmacotherapy. Finally, much of what follows is generally relevant to PTP–PCP relationships, and so will be presented in that context. References to pediatricians will be reserved for those issues that are specific to children and adolescents. The first issue that arises is how such relationships are established. In those states with prescriptive authority there is a legislative mandate to collaborate and consult with the PCP serving the individual; many of the bills that have been drafted to award prescriptive authority to psychologists actually prohibit prescribing unless the patient is also being seen by a PCP. As PCPs become aware of the potential for collaborating with prescribing psychologists, one can assume these relationships will become more formalized. PCPs are already familiar with some psychotropic agents. While less familiar with psychosocial interventions, they also tend to respect the potential for therapy as a healthcare tool. Accordingly, a provider who can deliver both services tends to make a great deal of sense to the PCP. In fact, prescriptive authority may well prove to be the most potent tool for convincing PCPs to recruit psychologists to participate in integrated primary care teams. In many instances where students of psychopharmacology already have strong professional relationships with PCPs, they report that their colleagues are eager for them to reach a point in their training where they can collaborate more effectively even in states without prescriptive authority. The PTP who has not traditionally worked closely with PCPs, however, has to figure out how these new skills can be used to enhance his or her practice. This may require reaching out to PCPs more than in the past. In some cases, these contacts can be confusing to the PCP. Some PCPs, aware of the spread of prescriptive authority even in nondoctoral professions, will be surprised to hear psychologists do not yet have prescriptive authority. Others who are unaware of the movement for prescriptive authority within psychology will have to adjust to perceiving some psychologists as having expertise in biological interventions. Still others tend to categorize psychologists with ancillary professions such as occupational therapy to which the PCP makes referrals, and can be resistant to the idea of active collaboration on primary patient care. Even PTPs who previously had little contact with PCPs and who practice in states without prescriptive authority can present active collaboration as a significant benefit to the PCP. One strategy is to develop a brief brochure that outlines what you can and cannot do, and describes how your services can enhance the PCP’s practice. The ability to present a certificate or even a master’s degree in clinical psychopharmacology carries with it a distinctive level of qualification to work effectively with physicians.

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Table  2.1  American Psychological Association practice guidelines regarding psychologists’ involvement in pharmacological issues Relevant Activities Providing Prescribing Collaborating Information General Guideline 1. Psychologists are encouraged to X X X consider objectively the scope of their competence in pharmacotherapy and to seek consultation as appropriate before offering recommendations about psychotropic medications. X X X Guideline 2. Psychologists are urged to evaluate their own feelings and attitudes about the role of medication in the treatment of psychological disorders, as these feelings and attitudes can potentially affect communications with patients. X X Guideline 3. Psychologists involved in prescribing or collaborating are sensitive to the developmental, age and aging, educational, sex and gender, language, health status, and cultural/ethnicity factors that can moderate the interpersonal and biological aspects of pharmacotherapy relevant to the populations they serve. Education Guideline 4. Psychologists are urged to identify a level of knowledge concerning pharmacotherapy for the treatment of psychological disorders that is appropriate to the populations they serve and the type of practice they wish to establish, and to engage in educational experiences as appropriate to achieve and maintain that level of knowledge. Guideline 5. Psychologists strive to be sensitive to the potential for adverse effects associated with the psychotropic medications used by their patients. Guideline 6. Psychologists involved in prescribing or collaborating are encouraged to familiarize themselves with the technological resources that can enhance decision-making during the course of treatment. Assessment Guideline 7. Psychologists with prescriptive authority strive to familiarize themselves with key procedures for monitoring the physical and psychological sequelae of the medications used to treat psychological disorders, including laboratory examinations and overt signs of adverse or unintended effects.

X

X

X

X

X

X

X

X

X

(continued)

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Table 2.1  (continued) Relevant Activities Providing Prescribing Collaborating Information Guideline 8. Psychologists with prescriptive authority regularly strive to monitor the physiological status of the patients they treat with medication, particularly when there is a physical condition that might complicate the response to psychotropic medication or predispose a patient to experience an adverse reaction. Guideline 9. Psychologists are encouraged to explore issues surrounding patient adherence and feelings about medication. Intervention and Consultation Guideline 10. Psychologists are urged to develop a relationship that will allow the populations they serve to feel comfortable exploring issues surrounding medication use. Guideline 11. To the extent deemed appropriate, psychologists involved in prescribing or collaboration adopt a biopsychosocial approach to case formulation that considers both psychosocial and biological factors. Guideline 12. The psychologist with prescriptive authority is encouraged to use an expanded informed consent process to incorporate additional issues specific to prescribing. Guideline 13. When making decisions about the use of psychological treatments, pharmacotherapy, or their combination, the psychologist with prescriptive authority considers the best interests of the patient, current research, and when appropriate, the needs of the community. Guideline 14. Psychologists involved in prescribing or collaborating strive to be sensitive to the subtle influences of effective marketing on professional behavior and the potential for bias in information in their clinical decisions about the use of medications. Guideline 15. Psychologists with prescriptive authority are encouraged to use interactions with the patient surrounding the act of prescribing to learn more about the patient’s characteristic patterns of interpersonal behavior.

X

X

X

X

X

X

X

X

X

X

X

X

X

X

(continued)

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Table 2.1  (continued) Relevant Activities Providing Prescribing Collaborating Information Relationships Guideline 16. Psychologists with prescriptive X authority are sensitive to maintaining appropriate relationships with other providers of psychological services. X X X Guideline 17. Psychologists are urged to maintain appropriate relationships with providers of biological interventions. Note: Copyright © 2009 by the American Psychological Association. Reproduced with permission

However, brochures are easily discarded, and personal contact is essential to establishing relationships. One student of mine asked to speak at a local association of pediatricians for 30 min. He ended up answering questions for more than 3 h, and within 2 days had received several new referrals. Guideline 17 in Table  2.1 urges psychologists at all levels of involvement in ­psychopharmacotherapy to maintain appropriate relationships with prescribers. There are a number of issues that are relevant to such relationships. The collaboration between PTP and PCP is very different than the traditional relationship where ­psychologists are only directly involved in psychosocial care for mental disorders. The latter relationship is often limited to information sharing, with medical management and psychotherapy proceeding in parallel. Occasionally the psychologist may believe that it is important to raise questions about the medical treatment with the patient or the PCP, but the psychologist’s role is usually minimal. The PTP–PCP relationship requires a greater level of interaction and collegial dialog. This is particularly true of the prescribing psychologist, for whom physicians treating the patient are an essential source of information about current medical status and drug regimen. Similarly, the PCP and other physicians should be aware of the psychologist’s treatment regimen. Regular communication about what drugs the patient is taking represents an essential component of competent care. For the collaborating PTP, the psychologist is serving as a consultant to the PCP about drug choices, evaluating the patient and providing recommendations to the PCP about medication. The PTP needs to be clear about the specificity of the information desired by the PCP. The latter may be interested in diagnostic information, a conclusion about whether medication is warranted, what class of medications to use, or even a specific recommendation about what to prescribe and in what dosage. If the patient is seen by the PTP for psychotherapy, the collaborating psychologist may also become the professional who is primarily responsible for monitoring patient participation in the treatment, patient understanding of the treatment, side effects, patient reactions to the medication, and effectiveness. When the patient is a child, and parents play a particularly important role in the medication regimen, the PTP can regularly gather such data from all participants in the treatment. This is information

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that must regularly be fed back to the PCP. Reactions to the medication and family patterns surrounding the medication regimen can provide insight into psychosocial issues to be addressed through the combination of pharmacotherapy and psychotherapy. Relationships between the PTP and PCP can become tricky. There are several factors that can easily cause the PCP to experience discomfort with a PTP. Gruber (2010) noted that the psychologist’s failure to use appropriate medical terminology or lack of understanding of how primary care settings function can sometimes cause physicians to devalue what the psychologist has to offer. For PTPs specializing in the treatment of children, familiarity with the practice parameters generated by the American Academy of Child and Adolescent Psychiatry (available at www. aacap.org/cs/root/member_information/practice_information/practice_parameters/ practice_parameters) represents an essential resource when justifying the recommendations one makes to pediatricians. More generally, psychologists and PCPs tend to approach illness in different ways. LeVine and Foster (2010) have recently suggested the term “psychobiosocial” to distinguish the psychological model of disease and treatment from the biopsychosocial perspective common among providers who come from a more traditional medical background. Psychologists must be sensitive to the relative importance psychologists and other therapists assign to contextual and situational factors versus symptom relief, and speak to PCPs in a manner that is likely to enhance rather than complicate collaborations. Some physicians may perceive the psychologist as potentially undermining their authority. The American Academy of Pediatrics and other primary care associations have been advancing the concept of a “medical home,” using PCPs as the coordinators of all healthcare services (American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, 2007). This perception of the PCP as the leader of the treatment team is further reinforced by the gate-keeping functions PCPs are often required to play in managed care plans. The PCP who refers a patient either to a prescribing or collaborating PTP may be assuming that some form of biological intervention is warranted. A response recommending psychosocial intervention alone can create conflict. Compounding the issues for some PCPs is suspicion of nonphysicians in general, and mental health professionals in particular, providing recommendations about the treatment plan. Yet another factor that can place the relationship at risk has to do with differences in scientific training. Many physicians have had very little training in scientific method and can be overly accepting of simplified conclusions and anecdotal evidence. Such an attitude can be especially dangerous given efforts by pharmaceutical companies to present research results in the most positive light possible. A PCP who regularly expresses enthusiasm to the PTP about some new medication only to hear expressions of skepticism from the PTP may well come to think of the PTP as simply negativistic and begin to limit those communications. Rather than responding immediately when confronted with excessive enthusiasm for a new treatment regimen, the PTP is better served by offering to research the matter further and replying

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to the PCP with a summary of what the research has to say, with references. Even if not trained in science, physicians respect it. The PTP who can provide and summarize research offering in a more nuanced perspective can enhance patient care, and perhaps even raise the PCP’s esteem for what the ­psychologist has to offer. The collaborating psychologist must always remember that final decisions about medication – and the legal implications of those decisions – are the responsibility of the physician alone. In fact, it is recommended that psychologists who formally collaborate with prescribers from other professions make the limitations of their authority explicit in the informed consent process with the patient. The collaborating PTP need not always agree with the decision, but the PTP has to accept it. This can be particularly difficult when the patient disagrees with the PCP’s decision. Even when addressing or helping the patient address concerns about the PCP’s treatment decision, the PTP should remain respectful of the PCP’s role in the process. Finally, it is important for the psychologist to keep in mind that psychosocial intervention can be a more expensive alternative to generic medications, and beyond the financial resources of many primary care patients. Another complicating factor for the collaborating PTP is potential ambiguity in the legal status of providing input to physicians on medication decision-making. Fourteen boards of psychology have generated opinions or clarifications indicating that consultation on medications (Level 2) is within the scope of practice of psychology: California, District of Columbia, Florida, Louisiana (for psychologists without prescriptive authority), Maine, Massachusetts, Missouri, New Hampshire, New Jersey, New York, Ohio, Oklahoma, Tennessee, and Texas. These statements are available on-line at www.rxpsychology.com/State_Opinions_on_ Consultation.pdf. The board statements vary in their particulars. In some instances, it is implied that only psychologists can monitor the medication. In others, psychologists are explicitly permitted to discuss medications with the patient’s physician, and in others, direct discussion with the patient is mentioned. None of the statements restricted such consultations to psychologists with postdoctoral training in ­psychopharmacology, but several noted that the psychologist should not discuss matters beyond his or her understanding of the medications involved. Given the differences, the psychologist in one of these jurisdictions should be familiar with the state board’s statement. On the other hand, several states – including Connecticut, Maryland, Illinois, Colorado, Minnesota, and Virginia – have passed legislation prohibiting school personnel from recommending the use of psychotropic medications (Bentley & Collins, 2006), and this would include any psychologist in the context of employment by a school. Psychologists who discuss medication decision-making with their patients in other settings where the authority for such discussions have not been officially approved or denied should be aware that the legal implications of doing so are ambiguous. Where there is ambiguity, the psychologist hoping to collaborate with physicians may well consider requesting a similar clarification from their board. Given the differences in the existing board opinions, such a request should specifically ask for (1) verification that the scope of practice of psychology includes on-going

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monitoring of the medication and its side effects, discussing medications with the patient, and recommendations to the prescriber; and (2) an indication that the psychologist is responsible for evaluating the limits of his or her competence to engage in such activities as per Guideline 1 in Table 1. Providing previous statements from other boards may help make the case that such an opinion is warranted, and help shape the opinion so it is consistent with the existing examples. It is unknown whether any psychologist has ever been penalized for rendering opinions on issues of medication management, though the fact that no such cases have ever come to light would suggest such cases may not exist. I would argue that it would be difficult to make such a case for two reasons. First, in the absence of prescriptive authority a recommendation from a psychologist to a prescriber is legally no different than the patient asking for a specific medication based on advertising or other sources of information. Second, all healthcare providers are expected to operate in what they see as the best interests of the patient. A final issue that sometimes arises in collaborative relationships is confusion for insurers and health facilities about how to handle the billing of psychologists as consultants on medication issues. It is best to consider such consultation as an aspect of psychotherapy and use codes that these entities already associate with psychologists. In fact, open discussion of feelings about the medication and physical reactions has a therapeutic value, as many patients prescribed psychotropic medications have never had the experience of talking with their prescriber about the medication.

Case Example: Childhood Bipolar Disorder Despite these concerns, the PTP whose judgment is trusted by the PCP can play an extremely important role as a foil to treatment as usual. The PTP’s greater understanding of the diagnosis of mental disorders, contextual factors in treatment, and treatment alternatives can allow for a unique perspective on the patient. In particular, the PTP can be a useful brake on efforts to medicate the child when medication is not the best option. The biological training of the physician is not the only factor that can contribute to excessive faith in the use of medications. Parents often prefer a biological explanation for their child’s behavioral problems because medication implies the potential for a quick fix, an implication reinforced by direct-to-consumer advertising; or because it reduces any concerns that the child’s problems reflect their failure to parent effectively. This is not to suggest psychologists will be immune to social influence, but to the extent that PTPs can be trained to apply their scientific training to information about drugs they may be able to reduce reliance on medication. This can be an important role, particularly in the case of children and adolescents. Many medications have never been studied in juvenile patients, and standard practice often involves simple extrapolation from treatment guidelines with adults. The long-term effects of many medications on the developmental process are

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unknown. An even more disturbing trend is the growing rate of polypharmacy in adolescents (Mclntyre & Jerrell, 2009) though even less is known about whether psychotropic medications have interactive effects on the developing individual. A useful example of the problems with the existing system of medication management for children and adolescents is offered by the recent explosion in the number of children diagnosed with bipolar disorder. Once considered a very rare disorder, the number of children diagnosed with bipolar disorder and prescribed appropriate medications has exploded in recent years (Carlson, 2005). Though part of this increase is attributable to changes in diagnostic criteria (Geller & Luby, 1997), Frances (2010) discussed it as an example of a “fad” diagnosis. He speculated that a diagnosis comes into vogue when it is associated with a pressing need, it generates compelling stories, and influential advocates publicize that story. In the case of childhood bipolar disorder, the diagnosis was a handy explanation for behavioral problems, one that came with an accepted method of treatment. A particularly insidious part of the process involved advocates for the diagnosis noting that because children with a family history of bipolar disorder demonstrate a wide array of symptoms, childhood bipolar disorder could not be identified using necessary or sufficient conditions. Instead, lengthy lists of “typical” symptoms were developed without any guidance about how many symptoms needed to be present for the diagnosis (Carlson, 2005). As a result, a large proportion of the child/adolescent population became eligible for diagnosis with a bipolar disorder in the absence of any evidence of mania or a family history of bipolar disorder. The availability of medication with proven effectiveness for the treatment of bipolar disorder in adults was an essential contributor to the fad. Many children were prescribed mood stabilizers and antipsychotics despite significant questions about whether children without mania reflect a syndrome that is continuous with adult bipolar disorder, a lack of research on the use of these medications with children, and an absence of information about their impact on child or adolescent development. It seems the phenomenon of the fad diagnosis is particularly prevalent in children, with attention deficit hyperactivity disorder most recently filling the role before childhood bipolar disorder. This makes some sense: parents are eager to find a solution for their children’s behavioral problems, diagnoses are often imposed on children without their collaboration or consent, and it is tempting to generalize treatment information that is clearly true for adults to children. However, a mental health provider who has a clear understanding of the diagnostic nosology of mental disorders and why that nosology relies on necessary and sufficient conditions rather than symptom lists (an approach rejected in academic psychiatry with the third edition of the diagnostic manual), demonstrates a sense of scientific skepticism about conclusions drawn on the basis of insufficient information, and is familiar with psychosocial alternatives to medication should be a more cautious consumer of information than the PCP. At the least, the psychologist can raise important questions about the irrational exuberance often demonstrated over mental disorders and their treatment via medication.

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Conclusions There is an important role for the psychologist who has received advanced training in pharmacology to play in the treatment of mental disorder in pediatric settings. There are significant obstacles to be addressed, including providers and healthcare settings that are uncomfortable or unfamiliar with psychologists as collaborators in medication decision-making, psychologists’ lack of understanding of the primary care setting, and the potential for competition or conflict between PCP and PTP. That being said, the PTP also has much to offer. In the case of the prescribing psychologist, these benefits are often obvious to the PCP, in that the psychologist removes the burden of treating mental disorders from the PCP completely. In the case of the collaborating psychologist, the benefits are not quite as clear but can still be made evident to most PCPs. Depending upon the PCP’s comfort with the PTP, the PTP can still take on much of the burden of treatment with the one exception of writing the prescription. If the patient is also in therapy with the PTP, the PTP can take responsibility for the on-going monitoring of the patient’s pharmacotherapy. Often, this model can also allow the family to be more honest about compliance with the prescription. As the number of psychologists with advanced training in psychopharmacology increases, the role of the psychologist in the relationship with the pediatrician or other PCP will inevitably change. Once members of a profession are trained in a skill, they begin to use that skill. As PCPs realize the benefits of working collaboratively with PTPs, greater collaboration will take place. Collaborative relationships of the type described in this chapter can benefit the patient, through a better standard of care; the PCP, who is relieved of at least some of the burden of treating disorders for which he or she is poorly prepared; and the psychologist, who experiences increased opportunities as a provider.

References American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association. Joint principles of the patient-centered medical home. (2007) Downloaded June 22, 2010 from http://www.acponline.org/advocacy/ where_we_stand/medical_home/approve_jp.pdf. American Psychological Association Board of Educational Affairs Working Group on Psychopharmacology Education and Training. (1997). Curriculum for Level 2 training in psychopharmacology: Curriculum for psychopharmacological training for particular populations using a collaborative practice model. Washington, DC: American Psychological Association. American Psychological Association Board of Professional Affairs. (1981). Task force report: Psychologists’ use of physical interventions. Washington, DC: American Psychological Association. American Psychological Association Council of Representatives. (1996). Recommended postdoctoral training in psychopharmacology for prescription privileges. Washington, DC: American Psychological Association Council of Representatives.

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American Psychological Association Council of Representatives. (2009a). American Psychological Association policies and procedures for the designation of postdoctoral education and training programs in psychopharmacology in preparation for prescriptive authority. Washington, DC: American Psychological Association Council of Representatives. American Psychological Association Council of Representatives. (2009b). American Psychological Association recommended postdoctoral education and training program in psychopharmacology for prescriptive authority. Washington, DC: American Psychological Association Council of Representatives. American Psychological Association Council of Representatives. (2009c). Practice guidelines regarding psychologists’ involvement in pharmacological issues. Washington, DC: American Psychological Association Council of Representatives. Ax, R. K., Fagan, T. J., & Resnick, R. J. (2009). Predoctoral prescriptive authority training: The rationale and a combined model. Psychological Services, 6, 85–95. Bazaldua, O. V., Ables, A., Dickerson, L., Hansen, L., Hoehns, J., Harris, I., et  al. (2005). Suggested guidelines for pharmacotherapy curricula in family medicine residency training: Recommendations from the Society of Teachers of Family Medicine Group on Pharmacotherapy. Family Medicine, 37, 99–104. Bentley, K. J., & Collins, K. S. (2006). Psychopharmacological treatment for child and adolescent mental disorders. In C. Franklin, M. B. Harris, & P. Allen-Meares (Eds.), The school services sourcebook: A guide for school-based professionals (pp. 15–30). New York: Oxford University Press. Brauer, D. (2010). Pilot program aims to combat shortage of child and adolescent psychiatrists. Medscape Medical News. Downloaded June 21, 2010, from http://www.medscape.com/ viewarticle/722981. Carlson, G. A. (2005). Early onset bipolar disorder: Clinical and research considerations. Journal of Clinical Child and Adolescent Psychology, 34, 333–443. Cunningham, P. J. (2009). Beyond parity: Primary care physicians’ perspectives on access to mental health care. Health Affairs, 28, w490–w501. Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136. Fox, R. E. (2003). Early efforts by psychologists to obtain prescriptive authority. In M. T. Sammons, R. U. Paige, & R. F. Levant (Eds.), Prescriptive authority for psychologists: A history and guide (pp. 33–45). Washington, DC: APA. Frances, A. (2010). Psychiatric diagnosis gone wild: The “epidemic” of childhood bipolar disorder. Psychiatric Times. Downloaded June 25, 2010 from http://www.psychiatrictimes.com/ blog/couchincrisis/content/article/10168/1551005. Geller, B., & Luby, J. (1997). Child and adolescent bipolar disorder: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1168–1176. Gruber, A. (2010). Psychologists in primary care. In R. E. McGrath & B. A. Moore (Eds.), Pharmacotherapy for psychologists: Prescribing and collaborative roles (pp. 193–226). Washington, DC: APA. Gunn, W. B., Jr., & Blount, A. (2009). Primary care mental health: A new frontier for psychology. Journal of Clinical Psychology, 65, 235–252. Hailey, D., Ohinmaa, A., & Roine, R. (2009). Limitations in the routine use of telepsychiatry. Journal of Telemedicine and Telecare, 15, 28–31. Kilbey, M. M., Bourg, E. F., Brown, R. T., Coursey, R. D., France, C., Johnson, D. L., et al. (1995). Final report of the BEA Working Group to develop a Level I curriculum for psychopharmacology education and training. Washington, DC: American Psychological Association Board of Educational Affairs. Kim, W. J. (2003). Child and adolescent psychiatry workforce: A critical shortage and national challenge. Academic Psychiatry, 27, 277–282. Krummel, S., & Kathol, R. G. (1987). What you should know about physical evaluations in psychiatric patients: Results of a survey. General Hospital Psychiatry, 9, 275–279. LeVine, E., & Foster, E. (2010). Integration of psychotherapy and pharmacotherapy by prescribing/ medical psychologists: A psychobiosocial model of care. In R. E. McGrath & B. A. Moore

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(Eds.), Pharmacotherapy for psychologists: Prescribing and collaborative roles (pp. 126–142). Washington, DC: APA. Lloyd, J. (2009). Doctor shortage looms as primary care loses its pull. USA Today. Downloaded June 21, 2010 from http://www.usatoday.com/news/health/2009-08-17-doctor-gp-shortage_N. htm. Manderscheid, R. W., & Henderson, M. J. (2004). Mental health, United States, 2002. Rockville, MD: US Department of Health and Human Services. McDaniel, S. H., & Fogarty, C. T. (2009). What primary care psychology has to offer the patientcentered medical home. Professional Psychology: Research and Practice, 40, 483–492. McGrath, R. E. (2010). Prescriptive authority for psychologists. Annual Review of Clinical Psychology, 6, 21–47. Mclntyre, R. S., & Jerrell, J. M. (2009). Polypharmacy in children and adolescents treated for major depressive disorder: A claims database study. Journal of Clinical Psychiatry, 70, 240–246. Muse, M., & McGrath, R. E. (2010). Training comparison among three professions prescribing psychoactive medications: Psychiatric nurse practitioners, physicians, and pharmacologicallytrained psychologists. Journal of Clinical Psychology, 66, 96–103. Myers, K. M., Stoep, A. V., McCarty, C. A., Klein, J. B., Palmer, N. B., Geyer, J. R., et al. (2010). Child and adolescent telepsychiatry: Variations in utilization, referral patterns and practice trends. Journal of Telemedicine and Telecare, 16, 128–133. Newman, R., Phelps, R., Sammons, M. T., Dunivin, D. L., & Cullen, E. A. (2000). Evaluation of the Psychopharmacology Demonstration Project: A retrospective analysis. Professional Psychology: Research and Practice, 31, 598–603. Pace, T. M., Chaney, J. M., Mullins, L. L., & Olson, R. A. (1995). Psychological consultation with primary care physicians: Obstacles and opportunities in the medical setting. Professional Psychology: Research and Practice, 26, 123–131. Patterson, C. W. (1978). Psychiatrists and physical examinations: A survey. American Journal of Psychiatry, 135, 967–968. Rao, N. R. (2003). Recent trends in psychiatry residency workforce with special reference to international medical graduates. Academic Psychiatry, 27, 269–276. Smyer, M. A., Balster, R. L., Egli, D., Johnson, D. L., Kilbey, M. M., Leith, N. J., et al. (1993). Summary of the report of the Ad Hoc Task Force on Psychopharmacology of the American Psychological Association. Professional Psychology: Research and Practice, 24, 394–403. Sammons, M. T., & Brown, A. B. (1997). The Department of Defense Psychopharmacology Demonstration Project: An evolving program for postdoctoral education in psychology. Professional Psychology: Research & Practice, 28, 107–112. Thomas, K. C., Ellis, A. R., Konrad, T. R., Holzer, C. E., & Morrissey, J. P. (2009). County-level estimates of mental health professional shortage in the United States. Psychiatric Services, 60, 1323–1328. Tiemens, B. G., Ormel, J., Jenner, J. A., van der Meer, K., van Os, T. W. D. P., van den Brink, R. H. S., et al. (1999). Training primary-care physicians to recognize, diagnose and manage depression: Does it improve patient outcomes? Psychological Medicine, 29, 833–845. VandenBos, G. R., & Williams, S. (2000). Is psychologists’ involvement in the prescribing of psychotropic medication really a new activity? Professional Psychology: Research and Practice, 31, 615–618. Vicente, B., Kohn, R., Levav, I., Espejo, F., Saldivia, S., & Sartorius, N. (2007). Training primary care physicians in Chile in the diagnosis and treatment of depression. Journal of Affective Disorders, 98, 121–127.

Part II

Collaboration with Pediatricians in Specific Settings

Chapter 3

The Clinical Experience of RxP-Trained Psychologists Working in Non-RxP States Thomas M. Kozak and Andrea Kozak Miller

The purpose of this chapter is to describe the clinical experiences of psychologists who have completed prescription privilege (RxP) training and who practice in states still awaiting the passage of prescription privilege legislation for psychologists. The vignettes used are a compilation of examples experienced by many clinicians from several states in this category. To insure confidentiality, anonymity was preserved. However, the material represents real cases and is used to demonstrate how RxP training improves and enriches the therapeutic work of practicing psychologists. While psychologists with RxP training service patient of all ages, this chapter will focus on pediatric cases.

RxP Training Since the inception of the Department of Defense (DoD) Prescribing Psychologist Demonstration Project in 1991, over 80 psychologists obtained prescription privileges in the United States and currently practice in New Mexico and Louisiana, and in the military. The first class of the DoD Project graduated in 1994, with actual prescribing beginning in 1993 and fully independent prescribing commencing in 1994 (Dittman, 2003; Lavoie & Barone, 2006; Stambur, 2006). Currently, there are some 1,500 psychologists in the United States who have completed the coursework required in RxP training (Ax, Fagan, & Resnick, 2009), and some estimate that over 2,200 may have completed the training to date (Samuel Feldman, 2010, personal communication). As more psychologists complete the training, psychologists introduce legislation in many states with the goal of allowing RxP-trained psychologists to prescribe psychotropic medications.

T.M. Kozak (*) Private Practice, The Woodlands, TX, USA e-mail: [email protected] G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_3, © Springer Science+Business Media, LLC 2011

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The Importance of Training in Psychopharmacology Regardless of whether or not psychologists prescribe, they should be proficient in psychopharmacology in order to best serve their patients and clients (Barnett & Neel, 2000). Medications are part of many empirically based treatments for psychological/psychiatric disorders (Norfleet, 2002) and, therefore, current and up-to-date training about their usage and side effects is essential. Training in psychopharmacology is available at a variety of levels, from continuing education courses to postdoctoral certification and Master’s degrees. When psychologists complete such training, they use their knowledge base from their prior psychological training and knowledge and subsequently build upon it while completing postdoctoral certificate and Master’s programs (Norfleet).

The Utility of Prescription Privileges Psychologists often practice in underserved or rural areas in which there is little access to affordable health care. Psychologists with prescription privileges are able to care for patients and clients in these underserved areas – for example, military personnel and veterans, residents of rural areas, and prison inmates – that may even extend to Canada (Ax et al., 2008; Norfleet, 2002). It has been suggested that changes in the health-care system call for changes in psychologists in order to meet the needs of society. Psychologists who prescribe deliver cost-effective services, since therapy and medication management are performed in the same session (Norfleet). Moore and McGrath (2007) discussed the difficulty of providing psychiatric care in the military, specifically in Iraq, where nonspecialist practitioners (such as physicians and nurses) prescribe the vast majority of medications for individuals with psychiatric disorders. In such settings, psychologists are asked by primary care providers to recommend medications to treat the psychiatric symptoms. Moore and McGrath suggested that psychiatric medications be used instead of proven psychological interventions because of restricted access to care, and recommended that psychologists in the military should be trained in psychopharmacology in order to better meet the needs of the soldiers. In addition to expanding their knowledge base, psychologists are motivated to complete RxP training for a variety of reasons – for example, for ensuring that any state seeking privileges will have a sufficient supply of RxP-trained psychologists “ready to go,” and waiting for legislation to pass (Dittman, 2003). In a brief survey of those enrolled in RxP training programs, many psychologists reported that they decided to enroll in the extensive training programs and bear the significant cost even though they were close to retirement and practiced in states without imminent RxP legislation pending, (from RxP enrollment Texas Oklahoma Prescribing Psychologists Register data forms). One psychologist who worked in the schools described her motivation as follows: “We have so many school children on medications, we think it’s important to know exactly what is going on. After all, we are charged with helping to plan their educational experience and provide the social/emotional environment best suited to their needs.”

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That psychologist’s dedication to a training program to develop an in-depth ­understanding of the pharmacokinetics and pharmacodynamics of various medications was clearly evident. The ability to assist students, even though the likelihood of prescribing in a school setting is remote, demonstrates the spirit of psychologists in this endeavor. Such is the general theme that guides psychologists through RxP training – to enhance treatment effectiveness significantly even in non-RxP states.

Viewpoints Opposed to RxP Not all psychologists are in favor of prescription privileges. Some are concerned about a potential decrease in collaboration with physicians and a decrease in referrals (Bush, 2002; Lavoie & Barone, 2006). Research results, however, suggest that knowledge of psychopharmacology improves collaboration with physicians (including psychiatrists), and collaborating psychologists help physicians become more knowledgeable about psychological services and help provide comprehensive care to mutual patients (Lavoie & Barone). Some psychologists are concerned that obtaining training in psychopharmacology may lead to the loss of commitment to psychological interventions, with shifting away from therapy and toward medication management, as has happened in psychiatry (McGrath et al., 2004). However, the training of psychologists still focuses primarily on psychotherapeutic interventions, so most psychologists are likely to continue to prefer to rely on psychological techniques, even after they have completed RxP training, and very few are likely to favor the use of medications.

General Consensus Not all psychologists are in agreement about obtaining prescription privileges (e.g., Bush, 2002), and the issue continues to spark some debate. However, in psychology, there is general agreement about the importance of training in psychopharmacology in order to provide competent and comprehensive care to the patients and clients (Barnett & Neel, 2000; Norfleet, 2002). In other words, psychologists are encouraged to pursue this training in order to enhance their current practice, regardless of whether they plan to pursue prescriptive privileges or work in a state that allows psychologists to prescribe.

Collaboration with Physicians Collaboration between psychologists and physicians is indispensible to provide comprehensive care to individuals. This collaboration is beneficial to both patients and providers, and encourages the focus on both the mind and the body as ­important

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in psychological functioning (McDaniel, 1995; Pace, Chaney, Mullins, & Olson, 1995). The biopsychosocial model frames this mind–body connection (Tovian, 2006) and encourages layered care (which is especially relevant to managed care),  where the patient is provided a number of treatment options in order to ­individualize the treatment plan. Effective collaboration between a psychologist and a ­physician promotes such a process (Arthur, 2005).

Building Relationships with Physicians Building relationships with physicians takes time. Some suggest that psychologists should work as part of a primary care medical team (Gunn & Blount, 2009). In such an arrangement, collaboration between the psychologist and the physician generally reduces the amount of time the patient spends in care. While implementing this model is not always possible, contacting physicians nearby (or even in the same building) can help build collaboration (Pace et  al., 1995; Tovian, 2006). When developing a relationship with a physician, a psychologist may also consider which managed care plans are accepted by the physician and try to become a member of those panels. To increase opportunities for collaboration, psychologists may consider targeting particular services or areas of specialty (Pace et al., 1995). Once collaboration has begun, staying in touch through thank you letters (for the referral), progress reports, and termination letters will help keep the communication flowing (Gunn & Blount, 2009). A psychologist may also keep track of the collaboration in a progress note and/or by using a tracking system. From a physician’s point of view, collaboration is promoted by the psychologist’s rapport, reputation, competence, and feedback, and by gaining knowledge of the psychologist’s treatment approach (Kainz, 2002). If the physician has a good working relationship with the psychologist and is familiar with his/her treatment style, the physician is then better able to discuss the services to be provided to the patient being referred. Some barriers to collaborating with psychologists may include high out-of-pocket expenses for patients, being unable to schedule an appointment for the patient, and losing track of the psychologist’s treatment of the patient (Kainz). Case #1 A parent complains her youngster has reverted back to his old irritable, depressed behavior, and that the antidepressant medication (sertraline) is a “waste of time” and is not effective. In fact, the mother points out that her son had even become worse over the last few days. In a quickly scheduled interview with the youngster, the psychologists finds that the boy has “not taken his pills for a couple of days.” “How many days?” queries the psychologist. “Four,” the young patient indicates. “My mom forgot to give it to me and then we ran out

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and she didn’t get a new prescription.” Further investigation reveals that the mother counted on her ex-husband to renew the prescription as she felt she should not have to spend the money.

Digging a little deeper, the psychologist learns that the boy had missed his medication longer than the mother knew. In this case, the psychologist was able to remind the mother that antidepressants are to be taken as prescribed, must not be withdrawn rapidly in the majority of cases, and that her son may be experiencing a discontinuation syndrome (Warner, Bobo, Warner, Reid, & Rachal, 2006) accounting for his new irritability. In this case, a supportive grandmother was enlisted, with permission, to monitor the administration of the medications. This situation also revealed what any competent and experienced psychologist knows very well – complicated family dynamics play an important part in the child’s behavior. Family sessions and work with both parents were needed to establish effective compliance with medication protocols. Of course, parental resentments, past conflicts, and unsettled expectations must also be addressed in such a case. Not only does the psychologist have to help solve these interfamilial conflicts, but he or she will also have to psychoeducate the parents effectively about the pharmacology of antidepressant medications and the need for consistent compliance. In this example, the complaint about the medication “not working” and the mother’s furtive call to the pediatrician with the same complaint were misleading. Following up with the pediatrician, to give valuable feedback about medication compliance, improves cooperation and strengthens the collaboration. Completion of an RxP training program allows the psychologist to acquire the formal language and in-depth knowledge necessary to address such situations. Although psychologists cannot yet prescribe medications in most states, many psychologists have requested their Boards of Psychological Examiners to adopt position statements that allow for such exchanges without the psychologist placing him or herself in jeopardy. When psychologists maintain good working relationships with physicians in the community, encounters such as the one described above help in establishing psychologists’ credibility in two significant areas: (1) The psychologist demonstrates that he or she is able to contain difficult cases that include a medication regimen (reducing the need for physician’s involvement). (2) The psychologist demonstrates that he or she possesses the working knowledge of pharmacology sufficient to manage such cases.

Working Through Working through (Greenson, 1967) refers to a psychoanalytic concept/technique in which the analyst recognizes and explores a particular theme in the patient’s behavioral style (one to which the patient is somewhat “resistant”) and works through the resistance toward resolution. Case #2 demonstrates an RxP variation of this technique.

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Case # 2 Mr. and Mrs. Smith brought their fourth grade son for an evaluation. They had been told by their pediatrician that “Johnny” may have ADHD. The parents asked whether his ­behaviors warranted the diagnosis or were merely a product of Johnny being “all boy.” ADHD checklists were utilized and the results suggested symptoms consistent with ADHD. Teacher comments revealed that these problems have been occurring since pre-Kindergarten. When the psychologist confirmed the diagnosis of ADHD, the difficult work began.

Some parents are sophisticated about ADHD and accept the diagnosis as ­verification of what they suspect. These parents quickly ask about treatment options, including medication. Other parents are reluctant to accept this diagnosis and wonder what other explanations are possible and what other treatment options are available. They often start the conversation with “We don’t believe in medication” or “We’ve heard a lot of bad things about medications.” When questioning the parents about what bad things they have heard, it is often striking to find that they are unable to recite any specifics and state, “Well, we just heard bad things.” It is precisely in these situations that RxP training proves particularly useful. A detailed physiological explanation of the mechanisms of ADHD (or any other identified disorder with strong biological bases), along with the mechanisms of action of medications, helps the parents develop a more comprehensive understanding of their youngster’s problems. This allows the parents to make the decision about what action to take after being exposed to all necessary information consistently communicated by both the psychologist and the pediatrician. This empowers the parents – they are using scientific information to make treatment decisions, instead of accepting a treatment regime that they do not fully understand, and they are less likely to succumb to rumors or misinformation. This approach also increases the pediatrician’s confidence in the psychologist, as he or she recognizes that the patient is now well informed. When parents subsequently work with the pediatrician, it is clear that the psychologist has helped them understand the process of (and subtleties involved in) medicating their child and develop reasonable expectations of success. The actual working through in such situations occurs in promoting a physiological understanding of the disorder, including an accurate explanation of possible side effects and their actual likelihood, along with methods to monitor and manage emerging side effects. During such encounters, parents learn that there is no “miracle drug” and that the psychologist will work with the youngster and his or her parents to implement behavioral strategies that will be of further benefit. This might also include assigning reading material to the parents to help them develop parenting strategies – for example, Kapalka’s (2007) Parenting Your Out-of-Control Child. A somewhat similar case illustrates how physiological problems need to be separated from those presumed to be psychological in nature:

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Case #3 A 16-year-old-girl was brought to therapy by her mother for “sleeplessness.” The mother suspected her daughter was depressed or anxious and wanted to explore the psychological reasons for her symptoms. The girl admitted to being a little irritable and her grades were falling slightly but reported her sleeplessness was not secondary to the usual concerns ­facing typical teenagers. She did not have “bad dreams,” had not broken up with her boyfriend, was not having problems with peers, liked her parents, and maintained she did not have any “secret” psychological problems to tell her mother or the psychologist. An examination of her habits, however, demonstrated that she drank up to six caffeinated beverages past 4:00 pm most evenings. A careful explanation of the effects of caffeine and its relatively long half-life, was able to convince the young patient to alter her beverage consumption habits and relieved the problem. Naturally, a referral was made to rule out medical issues, and a follow-up with the pediatrician revealed no other concerns. The adjustment in the intake of caffeine remedied the patient’s sleep problem.

This case demonstrates another benefit of RxP training – it allows psychologists to check for the presence of physiological factors before psychological problems are suspected. Another example illustrating this point is evident when “weight gain” is encountered. Although psychological factors may be responsible, weight gain may also be a side effect of some medications, and it is often insufficiently addressed by physicians. An RxP-trained psychologist will be able to know which medications are likely to cause weight gain, and will help the patient and the physician address this problem. The answer for one patient may involve a change in medication categories, while for another, a change to a different medication in the same category (or augmentation with other agents) may be sufficient. Similarly, patients may perceive a lack of sexual desire, anorgasmia, or difficulty ejaculating as a sign of psychological difficulties, whereas such symptoms are common side effects of certain medications – for example, some classes of antidepressants. These side effects can often be corrected with a change in medication or augmentation with a secondary drug (Ables & Baughman, 2003; Bhatia & Bhatia, 1999; Kiraly, Gunning, & Leiser, 2008).

Iatrogenic Problems Some problems are more difficult: Case Study #4 A mother called the pediatrician and psychologist and complained about a terrible side effect of the psychostimulant medication the pediatrician prescribed for her son. “He has been crying uncontrollably after taking the medication, and now he no longer wants to take it.” The psychologist pointed out that this is not a common side effect of this medication. When asked

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T.M. Kozak and A.K. Miller when the crying begins, the mother said, “within minutes. ...less than 5 min.” She was told that this particular medication typically starts working after 30–45 min. The mother became irate and stated she does not care, she just wants to stop the medication as she cannot tolerate the crying. During the next session, further investigation revealed the father who actually administered the medication to his son each morning, would say, “Here, go ahead and take your stupid pill. You wouldn’t have to take this if you would stop acting stupid in school.”

The psychologist called the pediatrician and related that something other than the medication was the cause of the “side effect.” It can be desirable, of course, to prevent these problems by engaging family members in treatment, but as this case demonstrates, psychologists often have limited access to all family members and can only hope that nonparticipating parents will act responsibly. Obviously, family consultation with continued explanation of typical side effects vs. iatrogenic induced side effects, along with some family therapy, was indicated in this case.

On The Capacity to Bear Uncertainty A great deal of what psychologists encounter is uncertain, and clinicians often delay implementing interventions until sufficient evidence is presented to clarify the nature of the problem. Howard Wolowitz, Professor Emeritus of Psychology at the University of Michigan, once admonished his young doctoral students stating “Stop worrying so much about getting the patient to tell you their problem. If they could tell you that, chances are they wouldn’t be there” (personal communication, October 1978). Ralph Greenson (1978) addressed this capacity to bear uncertainty and warned against intervening too early, since initial presentations sometimes mask deeper problems. When working with children, this uncertainty is evident on many levels. Sometimes a child’s acting out does not seem to be related to the lack of parenting skills, and parents wonder whether the condition is physiological and requires medication. The pediatrician may refer these parents to the psychologist to rule out other factors in the absence of any easily observable physiological issues responsible for the undesirable behaviors. The psychologist must determine whether the child may have ADHD, bipolar disorder, anxiety, or depression, or whether problems with teachers or peers may contribute to the symptoms. In addition, parents’ discipline methods may not be best suited to the child’s temperament or emotional style, and other stressors may also contribute to the overall problem. Psychologists face such complex questions every day. Psychologists trained in RxP are able to expand their abilities to cover this vast ground of possibilities with the knowledge of medical factors, thus further augmenting the comprehensive manner in which a case is conceptualized and treated. Children whose behavioral and/or learning problems occur in both home and school environments, especially when the home and school environments appear to be essentially nonproblematic, may demonstrate symptoms consistent with ADHD or bipolar disorder. When the symptoms are severe and easily observable, diagnosis is rapid and not often disputed. However, this is not always the case. How severe

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do the symptoms of ADHD or bipolar disorder have to be to warrant the diagnosis and treatment? When do we recommend the use of medications? These are difficult questions that may require longer periods of observation and data gathering. Psychologists are trained to avoid a rush to judgment until more evidence becomes apparent, and spend more time with the patient and the family than the brief period of time pediatricians can devote to each patient. Psychologists need to be patient and allow the treatment to develop. A famous story told in analytic circles relates an analyst presenting a case of a young man who had been in therapy for 3 years. At termination, the patient seemed to improve a great deal. When the treating analyst was asked why she thought the improvement occurred, she replied: “I don’t know. I’m still trying to figure out what I did.” In a similar vein, one psychologist explained his treatment of children’s phobias to the parents in this manner: “Sometimes we know why children’s phobias disappear. Those are interesting cases. Sometimes we never find out why they go away, and that’s as good as it’s going to get.”

Who is the Patient? Clinicians who treat children or adolescents often face the question, “Who is the patient?” In the traditional notion of the identified patient, i.e., the person who “needs” treatment, the primary patient is usually designated by the parent. Psychologists, however, commonly encounter situations when parents admit that the problem really lies with them. In these situations, initial presentations do not represent the actual problem at hand, and the question then becomes “Who should be the patient?” RxP-trained psychologists also consider the various physiological problems that may additionally create the presenting problems and how these may have been reflected in the parents’ personal or developmental history. This may come up when the psychologist formulates the child’s problems, and the parents respond with “You were just describing me in my childhood.” The benefits of knowing medication dose range: Even when psychologists are not writing prescriptions, the importance of ­knowing typical dose ranges for any one medication can make a significant difference. Case # 5 A mother brought her young son in for evaluation and possible treatment. He has been “acting up in school, not listening to the teachers and not completing his work. This has been going on for quite some time now.” The mother indicates she has taken him for an evaluation in the past and he was diagnosed with ADHD. “We even tried the medication but it didn’t work.” A review of the case did not suggest any other diagnosis however, and as a result the psychologist inquired about the medication regime that had been attempted. The mother indicated she was reluctant to try the psychostimulant, (methylphenidate) and

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T.M. Kozak and A.K. Miller asked the pediatrician to administer it at the lowest dose, “just to see.” More careful questioning revealed the originally prescribed 5 mg of methylphenidate was being cut in half by the mother who thought she was now being “extra careful.” After a week, she concluded that the medication “did not work” and stopped giving it. The mother did not follow-up with the pediatrician or the original evaluator and several months later, enlisted the current psychologist to find out what was “really wrong” with her son. The likelihood of such a sub-therapeutic dose of methylphenidate being effective was not high and the mother was shown a chart of dose ranges for various psychotropic medications, including methylphenidate. She recognized that “her” dose was below even the minimal recommended range.

In such cases, there are two obvious issues: one was the erroneous conclusion that the medication was ineffective and two, the mother’s personal feelings about administering medication to her son. This is, again, a case where the RxP-trained psychologist can cover the scientific ground involved in medication dose ranges and work through the difficulty and reluctance some parents have with medicating their youngsters. While the pediatrician likely gave the mother proper instructions when the prescription was written, she did not follow them. From yet another angle, this second example brings to light the benefit of knowing medication dose ranges. Case #6 An impulsive young boy had been tried on various psychostimulants, at various recommended dosages, but only achieved partial reduction in his symptoms. The pediatric psychiatrist wished to administer risperidone to further reduce symptoms. The parents were reluctant to agree as risperidone is classified as an antipsychotic medication. The psychologist explained, in a family session, that he, in fact, had seen several patients with whom this medication regime was employed with good results. When the dose range was shown to the parents, it became clear to them that the 0.5 mg dose, recommended by the pediatric psychiatrist, was not in the 4–16 mg dose range typically used for psychosis. The psychiatrist’s comment, “It acts like an emotional shock absorber,” resonated with the parents and a review of the medication dose range chart by the psychologist demonstrated that 0.5 mg was actually at a sub-therapeutic level as compared to the dose used to treat psychosis. This helped assure the parents their son was not being treated for a condition he did not have and gave them a clearer sense of how this medication was being used.

In these two cases, it is obvious how the psychologist’s knowledge of therapeutic dose ranges helped assure and dissipate the parents’ fears about the use of medication. It also promoted effective treatment.

Summary This chapter does not intend to short-change psychologists without RxP training, as they are able to deliver competent care in many of the cases as those described above. RxP training, however, allows psychologists to cover a broader spectrum of problems and interventions. Many psychologists have completed at least some

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additional training in psychopharmacology. The more comprehensive such training is, the more it prepares the psychologist to undertake difficult, complex cases and deliver the highest standard of care. Among the skills gained in RxP training are improved abilities in the following areas: • Knowledge of the benefits of medications and which cases are most likely to respond better to medications than psychotherapy. • Parent education about choosing medications vs. psychotherapy, understanding the differences between both treatments, and the benefits and drawbacks of each. • Knowledge of dosing, expected effects and side effects. • Importance of medication compliance and dangers associated with inconsistent administration. The cases reviewed herein were sufficiently broad as to allow readers to reflect on the experience of RxP training and the difference it is likely to make in their own practice. Psychologists are encouraged to review similar cases they have encountered and consider how the addition of RxP knowledge can broaden the effectiveness of the therapeutic methods they currently utilize when treating their patients. Although medications help various psychiatric/psychological conditions, there is no “silver bullet.” Psychologists remember that the vicissitudes of life can be intense and trying. The developmental forces that govern us require support, reflection, and personal growth that cannot be obtained by medication alone. As psychologists, even after completing RxP training, we avoid biochemical reductionism and its tendency to lead us away from the struggles and challenges our patients face. The crux of our work still remains as it always has – to participate in the patient’s psychological life, help clarify their needs, resolve internal conflicts, and reflect on their decisions.

References Ables, A. Z., & Baughman, O. L. (2003). Antidepressants: Update on new agents and indications. American Family Physician, 67, 547–554. Arthur, A. R. (2005). Layered care: A proposal to develop better primary mental health services. Primary Care Mental Health, 3, 103–109. Ax, R. K., Bigelow, B. J., Harowski, K., Meredith, J. M., Nussbaum, D., & Taylor, R. R. (2008). Prescriptive authority for psychologists in the public sector: Serving underserved health care consumers. Psychological Services, 5, 184–197. Ax, R. K., Fagan, T. J., & Resnick, R. J. (2009). Predoctoral prescriptive authority training: The rationale and a combined model. Psychological Services, 6, 85–95. Barnett, J. E., & Neel, M. L. (2000). Must all psychologists study psychopharmacology? Professional Psychology: Research and Practice, 31, 619–627. Bhatia, S. C., & Bhatia, S. K. (1999). Depression in women: Diagnostic and treatment considerations. American Family Physician, 60, 225–234. Bush, J. W. (2002). Prescribing privileges: Grail for some practitioners, potential calamity for interprofessional collaboration in mental health. Journal of Clinical Psychology, 58, 681–696. Dittman, M. (2003). Psychology’s first prescribers. Monitor on Psychology, 34(2), 36.

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Greenson, R. R. (1967). The technique and practice of psychoanalysis. New York: International Universities Press. Greenson, R. R. (1978). Explorations in psychoanalysis. New York: International Universities Press. Gunn, W. B., & Blount, A. (2009). Primary care mental health: A new frontier for psychology. Journal of Clinical Psychology, 65, 235–252. Kainz, K. (2002). Barriers and enhancements to physician-psychologist collaboration. Professional Psychology: Research and Practice, 33, 169–175. Kapalka, G. M. (2007). Parenting your out of control child: An effective, easy-to-use program for teaching self-control. Oakland: New Harbinger Publications. Kiraly, B., Gunning, K., & Leiser, J. (2008). Primary care issues in patients with mental illness. American Family Physician, 78, 355–362. Lavoie, K. L., & Barone, S. (2006). Prescription privileges for psychologists: A comprehensive review and critical analysis of current issues and controversies. CNS Drugs, 20, 51–66. McDaniel, S. H. (1995). Collaboration between psychologists and family physicians: Implementing the biopsychosocial model. Professional Psychology: Research and Practice, 26, 117–122. McGrath, R. E., Wiggins, J. G., Sammons, M. T., Levant, R. F., Brown, A., & Stock, W. (2004). Professional issues in pharmacotherapy for psychologists. Professional Psychology: Research and Practice, 35, 158–163. Moore, B. A., & McGrath, R. E. (2007). How prescriptive authority for psychologists would help service members in Iraq. Professional Psychology: Research and Practice, 38(2), 191–195. Norfleet, M. A. (2002). Responding to society’s needs: Prescription privileges for psychologists. Journal of Clinical Psychology, 58, 599–610. Pace, T. M., Chaney, J. M., Mullins, L. L., & Olson, R. A. (1995). Psychological consultation with primary care physicians: Obstacles and opportunities in the medical setting. Professional Psychology: Research and Practice, 26, 123–131. Stambur, Z. (2006). Psychology’s prescribing pioneers. Monitor on Psychology, 37(7), 30. Tovian, S. M. (2006). Interdisciplinary collaboration in outpatient practice. Professional Psychology: Research and Practice, 37, 268–272. Warner, C. H., Bobo, W., Warner, C., Reid, S., & Rachal, J. (2006). Antidepressant discontinuation syndrome. American Family Physician, 74, 449–456.

Chapter 4

The Practice of Medical Psychology in an RxP State: New Opportunities for Comprehensive Pediatric Care Darlyne G. Nemeth, Sandra Franz, Emma Kruger, and Maydel M. Schexnayder

Psychologists and pediatricians have enjoyed a robust collegial relationship for many years. Primary areas of pediatrician collaboration have included, but are not limited to, general medical concerns, oncology, and neurology. Primary areas of psychological collaboration have included, but are not limited to, learning and attentional problems, affective and behavioral problems, enuresis and/or encopresis, trichotillomania, mental retardation, pervasive development disorders, eating disorders, parent–child interaction difficulties, and brain-behavior dysfunction/ trauma. Psychologists have been instrumental in developing specific interventions for children, which have greatly reduced the need for pediatric primary care appointments – for example, behavior modification (Martin & Pear, 2006), toilet training (Azrin & Foxx, 1974), and oppositional defiance (Barkley, 1987). Furthermore, psychologists have made major contributions to the understanding of children’s developmental and intellectual functioning. Theorists like Jean Piaget have offered a unique understanding of children’s cognitive development and “how human beings, through development, become ever more sophisticated thinkers about the world” (King, 2008, p. 117). Piaget identified two important developmental processes: assimilation – wherein new information is incorporated into existing knowledge, and accommodation – wherein schemas (concepts/beliefs) are adjusted to fit this new information (King). These processes undergo adjustment from birth throughout adulthood. Children’s intellectual abilities were first quantified by Alfred Binet in France. In 1904, Binet designed the first intelligence test, wherein mental development, relative to same age peers, was quantified. Now in its fifth edition, the StanfordBinet Intelligence Scale is still “one of the most widely used individual tests of

D.G. Nemeth (*) Neuropsychology Center of Louisiana, Baton Rouge, LA, USA e-mail: [email protected] G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_4, © Springer Science+Business Media, LLC 2011

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intelligence” (Kamphaus & Kroncke, 2004, as cited in King, 2008, p. 340). This test developed “the concept of mental age (MA)” (King, p. 340). Since the groundbreaking work of Piaget and Binet, many psychologists have spent their entire careers refining, reworking, and restructuring these concepts (e.g., Erikson, 1968; Stern, 1912; Terman, 1916), while others have developed entirely different approaches (e.g., Wechsler, 1939, as cited in King, 2008). For example, the current Wechsler Intelligence Scale For Children, Fourth Edition (WISC-IV, Wechsler, 2003), not only gives an overall Full Scale IQ, but also gives Index Scores for Verbal Comprehension, Perceptual Reasoning, Working Memory, and Processing Speed. According to Myers (2007), “Striking differences among these scores alert the examiner to possible learning problems or brain disorders” (p. 445). Neuropsychologists (e.g., Goldstein & Schwebach, 2009; Reed, 1967a, 1967b; Reitan & Wolfson, 1992) have focused on brain-behavior dysfunctions in children and how these difficulties interfere with their ability to acquire knowledge. Likewise, psychologists, who have focused on specific learning and attentional problems (e.g., Baddeley, 2007; Brown, 2005; Eichenbaum, 2008; Kamphaus, Reynolds, Hatcher, & Kim, 2004; Swanson, Harris, & Graham, 2003; Wong, 1991), have highlighted their neurodevelopmental etiology. These metacognitive perspectives offer pediatricians and psychologists a special bond that entwines their two areas of specialization. Thus, a very natural language of understanding children’s development has evolved.

Practice Settings Typically, pediatricians and psychologists practice in different outpatient settings. Today, pediatricians practice in either small or large pediatric clinics, often in multiple locations. At times, they may be woven into larger outpatient multispecialty medical clinics that may include other specialists, like pediatric neurologists and oncologists. On occasion, these groups may be affiliated with local hospitals that have actually purchased their buildings and practices. In the latter case, pediatricians are frequently restricted in their ability to refer children to the psychologist of their choice. When/if psychologists are members of hospitalbased practices, they typically do not enjoy the same stature as physicians and are not members of the Medical Staff. This is true even in spite of recently passed laws (Louisiana State Legislature R.S. 40:2114) affording psychologists admit and discharge hospital privileges. Typically, psychologists continue to be relegated to the “Allied Health Professional” staff with physical, occupational, and speech therapists, outpatient consultants, and social workers. This chapter will instead focus on collegial relationships wherein pediatricians and medical ­psychologists located in separate outpatient practices benefit from the consultation and collaboration process.

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The Collaboration Process The Medical Psychologist’s Perspective Before the passage of Louisiana’s prescriptive authority law (RS 37:2371-2378), psychologists were restricted to making general psychopharmacological recommendations (e.g., psychostimulant medication is suggested). Now medical ­psychologists can not only make recommendations for specific medications, but, with pediatric concurrence, they can also prescribe and titrate these medications. According to LRS Title 37, Chapter 28: 2375, Section C. 1: A medical psychologist holding a valid certificate to prescribe shall prescribe only in consultation and collaboration with the patient’s primary or attending physician, and with the concurrence of that physician. The medical psychologist shall also reconsult with the patient’s physician prior to making changes in the patient’s medication regimen, including dosage adjustments, adding or discontinuing a medication. The medical psychologist and the physician shall document the consultation in the patient’s medical record (Ward, 2005).

As of January 1, 2010, a new law, “The Medical Psychology Practice Act” (LA: Act 251, 2009), transferred the authority to regulate the Practice of Medical Psychology from the Louisiana State Board of Examiners of Psychologists to an Advisory Committee for Medical Psychology that functions under the umbrella of the Louisiana State Board of Medical Examiners (LSBME) (Louisiana State Board of Medical Examiners, 2009). Now, medical psychologists with 3 years of experience can be awarded Certificates of Advanced Practice, allowing them to practice without physician concurrence. Most medical psychologists will, however, continue to consult and collaborate with physicians, for this is good practice. Pediatricians are usually very pleased to receive comprehensive psychological reports that they can include in their patients’ medical charts. Furthermore, as they are typically very busy and are often only able to spend 15 min or less with each patient, pediatricians are only too pleased to share the case management responsibilities with their medical psychology colleagues. When medical psychologists serve as case coordinators, all contacts that require medication checks are well-documented. They include initiating, titrating, ­changing, discontinuing, and refilling medications. All but refilling medications require documented pediatrician–psychologist phone/fax consultation. Typically, the pediatrician will set the parameters for contact, either requiring input on all changes or allowing the medical psychologist to make these decisions. The latter usually occurs when the pediatrician and the medical psychologist are quite familiar with one another and/or have mutual respect for each other’s abilities. When these two parameters are not present, the pediatrician may request a second opinion, typically from a pediatric neurologist. The latter is more likely to happen when the pediatrician practices in a large multispecialty medical clinic. On occasion, however, the patient/parent/guardian/legal representative either independently recognizes the problem early on or is told by the child’s school that there is a problem. Then, psychological services are sought directly. After the

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evaluation process is completed and a report is issued and faxed to the pediatrician, if the psychologist is also a medical psychologist, a call will be made to the pediatrician. Typically, the pediatrician’s nurse will field this call and relay the information to the pediatrician. In straightforward cases, the nurse will simply call back with the consensus authorization. In more complicated cases, the pediatrician will return the call directly. After thorough discussion and an agreement on the parameters of the consensus (e.g., authorization to titrate), the psychologist will document the consultation and fax a copy to the pediatrician for the patient’s medical chart. All original documentations are placed in the child’s psychological chart. If the child is taking other medications, the medical psychologist will typically run a drug–drug interaction program – for example, InfoScriber (Netsmart Technologies, 2010) or Epocrates (Epocrates, 2010) – with and without the ­suggested medication. This information is then faxed to the pediatrician and included in the physician– medical psychologist phone consultation note. When consensus is obtained, a thorough explanation of the drug and its expected effects and side effects is given to the family. This is usually followed by offering printed material regarding that particular drug choice. The parent/guardian/legal representative is then asked to sign an acknowledgment form. It is important to make sure that the child’s representative (e.g., parent, grandparent) actually does have the legal authority to initiate treatment. If the parent/guardian/legal representative is unwilling to sign the acknowledgement form, no prescription is written and the consultation is terminated. At times, children do not need to be seen regularly for intervention. For example, some may have completed the psychological component of their treatment and merely require refills (e.g., psychostimulants and/or mood stabilizers). In the case of attention deficit hyperactivity disorder (ADHD) stabilization, three prescriptions can be written for psychostimulants with one current prescription and two “Do not fill until xx/xx/xxxx” prescriptions. For children with ADHD, quarterly appointments are required. For children with mood/bipolar disorder, quarterly or biyearly appointments are required (depending on medication selection and required labs). Ongoing pediatrician–medical psychologist consultation allows the pediatrician to separate mental health from physical health symptoms to treat the latter (e.g., a true stomach virus vs. somaticization). Pediatricians are very pleased to receive faxed documentation (i.e., a Patient Contact Note) for their files, and many complain that, in the past, when they referred to psychiatrists or other mental health professionals, such information would not be forthcoming. It is important to note that current Louisiana Law for the practice of Medical Psychology requires such communication for those medical psychologists who do not have an Advanced Practice Certificate (Nemeth, Olivier, Whittington, & May, 2010). Whether required or not, it is simply good practice. It is extremely important that all children be monitored in a responsible way. In general, prescriptions should not be refilled for children with whom the medical psychologist has had little or no ongoing contact. A simple rule of thumb is, if you cannot remember the child, do not refill the prescription. Instead, refer that child to his/her pediatrician.

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The Pediatrician’s Perspective “Best practice” has always meant incorporating into a clinical setting the most recent evidence-based medicine with the more germane objective testing and assessment tools available. This is a particular challenge in the ever-evolving field of child brain development. It is an exciting time with new information, behavioral tools, and medications evolving so quickly. However, it is a daunting task to incorporate best practice into the constraints of a busy pediatric office setting. Structuring a model to successfully meet the needs of our pediatric patients requires some deliberate planning and committed effort from pediatricians and psychologists to contribute their different strengths to the equation. Coordinated efforts between fields can yield excellent comprehensive care for our patients. Pediatricians should uncover physiologic components contributing to learning issues utilizing a detailed history and physical exam to uncover underlying perinatal, congenital, and/or metabolic abnormalities. Nutrition, recurrent illness, and sleep issues as well as vision or hearing problems should be identified. Impact of chronic illnesses and daily medications on behavior should be considered. Pediatricians should direct patients to psychiatric care if symptoms or family ­history suggest true psychiatric disease. Psychologists excel in selecting appropriate tools to evaluate the various aspects of learning, thus identifying strengths and weaknesses. This enables behavioral techniques and medications to target identified areas. Gathering and interpreting this information fits the educational background and clinical setting of our psychologist colleagues. With focused, excellent education on behavioral medications, it naturally follows that choosing and titrating these medications in collaboration with physicians could be of great benefit to our patients. One model which has worked well includes an initial evaluation by a pediatrician followed by appropriate referral to a trusted neuropsychologist for a comprehensive evaluation. This thorough evaluation generates specific information about family dynamics, school setting issues, and objective measures of learning abilities. Phone collaboration and written report follow and conclude with detailed suggestions for behavioral interventions, medication, and follow-up plans. The medical psychologist who has advanced medical training then prescribes and titrates medication. Follow-up visits and progress are communicated through fax or phone follow-up. Physicians are happy with the quality of care their patients enjoy through this approach and they appreciate it; they feel that this is possible only through easily available and open communication between trusted colleagues. Hindrances to this model include unfamiliarity, lack of awareness of ­psychologist/ physician resources in one’s area, and concerns over liability and reimbursement. People who care for children should work together towards changes that value best practice care for learning and behavioral issues.

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A Metabolic Perspective On occasion, children may not be able to properly metabolize medication. Either their bodies absorb the medication too slowly or too quickly. This is a puzzle to be solved. In communities where a physician who specializes in metabolic medicine is available, a consultation should be arranged. This metabolic consultation would focus on finding biochemical features unique to a child. We have known for a long time that each one of us is different from the other in the way we age, develop ­illnesses, and respond to treatment. This uniqueness is often referred to as biochemical individuality. Metabolic medicine utilizes a different approach. One of the most promising ways to help a child with unpredictable medication response is through metabolic mapping. An analysis of the metabolites (chemicals that are produced as a result of different biochemical processes that take place in the human body) can give insight into the child’s unique features in handling medications and other substances in the body. This approach may further our understanding not only of the child’s response to medication, but also may provide a deeper understanding of the illness itself. Custom-designed interventions based on the child’s individual needs have a greater chance of success as they take into consideration the uniqueness of the child’s biochemistry.

The Parent’s Perspective As a parent the thought that your child may be experiencing any type of medical or psychological problem is extremely scary. The moment your child starts showing signs that he/she may have clinically significant affective distress, concentration/ attentional problems, learning problems, behavioral issues, and/or any other type of psychological issue, there is no doubt that the faster the treatment is obtained the better it will be for the child and the family. But, where does a parent go to get the best care for his/her children’s needs? If it is a rash, cold, flu, or other medical issues, it is easy – the parent contacts the pediatrician. The parent feels very comfortable with this individual as this is the person who has been chosen to care for the child’s medical needs. The same is often very true when dealing with affective, behavioral, and/or learning issues. Unless the parent has exposure to (and comfort with) psychology and contacts the psychologist directly, the parent usually contacts the pediatrician first. When dealing with emotional or behavioral issues, a lot more time is needed than the usual 15–30  min medical appointment that the pediatrician’s office allows. Since pediatricians do not have in-depth measures to differentially diagnose ADD/ADHD, learning disability, anxiety, etc., they often will refer the family to a psychologist for evaluation. Treatment is then coordinated with the psychologist, the pediatrician, and the family. In the past, only the pediatrician could prescribe medication; however, now that medical psychologists in Louisiana

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are able to prescribe medications and consult with the child and the family, the process seems to be more efficient. Medical psychologists are first and foremost psychologists. They have the ­training and time to sort out the “real” (underlying) issues. This is probably the most important thing for a parent – the “real issues” are going to be addressed. A parent’s biggest fear is that the child will be misdiagnosed or that the treatment will not be the right one for the child. It is often hard for a parent to tell if some behaviors are due to concentration difficulties, impulsivity, anxiety, disobedience, or are just simply normal ageexpected conduct. Also, biological differences must be taken into account. Boys by nature tend to be more impulsive and they tend to move from one activity to the next; whereas girls can often entertain themselves for hours with just one activity. When the expected behaviors seem excessive (i.e., taking too long to finish an activity, constantly acting without thinking, forgetting what they were going to do, etc.), family life can become a constant battle over the same issues. These problems usually become even more evident after children start school and have to complete homework assignments. As children are getting older, some of the behaviors may be getting worse. Is it misbehavior or is it something else? Something has to be done in order to reduce chaos in the family. These days, time at home is already limited due to work, school, homework, and extracurricular activities. The last thing parents want is to spend time with their children being upset and having to punish them, especially if they are not able to control their behavior on their own. Therefore, appropriate assessment, diagnosis, and treatment must begin immediately. Because of their background in psychology and medicine, medical psychologists are the obvious choice for parents seeking help for their children with emotional or behavioral problems. Different treatments are needed for different problems, and the medical psychologist has the knowledge, experience, and now the right tools (i.e., being able to prescribe) to be able to totally assist children and families with these problems, while in the past the families had to go back and forth between the pediatrician and the psychologist. Now, the concerns can be addressed not only by the use of appropriate medication, but also by employing behavioral techniques to facilitate change. If medications are used, it is very important to be vigilant about potential side effects (i.e., lack of appetite, irritability, headaches, constant talking) and to know how to deal with them. Some side effects decrease after a few weeks, but others do not. Having the opportunity to discuss these issues with a medical psychologist and knowing that your child’s pediatrician trusts this individual with prescriptive privileges makes a huge difference to many parents. It is almost like getting two opinions for the price of one. Medicine is not an easy fix, but it can be very effective if prescribed and managed appropriately. Having a medical psychologist prescribe medication in collaboration with the pediatrician allows for a better and more thorough treatment plan. It reduces a parent’s fears and stress levels and improves ­family interactions and home life in general.

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When to Medicate It is the responsibility of the medical psychologist to determine if medication is really necessary. Some parents may not wish to exert the consistent effort over time that it takes to change behavior. Oftentimes, parents seek simple solutions to ­complex problems. But, medication is not a simple solution. Therefore, the medical psychologist must remain vigilant during these consultations. Because a ­medical psychologist is first and foremost a psychologist, he or she has the training and time to sort out the “real” issues.

Family Dynamics Being that affective and behavioral problems often have a strong environmental component (Barkley & Benton, 1998), pediatricians typically refer to psychologists for intervention. With many psychological difficulties (for example, anxiety disorders), medication alone is not the treatment of choice (Andrews, Crino, Lampe, Hunt, & Page, 1994), and a combination of short-term medication and cognitive behavioral therapy is recommended (Andrews et al., 1994). Many problems may be a manifestation of family dynamics, wherein the child has become the “identified patient.” All efforts are then focused on the child, rather than on the family dynamics that underlie the child’s symptoms. When these children become symptomatic, they are often “dropped off” at the psychologist’s office to be “fixed.” Medications may have been prescribed, yet the symptoms remain. A medical psychologist, because of his or her background in psychology and experience with therapeutic interventions, will recognize that this may call for a family intervention. Regardless of socioeconomic status, the myth of “fixing” the child must be breached (Novella, 2009). Oftentimes, there is considerable resistance from the family. Excuses from “I don’t have time” to “You don’t understand” are commonly given. Parents may be very resistant to acknowledging, yet alone changing, their involvement in the child’s symptom presentation. Restructuring parents’ behaviors and helping them understand their own emotional baggage is often the first step toward meaningful change (Nemeth, Ray, & Schexnayder, 2003). Disorders in childhood may be predictive of other psychiatric disorders later in life – for example, Barrett & Farrell (2007) point out that anxiety-related symptoms, including excessive worry, physiological arousal, psychosomatic complaints, and extreme avoidance of specific situations, often disrupt peer and social relationships and result in academic achievement problems. Concurrent psychosocial difficulties, such as immaturity, attention and concentration problems, oversensitivity, low self-esteem, and low social competence, are frequently present. Even though there may be a biological vulnerability component, parental/family interactional factors play a significant role in the maintenance of these symptoms. Therefore,

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psychological intervention approaches including the family are very beneficial. For  example, the FRIENDS for Life program (Barrett, 2004, 2005, as cited in Barrett & Farrell, 2007) offers specific ideas about how parents and families can be involved in the child’s treatment. Thus, for many emotional disorders, medication, if used at all, should be an adjunct to the psychological intervention process.

Unconscious Expectations Unconscious expectations are frequently at work – directed from the parent to the child or vice versa. For example, one parent with a degree in music kept signing his son up for violin lessons. The son, who had no musical talent, developed many passive-aggressive strategies to avoid these lessons. He did not wish to disappoint his father; however, he became highly anxious. When brought in for treatment, the intervention did not involve medication, but rather parent–child consultation. When relieved of this burden, the child’s symptoms remitted. Similarly, the daughter of a professional athlete was referred for evaluation by her pediatrician. Her athletic mother had no desire to impose such strenuous standards on the child. Yet, this very awkward girl was trying so hard to please her mother that she became highly anxious and could not function. Freeing the daughter of the burden to be “like Mother” relieved her symptom presentation. These examples reinforce the idea that medical psychologists are best prepared to assess and treat children with a variety of psychological difficulties, and their unique background in both medicine and psychology allows them to determine which approach is best suited for which child.

Comorbidities Another difficult problem that must be addressed is the differential diagnosis between disorders that may present similar symptoms. Perhaps the best example is the similarity between some symptoms of ADHD and childhood bipolar disorder. According to Biederman (2000), pediatric mania is difficult to differentially diagnose because ADHD and mania share three common symptoms: distractibility, motoric hyperactivity, and talkativeness (p. 460). Biederman notes that “subjects with mixed mania tend to have a chronic course, absence of discrete episodes, onset of the disorder in childhood and adolescence, a high rate of suicide, poor response to treatment, and an early history of neuropsychological deficits highly suggestive of ADHD” (p. 459). Typically, the medical psychologist is consulted by either the parents or the pediatrician when most psychostimulant medication trials have either resulted in too many side effects or have been ineffective in controlling the symptoms and behaviors. Just merely raising the dose or changing the psychostimulant does not work. Attentional testing (e.g., with the Test of Variables of

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Attention – TOVA) typically shows a pattern of deviant response time and ­excessive variability scores, both on and off medication, with relatively adequate inattention/ omission and impulsivity/commission scores (Nemeth, Marceaux, Lewis, Lee, & Schechter, 2007). This provides an important cue to the medical psychologist to evaluate for childhood bipolar disorder. A trial of either an antidepressant (e.g., fluoxetine – Prozac), traditional mood stabilizer (e.g., valproate – Depakote), or an atypical neuroleptic (e.g., risperidone – Risperdal or aripiprazole – Abilify) may be considered. Biederman (2000) suggests that more optimistic findings have resulted from atypical neuroleptics in children with bipolar disorder (p. 463). Pediatricians often prefer that the medical psychologist prescribes and closely monitors these medications. At times, a child may have both an attentional disorder and a mood disorder. Henin et  al., (2007) report that youths with both ADHD and bipolar disorder ­perform more poorly on measures of processing speed. They conclude that comorbidity with ADHD may account for many of the neuropsychological deficits, such as verbal learning and interference control, observed in children with bipolar disorder (p. 210). Again, close monitoring is needed because, according to Biederman and colleagues, neurological impairments are less pronounced among those who are treated with medication (p. 217). Usually, this monitoring is done in half-hour or full-hour bimonthly or monthly appointments. As pediatric appointments are typically limited to 15  min, the responsibility for either a half-hour or full-hour appointment to assess symptoms, adjust medications, and develop behavioral interventions falls to the medical psychologist.

Development Problems Children with developmental delays often present a unique set of challenges. Autism-spectrum disorders are among the most salient examples in the world of pediatrics. Often, interventions to treat symptoms of autism must include educational and behavioral programming and psychological management. Problem behaviors like aggression, tantrums, agitation, self-injury, irritability, rigidity/desire for sameness, hyperactivity, and repetitive actions/thoughts must be addressed (Hollman, 2010). These problems may be exacerbated by concomitant conditions such as ADHD, Anxiety, Obsessive-Compulsive Disorder, Affective/Mood Disorders, Seizures, Tic Disorder, or Sleep Disturbance (Hollman). Frequently, the pediatric neurologist will be consulted either directly by the parents or upon a referral from the pediatrician. Every effort must be made to ­stabilize the autistic child on appropriate medication. Then the medical psychologist is called upon to assist the family in long-term management. Regular communication with the pediatric neurologist and/or pediatrician prevents many problems. In the case of Asperger’s Disorder, the medical psychologist is usually consulted first. Oftentimes, this consultation is recommended by either the teacher or the school. The child is seen as verbally rigid, socially unskilled, and academically

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problematic. Treatment may include medications (e.g., antidepressants and/or medications to improve attention and working memory) and cognitive behavioral interventions. Assisting the child/adolescent to move from literal to figurative speech is essential. Resources such as An Asperger Dictionary of Everyday Expressions (Stuart-Hamilton, 2007) may be very helpful. As opposed to autism-spectrum disorders, most children who are mentally retarded have usually been diagnosed at an early age (e.g., before age 5). Medication decisions typically involve management issues (e.g., aggression). Frequently, neuroleptics and mood stabilizers are chosen. If medical psychologists are involved in the care of these children, the treatment is often institutionally based.

Trauma Children experience many types of trauma in their young lives. The loss of a family member through separation, murder, accidents, war, divorce, death, etc.; the loss of friends through death, relocation, or accidents; or bullying and other school-related problems. There are so many ways in which children can directly or indirectly experience trauma. Trozzi & Dixon (2000) note the emergence of the following symptoms as cues that a child may have witnessed violence: “Hypervigilance, Hyperactivity, Nightmares, Separation Anxiety, Risk-taking Behavior, Withdrawal, and Emotional Numbing” (p. 564). Experiential learning techniques involving play, stories, drawings, etc. are helpful to both children and adults as they attempt to recognize, label, and deal with the aftermath of trauma (Nemeth, Marceaux, & Lewis, 2006). If there has been physical involvement (e.g., being abused, shot, burned, etc.), children are initially seen by either emergency room physicians or outpatient medical specialists. After medical stabilization and appropriate legal reporting have taken place, the medical psychologist may be consulted for trauma/grief counseling and/or mental health medication. Short-term intensive intervention, along with long-term follow-up care, is typically needed. Anniversary reactions, which take place approximately 1 year posttrauma, may be very difficult (Nemeth et al., 2006). Interventions must be arranged to coincide with these events. As most prescribers prefer to avoid anxiolytic medication for traumatized children, when needed, antidepressant medication, usually a selective serotonin reuptake inhibitor (SSRI) – such as fluoxetine (Prozac) – is preferred. In some cases, traumatic brain injuries (TBIs) are a part of the child’s traumatic  experience. “Mild head injury constitutes approximately 50–75% of all ­traumatic head injuries” (Frankowski et  al., 1988, as cited in Semrud-Clikeman, 2001, p. 9) and is on the increase. Fletcher et al. note that “children under 15 years of age with head injuries account for more than half of all deaths due to trauma” (as cited in Semrud-Clikeman, 2001, p. 10). For those who did not die, “a significant proportion had learning and behavioral difficulties” (Semrud-Clikeman, p. 10). Thus, a good medical recovery does not always mean a full recovery of functioning. For example, Reitan & Wolfson (2000) point out that “mild head injury does not always

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mean mild impairment” (p. 86) and most children with TBIs have ­significant difficulty with the acquisition of knowledge. Ewing-Cobbs et al. (1991, as cited in Semrud-Clikeman, 2001) report that 80% of severe TBI children had learning problems requiring educational modification even 2 years postinjury. Affective and behavioral problems are usually a part of the clinical picture. These often require medication management. In such cases, usually a pediatric neurologist, a pediatrician, a pediatric neuropsychologist, and a medical psychologist are involved in the child’s care. In some cases, preexisting conditions (like ADHD) may have placed the child at a higher risk for a head injury (Teeter & Semrud-Clikeman, 1997, as cited in Semrud-Clikeman, 2001) and must be addressed in the postinjury prescriptive intervention plan. Typically, these children’s aggressive, impulsive, hyperactive, and inattentive behaviors continue postinjury (Semrud-Clikeman, p. 11). When educational modifications are needed, Public Law 101-476 (Individuals with Disabilities Education Act [IDEA], Federal Register, 1990) and Section 504 of the Rehabilitation Act of 1973 (Semrud-Clikeman, p. 54) are usually invoked. One of the difficulties with these laws is the way TBI is defined. Specifically, the Code of Federal Regulations Part 300 (1993), as cited in Semrud-Clikeman (2001), states that TBI must be “an acquired injury to the brain caused by an external physical force” (p. 55). Congenital, degenerative, cardiovascular, birth, or other brain traumas are excluded. It is often a struggle for professionals to find an appropriate classification that will meet IDEA/504 requirements. Therefore, comorbid psychological disorders, rather than TBI, are often vehicles used for educational classification. These diagnoses are frequently the focal points of medication management as well. For example, a 12-year-old child who suffered a TBI in his early childhood required a mood stabilizer (e.g., valproate – Depakote) to manage his impulsive aggression and a nonpsychostimulant (e.g., atomoxetine – Straterra) to manage his hyperactive, inattentive behaviors. There is no magical combination. Trial and error efforts will lead the medical psychologist to a workable solution. But, these cases tend to be unpredictable – just when things appear to be on track, they may unexpectedly get offtrack for some reason (for example, a change in the family environment). At such times, parents will request a change in medication. The medical psychologist, however, must look below the surface symptom presentation and examine the current family stressors. Frequently, family therapy, not changes in the child’s medication regimen, is needed. At times, it may be more practical for the family therapy to be delivered by another mental health provider with the medical psychologist receiving appropriate feedback.

Concurrent Medical Conditions Pediatricians and pediatric neurologists often see children who have either attentional and/or anxiety/behavioral disorders and a major medical condition. Whether these are concurrent with or secondary to the medical condition has been argued for years (Goldman, 2000). More important is the fact that both must be addressed. This presents major challenges for the professionals, the parents, and the teachers.

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One such example is a 9-year-old child with Charcot-Marie-Tooth Disease, referred by his pediatric neurologist for neuropsychoeducational evaluation and treatment recommendations. Although having a major medical condition that is resulting in the peripheral neuropathy of his limbs, this child presented as warm, loving, and eager to please. The data revealed that he had significant attentional problems that were interfering with learning. Due to his Charcot-Marie-Tooth Disease, however, there were no obvious signs of hyperactivity and impulsivity; thus, the pediatric neurologist needed clarification regarding his attentional ­status. As a result of this evaluation and pediatrician–medical psychologist collaboration, the child was placed on appropriate psychostimulant medication and is now ­functioning better in the classroom. His loving parents have also followed all the recommendations that were offered. This is just one example of a child with a major medical condition whose parents have accepted him “as is,” who have limited their role expectations, and who are willing to be a part of the process, rather than a part of the problem. These dynamics of acceptance and appreciation may not be as readily apparent in “medicallywell” children who present with mental health problems. Oftentimes, it is hard for parents to value their “medically well” children “as is.”

Adverse Reactions On occasion, children may develop troubling psychological symptoms in reaction to medications. For example, one 7-year-old boy developed hallucinations secondary to the use of the Daytrana Patch. When the medication was discontinued, these symptoms abated. Medical psychologists are trained in the nuances of psychological disorders, as well as adverse effects of medications, and are well-prepared to assess whether a set of symptoms may potentially be secondary to a medication that is being administered. While pediatricians are also well-versed in the side effects of medications, medical psychologists usually are able to devote more time to their patients and therefore are able to perform careful “detective work” to determine the origin of a set of symptoms. Thus, once again, contributions by the medical ­psychologist can be invaluable to the treating pediatrician, the patient’s family, and most importantly, to the pediatric patient.

Practical Issues Prescriptions Triangulation is a common phenomenon in dysfunctional families, wherein two people are turned against one another by a third person (Brown, 1999). At times, children may engage in triangulation in order to split parental authority. Although

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this pattern is seen in dysfunctional families, it can easily generalize to other ­systems. Thus, this behavior can occur at all levels – both within the family per se and between family members and healthcare professionals. In such cases, whether the parents are married to one another or divorced, the medical psychologist must act as case coordinator. Every effort must be made to keep the pediatrician and/or pediatric neurologist fully informed. When a parent manages to split the healthcare team, prescriptions can be obtained that can cause significant affective and/or behavioral dyscontrol. In one such case, two divorced parents had very different parenting styles for their 11-year-old brain-injured child. This girl, with the agreement of her treatment team (pediatric neurosurgeon, pediatrician, and medical psychologist), had been properly maintained on an antiseizure medication. One parent became dissatisfied with the difficulties that this child had with homework. Without the knowledge of the pediatric neurosurgeon and the medical psychologist, that parent obtained a psychostimulant prescription from the pediatrician. This resulted in a severe incident of behavioral dyscontrol toward another child at school over which charges were filed. The medical psychologist had to act on the child’s behalf and explain to the school system and the legal system that this episode of behavioral dyscontrol was a result of a drug–drug interaction and not willful behavior. After this episode, all parties involved agreed that only the medical psychologist will issue prescriptions for mental health medications. In Louisiana, checking for potential drug–drug interactions is the responsibility of the pharmacist (Ch. 29, Louisiana State Board of Examiners of Psychologists, 2009). At times, multiple medications from separate pharmacies may be obtained, thus complicating the process even further. Recently, the Louisiana State Board of Pharmacy set up The Prescription Monitoring Program, a system for statewide tracking of prescriptions (Ch. 29, Louisiana State Board of Examiners of Psychologists). Now, any prescriber who has reason to be concerned about splitting, multiple prescribing, etc. may log onto www.labp.com to check a patient’s current prescription status.

Settings When a child has both attentional and affective symptoms, a pediatrician is more likely to refer to a medical psychologist for consultation and intervention. Some psychostimulant medications can actually exacerbate anxiety and/or behavioral problems (e.g., tics, erections). One such male child who had been on methylphenidate (Ritalin) kept having erections in the classroom. As the parents chose not to notify the school of the child’s medication regimen, the teacher interpreted the child’s behavior as voluntary, and he was suspended. A letter from the prescribing practitioner was necessary to have the child readmitted to school. This example highlights the importance of notifying school officials of the child’s medications. Oftentimes, parents are reluctant to do so for fear of having their child “labeled.”

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Therefore, rather than having their child “labeled,” they risk the chance of having their child’s behavior misunderstood. The role of the medical psychologist, therefore, not only includes collaboration  with the pediatrician, intervention with the child and parents, but also ­consultation with the parents and the school. At times, this may include a school visit for both observation of the child’s behavior and consultation with school officials. Medical psychologists are well-prepared to navigate this delicate terrain. If the medical psychologist will write reports used by school professionals, he or she must also be aware of the inherent difference between a P.L.-94:142 (Louisiana Bulletin 1508) report for use in schools and a typical neuro/psychological or psychoeducational report. Proper formatting is essential. If the report does not meet the majority of the Individualized Educational Plan (IEP) standards, needed services will often be delayed. When there appears to be resistance on the part of school personnel to consider/accept/implement the psychologist’s recommendations, having the pediatrician/pediatric neurologist review, concur, and sign the report can greatly facilitate the process. Some psychologists who have fought hard to separate psychological practice from medicine may be hesitant; however, children suffer when professionals become too territorial. In one such example, a child was originally referred for a comprehension evaluation by her local pupil appraisal office. Results revealed multiple clinical and developmental diagnoses that had not been previously rendered. Interventions were not approved until the child’s pediatrician signed the Bulletin 1508 report that was jointly prepared by the clinical psychologist, medical psychologist, and neuropsychologist.

Conclusions There appears to be a natural bond between pediatricians and psychologists. Both professionals are focused on children’s development and well-being. This bond easily extends to medical psychologists who can serve two important roles: (1) the prescribing agent and (2) the psychotherapeutic agent. In these roles, the medical psychologist can focus on the child’s mental health from both a pharmacological perspective and a psychological perspective. Both are inextricably linked. Changes in behavior and cognition produce changes in brain functions and vice versa. Brain plasticity is truly an amazing phenomenon. As the medical psychologist and pediatrician develop a positive collegial relationship, the result becomes beneficial to all. Knowing that each can count on the other to deliver the highest quality of professional care allows a bond of mutual respect and trust to emerge. Such collegiality is a great comfort to families. One good consultation experience, however, does not ensure a lasting bond. Rather, consistent communication over time is required to maintain a trusting relationship. Knowing that each can count on the other is the key. Collegial relationships, mutual respect, team work, and serving the best interest of the patient are not just platitudes. They are the behavioral and ethical

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r­ esponsibilities necessary to (1) enhance the physician–medical psychologist bond and (2) ensure the future of pediatric medical psychology. Acknowledgments  The authors wish to thank the following staff members at The Neuropsychology Center of Louisiana, LLC for their assistance: Ms. Taighlor Whittington, and Mrs. Traci Olivier.

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Martin, G., & Pear, J. (2006). Behavior modification: What it is and how to do it (8th ed.). Upper Saddle River: Prentice Hall. Myers, D. G. (2007). Psychology (8th ed.). New York: Worth Publishers. Nemeth, D. G., Marceaux, K. S., & Lewis, A. L. (2006). Group intervention in the aftermath of hurricanes Katrina and Rita: The efficacy of hurricane anniversary wellness workshops. Presented at the 114th Annual Convention of the American Psychological Association, New Orleans, LA. Nemeth, D. G., Marceaux, K. S., Lewis, A. M., Lee, S. R., & Schechter, L. R. (2007). The neuropsychological profiles of bipolar male children. Presented at 29th Annual Convention of the Louisiana Psychological Association, Baton Rouge, LA. Nemeth, D. G., Olivier, T. W., Whittington, L. T., & May, N. E. (2010). Integrating the practices of outpatient clinical neuropsychology and medical psychology. Presented at the 38th Annual Meeting of the International Neuropsychological Society, Acapulco, Mexico. Nemeth, D. G., Ray, K. P., & Schexnayder, M. M. (2003). Helping your angry child: Worksheets, fun puzzles, and engaging games to help you communicate better (1st ed.). Oakland: New Harbinger. Novella, J. (2009). Attention deficit hyperactivity disorder or additional difficulties hampering development. Retrieved March 25, 2010 from http://pubs.ext.vt.edu/350/350-051/350-051.html. Reed, J. C. (1967a). Lateralized finger agnosia and reading achievement at ages 6 and 10. Child Development, 38, 213–220. Reed, J. C. (1967b). Reading achievement as related to differences between WISC verbal and performance IQs. Child Development, 38, 835–840. Reitan, R. M., & Wolfson, D. (1992). Neuropsychological evaluation of older children. South Tuscon: Neuropsychology Press. Reitan, R. M., & Wolfson, D. (2000). Mild head injury: Intellectual, cognitive, and emotional consequences. Tuscon: Neuropsychology Press. Semrud-Clikeman, M. (2001). Traumatic brain injury in children and adolescents: Assessment and intervention. New York: Guilford. Stern, W. (1912). The Psychological Methods of intelligence Testing. Baltimore: Warwick and York. Stuart-Hamilton, I. (2007). An Asperger dictionary of everyday expressions (2nd ed.). Philadelphia: Jessica Kingsley/Harbinger. Swanson, H. L., Harris, K. R., & Graham, S. (Eds.). (2003). Handbook of learning disabiltiies. New York: Guilford. Terman, L. (1916). Stanford Revision of the Binet-Simon. Trozzi, M., & Dixon, S. (2000). Stressful events: Separation, loss, violence, and death. In S. Dixon & M. Stein (Eds.), Encounters with children: Pediatric behavior and development (3rd ed., pp. 547–567). St. Louis: Mosby. Ward, B. C. (2005). Louisiana State Board of Examiners of Psychologists directory and statutory reference. (Available from Louisiana State Board of Examiners of Psychologists, 8280 YMCA Plaza Drive, Bldg. 8-B, Baton Rouge, LA. 70810). Wechsler, D. (2003). Wechsler Intelligence Scale for children (4th ed.) (WISC-IV ®). San Antonio: Harcourt Assessment. Wong, B. Y. L. (Ed.). (1991). Learning about learning disabilities. San Diego: Academic.

Chapter 5

Integrated Care in Rural Settings Nancy Boylan Alford

In The City Mouse and the Country Mouse fable by Aesop (Percy, 2009), the city mouse comes to visit the home of the country mouse. According to the tale, the country mouse was satisfied with his humble home until he heard how elegantly the city mouse lived. A visit to the city mouse resulted in the introduction of a home of finery and good food, but alas, a cat living in the home. All of this prompted the country mouse to decide that the safety of his humble home was preferred despite the lack of comforts enjoyed by the city mouse. In the United States, we see the same comparisons; people who live in the ­country feel they have kept values that exceed the gains of living in the city. But the truth is, in our country, more people live in the city. Like the city mouse, they have learned to deal with the issues of “the cat in the house,” and adaptation to city life has yielded them, either in reality or in perception, a higher standard of living and, cat or no cat, one with which they are comfortable. The city life standard of living has also yielded them access to higher income employment opportunities (and a higher probability that the employment will also include health insurance coverage), transportation services, increased availability of medical (including mental health) services (both general and specialist), and decreased isolation (there are some exceptions to that, for instance the one room occupancy problem seen in very large metropolitan areas, however that is countered with the rural isolation of ­farmers for instance, who may live miles from the nearest neighbor). Although levels of poverty exist in the worlds of both the city mouse and the country mouse; the country mouse wins the race for percentages of population ­living at or below the poverty levels. The country mouse also has little privacy in the rural setting with regards to personal business, including medical; and there is a greater stigmatization for seeking mental health services. Providers frequently are spread thin, see multiple generations of families and neighbors, and too often treat both parties to a dispute. In addition, cultural beliefs die hard in the rural areas, and beliefs in spirits, hanks, palm readers, and religious doctrines are sometimes in N.B. Alford (*) Carriage House Psychological Associates, PLLC Roanoke Rapids, North Carolina e-mail: [email protected] G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_5, © Springer Science+Business Media, LLC 2011

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conflict with best level of care standards, thus medical care is rejected (especially including mental healthcare). Significant diversity is evident in the rural areas. As generations grow up and leave the area, new cultures move in to take the low-paying jobs. In the south, for instance, migrant workers are now more likely to be Hispanic while generations ago they may have been African-American. Language barriers are difficult to overcome with the lack of resources so, the Latino mouse may never really adopt the American-English that prevails, and consequently communicating health needs (and others) may remain difficult. Providing mental health services with an interpreter is difficult and is almost always affected by the bias of the interpreter (Vasquec & Ravier, 1991; Wu, Leventhal, Ortiz, Gonzalez, & Forsyth, 2006). In addition, it is this author’s experience that rural or intensely impoverished areas are likely to have entry level (inexperienced) healthcare providers who come to these areas to gain experience and sometimes to also pay back government loans. It is also not unlikely that they may chose to move on in a few years, leaving the area underserved. Consequently, members of the community tend to adapt to that phenomenon and do not expect long-term relationships with their healthcare providers, and tend to be distrustful of them (Bushy, 1993; Wagenfeld, Murray, Mohatt & DeBruyn, 1993). The demographics are changing as families become smaller, both in the number of children and in the make up of the family parenting system (Federal Interagency Forum on Child and Family Statistics, 2010). There are also emotional barriers between these “mice.” Issues of trust, shame, guilt, and fear prevail and create a chiasm between service provider and patient, even more if the service provider is a stranger to the area. “If your people aren’t from here, you are a stranger,” a rural mill worker once told this author.

Integrated Models of Treatment and Rural Communities Rural America is a concept formed by our life experiences and our exposure to movies and television programs; as such it differs from person to person. One ­person may reference rural and think of corn fields, another of tobacco fields, and a third may think of isolated farms on top of a mountain, or perhaps small communities on the barrier islands off the eastern coast of North America or in the Atlantic ocean where children are ferried to the mainland for schooling (weather permitting). Officially, the concept of rural is defined by multiple criteria, such as administrative, land use, economic, geography, or distance from urban areas. It is also defined as what it is not. For instance, it is not a bedroom community to a larger urban area, it is not an area that provides its’ citizens with dependable and affordable transportation to needed services. The best definition of rural may be any populated land area that is not considered urban (Cromartie & Bucholtz, 2008; Smith, 1995). Over the years, the United States Census Bureau has refined its’ definition of what constitutes a rural area. In 1910, a rural area included some set of towns and villages below a population threshold of 2,500 people. Since that time the definition has become a population threshold of less than 20,000 people. In 2001, 21% of the U.S. population

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was designated rural, according to the U.S. Census Bureau’s land-use ­definition (US Department of Transportation, Federal Highway Administration, 2004). Some trends are consistently evident across rural populations in the United States. Rural areas exhibit lower education levels and lower income levels than the overall U.S. population. As our country has grown, the number of rural areas has decreased, thus intensifying the minority status of those residents living in rural areas. The United States Census population statistics show that in 20,000, less than 21% of the U.S. lived in rural areas. Hicks (1990) noted that one fifth of America’s population lives in rural areas. These rural areas also reveal “higher poverty rates, a larger percentage of the elderly, residents tend to be in poorer health, have fewer physicians, hospitals and other health resources, face more difficulty getting to health services, and face worse outcomes and higher risks of death from traumatic injuries.” Similarly, 60% of rural areas are designated as having Mental Health Professionals shortages (U.S. Department of Health and Human Services, Health Resources Administration, 2009; Wagenfeld, Murray, Mohatt, & DeBruyn, 1994). Integrated Models work well in rural communities where the community itself is often not able to support both services independently and the need to address all issues at once is a distinct advantage. In the following vignettes issues related to the needs of patients will be explored within models of Integrated Services; Tertiary Provider, Consultation Provider, and Interdisciplinary (Team) Provider (Drotar, 1995). Models of Collaborative Care will be viewed in Fully and Partially Integrated Models (Ruddy & Schroeder, 2004), Co-located Practice Models, Consultation Models, and Tertiary or Independent Provider Models (Robinson & Reiter, 2007). Barriers will be addressed that include geography; transportation; isolation; financial resources; stigmatization; and availability of providers. Also addressed are the issues associated with poor insurance coverage and lack of privacy (note that this is different than confidentiality). Ancillary issues related to travel costs – time, absence from school and work, gasoline cost, availability of car and driver – are included, and cultural taboos and beliefs, as well as cultural diversity issues regarding nationality, language, race, gender, socioeconomic status, educational and intellectual functioning, are addressed. Emotional issues that emerge include trust, shame, guilt, and fear.

Tourette’s Disorder and Kyle Kyle is a handsome young man, the older son in a family who makes their home in a rural community. He is just barely 17 and a senior in high school. Since he was a little boy, he has been treated for ADHD, and at the first introduction of medications he demonstrated tics. Medications were stopped and he was referred to a medical complex in a city 3 h away for a neurological consultation. The neurologist referred him to the near-by university’s counseling center for behavioral treatment. Kyle’s ADHD symptoms responded well to treatment, but the tics persisted and he was diagnosed with Tourette’s Disorder. He exhibited extensive head jerks, mouth distortions, barking noises, hand movements, and obsessive compulsive behaviors that distracted him

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from age-related tasks. He often obsessed over details and issues, and had difficulties understanding why his friends don’t share his thoughts. He was especially obsessive about his looks, and worked hard to keep his hair the way he desired. Kyle is anticipating leaving home for college after the summer, and is now ­seeing Dr. Allen for his last scheduled pediatric examination. He and Dr. Allen discussed moving from pediatrics to adult services, but Kyle is uncomfortable about changing doctors since he has been treated by Dr. Allen for a long time. Kyle is invested in his college plans. His high school class contains only fifteen people, and none of the girls seemed interested in him. He believes he will meet the perfect girl in college. He knows that he is handsome and feels sure when he gets away from “this town” he will find girls “following him at every street corner.” He  also plans to study medicine, sharing with Dr. Allen, “when I was young I wanted to be a doctor like you, but now I think I want to study to be a surgeon.” At present, Kyle has taken no medications for some time, has not followed-up with the recommendations of the neurologist, and has refused to follow-up further with the psychologist in the medical complex 3 h away. He liked going to the city, but it demanded too much of his time and his parents, very wisely, wouldn’t allow him drive there alone. His father accompanied him to his visit last with Dr. Allen. The father and Dr. Allen are friends and chatted at first about fishing, then about Kyle. Dr. Allen has integrated his practice in this rural town with a psychologist (Dr. Baker) who is trained in pediatric issues. The psychologist practices with Dr. Allen 3 days a week and their office is only 30 min from Kyle’s home. There are several options open to Dr. Allen in addressing Kyle’s mental health issues: 1. Send Kyle back to the neurologist (a 3 h drive away), and a follow-up with the psychologist who saw him the first time. 2. Ask Kyle to see Dr. Baker and arrange an appointment. 3. Ask Dr. Baker to join him in the examining room with Kyle and his Dad to ­discuss options with them. 4. Talk to Kyle about how unrealistic his plans to be a surgeon are, how girls will probably not fail to notice his Tourette’s Disorder, and point out how his obsessive-compulsive behaviors irritate those around him. Clearly choices one to three are options that have merit, but in a rural setting, even the best plans can be problematic.

Barriers Transportation.  From Kyle’s home, the office is located about 25 miles away, from Kyle’s school the distance is 15 miles, and from dad’s work the distance is 20 miles. For Kyle to be at this appointment, dad had to drive from work to Kyle’s school (to pick him up), and then to the office. Dad chose to take a half day off work and kept Kyle out of school a half a day – he had to do that in order to come to the ­appointment, drive Kyle back to school, and then return to work. He cannot stay too

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long in the office as he must make the return trip and still get to work in time to work a half-day. If Kyle was referred back to the medical complex in the city, this would be a whole day trip, and dad would likely want Kyle’s mother to go with them because “she understands these things better.” That means both adults would have to lose a day’s wages and there would be no one at home to take care of the younger children. So, the younger children would also need to go and miss a day from school. Finances.  Kyle’s father has a job with the state, affording him not only a fair income (for this section of the country), but also health insurance. Kyle’s mother works, also drawing a reasonable income for the area. They are able to afford to take Kyle to the medical complex. They are also prepared to pay Kyle’s college costs, as long as he attends a State College or University, which he will do. Privacy.  Kyle does not like to be seen going into the offices of a psychologist. He is more comfortable in the pediatrician’s office, though one of the part-time nurses is his aunt, and he knows the other two nurses from church. Thus, even though the psychologist practices with the pediatrician, a family friend or an extended family member is likely to know that Kyle saw a psychologist. Cultural beliefs.  Neither Kyle nor his dad see any real problems with Kyle – he has been like this for a long time, their friends and neighbors are accustomed to his symptoms, and friends or acquaintances don’t make fun of him. However, girls have not accepted his invitations to go out with him on a date. In addition, Kyle’s expectations may be unrealistic. Kyle’s Dad has never been to college, so he has no real idea what his son should expect, and whether Kyle is likely to become a surgeon. Additional issues.  A referral to a neurologist would involve much planning and coordinating, as the medical center often is not prepared to accommodate the needs of rural families. For example, if any neurological tests are needed, these may not be able to be performed on the same day. Ideally, multiple services can be held on the same day, but some insurance plans may not cover multiple services provided on the same date. In this case, Dr. Allen chose the third option and asked Dr. Baker to join Dr. Allen, Kyle, and his dad in the examining room. Dr. Allen shared with Dr. Baker a brief history of the problem, noting the extent of Kyle’s symptoms, adding information about Kyle’s ambitions, and relating the history with the neurologist, current and past medications, and that the family needed to leave this building within the next 15–20 min for Kyle to get back in school and dad to make his half a day at work. Dr. Allen asked Dr. Baker if she might have some thoughts, and she expressed a willingness to talk with the family for a few minutes now, to determine if she could be helpful to them. Dr. Allen left the room, and Dr. Baker turned to Kyle and asked him if there was anything Dr. Allen failed to tell her. She asked dad about his concerns, and then “applied a psychological band-aid,” making a few suggestions, and asking if she could schedule them to come back, so Dad could return Kyle to school and get back

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to work. Kyle and his dad agreed to come back, and to bring Kyle’s mom (and the other two children). A time was set, and Dr. Baker thanked them for including her. She promised to get his records from the neurologist in the medical complex, and reminded them that they would probably need to see the neurologist again, but there were some things that could be done here to help.

Integrated Model What were the facilitating factors that enabled Dr. Baker to intervene on such short notice? The prime factor was her availability – she was in house and had enough flexibility in her schedule to be able to respond. This is an example of an integrated model, where there is one record in which each clinician makes notes and all information is available to any treating clinician. Services are billed by the same agency. Dr. Baker and Dr. Allen work together often  – they pass information easily and respond to each others’ needs and the tempo of the day. Factors such as Dr. Baker’s familiarity with Kyle’s family, including his mother who suffers from a much milder form of Tourette’s Syndrome, assist in the provision of care. Dr. Baker’s psychopharmacological training, as it relates to medications to treat ADHD and Tourette’s Disorder, enables her to address medication issues and provide medication education. Her awareness of the factors involved in seeking treatment 3 h away is important to her decisions; and the professionalism extended by Dr. Allen allows her to deal with the family without making anyone feel “passed off.” Her abilities to rapidly assess and intervene allow her to substantially augment the pediatrician’s practice. Dr. Baker’s training in child development and family systems enables her to quickly assess and determine the issues and the patients’ needs. Her experience within the field of psychology, psychopharmacology, and integrated care allows her to intervene in a way that is not perceived as unusual or frightening to the patient. Her sensitivity to the barriers to service allows her to creatively solve problem and come up with the best course of action available under the circumstances.

Collaborative Care Implementation of collaborative care models, including this integrated model of patient care within the primary care setting, may be valuable in urban as well as rural settings. Rural integrated care, like urban integrated care identifies the community, assesses their needs, and then allows us to assess the diversity of those needs and determine how to address them. The next vignette presents a different treatment model that requires creative treatment planning.

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Charlie in the Fishing Village Charlie is 10 years old and lives with his grandparents in a small fishing village on the coast, in an area not particularly inviting to tourist. The town has one country store, which also sells gasoline, and there is a small diner in a trailer on the edge of the driveway to the house where Charlie’s cousins live with their family. His grandfather, a man of 60 who could easily pass for 70 or 75 years of age still earns a living through fishing. Charlie’s grandmother cleans fish for a fee. In inclement weather, Charlie must stay near his grandmother when the boats are out, “just in case.” There have not been many overboard deaths (or fishing boats that don’t return) in recent times, but his grandmother lost her father and brothers when she was young, and Charlie’s grandfather gave him firm orders to stay near his grandmother when the boats are out. He does go to school most days, but if there is a storm, he leaves school and returns to his grandmother’s side. Neither of his grandparents talks much; his grandfather lost his hearing when he was young from ­working on boats with loud motors. His grandmother became used to not talking, and when Charlie moved in, the family did not change much. Charlie’s mother and father went to the big city before he was born. He remembers them coming to visit him at his grandparents home when he was small, but after a while only his mother continued to come, and then she gradually stopped. His parents send money to his grandparents, but checks from both come from ­different cities, so he thinks they are not together anymore. Charlie’s grandparents completed about a third grade education, though they both report they stayed in school, “when we could,” until the eighth grade. Charlie doesn’t play with the other children at school. He sometimes plays with his cousins up the path, but overall he tends to stay alone, close to his grandmother, and his teachers think he might be “slow.” Charlie’s grandparents don’t believe in doctors – a major problem occurred when it was time for him to start school and he had to go get “his shots.” With regard to Charlie’s custody, the state could not locate his parents and eventually gave temporary custody to the grandparents so he could be enrolled in school. His grandparents really didn’t understand the problem, but went along with the “nice social worker” who came down to talk to them. Recently, Charlie caught ring worms and had to go to the doctor before he could return to school. His grandfather took him, but he waited for a rainy day, so Charlie missed 9 days of school. In his office, Dr. Crawford noticed that Charlie was behind in some of his shots. He also noted that Charlie’s communication skills were ­significantly below those of other children his age. He encouraged Charlie to talk with him, but Charlie, who was distrustful, became more withdrawn. Dr. Crawford began to suspect that Charlie may have some special needs. Dr. Crawford has an office sharing arrangement with Dr. Davis, a psychologist who works in the same office 1 day a week on a day when Dr. Crawford is not there. Dr. Crawford called Dr. Davis and explained his decision to treat Charlie pro bono, and asked if Dr. Davis would be willing to do the same. Dr. Davis was agreeable and set a time the next week, when he would be back at the village office.

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Dr. Crawford emphasized to Charlie’s grandfather how important it was for Charlie to return the next week, and arranged to see him for some shots 1 day and for him to meet with Dr. Davis the next day. He tried to talk to Charlie’s grandfather about his medical concerns, but Charlie’s grandfather seemed not to hear him. Unfortunately, Charlie did not show up for either of his appointments. Several appointments were made before the two doctors realized that the only way they could get Charlie to the office was to solicit local help. Dr. Crawford admitted he had no real relationship with Charlie’s family, even though he had been their doctor for 30 years. In fact, he had not seen the family more than a dozen times in all of those years. Dr. Crawford does have a relationship with many residents of the town, which may prove helpful. In this scenario, Dr. Crawford and Dr. Davis have several choices: 1. Dr. Crawford can call the Department of Human Resources and make a medical neglect complaint, requesting assistance in getting Charlie back into his office to see him and to see Dr. Davis. 2. Dr. Crawford and Dr. Davis can visit Charlie and his family and explain to the grandparents how important it is for Charlie to be seen by both of them for follow-up. 3. Dr. Crawford can ask the extended family for help in getting Charlie back to see him. 4. Dr. Crawford and Dr. Davis can chose to ignore the situation and wait for the next crisis. In communities where survival often requires working together, the boundaries between professionals and the community become less clear and often need to be blurred to remain helpful. In the above example, the school principal telephoned the clinic about 2 weeks after Charlie returned to school and said he suspected that Charlie needed to return to see Dr. Crawford. He also knew Charlie had an appointment with Dr. Davis, and wondered whether he could help with the arrangements. In a small town until someone asks for help or a significant problem is apparent, people tend to avoid intruding. In Charlie’s case, ringworms provided enough of a spark for the principal to make a phone call. Within hours, the principal was at the doctors’ office, accompanied by the local preacher, and presented a signed release for Dr. Crawford and Dr. Davis to share information with the principal and the preacher. Dr. Davis drove over to join them for dinner and a planning session. The principal spearheaded the community involvement and together with the preacher, the two implemented the treatment plan. The preacher arranged to visit the grandparents and work with them to help them understand Charlie’s needs. He volunteered his wife to do some after school ­tutoring, and together they approached the local deputy, who is distantly related, about providing transportation to insure Charlie keeps his appointments. The Deputy proved to be quite helpful – he not only agreed to pick Charlie up to be sure he kept his appointments, he also allowed Charlie to sound the siren on his deputy’s car each time he went to either doctor. Probably no one in the village failed to know when Charlie was being seen by Dr. Crawford or by Dr. Davis. Both doctors were able to identify and address Charlie’s problems. They determined that he needed hearing aids; he was behind in his reading skills; and he was frightened for his grandmother, feeling that if something bad happened (he had no idea

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what that might be) he would not know what to do. Dr. Crawford took on the hearing issues, and eventually Charlie got a new set of hearing aids. Since there was no insurance, the preacher spearheaded a donation to pay for them. Dr. Davis worked on the learning issues and arranged for a psychology intern to come to the village and test Charlie. The results of the testing indicated that Charlie’s IQ score falls well within the range of mental retardation and his adaptive skills support the diagnosis of Moderate Mental Retardation. He struggles with reading, but does much better in mathematics. Dr. Davis was able to guide the school in addressing Charlie’s educational needs. The “volunteered” preacher’s wife worked with Charlie around issues of selfconfidence and “deportment” (etiquette and good manners) and provided some academic tutoring, while the school arranged individual instruction in reading skills. The preacher also worked out a deal where Charlie’s older cousin would watch out for grandmother while he was at school on rainy days. The school counselor, who is also the school principal and the English teacher for lower grades, helped the family apply for disability benefits for Charlie. If he qualifies, this can provide an income and health insurance. No one in the village knew how to find Charlie’s parents. There was no contact except for intermittent checks with general delivery addresses. The deputy, along with members of extended family took on the task of making plans for Charlie’s care when his grandparents were no longer available to him. They helped him learn to feel safe in other homes, and took turns taking him on weekends. Charlie is planning to get a job when he finishes school; he wants to be the siren helper for the sheriff’s deputy.

Barriers Cultural diversity.  Charlie’s grandparents lacked education and did not understand how to meet Charlie’s needs. They also did not believe in medications or medical providers. Financial.  Charlie’s grandparents had limited financial resources and they often sought help from extended family for basic needs. The village itself is poor and pooled resources are seen as acceptable. It is important that Dr. Crawford and Dr. Davis were willing to provide treatment at no cost to Charlie’s family. Privacy.  There is little privacy in this tiny village. People are aware of each ­others’ business. Dr. Crawford’s office is located in the middle of town, next to the post office and across from the general store. Of course, the deputy’s siren helped the town keep up with Charlie’s appointments too. Transportation.  Transportation would have been an insurmountable problem had Charlie needed services outside of the community. The two doctors brought ­services to Charlie, including the intern who provided the psychological evaluation that was useful in school as well as in the disability determination application. Incidentally, Charlie did need transportation to take him from school to Dr. Crawford’s office, even though he can actually see the office from his classroom window – he needed transportation to be sure he kept his appointments.

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Consistency of providers.  Dr. Crawford has been practicing in the town for more than 30 years. He is a consistent figure. Dr. Davis is the third Psychologist to accept the office sharing arrangement, and each psychologist thus far has been recruited from the University, thus making intern services available on an intermittent basis. Additional issues.  The disadvantage of the collaborative care arrangement ­presented in this example was that it was not possible for Charlie to meet Dr. Davis the day he met with Dr. Crawford. While that is not optimal, it is still preferable to Dr. Crawford handing a card to Charlie’s grandfather and telling him to call this man in a town many miles away and arrange to take Charlie there. Dr. Davis’ willingness to drive down and meet with Dr. Crawford, the principal, and the preacher are examples of the flexibility and willingness needed to provide needed services to a child residing in such a setting.

Colocated Treatment Models Collaborative Care is defined by multiple arrangements and reflects the strength of the relationship between medical and behavioral providers (Robinson & Reiter, 2007). These arrangements can vary widely – from minimal collaborative care to connections that are more involved and offer multiple components. In Charlie’s story the colocation model is not minimal; the two doctors share the same office space by working on different days. They also talk on the phone about patients needs and, as seen in the above story, they sometimes meet for dinner to coordinate treatment plans. Their records and billing are separate; Dr. Davis simply rents office space from Dr. Crawford. This type of Collaborative Care is a reality in towns of all sizes, but probably lends itself especially well to small areas where a one or more primary care physician (PCP) shares the same limited patient population with one or more psychologist, social worker, or mental health counselor available in the area. These models of coordination and sharing vary from doctor to doctor – one PCP and behavioral health provider may elect to share treatment plans, medication recommendations, and family histories, while another PCP who is less comfortable with this arrangement may accept recommendations but avoid integrating plans. Psychologists also vary in their comfort with loosening boundaries and allowing physicians to become involved in psychological care.

Wally and Grandfather Jones Dr. Etheridge, MD. and Dr. Fitzgerald, PsyD. work in the same town. Dr. Etheridge works for a small medical group practice that includes several nurses and one ­physician’s assistant (PA), all providing pediatric care. An adjoining office is staffed with professionals providing adult medical services. Dr. Fitzgerald works across

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town in an independent psychological practice that includes a social worker, Ms Bell. Though the professionals in the two groups are friends, there is no established working relationship, other than an evolving attention to mutual referrals. The two doctors then collaborate or not, depending on their preferences in any given case. Mr. Jones is an elderly gentleman who has developed serious substance abuse issues exacerbated by his medical and marital difficulties. His grandson, Wally lives with Mr. Jones and his second wife, and neither Mr. Jones nor Wally have adjusted to her temperament and her scolding remarks. This is complicated even more by Mr. Jones’ illness and now the substance use. Wally has been in the home for over a year, and does not approach his step-grandmother for any of his needs. Now with his grandfather intoxicated on a combination of alcohol and pain medications, Wally has no one to whom he can turn and has subsequently become withdrawn. Dr. Etheridge saw Wally this week for the fourth time in almost as many weeks for a stomach ache. Wally claims it came on when he was getting dressed for his preschool day care, and he stayed home again today. When Dr. Etheridge asked him what he does when he stays home he said he goes to his room and watches TV. Dr. Etheridge felt Wally might be stressed over something. She asked the nurse to take Wally to the nurses’ station and allow him to color for a few minutes while she talked to his step-grandmother. Mrs. Jones had plenty to say, and as soon as Dr. Etheridge asked why Mr. Jones had not come, she poured out her story. She didn’t know if she could continue to stay in this marriage given her husband’s current use of alcohol and pills. The child didn’t bother her, in fact he rarely spoke to her, and she thought it was strange that he has all of these stomach aches while he seems fine when he is watching TV. She described the anger and arguments between her and Mr. Jones – she was upset that Mr. Jones was not getting well and did not help take care of Wally, and concluded that she might prefer to live by herself than to continue to live like this. Dr. Etheridge asked what Wally liked to do besides watch TV, and after thinking about it Mrs. Jones said he liked to go to church – he liked Sunday School, the children’s church program, and the Wednesday evening family program. However, since Mr. Jones had been sick, she had just been dropping Wally off and a neighbor returns him after the services and programs. Dr. Etheridge promised Mrs. Jones that she would try to help, and explained that she needs to talk to Mr. Jones about the problem. She asked Mrs. Jones to bring Mr. Jones into her office next week, so they could discuss a plan. Mrs. Jones was very willing to arrange that visit. Dr. Etheridge knows Dr. Fitzgerald’s practice, and knows that the social worker in his office sometimes works with substance abuse cases, while Dr. Fitzgerald primarily specializes in family systems and child/adolescent treatment. Dr. Etheridge also knew that Dr. Fitzgerald and Ms. Bell see both child and adult patients; she received feedback that their patients liked them, and had seen positive evidence of their work. Dr. Etheridge examined her choices: 1. She could call the Department of Social Services, Child Protective Division, and ask them to intervene, but she had no evidence that Wally was being abused or neglected (in accordance with the legal definition of those terms).

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2. She could talk to the grandfather about his substance abuse issues and ask him to seek assistance and to attend Alcoholics’ Anonymous (AA). 3. She could refer Wally to Dr. Fitzgerald, give Dr. Fitzgerald a heads up on what is happening, and allow him to address the substance abuse issues and Wally’s needs. 4. She could ignore the alcohol and pain medication issue; it doesn’t pertain to Wally, and see what develops. Dr. Etheridge chose to call Dr. Fitzgerald. He agreed to the referral but suggested that his involvement may be more successful if she were honest with Mr. Jones and shared her impressions with him. Reluctantly, she agreed, not because she wanted to deal with this issue, but because she understood that she would be validating Mr. Jones’ denial if she ignored the issue of substance abuse. Mr. Jones came in the next Wednesday. He did not seem happy to be there, and made it clear that he didn’t know why Wally was having stomach aches. He insisted he didn’t know what caused the problem, but it had to be something at the preschool because Wally was around children at church and he loved to go to church. Dr. Etheridge explained to him that children pick up on the stress from adults around them. Wally had left his own home when his parents were killed in an automobile crash when he was three. The safety in this home, she explained, was now being threatened by Mr. Jones’ health and his use of pain medications and alcohol. He was no longer there for Wally, and Wally had reason to fear going to school because he couldn’t know what was happening at home when he was gone. Mr. Jones didn’t like this feedback, but since Dr. Etheridge was the preacher’s wife, he controlled his reaction. With insistence, Dr. Etheridge outlined her recommendation to schedule an appointment with Dr. Fitzgerald for Wally and an appointment with Ms. Bell for himself. She told him she would also contact Dr. Fitzgerald and gave him the ­number for him to call for an appointment. Then, as he was leaving the door, she reminded him that she would call Dr. Fitzgerald to be sure Mr. Jones kept the appointment. Mr. Jones was quite upset when he showed up for his intake with Wally, and even more upset when he was scheduled to see Ms. Bell. Immediately after his intake, Dr. Fitzgerald wrote Dr. Etheridge a note thanking her for the referral and outlining his treatment plan. He related his recommendation that Wally did not require the use of medications at this time, as the psychological issues would be addressed cognitively and behaviorally within the family system. He left the door open for her recommendations and for a sharing of the treatment plans. Intermittently during treatment, Dr. Fitzgerald sent copies of his treatment notes to Dr. Etheridge. These contained an evaluation of Wally’s progress and noted issues not yet resolved. On one occasion Dr. Etheridge saw Dr. Fitzgerald at the service station, while both were filling their gas tanks, and thanked him for keeping her updated. During the course of treatment church attendance became an issue for Mr. Jones. He felt that people must be talking about him and the preacher must be preaching at him about his sin of drinking, and so it wasn’t long before Mr. Jones switched

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his family to a smaller church outside of town. Wally suffered as a result of the move. The new church had no programs for children, and few children attended the services – the congregation was mostly his grandparents’ age. Neither Dr. Fitzgerald nor Dr. Etheridge could dissipate Mr. Jones’ concerns. Once sober, he felt great shame at his prior behavior. On the other hand, Mrs. Jones assumed a more active maternal role with Wally and engaged with him as a parent. She went to school and met with Wally’s teachers, helped him with his homework, took him to see interesting and fun places. Gradually, she spent more time with him, and started hugging, laughing, and “doing stuff ” with Wally. Some months later Dr. Fitzgerald wrote a termination report and shared with Dr. Etheridge the success of the treatment. The family had addressed Wally’s nurturing needs and Mr. Jones substance abuse issues, and Mr. Jones was now involved in AA. Mr. and Mrs. Jones met independent of Wally to work on their marital issues and the feelings Mrs. Jones still harbored after, barely off their honeymoon, her new stepson became a part of their lives. Mr. Jones became more withdrawn a few years later, and although he never drank again, following a long illness he died. He left Wally to his step-grandmother who by now had a warm and engaging relationship with him. Collaborative relationships between psychologists and pediatricians have existed through time and in many communities, both rural and urban. They depend on mutual respect and opportunities for the recognition of the benefits of each other’s services. They thrive on “passing the flesh,” a warm handshake. Opportunities for professionals to develop a working relationship or even to “get to know each other” are the springboard for successful referrals. More extroverted and politically savvy psychologists are generally more successful in developing collaborative relationships. For example, joining the church and the country club can be very helpful. In very small towns, it might also mean frequenting the breakfast counter of the local diner to mingle with the locals. Such opportunities bring a mixed advantage – as personal relationships develop, they may serve to facilitate opportunities and yet they may also interfere with professional responsibilities and prevent opportunities (for example, by creating dual relationships). Resolving issues of personal relationships is a challenge for rural therapist, perhaps more often than for physicians. In this example, the collaboration is driven by personal knowledge and mutual trust, and by the psychologist’s availability. Records and incomes are not shared. The willingness to address coordination of care, which dictated that Dr. Fitzgerald keep Dr. Etheridge informed, allowed for Wally and Mr. Jones to follow a shared treatment plan from two separate offices.

Barriers Privacy. Substance abuse is always a difficult issue in small communities. Most of the community, as well as the preacher, knew about Mr. Jones’ problem, and he continued to feel ashamed and believed Dr. Etheridge did not maintain his confidentiality. Barriers to his privacy included small town shopping. He purchased his

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alcohol at the local liquor store, and he refilled his pain medications at the local pharmacy. Neighbors and relatives saw him not only buying his alcohol and his pain medications, but they saw him weaving when he left the store. In an urban area this same scenario is less likely. Mr. Jones’s quasiparanoid belief that his secrecy had not been maintained by Dr. Etheridge was precipitated by her dual relationship with him and individuals in his life. While it is not true she betrayed his confidence, it is true her husband knew about Mr. Jones’ drinking, as did everyone else in town. It was easy in that small culture for Mr. Jones to maintain his belief of having been wronged. It was also not possible to find another church where he was not as well known, and not possible to find another church that would have met Wally’s needs. Despite the more positive outcome, these obstacles could not be overcome. Geography.  Geography was a barrier only in the unavailability of other caregivers to whom Dr. Etheridge could refer Mr. Jones, availability of at least one other church with a children’s program, and the limited shopping availability in the local area. Had he pursued more privacy he might have sought out shopping arrangements outside of the small town. Such a decision would have potentially posed a greater risk because it would likely result in Mr. Jones drinking and driving.

Fully Integrated Collaborative Model In the following example, two psychologists (both pharmacologically trained) were contracted by the local clinic and paid for their services on hourly bases. The clinic, located in a small town, is federally subsidized, part of a larger organization that places clinics in areas demonstrating a need. The local clinic near Grandmomma Fanny’s farm is connected to the medical center where Annie and her family were seen by Dr. Godwin and Dr. Harris. Once a month, the adult treatment psychologist in this clinic travels to the smaller clinic and schedules patients, provides consultations, and participates in patient staffing meetings to make recommendations for referrals. This was not done for the pediatric population because the need for pediatric care was so great that most pediatric cases were sent to the larger medical center when they required expertise, as in this example. In the fully integrated collaborative model, all records are integrated and available to all staff providers. Additionally, the staff meets regularly to discuss specific cases, gain input, and coordinate services. In the following example, however, there is intraclinic staffing but no interclinic staffing, meaning there is no coordination of services, except informally, between the separate clinics.

Grandmomma Fanny and Annie Annie lives in a small community in an agricultural area. Her birth mother left her and her sister with their maternal grandmother to “raise” when Annie was three and her sister was four; she never returned. Both of the girls demonstrated major

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d­ eprivation issues – they had received no medical care since birth, they were undernourished, they had multiple body sores, and they had few clothes. It also became clear that Annie suffered from some form of a seizure disorder. Annie “fell out” in the grocery store right after her Grandmomma Fanny told her there was no money in this family for candy. The clerk reached for the phone and called 911 despite Grandmomma Fanny’s protest. The rescue squad arrived about the time Annie stopped shaking. They wanted to take her to the clinic but Annie told her Grandmomma Fanny she was sleepy and wanted to go home. Grandmomma Fanny took her home against the rescue squad team’s advice. The girls shared a two-room home, located on the edge of a field, with Grandmomma Fanny and her brother. The rooms are heated in the winter, with a wood heater. In the summer, the doors and windows are left open to allow what breezes exist in this southern climate to enter the rooms. Grandmomma Fanny and her brother farm the land, sharing the harvest and a percentage of the cash crops. A dirt road leads to the home and during rainy periods it is impassable. Life has been difficult for Grandmomma Fanny. She is a hard worker, a woman of few words, and she “doesn’t believe in doctors.” When it came time for the girls to start school, Grandmomma Fanny became quite upset; the school insisted they needed to be seen for a medical checkup and to verify their shot records. This was their first medical checkup since birth. The girls went to the local clinic that is open on Wednesday afternoons and Friday mornings. Located in a small trailer outside of the small cross road that passes for a town, the clinic staff asked a lot of questions about the girls that Grandmomma Fanny couldn’t answer. She didn’t know the race of their father, he wasn’t white and he wasn’t black, she told them. She knew their mother was black, and that was all she needed to know. She became angry during the interview; she couldn’t understand what the nurses were asking her and she couldn’t understand the doctor at all. They also had difficulty understanding her. She didn’t tell them about Annie’s fits (seizures) because she didn’t want them meddling in her business. She left the clinic muttering about how “it was no wonder folks didn’t go to doctors because they didn’t talk right.” She did consult the root doctor about Annie’s fits and was told what needed to be done. She followed those instructions to the letter. She did not plan to return to the small clinic. Grandmomma Fanny was not going to be able to ignore the local clinic for long. Annie had a seizure in the field one hot day before school started and nothing she did would bring her around. She put her in the car and headed for the root doctor, but the root doctor wasn’t at home. She had no choice, Annie was foaming at the mouth, she had bitten her tongue and her sister was screaming at the top of her lungs that Annie was going to die. Fortunately, it was Friday morning (when the clinic was open) and so, reluctantly, she took Annie to the clinic. After the doctor stabilized Annie, they called the ambulance and despite Grandmomma Fanny’s protest, they sent her to the City Hospital. Grandmomma Fanny was beside herself. The Department of Social Services (DSS) Child Protection Worker appeared on the scene and arranged to take Grandmomma Fanny to the hospital to be with Annie.

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Grandmomma Fanny was left at the hospital with no money and no food. When the hospital Social Worker came, Grandmomma Fanny was too ashamed to tell her she had no money. Eventually, the first DSS social worker showed up at the hospital and offered to help. All Grandmomma Fanny said was she wanted was to go home. So, Annie was left in the hospital alone, and Grandmomma Fanny went home to care for her older granddaughter and to help with the planting. When DSS brought Annie home, Grandmomma Fanny was given lots of medications to give to her and was told what to do in case of an emergency. Grandmomma Fanny didn’t want the nurse they sent to help her with the medications. She didn’t trust strangers in her home. Eventually, Annie started school where the teachers noticed her moods and her sleeping in class. She would sometimes terrorize her older sister, threatening to hurt her with a knife, but there was no knife at school. Her sister had bruises all over her most days and admitted that Annie hurt her. She insisted, “Annie doesn’t know what she is doing.” The school asked Grandmomma Fanny to take her back to the clinic to check her medications. Grandmomma Fanny said she would take Annie back to the clinic when the crops were harvested, so DSS stepped in. The Nurse Practitioner who saw Annie said she needed to go back to the City Hospital for her medications to be adjusted. There was concern that Grandmomma Fanny might not be giving her the medications regularly. The clinic records showed that 3 months worth of medications lasted 5 or more months. The nurse talked to Grandmomma Fanny without success – she wasn’t interested in what anyone had to say, and admitted she didn’t have any money for medications and, she added, loud enough for everyone in the clinic trailer to hear, “I don’t much cotton with folks giving me stuff I can’t buy myself. I is a proud woman.” Annie’s medications and her medical care were covered by a federally subsidized program that works with clinics in low income areas, so affording the medications was not an issue. However, Grandmomma Fanny resented “charity” and could not be convinced otherwise. Eventually, she begrudgingly accepted the medications because she didn’t want DSS to continue “to meddle in my affairs.” She believed Annie was just “touched” and the “fits” would not hurt her. Annie’s the blood test showed she had less of the medications than she needed. In the end, Annie went to the hospital and Grandmomma Fanny went home. After being released from the hospital, Annie began having seizures within the week. The local clinic felt they couldn’t handle the case and asked a larger medical center some thirty miles away to see Annie in their Pediatric Clinic. They also asked for Dr. Harris, the Psychologist, to consult. Grandmomma Fanny was not happy, but she had no choice – it was either take Annie or DSS would take her. So, she traveled to the medical center. In this facility, there are about 12 providers, including pediatricians and primary care physicians (PCP), physician assistants (PA), and several nurse practitioners (LNP). Integrated into the practice are two Psychologists, one who serves the adult population and Dr. Harris, who serves the Pediatric population.

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Annie was assigned to Dr. Godwin, a Pediatrician. He received records from the  clinic near Annie’s home indicating presence of pseudo-seizures that allow Annie to act out, attack her sister regularly, miss school, and maintain attention from those around her. The records from the city hospital where Annie was admitted were sketchy and validated the seizure activity that responded well to medications while Annie was in the hospital. The hospital records also indicated that a psychological evaluation for Annie had been ordered but Grandmomma Fanny refused. According to the records, Grandmomma Fanny also insisted that she gave Annie her medications regularly. Dr. Godwin and Dr. Harris saw several choices in providing treatment for this treatment-resistant family: 1. Annie could be treated strictly as a medical case, ignoring the psychological issues that could be addressed independently (in therapy) at a later time. 2. Annie could be sent back to the city hospital, 3 h away, with a request for further evaluations, extended inpatient care and psychological consults. Dr. Godwin could brief the hospital on the local issues. Funding could be an issue, as there had been no means to address this on a less invasive level, which is on an outpatient level. 3. Dr. Godwin and Dr. Harris could work together to address the issues. 4. Dr. Godwin could seek DSS assistance in monitoring medications for Annie. Dr. Godwin contacted Dr. Harris, and the two rearranged their schedules to allow them to jointly see Annie and Grandmomma Fanny. Dr. Harris noted that the key to this child’s treatment was with Grandmomma Fanny, and any attempts to leave her out of the treatment would surely be met with failure. They decided to stick to one goal – appropriate and consistent medications for Annie – and decided to jointly send this message to Grandmomma Fanny. The task was twofold – establish a diagnosis (medical and psychiatric) and establish a psycho-educational plan to meet the treatment goal. The question remained, are Annie’s seizures physiological or pseudo-seizures, as indicated by her first clinic notes? If pseudo-seizures are present, what is driving them and what is needed to intervene? If there are medical seizures (as both doctors suspected), what is needed to assure consistent medication for Annie? Since Dr. Harris is also African-American, his presence was of tremendous advantage in this case. It was hoped he would be effective in helping Grandmomma Fanny understand Annie’s needs. Because of his training in ­psychology and psychopharmacology, Dr. Harris was able to share briefly the medical concerns expressed by Dr. Godwin, hopefully in a way that Grandmomma Fanny understood. Grandmomma Fanny did not understand but she liked Dr. Harris from the start. Grandmomma Fanny was defensive with the clinic staff, but felt more comfortable with Dr. Harris because he was the same race and he could understand her dialect. She agreed to work with Dr. Godwin because Dr. Harris liked him. Through the course of treatment she listened politely to Dr. Harris, but made no agreements. She admitted to Dr. Harris that she thought all doctors should be men,

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so she decided that she could trust these two “men doctors.” Conversely, the doctor she spoke with in the city hospital was a woman. About a month after Annie and Grandmomma Fanny began regular appointments at the medical center, the family came in to see Dr. Harris. Annie’s eyes were beginning to roll back into her head and she was going limp as she entered the building. The staff moved quickly and emergency measures were initiated. The ambulance was called and Annie was stabilized and transported to the hospital again. Despite Dr. Harris’ urging, once again Grandmomma Fanny refused to go with Annie. Grandmomma Fanny did reach into her purse and handed Dr. Godwin the medications saying, “we should give her one of these now, they are for the fits.” This simple act of caring answered the question about how often Annie received her medications. In Grandmomma Fanny’s mind, medications were for when you needed them and not before you need them. Annie’s sister, left in the waiting room, became frightened. When Dr. Harris came out to talk to her, she was ready to tell him about last night. Annie hid a kitchen knife the night before with plans to use it on herself. Annie told her sister that she didn’t want to live like this and she was going to go into the back yard during the night and cut her own stomach open so she could die. Her sister had been afraid to tell Grandmomma Fanny, but with all the attention in the office, she thought her sister had actually cut herself open. While Annie was in the hospital, Dr. Harris met with Grandmomma Fanny and with Annie’s sister. They talked about her wanting to die, and how scared her sister was that afternoon in the waiting room. They talked about secrets, the kind we keep and the kind we don’t keep. They talked about seizures and the medications, how they worked, and what would happen to Annie without the medications. They also reviewed the things they needed to do to help Annie. Later, Dr. Godwin learned that different physicians saw Annie each time at the hospital, and conclusions were often based on what they learned from the local clinic when they called. Since they could not call Grandmomma Fanny, they had to rely on DSS information and clinic information. Annie, of course, did not talk to them at all. When Annie returned from the hospital, she returned to see Dr. Godwin and Dr. Harris. The family also continued to be seen by Dr. Harris as medication issues were worked out and attempts were made to help the family work together with DSS and Home Health services. Privately, Grandmomma Fanny told Dr. Harris that she had gone to the root doctor and followed her instructions. She insisted Annie was improving because of the changes by the root doctor. She promised though, to continue to give Annie Dr. Godwin’s medications because the root doctor told her it wouldn’t hurt Annie, and it would make Dr. Godwin happy. In her last session, Annie told Dr. Harris she did not remember the seizures, and she didn’t remember hurting her sister. She did remember her plan to cut her ­stomach open – she had tried to do that once before but she didn’t hold the knife right and it didn’t go in very far. Sure enough, there was a scar on her abdomen where she tried. She made him a “pinkie promise” not to do that again.

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Barriers Transportation. Grandmomma Fanny had a truck for transportation, however she lacked money for gasoline and she could not afford to be away from the farm during planting and again at harvest. Financial.  Grandmomma Fanny and her brother worked hard for the little income they made. Planting and harvesting are labor intensive, must be completed in a specific window of time, and without their combined labor they could not complete these tasks. They shared their resources, but Annie’s needs severely taxed their income. Of course, there was no insurance coverage, which qualified them for the federally subsidized medication program (which went against Grandmomma Fanny’s pride) and there were no savings for emergencies. Cultural.  Grandmomma Fanny did not believe in medical doctors, she believed in root doctors. She did not trust strangers or people who were not of color. She did not communicate well outside of her “own people.” Her dialect was thick and full of unusual and sometimes archaic terms. She had little formal education and was unable to understand much of what was being said to her because she didn’t understand the meaning of the words. She had no ability to understand the doctor whose speech was heavily accented. In addition, the presence of DSS “meddling” in her business hurt Grandmomma Fanny’s pride and made her angry and hostile. She felt pushed around and she recoiled from that control. The city hospital is a teaching hospital, and each time Annie was admitted, she was treated by a different resident. Apparently, each resident was a female. None of the residents were from rural areas and none of them were able to talk to Grandmomma Fanny. Grandmomma Fanny and Annie are not the norm in rural farming counties, but they are not unusual either. Grown children frequently return to the farm, or the small town, to drop off their children and leave again. Often when parents are asked about their own life, they recount the Grandmomma who raised them, not the momma. It is a cycle that continues, enhanced by the belief among poor families that there is always food on the farm.

Consultation Models Consultation models of service provision are not at all unusual in the medical field where physicians and their extenders frequently call on experts in a field to gain information to add to the treatment regime of a patient. They are particularly ­helpful when the person requesting the consultation is in a position to deliver the service.

Mary: Combined Diabetes with Eating Disorder Mary is a 15 year old obese female who was recently diagnosed with Type II ­diabetes. In a flare of histrionic behavior, she threw a fit when Dr. Irwin, her pediatrician,

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shared with her his findings of diabetes. He pointed out risk factors for her, but apparently aimed at deaf ears as Mary was not receptive. Dr. Irwin talked to her about her eating habits and the importance of exercise, and gave her some pamphlets to read about diabetes in general and the glycemic index in particular. He referred her to the Diabetes Educator who worked at the office on Fridays. Dr. Irwin set an appointment and strongly suggested that she not miss it. Mary stood up, held the literature in the air and said, “I am supposed to read all of this?” Dr. Irwin assured her that was the plan. She turned and tossed it in Dr. Irwin’s trash can proclaiming, “Fine, I have read it.” With that she left the office leaving her mother totally perplexed. Ms. Harrington, Mary’s mother, went immediately to the trash can and retrieved the literature. Her behavior was equally clear – she planned to read the literature. Dr. Irwin was frustrated and felt he needed assistance to help address Mary’s lack of cooperation. He arranged for a consultation with Dr. Jones, a psychologist who works in the nearest city and who has regularly consulted for Dr. Irwin and his group. Dr. Jones arranged a phone consultation with Dr. Irwin early the next week to discuss the case and formulate some possible interventions. Dr. Jones is on staff at the teaching hospital in a large urban area, and actually provides consultation to a number of small practices within a hundred and fifty mile radius. He is not connected to any of their medical practices, except by contract. His reduced-rate fees are paid directly to the hospital where he is employed, by Dr. Irwin, and the hospital pays Dr. Jones for the outreach component of his work there. As a result of this fee arrangement, he functions as a consultant with no third party reimbursement involved. The hospital fees for face-to-face consultation include mileage and time per hour from portal to portal. Since telephone consultation is less expensive, it is more frequently utilized. Dr. Irwin has several cases he wants to run past Dr. Jones when they talk, so the two have allowed a full hour in the middle of the day for their consultation. Dr. Irwin faxed information to Dr. Jones before their scheduled consultation appointment. Dr. Jones reviewed the blood sugar level, Mary’s diet, and her refusal to read the literature. He asked Dr. Irwin to check with Mary’s mother before the call to determine if Ms Harrington had read the literature and if she felt she could control any of Mary’s behaviors, including diet, adherence to medications, and her activity level. During the phone consultation with the mother Dr. Jones learned that Mary is in total denial with regard to the chronic disorder of Diabetes. She is also behaviorally out of control. She is taking none of her medications, she is not ­following an appropriate diet, and she continues to lie around the house, talking on her cell phone and arguing with her parents. She sleeps a great deal, and her idea of exercise is to play her handheld electronic games. Dr. Irwin summarized the family system for Dr. Jones, “Mary’s parents are older and she is an only child. They tend to allow her to do what she wishes, and thus have never managed her behaviors.” Dr. Jones suggested that they have school records sent to him and raised the question of depression. Dr. Irwin didn’t see the depression, but both doctors agreed the parental control, necessary in such a serious disease, is missing. They agreed to follow-up this initial plan and a second phone consultation was scheduled.

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Dr. Jones read the school records. Mary, meanwhile, had accelerated her acting out, now calling home once or twice a week, complaining of stomach cramps. Her mother regularly picked her up and Mary often missed school for more than 1 day. Dr. Jones noted that oral medications for diabetes often cause stomach cramps, especially when taken on an empty stomach. Dr. Irwin agreed to inquire about her oral medications. Neither doctor believed this was the full explanation, but might be fueling the problem. Dr. Jones suggested they bring the school nurse or counselor into the treatment and ask for her sugar level to be checked each time she demanded to leave school. Without a school nurse available, the school agreed, and elected to call her mother to the school to monitor Mary checking her sugar level. Mary was then not allowed to leave school unless her sugar count warranted medical treatment. The first time Mary’s sugar level was checked in school, it was too low, and she went to the clinic from school to have that addressed. The next three times her sugar levels were over 200 (very high) and Mary was taken to the clinic to have short acting insulin injected and monitored. Mary spent much time with the nursing staff and became more vocal about her life. She hated having diabetes, and she hated the things people told her about having your feet cut off, sores that would not heal, and similar horror stories. She was frightened and unrealistic in her demands that the diabetes just “go away.” Dr. Irwin and the nursing staff discussed what is happening – “she probably is depressed,” the nurses said. Dr. Irwin met with Mary each time she came in. When he asked about her appetite, she said “I can’t stop eating. I eat all of the time, even in the middle of the night.” He asked about her sleep pattern, “I can’t sleep, I just think about all of this and how unhappy I am and why did this happen to me. I was not sleeping before the diabetes though, I just think about everything.” He recalled her parents described her sleeping all of the time, and concluded she must be staying awake at night and sleeping during the day. He asked about her unhappiness and Mary began to cry, and she even admitted to having some thoughts of death. These thoughts scared her. She did not want to die. Mary had never shared this information with him. Prior to today, she presented animated, highly energetic, and playful. The next telephone consult between the psychologist and the pediatrician concluded in an agreement that Mary is very depressed. They agreed to start an antidepressant medication, and Dr. Jones suggested categories of medications that might not increase Mary’s appetite and that had proven effective in this population. He also suggested that they arrange some family therapy for Mary and her family to deal with the diabetes, lack of parental controls, and Mary’s depression. He recommended a clinic about fifty miles away, where the practice group contained a ­psychologist who had special training in some of these areas. He also recommended Mary’s parents attend the monthly Diabetes Education Class led by the visiting Diabetes Educator. Utilizing a paradoxical intervention, Mary could be allowed to attend, only if she felt she could academically afford to miss school for the class. Mary responded well to the antidepressant medications and stayed on them for almost a year. Expectedly, she did feel she could afford to miss school for the

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d­ iabetes educator’s class, and attended with her parents. Finally, they began to talk about the diabetes and the depression. In a breakthrough moment, Mary even admitted to having some thoughts of death, and that she did not want to die or kill herself, but she just couldn’t think of any other way out. Her parents were moved by this, but also prepared to respond, a result of the diabetes education class they had been attending. It is not unusual for diabetic patients to go through cycles of nonadherence to their medications and diets, Mary’s nonadherence was not a cycle, it was a part of her denial and her depression. Mary’s breakthrough led to her establishing reasonable goals for her diabetic care. Mary did not lose weight (a significant goal for obese diabetic patients) – this was the one issue Mary was not willing to entertain. However, she did respond to the diabetic education and began to adjust her diet to include fewer carbohydrates. She did not change her activity level. She and her parents attended the family therapy at the distant town, and Mary attended a half dozen sessions with the psychologist after the family work was completed. She may go back when she is old enough to drive out of town by herself, she informed Dr. Irwin. Dr. Irwin’s busy medical practice schedule only allowed him to prescribe Mary’s medications, but he asked his nurses to follow-up with Dr. Jones suggestions. Dr. Jones was aware of these limitations and adjusted her recommendations appropriately. While not the ideal, this model avails the patient of a wider range of services than otherwise might be available. Because of her training in child development, Dr. Jones helped design the intervention to put Mary in charge of her self-care, thus insuring her interest and establishing her role in decision-making. For diabetic patients, control of treatment is a paramount issue, one addressed early and often by treating physicians. Because of her training in psychopharmacology, Dr. Jones was able to make broad medication recommendations for Dr. Irwin to consider, outlining the mediations, individual dose ranges, and the side effect profiles of each (referring to efficacy data as appropriate). This proved very helpful to Dr. Irwin who does not usually prescribe antidepressants.

Barriers Geography. This small community did not have access to psychological services within a 50 mile radius. Distance to treatment, combined with the cost of travel, the time involved in travel, and the comfort of the parents in being willing to make the trip regularly were all significant obstacles. The trip to the psychologist was ­scheduled after Mary left school, thus requiring her elderly parents to drive back home after dark. While such a drive late in the evening may seem a minor concern to persons living in the urban areas, rural residents usually have to drive on country roads that lack street lights, and are abundant in wild life, including deer, which poses a danger to their safety.

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Financial.  Mary’s parents were both retired from a mill and drew a small pension, but did have medical insurance as part of their retirements. Not all of the services Mary required were covered by their insurance, and the parents had to use some of their savings to cover portions of Mary’s treatment. Dr. Irwin bore much of the cost of the intervention, as he contracted with Dr. Jones, and assumed the financial responsibility as part of his overhead cost for the level of care he felt appropriate in his office. This same model is sometimes seen in agencies supported by public funds (such as Federally-supported) or in larger practices where grant money is utilized to offset the financial loss of such a contract to the practice income.

Tertiary or Independent Private Practice By far, the most frequently encountered arrangement seen in communities involves independently practicing providers who provide treatment in a solo or group practice. Following are three patients in one vignette that addresses this model of ­service and the communications between providers.

Matt, Sam, and Grace Matt, Sam, and Grace all live in the same rural community. They attend the same consolidated school and ride the same bus to school. Matt is 9 years old and attends the 4th grade. Sam is 11 years old and is currently repeating the 5th grade. Grace is 7 years old and attends the 2nd grade. They live more than ten miles apart and know each other primarily through the school bus and the playground. Their ­parents do know each other, as they attended the same high school. None of the children attend the same church. Sam and Grace see Dr. West for pediatric care, Matt sees Dr. Smith. The two pediatricians are married and practice together in this rural area as part of a payback for their medical loans. They anticipate being in the area less than 5 years, and like their predecessors, they will “move on.” Since they have children at home, the couple work on different days and Dr. West handles all of the emergency calls. They fit well into the community and are devoted to the well-being of children. Matt is seen by Dr. West who immediately puts him on Focalin XR 10 mg qam and refers him to Dr. Young’s practice in town. He sends Dr. Young a letter, ­explaining that Matt has ADHD and is being treated with Focalin. He asks Dr. Young to work with Matt and his family. Sam is seen by Dr. West, has the same diagnosis, is given the same dose of Focalin, and is sent to Dr. Young in the same manner. Grace is seen by Dr. Smith who is more conservative than her husband. She discusses the medications with the family at this visit and arranges for Grace to

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be seen by Dr. Young for some testing. She explains to the parents that she would like to see what Dr. Young finds before she decides on medications, and as soon as she has Dr. Young’s report she will call the family and, if needed, start the medications. Grace’ parents are not happy – they thought they could get everything done in 1 day, and they had a letter from the teacher saying their daughter exhibits symptoms of ADHD and needs to be seen for treatment. Dr. Young receives these referrals the same week, schedules them immediately, and arranges to complete the evaluations. Sam and Matt are already on medications, while Grace is awaiting the results of the tests. The evaluation reveals that Matt indeed has ADHD, predominantly HyperactiveImpulsive Type. He is responding to the current medications but probably would benefit from a higher dose. Dr. Young also recommends some behavioral interventions at school and at home. He suggests some brief therapy for Matt individually and for his family. He sends the report to Dr. West who thanks him for seeing Matt and independently deals with the recommendation to increase the medications. There is no further feedback about Matt between the doctors. Sam’s evaluation reveals that he does demonstrate some inattention and hyperactivity-impulsive behaviors, probably associated with ADHD, but more important is Sam’s very high IQ score and the fact that he is bored in school. He is responding to the low dose of medications Dr. West started, and may benefit from a slight increase, but there are other interventions to implement. Dr. Young writes a report outlining his findings and suggests that the school should address his intellectual capacity and adjust his classroom assignments to challenge him. Dr. Young also outlines a behavioral plan to address Sam’s “clown” behaviors and suggests to Sam’s parents that they join Sam in some family therapy. In the family sessions they all agree that Sam might also benefit from a course of individual therapy to develop an understanding of his own skills and strengths. Dr. Young’s evaluation of Grace reveals that she is not able to read. Despite attending the second grade, she is not even able to identify her letters consistently. Thus, she is lost in the classroom and her inattention comes from not knowing what she is supposed to do. Grace admitted she just looked at the other children to see what they were doing, then opened her book and pretended to work. Dr. Young noted in his report that Grace is anxious and withdrawn, at least in part from being lost in school. Dr. Young recommended that the school address her learning difficulties and he provided the school with suggestions for classroom accommodations. He contacted Dr. Smith and followed-up with a letter in which he did not recommend medications at this time. When Dr. West and Dr. Smith received the reports, they integrated the findings into their treatment in the way they each saw it fit, in their role of providing medical care for each child. There was no communication with Dr. Young except a short note, generated by the nursing staff that acknowledged the receipt of Dr. Young’s report. Dr. Young dealt independently with the parents and the patients, and relied on them to advise him of the amount of medications their child received. He notified each doctor that he continued to follow their patient, and again, when he terminated each case.

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Barriers Financial.  In this setting, the financial burden is increased as each family must make two trips to town, to address each phase of the treatment. This often requires missed work days, missed school days, and transportation costs, which are basically doubled when two providers must be seen who practice independently. Privacy.  Privacy becomes one of the basic disadvantages to the nonintegrated model. People may be sensitive to being seen going into or sitting in the waiting room of mental health practitioners, while are more comfortable being seen entering a medical facility, sitting in a medical waiting room, and having their car parked in a medical center parking lot. Cultural beliefs, diversity.  In an integrated model, encountering diversity is more likely, as at least one of the healthcare providers may share some cultural, religious, or other personal similarities with the patient. When patients receive services from professionals practicing independently, there is greater potential for cultural and diversity barriers that may dissuade some people from taking advantage of the opportunity for treatment. Transportation.  Again, transportation is an issue not only in cost, but in availability. In this scenario, each family had their own transportation (cars or trucks), and was able to arrange the myriad of visits. Additionally, Dr. Young provided after school and evening appointments for his patients, thus eliminating some of the transportation and family/work issues. Still, the appointments were not coordinated, thus two trips were required initially and intermittently to achieve what would have required only one trip in an integrated model. Consistency of providers.  Dr. West and Dr. Smith are working in this rural area as part of their medical school payback program. The community is accustomed to these arrangements. Some people will describe feeling cheated when their favorite physicians leave after a few years, others describe this as an advantage, believing that in this way the community is able to secure the services of well-trained doctors they might not otherwise have attracted, and that, they conclude, is a plus for the community. Still, it is difficult to form trusting relationships when there is a high turnover of healthcare providers. Communication.  Because of the reduced information flow between the providers, gaps exist that might not have needed to exist. For instance, Dr. West sent Dr. Young a note advising him of his concerns, including the information that he had started Matt on Focalin but containing no information about dosing. Dr. Young is trained in psychopharmacology and is competent to make assessments about medications, to report side effects, and to provide education to the family about the medications as well as to make some minor interventions, such as checking to see that a child eats before he or she takes the medications. Dr. West may not be aware of that and does not share dosing information with Dr. Young. In an integrated model, Dr. Young would easily have become aware of the increase in medications when it was

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initiated and he would have been in a position to report back to Dr. West the status of the response to that increase. There are some commonalities in each of the three vignettes. In each story, there is a psychologist interacting with the patient and with the medical system from whom the patient initially sought assistance. In these examples of the independent practice model, which exemplifies, was much less integrated care than the other models, three children diagnosed with ADHD receive care from two excellent pediatricians who have set up a model of providing care to this population by including the psychologist. Although the integration is limited, they are in fact ahead of the curve, especially considering they are functioning in a rural area. Independent practitioners communicate, but not in a true dialog. They are communicating in a series of monologs. Letters written between the pediatricians and Dr. Young are formal, cordial, and informative. These letters are also infrequent, sent more as a matter of good manners and professional courtesy.

Summary Remarks As the author of this chapter on rural health and integrated behavioral health, it seems appropriate to share some of the progression in my own small area within which I practice. I am involved in a small group of psychology practice in a rural/ mill town located on the border of Virginia and North Carolina. The town holds much interesting history, and is located in North Carolina, a state that has a long history of progressive and innovative mental healthcare. Within this town exists a rural health group (medical and dental) that serves approximately ten towns. It is a Federally-funded health center whose mission is to serve the community at large, with a special emphasis on outreach to the underserved. This rural health group is fortunate to have at its’ helm a dynamic CEO who moved here from a “nonsouthern state” and brought with him experience in integrated healthcare. The program was set up from the beginning to be an integrated, not colocated, program, and to that end the initial three caregivers (two doctoral level psychologists and a Public Health Service Commander, licensed clinical social worker) were enrolled in a 6 month, six session course in primary care behavioral health, offered by the Mountain Area Health Education Center (MAHEC) in Western North Carolina. Collectively, the three providers brought a significant number of years of experience and a belief in the integrated model, which underwent major changes as we evolved and which was defined by our own skills and experience. An additional resource was found in the “I Care” program, a statewide program that is currently changing to be known as the North Carolina Center of Excellence for Integrated Care. In addition to direct consultation to our rural health group, and state-wide programming, “ICARE” offers downloadable resources, information bulletins, assessment tools, and eight of the 18 available

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continuing education (CE) modules for Primary and Behavioral Care (www. ICARENC.org). In a ­personal conversation with Regina Schaaf Dickens, Ed.D., LCSW, Director, NC Center of Excellence for Integrated Care (I CARE), Dr. Dickens provided a reminder to the history of NC as a leader in mental health, including the history of I CARE that began in 2006 and currently enjoys the support of the governor of North Carolina. (R.S, Dickens, July 29, 2010, personal communication). Medical staffs at the rural health group locations were and are open and receptive to the model. We each engaged in problem solving and, underwent a learning curve as we learned how behavioral health providers could best function in the setting, what skills we brought to bear, and how we will interact with medical providers. We continue to explore how we can be best utilized. Initially, shadowing was provided with the physicians and direct medical care staff, and we found that most helpful. Invaluable has been the “hanging out time” where we learn from them and we answer their questions about behavioral health, family systems, treatment options, and psychotropic medications. They make suggestions about our aches and pains and we have an unspoken agreement to avoid the weight scales.

Lessons Learned 1. Integrated Care is not accomplished by moving a psychological private practice into a building that houses a medical practice. The process evolves, creating a level of change for both medical and psychological practice. 2. As a clinician I bring a wealth of knowledge and skills from my training and experience. My task is to use these in the setting in which I am practicing to achieve the best outcome for my patients. 3. My Psychopharmacology training has been invaluable to me in the integrated model. One doesn’t have to be a psychopharmacologically trained clinician to function well in the integrated model. However, if you fall in the latter category, it will be helpful to locate a pharmacologically trained colleague. 4. The term “team player” does not originate on the ball field. I was told coming into my integrated care placement that I was also going to be a resource for the pediatric medical staff and that I could look to find ways to assist them in working out clinical as well as staffing issues. 5. I initially complained that “they” did not communicate with me, but gradually I learned that it was “I” who was not communicating and I don’t listen to their needs. Psychologists are trained to keep confidentiality and avoid releasing sensitive information about their patients. However, physicians need to know if the patient is being seen, if there are additional needs that need to be addressed, and if further referrals are needed from them or have been provided by me. I must provide this information in order to truly be a team player.

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References Bushy, A. (1993). Rural women: Lifestyles and health status. Nursing Clinics of North America, 28, 87–197. Cromartie, J., & Bucholtz, S. (2008). Amber waves: The economics of food, farming, natural resources and rural America. United States Department of Agriculture, Economic Research Service. Retrieved from http://www.ers.usda.gov/AmberWaves/June08/Features/ RuralAmerica.htm Drotar, D. (1995). Consulting with pediatricians: Psychological perspectives. New York: Plenum. Federal Interagency Forum on Child and Family Statistics. (2010). America’s children in brief: Key national indicators of well-being, 2010. Retrieved from http://childstats.gov/pd/ac2010/ ac10.pdf Hicks, L. L. (1990). Availability and accessibility of rural health care. The Journal of Rural Health, 6, 485–506. Percy, G. (2009). The city mouse and the country mouse. Mankato: Child’s World. Robinson, P., & Reiter, J. (2007). Primary care behavioral health consultation. New York: Springer. Ruddy, N. B., & Schroeder, C. S. (2004). Making it in the real world: Diverse models of collaboration in primary care. In R. G. Frank, S. H. McDaniel, J. H. Bray, & M. Heldring (Eds.), Primary care psychology (pp. 149–398). Washington: American Psychological Association. Smith, S. M. (1995). The changing rural context. Agricultural and Resource Economics Review, 24, 139–145. Retrieved from http://purl.umn.edu/31580 U.S. Department of Health and Human Services, Health Resources and Services Administration (2009). Shortage designation: HPSAs MUAs & MUPs. Retrieved from http://bhpr.hrsa.gov/ shortage/index.htm U.S. Department of Transportation, Federal Highway Administration. (2004). Census 2000 population statistics. US population living in urban vs. rural areas. Retrieved from http://www. fhwa.dot.gov/planning/census/cps2K.htm Vasquec, C., & Ravier, R. A. (1991). The problem with interpreters: Communicating with Spanish-speaking patients. Hospital and Community Psychiatry, 42, 163–165. Wagenfeld, M. O., Murray, J. D., Mohatt, D. F., & DeBruyn, J. C. (1993). Mental health and rural America: 1980-1993. Washington: U.S. Government Printing Office. Wagenfeld, M. O., Murray, J. D., Mohatt, D. F., & DeBruyn, J. (Eds.). (1994). Mental health and rural America: An overview and annotated bibliography 1978-1993. Washington: U.S. Government Printing Office. Wu, A. C., Leventhal, J. M., Ortiz, J., Gonzalez, E. E., & Forsyth, B. (2006). The interpreter as cultural educator of residents: Improving communication for Latino parents. Archives of Pediatrics & Adolescent Medicine, 160, 1145–1150.

Chapter 6

Collaborative Practice with Pediatricians Within the Indian Health Service: Taking Care of Frontier Children* Michael R. Tilus, Kevin M. McGuinness, Mimi Sa, Earl Sutherland, Bret A. Moore, Vincen Barnes, Johna C. Hartnell, and Anthony Tranchita

The distinction between rural and frontier living is much more than academic, particularly with regard to health care. In the United States, rural living is generally viewed as residing in a remote location, but having access to services such as ­specialty healthcare (e.g., pediatrics, psychiatry) within a 1  h or so commute. As with rural living, frontier living is also residing within a remote location, but individuals must travel several hours for services such as specialty healthcare. Today, many Native Americans residing on federal reservations find themselves hours away from adequate specialty healthcare services, making the need for creative and collaborative provision of healthcare all the more essential. Of particular note, within the Indian Health Service is the emergence of psychologists who have obtained specialized training in psychopharmacology and are licensed to prescribe psychotropic medications. The expanded skill set of such practitioners is evolving into an important means of closing a longstanding gap between healthcare need and availability. The juxtaposition of medical psychology and primary care medicine is also closing the communication gap between mental and physical healthcare practitioners. With the emergence of the medical psychologists in the primary care and hospital setting, the opportunities for collaboration between prescribing psychologists and other healthcare providers have never been better. The focus of this ­chapter is the pediatric realm with specific examples of the many ways in which two specialty fields (pediatrics and medical psychology) can work together to close the provider gap in frontier Indian Country.

* The views expressed herein do not necessarily reflect those of the Department of Health & Human Services, the U.S. Public Health Service, the Indian Health Service, the Federal Bureau of Prisons, or any Department of Defense Agency. M.R. Tilus (*) U.S. Public Health Service, Indian Health Service (IHS), Fort Totten, ND, USA e-mail: [email protected] G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_6, © Springer Science+Business Media, LLC 2011

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Indian Health Service The Indian Health Service (IHS) is the Public Health Service (PHS) agency that is tasked by the federal government with providing a comprehensive healthcare service delivery system for approximately 1.8 million of the nation’s estimated 3.3 million American Indians and Alaska Natives (AI/AN). Members of the more than 569 federally recognized AI/AN Tribes and their qualified descendants may be eligible to receive healthcare services provided by the IHS. A strategic goal within the IHS is to support the sovereignty of Tribal governments in meeting the health needs of their particular service populations residing, primarily, on or near Native American reservations and in rural, isolated, or medically underserved regions. In 1955, the IHS, a federal agency within the Department of Health and Human Services (HHS), was created to provide health care to Native Americans who are enrolled members of federally recognized tribes. The mission of the IHS is to provide a comprehensive health service delivery system for AI/AN with opportunity for maximum Tribal involvement in developing and managing programs to meet their health needs (Indian Health Service Manual 1996). In spite of the mission of the IHS, the provision of healthcare in general fails to meet the minimum needs of Native Americans, especially in rural and frontier regions of the United States. Although approximately 60% of Native Americans receive their healthcare from the IHS (IHS Fact Sheet, 2002), the funding for this agency has not kept pace with medical inflation and the increase in population. In fact, the funding available for patients in the IHS is so limited, that often patients must wait until their condition is life threatening in order to receive services. This lack of financial resources also makes paying for contract or specialty services difficult and need based. Some contractors now refuse to see Native American clients, because the IHS is unable to reimburse for those services (Democratic Policy Committee, 2004). The IHS is currently the primary agency responsible for the provision of mental health care to AI/AN. It is the third author’s observation that a lack of funding has reportedly resulted in four IHS service areas without child or adolescent mental health professionals. Further, the inability to meet financial needs within the IHS has led to isolation for provider and patients, difficult work conditions, cultural differences, and high turnover rates that impede efforts to provide mental health services to Native Americans. Native American children who live on federally recognized tribal reservations face very unique and oftentimes daunting socioeconomic and medical challenges. Generations of trauma, cultural abuse, racism, and violence against Native Americans by the dominant culture have led to conditions for children on tribal reservations that resemble those in developing nations. From gestation, the Native American child is more likely to face toxins, malnutrition, and violence than any other cultural group in the nation. The following are some of the most recent and daunting statistics currently available from the IHS on Indian Health Disparities (Indian Health Service, 2006):

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• Of the 564 federally recognized AI/AN Tribes and their descendants eligible for services provided by the IHS, approximately 57% rely on the IHS to provide all their healthcare services in 45 hospitals and over 600 other facilities. • The AI/AN people have a lower life expectancy and disproportionate disease burden with associations due to inadequate education, disproportionate poverty, discrimination in the delivery of health services, and culture differences. • AI/AN people born today have a life expectancy that is 4.6 years less than the U.S. all races population (72.3–76.9 years, respectively; 1999–2001 rates). • AI/AN die at higher rates than other Americans from tuberculosis (500% higher), alcoholism (519% higher), diabetes (195% higher), unintentional injuries (149% higher), homicide (92% higher), and suicide (72% higher). (Rates adjusted for misreporting of Indian race on state death certificates: 2003–2005 rates.) • The birth rate of Native Americans is 1.5 times higher than the national average. • The infant mortality rate is 20% higher than all races. • About 20% of Native Americans aged 12 and older used an illicit drug in the past year (vs. 12% in the total U.S. population), and about 7.8% were in need of illicit drug abuse treatment (vs. 2.7%). • Drug related deaths among Native Americans are two times the national average. • Within IHS the per capital allotment is $1,914 which is half of the allotment provided for federal prisoners. It is critical for the readers to grasp the significance and severity of these healthcare disparities that shape the grassroots emergence of the medical psychologist identity and mission. Ultimately, it is the public health crisis in Indian country to which the nonphysician prescriber is responding and from which the medical psychology is evolving as a natural outgrowth within the professional field of clinical psychology.

IHS National Model for Innovative Health Care Retired senior IHS Chief of Staff RADM (Ret.) Dr. Jerrold M. Michael (IHS 1961–1963) discussed with the first author his belief that the IHS was the national flagship of innovation in the delivery of health care (personal communication, June 6, 2010). Dr. Michael summarized his views with the following four points: 1. Health Care Leadership of the IHS: The IHS has served as a positive laboratory for the nation in regard to innovation in expanded function delegation of responsibilities of healthcare delivery since the PHS assumed full responsibility for care of the First Americans in 1955. “Radio practique” or the practice of ­assessing patients’ health condition through radio communication with health aides in

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remote villages of Alaska in the 1950s was the genesis of current-day remote diagnostic practices. The contribution of the Physician Assistant and Nurse Practitioner professions was facilitated by their early positive experience within the IHS. The Prescriptive Authority experience of psychologists within the IHS (and concurrently in the military services) is one more example of the forward looking healthcare advances which can be attributed to the healthcare team of the Indian Health Services. 2. Professional growth of psychologists: As DeLeon, Sammons, and Fox (2000), well-recognized psychologists involved in healthcare system improvement, noted “the increased autonomy of nonphysician healthcare professionals to prescribe is seen by many observers as an index of their maturation as a profession” (DeLeon et al. 2000, pp. 285–287). This experience in healthcare delivery that has served the AI/AN well should be fully extended to the healthcare system of our nation as well as the global health community. 3. Offsetting the healthcare manpower crisis: “The numbers of public healthcare professionals serving our nation has properly been described as in crisis. The projected shortage available to serve Federal beneficiary is equally in jeopardy. Innovations that extend the authorities of well-educated health professionals to serve a needy patient universe are part of the equation of healthcare reform that should be part of our national effort. The experience of psychologists with prescriptive authority is a positive example of that movement” (personal correspondence with first author, June, 2, 2010). These summary remarks from senior IHS leadership illustrate the grass roots response of the medical psychologist as another example of IHS innovation and adaption.

Medical Psychology in IHS: Responding to the Grassroots Need for Access to Quality Mental Health Care Medical psychologists are answering the call to serve in the isolated, remote, medically underserved Native American and Alaska Native communities. Officers of the U.S. Public Health Service (USPHS) Commissioned Corps, direct tribally hired personnel, and federal civilians are joining the primary healthcare teams at Service Units (SUs) of the Indian Health Service (IHS) as primary behavioral healthcare providers. All are attempting to help address the mental health problems that may be reaching epidemic levels within sovereign, Indian Nation regions that, in some ways, resemble third world countries. It was during this public health crisis that the American Psychological Association identified prescriptive authority as a major direction for the future of professional psychology. This emphasis on expanding the scope of practice of clinical ­psychology comes as American psychiatry continues its unsuccessful struggle to train psychiatric

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professionals in the numbers necessary to meet the needs of individuals in urban, remote, and other medically underserved areas of our country. At its core, the essence of the prescriptive authority agenda is the fundamental issue of access to the highest quality care for all Americans, including isolated, remote, medically underserved ,and unserved populations. These medical psycho­ logists, regardless of being a PHS Officer or federal civilian, are behavioral scientists and practitioners who potentially bring more “tools” to the trade than any other behavioral health discipline. Although the IHS has consistently been understaffed, underresourced, underfunded, and overbooked in their mission of trying to provide appropriate medical care to the Indian people, the medical psychologist is providing a service delivery model that will uniquely meet the needs of many SUs throughout Indian country. Appropriately trained and licensed medical psychologists, working in a collaborative fashion with demonstrated knowledge, skill, and ability to safely prescribe or unprescribe, are a “mission multiplier” to a medical system challenged every day to resolve and satisfy untold competing needs by juggling sparse resources. Medical psychologists are public health professionals dedicated to the mission of protecting, promoting, and advancing the health and safety of our nation. Many clinicians and their families have chosen to devote their personal lives and professional careers in the service of isolated, remote, and medically underserved populations. Success at such a mission demands steadfastness, heart, courage, and tenacity. Properly trained and licensed prescribing psychologists, once only imagined, are today tangible professional resources that increase the availability of comprehensive, quality mental health services. This is force multiplication “on the front lines” of rural mental health care that is critical to the provision of services in Indian country. As is true in most of rural and frontier American country, the lack of integrated mental health services to include psychiatric care is epidemic. All of the authors of this chapter who have worked in various Indian Health SUs as clinicians, are medical psychologists, and have realized that our patients lack access to the targeted level of health care. Lack of resources, harsh and inclement weather, chronic, frequent staff turnover, inability to recruit or retain qualified mental health practitioners, and overwhelming poverty have each and all together contributed to this crisis. The Indian people experience overwhelming health disparities, alcoholism, diabetes, injuries, homicide, and suicide. Suicide is the second leading cause of death behind unintentional injuries for Indian youth ages 15–24 years residing in IHS service areas and is 3.5 times higher than the national average (IHS Fact Sheet, 2010). Over one-third of the demands made on health facilities in Indian country involve concerns related to mental illness, alcoholism, and substance abuse. The system of services for mitigating mental health problems and treating mental illness in Indian country involves a complex web of tribal, federal, state, local, and community-based services. The availability of these programs varies widely across communities. Behavioral health services are often sparse, psychiatric care only exists hundreds of miles away, and access is often difficult and costly. The need for

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culturally appropriate, evidence-based, promising practices for the prevention and treatment of substance abuse and suicidal behaviors is critical. This has been identified as a public mental health crisis (HIS Fact Sheet). This is the context for the integrated and embedded medical psychologist.

Scope of Practice of Federal Prescribing Psychologist To practice as a psychologist within the IHS, one must have an unrestricted, state issued, psychology license from any U.S. state or territory. The prescribing psychologist must also obtain a State Certificate of Prescriptive Authority, and a U.S. Drug Enforcement Administration Controlled Substances Registration Certificate. Senior medical psychologist and PHS Officer, CAPT McGuinness and Tilus (2010) documented a legal opinion concerning the scope of practice as a PHS Corps officer after several experiences where such was challenged by state actors. For any IHS, or tribal, prescribing psychologist position, there are regular governmental application procedures that must be followed. With regard to prescriptive authority, the prescribing psychologist must submit credentials and licenses to the SU Clinical Director and medical staff for review and recommendation. Professional credentials must be accepted prior to the granting of delineated clinical privileges by the IHS Area Office under which authority the prescribing psychologist will practice. A recommendation report from the recommending body (local IHS SU) is submitted to the Area Level IHS for final approval. The SU directly authorizes all medical privileges, with the Area Headquarters’ administrative approval. All of the authors of this chapter have either received or are in the process of obtaining prescriptive authority from the state of Louisiana, and/or New Mexico.

Preparing Psychologists for Prescribing in the Indian Health Service The current policy of the IHS is to base a healthcare practitioners’ scope of practice upon each practitioner’s state license. In addition to maintaining a professional license, each healthcare practitioner must also be credentialed by their local medical staff. As healthcare providers and members of medical staffs, psychologists are governed by these requirements. After obtaining a state license, a prescribing (RxP) psychologist must apply to their medical staff for prescription privileges. At this time only the territory of Guam and the states of Louisiana and New Mexico have approved and implemented prescriptive authority for appropriately trained psychologists. The IHS has formed a national task force to develop recommendations for supporting the training of RxP psychologist. Three IHS Regional Areas, Albuquerque (NM), Billings (MT), and Aberdeen (SD) have successfully piloted a supervision protocol that meets the New Mexico Board of Psychologist

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Examiner’s license requirements. That protocol is being recommended as a model for supporting IHS psychologists in obtaining prescriptive authority and will be described below. New Mexico has two levels of prescribing psychologists, the Conditional Prescribing Certificate and the Prescribing Psychologist Certificate. The requirements for those certifications are detailed in the New Mexico Administrative Code (New Mexico Administrative Code, n.d.). Psychologists must complete the requirements for the Conditional Prescribing Certificate (CPP) and then complete an additional 2 years of supervision to be eligible for the Prescribing Psychologist Certificate. In addition to the academic/subject matter requirements and passing the Psychopharmacology Examination for Psychologists (PEP), CPPs must complete an 80 h physical assessment practicum and complete at least 400 h of supervision of their work with at least 100 patients with mental disorders. A primary, onsite supervisor is required. A secondary supervisor may be utilized but is not required to be onsite. All prescribing psychologists are required to work in collaboration with a patient’s primary care provider. Collaboration between IHS psychologists and primary care providers is an integral part of professional practice and has served as the basis for the training supervision protocol. Upon completion of their academic training, RxP psycho­ logists select a primary care physician to serve as their preceptor and supervisor for the 80-h physical assessment practicum. To successfully complete that practicum the RxP psychologist must demonstrate their competence in medical interviewing and history taking, basic physical assessment and interpretation of lab results, as well as planning for additional referral and follow-up consultations. After completing the physical assessment practicum, the RxP psychologist is eligible to begin the 400 h, 100 patients supervision program (400/100). The primary supervisor for the 400/100 must be onsite. A primary care physician familiar with psychotropic medications is recommended to be the primary supervisor. The secondary supervisor is recommended to be a psychiatrist. RxP Psychologists from the Billings and Aberdeen Area have been able to participate in a pilot phone consultation program with a psychiatrist through the University of Washington Psychiatry department. Negotiations are underway to contract and expand tele-med consultation/supervision services. Successful completion of the 400/100 supervision program requires the favorable evaluation and recommendation of the primary supervisor. It is expected that the RxP psychologist will pass the PEP during their 400/100 supervision period. Upon completion of the physical assessment, the 400/100 supervision requirements and passing the PEP, the RxP psychologist is eligible for the New Mexico Conditional Prescribing Certificate. IHS psychologists must maintain both state licensure and medical staff credentialing in order to practice at their facilities. Obtaining a Conditional Prescribing Psychologist Certificate allows the RxP psychologist to apply to their respective medical staffs for additional clinical privileges. Upon approval of additional privileges the RxP psychologists can begin prescribing in accordance with their state license and medical staff privileges. Medical staff privileging also permits the CPP to begin the 2-year supervision period required for the Prescribing Psychologist Certificate.

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Similar to the 400/100 supervision, a CPP must obtain a physician as their primary supervisor. Over 2 years time, the CPP is required to have at least 4 h of individual supervision per month and treat at least 50 patients for mental disorders. Upon completion of the 2 years of supervision the CPP is eligible for the Prescribing Psychologist Certificate. All of the present authors’ experiences in completing the supervision protocol have been very favorable. The medical and administrative staffs have been completely supportive. As a direct result of our interactions with our primary care physicians during our physical assessment practicum, our facilities have been able to advance our integration of behavioral health care in primary care practice. One of the authors now teams up with a primary care physician for 2 days a week. His facility is committed to increasing their number of fully functional integrated healthcare teams.

History of RxP Within IHS In 1988, the IHS granted a measure of prescription privileges to one psychologist (DeLeon, Folen, Jennings, Willis, & Wright, 1991). Although that policy was later reversed, those procedures for RxP psychologists are remarkably similar to the New Mexico requirements for conditional prescriptive authority. Twenty-two years later, it seems very fitting that the IHS should again be leading the way in advancing RxP psychologists toward independent practice in the public sector.

IHS Prescribing Medical Psychology Precedent: Dr. Floyd Jennings PhD The precedent for psychologists prescribing within the IHS was set some time ago. Dr. Floyd Jennings (personal communication, March 18, 2009) informed the first author that in the mid-1980s he was prescribing at the IHS Santa Fe Indian Hospital as a “dependent privilege provider from a limited formulary.” The reader will be well served to read Dr. Jennings’s full account of this groundbreaking RxP effort (Jennings, 2010). The IHS responded to an urgent need for skilled psychologists and a growing demand for psychotropic interventions by permitting one psychologist, Dr. Jennings, to provide psychopharmacology and psychotherapy services. Of the 378 patients that he treated with psychotropic medication in the first year of his practice as a prescriber (under a collaborative physician arrangement) no adverse events were encountered (DeLeon et al., 1991). Although all evidence may suggest that the patient care provided by Dr. Jennings to IHS beneficiaries was safe and effective, there were no licensing laws permitting such practice at that time. Even the New Mexico Psychological Association in 1988 recognized that there were no established professional standards for psychologist

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prescribers against which to form an opinion as to the ethics of such practice. That year, on December 9, 1988, a memorandum was released to IHS practitioners from the associate director, Office of IHS Health Programs, stating: In a limited number of SUs, clinical psychologists have been allowed by medical staff bylaws to prescribe psychotropic medications independent of physician supervision … Therefore … I am hereby advising you that effective with the date of this letter, is it IHS policy that no psychologist may be permitted to prescribe medications independent of physician supervision. Operationally, this policy means at a minimum that any order for medication written for inpatients or outpatients by psychologists must be countersigned by a physician, preferably, a psychiatrist (DeLeon et al., 1991, p. 257).

In effect, more than 20 years ago the IHS demonstrated that with or without physician supervision psychologists could responsibly prescribe. In the 1990s, psychologists in the IHS continued to make medication recommendations, often guiding the psychopharmacologic treatment of IHS patients.

United States Public Health Service (USPHS) Commissioned Corps Disaster Mental Health Deployment: Rosebud Reservation In 2008, tribal President Rodney Bordeaux and the tribal council of the Lakota Sicangua tribe on the Rosebud Reservation declared a state of emergency (Young, 2008) after recent years of young people killing themselves. Tribal sources reported that during 2005, an estimated 28 tribal members, mostly teens and early 20s had killed themselves by hanging, overdosing on drugs, or slashing wrists. In 2007, the reservation’s suicide rate soared to 141/100,000 people, which is a staggering 201/100,000 for males ages 15–24. The national rate in America is 11 or 12 per 100,000. In response to this epidemic, a request was made by the IHS for PHS mental health officers to be deployed to Rosebud, SD, in response to a critical shortage of mental health practitioners during what has been described as an unprecedented suicide epidemic among members of the Lakota Sicangu tribe, possibly the highest incidence in the world (Young, 2008). It was within this context that the Rosebud Nation declared a national disaster and requested help from the PHS and the Aberdeen Area IHS. Within the Health & Human Services, there are five disaster mental health response teams (MHT) comprised entirely of PHS Commissioned Officers. CAPT Kevin M. McGuinness, USPHS, was the Team Leader of Disaster Mental Health Team Four (MHT4). Members of various MHTs including MHT4 were deployed to support the Rosebud Tribe’s request for federal assistance. In addition to support from social workers and clinical psychologists, a specific request was made of the MHTs for practitioners with prescriptive authority. As CAPT McGuinness deployed from MHT4 to support this mission, he became the first licensed medical ­psychologist with a full and unrestricted license to obtain independent prescription privileges in the IHS at the Rosebud. The IHS faces many, often daunting, healthcare access problems. It also has a demonstrated willingness to consider reasonable solutions to healthcare access

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challenges without giving extraordinary weight to their popularity. From 1988, when Dr. Jennings became the first IHS psychologist to prescribe, to 2008, when Dr. McGuinness became the first licensed medical psychologist to be granted prescriptive authority by the IHS, there has been continuous, incremental effort to improve access to mental healthcare services within the IHS. Generally, the IHS has permitted psychologists, and now medical psychologists, to practice to the full extent justified by their training, experience, license, and law. The use of PHS medical psychologists as emergency clinical responders can be seen as a naturally evolving effort to meet the need on Native American reservations and continues today as the Corps has been called upon to expand its emergency preparedness capability both with increased calls to Indian country as well as other natural disasters across the U.S. and around the globe. Recent deployment orders to the first author specifically called for “prescribing medical psychologists” as part of the initial, rapid response, disaster deployment team. Licensed medical psychologists are tangible personnel resources that increase the availability of comprehensive, quality mental health services. This is force multiplication “on the front lines” of frontier and rural mental healthcare, especially within Native American communities.

Aberdeen Area IHS Behavioral Health Strategic Initiative The first author was asked in 2007 to research and lead a new strategic initiative to support prescriptive training and privileges among the psychologists serving in the Aberdeen Area IHS. Through the joint collaboration of the Aberdeen Area IHS Director and the Aberdeen Area Division Behavioral Health Director, a joint strategic plan was spearheaded supporting the clinical psychopharmacology training for seven IHS psychologists as a part of the overall 2007 Behavioral Health Initiatives. The IHS Aberdeen Area Behavioral Health Director Vickie Claymore-Lahammer joined this cohort and began formal training for prescriptive authority. Three members of the initial cohort were PHS Corps officers and four were Native American civilian psychologists. The Aberdeen cohort’s initial prescriptive training effort experienced delays and disappointments. Regrouping, the cohort found new resilience and support from the American Society for the Advancement of Pharmacotherapy (Division 55 of the APA). Donations and incentives from private sources, the Irving and Dorothy Rom Family Foundation, the Psychologists in Public Service (Division 18 of the APA), the APA, and Alliant International University propelled in a national collegial effort to see the Aberdeen Area Native American and PHS psychologist cohort become prescribing psychologists serving in Native American communities. Without the help of these national partners, the Aberdeen prescribing cohort’s goal might never have gotten off the ground. There are currently six Aberdeen area psychologists in prescriptive authority training now. Facing often overwhelming mental health needs, lack of healthcare funding, poverty, extreme isolation with little infrastructure resources, hazardous weather, and high levels of alcohol and substance abuse, the Aberdeen Area Division of Behavioral Health (DBH) Director saw the potential mission impact of having

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p­ sychologists in the small SUs who could also prescribe, monitor, and manage psychotropic medication. Recruiting psychiatrists to come to the upper prairies has been particularly challenging and future prospects remain dismal. Almost all practicing psychiatrists that have been identified thus far have been located in the few, larger, settled towns of the upper prairies, far from the reservations. Many of the IHS SUs have also been unable to find sufficient numbers of candidates for their psychologist positions, given the shortage of medical psychologists. After hearing about the Aberdeen Area IHSs decision to support medical psychology, psychologists working in the Montana IHS region began their own quest for prescriptive authority. The Montana IHS region, at the time of this writing, has two prescribing medical psychologists (both are coauthors of this chapter) and approximately four other psychologists who have completed or are currently enrolled in prescriptive authority training. In a collaborative effort between these psychologists, the Area’s Chief Medical Officer and Behavioral Health Consultant, the group has recently developed and implemented a practicum and supervision plan to emulate the requirements of New Mexico’s prescribing psychologists statute. A physician is the primary supervisor on site at each SU, and a psychiatrist provides teleconferencing consultation as an additional source of training and support. Several sites in the Montana Area IHS are also actively recruiting for prescribing psychologists. Senior USPHS Commissioned Corps and IHS psychologists and other behavioral health providers continue to offer guidance, support, and informed opinions on how the medical psychologist will be integrated into the IHS system at large. At the time of writing, these points have been discussed with the authors and appear to be the most germane: • Current law and regulations permit those medical/prescribing psychologists to practice in the IHS as either federal civilians or USPHS Commissioned Corps Officers so long as they have an appropriate license from one State. • Privileging does remain a local process. Each SU within the IHS establishes their credentialing procedures with administrative approval established at the Regional Level. • As an example, the New Mexico (NM) Board of Pharmacy and the NM Board of Psychologist Examiners in association with the NM Attorney General’s office has indicated, in the case of CAPT Kevin McGuinness, that the State cannot interfere in the practice of a USPHS Medical Psychologist licensed in another state (not NM). CAPT Kevin McGuinness has also practiced as a medical psychologist under his Louisiana license in South Dakota, on the Rosebud Sioux Reservation. • Privileging pathway already exists generally within the larger IHS structure, and has been successfully exercised in four of the eight authors of this chapter who received prescription privileges. • Efforts have been made at providing appropriate medical practicum and preceptorship training within select Indian Health SUs for prescribers. • There are four actively prescribing medical psychologists practicing in Billings, Aberdeen, and Albuquerque Regional Areas with New Mexico Conditional Prescribing Psychologist license and certification.

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• In addition, there are approximately twelve other psychologists (USPHS Corps officers and federal servants) who are in various stages of completing either their clinical or academic portions of training. • The USPHS Commissioned Corps is actively recruiting mental health officers (in the hundreds), to include prescribing medical psychologists, clinical psychologists, psychiatrists, psychiatric nurse practitioners, and social workers. The IHS is also actively recruiting medical psychologists. • Both the IHS and USPHS Commissioned Corps have created new federal job descriptions and/or billets defining the medical psychologist as a separate, primary, behavioral healthcare provider. • The medical psychologist as another model of care has broad, general, endorsement from both the local small SU and the chief administrative and behavioral health division IHS leadership.

IHS Headquarters Division of Behavioral Health: Interagency Collaboration In March 2010, psychologists involved in the national RxP effort from the APA Division 55, the APA President Elect, indigenous RxP psychologists already within the IHS system, and representatives from the American Psychological Association met with Dr. Rose Weahkee PhD, Behavioral Health Director for Indian Health Service, and senior IHS staff in a collaborative and cooperative effort to discuss the important role of the prescribing/medical psychologist working in the Native American communities. This successful interagency collaboration resulted in two strategic initiatives. First, Dr. Weahkee agreed to be a keynote speaker at the upcoming 2010 APA National Convention Mini-Conference celebrating the Indian Health Service and the Medical Psychologist. Second, Dr. Weahkee directed a work group to focus on the integration of the medical psychologist model into the IHS. One of the authors of this chapter is the Chair of this workgroup, with two other authors serving as steering committee members. The DBH primarily requested this workgroup to address the following tasks to more effectively integrate and support programs within IHS that may consider using a prescribing/medical psychologist (personal correspondence to fourth author, March 26, 2010): 1 . Define a standard scope of practice of prescribing psychologists 2. Determine the best way to incorporate that practice into existing IHS guidance (i.e., through the IHS Manual or otherwise see the Nurse Specialists and PA Models) 3. Identify and provide recommended guidelines on the following: (a)  Screening of applicants for suitability, education, experience, and safety (b)  Credentialing requirements (c) Privileging requirements including how competence in the particular privilege if requested as additional will be determined

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(d) Standards for supervision during the conditional/supervised portions of the licensure process (e)  Consultation support (f)  Collaborative Care Principles and requirements (g)  Peer-review structure (h)  Recommended PD outline (i)  DEA requirements Major concerns for the DBH are safe and effective patient care, systematic integration into the existing systems of care, balancing psychopharmacological expertise and support along with available resources within each SU, and avoiding duplication of services wherever possible, given the limited resources within IHS generally. The Medical Psychologist Model allows clinics a variety of care models and disciplines to access and implement as they work to meet the needs of their community. At the time of writing, this expansion and collaboration of the medical psychologist continues to grow with direct recruitment and retention efforts within the IHS. Both the USPHS and the Indian Health Service have redefined new job descriptions and federal billets for the medical psychologist. Multiple IHS Regions have strategically placed and hired medical psychologists in their isolated, remote, medically underserved SUs as the Behavioral Health Director with the expressed intention of integrating this new primary behavioral healthcare professional into the bread-andbutter of primary care.

Common Psychiatric Childhood Disorders Among Native American Children Within IHS, medical psychology has to be embedded within a cultural context that allows all of the scientific, clinical, and western medicine approach to be truly integrated within cultures that are far older with hundreds of years of oral tradition and history. This integration must be more than a theoretical nod of the head, but must embrace the general understanding that the western reductionist method of study, reason, and life is not compatible with most Indian cultures. Below are some examples of integration of personal Native American heritage and the practice of medical psychology.

Attention-Deficit/Hyperactivity Disorder (ADHD) This particular diagnosis has had much publicity, and many news programs assert that it is severely overdiagnosed. However, true Attention-Deficit/Hyperactivity Disorder (ADHD) is nearly unmistakable and very debilitating for the child and his environment. A thorough differential must be conducted, and the child should be compared to his peers and siblings in order to account for cultural normalcy.

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Some counterfeits of ADHD (especially among Native Americans) include trauma, mood disorders, anxiety disorders, lack of physical activity, boredom, and lack of environmental structure. In order to rule out any of these factors as the cause of ADHD-like symptoms, thorough interviews with the primary caretaker and school personnel are essential. Again, the child must be compared to his peers for levels of inattention, hyperactivity, tendency to lose things, distractibility, inability to finish tasks, etc. Continuous performance tests help round-out the diagnostic process for this disorder and are also very useful for determining proper medication dosages if a medication trial is started. The use of such tests is one example of an excellent way to collaborate with pediatricians. For example, many pediatricians report they get parents in their office who announce that their children have ADHD and they want psychostimulants for their children. The pediatrician often feels put on the spot, and is asked to make a very important decision about a child without enough information. This is the ideal time for the pediatrician to call in a medical psychologist for assistance with diagnosis and treatment of the child. Early detection and proper treatment of ADHD can help the child succeed academically and socially and can prevent the nearly inevitable blow to a child’s selfesteem due to often seen problematic behaviors and academic difficulties. From the start, it is important to ascertain if the family, school staff, and child all believe the child is functionally impaired. Without the cooperation of the school, family, and child, it will be very difficult to accurately diagnose and treat the child. Also useful may be a search for a possible genetic predisposition to the disorder. In most cases, the child with ADHD will have a parent who will admit to academic difficulties and will endorse a litany of similar symptoms as well. It is usually at this point that the parent will become cooperative. A thorough ADHD evaluation takes much longer than the time available to a pediatrician. Collateral information is needed from parents and teachers (which usually comes in the form of questionnaires) to confirm that the disruptive and/or inattentive behaviors are seen in more than one venue. Also, a complete history (medical, academic, and behavioral) is needed. A continuous performance test can provide the final confirmation of the diagnosis, and gives some sense as to the severity of the disorder. If a child is diagnosed with ADHD, that is the appropriate time for the medical psychologist to consult the pediatrician and discuss the medication (if warranted) that the medical psychologist intends to prescribe, and verify if there are no medical contraindications for the particular prescription. It is useful for the pediatrician to have detailed knowledge of the findings and treatment of the young patient as part of overall healthcare treatment. For example, the pediatrician, knowing a child is on psychostimulants, will know to keep a closer eye on the child’s growth rate, cardiac functioning, sleep patterns, appetite, and other possible negative results of stimulant use. The psychologist can then use the continuous performance test to verify that the selected dosage is efficacious based on the test scores of the child. Again, changes in dosage can be made with the pediatrician’s awareness, so that monitoring can take place by both providers.

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Mood Disorders Similar to ADHD, mood disorders have been the topic of much discussion on news programs, again pointing to the overdiagnosis and overmedication of children. However, the presence of a true mood disorder is incredibly dramatic and devastating to his or her family. Similar to ADHD, there is very strong genetic component in most cases. Usually a family member will confirm that someone in the family has severe temper outbursts, drinking problem and is very “moody.” In children, it is usually more useful to think of mood disorders as either cycling or noncycling (rather than uni- or bipolar), since the mood fluctuations seen in children can be very rapid. Unlike classic bipolar disorder in adults, “mania” in children can present as irritability, uncontrolled rage, exaggerated emotional reactions that are much exaggerated, giddiness, and insomnia. With a manic or mixed episode 1 week or more in duration, the child may experience rapidly alternating moods, cycling several times per day. By contrast, the hyperactivity and giddiness seen in children with ADHD is steady, does not cycle, and is independent of mood. Also, children with a singular diagnosis of ADHD do not suffer from insomnia as opposed to children with mood disorders. The rage seen in children with a cycling mood disorder is usually very frightening to on-lookers (i.e., school staff) and can last for hours. Oftentimes parents of children with mood disorders say the rage is like an emotional seizure. After the rage, children often do not remember what happened, and are full of remorse (which sets them apart from children with conduct disorder, Papolos & Papolos, 1999). The strength and intensity of the anger can appear almost super-human (i.e., a small child may throw a very heavy, large object). Among Native American children, because there is so often a component of trauma, it is essential to be very specific in questioning collateral sources. When differentiating a cycling mood disorder from posttraumatic stress disorder (PTSD), it is important to ascertain whether or not there are fluctuations of mood or energy, and if there is rage, what is the trigger. For example, if the child was triggered into a rage from an incident that reminded him of a past traumatic episode, the behavior is not likely a part of mania. By contrast, if there are frequent incidences of an observed rage that appears many times more magnified than the situation calls for, with no apparent trigger (especially if the child admits he or she does not understand the intensity of the reaction), then the practitioner may suspect mood problems more than trauma reactions. A medical psychologist can be of particular value when the pediatrician who is suddenly facing a differential diagnosis between bipolar disorder and some other cause of behavioral dysfunction. This can be a time consuming and challenging process, and even after accurate diagnosis, finding a medication regime that is beneficial and well tolerated by the child can be equally difficult. By assuming this task, the medical psychologist frees the pediatrician to focus on other health concerns of the child, while still keeping the physician informed.

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The medication treatment of bipolar disorder in particular often requires supportive lab work to monitor the child’s glucose, metabolism, and weight and lipid profile, among others. In addition to being critical to the safe prescription of psychotropic medications, the results of such lab work are essential to the adequate provision of health care by the pediatrician. Thus, the information gathered by the prescribing psychologist to treat a child can be invaluable for the pediatrician’s treatment as well.

Anxiety Disorders In the first author’s clinical experiences, the most common anxiety disorder among Native American children is PTSD, likely caused by trauma experienced in the home and community. This may be described as generational trauma because the traumatic experiences originated with colonization of indigenous people in the Americas, and have been passed down for seven generations. Thus, levels of trauma among Native Americans may be much higher than the general population, which may account for the higher levels of PTSD. In Native American children, some of the manifestations of PTSD are uncontrolled anger, excessive fighting in school, nightmares, bed wetting, hypervigilance, and alterations in the child’s appetite and subsequently blood sugar. Traumatic experiences can make it very difficult to focus and sit still in school, to socialize appropriately, to trust others, and to perform at an adequate level in society. The pediatrician will find it beneficial to refer a child who has obviously experienced a trauma, and is suffering from unexplained medical symptoms to a medical psychologist for a comprehensive evaluation and treatment. The objective in this case is to assist the child in getting his or her nervous system activation back to baseline or pretraumatic arousal levels and to prevent the child from overreacting to innocuous stimuli. Usually, this is accomplished by a combination of medications that help modulate the nervous system (i.e., beta blockers or SSRIs) along with cognitive-behavioral training to relearn calm reactions to nonthreatening stimuli.

Summary While there are clearly many more mental health disorders found among Native American children, the above-mentioned appear to the authors to be the most frequently observed and tend to be very frustrating for pediatricians. These were therefore chosen as illustrations of how medical psychologists can improve care for children by providing evaluation and medication management that pediatricians find difficult to complete. The end result is superior care for this group of highneeds children.

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Collaboration with Healthcare Providers: Challenges and Solutions – A Story from Standing Rock Reservation The reality of practicing in Indian country is exemplified by the experience of the sixth author practicing at the Standing Rock Reservation in North Dakota. During this author’s tenure with the IHS, there was only one type of physician, the overwhelmed physician. These physicians coped with the stress in various ways and they utilized their resources differently. This author started his career with the IHS on the Turtle Mountain Reservation as a staff psychologist. The reservation is home to a band of Chippewa Indians in the far northern part of North Dakota. The mental health department was well staffed with a group of dedicated providers. The office had six licensed providers, two mental health technicians, and a psychiatrist. This allowed the ability for the reservation to have on-call mental health service without over burdening the staff. The caseloads were always full and complex, but they were manageable. During the author’s 3 years at the Turtle Mountain hospital, the facility employed three full time, highly qualified pediatricians. These pediatricians were dedicated to helping the underserved populations of the reservation. There was an impressive teamwork between the pediatricians, psychologists, social workers, and psychiatrist. This IHS facility had a healthy atmosphere and was a joy to work in. In this northern isolated reservation region of North Dakota, the majority of the hospital’s staff lived in hospital housing. Walks through the neighborhood would often lead to conversations with colleagues outside the hospital that would not have been possible in a more urban setting. Referrals between the medical staff were frequent and inquisitive questions about treatment plans were asked during staff meetings and casual encounters. The majority of this author’s medical psychology work was completing Attention Deficient-Hyperactivity Disorder (ADHD) evaluations and therapy services with children, adolescents, and families. Referred families could have a mixture of poor diets, little sleep hygiene, psychological trauma, sexual abuse histories, substance abuse, and inconsistent parenting styles. Attempts to define a child as having ADHD were difficult in most cases. The evaluations were complex, but many clients received an increased level of care as a result of the evaluation. The presenting problem of inattention at school may have been the reason for the referral, but the causes of the behaviors were much more complex. Several children were treated for anxiety disorders instead of ADHD and families were given parenting skills to address behaviors and avoided incorrect diagnosis and unwarranted medications. Providers worked as a team to improve the health of many families in a system of care. Unfortunately, not every physician was part of the “team.” Some providers avoided mental health issues and any hint of symptoms created a mental health referral without a concern for follow-up. These overwhelmed physicians coped with their patients’ mounting issues by only focusing on the physical complaints, lab results, and prescriptions. When compliance was low the patient was quickly

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placed in the category of “difficult to manage.” This informal diagnosis would hinder the patient’s ability to receive quality care when the patient was sincere about change. The health provider’s self-serving bias frequently clouded judgments. Clinical directors and mental health providers would have to remind certain physicians that a mental health diagnosis does not make one immune from heart disease and other life threatening health illnesses. Too many times a mental health provider would be called to the emergency room or clinic for a consult to find that a physical assessment had not been completed. During this author’s third year at the Turtle Mountain reservation, an emergent disaster response deployment order was issued and the author deployed for 2 weeks to the Standing Rock reservation to assist with a suicide epidemic. Standing Rock reservation is occupied by a Lakota band of Sioux Indians. The reservation straddles the North Dakota and South Dakota state line. The reservation unfortunately ranks high in suicide prevalence comparatively to other tribes in the United States. Between the years of 2004 and 2005, Standing Rock Tribe suffered 26 suicides from a population base of 8,500. The overall rate for suicide death in the United States in 2004 was 10.9/100,000 people. The suicide rate on the Standing Rock Reservation in 2004 was 176.47/100,000 people. Seventeen times the national average. Standing Rock was a vastly different experience from the Turtle Mountain reservation. The populations of the reservations were similar, but the Turtle Mountain reservation is one of the smallest in the country and the people are packed closely together. Standing Rock reservation has been compared to the size of Connecticut. Whereas, the Turtle Mountain reservation has one major school system, Standing Rock has eight integrated school systems. The Standing Rock mental health department was also dramatically different. There were only four staff members with just two licensed. There was no clerical staff to assist with scheduling and no psychiatrist to manage medication issues. The hospital was a much smaller facility and although there was an emergency room and a clinic, the tempo felt like urgent care. When this author arrived, Standing Rock did not have a pediatrician. Once one was recruited the quality of care for the children increased, but she was only one physician. Although she was a very competent physician she did not appear to grasp the complexity of issues that surrounded the number of ADHD referrals she received. The attitude of ADHD on Standing Rock was much different than on the Turtle Mountain reservation. The Turtle Mountain team looked for the differential diagnosis to ensure the correct treatment plan was created. On Standing Rock the numbers of patients requesting services were so high and the resources so few that the ability to be as thorough as at Turtle Mountain was impossible. Medical and mental health staff hoped that the stimulant medication would give the child enough ability to function at school no matter what the lifestyle was at home. The suicide numbers did reduce after the PHS deployment, but a pessimistic Standing Rock elder related her belief that all of the suicidal people had merely died and she dreaded the cycle returning. During this author’s deployment, the IHSs Standing Rock mental health director resigned placing in motion this authors

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application and acceptance of the director position. It was a difficult decision to leave the Turtle Mountains, but this was an opportunity for this author to accept senior leadership and supervisory duties. The job description of a mental health director is what this author thought he was accepting. When in fact, due to the abysmal lack of resources, this author became a salesman and at times a pitchman for the ideas and funding needed to develop a mental health department and support the needs of the reservation. Native friends laughed with the author when he departed 3 years later, of the audacity and idealism he had when he started. The author is a white man, employed by the federal government, dressed in the uniform of a PHS officer asking for funds in return for services from tribal leaders and school administrators. The author had come to rely heavily on the psychiatrist on the Turtle Mountain reservation, but on Standing Rock, psychiatric patients had to drive seventy miles or more for an appointment with a psychiatrist. Due to the lack of a psychiatrist being easily accessible, patients on Standing Rock generally only visited the psychiatrist once and the Standing Rock medical staff would attempt to continue the regimen. Many patients lacked the funds to travel such a long distance for a psychiatric appointment and relied entirely upon the medical staff for all of their psychotropic medication prescriptions. When given the opportunity to take a postdoctoral masters degree in clinical psychopharmacology to start the journey to becoming a medical psychologist, this author quickly agreed. Something needed to change in order to help better meet the needs of the people on the Standing Rock reservations. This author had heard the debates about the possibility of psychologist prescribing psychotropic medications, but when the reality of the lack of psychiatric services at Standing Rock reservation settled in, this author became an avid advocate for the medical psychology movement. At a medical staff meeting one day, this author announced his intentions of becoming a medical psychologist and asked if the medical staff would be supportive of such an endeavor. The staff was excited and eager to learn what the training entailed. The medical staff had a clear understanding that the hospital’s budget could never afford a full-time psychiatrist. Psychiatrists performing tele-medicine are difficult to find, require significant I T infrastructure, and frankly, the hospital did not have the support staff needed to organize a tele-psychiatrist’s schedule. The physicians expressed how they were trying to prescribe the psychotropic medication with the most efficacy they could achieve, but preferred someone with more expertise and the training to diagnosis and speak with mentally ill patients. Suicide prevention, intervention, and postintervention issues encompassed daily agendas at the Standing Rock mental health clinic. The first daily duty as the director of the department was a briefing by the ER clinician about the number of mental health patients seen during the night and if anyone was sent to an inpatient hospital for suicidal ideation or gestures. In this author’s attempt to find funding to increase the number of mental health providers, it was extremely frustrating to discover large amounts of dollars available for suicide prevention, but no money for intervention. Suicide prevention grants created large educational campaigns about the warning signs and symptoms of depression and suicide. All of the training and

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material encouraged a person with symptoms to travel to nearest mental health clinic for services. Unfortunately, there were less than five licensed mental health providers to serve this fragile clientele over a land mass large enough to be a state. This author vividly remembers a young man in the emergency room who had lacerated both his arms. After inquiring why he had cut himself he related, “No one pays any attention to you unless you are bleeding.” In many ways, this author realized he was right. In the 3 years this author served as Director at the Standing Rock reservation, he relied upon the relationships between the IHS and Tribal government he had established. Ron His Horse Is Thunder, Tribal chairman of the Standing Rock, created the following summary of this medical psychologist’s work for submission to the PHS after hearing of his resignation. This Tribal Chairman’s words speak more clearly of what was accomplished during this author’s time at Standing Rock than listing notable benchmarks: Throughout the years the members of the Standing Rock nation have become cynical of mental health directors on our reservation. The mental health providers were believed to be uncaring, unresponsive, and under qualified. LCDR Barnes’ first goal as director was to increase access to mental healthcare so that our people would not feel forgotten. He also developed a plan to increase the number of qualified providers so that they would get the quality treatment they deserve. When IHS funding options were exhausted, LCDR Barnes, in his humble approach, presented ideas to Standing Rock Sioux Tribe and Standing Rock Public Schools that would accomplish these expansion goals. LCDR Barnes’ diplomatic and enthusiastic presentations made his ideas sound conceivable. For the first time, a tribe and a grant school assisted a federal program financially. We believed in LCDR Barnes and he delivered his promises of action every time. Our investments in his programmatic ideas have produced many returns for our people. Specific examples of these successful partnerships include the 1-year tribal funding agreement of a clinical psychologist to work within IHS with the intentions of LCDR Barnes finding third party reimbursement funds to allow that psychologist to become a federal employee as well as the creation and funding for both the Standing Rock Pre-Doctoral Psychology Internship and Post-Doctoral Psychology Residency program. These three acts of trust from our nation to LCDR Barnes resulted in the expansion of outreach from two mental health clinics available to our people to six clinics. The number of doctorate level psychologist has increased from one, counting himself, to five psychologists. The number of masters level therapists from zero to three. A total of seven qualified mental health professionals added to the reservation without an increase in his federal budget. The impact of his work has increased access and availability for mental health appointments for our people and expanded our nation’s ability to disperse suicide prevention information (personal communication, August 20, 2009).

In 2007, this author was awarded “The Most Improved Mental Health Department Award” by the IHS Aberdeen Area Office and the PHS Commendation Medal for leadership of a mental health clinic in an isolated service area and the development of a strategic suicide intervention plan. In 2008, he was awarded the IHS Aberdeen Area’s Supervisor of the Year Award and IHS National Director’s Award for implementation of the predoctoral psychology internship.

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At the end of this author’s tour of duty with the IHS, even with these accomplishments, this author was exhausted and the stress was taking a toll. Stress was affecting his relationships with his wife and children, and his own health. This author would like to believe that the Standing Rock reservation is better equipped now, but the need and lack of resources is chronically overwhelming. This author wishes he had more stamina to have stayed longer.

How Medical/Prescribing Psychologists and IHS Can Improve Psychiatric Care for Native American Children Earlier sections of this chapter have dealt with the challenges of working in Indian Country, particularly the various psychosocial, environmental, and cultural problems that medical/prescribing psychologists are required to manage. In addition to (or because of) these difficulties, children in Indian Country receive less than optimal care. In supplement, the recommendations provided previously for ensuring that children of Indian Country get adequate psychiatric care, the comments below will also help medical/prescribing psychologists fulfill their ultimate responsibility of providing for the most vulnerable on the reservations.

Credential More Psychologists The need for competent and comprehensive mental healthcare for children in Indian Country is great. Although some reservations have psychiatrists who provide care, the vast majority of Native American children, particularly in very rural or frontier areas, do not have ready access to this resource. Much of the psychiatric care of children in Indian Country is managed by general and family physicians, pediatricians, and nurse practitioners. Many of them feel uncomfortable with mental healthcare because of their lack of training and experience in psychopathology and psychopharmacology. As a result, many children may be underdiagnosed, undertreated, or conversely, treated too aggressively which can cause unnecessary adverse effects. With their advanced training in developmental psychology, psychopathology, pathophysiology, and psychopharmacology, medical/prescribing psychologists are the ideal providers to minimize the aforementioned problems and ensure that adequate mental healthcare is provided to Native American children. However, before this can happen there must be medical/prescribing psychologists credentialed to provide this service. At the time of this writing, there are three medical/prescribing psychologists in IHS credentialed to prescribe psychiatric medications and order laboratory tests relevant to this practice.

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However, to this author’s (BAM) knowledge, and there are at least six more psychologists in the Northern Great Plains area who are close to gaining prescriptive authority within a federal IHS SU. Not unlike those in New Mexico, Louisiana, and the different branches of the military, being an RxP trailblazer in IHS face many obstacles and challenges. There is opposition, which comes from two different segments: (1) those that do not understand the training and abilities of medical/prescribing psychologists; and (2) psychiatry. To be fair to the latter, it would be an error to assume that all psychiatrists within IHS are opposed to psychologists prescribing medications. Some are open to the idea, but wish to relegate medical/prescribing psychologists to midlevel providers and put psychiatrists in supervisory positions over these psychologists. Although supervision and consultation are much needed activities, having psychiatrists as the ultimate decision makers with regard to a medical/ prescribing psychologists practice may have many unwanted consequences. The lack of clear guidelines and recommendations are also a hurdle. Like the quest for state by state prescriptive authority, gaining prescribing privileges in IHS is a SU by SU process. There are no regional or national guidelines for giving medical/ prescribing psychologists appropriate and fair credentialing reviews. Developing credentialing guidelines similar to what the military has done may be most appropriate since IHS is a federal facility and licensing is not dictated by the state in which the SU is located.

Primary Care Integration The stigma of mental health treatment is as least as strong in Indian Country as it is anywhere else. Therefore, integrating medical/prescribing psychologists into primary care can mitigate this problem and ensure that children have readily available access to mental healthcare. Does this mean medical/prescribing psychologists must forego the 50-min therapy session and follow primary care providers in and out of treatments rooms? The answer is yes and no. Dedicating a portion of the work week to setting up shop in the primary clinic to see children and families in collaboration with the primary care provider is expected. This allows many effective brief interventions to be delivered to those that would never come to a mental health clinician’s office. But, one of the risks of training psychologists in medical psychology is the possibility of losing our psychosocial identity (McGrath, 2004), and so we must maintain traditional therapeutic roles and provide effective psychological interventions to children, which will limit overreliance on psychotropic medications. As has been said many times before, the power to prescribe is the power to unprescribe. For some children, removing medication from the their treatment regimen can be the best intervention for them and can be done in either setting.

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Educate Pediatricians About Medical Psychology Most people are fearful and suspicious of the unfamiliar, and pediatricians are no different. Before going to a pediatrician with recommendations for pharmacological intervention for one of the child patients, the medical psychologist must find the time in his or her busy schedule to educate the pediatrician on what medical/prescribing psychologists do – discuss the education, training, and the checks and balances built in state laws and federal agency guidelines for medical/prescribing psychologists. This will help instill a sense of collaboration and supplement the pediatrician’s existing knowledge of developmental issues and pharmacology. In short, normalizing their role, highlighting their training, and showcasing their knowledge, will help medical psychologists assume a greater role in helping child patients.

References DeLeon, P. H., Folen, R. A., Jennings, F. L., Willis, D. J., & Wright, R. H. (1991). The case for prescription privileges: A logical evolution of professional practice. Journal of Clinical Child Practice, 20, 254–267. DeLeon, P. H., Sammons, M. T., & Fox, R. (2000). Prescription privileges. In A. E. Kazdin (Ed.), Encyclopedia of psychology (Vol. 6, pp. 285–287). Washington: American Psychological Association and Oxford University Press. Democratic Policy Committee. (2004). A closer look at issues affecting Indian country, Part I: Health care. Democratic Policy Committee. Retrieved from http://democrats.senate.gov/dpc/ dpc-new.cfm?doc_name=sr-108-2-257 Indian Health Service. (2006). Facts on indian health disparities. Retrieved from http://info.ihs. gov/Files/DisparitiesFacts-Jan2006.pdf Indian Health Service Fact Sheet. (2002). Retrieved from http://info.ihs.gov Indian Health Service Fact Sheet. (2010). Retrieved from http://info.ihs.gov/Profile2010.asp Indian Health Service Manual. (1996). Chapter 14, Psychological Services. Retrieved from http:// www.ihs.gov/publicinfo/publications/ihsmanual/part3/pt3chapt14/pt3chapt14.htm. Jennings, F. L. (2010). An introduction to prescribing privileges for psychologists: A look back in time. Academy of Medical Psychology, Archives of Medical Psychology, I, 1–13. McGrath, R. E. (2004). Saving our psychosocial souls. American Psychologist, 59, 644–645. McGuinness, K. M., & Tilus, M. R. (2010). Prescribing in the Public Health Service. In R. E. McGrath & B. A. Moore (eds.), Pharmacotherapy for psychologists: Prescribing and collaborative roles (pp. 207–219). Washington: American Psychological Association. New Mexico Administrative Code. (n.d.). Title 16 occupational and professional licensing, chapter 22 (16.22.20) Psychologists and Psychologist Associates. Retrieved from http://www. rld.state.nm.us/psychology/ruleslaw.html Papolos, D., & Papolos, J. (1999). The bipolar child. New York: Broadway Books. Young, S. (2008). Why are Lakota young people killing themselves? Part 1. Sicangu Sun Times. Retrieved from http://sicangusuntimes.com/node/82

Chapter 7

The Practice of Medical Psychology in a Pediatric Hospital Setting: A Personal Account from an RxP State John C. Courtney

An important scientific innovation rarely makes its way rapidly winning over and converting its opponents; it rarely happens that Saul becomes Paul. What does happen is that its opponents gradually die out and that the growing generation is familiarized with the idea from the beginning. Max Planck (1936), The Philosophy of Physics

Psychologists around the world perform consultations within hospitals or in other “medical” contexts. The practice of “medical psychology” in Louisiana, however, is one that is specifically regulated by statute and the term “medical psychologist” throughout this chapter will be used to describe those psychologists who are now prescribing. As the chapter’s author, I appreciate that there is a lack of field-wide agreement as to the term, but for the sake of convention, I will refer to “medical psychologists” as those with a license to prescribe. It is impossible to cover the development and scope of the field of medical psychology in this chapter. The reader is referred to the works by Sammons and Schmidt (2001) and Wallace and Gach (2008). This chapter will cover how medical psychology developed within one facility, a review of the most common referrals, and case examples. I spent most of my graduate training focusing on neuropsychology, both pediatric and adult. After graduating and completing my postdoctoral work, I was employed as a neuropsychologist in psychiatric facilities, neurorehabilitation programs, and in private practice. Regardless of the venue, my exposure to my physician colleagues was generally very positive. Physicians seem to appreciate the sophisticated, neurobehaviorally oriented nature of neuropsychology. Frankly, less is made of psychologists’ psychotherapeutic recommendations, despite these suggestions often making far more positive impact on the long-term academic, emotional, and vocational success of the patients we care for. A steady percentage of my pre-prescription practice included responding to requests from physicians asking “what” and “how much” psychotropics to prescribe. J.C. Courtney (*) Children’s Hospital of New Orleans, New Orleans, LA, USA e-mail: [email protected] G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_7, © Springer Science+Business Media, LLC 2011

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At first, this was disconcerting, but it became common and I began to understand the root of the requests more clearly. I realized that a surprising number of MDs thought that I already had the authority to prescribe. The physicians with whom I discussed the basis for the professional and legal regulatory issues that prohibited my making recommendations directly to patients regarding medication felt that these rules would have to change. Simultaneously, nearly every physician commented that they didn’t fear my recommendations, but worried about other “nontrained” psychologists recommending medications. An evolving biological focus in our culture has led to a near universal desire to quickly fix most health problems. Usually this is with pills, surgery, or some other form of apparent physiological manipulation. This problem is paralleled in our fascination with the often unsupported and potentially unsafe use of supplements, diet pills, and herbal remedies. There is enough rational criticism of these quick-fix models to have created a fertile environment for the growth of psychotherapeutic and other less chemically dominated interventions. Perhaps as an indirect result, US psychiatric residencies are finally beginning to require more training in psychotherapy again (Tucker, Garton, Foote, & Candler, 2009). In 2002, I began Nova Southeastern University’s postdoctoral training program in psychopharmacology, followed by a 2-year proctorship with a pediatric neurologist and a board-certified psychiatrist. Roughly 10 months after Hurricane Katrina devastated the Gulf Coast, I accepted a position as a pediatric neuropsychologist and medical psychologist at Children’s Hospital, New Orleans. In accordance with the laws in Louisiana (http://www.lsbep.org/laws_&_rules.htm), I took and passed the Psychopharmacology Examination for Psychologists (PEP), applied for licensure, provided my passing PEP scores to Louisiana’s Board of Pharmacy (http://www. labp.com), and obtained a Controlled Dangerous Substance (CDS) license. I then sent my medical psychology license and CDS license number to the Drug Enforcement Agency (DEA, http://www.deadiversion.usdoj.gov) and was issued a DEA number. A few weeks and about a thousand dollars later, armed with crisp new DEA certificate and the approval of the licensing board, I wrote my first prescription: dexmethylphenidate XR 10 mg, 1 tab, p.o. q am, #30 for the treatment of ADHD. No refills. It was simple, straightforward, and not particularly exciting. It was, however, dramatically effective.

Evolution of Medical Psychology’s Role at Children’s Hospital To quote directly from the Children’s Hospital website (http://chnola.org), Children’s Hospital is Louisiana’s only full-service hospital exclusively for children, offering a full range of inpatient and outpatient care. A not-for-profit facility, it is governed by an independent board of trustees made up of community volunteers. The hospital has no stockholders and no dividends to pay. Revenue generated is used to operate the hospital and to expand and advance services.

In short, Children’s Hospital is a full-service facility and an active teaching facility for both Tulane and Louisiana State University’s Health Sciences Centers. Psychologists

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in the department provide direct care for patients who receive medical services in hematology/oncology, endocrine, cardiology, renal/transplant, gastroenterology, infectious disease, neuro/polytrauma, orthopedics, etc. We provide outpatient follow-up care and consultation for the patients of the more than 50 pediatricians affiliated directly with the Children’s Hospital Medical Practice Corporation (CHMPC) and for the residents/fellows of varying specialty clinics. It would be unfair to say that medical psychology as a licensed profession was an instant success in the metropolitan New Orleans area. Medical psychologists were a new hybrid and physicians were understandably unprepared. The initial referrals to my service were simple and easily allowed for the statutorily required collaboration. Opportunities quickly arose to lecture to the departments of pediatrics, neurology, etc., providing an environment for mutual teaching and learning. In retrospect, these events were invaluable. As physicians became more comfortable with what a medical psychologist knew, the number and complexity of referrals increased. The education was a two-way street, with my learning much from my very gracious physician colleagues about the procedures and politics of a prescribing practice. However plentiful psychiatrists had been prior to Hurricane Katrina, the subsequent repopulation of mental health services in New Orleans lagged far behind the return of the general population. Moreover, people remaining in New Orleans after the storm tended to demonstrate significant psychiatric problems, were often impoverished, and many could be quickly categorized as “insurance indigent.” Worse, the U.S. production of child psychiatrists has remained woefully less than the need, with no cure on the horizon (Council on Long Range Planning and Development, 1990). With all of these factors at play, Children’s Hospital’s administration put a bit of its political “neck on the line” in hiring a medical psychologist, particularly given that the hospital was situated in a large and powerful psychiatric community that had been starkly averse to extending prescriptive authority to appropriately trained psychologists. In the months immediately following the storm, the members of the Board of Trustees at Children’s Hospital recognized that psychiatric conditions were taking up far too much time for the area’s pediatricians’ practices. Moreover, trying to treat these conditions often pressed the pediatrician to the edge of their skills. While the treatment of simple ADHD may not be particularly challenging, psychiatric comorbidity is the norm and ODD, Autism, Bipolar Mood Disorders, psychosis and other psychiatric disorders rapidly leave pediatricians or other nonpsychiatric specialists feeling out of their comfort zone. Even with “simple” ADHD, the pediatrician may not have the time to spend at each visit reviewing the history, response, and titrating the medications if necessary. Thus, the timing for the introduction of medical psychology to New Orleans could not have been better, albeit at the cost of a horrific natural disaster. I was the only medical psychologist in metropolitan New Orleans in December 2006. Now the number has grown both inside and outside of the hospital. Children’s Hospital itself has employed two additional medical psychologists and is supporting the training of another. Our neuropsychological postdoctoral program encourages the candidates to simultaneously complete psychopharmacology training, and since

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2006, all of our postdoctoral fellows have done so. While it will be hard to ignore the impact of increasing medical psychologist from 1 to 10 or 15 over the next 4–5 years in New Orleans, or the resulting influence on the healthcare landscape that occurs with improved access to appropriately provided psychotropic therapies, we have enormous ground to gain with regard to providing sufficient access to mental health care in this city (Lamberg, 2008).

Inpatient Medical Psychology Consultation Being able to diagnose and treat patients, without the unnecessary oversight of others, has been a critical part of psychology’s professional maturation. In contrast, the medical model of specialty consultation within an acute care setting may initially seem foreign to medical psychologists when they begin practice. The issue of “independence” in the context of performing consultative services is far less important than might be anticipated. Rather, it is more important to understand that your opinion, while independent, can be completely and appropriately ignored. Psychologists have a history of experiencing such “ignoring” as a reflection of being devalued. However, in the matrix of all of the things an attending physician may be trying to manage with any particular patient, the psychopharmacological or psychotherapeutic input from a very competent and thoughtful psychologist may be experienced as offering a relatively low immediate value. This is against the backdrop of other evolving information about the child’s physical condition and illness that might reasonably take precedence. Alternatively, the input from a medical psychologist can change the course of treatment and relieve the attending from having to manage the psychotropic medication(s), psychotherapy, or psychosocial or compliance issues before they arise. As a consequence, the cooperative and collaboratively developed relationship between the attending physician and medical psychologist can result in treatment gains that are both rapid and often long lasting. The use of psychotropic medications to treat pediatric psychiatric conditions does not reflect a solid number of randomized controlled studies with children. Yet, because of the severity of many of the conditions presented, the literature is beginning to produce a rich body of information regarding intervention models. The Multimodal Treatment of Attentional Disorders (MTA) and the Texas Childhood Depression Algorithm study are good examples (Hughes et al., 1999; MTA, 2004). A number of factors likely influence this increase, including the advocacy to identify and treat disorders as early and quickly as possible. With the access to the authority to prescribe comes the responsibility to recognize when the use of psychotropics is unwise. Ultimately, writing a prescription can be the easiest thing to do, compared to the difficult and time-intensive work of psychotherapy. Patients, parents, guardians, and often physicians need to be educated regarding the safety, efficacy, and high rate of return for psychotherapy.

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The ability not to prescribe is often extrapolated to mean that the medical psychologist will frequently act to reduce or remove medications previously prescribed in the place of more effective psychotherapy. To date, no literature supports this hypothesis, but it stands to reason that psychologists having historically been rigorously trained in psychotherapeutic interventions will continue to opt to use these methods. Whether this theory holds true has yet to be determined and research discriminating medical psychologists from other prescribing providers has been very slow to develop. The hospital setting presents the medical psychologist with a number of unique challenges. Physically ill children treated with psychotropic medications have coexisting medical conditions that may increase the risk and likelihood of adverse drug reactions. Furthermore, despite psychology’s long battle to discourage dualism (mind vs. body), this splitting of patients based upon their functional and physical symptoms is more common than not. As a result, the medical psychologist is regularly faced with explaining to a family and patient that a problem both is, and is not, “in their head.” Perhaps partially related to this dualism, inpatient referrals to medical psychology tend to fall into these three categories: anxiety and agitation; pain; and problems with sleep.

Anxiety and Agitation Agitation in the hospital setting typically refers to a constellation of behaviors that disrupts the ability of the staff to provide care, diminishes the patient’s ability to care for him or herself, and risks the health and safety of others (Yildiz, Sachs, & Turgay, 2003). The list of medical conditions that can create agitation is long and includes substance intoxication, drug interactions, delirium, dementia, hypoglycemia, brain injury, thyroid disorders, etc., aside from the psychiatric conditions known to produce similar symptoms. Suffice it to say that a thorough examination and history taking serves as the absolutely necessary foundation for any intervention with an agitated patient. Therefore, the safe management of these children requires that the clinicians have sufficient understanding of the underlying medical disorders, the potential consequent alterations in pharmacokinetics, and the mechanisms of action of the medications to be prescribed. Unfortunately, even though agitation is common in pediatric facilities, there is a dearth of literature specifically related to its management. When performing consults regarding agitation, I have a cue card in my pocket that reminds me of the factors to consider in each case (Table 7.1). In severe agitation, psychotherapy skills can be valuable as you try to reassure the patient, family, and staff. The more severe the agitation, the more you will have to reassure the family that you will work with them to relieve their child’s condition. Establishing an alliance with them is critical, but if it is not maintained, they will tire quickly and their lack of trust can easily turn into a complaint. As a result, both the family and staff must be made part of the treatment team to manage the

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Table 7.1  Anxiety and agitation Why is this patient experiencing anxiety or agitation? What medical disorder is being treated and what disorder might have been missed? Is the patient in pain? What medications is the patient taking? What might the patient be taking that hasn’t been listed or admitted to? How has the family dealt with the agitation? Are they comfortable with this, is it common for their family, are they still connected to the patient? Can I reassure the patient? If so, are they a good candidate for cognitive intervention? Do not provoke more agitation! Recommend frequent reorientation and make the room/environment familiar and safe(r). Make sure there is adequate/appropriate staff to ensure safety. Set reasonable limits with the patient, family, and staff. In agitation, prescribe medications carefully and in a reasonable sequence until patient is no longer agitated: haloperidol → atypical antipsychotics → lorazepam → (antipsychotic + benzodiazepine). For anxiety, concomitant therapy if possible and do not resist coadministration of SSRI with benzodiazepine with the goal of removing the benzodiazepine after a couple of weeks. Remember that the attending has to be comfortable with your approach, since their team may be carrying out your recommendations.

agitation. Furthermore, don’t disappear once the agitation is “managed,” as your attending to their child’s ongoing care maintains the alliance if it is needed again during the child’s stay.

Pain Medical psychologists in Louisiana are specifically prohibited from treating pain directly. For instance, while we have access to an otherwise open formulary, we may not prescribe any opiates. So, while treating pain as a primary condition is forbidden by law, it is common that chronic pain conditions are comorbid with depression and anxiety. Moreover, these chronic pain conditions often improve as the treatment for depression or anxiety is successful. There are few symptoms that equal pain for its ability to separate clinicians into disparate camps. Defining pain as an unpleasant sensory and emotional experience that is associated with tissue damage or perceived as representative of such damage (Basbaum & Jesell, 2000) suggests that pain may have demonstrable effects on the body, as well as intrapsychic complexities. Despite the frequency of chronic pain complaints, there are very little data to guide our treatment of children with somatoform disorders. As a consequence, treatment interventions that may provide considerable relief are generally based upon adult studies with phenomenologically similar psychopharmacological responsive states. Garber, Walker, and Zeman (1991) noted that 5% of children had at least one somatic complaint during a 2-week period, with 15% reporting at least four symptoms in that same period. While it is important to attend to the role of anxiety or other functional explanations

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of somatic complaints, every hypothesis that the clinician entertains should include the possibility that the patient’s symptoms are due to an as yet undefined medical condition. Perhaps the most common somatic complaints are headache and gastrointestinal pain. At least one of these topics is covered in detail elsewhere in this text (see Chap. 12). Clinicians should be reminded that somatic symptoms can be characterized either as general medical complaints or via their psychiatric presentation (generalized anxiety disorder, disorders of adjustment, etc.). If diagnosing the latter, the medical psychologist is inherently articulating that not all of the symptoms are easily explained solely by the medical condition and deserve equal attention. It is important to remember that there are no large randomized, placebocontrolled trials (RCTs) regarding chronic pain treatment in childhood or adolescence. There is literature support for tricyclic antidepressants (Fallon, 2004), clomipramine (Hollander et  al., 1999), and fluoxetine (Phillips, Albertini, & Rasmussen, 2003), and case reports supporting other serotonin selective reuptake inhibitors (SSRIs, Sondheimer, 1988).

Sleep Disorders Difficulties in initiating, maintaining, or regulating sleep rhythms are a problem for at least 1–6% of children. If sleep phase delays and bedtime refusal are added to this population, the number rapidly climbs to 30% (Mindell et al., 2006). Children with pervasive developmental disorders (PDD) appear particularly vulnerable with rates as high at 75% evidencing some degree of insomnia. Sleep disorders represent roughly 3% of the cause for all visits to pediatricians (Owens, Rosen, & Mindell, 2003). Common sleep-inducing agents used with children are included in Table 7.2. While there is a general consensus that sleep problems in children and ­adolescents are troublesome, there is no consensus regarding management. Absent sound safety

Table 7.2  Common sleep-inducing agents

Diphenhydramine HCl Clonidine Trazodone Mirtazapine Cyproheptadine Melatonin Zaleplon Chloral hydrate Lorazepam Zolpidem Ramelteon Eszopiclone Quetiapine Risperidone

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data, these agents are generally prescribed off-label, with antihistamines being the more frequently recommended medications (Owens, Rosen, & Mindell, 2003). Sleep hygiene promoting practices are recognized, but I have found that families almost never implement them without considerable pressure. This suggests that improved education is needed for physicians and families, since a large number of sleep disorders “self correct” with simple behavioral interventions (Owens, Rosen, & Mindell). Clinicians working with adolescents, and particularly those adolescents with ADHD, are aware of the high frequency with which these youngsters are described as having either sleep phase delays or frank insomnia. A recent interest in the sleepinducing properties of melatonin has resulted in several studies reviewing its efficacy. Melatonin is a naturally occurring neurotransmitter synthesized from serotonin. Derived subsequent to enzyme release by the pineal gland in response to light reduction’s influence on retinal signaling, melatonin peaks in the evening and declines in concentration as sleep is replete. Herxheimer and Petrie (2002) reported that melatonin was effective in problems related to sleep cycle disorders (jet lag, shift work, etc.), although later work identifies that it does not seem to be effective for sleep’s persistence through the night (Smits, 2003). Thus, it appears most effective in initiating sleep only. Fortunately, there are several studies demonstrating melatonin’s safety and efficacy, including a thoughtful randomized, placebo-controlled study (Ivanenko, Crabtree, Tauman, & Gozal, 2003; Jan, Freeman, & Fast, 1999; Phillips & Appleton, 2004; Smits et  al., 2003; Stores, 2003). The reader is cautioned, however, that melatonin is an unregulated drug, typically found in the supplement section of most stores, and its purity may vary. Given the melatonin’s apparent efficacy, it seems reasonable that so much interest is evolving for other methods of melatonin agonism (e.g., ramelteon). Antihistamines have long been used by adults and children for sleep promotion. There is, however, considerable evidence for paradoxical excitation and next-day drowsiness or impaired cognition (Turk, 2003) and tolerance to the agents is common (Younus & Labellarte, 2002). Impairments in cognition are likely related to diphenhydramine’s well-known irreversible antagonism at CNS receptors. Increased appetite and weight gain further complicates the chronic use of antihistamines. While children with ADHD might be able to tolerate the weight gain, most could not afford the clouded or reduced attention quality caused by histamine blockade. Trazodone is commonly used to improve sleep, however, without support in RCTs. In 2001, Posey, Guenin, Kohn, Swiezy, and McDougle reported a small open-label study with mirtazapine (an antidepressant with antihistamine properties) used with children with PDD. While apparently effective in this population, careful, balanced, and blinded studies have never been done. Newer sleep agents popular with adults (zolpidem, eszopiclone, etc.) are now showing increased use with children. These type 1 benzodiazepine receptor agonists lack the muscle-relaxing qualities of their typical benzodiazepine cousins. As a consequence, they should demonstrate a relatively safer side-effect profile. Once again, adequate safety and RCT studies have not been completed with children. Clonidine and guanfacine are a2-adrenergic agonists. They have been commonly used to improve ADHD and sleep problems by practitioners for at least two

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decades. Until recently, neither medication has been approved for anything other than hypertension. (In 2009, Shire Pharmaceuticals obtained FDA approval to market Intuniv, a long-acting guanfacine formulation, with an indication for ADHD only). While popular, clinicians have been cautioned about their use because of potential adverse cardiovascular effects, although these concerns seem to be more common with clonidine (Harmon & Riggs, 1996). Typical and atypical neuroleptics have been used for sleep induction for many years. The mechanism supporting their sleep aiding effects appears to be related to their relative antihistaminic effects. As such, similar cautions are raised consistent with those already mentioned above. Furthermore, because of their potential for adverse effects, barbiturates and chloral hydrate are not recommended as first, second, or third tier interventions outside of a well-controlled medical environment or do not have a history of successful use.

Case Examples Jenny: End-Stage Renal Disease Jenny is a 14-year-old female with end-stage kidney failure. The initial consult came via her consulting gastroenterologist who was asked to see her because she was struggling with severe nausea, vomiting, and diarrhea. Her kidney dysfunction was marked by significant elevations in both her BUN (blood urea nitrogen) and creatinine (a toxic byproduct of muscle breakdown usually cleared by the kidney), although she was not yet on dialysis. Previous use of steroids (which had recently been discontinued) had resulted in considerable weight gain, although she had lost this additional weight by the time of the consult. She was, however, scared and in pain. The GI specialist had ordered ondansetron to reduce her nausea and requested a consult from psychology. Upon arrival, the child’s primary concerns related to heightened anxiety, a lack of sleep, poor appetite, and nausea/vomiting. Jenny’s renal condition was slowly deteriorating and ultimately she would require dialysis and a transplant. However, in the interim, her nausea and vomiting, coupled with sleeplessness, were conspiring to increase her agitation and anxiety. The vicious cycle of her anxiety, in part related to issues of body integrity and the impending dialysis, were interfering with any chance of adequate sleep and worsening her nausea. Her family history revealed that individuals with anxiety disorders were successfully treated with SSRIs. This suggested that, in addition to a cognitive behavioral management approach that included careful attention to her sleep hygiene, a similar intervention might be beneficial to her. The dialysis that would be necessary to save Jenny’s life would also come with some costs that make recommendations for medication more difficult. Dialysis, in short, removes toxins and other blood products. These other blood products include the proteins to which medications are bound and the unbound product intended to cross into the tissue. Furthermore, since she would ultimately be receiving a

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t­ransplant, it was important to consider that she would likely be back on steroids and antirejection medications. As a result of the information above, and in addition to psychotherapy specifically intended to aid her in adapting to her illness and to learn to manage her anxiety, it was recommended that Jenny be removed from odansteron and placed on mirtazapine. The reasoning was that the initial benefits would relate to mirtazapine’s well-known sedative (antihistaminic), nausea relieving (5HT3 blockade, essentially similar to ondansetron), and anxiolytic properties. Jenny was reassured, the intervention was carefully explained, and she was given the opportunity to choose the treatment she preferred. She opted to start the mirtazapine. Shortly after starting the mirtazapine, Jenny’s sleep improved, her nausea abated, and the weight from the steroid use diminished. Fortunately, the weight gain often associated with mirtazapine use has not been an issue. She continued to use low-dose mirtazapine during dialysis and transplantation, benefiting from the sedative properties inherent to its antihistiminic properties. Further, after transplantation, she continued with the medication at 15 mg at bedtime, finally successfully ceasing the use altogether 6 months after the transplantation. Both Jenny and her parents credit the psychotherapy and the mirtazapine, which helped them recover a sense of sanity in the context of a serious and frightening time.

Joey: Atypical Neuroleptic Malignant Syndrome Joey is a 9-year-old male with a history of pervasive developmental delay who was also diagnosed with ADHD by his pediatrician. Joey lives with his mother and her boyfriend in a very small town, where psychiatric services are not readily available. Early in Joey’s development, his pediatrician recognized his developmental delay and referred him to a geneticist in a nearby larger city. The geneticist was unable to identify a specific abnormality, but was the first to identify Joey as having a pervasive developmental delay. As Joey aged, his behaviors became more and more erratic. His pediatrician attempted to give him a trial of low-dose risperidone, which was initially successful. However, over time, Joey’s behavior became more unpredictable, aggressive, and hyperactive. Mother noted that stimulants did decrease his hyperactivity, but his aggressiveness continued. With that, the pediatrician continued to increase Joey’s dose of risperidone. Joey was hospitalized via the emergency room when his behavior became bizarrely hyperkinetic and included odd posturing and a deterioration in his mental state. His mother brought him to the local emergency room, which then transferred him to Children’s Hospital. In the weeks prior to Joey’s hospitalization, he had started to see a new clinician for his medication. This individual had maintained his stimulants, but discontinued his risperidone while very quickly escalating aripiprazole. After a month of rapidly increasing doses of aripiprazole (to 30 mg) which only led to dramatically worsened behavior, the clinician immediately discontinued the aripiprazole and started Joey on valproate. After three doses of valproate, Joey apparently began what was

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described as dystonic posturing, coupled with a clear loss of mental clarity (delirium). He was hospitalized and a medical psychology consult was requested. In the complement of labs ordered by the attending physician, several notable findings were revealed, including elevated ALT, AST, BUN (elevated liver enzymes and blood urea nitrogen). The consulting medical psychologist, after seeing the child, also ordered a CPK test, (creatinine phosphokinase is an enzyme often elevated when heart, muscle, kidney, or brain tissue is being broken down) which was 20 times normal. This latter elevation led to the conclusion that regardless of what might be causing the change in his behavior, the possibility of neuroleptic malignant syndrome (NMS) could not be ignored and that presumptive intervention based upon that hypothesis was in the patient’s best interest. Bromocriptine was introduced and the boy was discharged home 60 h later, having returned to his usual state. An appointment for medical psychology follow-up was made at the time of discharge and plans for an alternative neuroleptic in collaboration with his attending pediatrician.

Conclusion To date, medical psychologists in the U.S. have written hundreds of thousands of prescriptions, successfully managed common and uncommon adverse reactions, and collaborated with hundreds of physicians of varying specialties. We work hard to be careful and to take seriously the responsibilities we have to our patients, their families, and to the future of our profession. Unfortunately, despite the increased access to care that we provide, we also still have long waiting lists of patients. Until we dramatically increase the number of medical psychologists and open the regulatory doors in states beyond Louisiana and New Mexico, the needs will continue to outstrip our resources. I fear this is true even if 20,000 new medical psychologists were available nationally right now. No suffering patient should have to wait so long for care. During my experience at Children’s Hospital, I have learned three important pearls: • Expect the unexpected. Children with unusual conditions have unusual reactions. • Get good supervision. Treating children means spending a considerable amount of time prescribing off-label. Working with someone who has more experience makes sense in every profession. Your degrees and experience won’t protect your patient if you are arrogant. • Never, ever worry alone. If you have a difficult case that you’re reasoning through, or you think you’ve made a medication error, talk to a knowledgeable colleague. Do not wait and hope that nothing will go wrong. Never, ever, ever worry alone. A seasoned clinician will tell you that yielding to the awareness of your own ignorance is central to the growth of wisdom. Obtaining the advanced training gave me tools to be more effective as a clinician. I developed a new appreciation for the

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roles my physician colleagues had been playing in the lives of my patients. I developed a new and humbling appreciation of how much I did not know. Had I never written a single prescription, obtaining the advanced training in psychopharmacology would not have made me a better psychologist.

References Birmaher B, Brent D, AACAP Work Group on Quality Issues. (1998). Practice parameters for the assessment and treatment of children and adolescents with depressive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37(suppl), 63S–83S. Basbaum, A. I., & Jesell, T. M. (2000). The perception of pain. In E. R. Kandel, J. H. Schwartz, & T. M. JEsell (Eds.), Principles of neural science (4th ed., pp. 1480–1482). New York: McGraw Hill. Cooperative Group, M. T. A. (2004). National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: Changes in effectiveness and growth after the end of treatment. 37. Pediatrics, 113, 762–769. Council on Long Range Planning and Development. (1990). The future of psychiatry. JAMA, 264(19), 2542–2548. Fallon, B. A. (2004). Pharmacotherapy of Somatoform Disorders. Journal of Psychosomatic research, 56, 455–460. Garber, J., Walker, L., & Zeman, J. (1991). Somatization symptoms in a community sample of children and adolescents: Further validation of the Children’s Somatization Inventory. Psychological Assessment, 3, 588–595. Harmon, R. J., & Riggs, P. D. (1996). Clonidine for posttraumatic stress disorder in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1247–1249. Herxheimer, A., & Petrie, K. J. (2002). Melatonin for the prevention and treatment of jet lag. Cochrane Database of Systematic Reviews, (2), CD001520. Hollander, E., Allen, A., Kwon, J., Aronowitz, B., Schmeidler, J., Wong, C., et  al. (1999). Clomipramine vs. desipramine crossover trial in imagined ugliness. Archives of General Psychiatry, 56, 1033–1039. Hughes, C. W., Emslie, G. J., Crismon, M. L., Posner, K., Birmaher, B., Ryan, N., et al. (1999). The Texas Childhood Medication Algorithm Project: Update from the Texas Consensus Conference Panel on medication treatment of childhood major depressive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1442–1454. Ivanenko, A., Crabtree, V. M., Tauman, R., et al. (2003). Melatonin in children and adolescents with insomnia: A retrospective study. Clinical Pediatrics, 42, 51–58. Jan, J. E., Freeman, R. D., & Fast, D. K. (1999). Melatonin treatment of sleep-wake cycle disorders in children and adolescents. Developmental Medicine and Child Neurology, 41, 491–500. Lamberg, L. (2008). Katrina’s Mental Health Impact Lingers. JAMA, 300(9), 1011–1013. Mindell, J. A., et al. (2006). Behavioral treatment of bedtime problems and night wakings in infants and young children: An American academy of sleep medicine review. Journal of the American Academy of Sleep Medicine, 29, 1263–1276. Owens, J. A., Rosen, C. L., & Mindell, J. A. (2003). Medical use in the treatment of pediatric insomnia: Results of a survey of community based pediatricians. Pediatrics, 111, e628–e635. Phillips, K., Albertini, R., & Rasmussen, S. (2003). A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Archives of General Psychiatry, 59, 381–388. Phillips, L., & Appleton, L. (2004). Systematic review of melatonin treatment in children with neurodevelopmental disabilities and sleep impairment. Developmental Medicine and Child Neurology, 46, 771–775.

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Posey, D. J., Guenin, K. D., Kohn, A. E., Swiezy, N. B., & McDougle, C. J. (2001). A naturalistic open-label study of mirtazapine in autistic and other pervasive developmental disorders. Journal of Child and Adolescent Psychopharmacology, 11, 267–277. Sammons, M. T., & Schmidt, N. B. (Eds.). (2001). Combined treatments for mental disorders: A guide to psychological and pharmacological interventions. Washington, DC: American Psychological Association. Smits, M. G., van Stel, H. F., van der Heijden, K., Meijer, A. M., Coenen, A. M., & Kerkhof, G. A. (2003). Melatonin improves health status and sleep in children with idiopathic chronic sleep-onset insomnia: A randomized placebo controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1286–1293. Sondheimer, A. (1988). Clomipramine treatment of delusional disorder, somatic type. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 188–192. Stores, G. (2003). Medication for sleep-wake disorders. Archives of Disease in Childhood, 88, 899–903. Tucker, P. M., Garton, T. S., Foote, A. L., & Candler, C. (2009). In support of early psychotherapy training. In Psychiatric Times. UBM Medica, 26(12). From http://www.psychiatrictimes.com/ display/article/10168/1491210 Turk, J. (2003). Melatonin supplementation for severe and intractable sleep disturbance in young people with genetically determined developmental disabilities: Short review and commentary. Journal of Medical Genetics, 40, 793–796. Wallace, E. R., & Gach, J. (2008). History of psychiatry and medical psychology. New York: Springer. Yildiz, A., Sachs, G. S., & Turgay, A. (2003). Pharmacologic management of agitation in emergency settings. The Journal of Emergency Medicine, 20, 339–346. Younus, M., & Labellarte, M. J. (2002). Insomnia in children: When are hypnotics indicated? Paediatric Drugs, 4, 391–403.

Part III

Collaboration with Pediatricians in Treatment of Specific Disorders

Chapter 8

Collaborative Treatment of Disruptive and Mood Disorders George M. Kapalka

In the past few decades, the treatment of psychological disorders has changed. While psychotherapy was once regarded as the treatment of choice for most ­psychological disorders, the use of psychotropic medications has now become commonplace. Although psychological research literature continues to suggest that some psychotherapeutic treatments are at least equally as effective as medications (for example, see Hollon, Thase, & Markowitz, 2002), many factors (for example, economic) propel the continued growth of the use of medications. As managed healthcare plans curtail the primary physician’s referrals to specialists, there is a trend to shift mental health care onto primary care physicians. Since family doctors must weigh whether to use up a precious referral to address psychological symptoms (like attention-deficit/hyperactivity disorder (ADHD) or depression) or a potentially life-threatening medical disorder (like a heart problem), most physicians opt to address the psychological problems in-house. This trend is especially evident among pediatricians (Koppelman, 2004), who face additional pressures. When they refer patients to pediatric psychiatrists, they find that making such referrals does not necessarily lead to the delivery of needed mental health services. In the United States, there is a nationwide shortage of psychiatrists (Goldman, 2001), which is especially evident among pediatric psychiatrists (Thomas & Holzer, 2006); as a result, psychiatrists often refuse new patients and require several months’ wait time for the initial appointment. Not surprisingly, research findings reveal that most psychotropic medications are prescribed to ­children by their pediatricians (for example, Olfson, Marcus, Weissman, & Jensen, 2002). Although highly knowledgeable about medicine and medications in general, most physicians complete only 6 weeks of exposure to psychiatry during medical training (Serby, Schmeidler, & Smith, 2002) and receive no further required training in psychiatry during pediatric residency (Kersten, Randis, & Giardino, 2003). Thus, it is likely that pediatricians who feel compelled to address psychological

G.M. Kapalka (*) Department of Psychological Counseling, Monmouth University, Monmouth, NJ, USA e-mail: [email protected] G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_8, © Springer Science+Business Media, LLC 2011

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disorders in-house are likely to welcome contributions from clinical child ­psychologists who are especially competent in the delivery of mental health care to children and adolescents.

Pediatrician/Psychologist Collaboration Before any treatment can be planned and delivered, proper diagnosis must be established. Many psychological disorders, at first glance, present with similar symptoms, and a significant amount of information is needed to perform adequate differential diagnosis. However, because of their busy schedules, pediatricians spend a limited amount of time with each patient and cannot perform in-depth reviews of personal, family, developmental, health, and social history necessary for proper diagnosis of most psychological disorders. Conversely, psychologists are specifically trained in the diagnosis and treatment of mental disorders and traditionally see patients for 1-h appointments, usually weekly or biweekly. Thus, pediatricians can benefit from collaborative relationships with clinical child psychologists. After accurate diagnosis, treatment options must be considered. Competent clinical child psychologists are familiar with the results of research literature and are well-prepared to recommend treatment options. Often, the question of whether or not to use medications must first be considered. Here, psychologists need to be aware of the research literature that compares the effectiveness of pharmacological and psychological treatments. Where psychological treatment is likely to be effective and the use of medications is not necessarily indicated, psychologists can make such a recommendation to the pediatrician and the patient’s family. If the family is receptive to this recommendation, the psychologist then may be able to deliver this treatment. When this option is utilized, the psychologist needs to provide the pediatrician with periodic updates about the patient’s progress. Psychologists must also be aware of various factors that weigh in when parents make a decision about psychological treatment. In cases where either medication or psychotherapy may be effective, psychologists usually assume that the ­psychological treatment will be preferred. While the parents of many youngsters may agree, ­others may not have adequate insurance coverage to pay for psychotherapy and therefore may be forced to choose treatment with medications, even though psychotherapy may be equally effective. In addition, the availability of child therapists may be limited, or busy families may find it too difficult to commit time for regular therapy visits. While psychologists may not necessarily agree with the reasons why some families may choose medications rather than psychotherapy, they must accept the family’s right to make a choice that is right for them. When a decision is made to treat a patient with medications, pediatricians may choose to write the prescriptions, especially when the disorder is one with which they have some familiarity (like ADHD) and the level of severity does not appear unusually high. When medications are used, the patients’ progress and side effects

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must be monitored. Many pediatricians, however, may not be conversant with ­dose-response profiles and side effects of psychotropics. In addition, pediatricians may not be able to see their patients frequently enough, and long enough during each visit, to accurately screen these issues. Clinical child psychologists with extensive, formal training in psychopharmacology can assist pediatricians with these tasks. In New Mexico and in Louisiana, psychologists with such training can write prescriptions for medications. However, in states that have not yet enacted prescriptive privileges for psychologists (RxP), psychologists with RxP training can still be a valuable resource to pediatricians. Throughout the treatment regimen, psychologists with RxP training can perform medication monitoring and track the patient’s progress and adverse effects. When medication changes are warranted, psychologists with RxP training can have input into the nature of the adjustments. In providing this service, psychologists can offer relief to busy pediatricians who, instead of spending office visits troubleshooting psychotropic medications, will be able to devote these appointment times to the care of patients with medical problems. In this way, efficiency of the use of the pediatricians’ time is greatly improved.

Psychologists as Consultants: Models of Practice Consultation research has a long tradition within professional psychology. Psychologists commonly act as consultants within many settings, including business, sports, entertainment, and marketing. Thus, most psychologists are wellfamiliar with models of consultation and can easily adapt to consultation practices in medical settings. The most basic division of roles differentiates between consultant-centered and system-centered models of consultation (Kurpius & Brubaker, 1976). In the consultantcentered approach, the focus of the consultation is on the contributions that the consultant can make to solve a specific problem. The role of the consultant is to provide suggestions to address problems in one specific situation. The consultant is usually hired with limited scope and predefined, closed-ended term of service. Consultant-centered approaches can further be divided to include expert consultant, prescriptive consultant, and trainer consultant methods. Expert consultant is usually hired to assess the needs and provide general recommendations for remediation strategies. Prescriptive consultant goes one step further, in that the expectation is to provide specific suggestions about what should be done to remedy the problem. Trainer consultant provides the above, but augments the contribution to providing any training that becomes necessary in order to provide the services necessary to solve the problem. By contrast, system-centered consultants do not focus on the needs of a specific case. Instead, they seek to identify problems within the system that produce problems in specific situations. Thus, the focus of the consultation is on changing the system, rather than case-specific interventions. System-centered approaches are

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further divided to include facilitator consultant, collaborator consultant, and ­process-oriented consultant models. Facilitator consultant provides specific recommendations to administrators about the systemic changes that will improve overall outcome. Collaborator consultant provides active contributions to systemic changes, for example, by participating in developing policy changes. Process-oriented consultant provides the above components in addition to an active participation in the process of assessment and implementation of multilevel systemic changes. Many consider the models discussed herein to lie on a continuum, based on the scope of the consultant’s influence, with consultant-centered models on one end (with least influence) and system-centered models on the other (with most influence), and models that allow the consultant the greatest input into systemic changes are considered to be most effective in the long term (Cole & Siegel, 2003). Which of these models is most useful depends not only on the level of comfort of each pediatrician with the amount of input welcomed from the psychologist, but also on the demands of the specific settings where the consultation services take place.

Consultation in Primary Care Outpatient Settings When psychologists consult with pediatricians within primary care outpatient settings, most of the time this relationship takes place when the pediatrician refers his or her own patient to the psychologist for a consultation. It is important to remember that in this situation, the nature of the consultative relationship is determined on a case-by-case basis. The referring pediatrician usually has a longstanding relationship with the patient and the family and is initially seeking input from the psychologist about where to proceed with the case. The psychologist is expected to act as a prescriptive consultant who will assess the needs of the patient, perform a differential diagnosis, and recommend further treatment. In such a scenario, the pediatrician expects that the results of the consultation will be communicated to the pediatrician who will then meet with the family and discuss further treatment options. While many pediatricians appreciate verbal feedback, most require a written report to include in the patients’ records. Further role of the psychologist depends on the course of treatment that was recommended and becomes implemented. Three outcomes are possible. Limited consultation.  Limited consultation takes place when the psychologist’s input becomes limited to providing diagnostic feedback and recommendations for further treatment. This may occur when the psychologist recommends no mental health services, or when further psychological treatment is recommended, but the family is not receptive to this recommendation, or seeks further treatment with another provider (for example, one within their insurance network). In such situations, the psychologist should act as an expert consultant or prescriptive consultant, and the consultative relationship terminates after the feedback is provided to the pediatrician.

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Collaborative treatment.  If the psychologist recommends psychotherapy, and the family and the pediatrician are receptive to this recommendation, the psychologists and the pediatricians will enter a consultative relationship. In this case, the psycho­ logist will maintain autonomy with regard to the mental health care, the number and frequency of sessions, and the type of psychotherapeutic care that will be provided, and the pediatricians will commonly ask for periodic feedback about the patient’s progress. In turn, the pediatrician will continue to deliver any necessary medical services and (ideally) will inform the psychologist about any changes in the patient’s medical status. In this model, both professionals act as equals, each delivering various types of treatment that the patient requires. In cases where a psychologist with RxP training recommends treatment with psychotherapy and medications, the collaborative relationship with the pediatrician may become more complicated. When the same psychologist becomes the treating psychotherapist and a pharmacological consultant, the psychologist must be aware that he or she will be playing two different (although complementary) roles. Each of these roles carries different limits and expectations. When delivering psychotherapy, the collaborating psychologist should seek autonomy over the psychotherapeutic interventions and use his best judgment about the nature of the interventions, the frequency of the visits, and other aspects of psychological care. However, when the same psychologist delivers pharmacological consultation with the pediatrician and suggests the use of specific medications and dosages, psychologists must recognize that pediatricians will generally appreciate this input, and many specifically seek it, but still reserve the right to make a final decision about what medications will be prescribed. Both of these roles can be categorized as falling broadly within the definition of prescriptive consultant, but the psychologist will have much more autonomy in the role of being the patient’s psychotherapist than in the role of being the pediatrician’s pharmacological consultant. Pharmacological consultation.  In cases where the family chooses not to enter psychotherapy and opts to try pharmacological treatment, psychologists with RxP training may continue a limited consultative relationship. In this case, the pediatrician will remain the main treating professional, and the psychologist will provide input to help the pediatrician select the best pharmacological treatment, while the psychologist will deliver little, if any, direct services to the patient. The specific nature of this consultative relationship will depend on the level of confidence that the pediatrician has in the psychologist’s knowledge of psychotropic medications. Some pediatricians are only comfortable with psychologists remaining in the role of expert consultants, providing general recommendations for care (for example, that a patient may benefit from the use of medications) but refraining from suggesting specific medications and dosages. Other pediatricians are comfortable with psychologists acting as prescriptive consultants, recommending specific medications and dosages. However, in those cases, pediatricians still reserve the right to make the final decisions about what is in the patient’s best interests. In other words, in those cases, pediatricians remain in charge of the mental health care (the use of medications) but welcome psychologists’ input about potential treatment choices.

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Collaborative Care in Treatment of Disruptive Disorders Disruptive disorders are those in which problem behaviors disrupt the youngster’s environment. Commonly, these problem behaviors occur within the home as well as in school and in social settings. Consequently, children and adolescents who suffer from disruptive disorders often experience conflicts in most settings. The most common disruptive disorders include ADHD, tic disorders (most notably including Tourette’s disorder (TD)), oppositional defiant disorder (ODD), and conduct ­d isorder (CD). As a group, these are among the most frequently diagnosed disorders in children and adolescents (American Psychiatric Association (APA), 2000).

ADHD ADHD is evident in 6–8% of school-aged children (Barkley, 2006), and children and teens with ADHD commonly exhibit a variety of problems across different settings. In accordance with the DSM-IV-TR diagnostic guidelines (APA, 2000), these symptoms fall along the dimensions of hyperactivity/impulsivity and inattentiveness. However, a child with ADHD is a member of his family, his class, and his peer group, and his interactions with his parents, siblings, teachers, and peers are negatively affected by those core symptoms. Consequently, children and teens with ADHD commonly develop secondary symptoms that include problems with anger management, low self-esteem, poor frustration tolerance, and limited social skills. Collectively, symptoms of ADHD can be quite debilitating and frequently impair almost all activities and age-expected pursuits of children and adolescents. Most patients with symptoms of ADHD are initially brought to the attention of the pediatrician. However, since symptoms of ADHD resemble many other disorders, an in-depth diagnostic work-up is usually required, including a detailed interview with the youngster and the family and the use of behavioral rating scales completed by parents and teachers, as well as (if further clarification of symptoms is necessary) the administration of a continuous performance test (for example, Test of Variables of Attention (TOVA), Leark, Greenberg, Kindschi, Dupuy, & Hughes, 2007). This entire process requires two or three visits (of about 1 h duration) and therefore calls for more time than most pediatricians are able to devote to a single patient. Thus, pediatricians usually welcome input from a pediatric psychologist, and most parents are receptive to a referral to a psychologist for a diagnostic work-up. If the purpose of the referral is to only provide diagnostic feedback, the ­psychologist acts as an expert consultant and performs a limited consultation. If further psychological treatment is warranted (for example, individual counseling for the child and parent training for the family), and the family is receptive to this recommendation and agrees to continue in treatment with the psychologist, the psychologist and the pediatrician may provide collaborative treatment.

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If treatment with medications is considered, psychologists with RxP training can be a valuable resource to the referring pediatrician. Some parents feel that medical professionals overuse medications and are not receptive to nonmedical treatments. Those parents, and the referring pediatrician, can be confident that the psychologist is able to objectively determine whether medications are undeniably needed to treat the symptoms. In cases where treatment without medications is not likely to produce much benefit, parents may be more receptive to receiving such feedback from a nonmedical professional and may become more amenable to the need to return to the pediatrician to seek the necessary medications. On the other hand, in those cases where medications may not be absolutely necessary and utilizing nonmedical options (for example, behavior modification) is a reasonable alternative, a psychologist can deliver such a service and monitor the child’s progress. If the child responds sufficiently, the family received the necessary service and unneeded use of medications was avoided. If the response was insufficient, a referral for medications can be made along the way. If the child was placed on medications and continues to see a clinical child psychologist with RxP training for psychotherapy, the pediatrician can benefit from the psychologist’s knowledge of medications. The psychologist will have regular contact with the patient and will therefore be able to monitor the patient’s response to the medications and any emerging side effects. The psychologist can then give valuable feedback to the pediatrician about medication adjustments that are needed to maximize their benefit and minimize any adverse effects. In this way, the ­psychologist and the pediatrician will deliver collaborative treatment. The ­psychologist needs to remember, however, that the pediatrician will still retain the right to make the final decision about the choice of medications, dosage, schedules of administration, and all other medication-related issues. Psychologists with RxP training can also provide pharmacological consultations to pediatricians. When a recommendation was made to use medications and the patient will not continue further psychological treatment, a pharmacologically trained psychologist can provide suggestions to the pediatrician about possible choices of medications and starting dosages that may be appropriate. Input in this area may be very valuable to the pediatrician. Review of over 200 randomized, controlled studies suggests that about 73–77% of children with ADHD respond positively to stimulant medications (Barkley, 2006), and conversely, about 23–27% do not. Children with comorbid conditions are especially likely to have a poor response to psychostimulants. For example, when a child presents with ADHD and comorbid depressive symptoms, the use of psychostimulants may not be a preferred first-line treatment. Studies have shown that some antidepressants exhibit efficacy rates for ADHD similar to those of psychostimulants, while concurrently addressing the symptoms of depression. Tricyclic antidepressants have historically been known to improve ADHD symptoms (Higgins, 1999). However, the side-effect profiles of these medications (including, weight gain, sedation, and possible cardiac problems) are often difficult to tolerate. Newer antidepressants, including buproprion (Conners, Casat, & Gualtieri, 1996) and a newly approved compound atomoxetine (Kratochvil et  al., 2002), have

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shown efficacy in the ­treatment of both ADHD and depression with more favorable side-effect profiles. A pharmacologically trained psychologist can assist the pediatrician in selecting a medication (or a combination thereof) that is more likely to be effective in ­addressing all of the child’s symptoms.

Tic Disorders Children and adolescents with tic disorders exhibit repetitive sounds or motor behaviors, and in some cases both sets of symptoms are present. These interfere with the youngster’s ability to focus in school, hold a conversation, remain still when doing work, or attend places where it is necessary to remain still and quiet (for example, school or a house of worship). Because these behaviors bring attention to the child or adolescent, patients with tic disorders often exhibit secondary social and emotional difficulties because they often encounter ridicule from their peers and frustration from adults around them. Tics are generally divided into motor and vocal and may further be divided into simple and complex. Simple motor tics are characterized by rapid, meaningless muscle contractions, such as eye blinking, and simple vocal tics include individual sounds, such as grunting or throat clearing. Complex motor tics are composite movements that involve the coordination of various muscle groups to perform a complex movement, such as touching, flexing, jerking, or stiffening of the head or neck, or striking oneself, and complex vocal tics include words or short phrases. The duration of the behavior generally separates the tic disorders listed in the DSM (APA, 2000). When a child or adolescent exhibits vocal and/or motor tics that occur many times per day, consistently (nearly every day) for a period of at least 1 month but less than 1 year, transient tic disorder (TTD) can be diagnosed. This is the most common of all tic disorders and may be evident in as many as 19% of all children (BezchlibnykButler & Virani, 2004). TTD is rarely treated, and usually a wait-and-see approach is recommended. Because the tics come and go, there usually is no need for medical treatment, and therefore, it is not likely that any medical treatment will need to be used to treat symptoms of this disorder. If any treatment is needed, psychological approaches are generally utilized to help identify specific settings (like school or home) where the tics are more likely and psychological states (like feeling anxious or stressed, sleepy and tired, or hungry) that may trigger the tic episodes. Transient tics may progress to chronic tics. When a child or adolescent exhibits vocal or motor tics (but not both) that occur many times per day, consistently (nearly every day) for a period of at least 1 year, and the patient has not exhibited a tic-free period that lasted more than three consecutive months, chronic tic disorder (CTD) can be diagnosed. This disorder occurs in about 2–5% of all children (Bezchlibnyk-Butler & Virani, 2004). Only motor CTD or vocal CTD may be diagnosed, and both cannot coexist. Generally, CTD is not diagnosed if the patient has a history of Tourette’s. Usually, tics are more consistent than those evident in TTD, and motor tics are more common than vocal tics. It is possible for children or

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a­ dolescents to exhibit tics for many years, and the usual pattern is that the frequency and severity of tic episodes diminishes with age and eventually disappears. CTD is not usually treated with medications, and therefore, it is not likely that any medical treatment will need to be used to treat symptoms of this disorder. As before, if treatment is needed, psychological approaches are generally utilized to help identify specific settings (like school or home) where the tics are more likely, and psychological states (like feeling anxious or stressed, sleepy and tired, or hungry) that may trigger the tic episodes. However, when the tics are very bothersome and/or embarrassing (for example, striking of oneself), or if vocal tics interfere with functioning in some settings (like in school), a trial of medications may be utilized. In those cases, clinicians should try those compounds that have been shown to be effective in treating symptoms of TD (as described later in this chapter). Either TTD or CTD may progress to TD. When a child or adolescent exhibits vocal and motor tics that occur many times per day, consistently (nearly every day) for a period of at least 1 year, and the patient has not exhibited a tic-free period that lasted more than three consecutive months, TD can be diagnosed. Usually, tics are consistent (although active episodes usually wax and wane) and, along with vocal tics, complex motor tics are more common. Although symptoms of this disorder usually diminish with age and eventually disappear, a small portion of patients continues to exhibit symptoms into adulthood. TD is much more common in males, and some estimate the ratio to be as much as ten to one (Bezchlibnyk-Butler & Virani, 2004). The severity, number, location, frequency, and complexity of tics may change over time. Motor tics may include self-striking, or other extreme behaviors (including falling to the floor, jerking, twitching, flexing, etc.). Vocal tics may include barking, whistling, grunting, throat clearing, or other sounds. Complex vocal tics may include a variety of words, and rarely coprolalia (uttering of obscenities) may be evident, but it is neither common – less than 10% of patients with TD exhibit this symptom (APA, 2000) – nor necessary for diagnosis. However, other unusual features may be present. Echolalia-like symptoms may be evident in a tendency to mirror the speech of others. Youngsters with TD may find themselves repeating, along with a body jerk, the last word or words of a sentence that they just heard. Echolalia may also occur when children read a word or even think of a word or of the object that the word represents (Comings, 1990). Palilalia (repeating one’s own words) and echopraxia (mimicking of other people’s actions) may also be evident. These can appear quite bizarre to others. Symptoms of TD are usually more consistent and more evident than symptoms of TTD or CTD, and patients with TD usually present with greater impairment. For this reason, symptoms of TD are often treated with medications. As with other disorders, most patients with tics are initially brought to the ­attention of the pediatrician. Because some forms of tics are common, an in-depth diagnostic work-up is usually required, including a detailed interview with the youngster and the family, which is likely to be difficult for most busy pediatricians to perform. Thus, pediatricians usually refer patients with tics to a specialist for a diagnostic evaluation. However, since pediatric neurologists and psychiatrists are in

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short supply, it is likely that a pediatric clinical psychologist will be more available. If experienced in evaluating and treating patients with tic disorders, such a ­psychologist will be a valuable resource to the pediatrician. If the purpose of the referral is to only provide diagnostic feedback, the psychologist acts as an expert consultant and performs a limited consultation. If further psychological treatment is warranted (for example, behavioral treatment), and the family is receptive to this recommendation and agrees to continue in treatment with the psychologist, the psychologist and the pediatrician may provide collaborative treatment. For most patients with TDs, treatment with medications is considered to be an indispensible part of the overall approach, and psychologists with RxP training can be a valuable resource to the referring pediatrician. Pediatricians may not be familiar with the medications most commonly used to treat tics (for example, antipsychotics) and may welcome the expertise of psychologists who have significant familiarity with these medications. The psychologist will have regular contact with the patient and will therefore be able to monitor the patient’s response to the medications and any emerging side effects, which are common with the classes of medications most frequently used to treat severe tics (antipsychotics and antihypertensives). The psychologist can then give valuable feedback to the pediatrician about medication adjustments that are needed to maximize their benefit and minimize any adverse effects. In this way, the psychologist and the pediatrician deliver collaborative treatment, but as always, the pediatrician still retains the right to make final decisions about the choice of medications, dosage, schedules of administration, and all other medication-related issues. Because child clinical psychologists with RxP training have extensive knowledge of pediatric mental health disorders and their pharmacologic treatments, they can offer valuable service to pediatricians in cases where comorbidities complicate the choice of treatment. For many years, conventional wisdom has been that psychostimulants may exacerbate tics. Thus, it may appear that any child with TD and comorbid ADHD is not a candidate for stimulants. However, recent research has shown that this approach may be erroneous. The comorbidity between TD and ADHD is significant, with more than 50% of children with TD suffering from comorbid ADHD (APA, 2000). Both disorders are likely due to dopamine transporter gene anomalies. Several studies have shown that children with TD and ADHD do respond to stimulant medications (e.g., Gadow, Sverd, Sprafkin, Nolan, & Ezor, 1995). When stimulants are used, both the ADHD and TD symptoms diminish. So, a pharmacologically trained psychologist can help a pediatrician decide that a trial of stimulant medications may be warranted in children with ADHD and comorbid tic disorders.

ODD and CD Children and adolescents who exhibit argumentativeness and acting out behaviors are often diagnosed with ODD and/or CD. While the symptoms of the two ­disorders

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overlap to some degree, important differences between are also evident, and the two disorders may require different treatment. ODD is primarily characterized by argumentativeness, defiance, and temper tantrums, although violence is limited (with the possible exception of destructive behaviors in the midst of a tantrum), and the primary problem that most parents report is the youngster’s inability to handle things that do not go his or her way. By contrast, behaviors associated with CD are often more severe and involve more destructive acts that may not be associated with a tantrum – for example, criminal behaviors like stealing or damage to someone else’s property. ODD is the most common diagnosis among preschool children, and for schoolaged children and adolescents, prevalence rates of 3–16% have been reported, although changes in the diagnostic criteria from DSM-III-R to DSM-IV resulted in a decline in the rate of diagnosis (APA, 2000). The average age of onset is six with behaviors tending to peak at age 8, and the male to female ratio is 4:1, but the rates become more similar during adolescence. CD is one of the most frequently diagnosed conditions in outpatient and inpatient mental health facilities for children, and CD has increased over recent decades and is higher in urban than in rural settings. It is estimated that 6% of all children have CD, with a male–female ratio of four to one (APA, 2000). Childhood and adolescent onset are recognized, and for boys, the presence of a childhood-onset pattern of conduct predicts greater stability of the disorder and progression of the symptoms into more severe diagnoses (for example, adult antisocial personality disorder). Patients with symptoms of ODD or CD may come to the attention of pediatricians when the symptoms become too severe to handle within the home. Once again, since symptoms of these disorders (especially ODD) resemble and/or are comorbid with other disorders (for example, ADHD or a mood disorder), an in-depth diagnostic work-up is needed. This process may require several visits and a consultation with school professionals, and therefore, the time requirement easily exceeds what most pediatricians are able to devote to a single patient. Especially in the case of these disorders, pediatricians are likely to welcome the input from a pediatric psychologists to clarify the diagnosis and recommend the most sensible treatment plan. Since further psychological treatment is usually warranted (for example, individual counseling for the child and parent training for the family), and the family is receptive to this recommendation and agrees to continue in treatment with the psychologist, the psychologist and the pediatrician may provide collaborative treatment. ODD is rarely treated with medications. However, serious cases of CD are sometimes treated with medications (for example, mood stabilizers). Once again, if treatment with medications is considered, psychologists with RxP training can be a valuable resource to the pediatrician. If the pediatrician prescribes medications and the youngster continues to see the psychologist with RxP training for psychotherapy, the pediatrician can benefit from the psychologist’s knowledge of medications to monitor the patient’s response and any emerging side effects. Since pediatricians are not likely to have much experience with mood stabilizers, the psychologist can

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give valuable feedback to the pediatrician about medication adjustments that are needed to maximize their benefit and minimize any adverse effects. In this way, the psychologist and the pediatrician will deliver collaborative treatment. Of course, the prescribing physician will retain the right to make the final decisions about the choice of medications, dosage, schedules of administration, and all other medication-related issues. Psychologists with RxP training can also provide pharmacological consultations to pediatricians. When a recommendation was made to use medications and the patient will not continue further psychological treatment, a pharmacologically trained psychologist can provide suggestions to the pediatrician about possible choices of medications and starting dosages that may be appropriate. However, because patients with CD are not likely to be treated with medications alone, and such an approach is not likely to be very effective, pediatricians generally do not prescribe medications for this disorder unless the family is participating in some sort of mental health treatment. Thus, if the family refuses to continue to work with the consulting psychologist, the pediatrician is not likely to agree to prescribe the medications.

Collaborative Care in Treatment of Mood Disorders Mood disorders are those in which deviations in mood states result in significant disruptions in the youngster’s functioning at home, in school, and in social settings. Consequently, children and adolescents who suffer from mood disorders usually experience problems in most settings and a significant level of overall impairment. Mood disorders are categorized by the nature of the mood disturbance – expansion of mood (mania or hypomania) or depression. Although most commonly evident in adults, many youngsters experience symptoms of mood disorders during childhood and adolescence.

Depression Depression in children and adolescents has often been overlooked or minimized as normal mood swings that accompany developmental changes. In fact, until the past few decades, the spectrum of depressive disorders was not considered applicable to the pediatric population. Depression in children is no longer being dismissed, and researchers and clinicians now recognize it as a substantial problem affecting peer relationships, home life, academics, and physical well-being. Recognizing depression in children is complicated by several factors. Selfreports usually are not obtainable with infants and toddlers. Since most young children are not able to adequately verbalize what they are feeling, clinicians and researchers must rely on information gathered from parents, teachers, and other significant adults in the child’s life. Although teenagers are usually able to express

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their feelings, they may resist doing so and view depression as a sign of weakness. In addition, depressive symptoms may be masked by cooccurring conditions (for example, anxiety). For children, adolescents, and adults, the necessary symptoms for a diagnosis of depression are similar; a consistently depressed mood and lack of interest in activities once deemed pleasurable. To receive a diagnosis of major depressive disorder (MDD), at least one major depressive episode must have occurred, with no history of manic episodes. In contrast, dysthymia is a more chronic, low-grade depression that does not include a major depressive episode. Rarely, both MDD and dysthymia may occur simultaneously, a syndrome commonly referred to as double depression. The DSM expanded its diagnostic descriptions of depressive disorders to include some varied expressions of symptoms specific to children and adolescents, but some researchers argue that the DSM system still does not sufficiently recognize the different presentation of symptoms in youth (Weiss & Garber, 2003). As with other disorders, most patients with symptoms of depression are likely to be initially brought to the attention of the pediatrician. This may be especially true because many parents may not recognize that the youngster is depressed – they have a sense that something is wrong and may suspect that a medical illness may be to blame. As with other mental health disorders, symptoms of depression resemble (or be comorbid with) other disorders, and therefore, an in-depth diagnostic work-up is often required, including a detailed interview with the youngster and the family and the use of formal psychological testing instruments. Pediatricians neither have the time nor the training to perform such evaluations, and therefore, they usually welcome input from a pediatric psychologist, and most parents may be receptive to a referral to a psychologist for a diagnostic work-up to properly identify the symptoms. Once again, if the purpose of the referral is to only provide diagnostic feedback, the psychologist acts as an expert consultant and performs a limited consultation. If further psychological treatment is warranted (for example, individual counseling), and the family is receptive to this recommendation and agrees to continue in treatment with the psychologist, the psychologist and the pediatrician may provide collaborative treatment. Especially when treating symptoms of depression, if treatment with medications is considered, psychologists with RxP training can be a valuable resource to the pediatrician. Much has been written in the past several years about the danger of antidepressant medications, particularly with regard to antidepressant-precipitated suicidality. This has resulted in the black box warning about the danger of suicidal behaviors on all antidepressants marketed in the United States. For this reason, many parents and pediatricians are cautious about using antidepressants with children or adolescents. In addition, as of this writing, fluoxetine (Prozac) is the only antidepressant specifically approved by the Food and Drug Administration (FDA) for treatment of depression in children, and most antidepressants prescribed to children and adolescents are dispensed off-label. For these reasons, pediatricians are reluctant to prescribe antidepressants unless a mental health professional is involved to help monitor the patient’s response to the medications.

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If the child or adolescent was placed on medications and continues to see a p­ sychologist with RxP training for psychotherapy, the psychologist will have ­regular contact with the patient and will therefore be able to monitor the patient’s response to the medications and any emerging side effects. This is especially important given the danger of initial suicidality that is evident when some of the patients start these medications. When collaborative treatment is utilized, the psychologist can give valuable feedback to the pediatrician about medication adjustments that are needed to maximize their benefit and minimize any adverse effects. Psychologists with RxP training can also provide pharmacological consultations to pediatricians, although treatment of depression through medications alone is gradually growing out of favor. When a recommendation is made to use medications and the patient refuses to continue further psychological treatment, a pharmacologically trained psychologist can provide suggestions to the pediatrician about possible choices of medications and starting dosages that may be appropriate. However, pediatricians are becoming less willing to prescribe medications to children and adolescents who are not participating in some form of psychological treatment, and therefore, pharmacological consultations (in absence of collaborative treatment) are becoming less common. Usually, when a family is refusing to ­participate in psychological treatment for depression, pediatricians are more likely to refer the patient to a psychiatrist to perform appropriate medication monitoring.

Bipolar Disorder Until recently, bipolar disorder in children and adolescents has largely been overlooked, and bipolar disorder was thought to occur almost exclusively in adults. Although some researchers urged recognition of the fact that bipolar disorder also exists in children and adolescents (Garber, 1984), Biederman was one of the first to sufficiently call attention to the fact that bipolar disorder may be more common in children and adolescents than was previously recognized (Biederman et al., 1996). At this time, it is widely accepted that bipolar disorder does occur in children and adolescents, although some feel that nowadays it is diagnosed too frequently in this population (Hammen & Rudolph, 2003), especially in the United States. However, epidemiological studies from abroad confirm that any variant of bipolar disorder is present in about 1% of children (Verlhurst, van der Ende, Ferdinand, & Kasius, 1997), a rate that is similar in adults (APA, 2000). One reason for the disagreement in prevalence is that bipolar disorder in the juvenile population presents symptom profiles that are different from those ­commonly seen in adults. Indeed, bipolar I characterized by “classic” mania seems quite rare in children and adolescents (Hammen & Rudolph, 2003). Instead, ­children and adolescents with bipolar disorder are much more likely to exhibit variants where major depressive symptoms are interspersed with hypomanic episodes (bipolar II disorder), or full-blown mania is characterized by agitation, rather than classic elation (mixed mania).

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Core symptoms of bipolar disorder include a wide range of disturbances, i­ncluding changes in mood, self-control, and various aspects of physical ­functioning, including sleep, psychomotor agitation, and changes in speech patterns. Children and adolescents who present with significant depression, agitation, and loss of selfcontrol face many obstacles that can compromise their quality of life. Their family life is usually impacted and juveniles with symptoms of bipolar disorder usually have intense conflicts with parents and siblings. Because they tend to be violent, parents become very distraught and authorities may become involved when police are called in response to major episodes (or threats) of violence. After these outbursts, they may experience much guilt and remorse, which may further exacerbate their symptoms of depression, possibly increasing suicidal tendencies. Patients with symptoms of mania are likely to be brought to the attention of the pediatrician when the problems within the home and/or school become unbearable to the family or school personnel. As with depression, many parents may not ­recognize the nature of the disturbance, may only have a vague sense that something is wrong, and may seek answers from a medical professional. As with other mental health disorders, symptoms of mania resemble (or are often comorbid with) other disorders, and therefore, an in-depth diagnostic work-up is usually required, including a detailed interview with the youngster and the family and the use of formal psychological testing instruments. Pediatricians do not have the time or the training to perform these evaluations, and therefore, an opportunity exists for a pediatric psychologist to assist by providing a diagnostic work-up to properly identify the symptoms. If the purpose of the referral is to only provide diagnostic feedback, the psychologist acts as an expert consultant and performs a limited consultation. If further psychological treatment is warranted (for example, individual counseling), and the family is receptive to this recommendation and agrees to continue in treatment with the psychologist, the psychologist and the pediatrician may provide collaborative treatment. Especially when treating symptoms of mania, if treatment with medications is considered, psychologists with RxP training can be a valuable resource to the pediatrician. Most pediatricians have little experience with mood stabilizers, and many patients with bipolar disorder require polypharmacy to achieve significant symptom remission. This is an area where pediatricians are not usually comfortable prescribing medications, but if the availability of psychiatric care is particularly limited in an area where the patient lives, a pediatrician may agree to provide prescriptions for mood stabilizers if a psychologist with RxP training and significant experience in treating bipolar disorder collaborates with the pediatrician. In such a case, the psychologist will have regular contact with the patient and will therefore be able to monitor the patient’s response to the medications and any emerging side effects, providing valuable feedback to the pediatrician about medication adjustments that are needed to maximize their benefit and minimize any adverse effects. Psychologists with RxP training can also provide pharmacological consultations to pediatricians, although most pediatricians are likely to be very reluctant to ­prescribe mood stabilizers without involvement of another mental health professional. When a recommendation is made to use medications and the patient’s

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f­ amily refuses to participate in psychological treatment, pediatricians are more likely to refer the patient to a psychiatrist to perform appropriate medication monitoring. Thus, opportunities to provide pharmacological consultations (in absence of ­collaborative treatment) to pediatricians about treatment of bipolar disorder with medications are rare.

Outreach to Pediatricians Many pediatricians are not aware that some psychologists possess significant background in psychopharmacology. Traditionally, American psychologists have not received extensive training in medicine and the use of psychotropics, and many were generally critical of the use of psychotropic medications. Over the past two decades, however, more psychologists have been pursuing extensive training in psychopharmacology. To educate physicians that some psychologists have ­sufficient background and training to contribute to decisions about treatment with ­psychotropics, significant outreach efforts are necessary. Psychologists need to communicate to physicians that (where appropriate) they are not only receptive to the use of medications, but also are competent in selecting, dosing, and monitoring the use of these medications. Those psychologists who possess such a background in psychopharmacology, and are willing to perform focused, time-limited services, will complement pediatrician’s services, and most pediatricians are likely to be comfortable jointly treating patients with such psychologists. A collaborative ­professional relationship between a pediatrician and a pediatric psychologist will be rewarding for both professionals and will allow patients to receive efficient, efficacious, and cost-effective services.

References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington: APA. Barkley, R. A. (2006). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (3rd ed.). New York: Guilford. Bezchlibnyk-Butler, K. Z., & Virani, A. S. (2004). Clinical handbook of psychotropic drugs for children and adolescents. Seattle: Hogrefe & Huber. Biederman, J., Faraone, S., Mick, E., Wozniak, J., Chen, L., Oulette, C., et al. (1996). Attentiondeficit hyperactivity disorder and juvenile mania: An overlooked comorbidity? Journal of the American Academy of Child and Adolescent Psychiatry, 35, 997–1008. Cole, E., & Siegel, J. A. (2003). Effective consultation in school psychology (2nd ed.). Ashland: Hogrefe & Hueber. Comings, D. E. (1990). Tourette syndrome and human behavior. Duarte: Hope Press. Conners, C. K., Casat, C. D., & Gualtieri, C. T. (1996). Buproprion hydrochloride in attention deficit disorder with hyperactivity. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1314–1321.

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Gadow, K. D., Sverd, J., Sprafkin, J., Nolan, E. E., & Ezor, S. N. (1995). Efficacy of ­methylphenidate for attention deficit hyperactivity disorder in children with tic disorder. Archives of General Psychiatry, 52, 444–455. Garber, J. (1984). Classification of childhood psychopathology: A developmental perspective. Child Development, 55, 30–48. Goldman, W. (2001). Is there a shortage of psychiatrists? Psychiatric Services, 52, 1587–1589. Hammen, C., & Rudolph, K. D. (2003). Childhood mood disorders. In E. J. Mash & R. A. Barkley (Eds.), Child Psychopathology (2nd ed., pp. 233–278). New York: Guilford. Higgins, E. S. (1999). A comparative analysis of antidepressants and stimulants for the treatment of adults with attention-deficit hyperactivity disorder. Journal of Family Practice, 48, 15–20. Hollon, S. D., Thase, M. E., & Markowitz, J. C. (2002). Treatment and prevention of depression. Psychological Science in the Public Interest, 3, 39–77. Kersten, H., Randis, T., & Giardino, A. (2003). Evidence-based medicine in pediatric residency programs: Where are we now? Ambulatory Pediatrics, 5, 302–305. Koppelman, J. (2004). The provider system for children’s mental health: Workforce capacity and effective treatment. National Health Policy Forum Issue Brief No. 801. Washington: George Washington University. Kratochvil, C. J., Heiligenstein, J. H., Dittmann, R., Spencer, T. J., Biederman, J., Wernicke, J., et al. (2002). Atomoxetine and methylphenidate treatment in children with ADHD: A prospective, randomized, open-label trial. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 776–784. Kurpius, D. J., & Brubaker, J. C. (1976). Psychoeducational consultation: Definitions, functions, preparation. Bloomington: Indiana University Press. Leark, R. A., Greenberg, L. M., Kindschi, C. L., Dupuy, T. R., & Hughes, S. J. (2007). Test of variables of attention continuous performance test, version 7.3. Los Alamitos: TOVA Company. Olfson, M., Marcus, S. C., Weissman, M. M., & Jensen, P. S. (2002). National trends in the use of psychotropic medications by children. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 514–521. Serby, M., Schmeidler, J., & Smith, J. (2002). Length of psychiatry clerkships: Recent changes and the relationship to recruitment. Academic Psychiatry, 26, 102–104. Thomas, C. R., & Holzer, C. E. (2006). The continuing shortage of child and adolescent psychiatrists. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 1023–1031. Verlhurst, F. C., van der Ende, J., Ferdinand, R. F., & Kasius, M. C. (1997). The prevalence of DSM-III-R diagnoses in a national sample of Dutch adolescents. Archives of General Psychiatry, 54, 329–336. Weiss, B., & Garber, J. (2003). Developmental differences in phenomenology of depression. Development and Psychopathology, 15, 403–430.

Chapter 9

Collaboration Between Pediatricians and Pharmacologically Trained Psychologists in the Treatment of Anxiety Disorders in Pediatric Patients Sean R. Evers “I can’t go to school,” she said rubbing her eyes with one hand and pulling up the covers to hide her head with the other. “NO!” came as the response to mother’s pleas to get out of bed. “You don’t understand, my stomach hurts, and the bus driver doesn’t like me.” This scene is replayed over and over again with the anxious, school-refusing child. Even when the symptom is temporarily dormant and the child is attending school, possibly with an underlying social phobia, the symptoms tend to return after each extended school vacation, and at the beginning of each school year. Tearful and angry Meredith stomps her feet yelling. “Who moved my book bag?” “I put it here last night and now it is moved; now I’ll have to take everything out of it again and make sure nothing is missing. It was just right and now it’s ruined.” “Its fine honey,” mom intones. “NO, it’s not. Look. And now my skirt is wrinkled, and it doesn’t feel right, the tag is itching me. Don’t touch that – I’m going to be late, and the teacher will be mad at me and then I will miss recess and nothing will go right. Nothing ever goes right.” And the day begins for Meredith who has obsessive compulsive disorder. “At first we thought it was ADHD. He was having so many problems at school. But that wasn’t it. What should we do?” Alfred seemed to always be angry, short tempered, nervous and easily upset. “It doesn’t matter where we are – something triggers him and he says he feels all funny inside, overheated, and has difficulty breathing. He just wants to run outside wherever it happens. Everyone looks at us and I feel embarrassed.” Whether it was doing homework, completing an assignment in class, attending a family gathering or even walking through the mall, every event could trigger an outburst. His parents were at a loss, Mom, who acknowledged herself as a worrier became increasingly driven to find a solution for her son’s problem and explored every medical option available to her to no avail. She was not willing to accept a psychological cause to his problems, much less acknowledge that her son, like herself, was experiencing an anxiety disorder that needed treatment.

Anxiety disorders constitute the most frequent class of psychological problems experienced by children (Perlmutter, 2000). The Anxiety Disorders as a group include generalized anxiety, social phobia, panic disorder, phobias, obsessive– compulsive disorders, school refusal, separation anxiety, and trauma-related stress disorders. Beyond being psychologically significant, these problems (dependent S.R. Evers (*) Evers Psychological Associates, P.C + Kids Korner, Inc. Manasquan, NJ, USA e-mail: [email protected] G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_9, © Springer Science+Business Media, LLC 2011

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upon the age of the child) can lead to significant impairment in the developmental process, inhibiting emotional growth and socialization. These disorders also hold the special risk that if left untreated, they may become a permanent part of the child’s psychological functioning, disturbing and distorting the child’s normal development and creating social and learning difficulties that will impact the child throughout life. Early identification and aggressive treatment is important to stop these problems from lingering indefinitely. Pediatric mental health experts stress that it is important to correct these problematic behaviors and emotions as soon as they are discovered. The panicked, tearful children paralyzed with fear about going out to play or attending school, worrying that some horrific event will occur when they get a ­spelling word wrong on a test, and being afraid to go to sleep are all experiencing differing types of anxiety disorders. These children present challenges to their ­parents, ­teachers, and pediatricians. While some worry and discomfort are necessary to allow the child to develop appropriate coping skills, anxiety disorders represent the intensification of these common experiences to a level of severity that interferes with the child’s ability to function normally. These disorders can also disrupt family functioning and trigger a cascade of family conflicts that can only serve to intensify the child’s worry and anxiety. Proper identification and intervention can stop the avalanche of consequences resulting from an untreated or inadequately treated anxiety disorder. There are many different psychological approaches to treat anxiety disorders in children. Regardless of which psychological approach is selected, psychopharmacological interventions are sometimes necessary to augment the treatment of these troubling disorders. The present discussion is not based upon the strict adherence to one theoretical orientation. It is not designed to propose a model of treatment that will fit all situations or to act as a model for a specific treatment for a specific ­disorder. Rather, this discussion is based upon the recognition that there are many different models of treatment for childhood anxiety disorders and many different theoretical schools of thought on how to address specific problems and situations. Regardless of the theoretical differences, there are times when the pediatrician or psychologist must consider the use of psychopharmacological interventions with children. Additionally, due to the nationwide shortage of pediatric psychiatrists, the pediatrician has reluctantly become the de-facto primary provider of psychopharmacological medication for most children (USDHHS, 2000; Wang, 2010). This reality places pediatricians in an awkward position of providing treatment in an area of practice where their training is limited and requiring pediatricians to manage and monitor the effects of anxiolytic medications. In addition, recognizing that the pharmacological intervention is only one aspect of the treatment necessary to address anxiety disorders, pediatricians are at a disadvantage, since they do not have the time (or the training) to perform psychotherapy. This situation places the pharmacologically trained psychologist in a prime position to consult with the pediatrician about the psychopharmacological treatment of the child and deliver additional psychological services. Since the pharmacologically trained psychologist can consult knowledgably on pharmacological treatment, offering ongoing

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monitoring of the medications’ effects and side effects, and provide psychotherapy for the child and his or her family, the benefits to the pediatrician (and the child and family) are considerable. Pharmacologically trained psychologists are a relatively new specialty in ­psychology. Currently in New Mexico, with the label “Prescribing Psychologists,” and in Louisiana, with the label “Medical Psychologists,” pharmacologically trained psychologists prescribe medications (RxP). RxP psychologists are also recognized within the armed forces and the Indian Health Services. In other locations, psychologists with RxP training collaborate with physicians to recommend and monitor pharmacological interventions. Currently, there are approximately 1,500 pharmacologically trained psychologists in the United States (Ax, Fagan, & Resnick, 2009) and their numbers are growing as the need for their services increases. For the purpose of clarity definitions used in this chapter, a pharmacologically trained psychologist is a licensed psychologist who has, after being licensed to practice psychology, returned to school to attain postdoctoral training in psychopharmacology (RxP). This may include a postdoctoral masters in Clinical Psychopharmacology or equivalent training that meets APA’s guidelines for pharmacological training. The present chapter describes a model for consultation between the pediatrician and the pharmacologically trained psychologist. The need for this consultative model is based upon the recognition of several factors. First, there is a shortage of Pediatric Psychiatrists. Projections based upon pediatric psychiatrists in training and the aging of the currently licensed psychiatrists point to this shortage becoming more critical in the future (Thomas & Holzer, 2006). Second, there are a growing number of trained psychologists who are capable of offering the collaborative services to pediatricians treating children. Third, in this era of spiraling medical costs there is heightened interest in providing cost-effective care. The pharmacologically trained psychologist, in consultation with the pediatrician, can offer a more costeffective treatment than the current model, which includes the pediatrician, the psychologist, and a pediatric psychiatrist. And finally, while in some large medical centers (where there may be state or federal funding) treatment teams can delegate the tasks of treating children to a variety of specialists often without consideration of cost, in the vast majority of the country the pediatrician and the psychologist form the entire treatment team and they must provide all the services the child needs.

The Pediatrician’s Dilemma Anxiety disorders present a dilemma for pediatricians. Frequently the pediatrician is the child’s first contact with healthcare treatment. Children generally do not ­possess the emotional self-awareness, verbal skills, or insight to understand that their symptoms may not be related to a physical problem, but rather a psychological issue. Most parents who bring their children to the pediatrician are typically more comfortable with their child having a physical problem rather than an emotional one.

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The child is in pain and this pain is presented as an ­undifferentiated mixture of physiological and psychological symptoms. Sorting out the causes and ­treatments for the symptoms places a challenging burden on the pediatrician who is limited, by the reality of modern medical practice, to brief office visits. In addition, children may not be able to identify the psychological origin of their symptoms, but rather present the physical sequelae of them. At the same time, the family that brings the child for treatment may not recognize its role in creating or perpetuating the psychological symptoms, or the family may be embarrassed to reveal its own psychological difficulties and purposefully withhold information. The pediatrician, during the brief visit with the child, must assess both physical and psychological needs. The American Academy of Pediatrics estimates that for practice efficiency the target time for the face-to-face encounter is 15–18  min (Pediatric Care Online, 2008). During this limited time, the pediatrician is asked to evaluate the child, listen to the parents’ description of the issue, differentiate the symptoms they present into physiological and psychological conditions, understand the dynamics of the family, and recommend a course of treatment. If a psychological problem is suspected, the pediatrician must then convince the parents that a referral to a specialist is needed, reassure them and dissipate their own anxieties and guilt, and then negotiate the maze of in and out of network referrals to find a mental health provider appropriate for that child and family. Implicit in this referral is the pediatrician’s awareness that the child may need more than psychological intervention alone to address the anxiety and that the shortage of pediatric psychiatrists may result in the child coming back to the pediatrician for psychopharmacological treatment. To treat anxiety disorders, the pediatrician is frequently called upon to refer to a psychologist (to provide psychological intervention and close follow-up with the child and family) and a pharmacologist (to provide medications). The pharmacologically trained psychologist is uniquely qualified to provide multiple services in this collaborative effort. The pharmacologically trained psychologist can provide the mental health care needed to address the needs of the child and the family, including individual and family therapy, coordination of efforts of school and other personnel that deal with the child on a regular basis, and consultation with the pediatrician about pharmacological interventions. While there are other medical professionals who can serve as psychopharmacological consultants, none is trained in the multiple roles necessary to fully address the child’s needs. Pediatric psychiatrists are in short supply and their fees are typically higher than those of a psychologist. Also, because of this shortage and the psychiatrists’ focus on the medical model of treatment, they usually do not provide the psychotherapeutic treatment necessary for the child’s comprehensive care. Psychiatrists most often provide ­circumscribed pharmacological consultation and not actual hands-on psychotherapeutic care. Other master’s level pharmacological providers (like psychiatric nurses), while able to provide medication consultation, do not have the ­psychological ­training to address the psychotherapeutic needs of the child and family. Thus, the pharmacologically trained psychologist can provide a valuable and efficient ­service,

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collaborating with the pediatrician to manage both the psychological and medical needs of the anxiety-ridden child and his or her family.

Anxiety Disorders in Children Anxiety disorders in childhood include some of the most behaviorally disruptive disorders that children experience. While depressive and attention deficit disorders attract more attention of the media, anxiety disorders may actually occur more frequently (and touch more lives) than the other two categories combined. The DSM IV-TR (American Psychiatric Association (APA), 2000, p. 429) lists the following Anxiety Disorders: Panic Disorder, Agoraphobia, Panic Disorder with Agoraphobia, Agoraphobia without a History of Panic Disorder, Specific Phobia, Social Phobia, Obsessive–Compulsive Disorder, Posttraumatic Stress Disorder (PTSD), Acute Stress Disorder, Generalized Anxiety Disorder, Anxiety Disorder Due to a General Medical Condition, Substance-Induced Anxiety Disorder, and Separation Anxiety Disorder. Many of these disorders impact adults as well as children. Anxiety disorders in children frequently begin with physical complaints that bring the children to the attention of their pediatrician. In addition to these sometimes vague complaints, psychological symptoms that define the disorder are present. These may include crying and tantrums, clinging, staying unusually close to a familiar person, appearing excessively timid in unfamiliar settings, shying away from contact with others, refusing to participate in group activities, remaining on the periphery of social situations, worrying excessively, anticipating worst outcome in various situations, and exhibiting overwhelming fears not based upon the reality of their current situation. Central to all anxiety disorders is the experience of fear and the child’s response to that fear. Although Anxiety Disorders can manifest in a number of different ways, the central features of the anxiety disorders are fear and avoidance. LeDoux (2002) comments that “pathological avoidance of possible threat sources is a paramount behavioral symptom of anxiety disorders” (p. 289). Although there are many different proposed explanations for anxiety symptoms and explanations dependent upon one’s theoretical orientation, the fact that the symptoms are disruptive to a child’s life is consistent in all approaches, and everyone recognizes that the longer the symptoms remain uncontrolled, the harder they will be to reduce and eliminate (LeDoux, 1996). These basic assumptions play the central role in the use of psychopharmacological interventions with children. While it is generally accepted that “psychotherapy is more effective in treating Anxiety Disorders than any other group of mental problems” (LeDoux, 2002, p. 282), there are times when the duration of the symptoms and their intensity make it necessary to augment the therapy with medications. However, it is also important to recognize that medication alone is not the most effective treatment model for these disorders.

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Based upon DSM IV-TR (APA, 2000, pp. 437, 453) incidence data, anxiety issues seem to have some genetic or family linkage, making it more likely that the child with an anxiety disorder will have relatives with the same problems. This becomes important in practical considerations of the treatment of children who have one or more parent simultaneously experiencing marked anxiety. If not acknowledged and addressed, this can act as a major impediment to psychotherapeutic treatment, as treatment of an anxious child often requires active participation of the family.

Trauma Disorders in Children It was not until the introduction of the Diagnostic and Statistical Manual of Mental Disorders III (APA, 1980) that PTSD became a recognized diagnostic entity (Current Medical Diagnosis and Treatment in Psychiatry, 2006). In relative terms, this disorder is new and our understanding of it (and research into it) is in its early stages. The major disorders that capture the symptoms of traumatic stress in children are PTSD, Acute Stress Disorder, and the Adjustment Disorders. The DSM IV-TR also recognizes that additional disorders may be triggered by stress. These include other anxiety disorders, brief psychotic disorders, and depressive disorders. Significant debate continues about the expansion of these diagnoses to address the issue of trauma in children. The National Child Traumatic Stress Network Complex Trauma Task Force (2003) encourages the diagnosis of trauma disorders in children by placing them in a larger context. The term “complex trauma” is used to describe the dual problem of children’s exposure to traumatic events and the impact of this exposure on immediate and long-term outcomes. Complex trauma attempts to address the recognition that for children with a traumatic stress disorder, we have to consider the added layer of complexity that may occur as a result of the ongoing traumatic nature of their environment and family structure. The ability to use a label that ­captures children’s conditions more comprehensively will allow for more effective communication of the child’s condition and more focused and effective treatment (Cook, et al. 2003).

Pediatric Consultation The relationship between the psychopharmacologically trained psychologist and the pediatrician is reciprocal. Referrals and consultations flow in both directions as the psychologist refers children for their medical needs and the pediatrician refers to the psychologist for psychotherapeutic evaluation and treatment. Working together the psychologist and pediatrician can tailor a psychopharmacological regimen that matches the needs of the individual child. Since this type of consultation is new, the first step in developing a consulting relationship with a pediatrician is

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educating the pediatrician about this new role for psychologists. Pediatricians ­frequently refer their patients for psychological care. Often this relationship involves an initial referral and intermittent feedback describing the child’s progress. Issues of psychopharmacological consultation, if they arise, are reserved for a ­second referral to a pediatric psychiatrist. The expanded role of pharmacologically trained psychologists allows the pediatrician and psychologist to interact directly, follow the progress of the child more closely, and work together to select and monitor appropriate medications. This new consultative relationship raises several issues. First, while pediatric psychiatrists are generally comfortable prescribing psychotropic medications for children, pediatricians are often hesitant since there are few psychiatric medications with approved indications for use with children, and therefore, 50–75% of medications prescribed for children are prescribed off-label (Edersheim, 2009). In addition, not all state licensing boards have approved psychologists’ active consultation on pharmacological matters, although several have done so and none seem to prohibit such consultations (see McGrath, Chap. 2). The regulations that control the practice of psychology are evolving to match the changing reality of psychological practice to include pharmacology consultation. A thorough discussion of these topics can clear the way to a productive consultative relationship.

Psychopharmacological Interventions A fundamental assumption in the treatment of children with anxiety disorders is that they have either lost their ability to regulate their emotional states or are facing environmental stressors that outstrip their ability to cope. Psychological interventions in their various forms are designed to teach them both experientially and didactically the skills necessary to regain these abilities and coping skills. Psychopharmacological interventions can play a critical role in assisting the children cope with their emotional turmoil, while in psychotherapy, they learn the skills they need. Psychotherapy needs to be the primary treatment modality for anxiety disorders (LeDoux, 2002), but when psychotherapy alone is not offering relief or the symptoms are of such intensity that the children cannot engage productively in the therapeutic process, pharmacological interventions may be necessary. No one wants to see children taking medication unless it is absolutely necessary. One of the dangers is that children may learn that medication is the answer whenever they feel uncomfortable. This is especially important in anxious children, who experience significant anxiety and panic and frantically want to eliminate that uncomfortable state. Just as in adults with anxiety issues, the judicious use of medication can assist children to cope with their discomfort as they learn the long term skills to manage their anxiety in psychotherapy. Pharmacological consultation between pediatrician and RxP-trained psychologists cuts through the various theories of psychotherapy and instead addresses the

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issue pragmatically in an atheoretical way. Regardless of the psychotherapeutic interventions being used in a child’s treatment, there are times when, because of the intensity of the symptoms, the damage the symptoms are doing to the child’s development and socialization, or the duration of the anxiety symptoms, psychopharmacological intervention becomes necessary. However, psychologists must help pediatricians recognize that psychopharmacological treatment is not in lieu of psychotherapeutic treatment, but must be in addition to it.

Case Studies The following cases are included for illustrative purposes. They are representative of actual cases that involve the collaborative treatment of a pharmacologically trained psychologist and the child’s pediatrician.

Fred Fred, age 12, was the only child of his father’s second marriage. His father was a Viet Nam combat veteran. Fred’s father initially sought treatment to address problems with his job. The father was screened and determined to be exhibiting symptoms of PTSD. He was experiencing PTSD as a result of his wartime experiences. The father was initially refractory to treatment, did not want to accept that he had any difficulties as a result of the war, and repeatedly said that he was fine and if things would just go smoothly for a while he would be able to cope. A detailed history of his life since returning from overseas revealed many failed jobs and relationships. He had a history of alcohol abuse, although he was alcohol free at the beginning of treatment. He admitted to losing his temper frequently and getting into fights. The father entered treatment because of his desire to pursue a claim for compensation with the Veteran’s Administration, but as he became more aware of his PTSD symptoms, he recognized that he had psychological issues to work on. It was at that time that he began to raise questions about his son Fred. Fred had been referred to his school’s child study team for an evaluation. After that evaluation was completed, he was recommended to seek treatment for possible symptoms of ADHD. Fred’s father did not have medical insurance and could not afford a psychiatric consultation. He turned to his son’s pediatrician. The pediatrician was initially uncomfortable prescribing stimulant medication, but after a brief discussion with the family, he agreed. Fred was begun on a course of methylphenidate. His symptoms did not improve, in fact they got worse. Over the next 6 months, his behavior in school worsened as did his performance. He was tried on several different stimulants to no avail. Fred’s behavior was one of the stressors that his father had been coping with and an aggravating factor in his father’s PTSD symptoms.

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The father’s treatment intensified and he began to discuss his home life and the chaos in his marriage before he stopped drinking. Verbal and physical abuse was present between him and his wife. This abuse was witnessed by Fred. At times the father admitted that Fred was the target of his verbal tirades. The state-sponsored treatment program for veterans that the father was enrolled in allowed for the evaluation and treatment of family members. Fred and his mother were evaluated. As a result of this evaluation, it was determined that Fred was experiencing a complex trauma disorder, and his symptoms of ADHD were secondary to his complex PTSD. Fred’s pediatrician was contacted. Based upon the failure of his ADHD treatment and the results of his psychological evaluation, Fred’s stimulant medication was discontinued. Fred’s family still could not afford a psychiatric consultation, so a consultation was set up with Fred’s pediatrician. After a discussion of his evaluation results and possible treatments, it was decided that he would be treated ­collaboratively by his psychologist and pediatrician. Fred was seen in weekly individual and family therapy while being tried on a course of fluoxetine 10 mg each morning (qd/am). His case was discussed in weekly telephone consultations between the psychologist and the pediatrician. Over the course of the next several months, his medication was increased to 15 mg qd/am. His behavior improved and his attention issues in school became less problematic. As a consequence of Fred’s improvement, the stress in his household was reduced. Treatment was concluded after 13 months and the medications were gradually discontinued, without a return of symptoms. Fred’s father’s condition also improved. Although at the end of treatment symptoms of PTSD were still present, they were more manageable. The father continued treatment in a veteran’s support group.

Jennifer Jennifer, age 9, was referred for by her parents who were concerned about her ­perfectionism and her lack of friends at school. Jennifer was reported to have a ­history of excessive worry and a need to spend hours each night working and reworking her homework. This pattern often resulted in going to bed very late and obsessing over her homework and caused conflict with her parents. Jennifer was also very controlling with her peers and this put a strain on making and keeping friends. This issue came to a head when everyone in class was invited to a classmate’s birthday party and she was not. Jennifer was psychologically evaluated and it was determined that she was experiencing an Obsessive–Compulsive Disorder. Jennifer’s initial treatment was a combination of individual psychotherapy (including play therapy) and family therapy. Behaviorally, she was taught relaxation techniques, and cognitively, she was given tools to understand the nature of her overwhelming feelings and experiment with response inhibition. Although she quickly understood the nature of her problems, she could not control her behaviors. Although she attempted to inhibit her OCD behaviors, they frequently broke

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through and she felt like a failure. After several months of treatment she was ­beginning to feel hopeless. The topic of medication was raised with her parents. They were reluctant to have their daughter on medication because they had a family member with a chronic mental illness and heard from relatives many stories about ever-changing medications and side effects. Finally, the parents agreed to a medication trial, but were not comfortable with Jennifer seeing a psychiatrist. Jennifer’s pediatrician was approached by a pharmacologically trained psychologist (who had a long-standing relationship with the pediatrician) and agreed to start Jennifer on sertraline 25 mg qd/am. Side effects were minimal and after 4 weeks the dosage was increased. Jennifer continued in psychological treatment and with the aid of the medication she began to have increased success in inhibiting her behaviors. Within 4 months of medication, she found herself increasingly able to inhibit her compulsive behaviors using the skills she had gained in treatment. Her obsessive thoughts were more resistant to change, although they gradually receded, helped by environmental changes and a new school year where she felt that she could begin to exercise her newly-acquired social skills with a new group of peers.

Mary Mary, age 8, was referred for psychological evaluation and treatment by her plastic surgeon. She had been attacked by a dog in her neighborhood and had suffered significant damage to her face. The plastic surgeon discovered during the course of his repeated surgeries that Mary had developed a fear of dogs that was stopping her from playing with her friends at their homes. He referred Mary for what he thought was a simple phobia. An evaluation was set up and upon interview her mother revealed that Mary was also experiencing frightening nightmares, was having difficulty sleeping through the night, was irritable and angry all the time, and seemed obsessed with avoiding dogs or places where she might run into a dog. Mary was diagnosed with PTSD. She began a course of psychotherapy that included play and art therapy techniques. She initially responded well to psychological interventions and seemed to be making progress. Her fear of dogs that had begun to generalize to other small animals began to abate. As part of her treatment, it was agreed that she undergo systematic desensitization with controlled exposure to a therapy dog who had been trained for work with children. As the stimuli became more stressful to her, she exhibited increased difficulties. Simultaneously, her mother reported that Mary’s asthma had worsened. Mary was being treated by her pediatrician for her asthma. Her asthma had improved prior to her dog bite experience. Since that time it had exacerbated and seemed to be getting worse as her systematic desensitization neared its conclusion. During her therapy sessions Mary discussed getting a pet and planning to visit her friend who had a dog, while at the same time she was experiencing increased trouble with her asthma. There seemed to be a direct link between her increased symptoms, her asthma medication, and psychological desire to address her fears.

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Mary’s pediatrician was consulted. After a discussion of her history and condition it was determined that her asthma treatment was aggravating her anxiety and her psychological treatment was triggering her asthma. A collaborative treatment plan was developed modifying her asthma and psychological treatments. The pediatrician modified Mary’s medication and desensitization continued on a slower schedule. The collaboration allowed her fears to be treated, gave her relief from her asthma, and taught her the important lesson of the link between her stress responsiveness and her breathing difficulties.

Alice M Alice, age 10, was referred for evaluation and treatment by her mother who was concerned that her 10-year-old daughter was behaving strangely since her father was deployed overseas as part of his National Guard commitment. Alice was very anxious, had difficulty in sleeping, and was convinced that the terrorists that caused her father to be activated and sent overseas were in her town. She had a panic attack in the local mall when she saw a Muslim woman with a head scarf. On a rare phone call to her father in Iraq, she mentioned the incident and, after asking her father to come home and defend her against the terrorists, assured him that she would not go back to the mall or any public place where they could get her until he returned. Alice was referred to a pediatric psychiatrist who had seen her once and prescribed medication. After the initial visit she told her mother that she felt uncomfortable with the doctor who was not American and talked funny. Alice stayed under the care of the psychiatrist for only 2 months and then stopped after only seeing the psychiatrist twice. Alice had been prescribed Prozac 10 mg qd/am. She discontinued the medication once her visits with the psychiatrist stopped. Alice’s symptoms continued and actually worsened as her father’s deployment continued and she was exposed to news of the combat in parts of Iraq where her father was stationed. Alice’s mother took her to the pediatrician and she was then referred to a psychologist for treatment. Alice was evaluated and it was determined that she was experiencing an anxiety disorder in response to her father’s deployment. Her symptoms, while not qualifying for PTSD using the DSM IV-TR ­diagnostic criteria, would have qualified for a diagnosis of PTSD under the ­proposed changes in the DSM V with its broadened trauma criteria (APA, 2010). Alice liked the idea of talking to someone and seemed relieved that the psychologist did not have an ethnic appearance. Alice was interested in treatment and was an active participant from the outset. She was intrigued that someone would want to talk to her and listen to her concerns. She did not want to return to the psychiatrist who she felt was not concerned with what she had to say and seemed more involved in ­giving her medication. Nevertheless, her symptoms did not remit with psychotherapy. Her maladaptive behaviors had been dominating her behavior for several months and she found it difficult to alter her fears. She focused on her father and the fact that he was in

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danger. Medication was once again raised as a modality in her treatment. After a discussion with her mother it was discovered that Alice felt very comfortable with her pediatrician who had been her doctor since birth. Her pediatrician was ­consulted, and although reluctant to prescribe antidepressants, the pediatrician decided to take on the case. The pediatrician renewed the Prozac prescription ­initially started by the psychiatrist. Given the supportive environment of psychotherapy and her comfort with the pediatrician, Alice began to improve. Treatment continued after her father’s return from deployment. She experienced a setback shortly after he returned, when Alice said that her father had changed since his deployment. Her father was having a difficult time since returning from his combat tour and was concerned that he might be redeployed in the near future. Eventually it became clear that he was suffering from PTSD from his wartime experiences. Alice’s treatment continued. Her father entered therapy and began to work on his PTSD symptoms. Alice’s mood improved as the family dynamic gradually returned to normal. The medication was gradually discontinued and psychotherapy ended shortly thereafter. She remained with her pediatrician who periodically screens her for anxiety symptoms as part of the pediatric follow-up visits.

Ralph Ralph, a 17-year-old white male, was referred for evaluation and treatment because of his legal problems. He had a history of Attention Deficit Hyperactivity Disorder and was taking methylphenidate for that condition. He had responded well to that treatment and had been on varying dosages of the medication for over 8 years. He did not excel academically, but passed with low average grades. His social adaptation was poor, and except for involvement with the school band and track, he did not participate in out-of-school social activities. His level of social involvement changed with his first boyfriend/girlfriend relationship. This relationship opened a new social world to him, but a world that was focused on his girlfriend. Ralph’s relationship ran its course and eventually the relationship became filled with frequent arguments that occurred both in person and by cell phone (both ­verbal and text messages). As the relationship worsened, the arguments intensified. The number of text messages between him and his girlfriend exponentially increased, and the content of his emails became more and more hostile and eventually threatening. Ralph also became involved with a group of “Facebook friends” and the postings and blog entries describing the relationship that passed between his social group fueled his anger. Ralph became obsessed with retaining his ­girlfriend, but his lack of social skills made his attempts less and less successful and more and more inappropriate. Eventually, his messages came to the attention of his girlfriend’s parents, who complained to the school and Ralph’s parents. These ­complaints came at the same time as the final breakup of the relationship and

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his ­girlfriend, with her parents’ insistence, refused to communicate with him. Ralph could not accept the breakup of the relationship. His attempts at communicating with his now former girlfriend continued in an escalating number of text and emails. He also embarked on an Internet campaign and left negative, hostile posts for mutual friends and acquaintances in an attempt to reengage his former girlfriend in conversation. He felt that if he could talk to her their relationship could be rekindled, but every attempt to talk to her ended in more threatening arguments. Eventually, the girlfriend’s parents filed a formal complaint with the police. Ralph was ordered to have no communication with his former girlfriend, but he could not control his behavior and continued to try to communicate with her. Ralph initially sought help from the pediatrician, who referred him for psychotherapy. It became immediately apparent that Ralph’s obsession with his former girlfriend was out of control and that without aggressive intervention he would be faced with serious legal consequences since the initial complaint was made under the stalking statute. In consultation with the pediatrician, Ralph was started on Prozac 20 mg qd/am. This dosage was increased over the next 3 months to 60 mg/ day. This increase in medication, along with individual cognitive/behavioral therapy, family therapy (which focused on controlling his behavior at home and limiting his cell phone and computer use), and educational interventions (eventually requiring homebound instruction to eliminated casual contact with his former girlfriend in the school hallways), resulted in the reduction in his obsession. Over the next year, he was able to return to his school placement, have his cell phone privileges returned, and reengage in unsupervised social interactions. He remained on the same dosage of Prozac for approximately 18 months. After 3 months of being obsession free, his dosage was reduced.

Summary Anxiety disorders are the most prevalent mental health problems experienced by children and adolescents (Perlmutter, 2000). These disorders present an excellent opportunity for the collaboration between pediatricians and pharmacologically trained psychologists. This collaboration grows out of the recognition of the unmet psychopharmacological needs of children and the growth of the field of psychology to include an increasing number of pharmacologically trained psychologists. Pharmacologically trained psychologists offer an important resource for pediatricians who treat children with anxiety disorders. This new area of collaboration benefits the patient and the family, offering them an expanded continuity of care and allowing for closer integration of medical and mental health treatment. Collaborative treatment by pediatricians and pharmacologically trained psychologists also effectively addresses the shortage of pediatric psychiatric providers and allows for the delivery of more cost-efficient comprehensive health care.

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References American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: APA. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: APA. American Psychiatric Association. (2010). Diagnostic and statistical manual of mental disorders: Proposed revisions. Retrieved from http://www.dsm5.org/ProposedRevisions/Pages/ proposedrevision.aspx?rid=165 Ax, R. K., Fagan, T. J., & Resnick, R. J. (2009). Predoctoral prescriptive authority training: The rationale and a combined model. Psychological Services, 6, 85–95. Cook, A., Blaustein, M., Spinozzola, J., & van der Kolk, B. (Eds.). (2003). Complex trauma in children and adolescents: White Paper The National child Traumal stress Network: complex Trauma Task Force, National Child Traumatic Stress Network, Los Angeles, Cauf. Dupham, N.C. Retrieved from http://www.NCTSNet.org Current Medical Diagnosis and Treatment in Psychiatry. (2006). Post-traumatic stress disorder (PTSD). Retrieved from http://psychiatry.Healthse.com/psy/more/post_traumatic_stress_­ disorder_ptsd/ Edersheim, J. (2009). Off-label prescribing. Psychiatric Times, 26(4). Retrieved from http://www. psychiatrictimes.com/display/article/10168/1401983 LeDoux, J. (1996). The emotional brain. New York: Simon & Schuster Paperbacks. LeDoux, J. (2002). Synaptic self. New York: Penguin. Pediatric Care Online. (2008). The timing of the visit. Retrieved from http://www.pediatriccareonline. org/pco/ub/view/BrightFutures/135111/0/The_Timing_of_the_Visit Perlmutter, S. (2000). Childhood anxiety disorders. Retrieved from http://www.acnp.org/g4/ gn401000163/ch159.html Thomas, C. R., & Holzer, C. E. (2006). The continuing shortage of child and adolescent psychiatrists. Journal of the American Academy of Child and Adolescent Psychiatry, 45(9), 1023–1031. US Department of Health and Human Services (USDHHS). (2000). Mental health: A report of the Surgeon General. Washington, DC: US Government Printing Office. Retrieved from http:// www.surgeongeneral.gov/library/mentalhealth.home.html Wang, S. (2010). Call for kids’ mental-health checks. Retrieved from http://online.wsj.com/article/ SB10001424052748704366504575278572580831644.html

Chapter 10

Collaborative Treatment of Eating Disorders Marla M. Sanzone

Experts agree that the most effective treatment of children with eating disorders is multisystem based and combines the expertise of several disciplines. Specialists in pediatrics, internal medicine, endocrinology, psychology, psychiatry, and nutrition, for example, may collaborate with one another at various relevant points in the course of treatment. Eating disorders, unique among mental/emotional conditions, influence a child’s development in broad, yet  also highly specific ways in all domains of function: physical/physiological, emotional/psychological, interpersonal/social, and behavioral. The comprehensive clinical behavioral training of doctoral level psychologists with advanced postdoctoral psychopharmacological specialization renders collaboration with pediatricians a natural fit. A multimodal model such as that described in The Multimodal Treatment of Eating Disorders (Halmi, 2005) recognizes that eating disorders neither have a single cause nor follow a predictable course. The unique integrated effects of and on one’s genetic, biological, psychological, and social constitution manifest a progression toward the development of an eating disorder. The effects of starvation physiologically, and in other domains of functioning, propel a reciprocally reinforcing cycle of core dysfunction at critical periods of biological, psychological, familial, and social vulnerability. Both the severity of illness and the specific eating disorder with which the patient is presenting will determine the appropriate treatment strategy. The primary elements necessary for therapeutic management of eating disorders include medical stabilization with regular periodic monitoring, family and individual therapy, behavior therapy, cognitive therapy, interpersonal cognitive–behavioral therapy, and group therapy, in this order, when treating children (APA, 2000; Halmi, 2003, 2005; Kleifield, Wagner, & Halmi, 1996). Individual therapy is primary to family therapy among adolescents of about 16 years of age or older, and adults (Halmi, 2005; Lock, Agras, & Bryson, 2004). Likewise, behavioral and cognitive modalities can often be combined with the older adolescent and adult population in large measure due to maturational brain processes characteristic of M.M. Sanzone (*) Independent Practice, Annapolis, MD 104 Annapolis St., Annapolis, MD 21401, USA e-mail: [email protected] G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_10, © Springer Science+Business Media, LLC 2011

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later adolescence and adulthood, as well as the interpersonal dynamics associated with identity separation and individuation of the later adolescent period of development. In contrast, the younger child’s brain functions at more concrete levels of cognitive development such that its relative capacity for abstraction, self-awareness, or insight is less extensive. This renders behavioral procedures more appropriate than cognitive restructuring for the young child. Individual therapy is thought to be the expected treatment for conditions such as eating disorders that appear to be so individually driven by a personal sense of control over one’s relationship with food and own body. Counterintuitively however, family therapy has been shown to be the most effective treatment of choice for children and adolescents (Eisler et al., 2000; Halmi, 2005; Le Grange & Eisler, 2009). Of course, each case must be assessed for unique factors that might contraindicate family therapy and suggest the preference for individual treatment, such as abuse whereby the patient may withhold necessary self-disclosure in order to protect the perpetrator and/or to reduce possible retaliatory actions following disclosure. Weight restoration and metabolic stability of anorexics and low-weight bulimics are essential to cognitive receptivity and affective availability to psychotherapy (Halmi, Agras, & Crow, 2005; Kaye, 1997). However, given the nature of the conditions, this is a complex decision and various forms of therapy may be needed: behavior therapy to address the severe phobic resistance to minute weight increases and enable weight gain, and/or reduce the frequency of binge/purge behavior; cognitive therapy to challenge distortions, pervasive illogical conclusions, and negative cognitive rehearsal; family therapy to identify, redirect, or rehabilitate disrupted interactions that contribute to the perpetuation of emotional and/or behavioral disturbances in the patient; and interpersonal and group therapy to reduce social anxieties and other forms of interactional avoidance that foster perceptual and affective distortions in self-concept and self-worth. Elemental to the nature of an eating disorder is an inverse relationship between one’s subjective sense of self-worth or self-efficacy and the severity of the eating disorder symptomology. In combination with the concomitant physiological premises of these conditions, this critical cognitive-affective psychological identity construct perpetuates the disturbed patterns of behavior and the intensity of resistance to symptom improvement. Successful treatment and resolution of an eating disorder requires not only physical improvement in the obvious symptoms of an eating disorder, but also a reduction in the degree of perceptual distance between these polarities that underlie self-identification or self-concept. Careful collaboration between the pediatrician and the psychologist enhances the chances that this psychological chasm is reduced, as without it, solely physiological manifestations of improvement will falter in service of the distorted psychological reality the ­individual has constructed as a function of the illness. Indeed, as more sophisticated genetic, imaging, and hormonal markers of predisposition suggest, it can be argued that some form of nonpsychological, biological, and/or congenital vulnerability may be found to predate the manifestation of the rigid psychological dichotomies that often differentiate an eating disturbance or syndrome from a clinical disorder diagnostically (Akkermann et al., 2008; Bulik, Devlin, & Vacanu, 2003; Farooqi et al., 2007;

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Grice, Halmi, & Fichter, 2002; Halmi, 1992; Jimerson & Wolfe, 2004; Kaye, Frank, & McConah, 1999; Lewinsohn, Striegel-Moore, & Seeley, 2000; Monteleone, Di Lieto, & Castaldo, 2004; Strober, 1992; Wade, Bulik, & Neale, 2000). Treatment realities, however, render this “chicken or egg” theoretical confound secondary, at least until sound evidence intimates more effective alternatives. As such, careful integration of medical and psychological treatment protocols is necessary in order to challenge effectively the conditioned factors that maintain precarious control over the individual’s biological and psychological processes. Collaboration between the pediatrician and the psychologist minimizes treatment inconsistencies, delays, miscommunications, splitting, or other obstacles to a smooth and productive treatment process. Increasing levels of physician receptivity toward consultation with psychologists are driven by numerous dynamics. Time demands and financial pressures are inherent in the current medical practice culture. In addition, identifying and treating mental health issues are not routinely covered in residency training programs despite welldocumented evidence that anxiety and depression are commonly occurring conditions in the population (Mojtabi, 2009; Perez-Pena, 2006). Consequently, in order to ensure adequate diagnosis and treatment of mental health issues for their patients, physicians often feel forced to seek psychological consultation whether or not they are personally receptive to the concept of collaborative care. The negative impact of managed care on the interaction between practice solvency and time available per patient necessarily constrains a pediatrician’s opportunity to develop a sufficient level of familiarity with psychotropics so that mental health issues can be sufficiently addressed. In contrast, pediatricians who work in practices that use a collaborative model with psychologists develop an appreciation for the level of training involved in preparing a psychologist to provide psychopharmacological consultation. In difficult to manage cases such as those involving children and ­adolescents with eating disorders, an in-depth assessment is critical to clarify the proper diagnosis and to identify relevant subtler factors regarding suitability for and timing of medication in concert with individual, family, and group psychotherapy as part of the treatment course. Assessment to determine recommendations about medication and therapy timing and types must involve a degree of depth and detail that are impossible to obtain within a 20-min standard medical appointment. Evaluation of the child’s symptoms and their onset and progression, current and historical family dynamics, school and social circumstances, eating and food-related patterns, medical history, recent and past illnesses, and exposures and/or changes to medical, psychological, and social/environmental status must carefully be explored during the ­eating disorder evaluation process with the child and his or her family. Pediatricians are among the specialists who recognize the importance of ­consultation with eating disorder specialists and, as a result, have become more receptive to consultation and collaboration with psychopharmacologically trained psychologists. This reflects a gradual, parallel change in attitudes among the US population. Between 1998 and 2006, Americans reported an increasingly favorable public opinion toward psychiatric medications and psychologists prescribing (Mojtabi, 2009).

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As much as we all would prefer it not be the case that media influences patient behavior to the degree it does, the shear proliferation of advertising and marketing campaigns for everything from breakfast cereal and action figure toys to sexual performance aids is testament to their persuasive power. It is no surprise to learn that the drug companies spend more money on marketing pharmaceutical products than on researching them (Harris, 2007). The effect has been significant consumer demand for psychotropic medications. Consequently, patient expectations that specific medications will be available to them if requested and that the medications advertised to treat the condition they self-diagnose to be suffering from are the best way to treat their condition (such as Paxil for social anxiety and Abillify for depression) should be no surprise. This type of simplistic marketing from the pharmaceutical advertising industry creates conditioned consumer demand, particularly in a culture already prone to jumping at quick fixes and oversimplifying complex processes. Patient demand for specifically identified treatments, the criteria of which they have already self-determined sufficiently meet, places additional pressure on doctors to make quick decisions. The through investigation and eventual diagnosis of complicated conditions can require time both with the patient, and outside the examining room as the physician interprets and integrates the results. However, the combination of patient expectations, reduced physician autonomy, insurance-driven limitations on testing procedures, and swollen patient caseloads can render careful conscientious practitioners frustrated and mentally exhausted. Physicians report increasing patient resistance to time-consuming evaluation processes, insufficient time to explain adequately the importance, and greater patient insistence on an on-the-spot prescription for their drug of choice (Seaburn, Lorenz, Gunn, Gawinski, & Mauksch, 1996). This dynamic tension between the patient and physician, and the decisions that result, can further increase treatment noncompliance, chances of adverse medication effects, dangerous medication interactions, physiological or hormonal vulnerabilities to complications, or obfuscation of other illnesses disguised by the action of a drug that may not be most appropriate for the individual. Despite these risks, this type of patient demand and advertising-driven practice of medicine has today become commonplace. A physician’s opportunity to educate patients about their medical status: the desired and adverse effects of medications; the relevance and necessity of examination, consultation, and/or treatment by other experts is becoming a thing of the past. Collaborative models reduce the intensity of the challenge to balance these competing demands and expectations.

Advantages of Pediatrician–Psychologist Collaboration When treating particularly reluctant patients, such as youngsters with eating disorders, a team approach helps parents begin to understand the severity of the problem. Collaborative treatment can allow family members as well as the patient to begin to conceptualize the unique manifestation of eating disorders – that a primary

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clinical eating disorder is not merely a physical or medical weight-related condition in which the person’s weight simply needs to be restored and the condition will be resolved. Similarly, it is not just psychological, emotional, or behavioral disturbances that happen to involve loss of weight, weight fluctuations, or obesity. Eating disorders are by definition a combination of all of these dimensions and more. Successful treatment requires involvement of professionals from at least medical and psychological specialties. When working with children and adolescents, parents/guardians are inherently involved in some (if not all) aspects of initiating and continuing treatment, except for an atypical case in which an adolescent is emancipated or is of an age and can seek treatment independent of parental knowledge or consent. Parents often ­initially consult the pediatrician when they encounter confusing or distressing physical and behavioral changes in their child. A study by Fox, Halpern, and Forsyth (2008) found that parents prefer to discuss mental health concerns with their pediatrician rather than school personnel (teachers, school nurses, or guidance counselors). Pediatricians are familiar with the typical call they often receive from a concerned parent of a preadolescent or adolescent daughter with precipitous weight loss or unusual eating and bathroom habits. In recent years, this type of call from confused and frightened parents of young boys is also becoming all too common as adolescent boys exhibit an alarming increase in the incidence of adolescent eating disorders (DiNicola, 1990; Mickalide, 1990; Woodside, 1993). When a pediatrician has an optimal collaborative arrangement, a consultation with a psychologist with specialized training in the treatment of eating disorders and advanced psychopharmacology provides an opportunity for rapid intervention with medical, psychological, and psychopharmacological evaluation and treatment. Such streamlined systems have fewer obstacles to treatment implementation and reduce pressures on pediatricians from managed care (Kapalka, 2009; Kvamme, Olessen, & Samamuelsson, 2001). The insurance industry demands for pediatricians to see more patients for less time have rendered fewer hours available for physicians to know patients and their families to the depth and degree that was possible in prior generations. Given these and other forces often curtailing opportunities for in-depth patient–doctor communication, pediatricians acknowledge that they have only little opportunity to screen adequately for eating disorders or other mental health conditions. Similarly, pediatricians admit to have relatively sparse training in the details of psychotropic medication management. Acutely sensitized to parent concerns with the idea of psychotropic medications with their children, and attuned to the scarcity of large-scale replicated efficacy and safety studies of these compounds, pediatricians and psychopharmacologically trained psychologists can collaborate compatibly and effectively (Kapalka, 2009; Rae et al., 2008). With pediatricians often being first to be contacted by a parent with concern about weight change, pediatricians referring to a collaborating psychopharmacologically trained psychologist can convey the relevance and complementary nature of a teamed medical/psychological approach to treatment. Pediatricians can reassure the parent that the psychologist will evaluate the child and communicate with

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the parents the breadth and depth of information involved in psychological (and potentially psychopharmacological) treatment specific to eating disorders, including the germane areas of diagnostic differentiation from other mental/emotional conditions often seen among individuals with eating disorders and/or family members, as well as how psychological and medication evaluation and treatment (medical monitoring and follow-up) are managed in a collaborative approach. It is typical of most consultation models, both within and separate from the primary care setting, that the parent makes the referral call to the psychologist for the initial evaluation. However, in some cases, the pediatrician may deem it necessary to make the initial call directly. The following are examples of scenarios in which the pediatrician may choose to do so: 1. The pediatrician believes that the eating problem has progressed in severity to a stage where possible inpatient or intensive outpatient may be in order. 2. The pediatrician has provided referral information and recommendation in the past and the patient/parent has not followed through. 3. The parent and/or child is resistant to evaluation and/or in denial of the problem despite evidence of considerable change in weight, laboratory values, or other symptoms logical change. 4. The pediatrician suspects other behavioral changes, mood disturbance, and/or anxiety conditions that might contribute to or result from eating abnormalities, and medication/therapy may be needed without delay. 5. The mental health circumstances are unclear and/or the parents are not likely to provide necessary data, and thus the pediatrician is hindered from having mental health information he or she needs to make relevant medical decisions. 6. The family interaction is in an unusually disharmonious state and the pediatrician is concerned about the emotional well-being of the child due to the family problems (not just directly related to the eating disorder), such as a contentious divorce or custody litigation. 7. The pediatrician believes that the information necessary for the psychologist to establish a therapeutic relationship with the child may be jeopardized or hindered by parent/family dysfunctional dynamics. 8. The pediatrician is aware of a mental disturbance in a parent and/or other family member that has been treated pharmacologically and this information, likely to be highly useful to the evaluation, should be conveyed prior to the initial consultation. The psychologist is generally the primary point of contact once the initial referral for evaluation is made and a treatment contract for therapeutic services is established. Following evaluation, the appropriate treatment team is developed in collaborative communication with the referring pediatrician (provided he or she is going to be the treating physician). The team comprises professionals with expertise in the treatment of children and adolescents with eating disorders, and/or specialists to address the individual needs of the presenting patient that may or may not be typical of others with eating disorders (such as endocrinologists). Standard teams generally include the pediatrician and psychologist, a nutrition counselor or dietician, and an

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endocrinologist (if metabolic, thyroid, autoimmune, and/or other hormonal anomalies are suspected). The following are some of the unique benefits to patients and their families coping with these complex and multilayered medical/psychological conditions of collaboration between the pediatrician and a psychopharmacologically trained psychologist: 1. Reciprocal support across the treatment team for decision making, without obstacles or time delays more common among noncollaborative care models. 2. Comprehensive care and frequent monitoring of at-risk patients across all specialty areas of providers. 3. An integrated education of patient and family about the complex nature of eating disorders and their psychological, family system, and behavioral factors. 4. Cooperative development of eating plans, exercise behaviors, food shopping, meal planning, meal preparation, and related decision-making skills. 5. Organized communication across treating professionals, thereby minimizing the chances of splitting by treatment-resistant patients. 6. Medication monitoring and the advantages of frequent observation because of frequent individual and family therapy contact. 7. Teaching patient and parents adaptive coping options to reduce inappropriate use of food and other indirect means of reducing distress, including mood regulation, stress management, and noncritical styles of communication. Teaching patient and parents core self-management skills to diminish maladaptive behaviors and communication styles of stress management and mood regulation. 8. Reduced utilization of inpatient treatment for eating disorders as a function of careful, tight integration of services. The last point is particularly relevant in this time of managed care reduction in services, resistance to inpatient treatment, diminished access to coverage for inpatient treatment, and intensive pressure to use less expensive forms of treatment. The team emphasis of collaborative models promotes comprehensive behavior change within the context of relationships forged to last over time. In collaboration with the patient and family, the pediatrician and the psychologist comprise the basic collaborative team that provides long-term follow-up, and each discipline offers unique foci toward maximizing optimal mental, emotional, and physical development.

Models of Collaboration The Stages of Change Model (McConnaughy & DiClemente, 1989; Prochaska, DiClemente, & Norcross, 1992) was originally developed for the treatment of alcohol dependence, but has been successfully adapted to treat other behavioral health conditions (Botelho & Skinner, 1995; Rollnick, Mason, & Butler, 1999). This model involves the physician assessing a patient’s presenting problem with a quick screening instrument intended to provide a focused, specific assessment of a particular condition

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as opposed to a broad comprehensive evaluation for other potential concerns. This is a model frequently implemented by pediatricians and other physicians who suspect that an eating disorder may be evident in a patient. A brief clinical evaluation and medical examination comparing past physical parameters with current ones is a more frequently used method of quick screening than a paper and pencil test. If the pediatrician suspects that the weight loss or gain may be due to pathological or disturbed eating behavior, and/or a change in mood, a referral to a psychologist with a specialty in eating disorders is often made.

Colocated Clinics Model This collaborative model addresses the logistical benefit of both medical and psychology services being available in the offices of the same building. Aside from the physical location, the “colocated clinics” model implies no inherent integration of services. Referrals from medical to psychological services or vice versa are handled on a need-based, case-by-case basis. If the psychologist’s office is part of the primary care clinic, psychological services are more likely to be perceived as part of a holistic approach to care. This model affords ease of referring and scheduling, particularly if one system-wide scheduling process is used. When psychological services can be accessed in the same location as other medical services, stigmas associated with mental health care may be reduced. Additional advantages include ease of communication between pediatricians and psychologists, and better than a 90% show rate for appointments (Gatchtel & Oocht, 1999). This model provides adequate accessibility of care, provided the parent/guardian or adolescent is compliant with treatment and the referrals are heeded with the degree of investment typical of integrated services clinics.

Behavioral Health Consultant Model In the behavioral health consultant model, fully integrated services are available for a variety of mental and behavioral health problems, and screenings by medical and behavioral disciplines of all patients to the clinic are a standard part of the initial intake and evaluation process. This model is ideal for eating disordered patients as both patient and parents have a thorough understanding at the onset of treatment that both physical and emotional evaluation procedures are pro forma. Inpatient and intensive eating disorder programs generally utilize this model. The only drawback is that this model generally is not a part of a pediatric medicine practice. Pediatricians are generally not colocated with psychologists, and therefore, parents have typically consulted the pediatrician by phone and/or in person prior to being referred from the pediatrician’s office to a behavioral health consulting practice. Given the resistance

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to treatment that is common in this population, anything that threatens to delay follow-through in securing comprehensive services can introduce another opportunity for denial or avoidance of the necessity for treatment to occur.

Staff Adviser Model In the staff advisor model, a psychologist serves as consultant to the pediatrician but does not actually see the patient and/or family directly unless specifically requested to do so. After the pediatrician consults with the psychologist, if the presenting concerns related by the pediatrician warrant further in-person evaluation, a referral is made for psychological care (Gatchtel & Oocht, 2003). This model is more typical of medical-surgical hospital settings that do not have an in-house eating disorder program. Other settings in which this model is used may include residential living settings such as boarding schools, dormitories, and/or sorority/fraternity houses.

Self-Medicating Reinforcement Cycles Physiological changes in the dopaminergic, serotonergic, and opioid neurotransmitter systems of the anorexic most likely reinforce starvation behavior. The process self-induced purging in bulimia leads to dopamine release, which is neuro-excitatory and mood enhancing (Akkermann, et al., 2008; Farooqi et al., 2007; Mond, Myers, Crosby, Hay, & Mitchell, 2008; Rinaman, 2007; Sokol, Gray, Goldstein, & Kaye, 1999). This biochemical effect of maladaptive behavior may promote its repetition as it provides physiological and psychological reinforcement of the positive mood following the binge and purge. Pharmacotherapy and psychotherapy aimed at reducing these conditioned patterns of biochemical and behavioral cycles simultaneously address affect regulation, cognitive re-evaluation and redirection, and behavior choice. Pharmacotherapy is an adjunct to individual and family psychological treatment modalities. Little research supports successful long-term resolution of clinical eating disorder syndromes in the absence of combined psychotherapy and pharmacotherapy. The psychopharmacologically trained psychologist, collaborating with the pediatrician in the medical monitoring of the anorexic or bulimic child/adolescent, has the advantage of acute in-depth knowledge of the interconnection among the disordered biological and psychological processes, and maintains frequent contact with the patient and family. As with many psychological conditions, identifying the most effective medication(s) for an individual and remaining persistent as the physiological and psychological response changes over time can be frustrating and challenging for patient and family, particularly as steady-state blood levels of medications are often not reached for several weeks. In order to ascertain a potential response (or lack thereof) to a compound, the psychopharmacologically trained psychologist, who sees the patient and family most frequently, has the opportunity to observe carefully

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any minor variations in eating behavior, sleep regulation, mood change, cognitive rigidity reduction, weight change, and degrees and targets of obsessionality during the initial weeks of a trial on a new medication. Unfortunately, studies of the efficacy of pharmacotherapy in severely underweight anorexics and bulimics reveal little positive effect on weight restoration or mood, though individual differences are apparent (Barbarich & McConaha, 2004; DeZwaan, & Roerig, 2003; Halmi, 1992; Kaye et  al., 1999; Kaye & Strober, 1999). The specific cause of this anomaly is not well understood. As weight is restored, it is not uncommon, however, for the antidepressant (of any class) to demonstrate efficacy in the reduction of negative mood symptoms, even if the same medication was previously ineffective in the individual at a low weight (Barbarich & McConaha, 2004; DeZwaan & Roerig, 2003; Goldbloom & Kennedy, 1993; Halmi, 1992; Kaye, 2004; Kaye et  al., 1999; Mitchell, Pyle, & Eckert, 1990; Mitchell, Pyle, & Hatsukami, 1989). The percentage of weight restoration necessary for efficacy of the agent is idiosyncratic to the individual. This factor must be kept in mind so as not to generalize the research data by spuriously failing to initiate a medication trial with a patient who may, in fact, have a positive response to medication while still significantly underweight. Timing of medication with anorexics is critical. Emotional and behavioral investment in psychotherapy generally predates medication receptivity and compliance, and progress in treatment can positively impact the eventual utility of medications as weight restoration ensues. For example, fluoxetine, which is approved by the FDA for the treatment of bulimia, has not been shown to be beneficial for weight restoration in anorexia, but does demonstrate some efficacy in decreasing the rate of relapse among anorexic patients who have reached at least 85% of normal weight (Barbarich & McConaha, 2004; Biederman, Herzog, & Rivinus, 1985; Lacey & Crisp, 1980). Findings regarding the utility of medications in the combined psychotherapy and pharmacotherapy of bulimia contrast those with anorexia in that the results consistently support efficacy of medications. Combined benefits are evident as the patient experiences relief from mood lability, appetite dysregulation, and intensity of binge/purge urges. Medication significantly increases psychotherapy compliance, improves the rate of symptom improvement across domains, and reduces the likelihood of relapse (Agras, Telch, & Arnow, 1997; Halmi, Agras, & Crow, 2005; Mitchell et  al., 1989, 1990; Pike, Walsh, & Vitousek, 2003). Specifically, citalopram and sertraline have shown moderate efficacy in reducing symptom severity of depression and anxiety during weight restoration among both anorexics and bulimics who respond to selective serotonin reuptake inhibitors (SSRIs). This holds true for obese binge eaters throughout the vacillations in anxiety and depression characteristic during weight loss and the associated therapy process (Agras et al., 1997; Fassino, Daga, & Amianto, 2002; Fichter, Uqadfileg, & Gnutzmann, 1998; Halmi, 2003; Kaye, Gendall, & Strober, 1998; Streigel-Moore & Rodin, 1986). Given the probable interconnected neuro-behavioral biology of the common eating disorders’ comorbidities (substance abuse, affective disorders, and anxiety), the treatment response that affects symptom change in one condition likely influences change in the co-occurring conditions. For example, changes in dopamine, serotonin,

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and opioid neurotransmission that are thought to transpire during self-induced ­starvation, bingeing, and/or purging can be self-reinforcing (Akkermann, Paaver, Nordquist, Oreland, & Harro, 2008; Kleifield et  al., 1996; Lilenfeld, Kaye, & Greeno, 1998). The behaviors become conditioned responses to the positive subjective experiences induced by these biochemical processes (Lock et  al., 2004; Mond et al., 2008; Wilson, Loeb, & Walsh, 1999). As mood and/or anxiety disturbances respond to treatment, binge/purge and obsessive–compulsive food restriction symptoms tend to improve as well (Agras et al., 1997; Halmi, 2003; Kaye, 1997; Kaye et al., 1998; Zhu & Walsh, 2002). Theoretically, the conditioned eating disordered behaviors may be an attempt at behaviorally inducing a biochemical homeostasis in the catecholaminergic neurotransmitter systems, a form of behavioral self-medication. Current pharmacological interventions used to treat eating disorders are generally thought to influence serotonin, dopamine, and norepinephrine neurotransmission regulation. Dysregulation of these systems is thought to mediate the maintenance, if not the development, of eating disorders and may share commonalities with their common comorbidities, particularly anxiety and mood disorders (Bruce, Steiger, Ng Ying, & Kin, 2005; Farooqi et al., 2007; Fernstrom, Weltzin, & Kaye, 1993; Strober, 1992). When serotonin levels are low and cortisol levels are elevated, disruptions in the biological response mechanisms to stress and to peripheral hunger/satiation signaling are seen (Farooqi et al., 2007; Fichter et al., 1998; Kaye & Strober, 1999; Rinaman, 2007). During states of starvation (as well as depression and anxiety), altered levels of norepinephrine, dopamine, endogenous opioids, enkephalins, and endorphins have been well-established (Akkermann et al., 2008; Bruce et al., 2005; Farooqi et al., 2007; Fichter et al., 1998; Goldbloom & Kennedy, 1993; Kaye, 1997; Wade et al., 2000). SSRIs, such as fluoxetine, sertraline, citalopram, escitalopram, and paroxetine, effectively reduce the intensity of appetite disruption, food preoccupation, and the urge to act on binge/purge impulses when combined with cognitive-behavioral therapy (Agras et  al., 1997; Akkermann et  al., 2008; Kaye et  al., 1998; Kaye, Nagata, & Weltzin, 2001; Kaye & Strober, 1999). Previously, cyproheptadine and tricyclic antidepressants such as imipramine were used in attempts to facilitate weight gain in anorexics with the hope of an antidepressant effect as well (Biederman et al., 1985; Goldberg, Halmi, & Eckert, 1979; Halmi, Eckert, & LaDu, 1986; Rossi et al., 2007; Vigersky & Loriaux, 1977; Walsh, 1993), but currently SSRIs are preferred in part due to a less severe side effect profile. Tricyclic antidepressants have been shown to diminish, the intensity of subjective binge urges that precipitate binge/purge behavior, and improved implementation of behavior regulation (Halmi, 2003; Rossi et al., 2007; Thase et al., 2007; Weisler et al., 1994). However, considerable anticholinergic side effects are typical, and tricyclics offer little benefit over SSRIs, although individual differences exist. In bulimia nervosa, the treatment of choice is cognitive-behavioral therapy with adjunctive treatment with antidepressants (Agras et al., 1997; Pike et al., 2003; Telch, Agras, & Linehan, 2001; Walsh, Wilson, & Loeb, 1997; Wilson et  al., 1999). Improvement in therapy compliance, and mood anxiety regulation occurs when antidepressant therapy is added. Augmentation with anticonvulsants has been shown to assist in the regulation of

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labile moods and self-destructive impulses (DeZwaan & Roerig, 2003; Halmi et al., 2005; Thase et al., 2007). Prior to the development of atypical or second-generation antipsychotics, chlorpromazine was administered to reduce obsessive–compulsive and agitated behaviors, and to take advantage of its common side effect, weight gain (Halmi, 1992; Kaye, 2004). However, compliance can be problematic because of other side effects, such as considerable sedation. Atypical antipsychotics, particularly those most likely to cause weight gain (i.e., olanzapine or quetiapine), may reduce the duration of the weight restoration phase of treatment and diminish the rigid, dichotomous, anxietydriven fear and obsessionality associated with rapid weight gain among anorexics. At doses slightly higher than that with anorexics, but considerably lower than that required to treat psychotic disorders, atypical antipsychotics have been shown to reduce lability and agitation in bulimics (DeZwaan & Roerig, 2003; Halmi, 1992; Kaye, 2004; Ruggiero et al., 2001; Vandereycken & Pierloot, 1982). Psychologists generally see patients with eating disorders (and their families) at least weekly, often twice weekly, and occasionally 3 times per week. This allows the development of highly nuanced familiarity with the subtleties of symptom manifestation and enables productive and frequent communication about these changes with the pediatrician. Together, the pediatrician and the pharmacologically trained psychologist can coordinate the information gathered from their respective assessments, evaluations, tests, interactions, and clinical observations to determine when to initiate, increase or decrease, augment, or switch medications, thus facilitating a seamless, guided treatment process progressing toward optimal therapeutic improvement.

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Rae, W., Jensen-Doss, A., Bowden, R., Mendoze, M., & Banda, T. (2008). Prescription privileges for psychologists: Opinions of pediatric psychologists and pediatricians. Journal of Pediatric Psychology, 33(2), 176–184. Rinaman, L. (2007). Visceral sensory inputs to the endocrine hypothalamus. Frontiers in Neuroendocrinology, 28(1), 50–60. Rollnick, S., Mason, P., & Butler, C. (1999). Training health professional. In Health behavior change: A guide for practitioners (pp. 169–184). New York: Churchill Livingstone. Rossi, G., Balottin, U., Rossi, M., Chiappedi, M., Fazzi, E., & Lanzi, G. (2007). Pharmacological treatment of anorexia nervosa: A retrospective study in preadolescents and adolescents. Clinical Pediatrics, 46(9), 806–811. Ruggiero, G. M., Laini, V., Mauri, M. C., Ferrari, V. M., Clemente, A., Lugo, F., et al. (2001). A  single-blind comparison of amisulpride, fluoxetine and clomipramine in the treatment of restricting anorectics. Progress in Psychopharmacology and Biological Psychiatry, 25, 1049–1059. Seaburn, D., Lorenz, A., Gunn, W., Gawinski, B., & Mauksch, L. (1996). Models of collaboration: A guide for mental health professionals working with health care practitioners (pp. 145–237). New York: Basic Books. Sokol, M., Gray, N., Goldstein, A., & Kaye, W. (1999). Methylphenidate treatment for bulimia nervosa associated with cluster B personality disorder. International Journal of Eating Disorders, 25(2), 233–237. Streigel-Moore, R., & Rodin, J. (1986). The influence of psychological variables in obesity. In J. Foreyt & K. Brownell (Eds.), Handbook of eating disorders (pp. 99–121). New York: Basic Books. Strober, M. (1992). Family genetics studies. In K. Halmi (Ed.), Psychobiology & treatment of anorexia nervosa & bulimia nervosa (pp. 61–76). Washington: American Psychiatric Association Press. Telch, C., Agras, W., & Linehan, M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting & Clinical Psychology, 69, 1061–1065. Thase, M., Pritchett, Y., Ossanna, M., Swindle, R., Xu, J., & Detke, M. (2007). Efficacy of duloxetine and selective serotonin reuptake inhibitors: Comparisons as assessed by remission rates in patients with major depressive disorder. Journal of Clinical Psychopharmacology, 6, 672–676. Vandereycken, W., & Pierloot, R. (1982). Pimozide combined with behavior therapy in the short term treatment of anorexia nervosa. Acta Psychiatry Scandinavia, 66, 445–450. Vigersky, R., & Loriaux, D. (1977). The effect of cyproheptadine in anorexia nervosa: A double blind trial in Anorexia Nervosa. New York: Raven. Wade, T., Bulik, C., & Neale, M. (2000). Anorexia nervosa and major depression: Shared genetic and environmental risk factors. American Journal of Psychiatry, 157, 469–471. Walsh, T. (1993). Pharmacological treatment. In A. Kaplan & P. Garfinkel (Eds.), Medical issues and the eating disorders: The interface (pp. 329–340). New York: Brunner/Mazel. Walsh, B., Wilson, G., & Loeb, K. (1997). Medication and psychotherapy in the treatment of bulimia nervosa. American Journal of Psychiatry, 154, 523–531. Weisler, R., Johnston, J., Lineberry, C., Samara, B., Branconnier, R., & Billow, A. (1994). Comparison of bupropion and trazodone for the treatment of major depression. Journal of Clinical Psycopharmacology, 14(3), 170–179. Wilson, G., Loeb, K., & Walsh, B. (1999). Psychological versus pharmacological treatment of bulimia nervosa: Predictors and processors of change. Journal of Consulting & Clinical Psychology, 67, 451–459. Woodside, D. (1993). Genetic contributions to eating disorders. In A. Kaplan & P. Garfinkel (Eds.), Medical issues and the eating disorders: The interface (pp. 193–212). New York: Brunner/Mazel. Zhu, A., & Walsh, B. (2002). Pharmacologic treatment of eating disorders. Canadian Journal of Psychiatry, 47(3), 227–234.

Chapter 11

Collaborative Treatment of Medical Disorders: The Management of Diabetes Lawrence R. Kotkin

Most psychologists in private practice have a clientele as varied as all other professionals in our field, limited only by local demographics and legal strictures. Either by personal interest, history, or by accidental training placement, specializations develop that fit us professionally. Some psychologists go so far as to limit the scope of their practice to a particular population and/or treatment modality. Originally, this was the standard path as many completed postdoctoral courses of study in psychoanalysis, family therapy, cognitive–behavioral methods, neuropsychological or forensic assessment, and myriad others, while some specialize in various clinical syndromes. The medical psychologist, who specializes in support of healing medical conditions, is a very special case – a combination of a health psychologist and a psychopharmacologist.

Scope of Practice of the Health and Medical Psychologist At this point, it needs to be clarified that where the term patient is used, that most often includes the family. For our purposes, a medical psychologist is a clinical psychologist who has completed a postdoctoral course of study in psychopharmacology conforming to the Department of Defense project (Lasko & Grill, 2003). Ordinarily, this also includes successfully completing the Psychopharmacology Examination for Psychologists and a physician supervised practicum. In certain jurisdictions, such psychologists may prescribe psychotropic medications. That is not the case in most states, yet this presentation regards the protocol regarding psychopharmacologically trained psychologist functions as a treatment agent in medical settings.

L.R. Kotkin (*) St. Joseph’s College at Patchogue, New York, NY, USA e-mail: [email protected]

G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_11, © Springer Science+Business Media, LLC 2011

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Treatment Adherence and the Health Belief Model A question arises as to whether to consider recipients of services to be patients (as in the medical model) or clients (as in many psychological models). The term “clientele” is used by some, for clients and patients are customers within a treatment adherence model (Koenigsberg, Bartlett, & Cramer, 2004). While this is an individual decision for the clinician, for those frequently consulting with physicians and treating chronic medical conditions, the term patient is preferred. In addition to treating patients, clinicians are often faced with the need to exert change on medical practitioners as much as on the clientele. Patients with medical illness often face caregivers who don’t treat them as intelligent, feeling people. It isn’t really the fault of caregivers, for their job is to keep people healthy or heal them when they may not have engaged in health-supportive behaviors. In other cases, physicians may become frustrated by diagnostic and treatment conundrums – for example, a pediatrician managing an adolescent with type 1 (insulin-dependent) diabetes who sticks with his or her diet, exercise, and medication regime compulsively and yet experiences severe blood glucose excursions. While emergencies do occur unpredictably, for that is the sine qua non of medical emergency, routine high and low blood glucose events over time cause structural as well as metabolic damage. Such events frustrate and confound pediatric endocrinologists as well as the rest of the treatment team. As a medical/health psychologist, one may encounter a preadolescent with the same disease process, perfect lab results, and family with virtually unlimited resources, who was nevertheless found unconscious with an empty pill bottle of (fill in the blank) by his or her pillow. In spite of a need to manage the emergent event, we must ask questions afterwards at consultative meetings with the team and parents, which include, but clearly are not limited to: whose responsibility was the incident? If the child is self-managing, as is often the case with adolescent diabetics, then assessment of attitudes, skills, and willingness to adhere to an agreed-upon treatment plan must be investigated. Logs of food intake, insulin administration, self-monitored blood glucose readings, thoughts, feelings, and situations must be examined for patterns and interventions. What does the responsible person do to correct and prevent future events? Antecedent and situational variations must be examined and may include peer actions, including bullying and teasing, disagreements between parents about important child-rearing issues, and/or coalitions across generational lines. The latter may, and often do, include the extended family. Self-blame may take the form of projection back to the patient wherein the caregivers and team feel victimized and, perhaps, manipulated. Some children may be more overt in their anger and frustrations about their disease and lack of control of their lives and may stop cooperating with treatment. One may encounter a child who decides, seemingly randomly, to stop taking its medication with short-term consequences (such as hypoglycemia with attendant convulsions), as well as long-term increases in risk of complications (such as kidney

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failure, peripheral neuropathy, and retinal degeneration). Often the solution involves a combination of interventions involving family contracting, instruction in communication skills, token economies, and psychopharmacological interventions. The latter may require assessment for attention deficit hyperactivity disorder (ADHD), a common complication of repeated episodes of hypoglycemia. Another indication for psychopharmacy stems from the high incidence of depression found with hyperglycemic excursions. In both situations, as symptoms may be physiological concomitants of diabetes, a combination of cognitive–behavioral interventions and psychotropic drugs may be indicated. To what extent is the chronic physical condition a primary focus of treatment, and yet involves the combination of diagnostic, psychotherapeutic, and psychopharmacological interventions specific to the practice of the psychopharmacologically trained psychologist? In this regard, collaboration with the medical team becomes critical, and psychotherapeutic skills are salient. Team approach is a core aspect of standards for diabetes program protocols. Its mission, attitudes, purpose, composition, skill sets, and available tools must be reviewed to ensure the patient is in agreement with the team’s actions. The most difficult agreement to get may be the one for psychological care, for some may perceive it as vague, intrusive, and threatening. Phenomenological contributions by the patient are central to formulating interventions, and the psychologist is best equipped to elicit this information, negotiate a plan with the team, and advocate for the patient and family in such a way as to encourage empowerment and increase health-enhancing actions. Donald Meichenbaum and Dennis Turk (1987) presented a comprehensive model for increasing the likelihood that people with medical conditions do what their health care providers recommend. He noted the data revealed that over time self-care of medical conditions tends to deteriorate. Therefore, a variety of chronic conditions (and even acute disorders) requiring strict medication plans present physicians with the daunting task of getting compliance with regimes with progressively diminishing returns. In the case of diabetes, increasing tight control over blood glucose has been shown to increase the probability of hypoglycemic incidents which can present as a medical emergency (The Diabetes Control and Complications Trial Research Group, 1993). Early attempts at improving on the traditional physicians’ view of behavioral medicine, such as “here is your medication and the behavior you will engage in is to take it,” include the Health Belief Model developed by researchers for the US Public Health Service (Hochbaum, 1958; Rosenstock, 1974). At the time, treatment of tuberculosis had become an increasing problem with difficulties in screening and diagnosing the condition. Likewise, the bacteria responsible for the disease were becoming progressively resistant to medications. This treatment resistance occurred chiefly because the medication regime is costly and complex. Often, it involved prolonged isolation and a combination of four drugs taken at regularly scheduled times of the day. As treatment adherence was often fair to poor, the disease became, for all intents and purposes, treatment refractory. Strict adherence to the treatment regime for periods often exceeding a year is, therefore, essential. As a public health issue, it is one of the most serious diseases, infecting some two billion

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people worldwide and killing more than ten million people a year (Rosenstock). For psychology and medicine, a solid behavior change model that reduces this risk has a high priority. This Health Belief Model, developed in the 1950s by Hochbaum (1956) and elaborated by others was conceived to address healthcare utilization in general and the tuberculosis issue in particular. Briefly stated, it is based on assumptions that individuals will engage in a health-related behavior if they believe that (a) a negative health issue can be avoided, (b) by taking a positive action, they can avoid a negative health issue, and (c) they can be successful at taking a recommended health action. Along these lines, ­people’s health-related behaviors balance the perceived threat and actions in terms of four constructs: susceptibility, severity, benefits (from action), and barriers. Bandura’s self-efficacy concept was added by Rosenstock et al. (1988) to apply to habitual health risk behaviors such as smoking, overeating, and being sedentary. Included subsequently was the concept of “cues to action” as expanded by Glanz (1997, p. 52). Conner and Norman (1996) identified three areas where the Health Belief Model could be applied in the medical care venue: (1) preventive behaviors such as vaccinations, increased exercise, dieting, and smoking cessation; (2) sick role behaviors referring to following a physician’s treatment plan once an illness has been identified; and (3) utilization of visits to the physician’s office or hospital. Like Salvatore Minuchin’s (1974) utilization of Structural Family Therapy to support healthy behavior in people with chronic illnesses, the Health Belief Model applies principles derived from nonmedical theories for the improvement of the health of the populace. Yet, there has not been a demonstration that such principles and practices have entered general usage. The pediatric medical practice is filled with complexities because developmental issues cloud diagnosis and treatment, and adding psychopharmacologic interventions further escalates risks. For example, most are now aware of Food and Drug Administration (FDA) warnings about the use of antidepressants with adolescents, some of whom appear to have increased risk of suicide attempts when treated with these medications (Schneeweiss et  al., 2010), yet Gibbons, Hur, Bhaumik, and Mann (2006) noted a decreased risk for adolescents with major depression who were treated with antidepressants. The risks inherent in such interventions require that we take a conservative approach to treatment for at least two reasons: first, the child may be more at risk for suicidal ideation and action due to impulsivity and low frustration tolerance, and second, the adverse side effects, interactions with other medications, and effects on metabolic rate may preempt an approach leading to aggressive psychopharmacological interventions. If the differences between utilizing any psychotherapeutic and/or family therapy interventions vs. psychopharmacy are negligible, a nonmedication approach is preferred. First, do no harm. Psychological interventions ­continue to be needed to get the rapidly developing youngster to follow the ­regimen, whether the child or the family is in charge of self-care. Again, the treatment will be most effective if the patient is at the center of the treatment team.

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The Task of the Health Psychologist Coursework in personality theory is a core of all programs of training in clinical, school, and counseling psychology. Notable is an absence of an integrated theory or even evidence that any theorists speak the same language. Even among behaviorists, extinction had different meanings for Ivan Pavlov (1927) and Skinner (1938). Yet, when medical researchers have disagreements about definitions, they all speak the language of biology, and there is no disagreement about what is meant by dopamine receptors or glycosolated hemoglobin A1c. Therefore, psychologists should not be surprised that many physicians are reluctant to enlist the aid of the psychotherapeutic community for treating their patients. To overcome this barrier, at a minimum, we must demonstrate the ability to understand physical illnesses before we can expect physicians to trust our ability to join the treatment team. There are reasons why the medical community doesn’t simply rely on psychiatry to fill this void, including the cost, the dearth of available services, and a reliance on somatic modalities of intervention. As a result, nonpsychiatric medical specialists account for most prescriptions for psychotropic medications (Goodwin, Gould, Blanco, & Olfson, 2001). While graduate study in clinical psychology does not typically include coursework in biology beyond basic neuroscience, this need has been addressed fairly well in the Department of Defense postdoctoral protocol for psychologists having prescriptive authority (Levant et  al., 2003). Coursework required in such a program includes pathophysiology, pharmacology, and neuroscience. Note that this is over and above that acquired during undergraduate and graduate study in clinical psychology. In addition, a clinical psychologist whose practice includes psychopharmacologic consultation, as well as specialization in behavioral medicine, needs to demonstrate extensive knowledge of certain chronic medical conditions. If the disease process is diabetes, this will include a myriad of complications, some primary and some secondary. A number of diabetes specialists, including endocrinologists, nurse educators, nutritionists, and pharmacists, repeatedly emphasize that diabetes is the most complex disease one can have. This is compounded during the developmental period, as are most diseases. It adversely affects every physical and psychological system in the body, from the skin to the central nervous system (CNS) and from the ability to inhibit one’s behavior to depression. As a result, everyone on a diabetes treatment team must have extensive knowledge of all of those areas. This includes the team leader: the patient. As discussed above, for the health and medical psychology specialist, the customers are patients. To do so is as much because that’s how they view themselves, as it is because everyone else on the team also uses the term. However, it is preferable to think of patients as customers, for they are, in the end, the arbiters of what is right for them. Since patients ultimately run the treatment team and can fire the other team members at will, it is advisable to keep this in mind. Medical/health psychologists must learn the physiology and pathophysiology of general medicine, specifically the aspects that are most relevant to their patients.

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This further encourages caution in prescribing psychotropics, as psychologists learn to appreciate pathophysiological processes and their interactions with psychotropic interventions (Raison & Miller, cited from Schatzberg & Nemeroff, 2009).

Assessment As with any other area of psychological intervention, a good intake includes a variety of assessment efforts – for example, a mental status evaluation including general observations of appearance, demeanor, estimates of intellect, and a variety of behaviors, as well as mood, affect, judgment, and insight. Suspicions about severe areas of dysfunction might elicit a need for a version of the MMPI (Tellegen et al., 2003), Millon Behavioral Medicine Diagnostic (Millon & Grossman, 2007), or some other personality test. The Millon is often, in practice, the most useful with people who have chronic illnesses. More to the point, a direct evaluation of the person’s disease-related knowledge and attitudes is essential. Additionally, an estimate about the extent to which the patient and family understand and retain instructions and skills is needed. The assessment of literacy should include general reading skills and ability to comprehend medically related information. Clinicians must know which patients may be unable to read instructions on a pill label, remember a three to four times a day dosage regime, follow a sliding scale of dosage, see the spot on the vial where the needle is inserted to withdraw insulin, and/or are terrified of needles (preventing both injections of medication and obtaining laboratory specimens). In the latter situation, an assessment of dependence on particular individuals by the child for his or her insulin injections must be performed. Moreover, availability of alternative caregivers must be assured – for example, in an Individualized Educational Plan as determined by a Committee for Special Education in collaboration with the child’s physician, when a primary healthcare provider, usually the school nurse, is unavailable, and it’s time for their prelunch bolus of regular insulin. In this situation, contingencies must be in place and may include the medical/health psychologist in the community to contact a trusted person to come to school to administer the insulin. The clinician must also learn other things about the family, including its socioeconomic status. For example, if a 13-year-old boy’s after meal blood glucose spikes into problematic ranges but is controlled by Symlin – yet his parents can’t afford the extra medication expense – he faces a greatly increased risk of secondary complications, especially if these run in his family. The medical psychologist may need to attend to both primary medical interventions and psychotropics and be able to provide information to the school team about therapeutic and adverse effects (for example, stimulants prescribed for ADHD which may mask symptoms of hypoglycemia). The clinician must be aware of such issues and be willing to address them. While ordinarily only older adult type 2 diabetics might be at risk for diabetic ketoacidosis (DKA) arising from administration of some psychotropics, the recent appearance of young children with this disorder (especially in minority populations

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such as native Americans) raises the risk of this lethal complication with people least able to cope with its appearance. They often live in isolated locations with minimal medical support and follow diets alien to their traditions, having recently been exposed to the diets found in modern culture. As Koenigsberg et al. (2004, p. 309) point out, “diet and exercise practices predict diabetes risk.” Further, the estimated 15–20% prevalence (with some incidence estimates upward of 60%) of diabetics with depression also demonstrates poorer treatment adherence and glycemic control (Gonder-Rednick, Cox, & Ritterband, 2002). Improvement on these health factors was shown when treatment effectively utilized antidepressants and cognitive–behavior therapy. This is a salient issue wherein familial conflict adversely affects glycemic control via impaired self-efficacy among adolescent diabetics (Sander, Odell, & Hood, 2010). The combination of type 1 diabetes, family conflict with high expressed emotion (known to adversely affect recovery and prevention of relapse of schizophrenic episodes) and resultant lowered self-efficacy and blood glucose monitoring in the adolescent, and risks associated with the combination of glycemic excursions and administration of antipsychotic medications (if needed to manage a comorbid psychiatric disorder) are examples of situations that often occur in the clinical practice of the consulting clinical psychopharmacologist. An effective protocol for assessing medical conditions must include psychosocial, educational, and family issues. Physicians rarely ask questions not directly pertaining to medical and health issues, perhaps because they don’t have the time, or it just never occurs to them to be proactive in exploring the adjustment of their patient. The sociological zeitgeist may be the critical factor in adherence to a medical and psychological regime. For example, psychological interventions may not be culturally accepted. In some, the treatment of choice may be somatic and the patient may only accept medication to treat depression, anxiety, or a psychotic disorder, rejecting any attempts at cognitive and behavioral, let  alone psychodynamic, interventions. Health beliefs and attitudes must be investigated in detail. These should include the person’s beliefs about how their illness affects them currently and what they expect for the future, the impact of adhering to treatments recommended by their healthcare providers, cultural tenets, and costs. Knowledge of their disease must be assessed in terms of pathophysiology, complications, and effects on their life adjustment. Further, the assessment should include the person’s knowledge about the medications they’ve been prescribed, the demands of various physical interventions (such as exercise or physical therapy), nutrition (a critical element in diabetes treatment), primary and secondary complications, and how to treat them. All these topics, as well as cultural supports and impediments, and family supports and barriers, require exploration with the medical psychologist. If some of this information is already obtained by nurse educators and dieticians, utilizing them as an ad hoc team resource is valuable. In cases where we are consulting and treating a person with a chronic medical condition, specific knowledge of that illness and a general knowledge of medicine

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are necessary. Here is where psychiatrists, with a medical degree, have distinct advantages. They already speak the language. To make up for this area of deficit in doctoral level clinical psychology, a series of coursework in physiology and pathophysiology, as well as general pharmacology, is provided in the clinical ­psychopharmacology curriculum aimed at psychologists. Completing this training allows psychologists to have meaningful discussions with physician general practitioners and specialists without having to flip feverishly through Taber’s Medical Dictionary (Venes, 2005). It can be overwhelming to deal with such generalized disorders as diabetes or the lupoid spectrum. Each may have a very specific etiological defect, yet both affect many other body systems. A low blood sugar (hypoglycemia) in a child with a relatively new diabetes elicits counterregulatory hormones (epinephrine and cortisol) which serve to raise the blood sugar. Unfortunately, the immediate effects of those hormones involve a variety of symptoms not unlike anxiety, agitation, and aspects sometimes associated with depression. Delirium with confusion may be present. Additionally, hypoglycemia may elicit seizures, especially in young boys. The anger and diminished impulse control can get a diabetic in serious trouble. Here, adherence to a treatment plan gives not only a reduced incidence of such events (although the opposite can also be true) but also a means to address them should they occur. Preparation and self-awareness become increasingly salient, with supports available to give the diabetic feedback about their behavior or take charge of care should the person require emergency intervention. Instructing and getting agreements with the family in care and treatment becomes a task for the health and medical psychologist, no matter what the disease or intervention. In this regard, the patient presents as center of the treatment team, for diabetic children may be prone to refuse to allow their families to be involved in their treatment. On the other hand, one may encounter a type 1 diabetic who is totally dependent on a family member for injections and phobic about needles administered by anyone else. In this case, separation anxiety and/or family enmeshments may be suspected as preceding the onset of diabetes. High blood sugar (hyperglycemia) presents its own emotional and behavioral picture, which may include depression. Among the estimated 60% of diabetics experiencing serious depression at some time in their lives (NIMH, 2002), treating the depression (as a side effect of hyperglycemia or as a primary disorder) becomes a decision conundrum, for the interventions operate on different timetables. Blood glucose control may not respond until the depression is treated, which has a multiweek timeline regardless of intervention. In addition, a presentation of major depression adversely affects the management of diabetes. Medical psychologists treating patients with diabetes must grapple with such issues. Although the medical model may not be accepted by some psychologists as functional, it was created by medical professionals treating physical conditions. For diabetes, however, this may include instruction in self-care skills such as blood glucose meter use, ketone testing of urine, record keeping, insulin injection technique, oral medications, the importance of nutrition (especially counting carbohydrates), label reading, alcohol use, using food records to solve problems, and

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combining food and exercise, food and work, and food and travel. How many people can accurately guess how many grams of carbohydrate are in a donut? Insulin-dependent diabetics must make such guesses to determine how much insulin they take to balance the carbohydrate load. To make matters worse, the fat in the donut affects the rate of absorption of the carbohydrate. For diabetics taking insulin, this becomes a long-term empirical process as they test the effect of varying doses of insulin on unknown quantities of carbohydrates in snacks obtained within or outside their home. The patient must also be instructed in medication management including dosage of oral agents and/or insulin, timing, testing, side effects, equipment use, technique, and care including syringes, pens, and glucose meters, and in the language of ­diabetes, self-care. Translating terms like hypoglycemia, hyperglycemia, and ­glycosolated hemoglobin A1c into lay terms is an essential skill. Sick day behavior, podiatric care, and dental care also are critical issues. Lifestyle changes can be seriously problematic. While a type 1 diabetic has a more seriously impaired pancreas producing little or no insulin, there is comparatively little change in overall lifestyle required compared to the type 2 diabetic who has likely developed a set of behaviors moderated by family sociology and structure. Some ethnic groups have an ethnic bent toward eating as a social and family activity, also encouraging extra adipose tissue as desirable. Being overweight has long been known as a primary risk factor for type 2 diabetes and it is a lifestyle issue, not a simple behavior to correct. So with all the physical damage such a disease can wreak, a thorough assessment by the medically oriented psychologist is essential. The workup taught to the medical psychologist in a pharmacology program includes doing a review of ­systems (hair to toenails), physical examination with taking vital signs, and doing a complete history as might be done by an internist. As an example, a patient with diabetes of one or another form (type 1, type 2, gestational, impaired glucose tolerance, or impaired fasting glucose) comes to the office with symptoms of a psychotic disorder accompanying a major depression. This may have been the concern of the referring physician. The patient refuses to see a psychiatrist, but reluctantly agrees to see a psychologist. After finding that attempting cognitive–behavioral therapy (CBT) has not produced desired changes, a psychotropic medication is indicated. In such a case, a trial of an antidepressant and an atypical antipsychotic may commonly be attempted. However, a medical psychologist will be aware that such medications may adversely affect blood glucose.

Psychopharmacological Interventions with Medical Conditions The patient is the center of the treatment team, but must be informed about the risks and benefits of any interventions and approaches, as well as alternatives with their risks and benefits. An SSRI or SNRI, or an atypical antipsychotic, may potentially raise blood glucose levels. There may be a risk of an acute complication such as

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DKA, although such events are rare and usually occur only when the patient is ­seriously ill. With some medications, there may be an increased risk of tardive dyskinesia because of the presence of diabetes. These are some of the risks that the medical psychologist must help the patient consider. Such a volume of information can be daunting to a sophisticated, educated adult, let  alone a child. This means that the issues must be reviewed with the parents/ guardians of the child. Clinicians making such recommendations, especially after therapeutic alliance has developed, have a great deal of influence on the patient’s decision process. One must be an informed provider to foster an informed patient. Not doing so, given all the possible risks, would be considered malpractice. Not every clinical psychologist must complete coursework comparable to a postdoctoral degree in psychopharmacology and additional education and training in chronic medical diseases. However, practicing clinical psychologists need a greater than cursory knowledge of medical issues and processes. While we can rely on the physician to care for our patients’ physical well-being, it becomes our task to be able to fill in any gaps in getting the patient to stick to the treatment plan and, at least for the pharmacologically trained clinical psychologist, to provide dependable consultation regarding the application of psychopharmacy to this treatment regime. Endocrinologists may say, “I’ll take care of the diabetes and you take care of the mental health issues.” While we don’t really split the patient in this way, in practice, it sometimes becomes reality. For example, the psychologist may engage a patient in therapy to support him/her through the survival skill acquisition period and any psychological symptoms he/she may have and may recommend a trial of an antidepressant for a few months. However, the medication may cause the patient to put on a few pounds and therefore the physician may need to increase the dose of the hypoglycemic agent.

The Session with a Medical Patient A medical psychologist received a referral for a 14-year-old male with a 4-year history of type 1 diabetes with a 32.2 BMI, 11% A1c, complaints of depression, overeating mostly in late evening and/or sneaking food, and being suspected of developing secondary complications. The referring physician wants to know what to do about the depression because it is affecting the patient’s diet and physical activity, vital factors in controlling diabetes. The patient’s laboratory values list his complete blood count (CBC) with a differential (a little anemic), urinalysis (3+ glucose, meaning the person has had recent blood glucose above 180 mg/dL, which is high), and a blood chemistry with a variety of minor problems (liver enzymes are slightly above normal levels perhaps with a lupoid hepatitis, and THC reflecting thyroid function is elevated suggesting the possibility of Hashimoto’s). The patient is on a three times per day insulin regimen, one of which uses intermediate acting insulin, takes Synthroid, an ACE inhibitor, as well as cholesterol lowering

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medication. The patient is getting special education support in school because of learning disabilities, but is barely passing most subjects. He’s been missing school because of inability to get out of bed some mornings from fatigue and depression. The nurse educator at the doctor’s office did a fair job of getting information about school work and educational ability (no barriers to treatment), basic skills measuring blood glucose at home, and general knowledge about the basics of ­diabetes. Dietary adherence is problematic, as is physical activity. Upon meeting the patient, what questions should be asked? First and foremost is the person’s understanding of the disorder, and how the person feels and thinks about having been diagnosed. Seeking signs of overt or covert denial is especially important. As personal identity (including sexual attitudes) is developing, especially in adolescents, attention needs to be paid to these and other developmental issues. The presenting problems may, in fact, involve depression and impulsive behaviors, when the deeper issues might include sexual orientation, feelings of being “damaged goods,” or being invaded by foreign objects (needles, catheters, and probing clinicians). The traditional task of a psychologist being a good detective is particularly salient with adolescents who may tend to present reticence and oppositionality. When getting information about knowledge and skills, should the patient’s blood glucose be measured with the psychologists’ meter or the patient’s? The rule is, whenever possible the patient should demonstrate the skills, so their meter is used when a blood glucose level is obtained in the office. If he makes a procedural error while taking his reading, how should it be corrected and recorded? Did he bring his medications or should the psychologist accept a verbal report? Too often, people don’t bring their medications with them. A written list is acceptable, but should be checked with the primary care physician for accuracy. Psychologists should also ask about physical activities and see whether the patient checks his blood glucose before and after the exercise. As this may take a substantial portion of the session, if there is a question, the patient should be referred to the physician’s office. The critical decisions regarding selection of psychotropic medications must not only be based on knowledge of clinical psychopharmacology but also especially consider physiological functions impaired by the diabetes. With diabetic patients, two targets for treatment commonly arise: symptoms of syndromes/symptoms, and sequelae of impaired organs. Depression is often the primary focus. Along with emotional and mental issues, neurological symptoms may also need to be targeted. Peripheral neuropathy carries with it significant pain, which often responds to SSRIs. Comorbid conditions may present a need to address sexual dysfunction, perhaps by replacement with venlafaxine or by adding bupropion. The margins of error affecting the physical condition may be narrow. As an example, a fatty liver (from diabetes or hepatitis of various etiologies) will affect, and be affected by, the selection of medications. Irritation evidenced by liver enzyme elevations and other functions can require treatment strategies to be changed.

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The patient may be under physician’s orders to lose weight, but an SSRI or other weight-increasing medication may have been added. Consider that the regimen can be augmented by bupropion to mitigate the issue. And as an aside, the patient mentions that after his mother read about it in a magazine in your waiting room, she started to worry about peripheral neuropathy and burning sensations in her feet. Consider that while a common treatment for pain from peripheral neuropathy may respond well to an SSRI, topical treatments are available (such as capsaicin, a derivative of chili pepper) that do not operate systemically. The treatment of the medically ill patient in the medical psychologist’s practice can get very complex.

The Interface with the Medical Practice Physicians are most familiar with a form of record keeping called the SOAP note. This acronym includes the subjective experience of the patient, the doctor’s objective findings, the doctor’s assessment, and finally, the doctor’s plan. The SOAP note completed by the medical psychologist must include all these data, and the plan aspect requires a communication to the physician (whether or not the psychologist has prescriptive authority) about the choice of treatments. All these must be communicated on a timely basis for inclusion in the medical record. Session notes can fill a medical chart very quickly, so it is necessary to be concise. At the interface of the physician and the health/medical psychologist is the very tricky aspect of getting the patient to accept the role of being the leader of the treatment team. In addition, many physicians might be uncomfortable with giving up the job of being in charge of treatment, for the medical model encourages a paternalistic approach. While physicians may be very directive about prescriptions, a basic issue in pharmacology is that no medication will be effective if the patient doesn’t take it. Physicians may forget to advise a patient about the effects of schedule on taking a medication. Synthroid, as an example, must be taken on an empty stomach and at least half an hour before eating. In some instances, a full hour may be recommended. If there are many other pills to take, it may be common for a patient to take them all at once, with food, especially if one or another is irritating to the stomach (such as prednisone). Many people will only take medication once a day. This limits selection of medications and dosages for some – for example, bupropion, which has an increased risk of lowered seizure threshold at higher dosages, may be taken at higher dosage when split into two or three doses a day. Consulting with the prescribing physician about these issues, and discussing how best to obtain an agreement for a patient and their families to be in charge of sticking to a well-being enhancing regime, is a vital task of the medical psychologist. It is what psychologists are supposed to be good at: getting people to do uncomfortable things. When the patient is placed at the center of the team, as the hub of the wheel, then the rest falls into place. There is no conception in this model of the patient being required to sign a waiver of “against medical advice” (AMA). Treatment becomes

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the means of serving the customer. Of course, the informed consent form may serve the same function as an “AMA” note, but the intent is different – to inform the patient of the medical findings, options for treatment, adverse possibilities and probabilities, medical recommendations, and to support patients in taking responsibility for their decisions. The referral from a physician may include a recommendation for a psychotropic medication. The medical psychologist must assure the physician that the recommendation will seriously be considered, but ultimately the treatment plan must be one the patient will accept and own. The psychologist must maintain a collaborative role with the patient and the physician as a team. This approach may be rejected by some physicians. In such case, the psychologist should support the patient in ­discussing this issue with his or her physician, and if needed, refer the patient to someone whose approach fits him or her well. The patient must remain the customer. This issue may partially hinge on what was communicated to the patient at the time of the referral. The psychologist should find out from the patient what his or her understanding is of what the physician said to them. Unfortunately, it may rarely coincide with what the physician actually said. For example, the physician may say, “I’m referring you to Dr. Larry who will take care of your mood swings and difficulties in coping and you’ll discuss a treatment plan. I’ll take care of prescribing any medications Dr. Larry might recommend. He may engage you in psychotherapy or some other treatments. I’m sure you’ll work out an effective plan.” On the other hand, the patient may hear, “Dr. Larry will see you on Tuesday and tell me to prescribe medications for you and you’ll be fine. He’ll know how much we should give you and then I’ll see you in 3 months.” In addition, an adage states that “if you don’t document it, it didn’t happen.” Many physicians are now required to utilize electronic medical records systems. Unless the psychologist’s office is located in the same office as the physician, the psychologist will not have access to the physician’s system. Communications with the physician must include an indication that the psychologist reviewed the patient’s records, including laboratory results and other consultations. Of course, it is presumed that the psychologist understands what is in those records. The clinical psychopharmacologist who follows the SOAP note format will find that it best reflects the needs of the patient. There are many ways to communicate the SOAP note to the physician – for example, via email. Psychologist must clarify with physicians how they want these communications established in terms of format and frequency. Labs results are very complex. During pharmacology training, courses on pathophysiology extensively cover common medical tests, such as the CBC with differential, liver, thyroid, and kidney panels, and urinalysis. Lab results have multiple imports and affect recommendations for therapy as well as psychopharmacological interventions. Most drugs are metabolized in the liver, interact with other drugs in a variety of ways, and may affect the functioning of the thyroid and kidneys. Profile of elimination from the body can also be affected, which, in turn, affects the dosages of medications. Medical psychologists must ask questions not only about smoking or chewing tobacco but also specifically about the kind of

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c­ igarettes or chew that is being used. Nicotine is known to accelerate elimination of certain drugs, requiring increased dosages. Then, and if the patient stops using tobacco, the person may suddenly overdose on a medication he or she was taking, at a given dose, for years. In the end, the prescription may be for psychotherapy. The medical psychologist is well poised to interface psychology, pathophysiology, and pharmacology. Consequently, physicians, nurses, and all the other medical staff learn to rely on the psychologist to help patients stick to the treatment plan they’ve prescribed and not countermand or sabotage the efforts of the medical practitioners. This process revolves around a therapeutic contract, and discussing the nature and form of your approach with the physician will enhance the process. Clarity of the contract makes it easier for the physician, the patient, and the psychologist, but it is the patient’s agreement first and foremost. This process applies equally well to psychodynamic, behavioral, cognitive, existential/humanistic, family therapy, and psychopharmacological interventions. The danger arises in attempting to fill too many roles with patients and their physicians. The psychologist does not know everything (and neither does the physician), so the best practice is to pay attention to what is evident and follow the principles of evidence-based treatments. Medical psychologists must be alert and current. At the same time, psychologists will do well to recall the admonition, “therapy is 5% deduction, 5% induction, and 90% seduction.” If the psychologist is unable to get the patient to follow the recommendations, even evidence-based treatments will not be effective.

The Training Needs in the Clinical Psychology Curriculum Clearly the clinical psychology curriculum lacks certain fundamental coursework to prepare psychologists for future pursuit of pharmacology training. As a minimum, beyond the background covered in physiological psychology (foundations of functional neuroscience), a course that covers basic physiological systems and pathophysiology would help introduce future psychologists to the language of medicine, and a course in pharmacology and psychopharmacology would allow psychologists to not only understand these medications better but also begin to develop a multidimensional team approach to total health for patients. This training is necessary in order to communicate with medical practitioners and become sufficiently conversant with medicine to research treatment approaches to specific diseases rampant among people who seek therapy.

The Endgame To remain current, the medical psychologist must be willing to look things up, seek advice, and consult a support network of other professionals (including other ­psychologists), especially when providing psychopharmacological interventions.

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Psychologists in private practice tend to become isolated from other psychologists. Making the effort to stay in touch provides countless dividends. Patients die, especially those with chronic medical conditions and comorbid psychological problems, because those are the patients who are most likely to have disorders that interfere with self-care and treatment adherence. Most at risk are children and adolescents whose willingness to follow directives, self-care skills, and identity are still developing. When a patient dies, the psychologist encounters a mourning process that in some ways is exaggerated and other ways suppressed. Some physicians have been shown to suppress or deny death-related anxiety (Kane & Hogan, 1986). There are a variety of effective and ineffective coping strategies for physicians and psychologists who encounter this event. The coping methods vary for psychologists in solo private practice, those in groups or working in physicians’ offices, and those working in hospital settings. Hopefully, this overview of a fully integrated model is not too overwhelming. It may seem as though a clinical psychopharmacologist has to know everything about medicine and psychology. This isn’t so, but education and training in pathophysiology, pharmacology, and clinical psychology allow the medical psychologist to develop an integrated treatment regime that interfaces seamlessly with physicians in the community.

References Conner, M. and Norman, P. (1996). (eds.) Predicting Health Behaviour. Buckingham, UK: Open University Press. Diabetes Control and Complications Trial Research Group. (1993). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulindependent diabetes mellitus. New England Journal of Medicine, 329(14), 977–986. Gibbons, R. D., Hur, K., Bhaumik, D. K., & Mann, J. J. (2006). The relationships between antidepressant prescription rates and rate of early adolescent suicide. American Journal of Psychiatry, 163(11), 1898–1904. Glanz, K. Relevance of health behavior research to health promotion and health education. in Oldenburg, Brian Gochman, David S. (Ed), (1997). Handbook of health behavior research, Vol. 4: Relevance for professionals and issues for the future, (pp. 143–161). New York, NY, US: Plenum Press, xxvii, 531 pp. Gonder-Rednick, L. A., Cox, D. J., & Ritterband, L. M. (2002). Diabetes and behavioral medicine: The second decade. Journal of Consulting and Clinical Psychology, 70, 611–625. Goodwin, R., Gould, M. S., Blanco, C., & Olfson, M. (2001). Prescription of psychotropic medications to youths in office-based practice. Psychiatric Services, 52, 1081–1087. Hochbaum, G. (1956). Why people seek diagnostic X-rays. Public Health Reports, 71, 377–380. Hochbaum, G. (1958). Public participation in medical screening programs: A sociopsychological study (DHEW Publication No. (PHS) 572). Washington, DC: US Government Printing Office. Kane, A. C., & Hogan, J. D. (1986). Death anxiety in physicians: Defensive style medical ­specialty and exposure to death. Omega, 16(I), 11–22. Koenigsberg, M. R., Bartlett, D., & Cramer, J. S. (2004). Facilitating treatment adherence with lifestyle changes in diabetes. American Family Physician, 69, 309–316.

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Laskow, G. B., & Grill, D. J. (2003). The department of defense experiment: The psychopharmacology demonstration project. In G. B. Laskow, D. J. Grill, M. T. Sammons, R. U. Paige, & R. F. Levant (Eds.), Prescriptive authority for psychologists: A history and guide (pp. 77–100). Washington, DC: American Psychological Association. xxiv, 228pp. doi: 10.1037/10484-005. Levant, R. F., Albino, J. E., Brown, A. B., Feldman, S. A., Folen, R. A., Kaczmarek, P., et al. (2003). The Department of Defense experiment: The psychopharmacology demonstration ­project. In M. T. Sammons, R. F. Levant, & R.U. Paige (Eds.), Training programs in prescriptive authority for psychologists (pp. 117–140). Washington, DC: American Psychological Association. xxiv, 228pp. doi: 10.1037/10484-005. Millon, T. and Grossman, S. (2007). Overcoming resistant personality disorders: A personalized psychotherapy approach. Hoboken, NJ, US: John Wiley & Sons Inc. Minuchin, S. (1974) Families & Family Therapy. Cambridge: Harvard University Press. Meichenbaum, D. and Turk, D. C. (1987). Facilitating Treatment Adherence: A Practitioner’s Guidebook, Plenum Press: New York. National Institute of Mental Health (NIMH) of the NIH. (2002). NIH Publication No. 02-5003, June 17, 2002. http://www.nimh.nih.gov/publicat/depdiabetes.cfm. Pavlov, I. P. (1927) translated by Anrep, G. V. (1927) Conditioned Reflexes: an investigation of the physiological activity of the cerebral cortex. articles, 25 and 36. in Classics in the History of Psychology: an internet resource developed by Christopher D. Green, (2001) York University, Toronto, Ontario, Canada. Raison, C. L. and Miller, A. H. (2009). Brain-immune System Interactions: Relevance to the Pathophysiology and Treatment of Neuropsychiatric Disorders. Chapter 8, pp 147–162. In Schatzberg, A. F. and Nemeroff, C. B. (Eds.). The American Psychiatric Association Textbook of Psychopharmacology 3rd ed. Washington, DC: American Psychiatric Publishing, Inc. Rosenstock, I. M. (1974). Historical origins of the health belief model. Health Education Monographs, 2, 328–335. Rosenstock, I. M. (1988). Why people use health services. Milbank Memorial Fund Quarterly, 44, 94–124. Sander, E. P., Odell, S., & Hood, K. K. (2010). Diabetes-specific family conflict and blood glucose monitoring in adolescents with type 1 diabetes: Mediational role of diabetes self-efficacy. Diabetes Spectrum, 23(2), 89–94. Schatzberg, A. F., & Nemeroff, C. B. (Eds.). (2009). The American psychiatric publishing textbook of psychopharmacology (4th ed.). Washington, DC: American Psychiatric Association Publishing. Schneeweiss, S., Patrick, A., Solomon, D., Dormuth, C., Miller, M., Mehta, J., et  al. (2010). Comparative safety of antidepressant agents for children and adolescents regarding suicidal acts. Pediatrics, 125(5), 876–888. doi:10.1542/peds.2009-2317. Skinner, B.F. (1938), The Behavior of Organisms: An experimental analysis. New York: AppletonCentury- Crofts. Tellegen, A., Ben-Porath, Y. S., McNulty, J. L., Arbisi, P. A., Graham, J. R., & Kaemmer, B. (2003). The MMPI-2 restructured clinical scales: Development, validation, and interpretation. Minneapolis: University of Minnesota Press. Venes, D. (Ed.). (2005). Taber’s cyclopedic medical dictionary. Philadelphia: F.A. Davis.

Chapter 12

Collaborating with Pediatricians and Gastroenterologists: A Biopsychosocial Approach to Treatment of Gastrointestinal Disorders* Lindsay D. Clendaniel, Paul E. Hyman, and John C. Courtney Gastrointestinal (GI) disorders are common in children. Functional constipation, for example, affects about 12% of children (van Dijk, Benninga, Groothenhuis, & Last, 2010), irritable bowel syndrome (IBS) is found in 14% of adolescents (Hyams, Burke, Davis, Rzepski, & Andrulonis, 1996), and cyclic vomiting syndrome (CVS) afflicts 2% of children (Abu-Arafeh & Russell, 1995). Pediatric gastrointestinal disorders include both organic disease (e.g., Crohn’s disease) and functional symptoms (i.e., irritable bowel syndrome, functional dyspepsia, rumination syndrome, etc.). The symptom expression of pediatric GI disorders depends on each child’s cognitive abilities and psychosocial considerations such as adjustment to physical symptoms and body image changes, impact of disease management and treatment, behavioral and emotional disturbances related to symptoms (pain, ­vomiting, incontinence, etc.), family and social functioning, activity restrictions, and school avoidance. Chronic illness also has an impact on parent and sibling adjustment, both emotionally and financially. The child’s understanding of the ­illness varies with their cognitive and emotional stage of development. Due to all of these considerations, a biopsychosocial approach to treating children with GI disorders is critical. This chapter will provide information related to the role of the psychologist working within a pediatric gastroenterology practice, including information about participating in a biopsychosocial approach to assessment and treatment. This chapter will outline the role that medical psychologists play in the biopsychosocial approach and provide examples and recommendations. Other topics include a

* Readers are cautioned that a significant number of the ­recommendations for psychotropic medications made in this chapter are “off label” and unendorsed by the Food and Drug Administration. As such, while rational ­literature exists to support their use, readers are cautioned to carefully weigh the risks and benefits of nonapproved medications with any population treated, and in this case, with children. L.D. Clendaniel (*) Department of Psychology, Children’s Hospital of New Orleans, New Orleans, LA, USA e-mail: [email protected]

G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_12, © Springer Science+Business Media, LLC 2011

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d­ iscussion of the role of cognitive and emotional development in the clinical expression of childhood gastrointestinal disorders, information about helping families understand the psychosocial and/or behavioral components of GI disorders, and case examples to illustrate this treatment approach.

Biopsychosocial Management of Pediatric GI Disorders The relationship between physiological and psychological factors in pediatric GI disorders contributes to both clinical presentation and treatment outcome. It is important to conceptualize and provide treatment that encompasses both factors. Cunningham and Banez (2006) suggest three reasons for using a biopsychosocial approach – (1) etiology and course of GI disorders are often influenced by psychological and environmental factors, (2) treatment is a dynamic process involving a developing child and steps should be taken to foster age-appropriate development and functioning, and (3) psychosocial interventions have the potential to reduce costs of care (Chiles, Lambert, & Hatch, 1999). The biopsychosocial model (Engel, 1977) considers both physiological and psychological factors with the goal to understand and treat all aspects of illness, rather than confining the effort to finding and curing disease. A biopsychosocial perspective helps clinicians recognize that symptoms develop from several different sources. Symptoms may stem from normal development (e.g., infant regurgitation), psychiatric illness (e.g., pain disorder, conversion disorder, pediatric illness falsification), cultural and/or community factors, and functional disorders, in which symptoms are real, but there is no easily discerned disease (examples include a runner’s cramp, shivering when you are cold, or irritable bowel syndrome). Rather than reducing a cluster of symptoms to a single pathophysiology (the goal of the traditional biomedical model), the biopsychosocial model expands the potential for understanding a problem from simultaneously interacting systems at subcellular, cellular, tissue, organ, interpersonal, and environmental levels. For example, an event such as changing schools may be a psychological stressor which in turn alters cellular immunity and susceptibility to viral pathogens. Similarly, a change at a subcellular level like hepatitis C infection may influence organ function as well as the adjustment of the child and family. There is an interactive relationship between psychosocial and biomedical factors in the clinical expression of illness and disease (Hyman & Fleisher, in press). Functional gastrointestinal disorders provide diagnostic and treatment challenges given the substantial overlap between physiological and psychological symptoms and the lack of a simple biomarker for diagnosis. Recently, the Rome III working teams established diagnostic criteria for the identification of functional GI disorders (Table 12.1, Pediatric Rome criteria). The clinical expression of the functional disorders depends upon genetics, early life experiences, and interactions between physiological and psychological factors via neural and hormonal ­connections between the CNS and enteric nervous systems (ENS). Morbidity accrues when several influences converge. For example, a disease such as Crohn’s may occur together with a functional disorder and the patient may experience

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Table 12.1  The Rome III diagnostic criteria for childhood functional GI disorders (Hyman et al., 2006; Rasquin et al., 2006) Disorder Symptoms Additional criteria Criteria fulfilled two or Abdominal Must include all of the following: more times in the migraine • Paroxysmal episodes of intense, acute preceding 12 months periumbilical pain that lasts for 1 h or more • Intervening periods of usual health lasting weeks to months • The pain interferes with normal activities • The pain is associated with two or more of the following: ○ Anorexia ○ Nausea ○ Vomiting ○ Headache ○ Photophobia ○ Pallor • No evidence of an inflammatory, anatomic, metabolic, or neoplastic processes that explain the subject’s symptoms Must include all of the following: Criteria fulfilled for the Adolescent • Repeated painless regurgitation and last 3 months with rumination rechewing or expulsion of food that: symptom onset at syndrome least 6 months prior ○ Begins soon after ingestion of a meal to diagnosis ○ Does not occur during sleep ○ Does not respond to treatment for gastroesophageal reflux • No retching • No evidence of an inflammatory, anatomic, metabolic or neoplastic process that explains the subject’s symptoms Criteria fulfilled at least Aerophagia Must include at least two of the following: once per week for at • Air swallowing least 2 months prior • Abdominal distention due to intraluminal air to diagnosis • Repetitive belching and/or increased flatus Cyclic vomiting Must include both of the following: syndrome • 2 or more periods of intense nausea and unremitting vomiting or retching lasting hours to days • Return to usual state of health lasting weeks to months Criteria fulfilled at least Must include all of the following: Childhood once per week for at • Episodic or continuous abdominal pain functional least 2 months prior • Insufficient criteria for other FGIDs abdominal to diagnosis • No evidence of an inflammatory, anatomic, pain metabolic, or neoplastic process that explains the subject’s symptoms Criteria fulfilled at least Must satisfy criteria for childhood functional Childhood once per week for at abdominal pain and have at least 25% of the functional least 2 months prior time one or more of the following: abdominal to diagnosis • Some loss of daily functioning pain • Additional somatic symptoms such as syndrome headache, limb pain, or difficulty sleeping (continued)

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Table 12.1  (continued) Disorder Symptoms Functional constipation

Functional diarrhea

Functional dyspepsia

Infant colic

Infant dyschezia

Must include two or more of the following in a child with a developmental age of at least 4 years with insufficient criteria for diagnosis of IBS: • Two or fewer defecations in the toilet per week • At least one episode of fecal incontinence per week • History of retentive posturing or excessive volitional stool retention • History of painful or hard bowel movements • Presence of a large fecal mass in the rectum • History of large diameter stools which may obstruct the toilet Must include all of the following: • Daily painless, recurrent passage of three or more large, unformed stools • Symptoms that last more than 4 weeks • Onset of symptoms that begins between 6 and 36 months of age • Passage of stools that occurs during waking hours • There is no failure-to-thrive if caloric intake is adequate Must include all of the following: • Persistent or recurrent pain or discomfort centered in the upper abdomen (above the umbilicus) • Not relieved by defecation or associated with the onset of a change in stool frequency or stool form (i.e., not irritable bowel syndrome) • No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms Must include all of the following in infants from birth to 4 months of age: • Paroxysms of irritability, fussing, or crying that start and stop without obvious cause • Episodes lasting 3 or more hours/day and occurring at least 3 days/weeks for at least 1 week • No failure to thrive Must include both of the following in an infant less than 6 months of age: • At least 10 min of straining and crying before successful passage of soft stools • No other health problems

Additional criteria Criteria fulfilled at least once per week for at least 2 months prior to diagnosis

Criteria fulfilled at least once per week for at least 2 months prior to diagnosis

(continued)

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Table 12.1  (continued) Disorder Symptoms Infant regurgitation

Infant rumination syndrome

Irritable bowel syndrome

Nonretentive fecal incontinence

 “Discomfort” means an uncomfortable sensation not described as pain

a

Additional criteria

Must include both of the following in otherwise healthy infants 3 weeks to 12 months of age: • Regurgitation two or more times per day for 3 or more weeks • No retching, hematemesis, aspiration, apnea, failure to thrive, feeding or swallowing difficulties, or abnormal posturing Must include all of the following for at least 3 months: • Repetitive contractions of the abdominal muscles, diaphragm, and tongue • Regurgitation of gastric content into the mouth, which is either expectorated or rechewed and reswallowed • Three or more of the following: ○ Onset between 3 and 8 months ○ Does not improve after treatment for gastroesophageal reflux disease, or to anticholinergic drugs, hand restraints, formula changes, and gavage or gastrostomy feedings ○ Unaccompanied by signs of nausea or distress ○ Does not occur during sleep or when the infant interacts with individuals in the environment Criteria fulfilled at least Must include both of the following: once per week for at • Abdominal discomforta or pain associated least 2 months prior with two or more of the following at least to diagnosis 25% of the time: ○ Improvement with defecation ○ Onset associated with a change in frequency of stool ○ Onset associated with a change in form (appearance) of stool • No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms Must include all of the following in a child with a Criteria fulfilled for at least 2 months prior developmental age at least 4 years: to diagnosis • Defecation into places inappropriate to the social context at least once per month • No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms • No evidence of fecal retention

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i­ntolerable abdominal pain and diarrhea even when Crohn’s disease is in remission (Grover, Herfarth, & Drossman, 2009). Another example is a child who wakes with a stomachache on the day of an important examination and uses the stomachache as an excuse to stay home and avoid both the test and the test-related anxiety. Thus, there is a functional illness (the bellyache) and a psychological component (somatization) occurring simultaneously. A patient with a diagnosis of Rumination syndrome (a functional disorder) may experience increased symptoms due to comorbid social anxiety (a mental health disorder) related to fear of leaving his/her home due to continuous “vomiting” (Chial, Camilleri, Williams, Litzinger, & Perrault, 2003). Thus, gathering a complete biopsychosocial history and supporting physicians in acting upon the information discovered provide a fundamental transformation capable of improving care. Through a biopsychosocial approach to treatment, psychologists can provide targeted and developmentally appropriate interventions that can improve treatment outcomes and prevent future difficulties. Coping methods and adjustment issues, for instance, vary by age. A psychological intervention targeted to an infant may include intervention for the parent to ensure appropriate coping skills and behavioral and emotional management of a patient’s siblings. With toddlers, behavior management strategies become essential to many treatment plans. As children reach school age, their cognitive skills become more advanced and may develop anticipatory anxiety related to medical procedures or school adjustment difficulties due to extended absences and peer issues. Adolescents are unique in their behavioral and emotional concerns. In this age group, increased social concerns occur including worries about “fitting in” and concerns about body image and/or appearance. Adolescents often strive for greater autonomy, both in their home and medical treatment, which may present as nonadherence. Within the medical setting, ­pediatric psychologists often treat young adult patients. More mature developmental concerns are apparent in this age group, such as adjustment issues and concerns related to romantic relationships, fertility, career choices, and late effects of treatment. When the traditional biomedical model is used, only disease is evaluated and treated. Emotional distress and other psychosocial problems as well as patterns of high symptom reporting, which are usually medically unexplained, are not recognized or managed. Physicians and parents often respond to children in ways that reinforce pain behavior and limits in daily functioning (Walker et al., 2004). Such ineffective care for adults with high symptom reporting has been shown to result in poor outcomes and direct costs estimated in the hundreds of billions of dollars annually (Barsky, Orav, & Bates, 2005). The financial and psychosocial costs are likely even greater among pediatric patients. Effects of psychosocial intervention on reducing length of inpatient stay and improving psychological well-being have been documented as cost effective, showing savings of approximately 20% resulting from the implementation of psychological interventions (Chiles et al., 1999). Among pediatric patients, psychological intervention has been shown to reduce the frequency of physician visits (Finney, Riley, & Cataldo, 1991). Mood problems and impairments in activities of daily living are also related to increased costs. This is particularly true among children with pediatric GI disorders,

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as persistent mental health or behavioral symptoms may increase physical ­symptoms (i.e., increased anxiety may lead to increased arousal and increased visceral ­sensitivity therefore increasing pain symptoms). Several evidence-based studies have shown that treating GI disorders using a biomedical approach that ignores psychological and behavioral factors are not as effective as those treatments that utilize a biopsychosocial approach (Finney, Lemanek, Cataldo, Katz, & Fuqua, 1989; Lackner, Mesmer, Morley, Dowzer, & Hamilton, 2004; McGrath, Mellon, & Murphy, 2000; Richter & Bradley 1996; Sanders et al., 1989). A biomedical approach to pediatric GI disorders may lead to negative consequences, including unnecessary surgery, unwarranted procedures and medications, additional pain, and increased costs. Biomedical evaluations are often normal in the functional disorders, but the uncertainty about diagnosis can increase parent and patient anxiety, leading to more maladaptive coping and increased stress (Walker & Jones, 2005). Masters (2006) presented a case of a young girl who exhibited ­frequent episodes of nausea and vomiting over a 3-year period. During that time, she missed several weeks of school, made numerous trips to the local emergency room and her pediatrician’s office, and underwent several diagnostic procedures (e.g., X-ray, blood work, stool analysis, ultrasound, upper endoscopy, biopsies, CT scan). Physicians prescribed a long list of medications and eventually surgery (e.g., exploratory laparoscopy and appendectomy). Three and half years into treatment, the child’s mother briefly mentioned some concerns about anxiety and a clinician prescribed a psychotropic medication. This was the first recognition of mental health issues that may be contributing to the patient’s symptoms. Soon after, the family consulted a psychologist. The psychologist prescribed biofeedback training (including diaphragmatic breathing, temperature, and heart rate training) and a home training program. After seven sessions of psychotherapy, the patient’s pain was greatly reduced. Research and clinical practice have increased awareness of functional disorders and the biopsychosocial approach to assessment and treatment in the pediatric GI community; however, psychological intervention may still be the “last resort” for many physicians and patients (Weydert, Ball, & Davis, 2003). Delays in appropriate treatment occur for many reasons including resistance from the physician and/ or family to psychology involvement, cost, personal beliefs about the disorder, lack of understanding of the biopsychosocial model, and the lack of integration of ­psychology in the treatment team (Masters, 20006). It is increasingly becoming the job of mental health professionals to educate the medical community about the biopsychosocial approach to treatment.

Brain–Gut Interaction An important aspect of care in pediatric gastrointestinal disorders is the brain–gut interaction. The connection between physiological and psychological factors can be seen within the GI tract. Negative affect (e.g., stress, anxiety, irritability, etc.) can amplify the autonomic nervous system response and in turn increase pain ­sensitivity

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and inflammation in the GI tract (Iovino et al., 2009). Conversely, positive affect, good coping skills, and absence of psychological comorbidity are associated with better prognosis (Pellissier, Dantzer, Canini, Mathieu, & Bonaz, 2010). The ENS is a self-contained unit, independent of other nervous system functions. It works on its own to ensure that food is digested and absorbed properly. There are nerve plexi intrinsic to the gut wall; therefore, if there is a high transection of the spinal cord, the gut continues to run programs for fasting, postprandial motility, and reflexes for vomiting. The ENS surrounds the GI tract and is connected to the central nervous system (CNS) by the vagus (parasympathetic) and dorsal root ganglia (sympathetic) nerves. Direct connection allows for continuous, bidirectional communication between the gut and brain (Mertz, 2003). It is this brain–gut connection that is thought to lay the foundation for the connection between psychological experiences and abdominal pain (Humphreys & Gevirtz, 2000; Plunkett & Beattie, 2005) and the reason that internal organs can be affected by the environment. Nervous system arousal can be effected by both external stimuli (such as a startling or stressful event) and internal stimuli (negative thoughts or emotions) and lead to changes in motility and sensation in the gut (Cunningham & Banez, 2006). Prolonged arousal increases visceral sensitivity and ultimately leads to greater pain and discomfort. Although the CNS does not control the ENS, there is a bidirectional flow of information. Many functional gastrointestinal disorders are caused by disturbances in brain– gut interaction. Precipitating events, either biological or psychosocial, ­dysregulate the functioning of the brain–gut axis via the ENS, CNS, or both, resulting in increased visceral sensitivity and/or hypervigilance to physical cues, both experienced as abdominal pain or discomfort (Naliboff et  al., 1997; Walker, Garber, Smith, Van Slyke, & Lewis Claar, 2001; Walker & Jones, 2005). Abdominal pain, in turn, acts as an independent stressor and impacts a child’s appraisal of pain and ability to cope with illness (Walker, Smith, Garber, & Claar, 2005). Appraisal of pain as a challenge, for instance, typically results in maintenance of daily life activities and continued achievement of developmental ­milestones. Conversely, appraisal of pain as a serious threat or danger can result in fear and avoidance of daily life activities, maladaptive coping (e.g., increased anxiety), and difficulty achieving developmental milestones (Walker, Claar, & Garber, 2002). Maladaptive coping leads to poor school attendance, emotional distress, reduced peer activities, and a reorganization of family roles, all of which may generate more stress and lead to increased brain–gut dysregulation (Walker & Jones, 2005).

Role of the Pediatric Psychologist in the GI Setting Psychologists in the hospital-based setting are involved in many aspects of patient care including inpatient consultation/liaison, outpatient medical clinics, and outpatient mental health. Psychologists also provide services within the primary care outpatient settings and private practice.

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Diagnostic Assessment Whether working with children in an inpatient or outpatient setting, the first objective of the psychologist should be to provide a thorough mental health assessment. Assessment is critical given the overlap between psychological and physiological symptoms in functional GI disorders and psychological sequelea of organic disease. The bidirectional communication between the brain and the gut places children with GI disorders at risk for emotional difficulties. Among children diagnosed with inflammatory bowel disease (IBD), rates of depression range from 10 to 20% (Burke et  al., 1989; Szigethy et  al., 2004) and rates of anxiety range from 4% (among a sample of children of varying disease duration) to 28% (newly diagnosed children) (Burke et al., 1989, 1994). Studies suggest that children with GI disease may use less effective coping strategies, such as avoidant coping, to cope with their illness and sequelea (Gitlin et al., 1991; van der Zagg-Loonen, Groothenhuis, Last, & Derkx, 2004). Children with recurrent abdominal pain (RAP) (i.e., functional abdominal pain (FAP), functional dyspepsia, irritable bowel syndrome, and abdominal migraine) have been shown to exhibit more internalizing symptoms compared to healthy controls, and their parents appear to have a greater prevalence of anxiety, depression, and somatization compared to parents of healthy children (Subcommittee on Chronic Abdominal Pain, 2005; Weydert et al., 2003). Children diagnosed with functional constipation are also at risk for psychological problems, with recent prevalence rates of overall, internalizing, and externalizing behavior problems estimated at 36.8, 36.1, and 27.1%, respectively. An extended duration of treatment is strongly associated with overall and externalizing behavior problems in children with constipation, and a history of nighttime urinary incontinence increases the risk of behavior problems. Fecal incontinence and large stools appear to be exclusively related to externalizing behavior problems (van Dijk et al., 2010). These findings further emphasize the need for behavioral screening of ­children visiting a GI physician. Life stressors contribute to greater emotional difficulties among children with GI disorders, particularly children with RAP. Children with RAP are not found to experience more major life stressors compared to children with organic abdominal pain (McGrath, Goodman, Firestone, Shipman, & Peters, 1983; Walker, Garber, & Greene, 1993; Walker & Greene, 1991; Wasserman, Whitington, & Rivara, 1988). Instead, daily life stressors, such as events related to family illness, play a larger role in precipitating episodes of abdominal pain (Walker et al., 2001). Children with RAP also frequently endorse psychological problems on standardized assessments. In a study examining behavior and mood of 238 children with RAP, Schurman and colleagues (2008) found that about 50% of patients in their sample endorsed psychological problems on the Behavior Assessment System for Children (BASC), including broad-based psychological problems (13%) and clinical elevations ­specific to anxiety (35–45%). The authors suggest that targeting treatments to ­specific psychological profiles of RAP patients may improve the effectiveness and efficiency with which health professionals address pediatric abdominal pain.

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Coping and Adjustment Children with gastrointestinal illness often experience changes in their lives as a result of illness, including changes to daily routine, school changes (e.g., school reentry after hospitalization, reduced attendance, changes in grades, peer issues), and mood changes. There are several protective factors that help reduce the risk of maladjustment, including social support and an approach coping style. Problems with adjustment to illness and life changes can result in fear and avoidance of daily life activities, maladaptive coping, and difficulty achieving developmental milestones (Walker et al., 2002). A multidisciplinary team approach to treating gastrointestinal disease, including a psychologist, can ensure proper screening and monitoring of children for coping and/or adjustment difficulties. Ensuring that children and parents understand the diagnosis, reasons for pain associated with the disease, and information about treatment (medications, nonpharmacological intervention) is the first step in fostering appropriate adjustment and management of the illness (Spirito & Kazak, 2006). Children who have problems with social or emotional functioning prior to illness are at greater risk for maladjustment (e.g., restriction of activities, withdraw, seeking attention for pain) and should be monitored closely (Walker, 1999). Recent research suggests that children with chronic abdominal pain vary in their pain coping styles. Walker, Baber, Garber, & Smith (2008) indentified six primary pain coping styles among children with abdominal pain and found a relationship between coping profiles and the quality of a child’s pain mastery efforts and interpersonal relationships. Avoidant copers endorsed both poor mastery efforts and withdrawal from interpersonal relationships when dealing with pain, often catastrophizing and escalating the seriousness of their pain and disengaging from managing pain symptoms. These children scored the highest on functional disability and depressive symptom scales. Dependent copers also reported poor mastery efforts but reported greater support-seeking and pain behavior (including catastrophizing), which may reinforce high levels of disability and low pain efficacy. Self-reliant copers reported a high level of pain mastery efforts but were avoidant in their social contact during pain episodes. These children also endorsed the use of acceptance, minimizing pain, and self-encouragement, resulting in higher levels of pain efficacy compared to avoidant and dependent copers. The stoicism and reluctance in seeking support of this group, however, led to high levels of depressive symptoms. Engaged copers reported both efforts to increase mastery over pain and frequent seeking of social support. These children endorsed the use of problem-solving and specific strategies to reduce pain and elevated self-efficacy. Compared to other coping styles, children with an engaged coping style exhibited an increased resilience to pain, as this coping style was associated with reduced levels of depressive symptoms and functional disability and overall confidence in academic, social, and global skills. Infrequent copers rarely engaged in any pain coping efforts and rated their pain intensity and seriousness low, suggesting that this groups of children did not believe their pain to be a significant stressor. Inconsistent copers represented a

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small portion of the sample and reported using all coping strategies, possibly ­suggesting response bias or nonstrategic coping strategies. These children also reported high levels of distress, which may be related to frustration in trying any and all strategies to manage pain. Information related to coping styles can inform psychological treatment approaches. Treatments should be adapted to the individual child, addressing problems with individual coping styles. Walker and colleagues 2008 provide several examples of how information about coping styles can inform treatment – family intervention (Robins, Smith, Glutting, & Bishop, 2005) may be effective for dependent copers while avoidant copers may benefit from psychotropic medications to address high levels of depressive symptoms (Campo et  al., 2004); self-reliant copers may be most responsive to interventions that emphasize self-management.

Pain Assessment and Management Another role of the psychologist in the pediatric gastrointestinal setting is participation in pain assessment and management. Pertinent pain questions include location of pain, pain duration for each episode, pain frequency, pain intensity, duration since onset, and the quality of the pain. More pertinent pain questions include the association of pain with physiological events, like eating, defecation, exercise, and sleep. Questions related to the onset of pain, such as events surrounding the onset of pain (i.e., after an illness or episode of food poisoning, after a stressor such as the death of a family member, or an insidious onset), are important to understanding pain history. When possible, the child should provide information about his/her pain experience because parental assessments poorly correlate with child’s perceived pain intensity (Kelly, Powell, & Williams, 2002; Singer, Gulla, & Thode, 2002). In addition to a clinical interview, assessment of acute and chronic pain can be achieved through the use of questionnaires. Chronic pain measures such as the Varni–Thompson Pediatric Pain Questionnaire (PPQ; Varni, Thompson, & Hanson, 1987) and the Children’s Comprehensive Pain Questionnaire (CCPQ; McGrath, 1990) are examples of measures that can be used among children with abdominal pain. The CCPQ has both a parent and child form. These measures utilize a variety of question formats (e.g., open-ended, rating scales, and visual analog scales (VASs)) to comprehensively evaluate the child’s pain experience. Measures of acute pain are helpful for understanding the child’s most recent pain episodes. Observational measures have been developed and standardized to assess pain among young children with and without verbal abilities and may be particularly helpful among younger children who are not developmentally capable of understanding seriation tasks. Such observational measures include the Faces, Legs, Activity, Cry, and Consolability Behavioral Pain Assessment (FLACC; Merkel, Voepel-Lewis, Shayevitz, & Malviya, 1997) and the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS; McGrath et al., 1985). The FLACC has ­demonstrated ease of use and may be helpful for parents to use at home when assessing their

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child’s acute pain. Although a child may have developed verbal skills, a child in distress may find it difficult to express the presence or intensity of pain. Self-report measures of acute pain are considered the gold standard of pain assessment for children (Franck, Greenburg,, & Stevens, 2000). There are many types of self-report measures including visual rating scales, numerical rating scales, and questionnaires. Among these choices, measures utilizing visual components are most popular. This is likely due to the ease of understanding among a range of children as well as ease of presentation and replicability (Belville & Seupaul, 2005; Keck et al., 1996). Many visual-based pain assessments for children include pictorial representations of faces depicting various degrees of pain or discomfort. These types of measures have been well validated for children as young as 3 years old. Examples of face-based measures include the Wong-Baker Faces Scale (Wong et  al., 1999), the Faces Pain Scale – Revised (Hicks, von Baeyer, Spafford, van Korlaar, & Goodenough, 2001), and the Oucher Scale (Beyer, 1984). Other self-report pain measures rely on less concrete estimates of pain and therefore may be more appropriate for older children and adolescents. A VAS is often effective for this population; however, researchers are unsure if children younger than 7 or 8 years of age can adequately comprehend the scale (Pothman, 1990; Shields et al., 2003). The Numeric Rating Scale (NRS) is also a widely adopted measure, and it involves asking patients to rate their level of pain on a scale from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable. This scale has been validated among children 8 years and older (von Baeyer et al., 2009). Providing pain management intervention is another component of the psychologist’s role on the GI team. Many children with GI illness present with pain as a primary or related symptom, including GI illness rooted in both organic disease and functional disorders. Cognitive behavioral therapy (CBT) is considered a “probably efficacious treatment” for RAP, per the guidelines formed by the Task Force on Promotion and Dissemination of Psychological Procedures. A randomized controlled trial conducted by Robins and colleagues (2005) produced results supporting the effectiveness of cognitive-behavioral family therapy for reducing pain sensitivity in children with RAP. Humphreys and Gevirtz (2000) compared four treatment approaches to RAP: intervention with fiber, combining fiber and biofeedback, combining fiber, biofeedback, and CBT, and combining fiber, biofeedback, CBT, and parental support. Results showed that increasing fiber in conjunction with biofeedback to reduce arousal was most effective in treating RAP. In a systematic review of behavioral and psychological treatment for functional gastrointestinal disorders, Brent, Lobato, and LeLeiko (2008) found five major treatment modalities being employed among mental health professionals, including psychoeducation, behavior therapy, relaxation-based therapies (including biofeedback and hypnotherapy), and CBT (including cognitive behavior family therapy). The researchers found that there was a wide variety of treatment and the most effective treatment interventions involved multiple types of therapy, including individual and family treatment. Those interventions employing a combination of psychoeducation, relaxation therapies (e.g., diaphragmatic breathing, progressive muscle

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relaxation, guided imagery, meditation, hypnotherapy, biofeedback), and CBT appeared superior to standard medical care alone. A recent study employing CBT for patients and their parents in the treatment of FAP was found to decrease pain symptoms (Levy et  al., 2010). Other studies have found both hypnotherapy (Vlieger, Menko-Frankenhuis, Wolfkamp, Tromp, & Benninga, 2007) and audiorecorded guided imagery (van Tilburg, Chitkara, Palsson, Levy, & Whitehead, 2009) highly effective in reducing pain among children with FAP and irritable bowel syndrome. Diaphragmatic breathing skills continue to prove useful for treating symptoms associated with rumination syndrome (Chitkara, Van Tilburg, Whitehead, & Talley, 2006; Wagaman, Williams, & Camilleri, 1998). Providing specific pain management tools (e.g., relaxation strategies, distraction) is important in helping children increase their feelings of self-efficacy regarding pain management. Teaching and practicing relaxation skills (e.g., diaphragmatic breathing, progressive muscle relaxation, imagery, hypnosis) are often initially challenging for children with chronic pain because the pain itself reduces the child’s ability to concentrate on the relaxation procedure. Relaxation training should therefore occur frequently and be individualized to each child. Incorporating positive self-talk and other cognitive strategies into relaxation training can help the child reduce negative thoughts about pain and increase positive self-statements, hence pain is viewed as manageable and the child can also play an active role in pain management (Spirito & Kazak, 2006).

Behavior Change Due to a chronic history of pain, some children with GI illness may become overly sensitive to physical changes in their body and thus exhibit frequent pain behavior (e.g., verbal complaints of pain, moaning, rubbing area of pain, guarding). Parents or other primary caregivers often monitor pain behavior and use it as a measure of their child’s pain. Increased monitoring results in attention to pain behavior and increased attempts to relieve discomfort in the child (and possibly parent anxiety). An immediate response to pain complaints may be appropriate in acute pain situations, but response should differ when pain becomes chronic or recurrent. Increased attention to pain behavior has been shown to increase symptom complaints, especially among girls with FAP (Walker et al., 2006). Pain treatment therefore must include parent training that focuses on discriminating between pain behaviors that are not urgent and acute symptoms that require immediate attention. Open discussion of parents’ fears and worries about their child’s abdominal pain may help facilitate a subsequent discussion of social learning of gastrointestinal illness (van Tilburg et al., 2009). A psychologist can help parents understand that providing frequent attention to pain behavior results in an inadvertent reinforcement of pain behavior (Sanders et al., 1994; Spirito & Kazak, 2006). Examples of positive reinforcement include comforting and soothing the child after each complaint, increased attention from

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teachers and peers, and giving gifts when the child is sick or in pain. A child may be excused from responsibilities such as chores or schoolwork due to pain, therefore negatively reinforcing the pain behavior. By improving the parents’ ability to discriminate pain complaints, they can begin to foster well behavior by decreasing their responses to pain behavior (i.e., ignoring nonverbal expression of pain) and increasing positive attention when the child is feeling less pain, including reinforcement of increased physical activity which has been shown to improve social– emotional functioning (Dahlquist & Switkin, 2003). Other interventions may include helping parents learn how to model appropriate coping behavior and avoid modeling sick behavior (Sanders et al., 1994). Children with chronic illness, including gastrointestinal illness, experience changes in daily living due to frequent medical appointments and medication regimens. As a result, adherence issues are common and may include missed medications or lapses in following medication, diet, or other lifestyle recommendations (Spirito & Kazak, 2006). Estimates of nonadherence in the pediatric chronic illness populations ranges from 40 to 60% (Riekert & Drotar, 2000). Consequences for nonadherence in children with pediatric gastrointestinal disease include increased morbidity (disease symptoms and complications), reduced control of symptoms (related to nonadherence to relaxation techniques), and sometimes mortality. The pediatric psychologist can play a role in treatment by assessing barriers to adherence and providing behavioral plans to improve adherence to medical regimens. Few studies have been conducted to examine adherence among children with gastrointestinal disease; however, data on adherence in other chronic illness are available (see below). Adherence problems can occur anytime during development, but it is most likely to occur in adolescence. Parent–adolescent conflict as well as a desire for greater autonomy can play a role in initiating and maintaining nonadherence. Because these issues can lead to increased family conflict, family-centered therapies have been commonly utilized and researched. Wysocki and colleagues (2000) suggest using four behavioral family systems therapy components when treating adolescents with Diabetes, including communication skills training, problem-solving training, cognitive restructuring, and functional and structural family therapy interventions (for further information on interventions see Donaldson, Spirito, & Overholser, 2003 and Quittner, Drotar, Ievers-Landis, & Hoffman, 2004). Although not yet established as effective for nonadherence, these therapy techniques are considered promising and frequently used for other adolescent problems and may prove useful among children with GI illness. Providing parents with information to help them understand normal adolescent development related to adherence can also be helpful (Steinberg & Levine, 1990). When addressing adherence issues, it is important to consider all possible causes. Important information to consider when addressing adherence issues includes the parent/child understanding of the treatment process (i.e., What is the family’s role in treatment? Do they feel they are a passive or active participant in the treatment process?), measurement issues, parent/child understanding of

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­ edication regimen, parent beliefs about their role in medication management m (i.e., Should the child or parent be responsible for ensuring that medication is available and it is taken?), costs of medication, and beliefs and cultural views of treatment (Spirito & Kazak, 2006). These issues should be addressed prior to beginning treatment. Plans for behavior change are also shown to be useful among children with fecal retention and incontinence; however, the results are mixed. Success with treatment of retentive fecal incontinence is shown to increase when behavioral interventions (i.e., positive reinforcement, dietary education, goal setting, skill building, relaxation skills) are applied in conjunction with medical management, thus reducing physician visits and inpatient hospitalizations for cleanouts (McGrath et al., 2000). In a study examining the effects of behavioral treatment versus conventional laxative treatment for functional fecal incontinence associated with constipation, defecation frequency was found to be significantly higher for conventional treatment, and fecal incontinence frequency and withholding behavior showed no difference between treatments. At 6-month follow-up, the proportion of children with behavior problems was significantly smaller for behavioral therapy (11.7 vs. 29.2%), suggesting that behavioral intervention may prove useful in reducing overall behavior and compliance problems among this population (van Dijk et al., 2008).

Role of Medical Psychology in Pediatric Gastroenterology Given the increased risk of adjustment and mood problems among children with gastrointestinal, medication may be utilized to help manage mood and related autonomic arousal. To this end, medical psychologists can play an important role in treatment. The majority of pediatric gastroenterologists are aware that their patients with chronic disease are prone to depression and anxiety but unfamiliar with treating chronic pain or prescribing a broad range of psychotropic medications. Therefore collaboration between gastroenterologists and medical psychologists can improve patient care through increased access to appropriate medication. Medical psychologists can assess for the benefits of medication to manage mood as well as reducing nonspecific CNS arousal, help to control the morbidity that accrues from functional symptoms, and use psychotherapeutic techniques to increase the likelihood of treatment compliance. Aside from potentially directly treating the gastroenterological disorder (Kast, 1998; Kast & Altschuler, 2001), antidepressants and anxiolytics are sometimes combined with other medications to help control pain and manage anxiety. DuPaul, McGoey, and Mautone (2003) suggested four main roles of the psychologist when considering pharmacotherapy, including determining when to use medication, considering developmental factors, consulting with physicians in the assessment of medication response, and promoting compliance with medication through behavior management.

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Treatment of Pain Related to Pediatric Functional GI Disorders with Psychotropic Medications Tricyclic antidepressants (TCAs). A number of studies have demonstrated ­considerable benefits for the management of neuropathic pain using low dose convention TCAs. Perhaps the best known of these is amitriptyline, the mechanism for which appears to be the simultaneous transport blockade of both norepinephrine and serotonin, coupled with being anticholinergic (Stahl, 2009). Results of animal models and human trials have provided evidence that tricyclics are effective for chronic neuropathic pain by at least two mechanisms (Broekaert et  al., 2006; Clouse et al., 1987; Doraiswamy et al., 2006; Ranjagopalan, Kurian, & On, 1998; Talley et al., 2008; Varia et al., 2000) – (1) decreasing afferent nerve transmission to the spinal cord, and (2) reducing CNS nonspecific arousal systems. Amitriptyline is often used to prophylax against episodes of CVS and abdominal migraine. When constipation is a problem, imipramine at the same dose may be a satisfactory substitute, with similar efficacy but less anticholinergic effects. A recent meta-analysis examining the effectiveness of TCAs for control of irritable bowel syndrome concluded that low dose TCAs exhibit clinically and statistically significant control of IBS symptoms (Rahimi, Nikfar, Rezaie, & Abdollahi, 2009). Perceptual hypersensitivity is a biomarker for irritable bowel syndrome (Van Ginkel, Voskuijl, Benninga, Taminiau, & Boeckxstaens, 2001) and dyspepsia (Di Lorenzo et al., 2001) in children and likely related to the effectiveness of TCAs among these populations. There are only two prospective, placebo controlled studies of low dose tricyclic for chronic abdominal pain in pediatric patients (Bahar et al., 2008; Saps et  al., 2009). Both studies compared 10  mg amitriptyline to placebo, but failed to show differences in the primary outcome variable. Low doses of TCAs appear most effective for pain management, and they do not have antidepressant properties at these doses. Given the possible comorbidity of pain and depression, one cannot forget that TCAs have a relatively narrow therapeutic window and that overdoses can lead to fatal results. Consequently, cooperative psychotropic and psychotherapeutic interventions addressing both pain and depression are generally necessary with low dose treatments with TCAs. Selective serotonin reuptake inhibitors (SSRIs).  For patients experiencing morning lethargy, symptoms may be improved with an activating antidepressant such as Fluoxitine. There is one prospective controlled trial of Celexa for chronic abdominal pain in children (Campo, 2007). For those with anxiety and poor sleep, paroxetine may offer considerable relief. It is important to remember, however, that paroxetine has never demonstrated efficacy as an antidepressant with children, tends to cause weight gain, and can cause considerable sexual side effects. These adverse reactions are likely due to paroxetine’s anticholingergic mechanism and negative impact on nitric oxide synthase. Simultaneously, paroxetine may be helpful for GI patients with elevated gastric motility because of the anticholinergic mechanism (Stahl, 2009). Gaba-active drugs.  There are no controlled, blinded trials of gabapentin or ­levetiracetam in children with FAP. There is anecdotal data that gabapentin is

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e­ ffective for reducing food refusal in toddlers (Davis, Bruce, Mangiaracina, Schulz, & Hyman, 2009; Zangen et al., 2000). The authors hypothesized that the cause of food refusal was dyspepsia, and the dyspepsia resolved with treatment that included gabapentin and continuous feeding into a gastrojejunal feeding tube to desensitize the hypersensitive esophagus and stomach.

Treatment of Disordered Sleep in Pediatric Functional GI Disorders Sleep difficulties are commonly reported among children with chronic pain disorders, including RAP and other GI dysfunction. Several medications are useful in achieving better sleep onset and duration among these patients. Several sleep inducing medications produce their sedative effects via irreversible H1 (histamine 1) receptor antagonism, while helpful in inducing sleep, many of these medications (e.g., diphenhydramine) also interfere with cognitive efficiency (Basu, Dodge, Stoehr, & Ganguli, 2003). Other substances such as the atypical neuroleptics also induce sleep via their histamine receptor blockade, but introduce the potentially unnecessary and potent dopamineregic antagonism. In short, the prescribing clinician is well advised to carefully consider both the pharmacokinetic and pharmacodynamic activities of the agents they use to assist with sleep. While the FDA has not approved any agent for the treatment of sleep in children, there is little debate that there is a need for formal guidelines regarding insomnia in this population (Mindell et al., 2006). Melatonin.  Also known chemically as N-acetyl-5-methoxytryptamine, melatonin is a naturally occurring compound found in animals, plants, and microbes. In animals, circulating levels of melatonin vary in a daily cycle, thereby regulating the circadian rhythms of several biological functions. In humans, melatonin is produced by the pineal gland, a gland about the size of a pea, located in the center of the brain but outside the blood–brain barrier. The melatonin signal forms part of the system that regulates the sleep–wake cycle by chemically causing drowsiness and lowering the body temperature. Infants’ melatonin levels become regular in about the third month after birth, with the highest levels measured between midnight and 08:00. Several double-blind, placebo controlled studies have been completed demonstrating melatonin’s efficacy in regard to initiating sleep onset. Amitriptyline.  Most commonly prescribed for d-IBS, Amitriptyline reduces several types of chronic pain (i.e., headaches, fibromyalgia), reduces stool volume, and regulates sleep. The total dose may be taken an hour or two before bedtime so that the patient quickly falls asleep. The dose is started low (0.25 mg/kg/day, or 10 mg in children >20 kg), and titrated upward in weekly increments until restful sleep is achieved. Similar positive trials of doxepine and trimipramine have been effective for sleep management, but the previously discussed side-effect profiles regarding TCAs have ultimately limited their use. Trazadone.  This agent appears to produce its sleep inducing action by potently antagonizing serotonin 2A. While no indication in children exists, several studies

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have demonstrated that its use with pediatric patients is becoming more common (Campo, 2007). In the case of the GI patient, if unwanted side effects from ­amitriptyline are too severe, including agitation, trazadone may be substituted to help achieve restful sleep. There have been no trials treating children’s pain with trazadone, but trazadone may be titrated in adolescents in 25 mg increments with success typically achieved by 100 mg 1–2 h before bedtime. If trazadone is chosen for use, it is important for the clinician to remember the risk of priapism in males. Eszopliclone, zolpidem, zaleplon, and zopiclone.  These novel hypnotics, often referred to as the “Zs,” have not been studied in children or adolescents. As of this writing, there is a single formal double-blind placebo trial ongoing regarding eszopliclone in ADHD, but the data for that trial is not expected until well after this text is published. Despite the lack of formal randomized control studies, these medications are becoming more popular with children because of what appears to be a more favorable risk profile. The mechanism for these agents includes activity at the benzodiazepine 1 receptor but is reported to avoid the muscle relaxing qualities of typical benzodiazepines. Without formal literature to guide the clinical use of these agents, clinicians should carefully monitor these patients, use small initiation doses and raise the doses cautiously. Mirtazepine.  This agent is approved only for the treatment of major depressive disorder in adults. However, among its complicated mechanisms of action are potent histamine 1 antagonism and mild anticholinergic effects. When prescribed in low doses, the drug has demonstrated considerable efficacy for inducing sleep (Stahl, 2009). Via this mechanism and its relatively potent serotonin 2 (A and C) receptor antagonism, mirtazepine also contributes to reducing the autonomic arousal of patients who are anxious or depressed. Mirtazepine also antagonizes serotonin 3 receptors, resulting in decreasing patient nausea. Clinicians are cautioned when using mirtazepine as it can cause significant weight gain and, rarely, agranulocytosis. Atypical antipsychotics.  In patients who are slow to respond to the drugs listed above, the atypical antipsychotics may be helpful. As with the other drugs, the doses begin low and are titrated to effective sleep. These drugs all cause weight gain, so if the patient is underweight, an atypical antipsychotic may be a good treatment choice. By treating anxiety, the nausea is treated as well. When nausea is constant and severe, and the patient does not meet criteria for CVS, pancreatic cancer, or chronic intestinal pseudo-obstruction, then the clinician may assume that nausea is directly proportional to anxiety and autonomic arousal.

Treatment of Comorbid Anxiety and Depressive Disorders in Pediatric Functional GI Disorders As illustrated in the paragraphs above, children with GI disorders are at a greater risk for developing comorbid psychological disorders. In addition, it is well documented

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and accepted in the field of treatment that chronic or acute pain can create both anxious and depressive disorders. The treatment of the psychological ­symptoms often leads to a reduction in the severity of GI complaints and/or an improved sense of control over their evolution and magnitude. Currently, very few medications are approved for the treatment of depression in children (fluoxetine and escritalopram) and a few of the TCAs. Furthermore, while paroxetine is included in the list of medications theoretically helpful in depression, there are no studies in children in which paroxetine successfully separates from placebo in the treatment of depression. In contrast, all of the SSRIs tend to be equally efficacious with regard to treating anxiety disorders, with paroxetine providing double benefits in terms of sleep induction and decreased gastric motility in the short term.

Suggested Treatment of Common Pediatric Gastrointestinal Diagnoses Cyclic Vomiting Syndrome CVS is defined by paroxysmal, stereotypical episodes of intense nausea and repeated vomiting lasting hours to days with intervening baseline periods lasting weeks to months. This disorder affects about 1 or 2% of the population and occurs at all ages (Abu-Arafeh & Russell, 1995). Several physiological factors are thought to play a role in CVS, such as migraine-related mechanism and neuronal hyperexcitability (Li & Misiewicz, 2003), sympathetic hyperresponsitivity and autonomic dysfunction (Gordon, 1994). Activation of the hypothalamic-pituitary-adrenal axis is also thought to trigger CVS episodes (Li & Fleisher, 1999; Li, Murray, Heitlinger, Robbins, & Hayes, 1999). Those people affected by CVS often identify triggers to the episodes including infection and stressful or excitatory events such as trips to the dentist office, sleep-overs, or birthday parties (Li & Fleisher, 1999; Withers, Silburn, & Forbes, 1998). Adolescents and adults with CVS often develop daily abdominal symptoms that are disabling. They can feel nauseated for days or weeks not punctuated by an acute episode. Often the severity of nausea is related and proportional to the severity anxiety they are experiencing. Families and patients can benefit from psychotherapy and drugs to regulate sleep and treat chronic anxiety disorders (Parkman et al., 2008). Episodes may be reduced or eliminated by one of several drugs taken daily. The most frequently used drug is amitriptyline titrated in three or four steps to 1 mg/ kg/day. Amitriptyline is effective in about 80% of CVS patients. Other drugs for prophylaxis include propranolol, cyproheptidine, and phenobarbital. These are slightly less effective than amitriptyline. Amitriptyline has anticholinergic, antihistamininergic, and antiserotonin activities, and likely effective for the norepinephrine and serotonin transport/reuptake antagonism noted above. The common feature of the drugs used for prophylaxis may be that all reduce the response to

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stress in either the central arousal systems or periphery. Once an episode starts, treatment goals are to prevent further suffering. Long acting benzodiazepines (e.g., intravenous ­lorazepam in the hospital, rectally administered valium) are titrated to restful sleep, and continued to the end of the episode. Antiemetics are nearly always unhelpful. Behavioral interventions for cyclic vomiting, especially during symptoms-free periods, should focus on identifying and treating emotional factors that may play a role in increasing emotional stress and autonomic arousal. Pain diaries, including events that occur before and after episodes and specific symptoms, may be helpful in identifying emotional triggers. Teaching the child relaxation skills and biofeedback to improve physiological control has been shown to decrease the frequency and severity of CVS episodes (Jellinek, 1997).

Chronic and Recurrent Functional Abdominal Pain Chronic or recurrent bellyaches are common, affecting more than 10% of schoolaged children, and more than 10% of teens and adults. Most chronic bellyaches are functional and meet symptom-based Rome criteria for one or more diagnosis (see Table 12.1). Children with FAP can also experience some loss of daily functioning and additional somatic symptoms such as headache, limb pain, or difficulty sleeping. The majority of children with FAP do not seek medical consultation, thus those presenting in the clinical setting are often the most severe. Distress and disability associated with FAP appears to be proportional to the severity of comorbid psychological conditions in the child and family. Pharmacological therapies may prove useful in some cases. Visceral pain and autonomic arousal can be targeted with TCAs such as a desipramine and amitriptyline. Anticholinergic medications (e.g., dicyclomine and hyoscyamine) are sometimes used for their antispasmodic properties as well as inducing sleep (via reduction of autonomic arousal). Other symptoms, such as constipation, should also be treated (e.g., laxatives, stool softeners) to relieve additional discomfort. CBT is shown to be an effective treatment approach in this population (Robins et  al., 2005). Biofeedback and relaxation skills are shown to reduce arousal and help improve symptoms among children with abdominal pain (Humphreys & Gevirtz, 2000). A systematic review of treatments for FAP revealed that psychological interventions employing a combination of psychoeducation, relaxation therapies, and CBT were superior to standard medical care alone (Brent et  al., 2008). Other studies employing CBT (Levy et  al., 2010), hypnotherapy (Vlieger et  al., 2007), and audio-recorded guided imagery (van Tilburg et  al., 2009) were found to be highly effective in reducing pain among children with FAP and irritable bowel syndrome. Diaphragmatic breathing skills continue to be found useful for treating symptoms associated with rumination syndrome (Chitkara et  al., 2006; Wagaman et al., 1998).

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Functional Constipation and Encopresis Functional constipation is the single most common presenting complaint in the pediatric gastroenterologist’s office, accounting for 20–30% of visits. To understand functional constipation requires that a clinician understand the child’s experience and reaction. Functional constipation may begin at any age, but typically presents during one of three developmental periods. The first is around 6 months of age, when the mother weans the child from the breast. When feeding habits change, such as a transition from breast milk to formula, the child’s stools can become hard and hurt as they pass through the anal sphincter. Second, similarly, a child may experience painful, difficult defecation during toilet training. The child’s response is to avoid further painful defecation. Finally, the third group comprises school children who discover that there are new limits to their bathroom access and/or experience embarrassment associated with having bowel movements in school. The child responds by developing voluntary stool retention to avoid discomfort or embarrassment. All of these scenarios result in the child responding to each urge to defecate by using pelvic floor and gluteal muscles to retain stool. A large and hard stool mass forms in the rectum. As the fecal mass grows, the child becomes more irritable and there is reduced appetite, because keeping the anal sphincter closed during propagating colon contractions is painful, and eating stimulates propagating colonic contractions. The psychologist helps these children and families by collaborating with the physician to educate the child and parents about functional constipation and dispel some of the myths associated with constipation (i.e., stool will not leak back into the body, the colon will not pop, functional constipation is not precancerous, the child can feel everything and there are no neurologic deficits in functional constipation). The clinician may add that the reason for episodes of incontinence is understood – as the child relaxes the sphincter relaxes to pass gas, liquid stool leaks out at the same time. Educating the child and parents, including assuring them that functional constipation is not a disease and will resolve, is a helpful step in the treatment process. Aside from education, treatment for functional constipation and encopresis is primarily behavioral. Paired with medical interventions (e.g., oral laxatives), behavior interventions, such as sticker charts and toilet sitting schedules, have shown a very high level of effectiveness for treatment of encopresis (for a review, see Christophersen & Mortweet, 2001). Anorectal biofeedback can also be an effective treatment, but is most effective when a patient volunteers for the anal manometry procedure to learn how to relax the external anal squinter (McGrath et al., 2000). Independent studies have documented improvement in encopresis symptoms (e.g., constipation and incontinence) with interventions that include behavioral intervention (e.g., bowel monitoring, fiber and fluid intake goals, sitting schedule, reinforcement, and skill building), compared to medical management alone (Stark, Owens-Stively, Spirito, Lewis, & Guevremont, 1990; Stark et  al., 1997), and/or biofeedback alone (Cox, Sutphen, Borowitz, Kovatchev, & Ling, 1998; Cox,

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Sutphen, Ling, Quillian, & Borowitz, 1996). Positive reinforcement programs have been shown to improve symptoms more than medical intervention plus biofeedback (Wald, Chandra, Gabel, & Chiponis, 1987). The most challenging children to treat are those with recognized or even unrecognized underlying cognitive deficits or emotional problems including global developmental delay, attention deficit disorder, learning disability, depression, anxiety disorder, phobic disorder, autism, conduct disorder or oppositional defiant disorder, posttraumatic stress disorder, and sexual abuse (Gertkin, Cocjin, Pehlivanov, Danda, & Hyman, 2005), therefore evaluation for developmental and mental health problems and directing the family to appropriate services can also be helpful to achieving treatment goals.

Inflammatory Bowel Disease Crohn’s disease and ulcerative colitis fall into the diagnostic category of IBD and affect about 1 in 500 children and adolescents. These disorders slow body growth by both their inflammatory activity and the loss of appetite that accompanies the diseases. In some patients, IBD delays the onset of puberty, destroys tissues of the pelvic floor, and causes permanent short stature. The use of chronic corticosteroid to treat IBD is associated with excessive weight gain and fat distribution on the back of the neck (buffalo hump), violations striae on the hips, abdomen and arms, bone loss, calcium oxylate renal stones, adrenal gland suppression, and mood changes. There is an increased GI cancer risk for IBD patients. Chronic treatment with immune modulator drugs such as 6-mercaptopurine and azithiprine and with biologic agents such as antitissue necrosis factor antibodies is associated with an increased risk of cancer. Preteens and teens are greatly aware of changes in their bodies and concerned about their appearance to others, which places them at greater risk for adjustment and coping difficulties. IBD is an ongoing stressor for the child and family. These children can benefit from increasing social support and learning coping skills to cope with body and mood changes. Sometimes adjustment and coping difficulties can lead to symptoms of depression or anxiety, and these children and adolescents may benefit pharmacotherapy to treat comorbid psychological symptoms. When there is disordered sleep and chronic pain and diarrhea, amitryptyline may address all of these complaints simultaneously.

Pain-Associated Disability Syndrome Pain-associated disability syndrome (PADS) is defined as a condition found in preteens and teens with a chronic history of pain or other discomfort (such as ­nausea) unresponsive to acute pain management strategies, with no overt mental

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health disorder, and an inability to accomplish daily activities (e.g., attend school, eat meals, etc.). Among children with GI illness, PADS is often associated with a passive coping style, family dynamic issues, and a functional gastrointestinal disorder (Hyman et al., 2002). PADS patients are high utilizers of medical care, as they seek consultation from many subspecialists without symptom relief. Several negative medical procedures often leave children feeling more anxious that rare and dangerous disease is being missed. PADS is an illness that falls in the gap between conventional medicine and conventional mental health. Gastroenterologists fail to find disease and refer the adolescent to a mental health professional. Mental health clinicians who are not familiar with PADS find the patients have anxiety and depression consistent with being ill from an unknown cause, no evidence of thought or eating disorders, and recommend that the family find another gastroenterologist. To close the gap requires collaboration between a medical clinician and mental health professional who are familiar with PADS. These two professionals may complete an initial evaluation together to provide strength to the idea that the brain and the gut are connected. Two primary shifts in thinking are presented to the patient and family at the first meeting: (1) PADS is the diagnosis – no further medical tests are necessary or desirable – and (2) there will be a change from an acute medical model (in which doctors do things to the patient) to a rehabilitation model (in which the patient takes responsibility for getting better). Nearly all patients with PADS experience abnormal sleep patterns and chronic fatigue. Correcting sleep with medication in the first week is helpful by providing a quick positive outcome and encouraging a therapeutic alliance. The clinician begins with a single bedtime dose of amitryptyline 10 mg (or imipramine 10 mg if the patient is constipated), and titrate the dose, increasing by 10 mg each day (or week) until the patient achieves easy, restful sleep through the night, or 50  mg. Amitryptyline reduces chronic pain and desensitizes hypersensitive pain nerves, so it is a good first choice. It effectively reduces symptoms about 80% of the time (Saps et  al., 2009). If amitryptyline causes anticholinergic side effects such as ­urinary retention or irritability, other drugs may be substituted. Mirtazepine 7.5 mg or trazadone beginning at 50  mg and increasing as needed, or the atypical ­antipsychotics, also titrated to restful sleep, may be helpful for sleep and for comorbid ­psychological issues. An additional role of the medical psychologist is to teach the patient means to reduce autonomic arousal. CBT is shown to be the most effective intervention (Toner, Segal, Emmot, & Myran, 2000), but hypnosis, guided imagery, Iyengar yoga, meditation, and biofeedback are also helpful for some patients (Zeltzer, 2005). Maynard, Amari, Wieczorek, Christensen, and Slifer, 2010 recently explored the efficacy of an inpatient, multidisciplinary approach to treatment of pain-­ associated disability, focusing on a rehabilitation model of pain management. They found that this approach resulted in significant improvements in school status, sleep, functional ability, physical mobility, and medication usage. Newer approaches to treatment of chronic pain and functional disability suggest that shifting the patient and family focus away from managing pain to achieving

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more adaptive functioning is beneficial. Benore, Wertalik, Beck, and Slifer, 2004 utilized a functional treatment approach among children with chronic pain and found it resulted in less termination of pleasurable activities, fewer school absences, and longer outings. Acceptance and commitment therapy (ACT), a version of ­traditional CBT, focuses on increasing functioning by improving the patient’s ability to act in concordance with personal values rather than emphasizing reductions in pain and distress. Case studies have shown promising results among pediatric patients with pain of unknown etiology (Wicksell, Dahl, Magnusson, & Olsson, 2005). A recent randomized controlled trial was conducted comparing the effectiveness of ACT versus medication trial (amitriptyline) among children with chronic pain. Result showed that ACT was superior to medication in improving perceived functional ability in relation to pain, pain intensity and pain-related discomfort, as well as reducing anxiety related to fear of re/injury or kinesiophobia, pain interference and improving quality of life (Wicksell, Melin, Lekander, & Olsson, 2009).

Rumination Syndrome Rumination is the effortless regurgitation of recently ingested food from the stomach into the mouth, with the subsequent spitting out or reswallowing of the material. Infants as well as some intellectually impaired and autistic children may develop rumination as a self-stimulatory behavior; the behavior typically resolves over time. Rumination is a common symptom in some healthy children and adolescents, although it is rarely recognized by primary care physicians or pediatric gastroenterologists unfamiliar with using Rome criteria, who lump it into the “reflux” designation. Rumination occurs in a wide variety of ages, with and without comorbidities and other symptoms. Half of normal children with rumination complain of upper abdominal discomfort following meals (e.g., dyspepsia). Children with rumination feel that the regurgitation is unpredictable, although it often occurs following meals and never during sleep. Rumination may occur as a means to relieve postprandial dyspepsia. Children, particularly adolescents, are at risk for adjustment problems related to rumination. To avoid ruminating in front of friends, adolescents may skip breakfast and school lunch or stay home from school for weeks or months due to continuous vomiting. Some children who ruminate have comorbid psychological symptoms, most often anxiety symptoms, which increase autonomic arousal and likely contribute to rumination symptoms. A careful history will establish whether there is medical and/or psychosocial comorbidity and inform proper treatment. Most otherwise healthy children who ruminate are eager to rid themselves of the problem. If their primary care clinician refers them to a surgeon, the surgeon may perform a gastric fundoplication to prevent regurgitation (Oelschlager, Chan, Eubanks, Pope, & Pellegrini, 2002). This surgical approach to a functional disorder seems counter-intuitive. A biopsychosocial approach to treatment seems a

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better solution. Both behavioral and medication treatments are available to treat rumination syndrome. The most common medication prescribed for the treatment of rumination is amitryptyline, as it helps to reduce the hypersensitive nerves in the gut and reduce nausea or other uncomfortable feelings in the stomach after eating. The dose is started low (0.25 mg/kg/day, or 10 mg in children >20 kg), and titrated upward in weekly increments until symptom relief is achieved. Behavioral intervention includes teaching the child habit reversal techniques to counteract the physiological response that occurs during rumination. It is thought that each time the child eats a meal, the gut transmits signals to the brain signaling discomfort, and the brain in turn transmits a signal to the gut telling it to rid the body of the food. Vomiting involves abdominal wall contraction; therefore teaching the child to extend the abdominal wall provides an incompatible response to vomiting and ultimately reduces the frequency of emesis. The primary habit reversal technique that achieves abdominal wall distention is diaphragmatic breathing. Not only does diaphragmatic breathing provide an incompatible response, but it will also help reduce autonomic arousal and gut sensitivity. Additional relaxation skills (e.g., imagery, muscle relaxation) and biofeedback can also help increase physiological control. Habit reversal via diaphragmatic breathing has been shown to be an effective treatment for rumination among both children (Khan, Hyman, Cocjin, & Di Lorenzo, 2000; Wagaman et al., 1998) and adults (Chitkara, et al., 2006).

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Part IV

Future Directions in Pharmacological Collaboration

Chapter 13

Brain Markers: An Emerging Technology with Potential to Enhance Collaboration Between Pediatricians and Pharmacologically Trained Psychologists Margaret B. Alvarez This chapter discusses the collaboration between pediatricians and pharmacologically trained psychologists and the importance of communication between pharmacologically trained psychologists and pediatricians to help them work together. Currently, there are several states in the US where psychologists with appropriate training in psychopharmacology are able to prescribe. However, psychologists with such training who do not reside in these states can also offer valuable services to their patients when working collaboratively with the patient’s physicians. Pediatricians, in particular, often seek such consultation from specialists in many areas, especially neurology and psychiatry. Psychopharmacologically trained psychologists are an asset in these areas, as well as pain management. The role of the psychologist is essential to diagnostics, promoting patient well-being, monitoring outcomes, and aiding physicians and parents in arriving at more accurate titration, which in the long run leads to greater patient compliance, often reducing the impact of potential side effects.

Why Should Psychologists Consult with Pediatricians? Psychologists with training in psychopharmacology are best equipped to consult with physicians, internists, and pediatricians in cases involving the prescription of psychopharmacological agents to treat maladaptive behavior disorders. Attention deficit hyperactivity disorder (ADHD) is one of the most prevalent disorders encountered by both psychologists and physicians, and is an area where consultation is especially beneficial. Psychologists can be invaluable to physicians attempting to correctly diagnose ADHD, not only by helping to assure diagnostic accuracy but also in paving the way to a smoother course of titration of medications and assessing M.B. Alvarez (*) Associate Professor of Psychology and Education, Departments of Psychology, Education and Mental Health Counseling, Touro College, New York, USA e-mail: [email protected] G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_13, © Springer Science+Business Media, LLC 2011

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adequacy of treatment response to psychopharmacological agents. Such consultation is also beneficial due to the fact that psychologists with psychopharmacological training can be a great resource when informing parents about how much and in which sensory processing modality medications can change behavior and performance. Rosack (2004) outlines that physicians typically have 8 years of biomedical training. Yet, physicians often admit that a bulk of training after medical school in the area of pharmacological intervention usually comes from drug company representatives. This has led to both benefits and problems, and there is a movement within psychiatry to organize continuing education activities independently from pharmaceutical companies (Stahl et al. 2008). As an example, innovations in the area of data collection management through the International Brain Database have allowed mental health professionals to have access to recent findings of neuroscientific studies. Brain Resources Corporation was established after consulting with international professionals and neurobehavioral theorists, such as Elkhonon Goldberg (2009). Gordon (2007) noted that brain markers have been used in identification and tracking of diagnostic, treatment, and outcome findings. These markers, therefore, may help in personalizing medication regimens and eliminating the problems that arise from misdiagnoses.

Brain Markers Brain Markers are measurable, identifiable pieces of evidence that can be linked to or definitively determined to impact brain performance. Brain markers can be biological, chemical, electrical, or behavioral/performance-based. The identification of specific brain markers and their links to specific disorders can help psychologists and physicians. Ultimately, it is hoped that the study of brain markers will lead to a more personalized approach to the diagnosis and treatment of individuals with brain disorders (Gordon 2003). Personalized medicine approaches are a wave of the future that will likely enhance practice based on the exponential advances currently being made in the understanding of both brain markers and the role of genetics (Malhotra, Murphy, & Kennedy, 2004). ADHD is in fact one of the most heritable neuropsychiatric disorders. In fact, it is likely that personalized plans for medical/psychological treatment that take into account one’s human genome and any present brain markers will begin being used more widely by physicians and psychologists with psychopharmacological backgrounds.

The Emerging Model for Use of Brain Markers in Clinical Practice An integrative neuroscience model has been developed to identify and measure brain markers and assist assessment and treatment selection to optimize cognitive interventions (Gordon, 2000). This approach, according to (Insel et  al. 2004),

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represented a move to large-scale brain health science with insights based upon an interdisciplinary approach combining psychology, clinical neuropsychology, psychiatry, neurology, and neuroscience. Gordon, Cooper, Rennie, Hermens, and Williams (2005) identified brain markers in four categories – Emotion, Thinking, Feeling, and Self Regulation. A model of how the brain functions within an integrated and dynamic system was illustrated by examining the motivation for selfpreservation in both avoiding danger and maximizing reward, a concept which underlies brain organization systems of emotion, thinking, feeling, and self-­ regulation processes (Williams et al., 2008). Theoretically, at a simplistic level, the drive for safety predominates; and at an abstract level, perceived rewards include such variables as status of profession and the ability to sustain personal relationships. These, taken together with physical and genetic traits, shape brain behavior functioning to avoid danger while maximizing rewards. The Integrated Model is characterized by the following assessment markers. Assessment of emotion markers:  Emotion processing, which can take place very rapidly (in a fifth of a second), occurs via lower-level brain networks that can pick up signals of potential danger or reward without conscious awareness (Williams et al., 2006). These networks trigger automatic emotional reactions without needing to communicate with the higher cortical functions of the brain (Liddell et al., 2004). Emotion signals most relied upon for automatic processing are the facial expressions of emotions shown by others (Mathersul et al., 2009). Facial expressions are read and processed, to produce a reaction, at a rapid and constant rate during social communication. Assessment of thinking markers:  Thinking processes are gauged using factual information (Williams et al., 2009) by examining the processes of attention (focus, selective attention), memory (working memory and recall, Clark et al., 2006), and executive functions (planning, flexibility, Gunstad et al., 2006). These elements are required to assess consequences of actions and plan ahead (Mathersul et al., 2009). Brain systems involved in thinking (Clark et al., 2006) include feedback between higher and lower-level networks (Gunstad et al., 2006), which yield an awareness of what is attended to, remembered, and acted upon. Over the lifespan, brain changes affect thinking processes (Brickman et al. 2006). For example, Zimmerman et  al. (2006) examined the relationship between age-related changes in MRIderived gray matter volumes and standardized cognitive summary scores of attention and executive function. The effect of age, gray matter volumes, and their interaction on the prediction of cognitive performance revealed a curvilinear relationship in that at younger and older ages, attention and executive functions are at lower levels than during midlife. Brickman et  al. (2006) studied younger (ages 21–30), middle (ages 31–54), and older (ages 55–79) age groups. The older group had significantly less overall relative white matter than the middle group, who had significantly less overall relative white matter than the younger participants. Differences in frontal lobe white matter were of largest magnitude, followed by temporal lobe. Age, and frontal and temporal lobe white matter were associated with performance on neuropsychological tests of executive functioning and memory.

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Frontal lobe white matter mediated the relationship between age and performance on tasks of executive functioning and memory. The results confirmed age-associated decline in frontal and temporal white matter, and age-related cognitive decline in several domains. Decline in neuropsychological functioning was partially mediated by a relative age-related reduction in frontal white matter. Gunstad et  al. (2006) investigated cognitive decline in processing speeded, executive function, and memory believed to typify normal aging. Significant variability in cognitive function with advanced age and reported relatively intact cognitive function among a subset of older individuals was found. They examined the patterns of cognitive function in middle-aged and older individuals. Analyses revealed three clusters of middle-aged adults, including an intact group, a poor motor speed cohort, and a group with reduced executive function. Three clusters were also identified for older adults, including a group with poor executive function, a cohort with reduced processing speed (attention, executive function, motor), and a group with global cognitive decline. This study supported the frontal aging hypothesis and provided important information about healthy cognitive aging. Nevertheless, training and experience throughout the lifespan have a positive impact and increase modifiability of cognitive variables. Based on a recent analysis of evidence-based studies (Rabiner, Murray, Skinner, & Malone, 2010), the American Academy of Pediatrics (AAP) has recognized neurofeedback (EEG brainwave biofeedback) and working memory training as clinically efficacious in the treatment of children and adolescents with attention and hyperactivity disorders. AAP’s analysis, using the PracticeWise Evidence Based Services (PWEBS) database, determined that using these interventions significantly improves attention and reduces hyperactivity. Assessment of feeling markers:  Feeling markers pertain to the experience of emotions and their influence upon thinking (Gordon, Barnett, Cooper, Tran, & Williams, 2008). Changes in the activation of brain and physical functioning are the biological bases of an individual’s experience, interpretation, and labeling of feelings (Williams, 2008). For example, increases in heart rate coincide with an experience of stress, while reductions in heart rate are associated with relaxation. The changes associated with stress tend to be similar across cultures (Cohen et al., 2006), and so the utility of training to enhance positive and reduce negative feelings may have universal benefits. Self regulation markers:  Self-regulation markers gauge the management of an individual’s emotion, thinking and feeling, and the associated brain processes. Key elements of self-regulation include the regulation of emotion processes, goal setting, and emotional intelligence (Craig et al., 2009). If aligned, these processes may optimize brain health and enhance adaption to the environment (Gordon et  al., 2008). Most individuals exhibit a natural bias to expect more negative than positive outcomes. Enhancing positive bias is associated with a greater capacity for resilience, more effective communication and increased productivity, and individuals with a positive bias tend to be more optimistic. Conversely, when the negative bias becomes exaggerated, it is associated with a more pessimistic outlook, and it may increase risk for stress reactions and poor brain health (Williams, 2008). The regulation of emotion tends to improve with age (Williams et al., 2006), indicating that

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experience and practice may be an integral contributor to the management of generalized well-being in mental and physical health.

Types of Brain Markers Brain markers in the categories described above can be measured along four dimensions – biological, chemical, electrical, or behavioral/performance-based. The identification of specific brain markers in each category and their links to specific disorders can be helpful to both psychologists and physicians. Biological brain markers: Brain markers classified as biological in nature involve structural changes present in the brain. In many cases, general or localized brain regions can be shown to be physically altered often through assessment of acquired brain injuries, and ancillary use magnetic resonance imaging (MRI), positron emission tomography (PET), or single-photon emission computed tomography (SPECT) scanning. For example, comparing similarity in findings based on clinical diagnostic assessment of Alzheimer’s patients reveals a significant percentage of accuracy in pinpointing the predicted areas of brain involvement, based on Broadman areas and evident on subsequent MRI exams (Valotassiou et al., 2009). Applications of integrative research extrapolation may in the future be applied to other improving diagnostics and treatment in other brain-based disorders (ADHD, autism, and depression). Researchers have uncovered similar findings over the last decade – for example, Sheline, Sanghavi, Mintun, and Gado (1999) at Washington University School of Medicine in St. Louis found key brain regions as significantly smaller in people who have suffered from clinical depression. Additionally, Sheline et al. found that people who have been depressed had a smaller hippocampus volume, a structure that plays an integral part in memory and learning. Using three-dimensional MRI, Sheline et al., found that otherwise healthy women with a history of depression had smaller hippocampal volumes than those who never had been depressed. In a previous, smaller study, Sheline, Gado, and Price (1998) also found a relationship between depression and loss of volume in the hippocampus, so they anticipated this finding; however, they also expected to see an effect from aging. They hypothesized that the hippocampus would be somewhat smaller in older subjects who had never been depressed. Instead, a significant volume loss was seen only in patients with a history of depression. Similarly, Holden (2003) found that the genetic basis or predisposition for depression is related to a physically shorter allele in some people. Chemical brain markers:  Brain markers classified as chemical in nature involve cases where the absence or presence of a chemical can be identified and viewed as predictive of (or predictive of the potential of) maladaptive brain behavior. Researchers at Washington University School of Medicine in St. Louis have linked a potential indicator of Alzheimer’s disease to brain damage in humans with no signs of mental impairment (Fagan et al., 2009). Although their cognitive and neurological assessments revealed normal results, study participants with lower levels of amyloid beta 42 (A-beta 42) in their cerebrospinal fluid (CSF) had reduced whole brain

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volumes, suggesting that Alzheimer’s changes might already be damaging their brains. Scientists previously showed that low CSF levels of A-beta 42 mark the presence of amyloid deposition in the brain, a key diagnostic marker of the amyloid plaques that characterize Alzheimer’s disease (Perrin, Fagan, & Holtzman, 2009). Evidence is mounting that Alzheimer’s harms the brain for many years before physicians and family members can detect symptoms, and this has led many to conclude that successful Alzheimer’s treatments may only be possible if scientists find ways to identify presymptomatic sufferers. The results are an encouraging sign that this search for new indicators, known as antecedent biomarkers, may be succeeding. Although it should be noted that the role of continued enrichment and intellectual/ cognitive stimulation and activity has been shown to slow detrimental effects to the point of the appearance of continued normal functioning, there are in fact plaques and tangles seen in the brain upon autopsy. In the famous nun study, Snowdon et al. (1997) cataloged the brain functioning longitudinally throughout the life span of these individuals. Educational level was assessed by ratings of their admission essay in their youth, studying their vitality health, attention, and memory later in life and brain autopsy upon their death. Snowden and his fellow researchers unexpectedly found that even the more cognitively intact nuns had plaques and tangles upon autopsy of their brains. It was hypothesized that perhaps their higher level of brain stimulation through continued education had a somewhat more protective effect on the brain. Following this logic (Sanford 2010), optimizing brain function through training and experience enhances function and modifiability of cognitive factors. Electrical brain markers:  Brain markers classified as electrical involve cases where electrical brain patterns can be linked to the presence of maladaptive brain behavior, and where the introduction of a pharmacological agent results in a distinctly identifiable change in electrical brain activity. For example, in a recent study from the University of California, Davis identified a distinct alpha-wave pattern that occurs in two brain regions just before subjects make mistakes on attention-demanding tests (Mazaheri, Nieuwenhuis, van Dijk, & Jensen, 2009). From spilling coffee to not noticing stop signs, Mazahari studied instances of occasional errors due to lack of attention and found a distinct electric signature in the brain, which predicted that such errors were about to be made. The discovery may prove useful in a variety of applications, from developing monitoring devices that alert air traffic control operators that their attention is flagging, to devising new strategies to help children cope with attention deficits. It can also provide new therapies for children with ADHD (Sanford 2010), further suggesting that ADHD is a deficit of interest with a genetic brain component, rather than a bratty child syndrome or the effects of lack of parenting, as a Washington Post columnist once characterized it (Snyder, 2007). Behavioral/performance-based brain markers: Brain markers classified as behavioral/performance based are those where behavior or performance patterns can be measurably altered due to the absence or presence of a controlled variable, most commonly a pharmacological agent. Examples of these include: • Deficient scores on any variety of repetitive verbal memory tasks at trials 3 and 4. • Go No Go testing which can clearly indicate impulsive responding with false positives. Patients may lack the ability to inhibit responding, such as pressing the

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space bar on the computer when the word “press” appears in red-colored ink on the screen, when it has been preceded by several trials of pressing the bar every time the green ink colored word “press” appears (Drewe, 1975). Similarly, reading of color words on the Stroop test (Golden, Espe-Pfeifer, Wachsler-Felder, Division, British, & Bibliography, Council, 2000) requires inhibiting an automatic act of reading to state just the color of the ink that the word is printed, especially when it is different from the color the word spells – for example the word “red” printed in blue ink. Timing differences between basic reading of the words versus color-word reading can manifest trends in subtle executive and attention deficits (Golden, 1978). • Difficulties in maintaining set on various measures that tap into executive functioning – such as on the Goldberg Executive Control Battery or Wisconsin Card Sorting Test, Maze testing, and Tower testing (Strauss, Sherman, & Spreen, 2006) – including rule violations as well as response bias. • False positives (as per McGrath, Scheldt, Welham, & Clair, 1997) and “Yay” saying on the California Verbal Learning recognition task (Delis, Freeland, Kramer, & Kaplan, 1988). This can be illustrated by a patient who continues to say, “yes” for recognition items even when they have not been previously presented, indicating a perseveration of pattern rather than true recognition (as per McCarthy & Warrington, 1990). It is as if those patients seemingly cannot stop themselves and their brain has gone on “automatic pilot” mode. Impairment in the orbital frontal region of the prefrontal cortex can be related to impulsive, “yay” saying, conversely, some dorsal lateral prefrontal cortex deficits may be related to behaviors including a preponderance of “nay” saying. Analyzing contrasting response patterns during assessment may clarify localization of dysfunction. Clinicians may reference research, in terms of differing response patterns, when conducting standardized assessments (Blair, Coledge, & Mitchell, 2001). Lesions can be linked to localized brain regions. Damage to the dorsallateral surface of the prefrontal cortex, as opposed to the orbital-frontal brain regions (Chudasama et al., 2003), may lead to a pattern of informative findings in terms of brain–behavior relationships. ADHD populations differ in their response to pharmacological agents based upon the localization of these lesions. Stimulants work better when orbital frontal regions are damaged. Dorsal lateral damage responds better to other agents. Similarly, analysis of differences in proliferation of nicotinic receptors in the frontal lobe of schizophrenics may prove key in future research into this disorder (Lai, Hong, & Tsai, 2001).

Brain Resources The Brain Resource Corporation (BRC) has been compiling an international brain database that has been generated from research institutions globally and has been integrated with information obtained from the combination of validated assessments and scientific literature. Although a for-profit corporation, BRC offers their

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data free of charge to graduate students and researchers at BRAINnet, an independently functioning network of over 200 scientists using an integrative neuroscience approach. The network is overseen by the BRAINnet Foundation (Gordon, 2010). BRC database is useful to both psychologists and physicians. This effort promotes brain health by encouraging personalized interventions aimed at improving brain functions as the key to achieving psychological, emotional, and cognitive health. This combination of technology and interventions based on neuroscience research allows a tailored process of assessment measuring brain functions for more objective diagnostics and personalized interventions thus helping individuals optimize their potential. Comprehensive assessment process compares brain functions and other physiological and cognitive measures to healthy norms so that imbalances and or disturbances are detected and identified. The assessment process combines traditional methods, including clinical interviews and scales, with the technology of brain imaging. Quantitative EEG is used for brain mapping – it identifies functional disturbances by comparing findings to pre-established norms, thus providing a personalized profile of current level of brain health and cognitive skills. The assessment process produces a report that links any mood-related symptoms (depression, anxiety, mood swings) or limitations in cognitive abilities (problems with learning, memory, attention, cognitive flexibility, executive functions) with objective, measurable imbalances in the brain and autonomic nervous system. The convergent validity of evidence from physiological measures (of both brain and autonomic functions) and cognitive profile (which, consists of assessment of how a person thinks or performs cognitively) offers a better understanding of the strengths and weaknesses, enabling development of a treatment plan based on individual physiology and cognitive style. Once a treatment plan is developed, various options are utilized to retrain the brain for optimal level of functions, promoting brain health, reduction of symptoms related to mood, or cognitive issues, and to optimize level of functioning depending on the demands of academic or work environment and life style. In clinical situations in which treatment with medications is recommended, the assessment can help in identifying the most effective class of medications, maximizing benefits and reducing the chance of undesired side effects. If the need for medications becomes evident, a psychologist trained in psychopharmacology can work with the patient’s physician, psychiatrists, neurologists, or internist, who can in turn prescribe and monitor medications, along with continued feedback from reevaluations performed both on and off the pharmacological agents. Personalized medicine is about delivering the right treatment to the right person at the right time to maximize the safety and efficacy of treatment. Personalized medicine has the potential to change the way we think about, identify, and manage health problems. Personalized medicine does not necessitate the use of medications, but objectively suggests the most efficacious interventions, such as medications, neurofeedback, cognitive/behavioral therapies, or cognitive rehabilitation. Neuroplasticity suggests that the brain can change by our experiences and training whereby one area not normally seen as responsible for certain functions may take over for another (damaged) area, at least to some extent. Work by

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Pascual-Leone et al. (2005) continues to demonstrate many unusual case ­examples, and Elkhonan Goldberg (2009) outlines the growing recognition of the role of plasticity in neurocognition and its future role in science and society. The personalized medicine approach impacts on both clinical research and patient care, with enhanced diagnostic conclusions, which can lead to more rapid and effective interventions. Objective, evidence-based data can lead to better treatment and better patient outcomes through more precise titration of psychopharmacological agents. Personalized medicine utilizes the patient’s own baseline as the control of a tailored, individually based assessment, rather than a one-sizefits-all approach or a trial and error model. This has the potential to eliminate many of the common pitfalls within the state of the current science of psychopharmacology. In addition, common standards and multimodal integration allow for pooling of data across disorders and brain function to be linked to genetic vulnerability, environmental factors, and insight into what is robust in subtle psychological processes. This integration allows identification of markers underlying these effects, as well as identification of treatment markers for mood and anxiety disorders, and ADHD. For example, Hu et al. (2007) found that depressed individuals were characterized by the shorter serotonergic allele, lowered EEG Alpha asymmetry, lowered frontal, rostral cingulate, hypocampal, and frontal volume, slowed response speed for hypoarousal, increased negativity bias, and increased bias for sadness, as well as history of early life stress. A multidimensional approach is of great benefit in the assessment of heterogeneous disorders like ADHD and depression and can also be used to detect comorbid conditions, such as depression with cardiac disease or diabetes. Even efficacy of cancer drugs may be linked to epigenetics (Pander, Gelderblom, & Guchelaar, 2007).

The Testing Process Baseline data can be gathered for developmental and acquired disorders, and progress can be charted over time. It is often very helpful to demonstrate to noncompliant patients, and/or their reluctant parents, the changes in their abilities during medicated as opposed to nonmedicated states. It is often beneficial to have another professional (such as a psychopharmacologically trained psychologist) to interview patients, review history, and uncover previously overlooked potential areas of deficit. In many cases, there are cumulative effects of many isolated factors that when summed together indicate greater potential for predisposition to various neuropsychiatric disorders. Training in assessment (especially in neuropsychological assessment) is also quite useful to the psychopharmacologically trained psychologist. According to the APA Division 40 guidelines, a neuropsychological evaluation is used to obtain several types of information, including: (1) to find possible problems with brain functioning, (2) to help lead to a diagnosis, (3) to definer brain-related strengths and

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weaknesses, (4) to guide treatment for personal, educational or vocational needs, and make relevant recommendations to other healthcare providers, and (5) to document possible changes in functioning over time (Division 40, 2001). The outcome of a neuropsychological evaluation produces a set of conclusions about the individual’s functioning, which includes specific recommendations to guide treatment or enhance the individual’s functioning. The conclusions and recommendations are developed by integrating information obtained from the standardized testing, interviews, records, and other observations. The standardized tests used in a neuropsychological evaluation typically assess functioning in the following areas: attention and memory, problem-solving and other complex abilities, visual-spatial functions, language functions, sensory perceptual functions, and motor functions. Assessment of academic skill development and emotional functioning is typically performed as well. The perspective of the neuropsychologist is frequently requested to understand subtle brain-related factors involved in academic failure or impaired emotional functioning, even when no biological causes are suspected. However, the specific areas assessed depend upon the referral questions presented. Results of interviews with the individual and/or family members, observations in other settings (for example, school or hospital), and review of school/medical records are usually included in the results of the evaluation. A neuropsychological evaluation typically involves assessment with a group of standardized tests that are sensitive to the effects of brain dysfunction. Unlike CT or MRI scans (which show abnormalities in the structure of the brain) or EEG (which shows electrical abnormalities in the brain), neuropsychological assessment is used to show the ways in which a person can or cannot perform certain functions or tasks that are dependent upon brain activity. These functions or tasks (for example, memory and learning) form the necessary building blocks of successful living in the individual’s daily life. Impairment in many of these functions may exist because of brain abnormalities that cannot be detected on CT or MRI scans. Therefore, neuropsychological assessment is a procedure with a unique purpose; it can be used to reveal or diagnose brain dysfunction when no structural brain abnormalities can be seen. When structural abnormalities have been found, neuropsychological assessment provides a way to determine what functions may be impaired because of the structural defects, and to determine the degree to which they may be impaired. Kapalka (2009) reported that in the United States, pediatricians prescribe the majority of medications used to treat children with psychological disorders, such as ADHD. Since pediatricians have a limited background in behavioral science, opportunities exist for psychologists to assist pediatricians in treating youngsters with psychological disorders. Additional training in psychopharmacology can enable psychologists to make greater contributions by aiding pediatricians select and monitor appropriate medications. ADHD appears to be one of the most prominent disorders both in pediatric and young adult populations (Kapalka, 2009). In addition, other disorders that cycle through the life span, such as schizophrenia and bipolar, can initially be misdiagnosed as ADHD. Communication between pediatricians and psychologists can

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improve patient outcomes by increased monitoring of the development of symptoms. For example, noting positive and negative symptoms can signal a plateau level before a decrement of functioning. In this way, consulting with other health professionals can help clarify a differential diagnostic profile. Arranz and de Leon (2007) suggest that although many patients may appear to have symptoms of ADHD, teasing out specific, unique symptoms may reveal another diagnosis through detrimental side effects of medication. For example, stimulant medication typically used to treat ADHD may exacerbate positive symptoms of psychosis, which is more effectively treated with novel antipsychotic medications. Likewise, better communication between health professionals can aid in the diagnosis of other disorders, such as the neurobehavioral and neurodevelopmental sequelae associated with congenital cytomegalovirus infection (Morgan, Baron, & Ricker, 2010), or lasting effects resulting from the streptococcus bacteria, leading to rheumatic fever, which has long been associated with organ failure (heart and kidney) later in life. If not treated effectively with antibiotics, these may have a role in cognitive dysfunction and attention disorders as well as obsessive-compulsive disorders. Similarly, Lyme disease may also be linked with attention disorders as well as rheumatic joint pain when not properly treated. Psychologists can use cutting edge innovations such as brain markers to guide pre and posttesting in consultation practice with pediatricians and other health professionals (Hermens et al., 2005). Since pediatricians write most of the prescriptions for medications to treat children with ADHD, pharmacologically trained psychologists are likely to initially assist pediatricians in this area. Over time, however, these psychologists may increase consulting with other medical professionals, including neurologists and internists, mostly in a diagnostic capacity to assist in differential diagnoses and monitoring the efficacy of pharmacological agents. Occasionally, these psychologists may also consult with psychiatrists to review evaluative findings, side-effect profiles, and changes in response to medications. On the whole psychologists with psychopharmacology training claim to feel more capable and empowered to intervene with physicians, including a better ability to diagnose patients’ symptoms, being more equipped to talk with physicians about medication regimens, and having a deeper understanding of medications and their potential side effects and contraindications (Foxhall, 2001). The benefits of psychopharmacological training for psychologists practicing in states that allow psychologists to prescribe include a greater opportunity for delivery of services to remote/rural areas as well as enhanced follow up with patients. Even in states that have not yet allowed psychologists to prescribe, psychopharmacological training can prove profitable. Such psychologists can act as informed liaisons to the medical profession and informed patient advocates. They can also help patients understand medical diagnostic information and aid in the better monitoring of medication for greater efficacy and less side effects. Psychologists with psychopharmacology training say that the education is enhancing their effectiveness, even without prescription privileges (Foxhall, 2001). Since pharmacologically trained psychologists have training in general pharmacological and physiological principles, overall well-being, general health, and

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interactions between medications, they can help recognize the symptoms of dangerous syndromes such as the serotonin syndrome, Stevens Johnson rashes, neuroleptic malignant syndrome, hypertensive crises, blood imbalances (such as elevated blood levels of homocystein, which can lead to memory concerns), and sodium potassium balance (especially relevant for patients on diuretics for hypertension). Student athletes need monitoring for acquired injuries as well. The use of computer-based drug interaction programs available through Epocrates is essential (Epocrates, 2010). Cataloging patient drug information and keeping interactions and side-effect profiles in the patients file help keep the patient and physician informed of changes that may affect the patient’s mental status and well-being. Training in clinical psychopharmacology enhances the performance of practitioners who are seeking careers in medical settings, private practice, or other arenas in which they regularly interact with healthcare professionals. According to Levant and Shapiro (2002), the psychopharmacology training programs aim to expand the knowledge base in biopsychology, pharmacology, and psychopharmacology; to ensure a more complex understanding of how medical conditions interact with psychological conditions; to develop a more sophisticated understanding of a client’s medications and the potential side effects and contraindications of those medications; and to enhance consulting skills with physicians and other healthcare providers. The faculty in psychopharmacology programs is drawn not only from colleges of psychology but also from schools of pharmacy, medical sciences, and at times adjunct faculty from other selected specialties. Completing a program of training in psychopharmacology enables psychologists to broaden their horizons and take a different perspective, improve interacting with their patients and medical professionals, and expand their practice and knowledge base. “To clarify the underlying causes of mental disorders, it will be necessary to define, measure, and link basic biological and behavioral components of normal and abnormal functioning. This effort will require integration of genetic, neuroscience, imaging, behavioral, and clinical studies. By linking basic biological and behavioral components, it will become possible to construct valid, reliable phenotypes (measurable traits or characteristics) for mental disorders” (Insel et  al., 2004). If psychologists are going to be able to sustain viable practices into the future, the field will need to embrace its expansion into clinical psychopharmacology and medical psychology.

References Arranz, M. J., & de Leon, J. (2007). Pharmacogenetics and pharmacogenomics of schizophrenia: a review of last decade of research. Molecular Psychiatry, 12. Retrieved from http://www. nature.com/mp/journal/v12/n8/abs/4002009a.html, doi:10.1038. Blair, R. J., Coledge, E., & Mitchell, D. (2001). Somatic markers and response reversal: Is there orbitofrontal cortex dysfunction in boys with psychopathic tendencies. Journal of Abnormal Psychology, 29(6), 499–511.

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Hu, X. Z., Rush, J., Charney, D., Wilson, A. F., Sorant, A. J. M., Papanicolaou, G. J., et al. (2007). Association between a functional serotonin transporter promoter polymorphism and citalapram treatment in adult outpatients with major depression. General Psychiatry, 64(7), 783–792. Insel, T. R., Volkow, N. D., Landis, S. C., Li, T. K., Battey, J. F., & Sieving, P. (2004). Limits to growth: Why neuroscience needs large-scale science. Nature Neuroscience, 7, 426–427. Kapalka, G. (2009). Pediatrician/psychologist collaboration: opportunities for clinical child psychologists. Comtemporary Psychotherapy, 39(2), 127–133. Lai, I. C., Hong, C. J., & Tsai, S. J. (2001). Association study of a nicotinic receptor variant with schizophrenic disorders. Neuropsychobiology, 43, 15–18. Levant, R. F., & Shapiro, A. E. (2002). Training psychologists in clinical psychopharmacology. Clinical Psychology, 58, 611–615. Liddell, B. J., Brown, K. J., Kemp, A. H., Barton, M. J., Das, P., Peduto, A., et al. (2004). A direct brainstem-amygdala-cortical ‘alarm’ system for subliminal signals of fear. Neuroimage, 24, 245–253. Malhotra, A. K., Murphy, G. M., & Kennedy, J. L. (2004). Pharmacogenetics of psychotropic drug response. American Journal of Psychiatry, 161, 780–796. Mathersul, D., Palmer, D. M., Gur, R. C., Gur, R. E., Cooper, N., Gordon, E., et al. (2009). Explicit identification and implicit recognition of facial emotions: II. Core domains and relationships with general cognition. Journal of Clinical and Experimental Neuropsychology, 31, 278–291. Mazaheri, A., Nieuwenhuis, I., van Dijk, H., & Jensen, O. (2009). Prestimulus alpha and mu activity predicts failure to inhibit motor responses. Human Brain Mapping, 30, 1791–1800, NA doi:10.1002/hbm.20763. McCarthy, R., & Warrington, E. K. (1990). Cognitive neuropsychology: A clinical introduction. San Diego: Academic. McGrath, J., Scheldt, S., Welham, J., & Clair, A. (1997). Performance on tests sensitive to impaired executive ability in schizophrenia, mania and well controls: Acute and subacute phases. Schizophrenia Research, 26(2), 127–137. Morgan, J., Baron, I. S., & Ricker, J. (2010). Casebook of clinical neuropsychology. USA: Oxford University Press. Pander, J., Gelderblom, H., & Guchelaar, H. J. (2007). Insights into the role of heritable genetic variation in the pharmacokinetics and pharmacodynamics of anticancer drugs. Expert Opinion on Pharmacotherapy, 8, 1197–1210. Pascual-Leone, A., Amedi, A., Fregni, F., & Merabet, L. (2005). The plastic human brain cortex. Annual Review of Neuroscience, 28, 377–401. Perrin, R., Fagan, A., & Holtzman, D. (2009). Multimodal technique for diagnosis and prognosis of Alzheimer’s Disasease. Nature, 461, 916–922. Rabiner, D. L., Murray, D., Skinner, A., & Malone, P. (2010). A randomized trial of two promising computer-based interventions for students with attention difficulties. Journal of Abnormal Child Psychology, 38, 131–142. doi:10.1007/s10802-009-9353-x. Rosack, J. (2004). Psychologist training options expand in quest to prescribe. Psychiatric News, 39(15), 1. Sanford, J. A. (2010). Turning on the brainpower!. Therapy Times. Retrieved from http://www. therapytimes.com/Turning_on_the_Brainpower_The_transformative_potential_of__cognitive_ rehabilitati/content 0602J84C487EBC84404040441 Sheline, Y. I., Gado, M., & Price, J. L. (1998). Amygdala core nuclei volumes are decreased in recurrent major depression. Neuroreport, 9, 2023–2028. Sheline, Y. I., Sanghavi, M., Mintun, M. A., & Gado, M. H. (1999). Depression duration but not age predicts hippocampal volume loss in medically healthy women with recurrent major depression. Journal of Neuroscience, 19, 5034–5043. Snowden, D. A., Gneimer, L. H., Mortimer, J. A. (1997). Brain Infarction and the clinical expression of Alzheimer’s disease. The Nun Study, JAMA 277, 813–7. Snyder, M. (2007). Trouble with tantrums. Washington: The Washington Post.

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Chapter 14

Internship and Fellowship Experiences: Preparing Psychology Trainees for Effective Collaboration with Primary Care Physicians Veronica L. Raggi

Over recent years, there has developed an increasing focus and demand for the training of psychologists with primary care experience through graduate and ­postgraduate training in psychology (Pisani, Berry, & Goldfarb, 2005; Sanchez & Turner, 2003; Sheridan, 1999; Spirito et al., 2003). This call for increased training in primary care is a result of a number of contributing factors. In our current managed care system, primary care physicians (PCPs) are the gateway or point of entry for a majority of patients with mental health needs (Rakel, 2002). Among those who are insured, the majority of patients are enrolled in a mental health carve-out program (Kiesler, 2000), through which physicians are required to authorize a mental health referral or visit (Sanchez & Turner, 2003). However, without established trust and rapport with local mental health providers and confidence in the services they provide, PCPs may be hesitant to provide appropriate and needed mental health referrals. Indeed, data suggest that although a majority of primary care visits involve a psychological concern (Cummings, Cummings, & Johnson, 1997; Fawzy, Fawzy, Arndt, & Pasnau, 1995), over half of these individuals are treated only within primary care (Narrow, Regier, Rae, Manderscheid, & Locke, 1993; Regier et al., 1993). Similarly, about 75% of children with behavioral health disorders are seen within primary care centers (Bernal, 2003), and about half of all pediatric visits involve a mental health or learning concern (Cassidy & Jellinek, 1998). Moreover, a national survey suggested that physicians who were less satisfied with referrals to mental health professionals compared to medical professionals were much less likely to refer their most recent patient to a mental health professional (Williams et al., 1999). As a result, many patients with clear mental health needs may not be receiving care by a mental health professional or may be denied needed services due to gatekeeping practices and attempts to address behavioral health concerns within the primary care clinic (Miller, 1996). The treatment of mental health needs by PCPs may result in minimal or ineffective V.L. Raggi (*) Clinical Psychologist, Alvord, Baker & Associates, LLC 11161 New Hampshire Avenue, Suite 307 Silver Spring, MD 20904, USA e-mail: [email protected] G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_14, © Springer Science+Business Media, LLC 2011

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psychosocial interventions, treatment that is primarily pharmacological, and the conceptualization of mental disorders in overly biological or reductionistic ways (Sanchez & Turner, 2003). In addition, even when a mental health referral is provided, collaboration between PCPs and the mental health community has traditionally been inconsistent, infrequent, and at times, resisted. Our traditional model of health care involves culturally and physically separated care for mental and physical health problems, with little communication across boundaries (Pisani et  al., 2005). Managed care regulations increase demands to provide brief, time-limited services, with no reimbursement for time spent communicating with medical colleagues. These pressures lead to the common practice of physicians providing a mental health referral but receiving no further information regarding the treatment plan, course and outcome (Pisani et al.). This is unfortunate given that when effective collaboration occurs, there is evidence that the quality and efficiency of care, as well as the satisfaction of patients, improves (German, 1994; Hemmings, 2000; Katon et al., 1995). For all of these reasons, recent attention has been given to training future psychologists in how to effectively establish relationships, elicit referrals, maintain communication, and collaborate effectively with PCPs, both through work within hospitals and academic medical centers, as well as through established partnerships with primary care clinics. Collaboration with PCPs can increase their trust and reliance on mental health professionals to provide needed mental health care, leading to the provision of a greater number of referrals and more integrated and effective health care. Further, with increased education, PCPs can play a role in increasing patient awareness of mental health problems, motivation to seek help, and reducing stigma toward seeking mental health care. Despite the strong rationale for systematic training in collaborative care with PCPs, significant limitations exist in the provision of this experience within graduate school programs. Graduate training in clinical psychology has traditionally focused on the preparation for research and clinical practice specific to discipline and theoretical orientation. Most graduate programs do not have formal coursework focused on collaborative care with psychiatrists or PCPs (APA Education Directorate, 1998; Pisani et al., 2005; Twilling, Sockell, & Sommers, 2000). Even when scholarly articles on this topic are integrated into the curriculum, they cannot substitute for direct interaction and hands-on experience with medical providers. Often graduate school clinics are housed on university grounds, limiting possible interdisciplinary collaboration due to a lack of access to medical providers and a lack of understanding in how to contact and regularly communicate with these professionals. Further, many clinical psychology faculty may not feel competent to provide supervision and teaching on collaborative care with PCPs. Many faculty-level psychologists have limited experience working with PCPs, and fewer still have had coursework in this area (Pisani et al., 2005; Seaburn, Lorenz, Gunn, Gawinski, & Mauksch, 1996). As a result, many graduate students encounter their first substantial interaction with medical providers during internship and postdoctoral fellowship. This can result in culture shock, role confusion, and challenging interactions due to a lack of a common language, culture, and work style between disciplines. Further, internship

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and postdoctoral fellowship programs vary considerably in the opportunities available for interdisciplinary collaboration. A 1998 survey of psychology internship programs found that only 36% offered training in behavioral medicine (APA Education Directorate, 1998; Twilling et  al., 2000). Billing and managed care pressures also provide constraints on the ability of postdoctoral programs to meet all of their goals for education. As a result, many young psychologists must learn about collaboration and develop competency in this area independently. Data indicate that most psychologists feel inadequately prepared to engage in collaborative care within healthcare settings (e.g., Sheridan, 1999).

Establishing Goals for Psychology Training in Collaboration with Primary Care Despite these challenges, there has been considerable progress in the development of predoctoral and postdoctoral training programs that include systematic training in primary care (Blount, DeGirolamo, & Mariani, 2006; Dobmeyer, Rowan, Etherage, & Wilson, 2003; Hunter & Peterson, 2001; Pisani et  al., 2005; Sears, Evans, & Perry, 1998; Stewart & Stewart, 1998; Twilling et al., 2000). For example, a survey of predoctoral internship programs offering rotations in pediatric or primary care psychology found that all programs reported interns interacted with physicians, and opportunities were provided to participate in an ongoing interdisciplinary medical team (Mackner, Swift, Heidgerken, Stalets, & Linscheid, 2003). In addition, 80% of programs surveyed reported interns interacted with nurses, social workers, child life personnel, school personnel, and occupational therapists. Similarly, family medicine programs frequently offer training opportunities in collaborative care to psychology trainees (Gawinski, Edwards, & Speice, 1999; Hepworth, Gavazzi, Adlin, & Miller, 1988; Patterson, Bischoff, Scherger, & Grauf-Grounds, 1996; Pfaffly, Baher, Jones, Juarez, & Brezinski, 2003), and their accreditation standards require at least one behavioral scientist to be on the staff (Accreditation Council of Graduate Medical Education, 1997). In these programs, medicine and psychology interns/residents are trained and supervised together, shadow each other, and often share cases and integrate care with psychologists and physicians. Further, “Primary Care Psychology” is emerging as a specialty within psychology that involves the psychosocial assessment and management of mental health problems associated with medical illness, maladaptive health behaviors, or chronic health conditions commonly seen in primary care patients. This specialty promotes effective collaboration with PCPs and other members of interdisciplinary teams, and encourages the use of appropriate referrals (Frank, Bray, McDaniel, & Heldring, 2003). Training in primary care psychology teaches trainees how to collaborate with other medical professionals to provide continuity of care through a biopsychosocial model that emphasizes the reciprocal and dynamic effects of biological, psychological, and social factors on the etiology, prevention, maintenance, and treatment of a disorder (Bray, 2004; Engel, 1977; McDaniel, Belar,

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Schroeder, Hargrove, & Freeman, 2002). This training recognizes that complex problems require multiple professionals (Bray, 1996; Frank et  al., 2003) and emphasizes an understanding of how medical, pharmacological, and psychosocial treatments interact to affect behavior and functioning (Bray, 2004). Some common activities of primary care psychologists include psycho-education, prevention, compliance with or adherence to medical intervention, management of stress and pain related to medical procedures, consultation, and evaluation. In sum, specific training in primary care psychology at the intern and postdoctoral level is an emerging specialty with a specific purpose and systematic training goals. In recent years, there has also been a strong movement toward delineating the aspects of training necessary for psychologists to function effectively in a primary care setting (McDaniel et al., 2002; Seaburn et al., 1996). For example, in 2002 the Interdivisional Task Force for a Primary Care Curriculum was commissioned by the American Psychological Association (APA) to identify curricular and programmatic recommendations for collaboration with primary care (McDaniel et  al., 2002). Specific guidelines for interdisciplinary collaboration include (1) acquiring knowledge of the roles and function, education and background, scope of practice, and values or priorities of other disciplines integrally involved in primary care, (2) acquiring expertise in collaborating with other professions through an ability to distinguish discipline differences from individual differences, cocreate an integrated treatment plan, coordinate care across the lifespan, and communicate clearly, (3) acquiring expertise and flexibility in consultation, and (4) acquiring skill in referral to and managing consultations with other specialty providers. Guidelines also emphasized the importance of training that provides competency in understanding the biological, cognitive, affective, behavioral/developmental, and sociocultural components of health and illness; understanding health policy and healthcare systems; understanding common primary care conditions; acquiring knowledge in clinical assessment and interventions in primary care; and ethical, legal and professional issues (McDaniel et  al.). These goals may be achieved through a variety of methods, models, and placements through which interns and postdoctoral fellows receive specific training in providing integrated care through a biopsychosocial model and have regular interaction and collaboration with physicians.

Collaborative Training Experiences Within Academic Medical Centers, Hospitals, Residential Treatment Facilities, and Outpatient Clinics The method and model of training in collaboration usually depends in part on the location or organization through which the collaboration will take place. Most commonly, collaboration with PCPs and other medical professionals takes place within academic medical settings, hospitals, and residential treatment facilities (Stewart & Stewart, 1998). Colocation opens the door to many opportunities

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for training in collaboration. Training programs within these settings have great opportunities to carefully structure experiences for interns and postdoctoral fellows who will foster collaboration. However, these models may not be feasible for all predoctoral and postdoctoral training programs. For many programs housed within outpatient mental health clinics, or for clinical rotations on a specialty inpatient unit, greater obstacles may be present in establishing formal and informal collaborative experiences with PCPs due to physical separation or limited interaction, as well as a lack of developed relationships between mental health professionals and PCPs. For these programs, lessons and training in interdisciplinary collaboration may be derived through interaction with psychiatrists and other medical professionals who may typically compose a multidisciplinary team (i.e., nurses, social workers, occupational and physical therapists, dieticians, and medical specialty doctors). Lessons learned from experiences with other physicians and medical professionals can be utilized when working with PCPs. Therefore, training in collaborative care can occur through a number of settings and types of experiences involving immersion in the medical culture and environment. The remainder of this chapter will be focused on a discussion of various methods, structure, and settings where systematic training in collaborative care with physicians can be developed at the intern and postdoctoral level and will highlight important considerations and common obstacles that may arise throughout training in collaboration with PCPs. The author will discuss specific personal experiences in collaborative care within two academic medical centers and various clinical rotations, and lessons learned from these experiences.

Consultation-Liaison in Hospital Settings One important method for teaching collaboration with PCPs is through the consultation-liaison model. Many predoctoral programs and some postdoctoral programs offer rotations in consultation-liaison, which most often occur in an academic medical center or hospital setting (Pisani et al., 2005; Strosahl, 1998). Consultation-liaison offers the psychology trainee the opportunity to collaborate with medical residents in primary care and other medical specialties through referrals made by physicians for mental health concerns related to acute and chronic illness. In this model, the PCP remains in charge of the overall treatment plan, with the trainee brought on board to answer a specific referral question, and provide targeted recommendations and time-limited intervention services (Dobmeyer et  al., 2003; Drotar, 1995). Consultation typically involves a brief assessment of 15–20 min followed by a concise, one-page summary of clinical impressions and recommendations. This model requires a number of adjustments and departures from psychology trainees’ traditional training in assessment and treatment commonly utilized within an outpatient mental health clinic. The interns must learn to provide a brief consultation focused on answering the main referral question through a survey of major

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symptoms and functional impairment and integration of information from multiple sources, followed by a succinct conceptualization and targeted, feasible behavioral plan (Dobmeyer et al., 2003). This model of practice is a significant departure from traditional training in the use of a comprehensive assessment approach that involves a broader, more detailed, and multilayered analysis of the social, developmental, academic/occupational, family, cultural, biological, and societal factors involved in the etiology, initiation, and maintenance of a current mental health problem. Transitioning to a primary care model requires interns to hone their skills in rapid and concise case conceptualization. Further, trainees must learn to communicate results confidently, effectively, and concisely to medical professionals, recognizing the demands on their time and the need for results to be presented in an efficient manner. PCPs may prefer brief, informal feedback, or findings may be presented during structured team meetings such as morning rounds. This is also typically a divergence from the psychology trainees’ background in process-oriented, clinical case discussions within graduate schools and requires the flexibility and willingness to adapt their approach to suit the medical environment. Equally important, trainees must learn to write notes and consultation summaries that are appropriate to be included in the medical chart, use common medical terminology and abbreviations, and include only relevant information presented in a way that is acceptable to PCPs. Notes written for the medical chart differ from the content and format of traditional psychotherapy notes, which tend to be lengthier and more process-oriented. Writing brief consultation notes is consistent with the primary care model, which requires time-efficient methods of assessing and addressing the problem at hand. After the initial consultation and recommendations, brief behavioral plans are commonly created to help patients adhere to medical treatment regimens, cope with stress or anxiety related to medical procedures, promote adaptive health behaviors, and/or produce positive changes in mental health symptoms or impairment. Behavioral plans on inpatient units need to be concrete and focused on specific, short-term behavioral outcomes. Lengthy psychotherapy sessions and excessive time spent building rapport with patients may deter trainees from completing all required tasks and seeing all patients (Dobmeyer et al., 2003). This can lead to trainee burnout and stress. Finally, the creation of goals which are individually tailored and feasible to accomplish within a few, 15–20 min sessions is another skill important for trainees to develop (Dobmeyer et al.). Setting inappropriate or unattainable goals will also contribute to time management difficulties and trainee stress. Within a consultation liaison model, supervisors can provide critical support to trainees by helping them learn to adapt their approach to effectively manage time demands while providing effective and integrated services for patients within the primary care setting. Supervisors can have trainees read journal articles, provide direct teaching and discussion, model-appropriate techniques, and provide relevant and timely feedback to trainees to support their development in this area. Without appropriate on-site supervisor support, trainees may feel disoriented and unsure of how to adjust their approach to the medical environment. Proactive guidance is critical so that trainees enter the consultation-liaison experience with appropriate expectations and a preliminary

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understanding of differences in expectations and requirements of the medical model of care as compared with traditional psychology training practices. This will allow trainees to adapt and transition more easily and gracefully to a new approach. Learning to understand the medical culture, modify their approach, and effectively respond to the needs of physicians within the medical setting will help prepare trainees to function effectively in future interactions with PCPs, regardless of setting.

Consultation-Liaison in Primary Care and Family Medicine Clinics Some predoctoral and postdoctoral training programs may experience challenges involving students in a consultative experience because of a lack of access to medical professionals or PCPs on a regular basis. In particular, programs housed within outpatient mental health clinics may experience greater challenges in providing these opportunities and will have to devote more effort and creativity to develop relationships with PCPs that will open the doors to collaboration and subsequently negotiating systematic training opportunities for psychology trainees. For example, Pisani et al. (2005) discuss a half-day pediatric placement in a primary care clinic that was established as part of a predoctoral internship experience. In this particular placement, intern roles involved the provision of brief behavioral health checks for all families in the clinic, brief consultation to providers, and psycho-education for families when needed. Intern roles did not include diagnostic assessment and traditional psychotherapy, as these functions were not considered feasible and relevant within the fast-paced, primary care setting. Therefore, they performed a consultative role similar to what may be provided by a psychologist within a hospital or academic medical center (Pisani et al.). Pisani et al. (2005) spent time elaborating how this partnership was established. They emphasize the importance of finding a willing PCP partner who is supportive of collaboration and attune to the psychosocial needs of their patients. They suggest looking for a placement by first examining existing relationships with PCPs, presenting information to PCPs on the ways in which using mental health services can maximize efficiency and improve care, increasing awareness of available mental health services, and treating PCPs like customers, assessing their needs before offering specific services. The authors also examine issues and challenges in developing an agreement for intern placements, including physician discomfort with intern supervision by off-site psychologists, uncertainty whether intern expertise is needed within the practice, and concerns regarding liability, documentation, billing, support staff services, space, and collegial and parental perceptions of the intern and his/her role within the clinic (Pisani et al.). The authors describe the importance of offering direction and goals for the placement to PCPs, setting up a formal structure for how and when communication will occur across providers, and establishing clear roles for the intern. Other important considerations include the intern’s willingness to meet early in the morning and adapt to the structure and routine of

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PCPs, openness of the psychology training program to provide intern services free of charge, and allowing the PCPs to maintain their other partnerships through continuing to make referrals to community psychologists. For many programs, funding resources to maintain the training program may need to be determined prior to offering trainee services free of charge (Drotar, 1995). As another example of consultation-liaison training outside of the hospital setting, a collaborative clinic was established within a family medicine residency training program to expose medical residents and psychology students to an integrated model of healthcare delivery (Pfaffly et  al., 2003). In this model, the collaborative team met for one-half hour prior to the start of clinic to review the physician’s schedule. During this meeting, patients who could potentially benefit from a consultation with one or more of the other team members were identified. In addition, each patient was told verbally about team members who were available that day. Patients could request to meet with a specific team member and/or the physician could make such a suggestion. Psychology trainees provided brief behavioral consultations for less than 10 min, patient education handouts, and arrangements for additional services if necessary. At the end of each day, team members reviewed the clinic flow and recorded comments regarding the collaborative process. Patients were also contacted by phone to provide verbal feedback on their experiences with the collaborative team. Through this structured experience, psychology trainees learned how to apply a consultation model within a primary care clinic and how to function effectively within the economic and time constraints of a family medicine practice. They also received specific training and feedback about collaborative practice with PCPs. Thus, a consultation-liaison model can be applied within both hospital and primary care clinic settings that will expose trainees to the medical culture, work style, and time demands. Trainees can learn integrated care through regular communication and consultation with physicians through the provision of patient interviews and behavioral health checks, and implementation of brief treatment plans.

Collaborative Training on Inpatient Unit Teams Training in collaborative care also occurs when trainees are members of a multidisciplinary treatment team on inpatient units within primary care, medical specialty, or psychiatry sections. Participation in a multidisciplinary team on an inpatient unit offers immersion within the medical culture, while also introducing the psychology trainee to experience with group dynamics and teamwork within a medical setting. Even when opportunities to interact directly with PCPs are not available, interaction with psychiatry and medical specialty physicians, as well as other medical professionals, can teach interns how to collaborate effectively within the medical culture. On inpatient units, interns and postdoctoral fellows have a variety of responsibilities and roles. For example, as a psychology trainee in an urban medical center, this author functioned as a clinician and member of the multidisciplinary team on

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the child and adolescent psychiatry inpatient units. On these units, morning rounds were led by the attending psychiatrist. Rounds included provision of status updates and presentation of intake summaries by team members, participation in collaborative decision making about treatment and discharge recommendations, and solution-focused discussion and problem solving of challenging patient issues. The multidisciplinary team included adolescent medicine, psychiatry, psychology, social work, education, nursing, nutrition, and physical therapy specialists. Weekly supervision was provided on a formal basis by an on-site psychologist with competence and experience in working on a psychiatric inpatient unit and collaborating with medical teams. The on-site supervisor provided regular guidance and support in understanding and acclimating to the culture of the medical team, managing and problem solving challenging interactions with members of the medical team and treating individual cases. When working as part of a multidisciplinary medical team, trainees obtain direct experience with the structure and format of meetings, and are exposed to unique group process, work style, and time allocation of physicians and medical personnel. During morning rounds, the author’s training was facilitated by having the intern read new intake summaries and provide regular case updates for current patients. These tasks offered exposure in how to use medical terminology and abbreviations, how intake summaries are written, and how to provide brief, relevant case updates consistent with the rest of the medical team. Team meetings were typically fast paced, solution-focused, and task-oriented, a contrast to more process-oriented graduate school clinical meetings. Team members engaged in regular division of responsibility, and the attending psychiatrist had final decision making power about case assignment and task distribution, as well as the timing of and recommendations for discharge. Further, as the intern was joining a team that was well-versed in working together prior to the trainee’s initiation, there was also the opportunity to learn from the observation of established and efficient team routines. Finally, as with other collaborative experiences within the medical environment, interns are exposed to differences in time allocation while observing physicians manage many cases simultaneously on the units. The brevity of most inpatient stays requires interns to adapt their approach to effectively provide brief assessment and initial diagnostic information, immediate responses to problems, short-term therapy with targeted goals and practical solutions, specific discharge recommendations including referral to more long-term care, and an appropriate and comfortable termination with the patient, all within a limited period of time. This necessitates effective time management and a significant transition from the typical 50-min psychotherapy session (and comprehensive assessment approach) characteristic of typical psychological practice. Interns must adjust to constant transitions and limitations in the services they can provide, and must develop an understanding of the timing, pacing, and scope of patient–therapist relationships on medical units (Seaburn et al., 1996). Further, interns also gain experience with case management, a common need on medical units. Case management tasks may include finding an appropriate placement postdischarge in a tertiary care facility, setting up additional outpatient services or supports for the patient or family, or collecting collateral information.

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These modeling and hands-on learning experiences can be facilitated and s­ upported by a knowledgeable, empathic supervisor who openly discusses these experiences with trainees, helping them to adapt to the medical culture and cope with stress or anxiety that may be involved in making adjustments to their own working style, handling emotionally stressful or difficult cases that are common on inpatient units, and negotiating differences in opinion and administrative issues such as shared space, administrative support, and use of equipment with medical professionals (Seaburn et al., 1996). Psychology supervisors may be able to structure program experiences so that trainees participate in teams with attending physicians who are identified as having an interest in playing a teaching role and collaborating with trainees from other disciplines. At the same time, onsite supervisors can help trainees stay connected to their own discipline so as not to feel marginalized (Seaburn et al.), recognize the unique skills they bring to the medical environment, accurately assess the amount of aid they can provide (and the amount of change that is realistic within a short time period), and find ways to maximize time efficiency (Seaburn et  al.). Through the development of collaborative skills and competencies within a medical setting, trainees will be well prepared for navigating future collaborative experiences with PCPs within both medical settings and primary care or outpatient clinics.

Multidisciplinary Group Supervision and Training in Outpatient Clinics In outpatient mental health clinics as well as academic medical centers, one method which is becoming more common is the joint supervision of medical residents and psychology trainees. Joint supervision can occur through a number of avenues, such as participation in the daily rounds on an inpatient unit or residential treatment facility, small or large group training, and supervision on a specific treatment intervention, or supervision in treatment of shared cases. In one example of a unique multidisciplinary experience, this author participated in a weekly joint supervision group in an outpatient mental health clinic housed within an urban, academic medical center. This group served a number of purposes and consisted of one senior psychologist, one senior psychiatrist, a psychiatry resident, and a psychology trainee. The main goal of these meetings was to improve collaborative care through the multidisciplinary supervision of the resident and trainee regarding the treatment of cases that were shared, with the resident providing medication management and the trainee providing behavior therapy. Supervision allowed for regular communication about behavioral treatment decisions and updates in medication status, and each change in one impacted decisions made about the other. For example, the psychology trainee coordinated an increase in the challenge of specific behavioral goals for a child with ADHD to coincide with the titration of the dosage of stimulant medication to achieve maximum benefit. By learning to take into account changes in medical intervention in the planning of psychological interventions, the

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psychology trainee developed skills in effectively integrating care and in ­functioning within a biopsychosocial context that recognizes the dynamic relationship between mind and body. While some differences naturally exist between collaboration with a psychiatrist and with a PCP, the trainee developed critical collaborative skills through experience with psychiatry – for example, the ability to effectively integrate care that involves both medication management and therapy. Subsequent to this experience, these collaborative skills can be generalized and applied to experiences interacting with PCPs. Moreover, psychiatry may be the most common medical profession with which psychology interns and postdoctoral fellows have the opportunity to collaborate on a regular basis. Multidisciplinary supervision also allows psychology trainees to learn how to work comfortably with medical professionals who have different histories and experiences with the group process. Generally, whereas psychologists tend to be more process-oriented, medical professionals often take a more leadership-focused and task-oriented approach (McDaniel, 1995). When establishing a new working group, this difference can initially create a challenging experience as group members attempt to reorient themselves to a new, integrated group dynamic. For psychology trainees, as previously mentioned, this learning requires a deeper understanding of the medical “culture,” group process, time allocation, and work style of physicians (McDaniel). It also involves learning multiple ways of looking at the same problem and accepting new approaches to assessment and treatment. For example, during joint supervision meetings, the psychiatry resident verbally models a concise case conceptualization for this psychology trainee. As the psychology trainee had been trained in more detailed case discussions, this manner of presentation offered the opportunity to learn a more succinct method of case presentation utilized by the medical community. In addition, the psychology trainee was regularly exposed to discussions of case-specific psychopharmacology issues and the use of medical terminology. Understanding the reasons why changes in medication dosage and type were made, the timing of these changes, and the manner in which physicians weigh desired and adverse effects of a given medication helped this psychology trainee learn the specific process and problem solving approach used by medical professionals. Further, this trainee learned to bring to the attention of the resident information obtained from the patient during individual or family sessions that would be relevant to psychiatric treatment. For example, when parents of a 10-yearold boy being treated for ADHD described symptoms of nocturnal enuresis during their family therapy session, joint supervision provided an opportunity to quickly bring this issue to the attention of the psychiatry resident and explore medicationrelated treatment options and other appropriate medical referrals. Conversely, while the psychiatry resident initially tended to use joint supervision for discussing medication management issues, such as changes in medication type, dosage, and side effects, participation in joint supervision encouraged the resident to discuss more therapy-oriented issues. The resident received detailed updates regarding changes in shared patients’ symptoms and functioning, treatment progress, and outcomes. This information was useful in helping the resident make decisions regarding medication changes and develop greater knowledge of psychological

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theory and therapy techniques. This arrangement also allowed the resident and the psychology trainee to present a unified approach during medication management and psychological treatment visits. In addition, when the resident started seeing an individual case for both medication management and cognitive-behavioral therapy, joint supervision discussions helped the psychiatry resident formulate appropriate and specific treatment goals, implement an effective treatment approach, modify treatment when necessary, and utilize appropriate outcome measures. Each of these issues was discussed collaboratively within joint supervision sessions and enabled the resident to further enhance his/her psychotherapy skills and improve the care given to the patient. Through these means, both resident and psychology trainee received training in integrative care and collaboration across disciplines, and both gained a greater appreciation and awareness of the unique niche, skills, expertise, and role of each discipline. Feelings of mutual respect and common understanding also developed over time as the group established a comfortable group process and rhythm. Finally, multidisciplinary group supervision includes not only navigating a new group process, learning new skills, and building on each other’s strengths but also challenging participants to accept their own limitations and put themselves in the position of a learner (Hansson, Friberg, Segesten, Gedda, & Mattson, 2008). Moreover, for psychology trainees, learning to effectively collaborate may also involve managing difficult interactions or experiences with medical professionals who have a more hierarchical view of the group process. Psychology trainees need to recognize and accept both the advantages and challenges of collaboration and learn to work effectively within those boundaries. For example, some physicians may initially question what can be learned from psychology professionals or may feel threatened in the unaccustomed role as learner (Hansson et al.). PCPs are considered generalists responsible for holistic knowledge of the patient, and usually provide the coordination of care (Rakel, 2002). For many PCPs, when working in a collaborative care team or sharing treatment with a mental health provider, there may be concerns regarding the specific role of each professional and sharing the responsibility of treatment with a mental health professional (Cook, Gerrish, & Clarke, 2001; Hansson et al., 2008). Further, there may be confusion regarding who ultimately makes decisions regarding referrals and specific guidance to be provided to patients, as well as how and when to communicate with interdisciplinary colleagues regarding these decisions. Consistent and effective communication with, and a clear understanding of, the treatment goals of the psychology trainee can reduce the provision of unnecessary referrals and inconsistent or contradictory advice across professionals. For example, if the psychiatry resident is aware that the treatment goals for a specific child with ADHD include teaching parents behavior management skills (such as increasing child compliance with the homework routine and use of organizational skills), this understanding will reduce the likelihood that the psychiatry resident will make an unnecessary referral to a learning specialist for overlapping services (such as organizational skills training). At the very least, this knowledge should result in the initiation by the physician or resident of a discussion with the ­psychology trainee to clarify whether any additional organizational skills support is

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­ arranted, prior to making another referral. Ideally, increased communication and w shared knowledge across professionals will result in a natural increase in joint ­decision making and the presentation of a unified message to patients, but these goals may be a work in progress within new collaborative groups, and challenges may arise in coming to an agreement on when and how decisions will be made about shared cases. These are important issues for psychology trainees and supervisors to be aware of that need to be discussed openly within the joint supervision group as they arise. In addition, psychology supervisors can help prevent potential pitfalls in the collaborative relationship in a number of ways. Supervisors can initiate open discussion of the collaborative group process with all multidisciplinary team members to model effective interpersonal problem solving for the trainees, as well as speak on the trainee’s behalf when necessary and appropriate. Supervisors who are adept at interdisciplinary collaboration will most effectively support the trainee in learning these same skills. Psychology supervisors can also offer support by giving psychology trainees the opportunity to individually discuss and process issues related to challenging or confusing interactions with physicians and other members of the multidisciplinary team, while also providing a context through which to understand those interactions as they occur within the medical culture, group process, work style, time demands, etc. For example, a trainee may interpret and label the abrupt style of a physician as “rudeness” without fully understanding the nature of the medical culture as one that accepts frequent interruption and quick transitions as necessary to effectively manage time (Dobmeyer et al., 2003). Psychology supervisors should provide empathic support, helping trainees make adjustments to their own style to adapt to the medical culture when necessary, as well as asserting their own professional opinion and ideas when appropriate. Further, psychology supervisors can work to establish joint supervision groups with physicians who are particularly open and willing to engage in collaboration, and with whom such a relationship has already been established. This can reduce obstacles in training, which may result when a physician does not see the potential benefits of regular collaboration. Collaborative meetings and supervision require a significant investment on the part of the physicians, especially given managed care regulations and the lack of reimbursement for time spent communicating with psychologists. Recognition of this investment and a realistic understanding of the limitations of the collaboration are important. As another example of collaborative training implemented in an urban, outpatient mental health clinic housed within an academic medical center, this author participated in a year-long, once weekly, structured training program to learn a specific, evidence-based, behavioral intervention. Through this training program, residents and psychology trainees cotreated cases using a team approach, which included supervision by a licensed psychologist with extensive experience in the implementation of the treatment protocol. Weekly group meetings included didactic content and role play exercises, case updates and discussion, problem solving of treatment resistant cases or challenges, and team-building activities. Through these joint meetings and shared cases, residents and psychology trainees developed a shared experience, which resulted in increased collaboration, better understanding

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and respect, and enhanced reliance on each other in treatment decision making. This likely facilitated greater integrated care within the outpatient clinic as a whole through increased knowledge, rapport, and trust shared among multidisciplinary professionals. Therefore, another specific method of offering training in collaborative care is through the formal training in a specific treatment approach that includes multiple disciplines within an outpatient mental health clinic. Many family medicine programs have also developed unique methods of multidisciplinary group supervision. For example, Blount et al. (2006) employed team precepting and dual interviews to supervise residents and psychology fellows. Team precepting entails live precepting by a team made up of medical and behavioral science faculty members using a one-way mirror. This process allows a faculty team to observe the resident interviewing patients and respond to all medical and psychosocial issues that arise in the moment, while also highlighting for the resident both medical and psychosocial aspects of the interview that went well. In this way, the resident learns to incorporate suggestions from multidisciplinary faculty in real time. Psychology fellows in primary care were included as part of the team, observing the process, learning the language, and discussing issues relevant to primary care medicine. Through shadowing and offering consultation to residents, psychology fellows developed peer experiences in collaborative care (Blount et al.).

Joint Treatment Sessions While cotreatment may involve learning a new treatment approach, joint treatment sessions that include both a medical and mental health professional can also be utilized when there is an indication that the patient would benefit from meeting with both professionals together. Joint treatment sessions may be relevant and needed for a number of reasons. They may be particularly beneficial when working with patients who present with complex problems in which medical and psychological issues are strongly intertwined and professionals are likely to benefit from each other’s support and knowledge within the session (McDaniel, 1995). There may also be a strong need to present a unified message or to reinforce treatment recommendations that the patient is having difficulty understanding or adhering to. Joint treatment sessions may also be indicated to avoid parallel care or splitting that occurs when medical and mental health professionals present differing recommendations or are unaware of each others’ treatment plans. When indicated for the patient, joint sessions can provide an important learning opportunity for the psychology trainee in how to use a team approach and collaborate within session with a physician. Prior to holding a joint session, it is particularly useful for both providers to proactively discuss and agree upon the purpose, structure, and information that will be provided during the joint session. Depending upon the extent and frequency of joint sessions, this may also involve cocreation of a treatment plan, determination of the modality of treatment to be utilized, and outcome measures to be collected. Without joint planning and

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purpose, misunderstanding, confusion, and frustration within session can result for the psychology trainee, physician, and the patient. For example, in a family therapy session, differing viewpoints may exist as to how each family member contributes to the existing problem, through what methods therapy can help the particular family, what knowledge needs to be conveyed to the family, and what skills family members need to develop. For the physician, time-related pressures may result in a more direct, psycho-educational approach, while the psychology trainee may be more accustomed to process-oriented methods. The physician may also experience limited time to discuss a joint plan prior to meeting with the patient. Finally, identifying and clarifying roles and issues of shared responsibility for each patient in advance can save time and reduce conflict (Hansson et al., 2008). For example, if the physician is responsible for coordinating care, who takes primary responsibility for leading the joint therapy or psycho-education sessions? How is time shared and who will bill for the time spent in joint sessions? Who makes referrals for other services and overall treatment decisions and when are these decisions discussed? Many questions and issues can arise in the collaborative process that may be averted if a common understanding is developed regarding why, when, and how often team meetings and joint sessions will occur, the specific role of each professional, and the rationale for collaborative activities. This will require the development of an integrated treatment plan and joint conceptualization of patient problems. Therefore, while joint sessions can provide rich learning opportunities, caution is also warranted and careful planning and collaborative effort necessary in order for joint sessions to be effective. With limited prior experience in this area, many psychology trainees may not have yet developed the collaborative skills necessary to navigate this venture independently. Psychology supervisors must play a critical role in helping trainees effectively decide when a joint session is appropriate and indicated for a given patient, as well as proactively plan the session through collaboration with the medical trainee or physician. By learning to problem solve the purpose, goals, and structure of the joint session (and the roles of each individual involved), trainees will become better prepared to negotiate the unique challenges of this form of collaborative practice.

Multidisciplinary Didactics, Seminars, and Case Conferences Multidisciplinary seminars, case conferences, and educational presentations offer other useful avenues for psychology trainees to increase their communication and rapport with physicians and obtain greater exposure to medical culture and knowledge. For example, grand rounds lectures within a hospital or academic medical center typically involve the presentation of unique or challenging medical cases and their treatment. These lectures are ideal occasions for psychology trainees to gain increased knowledge of medical procedures and approaches to treatment, medical terminology, medical structure, and format of medical case presentations. Through

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attendance at psychiatry grand rounds, trainees learn to appreciate and understand differences in case conceptualization across disciplines by listening to multiple perspectives about a given patient problem and its treatment, and how the biopsychosocial model is applied to understanding the etiology and maintenance of mental health disorders. Moreover, trainees are often given the opportunity to present a clinical case, enabling psychiatrists to learn about the unique role and set of skills that psychology trainees offer. Similarly, integrated, multidisciplinary case conferences held on a weekly or monthly basis provide other means through which physicians, psychologists, and trainees can present difficult clinical cases and elicit ideas from the team as a whole. It is important for training directors to reserve time within trainee schedules for these activities and to arrange a multitude of experiences through which trainees are immersed within the medical culture. For outpatient mental health clinics that develop partnerships with hospitals, family medicine programs, or primary care clinics, developing and coordinating multidisciplinary case conferences may require more effort and energy. However, these case conferences will provide valuable opportunities to review diagnoses and treatment approaches for complex shared cases that are managed by collaborating practices (Feierabrend & Bartee, 2004). Finally, multidisciplinary didactic seminars can also be used to increase the communication, rapport, common language, and integration of care between residents/psychiatrists and psychology trainees. Seminars may involve presentations by psychologists about mental health diagnosis and evidence-based treatment approaches that are relevant to physicians, and presentations by physicians may cover disease processes, pharmacology, and medical management. For programs with established relationships of integrated care and colocation with PCPs, incorporating these activities into the training curriculum may be feasible and more easily developed. For example, family medicine programs regularly incorporate didactic seminars that include psychology trainees, with the goal of providing trainees a broad exposure to the types of problems and symptoms commonly encountered in primary care settings (Bray, 2004). In contrast, other programs with less developed relationships with PCPs may find more obstacles to initiating and maintaining joint seminars. Training opportunities and seminars scheduled for medical residents may not be offered to psychology trainees, and time must be spent by psychology supervisors in developing relationships with medical training directors and finding ways to integrate seminars and case conferences. The relevance of topics for PCPs is particularly important to consider when planning joint seminars on mental health topics. Joint seminars should be targeted at the appropriate audience and must benefit all disciplines involved.

Conclusion Systematic training in collaborative care with PCPs at the intern and postdoctoral level can be established in a number of different clinical settings and may vary considerably depending upon the given setting. Training programs should assess and

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capitalize upon potential possibilities available within their particular ­organization, and/or develop partnerships with medical centers and primary care clinics. In ­hospitals and medical centers, the availability of clinical rotations on medical or psychiatric inpatient units offers tremendous opportunities for immersion within the medical culture and collaborative experience with PCPs. Family medicine and primary care clinics also offer numerous prospects for direct experience with PCPs. Finally, while outpatient mental health clinics often have fewer possibilities for direct collaboration with PCPs, there are a number of avenues through which structured training opportunities can be developed. Increasing the number of shared cases and establishing multidisciplinary supervision groups focused on integrative care with psychiatry will offer valuable learning experiences for psychology trainees. In such arrangements, psychology trainees may provide therapy and the psychiatrists or psychiatry residents may provide medication management. Through regular communication with psychiatrists, psychology trainees can learn collaborative skills that can be generalized to future interactions with PCPs. Other peer experiences with collaborative care may involve psychology trainees shadowing medical residents and offering consultation about specific psychosocial issues. Other methods for increasing collaboration within outpatient clinics may include establishing multidisciplinary weekly or monthly case conferences to discuss complex cases shared by psychiatrist and psychologists, and/or establishing multidisciplinary didactic seminars, in which psychiatrists provide education on medication management and disease processes and psychologists provide education on therapeutic approaches relevant to psychiatry. Psychology trainees can also be encouraged by training directors to attend regular medical training activities whenever available. Pediatric and psychiatry grand rounds and formal meetings, in which physicians discuss the details of particular cases, can increase trainees’ understanding of medical terminology and disease processes and offer new perspectives on case conceptualization and treatment.

Recommendations for Psychology Training Directors When negotiating a new training opportunity through a partnership with a primary care clinic or family medicine program, or through increased collaboration within an outpatient mental health clinic, it is necessary to structure the experience to be positive and beneficial for psychology trainees. Developing a relationship with PCPs requires giving considerable thought to assessing their needs and the goals for (and concerns about) the potential collaboration. Designing an experience through which PCPs feel they are obtaining benefit from the collaborative process is crucial. This may include an initial discussion outlining how collaboration will benefit their practice through more effective and integrated health care, how it may improve the functioning of their patients, and what specific services the psychology trainee has to offer. Other issues that may need to be addressed include physician discomfort with delegating responsibility to the mental health trainee and supervisor, billing

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issues, shared space considerations, administrative matters (for example, where mental health progress notes will be kept), supervision of the trainee, and methods of structured communication with the PCP. The psychology training director can offer the format, guidelines, and goals for the proposed collaboration to be considered by the PCP. Structured and explicit agreements between PCPs and mental health providers regarding the nature of collaborative activities can help reduce role confusion and initial challenges in working together. Moreover, frequent check-ins with PCPs to ensure they are satisfied with collaborative activities, and to elicit feedback about any needed modifications to the program (to serve the interests of either the trainee or the PCP), are paramount. Initially, it may be best to set up a collaborative experience with a PCP who is open to the idea of collaboration and has experience with similar professional relationships. The psychology supervisor can offer further support to the trainee through taking the lead in initiating conversations with the PCP regarding aspects of the collaborative process, such as modeling effective interpersonal problem solving, speaking on behalf of the trainee to negotiate complex cases and situations, and building trainee’s confidence in approaching PCPs to address these issues independently as the training year progresses. Some potential challenges that may arise in the collaborative relationship include confusion regarding specific roles and responsibilities for shared cases (e.g., who is responsible for providing specific referrals or making other treatment-related decisions), contradictory messages unintentionally provided to a patient by the PCP and psychology trainee, and uncertainty regarding how to effectively plan and navigate a joint session with both patient and PCP. Moreover, supervisors can help trainees learn to utilize medical information provided by the PCP to inform treatment-related decisions, provide relevant psychosocial information to PCPs to guide medication-related decisions, and consider the timing of behavioral interventions or changes to behavioral goals based on medication status. Finally, through individual meetings, psychology supervisors can help trainees learn to identify and value the unique strengths, skills, and services they offer to the medical community and become willing to assert their own professional opinion when appropriate, while also being open and receptive to new perspectives. Through careful attention to these issues and goals for supervision, psychology supervisors will be preparing trainees to competently and effectively collaborate with PCPs. Additionally, psychology trainees will need support from their supervisors in adjusting to the work style, pace, and time demands that are intrinsic to the medical culture and collaboration with physicians, especially if trainees are working on inpatient or emergency room rotations or provide brief consultation-liaison services. Opportunities for collaboration with PCPs through the provision of consultation-liaison, brief therapy, crisis counseling, and case management services should be highly valued by psychology training programs, as they provide intensive immersion within the medical culture and work style, allowing trainees to fully experience differences between psychology and medicine, and develop a deeper understanding of the demands placed on PCPs. Supervisors can provide consistent support and proactive education for trainees about how to conduct

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time-efficient assessments, develop concise case conceptualizations, understand patients through a biopsychosocial framework, set appropriate and realistic treatment goals that are consistent with the referral question, and determine how and when to exchange information with PCPs. Equally important, supervisors can help trainees understand how these hospital-based experiences are similar to and/or different from collaboration with PCPs in outpatient primary care clinics and how an understanding of the medical culture, work style, and time demands within the hospital or medical center will facilitate future interactions with PCPs in outpatient clinic settings. Finally, offering frequent opportunities for trainees to provide feedback both formally and informally is critically important to generate ideas for modifications to the structure and nature of collaborative activities and enhance the program for future trainees. By eliciting trainee feedback throughout the rotation, supervisors may be able to make more timely adjustments to training activities, thereby remaining responsive to current trainee concerns. Furthermore, many trainees may be hesitant to present their concerns verbally or may not be fully aware of specific weaknesses in the structure or nature of collaborative activities. Therefore, the use of rating scales that elicit feedback about progress toward attaining specific goals for collaborative training, concerns regarding the collaborative process, and satisfaction with collaborative activities may provide salient and worthwhile information not obtainable through informal discussions alone.

Recommendations for Interns and Postdoctoral Fellows While psychology trainees typically arrive at placements where structured training activities are already established, there are numerous ways in which trainees may facilitate a positive and valuable collaborative training experience. For example, maintaining openness to new experiences and perspectives and remaining flexible to adapt to the needs of the current environment can make the transition to collaborative work with physicians (and immersion in the medical culture) less stressful. Flexibility may involve a willingness to meet early in the morning to accommodate the PCPs schedule, assume new cases or responsibilities as needed by the PCP, adjust to brief, solution-focused meetings, and/or accept working within a medical hierarchy as may be present within a hospital setting. Trainees who are proactive in their attempts to understand the medical culture through reading articles, initiating conversations regarding the collaborative process, taking responsibility for maintaining regular communication with PCPs, and providing honest feedback to and eliciting regular support from supervisors, may experience a shorter learning curve in effectively collaborating with PCPs. Finally, recognizing and accepting both the benefits and challenges of the collaborative process will benefit trainees through allowing them to maintain realistic expectations, and will help them view the collaboration as a positive and worthwhile experience, despite the challenges that they meet along the way.

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References Accreditation Council of Graduate Medical Education. (1997). Program requirements for residency education in family practice. Chicago: Accreditation Council of Graduate Medical Education. American Psychological Association Education Directorate. (1998). Interprofessional health care services in primary care settings: Implications for the education and training of psychologists. Final Report, Project on Managed Care, Health Care, and Primary Care. Washington: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMSHA). Bernal, P. (2003). Hidden morbidity in pediatric primary care. Pediatric Annals, 32, 413–418. Blount, A., DeGirolamo, S., & Mariani, K. (2006). Training the collaborative care practitioners of the future. Families, Systems & Health, 24, 111–119. Bray, J. H. (1996). Psychologists as primary care practitioners. In R. J. Resnick & R. H. Rozensky (Eds.), To your health: Psychology across the lifespan (pp. 89–100). Washington: APA. Bray, J. H. (2004). Training primary care psychologists. Journal of Clinical Psychology in Medical Settings, 11, 101–107. Cassidy, L. J., & Jellinek, M. S. (1998). Approaches to recognition and management of childhood psychiatric disorders in pediatric primary care. Pediatric Clinics of North America, 45, 1037–1052. Cook, G., Gerrish, K., & Clarke, C. (2001). Decision-making in teams: Issues arising from two UK evaluations. Journal of Interprofessional Care, 15, 141–151. Cummings, N. A., Cummings, J. L., & Johnson, J. N. (1997). Behavioral health in primary care: A guide for clinical integration. Madison: Psychosocial Press. Dobmeyer, A. C., Rowan, A. B., Etherage, J. R., & Wilson, R. J. (2003). Training psychology interns in primary behavioral health care. Professional Psychology: Research and Practice, 34, 586–594. Drotar, D. (1995). Consulting with pediatricians: Psychological perspectives for research and practice. New York: Plenum Press. Engel, G. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136. Fawzy, I., Fawzy, N. W., Arndt, L. A., & Pasnau, R. O. (1995). Critical review of psychosocial interventions in cancer care. Archives of General Psychiatry, 52, 100–113. Feierabrend, R. H., & Bartee, Z. L. (2004). A collaborative relationship between a community mental health center and family practice residency program. Families, Systems, & Health, 22, 231–237. Frank, R., Bray, J. H., McDaniel, S. H., & Heldring, M. (Eds.). (2003). Primary care psychology. Washington: APA. Gawinski, B. A., Edwards, T. M., & Speice, J. (1999). A family therapy internship in a multidisciplinary healthcare setting: Trainees’ and supervisors’ reflections. Journal of Marital and Family Therapy, 25, 469–484. German, M. (1994). Effective case management in managed mental health care: Conditions, methods, and outcomes. HMO Practice, 8, 34–40. Hansson, A., Friberg, F., Segesten, K., Gedda, B., & Mattson, B. (2008). Two sides of the coin – General practitioners’ experience of working in multidisciplinary teams. Journal of Interprofessional Care, 22, 5–16. Hemmings, A. (2000). A systematic review of the effectiveness of brief psychological therapies in primary health care. Families, Systems & Health, 18, 279–313. Hepworth, J., Gavazzi, S., Adlin, M., & Miller, W. (1988). Training for collaboration: Internships for family therapy students in a medical setting. Family Systems Medicine, 6, 69–79. Hunter, C. L., & Peterson, A. L. (2001). Primary care psychology training at Wilford Hall Medical Center. The Behavior Therapist, 24, 220–222.

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Katon, W., Von Korff, M., Lin, E., Walker, E., Simon, G. E., Bush, T., et al. (1995). Collaborative management to achieve treatment guidelines: Impact on depression in primary care. Journal of the American Medical Association, 273, 1026–1031. Kiesler, C. A. (2000). The next wave of change for psychology and mental health services in the heath care revolution. American Psychologist, 55, 481–487. Mackner, L. M., Swift, E. E., Heidgerken, A. D., Stalets, M. M., & Linscheid, T. M. (2003). Training in pediatric psychology: A survey of predoctoral internship programs. Journal of Pediatric Psychology, 28, 433–441. McDaniel, S. H. (1995). Collaboration between psychologists and family physicians: Implementing the biopsychosocial model. Professional Psychology: Research and Practice, 26, 117–122. McDaniel, S. H., Belar, C. D., Schroeder, C., Hargrove, D. S., & Freeman, E. L. (2002). A training curriculum for professional psychologists in primary care. Professional Psychology: Research and Practice, 33, 65–72. Miller, I. J. (1996). Managed care is harmful to outpatient mental health services: A call for accountability. Professional Psychology: Research and Practice, 27, 349–363. Narrow, W. E., Regier, D. A., Rae, D. S., Manderscheid, R. W., & Locke, B. Z. (1993). Use of services by persons with mental and addictive disorders: Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Archives of General Psychiatry, 50, 95–107. Patterson, J., Bischoff, R., Scherger, J. E., & Grauf-Grounds, C. (1996). University family therapy training and a family medicine residency in a managed-care setting. Families, Systems & Health, 14, 5–16. Pfaffly, C. J., Baher, T. D., Jones, K., Juarez, J. A., & Brezinski, K. L. (2003). Implementing collaborative clinics in a family medicine residency setting. Families, Systems & Health, 21, 449–456. Pisani, A. R., Berry, S. L., & Goldfarb, M. (2005). A predoctoral field placement in primary care: Keeping it simple. Professional Psychology: Research and Practice, 36, 151–157. Rakel, R. E. (2002). The family physician. In R. E. Rakel (Ed.), Textbook of family practice (6th ed., pp. 3–18). Philadelphia: W.B. Saunders. Regier, D. A., Narrow, W. E., Rae, D. S., Manderscheid, R. W., Locke, B. Z., & Goodwin, F. K. (1993). The de facto U.S. mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 50, 85–94. Sanchez, L. M., & Turner, S. M. (2003). Practicing psychology in the era of managed care. American Psychologist, 58, 116–129. Seaburn, D. B., Lorenz, A. D., Gunn, W. B., Gawinski, B. A., & Mauksch, L. B. (1996). Models of collaboration: A guide for mental health professionals working with healthcare practitioners. New York: Basic Books. Sears, S. F., Evans, G. D., & Perry, N. W. (1998). Innovations in training: The University of Florida Rural Psychology Program. Professional Psychology: Research and Practice, 29, 504–507. Sheridan, E. P. (1999). Psychology’s future in medical schools and academic health care centers. American Psychologist, 54, 267–271. Spirito, A., Brown, R. T., D’Angelo, E., Delamater, A., Rodrigue, J., & Siegel, L. (2003). Society of pediatric psychology task force report: Recommendations for the training of pediatric psychologists. Journal of Pediatric Psychology, 28, 85–98. Stewart, A. E., & Stewart, E. A. (1998). Trends in postdoctoral education: Requirements for licensure and training opportunities. Professional Psychology: Research and Practice, 29, 273–283. Strosahl, K. (1998). Integrating behavioral health and primary care services: The primary mental health care model. In A. Blount (Ed.), Integrated primary care: The future of medical and mental health collaboration (pp. 139–166). New York: Norton.

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Twilling, L. L., Sockell, M. E., & Sommers, L. S. (2000). Collaborative practice in primary care: Integrated training for psychologists and physicians. Professional Psychology: Research and Practice, 31, 685–691. Williams, J. W., Rost, K., Dietrich, A. J., Ciotti, M., Zyzanski, S. J., & Cornell, J. (1999). Primary care physicians’ approach to depressive disorders. Archives of Family Medicine, 8, 58–67.

Chapter 15

The New Face of Psychology Predoctoral Training: Psychopharmacology and Collaborative Care Traci Wimberly Olivier *

Psychologists began to fight for independent insurance coverage in the 1970s. In the 1980s and 1990s, psychologists sought to expand their scope of practice by securing the right to have access to hospital privileges and Psychologist’s Emergency Certificates (PECs). The United States territory of Guam was the first to pass legislation granting prescriptive authority to psychologists with the proper training. This legislation, which was passed in 1998, provided comprehensive mental health services to members of the United States military (stationed in Guam). Shortly thereafter, the states of New Mexico and Louisiana successfully passed legislation allowing psychologists with the proper training to prescribe psychotropic medications. At present, psychologists in 20 states are actively seeking legislation for prescriptive authority (Wimberly, 2008). Even though a state may not currently have laws allowing psychologists to prescribe, many institutions of higher education are beginning to offer psychopharmacological training to psychologists who are interested in this specialty. Psychologists have begun to realize just how valuable psychopharmacological training can be. It can prepare the psychologist to (a) collaborate with physicians in order to craft the right psychopharmacological regimen for their mutual patients, (b) recognize which symptoms are likely to benefit from the use of medications, (c) examine possible drug–drug interactions, and (d) make sure that the prescription decisions being made are actually in the best interest of the patient. Psychopharmacological training for psychologists is the new face of psychology.

* This chapter is dedicated to The Neuropsychology Center of Louisiana, and to my mentors, Darlyne G. Nemeth, Ph.D., M.P., A.B.M.P. & Joseph Tramontana, Ph.D. T.W. Olivier (*) Neuropsychology Center of Louisiana, Baton Rouge, LA, USA e-mail: [email protected] G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_15, © Springer Science+Business Media, LLC 2011

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How Does This Impact Students? Before psychologists were granted prescriptive authority in certain states, undergraduate psychology majors who were interested in graduate training focused mainly on applying to doctoral programs in the applied areas of clinical, counseling, school, and neuropsychology. Now, with the passage of these prescriptive authority laws (i.e., in Louisiana, New Mexico, and Guam), students are becoming more aware of the importance of integrated doctoral training in applied psychology and psychopharmacology. These programs, however, are quite rare. As it stands now, some professional schools offer courses that cover psychopharmacological content, but few offer a degree in clinical psychopharmacology. Currently, it appears that even fewer universities offer resources to students looking to acquire training in clinical psychopharmacology. Since more universities are beginning to perceive their doctoral students as consumers, however, more programs are being tailored to meet their current interests and future needs.

Prescriptive Authority in Louisiana: A Successful Model In order to become a (prescribing) medical psychologist in Louisiana, a psychologist must first be licensed to practice independently and must provide written documentation from his/her State or Provincial Board of Examiners as proof of a current and valid license (see LSBEP, 2008 – Title 46, §403 A.2, below). The psychologist must also complete a postdoctoral master’s degree in psychopharmacology. This degree is usually obtained in four semesters (i.e., 30 credits/450 h) of study. Although any psychologist may be accepted into one these degree programs, not all psychologists actually obtain prescriptive authority. As stated above, currently, prescriptive authority laws for medical psychologists have only been enacted in Louisiana, New Mexico, and some military settings (i.e., Guam). In 2004, House Bill Number 1426 was introduced in Louisiana by Representative Salter and Senator Hines. This bill allowed medical psychologists to prescribe mental health medications in the state of Louisiana. Subsequently, the Louisiana State Board of Examiners of Psychologists (LSBEP) established a rule “to set direction for the implementation and oversight of [Louisiana’s] new law” (LSBEP, 2008, p. 1). This “rule” is more formally known as Title 46, Professional and Occupational Standards, Part LXIII. Psychologists. Because many states are currently actively seeking legislation to grant prescriptive privileges to medical psychologists, Title 46 (LSBEP, 2008) is an excellent format to follow. Although state to state variations are likely to exist, the following guidelines give students baseline requirements to keep in mind when searching for an integrated graduate degree program. LSBEP established the following specific

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guidelines for obtaining a Certificate of Prescriptive Authority in Louisiana through Title 46: §403 Application for Certificate of Prescriptive Authority A.2 The psychologist holds a current Louisiana license to practice psychology with an applied clinical specialty. For the purposes of these rules, an applied clinical specialty is defined as a board-approved specialty in Clinical Psychology, Counseling Psychology, School Psychology, Clinical Neuropsychology, or other applied clinical specialty as may be approved by the board. A.3 The psychologist has successfully graduated with an approved postdoctoral master’s degree in clinical psychopharmacology from an institution accredited by a regional body recognized by the U.S. Department of Education. For the purposes of these rules, an equivalent to the postdoctoral master’s degree under the provisions of R.S.37:2373 (2) is defined as the successful completion of the Department of Defense Psychopharmacology Demonstration Project (DOD-PDP), or similar program developed and operated under the auspices of any branch of the United States armed forces. (LSBEP, 2008, p. 1)

It is important to note that, in Louisiana, the regulation of medical psychologists was transferred from LSBEP to the Louisiana State Board of Medical Examiners (LSBME) as of January 1, 2010. The following is an excerpt from LSBME’s website concerning this change: Act 251 of the 2009 legislature (the Medical Psychology Practice Act) transferred regulation of medical psychologists from the Louisiana State Board of Examiners of Psychologists (LSBEP) to the Louisiana State Board of Medical Examiners (LSBME) effective January 1, 2010. According to state law, medical psychologists will be required to hold a license issued by LSBME to continue practicing medical psychology after January 1, 2010. If a medical psychologist holds an unrestricted certificate of prescriptive authority issued by LSBEP, he/she is eligible for licensure by LSBME. Medical psychologists will no longer be required to hold a license to practice psychology issued by LSBEP but may continue to do so if they wish. (LSBME, 2009, p. 1)

Although this law undoubtedly affects the regulation of the practice of medical psychologists in Louisiana, House Bill Number 1426 and Title 46 are what originally established medical psychology in Louisiana and how it should be implemented. Therefore, for those who are interested in medical psychology and/or obtaining a postdoctoral master’s degree in psychopharmacology, they are still excellent guidelines to follow. Whether you are (a) currently seeking a graduate program, (b) already a graduate student, (c) an early career psychologist seeking licensure, or (d) a wellestablished applied psychologist, if you are interested in expanding your knowledge or practice into psychopharmacology, it is helpful to be familiar with the requirements for obtaining a degree in clinical psychopharmacology. For ­students who are seeking out graduate programs, focusing on those programs that offer integrated clinical psychology and psychopharmacology courses may prove quite beneficial. Although the clinical psychopharmacology degree is a postdoctoral master’s degree, any previous knowledge of psychopharmacology and pharmacokinetics will be valuable. For those who are already graduate

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s­ tudents, intern/externships that are either psychopharmacologically based or those that employ more of a medical rather than a strictly psychological model may be of assistance in obtaining further training in psychopharmacology. Those psychologists who have already obtained licensure (e.g., early career or wellestablished applied psychologists) will likely seek a psychopharmacology training program that suits their practice needs and schedule. Understandably, an established psychologist would have a much more difficult time relocating for further study than would a recent doctoral graduate, who has not yet built a practice in a certain geographic area. In clinical practice, the applications of psychopharmacology are far reaching. Psychologists today are not confined just to private practices. Many psychologists are employed by universities, hospitals, government agencies, inpatient and outpatient clinics, and other settings where they need a solid understanding of drugs and drug effects on brain–behavior relationships in order to competently and competitively perform their duties. An increasingly large number of patients seeking mental health services are becoming very familiar with popular medications on the market. Because technology is advancing so rapidly, patients can have access to medical information within seconds. It is not uncommon for a patient to present for an appointment with his or her own diagnosis and treatment plan already in mind. Consequently, psychologists must be fully informed about these options as well. Oftentimes the patient only has a piece of the puzzle and relies on the expertise and knowledge of the professional for the pieces he or she is missing. Although psychotherapy is still widely used, many patients’ treatment of choice is medication. When combined with either psychotherapy and/or neurocognitive rehabilitation (if and when warranted), medication can have significant positive effects on patients’ quality of life. Because medications are so frequently prescribed today, it is imperative that psychologists have a sufficient understanding of psychopharmacology and pharmacokinetics. More patients are now using a greater variety of medications than ever before, and in order to remain relevant and beneficial to their patients, psychologists must keep up with the times. According to Louisiana law, medical psychologists are only allowed to prescribe medications that treat Axis I or Axis II disorders that are included in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the most recent edition of the International Classification of Diseases (ICD) (LSBEP, 2008). It is beneficial, however, for psychologists to also have knowledge of medications used to treat other health problems. Various classes of prescription medications can have adverse effects on patients’ psychological and emotional functioning (e.g., mood changes, a worsening of original symptoms, suicidal thoughts, etc.). Unfortunately, physicians may prescribe medications without first checking for possible contraindications or harmful drug–drug interactions; or there may be little or no consultation and collaboration among physicians who prescribe multiple medications for the same patient. Psychologists with

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knowledge of possible side effects, possible contraindications, and potential drug–drug ­interactions in the patient’s current pharmacological regimen (or even with food – for example, grapefruit causes a harmful interaction when combined with certain medications) can offer a valuable service. When a psychologist encounters a patient on multiple medications, it is wise to assume that no one else has checked for drug–drug interactions, and to do so. This may be achieved quite easily with the help of some very useful tools – for example, the Internet is a useful resource for obtaining drug–drug interaction profiles. Some web-based services offer prescribing professionals access to a countless number of medications and related side effects, which can be conveniently accessed from the desktop screen of a computer. With information such as the patient’s sex, date of birth, and medication regimen, these programs are able to generate a comprehensive listing of all major, moderate, and mild drug–drug interactions. Pregnancy cautions may also be reported. Oftentimes, such programs will not only determine which drug–drug interactions may be occurring from the patient’s current medication regimen but also analyze possible drug–drug interactions that could occur from adding or discontinuing another medication. As it is clearly evident, psychopharmacological training for psychologists is extremely beneficial, even if every state has not yet passed a prescription privilege law for psychologists. Psychopharmacological training for psychologists paves the way for a more holistic, integrated view of mental health care, expands the psychologist’s clinical toolbox, and allows the patient to receive a greater breadth of care.

Sample Curricula Students interested in pursuing psychopharmacological training and/or prescription privileges should research not only the content of various programs but also the philosophical orientations of such programs. Title 46, described above (LSBEP, 2008), sets forth specific educational program guidelines for the postdoctoral degree in clinical psychopharmacology: §403 Application for Certificate of Prescriptive Authority [in Louisiana] A.3.a. The education program shall provide postdoctoral didactic instruction in the following content areas: i. ii. iii. iv. v. vi. vii.

Anatomy and physiology Biochemistry Neurosciences Pharmacology Psychopharmacology Clinical medicine/pathophysiology Health assessment, including relevant physical and laboratory assessment

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A.3.b. The training of a medical psychologist shall provide opportunities for the psychologist to review, present and discuss case examples representing a broad range of clinical psychopathologies; medical conditions presenting as psychiatric illness; and treatment complexities, including complicating medical conditions; diagnostic questions; choice of medications; untoward side effects; compliance problems; alternative treatments and treatment failures. A.3.c. Course work and/or training undertaken at a predoctoral level cannot be substituted for any educational or training requirement necessary to obtain a Certificate of Prescriptive Authority. (p. 1–2)

An online search is probably the fastest and most efficient way to find programs that offer a postdoctoral master’s degree in clinical psychopharmacology. Currently, one of the most notable programs in the United States is offered through The California School of Professional Psychology (CSPP) at Alliant International University, which “created the nation’s first and most successful Postdoctoral Master of Science Program in Clinical Psychopharmacology” (CSPP, 2009, p. 2). CSPP was also chosen by APA’s Division 18 (Psychologists in Public Service) to train 100 United States public service psychologists in psychopharmacology. To date, “over 400 psychologists in 32 states have graduated from or are currently enrolled in [the CSPP] program” (CSPP, p. 2). The current CSPP curriculum for the postdoctoral master’s degree in clinical psychopharmacology serves as a good model for students and psychologists who are interested in obtaining psychopharmacological training at other institutions. These elements of training may be incorporated into graduate programs and/or intern/externship training. It is noteworthy that CSPP constantly reviews this curriculum to make sure that it is up to date with all legislative requirements for prescriptive authority (CSPP, 2009). The current CSPP postdoctoral master’s degree in clinical psychopharmacology curriculum provides courses in the following areas: Clinical Biochemistry; Neurosciences, including Neurochemistry, Neurophysiology, and Neuroanatomy/Neuropathology; Clinical Medicine/Pathophysiology; Physical Assessment; Pharmacology and Clinical Pharmacology; Psychopharmacology, including Antidepressants, Anxiolytics, Antipsychotics, Mood Stabilizers, and Drug/Drug Interactions; Special Populations in Psychopharmacology, including Child/Adolescent Psychopharmacology, Gender Issues, Geriatric Psychopharmacology/Chronic Pain, PTSD/Borderline Personality/ Chronic Medical Conditions, and Ethnopsychopharmacology; Chemical Dependence; Pharmacotherapeutics, including Research Issues in Psychopharmacology, Professional, Ethical, and Legal Issues, and Integrating Psychotherapy and Pharmacotherapy; Case Seminar; and a Review Course for the Psychopharmacology Examination for Psychologists (PEP) (CSPP, 2009).

Consultation and Collaboration As more psychologists are seeking psychopharmacological training and/or obtaining prescriptive authority, the need for consultation and collaboration with physicians is becoming more apparent. Although consultation and collaboration between nonpharmacologically trained psychologists and physicians has been extensively

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researched, research on consultation and collaboration between physicians and pharmacologically trained psychologists seems to be lacking. Considering psychology’s advances in psychopharmacology and prescriptive authority/privileges, this is surprising. According to Drotar (1993), consultation is defined as “any professional activity that is conducted between a member of one profession and another” (p. 161). Drotar continues by explaining that consultation can occur between different members in professional organizations or at “a program level, that is, among groups of psychologists and pediatricians in a particular setting” (p. 161). Currently, professional training of both psychologists and physicians (for example, pediatricians) does not include much emphasis on consultation and collaboration practices. This can cause potential confusion regarding goals, guidelines, ethics, and standards of collaboration. Collaboration can also be hindered when professionals choose not to work with each other, even when doing so would be in the best interest of the patient (Drotar, 1989; Nathan, Lubin, Matarazzo, & Persely, as cited in Drotar, 1993). Research suggests that psychologists do not always “effectively utilize ­physicians’ expertise to manage their patients with medical problems or train their students to do so” (Davidson, as cited in Drotar, p. 160). Likewise, patients with behavioral and developmental disorders may not be properly recognized by pediatricians and referred to psychologists (or other mental health professionals) as often as needed (Drotar, 1993). Apparently, pediatricians and psychologists do not collaborate as frequently as is necessary, and an increase in collaboration may potentially result in more appropriate, individualized services and more effective preventive care. In some cases, services delivered by psychologists and pediatricians may overlap. This is due to psychopharmacological training (and in some states, prescriptive privileges) for psychologists, and specialized training for pediatricians, allowing them to “provide assessments and interventions for children with behavioral and developmental problems” (Haggerty, 1986, as cited in Drotar, 1993, p. 161). Because of the lack of training in collaborative practice, these professionals may be confused about the roles and services offered by the other. When clear boundaries and standards are not outlined, and treatment goals are not properly defined, conflict is more likely. The need for an effective and relevant consultation and collaboration training model for students of both professions, and a clearly defined set of guidelines, standards, and ethical considerations for collaborative practice, is evident. Although medical psychologists are required by law to consult, collaborate, and concur with the patient’s physician before prescribing medicine, consultation and collaboration is important in all fields of psychology. As our world moves closer to a holistic approach to health care, both fields must find new, innovative ways to develop treatment plans and integrate patient care. Many curricula do not currently include formal training in these areas. Core values, guidelines, and standards have not yet been developed. As mentioned previously, there is a shortage of research on collaborative care provided by pharmacologically trained psychologists and physicians. As Stabler and Whitt (as cited in Drotar, 1993) explain, the lack of “a guiding conceptual framework has…limited the development of training programs to foster the collaborative interest and skills of young professionals” (p. 161).

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In order for psychology students to become properly trained in the practice of consultation and collaboration, and for psychologists and pediatricians to corroborate effectively, certain key objectives must be accomplished. Drotar (1995) outlines five goals/content areas of collaboration: (1) teaching, (2) clinical care, (3) research, (4) program administration, and (5) professional organization. These may be implemented in medical (inpatient or outpatient) or nonmedical settings. Building on these five ideas, the author of this chapter proposes a new model, which consists of the following three key areas: (1) implementation of classroom instruction and supervised training, (2) research, and (3) development of standards. The following is an outline of these three “Core Values.” Core Value # 1:  Classroom instruction and supervised training • • • • • • • •

Cross-training Follow-up Accessibility Availability Interpersonal skills Understanding needs of physicians Heterogeneous goals Mentorship

Core Value #2:  Research • • • • •

Review past literature and research Generate current research Assess methods Professional satisfaction Patient care

Core Value #3:  A development of standards • Ethical guidelines • Boundaries • Standards of care These three Core Values are interdependent; that is, they are designed to work together to accomplish the goal of effective, functional, and beneficial consultation and collaboration activities. Neither is more important than any of the others, and each serves a crucial purpose. A detailed explanation of the Core Values is as follows.

Classroom Instruction and Supervised Training In many (if not all) psychology graduate programs, courses are taught by psychologists. In university settings, these psychologists are primarily academicians, many of whom are heavily involved in research. In other settings, such as professional

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schools, some may be academicians, but most are applied psychologists; that is, they may maintain a private practice in addition to teaching courses, or they may work at an outpatient clinic, such as a local mental health facility, or at an inpatient clinic, such as a hospital. Still, they are all psychologists. In order for effective and functional consultation and collaboration practices to be modeled, it is important for students to have interdisciplinary exposure. Therefore, students should also be taught by physicians (e.g., pediatricians), since these are professionals with whom these students will be consulting and collaborating in the future. Ideally, crosstraining should include some instruction to psychology students by physicians, and vice versa. By knowing beforehand what each collaborative partner needs and expects, confusion will be minimized, and goals for patient care and treatment will be more clearly outlined. In addition, collaboration requests must be “clear, feasible, and fit with a colleague’s skills” (Drotar, 1993, p. 166). It is important for psychologists to frame information in ways that are relevant to physicians. Similarly, physicians should present medical information in ways that are concise and useful. In addition to cross-training, classroom instruction and supervised training must also include coverage of the importance of follow-up, availability, accessibility, and interpersonal skills conducive to collaboration with physicians. Olson et al. (1988) found that “many physicians expect their psychologist colleagues to provide prompt and specific feedback based on their evaluation, effective treatment recommendations, and in many cases, follow-up for their patients” (as cited in Drotar, 1993, p. 165). In order to minimize confusion and conflict, the expectations and needs of both collaborating professionals must be addressed and outlined. Collaborating professionals must also be available and accessible to each other. Studies have shown that the belief of accessibility will affect whether or not one chooses to collaborate with another professional (Drotar, 1993). Psychology students must be taught to be available and accessible to their physician colleagues, and must avoid appearing remote or detached. Finally, the importance of interpersonal skills must be addressed. In closing, Drotar (1993) explains how the lack of interpersonal skills may negatively impact future collaborative interactions: A different set of beliefs and expectations may be necessary to maintain collaboration once it is initiated. Following initial contact with a colleague, collaborators may review their experience by asking themselves questions such as, “Did things go smoothly?” “Was this person easy to work with?” “Was this an effective intervention?” If participants judge their efforts as reasonably successful, they may decide to work together again. On the other hand, if they encounter significant problems or if their expectations are not met, subsequent interactions may be limited are abandoned entirely. (p. 165)

Consultation and collaboration requires a creative blend of time, effort, and respect. Drotar (1995) describes a collaborative team model as “the sharing of the expertise of different disciplines in clinical management, research, or teaching roles” (p. 26). For pediatricians and psychologists to collaborate effectively, each must adapt his or her current way of doing things, if necessary, in order to achieve the best possible outcome for the patient. Consultation and collaboration expands the borders of clinical practice, allowing a fresh exchange of new ideas and information. “Psychologists learn to be savvy about differential medical diagnosis and to consider relevant medical factors in evaluating physical or psychological symptoms”

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(Drotar, 1995, p. 26). Likewise, a pediatrician may decide to take a more detailed family history and use other family members as informants in order to develop a relevant intervention plan (Drotar, 1995). It is important to note that complex issues sometimes arise when evaluating and treating children. At the request of teachers, parents, and/or physicians, children are often referred for comprehensive evaluations. Such evaluations may include assessments of intellectual, educational, attentional, executive, behavioral, affective, and/or personality functioning. At first, parents usually are concerned about their children’s difficulties and willing to cooperate. “Yet, when the etiology of the problem is defined and treatment recommendations are made, it is not uncommon for parents to question the findings and request a second opinion…Dealing with parents’ resistance to the results is often more problematic than the actual testing experience” (Lewis, Nemeth, Wimberly, & Lamar, 2008, p. 1). In regard to school evaluations, research has found that many parents would rather remain unaware of the true nature of their children’s difficulties rather than chance losing their “normal” or “gifted” classification (Lewis et al. 2008). Although the aforementioned issues are primarily encountered by clinical and school psychologists, they oftentimes are also relevant for medical psychologists. Parents may be hesitant to accept psychiatric diagnoses and medication recommendations. When psychologists and pediatricians collaborate, however, the child has a greater chance of receiving appropriate treatment and/or intervention. This is another benefit of cross-training. Students pursuing doctoral degrees in any applied psychology field should be aware of these dilemmas and should be trained by both psychologists and pediatricians in order to learn how to effectively handle such issues. Lewis et al. (2008) offer the following recommendations to assist psychologists (and pediatricians) in addressing parents’ resistance: • Recommend self-help books to parents to increase their knowledge of the difficulties their child is experiencing. • Make efforts to frame the diagnosis to emphasize the child’s strengths (i.e., explain how strengths may result in techniques that compensate for difficulties). • Place more emphasis on the neurobehavioral etiology of the diagnosis, if applicable. Sometimes, parents think that certain diagnoses are simply learning problems. Education in areas such as brain-behavior functions may be helpful. • Parental education and intervention programs should be established. • Detailed feedback and regular medication follow-up visits (if applicable) should be scheduled and maintained.

Classroom Instruction and Supervised Training: Mentorship and Networking Years ago, students were primarily taught through a system known as apprenticeship, in which an experienced professional took a young hopeful “under his wing” to teach him or her the skills required for the trade and slowly craft the individual into

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a tradesman. When the teacher was confident that the student acquired enough knowledge to perform the task, the teacher shadowed the student for a while to offer guidance and monitor his or her performance. Finally, when the student demonstrated that he or she was competent enough to work on his or her own, he or she was sent out to begin his or her own business, trade, or practice. Today, few people acquire their education in this way, and the use of mentors has greatly diminished. New graduates often project inflated confidence, and some are very difficult to mentor. Although acquiring a graduate degree is a significant accomplishment, it is not the mark of arrival. It is the mark of beginning, and beginners should not forget the importance of learning from the veterans of their profession. One can learn lessons from interactions with mentors that cannot be learned in a classroom. The majority of graduate students in psychology are enrolled in doctoral degree programs, and few programs in psychology offer a master’s degree. Some recent college graduates, however, seek out master’s degree programs in hopes of gaining more experience and enhancing their vitas before continuing their education further. In states where such practice is allowed, some of these students gain experience and enhance their credentials by working as clinical assistants for psychologists. In addition to learning the hands-on aspects of clinical practice, these trainees may have the opportunity to learn how to administer and score psychological measures, compile and prepare data for comprehensive psychological reports, and make detailed behavioral observations. Some students also collaborate with psychologist researchers and prepare poster/paper presentations and workshop presentations for state, national, and international conferences. Working with psychologists may also provide an excellent way to observe, first hand, how to consult and collaborate with physicians. While working with mentors, students also learn the importance of joining professional organizations and attending professional conferences. Students can join many of these organizations while they are still completing their bachelor’s degrees in psychology. Usually, these organizations offer reduced membership rates to student affiliates, and students are frequently offered a substantial discount on conference registration fees. The benefits of membership in these professional organizations/associations are numerous. Many memberships include access to the “listserve” associated with that organization. Listserves provide an excellent way to keep up with current events in psychology and psychopharmacology, give students the opportunity to contact experienced psychologists with questions, and help them identify valuable professional resources. Membership in professional organizations allows students to expand their professional network (or begin to establish a network). One of the best ways to continue to build or expand one’s network is by attending conferences. It is understandable that students may have limited financial resources, but some organizations may offer scholarships to students (e.g., first time student attendees, first author of a presentation), and mentors and/or professors may also be willing to help students offset the cost of attending a conference. As a good rule of thumb, conference attendees are encouraged to learn two new things or to make two new contacts.

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More often than not, opportunities will be available to meet distinguished clinicians, authors, and/or scientists, obtain information about the newest products in psychology, receive discounts from exhibitors on products purchased at the conference, and enhance one’s general knowledge. For students interested in clinical psychopharmacology, several professional psychological organizations/associations offer valuable resources: • • • • • •

American Psychological Association (APA) American Society for the Advancement of Pharmacotherapy (APA’s Division 55) Academy of Medical Psychology (AMP) The International Neuropsychological Society (INS) National Academy of Neuropsychology (NAN) State Psychological Associations

Mentorship and hands-on experience are vital to psychology students’ success, and many learning opportunities only become available as a direct result of mentorship and guidance. Psychology is a vastly evolving scientific field. Experiencing a mentor’s guidance, especially during the early steps of psychologists’ careers, is a crucial component of future professional success.

Research In order for a new model of consultation and collaboration training to be effective, it must be built on a solid foundation of the results of empirical research. Because psychopharmacology and medical psychology are new specialties within professional psychology, contemporary research is needed to address current issues and trends in consultation and collaboration. Research is also needed to assess training methods and ensure that the evolving models of collaboration and consultation are functioning properly and efficiently, and it offers advantages to the patients and collaborating professionals. Finally, patient as well as physician/psychologist satisfaction measures need to be developed to give an insider’s view of how patients and professionals perceive collaborative care.

Development of Standards An effective framework must be developed to guide the training of consultation and collaboration. Without mutually accepted goals, standards, ethical guidelines, and boundaries, training models lack necessary structure. This new framework can serve as a syllabus for future training programs. This is yet another aspect that will greatly benefit from focused research with input from physicians, psychologists, and patients in order to identify the needs and expectations of all constituents.

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None of these Core Values can stand alone, and none is greater than any other. Just as the gears of cog mechanism turn in synchrony, each of these core values works closely with the others to jointly accomplish the development and implementation of a successful, relevant, and functional training model of consultation and collaboration.

Future Implications: The Importance of Integrated Care It is vital for prospective students who are interested in training in psychopharmacology and possible prescriptive privileges to seek out programs that are philosophically and educationally supportive of prescription privileges for psychologists. One may inquire directly about whether or not a doctoral program is supportive of prescription privileges for psychologists, but not all programs are willing to publicly state their positions. It is possible, however, to find subtle clues. For example, a doctoral program is most likely to be supportive if it offers classes in both applied psychology and psychopharmacology (i.e., Anatomy and Physiology; Neuroscience, Pharmacology and Psychopharmacology; and Ethical Issues regarding Applied Psychology and Psychopharmacology). As stated previously, psychopharmacology is the new face of psychology, and appropriate training is needed to help psychologists learn effective methods of collaborating with pediatricians and other medical professionals. This, in turn, can potentially lead to a more holistic model of health care. According to Nordal (2009), “At least half of the care provided for common psychological disorders is delivered in primary-care settings” (p. 74). Nordal explains that in these settings, the treatment of choice is usually prescription medication without a recommendation for psychotherapy. Although prescription medications may sometimes be more cost-effective than other treatments, psychologists understand that prescription medication alone does not always suffice. Consequently, Patients who access the primary-care system could benefit tremendously by having prescribing psychologists as an integral part of their health-care team. Prescribing psychologists use a biopsychosocial model of care and have much more training regarding psychological disorders and psychotropic medications than any other prescribing healthcare professionals aside from psychiatrists. But there is a dearth of psychiatrists and their ranks continue to diminish. Psychologists are the logical providers to fill these dire gaps in care. (Nordal, 2009, p. 74)

What does the research say about this issue? Studies have found a significant decrease in the utilization of primary care when psychological intervention was employed (Nordal, 2009). Medical psychologists are trained to integrate psychotropic medications (when needed) with traditional psychotherapy and to properly monitor patient response and adverse effects. When medical psychologists collaborate and consult with other healthcare professionals (such as pediatricians, primary care physicians, etc.), patients receive comprehensive care that includes appropriate medical and psychological treatment interventions.

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References California School of Professional Psychology – Alliant International University. (2009). Postdoctoral master of science in clinical psychopharmacology [Brochure]. San Diego: California School of Professional Psychology – Alliant International University. Drotar, D. (1993). Influences on collaborative activities among psychologists and pediatricians: Implications for practice, training, and research. Journal of Pediatric Psychology, 18(2), 159–172. Drotar, D. (1995). Consulting with pediatricians: Psychological perspectives. New York: Plenum. Lewis, A. M., Nemeth, D. G., & Wimberly, T. E. (2008). Addressing parents’ resistance to neuropsychodevelopmental findings. Poster presented at the 116th Annual Convention of the American Psychological Association, Boston, MA. Louisiana State Board of Examiners of Psychologists. (2008). Certificate of prescriptive authority (chap. 4). Retrieved March 13, 2010 from http://www.lsbep.org/rules_ch_4.htm Louisiana State Board of Medical Examiners. (2009). Medical psychology. In In the News. Retrieved March 13, 2010 from http://www.lsbme.louisiana.gov/Blog/inthenews.aspx Nordal, K. C. (2009). Integral contributors to integrated care. Monitor on Psychology, 40(5), 74. Wimberly, T. E. (2008). Preparing for RxP in graduate school. The National Psychologist, 17(6), 23.

Chapter 16

RxP Training Informs the Practice of Supervision of Nonpharmacologically Trained Mental Health Practitioners Andy Lopez-Williams

Over the years since the inception of clinical psychology, the role of the clinical psychologist has evolved tremendously. Clinical psychology has grown from a profession that in many aspects was founded within a medical model of treatment, and de facto, relegated to a subservient role in the treatment of persons with mental health disorders. Over the decades, since the formal beginnings of clinical psychology, the role of the clinical psychologist has gained in credibility, scope, and autonomy of practice. In recent decades, the role of clinical psychology in relation to pharmacological treatments has grown – albeit with much debate and little clarity as to what role clinical psychologists should play in the pharmacological treatment of persons with mental health disorders (Gutierrez & Silk, 1998). This chapter presents a model for clinical psychologists with phasmacological training in the supervision of mental health practitioners with phasmacological training. The primary role of prescribing for mental health disorders in children and adolescents has historically fallen and continues to fall upon two major groups: psychiatrists and pediatricians. However, for different reasons, these two groups are not adequately poised to fully address the mental health needs of children and adolescents. First, the decreasing availability of child psychiatrists (Gragg, 2010) is increasingly leaving a major gap in the care of children and adolescents with mental health disorders. Concerns over the availability of psychiatrists in general, and outside of major metropolitan areas in particular, are growing, and efforts to increase the overall numbers of psychiatrists have not shown any significant progress, especially outside of urban areas. The paucity of psychiatry leaves primary care physicians – often pediatricians – at the front lines of treatment for children and adolescents with mental health disorders (Harpaz-Rotem, Leslie, Martin, & Rosenheck, 2005). However, pediatricians often lack the training – either in scope or depth – to adequately address the mental health needs of children and adolescents (Fox et al., 2008). Because pediatricians are

A. Lopez-Williams (*) ADHD & Autism Psychological Services and Advocacy, Utica, NY, USA e-mail: [email protected]

G.M. Kapalka (ed.), Pediatricians and Pharmacologically Trained Psychologists: Practitioner’s Guide to Collaborative Treatment, DOI 10.1007/978-1-4419-7780-9_16, © Springer Science+Business Media, LLC 2011

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not typically rigorously trained to assess and treat mental health disorders, children and adolescents who present with significant mental health problems may not be receiving adequate identification and care. Thus, the current state of affairs with decreasing numbers of child psychiatrists is not adequately addressed by the diversion to pediatricians and the gap in service for children and adolescents with mental health disorders remains. In response to these aforementioned gaps in the pharmacological treatment of children and adolescents with mental health disorders, there have been numerous initiatives to increase the purview of clinical psychologists in pharmacological treatment including efforts to achieve prescription privileges. In fact, some states have successfully passed laws to allow appropriately trained clinical psychologists to prescribe medication. However, there is no universal mechanism for clinical psychologists to gain prescription privileges. Therefore, most practicing clinical psychologists seek to gain greater clarity on how they can serve a significant role in the pharmacological treatment of persons with mental health disorders without having prescription privileges. Further complicating the issues surrounding the void of pharmacological providers is the fact that the majority of mental health practitioners are not doctoral-level psychologists. Rather, the majority of mental health counseling is provided by nonpharmacologically trained mental health practitioners such as social workers, mental health counselors, and marriage and family therapists (Bureau of Labor Statistics, 2010). In summary, the current systems of care for children and adolescents with mental health problems are characterized by the paucity of availability of appropriately trained practitioners who have both mental health training and prescription privileges. The degree of interest and training in pharmacology is arguably greater than ever before in professional fields such as clinical psychology (Grandin & Blackmore, 2006). However, the current state of affairs remains that the overwhelming majority of practicing mental health therapists do not have the adequate training to address and integrate pharmacological components into their assessment and treatment plans, a fact that emphasizes the critical need for a remedy. In the absence of any immediate and systemic amelioration of these problems, practitioners from varying disciplines (e.g., mental health practitioners, pediatricians) require guidance on how best to work collaboratively to address the needs of children and adolescents with mental health disorders. Chapters in this text have focused on issues related to the rationale for a collaborative model between pharmacologically trained clinical psychologists and pediatricians. This chapter extends the discussion to the supervision of doctoral- and master-level therapists by pharmacologically trained clinical psychologists toward the goal of collaboration with pediatricians. Such a discussion is predicated upon the supposition that supervision of doctoral- and master-level mental health practitioners who are not pharmacologically trained is best accomplished within the context of a supervision model that focuses on skill acquisition and includes objective methods of assessment of treatment response. Regardless of the theoretical orientations that guide a particular therapeutic process, medication effects can

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arguably be viewed as existing outside of the operating theoretical context of therapy and, by extension, operating outside of the theoretical context of supervision. The theoretical orientation that a mental health therapist adopts is vital to the therapeutic process and is considered to be the impetus for change in a patient; however, medication is arguably not a therapeutic process and is not bound by the same factors. That is, the effect of medication is not directly under the control of the same factors that manipulate psychological constructs in the therapy process. Therefore, mental health practitioners from varying theoretical orientations are able to utilize a singular framework wherein medication considerations and effects can be determined systematically and objectively. The relevance of this point has direct implications for supervision of nonpharmacologically trained mental health practitioners. Before providing any framework for the role of clinical psychologists and their supervisees in pharmacological treatment of persons with mental health disorders, a brief overview of the rationale for such a framework is necessary. There are numerous and converging reasons why clinical psychologists should assume a unique role in prescription practices for mental health disorders. Given the space limitations of this chapter, two major points will be covered concisely. Unlike the above-stated qualifications of pediatricians, clinical psychologists are trained in the assessment and treatment of mental health disorders. What they do often lack is the rigorous training in pharmacological treatments or the legal privileges to pharmacologically treat children and adolescents. Since its inception, clinical psychology has been often associated with principles of quantified assessment, with personality and intelligence measurement being among the foundations of the field. The field of clinical psychology has also come to be largely associated with treatment of mental health disorders. Today, many of the most rigorous doctoral programs train students to become scientist-practitioners who have the abilities to validly assess and treat mental health disorders and to systematically measure the change process throughout treatment. Arguably then, clinical psychologists – especially those with pharmacological training – may be in the most poised position of any other likely group to assume a useful and unique position in the pharmacological treatment of children and adolescents with mental health disorders. Supervisory roles are prominent in the duties of clinical psychologists, as such roles are related to their training in the assessment and treatment of mental health disorders. Thus, in addition to providing a direct and relevant role in the pharmacological treatment of children and adolescents with mental health disorders either as prescriber or collaborator with pediatricians, clinical psychologists are also wellversed in the supervision of mental health practitioners thereby providing another facet of their unique ability to influence and address the gaps in pharmacological services for children and adolescents with mental health disorders. Both publically and professionally, there is a great deal of concern in the use of psychotropic medication with children and adolescents. With the rise in availability of psychotropic medication, an increase in the concern of safety has also been witnessed. A more recent example of these concerns has been demonstrated in the case of selective serotonin reuptake inhibitors (SSRIs). In the last decade, public

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and professional awareness of the potential adverse side effects of increased suicidality in children and adolescents taking SSRIs has led to decreased use in these medications in children and adolescents, which has arguably led to an increase in the use of antipsychotics to treat mental health symptoms in children and adolescents – an increase that has been accompanied by much fervorous debate (Brown & Sammons, 2002). This example is but one of many that highlight the fact that the pharmacological treatment of mental health disorders in children and adolescents often lacks the empirical support to safely and ethically guide practice. Rather, it appears that prescription of psychotropic medication in child and adolescent populations often does more to inform our research agenda than does research guide clinical practice (Spetie & Arnold, 2007; Vitiello, 2007). This point has sparked much concern and debate. Several factors, including most notably issues of ethics, account for the paucity of research in the pharmacological treatment of children and adolescents with mental health disorders (Spetie & Arnold, 2007; Vitiello, 2007). Although major efforts to increase the evidence base for psychotropic use in children and adolescent are increasingly underway, the current state of affair in clinical practice is one that cannot simply wait given that the prevalence and complexity of presentations of child and adolescent mental health are increasing (Tolan & Dodge, 2005). It is no wonder that, in the absence of research, the use of psychotropic medication in children and adolescents has grown with occasional deleterious results. In the absence of research to dictate the specific use of treatment modalities for a particular population, practitioners should employ valid and systematic measurement strategies to determine if the treatment as administered is effective (McFall, 1991). In addition, “The data on hand (from group-based studies) inform on drug effects at the group mean level but not on how [to] individualize treatment according to patient characteristics” (Vitiello, 2007, p. 9). It is fundamentally ethical and individually informative to measure the effects of treatment – in this case, psychotropic medication – because the use of pschotropic medication in children and adolescents is typically not well-informed by research and because, despite overall group-level data to support the efficacy of a particular medication, there is no a priori manner to determine the effectiveness of psychotropic medication for any individual child or adolescent. However, this is typically not the case in community practice where the initial and ongoing uses of psychotropic medications are not based upon a valid and systematic measurement. Rather, initiation and changes to medication regimens appear to be primarily based upon retrospective recall of caregivers which has been found to be highly suspect due to factors including accuracy of memory (Finkel & McGue, 1993) and biases often inherent in caregivers of children and adolescents with mental health disorders (Chronis et al., 2007). In summary, the lack of child psychiatrists often leads to the informal diversion of children and adolescents with mental health disorders to pediatricians. However, pediatricians often lack the expertise to assess and treat mental health disorders. Clinical psychologists possess expertise in the assessment and treatment of mental health disorders and in the supervision of other mental health practitioners. In addition, the need for systematic and valid measurement of the effects of psychotropic

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medication in children and adolescents is undeniable. Principles of measurement and treatment are embodied in the training and practice of clinical psychology. For these two latter reasons, clinical psychologists are poised to serve a unique role in the pharmacological treatment of children and adolescents with mental health disorders. Thus, it is logical that the two fields of clinical psychology and pediatrics can serve a complementary relationship with each other to meet the treatment needs of children and adolescents with mental health disorders. Finally, most mental health services are provided by professionals other than clinical psychologists. Thus, clinical psychologists must develop means to appropriately supervise and engage doctoral- and master-level therapists in the process of collaboration with pediatricians toward informing the prescription practices of children and adolescents with mental health disorders. There are several reasons why this complementary relationship makes good sense. It is likely that most pediatricians, clinical psychologists, and master-level therapist would not engage in the necessary rigorous training to be able to adequately serve a hybrid role of providing psychosocial and pharmacological treatments (Gutierrez & Silk, 1998). It is also worthwhile to note that many mental health disorders are more effectively treated using combined psychosocial approaches and pharmacological approaches (Pampallona, Bollini, Tibaldi, Kupelnick, & Munizza, 2004; Pelham et al., 2000), and that the sequencing of psychosocial and pharmacological treatment components may be important to outcomes (Pelham, 1999; Schmidt, Wagner, & Kiesler, 1999). Finally, because clinical psychologists and other mental health therapists see persons with mental health disorders on a much more frequent schedule (e.g., once per week) than do pediatricians for typical medication management, the former professionals are in a much better position to assess ongoing response to treatment, both psychosocial and pharmacological. Based upon the arguments above, the suggested guiding framework for the role of clinical psychologists (who do not possess prescription privileges) in the pharmacological treatment of children and adolescents is that of a complementary collaborator. By extension, those mental health practitioners who are supervised by pharmacologically trained clinical psychologists would also serve a complementary role to pediatricians in the pharmacological treatment of children and adolescents with mental health disorders.

A Guiding Framework for Pharmacological Treatment of Mental Health Disorders As previously mentioned above, a major role of clinical psychologists involves supervision of other mental health practitioners. Various models of supervision currently have been explicated and are often derived from a particular theoretical orientation that guides the therapeutic process (Bernard & Goodyear, 2004). Given the relatively recent emergence of interest in pharmacological training for clinical psychologists, models that inform and guide the supervision process as it relates to

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the role of mental health practitioners and pharmacology are lacking. The goal of this chapter is to provide the basis for such a model. The rationale for the model presently proposed stems from the fact that most mental health practitioners are doctoral- or master-level trained professionals with likely very little training in issues related to pharmacology. It is highly improbable that any degree of proficiency in pharmacological issues can be gained vis-à-vis the supervision process, even in cases when the supervisor is very knowledgeable and/ or trained in pharmacology. Thus, any proposed supervision model must provide for a methodology that facilitates pharmacologically trained clinical psychologist to supervise nonpharmacologically trained mental health practitioners in a manner wherein nonpharmacologically trained mental health practitioners (a) do not require extensive degrees of training and experience in pharmacology and (b) can viably serve a complementary role to pediatricians vis-à-vis supervising pharmacologically trained clinical psychologists. These goals can be met when highly structured, systematic, and objective methods are employed. Such a concept is not novel and is one of the rationales behind highly structured assessment and diagnostic devices. The following framework has several important characteristics. It is well grounded in the existing training and practice principles of the scientist–practitioner model, which arguably and implicitly dictate a skeptical, data-driven approach to assessment and treatment. The framework is also very well aligned with current cognitive and behavioral methods ubiquitously utilized by clinical psychologists. Finally, the objective, data-driven nature of the framework allows for a necessary degree of clarity in the supervision of doctoral- and master-level mental health practitioners who are not trained in pharmacological treatments for mental health disorders. The objective quality of the framework may perhaps be its most attractive aspect, given that most mental health service providers are not pharmacologically trained clinical psychologists. Thus, for many clinical psychologists, there is a need for not only a guiding framework to help serve a complementary and collaborative role with pediatricians but also an efficient manner of supervising practitioners with less pharmacological training for the same purposes. It is critically important that any framework that guides the decision-making process in the use of psychotropic medication includes a predominance of prospective measurement. A stereotypic medication procedure in community practice begins when the pediatrician determines the need for a medication trial and chooses a medication based upon a number of factors such as severity of symptoms, clinical experience, and potential contraindications. According to common practice parameters espoused by groups such as the American Academy of Pediatrics and The American Academy of Child and Adolescent Psychiatry (Pliszka, 2007; Pliszka et  al. 2003), pharmacological treatment of child and adolescent mental health disorders should be conducted in a fashion that includes regular monitoring of symptoms and side effects, as well as timelines for follow-ups for different medication types. Oftentimes, follow-up appointments consist of the pediatrician asking the caregiver and/or the child or adolescent if the medication has been effective and if any side effects are present. In essence, this brief follow-up requires persons to (1) retrospectively recall data across days and weeks, different settings, and different persons and, (2) to validly summarize that retrospectively recalled data into summary

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statements that convey accurate information to the prescribing physician and will be used to make decisions about continuation or discontinuation of medications and doses. This process implicitly requires a great deal of veracity on the part of the reporter, which for several reasons is highly unreliable due to several factors including, but not limited to, (1) the limitations of retrospective recall, (2) conscious reporter biases, (3) cognitive abilities and states of reporters that include limited insight and cognitive capacity of children and adolescents (e.g., Owens, Goldfine, Evangelista, Hoza, & Kaiser, 2007), (4) potential distortion by parents due to stress and emotional symptoms part and parcel of having a child or adolescent with a mental health disorder (Chronis et  al., 2007), and (5) missing or invalid summarized data from persons not present at the follow-up appointment (e.g., teachers, other caregivers). Thus, it is likely that inaccurate impressions of medication response are the rule rather than the exception, resulting in pediatricians’ decisions being potentially less than optimal. It is possible that, given enough time and trials, a pediatrician could arrive at a reasonable medication regimen for a child or adolescent. However, the question of time and resources is very important and cannot be overlooked. There is no guarantee that this iterative process would result in a timely conclusion and would thereby often cause children and adolescents to spend months of their lives without the most optimal care. In addition, this iterative process that is dependent upon retrospective recall can be exponentially more difficult when multiple medications are introduced into the regimen. For a child and adolescent who is engaged in concurrent psychosocial treatment, it can lead to a great deal of frustration for the patient as well as the mental health therapist who may be unable to make determinations regarding the effectiveness of treatment because of the lack of a systematic approach to medication decisions. The guiding framework presented herein addresses the above-stated concerns and allows for clarity in the collaboration between clinical psychologists and pediatricians, while giving a much more objective means for making iterative medication decisions, especially when mental health therapists without substantive pharmacological training are involved in the care of children and adolescents with mental health disorders. Any framework must involve reducing the need for retrospective recall by increasing the use of prospective recall, providing a means for validly gauging changes across time and settings using a common measurement system, and increasing the degree of internal validity which will allow for having greater confidence in attributing any changes in functioning to changes in treatment regimens. There are clear distinctions that need to be made between clinical psychologists who possess training and knowledge in pharmacological treatments for children and adolescents with mental health problems and clinical psychologists who do not. A minority of clinical psychologists who posses psychologists training are able to acquire prescription privileges. For this minority, their interface with pediatricians may be arguably similar to the relationship between psychiatrists and pediatricians. Because their counseling and prescribing practices are likely to be fairly autonomous, the following framework may be more relevantly applied to inform their own prescription practices. However, they may still require interface with pediatricians given that many prescription decisions must be couched in the context of overall medical functioning of children and adolescents, which is most often appropriately

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informed by pediatricians. Clinical psychologists who do possess prescription privileges would still be encouraged to discuss medication decisions with ­pediatricians to ensure that both practitioners are not treating patients in manners that would be contradictory to each other. For those clinical psychologists who possess training in pharmacology but do not practice in a geographical area that allow them to acquire prescription privileges, the following framework is informative as it directly relates to a collaborative relationship between clinical psychologists and pediatricians for the optimal benefit of children and adolescents under their care for mental health problems. Lastly, the following framework is relevant to clinical psychologists – whether or not they possess prescription privileges – who engage in supervision of other mental health practitioners who do not possess training in pharmacological treatment of children and adolescents with mental health problems. The steps of the framework will be discussed as primarily relevant to clinical psychologists who do possess training in pharmacological treatment of child and adolescents with mental health problems but do not possess prescription privileges. The role of the framework in relation to supervision will be discussed thereafter.

Step 1: Determining the Need for Pharmacological Treatment It is quite possible that, given today’s climate of easy access to information (e.g., internet, television, and radio commercials), patients may present with ideas of pharmacological treatments they are interested in pursuing. They may have been referred by their pediatrician with questions concerning the diagnosis and the need for pharmacological intervention. There is no clear standard for determining a need for pharmacological intervention, but decisions are likely to be best when they involve collaboration between treatment providers and patients. Initial assessments should include components that help facilitate decisions and recommendations regarding pharmacological interventions. The diagnosis is a clear starting place, but the severity of symptoms and impairments is also very important to consider. For example, a child who is diagnosed with attention-deficit hyperactivity disorder (ADHD), whose primary difficulty is trouble in paying attention during class, is likely to have different considerations from a child who is also diagnosed with ADHD and is threatened to be expelled from school. In the latter case, the risk of expulsion from school may require that a medication trial begin immediately, whereas the former case may allow for a more conservative approach that begins with evidence-based behavioral management strategies in the classroom. Questions about the pace of progress desired and prognosis given ­different treatment scenarios are vital to consider, as well as a patient’s (and/or caregiver’s) expectations for change. As mentioned above, answers to these questions are often better handled by the mental health provider since the frequency and duration of his or her contact with the patient is often much greater than that of the pediatrician. Thus, it behooves a mental health provider to have a solid understanding of the pharmacological options for specific mental health disorders as well as an appreciation for the logistics of different medications and regimens. For example, knowledge

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of dosing parameters, contraindications, timelines for behavioral effects to be noticed, and potential side effects are some of the key pieces of information and the bases for many patient questions about medication. In this framework, clinical psychologists – whether in supervisory roles or not – are virtually freed from practicing outside the scope of their trainings and licenses, leaving decisions about pharmacokinetics, pharmacodynamics, and other medical-related considerations to pediatricians who are legally qualified to make such judgments. The determination of need for pharmacological treatment must take into consideration the expectations that the patient has for treatment gains, including how much improvement can be expected over what timeframe. Candid conversations between a patient and the mental health provider are highly recommended and should include topics such as whether the patient is making steady progress with psychosocial treatment, if the patient is feeling effective in the process of making changes, whether greater and/or more immediate treatment gains can be facilitated by medication, and if psychosocial treatment has been perceived by the patient or the provider to have achieved a reasonable amount of improvement but more improvement is desired by the patient or provider. Different medications for the treatment of a patient’s symptoms should be considered with the patient’s direct input into the decision. There are several medications that are viable for most given mental health disorders in children and adolescents with ADHD, for example, with stimulants typically considered a first-line pharmacological approach. Thus, beyond symptom presentation, the choice of medication to begin with is often made based upon preferences of prescribing physicians, history of previous medications used to treat similar symptoms, and practical considerations such as whether a parent would like to administer one pill in the morning with the idea of having symptom improvement over a longer period of the day or whether short-acting doses are preferred to dose only in the instances when the child or adolescent needs to demonstrate greater degrees of concentration (e.g., during test-taking situations). Deciding on a few options with the patient and the caregivers is recommended, followed by a discussion with the pediatrician. In instances when a patient is referred from a pediatrician, this discussion may be about changing a medication regimen that is considered by the patient or pediatrician to be less-than-optimally effective. It is also possible that children and adolescents may be presenting for psychosocial treatments after fairly extensive histories of trials with psychotropic medication. Thus, it is important to understand the historical use of psychotropic medication of each patient, including why and when the decisions were made to discontinue a particular type of medication.

Step 2: Developing a Plan for Measurement and Administration of Pharmacological Treatment As mentioned above, the gold standard for determining any drug’s effectiveness is usually a double-blind, placebo-controlled, randomized experiment. Although this

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is highly impractical in most real-world settings and situations, some of the basic principles of this design can be incorporated into a practical framework to offer a better approach to determining the necessity and effectiveness of medication, which includes type and dose of medication. For example, medication conditions can be randomly assigned and persons who are judging the effectiveness of medication can be kept unaware of the type and dose of medication assigned. These factors will allow for a greater ability to detect true differences between medications and doses by minimizing potential biases. When first beginning a collaborative relationship with a particular pediatrician, it will be necessary to spend some time describing the following methodology as it is very unlikely that many pediatricians have encountered such methodology in practice outside of any clinical trials. Clinical researchers at the University at Buffalo, Center for Children and Families recommend a clinical trial of stimulant medication under very strict conditions that employs a daily randomized design where stimulation medication is changed daily according to a predetermined randomized schedule (Comprehensive Treatment for Attention Deficit Disorders, 2010b). However, there are several limitations to the design when utilized outside of the academic-research setting. Primarily, despite their recommendations to randomize medication daily, many pediatricians may be hesitant to actively participate in such a design, often citing that it is not beneficial to change medications daily, as they are very wary of the perceived harm that can be done to a child or adolescent with daily changes in stimulant medication. Whether or not there are data to support pediatricians’ concerns of daily randomization is irrelevant if a pediatrician is unwilling to prescribe under daily randomized conditions. Secondly, pharmacies often do not understand, or are not willing to handle, the request for several pills of different stimulant medications at once, especially given the highly controlled nature of stimulant medication. Third, many medications for child and adolescent mental health disorders require consistent dosing over weeks to determine the effects, thus precluding a daily randomized design. Finally, third-party payers can require a larger out-of-pocket expense from patients for filling several medications at once, despite the fact that there may only be several pills of each medication. Based upon these and other factors, alternative methods will likely need to be employed. Instead of randomizing daily, it is usually much more palatable to pediatricians and parents to randomize weekly if possible, given the dosing requirements of the medication. In the case of medications that require steady dosing for a longer period of time (e.g., 4–6 weeks), weekly randomization is not possible. Regardless of the type of design, the underlying principle that should always be adhered to is that of prospective measurement across conditions, settings, and persons. Questions as to who will complete the measurements, at what times, and over what time periods are very important to determine prior to beginning any regimen. In addition, it is critical to communicate to the pediatrician to only make changes to the regimen – outside of any emergencies – in collaboration with the mental health provider so that decisions can be fully informed from a data-driven perspective. The type of data collected is also critically important. Ratings on each symptom that the medication is expected to impact as well as side effects and general

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impairment data should be collected. This is vital since decisions between ­medications and doses should always consider the degree of improvement in ­symptoms and impairment as well as the degree of any adverse reactions.

Step 3: Implementing the Protocol Once the fundamental decisions concerning types and doses of medication, schedules of administration (e.g., daily randomized, weekly randomized, nonrandomized), and who will complete ratings in what settings and at what times have been made, the protocol can be implemented. Clearly written instructions and copies of ratings should be provided to each person expected to complete the ratings, with instructions on how and when to return the completed ratings. A baseline period should be implemented first prior to any medication or changes in medication to provide a comparison condition once treatment conditions begin to change. This baseline period should allow for valid comparison to treatment with active medications.

Step 4: Evaluating the Data and Making Iterative Decisions As the ratings are completed and returned, they can be analyzed using simple means and standard deviations within conditions (e.g., means and standard deviations of all days on a particular dose of a particular medication compared to all other particular doses of particular medications) and comparison of effect sizes. Graphing data (e.g., ratings of each symptom by daily rating) can also be very helpful in having an illustrative way to demonstrate response to medication. Once the data are processed into meaningful statistics and graphs, collaboration between the mental health provider and the pediatrician can be formed with a much better informed process for making treatment decisions. These tentative decisions can then be shared with the patient (and patient’s caregivers) who should fully understand the impact of pharmacological treatment on their symptoms and impairment and have input as to how to proceed with treatment.

Supervision of Nonpharmacologically Trained Mental Health Professionals The following supervision model is provided to offer guidance to pharmacologically trained clinical psychologists in the supervision of practitioners who do not possess pharmacological training. Unlike graduate programs that may be more centrally focused on a particular theoretical orientation, supervision of mental health professionals in practice is likely to involve a greater variety of supervisees.

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It is possible that supervisors will be supervising mental health practitioners with a variety of backgrounds, education, training, and years in practice. Regardless of the variety of supervisees, the fundamental commonality among them is the need for education, training, and supervision as it pertains to medication treatments and the collaboration with prescribing physicians. Skovholt and Ronnestad (2003) posit a model of professional development that includes several phases of development, including a novice professional phase, an experienced professional phase, and a senior professional phase. Although pharmacologically trained clinical psychologists may supervise mental health professionals at each of these phases, it is likely that the supervision process may resemble components of the advanced student phases, wherein mental health practitioners may experience a sense of circumscribed studentship, a phase that may include feelings of having to perform correctly, and a more conservative, cautious, and thorough approach to, in this case, medication issues in the therapeutic process. As supervisees progress in their knowledge and skill of integrating medication matters into their practice, supervision may evolve to collaboration with the pharmacologically trained clinical psychologists. The concept that professional development vis-à-vis the supervisory experience should be intentional (Granello, 2000) supports the employment of a specified training model to promote competency in medication matters as it relates to mental health professionals and treatment of children and adolescents. The process of engendering growth of mental health practitioners from novice professionals to more experienced professionals in the area of medication treatments may be best facilitated by considering Bloom’s Taxonomy (Bloom, Englehart, Furst, Hill, & Krathwohl, 1956) as applied to professional development by Granello (2000) wherein six competencies are explicated: Knowledge, Comprehension, Application, Analysis, Synthesis, and Evaluation. A full exploration of Granello’s (2000) application of Bloom’s Taxonomy is beyond the scope of this chapter and the reader is encouraged to consult the article. Each of these areas of Granello’s model will be applied to the present model of supervision of nonpharmacologically trained mental health practitioners and their professional development toward collaborators with pediatricians in the treatment of children and adolescents with mental health disorders. Knowledge. Supervised mental health professionals will require basic knowledge about the logistics of different medications and regimens, including medications approved or typically utilized for particular conditions (e.g., stimulants for ADHD), knowledge of dosing parameters, contraindications, timelines for behavioral effects to be noticed, potential side effects, pharmacokinetics, and pharmacodynamics. It is recommended that basic readings on these topics include a variety of sources, including peer-reviewed articles of scientifically studied effects of medications and the combination of psychosocial treatments and medications for particular populations, Food and Drug Administration approved factsheets on specific medications, and the Prescription Drug Reference for Behavioral Health Practitioners. Reading brief reports and newsletters may also be a reasonable way to keep up with the latest scientific data. As with any scientific literature, the data

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are constantly forthcoming and both supervisors and supervisees are encouraged to stay current with the latest scientific reports. In order to build sound knowledge bases in their supervisees, supervisors are encouraged to create syllabi of required readings for new supervisees and to provide access to other sources (e.g., journals, newsletters) for continuing education of supervisees. Supervisors should also engage in regular didactic sessions with supervisees to discuss medication and psychosocial assessment and treatment topics. Attendance at local grand rounds or conferences may also help bolster a supervisee’s pharmacological knowledge. Comprehension.  Supervisees who conduct initial assessments should be fully capable of inquiring about medication history and current regimens. A basic knowledge of medications and their uses will also be beneficial in initial and ongoing assessment. Children, adolescents, and parents are sometimes poor reporters of current and historical treatment regimens. Although structured forms and interviews can be utilized to gather this information, a sound understanding of medications and typical uses is highly useful in conducting assessments. Supervisors are encouraged to help supervisees prepare for gathering relevant information on medication issues during the initial assessment phase. Such information should include but is not limited to historical and current medication use, compliance with prescribed medication, reasons for changes in medication, perceived effectiveness of medications, timelines for administration and discontinuation of each medication, adverse side effects, and key stakeholders’ (e.g., parents, child/adolescent, teachers) perceived need for medication. Many persons have preconceived beliefs and ideas about medication use. Some parents may be open to medication use, whereas others may have already concluded that they are not interested in medications for their children or adolescents. In addition, adolescents often possess their own desires for treatment or medication, which must be accounted for given the fact that many adolescents do not comply with medication regimens for various reasons. Once the initial assessment is concluded, supervisors and supervisees should collaborate in treatment planning. Although supervisees may be fully capable of creating a psychosocial treatment plan with input from the child/adolescent and parent, medication considerations in the treatment plan should be discussed (see Sect. 1.1). Supervisors and supervisees should have initial discussions as to whether medication appears to be immediately necessary or if psychosocial treatments appear to be adequate in addressing the presenting problems, and if current medication regimens appear to be effective. Parents may also have clearly expressed an interest in pursuing medication treatment options in addition to psychosocial treatment. In any case, a supervisee should have clear ideas of the treatment plan when discussing it with the child or adolescent and parent. All options should be explored and opinions may be offered by the supervisee as to what the most treatment should consist of and, if relevant, in what sequence (e.g., no medication necessary, psychosocial treatment and reassessment of need for medication, concurrent psychosocial treatment and medication).

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Application and analysis.  Granello (2000) discussed the competencies of application (e.g., use of research to guide therapeutic decisions) and analysis (e.g., need to analyze client history, interaction effects of presenting problems in making treatment decisions, and positive and negative artifacts of interventions on secondary functioning). A firm grasp of the scientific literature on pharmacological treatment of children and adolescents is essential to understand and utilize these competencies. However, it is the application and analysis of the knowledge of the scientific literature that is necessary to achieve this level of professional development. Questions such as, “What symptoms and impairments of this patient support the use of this medication?;” “What side effects might be produced from the use of this medication?;” and “Are the side effects likely to be adverse or beneficial?” should be considered when revising a treatment plan. For example, a child who is diagnosed with ADHD and is overweight may benefit from a stimulant medication not only for the primary symptoms of ADHD, but also secondarily from appetite suppression which, in this case, might positively affect weight. Ongoing discussions between supervisors and supervisees are likely to yield improvements in this area of professional development. Synthesis.  For the competency of synthesis, Granello (2000) suggests the goal of conceptualizing the case using all relevant information and employing necessary intervention components. Consideration of use of medications should always be placed in context of psychosocial treatments, making it necessary to fully explore the options of psychosocial treatment alone, combined psychosocial and pharmacological treatment, and the sequencing of treatment components. If the treatment recommendations include medications, it will be necessary to develop a plan (see Sect. 1.2). Once the treatment plan has been discussed and agreed upon by the child or adolescent and parent, a coordination of care letter should be forwarded to inform the pediatrician of the recommended course of treatment. In consultation with the pediatrician, the type(s) and dose(s) of medication(s) should be clarified, and the plan should then be implemented (see Sect. 1.3). Evaluation.  Assessment of psychosocial and/or medication effectiveness and side effects along with subsequent recommendations to pediatricians is a key step in the process. For children and adolescents who are not receiving medication, assessment of effectiveness of psychosocial treatments is a valuable approach to understanding whether medication may be beneficial at some point in the treatment process. It is important to periodically update the pediatrician in order to fully collaborate on whether the need for medication is indicated at any point in the treatment process. For children and adolescents who are being actively medicated, evaluation of the effects of medication and side effects is crucial to guide treatment decisions (see Sect. 1.4). The acquisition of the competency of evaluation translates into the ability to critically reason and inform the overall treatment process in a manner that takes all relevant information into account, places medication recommendations and decisions in the context of psychosocial treatments, and uses data-driven approaches to develop and adjust treatments as necessary to achieve positive treatment outcomes.

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Certainly, the use of a data-driven framework for medication decision making enhances the ability of mental health practitioners to develop each of the competencies of Granello’s (2000) application of Bloom’s Taxonomy (Bloom et al., 1956). The development of these professional competencies is likely to be best facilitated with structured approaches to supervision that include individual and group ­supervision, case presentations, and didactic sessions and utilize structured methodologies in the assessment of overall, and especially in this case, medication effects in the treatment of children and adolescents with mental health disorders.

Summary A brief discussion and rationale for a data-driven model of assessment of medication effects was provided, followed by a supervisory model in which clinical psychologists with pharmacological training could facilitate professional development in supervisees toward the goal of serving as collaborators with pediatricians in the pharmacological treatment of children and adolescents with mental health disorders. The need for such models is greater than ever before and that need will likely continue to grow as the number of professionals with both mental health training and prescription privileges continues to shrink or fails to grow commensurately with the need for services. Until such a time that systemic fixes to this problem are employed (e.g., prescription privileges for appropriately trained clinical psychologists), mental health practitioners must continue to collaborate with primary care physicians in order to fill the gaps. Thus, models of supervision and collaboration should continue to be developed, posited, and evaluated for their effectiveness.

References Bernard, J. M., & Goodyear, R. K. (2004). Fundamentals of clinical supervision. Needham Heights: Allyn & Bacon. Bloom, B. S., Engelhart, M. D., Furst, E. J., Hill, W. H., & Krathwol, D. R. (1956). Taxonomy of educational objectives: The classification of educational goals. New York: David McKay. Brown, R. T., & Sammons, M. T. (2002). Pediatric psychopharmacology: A review of new developments and recent research. Professional Psychology: Research and Practice, 33(2), 135–147. Bureau of Labor Statistics, U.S. Department of Labor. (2010). Occupational outlook handbook, 2010-11 edition. Retrieved from http://www.bls.gov/oco/ocos067.htm Chronis, A. M., Lahey, B. B., Pelham, W. E., Williams, S. H., Baumann, B. L., Kipp, H., et al. (2007). Maternal depression and early positive parenting predict future conduct problems in young children with attention-deficit/hyperactivity disorder. Developmental Psychology, 43(1), 70–82. Comprehensive Treatment for Attention Deficit Disorders. (2010b). Guide to an outpatient medical assessment. Retrieved from http://ccf.buffalo.edu/pdf/MedAsses.pdf Finkel, D., & McGue, M. (1993). Twenty-five year follow-up of child-rearing practices: Reliability of retrospective data. Personality and Individual Differences, 15(2), 147–154. Fox, H. B., McManus, M. A., Diaz, A., Elster, A. B., Felice, M. E., Kaplan, D. W., et al. (2008). Advancing medical education training in adolescent health. Pediatrics, 121(5), 1043–1045.

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Gragg, R. A. (2010). Mental health services and schools: A necessary collaboration. The Brown University Child and Adolescent Behavior Letter, 26(2), 1–6. Grandin, L. D., & Blackmore, M. A. (2006). Clinical psychology graduate students’ opinions about prescriptive authority: A discussion of medical versus psychological training models. Journal of Clinical Psychology in Medical Settings, 13(4), 403–410. Granello, D. H. (2000). Encouraging the cognitive development of supervisees: Using Bloom’s taxonomy in supervision. Counselor Education and Supervision, 40(1), 31–46. Gutierrez, P. M., & Silk, K. R. (1998). Prescription privileges for psychologists: A review of the psychological literature. Professional Psychology: Research and Practice, 29(3), 213–222. Harpaz-Rotem, I., Leslie, D. L., Martin, A., & Rosenheck, R. A. (2005). Changes in child and adolescent inpatient psychiatric admission diagnoses between 1995 and 2000. Social Psychiatry and Psychiatric Epidemiology, 40(8), 642–647. McFall, R. M. (1991). Manifesto for a science of clinical psychology. The Clinical Psychologist, 44(6), 75–88. Owens, J. S., Goldfine, M. E., Evangelista, N. M., Hoza, B., & Kaiser, N. M. (2007). A critical review of self-perceptions and the positive illusory bias in children with ADHD. Clinical Child and Family Psychology Review, 10(4), 335–351. Pampallona, S., Bollini, P., Tibaldi, G., Kuplenick, B., & Munizza, C. (2004). Combined pharmacotherapy and psychological treatment for depression. Archives of General Psychiatry, 61, 714–719. Pelham, W. E. (1999). The NIMH multimodal treatment study for attention-deficit hyperactivity disorder: Just say yes to drugs alone? Canadian Journal of Psychiatry, 44, 981–990. Pelham, W. E., Grnagy, E. M., Greiner, A. R., Hoza, B., Hinshaw, S. P., Swanson, J. M., et al. (2000). Behavioral versus behavioral and pharmacological treatment in ADHD children attending a summer treatment program. Behavioral Science, 28(6), 507–525. Pliszka, S. R. (2007). Pharmacologic treatment of attention-deficit/hyperactivity disorder: Efficacy, safety, and mechanisms of action. Neuropsychology Review, 17(1), 61–72. Pliszka, S. R., Lopez, M., Crismon, M. L., Toprac, M. G., Hughes, C. W., Emslie, G. J., et  al. (2003). A feasibility study of the children’s medication algorithm project (CMAP) algorithm for the treatment of ADHD. Journal of the American Academy of Child & Adolescent Psychiatry, 42(3), 279–287. Schmidt, J. A., Wagner, C. C., & Kiesler, D. J. (1999). Psychometric and circumplex properties of the octant scale impact message inventory (IMI-C): A structural evaluation. Journal of Counseling Psychology, 46(3), 325–334. Skovholt, T. M., & Ronnestad, M. H. (2003). The hope and promise of career life-span counselor and therapist development. Journal of Career Development, 30(1), 1–3. Spetie, L., & Arnold, L. E. (2007). Ethical issues in child psychopharmacology research and practice: Emphasis on preschoolers. Psychopharmacology, 191(1), 15–26. Tolan, P. H., & Dodge, K. A. (2005). Children’s mental health as a primary care and concern. American Psychologist, 60(6), 601–614. Vitiello, B. (2007). Research in child and adolescent psychopharmacology: Recent accomplishments and new challenges. Psychopharmacology, 191(1), 5–13.

Index

A Access to health care, 98–100 American Indian/Alaska Native, 96 Anorexia, 176 Antidepressants, 7, 40, 41, 43, 58, 59, 87, 88, 125, 126, 141, 147, 164, 176, 177, 186, 189, 191, 192, 213, 214, 276 Anxiety, 4–6, 11, 12, 14, 44, 54–56, 58–60, 62, 108, 110, 111, 123–125, 127, 128, 147, 153–165, 169, 170, 172, 176–178, 189, 190, 197, 204–207, 211, 213, 214, 216–217, 220–222, 240, 241, 254, 258 B Binge, 168, 175–177 Biopsychosocial model, 18, 40, 200, 205, 251, 252, 264, 283 Bulimia, 175–177 C Certificate of Prescriptive Authority in Louisiana, 273 Chronic illness, 53, 186, 188, 199, 212, 253 Chronic visceral pain, 218 Clinical psychologist, 63, 103, 106, 114, 144, 183, 187, 192, 285–293, 295, 296, 299 Cognitive behavioral therapy, 56, 165, 167, 177, 191, 210, 260 Collaboration, 8, 14, 17–32, 39–46, 49–55, 61, 63, 79, 95, 101, 104, 106–107, 111–117, 121, 129, 136–139, 153–165, 167–175, 185, 188, 213, 221, 233–244, 249–267, 274, 276–283, 286, 289, 291, 292, 294–296, 299

Collaboration with physicians, 39–46, 53, 252, 266, 276, 279 Collaborative care, 69, 72–76, 107, 140–150, 169, 173, 250, 251, 253, 256, 258, 260, 262, 264, 265, 271–283 Collaborative practice, 95–117, 256, 263, 277 Collaborative prescribing, 24, 95, 296 Comprehensive care, 39, 53, 156, 173, 283 Core values, 277, 278, 283 D Depression, 4, 5, 7–13, 44, 86–88, 113, 122, 124, 135, 141, 142, 146–149, 169, 170, 176, 177, 185–187, 189–193, 207, 213, 214, 217, 220, 221, 237, 240, 241 Diabetes type 1, 184, 189–192 Diabetes type 2, 85, 191 Dieting, 86, 88, 111, 120, 172, 184, 186, 189, 192, 212 Dopamine, 144, 175–177, 187 E Eating, 45, 85–88, 167–178, 191, 194, 209, 219, 221, 223 Endocrinology, 167 F Family therapy, 11, 13, 44, 60, 87, 88, 90, 156, 161, 165, 167, 168, 173, 183, 186, 196, 210, 212, 259, 263 Frontier rural mental health, 99, 104 Functional gastrointestinal disorders, 200, 206, 210, 221

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302 H Health belief model, 184–186 Health psychologist, 183, 184, 187–188, 206 Hyperalgesia, 224 I Indian Health Service, 95–117, 155 Inflammatory bowel disease (IBD), 207, 220 Integrated primary care, 23, 24 Internship training, 250, 251, 255 L Louisiana’s Medical Psychology Practice Act, 51, 273 Louisiana’s Prescriptive Authority Law, 51, 272 M Medical psychologist, 6–14, 20, 50–64, 95, 97–100, 103–110, 113, 114, 117, 119–125, 129, 155, 183, 188–192, 194–197, 199, 213, 221, 272–274, 276, 277, 280, 283 Medical psychology, 7–11, 49–64, 95, 97–100, 102–103, 105, 107, 111, 113, 116, 117, 119–130, 187, 213–217, 244, 273, 282 Medical Psychology Practice Act, 51, 273 Medication, 3, 17, 37, 51, 69, 95, 120, 135, 154, 169, 183, 205, 233, 258, 271, 286 Medication monitoring, 137, 148, 150, 173 Medications and psychotherapy, 7, 47, 122, 169, 176 Medicine-psychology collaborative roles, 63 Metabolic issues, 53, 184 N Native American, 95–98, 104, 106–110, 115–117, 189 O Obsessive-compulsive, 4, 58, 69, 70, 153, 157, 161, 177, 178, 243 P Pediatric medical psychology, 64 Pediatrician, 3, 17, 41, 49, 71, 95, 121, 135, 153, 184, 199, 233, 277, 285 Pediatrics, 3–15, 21–23, 37, 49–63, 70, 95, 119–130, 135, 153–165, 167, 184, 199, 213–217, 236, 249, 277, 289

Index Pediatrics-child psychology collaborative roles, 63, 206–213 Pharmacologically trained psychologists, 6–10, 12, 14, 17–32, 141, 142, 144, 146, 148, 153–165, 169, 171, 173, 175, 178, 183, 185, 233–244, 276, 277 Physician-psychologist collaborative roles, 290 Postdoctoral master’s degree in clinical psychopharmacology, 113, 273, 275, 276 Postdoctoral training, 6, 17, 18, 29, 120, 155, 251, 253, 255 Posttraumatic stress disorder (PTSD), 10, 14, 109, 110, 157, 158, 160–164, 220, 276 Prescribing psychologist, 6, 19, 22, 24, 27, 32, 37, 38, 95, 99–102, 104–106, 110, 115–117, 155, 283 Prescription practices, 119, 287, 289, 291 Prescription privileges, 37–39, 100, 102, 103, 105, 243, 275, 283, 286, 289, 291, 292 Prescriptive authority, 6–8, 11, 14, 17–21, 24, 29, 30, 51, 98–105, 116, 121, 187, 194, 271–277 Primary care, 3, 4, 6, 19, 22–24, 28, 29, 38, 40, 49, 72, 76, 82, 92, 95, 101, 102, 107, 108, 116, 135, 138–139, 172, 174, 193, 206, 211, 222, 249–267, 283, 285 Primary care providers, 3, 4, 38, 101, 116 Primary care psychology, 251, 252 Professional issues in psychology, 23–30 Psychiatry, 17, 21, 22, 28, 31, 39, 95, 98, 101, 116, 135, 158, 167, 187, 233–235, 256–260, 264, 265, 285, 290 Psychology training, 251–252, 255, 256, 265–267 Psychopharmacology, 6, 7, 9, 17–20, 24, 29, 38, 39, 47, 72, 83, 88, 91, 93, 95, 101, 102, 104, 113, 115, 120, 121, 137, 150, 155, 171, 183, 190, 192, 193, 196, 233, 240–244, 259, 271–283 Psychopharmacology training, 11, 93, 104, 121, 243, 244, 274 Psychotherapy, 7, 10–12, 18, 19, 27, 28, 30, 47, 102, 120, 122, 123, 128, 135, 136, 139, 141, 145, 148, 154, 155, 157, 159, 161–165, 168, 169, 175, 176, 195, 196, 205, 217, 254, 255, 257, 260, 274, 276, 283 PTSD. See Posttraumatic stress disorder Purge, 168, 175–177

Index R Ron His Horse Is Thunder, 114 RxP, 137, 139, 141, 144–149, 155, 159 S Sample curricula, 275–276 Serotonin, 10, 59, 125, 126, 176, 177, 214–217, 244, 287 Serotonin reuptake inhibitor (SSRI), 10–12, 59, 110, 125, 127, 176, 177, 191, 193, 194, 214, 217, 287, 288 Shortage of pediatricians, 154–156, 165, 277 SSRI. See Serotonin reuptake inhibitor Standing Rock psychology internship, 114 Standing Rock reservation, 111–115 Starvation, 167, 175, 177 Supervision, 21, 100–103, 105, 107, 116, 129, 250, 255, 257–262, 265, 266, 285–299

303 T Therapy, 7, 11–14, 23, 24, 38, 39, 43–45, 56, 60, 83, 87, 88, 90, 111, 116, 136, 156, 157, 161, 162, 164, 165, 167–169, 172, 173, 176, 177, 183, 186, 189, 191, 192, 195, 196, 210, 212, 213, 222, 257–260, 263, 265, 266, 287 Training, 3, 17, 37–39, 49, 72, 95, 119, 135, 154, 167, 183, 196, 205, 233, 249, 251–267, 271–283, 285–299 Turtle Mountain reservation, 111–113 W Weight, 10, 43, 88, 93, 104, 110, 126–128, 141, 168, 171, 172, 174, 176–178, 191, 194, 214, 216, 220, 298