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Problem:
Psychosocial and psychiatric problems make up a substantial proportion of primary care pediatric visits, yet remain under-identified and under-attended. This project seeks to increase pediatricians’ abilities to identify, treat, and refer children and families with these problems.
Goals and Objectives:
Goal 1: Enhance the skills of pediatric primary care providers in the diagnosis and management of behavioral disturbances
Objective 1: To obtain information from child, parent, family, and other professionals with sensitivity, accuracy, and thoroughness.
Objective 2: To implement several different treatment modalities in a family framework, especially counseling, behavioral management, and psychopharmacology.
Goal 2: Increase awareness and skills regarding normal development, developmental disabilities, psychophysiologic disorders, psychopathology, "difficult" patients, and families from different backgrounds.
Objective 1: To enhance effectiveness in caring for patients from a variety of cultural/ethnic backgrounds, and to cope with the stresses of the profession
Objective 2: To assist families struggling with normal developmental hurdles, physical illness, developmental disability, or psychophysiologic disorder.
Goal 3: Foster positive attitudes about caring for children with these problems and about collaborating with mental health professionals in case management.
Objective 1: To differentiate normal from pathological reactions at different developmental stages and to make appropriate, effective referrals to mental health and community resources.
Objective 2: To collaborate smoothly with child psychiatry and other mental health professionals in patient care.
Methodology:
Through case-oriented group discussions, participants receive training in the prevention, recognition, and management of common problems of children at various developmental stages and in the differentiation of normal from pathological functioning in child and family. The program uses a stress and coping paradigm which is applied to preparing children for office procedures, helping them manage pain and anxiety, facilitating adjustment to acute and chronic illnesses, managing children with behavioral adjustment problems and families with adaptational problems and helping families cope with complications, such as hospitalization, death, and dying. The issues of screening for developmental disabilities and assessing the child with suspected delay are also covered. The approach incorporates preventive psychosocial management of child and family with disabling conditions, management of families and children with problematic reactions, and participation on the multidisciplinary teams that are required for optimal care of the disabled. Training also focuses on developing understanding of the roles of psychological or behavioral factors in the etiology or exacerbation of physical disease. Treatment modalities for psychophysiologic disorders, with emphasis on behavioral management, relaxation-imagery, and counseling for child and family, are discussed. Cases involving “difficult” patients and issues facing poor and/or minority families are regularly presented.
Coordination:
All behavioral/developmental pediatricians at the University of Michigan participate, including co-moderate Lozoff. Co-moderator Krasnow is affiliated with the Department of Psychiatry. Group members provide important links with Title V programs. For instance, Sheila Gahagan, as President of the Michigan Chapter of the American Academy of Pediatrics, works closely with the medical director of the Michigan CSHCN program to ensure that these children have ongoing general pediatric care.
Evaluation:
Evaluation occurs at several levels: 1) the individual session, 2) participant attitudes and behavior in identifying behavior and development problems and in making consultations or referrals to schools, child psychiatry, psychology, behavioral pediatrics, etc., 3) feedback from participants toward the end of each year, and 4) participant interest in staying involved the COR group.
Experience to Date:
This year’s sessions have again been a combination of topic- and case-based discussions, with case sessions predominating. The group focused on chronic illness for most topic sessions, with 3-4 sessions involving live interviews with families where chronic illness or disability is the main concern. Two families were interviewed in fall, 2004 and one in spring, 2005. The idea has been to consider a range of relevant issues, such as impact on child, sibling, parent, coping strategies, resources in the community, end of life, palliative care, and grief and loss. The group discussed Leora Cuttner’s teaching video on palliative care. Some case discussions have drawn on the Journal of Developmental and Behavioral Pediatrics Special Issue Supplement: Challenging Cases, Vol. 25, October 2004, but most such sessions are devoted to families and children cared for by group members. In addition, the group had a potluck dinner to watch and discuss “Spellbound,” a documentary that brought up a number of issues related to children’s development and parental involvement. This year’s group consists of 11 primary care pediatricians, 1 family practitioner, 3 behavioral/developmental pediatricians and 1 pediatric psychologist. A behavioral/developmental pediatrician and a child psychiatrist moderate the group. Average attendance is 12 members, meeting 1 ½ hours every other week throughout the year, except during July and August and the end of December, for a total of 22 sessions this year.
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