Journal Article Annotations
2022, 1st Quarter
Annotations by Jeylan Close, MD
Pediatric consult-liaison (C-L) psychiatry lacks national guidelines on training requirements, in contrast to adult C-L psychiatry. The American Academy of Child and Adolescent Psychiatry (AACAP)’s Physically Ill Child Committee (PICC) developed a special interest group that recommended core competencies for pediatric CL training based on expert consensus, published in 2019. Meadows et al. in this publication describe how the same group from PICC conducted a needs assessment survey about pediatric C-L educational resources, materials, barriers, and current training experiences. A needs assessment survey was emailed to the PICC committee listserv, which includes over 200 child and adolescent psychiatrists (CAPs), mostly located throughout North America. They received a response rate of 28%, with a total of 39 responses. There was wide variability in the training programs, including the amount of faculty time available, number of consults per week, and number of CAP fellows per year. From the survey respondents, 41% of CAP fellows receive C-L training within a children’s hospital and 24% partially within an inpatient children’s hospital. About half of the programs reported having formal didactics as part of the curriculum, with most reporting doing bedside teaching (32/39) and informal didactics (28/39). Identified barriers to formal education include lack of available teaching time and service obligations. All respondents indicated that good quality standardized learning modules on common topics would be useful. The topics most identified as useful included psychiatric complications of medical illness, catatonia, autoimmune encephalitis, and delirium.
Strength and weaknesses:
A limitation of the study is that they restricted the needs assessment survey to the PICC listserv—which included members from each North American CAP training program—but may have excluded some relevant potential responders. The authors had a goal of receiving a response from a faculty member at each of the North American CAP training programs but received responses from about 28%. A strength is that within programs that responded, there appeared to be variation in size of programs and types of learning environments, which led the authors to believe it was a relatively representative sample. Nevertheless, a fuller picture from a higher percentage of respondents would have been more informative. The study also did not examine the usefulness of current educational materials but rather focused on a broad needs assessment survey.
Core competencies and standardized curricula are tenets of physician training. Pediatric C-L psychiatry is gaining importance in this era of a national pediatric mental health crisis and increasing awareness of the interplay between physical and mental health. There remains wide variability among training sites and a need for a standardized training curriculum. The needs assessment responses indicate that CAP training programs would be interested in utilizing a high quality standardized educational materials on common pediatric C-L topics.
This study describes an open trial that examined the feasibility of Acceptance and Commitment Therapy (ACT) for parents of children with disabilities. The study took place at six centers within Sweden and enrolled parents of children 17 or younger with severe disability of developmental delay who also had symptoms of anxiety or depression related to their child’s disability. The study used a transdiagnostic manualized treatment entitled Navigator ACT, which was a modified version of ACT to focus on dealing with stress and promoting health. There were 94 parents enrolled; 86 came to the first session, 69 completed at least 4/5 sessions, and 65 completed through the 3 month follow up. At enrollment, parents on average had mild clinical depression and moderate to severe anxiety. The ACT intervention consisted of groups of 8-16 with five 3.5 hr sessions and one booster 2.5 hour session, for a total of 20 hours of treatment, excluding homework done individually by participants. After the ACT group intervention, there were significant improvements shown in parents’ depression, anxiety, mindfulness skills, and satisfaction in parenting. There were also significant reductions in parents’ assessment of their child’s total difficulties, the impact of the child’s difficulties on the family, and the experienced burden of care. The study was determined to have good feasibility based on the percentage of participants who completed at least 4/5 sessions (80%).
Strength and weaknesses:
Weaknesses of this study include being an open, non-randomized trial, and utilizing analysis per protocol instead of intention to treat. The study was not powered to identify differences between completers and non-completers. Most enrolled parents were female, and most of the children had Autism Spectrum Disorder. Race and ethnicity were not reported. It is unclear how the study would generalize to other populations, and how treatment effects may differ in countries with different levels of support for parents of children with disabilities. Strengths of the study included its natural clinic setting with novice group leaders, which aids the evaluation of feasibility of implementation in other places. The study collected a sizeable amount of data from participants, including doing a thematic analysis of parental feedback after the intervention. Other strengths included having a follow up point about 3 months after the intervention to assess maintenance of effects.
Within pediatric hospitals, C-L psychiatrists are likely to be consulted for patients with chronic illness or disability. It has been shown previously that having a child with serious illness or disability is associated with parental stress, and this stress affects the physical and mental health of children. Being familiar with effective interventions for parents has the potential to make a meaningful difference for both the parents and children. Another takeaway from this article is that parents’ primary feedback included wanting more time with other parents to share experiences; support groups without formal intervention may also be beneficial.