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 c