6. Preface
Many years ago, when symptoms of most psychological disorders were just
b
eginning 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 differ-
ences 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 symp-
toms. Indeed, many of these have proven effective in reducing (and, sometimes,
eliminating) the symptoms of some psychological disorders, and intervening phar-
macologically 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
m
ental 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 pharma-
cological 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 symp-
toms 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
7. vi Preface
“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 regu-
larly. 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.
8. Preface vii
However, in many states, CMHCs are overextended and long wait times are
n
ecessary (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 psychia-
trists (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 deci-
sion 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 sychological
p
problems in-house.
9. viii Preface
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 psychophar-
macological 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 collabo-
ration 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
p
sychologists (Guam Public Law 24-329), and in 2002, the state of New Mexico
enacted prescriptive authority for psychologists (New Mexico Administrative Code
10. Preface ix
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 legis-
lative 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, phar-
macologically 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 ques-
tion of whether or not to use medications must first be considered. Where psycho-
logical treatment is likely to be effective and the use of medications is not
necessarily indicated, psychologists can make such a recommendation to the pedia-
trician 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, pediatri-
cians may not be able to see their patients frequently enough, and long enough
during each visit, to accurately screen these issues. Psychologists with pharmaco-
logical training can perform medication monitoring and track the patient’s progress
and adverse effects. When medication changes are warranted, sychologists with
p
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,
11. x Preface
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 medica-
tions are referred to as “prescribing psychologists.” In Louisiana, however, psycholo-
gists 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 psycholo-
gists 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
12. Preface xi
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 pedi-
atric 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 pharmaco-
logically 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 collabora-
tive 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 psycholo-
gists to make a meaningful contribution within portions of the country that experi-
ence 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 treat-
ment of eating disorders. Collectively, these constitute the vast majority of disor-
ders 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 opportu-
nities 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
13. xii Preface
of psychopharmacology attain a solid base of knowledge during their professional
development. The volume concludes with a chapter by Lopez-Williams who
d
iscusses 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 prac-
tice 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 psychia-
trists. 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.
14. 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 previ-
ously 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 supple-
ments 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
m
edical and mental health professionals, teachers, and parents. Dr. Kapalka has
been interviewed in newspapers, Internet publications, and on television.
xiii
15.
16. Contents
Part I Foundations of Collaborative Care
1 Psychology, Psychopharmacotherapy, and Pediatrics:
When to Treat and When to Refer......................................................... 3
Mark Muse, Syd Brown, and Tanya Cothran-Ross
2 Collaboration Between Pharmacologically Trained
Psychologists and Pediatricians: History
and Professional Issues............................................................................ 17
Robert E. McGrath
Part II Collaboration with Pediatricians in Specific Settings
3 The Clinical Experience of RxP-Trained Psychologists
Working in Non-RxP States..................................................................... 37
Thomas M. Kozak and Andrea Kozak Miller
4 The Practice of Medical Psychology in an RxP State:
New Opportunities for Comprehensive Pediatric Care.......................
. 49
Darlyne G. Nemeth, Sandra Franz, Emma Kruger,
and Maydel M. Schexnayder
5 Integrated Care in Rural Settings.......................................................... 67
Nancy Boylan Alford
6 Collaborative Practice with Pediatricians Within
the Indian Health Service: Taking Care
of Frontier Children................................................................................
. 95
Michael R. Tilus, Kevin M. McGuinness, Mimi Sa, Earl Sutherland,
Bret A. Moore, Vincen Barnes, Johna C. Hartnell,
and Anthony Tranchita
xv
17. xvi Contents
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
18. Contents xvii
16 RxP Training Informs the Practice of Supervision
of Nonpharmacologically Trained Mental
Health Practitioners................................................................................. 285
Andy Lopez-Williams
Index.................................................................................................................. 301
19.
20. 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 deploy-
ments 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
21. xx Contributors
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 neurop-
sychologist. 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 prac-
tice 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
22. Contributors xxi
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
m
edication 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 adoles-
cents 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.
23. xxii Contributors
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 main-
tains 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 com-
pleted 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 com-
pleted 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 numer-
ous scholarly journals on topics related to academics, homework and school func-
tioning, parenting skills, and the treatment of ADHD and other disruptive behavior
disorders.
24. Contributors xxiii
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 treat-
ment 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, behav-
ioral 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
25. xxiv Contributors
Force Base in North Dakota. He is currently completing psychopharmacology
training at Alliant International University in San Francisco. Dr. Tranchita previ-
ously 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.
30. 4 M. Muse et al.
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 pre-
ferred 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 com-
bine the first two approaches in order to determine the optimal integration of
p
sychology and pediatrics, according to the behavioral/pharmacological manage-
ment 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/separa-
tion 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 man-
agement 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.
31. 1 Psychology, Psychopharmacotherapy, and Pediatrics 5
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 condi-
tion 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 dis-
orders, 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 differen-
tiating the diagnosis of ADHD from mere ADHD-like behaviors, if the combina-
tion 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 instru-
ments 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, inat-
tentive 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 diag-
nosing 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 condi-
tions pose even greater challenge and require the discerning eye of the specialist
32. 6 M. Muse et al.
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 thera-
peutic 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 appli-
cation 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 psy-
chologists 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 contem-
plated in the rulings of many state psychology licensing boards which find medica-
tion consultation by pharmacologically trained psychologists with primary care and
pediatric physicians to be within the purview of the psychologists’ license to prac-
tice psychology according to their competency in specialty areas such as clinical
psychopharmacology. The advent of the specialty of “medical psychologist,”1
r
ecognized by the Drug Enforcement Agency (DEA) in the granting of the control
substance registration number to prescribing psychologists, has expanded this role
The term medical psychologist, as adopted by Division 55 of the American Psychological
1
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 quali-
fied 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).
33. 1 Psychology, Psychopharmacotherapy, and Pediatrics 7
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 pharmacologi-
cally trained psychologists, in particular, should play a role in the behavioral medi-
cation 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
s
ubstance 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
2
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 exposure-
based 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 (medication-
behavioral 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).
34. 8 M. Muse et al.
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 contrain-
dication 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 psycholo-
gists 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 psycholo-
gists practicing where prescriptive authority currently exists, and pharmacologi-
cally 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 recom-
mendations 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 collabo-
ration 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 psycholo-
gist 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 algo-
rithm. While the algorithm indicates that certain conditions that may benefit from
pharmacotherapy be initially referred to a pharmacologically trained psychologist,
35. 1 Psychology, Psychopharmacotherapy, and Pediatrics 9
Presenting
Problem
Cognitive Affective Behavioral
Developmental Academic Thought Anxiety Impulse Impulse
Depression
Disorders Disorders Disorders Dyscontrol Dysfunction
1,4,2
Attention 2
Adjustment
2
Conduct
3,2 4,2 2
Tourette's, Deficit/Hyper- Psychoses Disorder, Adjustment 2
Oppositional Disorder
Organic Brain activity Generalized Disorder, Defiant
Syndromes, Anxiety Dysthymia Disorder,
Mental 3,2 Disorder, Explosive Anger 4,2
Retardation; Learning Addiction
Disabilities Phobias 4,2
*Pervasive Major
Developmental Depression,
4,2
Disorders, Autism Posttraumatic Bipolar
Spectrum Stress Disorder, Disorder
Obsessive
Compulsive
Disorder, Panic
Disorder
Key::
Preferred Provider:
fe ide :
1 Pediatrician
e i ri an
2 Clinical, Counseling, or School Psychologist
l ic g, o h o h o
3 Neuropsychologist or Psychodiagnostician
e ro yc o gis r gn t
4 Medical Psychologist
i al l st
*Often in conjunction with Developmental Pediatrics
e nc n n to h e lo m n 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 psycholo-
3
gists 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.
36. 10 M. Muse et al.
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 condi-
tions 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, pharmaco-
therapy, 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, coun-
seling, 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 con-
ceived 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 pharma-
cologically trained psychologist is cognizant of the various reinforcement contin-
gencies 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
37. 1 Psychology, Psychopharmacotherapy, and Pediatrics 11
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 iscontinued (Veale,
d
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 hierarchi-
cal 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 reduc-
tion 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 pres-
ent 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, com-
plained 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 recom-
mendation 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 psycholo-
gist 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
38. 12 M. Muse et al.
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 suc-
cess 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 accom-
panied 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 anxi-
ety 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
39. 1 Psychology, Psychopharmacotherapy, and Pediatrics 13
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 depres-
sive 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 treat-
ment 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 perti-
nent 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 func-
tioning. Teachers had hinted at hyperactivity through the years to the parents, but
the mother did not “believe” in the ADHD label.
40. 14 M. Muse et al.
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
c
ounseling with weekly drug testing was also instituted. The patient’s grades rap-
idly 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 con-
sulting on medication with patients and prescribing professionals is within the
competencies of a pharmacologically trained psychologist. The psychologist con-
sulted 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 physi-
cian 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 treat-
ment 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
4
preteen population. Thus, our case studies include teenagers, exclusively.
41. 1 Psychology, Psychopharmacotherapy, and Pediatrics 15
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 col-
laborative 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 disor-
ders: 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 conduc-
tistas 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 pedi-
atrics: When to treat and when to refer. In G. Kapalka (Ed.), Collaboration between pediatri-
cians 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.
42. 16 M. Muse et al.
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 mainte-
nance 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 rehabilita-
tion 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.
