Conceptual Models and Treatment Approaches

Several broad conceptual models and general principles also have relevance for mental health consultation in pediatric critical care. The medical crisis counseling (MCC) model proposed by Pollin and colleagues (Koocher and Pollin 1994; Pollin and Go-

lant 1994; Pollin and Kanaan 1995) offers a pragmatic crisis-oriented approach that has been adapted to working with medically traumatized children (Bronfman et al. 1998) as well as patients and families in the critical care setting (Meyer et al. 1996; Williams and Koocher 1999). MCC is based on the premise that traditional models of psychotherapy do not fully meet the emotional needs of individuals "caught up in the maelstrom of a medical crisis" (Koocher and Pollin 1994, p. 292). The MCC approach focuses on the disruption of normal life tasks that is spawned by medical crisis. The model emphasizes the degree to which accompanying emotional distress is a normal, expected, and even somewhat predictable response rather than reflective of a pathological process. MCC addresses eight common fears associated with chronic illness: loss of control, loss of self-image, dependency, stigma, isolation, abandonment, expression of anger, and death (Pollin and Golant 1994). Clinicians using MCC-based treatments focus on the medical condition and integrate psychosocial interventions with medical care delivery, normalize distress, and work with the client to collaboratively identify concrete actions toward adaptive coping, all within a limited time frame and with a focus on both symptom relief and prevention (Koocher and Pollin 1994). Williams and Koocher (1999) studied the utility of the MCC model with PICU patients and their families and found it to be effective across diverse medical and surgical presentations and psychological referral concerns. Of the common fears delineated by Pollin, loss of control, dependency, and death were those most often endorsed in the PICU setting, and consistent with the Pollin model, the mental health consultant in this setting functioned as a communicator, educator, and therapist (Williams and Koocher 1999).

Shulman and Shewbert (2000) proposed a model of crisis intervention for use in critical care settings that has great potential applicability with pediatric populations. They purported that traditional psychiatric consult services, wherein referrals are generated following identification of a specific mental health concern, fail to adequately address the extensive psychological needs of critical care patients and their families. As an alternative, Shulman and Shewbert proposed a holistic, systems-based, and comprehensive approach in which mental health interventions, involving both psychological consultation and ongoing supportive treatment, are integrated as a "standing consult" for all critical care patients and families. The model aims to provide an approach to treatment in which the entire scope of patient needs is addressed effectively and efficiently after being identified by interdisciplinary clinical staff. Family support is provided on a regular basis, and the consultant works with the team to ensure that patients and families are updated regularly with concrete, realistic medical and prognostic information. The model is preventive via the integration of mental health services with other aspects of patient care and the proactive identification of conflict among the family and care team. Finally, the model promotes the consultant's ability to facilitate follow-up support as needed following patient transfer from the unit (Shulman and Shewbert 2000).

Various other general principles can be of value when implementing psychosocial treatments and interventions with critically ill children. As in other settings, crucial steps in tailoring and implementing appropriate interventions include clarification of the referral question or concern, careful assessment incorporating multiple sources of information, and development of a working formulation (Shaw and DeMaso 2006). The consultant must be aware of sociocultural factors that may influence health-related beliefs, perceptions, and practices and help inform interventions (Stern et al. 1998). A biopsy-chosocial approach to case conceptualization is advised, with careful consideration of contextual factors related to critical illness and/or its treatment (e.g., pain, sleep deprivation, medications) that may impact mental status. Multimodal treatments, including psychoeducation, psychopharmacological treatment, supportive therapy, cognitive-behavioral approaches, and play therapy, may be warranted. The consultant should rely on clinical intuition regarding the presenting problem, as well as various pragmatic constraints, to determine the best course of action at any given time.

Treatment approaches are optimally guided by knowledge about the child's cognitive and developmental level and normative, expected behaviors during different stages of development. Children should be provided with developmentally appropriate information about their illness and treatment whenever possible, as well as some degree of control and choice regarding their care (Meyer et al. 1996). This involvement of children is particularly important given the degree to which children's coping with the trauma of illness can be facilitated by a cognitive understanding of the disease and its treatment (Sourkes 1995). Jansen et al. (1989) discussed a treatment model aimed at enhancing psychosocial and cognitive development for medically stable, chronically ill young children who require long-term critical care hospitalization. They described various pragmatic and developmentally motivated interventions, including consistency in medical caregiv-ers to foster children's growing sense of trust and stability, implementation of a predictable and comprehensive daily schedule to increase stability and consistency in day-to-day routines, and regular opportunities to engage with child life specialists in normal childhood play activities.

Physical limitations or restrictions imposed by the child's illness and/or its treatment are important considerations in determining effective interventions (Hansen et al. 1986). For example, implementation of a behavioral contingency plan must involve the inclusion of desirable behaviors and rewards that are permissible in the PICU. Consultation with a speech-language pathologist for augmentative and alternative communication strategies can be of great benefit in restoring a child's sense of autonomy and control and ensuring adequate pain management when medical interventions, such as intubation or tracheotomy, preclude typical communication ability (Costello 2000). Mobilization (e.g., getting out of bed, walking around the unit), when it is medically permissible, can be effective in promoting autonomy and independence (DeMaso and Meyer 1996).

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