Children with prematurity and complex medical histories are at increased risk for tube dependence, feeding aversion, and aspiration, which can interfere with completing a video fluoroscopic swallow study (VFSS) making it challenging to target broader feeding goals. This case report describes a bolus fading intervention designed to establish consistent oral intake and prepare a tube-dependent child for VFSS. An 18-month-old child born at 26 weeks’ gestation with severe bronchopulmonary dysplasia, a prior failed VFSS, and 100% gastrostomy-tube dependence participated in an intensive interdisciplinary home-based feeding program. A single-case reversal design evaluated a bolus fading treatment that included noncontingent reinforcement and escape extinction (initially), along with procedures to increase mouth clean. Bolus sizes increased systematically from empty spoon to full spoon while the clinician monitored clinical signs of aspiration. Caregiver acceptability was assessed using a questionnaire. Baseline responding showed no acceptance and high inappropriate mealtime behavior. During treatment, acceptance increased, inappropriate mealtime behavior decreased to near zero, and mouth cleans improved after targeted modifications. During the VFSS, the child accepted thin liquids by spoon without inappropriate mealtime behavior, and the hospital speech-language pathologist confirmed safe swallowing. Caregivers indicated high acceptability. Bolus fading effectively prepared a tube-dependent child to participate in the VFSS, making it possible to determine swallow safety and progress toward broader feeding treatment goals. Implications for Impact Statement Our findings highlight how individualized behavioral interventions can make swallow studies more successful for children who struggle with feeding, improving both the assessment process and ultimately treatment outcomes.
In a field where standards of care for subspecialty pediatric psychology services have become increasingly operationalized, the pediatric psychology consultation/liaison (C/L) service can vary substantially as a function of the hospital system in which the service resides. We explore the potential benefits of pediatric psychology C/L services integrated with psychiatry on an inpatient consult service (Integrated) versus existing as a standalone service embedded in pediatrics (Standalone). Data from two similarly sized children’s hospitals in academic medical centers in different regions of the United States were compared (Standalone and Integrated C/L services). Variables included total number of consults seen and nature of consult request for psychology, psychiatry, or both services (psychiatry and psychology). The Standalone C/L service also included data prior to, and following, the onboarding of a fully dedicated psychologist in C/L services. Across both models of C/L, the nature of referrals placed by inpatient medical teams reflected that pediatric psychology C/L provided a specialization separate from psychiatry, as evidenced by different presenting consult concerns. The Standalone C/L service also observed an increase in referrals placed to their service following the onboarding of a full-time psychologist in C/L services. Data suggest that pediatric psychology C/L services are desirable and sustainable regardless of whether they exist as a standalone or integrated model. Implications for Impact Statement The results of the study indicate that pediatric psychology C/L services hold similar value whether they are integrated within inpatient psychiatry C/L services or standalone services in pediatrics.
Objective: Inequities in accessing waitlisting for liver and kidney transplantation among pediatric and adult populations are well-documented, with disparities related to race, ethnicity, and socioeconomic status consistently present in both settings. Historically, studies examining barriers to transplant waitlisting have focused mainly on patient and family demographics. However, due to the complexity and subjectivity of pretransplant evaluations, other factors (e.g., provider biases) likely influence waitlisting decisions. This topical review brings awareness to how provider biases toward race, ethnicity, and socioeconomic status may impact access to pediatric liver and kidney transplant waitlisting. Methods: Searches using keywords such as ethnic and racial minorities, waiting lists, transplantation, poverty, and pediatrics were conducted in https://inPubMed.gov , CINAHL Complete (EBSCO), PsychINFO (EBSCO), https://Embase.com , https://Scopus.com , and Web of Science databases with no relevant findings including provider bias in pediatric liver or kidney transplant. A second search in only PubMed with no limit by age produced four relevant articles between 2004 and 2023. Results: Provider biases within the pretransplantation evaluation and waitlisting processes have been explored in adult populations and are starting to be explored in some pediatric subspecialties, though gaps remain in pediatric liver and kidney transplantation. Conclusions: Pediatric kidney and liver transplant waitlisting may be impacted by provider biases throughout the evaluation process. More research is needed to determine areas of susceptibility and how to reduce bias throughout the subjective processes of transplant evaluation. We provide recommendations for how pediatric psychologists can use their skillsets to decrease bias and advance equity in pediatric liver and kidney transplantation settings.
Maternal depression negatively impacts parenting practices and child development. Many mothers of young children screen positive for depression in our clinics. The objective of this quality improvement initiative was to use the SQUIRE 2.0 framework to evaluate a quality improvement initiative that focused on the integration of a brief parenting intervention in two family medicine clinic's routine depression screening. Patients who were caregivers of young children and who screened positive for depressive symptoms but did not endorse suicidality were invited to receive parenting tips via automated text, a few learning materials (e.g., books, blocks), and monthly support phone calls over a 5-month period. Though initially intended to include caregivers regardless of sex or identified gender, only caregivers who self-identified as females participated. Outcome measures included the Patient Health Questionnaire-2 and -9 (depression symptoms) and portions of the Family Map Inventories (parenting-practices). Sixty-two percent of participating patients completed pre- and postintervention surveys. Following intervention participation, patients' depression symptoms significantly decreased and their self-reported positive parenting practices (e.g., use of routines, parent-child play, positive guidance) significantly increased. Leveraging technology to improve parenting practices and mental health among parents of young children expanded access to support services and was effective in our setting.
Objective The purpose of this study is to understand baseline psychological functioning and protective factors for transmasculine, transfeminine, and gender expansive youth seeking services at a gender affirming outpatient clinic. This study also examines differences between these groups.Method 137 TGE youth aged 12-21 completed the Behavior Assessment Scale for Children, Third Edition. Of the 137 participants, 82 (59.4%) identified as transmasculine, 26 (18.8%) identified as transfeminine, and 29 (21.0%) identified as non-binary/gender expansive. Additionally, a majority (79.6%) identified as White. Several analyses were conducted to explore baseline psychological functioning across different groups and look at the impact of psychotherapy and the current political climate.Results Results showed no significant differences between gender identity groups for depression, anxiety, hyperactivity, attention problems, relations with parents, interpersonal relationships, self-esteem, self-reliance, external locus of control, and ego strength. For all variables except anxiety and self-esteem, participants scored in the average range. There was not a significant difference by identity in access to psychotherapy or treatment access on psychological functioning psychological functioning. We also found no significant differences between psychological functioning and sociopolitical events. However, gender identity moderated the relationship between self-esteem and attention problems.Conclusions These results suggest that there are few differences found between groups of TGE youth regarding mental health symptoms in this sample. The results suggest additional research is needed to understand what screening measures are appropriate for use with TGE youth and provides evidence that not all clinical samples of TGE youth are experiencing clinically significant mental health symptoms.
Objective: Fecal incontinence affects up to 7.8% of youth and can impact psychological and physiological well-being, including increased risk for loss of rectal nerve functioning, high family stress, and mental health disorders. Behavioral approaches can be combined with medical management, but have limited research support. This article describes the development, acceptability, and feasibility of a group-based, telehealth, caregiver-only behavioral intervention for pediatric fecal incontinence. Methods: Caregivers of children with fecal incontinence were referred by gastroenterology providers. Participants completed four virtual group sessions focused on psychoeducation and implementing strategies for shaping child behaviors related to medication adherence, toileting, and clean-up. Feasibility was assessed via recruitment and uptake, participant retention, and implementation within routine clinical operations. Acceptability was assessed via caregiver satisfaction. Caregivers stress, frequency of accidents, clean-up behaviors, and intervention satisfaction were assessed. Results: Mean child age was 5.80 (SD = 1.80) with 51.4% male. Of the 72 caregivers who began the intervention, 88.9% (n = 64) completed all 4 sessions. Most (98%; n = 52) respondents completing post-program questionnaires would recommend it. The majority thought the number (60%; n = 32) and length of sessions (79%; n = 42) were "just right." Child responsibility for cleaning increased (X-2 (1, N = 131) = 3.90, p = .04) and there were significant reductions in caregiver stress levels on all subscales of the POOP-C (p < .05-p < .01). Conclusion: Results support the initial acceptability and feasibility of a caregiver-only group behavioral intervention for pediatric fecal incontinence. Future research includes evaluation of program adjustments and clinical efficacy.
Pediatric burn injuries are a global health concern that significantly impacts children's well-being. Few cost-effective psychosocial interventions currently exist that focus on bolstering resilience in pediatric burn survivors and their surrounding support systems, specifically in resource-constrained contexts. Therefore, this study sought to explore caregivers' perceptions of an existing resilience-themed multimedia psychosocial intervention aimed at child burn survivors. This qualitative study's design was exploratory and utilized face-to-face, semistructured interviews. The caregivers of 13 child burn survivors were recruited from the Red Cross War Memorial Children's Hospital, South Africa. Thematic analysis yielded four themes revealing some key caregiver perceptions of the burn recovery video: (1) acceptance of burn injury promotes psychological recovery; (2) hope matters; (3) emotional support matters in all contexts; and (4) resilience matters, but & mldr; The themes echoed the resilience literature and emphasized the importance of support from all systems, including professional, and peer and familial groups, in postburn recovery. They also identified areas not usually foregrounded, such as the social contexts which may mitigate against resilience. Caregivers distilled some key aspects of resilience from the multimedia intervention and through this felt encouraged about the recovery process. The findings highlight the importance and utility of resilience-orientated multimedia and complementary interventions in pediatric postburn care.
Adolescents have experienced negative psychological and physiological effects during the COVID-19 pandemic, including sleep disturbances. Previous research has demonstrated a reciprocal relationship between sleep quality and psychological resilience, but there is a lack of evidence on their association. This study addresses this gap by examining the relationship between sleep quality and psychological resilience among adolescents using cross-sectional (Study 1) and longitudinal (Study 2) designs. The results revealed that poor sleep quality at the initial assessment point (T1) negatively correlated with psychological resilience at both T1 and the second assessment point (T2). Furthermore, the initial level of psychological resilience predicted better sleep quality and increased resilience at T2, suggesting a unidirectional influence of resilience on sleep quality over time. These findings imply that resilience can foster better sleep outcomes. These results suggest that schools and mental health professionals should consider integrating sleep hygiene practices and resilience-building exercises into their intervention programs.
Pediatric psychologists face unique ethical challenges in medical settings, especially in oncology, where psychological, social, and medical factors intersect. This case report explores the application of psychological and medical ethical principles in the care of a psychiatrically complex pregnant adolescent newly diagnosed with cancer. We present a case study of a 15-year-old pregnant female, "Jane," with newly diagnosed high-grade osteosarcoma, posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder. A multidisciplinary team collaborated to guide decision-making during an acute stage of treatment. Psychological and medical ethical frameworks informed treatment planning. Ethical tensions included balancing maternal and fetal health, aligning conflicting goals of care, and navigating barriers to effective communication. Additionally, conflicting legal and ethical obligations are addressed. Oncology treatment decisions were supported through multidisciplinary collaboration, ethics and legal consultation, and psychological conceptualization and recommendations. Psychology played a critical role in assessing and supporting psychological coping, facilitating family communication, and mitigating psychological harm during an acute and distressing phase of care. This case underscores the need for integrated psychological care in pediatric oncology, particularly when ethical dilemmas arise with complex patients. Pediatric psychologists are uniquely positioned to inform ethical decision-making by contextualizing psychological history, assessing risk, and facilitating communication.
The Diversity, Equity, and Inclusion Supervisor Self-Assessment Tool (DEI-SST) was developed to help psychology supervisors reflect on their supervisory practices regarding diversity, equity, and inclusion. The Society of Pediatric Psychology's Anti-racism Workgroup, Training Subgroup, adapted a preexisting psychology course syllabus evaluation tool for self-assessment in supervision to include aspects of clinical training, the APA multicultural guidelines, and the domains from the APA Guidelines for Clinical Supervision in Health Service Psychology. Following an expert review of the modified tool, the tool was administered in three settings, and qualitative themes were extracted from participant feedback. All participants (N = 38) endorsed that the DEI-SST helped them reflect on their supervisory practice. No participants provided feedback on the wording of the tool. All participants identified at least one area of supervision they had not considered previously. Suggested improvements to the tool included reducing the length of the tool, expanding the examples provided within each developmental stage, and including resources to enhance supervision. The DEI-SST shows promise to help supervisors incorporate aspects of DEI into their supervision that they may not have previously done. It provides a starting point for further growth needed to improve their practice. Future directions include investigating best practices for tool administration and a continued review of tool content to reflect advances in equitable and inclusive supervisory practices.
Objective Youth with juvenile arthritis (JA) frequently experience significant challenges including chronic pain, disability, and psychological concerns such as anxiety and depression. Additionally, adolescence is a critical period of development for body image and disordered eating concerns to emerge, and JA is associated with dietary and body changes. This study explored youth's experiences with juvenile arthritis, eating, and body image.Method Twelve youths with a JA diagnosis (M = 14.25 years; 66% cisgender girl) participated in a semi-structured qualitative interview examining their experiences with JA and their feelings about their bodies and food as they relate to their disease. Data was analyzed through a grounded theory approach.Results Four primary themes were identified: ability status, symptom severity, medication side effects, and dietary restrictions. Generally, participants attributed lower ability status, increased JA symptoms, medication side effects, and dietary restrictions to having a negative impact on their body image and relationship with food. Participants also attributed having a more positive body image and a better relationship with food during periods of remission.Conlusion Youth with juvenile arthritis have a variety of experiences unique to their disease that impact their body image and their relationship with food. Findings support the need for providers to be aware of the potential for risk of eating pathology and body image concerns in youth with juvenile arthritis. There is also a need for additional eating behavior and body image research in youth with juvenile arthritis and other autoimmune illnesses.
Objective: The pediatric mental and behavioral health (MBH) health crisis is a public health imperative. Identification and management of MBH crosses primary care, community mental health centers (CMHCs), and hospital systems. To deliver the best outcomes, active collaboration and coordination of care is required. However, coordinated approaches are hampered by data silos resulting from lack of parity between physical and MBH, overly restrictive privacy policies, and technical barriers arising from disparate electronic health records (EHRs) across systems. This proof-of-concept provides information on the development and initial implementation of one model as a blueprint for other systems seeking to improve continuity of care. Methods: With cross-system collaborators, the population behavioral health leadership team at a large pediatric hospital advanced solutions to break down data silos via a MBH patient attribution strategy. Elements of this build included developing the value proposition, navigating legal requirements, identifying a technical solution, and onboarding practices. Results: This strategy ultimately produced real-time, population-level visibility of community-delivered MBH services within the hospital EHR, democratized community-based providers' access to clinically actionable data housed within the hospital EHR, and is advancing MBH integration to enhance whole-child outcomes. Conclusions: MBH attribution has allowed for the creation of population-level dashboards that aggregate and share critical health information to external partner organizations and will serve as the backbone for additional clinical information exchange moving forward.
Objective Pediatric traumatic brain injury (TBI) is a significant public health concern, often leading to long-term impairments in social, behavioral, cognitive, and physical outcomes. Individuals living in Appalachian and/or rural regions of the United States may be at increased risk of poorer outcomes after pediatric TBI. The current study examines the role of social determinants of health, specifically rural and Appalachian residence, on recurrent TBI risk and post-injury quality of life (QoL).Method Participants were 150 adolescents aged 14 to 19 who were hospitalized with a moderate or severe TBI and enrolled in a family problem-solving intervention trial at least 1-month post-injury (M = 4.63 years). Demographic and injury characteristics, history of recurrent TBI, and adolescent and caregiver-reported QoL were collected at baseline. Addresses were collected and coded as rural/non-rural and Appalachian/non-Appalachian according to the Rural-Urban Commuting area codes and Appalachian Regional Commission guidelines.Results Rural adolescents were more likely to have had a history of recurrent TBI than non-rural adolescents. Adolescents who resided in both rural and Appalachian regions endorsed the poorest self-reported QoL. Recurrent TBI history was associated with poorer caregiver-reported QoL.Conclusions Clinicians serving rural and Appalachian communities should prioritize behavioral health screening and increasing access to services. Injury prevention efforts should target rural regions to reduce TBI prevalence and associated disparities. Overall, this study underscores the need for comprehensive, culturally responsive care and systemic interventions to improve outcomes for adolescents with TBI in underserved areas.
High levels of stress are frequently observed in children during hospitalization. Among available stress management tools, virtual reality (VR) represents a promising option due to its immersive, engaging qualities. While many VR platforms exist, most rely on passive distraction; few incorporate guided breathing exercises. Objective: This pilot study aimed to develop and assess the feasibility and acceptability of two immersive virtual environments (VEs) designed to promote relaxation in children through nature-inspired landscapes and guided diaphragmatic breathing. Before conducting randomized trials in clinical settings, a preliminary evaluation of the key design elements, essential for developing effective VR experiences in health care, is necessary. Methods: A total of 105 healthy children aged 6 to 15 years experienced both VEs. Feasibility and acceptability were assessed through perceived usefulness, satisfaction, cybersickness symptoms, and sense of presence. Anxiety levels before and after immersion were also measured. Results: Findings showed high satisfaction and a strong sense of presence for both environments, with minimal cybersickness reported. Preliminary data suggest a potential reduction in postimmersion anxiety. Age and gender effects on these outcomes are also discussed. Conclusions: This study provides initial evidence supporting the acceptability and feasibility of these nature-based VEs incorporating breathing exercises. It represents a fundamental step within a broader iterative process of design, evaluation, and optimization. The findings offer valuable insights to guide the refinement of future iterations of these environments, while also raising considerations for their potential clinical implementation.
Objective Mindfulness-based interventions (MBIs) may be suited to reduce stress and provide coping strategies for adolescents with type 1 diabetes (T1D). However, it is unclear how the experience of living on a lower income impacts how adolescents respond to such an intervention. As such, this present study explored whether household income moderates the effects of a novel, diabetes-tailored MBI on stress experiences, depression symptoms, anxiety symptoms, and glycemic control in adolescents with T1D. Methods Data were derived from a pilot randomized controlled trial of adolescents (ages 12-17) with T1D and elevated depression and/or anxiety symptoms. Participants were randomized to an MBI (n = 20) or a health education control group (n = 22), with data collection occurring at baseline, 1-month follow-up, and 3-month follow-up. Household income was categorized into two groups: lower (<$90,000) and higher (>=$90,000). Results Compared to the health education control group, the effects of MBI on stress experiences and depression symptoms were more pronounced among adolescents from lower-income households than those from higher-income families. Anxiety improved across all participants over time, regardless of income or group condition. Income did not moderate the effects of the group condition on glycemic control. Conclusions MBI has the potential to reduce stress and depression in adolescents with T1D, especially those from lower-income households. Our preliminary findings highlight the need for more interventions explicitly addressing the role of socioeconomic positioning to address individual and systematic factors impacting adolescents with T1D from lower-income families who experience elevated negative affect.
Objective: Pediatric primary care providers are increasingly asked to care for their patients' behavioral health needs, but few models of behavioral health integration emphasize practical strategies that are widely applicable to practices regardless of resources or size. A pilot cohort of pediatric primary care practices participated in a regional quality improvement (QI) project focused on improving each practice's levels of behavioral health integration using the Comprehensive Healthcare Integration (CHI) Framework (National Council for Mental Wellbeing, 2022) as a guiding framework. Method: Five practices joined the 10-month QI project pilot cohort. Each practice chose one subdomain from the CHI Framework's Multidisciplinary Teamwork domain as their project's focus. Participants attended monthly meetings and educational sessions, completed QI deliverables while implementing their identified interventions, and completed surveys and interviews pre- and post-project. Results: Four of the five practices (80%) reported increasing their behavioral health integration by at least one level on a subdomain of Multidisciplinary Teamwork CHI Framework domain. All practices (100%) reported increased satisfaction with their practice's level of behavioral health integration, with an average 60% increase from pre- to post-project. Conclusions: Practices made notable improvements to their behavioral health integration during the project. The CHI Framework was useful in structuring practices' behavioral health goals and assessing improvements. Elements of the QI project process, such as having access to content experts, the cohort format, and accountability provided by the project, appeared valuable to participants. Insights are shared for organizations aiming to support pediatric primary care providers in their behavioral health integration efforts.
Objective Parents of young children with type 1 diabetes (T1D) are at risk of experiencing elevated stress due to their responsibilities as caregivers. Despite this, there are limited interventions designed to enhance resilience in this population of parents. This pilot randomised controlled trial aimed to examine the acceptability, appropriateness, and feasibility of the Promoting Resilience in Stress Management for Parents (PRISM-P) intervention in parents of young children with T1D.Method Parents of children (aged 11 years and younger) with T1D participated in this study (N = 30). Participants were randomised (1:1) to a waitlist control or intervention group, with the intervention group participating in three one-on-one sessions via telemedicine with a trained coach. Intervention acceptability and appropriateness were assessed through a survey and semistructured interview. Feasibility was defined by a minimum study enrolment rate of 50% and a minimum retention rate of 70%. Validated instruments to assess psychosocial wellbeing were completed as secondary outcomes.Results Results provided strong support for the acceptability and appropriateness of PRISM-P. The enrolment rate for the study was 27% and the retention rate was 87%. The direction of change across psychosocial outcomes also provided preliminary support for the efficacy of the intervention.Conclusions PRISM-P was deemed an acceptable and appropriate intervention, as it was met with high satisfaction among the participants who completed it. There was mixed support for the feasibility of PRISM-P as completion was high, but enrolment rates were modest. Future large-scale trials should employ additional recruitment strategies to increase study enrolment rates.Implications for Impact Parents and caregivers play an essential role in the medical management and health outcomes of young children living with type 1 diabetes. This pilot trial highlights the potential value of the Promoting Resilience in Stress Management for Parents (PRISM-P) intervention in supporting the psychological wellbeing of parents. With further large-scale evaluation, interventions such as PRISM-P could serve as an accessible adjunct to paediatric diabetes care by providing targeted psychosocial support for parents and caregivers.
Objectives: Youth spend the majority of their time in school, making school-based health centers (SBHCs) an accessible and innovative health care delivery system. SBHCs initially targeted preventative medical needs of youth, while some now offer more comprehensive care including mental health services. Experts view SBHCs as one of the most effective ways to identify and treat youth with mental health difficulties, since over 6.3 million students in the United States have access to some form of school-based healthcare. There are approximately 3,900 SBHCs in the United States and the majority of these centers treat the underserved and uninsured at no out of pocket expense to students. Pediatric psychologists can leverage their expertise as advocates to inform public health policy and payment models in favor of SBHCs, thereby dismantling systems of racism, bias and oppression in schools and communities. This review summarizes the benefits of integrating a pediatric psychologist into existing models of SBHCs, and proposes future avenues. Methods: Review existing literature and multiple existing SBHC programs that have an embedded pediatric psychologist. Results: The vision of expanding access to culturally responsive behavioral health care, informed by clinical, research and outreach initiatives on a broad scale will be discussed. SBHCs that include a pediatric psychologist decrease health disparities among marginalized youth, particularly for those identifying as Hispanic or Black and with low socioeconomic status. Conclusions: Integrating pediatric psychologists provides another layer of mental health support for at-risk youth and this is particularly salient when providers practice cultural humility.
Objective: Many children with autism experience unmet needs, emphasizing the importance of research on service access. Methods: We surveyed English-speaking caregivers of children diagnosed with autism in 2018 at a tertiary Midwestern children's hospital. The survey assessed satisfaction with accessing services and included open-ended questions. Results: A total of 189 caregivers participated. Most accessed speech (86.2%), occupational (90.0%), and educational services (93.7%). Fewer received behavior therapy (35.6%), applied behavior analysis (23.8%), or group therapy (15.1%). While overall satisfaction was high, families who expressed dissatisfaction noted barriers such as difficulty navigating the system, limited availability, long waitlists, and high costs. Families cited advocacy and service navigation as key facilitators. Low uptake of certain services and persistent barriers underscore the need for systemic changes. Conclusions: We outline potential solutions, including expanding Medicaid and insurance coverage, redesigning service pathways, and implementing family navigation to improve access and outcomes.
Despite literature highlighting the adverse consequences of unregulated stress little work has discussed this risk factor and related interventions in young children with chronic health conditions. An inability to effectively utilize a caregiver to co-regulate both day-to-day stress and stress related to medical care leaves young children vulnerable to the psychological and physiological consequences of extended and intense stress. This brief case report outlines the mental health and neurodevelopmental trajectory of a young girl with Bartter Syndrome. The child's medical history is outlined, followed by a description of her presentation to an early childhood mental health clinic for a developmental assessment when she was 3 years old. An in-depth description of the patient's presenting behavioral, emotional, social, and neurodevelopmental state is discussed as well as dysfunction in the child-caregiver relationship and broader cultural stressors facing the family. A detailed case conceptualization from this assessment and treatment plan are outlined. This case is complemented by longitudinal information on the child's psychotherapy as well as the results of a neuropsychological assessment when they were 5. This rich case study highlights the role and possible benefit of early childhood mental health assessment and intervention in the ongoing care of children with complex medical conditions.
