PEDIATRIC AND CHILD PSYCHOLOGY: HISTORY AND PERSPECTIVE

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Clinical Psychology (PSY401)

Lecture 44

PEDIATRIC AND CHILD PSYCHOLOGY: HISTORY AND PERSPECTIVE

It has been estimated that at least 8 million children in the United States need mental health services. For

years, the mental health needs of children and adolescents have not been adequately met. Unfortunately,

this trend is likely to continue into the next century. Projections of demographic changes for the United

States between 1990 and 2025 suggest that although the overall population growth rate is expected to

decline for some groups (such as European Americans), the rates for groups whose mental health needs are

currently underserved (such as African American and Hispanic American children and adolescents) are

expected to climb dramatically. Two subfields of clinical psychology, pediatric psychology and clinical

child psychology are uniquely qualified to address these needs.

Before touching on historical aspects of these child specialties, we should first discuss the distinction

between clinical child psychology and pediatric psychology.

DEFINITIONS

The distinctions between pediatric psychologists and clinical child psychologists are somewhat blurred at

best. However, in clinical child psychology, a common activity over the years has been work with children

and adolescents once psychopathological symptoms have developed. This work has often been conducted

either in private practice settings or in outpatient clinic settings in the context of the traditional team of psy-

chologist, psychiatrist, and social worker, along with some collaboration with pediatricians.

In contrast, pediatric psychology (or child health psychology, as it is often called) has been described as

clinical child psychology conducted in medical settings, including hospitals, developmental Clinics, or

medical group practice. Pediatric psychologists frequently intervene before psychopathology develops for at

least at an earlier stage of the disorder) and their referrals often come from pediatricians. Specifically

Roberts Maddux and Wright (1984) have defined pediatric psychology as

"A field of research and practice that has been concerned with a wide variety of topics in the relationship

between the psychological and physical well-being of children, including behavioral and emotional con-

comitants of disease and illness, the role of psychology in pediatric medicine, and the promotion of health

and prevention of illness among healthy children".

Even though the overlap is considerable surveys of pediatric and clinical child psychologists reveal several

differences between the two for example, Kaufman, Holden, and Walker. First, pediatric clinicians are

characterized by behavioral orientation. With a related tendency to use short-term, immediate intervention

strategies. In contrast. Clinical child psychologists are more diverse in their orientations. Second pediatric

psychologists tend to place greater emphasis on medical and biological issues in their approaches to

training, research and service delivery. Their interests in health psychology and behavioral medicine, as

well as their consultations with pediatricians, are distinguishing features. Clinical child specialists tend to

place greater emphasis on training in assessment, developmental processes, and family therapy.

Because of the increased relevance of pediatric psychology to clinical psychologists of the twenty-first

century, we will focus a fair amount of discussion on this emerging specialty. Before reviewing the major

activities of pediatric and clinical child psychologists, however, it is important to survey briefly the history

of these specialties and to discuss the developmental perspective adopted by these psychologists.

HISTORY

The history of clinical child psychology goes back to at least 1896, when Witmer stimulated the profession

of clinical psychology by starting the first psychological clinic., this clinic was devoted to treating children

who were having learning problems or were disruptive in the classroom.

The scientific study of childhood psychopathology can probably be dated to the early 1900s. For a long

time, children were not recognized as being very different from adults in terms of their needs and abilities.

They were pretty much regarded as miniature adults. By the late 1800s and early 1900s, however, several

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developments occurred to increase the focus on children. These developments included the identification

and care of those with mental retardation, the development of intelligence testing, the formulation of

psychoanalysis and behaviorism, the child study movement, and the emergence of child guidance clinics.

Even the classification of childhood disorders has changed greatly, especially in the past 30 years. Both the

DSM-I and the DSM-II regarded childhood problems as downward extensions of adult disorders. However,

starting with the DSM-III and continuing today with DSM-IV, we now have diagnostic categories

specifically relevant to children. Currently, there are 43 specific diagnoses contained in ten groups

(American Psychiatric Association, 1994).

The foregoing trends have culminated in what is now referred to as clinical child psychology. Indeed, the

field is essentially oriented toward assessment, treatment, and prevention of a variety of problems.

Pediatric psychology evolved as a specialty when it became apparent that neither pediatrics nor clinical

child psychology could handle all the problems presented in childhood. Many "well-child" visits to

pediatricians require mainly support and counseling rather than medical interventions. Often at issue are

matters relevant to all child psychologists, including child rearing, behavioral management problems, or

questions about academic performance. When these problems reflect the psychological-behavioral

accompaniments of physical illness, handicap, or medical procedures, the pediatric psychologist typically

has more relevant expertise than a traditional clinical child psychologist.By 1966, some 300 psychologists

were working in pediatric settings in the United States. At about the same time, Wright (1967), recognizing

the "marriage" between pediatrics and psychology, called for a new specialty-pediatric psychology. Soon

the Society of Pediatric Psychology was formed. This society now has close to 1200 members, and in 1999

became an official division of the American Psychological Association (Division 54).

A DEVELOPMENTAL PERSPECTIVE

Those who work with children and adolescents recognize the importance of a developmental viewpoint.

From a developmental perspective, psychological problems in children and adolescents result from some

deviation in one or more areas of development (cognitive. biological, physical, emotional, behavioral, and

social) when compared with same age peers. At the same time, however, it is important to recognize that

(1) Development is an active, dynamic process that is, best assessed over time;

(2) Similar developmental problems may lead to different outcomes (clinical disorders);

(3) Different developmental problems may lead to the same outcome:

(4) Developmental processes or failures may interact; and

(5)Developmental processes and the environment are interdependent--each influences the other such that

they cannot be viewed separately, in isolation.

Pediatric and clinical child psychologists; beyond simply viewing children and adolescents as miniature

adults. Instead, children and adolescents are assessed and treated within the co text of the developmental

and environment challenges with which these individuals a faced. The age of children, stage of

development across spheres of functioning (cognitive, emotional, social), and their family and social

situations must be considered as one tries to conceptualize their problems and prescribe treatment Indeed,

failing to take into account the developmental stage of the child will lead to inaccurate assessments and

inappropriate treatments. For example bedwetting is a problem at age 12 but not at age 2. The prognostic

implications of a behavior such as temper tantrums will be different for toddlers than for adolescents. These

developmental considerations help the pediatric or clinical child psychologist decide whether a problem is

indeed present, how severe it is, how to conceptualize it, and what kind of intervention to recommend.

RESILIENCE

Why do some children, even though faced with what seems to be incredible adversity, seem to adapt well

with few noticeable problems? The term resilience refers to qualities in individuals that are associated with

their ability to overcome adversity and achieve good developmental outcomes. Psychologists have become

increasingly interested in studying factors that are associated with resiliency, especially among children

who are at risk for negative outcomes due to unfavorable environments (war, violence in the home)

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It is worth emphasizing that these factors have only been shown to be associated with good outcome; they

are not necessarily causal. Still, the theme that comes through is that factors promoting strong attachments

or bonds between child and parent and those indicating the capacity for good problem-solving skills seem to

help buffer the individual against adverse circumstances. As for practical applications, studies of resilience

and competence can lead to interventions aimed at preventing or eliminating risk factors, building or

improving resources, and enhancing relationships or processes such as self-efficacy and self-regulation.

MAJOR ACTIVITIES

Now we will run to a discussion of the many diverse and still evolving activities in which pediatric and

clinical child psychologists are involved. To simplify matters a bit, we will group these activities under the

headings of (a) assessment, (b) Intervention, (c)prevention, and (d) consultation. First, however, we will

consider several general issues relevant to all these types of activities.

GENERAL ISSUES REGARDING MAJOR ACTIVITIES:

Epidemiology. It is important to have some idea of how common various problems are across age groups

and other segments of the population. For example between the ages of 1 and 2 years, feeding and sleeping

problems are very common. Hyperactivity and conduct disorders occur more frequently in boys than in

girls. Even behaviors that might seem to indicate the presence of a mental disorder occur commonly in non

clinical groups. To properly understand and diagnose, the field must have information on how behaviors

change over time, how they covarv with one another, and how 'behaviors are distributed throughout the

community?

The Situation. Behavior is often situation-specific. A child may be quiet and withdrawn at home but not

with peers. Another child may be compliant with authority figures but hostile with other children. This is

not to say that general dispositional factors are unimportant. Rather, to adequately conceptualize a child's

problem (or presumed problem), those who work with the child must pay attention to the interaction

between factors in the child's environment and generalized personality characteristics.

Who Is the Client? It is sometimes difficult to determine exactly who in the group the real patient is. In

many instances, the most effective treatment is directed at the parents, because they are largely in control of

the child. Furthermore, children do not refer themselves for assessment or therapy. They are referred by

parents, physicians, teachers, or even court authorities. As Campbell (1989), puts it,

"The first task of the clinician working with children and families is to determine whether 3 problems

actually exist. Intolerance, ignorance, and misconceptions on the part of adults often lead to referral".

Diagnosis and Classification of Problems. The classification of childhood disorders has been of more

interest to clinical child specialists than to pediatric psychologists because the former have historically had

to deal more often with psychiatric cases. The DSM-IV incorporates the growing interest in childhood

disorders. There are ten major groups of disorders that are usually first diagnosed in infancy, childhood, or

adolescence. Often, diagnostic criteria or thresholds are modified so that then is more appropriate for

children or adolescents. For example to obtain a dysthymic disorder diagnosis, a child or adolescent can

present with an irritable (versus depressed) mood, and the duration of all symptoms can be only one year

(versus two years for adults). Conduct disorder is one of the most frequently encountered diagnoses in

inpatient and outpatient settings that treat children and adolescents. Further, a number of assessment and

treatment approaches have been developed to address the behavior problems that comprise this disorder.

Often, psychological problems experienced by children and adolescents are subdivided into internalizing

disorders and externalizing disorders.

Internalizing disorders are characterized by symptoms of anxiety, depression, shyness, and social

withdrawal. Examples of internalizing disorders are mood disorders (such as major depressive disorder) and

anxiety disorders (such as separation anxiety disorder).

Externalizing disorders are characterized by aggressive behaviors, impulsive behaviors, and conduct

problems. Examples of externalizing disorders are conduct disorder and attention deficit/ hyperactivity

disorder. Variety of assessment methods and techniques-including interviews, behavioral observations,

questionnaires and checklists, intelligence and achievement tests, and neuropsychological tests-can be used

to identify these types of problems in children and adolescents.

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A. Assessment

Assessment with children and adolescents differs n several important ways from that with adults. In contrast

to adults, children and adolescents rarely seek out treatment on their own. Further, with children and

adolescents, it is almost always necessary to seek information from other people besides the child: parents,

teachers, social workers, school psychologists, physicians, and others. Although parental consent is

required, it is also important to obtain the child's permission to seek information from these other sources.

This will help a great deal in building an atmosphere of trust and respect. Finally, children and adolescents

know less about the roles of mental health professionals and thus may harbor resistance or even fear.

The issue of multiple sources of information in child and adolescent assessment warrants further comment.

It should be recognized that these multiple sources of information may not always agree with one another.

For example, some have suggested that depressed mothers tend to exaggerate the nature and severity of a

child's problems compared to other informants. Although more recent evidence has challenged this claim,

there is currently no consensus as to how a clinician or researcher should integrate discrepant diagnostic

information. This problem is compounded in the area of clinical child psychology, where multiple sources

of data are tapped routinely. Fortunately, researchers are now beginning to investigate how best to integrate

assessment data from multiple informants.

When assessing children or adolescents, it is very important to estimate the nature and severity of the

problem early on. The complaint may be as specific as vomiting or fear of walking to school, or as general

as a "depression" or lack of interest in schoolwork. The examiner will want to learn why help is being

sought, how long the problem has existed, and what other steps have been taken to resolve the problem.

From all the sources available, a case history will then be generated in order to gain an understanding of ex-

actly how the problem has developed. Again, all this is done to determine the nature of the problem and

how best to deal with it.

For most problems, a comprehensive assessment will generally include information from multiple

informants (self, parent, peer, teacher) and from multiple assessment methods (self-report scales, behavior

checklists, interviews, intelligence or ability tests). In the sections that follow, we will present several issues

associated with some of the most common methods of assessment used by clinical child and pediatric

psychologists.

Interviewing:

Clinical child and pediatric psychologists interview parents to

(1) Elicit information about behavior, events, and situations;

(2) Gauge parental feelings and emotions; and

(3) Establish the basis for subsequent therapeutic relationships.

Interviews with children and adolescents allow them to "tell their own story." The psychologist asks ques-

tions aimed at the individual's perception of self, perception of others, and perception of the existence and

nature of the problem.

When interviewing children, it is important to remember that they have not always been told why help is

being sought, or they may understand only imperfectly what they have been told. Just being in a clinic

without understanding why, or without having been allowed to decide on treatment for them, can be very

anxiety provoking for children for anyone else). Therefore, it is important to find out how the child feels

and what the child understands as the real purpose for the visit. As much as possible, the clinician must set a

reassuring tone for the interview and then, within the limits of the child's understanding, explain what will

take place. In some cases, for example, it may be necessary to stress that the child will be going home after

the visit to the clinic or that the specific diagnostic procedures will not hurt.

It can be very difficult to interview children. They cannot always communicate their feelings and thoughts

in any precise way. Equally important, children can be highly suggestible or fearful. Consequently, they

may tell the examiner what they think he or she wants to hear or what others have told them. They may be

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so intimidated or nervous that they get their stories mixed up. The length of an interview with a child may

depend on factors such as age or intellectual level.

Behavioral Observation:

Whenever possible, direct observations of the child at home and school should be undertaken. A variety of

observational methods are available. For example, there are naturalistic, analogue, participant, and self-

observational techniques for use with children, and a variety of coding systems are available for rating

behavior. As is true with all behavioral observations, child and pediatric psychologists need to keep in mind

issues such as reliability of observations, reactivity to observation, and the validity of the observational data.

We know various observational methods and systems used in the assessment of children and adolescents.

One of these is the Behavioral Coding System (BCS) developed and used by Patterson 11971) and col-

leagues Jones, Reid & Patterson, 1975; Patterson & Forgatch. 1995). The BCS was designed for use in the

homes of pre delinquent boys with aggression and noncompliance problems. Trained observers spend one

to two, hours in the home observing and recording family interactions, using the BCS coding system.

Intelligence Tests:

When questions of intellectual achievement, academic deficits, or the development of an educational plan

for the child are involved, intelligence tests are often used. The most frequently used tests are the Wechsler

Intelligence Scale for Children, Third Edition (WISC-111), the Kaufman Assessment Battery for Children

(K-ABC), the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), the Stanford-

Binet Intelligence Scale, Fourth Edition, and the Peabody Picture Vocabulary Test Revised. These and

other measures are well suited for test batteries assessing learning disabilities, mental retardation,

neurological dysfunction, or pervasive developmental disorders in children.

Achievement Tests:

These tests are used to assess past learning particularly that associated with training or school programs.

They can address a variety of different academic subjects, from reading to arithmetic. Three widely used

screening devices are the Peabody Individual Achievement Test-Revised, the Woodcock Johnson Psycho

educational Battery, and the Wide Range Achievement Test-3 (WRAT-3).

Projective Tests:

Although the use of projective tests with children is somewhat controversial, some clinicians argue that they

can be useful when a more dynamic picture of personality is required. One argument for the use of

projective techniques in the assessment of children and adolescents is that the ambiguity of the stimuli in

these tests or their use of animals as subject matter may be less threatening for those youngsters whose

anxiety level is high. Both the TAT and the Rorschach are often used, as well as the Children's

Apperception Test, Incomplete Sentences Blank, and Draw-A-Person Test. Clinicians who use projective

techniques must consider the reliability and validity of their interpretations and guard against falling prey to

interpretive errors based on illusory correlations.

Neuropsychological Assessment:

Recent growth of child neuropsychology as a specialty can be attributed to an increased focus on

neurodevelopment disorders following passage of the Education for All Handicapped Children Act (Public

Law 94-142, Federal Register. 1976). as well as advances in medical care that have decreased mortality

from devastating diseases but increased the need for comprehensive assessment of their neurological effects

on surviving children. Current research areas for child neuropsychologist include assessing the

neurophysiologic correlates of conduct disorder of inattention/over activity, aggression/defiance, of anxiety.

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Family Assessment:

To a large extent, children's problems are embedded in the overall family context. The child is shaped by

the family, and the family in turn is shaped by the child. Therefore, to understand the child's problems and

intervene appropriately, one must also understand the family system. A variety of assessment devices exist

for this purpose. Several commonly used measures of family functioning are the Family Environment

Scale, or FES (Moos & Moos, 1981); the Family Adaptability and Cohesion Evaluation Scales, or FACES

III (Olson, Portner, & Lavee, 1985); and the Family Assessment Measure, or FAM (Skinner, Steinhauer, &

Santa-Barbara, 1983).

These assessments provide useful information regarding the issues at hand, and can be used separately as

well as in conjunction.

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