INTERVENTIONS & TRAINING IN PEDIATRIC AND CLINICAL CHILD PSYCHOLOGY

<< PEDIATRIC AND CHILD PSYCHOLOGY: HISTORY AND PERSPECTIVE

Clinical Psychology (PSY401)

Lecture 45

INTERVENTIONS & TRAINING IN PEDIATRIC AND CLINICAL CHILD PSYCHOLOGY

INTERVENTIONS

In the case of children, the intervention approaches are equally diverse and generally similar to those used

with adults. However, "child therapy is also different, for at least two reasons already noted. Children do not

typically refer themselves for treatment, nor do they possess the same capacity for introspection and self-

report as do most adults. Kazdin (1988) has conservatively estimated that more than 230 therapeutic

techniques are used in treating children or adolescents. If anything, this number has grown. The majority of

these treatments have not been subjected to empirical investigation regarding their efficacy and

effectiveness (Kazdin & Weisz, 1998).

PSYCHOANALYTICALLY ORIENTED THERAPY

Although psychoanalytically oriented treatments are frequently used in the treatment of children and

adolescents, modification of traditional techniques is often necessary. Children are unlikely to understand or

be able to adhere to the strict requirements of an orthodox analysis in the same way that adults can. They

usually cannot deal with the highly verbal, abstract, and introspective nature of the process. Children who

have particularly weak egos of are living in extremely threatening home situations with unsupportive

parents are not often good candidates for psychoanalytic procedures.

Modified psychoanalytic approaches, however have been widely applied to children. Although Anna Freud

(1946b) believed that children in therapy must achieve insight into their troubled feelings and defenses,

other less traditional analysts have proceeded differently. The frequency of meetings is usually reduced to

once or twice per week.

The approach is more symptom-oriented and is designed to teach the child that certain behaviors are really

defenses against anxiety. All of this may help the child to negotiate a certain developmental stage rather

than "cure" a fixation, for example. In general, the differences in approaches are in degree rather than kind.

For example, daydreams rather than nocturnal dreams might be solicited. In a greater departure, play rather

than direct verbalization may be used as a communication vehicle.

PLAY THERAPY

Rather than use dreams or free associations, some therapists have chosen to study the psychic life of the

child through play-either of a free or a structured variety. The child is brought to a playroom containing a

variety of materials such as a sandbox, clay, puppets, dolls, and toys of all kinds. How children play, what

objects they choose, and the nature of their verbalizations as they play can all be revealing, cathartic, and

therapeutic. Sometimes the therapist enters into the play and makes comments and suggestions or otherwise

guides the child toward certain conflict or problem areas. The nature of children's play may convey how

they relate to significant other figures in their lives, how they handle their anxieties, and so on. In essence,

play becomes a substitute for verbalization.

An example of play therapy is Solomon's (1955) approach. He brings the child into a room with a table on

which has been placed a number of dolls. He selects one and then asks the child what to do with it.

Sometimes the dolls are arrayed to represent the child's family. As the child arranges the dolls and plays, the

therapist interprets what the child is doing, which then facilitates the expression of feelings on the part of

the child. Concrete family experiences, wishes, and even unconscious urges may be expressed in the

process. In general, however, play therapy has evolved into a rather eclectic, amorphous set of techniques

and procedures.

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Play therapy is no longer associated solely with a psychodynamic orientation, but has also been used with a

cognitive-behavioral approach. Although children may not be able to process the verbal subtleties that

characterize cognitive therapy for adults, Knell (1998) argues that cognitive-behavioral play therapy can

effect cognitive and behavioral changes in children through techniques such as modeling adaptive coping

skills, indirectly communicating cognitive change through play and providing opportunities (again through

play) for the child to reenact problem situations and gain some mastery over them.

BEHAVIOR THERAPY

Behavioral techniques have overtaken psychodynamic methods as the treatment of choice to childhood

problems. For children, it has always seemed evident that their problems are the direct outgrowth of

environmental factors or the people who are in control of various aspects of the child's life. Either

respondent principles (behavior is acquired through classical conditioning) or operant principles (behavior

is maintained by its consequences) seem ideally suited to account for main childhood behaviors. Moreover,

these principle can easily be applied by parents and teachers a part of the therapeutic plan.

Most of these procedures whether systematic desensitization aversion therapy, or contingency management

techniques, is highly efficient in comparison to older, more traditional psychodynamic methods. Changes

that once took months or even years to occur can be achieved in 20 or fewer sessions. Parents and teachers

can be trained to enhance the effectiveness of the techniques and to help ensure that changes will generalize

outside the therapist's office..Parent management training involves a set of therapeutic procedures that are

designed to "train" parents to modify a child or adolescent's behavior at home. Parents master basic learning

principles (contingency management, reinforcement) and then implement them at home. Enlisting parents

in the treatment process makes it more likely that behavior change will be effected in the child or

adolescent. For example, Barkley (1987) has developed a program for teaching child management skills to

parents of children who are defiant and noncompliant.

BEHAVIORAL PEDIATRICS

Clinical child psychologists and pediatric psychologists can also contribute a great deal to the management

of children during their stay in the hospital. This includes help in preparing children for particular medical

procedures and in assisting the child and family in coping later with their medical problems. Techniques

used here range from behavioral rehearsal and stress inoculation to various methods of cognitive

reappraisal. Whether the problem is a simple fear of needles or the stress and pain associated with repeated

changing of bandages for burn patients, behavioral methods can be helpful. The management of pain and

headaches and ensuring compliance with medical regimens are also important provinces of behavioral

pediatrics.

COGNITIVE-BEHAVIORAL THERAPY

In recent years, cognitive-behavioral therapy has increasingly been applied to problems such as impulsivity,

hyperactivity, anxiety, depression, and conduct disorders. The basic idea is to improve problem solving and

enhance planning and delay of gratification. Through internal assessments and self-statements children are

taught to bring their previously distressing or problematic behavior under rational control. The vehicle

through which this is accomplished is the alteration or cognitions, and the ultimate goal is the creation of a

new, more adaptive "coping template".

GROUP AND FAMILY THERAPY

Many of the problems are learned and even nourished in the family setting; to relieve them often requires

the cooperation and .understanding of the family unit. Because children are so much influenced by and is

the product of their families. In some, cases it only makes good sense to treat the entire family. However,

the relatively modest evidence for the overall efficacy of family therapy suggests that family therapy might

be used selectively in those cases or disorders in which there is evidence supporting its effectiveness. For

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example recent reviews suggest that certain forms of family therapy effectively treat anxiety disorders and

conduct disorders in children and adolescents.

As for group therapy, a recent meta-analysis indicated that overall group treatments for children and

adolescents were more effective than wait-list and placebo control groups. The overall effect size across

treatments averaged .61, indicating that, on average, a child or adolescent who received one of these

treatments was better off than 73% of those in the control groups. Although the small number of studies

sampled by Hoag and Burlingame (1997) precluded adequate tests of the efficacy of different types of

group treatment and different types of clinical problems addressed, it seems likely that some forms of group

treatment for specific clinical problems (for example, cognitive-behavioral group treatment for depression)

are more effective.

PSYCHOPHARMACOLOGICAL TREATMENT

Medications may be used as adjuncts to psychotherapy in the treatment of the child. The medication most

frequently used is those that treat attention deficit/hyperactivity disorder, or ADHE. The most frequently

prescribed medication for ADHD is the psycho stimulant methylphenidate. Although studies have

demonstrated the positive effects of Ritalin in treating ADHD symptoms not all children and adolescents

have a positive response. The costs, in the form of side effects, may outweigh the benefits and there have

been few demonstrations of long-term benefit in the form of improved prognosis. These same points apply

to other forms of medication that are used to treat the range of clinical problem presented by children and

adolescents.

The research literature suggests that, in general, psychological treatments for childhood and adolescent

problems are effective. Further, recent reviews have identified specific interventions for specific child and

adolescent problems hat have empirical support.

PREVENTION

Clinical child and pediatric psychologists have been especially concerned about the prevention of childhood

problems. Of course, prevention and treatment are activities that blend and merge. Primary prevention is

defined as counteracting problems before they have a chance to develop, and secondary prevention involves

the prompt treatment of problems in order to minimize their impact. Certainly, the clinical child or pediatric

psychologist wants to either prevent problems before they occur or at least identify the problems before they

get out of control. In any case, the stance of either the pediatric or clinical child psychologist is a proactive

one.

In the context of pediatric practice, Roberts (1986) likes to use the term anticipatory guidance-the use of

counseling and education in advance of difficulties. For example, parents may be counseled about

"childproofing" their home at various stages of the child's development. This could cover almost anything

from covering electrical outlets to blocking off stairways. At a more psychological level, it may involve

providing information on preparing the child for the birth of a sibling or the death of a grandparent. In the

case of a child with cystic fibrosis, it might take the form of counseling the youngster on how to respond to

teasing from peers prompted by the physical limitations imposed by the disease.

One of the tenets of community psychology has always been the identification of people at risk for the

development of subsequent problems. One example is the child who is hospitalized. Programs have been de

signed to provide information to hospitalize children, to encourage emotional expression it such children, to

offer them coping strategies, of to just help build trusting relationships. In addition, numerous films and

videotapes also have been developed to help children cope with medical interventions.

To aid in the prevention of physical problems, safety programs directed toward children have addressed

issues that range from crossing the street safely to avoiding abduction or molestation. Programs to train so-

called latchkey children have also been developed. Research suggests that specific recommendations and

pediatric counseling with parents will increase the use o safety car seats. More recently attempts have been

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made to integrate child injury and child abuse/neglect research because similar interventions may be used to

prevent harm in both domains

Only pediatric psychologists (and not clinical child psychologists concern themselves with prevention,

prevention is not the sole province of pediatric psychologists; clinical child psychologists are becoming

increasingly more involved as well. Examples of prevention programs outside of medical settings include

an early intervention and prevention program to reduce anxiety disorders in 7 to 14-year-olds who were at

risk for these problems and the Children of Divorce Intervention Program aimed at improving the

adjustment of children and adolescents to divorce.

CONSULTATION Consultation-liaison relationships have long been typical in the professional lives of

pediatric psychologists. Drotar (1995) and Roberts (1986) have described the consultation process at some

length, although the focus here will be on the pediatric psychologist, many points apply equally to clinical

child psychologists.

Because of the problems presented in pediatric setting, consultation has become an integral part of the

psychologist's role. Consultation occurs with parents, pediatricians, medical school systems, welfare

agencies, juvenile systems, and other health or service agencies. The subjects of consultation may range

from psychiatric, psychosomatic, or developmental problems to any kind of illness-related difficulties

common to health care settings. In particular pediatric psychologists consult with pediatricians who call

upon the psychologist much as they might consult with other specialists such as cardiologists or

oncologists. Because pediatricians encounter such a wide range of both well and ill children often face

problems for which they have training, knowledge, or interest in treating. Hence, they may turn to the

psychologist.

Consultation may occur in hospital practice or in outpatient settings. It may involve requests or immediate

and very brief help or for term interventions. Requests may come in the form of hallway chats and quick

telephone, or in the shape of case workups and written reports. Some interventions are directly with child;

others involve work with the family with the pediatrician's staff. Indeed, several models of consultation

have been offered. Let us consider now.

Independent Functions Model.

Here, the psychologist functions as a specialist and independently carries out diagnostic and treatment

activities on patients referred by the pediatrician for other professional. On the surface seems relatively non

collaborative. However formation is exchanged between parties be fore and after the patient is seen. This

model several advantages. Medicals professionals, such as pediatricians, find it familiar and comfortable.

Further, the model is efficient and cost effective. However, the limited contact may lead to less

comprehensive consult, and fewer training opportunities.

Indirect Consultation Model. In this case, the pediatrician retains chief responsibility for patient

management. The psychologist has, at best, limited contact with the actual patient and makes a contribution

through analysis of information provided by the pediatrician for other specialist). This kind of consultation

is especially characteristic of medical center settings where teaching is a major function. Often the role of

the psychologist is an educational or supervisory one, especially when pediatric residents are involved. This

kind of consultation may involve

1) Brief contacts, such as phone-calls or informal hallway consultations);

(2)Presentation of information seminars, conferences, Workshops, or in-service training-for other

professionals; or

3) Situations where another professional carries out specific behavioral or psychosocial interventions

recommended by the psychologist. For example, the psychologist may develop specific guidelines and give

them to the pediatrician, who either implements them or else supervises parents who do the actual

intervention. These guidelines may involve how to handle problems such as temper tantrums, bedwetting,

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mealtime problems, or general behavioral management. Roberts (1986) has provided a list of sample

guidelines or protocols for the assessment and treatment of childhood problems.

As noted by Drotar (1995), indirect consultation is more likely to be well received and effective if the focus

is on clinical relevance and if there are practical applications that follow. However, there are some

limitations and drawbacks as well (Drotar, 1995). This model can be very time consuming and may be seen

as a detractor from time spent on direct clinical service. Further, pediatricians and other medical personnel

often want immediate solutions, to which complex clinical problems do not always lend themselves.

Collaborative Team Model. A third model represents what most consider true collaboration. Here,

pediatrician, psychologist, nurse, or others work together and share the responsibility and decision making.

This might be referred to as "conjoint case management." In this instance, the professionals involved act as

functional equals. Of course, such a model is not often possible in non-teaching / non-research settings for

several practical and financial reasons.

However, such a model is especially appropriate for those cases that clearly involve both medical and psy-

chological features. Effective collaborative team consultation evolves over time among those who have

worked closely together, who respect each other's viewpoint, and who offer expertise that complements

what other team members possess (Drotar, 1995). The biggest challenge is for team members to learn from

each other, develop new professional skills, and maintain their own professional identities (Drotar, 1995).

Training

Issues of training in both clinical child and pediatric psychology have come to the forefront in recent years.

This is due in part to the growing interest in health and medical issues and in the developing collaboration

between medicine and psychology.

Roberts et al. (1998) recently presented a training model for psychologists who will provide services for

children and adolescents. These recommendations apply to those seeking to become either clinical child

psychologists or pediatric psychologists, although in both cases some additional specialized training might

be required. Roberts et al. (1998) listed their recommendations by topic area.

1. Life span developmental psychology: Trainees should obtain knowledge and expertise in developmental

processes (social, cognitive, emotional, behavioral, and physical) and how these processes may influence

assessment, diagnosis, treatment, and outcome.

2. Life span developmental psychopathology: Trainees must be exposed to information about mental,

emotional, and developmental disorders and abnormal development.

3. Child, adolescent, and family assessment methods: Trainees should learn to administer and interpret

assessments (intellectual, personality, behavioral, family, socio-cultural context) commonly used with chil-

dren and adolescents. Trainees should focus on assessments with empirical support and appreciate how

assessments can be influenced by ethnic or cultural background, or disability.

4. Intervention strategies: Trainees should be exposed to leading child, adolescent, parent, family, and

school and community interventions, as well as the research literature on their effectiveness.

5. Research methods and systems evaluations: Trainees should be familiar with research methods so that

critical evaluations of assessments, treatments, and services are possible. Further, trainees should be able to

conduct research on important topics.

6. Professional, ethical, and legal issues: Trainees must be familiar with issues that pertain to children,

adolescents, and families. These issues include child abuse reporting, custody, confidentiality, duty to

protect, and relevant state and federal laws.

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7. Issues of diversity: Trainees must appreciate the role of ethnicity and culture and how diverse beliefs and

expectations affect assessment, intervention, and the interaction between service delivery systems and chil-

dren or adolescents and their families.

8. Multiple disciplines and service delivery systems: Services for children and adolescents have become

more interdisciplinary in nature and involve different service delivery systems. Trainees should be exposed

to other disciplines (pediatrics and family practice. social work) and how professionals from these

disciplines seek to address problems.

9. Prevention. Family support and health promotion: Trainees should have expertise in other forms of

intervention that improve quality of life and can help prevent future problems.

10. Social issues affecting children, adolescents, and Families: number of social circumstances (natural

disasters, abuse and neglect, violence) can greatly impact the well-being of children, adolescents, and their

families. Trainees should have knowledge and appreciation of these potential adversities.

11. Specialized experience in assessrnent, intervention, and consultation: Trainees should acquire a broad

range of applied experiences with a diverse selection of children, adolescents, and their families. This

means working in several different settings (such as medical hospitals, public-sector mental health

agencies).

Roberts et al. (1998) believe that training in these areas should occur through didactic coursework,

observation in an applied or research setting, and supervised service delivery. These experiences can be

obtained at the pre-doctoral, internship, and postdoctoral phases of training.

Regarding specialized training in pediatric psychology, Drotar (1998) notes that the needs of pediatric

psychology trainees are complex. At a minimum, pediatric psychologists must learn to consult and

collaborate with physicians, to recognize and manage the clinical problems that are typically encountered in

pediatric settings, to teach primary care providers about principles of behavior and development, and to

engage in interdisciplinary research. These training goals may be attained through didactic coursework,

observation of pediatric psychologists in these situations, and hands-on experience in the field.

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