INTERVENTIONS & INTERVENTIONS & TRAINING IN CLINICAL TRAINING IN CLINICAL CHILD AND PEDIATRIC CHILD AND PEDIATRIC

PSYCHOLOGYPSYCHOLOGY

LECTURE 45LECTURE 45

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

However, "child therapy is also different, for at least However, "child therapy is also different, for at least two reasons already noted. two reasons already noted.

Children do not typically refer themselves for Children do not typically refer themselves for treatment, nor do they possess the same capacity for treatment, nor do they possess the same capacity for introspection and self-report as do most adults.introspection and self-report as do most adults.

Kazdin (1988) has conservatively estimated that more Kazdin (1988) has conservatively estimated that more than 230 therapeutic techniques are used in treating than 230 therapeutic techniques are used in treating children or adolescents. children or adolescents.

If anything, this number has grown. The majority of If anything, this number has grown. The majority of these treatments have not been subjected to empirical these treatments have not been subjected to empirical investigation regarding their efficacy and investigation regarding their efficacy and effectiveness.effectiveness.

Psychoanalytically Oriented Therapy.Psychoanalytically Oriented Therapy. Although psychoanalytically oriented treatments are Although psychoanalytically oriented treatments are

frequently used in the treatment of children and frequently used in the treatment of children and adolescents, modification of traditional techniques is adolescents, modification of traditional techniques is often necessary. often necessary.

Children are unlikely to understand or be able to Children are unlikely to understand or be able to adhere to the strict requirements of an orthodox adhere to the strict requirements of an orthodox analysis in the same way that adults can. analysis in the same way that adults can.

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

Children who have particularly weak egos of are living Children who have particularly weak egos of are living in extremely threatening home situations with in extremely threatening home situations with unsupportive parents are not often good candidates unsupportive parents are not often good candidates for psychoanalytic procedures.for psychoanalytic procedures.

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

Although Anna Freud (1946b) believed that children in Although Anna Freud (1946b) believed that children in therapy must achieve insight into their troubled therapy must achieve insight into their troubled feelings and defenses, other less traditional analysts feelings and defenses, other less traditional analysts have proceeded differently. have proceeded differently.

The frequency of meetings is usually reduced to once The frequency of meetings is usually reduced to once or twice per week. or twice per week.

The approach is more symptom oriented and is The approach is more symptom oriented and is designed to teach the child that certain behaviors are designed to teach the child that certain behaviors are really defenses against anxiety. really defenses against anxiety.

All of this may help the child to negotiate a certain All of this may help the child to negotiate a certain developmental stage rather than "cure" a fixation. developmental stage rather than "cure" a fixation.

In general, the differences in approaches are in In general, the differences in approaches are in degree rather than kind.degree rather than kind.

In a greater departure, play rather than direct In a greater departure, play rather than direct verbalization may be used as a communication verbalization may be used as a communication vehicle.vehicle.

Play Therapy.Play Therapy. Rather than use dreams or free associations, some Rather than use dreams or free associations, some

therapists have chosen to study the psychic life of the therapists have chosen to study the psychic life of the child through play-either of a free or a structured child through play-either of a free or a structured variety. variety.

The child is brought to a playroom containing a variety The child is brought to a playroom containing a variety of materials such as a sandbox, clay, puppets, dolls, of materials such as a sandbox, clay, puppets, dolls, and toys of all kinds. and toys of all kinds.

How children play, what objects they choose, and the How children play, what objects they choose, and the nature of their verbalizations as they play can all be nature of their verbalizations as they play can all be revealing, cathartic, and therapeutic. revealing, cathartic, and therapeutic.

Sometimes the therapist enters into the play and Sometimes the therapist enters into the play and makes comments and suggestions or otherwise makes comments and suggestions or otherwise guides the child toward certain conflict or problem guides the child toward certain conflict or problem areas. areas.

The nature of children's play may convey how they The nature of children's play may convey how they relate to significant other figures in their lives, how relate to significant other figures in their lives, how they handle their anxieties, and so on. In essence, they handle their anxieties, and so on. In essence, play becomes a substitute for verbalization.play becomes a substitute for verbalization.

An example of play An example of play therapy is therapy is Solomon's (1955) Solomon's (1955) approach. approach.

He brings the child into a room with a table on which He brings the child into a room with a table on which has been placed a number of dolls. has been placed a number of dolls.

He selects one and then asks the child what to do with He selects one and then asks the child what to do with it. it.

Sometimes the dolls are arrayed to represent the Sometimes the dolls are arrayed to represent the child's family. child's family.

As the child arranges the dolls and plays, the therapist As the child arranges the dolls and plays, the therapist interprets what the child is doing, which then facilitates interprets what the child is doing, which then facilitates the expression of feelings on the part of the child. the expression of feelings on the part of the child.

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

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

Play therapy is no longer associated solely with a Play therapy is no longer associated solely with a psychodynamic orientation, but has also been used psychodynamic orientation, but has also been used with a cognitive-behavioral approach. with a cognitive-behavioral approach.

Although children may not be able to process the Although children may not be able to process the verbal subtleties that characterize cognitive therapy for verbal subtleties that characterize cognitive therapy for adults, adults,

Knell (1998) argues that cognitive-behavioral play Knell (1998) argues that cognitive-behavioral play therapy can effect cognitive and behavioral changes in therapy can effect cognitive and behavioral changes in children through techniques such as children through techniques such as

Modeling adaptive coping skills, Modeling adaptive coping skills, Indirectly communicating cognitive change through Indirectly communicating cognitive change through

play and providing opportunities (again through play) play and providing opportunities (again through play) for the child to reenact problem situations and gain for the child to reenact problem situations and gain some mastery over them. some mastery over them.

Behavior Therapy.Behavior Therapy. For children, it has always seemed evident that their For children, it has always seemed evident that their

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

Either respondent principles or operant principles Either respondent principles or operant principles seem ideally suited to account for main childhood seem ideally suited to account for main childhood behaviors. behaviors.

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

Most of these procedures whether systematic Most of these procedures whether systematic desensitization aversion therapy, or contingency desensitization aversion therapy, or contingency management techniques, is highly efficient in management techniques, is highly efficient in comparison to older, more traditional psychodynamic comparison to older, more traditional psychodynamic methods. methods.

Parents and teachers can be trained to enhance the Parents and teachers can be trained to enhance the effectiveness of the techniques and to help ensure effectiveness of the techniques and to help ensure that changes will generalize outside the therapist's that changes will generalize outside the therapist's office.office.

Behavioral Pediatrics.Behavioral Pediatrics. Clinical child psychologists and pediatric psychologists Clinical child psychologists and pediatric psychologists

can also contribute a great deal to the management of can also contribute a great deal to the management of children during their stay in the hospital. children during their stay in the hospital.

This includes help in preparing children for particular This includes help in preparing children for particular medical procedures and in assisting the child and medical procedures and in assisting the child and family in coping later with their medical problems.family in coping later with their medical problems.

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

Whether the problem is a simple fear of needles or the Whether the problem is a simple fear of needles or the stress and pain associated with repeated changing of stress and pain associated with repeated changing of bandages for burn patients, behavioral methods can bandages for burn patients, behavioral methods can be helpful. be helpful.

The management of pain and headaches and The management of pain and headaches and ensuring compliance with medical regimens are also ensuring compliance with medical regimens are also important provinces of important provinces of behavioral pediatricsbehavioral pediatrics

Cognitive-Behavioral Therapy. Cognitive-Behavioral Therapy. In recent years, cognitive-behavioral therapy has In recent years, cognitive-behavioral therapy has

increasingly been applied to problems such as increasingly been applied to problems such as impulsivity, hyperactivity, anxiety, depression, and impulsivity, hyperactivity, anxiety, depression, and conduct disorders. conduct disorders.

The basic idea is to improve problem solving and The basic idea is to improve problem solving and enhance planning and delay of gratification.enhance planning and delay of gratification.

Through internal assessments and self-statements Through internal assessments and self-statements children are taught to bring their previously distressing children are taught to bring their previously distressing or problematic behavior under rational control. or problematic behavior under rational control.

The vehicle through which this is accomplished is the The vehicle through which this is accomplished is the alteration or cognitions, and the ultimate goal is the alteration or cognitions, and the ultimate goal is the creation of a new, more adaptive "coping template”.creation of a new, more adaptive "coping template”.

Group and Family TherapyGroup and Family Therapy. . Many of the problems are learned and even nourished Many of the problems are learned and even nourished

in the family setting; to relieve them often requires the in the family setting; to relieve them often requires the cooperation and understanding of the family unit.cooperation and understanding of the family unit.

Because children are so much influenced by and is Because children are so much influenced by and is the product of their families. the product of their families.

In some, cases it only makes good sense to treat the In some, cases it only makes good sense to treat the entire family. However, the relatively modest evidence entire family. However, the relatively modest evidence for the overall efficacy of family therapy suggests that for the overall efficacy of family therapy suggests that family therapy might be used selectively in those family therapy might be used selectively in those cases or disorders in which there is evidence cases or disorders in which there is evidence supporting its effectiveness. supporting its effectiveness.

For example recent reviews suggest that certain forms For example recent reviews suggest that certain forms of family therapy effectively treat anxiety disorders and of family therapy effectively treat anxiety disorders and conduct disorders in children and adolescents.conduct disorders in children and adolescents.

Psychopharmacological Treatment.Psychopharmacological Treatment. Medications may be used as adjuncts to Medications may be used as adjuncts to

psychotherapy in the treatment of the child. psychotherapy in the treatment of the child. The medication most frequently used is those that The medication most frequently used is those that

treat attention deficit/hyperactivity disorder, or ADHE. treat attention deficit/hyperactivity disorder, or ADHE. The most frequently prescribed medication for ADHD The most frequently prescribed medication for ADHD

is the psycho stimulant methylphenidate. is the psycho stimulant methylphenidate. Although studies have demonstrated the positive Although studies have demonstrated the positive

effects of Ritalin in treating ADHD symptoms not all effects of Ritalin in treating ADHD symptoms not all children and adolescents have a positive response. children and adolescents have a positive response. The costs, in the form of side effects, may outweigh The costs, in the form of side effects, may outweigh the benefits and there have been few demonstrations the benefits and there have been few demonstrations of long-term benefit in the form of improved prognosis.of long-term benefit in the form of improved prognosis.

The research literature suggests that, in general, The research literature suggests that, in general, psychological treatments for childhood and adolescent psychological treatments for childhood and adolescent problems are effective. problems are effective.

PREVENTIONPREVENTION Clinical child and pediatric psychologists have been Clinical child and pediatric psychologists have been

especially concerned about the prevention of especially concerned about the prevention of childhood problems. childhood problems.

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

Primary prevention is defined as counteracting Primary prevention is defined as counteracting problems before they have a chance to develop, and problems before they have a chance to develop, and

secondary prevention involves the prompt treatment of secondary prevention involves the prompt treatment of problems in order to minimize their impact. problems in order to minimize their impact.

Certainly, the clinical child or pediatric psychologist Certainly, the clinical child or pediatric psychologist wants to either prevent problems before they occur or wants to either prevent problems before they occur or at least identify the problems before they get out of at least identify the problems before they get out of control. control.

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

CONSULTATIONCONSULTATION Consultation-liaison relationships have long been Consultation-liaison relationships have long been

typical in the professional lives of pediatric typical in the professional lives of pediatric psychologists. psychologists.

Drotar (1995) and Roberts (1986) have described the Drotar (1995) and Roberts (1986) have described the consultation process at some length, although the consultation process at some length, although the focus here will be on the pediatric psychologist, many focus here will be on the pediatric psychologist, many points apply equally to clinical child psychologists. points apply equally to clinical child psychologists.

Because of the problems presented in pediatric Because of the problems presented in pediatric setting, consultation has become an integral part of setting, consultation has become an integral part of the psychologist's role. the psychologist's role.

Consultation occurs with parents, pediatricians, Consultation occurs with parents, pediatricians, medical school systems, welfare agencies, juvenile medical school systems, welfare agencies, juvenile systems, and other health or service agencies. systems, and other health or service agencies.

The subjects of consultation may range from The subjects of consultation may range from psychiatric, psychosomatic, or developmental psychiatric, psychosomatic, or developmental problems to any kind of illness-related difficulties problems to any kind of illness-related difficulties common to health care settings. common to health care settings.

In particular pediatric psychologists consult with In particular pediatric psychologists consult with pediatricians who call upon the psychologist much as pediatricians who call upon the psychologist much as they might consult with other specialists such as they might consult with other specialists such as cardiologists or oncologists. cardiologists or oncologists.

Because pediatricians encounter such a wide range of Because pediatricians encounter such a wide range of both well and ill children often face problems for which both well and ill children often face problems for which they have training, knowledge, or interest in treating. they have training, knowledge, or interest in treating. Hence, they may turn to the psychologist.Hence, they may turn to the psychologist.

Consultation may occur in hospital practice or in Consultation may occur in hospital practice or in outpatient settings. outpatient settings.

It may involve requests or immediate and very brief It may involve requests or immediate and very brief help or for term interventions. help or for term interventions.

Requests may come in the form of hallway chats and Requests may come in the form of hallway chats and quick telephone, or in the shape of case workups and quick telephone, or in the shape of case workups and written reports. written reports.

Some interventions are directly with child; others Some interventions are directly with child; others involve work with the family with the pediatrician's involve work with the family with the pediatrician's staff. staff.

Indeed, several models of consultation have been Indeed, several models of consultation have been offered. Let us consider now.offered. Let us consider now.

Independent Functions Model.Independent Functions Model. Here, the psychologist functions as a specialist and Here, the psychologist functions as a specialist and

independently carries out diagnostic and treatment independently carries out diagnostic and treatment activities on patients referred by the pediatrician for activities on patients referred by the pediatrician for other professional. other professional.

On the surface seems relatively non collaborative.On the surface seems relatively non collaborative. However formation is exchanged between parties be However formation is exchanged between parties be

fore and after the patient is seen. fore and after the patient is seen. This model several advantages. Medicals This model several advantages. Medicals

professionals, such as pediatricians, find it familiar and professionals, such as pediatricians, find it familiar and comfortable. comfortable.

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

comprehensive consult, and fewer training comprehensive consult, and fewer training opportunities.opportunities.

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

for patient management. for patient management. The psychologist has, at best, limited contact with the The psychologist has, at best, limited contact with the

actual patient and makes a contribution through actual patient and makes a contribution through analysis of information provided by the pediatrician for analysis of information provided by the pediatrician for other specialist). other specialist).

This kind of consultation is especially characteristic of This kind of consultation is especially characteristic of medical center settings where teaching is a major medical center settings where teaching is a major function. Often the role of the psychologist is an function. Often the role of the psychologist is an educational or supervisory one, especially when educational or supervisory one, especially when pediatric residents are involved. pediatric residents are involved.

This kind of consultation may involveThis kind of consultation may involve 1) Brief contacts, such as phone calls or informal 1) Brief contacts, such as phone calls or informal

hallway consultations); hallway consultations); (2)Presentation of information seminars, conferences, (2)Presentation of information seminars, conferences,

Work shops, or in-service training-for other Work shops, or in-service training-for other professionals; orprofessionals; or

3) Situations where another professional carries out 3) Situations where another professional carries out specific behavioral or psychosocial interventions specific behavioral or psychosocial interventions recommended by the psychologist. recommended by the psychologist.

For example, the psychologist may develop specific For example, the psychologist may develop specific guidelines and give them to the pediatrician, who guidelines and give them to the pediatrician, who either implements them or else supervises parents either implements them or else supervises parents who do the actual intervention. who do the actual intervention.

These guidelines may involve how to handle problems These guidelines may involve how to handle problems such as temper tantrums, bedwetting, mealtime such as temper tantrums, bedwetting, mealtime problems, or general behavioral management.problems, or general behavioral management.

Roberts (1986) has provided a list of sample Roberts (1986) has provided a list of sample guidelines or protocols for the assessment and guidelines or protocols for the assessment and treatment of childhood problems.treatment of childhood problems.

As noted by Drotar (1995), indirect consultation As noted by Drotar (1995), indirect consultation is more likely to be well received and effective if is more likely to be well received and effective if the focus is on clinical relevance and if there the focus is on clinical relevance and if there are practical applications that follow. are practical applications that follow.

However, there are some limitations and However, there are some limitations and drawbacks as well (Drotar, 1995). drawbacks as well (Drotar, 1995).

This model can be very time consuming and This model can be very time consuming and may be seen as a detractor from time spent on may be seen as a detractor from time spent on direct clinical service. direct clinical service.

Further, pediatricians and other medical Further, pediatricians and other medical personnel often want immediate solutions, to personnel often want immediate solutions, to which complex clinical problems do not always which complex clinical problems do not always lend themselves lend themselves

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

collaboration.collaboration. Here, pediatrician, psychologist, nurse, or others work Here, pediatrician, psychologist, nurse, or others work

together and share the responsibility and decision together and share the responsibility and decision making.This might be referred to as "conjoint case making.This might be referred to as "conjoint case management." . management." .

Such a model is not often possible in Such a model is not often possible in nonteaching/nonresearch settings for several practical nonteaching/nonresearch settings for several practical and financial reasons. and financial reasons.

However, such a model is especially appropriate for However, such a model is especially appropriate for those cases that clearly involve both medical and those cases that clearly involve both medical and psychological features. psychological features.

Effective collaborative team consultation evolves over Effective collaborative team consultation evolves over time among those who have worked closely together, time among those who have worked closely together, who respect each other's viewpoint, and who offer who respect each other's viewpoint, and who offer expertise that complements what other team members expertise that complements what other team members possess.possess.

TRAININGTRAINING Issues of training in both clinical child and pediatric Issues of training in both clinical child and pediatric

psychology have come to the forefront in recent years. psychology have come to the forefront in recent years. This is due in part to the growing interest in health and This is due in part to the growing interest in health and

medical issues and in the developing collaboration medical issues and in the developing collaboration between medicine and psychology.between medicine and psychology.

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

These recommendations apply to those seeking to These recommendations apply to those seeking to become either clinical child psychologists or pediatric become either clinical child psychologists or pediatric psychologists, although in both cases some additional psychologists, although in both cases some additional specialized training might be required. specialized training might be required.

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

1. 1. Life span developmental psychology:Life span developmental psychology: Trainees Trainees should obtain knowledge and expertise in should obtain knowledge and expertise in developmental processes (social, cognitive, emotional, developmental processes (social, cognitive, emotional, behavioral, and physical) and how these processes behavioral, and physical) and how these processes may influence assessment, diagnosis, treatment, and may influence assessment, diagnosis, treatment, and outcome.outcome.

2. 2. Life span developmental psychopathology:Life span developmental psychopathology: Trainees must be exposed to information about Trainees must be exposed to information about mental, emotional, and developmen tal disorders and mental, emotional, and developmen tal disorders and abnormal development.abnormal development.

3. 3. Child, adolescent, and family assessment Child, adolescent, and family assessment methods:methods: Trainees should learn to administer and Trainees should learn to administer and interpret assessments (intellectual, personality, interpret assessments (intellectual, personality, behavioral, family, sociocultural context) commonly behavioral, family, sociocultural context) commonly used with children and adolescents. used with children and adolescents.

Trainees should focus on assessments with empirical Trainees should focus on assessments with empirical support and appreciate how assessments can be support and appreciate how assessments can be influenced by ethnic or cultural background, or influenced by ethnic or cultural background, or disability.disability.

4. 4. Intervention strategies:Intervention strategies: Trainees should be ex Trainees should be ex posed to leading child, adolescent, parent, family, and posed to leading child, adolescent, parent, family, and school and community interventions, as well as the school and community interventions, as well as the research literature on their effectiveness.research literature on their effectiveness.

5. 5. Research methods and systems evaluations:Research methods and systems evaluations: Trainees should be familiar with research methods so Trainees should be familiar with research methods so that critical evaluations of assessments, treatments, that critical evaluations of assessments, treatments, and services are possible. Further, trainees should be and services are possible. Further, trainees should be able to conduct research on important topics.able to conduct research on important topics.

6. 6. Professional, ethical, and legal issues:Professional, ethical, and legal issues: Trainees Trainees must be familiar with issues that pertain to children, must be familiar with issues that pertain to children, adolescents, and families. These issues include child adolescents, and families. These issues include child abuse reporting, custody, confidentiality, duty to abuse reporting, custody, confidentiality, duty to protect, and relevant state and federal laws.protect, and relevant state and federal laws.

7. 7. Issues of diversity:Issues of diversity: Trainees must appreciate the Trainees must appreciate the role of ethnicity and culture and how diverse beliefs role of ethnicity and culture and how diverse beliefs and expectations affect assessment, intervention, and and expectations affect assessment, intervention, and the interaction between service delivery systems and the interaction between service delivery systems and children or adolescents and their families.children or adolescents and their families.

8. 8. Multiple disciplines and service delivery sys Multiple disciplines and service delivery sys tems:tems: Services for children and adolescents have Services for children and adolescents have become more interdisciplinary in nature and involve become more interdisciplinary in nature and involve different service delivery systems. Trainees should be different service delivery systems. Trainees should be exposed to other disciplines (pediatrics and family exposed to other disciplines (pediatrics and family practice. social work) and how professionals from practice. social work) and how professionals from these disciplines seek to address problems.these disciplines seek to address problems.

9. 9. Prevention. Family support and health promo Prevention. Family support and health promo tion:tion: Trainees should have expertise in other forms of Trainees should have expertise in other forms of intervention that improve quality of life and can help intervention that improve quality of life and can help prevent future problems.prevent future problems.

1010. Specialized experience in assessment. Specialized experience in assessment, , intervention, and consultation: intervention, and consultation: Trainees should Trainees should ac quire a broad range of applied experiences ac quire a broad range of applied experiences with a diverse selection of children, with a diverse selection of children, adolescents, and their families. This means adolescents, and their families. This means working in several different settings.working in several different settings.

Roberts et al. (1998) believe that training in Roberts et al. (1998) believe that training in these areas should occur through didactic these areas should occur through didactic coursework, observation in an applied or coursework, observation in an applied or research setting, and supervised service research setting, and supervised service delivery. delivery.

These experiences can be obtained at the pre-These experiences can be obtained at the pre-doctoral, internship, and postdoctoral phases of doctoral, internship, and postdoctoral phases of training.training.