Family Context in Pediatric Psychology: A Transactional Perspective

The degree to which the family is seen as a significant contributorto child health conditions impacts directly on the successfulfunctioning of the pediatric psychologist. A transactional modelof family functioning is proposed for pediatric psychology.Development is considered to be the result of a three-part processthat starts with child behavior that triggers family interpretationthat produces a parental response. Family interpretation ispresented as part of a regulatory system that includes familyparadigms, family stories, and family rituals. Correspondingto the proposed three-part regulation model, three forms ofintervention are discussed: remediation, redefinition, and reeducation.Clinical decision making based on this model is outlined withexamples given from different treatment approaches. Implicationsfor the treatment of families in pediatric psychology are discussed.     

Managing Family Accommodation of OCD in the Context of Adolescent Treatment Refusal: A Case Example

Family accommodation is a common and widely studied phenomenon in families of youth with obsessive‐compulsive disorder (OCD). Family accommodation has been associated with increased symptom severity, poorer functional outcomes, and reduced treatment response. While family accommodation is increasingly targeted in family‐based treatment of OCD, there are cases where youth refuse treatment. In these circumstances, parent‐focused treatments that target reduction of family accommodation can be used to improve outcomes for youth with OCD. This case study illustrates the conceptualization and treatment of family accommodation in childhood OCD in the context of treatment refusal. Treatment was implemented without explicit involvement of the child. Parents reported moderate improvement in OCD symptoms at the end of treatment and a decrease in overall parent–child conflict. The findings illustrate how exposure and response principles can be implemented without direct involvement of the child in cases where youth show low motivation or refusal of treatment.     

Factors Influencing Family Participation in a Longitutdinal Study: Comparison of Pediatric and Healthy Samples

Compared participation levels in a longitudinal study of parent-childrelationships from infancy to 4 years in families of childrenwith cystic fibrosis, congenital heart disese, and with no chronicillnes. Demographic (parent's age, education) and child, parentand family variables (medical status, family environment) wereinvestigated for their predictive value of families' participation.34% of families (71/209) were lost to the study at a later date.Families of children with cystic fibrosis were the least likelyto be lost. Parents' age and /or education predicted participationin all groups. Families in both pediatric samples participatedless when parental well-being was less optimal, and the levelof mother-infant attachment organization was lower. Unlike demographicfactors, family factors have diferential impact on participationin families in pediatric and nonpediatric samples.     

Society of Pediatric Psychology Task Force Report: Pediatric Psychology and Injury Control

Injuries are the major causes of death for children. Pediatricpsychology offers significant contributions to the multidisciplinaryefforts necessary to prevent injuries and reduce harm to children.This Task Force Report reviews epidemiological data, characteristicsof children's injuries, passive and active interventions forreducing injuries, and research, policy, and evaluation issuesfor individual and community injury control efforts. Directionsfor future pediatric psychology efforts are identified and placedin a context of collaborative efforts required to advance thecontrol of children's injuries.     

Family Coping with Pediatric Leukemia: Ten Years After Treatment

As part of a longitudinal study of family coping with pediatricleukemia, 28 former patients (16 male; 12 female; M age = 19.1years) and their parents (23 mothers; 12 fathers) participatedin a follow-up study at 10 years posttreatment. Measures includedthe Current Adjustment Rating Scale, the Brief Symptom Inventory,the Ways of Coping Scale, the Family Coping Scale, and a semistruc-turedinterview. Long-term survivors and their parents continued tobe well-adjusted to life posttreatment. Coping and perceivedadjustment in long-term survivors were positively related tosocioeconomic status and mother's coping and negatively relatedto academic problems. A strong bidirectional relationship wasfound between survivors' and mother's adjustment. Coping strategieswere variable and not significantly correlated with coping adequacyor adjustment.     

A Contextual Family/Systems Approach to Pediatric Psychology: Introduction to the Special Issue

Introduced the special issue on "Family System in PediatricPsychology" by organizing the papers around a series of themesrelevant to understanding families in pediatric psychology.Themes reflect the relationships between parent and child adjustment,family subsystems, legacies and traditions, social support systems,family interventions, the constancy of change in families, thechallenges of conducting longitudinal research, the inclusionof fathers, and the importance of a competency framework inpediatric family psychology. The paper concludes with recommendationsfor pediatric family psychology, including suggestions for increasingdiversity, expanding methodological approaches, and enhancingfamily competence.     

Training in Pediatric Psychology: Survey Results and Recommendations

Little specific information is available on the types of experiencesthat are important for training in pediatric psychology. Toaddress this need, the membership of the Society of PediatricPsychology (SPP) was surveyed regarding their views on the structureand content of training. A total of 160 completed forms werereceived, representing a return rate of approximately 32%. Surveyresults suggested that training in pediatric psychology should(a) encompass course work and applied experiences in developmentaland clinical child psychology, behavioral assessment and intervention,and child health psychology; (b) move from broad-based activitiesoccurring early in graduate training, to more specialized experienceslater on (internship and postdoc); (c) consider viewing postdoctoraltraining as a necessary step in the preparation of pediatricpsychologists. Distinctions between pediatric psychology andclinical-child and health psychology are discussed with respectto training needs.     

Behavioral Assessment: Advancing Methodology in Pediatric Psychology

The value of applying behavioral assessment methods to the fieldof pediatric psychology is addressed. Three major areas of behavioralassess ment are examined: behavioral interviews, rating scales,and direct observa (ion measures. Examples of recently developedinstruments with particular utility in pediatric research andclinical practice are described. The paper emphasizes the potentialof behavioral measurement to advance our knowledge of the behavioralcorrelates of childhood illness and the effects of interventionand to facilitate precise communication of this informationamong professionals.     

Family rituals as a protective factor for children with asthma

OBJECTIVE: To examine how one aspect of family life, notably family rituals and routines, may protect children with asthma from anxiety-related symptoms. METHODS: Eighty-six families (43 children with asthma, 43 healthy comparison children) participated in the study. Children completed measures of anxiety (Revised Child Manifest Anxiety Scale) and health. Parents completed measures of stress (Parenting Stress Index), family rituals (Family Routines Questionnaire), and family health. RESULTS: Families that reported more meaning in their family routines had children who reported lower levels of anxiety. Mother endorsement of family ritual meaning and father endorsement of family ritual routine were most strongly related to lower levels of anxiety. Support for the protective function of meaningful family rituals was stronger when a general health stress model was used rather than the presence or absence of asthma alone. CONCLUSIONS: Family rituals may serve a protective function for children with asthma under conditions of heightened parenting stress.     

Health Promotion and Problem Prevention in Pediatric Psychology: An Overview

This paper provides an overview to the special issue of theJournal on health promotion and problem prevention in pediatricpsychology. Key terms are defined and critical concepts outlinedfor topics of active versus passive intervention, individualversus population approaches, developmental perspectives, preventivemedicine, and motivating behavior change. Information resourcesare noted.     

Family mediators and moderators of treatment outcomes among youths with poorly controlled type 1 diabetes: results from a randomized controlled trial

OBJECTIVE: To determine whether multisystemic therapy (MST) improved family relationships among youths with poorly controlled type 1 diabetes and whether these changes mediated MST effects on health outcomes. The moderating effect of family demographics on study outcomes was also assessed. METHODS: A randomized controlled trial was conducted with 127 youths. Changes in general family relationships and caregiver support for diabetes care from baseline to treatment completion were assessed. Structural equation modeling (SEM) was used to test whether changes in family relations mediated improvements in frequency of blood glucose testing (BGT) and metabolic control. RESULTS: MST increased support for diabetes care from both primary and secondary caregivers in two-parent but not in single-parent families. However, MST had the strongest effects on BGT and metabolic control in single-parent families. SEM did not support family relations as the mediator of improved BGT or metabolic control. Rather, MST had a direct effect on BGT for all participants. BGT mediated improvements in metabolic control among single-parent families. CONCLUSIONS: MST improved family relationships for youths with diabetes in two-parent but not in single-parent families. Objective outcomes related to diabetes were strongest for single-parent families. Other processes such as increased parental monitoring may have been responsible for improved health outcomes among these families.     

Case Reports in Pediatric Psychology: Uses and Guidelines for Authors and Reviewers

Described uses of case reports in pediatric psychology and guidelinesfor authors and reviewers. Case reports have several importantfunctions: to document the efficacy of new treatment applications,describe interesting new clinical phenomena, to develop hypotheses,to illustrate methodological issues, difficult diagnostic issues,or novel treatment approaches, and to identify unmet clinicaland research needs. Authors should carefully document the scientificpurpose and clarify the new information contributed by theirreports, provide evidence for their conclusions, and articulateclinical, theoretical, and/or research implications.     

Clinical trials in the Journal of Pediatric Psychology: applying the CONSORT statement

OBJECTIVE: To determine how well therapeutic randomized controlled trials (RCTs) in the Journal of Pediatric Psychology (JPP) met the CONSORT criteria as compared to pediatric trials in the Journal of Clinical and Consulting Psychology (JCCP), which served as a control. METHODS: Nine trials were found in JPP and 19 clinical trials were retrieved from JCCP. The modified Consort Checklist and Flow Chart was applied to each trial by two unblinded independent raters. RESULTS: The number of CONSORT items not reported between the two journals was strikingly similar. One half (11/22) of the CONSORT items were reported less than 25% of the time. Information provided on the flow of participants in the trials was similar across the two journals; however, JCCP more often reported on those assessed to be eligible overall, chi(2) = 5.241, p <.05. JPP reported on recruitment 33.3% of the time, while it was not reported at all in JCCP, chi(2) = 7.093, p <.05. CONCLUSIONS: Although many of the items in the CONSORT statement were not adhered to by the two psychological journals, most of the CONSORT items can clearly be applied to psychosocial trials.     

Pediatric asthma morbidity: the importance of symptom perception and family response to symptoms

OBJECTIVE: To determine whether family response to asthma symptoms mediates the relationship between child symptom perception and morbidity. METHODS: A total of 122 children with asthma, aged between 7 and 17 years (47% females; 25% ethnic minorities), were recruited from three sites. Participants completed a family asthma management interview and 5-6 weeks of symptom perception assessment. RESULTS: Family response to symptoms mediated the relationship between child underestimation of symptoms and asthma morbidity and partially mediated the relationship between accurate symptom perception and morbidity. In contrast, although child overestimation of symptoms and family response to symptoms were independently related to asthma morbidity, a mediational model was not supported. CONCLUSIONS: Our study found support for the role of family response to symptoms in mediating the relationship between child symptom perception and morbidity, particularly with regard to underestimation of symptoms, underscoring the need for behavioral tools to accurately recognize and optimally respond to exacerbations.     

I Get by with a Little Help from my Family and Friends: Adolescents' Support for Diabetes Care

Evaluated and compared the support provided by family membersand friends for adolescents' diabetes care. Family and friendsupport also were examined in relation to other measures ofsocial support, to demographic variables (age, gender, durationof diabetes) and to adherence. Using a structured interview,74 adolescents with diabetes described the ways that familymembers and friends provided support for diabetes management(insulin shots, blood glucose monitoring, eating proper meals,exercise), and for helping them to "feel good about their diabetes."Families provided more support than friends for three managementtasks (insulin injections, blood glucose monitoring, meals);this support was largely instrumental. In contrast, friendsprovided more emotional support for diabetes than families.Greater family support was related to younger age, shorter diseaseduration, and better treatment adherence. Implications of thefindings include encouraging parents to remain involved in adolescents'treatment management, and involving peers as supportive companionsfor meals and exercise.     

Pediatric asthma management in the family context: the family asthma management system scale

OBJECTIVE: To examine psychometric properties of a revised version of the Family Asthma Management System Scale (FAMSS), a clinical interview to assess asthma management. METHODS: The FAMSS was administered to 115 children with asthma and their primary caregivers, along with a measure of asthma morbidity. A subset of families (n = 53) participated also in objective-adherence monitoring and completed measures of asthma knowledge and self-efficacy. RESULTS: The FAMSS demonstrated good internal consistency (alpha = .84). The FAMSS summary score was unrelated to age, gender, race, or minority status, but was related to socioeconomic status (SES) and to functional morbidity at baseline and prospectively. Convergent validity of the FAMSS was documented. The FAMSS explained additional variance in concurrent-asthma morbidity beyond self-reports or objective adherence monitoring. CONCLUSION: The FAMSS is a valuable tool to assess family-based asthma management that addresses gaps in available assessment methodologies and holds promise for research and clinical applications.     

The Family Environment in Nonorganic Failure to Thrive: A Controlled Study

Compared 48 families of nonorganic failure to thrive (NOFT)infants with those of 52 physically healthy infants of similardemographic characteristics using the Family Environment Scale(FES). Families of NOFT infants had more problematic relationshipsas indicated by lower scores on the Family Relationships Inventory(FRI) components of the FES, including lower Cohesion and Expressiveness,than families of physically healthy infants. Contrary to predictions,families did not differ in level of Conflict or Organization.Families of NOFT infants had lower intellectual and CulturalOrientation. These findings suggest that problematic intrafamilialrelationships are associated with NOFT and may influence thepsychological outcomes of children with this condition. Studiesare needed to document the effects of family functioning onthe physical growth and psychosocial development of NOFT children.     

Family Resources as Resistance Factors for Psychological Maladjustment in Chronically Ill and Handicapped Children

The hypothesis that their psychological adjustment is relatedin part to resources present in their families was investigatedin 153 children, age 4–16, who had one of five chronicphysical disorders: juvenile diabetes, juvenile rheumatoid arthritis,chronic obesity, spina bifida, or cerebral palsy. Their motherscompleted standardized psychometric instruments to measure specificdimensions of family psychological and utilitarian resourcesand of child adjustment. Variation in children's psychologicaladjustment was related both to their psychological and utilitarianfamily resources. Psychological family resources contributeduniquely to the prediction of adjustment beyond that providedby utilitarian family resources. These results are discussedas having implications for the identification of chronicallyill and hadicapped children at risk for adjustment dificulties.     

Family and Illness Predictors of Outcome in Pediatric Brain Tumors

Investigated the prediction of cognitive and behavioral outcomesin 63 children with heterogenous brain tumors. Hierarchicalmultiple regression analyses were used to determine how family-relatedvariables added to the prediction of children's outcome overand above illness measures. The best predictors of children'sbehavior problems and adaptive behavior were family and demographicvariables, whereas the best predictors of achievement were illnessand demographic variables. A combination of family and illnessvariables, however, was the best predictor of intellectual functioning.In addition to identifying specific predictors of cognitiveand behavioral outcome in children with brain tumors, theseresults lend initial support for the inclusion of contextualfactors such as family stress, maternal coping, number of parentsin the home, and family SES measures in studies of how diseasefactors affect outcomes in pediatric brain tumor patients.