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Journal of Pediatric Psychology, Vol. 25, No. 1, 2000, pp. 47-52
© 2000 Society of Pediatric Psychology
Growing Older in Pediatric Psychology
University of Miami
ll correspondence should be sent to Donald K. Routh, Department of Psychology, University of Miami, P.O. Box 249229, Coral Gables, Florida 33124. E-mail: drouth{at}miami.edu .
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Introduction |
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 Top Introduction |
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Not long ago, the Society of Pediatric Psychology (SPP) celebrated its 30th anniversary. One clear implication of this event was that those of us who participated in its founding in 1968 are now 30 years older. There is a lot of gray hair in this group. In fact, it contains several people like myself whose scalp has almost no hair at all. Anne E. Kazak, the Editor of the Journal of Pediatric Psychology, recently asked me to write a historical article about the field. In speaking with her about this, I found that she wanted an article based on personal memories rather than on any archival research, in other words, the kind of thing one asks a senior colleague to do. I agreed to try to write such an article, but my focus here will be not so much on the early days but more on what it is like to grow older in a field that previously had few elders around to tell stories. A colleague who read a preliminary draft of this article was kind enough to say that she did not think I was old enough to do such a retrospective article. Of course, if things work out as I plan, I may look back in 20 years and laugh at myself for speaking about being "older" at my present age.
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I first heard about the concept of pediatric psychology in 1966 from Logan Wright, who was my psychology internship supervisor at the University of Oklahoma Medical Center. I was part of a cohort of clinical psychology students who had been exposed to the beginnings of the behavioral and cognitive behavioral movement. We tended to feel a little rebellious against a field seen by many of our supervisors only as a mental health discipline, usually defined in psychodynamic, Freudian terms. We wished to resist the temptation to become "little psychiatrists." From this perspective, Logan Wright's behavioral emphasis and his focus on pediatric psychology as a discipline concerned with the psychosocial aspects of physical health in children seemed like a breath of fresh air. I made what turned out to be a lifetime commitment to pediatric psychology.
My first job out of graduate school in 1967 involved a joint appointment to the Department of Pediatrics and the Department of Psychology at the University of Iowa. These departments had a training grant from NICHD with the goal of carrying out joint training in these two fields. Dennis Drotar, a person I am now proud to claim as a former student, was a product of that training program. I have asked myself many times since then how Iowa was able to pick Drotar out of the line-up of applicants. Certainly, he showed early promise as co-author of published articles based on some of his undergraduate work at Rutgers. He also had a reputation among his graduate student peers for unusual power of concentration on the project at hand.
I joined the SPP when it was formed, and it was not long until Logan Wright suggested that I run for the position of secretary treasurer. Usually a group is pleased to have someone take on that job, which can be a lot of work. By 1973, when I was at the University of North Carolina at Chapel Hill, I found myself serving as president of this fledgling group. As such, I was able to recruit colleagues such as Carolyn Schroeder and postdoctoral trainees such as Gary Mesibov into the field. Incidentally, in Chapel Hill, we selected our postdocs in part on the basis of an established track record of published research, and Mesibov's subsequent career certainly justified the confidence we felt in inviting him. More relevant to the present story, by the mid-1970s, I was but a "former" president of the organization. For many people, this would be the impetus to "move on" to other activities. However, I found that unlike others who have worked their way up to such leadership positions, I wanted to hang around and somehow make myself useful.
What to do for an encore? I was fortunate to be appointed by Thomas Kenny as the editor of the Journal of Pediatric Psychology in 1976, shortly after it had been given that name by Diane Willis and transformed from a newsletter into a scholarly journal. Soon Phyllis Magrab made contact with Plenum Press and carried out the negotiations to have the journal produced for the first time by a commercial publisher. Plenum advertised the journal effectively, and over the 7 years I served as its editor, it managed to find a significant niche and began to attract excellent manuscripts. When it was time to make the transition to a new editor, we had nine colleagues apply for the position.
Again, I was out of a job with the SPP but still found myself wanting to be involved in its activities. At the time, it seemed to me that editing the Journal of Pediatric Psychology was the most significant thing I had done in my professional life. In fact, I recall thinking in those days (no doubt a bit grandiosely) that pediatric psychology was "the meaning of life," at least a large part of the meaning of my life. I felt grateful for the opportunities I had been given in the field and wanted to "give something back" to it. At this point I worked out an agreement with the society (I believe Gary Mesibov was its president at the time) to begin a permanent fund, donating any book royalties that came my way to the SPP. I have continued regular donations to this fund ever since, eventually going well beyond just book royalties, and many colleagues eventually donated to it as well. The society was gracious enough to call it the "Routh Fund" and to solicit additional donations from members via dues statements. As it accumulated, it was used mainly for student research grants. As the fund has grown, the thought has often occurred to me that these dollars, unlike aging human beings, will always have strong muscles, and they will never have memory problems.
Meanwhile, I kept involved in pediatric psychology in various ways, for example by editing the first edition of a Handbook of Pediatric Psychology (taken over in the second and now the third edition by Michael C. Roberts). I served on more than one occasion as the SPP's representative to Division 12, the Division of Clinical Psychology. I believe I still hold the record for the number of executive committee meetings of the SPP attended.
When I moved to the Department of Psychology at the University of Miami in 1985, it was my good fortune that a young colleague, F. Daniel Armstrong, came to the Department of Pediatrics at just the same time. He and I, together with several students, carried out a series of research projects, many concerned with children's adaptation to pain associated with medical procedures. Other studies we did were concerned with children with cancer, or mothers and children with HIV/AIDS. These projects were generally published in our favorite periodical, the Journal of Pediatric Psychology. Annette La Greca, a colleague in the Department of Psychology at Miami, served as editor of the journal for a number of years. She and Alan Delamater, in the Department of Pediatrics, applied for a training grant from the NIH so that the University of Miami presently is able to offer research training in pediatric psychology at the doctoral, internship, and postdoctoral levels. Annette is probably more responsible than anyone else for the idea that the SPP should be an APA division and not just a section.
In 1988, tragedy struck in my family. Our daughter Rebecca, then age 24, was killed in an automobile accident. At that time, she had graduated from college, had gotten married, and was working as a registered nurse on the obstetrics ward of a hospital in rural Virginia. In trying to cope with this event, my wife Marion and I thought of setting up some sort of charitable fund in her name. Eventually, the donations we and others had made over the years to the SPP were transformed into the Rebecca Routh Coon Injury Research Fund. This fund is now administered by the American Psychological Foundation, with the advice of the SPP (now Division 54 of APA). It supports research on the psychosocial aspects of physical injury to children and young adults (the leading cause of death in that age group), including those resulting from accidents, violence, abuse, or suicide. In thinking about this injury research fund, my viewpoint is really more that of a consumer than that of a researcher. My own research in pediatric psychology was not focused on this area to any great extent. I would simply like to encourage such research to ensure, as much as possible, that other parents do not have to undergo the pain associated with losing a child, as we did. In my experience, there is nothing worse than that.
At this point in my life, my participation in empirical research involving the psychosocial aspects of child health is waning a bit. As one would expect, my colleague Daniel Armstrong became increasingly independent in his own research activities, so that collaborative research with him in pediatric psychology became less frequent. Indeed, Armstrong was so successful that he has recently been appointed to the position of director of the University of Miami's Mailman Center for Child Development. As a faculty member in an arts and sciences psychology department, I find access to pediatric populations more difficult. Meanwhile, about 5 years ago, I wrote a book on the history of APA Division 12 (including, of course, its Section 5, the SPP) and found my scholarly interests in historical writing on the increase. As many colleagues have found, as they grow older, teaching and writing about the history of psychology is a way of putting to use a professional lifetime of involvement in the field. The main undergraduate course I teach these days is History and Systems of Psychology, and I have begun to collaborate with student colleagues in this field.
In not being so directly involved in pediatric psychology research or clinical work, I miss contact with children. I first began to work with children when I helped raise two of my brothers, respectively 9 and 12 years younger than I. My graduate students have asked me why I prefer to work with children, and I could only answer that they just seemed to me to be much cuter than adults. I assume that many readers will know what I mean. At this point, I have no grandchildren of my own. My substitute has been mostly my nephews and nieces, including the children of the brothers I helped to raise. A month does not go by when one of these children does not need a birthday card, a new book to read, or (now) a graduation gift. It is a great delight to visit each of them, when we can.
One of the reviewers of this manuscript asked about what I would identify as my "core values." These are no doubt principles I learned at my mother's knee, such as the satisfaction one gains from successfully caring for children and the resultant long-term rewards. My mother, Fay Campbell Routh, now 88 years old, raised four sons. I mention as a tribute to her careful nurture of us the facts that all of us graduated from college, none of us is in prison, and we all married and have children of our own. Now I find that she has become my role model for successful aging as well. She is in good health and takes care of herself.
In recent years, I have often taught undergraduate developmental psychology courses and often took the option of making the courses not just about child and adolescent development but about the lifespan, in other words, not only "growing up" but also "growing old." In this way, I engaged in frequent rehearsals of the facts concerning old age. So, given what I know, should a 62-year-old man regard himself as "old"? Well, my father retired from the military at age 59 (and drove people in the family sort of nuts until he managed to find an interesting hobby). My older brother Rob also retired relatively early and spent some of his time helping take care of his grandchildren, so maybe there is something to this idea. The federal government allows one to begin drawing Social Security benefits as early as age 62, albeit with something of a financial penalty. On the other hand, I have aunts who are still quite lively and engaged with the world into their 90s. So the transition to aging does not occur at the same time for everyone.
The event that had the most obvious impact on me in this respect was not any arbitrary number on a calendar but being diagnosed with colon cancer a few months ago. Like entering old age, being a cancer patient provides a strong impetus to draw back from certain activities in life, including work, travel, and organizational duties. My number one goal has changed. I have been drafted as a foot soldier in the war against cancer (this is a battle few people volunteer for, so far as I know). Oddly enough, I realize that in this experience, I have not left pediatric psychology behind me at all. I have spent much of my career studying how children and their families cope with life-threatening or chronic illness, and I am getting a sort of first-hand practicum course on this topic.
So what have I learned from this so far? The first lesson is a familiar one to pediatric psychologists, about the importance of the family. It is not simply that a person gets cancer. Instead, the entire family experiences this affliction. Even though I have a family history of colon cancer (my father, two uncles, and an aunt had this disease), I was rather casual about going for screening. I had had a sigmoidoscopy about 5 years ago and tended to assume that things were OK. My wife Marion was the one who was most concerned by my family history. She began to try to persuade me to go for a colonoscopy, despite the lack of any obvious symptoms. I replied to this by noting that in some ways she was not very attentive to her own personal health. For example, she smoked and had made no attempts to stop. All right, she said, if I would go for a colonoscopy, she would quit smoking. Amazingly, after 44 years of smoking and never trying to quit before, she did so, last New Year's Eve, and has not had a cigarette in several months. That is true love. More than one physician has since told her that she saved my life, and that is so. After her promise to quit smoking, I had no choice but to go for the colonoscopy. The gastroenterologist recognized one cancerous tumor right away, and the pathology report the next day confirmed a second one. Messages went out immediately by phone and by E-mail about this to my daughter, my mother, my brothers, and to nephews, nieces, and cousins in Vermont, Texas, Kentucky, France, and Indonesia. They expect frequent progress reports and want to know the details of what is happening in my treatment. I do not suppose I have ever been in so many people's thoughts and prayers. Psychologists should never forget that in the medical care of adults, just as in that of children, family members play a key role.
A second set of personal experiences relevant to pediatric psychology concerns the managed care system. I feel very fortunate under the circumstances to have good health insurance. I certainly feel sympathy for anyone who does not have such insurance, in this day and time. So far I have consulted my primary care physician, two gastroenterologists, an oncologist, two surgeons, two radiologists, and a urologist, not to mention frequent contact with receptionists, nurses, and technicians. As yet I have seen but one social worker and no psychologists but have no doubt that these are potentially available within the managed health care system if the need for them should arise. So far, all the bills have been paid, other than small co-payments of $10 per physician visit or $5 per prescription. The medical staffs have been uniformly competent and caring. This makes one proud, as a pediatric psychologist, to be so closely allied with the medical community.
On the other hand, the managed care apparatus itself often comes across as a faceless bureaucracy. I can only assume that the same must be true for families seeking medical care for their children these days. To get an appointment with a specialist, I have to call my primary physician's office, listen to a complex menu, and push the correct number for the referral line. Then, a recorded voice asks me to leave six specific items of information on an answering machine. Next, I wait three days and call the "link line" of my HMO. An automated voice then reads out as many messages as it has for me, each one including the name of the referring physician, the specialist, and a 16-digit authorization number. Some days the "link line" does not work, and the only alternative seems to be to call the member services line of the HMO. In one such experience, I was asked for my 11-digit membership number on four separate occasions and finally was told they had not received a referral request from my primary physician. At last I was able to speak to a supervisor who gave me the name of the actual person in my primary physician's office who handled referrals. When I was able to talk to the actual person responsible, she was very courteous and helpful, unlike the automated electronic system.
Similarly, at one point, I was trying to get started on my chemotherapy and needed an infusion device or pump for this purpose. A child with cancer might have the same kind of treatment. The oncologist's office had such pumps available but was not allowed by the HMO to use them. Instead, the HMO had designated a particular contractor to supply a slightly different kind of pump, but these were not yet available. I was understandably quite anxious to get the chemotherapy started but was delayed for several days by this snafu. I was on the phone constantly, trying different ways of blasting through the bureaucratic barriers to find someone who would take responsibility for the situation, to no avail. After several days, the new pump suddenly appeared. The chemotherapy nurse told me she wished all patients were like me in refusing to put up with the HMO's red tape. Such experiences make one reflect on all the hassles and stress in the lives of all patients and their families that must result simply from inconsiderate routine adopted by HMOs.
These administrative barriers to seeking specialized care may also prove too formidable for many patients to handle. Though I have not reviewed the issue systematically, I would not be surprised to hear that such barriers reduce adherence to medical regimens in cancer patients and contribute to poor outcomes.
Some additional things I have learned as a cancer patient have to do with managing pain. I noted already that much of my own research as a pediatric psychologist had to do with procedural pain. In this research we dealt mostly with simple, relatively universal situations such as vaccinations or blood drawing for infants and young children. As an adult cancer patient, I did not find these to present serious problems (I had a porta-cath in my chest installed for the chemotherapy to make so many separate needle sticks unnecessary, and I can testify that this is a useful device). But procedural pain in general is quite important. Indeed, in my situation it was one of the main challenges. The cancer itself in my case has caused no pain whatsoever, indeed has virtually no symptoms. That is one reason why it is so dangerous in the first place. Just about all of the aversive experiences are those associated with diagnostic or therapeutic procedures: to speak frankly, these include the discomfort associated with colonoscopy, feeling tired all the time as a result of chemotherapy, having diarrhea almost daily, and, as a result of the radiation, having pain associated with bowel movements. I found it helpful for the medical staff to be frank with me about any such anticipated pain and offer advice on how best to deal with it. To give a simple example, I almost had to learn the hard way to avoid opiate medications because they cause constipation and difficult elimination, but the radiologist warned me about this soon enough to avoid most of the problem. In this situation, Tylenol is better.
What about the emotional challenges involved in dealing with cancer? Like anyone, I found the diagnosis to be quite depressing, especially the thought that I might ultimately end up with a colostomy. My worries about death were mostly from the point of view of wanting to make sure my wife would be provided for in that eventuality. I became much more conservative in allocating the funds in our retirement nest egg, focusing intensely at least for a time on secure investments rather than on long-term growth. My wife accused me of becoming more like my father (an economics major and Army finance officer). I confess that I now have memorized the 800 number that can be used for automated, updated reports on my retirement account. I got into the habit of phoning it every day. I know well from my work in pediatric psychology that, like adults, children with cancer must face the prospect of their own death or disfigurement and can use support from other people.
I have always heard, and believe, that people who are optimistic about life do better as cancer patients. It helps that the objective data on my prognosis are relatively good (the odds of survival for 5 years with stage III colon cancer are about 7 out of 10). In fact, in the psychology department where I work, I am surrounded by experts on behavioral medicine who seem to share a consensus on the importance of an upbeat attitude in chronic or life-threatening illness. Fortunately, I was able to shake off depressive thoughts within a few days and managed to approach life in a relatively cheerful way again within a week or so after I received the diagnosis of cancer. In doing so, it was very important to have some projects to work on, including writing articles such as this one, to keep me from focusing too exclusively on my illness. Later, when I was just recovering from surgery, I experienced another episode of the blues, and my daughter Laurie, who joined us in Miami when the surgery occurred, cheered me up by reading passages from the local humor writer, Dave Barry. Laughter is a healing experience in itself.
Because of photosensitivity associated with chemotherapy, I had to stay pretty much out of the sun (obviously, this can be a problem in Florida), but I was able to use my computer at home and come into the office in the evening to get my mail. I am certainly grateful that I was scheduled to be on sabbatical this past semester, for I do not think I would have been able to manage teaching classes or going to committee meetings during this time. It has actually been a very productive semester despite the need to be at the hospital radiology department practically every morning. I know from my work in pediatric psychology in the past that children with cancer, like adults, need the opportunity to focus on the normal part of their lives, not just their disease. For this reason, playrooms and child activity staff are crucial in hospitals.
Readers of this journal will not be surprised to hear that social support is a crucial factor in dealing with life-threatening or chronic illness. My wife has been my key supporter, of course. I already mentioned the importance of other family members. Also, I have found that colleagues and students at the university and our friends at church have played a strong role in this way. For one thing, I had never known before that there were so many cancer patients around. I have spoken to a large number of them and have found their stories to be encouraging and helpful. I think that children, like adults, benefit from the opportunity to share their experiences with others "in the same boat."
In conclusion, I am certainly pleased that I discovered pediatric psychology just when my professional career was taking shape. It has been a most rewarding field and has benefits beyond those that were obvious at the time. I have been able to draw on my knowledge and experience from pediatric psychology even now, in the face of personal illness. I guess my commitment to pediatric psychology is for life.
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Acknowledgments |
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Neena Malik, Annette La Greca, and Marion Routh made helpful comments on a preliminary draft of this article. I thank two reviewers who were initially anonymous but who turned out to be Dennis Drotar and Gary Mesibov.
Received June 8, 1999; revision received July 30, 1999; accepted August 2, 1999
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