Journal of Pediatric Psychology, Vol. 28, No. 2, 2003, pp. 115-122
© 2003 Society of Pediatric Psychology
Training Experiences and Theoretical Orientations of Pediatric Psychologists
Oklahoma State University
All correspondence should be sent to Larry L. Mullins, Department of Psychology, Oklahoma State University, 215 North Murray, Stillwater, Oklahoma 74278. E-mail: lmullin{at}okstate.edu.
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Abstract |
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Objective To reexamine members of the Society of Pediatric Psychology (SPP) to document trends in training experiences of individuals who identify themselves as pediatric psychologists. Methods Using the 1999 SPP membership list, we asked respondents to complete a survey describing their degree status, theoretical orientation of graduate program, type of internship/fellowship, current employment setting, and orientation to assessment and treatment of pediatric problems. Results The majority of the respondents matriculated from doctoral programs in the last two decades. Compared to a previous survey (Mullins, Harbeck-Weber, Olson, & Hartman, 1996
), this survey had a
higher percentage of respondents who completed accredited predoctoral or
postdoctoral training in pediatric psychology. Over half of the respondents
were primarily employed in medical centers or academic institutions; fewer
respondents reported working in private practice settings than in the previous
survey 10 years ago. Respondents' current orientation was most often described
as cognitive-behavioral. In this survey, the percentage of respondents
endorsing an eclectic orientation was lower; the percentage endorsing
cognitive-behavioral, behavioral, and systems orientations increased. Conclusions We discuss implications of these findings as they relate to training and practice in pediatric psychology.
Key words: training; theoretical orientation.
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Introduction |
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Pediatric psychology as a specialized field of study and practice remains a relatively young discipline. As in other specializations within applied psychology (e.g., clinical child psychology), clearly defined recommendations for predoctoral and postdoctoral training that move beyond previous aspirational guidelines have emerged only recently (i.e., La Greca & Hughes, 1999
;
Roberts et al., 1998; Spirito
et al., this issue). Such recommendations delineate the proposed competencies
(e.g., life span developmental psychology/psychopathology, assessment,
intervention strategies, prevention and health promotion strategies,
multicultural competencies, systemic interventions, interdisciplinary
collaboration, ethics, research methodology, and program development) deemed
necessary for quality training of graduate students and subsequent
professional practice in pediatric psychology. The development of such
guidelines presages the coming of age of pediatric psychology as a highly
recognized and visible area of study and practice
(Mullins & Chaney,
2001).
Unfortunately, little is known about the actual training experiences of
pediatric psychologists at the graduate school, internship, and postdoctoral
level, nor is there substantive information about pediatric psychologists'
theoretical orientation to assessment and treatment. In one of the only known
surveys of professional training specific to pediatric psychologists, Mullins,
Harbeck-Weber, Olson, and Hartman
(1996) utilized a 1990 listing
of Society of Pediatric Psychology (SPP) members to examine their training
experiences and clinical practice approaches. Over two thirds of the
membership responded to the survey. The findings revealed that the majority of
the respondents completed an American Psychological Association
(APA)—accredited internship; however, less than a fourth completed an
internship with a specific focus on pediatric psychology. Further, only a
third of the respondents completed a postdoctoral fellowship, and only half of
those receiving postdoctoral training did so specifically in pediatric
psychology. These findings suggest that the majority of the members of SPP at
that time had not necessarily received specialized, formal training in
pediatric psychology at either the pre- or postdoctoral level. The results
also indicated that the majority of respondents received graduate training in
either cognitive, behavioral, or eclectic theoretical models; assessment of
their subsequent orientation in clinical practice similarly reflected use of
these models.
Since the time of the original survey, significant changes have occurred in
the context of professional psychology. Clearly, managed care has altered the
nature and manner of mental health service delivery, with mandates for
short-term treatment models, accountability for outcomes, and restricted
access to patient populations (e.g., Reed,
Levant, Stout, Murphy, & Phelps, 2001). Most psychologists
believe that such changes associated with managed care have negatively
affected their practice (Phelps, Eisman,
& Kohout, 1998). At the same time, psychologists have
increasingly focused on the development of empirically supported, time-limited
treatment models for specific clinical problems, in part to meet the demands
of the evolving managed care system (e.g.,
Chambless & Hollon,
1998).
Concomitantly, the role of prescriptive authority for psychologists has
been debated extensively (e.g., Sammons,
Gorny, Zinner, & Allen, 2000). Within the organizational
framework of the APA, the move has begun to develop specific guidelines for
competencies and proficiencies in subspecialization. Demographic trends are
also apparent. Increasingly, women are entering doctoral graduate training
programs and becoming a part of the work-force
(Kohout, Wicherski, & Woerheide,
1999). The impetus to recruit and retain psychologists of various
ethnic and racial backgrounds has intensified through formal mechanisms
(APA, 1996), with the number of
new graduates of ethnic minority status slowly increasing
(Kohout et al., 1999).
The extent to which these and other developments have influenced the actual training of graduate students in pediatric psychology is unclear. However, the number and magnitude of such changes argue for the continued assessment of current training practices. Such assessment would serve multiple purposes. First, it would document the nature of existing training models. Second, assessment of individuals who identify themselves as pediatric psychologists would permit a broad comparison of historical as well as recent training approaches. Finally, assessment of training practices would aid future planning and curriculum design for doctoral programs, internships, and fellowships that seek to train students in pediatric psychology.
Thus, we elected to reexamine SPP members approximately one decade later,
seeking to document training experiences of individuals who currently identify
themselves as pediatric psychologists. Using the 1999 membership list, we
asked respondents to indicate their degree status, orientation of graduate
training program, type of internship/fellowship training, employment setting,
current theoretical approach to assessment and treatment, and involvement in
empirical endeavors. We expected the findings of this study, although
speculative, to reflect a number of trends, including continued endorsement of
training in and subsequent adherence to cognitive and behavioral models,
increasing numbers of pediatric psychologists completing postdoctoral
fellowships to obtain specialized training, and a proportionally high
percentage of pediatric psychologists seeking employment in medical school and
university settings rather than private practice settings. Also, we expected
to find an increase in the number of women entering pediatric psychology.
Finally, we expected that the majority of pediatric psychologists would be
actively involved in empirical endeavors. Such trends would be consistent with
both our previous data as well as those documented by the APA for applied
psychologists as a group (Kohout et al.,
1999).
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Method |
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Participants
Participants were recruited from a 1999 listing of the full members of the SPP. In total, 680 questionnaires were mailed, and 377 questionnaires were returned by full members. Eleven questionnaires were excluded due to incomplete or missing data, resulting in a return rate of 53.8% (N = 366). This rate is somewhat lower than that in the previous survey, possibly as a function of different types of incentives offered to participants. Of the completed surveys, approximately 35% (n = 129) were completed by men, and 65% (n = 237) were completed by women. Respondents were between 30 and 76 years of age, averaging 44 years (SD = 8.9). Ethnic characteristics were as follows (N = 366): 93.7% (n = 343) Caucasian; 2.2% (n = 8) Asian; 1.9% (n = 7) Hispanic; 1.1% (n = 4) African American; 0.5% (n = 2) Native American; 0.3% (n = 1) Pacific Islander; and 0.3% (n = 1) biracial. Although direct statistical comparisons were not possible, the age and ethnic break-down of this sample appear largely representative of the 1999 Division membership obtained through the APA research office (APA research office, personal communication, May 3, 2001). However, the female to male ratio (65:35) obtained in this survey suggests that a higher percentage of female members of the SPP responded to the survey compared to the ratio in the database compiled by the APA (i.e., 55% female, 45% male). A potential gender response bias may therefore exist for this sample.
Measure
The original 1990 questionnaire was modified to include 25 questions
assessing the following areas: select demographics, degree status, orientation
of graduate training program, areas of specialization during graduate
training, level and type of postgraduate training, current work setting,
involvement in empirical endeavors, and current theoretical orientation. Type
of orientation was broken down into nine discrete categories, including
behavioral, cognitive, cognitive-behavioral, analytic, interpersonal, dynamic,
systems, integrationism, and eclectic. Such descriptive labels reflect the
predominant models most commonly utilized in contemporary applied psychology
(Prochaska & Norcross,
1999). No operational definitions were provided for these models
so as not to introduce any subtle bias. In this manner, participants could
self-identify with a particular model.
Procedure
The survey and a self-addressed stamped envelope were mailed to each full
member of the SPP. Participants were informed in the cover letter that $50
would be donated to the Rebecca Routh Coon Injury Research Fund for every 100
returned surveys. All procedures were approved by the institutional review
board and were in keeping with the ethical standards of the APA.
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Results |
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Overview of Analyses
Most of the analyses were descriptive. Chi-square analyses were conducted to examine trends in training and adherence to theoretical models by decade of graduation, as well as between male and female respondents.
Training and Employment Characteristics
Table I describes graduate
training characteristics by gender, including decade of graduation, type of
degree obtained, and area of specialization. The majority (78%) of respondents
graduated during the 1990s and 1980s; only 21.9% graduated during the 1960s
and 1970s combined. By far, the majority of the sample received the PhD degree
(n = 351, 95.9%). Over 75% of all male and female respondents
matriculated from doctoral programs in clinical psychology (n = 287,
78.6%). There were no significant gender trends for type of degree earned,
2 (2, N = 365) = 3.77, p > .05, or area
of specialization in graduate school, 2 (7, N = 366)
= 5.95, p > .05. Chi-square analysis, 2 (3,
N = 365) = 21.70, p < .05, revealed that a higher
percentage of male respondents graduated during the 1980s, whereas a higher
percentage of female respondents graduated during the 1990s.
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Table II describes
predoctoral internship and post-doctoral training data. The majority of the
respondents completed an APA-accredited predoctoral internship (n =
308, 84.2%); only 15.8% completed a nonaccredited internship. Examination by
decade of graduation revealed that 90.3% (n = 139) of the respondents
who graduated during the 1990s and 89.5% (n = 17) of the respondents
who graduated in the 1960s completed an APA-accredited internship, whereas
only 83.1% (n = 108) and 70.5% (n = 43) of those graduating
during the 1980s and 1970s, respectively, completed an APA-accredited
internship, 2 (3, N = 364) = 13.48, p <
.01. There was no significant relationship, 2 (1, N =
365) = 3.12, p > .05, between gender of the respondent and
completion of an APA-accredited internship.
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As shown in Table II,
approximately 40% of the total respondents completing an APA-accredited
internship indicated their training had a primary focus in pediatric
psychology. Examination of training trends by decade of graduation revealed
that a higher percentage of respondents graduating in the 1990s (52.5%,
n = 73) and 1980s (45.4%, n = 73) completed an internship
with a reported focus in pediatric psychology, whereas only 30.2% (n
= 13) and 5.9% (n = 1) of those graduating during the 1970s and
1960s, respectively, completed an internship with such a focus,
2 (18, N = 307) = 45.03, p < .01. There
was no significant relationship between gender of the respondent and primary
focus of the internship, 2 (6, N = 308) = 5.09,
p > .05; however, a trend existed for more female respondents to
complete an internship with a focus in pediatric psychology, whereas more male
respondents completed an internship with a focus in clinical child
psychology.
Approximately half of the total respondents completed a postdoctoral
fellowship. Chi-square analysis yielded no significant relationship between
gender of the respondent and completion of a postdoctoral fellowship,
2 (1, N = 366) = .04, p > .05. According
to trends by decade of graduation, 64.3% (n = 99) of the respondents
graduating in the 1990s completed a postdoctoral fellowship, whereas only
44.3% (n = 58), 37.7% (n = 23), and 21.1% (n = 4)
of the respondents who graduated in the 1980s, 1970s, and 1960s, respectively,
completed a post-doctoral fellowship, 2 (3, N = 365)
= 24.32, p < .01. The average length of postdoctoral fellowship
was 1.5 years (SD = .69), with a range of 6 months to 5 years. The
majority of the respondents (n = 165, 89.7%) completed a 1- or 2-year
fellowship.
Just over half (57%) of the respondents completed a postdoctoral fellowship
with a reported training emphasis in pediatric psychology. Less than 25% of
the respondents completed fellowships in other child-related areas, including
clinical child and behavioral medicine child. There was no significant
relationship between gender of the respondent and training emphasis of the
fellowship, 2 (12, N = 184) = 18.95, p >
.05. However, a trend existed for more female respondents to complete a
fellowship with a focus in pediatric psychology, whereas more male respondents
completed a fellowship with a training emphasis in clinical child psychology
or behavioral medicine with children.
Table III provides a listing
of employment setting by gender. Over a third of the total respondents were
currently employed in medical school settings, followed by university academic
settings, and outpatient private practice settings. Employment settings less
frequently endorsed included private pediatric hospitals, private general
hospitals, and community mental health centers. Chi-square analysis revealed a
significant relationship between decade of graduation and current employment
setting, 2 (21, N = 365) = 34.16, p <
.05. Approximately a third of the respondents graduating in the 1990s (33.8%,
n = 52), 1980s (37.4%, n = 49), and 1970s (36.1%, n
= 22) were employed in medical school settings, whereas the highest percentage
of graduates from the 1960s were employed in academic university settings
(36.8%, n = 7). There was a significant relationship between gender
of respondent and current employment setting, 2 (7, N
= 366) = 21.54, p < .01. A higher percentage of male respondents
were employed in university academic settings and medical school settings,
whereas a higher percentage of female respondents were employed in private
pediatric hospitals and private practice. Examination of trends related to
postgraduate training and the respondents' current employment setting revealed
that 61.9% (n = 78) of the respondents employed in medical school
settings completed postdoctoral fellowships. Approximately 60% (n =
30) of the respondents employed in private pediatric hospitals completed
postdoctoral fellowships, whereas only 36% (n = 27) of those employed
in academic university settings completed postdoctoral fellowships.
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Approximately two thirds (n = 247, 67.5%) of the total respondents
indicated that they were involved in research endeavors. Most of those
conducting research were employed in medical school or university settings
(n = 165, 66.8%). Analyses within employment settings indicated that
83.8% (n = 62) of those employed in academic university settings and
81.7% (n = 103) of those employed in medical school settings were
involved in empirical endeavors. Approximately 50% (n = 66) of the
respondents employed in nonacademic settings (i.e., private practice, private
hospitals, community mental health centers) were also involved in empirical
endeavors. There was no significant relationship between decade of graduation
and involvement in research endeavors, 2 (3, N = 365)
= .58, p > .05, with greater than 65% of the respondents
graduating in each of the last four decades involved in research endeavors.
Chi-square analysis revealed a significant relationship between gender of the
respondent and research endeavors, 2 (1, N = 366) =
4.36, p < .05, with a higher percentage of male respondents
involved in research activities.
Analyses of Orientation Trends
Orientation data for this sample is provided in
Table IV. Overall, the primary
orientation of the respondents' graduate program was most often described as
cognitive-behavioral (n = 131, 35.8%). Chi-square analyses yielded a
significant relationship between program orientation and decade of
graduation, 2 (27, N = 364) = 57.53, p <
.01, with greater than a third of the respondents graduating during the 1990s
and 1980s matriculated from programs with a cognitive-behavioral orientation,
whereas an eclectic program orientation was most common among respondents who
graduated during the 1970s and 1960s. There was no significant relationship
between gender and personal orientation in graduate school,
2 (9, N =365) = 7.64, p > .05. The
majority of respondents described their personal orientation during
graduate training as cognitive-behavioral (43.8% women, 41.9% men), followed
by eclectic (18.3% women, 14.0% men), behavioral (8.9% women, 15.5% men), and
systems (9.8% women, 10.9% men).
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With regard to current orientation, chi-square analysis yielded no
significant relationship between gender of respondent and current orientation
to assessment and treatment, 2 (8, N = 366) = 7.69,
p > .05, or decade of graduation and current orientation to
assessment and treatment, 2 (24, N = 361) = 24.96,
p > .05. The majority of the total respondents (65.8% women, 96.1%
men) endorsed a single orientation. Respondents who endorsed a single
orientation to assessment and treatment most often adhered to a
cognitive-behavioral approach (n = 121, 33.1%). Approximately a
fourth of the total respondents indicated that they currently adhere to two or
more primary orientations in assessment and treatment. The majority of the
respondents adhering to two or more approaches most often identified
themselves as adhering to systems orientation in combination with
cognitive-behavioral approaches to assessment and treatment.
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Discussion |
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The findings of this survey of SPP members reveal interesting trends in the training of pediatric psychologists. First, the field of pediatric psychology is a relatively young and growing specialty; over 75% of the respondents matriculated in the last two decades. Second, more women are entering graduate training with a focus on pediatric psychology, a trend consistent with that of psychology in general (Kohout et al., 1999
). At the same time, ethnic minority psychologists remain
underrepresented in pediatric psychology. Third, the majority of members have
completed an accredited internship, with approximately 45% of the internship
sites having pediatric psychology as a primary focus of training. It is
encouraging to note that the percentage of individuals receiving training in
pediatric psychology during internship increased since the previous survey
(cf. Mullins et al., 1996),
suggesting that more individuals are able to obtain such training experiences
during their predoctoral internship, rather than having to wait until the
postgraduate training period of their career.
A higher percentage of SPP members, particularly those subsequently
employed in medical school settings, are completing postdoctoral fellowships
with a training emphasis in pediatric psychology. This trend mirrors the
general trend for applied psychologists to complete a postdoctoral fellowship
before entering the workforce (Kohout et
al., 1999). Such an increase may reflect the career-enhancing
aspect of postdoctoral experience, that is, research, publication,
grant-writing opportunities, and refinement of clinical skills within specific
areas of practice. The need to acquire additional clinical hours for licensure
before entering the workforce may also have resulted in an increase in the
number of pediatric psychologists securing postdoctoral training. However, an
unfortunate potential byproduct of postdoctoral training is increased debt
load, an issue for both graduate students and APA members
(Chamberlin, 2000).
Over half of the current respondents report primary employment in medical
school settings or university settings. Although the number of pediatric
psychologists employed in medical school settings appears relatively stable
over the last 10 years, the percentage of SPP members employed in academic
settings appears higher (cf. Mullins et
al., 1996). In contrast, our data indicate that a lower percentage
of pediatric psychologists are now working primarily in private practice
settings. This trend may indicate the desire among contemporarily trained
pediatric psychologists to work in settings that allow for interdisciplinary
work in health care settings or to engage in academic pursuits (e.g., teaching
and research). At the same time, these numbers may reflect the demands of the
managed care marketplace. The current SPP member employment data stand in
contrast to recent APA Division 12 (Clinical Psychology) survey data, which
indicate a lower percentage of psychologists employed in medical settings and
a higher percentage in private practice
(Norcross, Karg, & Prochaska,
1997b). It is noteworthy that approximately two thirds of the
respondents indicated that they were currently involved in research endeavors.
Given the history of pediatric psychology and its empirical underpinnings, not
to mention the number of pediatric psychologists employed in academic
settings, such figures are not surprising. Future research would do well to
compare these findings to other subspecialties in applied psychology.
By far, the majority of pediatric psychologists report having matriculated
from programs with a cognitive-behavioral orientation and currently espouse a
cognitive-behavioral orientation to assessment and treatment. In contrast to
data from a decade ago (cf. Mullins et al.,
1996), the percentage of respondents personally endorsing an
eclectic orientation is now lower, whereas the percentage endorsing a
cognitive-behavioral orientation is higher. Such trends may well reflect the
general movement in graduate training programs toward a cognitive focus (e.g.,
Robins, Gosling, & Craik,
1999), as well as a move toward training in empirically based
treatments. Compared to survey data on clinical psychologists from APA
Division 12 (Norcross, Karg, &
Prochaska, 1997a), our results suggest that a higher percentage of
pediatric psychologists endorse a cognitive-behavioral or behavioral
perspective, and fewer endorse a psychodynamic perspective. Also noteworthy,
our data indicate that approximately one fourth of SPP members in this survey
adhere to two or more orientations to assessment and treatment; most often, a
systems orientation appears to be utilized in combination with
cognitive-behavioral approaches. Such data may well reflect a move away from
eclecticism per se and a move toward assimilative integrationism
(Stricker, 1994).
A number of implications are suggested by our data. First, it appears that
graduate students in psychology are increasingly able to secure specialized
training in pediatric psychology at the internship and postdoctoral level. The
specific nature of such training (e.g., number of clinical hours, type of
experiences, level of supervision) is not clear, however, and further
examination of these issues is warranted. In particular, research is needed to
determine if internships and postdoctoral fellowships in pediatric psychology
have increased in number over the last decade, how this has been accomplished,
and whether there is consistency in training opportunities across training
sites. Second, it appears that a relatively high percentage of pediatric
psychologists are working in medical centers and university settings, with a
correspondingly lower number in private practice. If such a trend reflects the
impact of managed care on the workforce, it may not be long before the
marketplace for academic pediatric psychologists tightens. Robiner and Crew
(2000) have called for a
workforce agenda to address these issues within the APA, and it may serve
Division 54 well to evaluate the unique needs of pediatric psychologists in
the work place. Third, our data revealed a number of interesting gender
trends, with more women entering the field of pediatric psychology and seeking
particular types of training and work experiences. However, such gender
differences may also reflect an age effect, as the women in our sample were
younger than the men. Certainly, it will be important to evaluate the nature
of these findings systematically in future surveys. Finally, recruitment of
ethnic minority pediatric psychologists remains a significant problem for the
field. Continued efforts on the part of graduate programs to expand their
recruitment efforts is essential if we are to meet the needs of an
increasingly diverse population.
The findings of this study are limited by the survey format and resulting self-selection bias. Indeed, it may be that a select group of SPP members (e.g., researchers and academicians) chose to respond to the survey, making generalizability difficult. Further, we have assumed that the majority of those psychologists who identify themselves as pediatric psychologists are also SPP members, which may not be correct. Although our method of identifying potential participants (i.e., SPP membership) ensures a relatively high degree of identification with this area of specialization, it can be argued that a substantial number of psychologists who work in pediatric psychology may not have joined the SPP, or they affiliate with another APA division. Future surveys might also include other child-oriented divisions (e.g., Clinical Child; Child, Youth, and Family) to address this issue. Finally, any comparison of trends between this sample and that obtained in 1990 should be made cautiously, as no direct statistical comparisons were made between these two overlapping samples of the SPP membership.
In summary, our survey offers additional information on the training and theoretical orientations of pediatric psychologists, as well as trends in this area of specialization over the past 10 years. Additional research is needed to address the specific means by which graduate training institutions, predoctoral internships, and postdoctoral fellowships structure training opportunities in pediatric psychology. Indeed, little is known about the nature of course-work, practicum requirements, and supervisory models employed by these programs and the extent to which they conform to the guidelines being offered by the SPP Task Force on Training (Spirito et al., this issue). The new guidelines for training in pediatric psychology may alter the direction of existing training programs as they attempt to meet the demands of managed care ina changing marketplace.
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Acknowledgments |
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We thank the Society of Pediatric Psychology members who responded to the survey. Two hundred dollars has been donated to the Rebecca Routh Coon Injury Research Fund as a result of their assistance in this project.
Received February 15, 2001; revision received June 22, 2001; revision received September 8, 2001; accepted September 15, 2001
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