Journal of Pediatric Psychology, Vol. 28, No. 2, 2003, pp. 147-155
© 2003 Society of Pediatric Psychology
Preparing Psychologists to Link Systems of Care in Managing and Preventing Children's Health Problems
1 The Children's Hospital of Philadelphia/University of Pennsylvania, 2 Lehigh University
All correspondence should be sent to Thomas Power, Department of Psychology, The Children's Hospital of Philadelphia (CSH-116), 3405 Civic Center Boulevard, Philadelphia, Pennsylvania 19104. E-mail: power{at}email.chop.edu.
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Abstract |
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Objective To describe the need for innovations in training to link health, educational, and family systems and to illustrate how this can be accomplished through child-oriented psychology training programs. Methods We describe multiple pathways for the preparation of child-oriented psychologists to link health, educational, and family systems, in keeping with the National Institute of Mental Health guidelines for preparing professionals in child and adolescent psychology. These pathways include training embedded in graduate programs specializing in clinical child, pediatric, school, community, and family psychology. This article highlights a training initiative for preparing child-oriented psychologists based in a school psychology program. Results A partnership between Lehigh University and The Children's Hospital of Philadelphia has been developed to prepare school psychologists to coordinate community-based systems of care to promote positive educational and health outcomes for children. This program emphasizes both intervention and prevention and provides a set of integrated experiences in both health care and educational settings. Conclusions We highlight components of this program relevant to the preparation of pediatric psychologists. We identify and discuss potential challenges in establishing training programs for the preparation of professionals to link health, school, and family systems.
Key words: school psychology; training; systems; prevention.
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Introduction |
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Psychology training programs specializing in the preparation of child-oriented professionals historically have been designed to educate students to work within a particular range of settings and to focus on specific aspects of child development (La Greca & Hughes, 1999
). For example, clinical child psychology
programs traditionally have trained students to work in mental health settings
and to concentrate on addressing the behavioral, emotional, and social aspects
of child development. Pediatric psychology training programs, typically based
within clinical child and health psychology programs, have prepared clinicians
to work in health care settings and to focus on promoting the healthy
development of children coping with illness and disability. School psychology
training programs historically have prepared professionals to work in
educational settings and to focus on promoting cognitive and emotional
development by designing interventions to help children adapt in school.
Child-oriented psychology training programs traditionally have concentrated
on preparing professionals for the delivery of services to children and
adolescents with identified problems
(Kolbe, Collins, & Cortese,
1997). Components of training within a service delivery
perspective have included models of practice for screening and assessment,
intervention, and consultation. Historically, training programs in
child-oriented psychology have placed much less emphasis on program
development related to the prevention of health risk and the promotion of
positive development.
Although traditional models of preparing child-oriented psychologists have
numerous assets, reforms within psychology and the sociopolitical system of
the United States have created the need for innovations in training
(La Greca & Hughes, 1999).
This article considers the necessary evolution of child-oriented psychology
training programs by reviewing reforms within and outside of psychology that
have created the need for innovations in training, describing an innovative
training program being developed within school psychology, and discussing
implications of this program for the preparation of pediatric
psychologists.
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Need for Innovations in Training |
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Numerous developments within and outside of psychology since the 1970s have highlighted the limitations of a training agenda that prepares students to work within one type of setting, to focus on a limited range of developmental outcomes, and to restrict the scope of professional activity to service delivery without attending to important issues of public health.
Reforms Within Psychology: Emergence of a Systems Perspective
Child psychology has recognized the critical importance of the family in
resolving emotional and behavioral problems
(Patterson, 1982), coping with
chronic illness (Kazak & Simms,
1996), and attaining positive educational outcomes
(Epstein, 1995). Further,
researchers have highlighted the importance of linking systems of care (e.g.,
family, school, health care system, and community agencies) to promote
positive development for children and adolescents (Bronfenbrenner, 1977;
Comer, Haynes, Joyner, & Ben-Avie,
1996). The development of children within each system can be
optimized by building connections between major systems in a child's life and
capitalizing on potential synergies between systems
(Patrikakou, Weissberg, & Rubenstein,
1999). These contributions have established that collaboration
among families and professionals from varying systems is essential for
developing effective programs of intervention and prevention.
Health Care and Education Reforms
Reforms in health care, which have emphasized the need to contain health
care costs while improving access to services, have had a dramatic effect on
the provision of health and mental health services to children and their
families (American Academy of Pediatrics,
2000). These developments have shifted the focus of service
delivery from secondary and tertiary care settings to community-based
settings, including primary care practices and schools
(Brown & Freeman, in press;
Carlson, Tharinger, Bricklin, DeMers, &
Paavola, 1996; Dryfoos,
1994; Strosahl,
1998). Increasingly, primary care settings in schools are
fulfilling important gate-keeping functions and serving as sites for the
provision of health and mental health services. In these settings, there has
been an emphasis on health promotion and prevention. Health promotion and
prevention programs have been developed to address a broad range of areas
essential for healthy development, including nutrition education, literacy
development, promotion of physical exercise, violence prevention, drug and
alcohol prevention, injury prevention, child abuse prevention, and prevention
of sexually transmitted diseases (see
Benson 1997;
Durlak, 1997;
Wilson, Rodrique, & Taylor,
1997).
Recent reforms in education also have affected the practice of
child-oriented psychology (Tharinger et
al., 1996). The Goals 2000: Educate America Act
(1994) highlighted the role of
schools in promoting children's health and removing barriers preventing
children from attaining academic success. Barriers to instruction include
emotional stressors, peer problems, family—school conflict, and
health-related problems that have an impact on educational performance
(Adelman, 1996). This emphasis
within education has created an expanded mission for schools that includes the
promotion of health for all children and the removal of barriers to
instruction for children with health-related conditions
(Kolbe et al., 1997). Further,
recent amendments in special education policy, in response to the passage of
the Individuals with Disabilities Education Act—Amendments of 1997
(IDEA, 1997), have asserted
that children with disabilities, even those with relatively severe challenges,
are entitled to have their educational and health needs addressed in the same
schools that serve primarily healthy, typically developing children. Reforms
in special education have affirmed the importance of addressing the chronic
health needs of children in schools in collaboration with educational
professionals and families.
Impact on Practice and Training
These reforms have highlighted the need for professionals, regardless of
employment setting, to understand the multiple systems affecting children's
development and to develop strategies for linking systems to promote positive
outcomes for children (Carlson et al.,
1996; Spirito et al., this issue;
Tharinger et al., 1996).
Further, the reforms have affirmed the need for child-oriented psychologists
to become public health and prevention specialists in community-based settings
(see Power, 2000;
Short & Talley, 1997).
Political and professional reforms have created the need for changes in
models of training for students aspiring to be child-oriented psychologists
(La Greca & Hughes, 1999;
Roberts et al., 1998). As
early as 1985 at the Hilton Head Conference, leaders in clinical child
psychology and pediatric psychology recognized the importance of preparing
professionals to coordinate multiple systems of care to manage and prevent
health and mental health problems (Tuma,
1985). In response to this challenge, a National Institute of
Mental Health (NIMH) task group was convened in 1992 to establish guidelines
for the preparation of psychologists to serve the needs of children and
adolescents. This committee was comprised of psychologists from a broad range
of child-oriented specialties, including clinical child, pediatric, school,
family, and community psychology. This task force emphasized that students of
child-oriented psychology should have a solid foundation in developmental
psychology and psychopathology; assessment of children and the systems in
which they function; empirically supported strategies of intervention and
prevention; culturally sensitive approaches to assessment, intervention, and
prevention; research methods, including program development and evaluation;
strategies for coordinating community-based systems of care in the community,
including primary care practices and schools; and ethical standards for
clinical practice and research (see
Roberts et al., 1998). A task
force convened by the Practice Directorate of the American Psychological
Association (APA) in 1996, which also consisted of professionals from diverse
areas of child-oriented psychology, established highly similar priorities for
the preparation of professionals in child and adolescent psychology
(APA, 1998; see
La Greca & Hughes,
1999).
Alternative Pathways for Preparing Psychologists to Link Systems of
Care
Many avenues potentially are available for the preparation of
child-oriented psychologists to link systems of care in the community with a
focus on both service delivery and public health. Doctoral training programs
have been established at many universities to prepare clinical child and
pediatric psychologists to coordinate systems to provide comprehensive
services to children. For example, the Clinical Child Psychology Program at
the University of Kansas, through the collaborative efforts of the Department
of Psychology and the Department of Human Development and Family Life, has
established an innovative training program based on the guidelines recommended
by the NIMH task group (Roberts &
Sobel, 1999). Through an integrated set of courses and practicum
placements, this program is designed to prepare psychologists who will have a
strong foundation in four areas: (1) developmental-ecological psychology, (2)
the development of intervention and prevention programs consistent with
evidence-based practice and responsive to the cultural differences among
families, (3) coordination of systems of services through interdisciplinary
collaboration, and (4) advanced research skills for the development and
evaluation of innovative intervention and prevention initiatives (Roberts
& Sobel, 1998; Roberts & Steele, this issue). As another example, the
training program in Clinical Child Psychology at Vanderbilt University focuses
on preparing students for research and practice using a developmental
psychopathology framework. Consistent with this framework, students are
provided a solid foundation in developmental and ecological psychology and are
taught to conceptualize novel ways for linking research, practice, and policy.
This program emphasizes linking systems of care to develop intervention and
prevention programs and providing services in a culturally relevant manner
(van Eys & Dodge,
1999).
At the same time, leaders in school psychology have emphasized the need to
prepare professionals to coordinate health, educational, and family systems to
improve developmental outcomes for children
(Power, DuPaul, Shapiro, & Parrish,
1995; Short & Talley,
1997). Priorities for training emphasized within school psychology
are highly similar to those highlighted by the NIMH and APA task forces (see
Ysseldyke et al., 1997). The
following sections describe a model of training developed specifically for the
preparation of doctoral-level school psychologists. Although this model has
been established for training school psychologists, many of its elements have
relevance for the preparation of pediatric psychologists.
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Linking Pediatric and School Psychology: A Model Training Program |
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TopAbstractIntroductionNeed for Innovations in...Linking Pediatric and School...Implications and Potential...ConclusionsReferences |
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Through the joint efforts of Lehigh University and The Children's Hospital of Philadelphia (CHOP), a training program linking pediatric and school psychology was established in 1997 through a grant funded by the U.S. Department of Education, Office of Special Education Programs. A subsequent award was made in 2001 to continue the program with an expanded focus. This program has been designed for students in the doctoral school psychology training program at Lehigh University, which is fully accredited by the APA. Students in the third and fourth years of doctoral training may elect to enroll in this program. Although the grant project can fund only a limited number of positions each year, other students may enroll if they choose. All trainees who complete the project, both those who are funded and those who are not, are granted an endorsement to their doctoral degree documenting their successful participation in the program.
Project Goals
The goal of the Lehigh/CHOP training program is to develop school
psychologists as leaders in linking health, educational, and family systems to
address the needs of children with, or at risk for, chronic health conditions
and mental health disorders for the purpose of improving educational outcomes
for children. The program focuses on service delivery for children with
identified health problems, or those at risk for health problems because of
emotional/behavioral difficulties, as well as on health promotion for all
students. The program is especially designed to train leaders in practice and
research to address the needs of children from underserved populations living
in low-income, urban settings. Students in the Lehigh/CHOP program are
expected to attain the four core competencies in the standard Lehigh training
program (i.e., social and biological bases of behavior, research design and
application, psychological applications, and professional/multicultural
issues), as well as an additional set of competencies in pediatric and school
psychology. Table I presents
the domains of competence for the specialized Lehigh/CHOP program.
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Components of Training
Coursework. In the first and second years of doctoral training,
all students at Lehigh are required to take courses related to core
psychological knowledge (e.g., social basis of human behavior), historical
foundations of school psychology, assessment, intervention, and consultation.
Courses specific to the Lehigh/CHOP program are offered to students in the
third and fourth years of their doctoral training. Courses are taken in a
university (Lehigh) and a medical school (CHOP) setting. In the first year of
the specialization (i.e., during the third year in the doctoral program),
coursework focuses on strategies of intervention for children with identified
medical problems. During the first semester, a course offered at Lehigh
enables students to learn about a wide range of health conditions and to
develop a conceptual framework for intervention. During the second semester, a
course at CHOP focuses on principles linking research into practice in
providing interventions for children with health problems. In the second year
of the specialization (i.e., during the fourth doctoral year), the emphasis of
training is on prevention and health promotion. The first semester course at
Lehigh focuses on developing an understanding of basic principles of
prevention and health promotion, and the second semester course at CHOP
emphasizes translating research into practice by learning to develop
community-based prevention programs. In addition to these core courses,
students are expected to take advanced courses in child psychopathology,
neuropharmacology, child and family intervention, multicultural counseling,
organizational management, and child development at Lehigh.
Courses at Lehigh are taught by a cross-disciplinary faculty including professors in psychology, biology, school psychology, counseling psychology, special education, and educational leadership. The two courses offered at CHOP are taught by a psychologist who is on the faculty at CHOP and the University of Pennsylvania as well as Lehigh University. Additional faculty and staff in psychology and developmental and behavioral pediatrics from CHOP and the University of Pennsylvania School of Medicine contribute to the teaching of these two courses as part of their commitment to serve as clinician-educators at CHOP.
Practicum Experiences. A critical component of the
specialization is the integrated set of practicum experiences (see
Shapiro, DuPaul, Power, Gureasko, &
Moore, 2000). Because the goal of the training program is to
prepare professionals to effectively link health and educational systems,
practicum experiences are divided equally between school and health care
settings. In addition to limited practicum requirements prior to entering the
specialization, students spend approximately 3 full days per week across the
two settings during the 2 years of the Lehigh/CHOP program. The total number
of practicum hours required during the program (960 per year) exceeds the
requirements of most doctoral training programs.
School practica are conducted in the Allentown School District and School District of Philadelphia, and health care practica are conducted at CHOP, Lehigh Valley Hospital, and Sacred Heart Hospital in Allentown. During the school practica, students are expected to focus their efforts on developing strategies of intervention for children and families coping with chronic illnesses such as asthma, sickle cell disease, and traumatic head injury. In addition, they are trained to collaborate with school staff, family members, and community residents to develop prevention initiatives, such as nutrition education, literacy development, and playground-based aggression prevention programs. Some of the schools in which students serve their practica have school-based health centers, so students can learn about the operation of these programs as well. Supervision in the schools is provided by faculty from Lehigh and CHOP as well as site-based school psychologists.
Health care practica are offered in primary care hospital-based clinics in the Lehigh area and a tertiary care setting (i.e., CHOP). In the Lehigh area, students-receive training in assessment, child and family intervention, consultation, and health education in both general and specialty (e.g., pulmonary) outpatient pediatric clinics. At CHOP, students are placed in the Center for Management of Attention-Deficit/Hyperactivity Disorder, Behavioral Pediatrics Clinic, oncology programs, gastroenterology clinics, and neonatal follow-up programs and contribute to the development of intervention plans to address the school and family needs of children with health-related problems. Supervision in the health care settings is provided by faculty at Lehigh and CHOP, additional licensed psychologists, and pediatricians, including specialists in developmental and behavioral pediatrics.
Research Training. The primary research requirement during the specialization program is the development of the dissertation proposal. It should focus on topics of intervention and prevention for children with, or at risk for, health problems as well as on projects linking systems of care for children. Course assignments required during the specialization program are designed to prepare students for the dissertation proposal. For example, trainees are expected to write reviews of the literature, journal article critiques, and a grant proposal for their courses. In completing course assignments, students are encouraged to select topics related to their potential dissertation topic. Practicum placements are designed to support the development of research projects by affording students opportunities to develop and pilot intervention and prevention programs and methods of evaluating outcomes. Close collaboration between Lehigh/CHOP faculty and practicum supervisors has been invaluable in fostering the development of field sites that encourage research activities. With the support of faculty, many students in the program have been successful in presenting findings at professional conferences as well as publishing review articles and empirically based studies in peer review journals as they are completing their dissertations.
Program Evaluation
Because this training program was initiated recently, the outcomes are
currently being evaluated. The evaluation consists of the collection of
formative and summative evaluation data that are useful in improving the
quality of the students who enter and complete the program, improving the
quality of instruction and practicum supervision, and modifying the training
program to optimize the attainment of project goals and objectives.
Student Evaluation. Extensive admissions data are collected to evaluate potential changes in the number and diversity of program applicants and enrollees over time. Trainees are evaluated on their mastery of core competencies via tests, written class assignments, oral presentations in class, a sample of written reports generated in practicum placements, direct observation of performance, interviews, and evaluation forms completed by supervisors. Each student is required to develop a portfolio of products related to each of the program competencies. Examples of the types of activities students have been engaged in thus far are listed in Table II. Throughout the program, students and their faculty advisors evaluate progress in attaining each of the core competencies. The impact of the program on student performance is evaluated by tracking the outcomes of graduates with regard to the type and geographic location of the position attained, publications and presentations at national and regional meetings, student perceptions about the opportunities afforded by their position to engage in activities related to the management and prevention of health problems, and trainee perceptions of their competence in developing and evaluating intervention and prevention programs. Historically, the doctoral training program has placed its graduates in the following positions: 39% are university trainers, 48% are school-based practitioners or administrators, and 13% are employed in other settings, such as residential treatment programs for individuals with disabilities.
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Evaluation of Training Experiences. All courses are evaluated on a semester basis by students using the course evaluation scales required for all courses in the College of Education at Lehigh University. Practicum experiences also are evaluated by trainees using a standard rating scale. Trainees maintain logs of all practicum activities reviewed and approved by field and university supervisors. Faculty and field supervisors use this information to continuously evaluate and modify courses and practicum experiences. Evaluation of Program Structure and Process. A project advisory committee was formed at the outset to monitor program progress and to provide guidance about how to improve the quality of the project. This committee consists of educational administrators from the Allentown and Philadelphia school districts, clinical supervisors from the health care and school sites, and the faculty from CHOP and Lehigh University. In addition, a national expert in pediatric and school psychology has been designated to provide a formal review of the program and to make recommendations for improving the quality of the program and enhancing outcomes.
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Implications and Potential Challenges |
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TopAbstractIntroductionNeed for Innovations in...Linking Pediatric and School...Implications and Potential...ConclusionsReferences |
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Training to link systems of care for children with, or at risk for, health problems can be embedded in doctoral training programs related to a wide range of child specialties, as illustrated by the school psychology program at the Lehigh/CHOP partnership and the clinical child programs at the University of Kansas, Vanderbilt University, and other institutions. Although an intensive, 2-year sequence such as the one designed for the Lehigh/CHOP program may not be necessary, students need a sequence of interrelated courses and a wide range of practicum experiences in pediatric, community, and school settings to develop expertise as multisystem change agents (van Eys & Dodge, 1999
).
Implementing a specialized training initiative in the context of a clinical
child or pediatric psychology training program clearly presents challenges
different from those that arise in integrating this initiative in a school
psychology program. Pediatric psychology programs do not place as much
emphasis on providing services in educational settings as do school psychology
programs. Adapting this specialized program to a pediatric psychology training
program may require the addition of courses and practicum experiences to
enable students to understand the culture of schools, to learn strategies of
teacher consultation and family-school collaboration, and to develop skills in
developing and evaluating school-based intervention and prevention programs.
Similarly, implementing such a training initiative in the context of a school
psychology program requires additional training related to the provision of
care in health and mental health settings, as illustrated in the description
of the Lehigh/CHOP partnership. Developing a training program to prepare child-oriented psychologists to link health, educational, and family systems, consistent with NIMH training guidelines, requires enormous resources. The needed resources may not be available within the department in which the training program is situated, requiring creative partnerships between departments and perhaps institutions. The Clinical Child Psychology Program at the University of Kansas and the Clinical Child/Pediatric Psychology program at the University of Florida (see www.hp.ufl.edu/chp) are examples of innovative interdepartmental collaborations within an institution, and the Lehigh/CHOP initiative is an exemplar of a partnership between institutions. Through these collaborations, students are afforded opportunities to receive training from an interdisciplinary set of faculty and to learn how to conduct research and practice in a variety of systems serving children and families. Training programs fully committed to following the NIMH training guidelines for the preparation of child-oriented psychologists may need to establish partnerships with other departments within the institution or with departments in other institutions to acquire the needed resources.
Creating training programs such as this requires a strong investment on the part of university faculty and administration. Establishing and maintaining interdepartmental and interinstitutional partnerships can be challenging and time consuming. In addition, providing a set of practicum experiences that are integrated with one another, complement the courses being taught, and provide opportunities for students to engage in applied research requires careful planning and continual monitoring. Faculty must be committed to the training model and willing to invest the energy and time needed to create and sustain meaningful collaborations within and outside the university. Training grants, such as awards received from the U.S. Department of Education by the Lehigh/CHOP team, certainly support the development of these types of initiatives. However, university faculty and administrators need to find creative ways to sustain these programs when extramural funding is not available or when the funding is terminated.
Another challenge is that most doctoral training programs currently require a large number of courses and practicum experiences. Although the Lehigh/CHOP program does not require more coursework than the standard Lehigh doctoral program, the specialized program requires that students have 4 to 8 hours per week of additional practicum experience in the third and fourth years. The requirement of additional practicum experiences may increase the length and cost of training for students and require that the program make a commitment to offering additional training experiences. Opportunities for students to receive compensation for additional practicum experiences through the funding of training grants may help to address student concerns. Training grants can also offset the costs associated with creating and overseeing additional practicum experiences. However, a modified version of the Lehigh/CHOP training program has been developed for students who do not receive grant-funded stipend support. Students in the modified program take the same courses, but expectations for practicum involvement have been reduced.
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Conclusions |
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TopAbstractIntroductionNeed for Innovations in...Linking Pediatric and School...Implications and Potential...ConclusionsReferences |
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Reforms within our sociopolitical system and within psychology itself have created the need for professionals to link systems of care for children and to address the service delivery as well as the public health needs of children and their families. These reforms have generated questions about the relevance of traditional models of training that have focused on preparing professionals to understand a limited range of systems and domains of child development and that have emphasized training in service delivery to the point of excluding a focus on public health. These developments have emphasized the need to prepare professionals in child-oriented psychology to work in multiple contexts and to be effective in coordinating systems of care for children and families. Given that the preparation of child-oriented psychologists has been embedded in clinical child, pediatric, community, and school psychology training programs, there are multiple pathways for preparing these psychologists to link systems of care and to focus on service delivery (i.e., intervention) and public health (i.e., prevention).
The Lehigh/CHOP collaboration is an illustration of one model for preparing psychologists to link systems of care to address the health needs of children and their families. This initiative, based in a doctoral-level school psychology training program, is designed specifically to prepare professionals to capitalize on the resources in schools and communities to manage and prevent children's health problems. Key elements of this model, including the focus on training in intervention and prevention in both health care and school settings and the emphasis on training in clinical practice and research on behalf of underserved families, may have utility in designing innovative training programs in pediatric psychology. Implementing an initiative in a pediatric psychology training program may require that students receive additional training in school ecology, family—school collaboration, and program development and evaluation in school and community settings.
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Acknowledgments |
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A grant from the U.S. Department of Education, Office of Special Education Programs (#H029D70010-99), supported us in the preparation of this manuscript.
Received April 6, 2001; revision received August 16, 2001; accepted December 20, 2001
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