Journal of Pediatric Psychology, Vol. 28, No. 6, 2003, pp. 443-445
© 2003 Society of Pediatric Psychology
Commentary: Training in Pediatric Psychology: A Survey of Predoctoral Internship Programs
Emory University School of Medicine
All correspondence should be sent to Nadine J. Kaslow, Emory Department of Psychiatry and Behavioral Sciences, Grady Health System, 80 Jesse Hill Jr. Drive SE, Atlanta, Georgia 30303. E-mail: nkaslow{at}emory.edu.
Within the field of professional psychology, there is a growing emphasis on
a competency-based approach to the training and evaluation of psychology
students (Peterson, Peterson, Abrams, &
Stricker, 1997
). This movement has led to such recent events as a
major multinational conference, which was held to focus on the identification,
training, and assessment of core competencies of psychology trainees. In
general, competency connotes professional judgment of an individual's ability
or capacity to perform certain activities based on his or her education,
training, and experience. Additionally, competency refers to what people know
or are able to do in terms of knowledge, skills, and attitudes. Professional
competency has been defined further as the "habitual and judicious use
of communication, knowledge, technical skills, clinical reasoning, emotions,
values, and reflection in daily practice for the benefit of the individual and
the community being served" (Epstein
& Hundert, 2002). Based on these views, people are considered
to be competent professional psychologists when they are able to effectively
perform a complex set of tasks and have the capability to transfer their
skills and knowledge to new situations. Gleaned from survey data from multiple
constituency groups and from a review of the literature, the "2002
Competencies Conference: Future Directions in Education and Credentialing in
Professional Psychology"
(www.appic.org)
identified the following core competencies within professional psychology:
scientific foundations and research; ethical, legal, public policy/advocacy;
individual and cultural diversity; psychological assessment; intervention;
consultation and interdisciplinary relationships; supervision; and
professional development. While these core competencies apply to the broad
field of professional psychology training, there is a need for professional
psychologists who maintain areas of specialization (e.g., pediatric,
industrial/organizational, forensic) to articulate the areas of emphasis and
core competencies within their respective specialty areas.
The recommendations that emerged from a task force commissioned by the
Society of Pediatric Psychology (SPP), Division 54 of the American
Psychological Association (Spirito et al.,
2003), are consistent with the competency-based perspective that
is being widely touted both nationally and internationally. Specifically,
these recommendations highlight training in life-span developmental
psychology; life-span developmental psychopathology; child, adolescent, and
family assessment; intervention strategies; research methods and systems
evaluation; professional, ethical, and legal issues pertaining to children,
adolescents, and families; issues of diversity; the role of multiple
disciplines and service-delivering systems; prevention, family support, and
health promotion; social issues affecting children, adolescents, and families;
consultation and liaison roles; and disease process and medical management.
Using these recommendations as a guide, individual training programs and the
pediatric psychology field as a whole need to begin to assess what
competencies their training curricula already sufficiently emphasize and which
competency areas do not receive the necessary exposure and experience for
trainees to develop competency. Mackner and colleagues (this issue) should be
commended for their efforts to begin this assessment process. To ascertain how
closely internship training programs fit with the recommendations from the SPP
Task Force, they surveyed internship training directors whose programs,
according to the information they provide in the Association of Psychology
Postdoctoral and Internship Centers (APPIC) Directory
(www.appic.org),
offer training in pediatric psychology. As noted by Mackner and colleagues,
many sites that identify themselves in the APPIC Directory as offering
opportunities in pediatric psychology, when queried, actually do not do so.
This finding underscores the importance of truth in advertising by internship
training directors. If sites do not offer training that is relatively
consistent with the SPP Task Force recommendations described above, it is not
appropriate for them to indicate that they offer major or
informal/minor/external rotations in pediatrics.
It should also be noted that the "truth" according to the internship training director is sometimes not consistent with the "truth" according to the interns. In other words, training directors may perceive that their trainees gain a breadth and depth of exposure and experience in pediatric psychology when the interns do not believe that they receive sufficient didactic and actual practice to develop toward having expertise in pediatric psychology. Thus, future research must gather information from the trainees' perspective. In addition, a richer picture of what training programs actually entail and what they should encompass could be ascertained if data were collected from members of the interdisciplinary teams with whom interns train and work, as these team members play an integral role in the education and professional development of pediatric psychologists.
The survey by Mackner and colleagues also highlights the fact that the internship training programs that did report offering training opportunities in pediatric psychology may not have the necessary and sufficient opportunities for trainees to develop competency in pediatric psychology. A number of findings from the survey deserve particular note. First of all, the recommendations from the SPP Task Force underscore the importance of broad and general training. It is a cause of concern, but not surprising, to note that many internship training programs with a pediatric focus provide the majority of their training opportunities with school-aged children and adolescents and a relative paucity of experience with infants, toddlers, preschoolers, and adults, particularly older adults. In order to have a life-span perspective, it is imperative that pediatric psychology trainees have some meaningful exposure on internship to individuals who represent the entire life span. As another example, many trainees were reported to be exposed to only a narrow range of illness groups. Thus, they likely cannot develop the competency necessary to function effectively in multiple pediatric psychology contexts post-internship. To be more consistent with the SPP recommendations and to broaden the scope of training experiences, internship training programs must reevaluate and work to compensate for the current disparity between the vast opportunities they report being available to interns and the actual time spent with different populations.
Second, it is encouraging that Mackner and colleagues have found that in addition to individual and group interventions, the majority of sites offer family, parent-focused, and empirically supported interventions as well. Additionally, as recommended by the SPP Task Force, most training sites required didactic and actual experience with assessments of children and adolescents. However, given the well-recognized impact of family functioning on children's overall emotional, behavioral, and social development as well as their adjustment and adaptation to illness, it is a matter of concern that parental interviews, family assessments, and family- and parent-based interventions were not areas of emphasis for most training programs. In practice, parents and families are typically involved in every step of pediatric psychology, from illness evaluation, diagnosis, adjustment, and medical adherence to hospital-, school-, and home-based interventions. Accordingly, to meet actual practice demands and the SPP Task Force recommendations, training opportunities with parents and families should be at the root of and definitely an area of emphasis of all pediatric internship training programs. Unfortunately, the lack of in-depth training in family psychology appears to be a consistent theme for all types of internships throughout the United States and Canada.
Third, despite growing awareness of the links between psychology and public health and the invaluable role that professional psychologists can play in prevention and health promotion, a significant percentage of internship programs fail to emphasize or even offer training in prevention and health promotion and social issues affecting children, adolescents, and families. This finding may partially reflect the fact that many older-generation pediatric psychologists were not themselves trained in these areas. Furthermore, when many long-standing pediatric internship training programs were initially developed, these issues were not emphasized by the pediatric field. However, the field of pediatric psychology has evolved and accordingly our training programs need to follow suit. There are multiple job opportunities for graduates in the prevention field and in primary care settings. Thus, more training in this domain would be extremely beneficial to trainees and to the children and families they will serve.
Finally, the findings by Mackner and colleagues illustrate that there is
marked variability across pediatric psychology training programs in what
didactic and experiential opportunities are provided. These findings are
consistent with the tension in the field between having a competency-based
approach to education and training in psychology on the one hand
(Sumerall, Lopez, & Oehlert,
2000) and "letting a thousand flowers bloom" on the
other (Benjamin, 2001).
However, we do not believe that these two concepts are incompatible. Rather,
core competencies identified by such groups as the SPP Task Force are
guidelines for the basic exposure and experiences that should be available in
internship training programs. As written, these guidelines already allow for
variability in how training programs provide such opportunities and do not
suggest a "one size fits all" approach to psychology training.
Accordingly, individual programs can make adjustments in their curricula to
meet these recommended standards of training in ways that are appropriate
given their training environment while still maintaining the individual
strengths of their programs.
As widely recognized by the psychology field as a whole, the purpose of the
internship year is for students to complete training in the general practice
of clinical psychology and to extend specialty preparation in such areas as
pediatric psychology. Accordingly, the mantle of responsibility for the
development of competency in pediatric psychology should not rest solely on
the shoulders of internship training directors. Rather, the acquisition of
knowledge, skills, and attitudes and subsequent competency and expertise is a
developmental process that begins during undergraduate education and extends
through postdoctoral training. In order to offer appropriate training
experiences and to assess the appropriate development of core competencies,
articulation of levels of expertise expected at different developmental stages
with regard to the various domains of core competency noted above would be
useful. Of course, since there are multiple training routes to becoming a
pediatric psychologist, there needs to be flexibility built into these
developmentally based education and training recommendations. For example,
trainees should have an awareness of the Ethical Principles of Psychologists
and Code of Conduct (American Psychological
Association, 2002) as well as of the value of behaving in an
ethical manner by the end of graduate school, but skills in ethical decision
making may not be expected to be fully formed until the completion of
internship. Such an early foundation in ethics is particularly important to
the discussion of developing core competencies, as ethical trainees and
supervisors should know the limit of their skills and work to obtain
additional training to develop competency. As another example of the
development of core competencies over the training continuum, knowledge about
life-span developmental psychology and life-span developmental psychopathology
should be gained during graduate school. However, being considered an expert
in applying this knowledge to the practice of pediatric psychology and to
research in the field may not occur until the internship or postdoctoral
level. Thus, more attention needs to be paid to the level of exposure and
experience in pediatric psychology that should be provided at various levels
of the training continuum as well as how to continually assess the stage of
development of these abilities in order to slowly propel a trainee toward
competency and expertise.
Coordination between training directors across education periods as well as among leaders in the pediatric psychology field, individual supervisors, mentors, and students is essential to better represent the SPP Task Force recommendations in established training programs and to maintain ongoing evaluation and adaptation to keep up with the rapidly growing and maturing field of pediatric psychology.
Received March 26, 2003; accepted March 31, 2003
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