Journal of Pediatric Psychology Advance Access originally published online on June 12, 2008
Journal of Pediatric Psychology 2008 33(9):1062-1064; doi:10.1093/jpepsy/jsn061
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This article appears in the following Journal of Pediatric Psychology issue: Special Issue: Evidence-based Assessment in Pediatric Psychology [View the issue table of contents]
Commentary: Progress and Challenges in Evidence-based Family Assessment in Pediatric Psychology
The Children's Hospital of Philadelphia and The University of Pennsylvania
All Correspondence concerning this article should be addressed to Anne E. Kazak, PhD, The Children's; Hospital of Philadelphia, 34th Street and Civic Center Blvd., Room 1486, CHOP North, Philadelphia, PA 19104, USA. E-mail: kazak{at}email.chop.edu
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Abstract |
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 Top Abstract Why Families?Why Not Families?Next StepsLearn About FamiliesReframe a ProblemDebunk a MythAcknowledgmentsReferences |
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It is widely accepted that families are integral to biopsychosocial, social ecological, and other systemic approaches for understanding families and pediatric health. Pediatric psychologists are among the strongest advocates for families. At the same time, families pose challenges that we (pediatric psychology as a field) struggle with in terms of theoretical conceptualizations, assessment and intervention approaches, and training. We primarily use individual frameworks in our practice and research. In this brief commentary, prompted by the report of accomplishments in evidence-based family assessment in pediatric psychology (Alderfer et al., 2007
), I outline some of the background for an implicit "challenge" to our field to advance our family orientation and provide some concrete ideas about next steps.
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Why Families? |
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TopAbstractWhy Families?Why Not Families?Next StepsLearn About FamiliesReframe a ProblemDebunk a MythAcknowledgmentsReferences |
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Families are inherently complex in structure and function and dynamic at the individual, dyadic and family level. Pediatric conditions affect a broad range of families, from initial diagnosis/injury through varying intensities of treatments and with a range of potential outcomes. Children are embedded in social systems that include families (mothers and fathers, siblings, grandparents, and extended family), schools (including peers), and neighborhoods and communities. The illnesses and treatments themselves differ by condition but have common elements as well, particularly as they relate to caregivers (family members and professionals). Although pediatric healthcare crises are universally upsetting, most families cope and adjust quite well over time. At the same time, key elements of family functioning (such as cohesiveness, conflict, connectedness, and adaptability) are associated with health outcomes and can be influential in understanding the broader impact of illness on family members in addition to the pediatric patient.
Advances in Evidence-based Family Assessment
Given the prominence of families in pediatric health care and the consistent interest inclusion of families in pediatric psychology research, the data reported by the Evidence Based Assessment report on family assessment in a thorough and well constructed article (Alderfer et al., 2007) are particularly important and timely. Overall, the results of this comprehensive report are very positive. The authors found that two-thirds of the 29 family assessment measures reviewed met criteria for "well-established" approaches. The remaining instruments were noted to be "approaching well-established." The measures covered general family functioning and couples, parent–child and sibling relationships. These measures are generally well known and highly regarded in the broader family research community and importantly reflect multiple methodologies (e.g., self-report and observational approaches).
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Why Not Families? |
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TopAbstractWhy Families?Why Not Families?Next StepsLearn About FamiliesReframe a ProblemDebunk a MythAcknowledgmentsReferences |
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The impact of these optimistic findings is somewhat tempered by the realization that the measures may not be as effective as we might prefer in a practical sense in pediatric psychology research and practice. That is, while general family functioning is important and may contribute to adaptive reactions to chronic illnesses, for example, the more focal questions related to pediatric psychology will demand more specific measures. Alderfer et al. (2007
) shed important light on this; seven of the measures reviewed are classified as specific to pediatric psychology and tap into issues that have proven associations with pediatric illness. These measures are less known, less well validated and in more developmental phases than some of the more general family measures. More broadly, the need to identify ways in which family assessment in pediatric psychology can be strengthened is important.
The assessment of families remains a bit "countercultural" in psychology in general, where conceptualizations remain primarily at the individual level. The early "fathers" (they were mostly male and mostly not psychologists) of family therapy argued for interpersonal perspectives on psychopathology that challenged the predominant psychodynamic formulations and offered alternatives to traditional diagnostic categorizations. Some of the classic work in this area had direct relevance to pediatric psychology. For example, structural family therapist Salvatore Minuchin and colleagues (Minuchin et al., 1975) explored the family dynamics of adolescents with diabetes, asthma, and eating disorders and developed family therapy approaches to disrupt rigid family patterns that contributed to maintaining health threatening problems. While conceptually and clinically strong, measuring family constructs is complex and necessitates data from multiple respondents that can capture interpersonal interactions. This work continues to unfold across a broad range of populations.
Indeed, the fields of family therapy and family research are multidisciplinary. Although many leading family researchers are psychologists, family assessment, intervention, and research methods are not parts of the core curricula in many, if not most, clinical child and pediatric psychology graduate and internship training programs. This is concerning because, as pediatric psychologists, the importance of the family is accepted. But pediatric psychologists are not, in general, obtaining in-depth training in family assessment and treatment. As a result, relatively few pediatric psychologists have assumed leadership roles in advancing family measurement, treatment, and research.
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Next Steps |
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TopAbstractWhy Families?Why Not Families?Next StepsLearn About FamiliesReframe a ProblemDebunk a MythAcknowledgmentsReferences |
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The recommendations for future directions suggested by Alderfer et al. (2007
) are important. That is, attention to measurement development that includes psychometric properties in pediatric samples, data from multiple respondents, attention to the heterogeneity of families, and evaluating the clinical utility of measures in pediatric samples are all essential steps to advance the field. Some other next steps include focusing on how we might narrow the gap between research and practice in this area, using a wide angle lens on problems to include the family system in assessment and treatment, integrating family data with other assessment material, using family assessment a means of identifying strengths as well as vulnerabilities, and partnering with families to increase the acceptability and relevance of assessment. That said, assessment is a practical process and I conclude this commentary with three concrete (and hopefully do-able) steps that can be taken to advance evidence-based family assessment in pediatric psychology at a more personal level.
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Learn About Families |
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TopAbstractWhy Families?Why Not Families?Next StepsLearn About FamiliesReframe a ProblemDebunk a MythAcknowledgmentsReferences |
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- Take a course on family theory or treatment, marital/couples therapy, or on family research methodology.
- Request a supervisor with a family systems orientation.
- Add a lecture on family issues to any course on children and health.
- Read a book or article to learn more about current issues in families and health that may intersect with your work. Consider (among others) Fiese (2006) or Rolland and Walsh (2006) as recent examples of thought provoking summaries of children and families in a pediatric health context.
- Learn about new developments in relational diagnosis (Beach et al., 2006).
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Reframe a Problem |
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TopAbstractWhy Families?Why Not Families?Next StepsLearn About FamiliesReframe a ProblemDebunk a MythAcknowledgmentsReferences |
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- Apply a wide angle lens to refresh a difficult treatment case. Examples include understanding conflict in the family of a child with diabetes, anticipating the impact of parental substance use on adherence to treatment in a child with asthma, thinking about the parent–sibling relationship in a single parent family that has been involved in a motor vehicle collision in which a child was seriously injured, or assessing the impact of the parent–child relationship in an adolescent newly diagnosed with HIV who has not yet disclosed sexual orientation to the family.
- Reflect on whether you have evidence-based approaches to assess and intervene with families like these.
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Debunk a Myth |
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TopAbstractWhy Families?Why Not Families?Next StepsLearn About FamiliesReframe a ProblemDebunk a MythAcknowledgmentsReferences |
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- Are fathers really "too difficult" to recruit for research? Although the answer is—No—they can be recruited and what we have learn is interesting and important (Fabiano, 2007; Phares et al., 2005), most of us are guilty, at one time or another, of capitulating to the difficulties of recruiting fathers in research studies or including fathers in treatment.
- Are families of children with chronic illness more likely to divorce than those without an affected child? The data largely indicate that this is not the case (Sabbeth & Leventhal, 1984). Yet, our silence by not examining couples in pediatric psychology in more detail may inadvertently allow this message to prevail and miss opportunities to appreciate the intricacy of child illness on couple relationships.
Conflicts of interest: None declared.
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Acknowledgments |
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TopAbstractWhy Families?Why Not Families?Next StepsLearn About FamiliesReframe a ProblemDebunk a MythAcknowledgmentsReferences |
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Preparation of this commentary was supported by the Center for Pediatric Traumatic Stress (SM058139).
Received May 2, 2008; revision received May 2, 2008; accepted May 21, 2008
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References |
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TopAbstractWhy Families?Why Not Families?Next StepsLearn About FamiliesReframe a ProblemDebunk a MythAcknowledgmentsReferences |
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Alderfer MA, Fiese B, Gold J, Cutuli JJ, Holmbeck G, Goldbeck L, et al. Evidence based assessment in pediatric psychology: Measures of family functioning. In: Journal of Pediatric Psychology. (2007) doi: 10.1093/jpepsy/jsm083.
Beach S, Wamboldt M, Kaslow N, Heyman R, First M, Underwood G, et al. Relational processes and DSM-V: Neuroscience, assessment, prevention and intervention. (2006) Washington, DC: American Psychiatric Association.
Fabiano G. Father participation in behavioral parenting training for ADHD: Review and recommendations for increasing inclusion and engagement. Journal of Family Psychology (2007) 21:683–693.[CrossRef][Web of Science][Medline]
Fiese B. Family routines and rituals. (2006) New Haven, CT: Yale University Press.
Minuchin S, Baker L, Rosman B, Liebman R, Millman L, Todd T. A conceptual model of psychosomatic illness in children: Family organization and family therapy. Archives of General Psychiatry (1975) 32:1031–1038.
Phares V, Lopez E, Fields S, Kamboukos D, Duhlig A. Are fathers involved in pediatric psychology research and treatment? Journal of Pediatric Psychology (2005) 30:631–643.
Rolland J, Walsh F. Facilitating family resilience with childhood illness and disabilitiy. Current Opinion in Pediatrics (2006) 18:527–538.[Web of Science][Medline]
Sabbeth B, Leventhal J. Marital adjustment to chronic childhood illness: A critique of the literature. Pediatrics (1984) 73:762–768.
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