444 Child Health Psychology
offered by pediatric psychologists across a broad array of ill-
nesses and symptoms. Well-established treatments are re-
ported for headaches, procedural pain, enuresis, feeding
problems, obesity, asthma, chemotherapy-related distress,
and pediatric sleep problems. These interventions focus
heavily on behavioral approaches. For example, one of the
most highly established areas of intervention is procedural
pain where combinations of cognitive-behavioral therapies
(CBT; e.g., relaxation, imagery, distraction, self hypnosis)
are well-established. Targets of CBT also lend themselves to
measurement (e.g., observations of child behavior before,
during, and after an intervention), which has helped establish
their effectiveness and assured them a prominent place
among the variety of approaches a psychologist may use in
treating children and their families.
Even with well-established treatments, however, there is a
need to continue to pursue research regarding other
potentially effective treatments. Division 12 guidelines for
empirically supported treatments should not be taken as
blanket endorsement of an approach as necessarily better (or
preferred) over other approaches. As shown in Table 19.1, a
variety of treatments, largely similar to the well-established
treatments, meet criteria for probably efficaciousorpromis-
ing. Most of the reviews in the Journal of Pediatric
Psychologyseries include a relatively small number of pub-
lished reports. The studies often rely on maternal reports for
treatment outcomes. We are early in the process of testing
child health psychology interventions. Given the wide range
of child health concerns (and advances in medical and asso-
ciated technology) that impact diverse populations with
complex family contexts, it is essential that intervention
outcome research continue, exploring the ef“cacy and ef fec-
tiveness of other treatment modalities and new creative
intervention partnerships.
LEVELS OF RISK AND RELATED
PSYCHOLOGICAL INTERVENTIONS
The application of psychological practice across a wide range
of child health domains suggests the need for a broad
framework for understanding psychological child health in-
terventions. Often, psychological practice in child health is
associated with more severe and/or longstanding adjustment
problems. That is, a threshold exists for when a child with
diabetes, recurrent headache, or cancer is referred to a psy-
chologist (either internal or external to the health care setting)
for treatment of a disease or treatment-related concern. Other
approaches (e.g., behavioral and cognitive-behavioral inter-
ventions) have application when treatment is clinically
indicated but are also helpful in reducing the likelihood of
ongoing psychological distress under conditions of estab-
lished duress (e.g., medical procedures). Alternatively, in the
realm of primary prevention, for example, psychologists
have contributed to the literature on injury prevention (e.g.,
seat belts and bicycle helmets). The existing literature (or
descriptions of practice) is largely devoid of frameworks
(rather than speci“c theoretical approaches) that might
guide the systematic provision of effective intervention to
children and families. Intermediary frameworks are needed
to apply well-established and promising treatments, based
on cognitive-behavioral, family systems, or other theories, in
a clinically relevant manner. If psychological practice is to
continue to be increasingly integrated into child health care,
such •blueprintsŽ for the provision of effective and cost-
ef“cient psychological interventions to pediatric populations
will be critical.
The model that we present provides an organization for il-
lustrating examples of child health psychology research and
practice. Based on prevention guidelines from the National
Institute of Mental Health (NIMH), it has been applied to pe-
diatric psychology practice at The Children•s Hospital of
Philadelphia (CHOP). The model evolved at CHOP in the
mid- to late 1990s from a series of conversations among
physicians, psychologists, and hospital administrators about
models for providing psychological services at an academic
pediatric health care hospital and system. It is a competence-
based framework, which allows for the integration of re-
search and clinical practice in child health psychology.
Existing models of psychological services in child health
were threatened nationally during the 1990s when managed
care shifted the focus of psychological care and created
threats to the sustenance of mental health care generally. Psy-
chological interventions in child health psychology that were
based on fee-for-service payment or on contracts with public
and private health insurance companies (and Health Mainte-
nance Organizations [HMOs]) were threatened. At the same
time, funding from the National Institutes of Health was
limited.
These constraining forces were counterbalanced by the as-
tuteness of the prediction of a •new morbidityŽ in pediatrics
(Haggerty, Roghmann, & Pless, 1975). More children with
diseases that were often fatal (e.g., cancer, cardiac disease,
low birth weight infants) were surviving longer, but with
attendant serious and/or chronic health problems. The psy-
chological implications of intensive long-term care of an ill
infant, child, or adolescent for families were becoming more
evident. At the same time, the associations between behavior
and health outcomes were more apparent. Finally, in the
health care setting, the provision of increasingly highly
technological care within shorter hospital stays highlighted
the challenges and complexity of providing care in the face of