Handbook of Psychology

Levels of Risk and Related Psychological Interventions 445

psychological distress and dysfunction in the child patient
and/or the family. The child health psychology literature has
contributed directly to all of these concerns. What appeared
to be missing were models for explaining how research and
clinical care could be linked in a comprehensive, effective,
yet cost-effective, approach.
Any target patient group, whether broad (e.g., all patients
at a children•s hospital, all patients followed in an outpa-
tient pediatric practice) or narrow (e.g., patients seen by a
subspecialty clinic such as oncology, cardiology, adolescent
medicine) includes individuals representing a range of psy-
chological functioning. We have conceptualized three gen-
eral categories to describe children•s and families• responses
to child health crises. We further link these categories to pro-
posed levels of psychological care. These correspond to
NIMH prevention categories of universal, selective, and in-
dicated care, which is illustrated under each description and
graphically shown in Figure 19.2.

Universal Interventions

Most families maintain well-being by coping adaptively with
the disruption and distress associated with childhood chronic
illnesses. For example, in childhood cancer, psychological
adjustment improves over the “rst 12 to 18 months after di-
agnosis, irrespective of whether an intervention is provided
(Kazak, Penati, Brophy, & Himelstein, 1998), and psycho-
logical adjustment of children treated with heart transplanta-
tion improves after the “rst year posttransplant (Todaro,
Fennell, Sears, Rodrigue, & Roche, 2000). These children
and families were most likely functioning within normal

limits prior to the health crisis, and their underlying psycho-

logical resilience help to assure recovery from the stressors

associated with childhood illness and treatment. To draw a

parallel with the preventive, public health model, like having

”uoride in drinking water, these families receive the most

general types of psychosocial support available in the hospi-

tal, clinic, and community setting and function well with that

level of intervention. This group represents the largest of the

three proposed groups affected by pediatric health problems.

In this chapter, the interventions we discuss under univer-

sal interventions may also be described as preventive efforts

targeting a population of children who are not necessarily at

high risk for illness or psychological problems. Although all

interventions in child health require the collaboration of psy-

chologists with families, pediatricians, teachers, and others,

universal interventions are de“ned by interdisciplinary col-

laborations and are most successful when implemented on

multiple levels from the individual and family to the commu-

nity and to policy initiatives.

Selective Interventions

Selective interventions target children at moderate risk for

psychological dif“culties. These children may be at risk due

to stressful aspects of the treatment regimens required for

their illnesses or because of intense, recurring pain associated

with their illnesses. Children with cancer, for example, expe-

rience repeated painful procedures in their treatment regi-

mens. Children with SCD and children with recurrent

headache experience pain as part of the illness process.

Adherence is of concern for all children requiring medical

UNIVERSAL

Generally well-functioning children and families.

Coping with stressors associated with pediatric illness.

General psychosocial assessment and support.

Help families anticipate/prevent further difficulties related to adherence.

Expect course of recovery, coping competently, and improvement in functioning.

SELECTIVE

Some indication of factors that predispose family to risk.

More intensive psychosocial support.

INDICATED

Several high-risk indicators present.

Consultation suggested.

Figure 19.2 Levels of risk and implications for intervention approaches. Source:Adapted

from: Priorities for Prevention Research at NIMH: A National Advisory Mental Health

Council Workgroup on Mental Disorders Prevention Research, 1998.