446 Child Health Psychology
treatment but particularly for children with intensive regi-
mens such as children with IDDM and children with asthma.
Family factors may also place some families at risk for sus-
tained distress. For example, child behavior problems, marital
strain, or “nancial considerations that predate a child•s health
concern may result in parental expression of intense and sus-
tained levels of anxiety, exceeding that usually seen in parents
of patients. These families may also be at risk for problems
with adherence (e.g., assuring that a child with behavior prob-
lems takes medication regularly, transportation dif“culties
that result in irregular attendance at outpatient visits) and are
likely to bene“t from more intensive interventions.
Indicated Interventions
Some children and families show more obvious psychologi-
cal dif“culties and are at high risk because of the illness itself
or the presence of stress, intrapersonal, and social risk fac-
tors. These families may have preexisting psychological dif-
“culties (or psychopathology), be in the midst of divorce,
have recent life changes that tax their coping abilities, and so
on. They may also have a long-term history of dif“culty man-
aging a pediatric illness (e.g., maintaining desirable blood
glucose erratically in a child with diabetes, repeated hospital-
izations for pain in a child with sickle cell disease). In this
chapter, we focus our discussion around life-threatening ill-
nesses with treatments and long-term effects of suf“cient
severity that intervention is indicated in most cases. These ill-
nesses involve cognitive functioning, traumatic brain injury
and brain tumors speci“cally, and illnesses leading to solid
organ or bone marrow transplantation. While smallest in
number, these families tend to use a high level of hospital re-
sources and necessitate intensive and sustained intervention,
often from multiple members of the health care team.
UNIVERSAL INTERVENTIONS
Interventions in Primary Care Settings
Pediatricians in primary care settings routinely address care-
givers• questions and concerns regarding their children•s de-
velopment and behavior. Pediatricians are also charged with
the dual tasks of caring for ill children and promoting chil-
dren•s health. Because of their expertise, child health psy-
chologists are uniquely positioned to shed light on these
pediatric primary care issues. Collaborations among psychol-
ogists and pediatricians in primary care settings have a long
history, but few reports of the integration of psychologists in
the primary care setting are found in the literature. A notable
exception is Schroeder (1999), who outlined a long-standing
collaboration between pediatric psychologists and pediatri-
cians focused on assessment and intervention with a host of
issues from developmental concerns to pathological condi-
tions, from adherence to prevention. This model of collabo-
ration incorporated early intervention through telephone
consultation and recommendations. These collaborations, al-
though not without their dif“culties and pitfalls, may have
satisfactory outcomes from pediatrician, psychologist, and
family perspectives.
Kanoy and Schroeder (1985), in a prospective study, re-
ported on the effectiveness of brief interventions with parents,
provided by telephone or in person through a primary care
practice. They found that parental education regarding appro-
priate expectations for developmental concerns and sugges-
tions of speci“c behavioral interventions to address negative
behaviors and socialization problems were viewed as most
effective by parents. However, concerns of parents lingered
over the one-year follow-up, particularly in the area of sibling
and peer problems, suggesting that ongoing interaction with
families was needed for maintenance of improvements. We
focus the rest of our discussion of primary care settings on
prevention efforts in primary care through immunizations.ImmunizationsEfforts in the past 15 years to immunize children have led to
a dramatic reduction in previously common and serious in-
fectious childhood illnesses such as polio, tetanus, and diph-
theria. However, the number of immunizations developed,
along with the repeated administration required, place “nan-
cial, logistical, and emotional burdens on families and on the
health care system. It is recommended that, by age 2, children
receive four doses of diphtheria and tetanus toxoids and per-
tussis (DTP), three doses of Haemophilus in”uenzae type b
(Hib) vaccine, three doses of poliovirus vaccine, three doses
of hepatitis B vaccine, one dose of vaccine for measles,
mumps, and rubella (MMR), and the more recently added
doses of vaccine for pneumococcal meningitis and for vari-
cella (chicken pox; National Vaccine Advisory Committee,
1999). Infants may require up to four immunization injec-
tions at one appointment. Only about 60% of children receive
all the immunizations recommended by age 2; almost 1 mil-
lion children need one more dose of vaccine by age 2 to reach
full immunization (National Vaccine Advisory Committee).
Following a measles outbreak in the early 1990s, there was
renewed effort to address gaps in the systems that support im-
munization of young children (Freed, Bordley, & Defriese,
1993). Although a comprehensive and ef“cient immunization
delivery system has not yet been developed, immunization