Chapter One
Clinical Child Psychology Research and Practice Applications Michael C. Roberts, Bridget K. Biggs, Yo Jackson, and Ric G. Steele
Mental and behavioural problems during childhood and adolescence are a serious publichealth concern. About half of all lifetime mental disorders begin before the age of 14 years. Worldwide prevalence rates for child and adolescent mental disorders are around 20% with similar types of disorders across cultures ... the gap in mental-health services for children and adolescents with mental disorders is evident in virtually all countries at a time when the need has never been greater. (Belfer & Saxena, 2006, p. 551)
Clinical child psychology as a research and practice specialty of applied psychology seeks to investigate and remediate mental health problems for children, adolescents, and their families. Aspects of clinical child psychology are found in different countries with a broad range of populations, settings, problems, assessment, and intervention techniques. As noted in one definition,
The research and practices of Clinical Child Psychology are focused on understanding, preventing, diagnosing, and treating psychological, cognitive, emotional, developmental, behavioral, and family problems of children. Of particular importance to clinical child and adolescent psychologists is a scientific understanding of the basic psychological needs of children and adolescents and how the family and other social contexts influence socioemotional adjustment, cognitive development, behavioral adaptation, and health status of children and adolescents. (Clinical Child Psychology Formal Specialty Definition, 2005)
Several efforts and developments in the United States, as one example of formalizing the clinical child psychology specialty, include recognition as a specialty in professional psychology by the American Psychological Association (APA: Commission for the Recognition of Specialties and Proficiencies in Professional Psychology, 2009), establishment of board certification (American Board of Clinical Child and Adolescent Psychology, 2009), formation of divisions within APA (e.g., Society of Clinical Child and Adolescent Psychology, 2009; Society of Pediatric Psychology, 2009a), and development of accredited doctoral training programs providing substantiated training (e.g., University of Kansas Clinical Child Psychology Program; University of Denver Child Clinical Psychology Program). Other countries have also begun a process of developing their clinical child and adolescent psychology components (e.g., Australia, New Zealand, and England), but, in some countries, these types of specialists in child and adolescent mental health services are virtually nonexistent. The emergence of clinical child psychology as a specialty field is documented by numerous international professional journals devoted to its primary topics (e.g., Child and Adolescent Mental Health; Clinical Child and Family Psychology Review; Clinical Child Psychology and Psychiatry; Developmental Psychopathology; Journal of Abnormal Child Psychology; Journal of Child Psychology and Psychiatry; Journal of Clinical Child and Adolescent Psychology; and Journal of Pediatric Psychology).
Range of topics and problems for clinical child psychology
Clinical child psychologists provide services and conduct research on a range of problems and psychological concerns such as (a) infants born preterm, medically ill, or exposed to drugs; (b) youth with serious emotional disturbances such as schizophrenia and developmental disorders such as autism and mental retardation; (c) children with behavior and psychological disorders such as attention deficit/ hyperactivity, oppositional defiant or conduct disorders, anxiety, or depression; (d) children adjusting to life changes such as divorce, death, relocation, or remarriage; (e) children coping with trauma of disasters, war, terrorism, or community/family violence (including child physical and sexual abuse); (f) children living with physical illnesses, adhering to medical regimens, or coping with pain; (g) children with cognitive deficits and school performance problems; (h) adolescents with delinquency and high-risk behaviors of substance abuse or sexual behaviors; and (i) children in poverty and without adequate health care. Of course this list is illustrative at best, not comprehensive (see also Ollendick & Schroeder, 2003; Roberts & Steele, 2009; Walker & Roberts, 2001). The epidemiology and range of children's mental health problems appears to be similar for developing and developed areas of the world (Belfer & Rodhe, 2005).
Settings in which clinical child psychologists function
The settings in which clinical child psychological researchers and practitioners conduct their work include a diverse range of models, facilities, and units to organize services.
Mental health centers. In some countries, clinical child specialists primarily practice within a national health service in governmental units for child and adolescent mental health services. Similarly, in the US, mental health services are most commonly available through the public sector in a system of community mental health centers and child guidance clinics (Smith-Boydston, 2005). Responsive to cultural and community needs, these outpatient centers often involve teams of mental health professionals. Through concepts of "system of care" and treating individuals in the "least restrictive environment" (e.g., community-based services), professionals collaborate with agencies for social welfare, juvenile justice, alcohol and drug treatment, health care, and with schools. Outpatient services may include individual, group, or family therapy. Community outreach services may also be provided for school-based preventive programs or in-home interventions such as multisystemic treatment.
Schools. When children in educational settings display psychological problems that require intensive intervention to enhance developmental and educational outcomes, clinical child psychologists frequently consult, assess, and intervene with problems of behavior management and academic performance. For example, psychological services for children with serious emotional disturbances may be provided through school-based programs such as therapeutic classrooms or day treatment programs (Roberts, Jacobs, Puddy, Nyre, & Vernberg, 2003). School psychologists may also provide services for psychoeducational needs of children in educational settings (Lee & Jamison, 2005), but not all countries differentiate the specialties.
Children's hospitals and medical settings. Pediatric psychologists, as a subspecialty in clinical child psychology, provide clinical services for children through hospitals and outpatient clinics specializing in the care of children and adolescents. Their practice includes inpatient and outpatient modalities based in medical settings that address concerns related to health care and medical illness (Roberts & Steele, 2009). These services may be indirect (e.g., through consultation and collaboration with physicians and nurses) or direct interventions (i.e., involving the child or family), and focus on issues such as adjustment to disease, medical adherence, pain control, behavior management, health promotion, and problem prevention. In addition to children's hospitals, university-based medical centers frequently employ psychologists to provide services and investigate these phenomena in departments of pediatrics or departments of psychiatry. Psychologists conduct significant clinical research on pediatric psychosocial issues.
Inpatient treatment centers. In providing the most intensive form of intervention for severe disorders, clinical child psychologists work with a team of professionals in inpatient settings that include government-subsidized psychiatric hospitals and independent residential or inpatient treatment facilities. These centers often face the most acute challenges of psychosocial impairment and potential harm to self or others (Vargas & de Dios Brambila, 2005). Some centers focus on short-term stays of less than two weeks for stabilization while others allow longer-term residential care. Clinical child psychologists provide assessment and diagnostic services in addition to direct psychotherapy through individual and group modalities.
Private practice. In some countries, such as in the US, a sizeable number of child specialists in outpatient private practice receive reimbursement from health insurance plans or from personal payments by parents for providing psychological assessment and treatment services (Landolf, 2005). The private practitioner frequently works with the parents or family and consults with other professionals such as teachers or physicians. This model requires entrepreneurship and may be subject to limitations on reimbursement for certain activities or parental ability to self-pay. Although many work in individual private practices, psychologists and other mental health professionals may work together in groups in these settings for financial reasons and to coordinate different aspects of care (e.g., with social workers and psychiatrists).
University and research settings. Clinical child and pediatric psychologists serve on faculties of universities and colleges where they conduct research, teach, and supervise baccalaureate and doctoral trainees. University-based researchers investigate the full gamut of topics in child development, psychopathology, psychological interactions with physical health, and effective interventions to improve the quality of life for children and their families. Grants often support scientific activities. Research institutes, funded by philanthropies or grants, provide another setting in which child-oriented investigators work in teams to improve understanding of such issues as the etiology and course of developmental psychopathology or the organization and impact of mental health service delivery.
Trends and Key Developments in Clinical Child Psychology
Developmental psychopathology
As a field concerned with identifying and treating emotional, behavioral, and developmental disorders in childhood and adolescence, clinical child psychology is naturally concerned with how these disorders emerge and progress. In this regard, the thinking of clinical child psychologists is greatly influenced by the field of developmental psychopathology, defined as "the study of the origins and course of individual patterns of behavioral maladaptation" (Sroufe & Rutter, 1984, p. 18). Rutter and Sroufe (2000; see also Sroufe & Rutter, 1984) described the developmental psychopathology perspective in terms of the field's view on three key issues: (a) causal processes, (b) development, and (c) continuities and discontinuities between psychopathology and normality. Regarding causal processes, the field of developmental psychopathology aims to understand how risk and protective mechanisms operate and lead to either disorder or adjustment and the factors that influence the course of pathological processes after they first surface. Psychopathology is viewed as emerging from a complex interplay of multiple genetic, biologic, and environmental factors and transactions between an individual and the environment that unfold in a chain of effects over time (Rutter & Sroufe, 2000). The connection to clinical child psychology is quite intuitive: by identifying the factors and processes that give rise to disorder versus adjustment, developmental psychopathological research identifies potential targets for prevention and treatment for anxiety, depression, oppositional and anti-social behavior, and other childhood problems.
A focus on development is central to both clinical child psychology and developmental psychopathology. A central tenet of developmental psychopathology is that knowledge of typical development is needed to understand the emergence of disorder and, conversely, that understanding the development of psychopathology sheds light on basic developmental processes (Cicchetti, 1984). Although development implies change, development also includes continuity and coherence, as many aspects of the individual remain constant over time, and current behaviors and circumstances are connected to the individual's past and future. Attention to the developmental periods and their associated challenges and milestones are particularly germane to clinical child psychology. Treatments may need to address not only the presence of a disorder, but also the areas of development affected by the disorder. Further, the clinical child psychologist is mindful of development as it relates to the emerging skills of the child and the child's ability to benefit from a particular treatment modality.
The third central concept identified as by Rutter and Sroufe (2000) is the notion that there are both continuities and discontinuities between normality and psychopathology. That is, psychopathology, in some senses can be represented as an extreme of a characteristic present in normal existence. Conversely, psychopathology may represent a complete departure from typical development. The practice of clinical child psychology often necessitates a categorical view of psychopathology; psychologists often determine whether the presenting symptoms meet criteria for a disorder (i.e., for billing/insurance reimbursement purposes). Nonetheless, clinical child psychologists are aware that symptoms and behavior frequently occur along a continuum of severity. In addition, they are aware of consistencies and changes in the presentation of disorders across development. Calls for diagnostic systems that more strongly reflect developmental changes are illustrative of this awareness.
Evidence-based practice
The evidence-based practice movement in clinical child psychology strives to provide child and adolescent services that have adequate scientific support for their use. This movement is not unique to the field of clinical child psychology, because science-informed approaches to assessment, diagnosis, and treatment are emphasized by other professions including medicine, public health, and social work (Roberts & James, 2008). Although the term "evidence-based practice" and related terms including "empirically supported treatments" are relatively new, the notion of integrating science and practice is consistent with the longer-standing tradition of training doctoral level psychologists in both research and practice in many developed countries (APA Presidential Task Force on Evidence-Based Practice, 2006; Charman & Barkham, 2005).
The common thread in the messages of the evidence-based practice movement around the globe is that clinical practice should be based on evidence of what works from carefully designed and reviewed scientific study (see, for example, APA Presidential Task Force, 2006, in the US; Charman & Barkham, 2005, in Australia; and the World Health Organization, 2005). Most definitions of evidence-based practice (EBP) are based on empirically supported treatments (ESTs) and often mention the use of psychometrically sound assessment techniques. ESTs are typically defined as including a clear description of intervention procedures in a treatment manual and empirical evidence demonstrating the treatment's efficacy over a control or alternative treatment condition, with randomized controlled trials (RCTs) often held as the gold standard. Peer-reviewed publications summarizing evidence-based practice specific to clinical child and adolescent psychology include special issues and sections on psychosocial treatments (Lonigan, Elbert, & Johnson, 1998; Silverman & Hinshaw, 2008), evidence-based assessment (Mash & Hunsley, 2005), and special issues on assessment and treatment in pediatric psychology (Cohen et al., 2008; and Spirito, 1999; respectively). A growing number of edited books on EBP with children and adolescents have also been published (e.g., Carr, 2000; Hibbs & Jensen, 2005; Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Mash & Barkley, 2007; Steele, Elkin, & Roberts, 2008). The report of the American Psychological Association Task Force on Evidence-Based Practice for Children and Adolescents (2008) also provides applications of EBP to clinical child and adolescent psychology.
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Excerpted from IAAP Handbook of Applied Psychology Copyright © 2011 by Blackwell Publishing Ltd.. Excerpted by permission of John Wiley & Sons. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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