Pediatric Psychology

Pediatric psychology, the interface of health psychology and clinical child psychology, has grown over the past 35 years to become an independently recognized field. Pediatric psychology explores the interrelationship between the psychological and physical well-being of children, adolescents, and families, attending to developmental processes and physical, cognitive, social, and emotional functioning as they relate to health and illness. Specific topics of importance to this field include how psychosocial and developmental factors contribute to the etiology, course, treatment, and outcome of pediatric conditions; assessment and treatment of behavioral and emotional concomitants of disease, illness, and developmental disorders; and the promotion of health and health-related behaviors and prevention of illness and injury among youth. Entire volumes have been devoted to describing and summarizing the field of pediatric psychology. This article discusses some of the tenets of pediatric psychology, followed by an overview of four topic areas of concern to the field and a succinct discussion of two ethical issues confronted by pediatric psychologists.

Basic Tenets of Pediatric Psychology

To understand pediatric psychology, it is important to explore the basic assumptions that underlie and guide the field. The biopsychosocial model, the systems approach, a developmental perspective, and an emphasis on prevention reflect the basic assumptions of the field.

Biopsychosocial Model

As in health psychology, pediatric psychology recognizes that multiple factors converge and interact to influence the etiology, course, and outcome of mental and physical conditions. More specifically, biological, emotional, behavioral, interpersonal, and cultural factors are accepted as influencing health and illness.

Systems Approach

Pediatric psychologists generally accept that children are embedded within and reciprocally interact with various social systems. The social-ecological model provides a framework for understanding these various systems, which range from the child’s immediate family, to peers, to social institutions such as schools, hospitals, and religious organizations, to the broadest influences of the legal system, societal values, technology, and culture. Each of these systems influences and is influenced by childhood medical conditions.

Developmental Perspective

Childhood is a time in which many dramatic changes occur in biological, cognitive, emotional, and social abilities. Thus, pediatric psychologists espouse a developmental perspective, accepting that individuals of different ages have different abilities (e.g., physical, cognitive), needs (e.g., caretaking), goals (e.g., autonomy, intimacy), and social environments (e.g., home, school). Families, as systems, are also accepted to have developmental trajectories. The way in which health and illness issues are addressed by children and families is influenced by developmental stage.

Focus on Prevention

Much like pediatric medicine, pediatric psychology aims to promote healthy behaviors and prevent adverse health conditions. This tenet of pediatric psychology is evident in efforts to identify and intervene with families at risk for adjustment difficulties in response to chronic illness, promote adherence to medical regimens, educate children and parents regarding the development and sustenance of healthy lifestyle behaviors (i.e., exercise, proper diet/nutrition), and prevent drug and alcohol abuse, accidents, and injuries.

Topics of Interest in Pediatric Psychology

Pediatric psychology is a broad field. Four topic areas are presented to provide an overview of the types of issues important to this field: adaptation to chronic illness, adherence, management of pain and distress, and developmental disabilities.

Adaptation to Chronic Illness

Because of advances in medicine, previously fatal childhood conditions can now be treated with consistently applied, often long-term, medical regimens. Thus, the number of children living with chronic medical conditions such as asthma, cancer, cardiovascular disease, cerebral palsy, cystic fibrosis, diabetes, muscular dystrophy, renal disease, rheumatoid arthritis, sickle cell disease, and spina bifida has risen. Pediatric psychology is concerned with the emotional and behavioral adaptation of children and families to such chronic medical conditions.

Research has demonstrated that there is no simple or direct universal relationship between chronic physical conditions and psychological adjustment. Most children and families facing chronic medical conditions adjust well; however, these families are at increased risk for adjustment difficulties. To aid clinical remediation and preventative efforts, research within pediatric psychology has attempted to identify correlates and predictors of adjustment to chronic conditions. These research efforts suggest that children and families are at higher risk for difficulties when the child’s disorder impairs brain functioning, when the child reports high levels of stress and low levels of self-esteem, when the child’s mother is highly distressed, and when the child’s family is characterized by low levels of cohesion and supportiveness.


Rates of nonadherence (i.e., failure to adopt and/or maintain prescribed medical regimens) among pediatric samples have been estimated to range from 50% to 89%. Given these alarming numbers, a major effort within pediatric psychology has been the identification of factors contributing to treatment adherence and methods for improving adherence. Although this area of investigation faces methodological challenges, such as how to accurately measure this construct, certain factors have been identified across studies as contributing to adherence. These factors include characteristics of the child’s disease, the child’s developmental level, individual psychological characteristics of the child (e.g., emotional and behavioral problems), the functioning of the family, and the interface between the family and the health care team.

Research has suggested that adherence is more difficult to maintain when a disease is chronic and the treatment regimen complex. Furthermore, adolescents, compared to younger children, and youngsters with emotional and behavioral problems, contrasted with those who are functioning within normal limits, have more difficulty with adherence. The family plays an important role in medical regimen adherence. Generally, parents who are knowledgeable and skilled with the treatment regimen and who are supportive have youngsters who are more adherent. Finally, adherence is more common when there is a positive relationship between the medical team and the family. Successful interventions to improve adherence involve simplifying the medical regimen, educating the child and family about the treatment, ensuring parental involvement or oversight, encouraging developmentally appropriate self-monitoring of behaviors, and reinforcing desired behaviors.

Management of Pain and Distress

Managing pain and distress is one of the most difficult, yet common, problems for pediatric psychology. Because of this, research on assessment and management of pediatric pain has grown dramatically over the last 10 years. Experts generally agree that pediatric pain experiences can be classified into one of four categories: pain associated with chronic disease (e.g., arthritis, sickle cell), pain associated with injuries or traumas (e.g., burns), pain associated with nonobservable events (e.g., headache, abdominal pain) and pain associated with medical procedures (e.g., lumbar punctures).

By definition, pain is a subjective experience. As such, assessment of pediatric pain is complex, and often involves a combination of child report, parent report, and independent observation depending on the type of pain and the child’s developmental level. The majority of treatments for pediatric pain involve cognitive-behavioral techniques, including positive reinforcement, imagery/distraction, relaxation, modeling, role playing, and coaching by the therapist, medical personnel, or parents. Such techniques have been demonstrated to be effective in reducing pain and distress and improving cooperativeness of children during procedures and may be most effective when used in combination with pharmacologic strategies (e.g., numbing creams).

Developmental Problems

Pediatric psychology emphasizes developmental issues and therefore is also concerned with the assessment of and intervention for developmental problems. There is a wide range of developmental problems addressed by pediatric psychologists, including high-risk infancy, feeding disorders, failure to thrive, elimination disorders, habit disorders (e.g., tics), sleep disturbances, attention-deficit/hyperactivity disorder, autism and mental retardation, anorexia nervosa, bulimia, and obesity, and neglect, physical abuse, and sexual abuse. The majority of these issues overlap with the interests of clinical child psychology, but some have specific medically related aspects, and thus frequently come to the attention of pediatric psychologists. To illustrate the role of pediatric psychology in regard to a developmental problem, high-risk infancy will be discussed.

High-risk infancy may arise due to prematurity, congenital anomalies, prenatal exposure to substances or infections, or difficulties during labor and delivery. Pediatric psychologists serve high-risk infants and their families through assessing and fostering the infant’s health, the adjustment of the parent(s), the infant-parent relationship, and collaboration between the family and the neonatal intensive care unit team. The pediatric psychologist may also continue to assess the physical, cognitive, emotional, behavioral, and social development of high-risk infants as they age, to determine whether there are emerging difficulties to be addressed.

Ethical Issues Related To Pediatric Psychology

Ethical decisions in pediatric psychology are complicated because this field must attend to and balance the needs of the children, their families, the health care system, and society at large. Ethical decisions are further complicated by variations in laws across local jurisdictions (e.g., age of consent). Two particularly salient issues are informed consent and confidentiality.

Because children lack the necessary cognitive capacity to fully comprehend the gravity and nature of their treatment, they are not legally able to give informed consent for their treatment. Instead, parents give consent. Still, it is important to protect the child’s right to be an informed participant in his or her care. Therefore, children should have information presented in a way understandable to them and should be given the opportunity to assent voluntarily to treatment without coercion.

Similarly, pediatric psychologists must address issues of confidentiality. Children are not accorded the same right to confidentiality as adults due to their minor status, yet it is important to establish a trusting environment in which the child feels able to disclose sensitive information. Thus, pediatric psychologists must discuss and establish confidentiality guidelines in conjunction with the parent(s) and child, specifying the types of information that will be shared with the parent. Of course, the legal limits of confidentially (mandatory reporting of abuse and intention to harm oneself or others) must be upheld and explained to children in terms they can comprehend.

To summarize, pediatric psychology is a multidisciplinary field that has grown out of clinical child and health psychology. Pediatric psychology incorporates the biopsychosocial model, the systems approach, a developmental perspective, and an emphasis on prevention. Areas of interest to pediatric psychologists include adaptation of children and families to chronic disease, adherence, management of pain and distress, and developmental disorders. Informed consent and confidentiality are important ethical issues for this field.


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