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1. DONALD R. OTTINGER AND MICHAEL C. ROBERTS
A University-Based Predoctoral
Practicum in Pediatric Psychology
The development of a university-based clinical practicum in pediatric
psychology is discussed in terms of its history and function. The practicum
has become a year-long option within a Boulder-model training program in
clinical psychology. The source and nature of the referrals, the intervention
strategies, and the development of community relationships are presented.
It is concluded that pediatric psychology at a practicum level can be a
valuable clinical training and research experience within a clinical
psychology training program.
Pediatric psychology has had a short but lively history (Drotar, 1977; Friedheim, 1967;
Routh, 1977; Wright, 1967) and has accomplished its current state of maturation
without traditional academicparents. It is alive and thriving,and with the emergence
of its journals, internships, meetings, texts, and societies, we can concludethat it has
a healthy status and a robust future. Psychologists previously received on-the-job
training or even "self-training" in pediatric practices after assuming positions in medical
facilities, since most of them had no relevant, prior experiences. Pediatric psychologists
had to transfer and adapt previous training and procedures as well as develop new
approaches to therapy and research in the setting in which they found themselves. As
the area developed a content and established functions, training became more
formal.
Pediatric psychology training is now primarily a predoctoral internship event
available in several medical center settings or in postdoctoral programs that provide
training to psychologists with backgrounds in clinical, developmental, or educational
psychology. In 1972, Routh reported that 32 out of 100 medical schools offered
practicum training to graduate students in psychology and that "students at the
practicum level frequently have some other background than clinical psychology" (p.
588). University-based programs have not generally developed specialized training
in medical psychologyin pediatric settings. This is difficult to understand, given the
growth of research and practice in the field. This article will report on one training
model that provides practicum experience in pediatric psychologyas an option within
a clinical psychology training program at an academic institution. This program is
apparently unique and, though relatively small, is significant in the problems it en-
counters and the experiences provided the student in training.
Development of Pediatric Psychology Practicum
Purdue University has a long history of strongly emphasizing clinical childpsychology
within its American Psychological Association-approved graduate training program
in clinical psychology. Not only is clinical child psychology a common graduate major
at Purdue, but all students in the clinical program participate in at least two semesters
of child practicum. The program is organized around general and specialized practica
wherein each student participates in two semesters of general child and adult work.
Vol. 11, No. 5 October 1'980 PROFESSIONAL PSYCHOLOGY 707
Copyright 1980 by the American Psychological Association, Inc.
0033-0175/80/1105-0707J00.75

2. PEDIATRIC PSYCHOLOGY PRACTICUM
The advanced student can then opt for a specialized experience in a number of areas,
including behavior modification, group therapy, community psychology, family
therapy, and now, pediatric psychology. Purdue has operated a child psychological
clinic since the early 1930s, and five members of the faculty teach and supervise the
clinical child area. Out of this tradition, it was relatively simple to develop a practicum
in pediatric psychology and to attract interested students and appropriate referrals.
The pediatric practicum was developed after the establishment of a working clinical
and research relationship between a community-based pediatrician1
and a clinical
psychologist (the first author). The pediatrician subsequently was employed by the
department as a medical consultant tothe clinical training program. The practicum
was started with one 4th-year student in clinical child psychology, who was placed
on a departmental stipend for this trial practicum. The pediatrician referred pediatric
patients and families to the student and supervising psychologist for assessment and
treatment of psychological-behavioral problems accompanying or contributing to
medical problems. The clients were seen in the university'spsychological clinic, the
hospital, and the pediatrician's clinic. The student, pediatrician, and psychologist
met regularly to review individual cases and general problems occurring in the pediatric
practice. All parties had much to learn about conceptualizing both the antecedent
and consequent aspects of the interaction between psychological functioning and
physical illness/disabilities and their management. Learning to cooperate and respect
each other's professional contributions, while serving the best interests of clients, was
an important lesson for all participants.
For 3 additional years, the practicum included one or two students on the team who
not only responded to the referral of a single pediatrician but continued to offer ward
consultation and child management consultation to the hospital nursing staffs when
requested. Gradually the service came to the attention of other pediatricians, and the
referral base was broadened. The involvement of psychology with medical personnel
evolved through several stages rather than appearing spontaneously. The approach
used to establish a good liaison with the medical community was to offer a tentative
service rather than to come on in "gangbuster" style of "we can cure all your problems."
We presented our proposal by saying that we thought we had something to offer; the
physician could try us; and if we adequately fulfilled the need, then we would become
1
Robert Hannemann, M.D.
DONALD R. OTTINGER is Professor of Psychological Sciences at Purdue University and former
Director of Training in Clinical Psychology. His career training interest has been in clinical
child psychology.
MICHAEL C. ROBERTS if Assistant Professor of Psychology at the University of Alabama where
he is coordinator of the Clinical Child Psychology specialization. He earned an MS and PhD
in clinical psychology from Purdue University, with a concentration in the clinical child area.
He completed his clinical internship in pediatric psychology at the University of Oklahoma Health
Sciences Center. He has published research in the areas of social learning and clinical child
psychology and has a particular interest in issues of clinical training.
THE AUTHORSWISH TO ACKNOWLEDGE the assistance of thefollowing professionals who
aided in the development of thisprogram and in the preparation of this article: Paul Buck, Lynne
Cobb, Danita Czyzewski,AnnetteM. LaGreca, and Robert Hannemann.
REQUESTS FOR REPRINTSSHOULD BE SENT to Donald R. Ottinger, Department of Psy-
chological Sciences, Purdue University, West Lafayette, Indiana 47907.
708 PROFESSIONAL PSYCHOLOGY Vol. 11, No. 5 October 1980

3. more involved. If not, we would not receive any more referrals. We made every at-
tempt to provide competent, immediate action on each referral and to keep the physician
informed ofprogress through telephone and written contact. The pediatrician assumed
responsibility for instructing the student about the medical aspects of each case (e.g.,
etiology, diagnosis, and treatment of cerebral palsy) and the problems encountered
in handling the case (e.g., noncompliant resistive patient or family conflict over accepting
the disease). The student and supervising psychologist explained to the physician
the psychologicalfactors and the therapeutic intervention involved. The training was,
thus, reciprocal, and the pediatric psychology students benefited greatly from the ar-
rangement.
The next step was the presentation of a didactic graduate course by the pediatrician
entitled "Pediatrics for the Clinical Psychologist." It was designed for the student
in clinical psychology who desired to become acquainted with the field of pediatric
medicine, as seen by a practicing physician. The students were introduced to common
medical terminology, literature, and interrelated medical and psychological problems.
Topics included such medical problems as diabetes, seizure disorders, asthma, pre-
maturity, cystic fibrosis, leukemia, and many others. Contacts were arranged at a
local hospital with the medical social worker and the head pediatric nurse. Field trips
were taken to pediatric wards, a neonatal intensive care unit, and the private practice
clinic. This course has been opened to both clinical and nonclinical students; for ex-
ample, students in the special education and developmental psychology curricula can
take the course.
The current practicum now includes two 3rd-year students who are clinical child
psychology majors and who have had the didactic course. In order to function in the
hospitals as consultants, have access to the charts, visit referred patients, and receive
needed hospital support, the students are given the hospital privileges of the Allied
Health Staff. These privileges limit the recipient to direct patient contact only on the
referral ofthe patient/responsible physician. (Not the least ofthe privileges bestowed
was access to the doctors' parking lot.)
The students meet weekly with the pediatrician to either make hospital ward rounds
or to review and/or seechildren and parents in his office. The team members may
seea child or his/her family in the hospital or arrange to seethem in the Purdue Clinic
if they are outpatients. If it facilitates patient contact, the student may coordinate the
contact with the child's regular visit to the pediatrician and seehim/her or the parent(s)
in the pediatrician's office.
Types of Pediatric Psychology Referrals
The referral problems found in the pediatric psychology practicum are more varied
than those found in the Purdue Child Psychological Clinic. The latter serves as a
training clinic, and its population has a high frequency of behavior, family, and
school-related problems. The children served by the pediatric psychology practicum
more frequently are referred because of physical complaints (stomachache, back pain,
headaches) or because of difficulty in adjustment to a disease or condition. The
categories that account for the 94 cases referred over a 3-year period are shown in Table
1. The patients were seen by four students during that time. The categories were
adapted from Mesibov, Schroeder, and Wesson (1977), and our referral information
was fitted to their categories. As observed in Table 1, a large number of pediatric
Vol. 11, No. 5 October 1980 PROFESSIONAL PSYCHOLOGY 709

4. PEDIATRIC PSYCHOLOGY PRACTICUM
Table 1: Pediatric Practicum Referral Problems by
Primary and Secondary Classification Over 3 Years
Problemcategory
Negative behaviors
Toileting
Developmental delays
School problems
Sleepingproblems
Personality
Sibling/peer problems
Divorce, separation
Infant management
Family problems
Sex-relatedproblems
Food/eating problems
Specific bad habits
Physicalcomplaints
Guidance of talented child
Adjustment to disease,
handicap
Drug/alcohol abuse
Total
Frequency
primary
category
9
7
9
14
2
5
1
1
6
3
1
4
2
15
1
12
2
94
Primary
category
percentage
10
8
10
15
2
5
1
1
6
3
1
4
2
16
1
13
2
100
Note. Categories are adopted from Mesibov et al. (1977).
clients were still seen by this team for the category of problem typically seen in a tra-
ditional child guidance clinic (e.g., school problems). (That is, the child who was
initially brought to a pediatric clinicwas subsequently referred to the psychology team
by the pediatrician.) Apparently, schools and parents were sending the children for
psychological problems first to a medical practitioner who served on the "front line"
rather than to a mental health facility. (This may speak to the general image or
knowledge regarding psychological services in the community at large.)
The types and frequency of problems represented in Table 1correspond to the pe-
diatric psychology content areas outlined by Roberts, Quevillon, and Wright (1979)
and are consistent with the definition of this subdiscipline, as offered by Wright (1967).
Additionally, these data are quite similar to a summary of referral problems compiled
by Walker (1979) in the Pediatric Psychology service at Oklahoma Children's Me-
morial Hospital. However, this tally is in notable contrast to the frequency countof
Mesibov et al. (1977) of parental concerns as expressed in a telephone call-in or come-in
service run by pediatric psychologists. Their highest percentage of contacts was about
negative behaviors and toileting. Our practicum experience, as summarized in Table
1, may reflect a more severe type and a different nature of problem that necessitated
the referral from the pediatrician (physical complaints, adjustment to disease, school
problems). Mesibov et al. (1977) note there was a wide range in the severity of
problems discussed with a pediatric psychologist, with some problems less significant
than others. Approximately 60% of the clients seen in our practicum ranged from
6-20 years of age (school age), and the remaining 40%ranged from birth through 5
years of age. There were about equal numbers of femalesand males (43 and 51, re-
spectively). The slightly higher number of males reflects the more frequent referral
710 PROFESSIONAL PSYCHOLOGY Vol. 11, No. 5 October 1980

5. of negative behaviors or school problems. The females were slightly more represented
in the categories of physical complaints and adjustment to disease or handicap.
Types of Pediatric Psychology Interventions
The intervention approach taken varies, depending on the presenting problem. Be-
haviorally based techniques readily lend themselves to the often brief contact possible
or required, but the theoretical range of therapeutic intervention is large. Imple-
mentation is made of standardized procedures, where relevant literature is available.
For example, in the treatment of encopresis, Wright (1973,1975) may be relied on;
for enuresis, the procedures of Azrin and Foxx (1974) have been used. As necessary,
adaptation is made of other procedures, where direct application is not possible. For
example, the self-instructional statements of Meichenbaum and Goodman (1971) were
successfully used in assisting a hyperactive boy to complete his school assignments.
In other cases, procedures were implemented for minimizing "secondary gain" or
reinforcement from psychogenic pain. The use of earned time with parents is fre-
quently used and has been proved effective in increasing a number of desired behaviors.
In an interesting turnabout, one child earned time away from an overprotective mother.
Parent skills training is also frequently employed (Becker, 1971; Patterson & Gullion,
1971). Very often the pediatric psychology trainees find themselves developing new
procedures in attempts to assist patients. For example, the use of before and after
pictures of cleft-lip operations and interpretations of technical terminology with
supportive counseling assisted a teenage mother to adjust to her cleft-lip newborn. In
more extended cases or problems, therapeutic relationships are enhanced in play-
therapy settings. This occurs primarily for the supportive-based interventions for
the child's adjustment to such crises as divorce, death, or family problems. Home and
school visits are sometimes required, although kept to a minimum by the nature of the
referral from the pediatric practice.
The clinical assessment and intervention activities vary as a function of the referral
problem(s) of course, but they also vary as a function ofthe time the child and family
are available to the clinician. Many of the children either are in the hospital for only
a few days or live many miles from our community. Likewise, the children seen in
the outpatient service are frequently from another community and are available only
for brief or infrequent periods of time. Assessment and intervention activities are
frequently based on less than traditional or optimal data. This is a reality the clinician
must learn to live with when working in this area. The students must learn to utilize
techniques of crisis intervention, consultation with other professionals, and information
sharing and advice giving to parents, school personnel, and other professionals rather
than weekly visits or prescribed programs with close monitoring and follow-up.
Consistent with the scientists-professional model and Wright's (1967) initial for-
mulation, an attempt is maintained to integrate clinical activities and research on
problems in pediatric psychology. Single-case research on clinical problems is shown
in the description of the treatment of adolescent encopresis (Roberts & Ottinger, 1979)
and a behavioral approach to maintaining a program of painful but medicallynecessary
exercises in a teenage patient (La Greca & Ottinger, 1979). Current research by the
first author and the team members includes the study of the reaction of adults to the
cries and facial features of preterm infants and the relationship between locus of control
orientation and social skills in children.
Vol. 11, No. 5 October 1980 PROFESSIONALPSYCHOLOGY 711

6. PEDIATRIC PSYCHOLOGY PRACTICUM
Summary
The pediatric practicum is not intended to be an intensive training experience or a
substitute for an internship. Coming after 2 or 3 years of clinical child practica and
academic preparation, however, it does afford an opportunity for advancedstudents
to elect an additional practicum in an area in whichthey expectto function in the future
or wish to explore, short of a specialized internship. Students who have taken the
pediatric psychology practicum have gone on to take predoctoral internships offering
strong pediatric psychology experiences (University of Oklahoma Health Sciences
Center and University of North Carolina Memorial Hospital). After completion of
the program, two students are associated with university-basedclinicaltraining pro-
grams, two students are associated with pediatric medical settings, and other students
are still in the "system." Our experience to date indicates that the student can provide
a valuable serviceto children, parents, nurses, and physicianswhilelearning to function
in the emerging role ofa pediatric psychologist. The first author is preparing a cur-
riculum tailored to meet observed needs of pediatric psychologystudents. It is antic-
ipated that this curriculum will better prepare the clinician for the biological/medical
aspects of the field than does the traditional clinicalcurriculum. From our experience
with this program, we conclude that any academic training experience in pediatric
psychology should be conducted within the tradition of the Boulder model (Raimy,
1950). Pediatric psychology puts the clinician into many situations that call for re-
search-evaluation skills, and this emerging specialty has many problems to be solved
that will require the skills of a research-trained psychologist.
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Azrin, N. H., & Foxx, R. M. Toilet training in less than a day. New York: Simon & Schuster,
1974.
Becker, W. C. Parents are teachers. Champaign, 111.: Research Press, 1971.
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Friedheim, D. The role of the psychologist in the private pediatric practice. Journal of Pe-
diatrics, 1967, 71, 48-51.
La Greca, A. M., & Ottinger, D. R. Self-monitoring and relaxation training in the treatment
of medically ordered exercises in a 12-year-old female. Journal of Pediatric Psychology,
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Meichenbaum, D. H., & Goodman, J. Training impulsive children to talk tothemselves: A
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7. look. American Psychologist, 1972, 27, 587-589.
Routh, D. K. Postdoctoral training in pediatric psychology. Professional Psychology, 1977,
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Received April 16,1979
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