Introduction to the Special Issue: Time for Family-Based Interventions in Pediatric Psychology?

From its very inception, pediatric psychology has been committed to involving the whole family in the service of treating children. Yet, in many respects family-based interventions are still in their infancy. Recently, Kazak and colleagues presented a model of family systems practice in pediatric psychology (Kazak, Simms, & Rourke, 2002). They introduce their article with the statement “We write this article reflecting on the lack of established family intervention approaches in pediatric psychology” (p. 133). In the same issue of the Journal of Pediatric Psychology, Brown’s presidential address calls for greater attention to social ecologies and the reciprocal influence of children and families (Brown, 2002). Clearly, the need for family-based interventions in pediatric psychology has been endorsed. Why is it taking so long to heed the call from so many fine scholars? On the one hand, a marriage between family-based interventions and pediatric psychology makes sense. There are strong theoretical models suggesting that families affect children’s well-being and that children’s health affects family functioning (Fiese, 1997; Fiese & Wamboldt, 2001; Patterson & Garwick, 1994; Wood, Klebba, & Miller, 2000). There is a relatively large body of descriptive research linking family interaction styles, disease management practices, family belief systems, and communication patterns with children’s health and well-being (Kazak, Rourke, & Crump, 2003). Like most marriages, the relationship between family-based interventions and pediatric psychology is a work in progress and the best of intentions take time to materialize. The impetus for this special issue is to bring to the forefront a careful examination of not only strengths but also the obstacles in implementing family-based interventions. The articles in this collection draw our attention to five questions that must be addressed before the field can progress. Who do you engage? Families come in all shapes and sizes and given the changing nature of family structure, it is important to consider whom to involve in treatment. Phares addresses this point directly in her call for involving fathers in pediatric research. This call has been shouted throughout the developmental literature for over two decades (Parke, 1981). Before the researchers can truly have family-based interventions they must aggressively involve as many members of the family as possible. As the authors in this collection demonstrate this is not always an easy task. The next step is to consider where families can be found. How do you contact families? Family life is busy. For pediatric psychologists, families are not only dealing with the child who is at the source of the referral but they are likely juggling two (or more) work schedules, after school activities for several children, and navigating their way through the health care system. Taking advice from noted family therapist, Salvador Minuchin, it is important to begin relationships with families based on their current functioning, “as the therapist accommodates to join the family, the family must also accommodate to join him [sic]” (Minuchin, 1974, p. 124.). Many of the interventions described in this special issue have accommodated to the needs of the family. Kazak and colleagues contact families soon after the diagnosis is made and the child is still receiving medical treatment. Browne and Talmi provide parent–child interaction coaching while infants are still in the NICU. The authors of these articles note that not all families are receptive soon after diagnosis or during a successful hospitalization; however, contact at the hospital site provides access and connectivity with families. What do you do? Family-based interventions are just as multifaceted as the individuals they are designed to serve. Family functioning involves multiple domains such as problem solving, affect regulation, communication and interpersonal involvement. It is unlikely that a single therapy will incorporate all domains of family functioning, nor is that a reasonable goal. Families typically experience distress in one or two domains at a particular time. In some circumstances there is a need for education about a particular condition, in other instances focused problem solving is warranted, and in others support and knowledge that other families have faced similar challenges is indicated. In this regard, family-based intervention is not a singular type of intervention but embraces a host of strategies aimed at maintaining health and well-being in the system as a whole. When is it worth it? A potential barrier to implementing large-scale clinical trials of family-based interventions is concern about costs. Ellis and colleagues present a careful examination of the effects of multisystemic treatment on medical resource utilization. They conclude that MST has the potential to reduce direct care costs for adolescents with poorly controlled Type 1 diabetes. Medical resource utilization is but one way to estimate the economic effects of family-based interventions. Future research should include an assessment of effects on parents’ missing work, transportation costs, and economic burden on family life. Careful tracking of these economic indicators may provide a clearer picture of the potential overall benefits of family-based interventions. Where do we go from here? Several of the programs followed the CONSORT model in reporting who was eligible for treatment and who eventually completed the program. These are at times daunting (and disturbing) figures as they reflect the true challenge in engaging families in treatment. The obstacles noted by many of the researchers can be addressed in future studies and may increase participation rates. Providing transportation, childcare, and evening and weekend hours appear to be crucial in engaging families for intervention studies. Contacting families during a routine visit or soon after hospitalization may also increase participation by “putting a face” to a program. Details regarding the intervention programs also point to innovative ways to reach families, such as the use of videotapes in sharing information as presented by Kazak and colleagues. True to systems principles, several individuals have contributed to this special issue. In addition to the authors of the articles, many individuals provided careful and thoughtful reviews that are at the heart of the peer review process. Their names appear at the end of the issue. Two noted scholars have provided careful commentaries to the special issue and also warrant recognition. Carrie Rittle provided unwavering support in managing manuscripts and keeping records for the journal. I thank Ron Brown who initially proposed the idea for the special issue and provided support and encouragement throughout the editorial process. Finally, is the recognition of all the families who participated in this research and provide invaluable perspectives as we move the field forward to meet their complex and ever changing needs.