TY - JOUR
AU - R, Linscheid, Thomas
AB - Abstract What a surprise when Anne Kazak contacted me about writing an article for the Pioneers in Pediatric Psychology series. I never thought of myself as a pioneer. Those who have already written articles in this series are the true pioneers in the field. They were instrumental in defining the field, establishing the Society of Pediatric Psychology (SPP) and its journal, and making the discipline of pediatrics aware of our contribution to their mission. I believe that my colleagues and I built on the efforts of those early pioneers by establishing a model for pediatric psychology as an active and integral component of hospital-based pediatric practice, transforming the idea of psychology as a mental health service into a view of us as “doing pediatrics” through the use of psychological and behavioral principles I decided that I might contribute something to the understanding of the development of our field in two separate areas. First, I hope to share the on-the-job knowledge I acquired to build a large service, training and research psychology department that was fully integrated into the Department of Pediatrics at the Ohio State University. Navigating the medical and academic systems and the demands of the business component of a hospital was not part of any training I received, so I was unprepared for the demands of the task. Second, I can describe how to build a clinical service program (in my case, a program in feeding and eating disorders) in a collaborative manner with pediatric subspecialties. I have been retired for 12 years and offer the caveat that the things I will discuss in regard to program building may not be as relevant today as they were during my time. I have read most of the other articles in the Pioneers in Pediatric Psychology series and I am struck by how each of the authors talked about important individuals who helped shape their career opportunities. Without the support, encouragement and vision of many individuals I would not have been able to accomplish the things I did. It seems that many of us really did not know where we were going at first and were swept along by exciting new opportunities that the true pioneers opened up for us. I, too, will try to highlight those individuals and circumstances that shaped my career in a field that I did not know existed and for which I did not prepare. Education and Early Inspiration As my pathway into pediatric psychology education-wise was somewhat different than the norm, I will describe that pathway and how I think it was instrumental in my approach to the clinical applications of psychological principles. I entered undergraduate school in 1962 at Jamestown College, a small college in North Dakota, intent on being an engineer. After my freshman year, achievements in the preengineering courses left quite a bit to be desired; thus, I gravitated to a history major that I found interesting but worried how could this lead to a career. In my junior year, I took some psychology classes and became excited about the subject. I even enjoyed statistics. When I graduated in 1966, I had a major in history and enough hours for a major in psychology even though it was undeclared. Thanks to the Vietnam War, the draft, and the fact that I had no idea of what I might do for a career with a history major, I applied to graduate school in history and was accepted to the University of North Dakota. I soon realized that while the subject matter in history was interesting, I did not relish the idea of a career with no pragmatic applications. As I enjoyed my undergraduate psychology classes and had friends in the psychology department, I decided to transfer to the graduate program in psychology after the first semester. The idea of going to graduate school and then transferring to another department might be mind-blowing for today’s students, but, at the time, psychology was not as popular as it is today. I was accepted in the general experimental tract that emphasized training for a research career. This better fit my empirical and pragmatic orientation. Also, at the time, the field of clinical psychology, the other tract available in the psychology department, was psychoanalytically oriented and I had trouble with the nature of analytically oriented clinical conceptualizations. Human learning interested me as an area of study, and I was drawn to paradigms and theories of verbal learning. This was empirical, and hypotheses could be tested with observable outcomes. My dissertation was on the development of a mathematical model of paired-associate learning. In the last year of graduate school, the department hired a faculty member who was trained in Skinnerian-style operant conditioning, and I served as his teaching assistant. This introduced me to the world of Skinner boxes, schedules of reinforcement, and the beauty of the operant conditioning model for understanding behavior. The approach fit well with my pragmatism. It offered strict control of variables and yielded objective and observable outcomes. In those days, programming contingencies and antecedent events in the Skinner box was not done by computer but by circuitry using relays, timers, and counters and then wiring these by hand. Now I was getting closer to my core interests, an engineering-based approach applied to human and animal behavior. It was in graduate school that I met Robert J. Thompson Jr., who had a significant impact on my career. Bob was in the clinical track, but we took many of our courses together. In our second year, he suggested I take a course in cognitive assessment. There was reported to be an opportunity to do some intelligence testing for the state of North Dakota during the upcoming summer. While it was an unusual course for an experimental psychologist, I did so with the hope that I would be able to improve my finances with a great summer job. As it turned out, the testing job never came through, but the ability to do cognitive and behavioral assessments became a major part of what I was to do later. It was also about this time we began to hear the term “behavior modification.” For me, this was an exciting concept, as it carried the potential to use empirically derived psychological principles for the benefit of human beings. To some of my clinical colleagues, it meant mad scientists attempting to control the world. Behavior modification was intriguing to me, as it aligned with my empirical and pragmatic view of the world. This was my entrée into the world of applied psychology; it was scientific, observable, and exciting. Postdoctoral Training After graduating with my PhD in 1970, I took a teaching position at Bemidji State College in Minnesota. This was a total immersion in teaching, as I taught 13 different courses in 2 years. I loved the teaching and interaction with students, but I continued to be interested in the application of behavioral principles to change human behavior. I read what I could from scientific journals, but it was sparse, and the teaching load did not allow me time to explore research interests. I told Bob Thompson about my interest in pursuing an applied research career in behavior modification, and he suggested I apply to the postdoctoral program at the Institute for Psychiatric Research at the Indiana University Medical School. I applied to Joe Zimmerman, PhD, director of the psychology program at the Institute, and was accepted into that program. Joe proved to be a critical mentor and role model. He was a hard-core Skinnerian/behaviorist who had for years run an operant conditioning research laboratory using pigeons and rats. He too saw the possibilities of applying operant principles to benefit humans evidenced by his then recent work with his wife Elaine in classroom applications of behavioral techniques to improve learning and control behavior (Zimmerman, Zimmerman & Russell, 1969). He had also worked with Goodwill Industries helping to structure workshop training to produce more efficient and productive workers. Interesting, even though he had a strict Skinnerian approach, I think Joe was probably one of the first cognitive behaviorists. He shared with me his thought conversion from being an absolute stickler about observable scientific phenomenon to a realization of inner unobservable things (thoughts and feelings) that he thought were measurable. Several years earlier, he had crafted an abacus type wristband and had kept diligent count of the number of thoughts and feelings he had about different subjects. He would track these on a graph much as a cumulative recorder would document bar presses in a Skinner box. He believed that the rate of his inner thoughts and feelings could be modified by consequences (reinforcers and punishers) much the same way that external behaviors would respond to contingencies. On the first day of my fellowship, Joe loaded me up with the first 4 years of the Journal of Applied Behavior Analysis and told me to read and take notes on every article. This journal with its requirements for objectively defined behaviors, reliability assessment, observational behavior strategies, and the use of single-subject research designs to evaluate applied behavioral treatments fit beautifully with my orientation (Baer, Wolf, & Risley, 1968). Joe also had me read an article entitled “On being sane in insane places” (Rosenhan, 1973). The article described researchers who, despite having no history of psychiatric disorders, faked their way into inpatient psychiatric settings by describing hallucinations. Once admitted, the researchers were instructed to deny hallucinations and act as normal as possible. I found it enlightening that their “normal” behaviors inside the institution were deemed to be pathological by the hospital staff. For example, approaching the nurses’ station to ask when they could be talk to the attending psychiatrist was interpreted by the staff as an “obsession” with their physician. When they revealed that they had lied about hallucinations, this was labeled as denial and delusion. This study augmented my concern about psychiatric diagnoses in general because of the absence of contextual reference for many of the behaviors assumed to be pathological. In other words, the article suggested that once you were in an abnormal situation, normal behaviors are seen as abnormal. Once you are labeled a patient, then all behavior is pathological behavior regardless of the context or demands of the environment. From this viewpoint, Joe and I designed a treatment program for a teenage patient who had been admitted to a general psychiatric ward using discharge as the final consequence in her behavioral treatment program (Linscheid, Malosky & Zimmerman, 1974). The young woman had been admitted because of extreme weight loss following a traumatic event. She regained her weight but had developed behaviors the staff felt warranted her continued stay: attempts to escape, failure to complete her school assignments, and teasing of other, older patients. To us, these behaviors did not seem pathological given her age and the boredom of life on a psychiatric unit. We reasoned that if she knew the specific behaviors that would lead to her discharge, she would be motivated to exhibit these behaviors and thus should be discharged when she met certain behavioral criteria. We developed a program in which she earned points toward discharge by completing school assignments, and eliminating escape attempts and misbehavior on the unit. To implement this program, we essentially “forced” the attending psychiatrists to accept our definition of “good” or “normal” behavior and thus implicitly admit that the psychiatric unit environment itself encouraged behavioral problems. The lesson for me was that a therapist should always ascertain the environmental influences on behavior and define treatment success in observable and measurable behaviors. Thus, there is a target, and the therapy task becomes how to alter the environment to produce these behaviors, or as I came to call it “behavioral engineering.” This concept served me well later, as in pediatric psychology, we are often asked to assess behavioral issues with patients, and these must be assessed within the context of their illness and the medical settings they necessarily encounter during treatment. The Georgetown Years At the end of my fellowship, Bob Thompson again played a significant role in my career development. Bob had taken a position at the Georgetown University Child Development Center, working for Phyllis Magrab, PhD, and Phyllis and Bob constituted the Psychology Division of the Center, with Phyllis serving as Director. In the first year that Bob was there, Phyllis moved into the Training Director position for the Center and Bob assumed the role of Director of Psychology, leaving an open position in his department. He was interested in my ability to introduce behavior modification into the curriculum of the training program at the Center, as well as conducting intellectual and developmental assessments. I began my time at Georgetown in July, 1973. As many of the older members of the SPP probably know, but perhaps younger ones may not, University Affiliated Facility (UAF) programs were under the auspices of the Maternal and Child Health (MCH) division, Department of Health and Human Services. There were 20 programs around the country, for the most part all housed in or affiliated with departments of pediatrics in medical schools. The purpose of the programs was to improve and expand interdisciplinary training in Mental Retardation/Developmental Disabilities (MR/DD), as it was called at the time. What an incredible opportunity this was for me to learn to interact with 10 other disciplines, to participate in the training of nonpsychology and psychology graduate students, and to introduce a behavioral approach to faculty from the other disciplines. It also was an opportunity, because of the program’s affiliation with and housing in the same building as a Department of Pediatrics at Georgetown University, to interact with pediatricians on a regular basis. Without these opportunities at Georgetown, I doubt that my career interest in pediatric psychology would have evolved. After 2 years, Bob left to take a position at Duke University in medical psychology. I assumed the role of Director of the Division, my first experience in administration. Before Bob left, we collaborated on research involving the application of behavioral principles to treat feeding problems. I saw the behavioral treatment of feeding problems as the natural extension of the antecedent–behavior–consequence model for behavior change. For the antecedent aspect, the therapist controlled the setting in which the treatment was conducted (quiet, nondistracting environment) and the setting event or motivational state of the child at the time of treatment (hunger: time between treatment and last calorie intake). Feeding behaviors could easily be defined (e.g., bites accepted/bites presented) and outcomes defined by products (calories ingested, number of foods accepted). Consequences, such as differential social and tangible reinforcement, could be used to increase appropriate behaviors, and mild decelerating consequences such as ignoring and brief time-outs from positive reinforcement were easily controlled by the therapist. This was a model I could live with, and besides that, it worked incredibly well (cf. Linscheid et al., 1978; Linscheid & Valvano, 1987). I was also excited by the opportunity to introduce behavioral assessment and treatment strategies to graduate students from other disciplines. Working with my own graduate student and one from the speech and language pathology division, we were successful in teaching a young boy with autism to speak and use language to make his needs known, using a discrete trials behavioral approach using differential reinforcement and modeling. This direct and controlled approach was in stark contrast to the therapeutic approach to children with autism that was in vogue at the time, namely, gradually and slowly attempting to enter the child’s world by interacting in a nondirective manner. This behavioral intervention strategy, inspired by innovations in the treatment of children with autism by Ivar Lovaas at UCLA, was a dramatic departure from the current hands-off treatment approach. I will never forget the excitement in our staff and parents when we were successful in teaching this previously mute 3-year-old child to speak. We also introduced behavioral observation measurement strategies to our occupational therapy and physical therapy divisions to allow them to better assess progress during their therapeutic interventions (cf, DeGangi, Hurley, & Linscheid, 1983). Working for Phyllis Magrab allowed me to see firsthand some of the original organizational efforts in the field of pediatric psychology and the establishment of the Society Pediatric Psychology (Magrab, 2013; Roberts, 2015). Her success in working cooperatively with pediatricians within the Georgetown program blazed the trail for others within the child development program to work directly with pediatricians. Her competence helped convince pediatricians that they could benefit from using psychologists in their efforts to treat patients. As we slowly gained a reputation for being effective at modifying problem behaviors, pediatricians in the Department of Pediatrics outside of the Child Development Center began making referrals. What I learned about pediatricians through my efforts with them is that most are highly pragmatic. They have a specific job to do with their patients, and their success is judged by objective outcomes. In this regard, there was a natural affinity with my orientation toward outcome-oriented interventions. I think our successful treatments showed pediatricians we could help in their practical efforts to treat their patients and not just speculate on the patient’s psyche. As referrals grew, we successfully treated patients with feeding and eating disorders (Thompson, Palmer, & Linscheid, 1977), rumination syndrome (Cunningham & Linscheid, 1976), and nighttime sleep behavior disorders (Linscheid et al., 1981). Many of these treatments were conducted on the inpatient unit, further exposing our treatment success to all members of the Pediatrics Department. Treatment collaboration with pediatricians led to joint research projects (Abbassi, Linscheid, & Coleman, 1978) and to program development efforts such as the establishment of the EAT clinic (Eating Assessment and Treatment) staffed by a pediatrician, dietician, and psychologist. While I maintained my interest in the population of children with intellectual and developmental disabilities, I was increasingly drawn to interventions and collaborative research activities with pediatricians and working on the pediatric inpatient unit. Reductions in funding from MCH over my years at Georgetown meant that the Child Development program had to seek other sources of income, and these came in the form of service contracts with local agencies. Unfortunately, providing assessment and treatment consultation services in the community took me away from the excitement and satisfaction of treatment and research collaboration with hospital-based pediatricians. When I learned that the position of Director of Psychology at Children’s Hospital in Columbus, Ohio was open I applied. It was time to make a commitment to a career more oriented to pediatric psychology in a large children’s hospital affiliated with the Department of Pediatrics of a major medical school. The years at Georgetown convinced me that psychology could be a significant contributor to the successful practice of pediatrics, that pediatricians were open to collaboration in treatment and research, and that a strong psychology presence in a major pediatric facility could thrive and make major contributions to the welfare of children. The University Affiliated Programs were critically important in the development of pediatric psychology. These programs provided an entrée into the world of pediatrics through their affiliations with pediatric departments. UAFs produced many of the early leaders and contributors to the field. MCH supported periodic meetings for psychologists from the various UAFs. I was fortunate to serve as co-chair of the UAF psychologists group for several years and through this organization had the opportunity to meet many who became significant contributors to pediatric psychology: Donald Routh, PhD; Dennis Russo, PhD; Karen Budd, PhD; and Dennis Harper, Ph.D., to name only a few. The Children’s Hospital and Ohio State Years I moved from Georgetown to Children’s Hospital (now Nationwide Children’s Hospital) and the Ohio State University and started my tenure there on April 1, 1983, Grant Morrow, III, MD, Chair of the Department of Pediatrics and CEO of Children’s Hospital at the time I was hired, was not only a significant person in my career, but I believe his vision and guidance allowed for the development of a large service, training and research program at Children’s Hospital and also impacted the field of pediatric psychology in general. The development of the program was possible only because of his vision of an academic psychology division within the Department of Pediatrics. Administratively, I had a direct reporting line to him as Chair of Pediatrics allowing access on an equal basis with the other pediatric subspecialty areas. This structure insured that those of us in pediatric psychology were seen as an integral part of the Pediatrics Department and insured our peer-level status with pediatricians, helping to foster collaborative, teaching, research and service activities. I think Grant would be happy to know that his support of pediatric psychology served not just to insure the development of a large pediatric service, training and research department but that he contributed immensely to the development of pediatric psychology on a broader level through many graduate students, interns, and postdoctoral fellows who received clinical and research training through our program. There were two main components of Grant Morrow’s vision for pediatric psychology. The first was to make it an academic division and to that end, just before my arrival at OSU, he had moved the three current psychologists at Children’s Hospital onto academic tenure-line positions in the Department of Pediatrics, OSU. The second component was the establishment of a policy that all psychologists at the hospital would be administratively centralized in the Division of Psychology. This was in contrast to a common practice at other children’s hospitals in which a pediatric subspecialty division such as Hematology/Oncology would hire their own psychologist(s). The pluses of the latter model are that the subspecialty could determine the credentials for their position and define the job description as they saw fit (e.g., research only, clinical service only, or a combination). I strongly agreed with Grant’s idea of a single administrative division versus allowing various subspecialties to hire their own psychologists for the following reasons. First, the hiring of psychologists by other psychologists helped insure that a candidate’s credentials and training experiences were appropriate for the position. Second, having one administrative structure insured salary equity, we felt it was important not to have wealthier subspecialty areas pay better than “poorer” subspecialty areas potentially creating salary differentials for candidates who may have similar training and credentials. Finally, we reasoned that it would be easier to develop training programs (internship and postdoctoral levels) if psychologists shared similar interests in training and training activities were a recognized component of their jobs. Also, collaborative research seemed easier if psychologists did not have to serve different masters. This model certainly did not preclude hiring individuals with dedicated subspecialty interest areas, and as we grew, we worked with pediatric subspecialty areas to determine their needs and sought candidates with those interests. Pediatric faculty from the targeted subspecialty areas were included in the recruitment process as well. Once hired, these psychologists were free to pursue their clinical, training and research interests in the designated subspecialty. With this model firmly in place when I started my position, the potential for building a pediatric psychology program seemed in grasp. It turns out I had some lessons to learn to make this happen and, for the most part, these were administrative lessons. Prominently, I learned that academic positions in medical schools were funded differently than positions in other academic institutions. Most faculty positions in medical schools are funded by the faculty themselves through independent or group practice plans. Monies collected through direct clinical service or research grants and contracts are given to the university to hire those generating the money. In this model, pediatricians in university teaching and research positions, in effect, fund themselves. I had taught at a small state school, and funding for that position was budgeted through the college backed by state money. During my time at Georgetown, my position was funded entirely through a training grant. This was the first time that I had to insure financial accountability. While the pediatricians had a practice plan, I was responsible to Children’s Hospital for fiscal matters, as it was the hospital that funded our positions, paying part of our salaries to OSU so that we were also university employees. The hospital liked this arrangement, as having academic psychologists was in their interest for prestige and training purposes. So this was the dilemma, how do I build teaching and research opportunities for faculty while at the same time requiring them to do clinical service to support their positions? It was like serving two masters. The university was evaluating our department on teaching and research, and the hospital was evaluating us on our ability to generate funding. Nowhere in my training had I been schooled in preparing and monitoring operational and capital budgets, justifying requests for additional faculty or trainee positions, or attending monthly budget meetings where explanations for budget variances were expected. How to monitor each psychologist’s “productivity” (i.e., billing units) and relay this information to staff was a process I had to figure out. Since, at that time, psychologists were not typically trained in medical school settings, they were exposed primarily to professors teaching and doing research, not clinical service. Adjusting to the medical school model was difficult because now clinical service was added to their expected teaching and research activities. In that first year, I presented the case to administration that a 40-hr week did not allow sufficient time for teaching and research given the demands for clinical service. This argument was met with derision by both pediatric faculty and hospital administrators who simply said there is no such thing as a 40-hr week in a medical school. Indeed, it did not take long to note that most hospital-based pediatricians start their days at 7:00 a.m. or earlier, seldom leave before 6:00 p.m. and often have weekend duties (rounds, call, and research meetings). If our goal was to be seen as academic, service, and research peers, we would have to demonstrate our commitment in a similar manner. So what were the strategies for developing a clinical service presence and at the same time guarding time for training and research? My first thought was that we needed a noticeable presence on the pediatric units, and this would be accomplished by building an active consultation service. We were fortunate that, at the time, there were minimal psychiatry services available, allowing pediatric psychology to become the major player in consultation requests in the “mental health” area. Through consultation, we could show that pediatric psychology had much more to offer than just traditional mental health assessment. I remember stressing to my department members that pediatricians were looking for implementable recommendations as the reasons for consulting us, not clinical conceptualizations of the patient. Making practical and useful recommendations would put us in good stead if those recommendations lead to improved pediatric care. Strategies for pain management and reduction, medical regimen compliance, and addressing parental anxieties were just a few of the pragmatic contributions we could make and for which there was already a literature to support our recommendations. We had to make ourselves needed and to show our pediatric colleagues that we were “doing pediatrics” by using psychological and behavioral principles to improve pediatric outcomes. With increasing clinical service expectations, we needed a system to track productivity for faculty and later for interns and postdoctoral fellows. To that end, I designed a computerized data base for tracking billing hours and diagnoses for both inpatient and outpatient services. This system provided for timely feedback to faculty. Later, it proved to be an effective tool for introducing interns and fellows to the realities of the clinical demands of an academic medical setting. In addition, I felt we needed opportunities to interact with pediatric residents and medical students. Our faculty began to attend pediatric clinics for the purpose of modeling strategies for identifying behavioral and developmental issues in an outpatient setting and providing effective behavioral recommendations for common behavior problems (Mortweet & Christopherson, 2003; Schroeder, Goolsby, & Stangler, 1975). Also we agreed to be on 24-hr call to our emergency room, another effort to become fully integrated into pediatrics. Both activities meant more work for our faculty but were deemed essential to truly establishing us as a team player in pediatrics. The strategies proved wildly successful, as we went from being consulted only a few per week to receiving 15–20 per week after just a few years. To manage this increased service load, we began adding clinical positions (pediatric psychologists who were not in tenure-line positions therefore had little expectations for research) and proposed internship and postdoctoral positions as a way of managing the increased demands for inpatient service. Keith Kaufman, PhD, managed the application process in 1985 and served as our first APA-accredited Internship Director. James Mulick, PhD, developed the first postdoctoral position and that, along with the internship program, helped convince the hospital administration that having a training program allowed us to do more clinical service and was financially viable. The success of our inpatient consultation program for providing pediatric training was attested to by a survey of pediatric psychology internships (Mackner et al., 2003) that suggested our interns had significantly more inpatient consultation and treatment hours than other internship programs. A second strategy to fully ingrain ourselves into pediatrics was to increase collaborative research with pediatric faculty. In this realm, Kenneth Tarnowski, PhD, led the way in initiating a research program on our burn unit (Tarnowski et al., 1989), Tim Wysocki, PhD, began his line of research working with endocrinology on medical regimen compliance in patients with diabetes (Wysocki et al., 1989), Jim Mulick and I continued our contributions in the area of intellectual and developmental disabilities (Linscheid et al., 1990, Schreck & Mulick, 2000), and Keith Yeates, PhD, developed a collaborative research program in pediatric traumatic brain injury (cf, Yeates et al., 1995). I do not mean to ignore the research contribution of other faculty, but I mention the above names, as they were instrumental in our first efforts to establish a research presence in Pediatrics. We gained access to psychology graduate students through a graduate seminar in pediatric psychology that I taught every 2 years in the Clinical Child Psychology program in OSU’s Psychology Department (where I held a joint appointment). I taught several of the seminar sessions but also invited other faculty to give lectures in their clinical and research areas. Graduate students looking for research opportunities were linked with our faculty, in several cases leading to doctoral dissertations. I believe that the success of building a major pediatric psychology service, training and research program within a children’s hospital was the result of two major frames of reference. These were the vision of the then Chair of Pediatrics, Grant Morrow, and my own vision supported by our early faculty that pediatric psychology could be an integral part of pediatrics by “doing pediatrics” not mental health. Our shared mission was to grow the field by showing the pragmatic benefits of applying psychological and behavioral principles to pediatric issues. One measure of this success was the growth of pediatric psychology from 4 to 12 faculty positions and the creation of three intern and eight postdoctoral positions by the time I retired in 2006. Building a Collaborative Clinical Service Program My greatest satisfaction, though, was in the pediatric feeding program that was established in collaboration with the Gastroenterology division. This was never a formal program in the sense of a separate budget or administrative structure but rather a joint clinical service effort between psychology and gastroenterology. Early on, I tried to work collaboratively with faculty from gastroenterology because of my interest in feeding disorders. Gastroenterology treated many patients with gastroesophageal reflux disease (GERD). This disorder often resulted in infants and children losing interest in eating because of the discomfort following meals caused by acid reflux. One common surgical treatment for GERD following the failure of nonsurgical efforts is called Nissan fundoplication in which the sphincter at the top of the stomach is surgically strengthened so that stomach contents will not reenter the esophagus. During the procedure, a gastrostomy tube (G-tube) is usually placed so that the patient can be fed while the surgical site heals. Children often are reluctant to begin oral feeding after the surgery has healed because of a conditioned aversion to food and a lack of hunger, as their nutrient needs are meet via the G-tube. We had great success in getting children to resume oral feeding using behavioral strategies that I have outlined elsewhere (Linscheid, 2006). These treatments were usually conducted on an inpatient unit so that the gastroenterologists could monitor the child’s medical and nutritional status and our behavioral interventions could be conducted three times a day, 7 days a week. The success of these collaborative treatments led to referrals for other feeding problems and from other subspecialty areas in pediatrics. I remember one of the gastroenterologists telling me that their division had made my last name into a verb; in their case discussions, it was not uncommon to have someone suggest it was time to “linscheid” this patient. The entire gastroenterology department was supportive of our collaborative efforts, as they could see their patients returning to normal eating and they relished the training opportunities for their medical students and residents. I have to thank H. Juling McClung, MD, who was the head of Gastroenterology when I began at Children’s and Carlo DiLorenzo, MD, who headed the division in my later years at Children’s, for their strong support of the feeding program. We originally treated these children on the gastroenterology unit but later moved to the rehabilitation unit because the daily census there allowed access to private rooms making it easier to conduct our treatments without disturbing other patients and families. This meant that the GI doctor and their students and residents rotating on the GI service had to “travel” off their home unit to monitor our patient’s status. I never heard a complaint about this inconvenience which I believe was a measure of how committed they were to supporting the program. I was pleased when they asked me to provide monthly lectures on feeding and eating disorders to their residents and rotating medical students. Later, as our success became known nationally, we received many referrals from all over the United States. Even though these were not patients of the GI physicians, they readily agreed to admit them to their service and provide medical monitoring while at Children’s. As these out-of-state referrals increased, patients often did not have a gastroenterological condition (e.g., autism spectrum, prematurity, and extreme picky eating), but I could count on GI to be willing to admit and follow them medically. I felt good that having patients admitted to a pediatric unit specifically for treatment by psychology was a significant step for pediatric psychology and an indication that we were indeed, “doing pediatrics.” Collaboration clinically with GI also provided benefits for both pediatric psychology research and GI studies. One such study investigated the effectiveness of using developmental language concepts to improve the effectiveness of information when preparing patients for a medical procedure (Rasnake & Linscheid, 1989). GI allowed us to conduct this study with their patients undergoing proctoscopy. Behavioral observation methods a la Katz, Kellerman, and Siegel (1980) were used to assess the child’s level of distress during the procedure. Later, we collaborated with GI physicians by using these behavior observation methods in their studies of the relative effectiveness of various drug combinations used in conscious sedation during GI procedures (cf, Bahal-O'Mara et al., 1993) This model of cooperative clinical service, teaching and research was not restricted to GI but was accomplished by other pediatric psychologists and led to the strong support for psychology within the Department of Pediatrics. Psychology’s involvement with cancer patients expanded to the point that the Hematology/Oncology Division made it a policy to consult psychology on all newly diagnosed patients. This established that pediatric psychology involvement was part of the standard of care and should begin at the time of diagnosis. Other examples where psychology became fully integrated into patient care included the sleep clinic, sickle cell clinic, and bariatric surgery program, to name a few. It all starts by showing that psychology can provide pragmatic benefits to pediatric patients, so my advice for any pediatric psychologist seeking collaboration with a subspecialty area is to make yourself needed clinically first and research and teaching will follow. I would be remiss if I did not mention the importance of networking with other pediatric psychologists from different settings. Sharing experiences, problems, and solutions with colleagues from academic settings and other hospitals was invaluable to me. This was frequently done at conferences, starting with the original “Florida Child Health Psychology” conferences, regional conferences, and later by SPP’s National Conferences. Regional conferences were especially important, as they brought together faculty, graduate students, interns, and fellows in a less formal setting leading to the establishment of consultative and collaborative activities. Thanks to Dennis Drotar, PhD; Sue White, PhD; and Terry Stancin, PhD, for sponsoring the first North Coast Regional Conference in Cleveland, Ohio, in 1986. These meetings were held biannually and rotated among the various pediatric psychology programs in the region. Through these conferences we shared research, administrative, and practical knowledge about the operation of programs. Ohio had seven children’s hospitals at the time, so there were many faculty and students taking part in these informal and informative meetings. The importance of networking with others in similar positions to mine cannot be overstressed. Children’s Hospital hosted two of these regional meetings before I retired, and the second one was held jointly with the Society for Developmental and Behavioral Pediatrics, another reflection of how the field was moving to true integration with pediatrics. Final Thoughts I have tried to outline some of the issues encountered in moving pediatric psychology into a fully integrated component of pediatric practice. Early researchers in the field gave us tools to use. Those with organizational skills gave us the SPP and the Journal of Pediatric Psychology, and, those of us who built large hospital-based pediatric psychology departments all helped to shape what is now an established and respected field. Looking back at the emergence of pediatric psychology, it is clear that there were many and varied routes to making the field what is today. The training backgrounds of many of the early leaders in the field were not restricted to traditional clinical training models. Influences from developmental and experimental/behavioral psychology were prominent in our history, and the impact of the UAF programs with their pediatric affiliations significantly affected our exposure to pediatricians. I hope the field continues to be open to other approaches and does not become too “regimented,” that is, you cannot be a pediatric psychologist unless you have satisfied x, y, and z requirements. As stated earlier, I was not prepared for the administrative tasks I had to learn on the fly while building my department. Should we not be preparing our trainees, especially those at the postdoctoral level for more of the structural realities of a career in a medical setting? I have been out-of-touch with the field because of retirement, so perhaps progress has been made in this direction, if not, there would seem to be a need to do so. 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TI - Pioneer Paper: Pioneers in Pediatric Psychology: “Doing Pediatrics”
JO - Journal of Pediatric Psychology
DO - 10.1093/jpepsy/jsy052
DA - 2018-10-01
UR - https://www.deepdyve.com/lp/oxford-university-press/pioneer-paper-pioneers-in-pediatric-psychology-doing-pediatrics-rF3eEMajfc
SP - 958
VL - 43
IS - 9
DP - DeepDyve
ER -