Pediatric topics in the school psychology literature: publications since 1981

Journal of School Psychology 41 (2003) 131 – 141

Pediatric topics in the school psychology literature: publications since 1981 David L. Wodrich a,*, Ara J. Schmitt b a

Psychology in Education, Arizona State University, P.O. Box 870611, Tempe, AZ 85287 - 0611, USA b Department of Psychology, Phoenix Children’s Hospital, Phoenix, AZ, USA

Received 24 April 2002; received in revised form 25 November 2002; accepted 25 November 2002

Abstract Pediatric topics have potential importance to school psychology given the field’s new, broadly conceived definition, reconceptualization of schools as health delivery sites, burgeoning pediatric knowledge with educational implications, and expansion of pediatricians’ roles into behavioral realms. This article addresses the rate at which pediatric-related articles were published among school psychology journals (Journal of School Psychology, Psychology in the Schools, School Psychology International, School Psychology Review, and School Psychology Quarterly) from 1981 to 2001. The overall number of such articles increased from 11 during the 1981 – 1983 interval to more than twice as many during every subsequent 3-year interval. Articles, some reporting empirical findings and others offering reviews or practice suggestions, concerning traditional health conditions and attention deficit hyperactivity disorder (ADHD) appeared to be ample. Fewer articles concerned with school psychologists as health care providers and school psychologist – pediatrician collaboration were found. The available literature seems to support school psychologists’ widening role definition. D 2003 Society for the Study of School Psychology. Published by Elsevier Science Ltd. All rights reserved. Keywords: School psychology; Pediatrics; Health concerns; ADHD

The knowledge and skills most crucial to school psychology practice have been vigorously debated on since at least midcentury (Cutts, 1955). Suggested as most important have been skills related to mental health consultation (Caplan, 1970), con-

* Corresponding author. Tel.: +1-480-965-7117; fax: +1-480-965-0300. E-mail address: [email protected] (D.L. Wodrich). 0022-4405/03/$ - see front matter D 2003 Society for the Study of School Psychology. Published by Elsevier Science Ltd. All rights reserved. doi:10.1016/S0022-4405(03)00030-X

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sultation to various levels of school systems (Meyers, 1995), behavioral consultation (Bergan & Kratochwill, 1990), psychometric assessment and special education gatekeeping (Sattler, 2001), crisis management (Poland, 1994), and health promotion (Zins, Coyne, & Ponti, 1988). In part to facilitate consensual role delineation, a boldly conceived definition of school psychology was recently reached by a working group and formally endorsed by the American Psychological Association (1998) Council of Representatives, making it the archival definition of school psychology. This resultant archival definition of school psychology explicitly embraces knowledge and skills traditionally viewed as within the purview of pediatrics. Specifically, the definition suggests that populations of interest to school psychologists are ‘‘those that experience chronic or acute conditions of childhood and adolescence that influence learning and mental health’’ (p. 108). Additionally, ‘‘consultation with physicians and other professionals concerning the school functioning and learning of children with disorders such as attention deficit hyperactivity disorder (ADHD), learning disorders, chronic illnesses, physical or genetic conditions, and substance abuse’’ (p. 109) is purported to be within the practice of school psychologists. For example, there is enumeration of specific biomedical disorders (e.g., eating disorders, headaches, recurrent abdominal pain, and traumatic brain injury) and behavioral conditions commonly treated by pediatricians with psychotropic medication (e.g., ADHD) and suggestions that school psychologists evolve illness prevention and disease deterrence programs. Further reflecting role expansion, pediatric settings like children’s hospitals, health departments, and pediatric outpatient offices are endorsed by this definition as legitimate venues for school psychology practice. It can be argued that societal and school changes compel school psychology –pediatrics cooperation. Pediatricians’ roles have evolved to include intensive involvement in diagnosis and treatment of behavioral or developmental conditions with direct school implications (Ferris et al., 1998). ADHD, a disorder diagnosed in 3 – 5% of school-age children in the United States (American Psychiatric Association, 1994), is the prime example. Medication is used for 90% of these children to improve school conduct, academic learning, or both (Safer, Zito, & Fine, 1996). Medical providers and schoolbased personnel must work together if medication is to be properly prescribed and its dosage adjusted to improve behavior and performance while minimizing side effects (American Academy of Child and Adolescent Psychiatry, 1997; Shea, Rahmani, & Morris, 1996). Technological and medical breakthroughs, such as advanced neuroimaging techniques and microscopic analysis and cataloging of genetic material (Filipek et al., 1997; Patenaude, Guttmacher, & Collins, 2002), further draw school practitioners toward biomedical information. Syndromes once thought to be rare (e.g., fetal alcohol syndrome, Tourette syndrome, and inborn errors of metabolism) are now acknowledged as common; recognizing them and understanding their educational implications are important for the practicing school psychologist (Batshaw, 2002; Comings, Himes, & Comings, 1990; Jones, 1996). Public health policy during the past 20 years has increasingly conceded the role of lifestyle in childhood morbidity and mortality (U.S. Preventive Services Task Force, 1989). Accordingly, prevention programs have been advocated for a wide array of conditions exemplified by head injury, HIV/AIDS, and eating disorders (Zins & Wagner, 1997). School settings are ideal sites for these programs (Short & Talley, 1997; Wodrich,

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Swerdlik, Chenneville, & Landau, 1999), and school psychologists can, and often do, participate in the construction, implementation, and evaluation of such programs. As access to health care has diminished for some children, schools’ roles have expanded to fill the vacuum (Hawkins & Catalano, 1990). School-based health clinics, unknown 20 years ago, now exist in many states. They have been endorsed by federal education mandates (e.g., U.S. Department of Health and Human Services, 1995) and by health providers (American Medical Association, 1990; U.S. Surgeon General, 1994) as a means of providing services in settings comfortable for families by wrapping services around children’s needs, rather than requiring families to accommodate to existing agencies’ locations and structures. School psychology seems to have embraced the need to increase pediatric competencies among its practitioners. For example, some programs offer pediatric content as a central aspect of their school psychology training (Power, DuPaul, Shapiro, & Parish, 1995). Notwithstanding the existence of well-conceived school psychology programs, there exists little documentation of an adequate knowledge base for accomplishing such pediatric school psychology training. Seeking empirical information about the field’s readiness to prepare school psychologists with pediatric competencies, we have conducted several surveys. Each survey explored a different aspect of the link between pediatric knowledge and the means necessary for school psychologists to acquire this knowledge and apply it in their practice (e.g., Brager & Wodrich, 1998; Chesire & Wodrich, 1999). Although interesting, these studies are necessarily constrained by dependence on involved professionals’ subjective ratings. The professional school psychology literature provides an alternative source of information regarding the knowledge readily available to school psychologists in practice and in training. The publication pattern among a field’s peer-reviewed journals can serve as an indicator of those subjects deemed important, in this case pediatric topics. The distribution of peer-reviewed articles over time may suggest topics of prime interest to a field over time and indicate the scientific and practical knowledge base available to members of a profession. For example, review of publication patterns has previously been used to ascertain the content of articles in pediatric psychology (LaGreca & Varni, 1993) and the prevalence of various psychological constructs in learning disability research (Morris, 1996). This type of information can suggest whether readers of the most immediately available school psychology literature possess sufficient exposure to pediatric disorders, pediatricians’ practice, and school psychologist –pediatrician collaboration to fulfill the role expansion proposed in the American Psychological Association’s definition of school psychology. Review of publication patterns further addresses whether top –down changes in school psychology practice suggested by leaders actually match broader trends in the field. School psychology historians suggest that the literature has become increasingly diverse (Fagan, 1995), but there are yet no reports of the extent to which this literature comprises more pediatricrelated articles. Specifically, this article investigates whether the total number of publications on pediatric topics appearing in five school psychology journals has matched the field’s changing definition. Also addressed is a finer-grain analysis of how those pediatric school psychology articles published are distributed among several topic areas.

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Methods Definition of Pediatric School Psychology Disorders For the present article, a definition of ‘‘pediatric’’ was adopted so that each school psychology article could be assigned ‘‘pediatric’’ or ‘‘nonpediatric’’ status. As this is a study of the school psychology literature, a definition of pediatric related to the practice of school psychology was implemented. Articles addressing any of three categories were counted as having pediatric status. Pediatric Conditions This category comprises articles dealing with distinct childhood diseases (e.g., diabetes mellitus and asthma) whose disease course itself or whose common treatment (viz., iatrogenic effects) may affect school functioning. Besides specific disorders with a known etiology and disease course, any class of physical disability (e.g., hearing impairment, low vision, and orthopedic impairment) that might commonly be treated by physicians was included. To further assure that all relevant pediatric articles were included, topics (e.g., substance abuse) or situations (e.g., death/dying and grieving) that might either be reported in the pediatric literature or might reasonably cause school/pediatric health care provider contact were included in this category. A complete list of diseases and conditions included comprising this category is presented in Table 1. ADHD After considering the first category’s emphasis on purely health-related issues and in recognition that a substantial number of articles addressed ADHD, we elected to create a separate category for ADHD. Although ADHD is arguably a behavioral phenomenon rather than a disease, physicians assign the diagnosis and implement pharmacotherapy for its treatment in the vast majority of cases (American Academy of Pediatrics, 2001). Moreover, unlike other ‘‘psychiatric disorders,’’ primary care pediatricians, not psychiatrists, are the physicians apt to be involved (American Academy of Pediatrics, 2001). Role Issues This category comprises articles concerned with school psychologist – pediatrician collaboration, development of pediatric competence among school psychologists, or the field of pediatric school psychology. These articles were generally conceptual in nature and concerned with broad issues of scope of practice and school psychologists’ roles; they did not address specific illness or condition-related topics as did those articles in Pediatric Conditions and ADHD categories. Some conditions considered pediatric in earlier school psychology writing (Power et al., 1995) were not considered pediatric here. These included disorders related to school failure (e.g., learning disabilities, mild mental retardation), those defined primarily by violation of cultural norms or laws (e.g., incest, child neglect, and abuse), or those with suspected but not as yet documented pathophysiologies and not requiring disorder-specific pediatric care (e.g., autism). Similarly, most DSM-IV (American Psychiatric Association, 1994) disorders were not included as we deemed these to be as much, or more psychological as medical or

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Table 1 Pediatric Topics Comprising Three Categories and Their 21-Year Publication Totals Empirical

Review

Pediatric conditions Abdominal pain Anorexia/eating disorders Asthma Blindness/low vision Cancer, leukemia and tumors Cough (psychogenic) Cerebral palsy and orthopedic impairments Deafness/hearing impairments Death/grieving Diabetes/endocrine disorders Encopresis/enuresis Epilepsy/seizures Failure to thrive Fetal alcohol syndrome Fragile X syndrome HIV/AIDS Headache Injury prevention Obstetrical and perinatal risk factors Neurological impairment as cause of LD Psychopharmacology (other than ADHD-specific) Sickle cell disease Substance abuse Teen pregnancy Traumatic (and other) brain injuries Tourette syndrome/tics

0 6 1 3 1 1 1 11 3 1 1 3 0 0 0 6 0 0 4 0 0 0 5 0 4 2

1 5 2 2 3 0 1 7 2 3 0 3 2 3 1 5 1 1 2 4 4 1 9 1 1 1

ADHD

54

28

0 0 1 0 0

9 1 3 5 1

Role issues Collaboration with physicians/school reentry Pediatric school psychology subspecialty Prescription authority/medication-related roles School psychologists as health care providers Working with developmental pediatricians

pediatric. The exceptions among DSM-IV conditions were those that have historically been viewed as neurological rather than psychiatric (e.g., Tourette syndrome) and those with physical manifestations often requiring medical treatment (e.g., anorexia nervosa). School Psychology Journals Reviewed We sought to select peer-reviewed journals identified with the field of school psychology and most routinely read by United States practitioners. We included four journals with school psychology in their titles: the Journal of School Psychology (JSP), affiliated with the Society for the Study of School Psychology; School Psychology International (SPI); School

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Psychology Quarterly (SPQ), affiliated with American Psychological Association Division 16; and School Psychology Review (SPR), affiliated with the National Association of School Psychologists. Also, Psychology in the Schools (PITS) was included because its editorial policy agrees with the other four journals regarding publishing empirical, conceptual, and school psychology practice-related articles. Procedure for Categorizing Articles Each article in JSP, PITS, SPI, and SPR was reviewed from the first volume of 1981 to the final volume of 2001. As SPQ, which was preceded by Professional School Psychology (PSP), did not commence publication until 1986, we reviewed its articles from 1986 to the end of 2001 and then supplemented them by reviewing PSP from 1984 to 1986. We reviewed all articles for each journal by year, defining articles only as those with abstracts and reference sections. Letters to the editor, brief reports and case reports without references, and test or book reviews were excluded from this review. All articles were assigned to either ‘‘pediatric’’ or ‘‘nonpediatric’’ categories by one of the authors (A.S.). These data were used to plot the frequency of pediatric topics over the 21-year period under review. Articles were also analyzed to determine if they: (a) reported original findings based on empirical, quantitative data of any type (i.e., were considered ‘‘empirical’’), or (b) consisted of literature reviews, conceptual or theoretical expositions, or explanations of proposed methods of practice that contained no quantitative data (i.e., were considered ‘‘review’’). Single subject and case reports were counted in the empirical category, as were meta-analyses. The distribution of articles in empirical and review classifications is presented in Table 1. Interrater Reliability of Article Categorization Subsequent to initial categorization of all articles, 50 articles were drawn randomly from the group that the first rater had categorized as pediatric, and the same was done with 50 articles appearing in the five journals but assigned nonpediatric status. These 100 articles were rated for pediatric/nonpediatric status blindly by one of us (D.W.). An agreement coefficient was calculated, showing 100% concurrence between the two raters regarding pediatric status. A similar procedure was executed regarding empirical versus review status. Twenty-five pediatric articles deemed empirical and 25 deemed review by one rater (D.W.) were subsequently rated by a second rater (A.S.). There was 98% agreement between the two raters. Finally, 50 articles considered as pediatric-related by both raters were subsequently rated independently by each of us for categorical (i.e., Pediatric Conditions, ADHD, Role Issues) status. There was 96% of agreement regarding categorical assignments.

Results Regarding the first research question, 220 pediatric-related articles were identified in the school psychology literature over the 21-year period reviewed. Relatively few such articles were published for the first 3 years of this search, but the numbers grew thereafter.

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Fig. 1 depicts the values for each 3-year interval with articles distributed into empirical and review categories. The total number of pediatric school psychology articles published was 11, 26, 24, 34, 55, 24, and 46 for the consecutive intervals from 1981– 1983 to 1998 – 2001. The 3-year sums are most easily seen graphically in Fig. 1 by attending to the combined area of the two columns, empirical and review, and recognizing that their collective areas depict the total pediatric articles published during each interval (e.g., 1981 –1983). Although not illustrated graphically, all five journals reviewed contributed to the available pediatric-focused school psychology literature. We found the following 21year totals by journal—JSP 31, PITS 61, SPI 36, SPR 65, and SPQ 27—although journalto-journal comparisons were not considered in light of vastly different total publication outputs and changing publication capacities over time. The second research question concerns the nature of articles published. Besides providing overall sums, Fig. 1 indicates empirical and review article totals and categorical divisions. The Pediatric Conditions category was the source of fairly numerous empirical articles over the length of the review (5, 10, 3, 8, 9, 5, and 12 during the 3-year intervals beginning in 1981– 1983). Also noteworthy was the variety of pediatric areas addressed, as listed in Table 1. The ADHD category also comprised a fair number of empirical publications, totaling 3, 5, 4, 6, 11, 9, and 16 for the consecutive 3-year blocks considered. Only one Roles Issues empirical article was found (school psychologists’ attitudes toward

Fig. 1. Three-year totals for empirical (E) and review (R) articles comprising various pediatric categories.

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prescription privileges; Kubiszyn & Carlson, 1995). This small number was expected in light of the category’s conceptual, rather than investigational, basis. It also appears that considerable review or nonempirical articles appeared in the school psychology journals, in numbers roughly equal to empirical publications. Review articles concerning traditional health-related subjects (the Pediatric Conditions category) were published at rates of 3, 9, 14, 6, 16, 4, and 14 during sequential 3-year periods. Some of these totals were influenced by special miniseries published on health topics (i.e., SPR and SPQ in 1995), but not all 3-year totals were impacted by miniseries. The moderately high value of 14 articles for 1987– 1989, for example, arose independent of any special topics editorial decisions. Like the Pediatric Conditions category, the ADHD category included review articles, although the numbers appear more modest and less consistent: 0, 0, 2, 13, 7, 5, and 1 over the succession of 3-year intervals. One ADHD 3-year article total, 1988– 1991, was also influenced by a miniseries (i.e., published in SPR during 1991). Nonempirical (review) articles published in the Role Issues category appeared to be few with the exception of a single 3-year interval (3-year consecutive totals were 0, 2, 1, 1, 11, 1, and 3). The large total for 1993– 1995 emanated primarily from the publication of topics related to school psychology practice boundaries and scope (e.g., school psychologists as health services providers) as part of two SPQ miniseries in 1995.

Discussion Regarding this study’s first purpose (determining the availability of pediatric-focused articles in school psychologists’ most readily available literature), support appears to be present. From the middle 1980s onward, substantial levels of articles related to pediatrics have come out. In fact, the appearance of 26, 24, 34, 55, and 24 articles during each 3-year blocks immediately before 1998 may have presaged, as well as supported, the healthrelated practice expansion that was ultimately codified in the school psychology definition adopted formally in 1998. It would seem that the field could interpret the signal from its available literature, when viewed in its entirety, as a green light for continued movement in the pediatric direction. Concerning this study’s second purpose (investigating the distribution of pediatricrelated articles), both of the main content areas of traditional pediatric illness and the specific condition of ADHD received considerable publications. Reports on physical illness and pediatric conditions seem eminently relevant for school psychology’s potential role expansion into nontraditional venues, such as clinics and hospitals. For those rankand-file psychologists who remain school-based, this information may also help in the performance of ‘‘health service provider’’ roles, as occasions warrant. The breath of the pool of articles, with 26 separate topics and disorders addressed, was unexpected. Nonetheless, no articles were detected for relatively common conditions with profound school implications, such as neurofibromatosis type 1, Klinefelter syndrome, and Turner syndrome, as examples. The school psychology literature remains incomplete. Proponents of school psychology practice informed by an empirical research base may be impressed, and perhaps surprised, by the wealth of empirical illness-related articles published. Our investigation suggests that the literature focusing on diseases and health

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issues now available to support school psychology’s new definition is both many-sided and frequently empirical. An equivalent research emphasis was also found regarding ADHD. Of the over 80 articles published on ADHD, nearly twice as many were empirical as review in nature over the 21-year time frame. As might be expected, behavior management and classroom interventions were often reported. It was also found that controlled medication trials employing classroom-based dependent variables were reported in the school psychology literature (Northup, Gulley, Edwards, & Fountain, 2001; Wodrich & Kush, 1998). The complexity of interdisciplinary consultation and collaboration with pediatricians has only lately been much addressed in the literature. While role-related articles published in the 1990s may have helped to pace school psychologists’ altered definition and its practice expansion, the fact is that there were relatively few articles of this type overall (a total of 20 over 21 years). Whereas topics such as prescription authority for psychologists and establishment of a pediatric school psychology subspecialty are addressed, subtle, but potentially important, issues related to scope and method of practice vis-a`-vis pediatricians’ roles are unaddressed. For example, little seems to appear either in the school psychology or the pediatric literature regarding pediatricians’ perceptions of school psychologists’ knowledge and expertise, and physicians’ willingness to share responsibilities for children’s care with school-based practitioners (HaileMariam, Bradley-Johnson, & Johnson, 2002; Wodrich & Landau, 1999). This study contains several limitations. First, the method used for counting may have overstated the prevalence of pediatric articles given the decision of terming ADHD as a pediatric topic. Many of the 82 ADHD publications used ‘‘ADHD’’ as an inclusion criterion or a basis for identifying a clinical population, but otherwise involved nothing inherently pediatric in their content or procedures. Second, we used an elementary definition for empirical articles. Some publications that involved simple surveys or generated only rudimentary data—several without inferential statistics—received empirical designation. As a result, a number of these articles provide only minimal means for drawing data-based conclusions; some afford little or no foundation for determining how best to practice. Third, this study may have been limited by the decision to survey only school psychology journals. School psychologists may, and certainly can, read the psychiatry, neurology, genetics, or pediatrics articles as well as the substantial relevant literature in pediatric psychology. Fourth, no judgment was made about either the quality of articles or the extent to which they may actually help front-line school psychologists. Even well-prepared articles that report empirical findings may fail to speak directly and authoritatively to classroom-based, illness-associated concerns. As school psychologists consider expanded health services roles and greater focus on pediatric topics, further empirical investigation seems warranted. It is yet unknown how many students school psychologists actually encounter cases for evaluation or consultation that bear health-related diagnoses. A series of epidemological school psychology practice studies may reveal the prevalence of students with pediatric conditions. Also largely unknown is the degree to which students with pediatric illnesses suffer associated educational impact, either directly (i.e., via changes in physiological functioning) or indirectly (i.e., via school absenteeism, peer relationship changes, and illness-related psychological stress). Expanded school psychology research (e.g., studies that address

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variables such as academic skill acquisition, school satisfaction, and dropout rates) involving chronic illness in general and those illnesses in particular that are most apt to jeopardize school functioning would appear to be fitting. The field of school psychology may require additional empirical information before it can completely anticipate and then ameliorate the educational effects of pediatric conditions.

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