Pediatric Uropsychology: A Growing and Diverse Subspecialty of Pediatric Psychology

Uropsychology is an emerging subspecialty of psychology that focuses on evaluation and intervention of patients with various urological needs (Hayes, et al. 2024). Within the field of pediatric psychology, uropsychologists have expertise in applying psychological theory and practice to pediatric urological health conditions. They play an integral role on interprofessional pediatric teams by helping to identify and treat co-occurring behavioral health conditions that impact patient care. The clinical responsibilities and structure of the positions of these few (but growing number of) uropsychologists varies between institutions. For example, some are general pediatric psychologists embedded in outpatient pediatric behavioral health clinics and become identified by urology colleagues as a referral source, whereas others are hired with full or part-time dedication to a pediatric urology clinic. Even among uropsychologists who are co-located or embedded in pediatric urology clinics at academic medical centers or children’s hospitals, involvement with specific programs or urologic patient populations can differ between institutions; this is the case with the authors, who each work in academic medical centers but provide clinical services to different urological populations (with some overlap, such as with urinary incontinence). Uropsychologists provide a spectrum of behavioral health services, including evaluation, evidence-based interventions, care coordination within an interprofessional team and with community providers, and consultation. In addition to evidence-based behavioral treatments, uropsychologists implement broadband or illness-specific questionnaires to help identify behavioral factors impacting the child’s urological symptom presentation, determine the need for more comprehensive psychological or developmental assessment, or track patient centered outcomes.

One of the most common presenting concerns is lower urinary tract symptoms (LUTS), specifically daytime urinary incontinence, nocturnal enuresis, and urinary frequency or urgency. Typically, patients are referred by their pediatricians to a urology clinic, where they are evaluated for anatomical or structural differences. The first-line intervention, or “urotherapy”, typically involves patient education, lifestyle modifications (e.g., increasing fluid intake, reducing bladder irritants), skill building (e.g., voiding posture, hygiene), implementing a timed voiding protocol, and constipation management if necessary (Shepard & Corbett, 2023). Pediatric uropsychologists offer evidence-based behavioral interventions that can either enhance the efficacy of urotherapy or provide the next level of intervention for children with treatment-resistant symptoms. Children with urinary incontinence are more likely to present with psychological concerns, externalizing disorders (e.g., attention deficit/hyperactivity disorder, oppositional defiant disorder), internalizing disorders (e.g., anxiety, depression), developmental conditions (e.g., autism spectrum disorder [ASD]), and related issues of non-adherence (von Gontard et al., 2019) compared to children without urinary incontinence. In fact, given the high prevalence of behavioral and psychiatric conditions in this population, routine psychological screening and behavioral health treatment for patients with urinary incontinence is now recommended (Austin et al., 2016).  

Pediatric uropsychologists also provide coping interventions related to the treatment of congenital or acquired urological conditions. Some patients present with short-term urological/behavioral health needs; for example, they may present with anxiety related to an upcoming circumcision surgery that resolves after surgery is complete. Others are born with congenital conditions, such as bladder exstrophy (when the bladder is formed outside the abdomen in utero and can impact the development of genitalia, stomach muscles, pelvic bones, and reproductive organs), that require life-long care involving numerous surgeries, medication management, clean intermittent catheterization, and urologic testing such as urodynamics studies or voiding cystourethrograms [imaging studies involving catheter placement and filling the bladder with saline to assess function; Hayes et al., 2024]). Some patients can cope with these interventions and procedures without issue, however, others struggle significantly in coping, especially in the context of comorbid psychological issues such as anxiety, ASD, or others. With these patients, intervention from pediatric uropsychologists can range from identifying coping skills used to help complete difficult procedures, practicing graduated exposure and response prevention to treat phobias related to catheterization or other medical care, and helping to manage family dynamics affecting patient coping. Additionally, in the role of a liaison between the family and the medical team, the pediatric uropsychologist can also coordinate care amongst the interprofessional care team and advocate for accommodations aimed to reduce distress (Hayes et al., 2024).

Pediatric uropsychologists are also often involved in care for individuals with uncommon variations in internal or external genitalia, sometimes collectively referred to as Differences of Sex Development (DSD) or Intersex conditions. While many of these diagnoses do not impact long-term health with adequate medical support (e.g., replacing deficient hormones), children and families are confronted with complex decisions and situations. These may include making decisions about gender of rearing along with future treatment/surgery options and timing. Individuals are also coping with potential variations in puberty, body image, sexual and reproductive functioning, and gender identity. These conditions can be associated with shame and stigma and secrecy that may impact medical information sharing with others and a fear of discovery.  Feelings of difference sometimes lead to social and internalizing concerns. Recognizing these complexities, psychosocial support has been highlighted as crucial in DSD care guidelines (Lee et al., 2006) and stakeholder-led publications (InterACT & Lamda Legal, 2018). Psychologists are ideally embedded on a team with other dedicated specialties (e.g., Urology, Endocrinology, Gynecology, Genetics, Social Work) working together in an interdisciplinary fashion. The first conversations that patients and families have is foundational to how they ultimately view and internalize thoughts about their condition. Psychology involvement from the beginning can help to reduce shame and stigma, promote improved adjustment, and provide additional space and opportunities for shared decision-making conversations (Sandberg & Gardner, 2022).

As most pediatric uropsychologists are situated in academic medical centers or children’s hospitals, many are also involved in supervision and training of the next generation of pediatric psychologists. Providing opportunities for practicum, internship, and fellowship through training experiences, presenting didactics, and offering supervision can help to educate upcoming pediatric psychologists about this subspecialty. Additionally, uropsychologists can also be involved in the training and education of urology fellows, which may help the latter to appreciate the collaboration with behavioral health providers as they move into their own practice. Consultation and advocacy for creation of uropsychology positions in other institutions will also help to increase access to behavioral health services for pediatric urology patients. Training pediatric psychologists and urologists to do this work and to appreciate this collaborative approach to care will build the foundation for successful programs in the future.

Finally, uropsychologists are involved in leadership, quality improvement initiatives, research, and education to the community. All three authors have served in leadership positions in pediatric psychology special interest groups in service of uniting psychologists who practice in Urology and DSD to promote education, shared resources, clinical consultation, training support, and to elevate the role of psychology in our fields. There is some existing research on the behavioral health and well-being of pediatric urology patients (such as the literature reviewed in this article [e.g., Von Gontard et al., 2019]), but with significant opportunity for growth. Pediatric uropsychologists can partner with their interprofessional team members within their institution, or with others in similar roles on a national level to advance the understanding of who these patients are and how to provide the best care. There are opportunities to advance the availability of resources patients and families can access whether or not they have direct access to a pediatric uropsychologist through their institution. Given the limited number of pediatric psychologists serving urology patients, creation of resources and education to the lay community through national urological organizations (e.g., Youth Rally, Association for the Bladder Exstrophy Community, Spina Bifida Association, Accord Alliance) will help to reach more patients and families in need of behavioral health information and consultation.

While pediatric urology patients are historically underserved in comparison to some other medical subspecialty populations, the number of pediatric uropsychologists in the United States is growing (Hayes et al., 2024). Currently, the way in which pediatric uropsychology services are utilized varies across programs and institutions. Ideally, integrating pediatric uropsychologists in interprofessional care teams will offer the best opportunity to care for youth with a variety of urological needs. As members of the interprofessional team working alongside nurses/advanced practice nurses, physicians, child life specialists, social workers, and administrative staff, pediatric uropsychologists have an opportunity to provide comprehensive behavioral health treatment that optimizes outcomes while reducing distress, burden, and cost. This interprofessional practice also promotes cross-collaboration, education, and training across subspecialties.

Pediatric psychology is not currently a recognized specialty by the Commission for the Recognition of Specialties and Subspecialties in Professional Psychology (CRSSPP) or by the American Board of Professional Psychology (ABPP). However, pediatric psychologists, including uropsychologists, could pursue board certification through Clinical Child & Adolescent Psychology, Clinical Health Psychology, or other specialty psychology boards. Board certification is a valuable way to demonstrate competency as a behavioral health provider, provides parity with physicians (who are required to be board certified), and may afford a higher level of respect and influence from the wider academic public. The collegial nature of board certification also fosters the opportunity for collaboration, camaraderie, networking, and additional training/continuing education, which may be especially appealing to pediatric uropsychologists who might be the sole behavioral health provider in their setting.