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Interdisciplinary Education Series Volume, Number December, 1999
Interdisciplinary Assessment An Effective Model for Understanding Maltreated Children
Christine Ludy-Dobson, Ph.D. Cathy Guttentag, M.S. Stephanie Schick, M.Ed. David Conrad, LMSW-ACP Christina Carrabine, B.A. Bruce D. Perry, M.D., Ph.D.
EDITING DRAFT
This booklet is one in a series developed by the ChildTrauma Academy to assist caregivers, and various professionals working with maltreated and traumatized children. Interdisciplinary Education Series Edited by B. D. Perry
Each year more than 5 million children in the United States experience or witness traumatizing events. More than 1.5 million of these children develop emotional problems as a result of this exposure. The ChildTrauma Programs were established to assist children and families who are emotionally troubled following their exposure to traumatic events. Trauma occurs when a child is exposed to a frightening, unfamiliar event that overwhelms them. Surprise and horror from this event combine to shock the unprepared child. A hallmark of trauma is the extreme feeling of helplessness it creates for the child and their caretakers alike. Though the real event may last only a brief time, the trauma becomes an emotional event that the child may struggle to come to terms with over their lifetime. Following a trauma, children often lose the sense of safety from danger that they had previously felt. Children can react to this newfound fear by becoming angry, depressed, or feeling out-of-control. Rather than embracing life with a sense of openness, a traumatized child may retreat into herself. However, with timely and appropriate intervention, children are often able to recover from the harmful effects of trauma (Monahon, 1993). Fearful children experiencing the impact of a trauma look first and foremost to protective parents and other trusted adults for reassurance and support. They search for signs of comfort and routine in their daily lives to erase the feeling that life has changed in dangerous and frightening ways. Immediately following a child’s encounter with trauma, and sometimes for many months thereafter, children need lots of comforting and reassurance. Parents or caregivers are often the best people to provide that reassurance and comfort. Their empathy and support provides a critical foundation for the child’s healing. Parents may be unable to be empathic toward their child, however, if they themselves have unresolved issues related to the trauma. Coping with the aftermath of a traumatic event can be stressful not only for the child who has been traumatized, but also for the adults caring for the child. Recognizing the far-reaching impact of the trauma on both the child and his/her family often leads families to seek out a professional evaluation in order to better understand how to help their child. The family’s involvement in the evaluation and treatment process is a critically important part of facilitating their child’s recovery.
The goal of the interdisciplinary assessment process is to identify and better understand how a child and her family have been affected by their involvement in a traumatic experience. Once the assessment has been completed, recommendations can be made regarding ways to help the traumatized child and their family to cope with and overcome any negative effects of the trauma. In this booklet, the phrase "Interdisciplinary Assessment" is used to describe a team approach to learning about children who have experienced or witnessed traumatic events. An interdisciplinary team includes professionals with many different types of training and approaches to understanding children. The core professionals involved frequently include child psychiatrists, psychologists, pediatricians, social workers, education specialists, and family therapists. Professionals from other ancillary disciplines, such as occupational and physical therapists, speech therapists, or other types of developmental specialists, may also contribute valuable perspectives. These individuals may all work in the same location such as a hospital or outpatient clinic. Alternatively, a multidisciplinary team may be composed of professionals who work out of their own separate offices but communicate with each other to coordinate the child’s assessment and treatment. More will be said about differences between these two types of teams in a later section.
Abuse, neglect and exposure to traumatic events during childhood can impact a child’s emotional, behavioral, cognitive, social, and physiological functioning in negative ways. Furthermore, children may display different behaviors and symptoms in different settings and with different people. In order to meet the needs of traumatized children most effectively, it is necessary to examine the child’s strengths and weaknesses across all domains of functioning and from the perspectives of different observers. This approach provides a more comprehensive and holistic picture of the child. There are three major reasons why the use of an interdisciplinary team is a highly desirable method of assessing traumatized children. First, completing comprehensive assessments of these children is a difficult undertaking. It involves gathering a significant amount of history on the child, family, and the event itself, current difficulties and symptoms the child may be experiencing, and other information related to child and family functioning. The compilation of such a large amount of information is a daunting task for one clinician. Second, in many cases, clinicians from one discipline alone may not be capable of assessing and treating the complex problems of traumatized children (Gilgun, 1988). Professionals from different training backgrounds bring their own skills, knowledge bases, and perspectives to the assessment process. They may also bring their own biases and particular areas of interest. For example, pediatricians bring to the assessment their expertise in physical development and overall health. Psychologists’ knowledge of children’s emotional development, as well as skills in using appropriate psychometric instruments, is particularly helpful in bringing objectivity to the assessment process. Psychiatrists can share with team members how and why certain medications might be beneficial to a child. Social Workers typically bring a depth of understanding about how their clients can benefit from, or be enriched by, other persons or organizations in their community. Thus, the use of an interdisciplinary approach to the assessment process allows both a rich and diverse understanding of the individual child. Cross-disciplinary communication and teaching among team members from the different professions is a critical part of this process. It maximizes the opportunity for the child and family to receive the most thoughtful, thorough, and integrated conceptualization and recommendations possible. Finally, for families already stressed and overwhelmed by trying to cope with a traumatic event, a streamlined and well-coordinated assessment process relieves the family of the added burden of scheduling visits to multiple providers in different locations, where paperwork and interviews may be redundantly administered. The rationale supporting this team approach is supported by studies that have shown that "decisions made by groups whose members have the opportunity to interact and discuss their perspectives are more accurate than judgments made by individuals" (Gilgun, 1988, p. 231).
The process of an interdisciplinary assessment is multidimensional and includes gathering both qualitative and quantitative information. Depending upon the particular assessment program or institution, information may be gathered across multiple visits to one or several assessment settings, or may take place all on one day and in one location. The assessment itself often includes observations, structured and extensive child/family interviews, self-report measures completed by the child, school consultations, physical examinations, lab tests, and standardized psychometric testing. Typically, each professional on the team is responsible for conducting a specific portion of the assessment. Like pieces of a complex puzzle, results from each portion of the assessment are then shared with the rest of the team during a post-assessment staff meeting. The integration of such diverse data sources adds to the validity of the information gathered and the conclusions drawn from the data. The ultimate goal is to provide the family with useful recommendations based on the specific needs of their child. Therefore, at the conclusion of the assessment process, written feedback is provided in the form of an integrated, comprehensive report. Feedback includes findings from all the different domains assessed (e.g., physical/medical, cognitive/academic, emotional/behavioral) and includes specific intervention recommendations. Multi-dimensional assessment areas facilitated by an interdisciplinary team. Recommendations may include suggestions such as: modifications in how the child’s behavior is handled at school and/or at home, medical treatment and/or a trial of new or alternate medications, brief or longer-term counseling for the child and/or the family, and participation in enrichment or other activities. Services may then be provided by the clinic conducting the assessment or referrals may be made to other professionals and resource agencies within the family’s community.
The ChildTrauma Clinic is a specialty clinic which operates within the psychiatry department of Texas Children’s Hospital in Houston, Texas. The following example illustrates the interdisciplinary process used within this setting. The model incorporates multiple visits with the child and family, thus further increasing the validity and reliability of the data gathered (Gilgun, 1988). Another important component of this type of assessment is the use of interdisciplinary staffing which guides the assessment process, allows discussion of findings and clinical impressions, and facilities collaboration regarding potential treatment strategies.
This model incorporates multiple visits with the child and family, thus further increasing the validity and reliability of the data gathered (Gilgun, 1988). Another important component of this type of assessment is the use of an interdisciplinary staffing which guides the assessment process, allows discussion of findings and clinical impressions, and facilitates collaboration regarding potential treatment strategies.
Not all professionals who desire to implement an interdisciplinary team approach are fortunate enough to have the opportunity to work in a clinical setting where all of the team members are part of the same organization. It is certainly more of a challenge to function as a team when individual professionals work in different locations, for different organizations with no formal structural and environmental supports in place. Nonetheless, the basic principles and philosophy of this approach can be modified to fit more traditional settings and structures. In order to construct and maintain any effective interdisciplinary assessment team, its members should believe in the value of the interdisciplinary approach and be committed to the following principles, which help guide interactions among team members.
When considering potential members of an interdisciplinary team, it is helpful to consider the individuals’ working styles and attitudes toward coordination across disciplines. Teams comprised of members who share a basic commitment to, and enthusiasm for, the process - in spite of the obstacles - and who possess strong communication and interpersonal skills, are most likely to be successful. In addition, the team must clearly address the following questions in order to clarify and organize the assessment process:
The wisdom and skills of an effective interdisciplinary team translate directly into an integrated understanding of each child and family evaluated by that team. The recommendations and interventions that follow from this assessment model allow clinicians, families, and other support systems to meet the complex needs of the traumatized child, and to set him or her back on the path toward healthy physical, cognitive, social, and emotional development.
Gilgun, J. F. (1998) Decision-Making in Interdisciplinary Teams. Child Abuse and Neglect: The International Journal: v12, n12, 231-239. Hanley, D., Nelke, C., & Perry, B. D. (1999, June). Development of a specialty clinic to assess traumatized children. Poster session presented to the annual national convention of the American Professional Society on the Abuse of Children, San Antonio, TX. Monahon, C. (1993) Children and Trauma: A Guide for Parents and Professionals. San Francisco: Jossey-Bass
There are many other places to learn more about interdisciplinary assessment of maltreated or traumatized children. A few starting places are listed below. ORGANIZATIONS American Professional Society on the Abuse of Children (APSAC) APSAC's mission is to ensure that everyone affected by child maltreatment receives the best possible professional response. This organization has many useful scholarly and clinical materials focused primarily at the professional audience. Caregivers working with abused or maltreated children may find this a useful resource, nonetheless. For more information contact: APSAC
Zero to Three is a national, nonprofit organization located in Washington, D.C., dedicated solely to advancing the healthy development of babies and young children. Founded in l977 by top developmental experts, ZERO TO THREE disseminates key developmental information, trains providers, promotes model approaches and standards of practice and works to increase public awareness about the significance of the first three years of life. ZERO TO THREE Collaborative Family Healthcare Coalition (CFHCC) CFHCC These resources will be periodically updated and posted in the web version of this article at www.ChildTrauma.org. Visit this site for updates and for other resource materials about traumatic events and children.
Collaboration: A relationship between two or more parties for the purpose of achieving a common goal(s). Discipline: A branch of knowledge, learning, or training (e.g., psychiatry, law, social work). Empathy: The ability to understand a person’s feelings almost as though they were one’s own feelings and effectively convey this understanding to that person through close attention, words, gestures and other forms of communication. Psychological / Psychometric instruments: Means of gathering information in a systematic and/or standardized way through use of questionnaires, surveys, interviews, and other similar methods. Interdisciplinary / cross-disciplinary: The combination or synthesis of two or more branches of learning.
Christina Carrabine, B.A. Christina Carrabine was a research assistant, a clinical support staff member and graduate student in clinical psychology. Her responsibilities included assisting in data collection/entry and the maintenance of clinic records. David Conrad, LMSW-ACP David Conrad is a clinical social worker and was Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston, Texas. Christine Ludy-Dobson, Ph.D. Dr. Dobson is a clinical social worker and Director of Programs for the ChildTrauma Academy in Houston, Texas. She also coordinates research conducted at The ChildTrauma Academy. Cathy Guttentag, M.S. Cathy Guttentag was doctoral candidate in Child Clinical Psychology at Pennsylvania State University, and a Clinical Psychology Intern at The Child Trauma Programs and Baylor College of Medicine. Stephanie Schick, M.Ed., LPC Intern Stephanie Schick is the Director of Education and Training as well as a clinician at The ChildTrauma Academy. In addition to her role in the assessment and treatment of traumatized children, she has coordinated various ChildTrauma Academy projects. Bruce Duncan Perry, M.D., Ph.D. Dr. Perry is the Senior Fellow of the ChildTrauma Academy - a not-for-profit organization he founded in 1990 focused upon improving the lives of maltreated children. From 1992 to 2001, Dr. Perry served as the Thomas S. Trammell Research Professor of Child Psychiatry at Baylor College of Medicine and Chief of Psychiatry at Texas Children's Hospital in Houston, Texas.
The ChildTrauma Academy is a not-for-profit organization based in Houston, Texas. The mission of the Academy is to help improve the lives of traumatized and maltreated children and their families. We do so by working to improve the systems that educate, nurture, protect and enrich these children. We believe that the most effective approach to systemic change is one that involves defining specific problems, and developing innovative, measurable, and replicable solutions -- within clinical practice, program development and public policy. For more information, please contact: The ChildTrauma Academy Email -
JLRcta@aol.com
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ADDITIONAL VIDEOS “What We Have Always Known” This 25 minute training and educational video features Dr. Bruce D. Perry, renowned expert in child trauma and early brain development. The video is a wonderful educational resource for Native American and Non-Native American communities at large – parents and primary caregivers, business, healthcare providers, education, faith groups, government, media and service organizations. The video presents key teachings of the Native American culture and the important positive impact that understanding early brain development can make on the lives of children. It reinforces learned historical practices and parenting skills passed on through Native American ancestry – generation to generation. It speaks of the importance and need for extended families and the benefits of reweaving the social fabric in the Native American Culture. SERIES 1 TRAINERS’ MATERIALS Educators’ Package This CD contains a set of six articles designed to complement and supplement the sex programs (programs 2-7) in Video Series 1. Content is presented with images, tables, figures, and teaching points. Each article is ready to print and distribute to trainees. The package also provides trainers with teaching objectives, pre-and post-tests, additional references, handouts and resources for additional learning. These materials can be used to provide up to 18 CEU credits per series through the ChildTrauma Academy for post-graduate continuing education and for approved foster care educational credit in selected states (please review your state’s specific requirements). Presentation CD For educators and trainers wishing to use our materials for ongoing training activities, our Presentation CD provides seven PowerPoint presentations (each approximately 35 slides) and accompanying handouts to complement Series 1. SERIES 2 TRAINERS’ MATERIALS Multimedia CD This CD contains nine articles, twelve handouts with exercises, one 55 slide PowerPoint presentation and short explanatory video clips designed to complement and supplement the programs in Video Series 2 (“The Six Core Strengths”). Content is presented with images, tables, figures, and teaching points. Each article is ready to print and distribute to trainees. The package also provides trainers with teaching objectives, pre- and post-tests and resources for additional learning. CUSTOMIZED TRAINING PACKAGES We are happy to assemble a personalized set of training materials to suit your specific needs and budget. Any selection of individual tapes, articles, handouts and presentations can be combined to meet the needs of the instructor, organization or institution. Please contact The ChildTrauma Academy at CTAproducts@aol.com for more information.
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