Team Teaching of the Multidisciplinary Approach

S. Ludwig, M.D.

Assistant Professor of Pediatrics, University of Pennsylvania School of Medicine, Educational Coordinator, S.C.A.N. Center, Philadelphia General Hospital, Philadelphia,

Pennsylvania, U.S.A.

The multidisciplinary approach to management of cases of child abuse/neglect has been widely advocated (1,2,3,4,5). The bene- fits of such an approach have been evident within the Supportive Child Adult Network (SCAN Center) in West Philadelphia. Three of the five hospitals affiliated with the Center have had func- tioning multidisciplinary teams, the first since 1971 (6). Recently, the Commonwealth of Pennsylvania has revised its child abuse law (7) to include that the local child protective agency include multidisciplinary teams 'I.. .for the purposes of develop- ing and implementing treatment plans for abused children and their families."

The teams currently functioning meet on a regular basis (two of the teams weekly), and their tasks can be enumerated as: 1) information sharing; 2) decision making; 3) planning; 4) educa- tion; and 5) providing mutual support. The teams consist pri- marily of hospital personnel, both "on-line" workers and consult- ants, and a representative of the Department of Public Welfare. Interested workers from other agencies may be invited for the discussion of a particular case. as in the case of any group,

The multidisciplinary teams, go through the stages of an evolu-

tionary process until all the workers become comfortable. The result is an efficiently functioning group whose members seem highly satisfied with this mode of operation. New members to the group may find it difficult to establish themselves in this setting because of their inexperience with the multidisciplinary team and its functioning.

One of the objectives of the SCAN Center is to provide training programs about child abuse/neglect to hospital personnel, com- munity workers, students within affiliated institutions and to other local agency personnel and community groups. Through our academic affiliation with the University of Pennsylvania, we were given the unique opportunity to attempt to teach informa- tion about child abuse/neglect and to convey the advantages we perceived in using a multidisciplinary approach. The teaching

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of a course to professional and pre-professional students exempli- fied many of the innovative ways of communicating information, attitudes, and skills.

The Interdisciplinary Health Care Committee of the University of Pennsylvania* sponsored a fully accredited 13-week semester tours e . Students were recruited separately by the Schools of Social Work, Medicine, Nursing, Allied Medical Professions, and Dentistry. The class size was 20, with nearly equal represent- ation by profession. Students varied in their level of training. For example, the social work students were in postgraduate train- ing, while those in allied medical professions were undergraduate. The nurses enrolled were from pre-degree, advanced degree, and faculty levels. Ten students were in placements or were employed in settings where they might have some contact with the problem of child abuse/neglect. Each professional school established its own rules for credits, grading, and registration to be com- patible with the standards of the more traditional curricula.

The faculty started several months before the start of the semester with the formation of a planning group. Like the stu- dents, the faculty represented several occupational categories, including nurse, psychologist, pediatrician, occupational thera- pist, family workes (lay therapist concept), and social worker. This group represented two hospitals, a mental health facility, the local Department of Public Welfare Protective Services Divi- sion, and the SC&V Center. All of the individuals in the plan- ning group had worked together on an actual case basis. Most of the planners were also members of functioning multidisciplinary teams. The planning group met on several occasions and formu- lated the topics in the course curriculum, discussed effective teaching techniques, enlisted additional faculty members, deter- mined course requirements, and established a list of suggested readings.

The final curriculum established had four main goals: 1) to con- vey information about the phenomenon of child abuse/neglect; 2) to stimulate the students to examine and modify their feelings and attitudes ; 3) to begin to teach some practical human inter- action skills; and 4) to demonstrate and thereby promote the advantages of the multidisciplinary approach. The topics listed for weekly discussion were as follows:

Session 1. Student attitudes and expectations - the starting point. Session 2. What is child abuse? Definitions - per- sonal, operational, and legal. Session 3. Societal view of child abuse - evolving societal legal view.

* The author acknowledges his appreciation to the members of com- mittee, Betty Bassoff, ACSW, School of Social Work, Executive Coordinator.

Team Teaching of the Multidisciplinary Approach

Session 4. Family dynamics. Session 5. "The Abusive Parent." Session 6. The family and helping contacts. Session 7. Evaluation of the family - the parent. Session 8. Evaluation of the family - the child. Session 9. Decision making. Session 10. The legal court system. Session 11. Organizing a community response. Session 12. Community resources - what's available - what's needed. Session 13. Review - evaluation.

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The faculty group was widened to include three lawyers and a Family Court Judge. Each class was taught by more than one pro- fessional, and there were always several other faculty members on hand as resource persons. All the faculty used an informal style which encouraged maximum participation by colleagues and students. The teaching techniques varied from week to week. There was major emphasis on role-play in order to convey the feelings of the parent, the child, the interviewer, and the court room witness. At times, students were asked to role-play professionals in disciplines other than own. Invariably, this resulted in the projection of rather stereotyped characters. Such presentations provided a chance to examine attitudes and to gain appreciation for the subtle difficulties of another's posi- tion. Particularly effective was the assignment of being placed in the parent role and feeling the stress of "professional intervention." Other teaching techniques used included small group work sessions, group discussion, panel presentation, didactic lectures, and audio-visual presentations. The course required three important field visits. First was an assignment to observe a family. This was included to encourage students to critically view family interaction and to report on their obser- vations. The field visit was integrated into the sessions on family evaluation. The second field visit involved attending a multidisciplinary team meeting at one of the hospitals. This was integrated with the class session on decision making. The final obligatory visit was to attend a session of the Family Court.* This too was integrated with a classroom presentation. Available also were optional field visits to get a more in-depth view of the hospital emergency department, occupational therapy, the protective service worker and others.

The students were given a pre-and-post test** which sought infor- mation about both their attitudes and their knowledge about child

* To Hon. Nicholas A. Cipriani, Judge of the Family Court Divi- sion of the Court of Common Pleas, and Alice Tuohy O'Shea of the Child Advocacy Unit of the Defender Association of Philadelphia, sincere thanks for their roles in guiding the students through the court experience.

** Instrument for measurement developed by Harold Whitney, psy- chologist with Get Set Dav Care Proiect, Philadelohia.

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abuse. This was a simple S-point scale (strongly agree to strongly disagree) paper and pencil exercise. Some sample ques- tions were:

1) Parents have a right to expect complete obedience from their children.

4) Child abuse would be eliminated if judges were less lenient with adults who assault little children.

27) A child subjected to prolonged undetected abuse can appear retarded.

29) Very few abusing parents are capable of providing adequate care for their children even with professional help and treatment.

37) Wait until all the facts are known before reporting a suspected case of child abuse to local welfare agen- ties.

There was a significant improvement in the scores at the conclu- sion of the course (p=.Ol using a pre-post test calculation). Of 18 students who completed both tests, 16 improved, one made no change, and one declined in score. The greatest increment in score was made by the medical students (x change 23.7) who started from the smallest base score (raw score x = 37.3). The least increment was made by the nursing students (x change 4.5) who had the highest base score (raw score x = 68). The students were given an open-ended course evaluation form in which they were asked about any value seen in having a course with students from other disciplines. For almost all students, this was the only course in their professional training where there were such students. All 20 students responded affirmatively. The value was stated in the following ways:

1) heard different points of view and attitudes;

2) learned about unique as well as shared problems faced by other professionals;

3) learned different approaches and techniques;

4) sharpened one’s own role ;

5) saw other professionals as resources;

6) learned to work together.

The students stated their expectations of the course. In 17 of 20, these expectations were fully met and in two partially met. Again in response to an open-ended summary question, ten of 20 students remarked that the course provided them an opportunity for broadening personal growth and views.

Team Teaching of the Multidisciplinary Approach 385

SUMMARY

If the multidisciplinary approach is to be an important element in the care of abused/neglected children and their families, professionals and para-professionals will need to learn how to function within its context. This paper has described one inno- vative way of teaching this approach. The technique described seems to have been successful by several measurable standards. The elements which seem to have had a positive contribution to this success are: 1) the use of a multidisciplinary planning group and faculty which was a multidisciplinary task-oriented group itself; 2) a heterogeneous group of students; 3) the fre- quent presentation of multidisciplinary role models; 4) varied teaching techniques which stressed classroom interaction, role-

play, and field visits. The course approval has been renewed and will be offered again in the 1976-77 academic year.

ACKNOWLEDGEMENT

The findings reported in this paper reflect the work of many dedicated workers at the Children's Hospital of Philadelphia, Child Guidance Clinic of Philadelphia, Philadelphia General Hospital, Philadelphia Department of Public Welfare, Presbyter- ian-university of Pennsylvania Medical Center, Hospital of the University of Pennsylvania, and the SCAN Center. These individ- uals went beyond their respective roles to become excellent teachers.

REFERENCES

(1) H. Delnero, J. Hopkins, and K. Drews, The medical center child abuse consultation team, Helping the Battered Child and His Family C. H. Kempe and R. E. Helfer, Eds., J. B. Lippincott, Phjladelphia, 1972.

(2) D. S. Rowe, M. S. Leonard, et al., A hospital program for the detection and registration of abused and neglected children, New Eng. J. of Med. 282, No. 17, 950 (1970).

(3) E. N. Joyner, Child abuse: The role of the physician and the hospital, Pediatrics 51, 4 Part II, 799 (1973).

(4) F. C. Green, Child abuse and neglect, a priority problem for the private physician, Ped. Clin. North Amer. 22, 2 (1975).

(5) E. H. Newberger, J. J. Hagenbuch, et al., Reducing the lit- eral and human cost of child abuse: Impact of a new hospital management system, Presented at Annual Meeting of the American Pediatric Society in May, 1972.

386 S. Ludwig

(6) E. P. Wilson and D. R. C. Hilbert, A hospital team approach to child abuse, Philadelphia Medicine 69, 419 (1973).

(7) Pennsylvania "Child Protective Services Law" Act 124, November 26, 1975.