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Infants & Young Children

Vol. 22, No. 3, pp. 211223


Copyright  c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Application of a
Transdisciplinary Model for
Early Intervention Services
Gillian King, PhD; Deborah Strachan, MRC;
Michelle Tucker, MClSc(OT); Betty Duwyn, BSc(PT);
Sharon Desserud, BSc(PT);
Monique Shillington, BScN(RN)
This article reviews the literature on the transdisciplinary approach to early intervention services
and identifies the essential elements of this approach. A practice model describing the implemen-
tation of the approach is then presented, based on the experiences of staff members in a home
visiting program for infants that has been in existence for over 30 years. The benefits and chal-
lenges experienced by therapists and managers of the program are considered, along with the
unique aspects of the program and implications for program management. The managerial and
team resources required to successfully implement a transdisciplinary model are high, but the po-
tential payoffs for children, families, and therapists development of expertise are considerable.
Key words: early intervention, infants, model, transdisciplinary

Isabella Garcia was a two-month-old little girl plex needs of children with disabilities and
who was diagnosed with a degenerative, neuro- their families (Carpenter, 2005). The trans-
muscular disorder shortly after birth. Her parents disciplinary approach (TA) has been recog-
were devastated by the news and overwhelmed nized as a best practice for early intervention
by the number of appointments they had with (Bruder, 2000; Guralnick, 2001), and many
medical specialists. They did not want to spend
early intervention programs adopt some form
their daughters short life going from appoint-
ment to appointment. A transdisciplinary early in-
of TA (Berman, Miller, Rosen, & Bicchieri,
tervention program with one primary therapist 2000). In contrast to other service delivery
helped simplify services. The family was able to approaches, TA is considered to reduce frag-
access the supports they needed through one key mentation in services, reduce the likelihood
relationship. of conflicting and confusing reports and com-
munications with families, and enhance ser-
Transdisciplinary models of practice aim vice coordination (Carpenter, 2005; Davies,
to provide more family-centered, coordinated, 2007).
and integrated services to meet the com- Transdisciplinary service is defined as the
sharing of roles across disciplinary boundaries
so that communication, interaction, and coop-
Author Affiliations: Bloorview Research Institute, eration are maximized among team members
Toronto (Dr King) and Child and Parent Resource (Davies, 2007; Johnson et al., 1994). The trans-
Institute, London (Dr King and Mss Strachen, Tucker, disciplinary team is characterized by the com-
Duwyn, Desserud and Shillington), Ontario, Canada.
mitment of its members to teach, learn, and
The authors thank Dina Barnes, Charlene Verbeek, work together to implement coordinated ser-
Mary Semotiuk, Joan Ross, Melissa Currie, and Sue
Davies for their contribution. vices (Fewell, 1983; Peterson, 1987; United
Cerebral Palsy National Collaborative Infant
Corresponding Author: Gillian King, PhD, Bloorview
Research Institute, 150 Kilgour Rd, Toronto, ON M4G Project, 1976). A key outcome of TA is the
1R8, Canada (gking27@uwo.ca). development of a mutual vision or shared
211
212 INFANTS & YOUNG CHILDREN/JULYSEPTEMBER 2009

meaning among the team (Davies, 2007; of the HVPI model and implications for pro-
McGonigel, Woodruff, & Roszmann-Millican, gram managers.
1994), with the family considered to be a key
member of the team.
Much has been written about the con- ESSENTIAL ELEMENTS OF THE
ceptual basis of TA, including its premises TRANSDISCIPLINARY APPROACH
and elements, but information is lacking
about transdisciplinary service delivery from Various researchers have highlighted the
a practitioners perspective (Ryan-Vincek, importance of the arena assessment (eg,
Tuesday-Heathfield, & Lamorey, 1995). McGonigel et al., 1994; Moodley, Louw, &
Practice-relevant information is needed about Hugo, 2000; Ryan-Vincek et al., 1995). Other
how to deliver transdisciplinary services. researchers have discussed the importance
Little is known about the roles of practition- of role release as a defining characteristic,
ers; the types of services that can be offered meaning that services are provided by one
within this approach (eg, home visits, parent team member with consultation from other
training); and how managers can provide members (eg, Rainforth, 1997; Ryan-Vincek
structures, supports, and opportunities to et al., 1995; Sheldon & Rush, 2001). Others
create and sustain smoothly functioning and have pointed to the importance of the inter-
effective transdisciplinary teams. dependence among team members; their in-
One exception to the lack of published terchangeable roles and responsibilities; and
practice models is a family-centered, trans- the need for them to exchange informa-
disciplinary model of early intervention ser- tion, knowledge, and skills (eg, Costarides,
vice delivery called Team Around the Child Shulman, Trimm, & Brady, 1998; Moodley
(Davies, 2007), based on work by Limbrick et al., 2000). More recent articles have
(2005) in the United Kingdom. Davies out- stressed the importance of a high degree
lines 10 model components, including phi- of collaborative teamwork (eg, Limbrick,
losophy, family role, key worker role, team 2005; Reilly, 2001; Stepans, Thompson, &
interaction, lines of communication, staff de- Buchanan, 2002).
velopment, and the assessment process. De- On the basis of a review of the literature, we
scriptions of practice models such as this propose that TA has 3 essential and unique op-
translate the rhetoric of TA into reality. The erational features, which, for the most part,
present article contributes to the literature correspond to those outlined by Foley (1990).
by providing information about how to im- The first is the arena assessment, where pro-
plement a transdisciplinary model of service fessionals from multiple disciplines assess the
for infants with special needs and their fami- child simultaneously, using both standardized
lies, developed in Ontario, Canada. It is hoped measures and informal methods (Foley, 1990).
that the article will inform managers and early One person assumes the role of facilitator, and
childhood intervention practitioners about 1 or 2 others interact with the child while
how to design a transdisciplinary service pro- members of other disciplines observe. Every-
gram and ensure its key aspects are sustained one present has a role, including the par-
over time. ent, who provides information about the child
The article is organized as follows. First, and who can, with guidance, administer struc-
we identify the defining elements of TA. Sec- tured tasks (Foley, 1990). Upon completion of
ond, we discuss the benefits and challenges the assessment, there is a brief discussion of
of the approach. In the remaining sections, information and impressions. A more defini-
we discuss the model adopted by the Home tive formulation is made once the team has
Visiting Program for Infants (HVPI), a trans- had time to analyze the data and reflect. Par-
disciplinary program in operation for over ents may or may not be present at this meet-
30 years. We end by discussing unique aspects ing, depending on their wishes.
The Application of a Transdisciplinary Model 213

The second essential feature is intensive, resulting in a more naturalistic intervention


ongoing interaction among team members (Foley, 1990).
from different disciplines, enabling them to The literature discusses other features of
pool and exchange information, knowledge, transdisciplinary models, such as a coordi-
and skills, and work together cooperatively. nated intervention plan and attention to the
This feature reflects Foleys (1990) notion of needs, desires, and goals of the family. How-
role expansion but clarifies the role of collab- ever, these features also characterize pro-
orative interprofessional teamwork in making gram models that are interdisciplinary and/or
this happen. family-centered in nature. Although the lit-
The third defining feature of TA is role re- erature often characterizes transdisciplinary
lease, which is the most crucial and challeng- models as family-centered, this is not a unique,
ing component in transdisciplinary team de- defining feature. In practice, the defining fea-
velopment. The team becomes truly transdis- tures of TA operate together, influencing all
ciplinary in practice when members give up aspects of service delivery, including plan-
or release intervention strategies from their ning (the arena assessment), the organiza-
disciplines, under the supervision and sup- tional context of practice (ie, operational
port of team members whose disciplines are mechanisms and strategies to ensure ongoing
accountable for those practices. The role re- exchange, communication, and development
lease process therefore involves sharing of ex- among team members), and implementation
pertise; valuing the perspectives, knowledge, (ie, the lead role played by a primary worker
and skills of those from other disciplines; and who receives role support from the team).
trustbeing able to let go of ones specific
role when appropriate. Role release also oc- BENEFITS OF THE TRANSDISCIPLINARY
curs with respect to the family (eg, parents APPROACH
can be educated about appropriate activities
to incorporate into daily routines). Following a home visit, Mrs. Garcia had questions
about the positioning suggestions that were pro-
Isabella had low muscle tone and limited strength vided as well as questions about an application that
and endurance. She was able to move her eyes to was submitted for the funding of specialized equip-
look about the room, but not able to move her ment. She knew to call her primary therapist for
neck, trunk, or limbs without assistance. One of clarification on both issues.
her parents priorities therefore was to find posi-
tions that were comfortable for her. Isabellas pri- The presumed benefits of TA include (a)
mary therapist (a speech-language pathologist) and service efficiency, (b) cost-effectiveness of
a physiotherapist together determined that sup- services, (c) less intrusion on the family, (d)
ported side-lying would be a good position for the less confusion to parents, (e) more coherent
primary therapist to try. Since positioning does not intervention plans and holistic service deliv-
typically fall within the realm of speech-language
ery, and (f) the facilitation of professional de-
pathology, this is an example of role release.
velopment that enhances therapists knowl-
The process of role release involves several edge and skills (Foley, 1990; Polmanteer,
aspects (Fig 1), including role extension, role 1998; Sheldon & Rush, 2001; Warner, 2001).
enrichment, role expansion, role exchange, These presumed benefits have not been ex-
role release, and role support (Johnson et al., tensively evaluated. Empirical research on the
1994). Role release is an ongoing process transdisciplinary model is very much needed
rather than a series of linear steps. In the (Foley, 1990).
role expansion phase, a common vocabulary First, with respect to service efficiency,
develops, along with expanded theoretical it has been argued that more children can
knowledge and the capacity to implement in- be served because fewer providers routinely
tegrated interventions that meet the holistic see a given child. Instead of each child re-
needs of the child within the family context, ceiving direct assessment and intervention
214 INFANTS & YOUNG CHILDREN/JULYSEPTEMBER 2009

Figure 1. Aspects of the role release process.

services from each team member, services the short- and long-term. Short-term overall
are funneled through one primary therapist, costs may be higher, but longer-term costs
freeing other team members to see other lower and longer-term outcomes superior.
children. Third, TA is considered to be less intru-
Second, one of the presumed benefits of sive because parents only need to build one
TA is cost-effectiveness, but this will occur key relationship (Foley, 1990) and often only
only if the process is going well. The arena one service provider visits the home (Rossetti,
assessment has been estimated to be at least 2001). There is less repetition of the same in-
40% more cost-efficient than an interdisci- formation to different service providers. En-
plinary approach for similar assessment ser- hanced and streamlined communication is
vices (Kiss, 1983, cited in Foley, 1990), and therefore considered to be a key benefit for
transdisciplinary play-based assessments have the family.
been found to take less time to complete Fourth, confusion is allegedly reduced for
than multidisciplinary standardized assess- parents, since recommendations are coordi-
ments (Myers, McBride, & Peterson, 1996). nated and prioritized by the team, which in-
Economic evaluations are required to deter- cludes the parent. Parents know whom to
mine system expenditures and societal out- contact when issues arise; however, they
comes associated with this model, both over may be confused about why, for example,
The Application of a Transdisciplinary Model 215

a speech-language pathologist is working on Challenges for service providers


their childs physical mobility. The intent Professional, personal, and interpersonal
and safeguards of TA therefore need to be challenges occur for service providers
repeatedly explained (in writing and ver- (Davies, 2007). These include the loss of
bally) so that parents are comfortable with professional identity, liability implications
the approach and understand its evidence- (including fear that negligent behavior may
base. In comparison with center-based in- occur through lack of sufficient supervision)
terdisciplinary services, home-based services (Ryan-Vincek et al., 1995), and inadequate
provided by one therapist have been found sharing of knowledge and roles due to the
to be associated with lower family stress experience of threat (Polmanteer, 1998;
and enhanced infant development (Shonkoff, Sheldon & Rush, 2001; Warner, 2001).
Hauser-Cram, Krauss, & Upshur, 1992). Child To practice in a transdisciplinary manner,
development and parent-child interaction are service providers must grasp the concepts
fundamentally intertwined in the early years, of role release and collaborative interprofes-
and no one discipline is more effective than sional teamwork and display the skills re-
another in providing early intervention ser- quired to deal with the practicalities each en-
vices, particularly for children younger than tails. Role release and teamwork reflect 2 of
1 year of age (Rossetti, 2001). the 3 essential elements of TA we have out-
Fifth, TA fosters a holistic approach to lined. The required professional competen-
care (Foley, 1990) through the development cies go beyond discipline-specific knowledge
of more coherent intervention plans and a and skills and include personal qualities such
shared meaning or a mutual vision among as empathy, self-awareness, self-reflection,
the team and family (Davies, 2007). The mu- emotional self-control, sensitivity, interact-
tual vision and good communication required ing with authenticity, listening effectively,
by this model lead to services designed to best facilitation skills, and interpersonal com-
meet the needs of the child. munication skills (Davies, 2007; Ebershon,
Last, from the managerial perspective, one Ferriera-Prevost, & Maree, 2007; King et al.,
of the benefits of TA is that it allowsin 2007; Pilkington & Malinowski, 2002). Ser-
fact requiressignificant professional devel- vice providers require self-confidence and a
opment. Professional skills and mutual re- positive professional identity, allowing them
spect are enhanced through the use of this ap- to share without feeling threat to professional
proach (Baine & Sobsey, 1983; Foley, 1990). identity (Foley, 1990) and accept feedback
with humility.
In general, the holistic, family-centered ap-
CHALLENGES OF THE
proach, breadth of knowledge, and interper-
TRANSDISCIPLINARY APPROACH
sonal and team skills required make it most
likely that therapists with higher levels of ex-
Isabellas family was experiencing a lot of stress and
grief related to her diagnosis, and was under finan-
pertise will be most comfortable and profi-
cial strain due to costs associated with equipment cient with TA. Novice practitioners may feel
she needed. The primary therapist felt that a refer- overwhelmed by the expectation that they op-
ral to the team social worker would be appropriate; erate in a collaborative team manner, espe-
however, the family had been recently connected cially if they have not received university train-
with a social worker from another agency. The pri- ing in interprofessional practice.
mary therapist therefore decided not to refer them
for a social work consultation to avoid duplication
Challenges for managers
of services, but met with the team social worker on
several occasions to learn how to best support the Practitioners may lack the peer support and
family during this very difficult time and to work professional development experiences they
through her own feelings of sadness. require to be effective in a transdisciplinary
216 INFANTS & YOUNG CHILDREN/JULYSEPTEMBER 2009

role (Maher et al., 1998). Managers therefore who have developmental disabilities or who
need to create an environment in which there are at risk for developmental delays due to
is openness to learning and opportunity for established, biological, and psychosocial risk
team members to learn from one another and factors (Table 1) and (b) to promote the qual-
discuss shared intervention strategies (Davies, ity of life of the child and family (Ministry of
2007). Role support is a critical component Community and Social Services, 2001). Ser-
of TA, requiring ongoing interaction among vices are often provided in conjunction with
team members. It may be difficult for man- other agencies.
agers to ensure frequent enough opportuni- Approximately 280 children and families re-
ties for the level of interaction required. Other ceive services from HVPI on an annual basis.
managerial challenges include building an ef- In 2008, an end-of-service satisfaction survey,
fective team, engaging in succession planning receiving a 40% response rate, indicated that
to ensure the transfer of expertise, ensuring 80% of families strongly agreed that they were
time for role release training (Foley, 1990; satisfied with the services received whereas
Ryan-Vincek et al., 1995), and providing op- an additional 15% agreed. In the last 3 years,
portunities and supports to encourage reflec- only 3 families expressed discontent with the
tion and self-development (King, in press-a). primary therapist role, preferring instead to
An appreciable amount of time is required receive direct service from multiple disci-
for teams to plan, practice, and critique their plines.
work together, and to be able to deliver The program provides family support, ser-
efficient and cost-effective services. As well, vice coordination, parent education, as well as
it takes a skilled and experienced manager assessment, treatment, and consultation ser-
to recognize problematic situations, such vices for the child, to families residing in 5
as when team members feel threatened by counties of Southwestern Ontario. Approx-
sharing knowledge with others. Another imately 50% of the families live in the city
challenge faced by managers is ensuring a of London and 50% live in small communi-
funding model that supports the indirect time ties and rural areas outside the city. Approx-
required to provide high-quality transdisci- imately 80% of the children reside with their
plinary services (Pilkington & Malinowski, biological or adoptive families and 20% are in
2002). a form of foster care. Services are typically
In the following sections, we describe a offered in the caregivers home but center-
practice model that applies the conceptual as- based therapy groups for children and sup-
pects of TA. We consider challenges experi- port groups for parents are also offered.
enced by therapists and managers of the pro-
gram, the unique aspects of the model, and
implications for program management. Program history
When HVPI was established in 1977, the
program was led by a psychologist, with
THE HOME VISITING PROGRAM nurses providing frontline services. The fo-
FOR INFANTS cus was on providing infant stimulation activ-
ities to promote child development in a vari-
HVPI mandate, clients, and services ety of domains. In the mid-1980s, the trans-
HVPI is an early intervention program based disciplinary model of service emerged and
at the Child and Parent Resource Institute staff members from other disciplines were
in London, Ontario, Canada, and part of a hired, including occupational therapy, physio-
continuum of early intervention programs in therapy, psychology, social work, and speech-
Ontario. The programs role is (a) to enhance language pathology, and the process of shar-
the growth and development of infants and ing roles and working across disciplines
young children younger than 6 years of age began.
The Application of a Transdisciplinary Model 217

Table 1. Risk factors determining eligibility for early intervention services at the Home Visiting
Program for Infantsa

Types of risk factor Description

Established These are related to diagnosed medical disorders that are known to be
associated with developmental delays (eg, genetic syndromes,
neurological disorders, cerebral palsy, congenital malformations of
the nervous system, infections of the nervous system, and metabolic
disorders).
Biological These are related to prenatal, perinatal, neonatal, and early
developmental events that increase the probability of developmental
difficulties (eg, exposure to alcohol and drugs in utero, premature
birth, and birth asphyxia).
Psychosocialb and These are external to the child and reflect the childs surroundings
environmental (eg, parental mental retardation, attachment relationship difficulties,
and abusive or neglectful home environment).

a Derived from guidelines provided by the Ministry of Community and Social Services (2001).
b Children who exclusively have psychosocial risk factors are not eligible for services.

Staffing remained stable for several years, standing of TA and insight into how to train
and clinicians became proficient and comfort- and support new staff members and build and
able in their roles and developed cohesiveness maintain the team. It became apparent that
as a team. Team members mastered the the- many team members were unfamiliar with
ories, methods, and techniques of other dis- the approach and that the team had deviated
ciplines and were able to provide seamless somewhat from the true definition of TA.
service across traditional disciplinary bound- On the basis of discussion at a staff retreat, a
aries. The arena assessment at that time had a work plan was created to develop a common
medical focus, with the primary purpose be- language, understand the aspects of role
ing to diagnose and assess the child; cross- release, reintroduce the arena assessment,
training between disciplines was simply a by- and examine how the teams transdisciplinary
product of these joint assessments. As medi- functioning could be improved.
cal services at the facility changed, the arena
assessment, a key component of TA, was lost. BUILDING THE HVPI
Over time, working across disciplinary TRANSDISCIPLINARY TEAM
boundaries became second nature and less at-
tention was paid to transdisciplinary team de- HVPI therefore developed a comprehen-
velopment. There was no explicit operational sive orientation program for new staff, lasting
framework for the ongoing development of about 9 months, that includes an orientation
the team, aside from a thorough orientation manual, peer mentorship, and participation
process and a peer mentoring program. By in activities designed to facilitate the role
2004, many seasoned clinicians had retired, release process. The purpose of the sys-
and newly hired professionals had minimal tematic orientation process is to develop
experience working in a transdisciplinary shared meaning so that new team members
model. A new program manager had little understand the terminology, roles, and basic
knowledge of and no experience managing a principles of each profession represented on
transdisciplinary team. In 2006, a small group the team as well as the importance of adopt-
reviewed the literature to gain a better under- ing a holistic view of the family. Although the
218 INFANTS & YOUNG CHILDREN/JULYSEPTEMBER 2009

formal orientation process takes 9 months, allows team members to view the family and
experienced team members concur that it child from different perspectives, and thera-
takes many years for new clinicians to feel pists serve as role models as they take turns
comfortable with TA. Expertise is widely facilitating the assessment and the debriefing
considered to require at least 10 years of session that follows. In time, team members
professional experience (Ericsson, Krampe, develop confidence in themselves and one an-
& Tesch-Romer, 1993; Goodyear, 1997). other, and role release begins to occur.
Performance appraisals, caseload reviews,
Orientation manual and peer mentor meetings provide team mem-
The specific learning expectations for new bers with opportunities for self-appraisal and
team members are outlined in detail in the to receive feedback from others. Families are
manual. The manual also includes a brief de- given the opportunity to provide feedback
scription of each of the disciplines on the through focus groups and a satisfaction sur-
team and their areas of expertise, suggestions vey completed during program involvement
for when to refer for consultation, a list of in- and upon discharge.
terventions that should not be released, and
resources available for role enrichment. The
manual outlines learning opportunities, such THE HVPI TRANSDISCIPLINARY
as reading relevant materials, meeting with PRACTICE MODEL
other team members to discuss their roles,
and participating and being observed in joint HVPI team functioning
home visits. It also provides opportunities for Each family is assigned a primary ther-
members from each discipline to comment on apist, who may be a nurse, occupational
direct teaching and other educational oppor- therapist, physiotherapist, psychometrist, or
tunities provided to the new staff member, speech-language pathologist. Caseload and ge-
and allows each discipline to provide written ography are typically the main factors used
feedback on the new staff members future to decide which therapist will work with a
learning needs. new family, but therapists professional back-
ground and expertise also play a role. The pri-
Peer mentorship mary therapist is responsible for developing
New team members are assigned to a more a therapeutic relationship with the family; of-
experienced peer mentor whose role is to fering emotional support; building advocacy
guide the orientation process and provide skills; and providing education on issues re-
support. During the orientation period, the lated to health, development, treatment op-
new team member meets regularly with her tions, and community resources. As well, the
mentor and manager, and is assigned respon- primary therapist is the key contact person
sibilities and clients gradually. The mentor typ- between the family and the rest of the team. It
ically follows fewer families so that she has is her role to facilitate communication and co-
more time to meet with the new staff mem- hesive teamwork. The primary therapist helps
ber and support her on home visits. parents set goals with the team and coordi-
nates and monitors the implementation of the
Activities facilitating role release plan of care.
Annual learning plans, ongoing profes- Depending on the childs needs and fam-
sional development, and monthly in-service ilys goals, the primary therapist may work
education allow team members to extend and to enhance parent-infant interactions; provide
enrich their roles. Completing joint visits, par- strategies to improve the childs participa-
ticipating in team assessments, and colead- tion in everyday activities; promote the de-
ing groups provide opportunities to teach and velopment of gross motor, fine motor, com-
learn from one another. The arena assessment munication, and social skills; and assist with
The Application of a Transdisciplinary Model 219

transitions to day care, school, and services that a physiotherapist make a home visit with her
from other agencies. to provide teaching and role support.
A common misconception of TA is that
one team member exclusively delivers all ser- The HVPI arena assessment
vices to the family. In reality, even though Families are offered the opportunity to take
a family may see one therapist most fre- part in an arena assessment, ideally within the
quently, every family is supported by the first 6 to 8 weeks of program involvement.
larger team. Arena assessments, consultation Prior to the assessment, the primary therapist
services, short-term therapy, and groups are speaks with the family about what they hope
examples of ways that team members other to gain, and then meets with the team to pro-
than the primary therapist provide direct ser- vide a summary of the issues and the parents
vices to families. Indirect support is provided goals for the assessment.
to the family via the primary therapist, who The assessment team typically consists of
regularly confers with other team members, a nurse, occupational therapist, physiother-
both formally (eg, mentor meetings) and in- apist, social worker, and speech-language
formally (eg, phone contact). pathologist. Because of scheduling con-
There are times when the transdisciplinary straints, a psychologist is included only when
model is not the best fit with family or child there are concerns about attachment or
needs or the abilities of the primary therapist. behavior management. The primary therapist
One model of service delivery is not appro- determines who would be the most helpful
priate for all situations. The family may pre- to have in the room with the family, and
fer separate services from individuals with dis- other team members observe the assessment
ciplinary expertise, the family and child may through a 1-way mirror. During the assess-
have so many complex needs that it is not ment, the child and his/her parents play with
possible for one person to meet them all, or developmentally appropriate toys, and team
the primary therapist may be a novice and the members use clinical observation and/or
family and child needs may be beyond her ex- screening tools to assess the childs strengths
pertise. In these cases, an interdisciplinary ap- and weaknesses across all developmental
proach is adopted. areas. Team members also make observations
about parent-child interaction.
Limits to role release Following the assessment, the team meets
with the family to discuss their priorities
Role release only occurs at HVPI when team and concerns, outline next steps, and answer
members have adequate understanding of the specific questions the family may have. The
theoretical and practical components of the team then engages in a debriefing process,
intervention. In addition, some components intended to support the primary therapist in
of assessment and intervention should not be working with the family. The debriefing also
released because they are too complicated, provides opportunities for team members to
beyond the skills of most other team mem- provide feedback to one another. The primary
bers, and risks to clients are too great. Ex- therapist then develops an intervention plan
amples include assessing feeding and swal- with the family, based on the assessment infor-
lowing and prescribing and adjusting mobility mation and family priorities, and implements
equipment. There are also some assessment the plan with the family while other team
tools that only individuals with specific train- members monitor implementation and pro-
ing and/or education may use. vide role support as needed.
Due to her limited mobility, Isabella was at high risk There are many benefits to the arena assess-
for the development of joint contractures. The pri- ment process. It provides a forum for parents
mary therapist felt that monitoring Isabellas range to meet team members face-to-face and ask
of motion was beyond her abilities, and requested them questions specific to their disciplines.
220 INFANTS & YOUNG CHILDREN/JULYSEPTEMBER 2009

It also makes it easier to reintroduce a team sary for novice clinicians, but, as skill sets are
member at a later date for consultations. The built, joint visits may be needed less often, and
assessment and intervention plan tend to be the primary therapist may benefit from other
broader, more holistic, and better integrated forms of role support. It is important for ther-
than any one discipline could do alone. Since apists to look at ways to enhance practice as
the role of facilitating the assessment is ro- their competence improves. The role release
tated, team members have opportunities to process requires each team member to con-
watch and learn from colleagues. The assess- tinually appraise his or her own skills, as well
ment also provides the opportunity for role as those of others.
enrichment through exposure to a variety of
families, diagnoses, and issues. Evaluating competence
Another challenge related to role expansion
and cross-disciplinary training concerns the
CHALLENGES IN MAINTAINING THE evaluation of competence. Clinicians find it
TEAM AND MOVING FORWARD difficult to perform self-appraisals, and it is
equally difficult for colleagues and managers
Ongoing skill enhancement to assess clinical reasoning skills and compe-
The creation of a transdisciplinary team is tence in a different disciplinary area. The pro-
an ongoing process. New members bring new gram needs to look for ways to measure com-
skills to the team, and members continually petence and identify learning needs through
build upon their expertise both within and self-appraisal and reflective practice. Without
across disciplines. One of the challenges in ap- these checks, the process of role release can-
plying TA is enabling the systematic and delib- not be complete.
erate teaching of skills to clinicians with dif- When team members retire or move on to
ferent viewpoints, experiences, and levels of other opportunities, managers need to find
understanding. Creating and including a cur- not only replacements who are skilled clin-
riculum in the orientation manual has helped icians in their own discipline but also, per-
to ensure that all team members receive the haps more importantly, individuals who can
same basic training and provides a way for learn to function in a team environment.
managers, peers, and staff members them- Hiring practices play a crucial role in the main-
selves to record and monitor learning needs. tenance of a transdisciplinary team. Individ-
The process of training and being trained uals who do well within the team are open-
results in close scrutiny of each others skills minded, comfortable working outside the
and can create an intimidating environment. expert model, good listeners, and receptive
This may be particularly difficult for novice to feedback. The ability to collaborate and
team members who often feel most comfort- work well with others is a key factor (Briggs,
able building expertise within traditional dis- 1997). Theories and skills can be taught to any
ciplinary boundaries. Ongoing formal sharing clinician who is receptive to learning.
of information during monthly in-services and
article reviews and informal, reciprocal ask- UNIQUE ASPECTS OF THE HVPI
ing and providing of advice help to create an TRANSDISCIPLINARY MODEL
atmosphere of learning and trust and break
down barriers between expert and novice. The description of the HVPI practice model
Despite challenges in educating and train- contributes to the literature by providing
ing staff, building a knowledge base is not more detailed understanding of several prac-
as difficult as changing practice. It can be tical aspects of TA. First, the HVPI program
easy for a primary therapist to habitually re- exemplifies a holistic and comprehensive
quest referrals from each discipline for each transdisciplinary program, in which there
client. Referrals and joint visits may be neces- is an emphasis on transdisciplinarity in all
The Application of a Transdisciplinary Model 221

aspects of the program. In contrast to other ered. Therapists also play an educational role
programs described in the literature, HVPI in- with respect to service providers from other
volves a large number of disciplines (not just agencies. An ongoing challenge is to provide
1 or 2), and role release occurs, within appro- education to community professionals about
priate boundaries, in all stages of assessment, the benefits and practical application of TA,
planning, and intervention (not just assess- so that agencies can work better together.
ment). Second, the HVPI program attempts
to include parents in all aspects of the inter- Personal responsibilities of service
vention process, including assessment, goal providers
setting, and intervention. The one exception In this model of practice, service providers
is team debriefing, which is done for teaching have personal responsibility to engage in
purposes. Third, the HVPI program deliber- role extension, enrichment, and expansion
ately places an emphasis on team building, through self-directed study, dialogue and
and there is ongoing discussion of issues interaction with other team members, and
related to group dynamics. This is considered self-appraisal and reflection. An attitude of
to be essential to the success of the model. openness to learning will enable them to em-
brace learning on the job. The skills necessary
IMPLICATIONS FOR SERVICE for collaborative interprofessional teamwork
PROVIDERS AND FAMILIES include listening and communication skills,
negotiation skills, skills in giving and provid-
Ensuring role clarity ing feedback, and skills in resolving conflicts
and reaching consensus (King, Batorowicz,
The intensive collaborative teamwork
& Shepherd, 2008). As well, therapists need
involved in TA requires clear articulation of
to be aware of their personal zone of com-
team members roles and responsibilities.
fort in enacting interventions from other
Following family-centered service principles,
disciplines.
parents should choose their role in the service
delivery process, but this requires that they Meeting family needs
understand the options presented to them
TA is presumed to have benefits for fami-
and the intents and safeguards of TA. To nego-
lies, including less intrusion on family life, and
tiate and clearly articulate roles, the primary
better outcomes for children due to more co-
therapist requires a sound understanding
herent intervention plans and holistic service
of principles of interprofessional teamwork
delivery. However, many of these presumed
and needs to appreciate the importance of
benefits have not been evaluated, and it is im-
appropriate documentation. Detailed and
portant for service providers to understand
up-to-date dual purpose reports documenting
that TA may not meet the needs of all families.
roles and treatment plans are required to meet
They need to be able to recognize when the
the needs of both families and staff members.
transdisciplinary model is not the best option
Since goals change in an ongoing manner,
for a family. Customized services designed to
reports should be revised to capture these
meet child and family needs are paramount in
changes, thereby ensuring clarity and shared
ensuring optimal outcomes (King, in press-b).
meaning about who is doing what and
why.
IMPLICATIONS FOR PROGRAM
MANAGEMENT
Educational role of service providers
Service providers have an educational role Managers need to pay careful attention
in explaining the premises and evidence-base to the needs of individual practitioners to
of TA to families, and in fostering clear ex- facilitate their development of competencies
pectations about how services will be deliv- and expertise. Managers need to provide
222 INFANTS & YOUNG CHILDREN/JULYSEPTEMBER 2009

appropriate formal and informal professional CONCLUSION


development experiences (King, in press-
a); provide time for sharing, mentoring, This article has reviewed the literature on
coaching, giving and receiving feedback, and the transdisciplinary model of service, out-
reflection; and facilitate a learning-based and lining its basic premises and operational fea-
supportive team environment. Such an en- tures. The application of TA in a long-standing
vironment is fundamentally necessary for transdisciplinary HVPI has highlighted the im-
the success of TA. The managerial and team portance, in enhancing the success of this
resources required to successfully implement model of practice, of clear roles, personal
a transdisciplinary model are high, but the responsibility for professional development,
potential payoffs for children, families, and and a learning-based and supportive team
therapists development of expertise are environment.
considerable.

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