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Child Abuse and Neglect, Vol. 4, 1980, 137-144.

Interdisciplinary Group Process in the Hospital Management of Child Abuse and Neglect

RICHARD BOURNE, J.D., PH.D.

Attorney, Trauma X Group, Children's Hospital Medical Center Boston, Massachusetts, and Associate Professor of Sociology Northeastern University, Boston, Massachusetts

ELI H. NEWBERGER, M.D.

Director, Family Development Study, Children's Hospital Medical Center Boston, Massachusetts, and Assistant Professor of Pediatrics Harvard Medical School, Boston, Massachusetts

Abstract—The group process aspects of child protection in a children's hospital are examined. A team approach to case management enables personal support for individual members experiencing the strong emotions attached to protective service cases, eases the burden of individual decision-making, and divides the complex tasks of data gathering and analysis. Confusion is fostered by inattention to personal and group expectations, individual roles, the status structure, and the methods for maintaining social cohesion. A team handbook may help to standardize decision-making, but in such efforts to reduce conflict, group norms may be obscured. Task-oriented and social-emotional norms are discussed, and guidelines are offered to foster a more adequate approach to group problem solving.

Resume—PRISE EN CHARGE À L'HÔPITAL, DES CAS DE MAUVAIS TRAITEMENTS ET DE NÉGLIGENCE À L'ÉGARD D'ENFANTS: L' APPROCHE INTERDISCIPLINAIRE-Les auteurs, travaillant dans un hôpital pédiatrique, se sont intéressés à l'approche en groupe du problème de la protection de l'enfance.

La prise en charge et la conduite d'un cas en équipe a l'avantage d'offrir aux membres de l'équipe le soutien psychologique dont ils ont besoin ; cette méthode diminue la charge que représente la prise de décision par un individu isolé, et facilite le travail compliqué que représentent la récolte des informations et leur analyse. On tombe dans la confusion, cependant, si l'on ne fait pas suffisamment attention aux besoins individuels et aux besoins du groupe, aux rôles individuels, à la structure de la fonction, et aux méthodes destinées a maintenir une certaine cohésion sociale. II est utile d'avoir à disposition des directives écrites à l'usage de l'équipe et destinées a uniformiser le processus de décision, mais de tels efforts en vue de diminuer les conflits peuvent reléguer au second plan les buts idéaux du groupe. Les auteurs se sont particulièrement intéressés aux règles établies en fonction des buts poursuivis et des situations sociales et affectives; ils offrent des directives destinées à améliorer l'approche du problème par le moyen du travail en équipe.

INTRODUCTION

Although the purpose of this paper is to discuss some of the management problems of multidisciplinary child abuse teams, we would first like to comment more generally on the present state of child protection.

These are troubled times for those concerned with the protection of children. Fifteen years after the promulgation of a model child abuse reporting law by the Children's Bureau, a law which was adopted in principle and subsequently broadened by every state, we are struggling to come to terms with a near-deluge of reported cases of child abuse and neglect.

Not only are scarce child welfare resources strained to meet the enormous demand, but also the very ability of child protective services to address the needs of troubled families is increasingly brought into question.

Concern for the Quality of Protective Service Practice

The steady expansion of the definitions of child abuse and neglect in state reporting laws, for example, is sharply questioned in the draft child protection standard of the American Bar Association's Juvenile Justice Standards Project. The underlying premise of this volume of the Project, which we have addressed elsewhere [1] is that the sanctity of the family must be preserved from the blundering efforts of state social workers. The basis for juvenile court jurisdiction is narrowed, too, in this model legislation, which would, in addition, make the professional reporting of child neglect discretionary rather than mandatory.

Further criticism of the quality of protective service practice appears in the initial volume of the report of the Carnegie Council on Children, 1977. After questioning not only the competency but the good faith of child welfare workers, the Commission endorses the findings and recommendations of the Juvenile Justice Standards Project. To quote from its report:

Large numbers of American families frequently find themselves in economic and emotional distress. Whether they are victims of chronic fatigue or of a crisis ranging from unemployment, not enough money, and depressing living conditions to physical disabilities, alcoholism, or mental illness, most of these families could be significantly helped by very practical aids such as more money, better housing, homemaking assistance, employment counseling or training, or temporary respite from the children in day-care programs. Sometimes they may need family counseling or individual treatment of the parent. But the parents in these families are not necessarily unfit; they are often responding to tremendous pressures. All too often, an arrogant state legal apparatus invokes the doctrine that the parents are "neglecting" their children and removes the children without attempting to give the family the supportive help it needs-for example, the money to buy food, pay the rent, or pay the homemaker who could care temporarily for the children while the parent recuperates from illness or goes out to look for a job. Even conscientious social workers and court personnel often have no power to command the tangible resources that might help the family continue intact. All they have is the coarsest implement: removal of the child.

This means that well-intentioned and even not-so-well-intentioned courts and social workers, acting in the "best interests of the child," can impose their norms of morality and upbringing upon families. Families live differently from one another, they treat children differently, they expect different standards of behavior, and they punish differently. Most families accused of abuse and neglect are minority families with low incomes, often one-parent families. Judges and court personnel, on the other hand, generally come from quite another social, economic, and ideological world. Behavior that may be quite normal in another social milieu may be shocking to them in terms of their own, and as a result they can be too quick to condemn and not eager enough to invest time and attention in trying to help [2].

Workers in the child protection field must take these comments seriously. At the least, they will partially discredit child welfare work. This discrediting, in turn, may lead to even fewer resources being appropriated by state legislatures.

Need for Critical Scrutiny of Practice

To come to terms with this serious challenge to child welfare work, we urge workers in the field critically to scrutinize their practice. Our own work convinces us of the strength of an interdisciplinary approach to child protection, and we offer the following critical analysis of the group process aspects of child protection in a children's hospital. We examine group process with the goal of recommending improvements in trauma-x team functioning.

GROUP PROCESSES

The Trauma X Group

The Trauma X Group at Children's Hospital Medical Center is an interdisciplinary team consisting of a pediatrician, attorney, psychiatric social worker, psychologist, nurse and occasional other consultants, all of whom assist in the management of child abuse and neglect cases seen within the institution. The Group was organized in 1970. Since its inception, it has served to focus attention on child abuse and neglect at Children's Hospital, and an early evaluation suggested its effectiveness in promoting case management and in lessening reinjury [3].

When considering the formation of an interdisciplinary team, a crucial issue is the advantage of team structure as opposed to individual management and decision-making. If tasks can be performed by one person working alone, then group involvement is unnecessary.

Group Dynamics Theory

Group dynamics theory gives a framework for understanding both positive and negative aspects of a team approach. In general, two principles maintain:

1. For tasks which involve creating ideas or remembering information, there is a greater possibility that one of several persons will find a good solution or produce information than will a single individual [4].
2. When several individuals work collectively on a single task, a division of labor is possible. This division of labor allows individuals to perform the tasks for which they are most qualified; prevents or reduces overlapping activity; and allows decisions to be made more rapidly than would occur were one person responsible for gathering data from a variety of sources or specializations. Protective service work lends itself to such task division.

Child abuse and neglect involve many specialties, each of which has differing and unique definitions of the situation presented. If, for example, a child enters the emergency ward with a fracture, the physician might determine whether the nature of the break indicates inflicted trauma; the social worker would interview the child's parents in order to evaluate their capacity to protect the child and to form a relationship on which might be based a program to prevent the injury from reoccurring; and the attorney might consider the desirability of a restraining order to prevent removal of the child from the hospital prior to a full assessment. The primary rationale for an interdisciplinary team, then, is that many skills are required for effective task performance.

A team approach, moreover, has other functions or advantages specifically in regard to child abuse and neglect: first, these problems stimulate strong emotional reactions in all of us: anger, sadness, and frustration are all too familiar. If group management exists, members can support one another and allay some of the personal distress inevitably associated with tragedy; second, decision-making in this area affects family welfare and the safety and health of children. It is easier for a group to bear the consequences of its decisions than for an individual alone to select, and live with, his or her recommendations; third, abuse and neglect cases are complex and take much time and effort to resolve. A team is able to divide the labor in such a way that outcomes are facilitated.

Team management, on the other hand, may make for confusion and conflict unless the following issues are resolved:

1. What are the norms of group practice? (i.e., what expectations or "rules" exist within the group?). In order for a group to function effectively, there must be consensus about what rules apply to the group and to individual participants. For example, all members might agree that everyone need participate in decisions concerning case disposition (this is consensus on a group norm), but that levels of participation might differ according to the nature of the decision, the personality of the participant and the member's status and expertise (this is consensus on individual norms within the group).
2. What roles do individuals play? By the word "role" we mean not merely professional identification, but form of participation: asking questions or giving opinions, increasing solidarity or showing disagreement.
3. What is the status structure? In a hospital setting physicians usually have the greatest authority or influence. Groups in general might emphasize collegiality or hierarchy depending upon their task.
4. How is social cohesion maintained? In the interdisciplinary team, multiple divisions exist which potentially disrupt group unity and harm morale: differing professional orientations and commitments; ideological variations [5]; diverse interpersonal styles; race and social class distinctions.

Problems Implicit in Interdisciplinary Practice

Interdisciplinary teams, moreover, create problems which may decrease effectiveness:

1. When an expert maintains influence outside his own areas of expert knowledge. An example might be a hospital setting where a physician, because of high status, has his or her assessment of family dynamics accepted merely because no group member dares to question authority.
2. When a group member conforms in order to buy social approval. To take a position different from one's colleagues may invite rejection; it may be easier to conform to the opinions or evaluations of the other participants.
3. When the responsible person is unwilling to assume the risks involved in making a decision himself, problems are often referred to committees for decision [6]. The group process would be a diffusion or spreading of responsibility, resulting in an increased tendency to risk taking.

This result has both positive and negative aspects: it allows action to be taken when fear of consequences might be inhibiting; on the other hand, it allows single individuals to escape full responsibility for ineffective or damaging intervention.

An example of the positive aspect is a case in which a child was brought to the Hospital with severe skull fractures. The parents were affluent and had much influence in their community. When confronted with an evaluation that the injury was inflicted, they denied both neglect and abuse and threatened suit if the case were pursued. Team management not only made the data base more reliable and valid (e.g., by producing medical and social indices of abuse) but also allowed decisions to be presented to parents as a group consensus-an evaluation that was more difficult to confront, rebut or alter than would be a recommendation by a single staffer.

An example of the negative is when everyone's business becomes no one's responsibility. Accountability under such a system is impossible.

4. Cases, or individual responses to cases, become routinized. Professionals who have worked in child protection know how easy it is to confuse cases (mixing the facts of one abuse incident, for example, with that of another). It is equally common to fall into group or individual patterns so that certain types of cases are managed similarly despite differences in facts. For example, the team might have conferred on cases where addicted mothers neglected or abused their children; each time an "addicted mother" case appears, the same recommendations may be made despite differences in type or degree of addiction, family supports, impact of mother's addiction on her charge, etc. Or, for example, a social worker might have seen one of her cases successfully resolved through the court process; in most subsequent decision-making, court to her becomes a preferred alternative. Such patterns, reinforced by group norms, must be avoided in order that each problem be treated sensitively and individually. It is an unending challenge to think each case through anew, instead of responding automatically once certain information is communicated (e.g., mother must have abused her child because mother herself was abused when she was a child).
5. Group members, and other hospital staffers, become so accustomed to depending on others that they do not think and learn on their own. When a legal problem arises, for example, the lawyer is automatically consulted—because he might be offended were someone else to enter his turf or because it is safer to share decision-making. Such discussion occurs even when the same or very similar issues have been discussed before; individuals do not expand their expertise and time is wasted.
6. Team members do not understand group process. An understanding of group process is not inborn, but arises from learning and experience. It is important, therefore, that members become aware of such process, probably through the use of a groups expert. An example of misunderstanding might be the attribution of group "problems" to personality factors (e.g., "we don't like one another... that's why the team isn't effective") instead of a more sociologically-based analysis (intermember conflict is symptomatic of differences over group goals or objectives).
7. Intelligent problem solving is limited by the fact that different disciplines view the same data in different ways and that, across disciplines, there is an inability to understand the concepts and tools of other specializations. Each profession is oriented to specific ethics, goals and methods of practice.

For example, a sociologist analyzing the causes of abuse would look to the social context in which the behavior occurs-the strains or pressures that triggered aggression. A psychologist, on the other hand, might focus on the individual perpetrator. Examining past experiences as a predictor of present action he would ask, "What sort of a person would act in this way?" and would attempt to construct a psychological type from developmental history and from attitudinal/behavioral data. To a psychologist social context is often the circumstances precipitating violence, not the primary cause of such; the violence, defined as endemic, was probably inevitable despite the chance stimulus which induced it.

A lawyer, moreover, would probably belittle the sociologist's conception of social forces pressuring behavior; he might also reject the common psychological orientation that the human being is irrationally motivated by unconscious forces and drives established in infancy or early childhood. To a lawyer a person might be viewed as rationally able to choose among alternatives; possessing "free will," the person chooses to commit a criminal act (unless legally insane) and must bear the legal and social consequences of his behavior.

The legal perspective also may differ from that of the physician and social worker. Though interested in treatment of the violence-prone, the lawyer accepts the need for punishment: the criminal is a wrongdoer who is responsible for his deviance, not a victim exculpated by forces beyond control.

Norms, Roles, and Status Structure in Shaping Conflict and Consensus

After observing the Children's Hospital trauma team and its interaction patterns, we believe that the press for social cohesion is a most important determinant of its functioning.

Though the team's norms, for the most part, are not codified, there is a handbook written by the group which outlines the tasks each participant is to perform. It also attempts to standardize decision-making by indicating when various procedures are appropriate (e.g., the taking of a trauma case to court). This handbook is felt important because it educates members and lessens arbitrariness, but a latent function is the reduction of conflict. We attempt to use guidelines to avoid differences of opinion and to resolve those differences which do arise.

Information on child abuse, if shared, is another basis of team consensus. If all members agree that "a mother who was abused is more likely to abuse," then decision-making is simplified and group unity facilitated. Except for group benefits it apparently matters little that some of this commonly accepted information is untrue, only occasionally accurate, or simplistic [7].

Norms. Group norms also encourage cohesion and harmony. They might be divided into two categories: the task-oriented and the social-emotional. The task emphasis is on consensus decision-making; that is, all participants should agree with a particular course of action. If strong differences do occur, especially as between the medical and social work perspectives, nothing is done until they are resolved. Social-emotional norms include the following: don't lose one's temper in disagreement (disagreement should be resolved through rational discussion); and members should be supportive of one another (by showing solidarity).

Task norm. The following cases illustrate how group unity is maintained through consensus decision-making.

In the first case, a child was brought into the Children's Hospital emergency ward; black and blue marks were scattered across his body with no particular pattern. His mother reported that in the past such marks had spontaneously appeared and, after a few days time, had gradually faded. Medical staff suspected inflicted injury, a suspicion which grew after testing failed to detect any organic basis for the discoloration. A social worker met with the parents who seemed appropriate and apparently lacked the characteristics associated with abusers (i.e., they were not socially isolated; they did not hold unrealistic expectations for their son; etc.). The parents denied ever having left the child with another caretaker.

The trauma team met to confer on the case, and medical and social service staff were strongly divided as to the nature of the problem and the preferred disposition: the first group urged court as a means of conducting a more thorough evaluation of the family, while the second felt any action would be unjustified as the failure to find a medical explanation did not exclude its possibility. After much discussion the group decided to file a mandatory report to the Department of Public Welfare, a middle course which reconciled and satisfied all participants.

In a second case, a child residing in another state was admitted to the Hospital for back surgery. Staff nurses noticed that the patient seemed depressed and urged a psychiatric consultation. This evaluation revealed not only depression but also self-destructive tendencies, most of which seemingly originated from a disturbed relationship with her parents. The child reported, for example, that for the past several years she had been sexually abused by her father with the passive acceptance of her mother; that her father had been physically violent to both her and her mother; and that a protective action had been initiated on these grounds in family court of the state of residence.

The team was conflicted over the appropriate alternative: one member argued that because the child was in our institution we had an obligation to protect her; that such protection (and the concomitant services and supports) was surer in Massachusetts courts and facilities than in those out-of-state; that under no circumstances could she be discharged home; and that the preferred disposition would be the initiation of a care and protection petition in Massachusetts if parents were uncooperative toward the recommendation of residential psychiatric placement. A second member, on the other hand, argued that since the family lived out-of-state; since our involvement with the child had been brief; since out-of-state authorities were aware of and had taken action to resolve the problem, that we, after informing these authorities of our findings, should essentially adopt a "hands off" position. Indeed, as between discharging the child home and initiating a Massachusetts petition, the former was preferable as the girl's parents could not easily receive therapy (or be involved in their daughter's treatment) so far from home. Massachusetts, moreover, would likely be unwilling to provide services to (spend money on) out-of-staters despite its obligation to do so if it accepted jurisdiction of the case and legal custody of the minor.

As these competing positions seemed impossible to reconcile, the hospital administration was called upon to determine the nature and extent of team involvement. That is, when consensus was not reached, the administration acted as a mediator, resolving the dispute in a way that was agreeable to all and, thus, lessening the likelihood of a protracted difference of opinion which would undercut group unity.

Admittedly, it is easier to arrive at a valid decision if medical and social data are corroborative. In those cases where the different disciplines lead to different conclusions, however, not only is case management less confidently conducted but also the team is strained and cohesion undermined. Therefore, a tendency exists to: (a) reach a compromise acceptable to all; (b) make no decision until further data clearly make one position more credible; (c) allow the decision to be made by an "impartial" arbiter.

The importance of consensus orientation is its impact on families. If a decision is reached because it flows from the facts of a case, then intervention can be rationally justified. But if a decision is made, not because of case data but because of team dynamics and group unity, then it might assist the team to the detriment of parents and children alike.

Social-emotional norm. The social support norm is functional because of the stress of decision-making in trauma cases: a child improperly discharged home might return to the hospital reinjured while a decision to remove a child from biological parents obviously has much impact on a family and on those who must determine the child's "best interests."

Social support is also important because of the way the team is defined within the hospital setting. Generally hospital staff do not like trauma cases: they are complex, unpleasant, and demanding. Though the team is supposedly a consultative group, moreover, it is frequently seen as "taking over" from the treating physicians (e.g., when discharge is delayed because of family conditions despite the fact that the child is medically ready to depart): it is not clear, that is, what decisions belong to the team and how authority should be divided between the team and other hospital professional staff.

These two factors—nature of the cases and unclear relationships with personnel—strain communications and feelings between the team and others and make it more important for trauma members to support their colleagues. The more hostile the external environment becomes, in fact, the more cohesive do the members of the team seemingly become. Group cohesion is sometimes increased by this we/them orientation which implies that foolish decisions are made by others in the hospital (e.g. orthopedists mending a bone think that such treatment alone is sufficient to aid an abused child). This orientation stems from a legitimate concern that the needs of children and families are being slighted, but also from a fear that our expertise is going unrecognized or that lack of consultations will threaten team survival (by showing that our input is unnecessary to effective case management—or will be so perceived). In a sense, we must emphasize our own worth because we are operating in an environment too willing to dismiss us and our role.

Conferring on cases also fosters group cohesion. Individual members meet together and the meeting itself reaffirms team existence.

It must be added that conflict among team members is not necessarily destructive or dysfunctional for the group [8]. A lack of conflict, indeed, might indicate that the team structure is so fragile that no one would risk confrontation because of a fear of dissolution. If disagreements are hidden or remain unresolved, then hostility builds up in such a way that the slightest difference can spark sudden and intense rupture.

In our experience, how conflicts are handled, not their existence, is the more appropriate focus. Goffman distinguishes "backstage" from "frontstage" [9] —in this context, between team disagreement which is private and that which is public. Private divisions of opinion are healthy and lead to the education of individual group members as well as to more effective decision-making. Public disagreement, on the other hand, may embarrass participants and confuse those who desire and request consultation and input. If there is much interpersonal and interdisciplinary conflict, however, the quality of group decisions might lessen, task effectiveness being partially dependent on the relationship among team members.

Roles. After operating in an interdisciplinary setting for a period of time, the different participants become comfortable with the language and thought processes of the various specialties. The pediatrician, for example, might venture a psychiatric assessment or the social worker, a legal analysis. This crossing of disciplines, however, is usually done with the realization that turf is being violated: apologies are given ("I don't mean to get into your area"), statements qualified ("I'm no lawyer, but. . .") or immediate deference shown if the non-expert statement is challenged by the authority. In this way, members feel sufficiently free to transcend their narrow roles but not so as to threaten or question the capacity of their associates.

Implicit in decision-making is the feeling that the person with the most first-hand information should playa pivotal role; that the opinions of outside staff should be respected, if not accepted (otherwise the team will not be voluntarily consulted on future cases); that participation should come from all members; that those who have seen the child and/or family describe, while the rest either question or suggest; that the lawyer is the skeptic—probing conclusions (e.g., "the parents are disorganized," "mother is crazy") and emphasizing the need for objective data.

Status. Despite the fact that in the larger society, and in the hospital, a physician has greater status than a nurse or social worker the team operates under a norm of collegiality, i.e., that all disciplines are equally important in decision-making; that the quality and logic of a suggestion is more important than the person offering it; that no person or role has the right to veto a recommendation acceptable to other group members. This norm, too, increases individual assertiveness and the feeling that one may operate without fear of sanction—all of which leads to group morale, commitment and cohesion. Task effectiveness is likewise enhanced as no single discipline has greater knowledge or insight into child abuse management and thus, no single discipline should be accorded weight merely because of what it is as opposed to what it contributes.

One of the ways to share power is to rotate the conference chairperson rather than having the same discussion leader at each meeting. This device, of course, might merely disguise the true power structure, but if used properly, it can enhance team collegiality.

CONCLUSION

Guidelines for More Effective Interdisciplinary Practice

We conclude with the following recommendations to foster a more nearly adequate approach to group problem solving and practice in child protection work.

1. Promote understanding of group process in professionals of each discipline.
2. Enable communication and conflict both individually, between members, and in the larger group context, by structuring sufficient private time for the members of the group to use to promote cohesion.
3. Develop group consensus on leadership style and the flow of decisions. (Our preferences is for a collective and interactive, as opposed to a hierarchical, model of organization, with each discipline on an equal footing.)
4. Identify in all conferences—at the outset—decision points to be reached, and to the extent possible enable discussion of their consequences, for child, for family, and for professionals. At the end of each conference decisions made should be explicitly stated so as to avoid misunderstandings among participants.
5. Enable expression, at conferences, of each discipline's perspective on the available data. This can be facilitated by rotating the chairing of the meeting among disciplines, with the person from the group most knowledgeable on a particular case assuming the leadership role.

REFERENCES

1. BOURNE, R. and NEWBERGER, E., "Family autonomy" vs "Coercive intervention"?: Ambiguity and conflict in a proposed juvenile justice standard on child protection. Boston U. Law Rev.57(4): 670-706 (1977).
2. KENNISTON, K. and the Carnegie Council on Children, All our children. The American Family Under Pressure. Harcourt, Brace, Jovanovich, New York (1977) pp. 186-187.
3. NEWBERGER, E., et al., Reducing the literal and human cost of child abuse: Impact of a new hospital management system. Pediat. 51(5):840-848 (1973).
4. COLLINS, B., GUETZKOW, H., A Social Psychology of Group Processes for Decision-Making. Wiley, New York (1964) p. 20.
5. ROSENFELD, A. and NEWBERGER, E., Compassion vs control: Conceptual and practical pitfalls in the broadened definition of child abuse. J. Amer. Med. Assoc.237:2086-2088 (1977).
6. MARQUIS, D.G., Individual responsibility and group decision involving risk. Indust. Manage. Rev. 3 (1962).
7. GELLES, R., Violence towards children in the United States. Am. J. Orthopsychiat.48:580-592. The estimates of the prevalence of family violence which can be drawn from this study suggest that there are many more child and adult victims of abuse than previously believed; the data impel re-examination of the common wisdoms which are based on studies of small samples of "caught" cases. We have compiled a series of essays which challenge existing assumptions in the protective service field in Bourne, R, Newberger E (eds): Critical Perspectives on Child Abuse. Lexington Books, D.C. Heath, Lexington, Massachusetts (1979).
8. COSER, L., The Functions of Social Conflict. Free Press, Glencoe, III. (1956).
9. GOFFMAN, E., The Presentation of Self in Everyday Life. Doubleday, Garden City, N.Y. (1959).

Presented in part at the session honoring Professor C. Henry Kempe with the first Vincent DeFrancis Award at the Eighth National Symposium on Child Protection, American Humane Association, Honolulu, Hawaii, October 8, 1977

The work presented in this paper was supported in part by grants from the Administration for Children, Youth, and Families, Department of HEW, (Project OCD-CB-141) and from the National Institute of Mental Health (Grant I T01 MH15517 01A2 CD).