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Undergraduate Module #2
INTRODUCTION TO THE MULTIDISCIPLINARY DIMENSIONS OF CHILDREN’S
MENTAL HEALTH
This module will briefly outline the scope of mental health issues for children, thus articulating the need
for inter-professional practice. Children’s mental health will then be placed within the broader context of
two paradigms for understanding health and well being. These paradigms underpin the philosophies and
theoretical frameworks of the various professions. The concepts of health, illness, disease and disorder
will be defined. This is followed by a discussion on children’s mental health within the context of a health
paradigm including a brief historical context and definitions of mental disorder and mental health. This
leads to a discussion on the different systems involved including levels of intervention from front line
practice to policy, and a continuum of care from promotion to specialized care. Issues specific to interprofessional practice including definitions of discipline versus profession and multidisciplinary versus
inter-professional practice, roles and responsibilities of professionals, and collaborative care across
systems will then be outlined.
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Learning Objectives:
1. To become familiar with the two paradigms of health, the mechanistic model or medical model and
the vitalistic or holistic model and how these influence inter-professional practice in children’s mental
health.
2. To understand the different systems involved and the levels of intervention thus understanding the
magnitude of inter-professional practice in children’s mental health.
3. To have a basic understanding of the continuum of care in services.
4. To identify the various disciplines and their roles and responsibilities.
5. To understand the concept of collaborative care in relationship to multiple systems and services.
6. To have a basic understanding of strategies and skills for working within an inter-professional
practice context.
7. To have a basic understanding of the concepts of health, illness, disease, disorder, mental health,
discipline, profession, inter-professional practice.
Key Terms and Concepts:
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Mechanistic or Medical Paradigm
Vitalistic of Holistic Paradigm
Health
Illness
Disease
Disorder
Mental Disorder
Mental Health
Children’s Mental Health
Discipline
Profession
Inter-professional Practice
Multi-disciplinary Practice
Multi-professional Practice
Systems: Family/Community/Societal
Levels of Intervention: Micro/Mezzo/Macro
Continuum of Care
Promotion
Prevention
Early Intervention
Basic Mental Health Services
Specialized Mental Health Services
Primary/Secondary/Tertiary Care
Collaborative Practice
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Content Notes:
The Multi-Dimensions of Children’s Mental Health
Scope of Concerns
Two Paradigms of Health
Concepts of Health, Illness, Disease and Disorder
Children’s Mental Health Within Health Paradigm
Multiple Systems In Children’s Mental Health
The Systems
Levels of Inter-Professional Practice
Services in Children’s Mental Health
A Continuum of Care
Summary of Continuum of Care
Inter-Professional Practice
Discipline Versus Profession
Multi-Disciplinary/Multi-Professional/Inter-Professional Practice
Why Inter-Professional Practice?
Roles and Responsibility of Professionals
Collaborative Care Across Systems and Professions
Skills for Competent Inter-Professional Practice
Assigned Readings
Case Example
References
The Multi-Dimensions of Children’s Mental Health

Scope of Concerns
The scope of children’s mental health concerns are vast and can be categorized within three broad areas;
cognitive experience or developmental disorders, affective experience or mood disorders and relational
experience or behavioural disorders. The concerns affect the child, his or her family, the community and
society. Many diagnoses appear with comorbidity. (Refer to DSM IV for classifications and descriptions).
Sometimes, two general categories are used: emotional versus behavioural disorders that are synonymous
with ‘internalizing’ versus ‘externalizing’ conditions to describe psychiatric disorders. Developmental
disorders are often treated in developmental pediatric settings and although they are contained in the
DSM IV, are often viewed as different from a psychiatric disorder.
These classifications will be elaborated on in further modules. At this time, it is important to know that
the scope of concerns means that many professionals are involved in the diagnosis, assessment and
treatment of children with mental health concerns. Thus, there is a rationale for inter-professional
practice.
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Two Paradigms of Health
There are two basic paradigms of health: a mechanistic school of thought and a vitalistic school of
thought. Mechanistic thinking is the foundation for all allopathic medicine or the medical model. Basic
tenets include the perspective of the body as a machine made of various interlocking parts and function
that can be understood and treated in isolation of the other parts. An expert, the physician, is responsible
for diagnosis and treatment utilizing a diagnostic-cure approach. It is a biomedical orientation that
separates person from social environment and focuses on the individual. The person is understood in
terms of physics, chemistry, anatomy and physiology. It is very important in emergency care. This model
is responsible for corticosteroids and antibiotics that have had remarkable results in prolonging life and
relieving pain through the palliation of symptoms and organs.
Vitalistic thinking is the foundation for traditional Chinese medicine, shamanism, homeopathy, the
medicine wheel, chiropractic and other so-called complimentary medicines. Basic tenets include the
perspective of a living system that is more than the sum of its parts and a body that is animated by an
organizing and vital force that directs the body and its healing process. The person, not a designated
expert, assumes responsibility for choice and healing. There is an acknowledgment of a context or a force
outside the individual. Thus, rather than a focus on the individual, the focus is on the whole which sees
the individual as one component.
No one system of medicine has all the answers. An either/or approach is limiting. An integrated approach
bridges the gap between mechanistic and vitalistic perspectives and promises a model that builds upon the
strengths of each. The trend in health care has been to integrate the perspectives and preserve the
strengths of each.

Concepts of Health, Illness, Disease and Disorder
The following provides some definitions of the concepts of health, illness, disease and disorder.
Health is a “state of complete physical, mental and social well-being and not merely the absence of
disease” (Constitution of the World Health Organization)
Both the Alberta and Ontario government define fundamental conditions for health to include peace,
shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity;
improvement in health requires a secure foundation in these basic prerequisites. Health is an
encompassing concept to denote well being at the personal, familial, communal and societal levels.
However, the concept of illness, not health, has been typically the central concept in health care. Illness is
an experience or that which is experienced.
“ Illness is … not the established result which scientific medicine declares as illness but, rather,
the experience of the person suffering..” (Gadamer, 1996, p.55)
“…illness is both subjective experience and observed appearance and behaviour. The distinction
is important between illness experience, the distress, suffering, and perceived loss of well being,
and illness behaviour, the impaired functioning that is observed by others and is attributed to
illness”. (Wynne, Shields& Sirkin, 1992, p.31)
In contrast to illness, disease is usually a biologically defined entity that exists within an individual.
Eisenberg (1977) states that “patients suffer ‘illness’; physicians diagnose and treat ‘disease’ (p.11).
“What is perceived by patients (and their families) as illness and what is viewed by health care
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professionals as disease involve fundamentally distinct constructs of reality…” (Wynne, Shields & Sirkin,
1992, p.7)
Disease is thus a medical professional construct “about a condition with more or less discretely identified
characteristics” (Wynne, Shields & Sirkin, 1992, p.7).
When a pathophysiological etiology has not been established then the terms “disorder” and “syndrome”,
a pattern of signs and symptoms, are commonly substituted for disease.
A mechanistic model of health is defined as a state when symptoms or visible manifestations of disease
are not evident. A vitalistic view identifies health as more than the absence of disease and as a sense of
well-being on physical, mental, emotional and spiritual levels. As with all concepts, health is culturally
defined. Spector (1996) fully examines cultural diversity in health and illness.
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Children’s Mental Health within a Health Paradigm
Brief Historical Context:
Children’s mental health was first addressed within the domains of psychology and then psychiatry, both
focusing on the individual. While psychiatry was considered a part of medicine, rooted in a mechanistic
paradigm, in its early development it was kept in a marginal position. Disease of the mind was explained
in physical terms, that is, an organic approach. However, mental disturbances, such as psychoses and
schizophrenia, were observed as psychological phenomena with obscure causes that did not respond to
medical intervention. Thus, psychiatry was on the periphery of medical practice. With the works of Freud
and the advent of psychoanalysis, psychiatry became a more accepted branch of medicine that attempted
to find a psychological explanation for mental disturbances.
Until Freud’s influence, psychologists’ observations of normal children had more impact on the
development of what is now child psychiatry than the writings and works of psychiatrists. Educational
reforms that emphasized the educability of mentally retarded children, the child-guidance movements,
and the attention given to the delinquent child were social movements that influenced the development of
child psychiatry. The mother-child relationship was pivotal in understanding pathology, with mothers
blamed for dysfunction.
Over time, children’s mental health has shifted from a medical/psychological perspective towards an
integrated perspective. This is a shift from institutionally-based treatment to community-based treatment,
directive care to supportive care, medical/disease based focus to health/prevention focus, passive patient
to consumer/participant, isolated care to connected/integrated care and individual focused to
family/community focused.
What is important in understanding inter-professional practice is that the two paradigms of health
influence the philosophical underpinnings of the various professionals. The medical model has strongly
influenced psychiatry, psychology and nursing. An ecological or more vitalistic model underpins social
work. An assessment by a psychiatrist, a psychologist and a social worker will have differing purposes
and thus, will provide different information. When integrated, these should complement and enhance the
understanding of the child within his or her context.
Mental health professionals tend to identify with biological, psychodynamic, behavioural, interpersonal,
social and existential groups or schools (Klerman, Weissman, Markowitz, Glick, Wilner, Mason & Shear,
1994). Ideological and theoretical differences contribute to inter-professional tensions with those involved
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in psychotherapy and pharmacotherapy in rivalry positions in the marketplace for patients or clients and
in the scientific and intellectual marketplace (Klerman et al., 1994).
Definitions of Mental Disorder and Mental Health:
Although there is no widely accepted definition of mental health, the concept is rooted in the study and
treatment of mental disorder. A mental disorder is a “medically diagnosable illness that results in the
significant impairment of an individual’s cognitive, affective or relational abilities” (Health and Welfare
Canada). They can develop from biological, developmental and /or psychosocial factors. Even if the
mental disorder is serious and/or chronic, it is never the only determinant of mental health. Since 1980,
the Diagnostic and Statistical Manual of Mental Disorders (DSM), a descriptive system developed by the
American Psychiatric Association, has become the major basis for diagnosing patients. Frances (1995)
developed a guidebook to using the DSM states:
The DSM “mental disorders” are best understood as descriptive syndromes
likely to assist in our increased understanding of the underlying disease, but only
in selected cases do they as currently defined actually represent such diseases
(p.17)
The American Psychiatric Association divides ‘psychiatric conditions’ into three major groups:
1. Those conditions caused by or associated with impairment of brain tissues such as trauma,
infection or metabolic disturbances
2. Mental deficiency
3. Disorders without clearly defined clinical cause, those not caused by structural change in the
brain, and those attributed to psychogenic causes
Mental health is a broader concept. It is the “capacity of the individual, the group and the environment to
interact with one another in ways that promote subjective well-being, the optimal development and use of
mental abilities (cognitive, affective and relational), the achievement of individual and collective goals
consistent with justice and the attainment and preservation of conditions of fundamental equality (Health
and Welfare Canada).
A child’s mental disorder may be well managed with medication but his or her mental health may be poor
because of poverty, family violence, an unsafe neighborhood, and/or stigmatization by friends.
Children’s mental health is usually conceptualized with a focus on growth and health in all domains of the
child’s life. Adult mental health is usually conceptualized as mental illness or within the context of
diagnosed disorder with a focus on pathology. Having said this, children’s mental health is often, in
practice, understood from a framework of dysfunction and pathology rather than from a framework of
strength and resiliency. Children and adolescents with long-term needs who have severe and/or chronic
conditions require high levels of services. The term most widely used to describe this population is
“severely emotionally disturbed”.
In 1970, the Joint Commission on Mental Health of Children defined the emotionally disturbed child as:
“… one whose progressive personality development is interfered with or arrested by a variety of
factors so that he shows an impairment in the capacity expected of him for his age and
endowment: 1) for reasonably accurate perception of the world around him; 2) for impulse
control: 3) for satisfying and satisfactory relations with others; 4) for learning; or 5) for any
combination of these (p.253).
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Most definitions of mental illness in children include these five factors but Looney (1988) argues that
these broad definitions are problematic in epidemiological studies because the criteria are difficult to
operationalize. He further queries if they should they be operationalized differently for the various
developmental stages and for different ethnic and cultural groups.
What has been most interesting in compiling this information in this module, is the lack of a clear
definition of children’s mental health. Most references speak of the concept with no definition given.
There is an assumption of a known or understood definition.
The Multiple Systems in Children’s Mental Health
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The Systems
Given the multiple aspects of children’s mental health, it is critical to understand the child within the
context of the family, the family within the context of the community, the community in the context of
society at large. Perspectives, such as eco-systems perspective, person-in-environment model and
ecological theory, assert that human beings are organisms that are constantly involved in reciprocal
interactions with their environments. Individuals and their environments are “mutually shaping systems,
each changing over time, each adapting in response to changes in the other” (Garbarino, 1982, p.16). The
following briefly describes the family, community and societal systems that are integral to the mental
health system.
The Family System: There are many family structures ranging from single parent, two parent, extended
family, blended family, adoptive family, foster family, large kinship families. These provide the context
for development physically, emotionally, socially and mentally. Families typically are the care providers
of children. The child’s most immediate environment is interpersonal.
The Community System: The community provides the context for the family. Within this context are the
systems of education, social welfare, criminal justice, mental health and physical health. How they
interface in a reciprocal manner with the child within the family can be either detrimental or enhancing to
mental health. The contextual environment for the child is the interface of school-family, family-work etc.
Despite a nurturing and well-functioning family environment, if the family has few community supports
and/or negative interactions with resources such as the school, is poor and has limited resources and is
isolated in an unsafe neighborhood, the child’s mental well-being may be compromised. In other words,
the family cannot function in isolation of the community in which it lives.
The Society: Society is shaped by a dominant paradigm that influences customs, norms, values and
beliefs that in turn shape laws, policies, practice and services. What is normal, what is acceptable, what is
right, what is privileged, is defined within this larger environmental context. Mental illness is a social
construct; thus its presentation, its definition and its treatment must be understood as such.
The Mental Health System: The multiple systems, both within the family, the community and society
and then across these three domains as they relate to the child’s mental well being, comprise the mental
health system. This system is complex. The primary systems are: family, school, medical and allied
health, and community services such as daycares, the Boys and Girls Club and other recreational services.
As concerns become more severe, the social welfare system and the criminal justice systems are involved.
Systems of care, the systems within mental health that provide services to children, traditionally were
either psychiatric inpatient services in hospital settings or free-standing clinics or community health
clinics. Services were often provided with little interface with other systems. Thus, services were
fragmented and interventions were specific to one area of concern.
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Over time, packages of care, called wraparound services that addressed the totality of the health, mental
health, educational and social needs of each child and family have become the desired system of care.
Implicit in this strategy is coordinated clinical case planning, advocacy, management, and therapeutic
services embedded in “a mosaic of systems” in which parents are important participant providers (Solnit,
Adnopoz, Saxe, Gardner & Fallon, 1997). Intervention is planned around the individual needs of the
child. The “mental health system of the future” promises increased capacity in the community to deal
with crisis and acute illness with supports such as community outreach programs, in-home support,
respite care, and education for family members and the general public (Mental Health Care at the
Crossroads, 1997).
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Levels of Inter-professional Practice:
There are three levels of practice: micro, mezzo and macro. Micro refers to practice with the child in the
family context. This would include assessments, therapy, brokerage and advocacy for services specific to
that child and family. This is often referred to as clinical practice. A mezzo level of practice includes
assessment and intervention at a community level, such as developing fast track programs, responsible
childcare programs, respite care for families, public education, and prevention programs. This is often
referred to as community practice. The third is macro level, which refers to assessment and intervention at
a societal level including legislation and policy making.
This conceptual framework can also be applied to levels of practice within a service of care. The micro
level is the front line worker or provider of service. The mezzo level is management and the macro level
is administration and policy and procedures that guide practice.
Services in Children’s Mental Health

A Continuum of Care
As adapted from Working in Partnership, August 1993, there are five areas of service on the continuum
of care in children’s mental health. These are promotion, prevention, early intervention, basic services and
specialized services.
Promotion: Promotion is public education targeted at the general population. The goal is to give the
public an awareness and understanding of health/mental health. Advertisements for healthy eating that
includes five daily servings of fruit and vegetables are an example of promotion. Other determinants of
health such as adequate housing, exercise, proper sleep, and the effects of drugs, cigarettes and alcohol
are other areas that promotion addresses.
Prevention: Promotion targets the general population while prevention targets at risk populations (see
McWhirter et al. 1998). At risk denotes a set of presumed cause and effect dynamics that place the child
or adolescent in danger of negative future events (see Rutter, 1985,1987,1990). Individuals in at risk
groups are vulnerable to a specific outcome. At risk populations are children who live in poverty, whose
parent(s) has a mental illness, who live in violent families and/or with few supports and resources or
unsafe neighborhoods. Risk is on a continuum; minimal, remote, high and imminent. Examples of
prevention would be a community coalition to address poverty or the development of recreational services
in a ghetto area. The primary goal of prevention is to provide children and their families with resources
that prevent ill health and mitigate risk factors.
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Typically, promotion and prevention are termed primary level interventions but some typologies also
include early intervention as primary level care.
Early Intervention: In early intervention, the child’s risk has been identified but symptoms have not yet
affected functioning. The primary goal is to identify and address concerns early in the child’s life to
prevent further progression of symptoms, to provide support and to teach strategies to cope. An example
is a teen parenting support group. A further goal of early intervention is to facilitate resiliency.
Recent studies examining the relationship between quality of child care on early brain development
indicate that care that does not provide sufficient stimulation, safety and nurturance during the first three
years of life compromises the development of the neuronal networks critical to normal development
(Shore, 1997). Early intervention would be providing adequate child care services. Or, for example, in the
case of children whose mothers abuse drugs and alcohol during and following pregnancy, the child
welfare system may intervene to place supports in the home or remove the child to a healthier
environment.
Basic Services: Basic services address those children and their families who have identified symptoms
that affect functioning. If a child has been diagnosed with a pervasive developmental disorder, he/she
might be placed in a community early intervention program such as a specialized daycare. Basic services
include community/school programs and short-term counselling. The primary goals of basic services are
to decrease symptoms and increase the level of functioning. They also promote well being and build on
resiliency or competence.
Early intervention and basic services are typically termed secondary level care interventions.
Specialized Services: Specialized services target children and their families with severe or persistent
symptoms that result in significant disability and/or dysfunction. These services typically are long term
and labour intensive. They involve multiple systems and professionals and thus are tertiary care level
interventions. The primary goal is to further assess and intervene to manage the disability and/or
dysfunction over the long term.
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Summary of Continuum of Care
Moves from Promotion to Specialized Services
Target population narrows
Severity of the problem increases
Resource demand and costs increase
Level of care moves from primary to secondary to tertiary
Age of child increases as does risk for further dysfunction
Family’s resiliency and coping is severely challenged
Community and societal risks increase
Follow up and ongoing support is a critical component, often omitted or poorly done by services. It is
essential that once a child is identified at risk and enrolled in an early intervention program that the child
and family are followed after completion of the program. The child and family need support and
appropriate resources to prevent escalation of concerns and to build competency skills.
As families and children move across the continuum, they have more professionals involved in their lives,
both in numbers and in intensity of service. This often undermines resiliency and competency, can foster
dependency on the system, and can result in fragmented services. Disempowerment can occur at all
levels, from the child and family to the service providers.
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As the child and family move across the continuum of care, inter-professional practice must be more
attentive to integration and collaboration of services. At all points in the continuum, accountability,
evaluation, advocacy, training of professionals, supports and resources and research are integral
components.
Inter-Professional Practice
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Discipline versus Profession:
Discipline refers specifically to an area of study or a branch of science, such as law, education, sociology
and biology. Profession refers to a group of practitioners who have a particular set of values, ethics, skills,
and practice methods, such as lawyers, teachers, social workers and nurses (Geva, Barsky & Westernoff,
2000, p.4)

Multi-Disciplinary/Multi-Professional /Inter-Professional Practice
Multi-disciplinary or multi-professional are often used interchangeably. The term implies that more than
one professional is involved with a particular client. Often there is a team composed of professionals from
various disciplines such as speech language pathology, occupational therapy, nursing, social work,
psychology, psychiatry and pediatrics. They all work within a setting that has a defined philosophical
framework with policies and procedures that define practice and standards of care. However, even though
they may work as a so-called team, their practice may be quite independent of each other and not involve
a high degree of interaction. They may consult with one another and work with the client in a sequential
series of interventions, but their goals and interventions are directed by their discipline’s theoretical
perspective rather than a common focus and purpose (see Geva, Barsky & Westernoff, 2000)
The fact that many disciplines work within the same setting does not constitute inter-professional
practice, which holds as its basic tenet a working together in a non-hierarchical, respectful and collegial
manner towards the common good of the client. Inter-professional practice suggests a “highly integrated
approach to assessment and intervention, one in which practitioners from different professional
backgrounds come together to work with clients/students/patients” (Geva, Barsky & Westernoff, 2000,
p.3). In many settings, hierarchical issues related to power and responsibility may challenge the functional
working of inter-professional practice. For example, the psychiatrist, the physician of record, in a hospital
setting, is ultimately responsible legally for the care of the patient/client and may thus unilaterally make a
treatment decision that does not necessarily have the support of other professionals. In another situation, a
child welfare worker, within the mandate of the law, may apprehend a child contrary to the position taken
by the teacher and social worker involved with that child.
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Why Inter-Professional Practice?
Geva, Barsky and Westernoff (2000, pp.5-6) present the following reasons:
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It is a response to the increasing specialized nature of human services and the fragmentation
of resource allocation
To better understand the person as a whole; person-in environment/ecological model and thus
provide better service
Complexity and chronicity of cases are increasing and demanding more collaboration of
expertise
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Can lead potentially to more cost-effective use of limited resources in health, social,
educational and legal systems
Roles and Responsibilities of Professionals
The roles and responsibilities of individual professionals are defined by professional codes of ethics and
standards of practice and are shaped by the expectations and mandate of the institution or mental health
setting wherein the professional works. Thus, what a professional does in one service context may be
different from what is practiced in another setting. For example, a psychiatric nurse in an inpatient setting
may administer medication, assess the child and family from a systemic perspective, develop individual
treatment programs and provide psychotherapy to the child and/or family therapy. Her roles and
responsibilities may overlap with those of a social worker and they may work together as a team. In
another setting, such as a school, the nurse may be responsible for addressing health concerns and for the
administration of psychotropic medications and the social worker responsible for individual work with the
child. In this example, within the school context the scope of practice is much more limited.
It is essential in inter-professional practice to understand the differences, not only in individual
professional practice but to understand the context in which practice occurs. To compound the complexity
of this are differences related to clinical experience, skill and expertise. Some psychologists, although
knowledgeable about many modalities of practice, utilize primarily a neuropsychological approach or a
behavioral cognitive approach. Their area of practice is highly specialized. Another psychologist may
have expertise in hypnosis, EMDR, family therapy, group psychotherapy and thus practice from multiple
perspectives using multiple modalities.
Towards the end of the 1980s, there has been a trend to streamline health care services with attempts to
redefine professional roles by function based on the needs of the individual rather than discipline specific
training. Thus, there was cross-training and trans-disciplinary teams with members (e.g., social workers
and psychologists) fulfilling some identical roles and blurring the recognition of discipline or professional
specific practice.
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Collaborative Care across Systems and Professions
Collaboration is a relational system in which two or more stakeholders pool together resources in order to
meet objectives that neither could meet individually (Graham & Barter, 1999). “Terms such as advocacy,
coalition building, communicating, consensus building, consortium work, cooperating, coordinating,
empowering, networking, partnership building, relating, striking a therapeutic alliance or task force can
be part of the broader umbrella of ‘collaborating’ …” (Graham & Barter, 1999, p.7).
Cooperation, which differs from collaboration, facilitates support and assistance for meeting goals. It is a
working together. Coordination includes joint activity and working together with individuals setting their
own goals, expectations and responsibilities. Thus, on a well-functioning multi-professional team there
would be cooperation and coordination between the professionals as each assesses the child and family.
Collaboration goes beyond this to include a commitment of all the stakeholders to mutually agreed upon
goals based on an established value base and has the basic tenets of shared decision making and
ownership (Graham & Barter, 1999). According to Bruner (1991), it requires joint goals to guide
collaborators’ actions. Stakeholders can mean two or more different disciplines or more commonly in
connection with collaboration, it refers to different systems such as the mental health system and the
education system.
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Children’s mental health is currently seen as under-funded and lacking in services and trained
professionals. Collaborative care refers to developing a service for children that includes the school,
social services (including child protection, foster and respite care) the corrections system, and other
community services. This means a coming together of the stakeholders to define a common problem,
establish common purposes and goals, and develop and implement a plan of action within a structure that
nurtures, evaluates and sustains collaboration (see Graham & Barter, 1999; Gray & Wood, 1991; Weil,
1996; Wimpfheimer, Bloom & Kramer, 1990). In its ideal state, this would be a seamless system wherein
the child moves within and without the various domains to have his or her needs met without duplication
of services and with a consistent treatment approach.
As is evident, this level of collaboration in children’s mental health services is very complex. It
necessitates a common philosophy, set of values, a common language of communication and a
sophisticated information system and so forth. It means a willingness to share power and resources; a
challenge in a resource scarce environment that has bred competition, power struggles and hierarchical
relationships, all of which have not served the needs of children well.
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Skills for Competent Inter-professional Practice
Collaborative practice is a postmodern perspective that is based on a social constructivist perspective that
acknowledges and values multiple realities. Thus, an essential skill is an openness to difference that
includes a capacity to listen, to be respectful, and to understand the implications of other professional
opinions, including those of the child and family. The focus must be on the best interest of the child and
family, not on positions (Bernard, 1989). Power differentials and professional hierarchical structures with
intrinsic expertise based on beliefs and values, or in simple language, turf problems, are the greatest threat
to competent inter-professional practice.
To provide for the best interest of the child and family demands a common language and common goals.
It entails thinking differently about providing flexible services to children and their families that are based
on their needs, not on the dictates of services or programs. It includes a comprehensive approach that
integrates multiple domains of life and builds interventions on strengths while also addressing
dysfunction. Thus, the inter-professional practitioner must not only have skills within their scope of their
discipline, but must have exceptional skills in conceptualization, planning, organization, flexibility and
openness, integration, mediation, cooperation and collaboration.
The challenge is to operationalize this!
Assigned Readings
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Case Example: Case Example Illustrating Inter-professional Practice:
To exemplify this, let us examine the presentation of a 12 year old child who presents with flat affect, is
withdrawn in the school situation, is achieving two grades behind the expected level and is beginning to
refuse to attend school, has difficulty sleeping, has dropped out of extracurricular activities after school
and complains of being very fatigued and lethargic. His mother is concerned that the child is pale and
stays in his room, often just lying on his bed. The psychiatrist would obtain a complete family medical
and psychiatric history and would first rule out an etiologic organic factor by doing a physical
examination and ordering appropriate tests such as blood work. From a medical perspective, the
psychiatrist would conclude with a provisional or confirmed diagnosis and prescribe the necessary course
of treatment including pharmacological and psychotherapeutic interventions. For the sake of this example,
the diagnosis is Dysthymia, a primary type with early onset, and with the query of a developmental
disorder.
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The social worker would meet with the child and family to do a psychosocial assessment that would focus
on family relationships, communication, dynamics, functioning, supports, relationships with other
systems such as the school, and with an assessment of strengths and vulnerabilities. From this the social
worker might assess the family is a recently blended family and is beginning the process of redefining
relationships, boundaries etc., that they have good social supports and overall have many strengths.
However, the identified problematic child is in a power struggle with his stepfather, who is of Chinese
descent and who has high academic expectations thus seemingly to exacerbate the school concerns. The
mother is protective of her son and has aligned with him against her spouse around the school issues. The
relationship with the school is stressed. The stepfather becomes angry with his stepson and sees him as
lazy. Thus, the boy’s behaviours in a reciprocal manner influence the family functioning and are
influenced by the family.
From these two initial assessments a referral was made to a psychologist who using standardized
measures did some cognitive and emotional testing. It was ascertained that the boy had a developmental
expressive writing disorder and some generalized anxiety around learning, felt incompetent as a learner
and was fearful that he was not acceptable to his stepfather. Thus, both learning and emotional needs were
identified.
The understanding of the child from these three assessments is far more comprehensive than if only one
perspective was obtained, thus arguing for the need for inter-professional practice. Interventions might
include a medication trial, negotiations with the school for some individualized programming, some
family therapy that is culturally sensitive to enhance a systemic understanding of the concerns and help
the family create solutions built on their strengths, and some individual therapy for the child using
cognitive behavioural strategies to enhance his sense of competence and self acceptance, and to develop
strategies for attending school and succeeding as student. From this example, it is apparent that the three
disciplines within this mental health team all contribute to the understanding and solutions to the
presenting concerns. Key is the acknowledgment of the child and family as active participants and
stakeholders in the interventions.
However, without the inclusion of the school, another system separate from the mental health system and
the family system, success of the interventions would predictably be limited. Practice now is expanded
from different professionals within one system to two different systems which both have different
agendas, policies and practice. The school system includes the professionals of teacher, resource teachers,
psychologists, social workers, family support workers, and community health nurses. The child and his
family interface with both systems and as such can be triangulated or caught in the middle of two
systems. Intervention has moved beyond simple interdisciplinary teamwork within a mental health setting
to collaboration across the systems, as the various professionals define roles and responsibilities.
Should the presenting problem over time intensify and the child become truant and engage in antisocial
behaviours, and the family become more stressed, other systems of care such as the child welfare and
legal system and the criminal justice system could become involved. Thus, there is a continuum of care as
concerns are not adequately addressed or as they continue to intensify and/or follow a predictable
developmental pattern.
Questions Arising From the Case Example:
Is the case example one of multidisciplinary/ multiprofesional practice or does it exemplify interprofessional practice? How do you distinguish the two?
Undergraduate Module #2 - Introduction to the Multidisciplinary Dimensions of Children’s Mental Health 13 of 16
What frameworks underpin the different professional assessments? How do these compliment or not
compliment one another?
What components are missing in this example?
Identify your profession and then articulate how you would contribute to this case. If you were
responsible, how would you proceed?
Materials Needed:
DSM IV
See List of references for suggested readings.
Review Questions:
What is your understanding of a mechanistic versus a vitalistic model of health?
How do you define health, illness, disease and disorder?
How do you understand the concept of children’s mental health, and what do you think are the critical
components?
Who are the professionals involved in children’s mental health?
What are the systems involved in children’s mental health?
How do you understand inter-professional practice? What are the strengths and the challenges of this
approach?
What has been helpful for you in this module? What would enhance this module?
14 of 16 Undergraduate Module #2 - Introduction to the Multidisciplinary Dimensions of Children’s Mental Health
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Gadamer, H. (1996). The enigma of health. Stanford,CA: Stanford University Press.
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