Child Abuse Training: A Community-Based Interdisciplinary Program Elizabeth Elmer, M.S.W.* Harriet G. Bennett, M.S.W. Norman Harway, Ph.D. Erma T. Meyerson, M.S.W., M.A. Carol G. Sankey, B.A. Lois Ann Weithorn, M.A.
ABSTRACT: In the area of child abuse, a scarce resource is trained personnel. This paper describes a training program focusing on the need for individuals representing diverse disciplines to work together. Subjects discussed are the rationale and the organization process for a multidisciplinary, community-based training program; the formulation of the educational experience and the curriculum; evaluation measures; and the implementation of the program in a typical site. Various activities related to child abuse have been initiated in communities where training has occurred. Plans are to provide more intensive training in the treatment area for those professionals trained so far.
Reliable estimates indicate that 1 million abused or neglected children will soon be reported each year in the United States (Besharov, New York Times, 1975). These reports stem from the child abuse reporting laws common to all the states since 1967. Many statutes have since been broadened to include a greater range of reportable deviant child care-for example, mental injury and sexual abuse and various states have expanded the categories of professionals mandated to report. The number of reports in some states has already reached overwhelming proportions (Child Protection Reports, 1975). In some of the larger dries a system of triage is practiced: Only the grossest cases have the benefit of immediate and thorough investigation. Such arrangements are dictated by the volume of reports plus severely limited resources. There is a scarcity of trained personnel who can identify, diagnose, and treat these difficult situations, which always involve many layers of complexity. This paper describes a training program that was developed in response to the acute need for knowledgeable personnel.. The program focuses on one Ms. Elmer, Ms. Bennett, and Ms. Sankey are affiliated with the Parental Stress Center, Pittsburgh, Pennsylvania 15232. Ms. Elmer is Associate Professor (Social Work), Department of Psychiatry, School of Medicine, University of Pittsburgh, Dr. Harway is Professor of Psycholosy, and Ms. Weithorn is a Graduate Research Assistant, at the University of Pittsburgh. Ms. Meyerson is Professor of Higher Education at the University of Pittsburgh. The program described in this paper was funded by the Pennsylvania Neighborhood Assistance Act and the Pittsburgh Foundation, Pittsburgh, Pennsylvania. The Child Abuse Training Program was begun under the auspices of the Pittsburgh Child Guidance Center, and continued at the Parental Stress Center, Pittsburgh, Pennsylvania. Community Mental H,alth Journal, Vol. 14 (3), 1978 0010-3853/78/1500-0179500.95 9 1978 Human Sciences Press
Community Mental Health Journal
of the pervasive problems in child abuse: how individuals representing diverse disciplines may work together to deliver meaningful help to these unfortunate families and their children. EXPLORATION OF COMMUNITY NEED For some years, Pittsburgh has been prominent in work with child abuse, and the authors believed that training resources and personnel were adequate to plan and execute a community training project. We thought it prudent first to determine whether the community felt the same need that we perceived. A list was made of all possible local training sources, for example, educational, legal, and social agencies. Each was called and two questions were posed: Was the source sponsoring a training program, and, if not, did they see a need for such a program? No existing programs were discovered but the respondents expressed much interest. We decided to go ahead with the planning, execution, and evaluation of a small experimental training program, keeping in mind three desirable criteria. The first was the importance of training individuals already exposed to or working with child abuse. We believed this would provide a foundation of experience with relevant problems and frustrations that would enhance the learning possibilities. A second criterion was that the trainees should be based in a circumscribed geographic area and hence might be expected, in the normal course of events, to deal with common cases, thus augmenting the possibility of actual collaboration among involved agency personnel. Finally, we wished to be able to choose the participants to represent the existing community agencies involved with abuse in the particular geographic area. This would always include protective services, health agencies, schools, and law enforcement. Depending on the community, there might also be a church, a private physician, a voluntary organization, and a variety of others. PRELIMINARY COMMUNITY ORGANIZATION The development and initial testing of the training program was sponsored by the Pittsburgh Child Guidance Center and funded locally. This provided for the following part-time staff: director, community organizer, secretary, and consultants for curriculum building and evaluation.
General Community Workshop Coincidentally with preliminary planning for the training, representatives of a group of agencies (Child Welfare Services of Allegheny County, Children's Hospital of Pittsburgh, Juvenile Court of Allegheny County, National Center for Juvenile Justice, and Pittsburgh Child Guidance Center) decided this was a propitious time to alert the professional community to the broad issues of child abuse. The agencies cosponsored a one-day seminar, an interdisciplinary effort for professionals with responsibility for abused and neglected children and their families. The seminar offered a broad
Elizabeth Elmer, Harriet G, Bennett,
overview of the entire system and encouraged interchange among the 225 participants. The meeting also provided an excellent kickoff for the community organization work considered essential for the success of the future training program.
Selection of Advisory Committee A most important task for the first phase of development was to obtain the endorsement of the administrators of the public agencies assigned a major role in the management of child abuse and neglect. Only with their help would it be possible to enlist the cooperation of district administrators and supervisors, who in turn could help select partidpants and arrange for release of their time for the training sessions. The projected training program was presented to each administrator and was positively received. These individuals were then asked to serve as members of the advisory committee along with others who were selected because of their expertise in special areas, for example, health, law enforcement, and behavior. Together with the committee, project staff conducted a half-day information session to interpret the program to field supervisors and to test out several training techniques. The advisory committee became very active and involved, offering consultation as to overall goals, curriculum content, choice of geographic sites for conducting the program, and the development of plans for the future. Additional tasks for the beginning phase were to develop the basic curriculum and to choose suitable evaluation procedures. Although these two activities are discussed separately, in reality they occurred simultaneously. FORMULATION OF THE EDUCATIONAL EXPERIENCE The concept of interdisciplinary collaboration dictated not only the selection o f content and methods but also the curriculum building process itself. The first step was the creation of a multidisciplinary task force to develop the curriculum. It consisted of the social work members of the project staff, a curriculum consultant from the field of higher education, and a psychologist as program evaluation consultant. Tentative program goals were formulated initially by the task force plus a subcommittee of the advisory committee. Several factors inherent in the nature of the project influenced the determination of these goals. Since trainees were to be drawn from several different social and community agency networks, each group would be heterogeneous, representing a wide range of educational levels, professional backgrounds, and experience. The goals had to be formulated with due consideration for the diversified composition of any given training group and with awareness that the program was to be carried out in different communities, each with a unique ecological and demographic makeup. Thus training goals had to be generic to meet varied educational needs but specific enough to insure that participants could apply
Community Mental Health Journal
the learning experiences to their own situations. The task force met these requirements by establishing a set of overall goals and subsets of specific objectives. Overall goals served as the basis for designing the broad program outline while specific objectives spelled out in more detail the aims of each session. The latter could be scheduled as desired during the program and could be implemented by a variety of techniques without altering the overall goals. A review of the tentative curriculum goals and objectives was carried out at a joint meeting of the task force and the advisory committee. This collective effort led to adoption of the following overall goals for the participants: 1. To acquire a common body of knowledge about abuse. 2. To perceive abuse as an interdisciplinary problem. 3. To be exposed to methods of interdisciplinary management of abuse. 4. To initiate or contribute to follow-up efforts in the community to deal collaborativelywith problems related to children. The program was seen as an introductory overview. Curriculum Content and Model Identification of content for cognitive learning was relatively dear cut. Trainees would have to become conversant with factual knowledge such as the incidence and scope of child abuse, common and unique characteristics of abusers and the abused child, the reporting law, the role and function of the protective agency and the judiciary, and initial development of the treatment program with emphasis on use of community resources in a multidisciplinary process. The task force unanimously agreed that child abuse Was not a subject that should be dealt with completely, or even primarily, on an intellectual basis. Therefore consideration of the gamut of personal feelings and attitudes aroused by abuse was seen as central to any professional training effort. The existence and import of feelings, both the worker's and the family's, had to be made manifest and understood if participants were to grasp the full nature of the p h e n o m e n o n with which they were dealing. Intensive sensitivity-type training was viewed as inappropriate and ill advised; rather, focus was to be on imparting phenomenological insight with personal application left to the discrimination of the learner. As content was defined, a methodological approach gradually emerged. Participant involvement was stressed, hence didactic teaching was minimal. Much of the basic information on abuse was available in selected articles and government pamphlets. These were chosen to illustrate the interdisciplinary focus and were assembled in individual packets for distribution at the first training session. This factual knowledge was briefly repeated, clarified, and integrated through a variety of teaching and learning techniques employed throughout the training sessions. The primary teaching method was expe-
Elizabeth Elmer, Harriet G. Bennett,
riential, a decision supported by the principle that individuals learn most w h e n they have an opportunity not only to hear, but also to see, feel, talk, act, and interact. Construction of a curriculum model was the next step. This served to order teaching concepts into a framework and provided a design for participants to move through a logical sequence of learning experiences. The model called for a cyclical learning process from (1) experiential learning, to (2) group debriefing that entailed utilization of factual knowledge, objectification, and generalization, to (3) application in new situations, to (4) more complex experiential learning. The learning techniques agreed on included the use of group dynamics exercises, sociodrama, case presentation and analysis, a professional resources panel, extensive group discussion, and a SCAN presentation. (SCAN is an acronym for Suspected Child Abuse and Neglect. In Children's Hospital of Pittsburgh, it refers to an interdisciplinary presentation of child abuse cases for identification, diagnosis, and treatment planning.) Each technique was analyzed to insure that it was appropriate to the particular concepts to be learned. METHOD
Objectives and Curriculum for Each Session of the Workshop Each training workshop consisted of four 3-hour sessions spaced I week apart. Although the participants were from the same community, often they were not acquainted with each other, a fact that underlined the need to develop immediately a positive climate for interaction and learning. Among the measures designed to accomplish this were name tags, lists of participants and their positions, coffee and snack breaks, and seating of trainees in an informal drde.
Session I Feelings and Attitudes (Experiential) The specific objectives were (1) to experience and understand the causes and effects of various emotions related to abuse; (2) to heighten the participant's awareness of his own feelings as well as those of others; (3) to understand the legitimate differences in the perception of emotionally laden events; and (4) to recognize and understand how feelings may affect the handling of situations of abuse. The facilitator of this session, a specialist in the area of group dynamics, elicited certain feelings and attitudes from the participants by involving them in a series of nonthreatening exercises. Emphasis was placed on debriefing after each exercise and relating it to the issues of abuse and neglect. In each training group, interaction noticeably increased as each exercise was developed.
Session II Case Presentations The objectives were to begin to understand (1) the roles and problems of the various agencies or disciplines--for example, legal, protective, police, medical; (2) the key issues in abuse---that is, the difference between punishment, discipline, and abuse or neglect-reporting procedures, confidentiality, and basic legal requirements; and (3) the interdisciplinary collaborative process. Each participant was asked to describe a case of child abuse or neglect. The trainee group was divided into four interdisciplinary subgroups, with a faculty resource person assigned to each group as facilitator. The subgroups briefly reviewed their cases, choosing one to present to the
Community Mental Health Journal
entire group, and formulating questions for discussion. Faculty persons served as a resource panel.
Session III Victim and Victimizer The objectives of this session were (1) to identify common characteristics of each member of the abusive family, and their interrelationships; (2) to understand the abusive parents' perceptions of their children; (3) to perceive the role of crisis as a precipitator of abuse; (4) to appreciate the necessity for support systems; and (5) to reinforce the value of the interdisciplinary collaborative process. The session began with a dramatic reenactment of an actual child abuse situation. Following the presentation the moderator led a discussion of the dynamics of child abuse, which also provided an opportunity for the participants to air the emotions aroused by the drama. As in Session I, they explored how their feelings might affect the handling of an abuse case.
Session IV The Community Process The objectives of this session were (1) to experience the process of multidisciplinary evaluation of a single case; (2) to develop, through information sharing, a multidisciplinary treatment plan for that case; (3) to establish a channel of communication within their community for ongoing agency collaboration. To accomplish this, we demonstrated the SCAN technique, using a case from the participants' community. The trainees, with input from the resource faculty, had responsibility for the development of an appropriate treatment plan. Following the SCAN meeting there was a half hour for informal discussion among the participants and the project staff. This gave immediate informal feedback and was an opportunity for the coordinator to begin consideration with the group of ways to continue interdisciplinary activities on behalf of children in their community. Special note should be made of the attitude with which the task force approached development of the training program, which was regarded as experimental and developmental. At frequent intervals formal and informal evaluation, designed and utilized in a formative sense, was conducted. The curriculum was modified as improvements seemed indicated. Overall goals remained fixed but content and methods were redesigned, reordered, deleted, or elaborated as the training experiences dictated change. The present refinement is still fluid. Although judged as highly successful at this point, the curriculum is subject to further development and continuous adaptation to keep pace with the participants' reactions and evaluations, new knowledge, and changing value orientations. IMPLEMENTATION OF THE TRAINING PROGRAM F a c u l t y s e l e c t i o n w a s b a s e d o n t h r e e criteria: 1. Professional competence in one of the disciplines involved in problems of child abuse. 2. Knowledge of and practical experience in dealing with abuse. 3. Teaching skill, particularly in use of group method. T h e i d e n t i f i c a t i o n of a q u a l i f i e d staff w a s n o t difficult; it is i n t e r e s t i n g to n o t e , h o w e v e r , t h a t t e a c h i n g skill p r o v e d to b e t h e m o s t t r o u b l e s o m e criterion. Besides t h e p r o j e c t staff, t h e f a c u l t y i n c l u d e d a n a t t o r n e y , a c h i l d p r o t e c t i v e a d m i n i s t r a t o r , a c h i l d p s y c h i a t r i s t , a n d a h o s p i t a l social w o r k e r , all b r o u g h t a b o a r d d u r i n g t h e e a r l y p l a n n i n g p h a s e . T h e y m e t p e r i o d i c a l l y as a f a c u l t y a n d att e n d e d all m e e t i n g s of t h e a d v i s o r y c o m m i t t e e .
Elizabeth Elmer, Harriet G. Bennett,
Another consideration in launching the training project was the determination of group composition and size. The actual makeup of the group was dependent to a large extent on the constellation of agencies and services in a given target community, b u t there were also certain requirements associated with the curriculum goals. The curriculum focused on experiential learning with emphasis on group process. The training group had to be small enough to allow for a reasonable degree of individual participation, but not so small that members felt threatened or unduly pressed to contribute. In accordance with findings in small group research, we set the optimal number of trainees in any one group at 15. The project staff identified several characreristics to help select communities in which to test the program. Concentration was on three different geographic types: rural, suburban, and inner city. Additional criteria considered were size, demographic factors such as predominant socioeconomic level, and ethnicity. The reported incidence of child abuse served as one index of community recognition of the problem. The entrance point in all communities was the mental health-mental retardation base service unit. This agency was chosen because it defines a geographic location and is a multipurpose service, relating to all other human services in the community. Since a catchment area contains a large population, it was necessary to select a geographic subdivision within it. The smaller area made it simpler to limit the size of the group to be trained and increased the likelihood of ongoing interagency collaboration at the conclusion of the training sessions. In the initial contact with the base service administrator, a contract was set up defining the responsibilities for implementation of the program. The responsibilities of the administrator were to designate a mental health-mental retardation coordinator for the training program who would initiate contacts with other agencies, arrange appointments with administrators, and participate with the project staff in interpreting the program. In addition the coordinator attended the training sessions as a trainee. The responsibilities of the project staff included consultation to the coordinator in contacting local agencies; interpretation of the program to the administrators for their endorsement; mailings to establish ongoing communication among the local agency administrator, the trainee, the mental healthmental retardation unit, and the project staff; and consultation to the coordinator u p o n completion of the program. The coordinator and the project staff had several collaborative respon~ sibilities. One of these was to select community agencies that should be included in the training in addition to the core group (health, law enforcement, schools, protective services). The coordinator and the staff also selected the individual participants, based on the participant's potential for impact within his or her o w n agency. The last shared responsibility was to choose a physical site for the program based on accessibility, parking, and layout of the room. This report is based on the implementatior~ of the program in three corn-
Community Mental Health Journal
munities. Since then workshops continue to be presented in different localities. EVALUATION METHODS AND RESULTS It seemed appropriate to focus on what Scriven (1967) has referred to as formative evaluation. The goals were to evaluate the process of program development and to provide information to the creators of the program as to how program might be modified and improved. By contrast, summative evaluation focuses on an external, objective assessment of program effectiveness. The latter evaluation model is more appropriate at a later stage, when the curriculum has been refined. The evaluation of the workshops was based on three procedures. The major instrument was a questionnaire filled out by the participants at the end of the fourth and final session of each workshop. The other procedures were (1) a form of the Mood Adjective Checklist (Nowhs, 1965) used to assess the effectiveness of the various small group techniques in inducing different emotions in the workshop participants during the first session, and (2) two administrations of the Semantic Differential technique (Osgood, Suci, & Tannenbaum, 1957), one at the beginning of the second session and one at the end of the last session, to assess the connotative meaning of several concepts and possible changes in connotations over the course of the last three sessions of the program. On the basis of the questionnaire responses there is little doubt that the workshops were positively and enthusiastically received in all three communities. As the curriculum was modified from one community to the next the questionnaire was, of course, modified accordingly. The questionnaire consisted of five sections, the first of which listed 15 topics related to child abuse. These topics can be separated into two categories, those dealing with professional activities and those dealing with the psychology and treatment of child abuse and child abusers. In all three workshops the participants indicated that they had learned more about the professional matters, which is consistent with one of the major goals of the curriculum. In accord with this emphasis, the following topics were rated above the median in all three workshops: reporting procedures, role of profes-
sional and para-professional personnel, legal aspects, documentation of child abuse, available community resources and use of other community agencies. Generally participants felt that they learned least about patterns of family interaction. Other items that fell below the median in all three groups were prevention of child abuse, treatment of abusive parent, treatment of abused child, role of the courts, and role of the police, topics that received relatively less emphasis in the presentations. Nevertheless, for all topics participants indicated a gain in information. The consistency between the participants' responses and the curriculum emphasis provides some evidence for the validity of the questionnaire. The remaining sections of the questionnaire indicated that the most suc-
Elizabeth Elmer, Harriet G. Bennett,
cessful exercises were the SCAN format, which was especially effective w h e n a current, local case was used, and the dramatic skit presented by the professional staff. Both of these exercises involved the participants in a problemsolving context around a specific case and contributed substantially to understanding the contributions of the various agencies within the community. In all three workshops the participants were consistent in their feeling that the presence of representatives of the different professions and the group discussions were highly effective. They all valued the opportunity to become acquainted with and interact with their colleagues in the community and to clarify attitudes regarding child abuse with them, dearly major advantages of an interdisciplinary program. The Mood Adjective Checklist was administered at the close of the first session, w h e n presentations were designed to induce several emotional experiences in the participants. At the end of the meeting the participants were asked to check the degree to which they experienced 10 different m o o d states, each state being represented by three descriptive adjectives. The 10 m o o d states were social affection, aggression, guilt, nonchalance, surgency, concentration, skepticism, fatigue; anxiety, and sadness. The participants went through the list of adjectives five times, each time with a different instructional set. Each set directed the participants to respond to the check list recalling their feelings after each of the exercises. At the completion of the first of the three workshops, we found that four of five exercises created the intended reaction in most participants and one exercise did not. The ineffective exercise was therefore dropped and replaced by another one which did create the desired emotional response. Three of the five exercises seemed to be especially effective. These were (1) the induction of a sense of group unity and positive regard to reinforcing positive statements and interaction among group members, (2) the experiencing of anxiety w h e n required to sit with eyes closed while anticipating having to reveal something of a personal nature to the other members of the group, and (3) the feeling of sadness w h e n required to discuss a hypothetical lifeboat situation and decide which predescribed characters were to be thrown overboard to save other occupants of the boat. The Semantic Differential measured possible changes in the connotative meaning of key concepts ~s a function of the workshop experience. The concepts were (1) discipline, (2) difficult child, (3) physical punishment, (4) neglect, (5) child abuser, (6) reporting, (7) interagency collaboration, (8) police notification, (9) legal action, (i0) child placement. The first five relate to child abuse, the second five relate to actions that may occur in relation to cases of suspected child abuse. Each term is presented with a series of scales which are defined by adjectives that are polar opposites. The scales tapped the three major dimensions of meaning that have been found in other studies using the Semantic Differential. These are the evaluative dimension (good-bad), the potency dimension (strong-weak), and the activity dimension (activepassive). On the whole there was little statistically significant change with respect to
Community Mental Health Journal
the Semantic Differential ratings between the first and second administration. There were some shifts in the rank ordering of the concepts particularly on the evaluative and potency dimensions. With the exception of one or two concepts, these shifts were not consistent across the three community workshops. One significant and systematic change was that legal action was perceived as more positive and more potent at the completion than at the beginning of the program. This supports the questionnaire response that participants had received considerable information as to legal aspects of child abuse. The most frequent comments made by the participants at the end of each workshop reflected their enjoyment of the program and the feeling that it was of significant value to them. They expressed a desire to develop some form of continuing program in the community. It may be appropriate to comment briefly on the evaluation process. Initially the workshop staff was concerned that the evaluation procedures might prove intrusive and inhibit the participation of those attending. This concern apparently was not necessary. The participants readily accepted the fact that the evaluation was geared to assessing the curriculum, not those attending the meetings. The questionnaire was the most useful instrument and the Mood Adjective Checklist did contribute to distinguishing the more effective experiential exercises. The Semantic Differential failed to provide as much information as we had hoped for, although it did reveal a dear change in attitudes toward legal action in child abuse cases. FOLLOW-UP An integral part of the training program is f o l l o w u p in each community. Project staff were aware that positive evaluations at the conclusion of training might represent a sense of gratitude to the staff, pleasure in the opportunity to associate with colleagues, or other favorable reactions not necessarily tied to the usefulness of the material. Until now, follow-ups have been informal and largely initiated by the mental health-mental retardation coordinators in the previous training sites. In one site the coordinator has organized SCAN sessions that are conducted regularly in conjunction with the pediatric department of the local hospital and are attended by the majority of the trainees in the community plus other interested individuals. The group plans to expand into other hopital settings in the catchment area. We are continuing to present the program in new communities. Ultimately we hope to offer training in other counties where the resources may be quite different from urban resources but where the need is fully as great. To offer the program on a wider basis, written materials and audiovisual aids are important. A training manual is planned; the dramatic role-play portion of the program is being made into a film. As experience is gained and the curriculum is firmed up, it may be possible to mount more detailed and objective evaluative procedures. Consistent evidence of the program's worth would of course enhance its value.
Elizabeth Elmer, Harriet G. Bennett,
This program was conceived as an introductory overview of child abuse and the interdisciplinary approach. Work to date has clearly shown the need for more intensive training in establishing and carrying out a treatment plan for abusive families and their children. The project staff is currently addressing this problem and hopes in the near future to offer such a program in the communities that have already received the training described in this paper. REFERENCES Child Protection Reports: A biweekly national letter on programs to prevent child abuse and neglect. Washington, D.C.: William E. Howard. June, 1975. New York Times. Child neglect an epidemic, study says. November 30, 1975. Nowlis, V. Research with the mood adjective check list. In S. S. Tomkins & E. E. Izard (Eds.), Affect, congition and personality. New York: Springer, 1965. Osgood, E. E., Suci, G. J., & Tannenbaum, P. H. The measurement of meaning. Chicago: University of Chicago Press, 1957. Scriven, M. The methodology of evaluation. In R. W. Tyler, R. M. Gagne & M. Scriven (Eds.). Perspectives of Curriculum Evaluation. Chicago: Rand McNally, 1967.