Improving Outcomes for Children With Developmental Disabilities Through Enhanced Communication and Collaboration Between School Psychologists and Physicians

Abstract

French

A renewed call for enhanced communication and collaboration between school psychology and medicine is envisioned, in light of a transdisciplinary model, where school psychologists, family physicians, and other health professionals transcend disciplinary boundaries. Recommendations for optimal communication and collaboration are described, as well as challenges inherent in such an endeavor. School psychologist–physician collaboration has the potential to result in significant improvements in outcomes for families and children with developmental disabilities. A case illustration highlights the major points mirrored in the discussion, and conclusions are drawn regarding necessary components for meaningful change to occur.

Keywords

collaboration and communication school psychologists physicians children with developmental disabilities transdisciplinary Canada

Introduction

The purpose of this article is to underscore the importance of communication and collaboration between school psychologists and physicians by suggesting a framework that has the potential to enhance the lives of children with developmental disabilities and their families. The goal of enhancing communication and collaboration between school psychologists and primary care physicians falls well under the purview of school-based health promotion, which has seen a surge of interest since the late 1990s (Walcott et al., 2008). Discussions about health promotion should also include how collaboration on behalf of families and children with developmental disabilities can be facilitated between school and medical personnel. Both professionals play a central role in promoting positive physical, emotional, and psychosocial development. Brown (2004) recognizes the critical role that primary care personnel play in promoting health, preventing disease, and assisting children and youth with chronic illnesses or disabilities to function successfully in school. Unfortunately, as Phelps and Power (2008) state, the systems of school and primary care “operate virtually independently from each other” (p. 88). Our goal here is to further discuss this gap, and to make a case for improved communication and collaboration between schools and primary care settings, and between school psychologists and primary care physicians in particular. As such, the primary aim of this article is to identify communicative and collaborative issues of import to school psychologists and physicians. A subsequent goal is to identify challenges that may affect successful collaboration. Recommendations regarding communication and collaboration will be incorporated throughout, and a case study will be presented to illustrate said points. Moreover, a transdisciplinary approach and empirically based recommendations will be suggested for effective communication between families of children with developmental disabilities, school psychologists, physicians, and other key players. The effect of enhanced communication and collaboration on outcomes for children with developmental disabilities will be highlighted and conclusions drawn.

Current State of Affairs

Particular Needs of Children With Developmental Disabilities

Many high-incidence childhood disorders require both psychological and medical care. Some examples include attention-deficit/hyperactivity disorder (ADHD), enuresis, encopresis, juvenile diabetes, juvenile-onset obesity, phenylketonuria (PKU), myriad types of developmental disabilities including autism spectrum disorders (ASDs), and other conditions that are of a chronic or long-term nature. Once diagnosed, it is estimated that children with special needs require four to eight times as much time and service provision as healthy children (Institute for Family-Centered Care, 1995, as cited in Burstein, Bryan, Chao, Berger, & Hirsch, 2005). They are more likely to visit primary care providers, and their medical encounters usually take more time than those of healthy children. According to a Statistics Canada report on the Participation and Activity Limitation Survey of 2006 (Foucreault, Hoffarth, Kowalchuck, & Lawrence, 2008), an estimated 4.6% of Canadian children between the ages of 5 and 14 had a disability. Of these, 57.6% were classified as having mild or moderate disabilities, whereas 42.4% had severe or very severe disabilities (Human Resources and Skills Development Canada, 2011). In addition, close to 75% of children with a disability were reported to have multiple disabilities (Statistics Canada, 2007). Most children were reported to have a formal diagnosis (88.4%) with long waitlists and high cost cited as the primary obstacles to obtaining assessment (Human Resources and Skills Development Canada, 2011). With regard to their perceived need for and access to appropriate educational services, one quarter of children with disabilities were reported by their parents to have a need for special education services that was not being met. Furthermore, even when children were receiving the services their parents felt they needed, 49% of parents reported having difficulty accessing services, and 59.4% of parents of children with emotional, psychological, or behavioural disabilities such as autism or ADHD reported facing barriers to accessing the services their children needed (Foucreault et al., 2008). Nearly one third of school-aged children with disabilities were reported to have visited either child psychologists or psychotherapists (Human Resources and Skills Development Canada, 2011). In terms of the long-term educational outcomes for children with disabilities, high school drop-out rates for youth between the ages of 15 and 24 were at 14.2% compared with 9.7% for youth without disabilities (Human Resources and Skills Development Canada, 2011). Moreover, adults with developmental disabilities have poorer health, increased morbidity, and earlier mortality than adults without disabilities (Ouellette-Kuntz et al., 2005).

Physicians

Medical personnel such as general practitioners, family physicians, and pediatric or developmental physicians represent the front line in primary care and have a crucial role in identifying which children are in need of special care or services. In 2006, general practitioners were the most commonly visited health care professionals for children with disabilities between the ages of 5 and 14 in Canada, with 76.4% of parents of children with disabilities reporting visits to general practitioners, while 50.8% of children with disabilities saw pediatricians and 42% saw specialist physicians (Human Resources and Skills Development Canada, 2011). Many physicians are hesitant to take on children with developmental disabilities, and they may see themselves as lacking sufficient qualification or knowledge to meet the family and children’s needs (Bryan & Burstein, 2000; Stein et al., 2008). Hart, Kelleher, Drotar, and Scholle (2007) indicate that primary care physicians represent not only the primary pathway for medical care but also for mental health care, and that primary care physicians play a crucial role in identifying and being asked to intervene regarding psychosocial concerns. Similarly, Willen (2007) states that parents regularly consult with their pediatrician for information related not only to physical health issues but for significant behavioural issues as well. As many as 50% to 90% of visits to the pediatrician’s office include a presenting problem of a behavioural, emotional, or academic nature (Cassidy & Jellinek, 1998; Howard, 2005). However, Williams, Klinepeter, Palmes, Pulley, and Meschan-Foy (2004) note that primary care physicians tend to underdiagnose behavioural and social-emotional problems in children and youth, and often only perceive themselves as knowledgeable regarding prevalent mental health concerns (e.g., conduct disorder, substance abuse). Primary care physicians report that a substantial concern is their lack of training and insufficient time to identify disorders of a psychological nature (Williams et al., 2004).

School Psychologists

School psychologists are in a unique position to promote healthy development in all children, but especially to engage in prevention, intervention, and active monitoring of children with diagnosed medical conditions (Walcott et al., 2008) or developmental disabilities. For instance, school psychologists receive extensive training in measurement, assessment, identification, and remediation of learning problems, as well as consultation skills (Daly, Kral, & Brown, 2008) and can provide much-needed expertise and assistance for children with chronic conditions, disabilities, or life-threatening illnesses (Shaw & McCabe, 2008). With inclusive classrooms becoming more and more common in Canada, school psychologists have had to adapt and tailor their skills to the changing needs of students (Margison & Shore, 2009) as children with disabilities are increasingly participating in mainstream educational programs. As described above, children with developmental disabilities are more likely than neurotypical children to experience complex behavioural and social-emotional reactions to chronic conditions and they are more likely to be prescribed medications which may affect their behaviour or academic functioning at school (Walcott et al., 2008; Wright, 1985), suggesting that monitoring by a school-based professional like a school psychologist is warranted for many students.

Collaboration

Multidisciplinary, Interdisciplinary, and Transdisciplinary

There are many forms of collaboration, each of which makes different demands on the collaborating parties. The three main models of collaboration are multidisciplinary, interdisciplinary, and transdisciplinary. For instance, Pohl and Hadorn (2008) define multidisciplinary research as that which “approaches an issue from the perceptions of a range of disciplines . . .; but each discipline works in a self-contained manner with little cross-fertilization among disciplines, or synergy in the outcomes” (p. 429). Similarly, in multidisciplinary clinical teams each discipline works independently within the specific parameters of the discipline; under the direction of a team leader, team members focus on their own goals and submit their own recommendations, usually with little or no coordination between disciplines (Garner, 1995; Hoeman, 2008). This is contrasted with interdisciplinary research, which is “a form of coordinated and integration-oriented collaboration between researchers from different disciplines” (Pohl & Hadorn, 2008, p. 428). Likewise, the primary difference between multidisciplinary and interdisciplinary teams is that communication between team members is collaborative at each stage of the problem-solving process, such that goals and strategies are decided on collaboratively, and team members are not confined to discipline-specific roles (Garner, 1995; Hoeman, 2008). Transdisciplinary teams, however, involve a blurring of the traditional boundaries between disciplines and require that team members be open to doing activities that fall outside their typical scope of practice, while continuing to abide by the professional practice guidelines of their discipline (Hoeman, 2008), and also require a willingness to share knowledge, skills, and responsibilities (Garner, 1995). Such a team makes for more efficient service delivery, especially in times of fiscal restraint (Hoeman, 2008). As with a multidisciplinary approach, transdisciplinary teams elect a team leader. However, in contrast to the multidisciplinary leader, the transdisciplinary leader does not unilaterally delegate roles. Instead, he or she serves as the spokesperson through which each team member’s ideas are conveyed (Dyer, 2003). Pohl and Hadorn (2008) indicate that transdisciplinary research

is needed when knowledge about a societally relevant problem field is uncertain . . . when the concrete nature of problems is disputed, and when there is a great deal at stake for those concerned by the problems and involved in dealing with them. Transdisciplinary research deals with problem fields . . . in such a way that it can: (a) grasp the complexity . . . of problems, (b) take into account the diversity . . . of life-world . . . and scientific perceptions of problems, (c) link abstract and case-specific knowledge, and (d) develop knowledge and practices that promote what is perceived to be the common good . . . (pp. 431-432)

When physicians and psychologists make efforts to collaborate, they typically adopt a multidisciplinary approach, wherein practitioners from each discipline work alongside each other, but retain their own approaches and work within the boundaries of their own disciplines (Patel, Pratt, & Patel, 2008; Wolfendale, 2000). In a multidisciplinary team, each practitioner has his or her own individual goals for intervention and works independently of the other disciplines, which may sometimes lead to conflicting views on which intervention would be most effective. As described above, interdisciplinary teams engage in a group process, wherein each practitioner shares expertise and team members work toward a common goal and develop an intervention plan together (Patel et al., 2008). Drawing on the recommendations put forth by Pohl and Hadorn (2008), we suggest that transdisciplinary approaches are the most effective for providing services for families with children with developmental disabilities. Children and youth with chronic conditions or developmental disabilities often experience significant behavioural and academic problems (Davis & Carter, 2008; Olsson & Hwang, 2001) as well as medical complications. Stress levels and coping mechanisms of parents of children with special needs may have a negative impact on the expression of children’s disabilities and on children’s developmental progress (Miodrag & Sladeczek, 2009a, 2009b). Thus, a coordinated intervention effort which involves all key individuals in the child or youth’s life is essential. The present authors propose that school psychologists and primary care physicians adopt a transdisciplinary approach, whereby they take leading roles in coordinating the consultation efforts of all service providers to promote the optimal adaptation of children with special needs.

Calls for Collaboration

Calls for interprofessional collaboration are being sounded across disciplines. In school psychology, the focus of collaborative efforts has typically been on relationships within the school, between psychologists, teachers, and administrators, and between school-based professionals and families (Canadian Psychological Association, 2007; Rivard, Deslandes, & Beaudoin, 2011; Sawatzky & Paré, 1996; Siegel & Cole, 2003). In the Canadian Psychological Association Professional Practice Guidelines for School Psychologists in Canada (Canadian Psychological Association, 2007), it is also stipulated that school-based psychologists should engage in collaborative consultation with other mental health professionals, and they may also take on the role of coordinator between school and community-based programs to provide the best services for students. In addition to calling for increased consultation (Siegel & Cole, 2003), some authors also highlight the need for a greater focus on consultation and collaboration at the level of pre-licensure training for school psychologists, as well as at the level of professional development training for practicing school psychologists (Choi, Whitney, Korcuska, & Proctor, 2008; Cochrane & Salyers, 2006; Sladeczek & Heath, 1998). Similarly, recognizing the need to bridge the gap between research and practice, Ronstadt and Yellin (2010) propose a model of transdisciplinary collaboration between researchers (in psychology and education) and clinicians (who work with children and youth) that fosters a collaborative relationship from the start of clinical training.

In medicine, similar calls for collaboration have been made. For instance, the Royal College of Physicians and Surgeons of Canada (2002) advocates for a collaborative role between different health care disciplines to facilitate appropriate patient care. The CanMEDS 2005 Framework (Royal College of Physicians and Surgeons of Canada, 2005) provides more detailed practice guidelines concerning collaborative expectations for physicians. Following these guidelines, physicians are expected to recognize the limits of their own competencies and to consult with other health care professionals as necessary. Within this role as collaborator, physicians are called upon to be flexible in their roles within multidisciplinary teams, at times taking on leadership positions and at other times acting as participants or problem-solvers. The framework stipulates that current best practice for health care provision in Canada requires physicians to participate in multidisciplinary teams and that this may involve collaboration with professionals at other institutions, rather than just their own. More recently, the Canadian Interprofessional Health Collaborative (CIHC; 2010) has further elucidated how both interprofessional collaboration and interprofessional education can promote positive health outcomes for Canadians. In contrast to the guidelines put forth by the Royal College of Physicians and Surgeons of Canada (2002, 2005), which apply only to physicians, the framework developed by the CIHC applies to all health care professionals. As such, the CIHC acknowledges the current health care landscape and attempts to provide a model that is easily adopted by all health care providers.

Absent in both the school psychology practice guidelines and those developed for health care professionals is any explicit mention of interdisciplinary collaboration that crosses the larger discipline boundaries of health care and education. Although a great deal has been written about pediatric psychologists working with pediatricians (e.g., Drotar, 2006), the same cannot be said for the relationship between school psychologists and primary care physicians. Notable exceptions include a 2010 special issue of the Journal of Educational and Psychological Consultation which focused on collaboration in special education (Cook & Friend, 2010), and the work of Shaw, Kelly, Joost, and Parker-Fisher (1995) among others, to promote collaboration between school psychologists and medical professionals.

Shaw (2003) attributes a lack of collaboration between school psychologists and health care professionals to a lack of training among school psychologists in areas such as psychopharmacology and health care. Shaw emphasizes the need for providing training opportunities that foster collaboration between school psychology and medicine at the pre-doctoral internship and postdoctoral fellowship levels, a call that is echoed by Sulkowski, Jordan, and Nguyen (2009) who discuss the need for psychopharmacology training within school psychology programs. Likewise, Margison and Shore (2009) suggest that school psychology would benefit from the adoption of similar interprofessional practice and training guidelines to those used in Canadian health care (as described above). This call to action needs to be heeded as parents of children with long-term disabilities ask more medical-related questions and have more social exchanges with professionals than parents of neurotypical children (Burstein et al., 2005). Therefore, a link in systems of care, in this case, between the school system and the primary care system is essential. Several researchers have underscored this very point and continue to do so (Bronfenbrenner, 1979; Comer, Haynes, Joyner, & Ben-Avie, 1996; Grenier, Chomienne, Gaboury, Ritchie, & Hogg, 2008; Power, Shapiro, & DuPaul, 2003; Sulkowski et al., 2009).

Barriers to Collaboration

Traditionally, there have been both intraprofessional and interprofessional barriers to collaboration, and this issue is only recently being addressed. One of the most important barriers to interprofessional communication between physicians and school psychologists is the persistence of a basic misunderstanding about roles and capabilities. To some extent, such confusion is a result of inadequate or incomplete training that may require a re-examination of instruction methodology (Power et al., 2003). However, at least some of this difficulty in communication arises from the professional perspective that is inherent to both psychology and medicine. The differences in perspective relate to training experiences and how each profession views science, diagnosis, and clinical diagnosis in particular (Fachado, Pereira, & Smith, 2009; Kingsbury, 1987). Unique points of view on hierarchy and differing types of clinical experience can affect the approach to client care. To clarify the proposed collaborative process between the psychological and medical community in the care of children with developmental disabilities, a clear elucidation of the current major links will be discussed.

Family physicians and psychologists

The links between family physicians and psychologists appear to be location- and individual-dependent, rather than in accordance with an organizational model (Grenier et al., 2008). While most family physicians are open to working with psychologists, there are no set ways of achieving this collaboration. Nonetheless, it is important to note that there is an ongoing effort to more directly link the primary care work performed by family physicians and the more specialized care provided by school and pediatric psychologists (McDaniel, 1995; Stein et al., 2008).

Family physicians are in a particularly important position in relation to psychological services because they are often involved in the care of an entire family, and will necessarily be required to make decisions about intervention and services (Grenier et al., 2008). In the North American context, anywhere between 70% and 90% of family physicians carry out counselling or mental health services (Watson, Heppner, Roos, Reid, & Katz, 2005); in so doing, they are seen by clients as primary providers of care in this area. However, the self-perception of family physicians is incongruent with this view. Most consider themselves a source of emotional support and a smaller percentage assume the role of semi-formal counsellor; neither role is equated with that of a psychologist (Grenier et al., 2008). Furthermore, the assessment, management, and follow-up of children with developmental disabilities are not core competencies of family medicine residency training, but rather a subspecialty. Thus, despite some potential overlap with psychologists, family physicians generally find themselves relatively unsupported in many situations involving children with special needs (Kates, 2002; McColl et al., 2008).

A framework for shared responsibility, in the form of collaboration between physicians and psychologists, is currently being developed in fits and starts. A key area for such collaboration is in the long-term management of children with developmental disabilities. In the medical conceptualization of care, family physicians are widely acknowledged as more than just a point of first contact with a health professional, and rather, as a health care manager. For instance, the family physician is often required to integrate information from disparate sources and convey an interpretation of results from tests to clients and families. Much like psychologists who must seek information from a number of professionals and sources (Arredondo, Shealy, Neale, & Winfrey, 2004), family physicians must also effectively communicate with other professionals. Quite often, psychologists are the ones most significantly involved in both assessment and intervention for children with developmental disabilities. Hence, it is imperative for family physicians to innovate and seek out new ways to share information with them (Derksen, 2009; Pace, Chaney, Mullins, & Olson, 1995; Twilling, Sockell, & Sommers, 2000; Witko, Bernes, & Nixon, 2005), given the lack of training family physicians typically receive in this area.

Pediatricians and school psychologists

In North America and Western Europe, the fields of pediatrics and psychology have been making attempts to collaborate since the 1930s, and successfully working in collaboration since the mid-1960s (LeBaron & Zeltzer, 1985). This liaison has been described as an intellectual connection between the behavioural sciences and medicine, in the context of child development, and it has been beneficial for both school psychologists and pediatricians (Kagan, 1965). From this early link, a more comprehensive professional relationship has grown, particularly because the majority of pediatric clients fall within the age range of academic instruction.

Pediatric care can be subdivided into general and subspecialty services. General pediatricians face many of the same issues as family physicians; for example, they often provide similar kinds of assessment and management as family physicians. Nonetheless, childhood psychosocial problems and developmental issues are increasingly becoming an important part of general pediatric practice (Stein et al., 2008) and in fact, some family physicians who are uncomfortable diagnosing developmental disorders will choose to refer patients to a general pediatrician when a developmental diagnosis is suspected. In part, this may be due to the fact that pediatricians themselves overwhelmingly support the notion that developmental disorders ought to be identified in the pediatric clinic rather than in other settings; at the same time, there is less consensus among pediatricians about identification of complex developmental disabilities, and the need for collaboration and input from school psychologists is seen as a major part of diagnostic evaluation (Stein et al., 2008). Thus, physicians can be seen to differ in their level of comfort when working with psychologists. This difference may stem from the fact that certain pediatric subspecialists are consistently and effectively working with psychologists on a team, and may regularly be communicating with school psychologists and other school officials (Bergman & Fritz, 1985; Leslie et al., 2000), while other more general practitioners may have fewer opportunities to engage with school-based professionals.

One subspecialty with an excellent track record for collaboration is developmental-behavioural pediatrics. The field of developmental-behavioural pediatrics emerged from the initial collaborative efforts between interested physicians and psychologists who joined their initiatives (LeBaron & Zeltzer, 1985). Most developmental-behavioural pediatricians work side by side with psychologists, occupational therapists, social workers, speech-language pathologists (S-LPs), and other allied health professionals (Williams et al., 2004). This provides a natural and straightforward means of communication with school psychologists after a diagnostic evaluation. Not only will the developmental-behavioural pediatrician often directly contact the school, but team members from a hospital clinic will also make inquiries about a child’s performance in the academic setting. As such, a distinct and efficient pattern of information exchange emerges, with routine updates provided (Stein et al., 2008).

While it is often the case that pediatricians feel overwhelmed when attempting to co-manage a child with developmental disabilities or psychosocial problems (Olson et al., 2001), there has recently been significant emphasis placed on the importance of shared health care responsibility as well as awareness of developmental trajectories in pediatric training (Stein et al., 2008). Both the Royal College of Physicians and Surgeons of Canada and the American Board of Pediatrics require pediatric residency trainees to complete clinical experiences in developmental pediatrics prior to obtaining their certification. In addition, repeated exposure to reports, presentations, and conferences including the professional contribution of psychologists is mandatory in most North American pediatric residency programs. This more consistent exposure to child psychologists, and in particular to many school psychologists, has a tremendous benefit to later professional interactions for pediatricians. A similar emphasis has been made within the field of pediatric psychology (Rozensky & Janicke, 2012; Spirito et al., 2004), but within school psychology there is a distinct lack of specialized training in this area.

In spite of a historical series of initiatives that stress the importance of collaboration as well as the training that emerges from shared client populations between pediatricians and school psychologists (Heneghan et al., 2008), it is clear that more can be done to foster communication between these disciplines. A pediatrician often provides ongoing care of the pre-school child, and this role gradually diminishes over time upon school entry (Forrest et al., 1999). From this point onward, especially in the vulnerable population that includes children with special needs, the school psychologist and other professionals in the school setting play a primary role. While a first contact is often easily established, subsequent discussions and follow-up sometimes remain difficult or less effective (Heneghan et al., 2008). This difficulty can result from limited availability of some professionals, conflicting schedules, disagreement on diagnosis, or even low motivation to completely elucidate details of assessment or follow-up; ameliorating these issues requires preparation, advanced skill development, and a fostering of relationships among professionals (Arredondo et al., 2004). Given the rich history of collaborative strategies discussed above, pediatricians and school psychologists can rely on successful models of interprofessional interaction. Furthermore, school psychologists and developmental-behavioural pediatricians can have an ongoing, increasingly linked pattern of collaboration, and these links can be strengthened with more focus on the shared goals and challenges that exist for all professionals caring for children with developmental disabilities.

Transdisciplinary Collaboration in Practice

Communication and collaboration between health care and psychological professionals can improve outcomes for children with developmental disabilities. As an example, consider the case of a child with an ASD. Children with ASD present with high rates of comorbid conditions (First, 2005; Simonoff et al., 2008) such as gastrointestinal problems, sleep disorders, and seizures (Bauman, 2010; Levy et al., 2010), which often require medication. Children with ASD are also more likely to experience comorbid behavioural and mental health difficulties, which necessitate additional supports in educational and community settings (Joshi et al., 2010). Symptoms of ADHD are also very common in children with ASD (Murray, 2010), and psychopharmacological treatment is often sought to help manage symptoms (Mahajan et al., 2012). However, adherence to prescribed intervention plans can be inconsistent and require extensive school–home collaboration (DuPaul & Power, 2008), as well as collaboration between the prescribing primary care setting and the school. Clinical factors, such as the clinician’s ability to work with families and identify their concerns (Hart et al., 2007) and to apply motivational interviewing strategies such as empathic understanding and affirmation of family efforts (DuPaul & Power, 2008; Hart et al., 2007), have been shown to significantly influence engagement in interventions. It is important that the families and professionals implementing the intervention are engaged in designing, implementing, and evaluating the strategies. Thus, a critical responsibility for the school psychologist and the family physician is to promote partnerships between the family, school professionals, and health professionals, so that all necessary system dynamics are in place for meaningful change to occur.

The school psychologist plays an important role in a health care context. When medication treatments are involved, a school psychologist can collect and interpret diagnostic data relevant to treatments involving medication, collaborate with the physician regarding the evaluation of medication responses to determine the optimal dosage of medication, design and evaluate educational, psychosocial, and medical interventions, and serve as a liaison between all parties involved in the intervention process (e.g., DuPaul & Carlson, 2005; Sulkowski et al., 2009). To evaluate the behavioural, academic, social, and cognitive effects of medication, assessment methods can include behaviour rating scales, direct observations of behaviours, reviewing the child’s school records (e.g., completion of assignments), measurement of the child’s academic performance (e.g., curriculum-based measurement), and cognitive testing (Derksen, 2009; DuPaul & Carlson, 2005).

It is important to establish a truly functional collaborative transdisciplinary exchange that extends beyond discipline boundaries, bringing together each collaborator’s expertise. For example, Fachado et al. (2009) examined the collaborative process between psychologists and physicians in a health care practice via a qualitative study. Both disciplines acknowledged the need for collaboration in training and practice to improve integrative care. Both groups indicated that collaboration allowed a better vision of the problem with more efficiency, more complementarity, and better problem resolution. Both disciplines also acknowledged some difficulties, including different perspectives concerning psychologists’ work, psychologists not being available full-time at the centre, or lack of communication between psychologists and physicians. Nevertheless, both groups of professionals were clear about the emphasis which should be placed on considering the patient in context, and both were also clear in their belief that collaboration was beneficial for all parties involved. Dang, Warrington, Tung, Baker, and Pan (2007) examined the communication and quality of care received by children with ADHD, and found that the ADHD Identification and Management in Schools (AIMS) project, which consisted of a team including a pediatrician, school psychologists, nurses, and school personnel, improved not only communication among these professionals but led to an improvement in the quality of care for the children.

As part of effective communication efforts, emphasis must be placed on routine updates, monitoring of progress, and evaluation of goal attainment. One useful tool that can help in the assessment of all of these dimensions is the implementation of goal attainment scales (GAS; Elliott, Sladeczek, & Kratochwill, 1995; Karagiannakis, Sladeczek, Yule, & Miodrag, 2007; Sladeczek, Elliott, Kratochwill, Robertson-Mjaanes, & Stoiber, 2001). The use of GAS involves an individualized and criterion-based method that can document changes in the academic, social, and behavioural performance of children. This procedure involves selecting a target behaviour, describing the selected behaviour in objective terms, and developing between three and five descriptions of probable outcomes from the least favourable to the most favourable (Elliott et al., 1995). For example, in Roach and Elliott’s (2005) study, teachers completed GAS ratings for students with academic difficulties. These authors found significant improvements over the four to six weeks using the GAS rating scales, with teachers reporting that this was an acceptable and useful method to indicate a child’s progress toward a desired goal. In another study, DuPaul and Carlson (2005) emphasized that a closely monitored intervention has important implications regarding the involvement of school-based professionals who have access to much educational and classroom performance data on children with a variety of externalizing and internalizing disorders. School psychologists can be involved in helping physicians and families to make important decisions and in assisting with the monitoring of psychopharmacological treatments. Emphasis should be placed on identifying, prioritizing, and communicating target behaviours that are changing. These results must be shared with the family physician to assist with other possible intervention options. Enhanced communication and collaboration can be efficacious if the key players have a mutual goal, participate in collaboration voluntarily, contribute equally in terms of personal or professional resources, share resources, share the decision-making process, and are all accountable for the outcome of the collaboration (Cook & Friend, 1991; Patel et al., 2008). For example, when the psychologist has conducted a medication evaluation and data are obtained for a child, those findings need to be communicated to parents, school personnel, and the physician, who will outline the next plan of action, for example, the continuation or termination/adjustment of medical treatment. It has been documented that the results of treatments are effectively communicated through graphs or tables that summarize key changes in and/or side effects across different conditions (DuPaul & Carlson, 2005; Grenier et al., 2008). Given the different schedules of the team members, coordinating meetings can be challenging. Yet, open-access and easy-to-use scheduling programs are increasingly popular ways to determine mutually convenient meeting times, and teleconferences allow all parties to participate in team discussions without having to physically be in the same location. Current advances in communication technology should be embraced as they are likely to hold the key to removing barriers that have historically stood in the way of effective collaboration.

Case Example

Jay is an 8-year-old boy with a diagnosis of ASD. While he is reported by his parents to be generally healthy and happy, at home he experiences explosive outbursts of frustration and aggression. During these episodes, Jay can become aggressive toward his family members, often hurting his younger sister. At school, Jay’s teacher reports that he has difficulty staying focused and rarely finishes assignments independently. Even though Jay has been assigned an educational assistant (EA), there are two other children in Jay’s class who have been identified as requiring additional support, and so the one EA assigned to the class must divide her time between these three students. Jay displays aggressive behaviour at school as well; sometimes his meltdowns can escalate into full-fledged temper tantrums that require two adults to physically restrain him. Although the cause of Jay’s outbursts is sometimes evident (he may become frustrated with his schoolwork, or upset following an interaction with a peer), his teacher and EA report that they are often caught off-guard by his behaviour and do not know what triggered it.

Given these disruptive behaviours, the classroom teacher has solicited the help of the school psychologist. After meeting with the teacher and observing Jay in his classroom, the school psychologist recommends a transdisciplinary team approach and sets about putting together the team. The transdisciplinary team includes the school psychologist, Jay’s classroom teacher, a S-LP, Jay’s family physician, and Jay’s parents. The role differentiation is defined by the situation rather than the discipline affiliation (as suggested by Bruder, 1994). Given their different locations and schedules, these professionals each perform their own individual evaluations in separate visits, but the expertise of all team members is pooled and there is a continuous give and take between all members. For instance, as the team leader the school psychologist obtains updates by phone from each of the team members. Then, using an electronic scheduling program, the school psychologist coordinates teleconference meetings in which all members participate.

As the primary diagnosticians, the school psychologist and the family physician advise the school administrators, teacher, and EA regarding Jay’s individualized education plan (IEP). His IEP incorporates recommendations from all of the evaluating professionals (derived at via an integration of Jay’s developmental needs across disciplines) and includes strategies and interventions for both home and school. Members of the transdisciplinary team share the same goals for Jay’s intervention plan and may work on such goals even if they are outside of their discipline. For instance, the school psychologist will provide behaviour support, conducting functional behaviour analyses with his teacher and EA to determine the cause of Jay’s behaviours at school and with his parents to uncover the cause of his tantrums at home. The school psychologist will then teach behaviour management strategies to both the school team and Jay’s parents, which will include the use of GAS for specified target behaviours of concern like Jay’s temper tantrums. The school psychologist may also monitor Jay’s neurological functioning.

The team decides that Jay might also benefit from psychopharmacological intervention. The family physician is aware of a hospital-based psychopharmacology clinic that has a great amount of experience working with children with ASD, and so a referral is made for Jay to be seen at the clinic. So that there will be continuity of care for Jay after he is seen at the clinic, his family physician will act as the liaison and will monitor Jay’s medications in between his visits to the clinic, providing regular updates to the transdisciplinary team.

Currently, Jay is receiving weekly speech and language therapy from the school S-LP who has been working primarily on prosody. In discussions with the team, it is determined that Jay would benefit from training in social skills as well as self-advocacy. Although neither of these training programs are traditionally the responsibility of the S-LP, Jay’s S-LP eagerly accepts the challenge to work on these skills with him. The S-LP is well supported as the team works together to develop a plan for both what to teach Jay and how to implement it. In fact, as time goes by, the S-LP identifies other students on her caseload whom she believes would benefit from similar instruction and so she initiates a social skills building group that teaches through role-play and modeling.

Jay’s parents are included throughout the process and are engaged in tracking and monitoring his behaviour and response to medication at home. His parents have been attending a monthly support group for parents of children with ASD. At one of these meetings, his parents learn about an integration workshop that can be used to teach the other students in the classroom about autism. The team agrees that a similar workshop would be very beneficial for Jay’s peers, particularly given that his school is small and there is only one class per grade. Thus, Jay will likely be with this same group of students for several years, and fostering a positive relationship early on will be integral to a positive outcome. Jay’s parents take on the role of facilitators for this workshop, working closely with the team to develop the best curriculum for Jay’s class. The teacher will continue with the program as the school year progresses, returning to the team for feedback if issues arise, and reporting to the team about the progress the class is making toward including Jay in their activities.

Continued collaboration of this type will allow emerging issues to be identified in a timely fashion as Jay progresses through the school system. It is expected that ongoing communication and intervention will help him to realize his potential and maximize his performance both in school and beyond. Jay’s parents report less stress, better coping mechanisms, improved perceptions of themselves as parents, and more positive and less negative attributions in terms of having a child with a disability.

Conclusion

The aim of this article was to highlight the importance of communication and collaboration between physicians and school psychologists, particularly with regard to children with developmental disabilities. In Canada, both disciplines have professional practice guidelines, which include provisions for interprofessional collaboration. However, interprofessional collaboration between the domains of health care and education remains elusive. Thus, in this article, we have underscored the importance of early contact and clarification of roles, clearly defining terminology, understanding modes of diagnosis, recognizing similarities and differences between disciplines, and establishing clear lines of communication. It is important that both school psychologists and physicians understand each other’s concerns, theoretical frameworks, types and range of therapies, and goals for children. Mutual respect and an understanding of the capabilities and limitations of one another’s interventions are essential to enhancing communication among professionals (Fachado et al., 2009; Sabbeth & Stein, 1990; Twilling et al., 2000). Transdisciplinary collaboration facilitates earlier and more effective intervention (Bell, Corfield, Davies, & Richardson, 2010; Sabbeth & Stein, 1990; Twilling et al., 2000) and reduces duplication of services (Hoeman, 2008). Pohl and Hadorn (2008) advocate for transdisciplinary teams when the domain in question is uncertain, when solutions may be disputed, and when the stakes are high. Similarly, we advanced the position that professionals working with children with developmental disabilities should form transdisciplinary teams to efficiently and effectively address the complex needs of these children.

We recommend that physicians and school psychologists act as co-therapists, taking equal responsibility for the care of children with developmental disabilities, thereby reducing fragmentation of services. Regarding leadership, Holloway and David (2005) suggest that if a case begins in the physician’s office and the physician requires consultation from the psychologist, then the physician may be viewed as the leader. Likewise, if a case begins in the psychologist’s office and the psychologist asks for consultation from the medical field, then the psychologist may be seen as the leader. We suggest that neither be viewed as a leader but that both are seen as collaborating professionals working toward common goals. The silos of education and health care must be bridged for children with developmental disabilities to access the integrated care they require.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Anne M. Ritzema, MA, is currently a doctoral candidate in the School/Applied Child Psychology program at McGill University. She joined the Centre for Research on Children and Families in September 2010 to work with the CIHR Team in “PARENTING MATTERS! The Biopsychosocial Context of Parenting Children with Neurodevelopmental Disorders in Canada.” Her primary research and clinical interests lie in supporting children with neurodevelopmental disorders and their families. Her doctoral research is currently funded by a Vanier Canada Graduate Scholarship.

Ingrid E. Sladeczek, PhD, is currently an associate professor in the Faculty of Education at McGill University. Her primary research interests include early intervention (EI) with children who have developmental disabilities, problem-solving consultation, bullying and violence in schools, and policies related to EI. Furthermore, she works as a child psychologist with teachers, families, and children with developmental disabilities.

Shuvo Ghosh, MD, is a researcher and developmental pediatrician at the Montreal Children’s Hospital of the McGill University Health Centre (MUHC). His research and clinical work include working with families and children who have a diversity of developmental disabilities, gender identity conflict, and eMedicine.

Anastasia Karagiannakis, PhD, received her PhD from McGill University in educational psychology. Her research interests focused on intervention research, classwide-peer tutoring, socio-emotional functioning, and inclusion in the fields of behaviour disorders and developmental delays. She currently works as a psychoeducational consultant at the Learning Associates of Montreal, a non-profit community organization that offers educational services to individuals with learning difficulties in the Montreal area as well as the Northern Communities of Quebec.

Natalia Manay-Quian, MA, is currently a PhD candidate in the School/Applied Child Psychology program at McGill University. Her research interests include the psychological well-being of children and their families and mental health of parents who have children with developmental disabilities. She has experience working with children with developmental disabilities and their parents in both applied and research settings.

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