Fall 1999

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Transdisciplinary approach to pediatric undernutrition

by Daniel Kessler, M.D. FAAP, Phoenix, AZ

Why Transdisciplinary

Pediatric Undernutrition, a term my colleague Peter Dawson and I prefer to Failure to Thrive, is often a complex problem in pediatric practice that requires the skills of several professionals. We have all heard about and probably worked in "multidisciplinary" or "interdisciplinary" teams, but what is "transdisciplinary" and why use it instead of the other more commonly used terms? The issue here is more than semantics.

In the multidisciplinary model, professionals from a variety of disciplines come together to work as a team; and although each team member is viewed as important, members function as independent specialists rather than interactive team members. The child or the family may be assessed individually by several disciplines but generally at the discretion of the team leader, usually a physician in medical settings.

In interdisciplinary teams, team members may come together as a whole to discuss their individual assessments and develop a joint service plan. However, each team member still is responsible solely for his or her assessment and for developing those aspects of the treatment plan that are related to his or her professional discipline.

The Transdisciplinary Approach

Dorothy Hutchison originally described the transdisciplinary approach. A 1976 United Cerebral Palsy publication defines the approach as involving "deliberate pooling and exchange of information, knowledge and skill, crossing, and re-crossing traditional disciplinary boundaries by various team members." This model aims to increase the opportunity for family members to make meaningful decisions and participate in early intervention as much as they want. Team members under this model share roles as each specialist helps other members to acquire skills related to the specialist's area of expertise. This requires both role release (accepting that others can do what the specialist was trained specifically to do) and role expansion (allowing that one's job can include more than what one was specifically trained to do).

Excellent clinicians always have used a transdisciplinary paradigm, working alongside and learning from their colleagues in nursing, social work, psychiatry, psychology, nutrition, education, and physical, occupational and speech-language therapy, to name just a few.

The physician works in a transdisciplinary manner when he or she inquires sensitively about mealtime routines and the lack or availability of adequate refrigeration and meal preparation facilities for the family.

The dietician or nutritionist works in a transdisciplinary manner when he or she asks about interpersonal stresses and behavior problems that make it harder for parents to feed their children. Clinicians always learn from each other in their discussions of the complex clinical and family situations that compose a large portion of our work.

Case Example

Billy was a small and thin child at 28 months of age who was referred to the pediatric endocrine clinic because of his "small size." When history and physical examination ruled out an endocrine disorder as the source of Billy’s small size he was referred to the Pediatric Protocol for Growth and Feeding Problems at a large pediatric teaching hospital. Feeding had always been a struggle in the Brady household and these food battles were simply intensified by the common pediatric advice that Billy had to eat more in order to "catch up."

There was certainly enough tension around mealtimes for this to be suspected as a possible source for his lack of weight gain. However, when providing behavioral guidance to the family about the appropriate "division of responsibility" during mealtimes ("parents provide the food but the child has to do the feeding") and a high calorie diet failed to result in the expected weight gain we knew there were other difficulties.

After speaking with the family our speech-language therapist, who had been asked to see Billy because of an expressive language delay, went back to review the history taken from the parents during the admission. Billy’s mother had complained about Billy’s noisy breathing and his wakening several times each night in distress. This, she knew (from participating in transdisciplinary team meetings) could be consistent with a pattern of obstructive sleep apnea (OSA), and OSA can be associated with poor growth. After an appropriate evaluation Billy had his tonsils and adenoids removed and his growth and weight quickly rebounded. — DK

Involving Parents

Parents are the experts regarding their own children, and all parents (certainly the overwhelming majority of parents) who are given equal access to information and resources want only what is best for their children. Obtaining accurate and complete information about a child and his or her world and early consideration of environmental and psychosocial factors in the etiology of growth disturbance requires the establishment of rapport between program staff and family.

The team needs the time and skill for detailed and frequently serial interviews with parents that permit the development of a trusting alliance. Rapport will definitely not be established if the staff automatically takes a stance that blames the parents. Parents should be invited as full members if not, in fact, as leaders of assessment teams.

Recommended Reading

Foley, G. (1990). Portrait of the arena evaluation: Assessment in the transdisciplinary approach. In B. Gibbs & D. Teti (Eds.) Interdisciplinary assessment of infants: A guide for early intervention professionals (pp. 271-286). Baltimore: Paul H. Brookes Publishing Co.

Frank, D.A., & Drotar, D. (1994). Failure to thrive. In R.M. Reece (Ed.), Child abuse: Medical diagnosis and management (pp. 298-324). Philadelphia: Lea & Febiger.

Hutchison, D. (1974). A model for transdisciplinary staff development: A monograph (Technical Report No. 8). In The first three years: Programming for atypical infants and their families. New York: United Cerebral Palsy Associations.

Kessler, D.B. & Dawson, P. (1999). Failure to Thrive and Pediatric Undernutrition: A Transdisciplinary Approach. Baltimore: Paul H. Brookes Publishing Co.

United Cerebral Palsy Associations. (1976). Staff development handbook: A resource for the transdisciplinary process. New York.

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updated December 03, 1999