Monday, June 19, 2017

How Did Early Intervention for Infants and Toddlers Get to Be Such a Mess, in Some States?



In a New York Times editorial this morning (June 19, 2017), Christy Ford Chapin, a historian at the University of Maryland, Baltimore County, blames the insurance company model on our messed-up health care system. She points out it’s not the care that’s messed up; it’s the cost structure. When the American Medical Association went to bed with insurance companies, health care moved to a fee-for-service payment approach. 

In early intervention for children 0-3 and their families, we have a similar history but it most definitely has hurt the quality of services or “care.” State administrators of Part C programs and some consultants realized that insurance would pay for the therapies—occupational, physical, and speech-language. Furthermore, Medicaid would pay for these and “targeted case management.” Some states have even persuaded their Medicaid programs to pay for “developmental therapy,” or whatever term is used in that state for special instruction or family counseling. A side note is that states are all over the place with the service provided by the nontherapy generalist—from states that rigidly insist on hiring only early childhood special educators to those that hire a myriad of professionals in that role: early childhood educators, psychologists, counselors, and so on.

Back to the insurance company model, the fee-for-service method, in which people are paid only for the time they spend in direct service with the child, is the main method in states using a vendor model. Here, the service coordinator, a technically defined position, finds services, theoretically to address the outcomes/goals on the individualized family service plan. These “dedicated” service coordinators are not service providers in vendor-model states; they help the family arrange for resources including services and they are not necessarily trained in child development or family functioning. They are therefore in a difficult position to make decisions about what services are needed. So they often resort to mindless assignment of services matching any deficits the child has. For example, if the child is behind in language development, a speech-language “pathologist” is put on the plan; if behind in gross motor development, a physical therapist; if behind in fine motor, an occupational therapist; if behind in cognitive or social, a special instructor. This idea that you have a different specialist for each area of development is the multidisciplinary approach, in which each person does his or her own thing and they don’t talk to each other. In fact, in the vendor model, they might all come from different agencies or be independent vendors.

They often resort to mindless assignment of services matching any deficits the child has

Not only do we have the mindless piling on of services, but the incentives are in place to have a high frequency of services. The first incentive is that, in the fee-for-service model, the more you see the child the more money you get. The second incentive is that, when you operate in a multidisciplinary approach, you think only of your interventions; you might not even know about the other professionals’ interventions. So your demands on the family might not be appropriate for their daily life. 

One of the worst outcomes of the insurance company model is that families get the wrong idea about how children learn and how services work. They see what’s recommended and what professionals do (seeing the child every week for a 1-hour session) and they come to the logical conclusion that these sessions are effective. Yet everyone understands that children don’t learn in single sessions in a week. I hope everyone understands that! Furthermore, any one so-called intervention in that session lasts probably no more than 15 minutes, because of the child’s attention span and tolerance level. So, really, 15 minutes a week—for an infant or toddler….

In the past 10 years or so, a number of states have realized the error of their ways, but breaking out of the golden handcuffs of insurance and Medicaid payment isn’t easy. States organizing services in geographic teams under contracts with the state have provided better services—more coordinated, generally addressing the whole child and family instead of a blinkered discipline focus. And this nonvendor or “program” approach doesn’t preclude using third-party payments. That’s the important part that state administrators need to realize. Insurance companies often won’t pay for special instruction, which is the most common service in Part C. Some states have, as I mentioned earlier, worked with their Medicaid office to get developmental intervention paid for, but they have to be careful that the tail doesn’t wag the dog: If Medicaid uses a fee-for-service method of payment, quality can suffer.
States organizing services in geographic teams under contracts with the state have provided better services
 What exactly is wrong with fee for service? First, it encourages a more-is-better mentality, and we have emerging evidence that more is worse, in some situations, such as more services and more frequent visits by multiple providers. Second, much early intervention happens when not in direct contact with the child, which fee for service usually doesn’t cover. For example, meeting with the family without the child or when the child’s asleep. Or meeting with other people working with the family. Or looking for a resource for the family. 

When we know how messed up the health care system is, why would we replicate it in early intervention?

Monday, May 15, 2017

Mental Shift 10. It's about helping families feel confident in their competence with their children


Since September 2015, I've been addressing the following mental shifts required to take a family-capacity-building, routines-based approach to early intervention:
12 Mental Shifts
1.       All the intervention occurs between visits.
2.       Whose child is it anyway?
3.       Children are learning from their caregivers, whether you want them to or not.
4.       Anyone spending time with the child has the opportunity to teach the child.
5.       Passing judgment on parents or other caregivers is a self-fulfilling prophecy.
6.       Parent failings don’t exist; only professional ones.
7.       What matters is how children function in their everyday lives. Function = participation = engagement = learning.
8.       The rush to get ahead leads to failure in early intervention.
9.       It’s about getting children engaged, independent, and in social relationships.
10.   It’s about helping families feel confident in their competence with their children.
11.   Too many cooks spoil the broth.
12.   Teamwork can work through collaborative consultation.

Helping Families Feel Confident

Here are four things to do with families and one thing not to do. I then discuss specific practices in the Routines-Based Model that help families feel confident.

Some Level of Covertness

The indirect approach is sometimes the best way to appear sincere. Although we talk about the value of being positive in our interactions with families, it we’re too gushy about how great they are, they might question our sincerity. For example, if we say on every visit, “Oh, you’re awesome in teaching Nigel,” after a few visits Nigel’s mother is going to wonder if you’re just saying that to be nice. So it’s a good idea to change it up, such as, “I was just thinking on my way over here that I wish other mothers I work with could see how you teach Nigel.” You’ve inserted the compliment by reflecting on your own thoughts.
Home visit in Paraguay

Better Than You

To build others’ confidence, it’s helpful to be confident yourself—confident enough to acknowledge when they’re better than you in some way. For example, “Wow! I wish I had your patience.”

Appreciate Them

This can be overt, somewhat contradicting “some level of covertness.” It is about finding something the caregiver is responsible for—something said, something done, something in his or her environment—and letting the caregiver know you value it. It could be, “You’re really sensitive to his feelings,” or, “You make diaper change so fun,” or, “He’s so cute in that outfit.” Feeling appreciated is such a basic need.
Along with being responsive, oriented to the whole family, friendly, and sensitive, being positive—appreciating caregivers—is one of the characteristics we found of family-centered professionals working with families of young children with disabilities (McWilliam, Tocci, & Harbin, 1998).

Encourage Them in Their Chosen Role

If we’re living a life we chose, we like our choices to be validated. For example, if a person with a good job decides to stay home with her child, we should covertly make statements about how much time she spends with her child or how focused she is on helping her child be engaged.
Some people are not living a life they chose but they’ve talked themselves into believing it was their choice. This cognitive dissonance is a way for people to deal with competing values. What you get and have to take at face value is their saying they’re living a life they chose.
Other people are not living a life they chose and they feel it was their fault or someone else’s fault. If they talk to you about it, either putting themselves or others down, you have an opening to find out what in particular they would like to change and then using family consultation to help them find a solution. You have to start by asking them if they want to do something about the particular bother. They might say no—they just want to vent… and to have you listen.

Don’t Positively Reframe Their Negative Statements

The chirpy positive reframe, like, “No, you’re really good at that!” or “Oh, all parents go through that!” or “That’s no way to think! Everything will turn out fine!” is annoying at best and insulting at worst. It’s negating what the caregiver is saying. We listen and acknowledge. It can be difficult when much negativity is coming out.
In all these situations, the stronger the relationship you have with the caregiver, the more direct you can be in your helping them.

From the Routines-Based Model

In the Routines-Based Model, various practices build families’ confidence. Four such practices are as follows:
1.     The ecomap shows them (a) they can identify many people in their informal- and formal-support networks and (b) they’re not alone;
2.     The Routines-Based Interview (RBI) shows them they can report on details of child and family functioning and can choose 10-12 meaningful outcomes/goals;
3.     Family consultation shows them they are solution finders and interventionists;
4.     The Measure of Engagement, Independence, and Social Relationships (MEISR) shows them they can assess their child’s functioning in everyday routines

Families’ Competence

We’re helping families to feel confident about their competence in four roles.

Parents

Early intervention is a parenting program. We enhance families’ ability to address specific outcomes/goals for their children. In the Routines-Based Model, we also encourage their competence in talking to their children, reading with their children, playing with their children, and teaching their children.

Family Members

Watching home visit with GuaranĂ­-speaking professional
The mother we might visit regularly might not be only the mother of the child in early intervention. She might be a mother of other children too, a wife, a daughter, a daughter-in-law, and so on. The Routines-Based Model teaches professionals to be oriented to the whole family, helping caregivers be the kinds of family members they want to be.

Interventionists

In their role as parents, parents are teaching their children, both addressing outcomes/goals and the usual teaching parents do. Helping parents be effective teachers of their children is a huge part of what we do.

Collaborators

We help families feel confident in working with us, together, to find solutions to needs they identified. Some families are natural partners; others are not used to being in that role and require some hand-holding to get there. We are helping prepare them for the marathon of parenting, not just the sprint in early intervention. As they move to other systems of support, we want them to be confident in determining their own needs and in working with professionals.
Let’s end with a saying from Lao Tzu: 
“Kindness in words creates confidence. Kindness in thinking creates profoundness. Kindness in giving creates love.”

 

McWilliam, R. A., Tocci, L., & Harbin, G. L. (1998). Family-centered services: Service providers’ discourse and behavior. Topics in Early Childhood Special Education, 18, 206-221.