Sunday, November 17, 2019

The Routines-Based Model Internationally Implemented: 1. The Model


On February 19, 2019, I vowed to write my next seven posts about the Routines-Based Model internationally implemented. Well, I got distracted by other pressing issues but now I’m back on track. Please click on the link for that post to see colleagues from The RAM Group who have contributed this information.
The Routines-Based Model Internationally Implemented
In Minga Guazú, in the hot eastern side of Paraguay, where many of the families in early intervention (birth-6 years of age), are indigenous Guaraní, a young occupational therapist (OT) welcomes a family to the early intervention center. The center is for children with physical disabilities. This OT has been trained in the Routines-Based Model (RBM) and, today, she will talk to the family about 2 or 3 of the 12 goals on the child’s and family’s intervention plan. 

Meanwhile, in Lisbon, a physical therapist (PT) is going on a home visit. The family has 10 goals, and this PT will talk to the family about, perhaps, 3 of these goals. In one of them, she will ask the family if they would like to show her what they’ve been doing, and she will guide them through some strategies that, together, they have decided might help the child participate meaningfully in breakfast time.

In Cieszyn, Poland, workers are still hammering nails, as a dorm on a university campus is being remodeled to become a preschool (“kindergarten” in Polish parlance) following the Engagement Classroom Model. This model demonstration site will show how you can run a classroom to promote child engagement.

In this series of posts, we discuss the Routines-Based Model; how it became of interest, internationally; what practices implementers adopted; what challenges they faced; what successes they had; and our conclusions about what has to happen to improve early intervention around the world.
The Model
McWilliam and colleagues developed the Routines-Based Model over many years (McWilliam, 2016b; McWilliam, Trivette, & Dunst, 1985). The model has three main components: needs assessment and intervention planning, a consultative approach, and a method for running classrooms.
Needs Assessment and Intervention Plan Development
In the RBM, nothing good can happen unless we have a list of goals meaningful to the family and other caregivers spending time with the child. To develop an intervention plan, which goes by different names in different countries, we conduct an ecomap and a Routines-Based Interview, from which the family chooses functional goals and family goals.

Ecomap. The ecomap is a picture of the family’s ecology (Jung, 2010). Most important, it identifies the family’s informal supports. In most early intervention services, they don’t find out the extended family, friends, and neighbors the family might be able to count on for support, before resorting to formal supports.

Routines-Based Interview. The Routines-Based Interview (RBI) is the best known component of the RBM, but it is only one of 17 components (McWilliam, 2016a). A professional interviews the family about the details of child and family functioning in daily routines, and the family chooses goals/outcomes. In New Zealand, they try to avoid “interview,” because some people thought it was a formal 2-hour bombardment of the family with questions (Woods & Lindeman, 2008). From an implementation and branding perspective, however, we encourage implementers to keep using “Routines-Based Interview,” but of its name recognition. 

Functional goals. Goals for child functioning are written to emphasize the child’s participation in routines, such as, “Jared will participate in breakfast time, hanging out time, and outside time by using single words” (Fleming, Sawyer, & Campbell, 2011). Furthermore, we write the goals with criteria for acquisition, generalization, and maintenance, such as, “We will know he can do this when he uses five different single words, in two of these three times of day in one day, over four consecutive days.”

Family goals. As a result of the RBI, the family chooses goals for other members of the family. The most common goal is time for oneself, such as, “Diane will have two hours for herself every two weeks, for 10 consecutive weeks.”
Consultative Approach to Early Intervention
A principle of the RBM is that all the intervention occurs between visits, so the point of visits with caregivers is to build their capacity to meet child and family needs when the professional is gone (i.e., during all the other hours of the week). 

Family consultation. Family consultation involves the professional, usually a home visitor, working with the family to identify (a) why a child isn’t doing something, (b) what might be a viable solution, and (c) whether the strategy worked. This involves the professional’s asking many questions to find out what’s being going on so far before making a suggestion (Boyer & Thompson, 2014; Dougherty, 2013; Horne & Mathews, 2004). He or she also asks the family whether they would like to try it out during the session and whether they think it is feasible.

Collaborative consultation to children’s classrooms (CC2CC). Similarly, when professionals see “a child” in child care or preschool, they actually go to visit the teaching staff. Again, they jointly decide why a child isn’t doing something, what the strategy might be, and whether it has worked. This practice is based on seven years of research on “integrated therapy” (McWilliam, 1995).
Engagement Classroom Model
The RBM include procedures for running classrooms to promote child engagement, which we have dubbed the Engagement Classroom Model (McWilliam & Casey, 2008). Implementers focus on five components:

  1. Conducting RBI to establish functional, routines-based goals;
  2. Incidental teaching to address all goals in all routines, by following the child’s lead and eliciting higher order functioning;
  3. Integrated therapy, meaning specialists work with teachers in the classroom and never pull the child out;
  4. Zone defense schedule to arrange the room in zones, to organize the adults, and to decrease nonengagement time during transitions between activities;
  5. Incorporating Reggio Emilia concepts to promote children’s exploration, to encourage creativity in art, and to make the environment “provocative” and beautiful.
Here, I have described the model, focusing on needs assessment and intervention plan development, our consultative approach to early intervention, and the Engagement Classroom Model. Next time, I address how the model became of interest, internationally.



Boyer, V. E., & Thompson, S. D. (2014). Transdisciplinary model and early intervention: Building collaborative relationships. Young Exceptional Children, 17, 19-32.
Dougherty, A. M. (2013). Psychological consultation and collaboration in school and community settings. Belmont, CA: Cengage Learning.
Fleming, J. L., Sawyer, L. B., & Campbell, P. H. (2011). Early intervention providers’ perspectives about implementing participation-based practices. Topics in Early Childhood Special Education, 30, 233-244.
Horne, S. G., & Mathews, S. S. (2004). Collaborative consultation: International applications of a multicultural feminist approach. Journal of Multicultural Counseling and Development, 32, 366-378.
McWilliam, R. A. (1995). Integration of therapy and consultative special education: A continuum in early intervention. Infants & Young Children, 7, 29-38.
McWilliam, R. A. (2016a). Metanoia in early intervention: Transformation to a family-centered approach. Revista Latinoamericana de Educación Inclusiva, 10, 155-173.
McWilliam, R. A. (2016b). The Routines-Based Model for supporting speech and langauge. Logopedia, Foniatría y Audiología, 36, 178-184.
McWilliam, R. A., & Casey, A. M. (2008). Engagement of every child in the preschool classroom. Baltimore, MD: Paul H. Brookes Co.
McWilliam, R. A., Trivette, C. M., & Dunst, C. J. (1985). Behavior engagement as a measure of the efficacy of early intervention. Analysis and Intervention in Developmental Disabilities, 5, 59-71.
Woods, J., & Lindeman, D. P. (2008). Gathering and giving information with families. Infants & Young Children, 21, 272-284.

Sunday, November 10, 2019

The Comprehensive Service Provider


The early intervention field apparently needs another type of professional. The primary service provider’s role was first articulated, to my knowledge, in a 2003 article, “The Primary-Service-Provider Model for Home- and Community-Based Services” (McWilliam, 2003). A thorough treatment of this approach has subsequently been published in the book The Early Intervention Teaming Handbook: The Primary Service Provider Approach, by M’Lisa Shelden and Dathan Rush (2013). To function as a primary service provider (PSP), you need the cooperation of your teammates. They need to agree to serve as secondary service providers, making visits with the PSP as needed, and not being on the plan at a regular, frequent rate. Two situations have arisen to create the need for this new type of professional.

In one state with which I worked, special instructors, as they’re known in Part C of IDEA, make weekly visits to families. Good news! Weekly! But service coordinators are also putting therapy services (OT, PT, SLP) on the plans for weekly visits. In this particular state, therapies are usually provided in clinics/centers/offices—definitely not the natural environment. The state can get away with this because what they report to the Office of Special Education Programs is the percentage of children receiving their primary service (special instruction) in natural environments. This state, therefore, looks good in “Indicator #2: Settings: Percent (sic) of infants and toddlers with IFSPs who primarily receive early intervention services in the home or programs for typically developing children.” 

In this situation, by definition, no one is the PSP: If more than one service is being provided at the same frequency, an interdisciplinary or multidisciplinary approach is in place. Who is looking at the whole child and family? In this situation, it is clearly the special instructor—the person in the home or child care program, attending to all the outcomes on the IFSP.

The other situation creating the need for a new type of professional is reflected in another state with which I work (I work with many states). Here, families are often visited weekly, by different people. For example, the special instructor might visit the family twice a month and a therapist (OT, PT, SLP) might also visit the family twice a month. Again, we have equal frequency, so inter- or multidisciplinary. Or the special instructor might visit the family twice a month, one therapist might visit them once a month, and another therapist might visit them also once a month, with the family receiving four visits a month from three different people. Some families have monthly visits from (a) a special instructor, (b) an SLP, (c) and OT, and (d) a PT. That means any one professional is seeing the family only once a month—what Dathan Rush calls “checking in, not digging in.”

Because of these situations precluding the use of a PSP, I have created the role of a comprehensive service provider (CSP). This professional takes responsibility for addressing the whole child and family. When a Routines-Based Interview (RBI) has been conducted, and the family has identified 10-12 outcomes/goals, the CSP provides support around all those outcomes/goals, regardless of who else is involved. 

The extent to which the CSP and the other service providers collaborate depends on many factors, but probably most saliently on (a) how willing the teammates are to discuss their work, (b) how functional the teammates’ work is, and (c) how much interdisciplinary respect the teammates have for each other. When I say “teammates,” I mean the people who are on a child’s IFSP/IEP.
In the rest of this blog post, I provide an overview of the CSP’s role, why we need one, how the CSP works, who decides on the CSP, where the CSP works, and when the CSP changes.

What Is This Person?

The CSP is an early intervention provider from any discipline on the child’s IFSP/IEP. He or she accepts the role of supporting the family with all child and family needs, with the support, to the extent available, of professionals with other qualifications. Because other professionals on the IFSP/IEP are seeing the child separate from the CSP, rather than in joint visits, the collaboration between the CSP and others ranges from nonexistent to close. If they are not employed by the same agency, the collaboration tends to be minimal. Somewhat more collaboration occurs if everyone on the IFSP/IEP is employed or contracted by the same agency.

Why Do We Need a CSP?

We need a CSP in these multi- or interdisciplinary scenarios for three reasons: blinkers, duplication, and contradiction. When professionals from different disciplines work independently with the child, they tend to restrict themselves to the areas in which they were trained. They often refer to this as their scope of practice, thinking they should not exceed it. The problem is that the scope of practice (a) is different depending on the age of the child, the setting, and the problems addressed; (b) assumes the professional knows only about his or her area of training; and (c) ignores the fact that development in one area (e.g., domain) is influenced by development in other areas—sometimes for better and sometimes for worse. When each professional makes visits with disciplinary blinkers on, we find that many RBI-generated outcomes/goals do not fit neatly into the scope of any of these professionals’ traditional practice. This blinkering has led to the phenomenon of more professionals on children’s plans, resulting in fewer child and family needs met.

Duplication and contradiction occur when each person seeing the family claims to be addressing the whole child and family. If they are seeing the family without other IFSP team members and communicating minimally, we could have duplication of services. Both the speech-language pathologist and the special instructor are working with the family on finding opportunities for the child to interact with peers. We don’t need to pay two people to do this. Furthermore, the two professionals might give contradictory advice about how to help with child functioning or family needs.

How Does the CSP Work?

The CSP works by addressing all child and family outcomes/goals, using a family consultation approach, and employing three critical tools.

Types of Goals

Plans can have three types of goals: child goals, child-related family goals, and family-level goals. Child goals are those skills the family has indicated they would like their child to learn. For example, they could be rolling from stomach to back, using two-word combinations, persisting when something doesn’t work the first time, using the potty, playing with another person, and so on. Child-related family goals are those for the adults that have to do with the child, such as learning sign language to help the child learn signs, getting information about the child’s disability, or obtaining equipment that will help the child function. Family-level goals are for things the adults want, not directly related to the child, such as a different job, change of housing, enrolling in classes, and having time for him- or herself. The CSP consults with families about all these types of needs.

Routines-Based Visits

The CSP works by making routines-based visits, which are designed to meet the family’s need and to build the family’s capacity to meet their child and family needs. They include

  • ·       Giving families the opportunity to set the agenda;
  • ·       Referring to what the family said they wanted to work on;
  • ·       Referring to what the family said they wanted the focus of the visit to be;
  • ·       Talking about skills always in the context of everyday routines;
  • ·       Action in the form of demonstration by the child, family, or CSP;
  • ·       Discussion of other skills in that routine;
  • ·       Discussion of other routines for that skill;
  • ·       What we will do between now and the next visit; and
  • ·       What the focus of the next visit will be.

The visit is therefore responsive to the family’s needs, agenda, and experiences. It also includes sticking the landing: actually coming up with suggestions, but only after obtaining context.
The CSP also makes collaborative consultation visits to children’s classrooms, to build the teachers’ capacity to meet child needs. These visits include

  • ·       Giving teachers the opportunity to set the agenda;
  • ·       Referring to what the teachers said they wanted to work on;
  • ·       Referring to what the teachers said they wanted the focus of the visit to be;
  • ·       Talking about skills always in the context of everyday routines;
  • ·       Action in the form of demonstration by the child, teacher, or CSP;
  • ·       Discussion of other skills in that routine;
  • ·       Discussion of other routines for that skill;
  • ·       What we will do between now and the next visit; and
  • ·       What the focus of the next visit will be.

Tools to Help

The CSP has three tools at every home visit and two of these at every classroom visit. At every visit, the CSP should have the Next-Steps Form (NSF) and the matrix, at home visits, the /ecomap. The NSF is needed to review with the family what they have been working on (see www.eieio.ua.edu/materials). It also specifies what the focus of this visit should be. When asking the family about that focus, the CSP should show the family the matrix, because that lists all child and family goals. The matrix shows the routines for which each child goal is targeted (see www.eieio.ua.edu/materials).
 

The matrix is also used sometimes to make a transition from one topic to another. For example, if a professional and a parent have been talking about strategies to help the child sit through “big church” without being a distraction, the professional can ask about other times when being noisy and fidgety interferes with functioning or other skills needed during big church time.
 

The ecomap shows a family’s informal, intermediate, and formal supports. It is used whenever a new need comes up, especially a family-level one, or a new strategy needs to be found. The purpose is to use existing resources rather than seeking out additional services, unnecessarily. When families see their own assets can be used to meet needs, it empowers them. For example, the parents want to have a date night but they have no babysitter. The CSP prompts them to look at their ecomap—at their informal resources—to identify a possibly babysitter.
 

Who Decides Who the CSP Is?

The need for a CSP arises in a multi- or interdisciplinary environment, where more than one professional is seeing the child and family at roughly the same frequency. In other words, no one is the primary service provider, which is the preferred approach. A professional from any discipline can be the CSP, but it must be someone who is prepared to help caregivers with all child needs and family needs, not only those related to the person’s area of formal training. If the Routines-Based Interview or other functional, family-centered assessment of needs has been conducted, many outcomes/goals will fall outside any discipline’s scope of practice. Which of the two or more professionals on the IFSP/IEP should serve as the CSP? 

The family can decide who is most likely to fill this role, if they know the professionals already. In American early intervention under Part C of IDEA, the service coordinator can decide on the most appropriate professional. If a blended service coordinator (i.e., a service provider who also works as the service coordinator) is used, that person is probably best suited to be the CSP. For preschoolers, the decision maker about who the CSP is could be the person managing the IEP meeting.

Where Does the CSP Work?

The CSP works in homes, the community, classrooms, or even offices (e.g., centers, clinics). The important point is that the CSP spends time with natural caregivers, using collaborative consultation. With families, we call this family consultation. The visit consists of

  • ·       Reviewing what the caregiver has been working on since the previous visit,
  • ·       Focusing on what the caregiver wanted the current visit to be about,
  • ·       Discussing child skills in the context of regularly occurring routines,
  • ·       Assessing and promoting the child’s meaningful participation in routines (engagement, independence, social relationships),
  • ·       Hearing about progress towards family goals (in the case of visits with families),
  • ·       Strategies to improve classroom management, and
  • ·       Plans for follow up to the visit.

When Does the CSP Change?

Ideally, never. In the Routines-Based Model, we say The PSP changes only upon death. Because families form strong relationships with their CSPs, we follow the principles of continuity of care. In a PSP/CSP environment, the background of the professional can be from any of the main occupations: early childhood special education, child development and family studies, occupational therapy, speech-language pathology, physical therapy, social work, psychology, nutrition, nursing, and so on. Just because the main areas of concern shift from motor to communication, therefore, it doesn’t mean we change CSP. Internationally, the most common reason for change is when the family moves, either because the child is now served by a new program or the program assigns CSPs by geography.

Conclusion

Using a CSP is a powerful way to garnish the benefits of a PSP approach, when one can’t actually have a PSP. A CSP can ensure that caregivers receive help in all areas of child functioning and family life. The CSPs ability to secure help from other people on the IFSP or IEP varies, so he or she needs to be resourceful and hard working. If an RBI is used in a multi- or interdisciplinary environment, one service provider must assume the role of a CSP, because many outcomes/goals will fall outside the traditional confines of the standard disciplines.

McWilliam, R. A. (2003). The primary-service-provider model for home- and community-based services. Psicologia: Revista da Associacao Portuguesa Psicologia, 17, 115-135.
Shelden, M. L., & Rush, D. D. (2013). The early intervention teaming handbook: The primary service provider approach. Baltimore, MD: Paul H. Brookes.