It would be impossible for me to describe the Routines-Based
Model (RBM) in detail in only a few paragraphs. This post is designed to show
how all the practices fit together and to show the scope of the model. I
thought I’d throw together a short, accessible blog post that turned into this
monster. I’ve ended up describing what the model is, attending to the
principles, followed by the three major categories of practices in the model
(assessment and intervention planning, working with families and teachers,
Engagement Classroom Model), and how we evaluate the Routines-Based Model.
What Is It?
The Routines-Based Model is a collection of practices that,
together, provide a unified approach to working with young children with
disabilities and their families (McWilliam, 2010). It emphasizes (a) children’s functioning in
their everyday routines and (b) supporting families. Many early intervention
(birth to 5 years) have or claim this focus, so what’s different about the RBM?
First, the practices are well defined, have implementation checklists, and are
supported by research. Second, they work together. Third, they adhere to the
following set of principles.
Principles
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All the intervention occurs between visits
(caregivers provide intervention; visits are for professionals to provide
service or support)
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Early intervention sessions aren’t golf lessons
(we don’t work directly with the child, using massed trials, expecting the
child to generalize to nonsession time)
- ·
Caregivers address children’s learning needs in
everyday routines (rather than in separate lessons or sessions)
- ·
We don’t abnormalize children and families
(early intervention matches families, not vice versa)
- ·
We promote evidence-based, functional strategies
(not popular techniques that claim to get at underlying causes of dysfunction)
- ·
Whose child is it anyway (families not
professionals decide what’s right for children)?
My colleagues and I have followed these principles in
developing the model, and implementers of the model have used them as mantras.
One can think of the model in terms of four general areas: assessment and
intervention planning, working with families and teachers, the Engagement
Classroom Model, and evaluation.
the
family has to have the capacity to help their child and other family
members—as they define that capacity
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Assessment and Intervention Planning
We follow the logic represented below, which is best viewed
through backward mapping. Our distal outcomes are children’s learning and
development and family quality of life
(Garcia Grau, McWilliam, Martínez-Rico, & Grau Sevilla, 2016). For those to happen we
believe children need to be able to function maximally in their daily routines,
the family has to have the capacity to help their child
and other family members—as they define that capacity—and family needs must
be at least addressed and at most met. For those outcomes to be realized,
professionals need to provide collaborative consultation, including family
consultation (a consultative or “coaching” approach), using the Next-Steps Form
to emphasize how much families do with their children and to give them control
over the visits.
RBI
Many people consider the heart of the RBM to be the
Routines-Based Interview, for good reason: Without a decent needs assessment,
how should we help families and their children (Hughes-Scholes, Gavidia-Payne, Davis, & Mahar, 2017)? In the RBM, we provide
professionals with professional development through an annual institute and
state bootcamps (including hands-on practice with families), with a protocol,
with an outline, and with a practice-based checklist.
Institute and Bootcamps
Almost every year, since 2008, we have conducted an
RBI Certification Institute, in which
professionals from around the world have received training in conducting these
needs assessments. In addition to the U.S., Spain, Costa Rica, Portugal, and
Australia have been represented. I run these week-long institutes with Cami
Stevenson from Portland, OR, along with certified trainers who work as coaches.
Participants get to practice with families in early intervention. About two
thirds of participants make it through to certification.
We also help states organize state bootcamps—versions of the
international certification institute. We have held these bootcamps in
Australia, Colorado, Kentucky, Mississippi, Montana, Nebraska, New Zealand, and
other places.
Protocol
The RBI Protocol (McWilliam, 2009) is a step-by-step guide through the RBI,
providing professionals with the wording, the structure, and the framework for
the interview. It takes the guesswork out of this semi-structured interview,
although, of course, the meat of the interview cannot be scripted. To conduct
the RBI with fidelity, however, certain parts must be done according to
well-tested rules. For example, the three “magic” questions at the end of the
interview have to be asked a certain way, to avoid awkwardness:
·
Do you
have enough time for yourself or yourself and another person?
·
When you
lie awake at night worrying, what do you worry about?
·
If there’s
anything you could change in your life, what would it be?
Because some professionals find these questions difficult to
ask, we have learned to script the questions. In fact, we are building a bank
of scripts for introducing different parts of the model to families and
professionals.
Outline
The RBI Outline provides the structure for the interview.
The beginning and end of the interview are structured. Even the middle—the
discussion of child and family functioning in routines—has a hidden structure.
To keep interviewer and note takers on track, the one-page Outline is useful.
Checklist
The
backbone of the RBM is its performance checklists
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The backbone of the RBM is its performance checklists (Boavida, Akers, McWilliam, & Jung, 2015). These define the practices,
provide a platform for feedback, and constitute the fidelity measure. We have
operationally defined each practice in the model to reduce ambiguity about what
should be done and what should not be done. When training professionals, we
observe them, check their performance on the checklist, and provide feedback.
This, rather than workshops, is real training. By using checklists to observe
the model in action, we obtain fidelity and implementation data: We can quantify
the extent to which the practice is implemented as designed. In this case, we
use the RBI With Ecomap Checklist to explain the practices (RBI, ecomap,
functional outcome/goal writing), to train people, and to document fidelity to
the model.
Ecomap
The ecomap is the method we use to determine the composition
of the family’s ecology (Jung, 2010).
We complete it early in our encounters with families—at intake or at the
beginning of the RBI. As is true in all the practices in the model, the professional
completing it usesan informal, respectful style with the family. To ascertain
the level of support from informal supports (i.e., extended family, friends,
neighbors), we ask about the frequency of contact, even though we understand
the closeness you feel to someone goes beyond frequency of contact. To
ascertain the level of support from formal supports (i.e., professionals,
financial assistance, medical professionals), we ask how the family likes the
support, because we don’t want to ask them to judge the quality of their
professional practice. The ecomap shows supports and different thicknesses of
lines to indicate level of support but the process of asking about these
supports is more important than the product. We say in the model that we are
not trying to capture the truth; we’re trying to capture what families want to
tell us. Later, when providing support to the family, the professional refers
to the ecomap, when they discuss a need, particularly a family-level need, to
see if anyone in the family’s existing network can help. Here is an example.
Participation-Based Goals
The deliverable from the RBI is the list of family-chosen
goals (known as outcomes in Part C of IDEA). Because the interview is about
what happens in daily routines, families choose functional skills they want
their child to do, such as use words or signs to indicate what they want for
breakfast, look for toys that fall out of sight during hanging-out time, walk
down the hallway at bedtime, pick up food at lunch time, say hi to Grandma when
she walks in the door, or take off shoes when coming inside. These examples, by
the way, cover all developmental domains, even though we use engagement, independence, and social
relationships as our domains.
In writing goals, we emphasize that the reason for the goal
is for the child to participate meaningfully in routines. Participation is
widely considered a core concept of the functioning of people with
disabilities. For example, it is one of the three parts of the International
Classification of Functioning, Disability and Health (ICF), along with body
structures/functions and activities. How “disabled” a child is can be thought
of as how meaningfully the child can participate in routines of home, school,
and community.
Therefore, we write goals in the RBM beginning with [child’s name] will participate in…,
followed by the routines for the skill in question. For example, Mats will participate in breakfast, lunch,
dinner, and snacks by using words or signs to indicate what he wants (Fleming, Sawyer, & Campbell, 2011). The social relationships
(language) goal doesn’t hang out there on a goal, with no context. The reason
for his using words or signs is to participate in meal times meaningfully. This
doesn’t mean Mats won’t learn or use words in other routines, but these are the
ones the family targeted as particularly important.
How will we know he is using words or signs? To answer this,
we establish criteria. First, we work with the family to answer how many words
Mats might be able to learn in 6 months, considering where he’s starting from.
This is an acquisition criterion. Second, we have a generalization criterion,
when appropriate. In the RBM, it is almost always generalization across
routines. In this example, we might target the use of words or signs in all
four routines: breakfast, lunch, dinner, and one snack. Finally, to make sure
the skill sticks, we establish a maintenance criterion, such as the number of
consecutive days in which the skill is displayed. Therefore, the final
participation-based goal might read Mats
will participate in breakfast, lunch, dinner, and snacks by using words or
signs to indicate what he wants. We will know he can do this when he uses five
different words or signs at breakfast, lunch, dinner, and one snack on four
consecutive days.
In the RBM, we use these criteria and goal-attainment
scaling for monitoring progress on goals, but some professionals choose
different measurement systems. Some use a rating scale for the family’s
satisfaction with the child’s performance, for example. In this system, the
goal is attained when the family is happy with what the child is doing. For
full fidelity to the RBM, however, we use the three criteria (acquisition,
maintenance, generalization).
Family Goals
Some goals the family chooses at the end of the RBI are
goals for members of the family other than the child in early intervention.
Family goals can be child related or family level. Child-related family goals
are those things the family wants to happen, related to the child in early
intervention. They might be about information, obtaining equipment, looking for
resources (even services), learning a skill that will help the child (e.g.,
sign language), and so on. Family-level goals are not directly related to the
child but specifically for other members of the family, such as meeting basic
needs, getting a job, having recreation time, helping a sibling of the child,
or—the most common one—having time for yourself or yourself and another person.
To keep track of the family and child goals, home visitors use a matrix.
Matrix
The matrix writes itself from the RBI, because it lists the
informal outcomes/goals on the left-hand column and the routines on the top
row. Outcomes are listed in the family’s order of importance priority. In the
corresponding cells, you put an X for the routines in which the child will
participate by performing the skill. It looks like this:
Outcomes
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Dressing
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Meals
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Outside
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Play
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Before dinner
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Bath
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Bedtime
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Other
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Other
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1. Persist
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X
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X
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X
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2. Follow 2-step directions
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X
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X
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X
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3. Mother resume education
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4. Use 3 different pieces of playground equipment
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X
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5. Use fork with little spilling
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X
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6. Parents info about Fragile X syndrome
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7. Wait for others’ turns
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X
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8. Put on shirt and pants
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X
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X
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9. Parents time for themselves
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10. Count to four when upset
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X
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X
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X
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11. Express opinion without whining or crying
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X
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X
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X
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12. Visit transition programs
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13. Stay in bed without protesting
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X
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We leave a couple of columns for other routines that the
family wants addressed—perhaps those we didn’t have enough time to get to in
the RBI.
Assessment and intervention planning according to the RBM,
therefore, consist of the RBI, the ecomap, participation-based child goals, and
family goals. All outcomes/goals are represented on the Outcomes x Routines
matrix.
Working With Families and Teachers
In the RBM, working with families and teachers is
essentially a consultative endeavor, similar to what others call coaching. We
provide this collaborative consultation through support-based home visits,
during which we provide family consultation, and collaborative consultation to
children’s classrooms (CC2CC).
Support-Based Home Visits
Years ago, we defined home visits as support based (McWilliam & Scott, 2001). The three types of support
are emotional, material, and informational. Home visitors should be aware of
their obligation to provide all three, although not necessarily at every visit.
Nevertheless, they should be alert to the needs for any of the supports and to
the opportunities to provide these three types of support.
Emotional
We have found five supportive behaviors seen in
family-centered early intervention service providers:
- ·
Saying positive things about both the child and
the adults;
- ·
Being responsive to families, reading between
the lines yet not operating on too many assumptions;
- ·
Being oriented to the whole family, not only the
client child, especially to the child’s primary caregiver’s well-being;
- ·
Being friendly, beyond rapport; and
- ·
Being sensitive—walking in the family’s shoes.
Other emotionally supportive behaviors are important also,
such as being encouraging and empowering. We found these five in some research
we conducted on patterns of service use in early intervention 0-5 (McWilliam, Tocci, & Harbin, 1998).
Material
In the RBM, we think about two kinds of material support:
ensuring families have basic needs met and ensuring they have the necessary
adaptive equipment for the child’s engagement in routines. Home visitors cannot
ignore basic needs even if they aren’t service coordinators. They have to help
the family find solutions if the family has problems with housing, safety, food,
clothing, and so on. They should use the family’s ecology (i.e., whip out the
ecomap), especially the informal network, but also the formal network,
including the service coordinator, case manager, or whatever the person serving
in that role is called.
Adaptive equipment can include alternative and augmentative
communication devices, adaptive furnishings (e.g., corner chairs, adapted
strollers), and adaptive technology (e.g., switch toys, augmented reality). We
don’t like to abnormalize families with excessive adaptations but neither do we
want children to go for long without the necessary equipment to function in
routines.
As mentioned earlier, a principle of the model is not to
abnormalize families, which means not create situations when an intervention disrupts
the family’s natural routines. For example, we wouldn’t recommend that a family
sit down to “work on goals.” First, the goals should be for functions that
occur in regular routines—not lessons or sessions. Second, the intervention
should be a strategy that the family can use while parenting, playing, or
otherwise going about their everyday lives with their child. The
no-abnormalization principle can be more positively stated: Early intervention
should help families lead as normal a life as possible.
Informational
Families always want information. The four kinds of support
they typically want are about
- ·
Child development: What other children my
child’s age do or what comes next;
- ·
Resources, including services;
- ·
The child’s disability; and
- ·
Interventions: what to do with the child. This
last one takes up about 80% of the support professionals provide.
The core of early
intervention visits, whether to the home or elsewhere, is support. Think of
support in terms of emotional, material, and informational support.
Family Consultation
Encounters with the family, according to strong U.S.
commitments (e.g., federal law), occur in natural environments. In other
countries implementing the model, however, such as Spain, Paraguay, and Taiwan,
early interventionists have not found a way to rip themselves from their
centers. Recognizing that the quality of a visit doesn’t rest entirely on the
location, we have developed procedures for family-centered, functional visits
occurring in centers, clinics, or offices. We have seen that home visits can be
clinical, nonfunctional, and noncollaborative. We have also experienced
functional, capacity-building encounters in offices. One of the key practices
in the RBM for making visits effective, regardless of location, is the use of family consultation.
Solution Finding
We have coined the term family
consultation to describe a carefully selected series of steps for
Reports-Based Home Visits (McWilliam, 2010). When the family chooses to discuss child
functioning, the professional first asks what time of day (routine) the family
has in mind, for discussing the child skill. Child functioning is never
discussed outside the context of routines. Even if the parent says, “All the
time,” as they might for language learning, we ask them to identify routines
when it would be especially helpful for the child to communicate. Once the
professional understands the skill the parent wants, the professional asks many
questions in the quest for the best potential solution (i.e., strategy).
Hoosiers Rule
I have borrowed from one of the best sports movies made the
Hoosier’s Rule, which says that a home visitor cannot make a suggestion until he
or she has asked four questions. From the movie, the rule was you can’t shoot
until you’ve passed the ball four times. The four-question rule (a) increases
the likelihood of understanding the child’s current level of performance, (b)
provides you with enough context to make a reasonable suggestion, (c) conveys
to the family you’re really interested in working with them; and (d) helps the
family see they’re part of the solution finding (i.e., developing strategies).
Feasibility Questions
Once we’ve hit on a strategy and perhaps shown the family
how to do it, or they’ve practiced while we coached, we ask two important
questions:
- Do you think this strategy will work?
- With everything you have going on at this time
of the day, do you think you’ll be able to carry out this strategy?
If our relationship with the family is good, they’ll tell us
honestly if the answer to either question is no. That allows us to pull another
arrow out of our quiver, after probably some more questions.
Key Tools
The support-based home visit includes three tools—pieces of
paper.
NSF
The Next-Steps Form (NSF) has three essential pieces of
information:
- What we did today
- What we will do until the next visit
- What we will concentrate on during the next
visit
What we did today helps the early interventionist reflect on what happened
during the visit. The activities of some visits are clear. Those of other
visits, such as listening to the parent talk about something bothering him or
her, aren’t as clear. Each visit should serve a purpose. Knowing you’re going
to have to complete this first box helps the early interventionist focus on
what happened today.
Documenting what the family said they want to try doing with
their child is another box for closure and it serves as a reminder to the
parent. It also reminds the early interventionist before the next visit.
Because we have many outcomes/goals in the RBM, we ask the
family to look at the entire list of outcomes to tell us what they’d like to
concentrate on during the next visit. This is helpful if some outcome/goal
hasn’t been discussed in a while. Families can also mention other topics that
aren’t outcomes/goals, such as an upcoming doctor’s visit, a concern about a
sibling, or another issue with the target child.
Matrix
The second key tool for family consultation is the matrix
which was described in the Assessment and
Intervention Planning
section above.
Ecomap
The ecomap is the third tool the home visitor has available
on Routines-Based home visits. It also was described in the Assessment and Intervention Planning section.
CC2CC
In addition to making support-based home visits and using
family consultation during visits, the model includes collaborative
consultation to children’s classrooms (CC2CC) and, within those visits,
integrated therapy (McWilliam & Bailey, 1994; Woods, Wilcox, Friedman, & Murch, 2011).
Collaborative Consultation
“I’m
here to help you because you have a child with disabilities in your room.”
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Using CC2CC is best done by establishing a role with classroom teachers that
probably is new for most itinerant ECSEs and therapists. This role is that of
classroom consultant, rather than that of a professional ostensibly assigned to
work directly with or about a single child in the classroom. The environment of
the classroom program (administration, philosophy, layout, materials, etc.)
make a difference to the functioning of children, including the one with
disabilities
(McWilliam, deKruif, & Zulli, 2002). We like to introduce
ourselves to teachers with the statement,
“I’m here to
help you because you have a child with disabilities in your room,” rather
than “I’m here to help you with the child with disabilities” or, worse, “I’m
here to work with the child with disabilities.”
Once the teacher and visitor begin working together, the
visitor uses a collaborative not expert consultation approach. Early
interventionists will notice the similarities of CC2CC with the popular coaching, which had been defined and
redefined by numerous experts. I don’t use that term to talk about working with
families or teachers because I respect the tight definitions experts have
applied to coaching practices, and my methods don’t fit those tight
definitions, and I reserve coaching
for training professionals. For example, in our RBI institutes, the trainers
are coaches. Years ago, Sue Sheridan’s (Sheridan, Kratochwill, & Bergen, 1996) work on Conjoint Behavioral
Consultation influenced me to think about three stages of consultation and the
difference between an expert and a collaborative approach, as follows:
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Expert Consultation
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Collaborative Consultation
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Problem identification (why can’t the child do this?)
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Specialist
informs teacher
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Specialist
and teacher decide together why the child can’t do this
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Solution identification (what strategy should be used?)
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Specialist
makes recommendation to teacher.
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Specialist
and teacher decide on strategy together
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Evaluation (did it work?)
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Specialist
determines success of intervention
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Specialist
and teacher decide together whether strategy was feasible and successful
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When specialists and teachers have the luxury of actual
meeting time, the RBM has no specific format… yet. Rush and Shelden (2011)
provide good ideas for meetings. To be consistent with the model, I recommend a
problem-focused (also known as solution-focused) approach:
- What’s the problem?
- In what routine
does the problem occur or let’s pick a representative routine?
- What are the demands of the routine (i.e., how are children supposed to be
engaged—to participate)?
- Is our child able to meet those demands or does he have a disability-related
reason for not being able to?
- Is our child interested in this routine and its activities?
- How can we change
the routine (e.g., environment, materials, activities) to better match the
child’s abilities and interests?
- Instead or in addition, skills should we teach the child to increase his or her
engagement?
- Should we change our expectations and no longer
consider this a problem (i.e., pick our battles)?
Although nowadays I concentrate on CC2CC, with an emphasis
on specialists’ collaborating with teachers, our work in this area began with
integrated therapy. We were first interested in the relative merits of pulling
kids out for therapy and instruction versus having specialists go into the
classroom. We soon realized it was a more nuanced question, especially what the
specialist does in the classroom, from one-on-one
in classroom, separate from the ongoing activity (i.e., pull-aside,
push-aside) through group activity to
individualized within routines.
Integrated therapy we now know is best done through
individualized within routines. This entails the specialist going into the
classroom, talking to the teachers, joining the child in what the child is
already engaged with, and weaving intervention into the ongoing activity—to
show teachers how the intervention can be embedded in their activities. The
consultation occurs in the classroom, with specialists and teachers talking
during the classroom activity. This consultation makes it in vivo.
Working with families and teachers in the RBM includes
support-based home visits, family consultation during visits, and collaborative
consultation to children’s classrooms. As always, the focus is on promoting
children’s functioning and on family well-being.
Engagement Classroom Model
The RBM receives much attention for its impact on home- and
community-based supports, but it has strong roots in classroom management. My
first work, in fact, was in the co-ops of Project SUNRISE, with Carl Dunst.
Over time, the SUNRISE model became the Individualizing Inclusion model and now
the Engagement Classroom Model (McWilliam & Casey, 2008; McWilliam, Wolery, & Odom, 2001; Wolery,
Sigalove Brashers, & Neitzel, 2002).
The model has five components. First, the RBI is the method
for determining children’s and family’s goals. Both the family and the teacher
are interviewed, because both home and classroom routines are important for
assessing children’s functioning and for promoting it. Second, incidental
teaching is the main method of intervention, with teachers (a) ensuring child
engagement, (b) following the child’s lead, (c) eliciting higher forms of
engagement, and (d) ensuring the interaction was reinforcing. Incidental
teaching can be used across routines for all kinds of goals. Third, therapy is
integrated into ongoing classroom routines. Therapists and itinerant special
instructors/ECSEs work with teachers to build their capacity to intervene with
the child throughout every day. Fourth, the zone defense approach is used to ensure,
wherever a child is in the classroom, an adult is responsible for ensuring that
child’s engagement and using incidental teaching with him or her. The zone
defense schedule uses the teaching staff efficiently, with each teacher having
his or her own column on the schedule. Fifth, we have drawn inspiration from
Reggio Emilia to make classrooms beautiful for children and adults alike, to
use natural colors and materials, and to organize the environment to promote
engagement, social interaction, and creativity.
Evaluation
To determine the efficacy of the RBM, we are interested in
both formative and summative evaluation. In formative evaluation, we measure
professional practice and fidelity to the model. We assess professional
practice by having professionals complete the FINESSE II (McWilliam, 2000) and having families complete the Family FINESSE (McWilliam, 2015). These two measures are used to rate typical and
ideal practice, in the case of the FINESSE II, and typical practice and
importance, in the case of the Family FINESSE. We measure fidelity to the model
with performance checklists, such as the RBI With Ecomap Checklist, the
Routines-Based Home Visit Checklist, and the Collaborative Consultation to
Children’s Classrooms Checklist.
In summative evaluation, we measure goal attainment, child
progress, family confidence, and family quality of life. We measure goal
attainment with a version of goal attainment scaling. Child progress we measure
with the Measure of Engagement, Independence, and Social Relationships (MEISR) (McWilliam & Younggren, in press) and the Classroom MEISR (ClaMEISR)
(McWilliam, 2014). Family confidence we measure with the Fam-Con (McWilliam & Garcia Grau, 2017). And family quality of life
we measure with the Families in Early Intervention Quality of Life Scale (FEIQoL)
(McWilliam & García Grau, 2017).
Conclusion
What began as an overview of the Routines-Based Model has
turned into a dissertation. It can serve as an update to Routines-Based Early Intervention (McWilliam, 2010), which was published 8 years ago.
The concept is simple: Focus on children being engaged
and on families being able to teach their children when we’re not there.
The model doesn’t solve all the problems or have all the
answers, but it does pave a way for early intervention to address children’s
functioning, to build families’ capacity, and to make our professional practice
common-sensical, fun, and valid. This pavement can help professionals with
concrete practices, moving us beyond well-meaning theoretical pronouncements.
Our approach to needs assessment, intervention planning, service delivery
models, home visits, and classroom visits works with most situations in serving
infants, toddlers, and preschoolers. And it works with families from diverse
cultures and in foreign lands. The concept is simple: Focus on children being engaged
and on families being able to teach their children when we’re not there. Look at
the practices in the RBM for the tools to make this simple concept work.
Thanks to Cami Stevenson
for edits and suggestions.
References
Boavida, T., Akers, K., McWilliam, R. A.,
& Jung, L. A. (2015). Rasch analysis of the Routines-Based Interview
Implementation Checklist. Infants &
Young Children, 28, 237-247. doi:10.1097/IYC.0000000000000041
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.
Garcia Grau, P.,
McWilliam, R. A., Martínez-Rico, G., & Grau Sevilla, M. D. (2016).
Factorial structure and internal conistency of a Spanish version of the Family
Quality of Life (FaQoL) Scale. Submitted
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