Wednesday, December 15, 2010

Toddler Groups

I have recently been asked to comment on toddler groups. This was the situation:

I am currently part of a committee that includes staff from our Early Intervention Program and we have been given the charge to explore ways to provide integrated developmental groups for toddlers receiving services. To date this attempt has not proven successful due to a number of factors including low rate of reimbursement, ratios, and trying to come up with incentives for parents to pay to bring their toddlers to such a group.

There’s probably a good reason families have been reluctant to take their toddlers to a group: They don’t see the value, especially when taking the hassle of getting there into consideration. The argument that groups would give families more options would only be valid if it were an option they valued. Most states and local programs have considered them more from a logistical, staff convenience standpoint. A few staff can be at one location, and families can do the traveling, and we can “serve” multiple children at once. In addition to the potential spuriousness of the option argument, the assumption that peer interaction opportunities should be provided by the early intervention program should be questioned. First, toddlers don’t need to interact with peers; as you know, developmentally, the best we can expect in 2-year-olds is parallel play and attentional engagement with peers, with occasional bursts of associative play. Especially when the children might have developmental delays, the argument that it’s good for them to be in groups for a few hours a week is pretty weak.

The amount of time is another issue. We know that experiences in small amounts of time are less valuable for little kids than they are for adults, who can benefit from short (e.g., 1 hour) weekly sessions.

In some states, groups have been discouraged or even disallowed. In other states, people are using them as you describe. Still others have a hybrid, where toddlers get together a number of times a week (e.g., two to four) for short periods (e.g., 2 or 3 hours). Even at 4 days x 3 hours, this is 12 hours. No one knows whether this is long enough to have a meaningful effect, but we do know that it’s an inconvenience or even hardship for families to take their children on this kind of schedule. It makes it very difficult for working families, for example.

Is there a way you could make a group effective? If it were designed primarily for emotional, material, and informational support for families, it has a chance. I have published on taking a support-based approach to home visits with the same three types of support. At the group, families could spend time with each other, which some families really like. They could get information about the four things families typically want information about: child development, resources including services, their child’s disability, and, most important of all, what to do with their child (i.e., interventions). The materials support could come from equipment, toys, diapers, food, clothing, and so on, provided by both the program and some families themselves. If the group of families wanted to meet as a group, they could rotate who plays with the children in an adjacent room, ensuring appropriate ratios, furnishings, toys, and so on. If they wanted to make it more like a gaggle of parents talking while playing with their children, they could do that. As professionals or even other parents make suggestions about how to do something with a child, they can demonstrate with the child, but the hands-on with the child is for the purpose of supporting the family, not with a false premise of actually teaching the child at that time.

Why would families like this option? Perhaps to get out of the house and to meet other parents. They might also want to see how their child acts around other children, but we should be very careful not to insinuate that peer interactions before the age of three are necessary. If we take this preparing-for-the-next-environment to its logical conclusion, before you know it, we’ll be teaching babies to hold crayons, to sit on carpet squares, and to wash their hands, because that’s what they’ll have to do when they reach toddlerhood.

Therefore, you can see that I don’t believe child-directed groups are theoretically sound, effective, or a good use of resources.

Tuesday, December 14, 2010

How to Address Autism From a Natural-Environments Perspective: Talking to Parents

I address this thorny issue by showing you an adapted version (for confidentiality reasons) of some correspondence I had with a mother of a 3-year-old who was about to be diagnosed with autism. The parents were already thinking about what services might be appropriate for their child. It’s unfortunate that the way we provide early intervention and early childhood special education emphasizes type and amount of service rather than type and amount of support or intervention.

The mother described her child, whom I knew somewhat, as having challenging behaviors, poor expressive language—even gestural, self-stimulation, mild but extremely pervasive self-injurious behavior, apparent lack of pain sensation, poor direction following, rigidity, and failure to play with toys as intended. To me, behaviors related to engagement, independence, and social relationships are more important than the diagnosis. She had requested 10 hours a week of applied behavior analysis: “I want him to be able to get the services/help that will benefit him the most. I am afraid if he doesn’t start getting services [there it is again] it will be harder for him in the future.”


In my opinion, 10 hours of traditional ABA would not be enough to address the problems you’ve described. He probably needs more hours of contingent learning (what ABA tries to do), spread out through the day, in the contexts where he needs to learn skills and behaviors. Discrete-trials training, which is what traditional ABA is, tends to be decontextualized and to have poor generalization to meaningful routines. But the principles of ABA (systematic reinforcement of desired behavior, stimulus control, data-based instruction) would probably be helpful for Kenny, regardless of diagnosis. He’s still a little kid, so applying methods for older children are at best inappropriate and ineffective and at worst robbing him of his childhood. But your description makes it clear he needs to be taught to play and function as a kid. If you think the autism diagnosis/label (only MDs and licensed psychologists can diagnose) would help Kenny get appropriate services, I can see why you’re anxious to explore that. I, however, wonder whether that’s true. It’s not services that make a difference, it’s intervention. Do you see the distinction I’m making? You probably want to specify the most effective interventions for him and then see what services can provide them, but note that parents don’t have the right to mandate methods (interventions) in the IEP world, whereas they can advocate for services. So my suggestion is to base your decision about what services you go after on the types of interventions they would apply. The law pretty much forces us to think backwards.

I have a picture of Kenny’s spending at least his school day and possibly much of his home time, if it’s not too disruptive to family life, where (a) there is a at least one clear goal for what he is being taught in each routine (i.e., activity or time of day); (b)where those goals increase his participation, engagement, independence, communication, or getting along with others; (c)where the rate of systematic incidental teaching is high; and (d) where one or two goals are addressed through precision teaching in context. This is doable but requires the team to be smart, organized, and creative and always respectful of Kenny’s developmental age and interests of his parents’ priorities.

Do you see then what I mean about the 10 hours of ABA not being enough? I have seen it used to teach discrete trials out of context; the child doesn’t learn to generalize the skills to nonteaching times; and the other adults in the child’s life can’t use the same techniques for a host of reasons. The child then displays great “gains” in highly particularized areas—those the discrete-trials training addressed (e.g., sorting colored objects into correct little trays), suggesting the method is highly effective. Meanwhile, the child’s engagement, independence, and social relationships might not have improved or even have deteriorated. So it all depends on how applied behavioral analysis is used. (Full disclosure: I am a behaviorist, with a degree from one of the most behavioral master’s programs in existence, and a teacher of board-certified behavior analysts.)

Forgive me for sounding as though I really know Kenny and his specific needs. I’m speaking on the basis of your description of him, what you say you want for him, and what I have seen with hundreds of other children with similar characteristics, whether they have the autism diagnosis or not.

The mother then asked me what specific interventions to request at the IEP meeting.


I received your message about specific interventions to request at the IEP meeting. To elaborate on what I said about more than the 10 hours a week of traditional ABA, it seems that Kenny needs to be working on engagement (this is a big issue in autistic-like behaviors and it is what a child should be doing instead of self-hitting or -biting), independence, and social relationships. Social relationships consist of communicating and getting along with others. I don’t know the specific goals Kenny might have but they should generally fall into these categories, because these categories are pretty much what is functional for young children, especially those with disabilities. Furthermore, they apply regardless of disability. I would say that they apply for Kenny. You all and the IEP team might need to get at the specifics. So that’s the deal about what to work on. Now let’s talk about when to work on them.


I don’t know Kenny’s classroom schedule but they are using the zone defense schedule, which tells me the day is broken into 15-minute increments, except possibly for nap time. So let’s assume Kenny is in the room for 3 hours before nap (i.e., 9-12) and 3 hours after nap (i.e., 2-5). That’s 24 fifteen-minute intervals or activities. In each of those, we should aim for about 4 incidental-teaching contacts and for a minimum of 5 minutes engagement. The 4 comes from research Amy Casey and I have done showing this is a feasible rate. The 5 minutes of engagement is equal to 33% of the time, which is low, according to numerous studies of ours, but might be ambitious for Kenny right now. Incidental teaching is a form of ABA in which an adult addresses engagement, independence, or social relationships—including specific goals on Kenny’s IEP—by getting him engaged, responding to his interest, eliciting more sophisticated behavior, and ensuring it was reinforcing. Engagement time can range from low-level engagement, such as doing things repetitively (but not perseveratively or “stimming”), up to high-level engagement, such as solving problems, communicating with language, or making something. Now let’s multiply: 4 incidental-teaching contacts x 24 activities or “routines” = 86 learning opportunities. In incidental teaching you count learning opportunities rather than trials, which is what you count in discrete-trial training or traditional ABA. A learning opportunity can involve one or more discrete trials, but they are in context, making each one more salient than a decontextualized “trial.” Multiplying engagement amounts, we would have 5 minutes x 24 routines = 120 minutes or 2 hours a day. Multiply this by 5 days and we have the same number of hours as 10 hours of ABA a week, but the engagement time is (a) in playful contexts—and Kenny’s still a little kid, (b) delivered by Kenny’s familiar caregivers (i.e., teachers), and (c) spent learning meaningful skills.


Therefore, if I were you (I’d be exhausted), I would request continued classroom services at his current program, with systematic incidental teaching being used in each routine to address engagement, independence, and social relationships. That means that, before you talk about services, you need to make sure you have good functional goals that get at these areas of development. I believe you’ve completed the MEISR, which should help with goals. As for therapies, the best value they provide is guiding the teachers and you all (i.e., Kenny’s regular caregivers) about how to elicit the desired behaviors during incidental teaching. The OT would have ideas about how to elicit his self-help and maybe some fine motor skills. The SLP would have ideas about how to elicit his communication. But ultimately we need the teaching staff and you to own those intervention ideas so you can use them 24/7 so to speak. Therefore, you might not need a high intensity of these services. After all, how much information do the teaching staff and you all need, week in and week out. You don’t want the therapists working with Kenny directly, even though everyone says parents should try to get the most therapy possible; you want them working with the teachers, so Kenny gets even more intervention than he would if the therapists worked directly with Kenny. At the IEP meeting, the most you can really talk about is the frequency and intensity of different services, not the approach used: That’s beyond the purview of parents’ rights.

I hope this gives you something to go on. I’ve tried to give you as much information as possible while leaving room for you to determine the specific goals. You’ll notice that this approach involves individualizing intervention for Kenny, meeting him where he is, with his strengths and needs in specific routines, rather than thinking of him in terms of a specific disability or conglomeration of disabilities. I also want you to know that I’m not pushing his existing program over other settings, although I would “push” a normalized, developmentally appropriate setting over a clinical, decontextualized setting. It just so happens that his existing program provides the former.

The parents liked this approach: After all, they want the best help for Kenny, which does involve lots of intervention. It’s just that that intervention needs to be distributed throughout the day and has to be meaningful. We are going to document how many incidental-teaching episodes occur per routine and how many minutes of engagement per routine he has.

Sunday, December 5, 2010

RBI With Recent NICU Graduates

Question: I work specifically with families that have babies coming out of the NICU. They most times are eligible based on an established condition due to being “at risk” for developmental delay. They don’t always have delays or the family doesn’t have concerns. In talking about our program at the initial visit we emphasize supporting them in their daily activities and routines, however during the interview everything is fine. This often results in a struggle to develop IFSP outcomes. I will say when there are clear concerns and issues it is much easier to develop routines based outcomes.

Answer: The two important things to remember are that this is a plan for the family, not just the child, and that it’s about what child skills come next. So, as you’re going through the day, make sure the interviewer is asking the parent about what would make that time of day easier or better for him or her, what the parent’s hours from Hell are, and what things the parent would like to be doing that he or she hasn’t been able to figure out. When asking about child engagement, independence, and social relationships, find out what the child is currently doing of course, which will be quite rudimentary for a child just out of the NICU. The questions then aren’t about what the child isn’t doing but what he or she will do next. This requires interviewers really to know their infant development. As options for what the child will learn to do in each routine get listed, they should be starred on the notes. As you know, these are then recapped, and the family is prompted to pick them as outcomes, if necessary. Between desires for what the parent wants to be doing and the myriad things the infant will learn to do, you should end up with a pretty meaty IFSP.

If you haven’t seen these books, they might be of interest: Working With Families of Young Children With Special Needs and Routines-Based Early Intervention. They both have chapters on the RBI.