Monday, December 2, 2013

Out of Clinics Into Natural Environments

Children are still receiving way too many services in clinics. I’ve just returned from Spain, where the prevailing method of providing early intervention 0-5 is still to have children go to clinics to receive a 45-minute session from, most commonly, a psychologist, although it could be for occupational therapy, physiotherapy, or speech therapy.

This isn’t just a Spanish issue. In the U.S., states can get away with massive amounts of clinic-based services by reporting to the feds that the setting in which infants and toddlers primarily receive services is the home. In some states, all the special instruction or “developmental therapy” might be in the home, but almost all OT, PT, and SLP are in clinics. 

Here are some points about clinic-based services.

  1. A clinic-based clinician can still be consultative in a clinic. A clinician can still see that the value of the encounter is supporting the child’s caregiver, rather than doing hands-on work with the child.
  2. It looks more economically feasible to see eight inconvenienced clients a day than to travel to four. But that assumes a multidisciplinary model of service delivery. If you use a primary service provider, and you (not third-party payers) are responsible for the costs, you can make natural environments economically feasible.
  3. In Spain, I visited a center that pays 40 professionals to work with 160 children in three clinic buildings. Needless to say, the manager was very interested when I pointed out that that many children could be served a quarter the number of professionals from—not “in”—just one building. They would, however, have to pay the professionals’ travel costs.
  4.  Many clinic-based clinicians talk about teaching the child a skill in the clinic and then transferring the skill to the home, school, or community. The problem is nothing is done to effect this transfer. Little kids, especially with developmental disabilities, have difficulty generalizing. And you can’t expect the adults to foster the transfer if they’re out in the waiting room, not learning the prompts. Even if they are in the room with the therapist, the skill or the strategies might not be necessary or feasible in the real world. As Stokes and Baer pointed out in the 1970s, we might as well program for generalization and teach the skills in the contexts where they’re needed. That way, we’re teaching only once, not twice.
  5. People become attached to place—their building. It’s the symbol of their identity. It’s amazing, however, that in the 21st century many clinics make parents sit in waiting rooms, while children go to either boring rooms (“free of distractions”) or rooms designed to bombard children with noncontingent stimulation (e.g., Snoezelen rooms). For some people, the promise of natural environments is a threat to their space.

To many people in U.S. early intervention, all this might seem obvious, but the vestiges of clinic-based services are still strong overseas and even here. The Spanish assumed that all American early intervention was home or community based. I reassured them, if that’s the right word, that we had plenty of clinic-based early intervention. But at least we have a law that promotes natural environments. The problem is our reporting system allows for massive amounts of clinic-based early intervention to go unreported. States that have used their state-level authority to discourage or ban clinic-based therapy services are dealing effectively with the five points above. They promote consultation to caregivers, they do not allow money to overshadow quality, they promote efficiency, they program for generalization, and they respect families’ and children’s spaces more than professionals’ spaces.