Monday, September 28, 2015


In my August 23, 2015, post, “Routines-Based Practices to ReplaceCenter-Based Services, I threatened to address 12 mental shifts that have to occur, to move from a clinical approach to a family-centered, functional approach. I wrote that the next 12 posts would each address one of the mental shifts but I posted two entries that weren’t on this list. So today’s is Mental Shift 1.
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.

Perhaps no phrase better describes the Routines-Based Model than All the intervention occurs between visits. It implies that intervention is what the child receives from his or her regular caregivers. Intervention is the steady dose of learning opportunities, as Bruder and Dunst called them, that children need in order to learn. Understanding that young children do not learn in single small lessons, provided perhaps once a week, is central to this idea. Children learn through repeated interactions with the environment, distributed over time. The environment is most commonly a more competent person, such as a parent or a sibling. These more competent people were who Vygotsky talked about as essential to a child’s zone of proximal development

Regular caregivers are those people who spend substantial time with the child, which will be addressed in Mental Shift 4, as you can see in the list.

If all the intervention occurs between visits, what should we do during the visit? Working directly with the child is mostly a waste of time, unless the child is old enough to transfer what happens in a visit to nonvisit time—say developmental age of 8 years or something. So home visits where the early interventionist is on the living room floor, going through activities with the child are pretty useless, especially if the parent is not involved—by the home visitor. A visit to a clinic, while the parent sits in the waiting room, observes through a window, or observes in the room, while the clinician “works with” the child, is similarly a wasted opportunity. A child going to a play group for a couple of hours a week might get to have fun with other children, which is great. But to call it early intervention, if the parents are really not gaining meaningful support (e.g., information), is misleading. Sometimes, professionals “work with” (don’t you love this expression when interacting with infants, toddler, and preschoolers?) children, while the parents meet, with or without a professional facilitator. That’s a waste of money. They should hire good babysitters instead of therapists or teachers, because that single-shot of professional time while the parents are busy elsewhere isn’t effective. The parent support might be, for those who like that kind of thing, as Glen Affleck discovered years ago (i.e., that support group meetings are not effective for everyone). 

What we should do during visits is support the family for the time we’re not there. Build their capacity. We’ll talk about that more in Mental Shift 10, and we’ll address nonparental caregivers in Mental Shift 4.

How do we build up caregivers’ capacity to be effective interventionists with the child? Through family consultation and collaborative consultation, which are forms of “coaching,” a term M’Lisa Shelden and Dathan Rush have arrogated to describe a nondirective, reflective, and respectful approach to teaming between professionals or between professionals and families. Key features of family consultation, as I’ve defined it, are

  • Families determine the outcomes/goals.
  • Professionals help determine why the child isn’t doing the skill yet and what interventions might work
  • The professional making the visit uses other team members’ expertise, as needed.
  • In working with families, the professional asks at least four context questions before the “ask-to-suggest,” which is “Have you ever tried _____?” The ask-to-suggest is a suggestion in the form of a question.
  • The professional and the family discuss a potential solution, which is another name for an intervention.
  • The professional offers to demonstrate or to watch the parent.
  • The professional makes suggestions for modifications to what the parents do.
  • The professional asks the parents to determine the feasibility of the intervention (“Do you think this will work?”). Families are encouraged to say no, if they have doubts.
  • At the next visit, the professional asks how the intervention went.
  • The quality of the relationship between the professional and the family is important for developing trust and honesty.

In later posts, I’ll discuss the key features of collaborative consultation to group care programs, such as day care and preschool. They’re similar.

If early interventionists working with children birth-6 would remember ALL THE INTERVENTION OCCURS BETWEEN VISITS, their time spent with the family and other caregivers would be effectual.

Thursday, September 10, 2015

The Triangle Method of Research Design

How do you start thinking about a research project? I find that an adaptation of Baron and Kenny’s (1986) mediating-effects design is helpful. That design showed three variables, as shown here. A student of mine is interested in the effect of the quality of early intervention programs in a couple of European countries on family empowerment. So her independent variable is the quality of programs, and her outcome variable is empowerment. To make the question interesting but also to see determine what might explain (i.e., mediate) or alter (i.e., moderate) the effects of quality on empowerment, she needs to think about a third variable. Is it a demographic variable, like family socio-economic status or the severity of the child’s disability? Is it another psychological variable, like the respondent’s locus of control or parenting beliefs? Is it a specific characteristic of the independent variable (i.e., quality), like dosage—how much service time the family experiences—or the number of professionals?

By inserting the third variable, the study becomes interesting and relevant and not (yet) too complicated. I usually then ask how the mediator or moderator, pictured here, works for different conditions. These are often background variables, such as demographics. How do these relationships work for different SES levels or different child ages, for example? They might be more socio-demographic, such as different countries, different states, or different program types. 

When starting to think about a research project, remember the triangle!

Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of personality and social psychology, 51, 1173.

Wednesday, September 2, 2015

Ecomap and Respite

Respite services are notoriously hard to come by, for families of children with disabilities. Respite means having a break and tends to be used instead of the more normalized babysitting. Indeed, some children require babysitters with special training and who probably prefer the fancier name of respite providers. Some families might feel more comfortable having specialized people, given society’s proclivity for specialization. 

Some respite opportunities involve families’ dropping their children off somewhere like a church, where volunteers watch the children for a few hours. For some families, these are no doubt a great resource. They do, however, involve having to transport the child to the babysitting place and leaving the child with people the family might not know. Furthermore, there might be a number of children being looked after. As beneficial as drop-off respite can be, for some families in-home respite is preferred. The advantages are (a) that the child doesn’t move, the babysitter does, which can be especially helpful if the child comes with much equipment, as in the case of some medically fragile children; (b) the child has only one caregiver; and (c) unless the child has siblings also being babysat, the caregiver has only one child to care for. Even harder to find is in-home, overnight babysitting, which might be especially valuable for some parents. 

In my Routines-Based Model, we ask parents if they have enough time for themselves as individuals or, if relevant, a couple. Many intervention plans therefore include this goal. I heard about one state that suffered through a monitoring review where the monitor questioned the “date night” goal—and this was for an individualized family service plan. A cursory understanding of family systems theory and of social-support theory should make it obvious that a date night goal can have an impact on the child. 

Karen's Ecomap
If a plan does have a goal for adults to have time for themselves, the ecomap should be the first tool the early interventionist should use when using family consultation to help the family meet the goal. Here you see an ecomap for Karen’s family and her intervention goals, as written at the end of the RBI. Later, they were written to be measurable. 

Karen’s Goals

3. Potty trained
9. No pacifier (nap, bedtime, car)
2. E cooperate and not be so confrontational (dressing, tooth brushing, home from school, dinner prep, evening time)
6. G dressing
5. K behavior management strategies (dinner)
4. G speak clearly (breakfast, car rides, play time)
8. Independently use whole sentences (outings, meals, play times)
1. E and G play independently (not breaking down; dinner prep)
7. Info about G being patient
8. Time for Karen

As is common, time for Karen was one of her lowest priority goals but it’s on the plan. Therefore, when Karen is ready to tackle this goal, the early interventionist might say, “Are you able to do this? Is there anything getting in the way?” 

Karen would presumably say, “Giada,” the babysitter.

“You said you like her OK when we drew this ecomap. Is that still true?”

“Yes, but she’s in school, so she’s not always available.”

“Is there anyone else who might be available?” the early interventionist might ask.

“I’ll have to think about that.”

“Let’s have a look at the ecomap.”

“I suppose we could ask the couple who live next door,” says Karen. “They have no children and get on really well with all three of ours.”

“Is that what you’d like to do then? Ask them to babysit one evening so you can have time for yourself?”

“Yes, I can ask them.”

“OK,” says the early interventionist. “Next week, I’ll ask you how it went. Asking them, I mean.”

One of the main purposes of the ecomap is to be able to whip it out when looking for resources to find a solution, which means address a goal.