Monday, September 28, 2015

MENTAL SHIFT 1: ALL THE INTERVENTION OCCURS BETWEEN VISITS



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.

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