Monday, March 23, 2020

Tele-Intervention and the Routines-Based Model


Home visits have been suspended during the Covid-19 pandemic, but early interventionists can still provide supports to families. I discuss here how the principles of the Routines-Based Model match the demands of distance service delivery, the definition of tele-intervention, the research behind telepractice, how to use telepractice for the Routines-Based Interview, and how to use tele-intervention for home visits.

 woman smiling holding glass mug sitting beside table with MacBook

How the Principles of the Routines-Based Model Match the Demands of Distance Service Delivery

The Routines-Based Model of Early Intervention (Birth to Five Years) is a method of providing supports to children with disabilities and their families that focuses on functioning in children and on meeting families’ needs. Numerous countries, states, and programs are implementing this evidence based model (see www.eieio.ua.edu and http://robinmcwilliam3.wixsite.com/ram-group). The following table shows important principles in the Routines-Based Model (RBM) and the demands of distance service delivery. The table shows that the RBM can be used to deliver useful tele-intervention and that tele-intervention can be used to apply the RBM.
Principles of the Routines-Based Model
Tele-Intervention Application
All the intervention occurs between visits
“Visits” build the family’s capacity to meet child and family needs
Family sets the agenda
The Next-Steps Form is virtually completed and reviewed during visits
Parents are competent adults
We collaborate to determine interventions parents will carry out
Family consultation is how we work with families
We ask many questions to help families arrive at solutions they want to implement
The two-bucket principle
The visit includes discussion of family outcomes/goals and other family needs
We provide support-based visits (McWilliam & Scott, 2001)
We provide emotional, material, and informational support

Definition

Early intervention has been delivered via tele-intervention for many years, especially in remote, rural areas (Davis, Hopkins, & Abrahams, 2012). We define tele-intervention as the provision of support to families via videoconferencing technology. Providers can use Zoom, Skype, FaceTime, or other methods of connecting with families via both video and audio. These platforms allow for both the interventionist and the family to be on camera. Zoom, Skype, and other platforms also allow for screen sharing, which might be helpful as early interventionists provide families with information.
Tele-intervention requires families to have Internet connection and a device for communicating via videoconference, such as a smart phone, a tablet, or a laptop. By definition, these devices have embedded cameras.

Research

Much of the research on telepractice has been conducted in providing early intervention to children who are deaf or hard of hearing. In a study of 48 children who were deaf or hard of hearing and their families, one group received telepractice and one group received traditional in-person home visits (Behl et al., 2017). Children in the telepractice group scored higher than children in the in-person group on some language scores, and the groups were equal in other language scores. Family measures did not differ. In the telepractice group, providers were more responsive, and families were more engaged.
In an evaluation of tele-intervention, parents rated their comfort with seven steps required to use the videoconferencing platforms:
“(1) turning on the computer,
(2) connecting the camera and microphone,
(3) connecting to the Internet,
(4) connecting to the VHV Project website,
(5) logging on to the website,
(6) starting the camera, and
(7) locking the microphone to talk.”
Parents' initial comfort with these technical skills was high and remained so. Conclusions from this study were that “virtual home visits” had pros and cons for different families and providers but that they “can be useful in accomplishing the mission of early intervention.” (Olsen, Fiechtl, & Rule, 2012).
In addition to tele-intervention with families, telecoaching can be successfully used to train early interventionists (Neely, Rispoli, Gerow, & Hong, 2016; Tomeny, 2020)

Routines-Based Interview

Service coordinators can conduct an RBI via a teleconferencing platform. The following table shows the main steps of the RBI and how they are accomplished via tele-intervention.
Major Steps of the RBI
How Tele-Intervention Applies
Ecomap development
Ask families the usual questions and draw the ecomap.
Once concluded, take a picture of it.
Save the picture.
Either share it with the family through Messenger, email, or another method or share your screen and show the family the saved ecomap.
Ask them about any changes, what they think of the ecomap, what will be done with it, and how it will be used.
RBI
Looking at parents, proceed from main concerns, through routines, all the way to the time, worry, and change questions. Take notes. If you take notes by hand, copy them and save them. If you take notes electronically, save them. If you type notes, highlight, bold, or in some other way indicate starred items.
Recap
Share the screen to show either your picture of your notes or your typed notes.
Recap the starred items
Goal decision making
Looking at parents, ask for the things they want to work on.
When they need it, share your screen, showing your notes.
Ask the family when you should move ahead.
After they have added some outcomes/goals, you, still sharing your screen, go through the notes until you have at least 10 outcomes/goals.
 woman sitting and holding white Acer laptop near brown wooden wall

Routines-Based Home Visits

Providers can similarly use tele-intervention for visits. I concentrate on home visits, because during the Covid-19 season, children’s classroom programs have been suspended. After discussing synchronous versus asynchronous visits, I address the essential stages of Routines-Based Home Visits: the agenda, reviewing progress, reviewing interventions, developing strategies, and planning for the next visit.

Synchronous Versus Asynchronous Visits

Visits can be in real time, in which the family turns on the device, and the early interventionist communicates with the family in real time. This method is most like a live home visit. A family can also record what goes on in one or more routines and share them, electronically, with their early interventionist, who then gives feedback. In the following sections, I assume synchronous (i.e., live) electronic visits, but, remember, you can communicate not IRL (in real life).

Agenda

Once connected, the early interventionist proceeds the same way she[1] would as if she were there in person. She gives the family an opportunity to talk about anything they want to talk about.

Focus of Visit

If the family has nothing in particular they want to talk about, the early interventionist refers to the bottom panel of the Next-Steps Form: what the focus of the next visit should be. This might be a child outcome/goal, so the early interventionist might say, “You said you wanted to talk today about Vinny’s standing independently. How’s that going?” The answers to this question could be “not much improvement,” “child is improving,” or “child can do it.” Each of these answers leads to questions the early interventionist can ask: See the family consultation flow chart at http://eieio.ua.edu/uploads/1/1/0/1/110192129/family_consultation_english.pdf.

Review Interventions

In this flow chart, we see “How’s intervention going?” This important question can lead to a number of adjustments: refine the skill to be tackled, tweak the implementation change the intervention or the routine, decide whether to change or persist, or try the matrix. Offering to demonstrate again is virtually (to coin a term) impossible via technology. Reviewing interventions include the other two actions: child demonstration and caregiver demonstration.
Child demonstration via technology occurs when the early interventionist observes what the child typically does. The caregiver might say, “I want you to see what he usually does.” This could be something good (i.e., an accomplishment) or something bad (i.e., something the child cannot do or does badly). It can be initiated by the caregiver, as in “I want you to see what he does.” Or it can be initiate by the early interventionist, as in “Would you mind showing me what he does?”
Caregiver demonstration via technology occurs when the early interventionist observes what the caregiver does to help the child. Again, this could be initiated by the caregiver, as in “I want you to see what I do.” Or it can be initiated by the early interventionist, as in “Would you mind showing me what you do?”

Develop Strategies

Strategy development with families via technology, using the RBM, is little different from doing so live. Early interventionists should follow the steps in the Routines-Based Home Visit Checklist and the Family Consultation flow chart. In case it hasn’t been obvious, life conversations, such as through Zoom, Skype, and WhatsApp are better than email or chats. Follow-up summaries by email, however, are extremely valuable (Barton, Kinder, Casey, & Artman, 2011; Tomeny, 2020).

Plan for Next Visit

As with a regular home visit, the tele-intervention visit should include what the caregiver will work on from now until the next visit and what the focus of the next visit should be: the right-hand and bottom panels of the Next-Steps Form. The early interventionist should scan, screen shot, or save the NSF and send it to the caregiver.

 two babies and woman sitting on sofa while holding baby and watching on tablet

Principles Revisited

Supporting families without visiting them seems anathema to early intervention in the U.S. Nevertheless, we realize that, in the RBM, it’s about providing emotional, material, and informational support to families. This support does not require us to be natural environments. We learned that in working with international implementation sites that could not see their way out of their clinics and rehab centers. It’s not where you support families: it’s how you support them. Therefore, get families online and support them by attending to the following principles:
Principles of the Routines-Based Model
All the intervention occurs between visits
Family sets the agenda
Parents are competent adults
Family consultation is how we work with families
The two-bucket principle
We provide support-based visits (McWilliam & Scott, 2001)

References

Barton, E. E., Kinder, K., Casey, A. M., & Artman, K. M. (2011). Finding your feedback fit: Strategies for designing and delivering performance feedback systems. Young Exceptional Children, 14, 29-46.
Behl, D. D., Blaiser, K., Cook, G., Barrett, T., Callow-Heusser, C., Brooks, B. M., . . . White, K. R. (2017). A multisite study evaluating the benefits of early intervention via telepractice. Infants & Young Children, 30, 147-161.
Davis, A., Hopkins, T., & Abrahams, Y. (2012). Maximizing the impact of telepractice through a multifaceted service delivery model at the Shepherd Centre, Australia. The volta review, 112, 383.
McWilliam, R. A., & Scott, S. (2001). A support approach to early intervention: A three-part framework. Infants & Young Children, 13, 55-66.
Neely, L., Rispoli, M., Gerow, S., & Hong, E. R. (2016). Preparing interventionists via telepractice in incidental teaching for children with autism. Journal of Behavioral Education, 25, 393-416.
Olsen, S., Fiechtl, B., & Rule, S. (2012). An evaluation of virtual home visits in early intervention: Feasibility of "virtual intervention". The volta review, 112, 267-281.
Tomeny, K. R. (2020). Telecoaching in early intervention: Supporting professionals and families of toddlers with or at risk for autism spectrum disorder. The University of Alabama, Tuscaloosa, AL.  
3/23/2020


[1] The feminine pronoun is used for convenience, recognizing early interventionists, like me, can be men.

Thursday, March 12, 2020

The Routines-Based Model Internationally Implemented: 2. How the Model Became of Interest, Internationally


When we talk about global implementation, we need to remember that U.S. implementation counts too. The Routines-Based Model (RBM) is implemented, to one extent or another, in many places in the U.S. The RBI or the RBM are the most frequently cited strategies for improving federal child or family outcomes, in state systemic improvement plans (SSIPs). Some states, like Alabama, Maine, Mississippi, and Tennessee have adopted the model and are at different stages of implementation. Siskin Children’s Institute, where I used to work, still demonstrates most of both the home-and community-based components of the model as well as the Engagement Classroom Model, under the leadership of Deidra Love and Julie Mickel, respectively. 

In addition, Multnomah Early Childhood Program in Portland, Oregon, is adopting the home- and community-based practices in a large metropolitan environment, with Cami Stevenson, the RBM Enterprise[1] associate director and an administrator and coach there, as a key player. Other states adopted the model but drifted away from it, to other similar models or approaches—an object lesson in distractibility, sustainability, and compatibility, in implementation work. 

Figure 1. Implementation of the Engagement Classroom Model (part of the RBM) at the Slownezna Kraina Preschool in Cieszyn, Poland

The first country outside the U.S. to show an interest in implementation of the RBM was Portugal, because I had been working intensively with the University of Porto (under the leadership of Professor Joaquim Bairrão) (Grande & Pinto, 2009; Pessanha, Pinto, & Barros, 2009) Pessanha, Pinto, & Barros, 2009). Eventually, the Portuguese national association for early intervention adopted the model, wrote a manual, and provided sporadic training around the country. Meanwhile, students I had worked with, such as Cecília Aguiar and Tânia Boavida, began their own leadership in Lisbon. 

Figure 2. Rita, Robin, Cecilia, Nadia in Lisbon

Spain followed suit, when Marga Cañadas became an indefatigable ambassador for the approach. Within countries, the spread of the model is something we try to keep track of. In Spain, for example, implementation sites are gradually growing, and, even within comunidades autónomas (states) such as Castilla La Mancha, officials are documenting the extent to which the RBM is being adopted. Pau García Grau and Catalina Morales Murillo have recently conducted some intensive training in Castilla La Mancha. Some Canadians were interested, in particular Kamal Haffar, who worked to spread the word in Ontario. Quietly, Ai-Wen Huang went about conducting research on the model, and she has produced the only randomized control trial on the RBM (Hwang, Chao, & Liu, 2013). 

In Singapore, Lim Hong Huay led Project ECHO, which used the model for classroom practices. In New Zealand, Julia Woodward and colleagues at the Ministry  of Education, decided that all children and families receiving early intervention through their system would receive practices under the RBM. In Australia, a program in Victoria and Canberra, Noah’s Ark, under the leadership of John Forster and his lieutenants, Kerry Bull and Stephen Carberry, implemented the model. Meanwhile, in Western Australia, Denise Luscombe was also using many of the model’s practices in her training and consultation to others in the Perth area. 

Through connections Cañadas had made, a large agency serving children with physical disabilities, Teletón Paraguay, adopted the model. This agency is one of a number of rehabilitation organizations in Oritel, a federation of Teletones, meaning that we might have the opportunity for implementation throughout Central and South America. The most recent implementer has been an agency in Silesia, in Poland, the Słoneczna Kraina, whichis implementing the Engagement Classroom Model, under the leadership of Krystian Kroczek, Lucyna Legierska, Sylwia Wrona, and Natalia Józefacka. 

I insert here a sad note about our Portuguese implementers. Ana Pinto and Tânia Boavida both died within the past year. When I began working in Portugal, Bairrão appointed Ana as my baby-sitter, so we spent much time together and worked collaboratively. She even visited me at my home in Nashville. My dean, Peter Hlebowitsh, and I visited Ana a couple of years ago. 


Tânia was my post-doctoral fellow and a true friend. She had her baby, Leonor, the day after she defended her dissertation, dragged Leonor and José to Chattanooga, and spent two years having fun with me. She was my intellectual granddaughter, having been lucky enough to be a student of Cecilia Aguiar at ISCTE, and Cecilia was a student of mine. I miss Tânia enormously. Both of these consummate professionals gave the field so much and have been stripped from our lives way too early.

Countries have their cultural anomalies and identities, yet we find that, universally, professionals want to help caregivers provide the most support possible to caregivers and children, families want their children to participate meaningfully in their everyday lives, and programs want professionals to carry out practices at a high quality. We make adaptations as necessary, to be culturally responsive, but we don’t sacrifice needs assessment by interviewing families, strategy development by collaborating with caregivers, or evaluation by determining (a) how well goals are met, (b) families’ quality of life, and (c) how well children are functioning in their daily routines.

Grande, C., & Pinto, A. I. (2009). Estilos interactivos de educadoras do Ensino Especial em contexto de educação-de-infância. Psicologia: Teoria e Pesquisa, 25, 547-559.
Pessanha, M., Pinto, A. I., & Barros, S. (2009). Influência da qualidade dos contextos familiar e de creche no envolvimento e no desenvolvimento da criança. Psicologia, XXIII, 55-71.



[1] The RBM Enterprise is our name for the implementation of the RBM around the world. It includes using the EIEIO at the University of Alabama as a hub for materials and other information; coordinating training and presentations around the world; and assisting individuals, agencies, districts, states, and countries in implementation of the model.