Early Intervention in Natural Environments

Siskin Children's Institute's International Activities

2012-01-24T03:30:00.000-08:00

http://www.chattanoogan.com/articles/article_217778.asp

McWilliam working with Tania Boavida and Cecilia Aguiar

Two-Year-Olds With Autism Having Fun? Horrors!

2012-01-02T19:31:00.000-08:00

I just finished writing a draft of a research article that ends as follows:

Inthe classroom observed in this study, incidental teaching, an evidence-basedmethod , was the primary intervention method. But perhaps it was notimplemented with as much intensity as it should have been. Programs shouldensure teachers receive systematic, checklist-based feedback to increase theirrate of incidental teaching, and future studies should compare a variety ofmeaningful outcomes between intensive, one-on-one intervention sessions and well-implementedincidental teaching in inclusive environments, with 2-year-olds with autism. Becauseof the age of these children, it might be more effective to teach them bydispersing trials through the day than massing them in drill sessions.Furthermore, the children might have more fun—a value minimized in thedesperate discourse about educating very young children with autism.

Sometimes, it's hard to tell whether a little kid with autism is having fun, but if he or she is engaged (busy, absorbed, meaningfully participating in what's going on around him or her) it's a pretty good sign. Let's not rob toddlers of what should be a fun time in their lives, just because we're too unimaginative to figure out how to teach them through play.

Systematic Incidental Teaching

2011-12-17T13:31:00.000-08:00

We have not yet secured funding to study the effects ofteaching parents to use systematic incidental teaching. So here’s where westand on related research:

Amy Casey and I have shown that it is possible totrain early childhood teachers to increase their rate of incidental teaching:

Casey, A. M., & McWilliam, R. A. (2008). Graphicalfeedback to increase teachers' use of incidental teaching. Journal of EarlyIntervention, 30, 251-268.

Ann Kaiser has shown that it’s possible to teachparents to use milieu language interventions, which include incidental teaching:
http://jei.sagepub.com/content/16/1/31.short
http://jei.sagepub.com/content/18/3/269.short

She has also shown that parent-implemented milieuteaching has a positive impact on children’s social communication:
http://www.tandfonline.com/doi/abs/10.1207/s15566935eed1104_4

These researchers have shown that it’s possible totrain parent trainers in the use of milieu teaching:
http://jei.sagepub.com/content/20/1/30.short

…it goes on. You might ask Why aren’t you just teachingparents this “milieu teaching”? Because most of the training was done in alab setting and the outcomes were communication ones only. We want to “train”parents in the home for all kinds of outcomes, across routines and domains. Theessence of milieu teaching (teaching in context, following children’sinterests, eliciting more sophisticated behavior) is also the essence of SIT.

Many states face the issue of therapists’ POLITICAL claims that the routines-based, family-centered approach is watering down services or even denying services to families .They might believe what they’re saying, but those beliefs are wrong and mightbe a consequence of cognitive dissonance: They have to believe what theybelieve, otherwise they lose money and professional face. Unfortunately, theydon’t listen when we say that the routines-based approach actually increasesthe importance of therapists, because we need them to support the naturalworkforce (regular caregivers) and the paid workforce. It’s easy to do therapywith a child in a distraction-free environment; it’s hard as hell to figure outthe right interventions to teach to lay people that fit into their lives. Soweariness or laziness also must factor in to their claims.

The key about how to support families effectively lies morein the family consultation approach than in SIT, which is really content (i.e.,a skill we teach families). The method for teaching families is familyconsultation. Although I have developed this model for early interventionspecifically, the roots are found in existing research on parent-implementedearly language intervention (again—sorry! http://informahealthcare.com/doi/abs/10.1080/136828298247758),variables that influence collaborative relationships (http://tec.sagepub.com/content/16/3/322.short),and vocational programming (http://eric.ed.gov/ERICWebPortal/search/detailmini.jsp?_nfpb=true&_&ERICExtSearch_SearchValue_0=EJ421457&ERICExtSearch_SearchType_0=no&accno=EJ421457).Again, we haven’t yet secured funding to study family consultation per se. It’salmost impossible to get the Institute of Education Sciences to fund studieswith family behaviors as the outcomes.

Don't forget to look at additional information at www.siskinresearch.org.

Toy Bags Again

2011-11-28T20:24:00.001-08:00

Banishing toy bags from home visits is both symbolic and meaningful. I have written about this issue before: http://naturalenvironments.blogspot.com/2007/10/toy-bags.html. Here's a summary:

Working from a toy bag implies that the home visitor’s interaction with the child for 1 hour a week is intervention.	The hour is better spent working with the parents, because adults can benefit from 1-hour, weekly sessions.
The toy bag implies that what the family has is inadequate.	The home visit should be, in part, about reassuring families’ of their competence.
If the toys are so important, why are they removed at the end of the visit?	The home visit should prepare the family to intervene during all the many hours between home visits.
Toy bag ladies (and gentlemen) spend 80% of the home visit on something that consumes 5-15% of a child’s time: adult-child-toy play.	Home visits should provide consultation to families on interventions that can happen in all naturally occurring routines.
Toy bag play tends to be adult-directed.	Intervention is most effective when it follows a child’ interest.

How Cognitive is Engagement?

2011-11-28T13:26:00.001-08:00

In the early days of engagement research, engagement was measured as happening or not happening in planned activities. Our research, first with Carl Dunst and then with Don Bailey, and much since both of them, has emphasized the fact that engagement is not dichotomous variable. It is instead one that ranges from nonengagement (same as the dichotomous way of looking at it) to sophisticated behavior--a pot into which we put encoded, constructive, persistent, and symbolic). We usually array these codes in a developmental sequence, acknowledging that there is a "cognitive" component to the construct. Our studies have shown that Battelle scores were somewhat correlated with engagement levels.

In a study currently under review, conducted by the brilliant young Portuguese researcher, Cecilia Aguiar, sophisticated-engagement levels in classrooms were associated with sophisticated-engagement levels in homes. Does this mean children are carrying around their engagement trait from one setting to another?

Aguiar found that sophisticated engagement was correlated with age: Older children have more of it. Because children obviously carry around their age from one setting to another, ipso facto, engagement will look like a trait.

Engagement and developmental age are not exactly correlated, however, so we recognize that there is something of a developmental or "cognitive" dimension to engagement. But don't discount the environment. Within children who spend quite a lot of time engaged in a sophisticated manner, those in interesting environments are more likely to spend time in sophisticated engagement. Even more important, perhaps, children who spend much time nonengaged are more likely to be nonengaged in uninteresting settings.

Functionality in School-Aged Children

2011-11-13T17:29:00.001-08:00

Question from Ireland: Whatin your opinion are the critical functional outcomes that apply generally toschool-age children and their families?

Forchildren and youth with disabilities, I believe the core outcomes ofengagement, independence, and social relationships (EISR) still apply—as wellas quality of life for their families. My so-called expertise is limited toyoung children but I am the father of a person with disabilities, and otheroutcomes people mention for older children and adults (e.g.,self-determination, feelings of belonging or membership, quality of life) in myexperience are all tied to the big three. Of course, that might just be me,seeing everything through that lens.

Forschool-aged children, academic success is also important, but I see EISR asprecursors to the ability to learn academic content. It’s just that we can’tstop at EISR. We have to ask what they will be useful for—self-fulfilment,becoming an interesting person and therefore having friends, getting a job, andso on.

Ido think that self-determined satisfaction with one’s life is huge, withinreason. You and I might share some common ideas about what should be asatisfactory life, based on our shared ability level and possibly some sharedinterests, but that doesn’t qualify us to determine what a satisfactory life isfor someone else. On the other hand, we might have a responsibility to protectpeople. If a person likes sitting in front of a video game hour after hour, wemight think this is a shallow, empty existence. The individual might think it’sa rich, interesting, exciting existence. If the person’s hours in front of thevideo game are during recreation time, that’s one thing. If the person doesn’thold down a job, because of his or her obsession with video gaming, that’sanother thing. We would presumably try to protect the person from penury byteaching him or her that that the decision to forego employment in favor of thevideo game is a bad one. A tricky issue. But the point I began with is that thevariety of ways people with disabilities define their quality of life might beeven bigger than the variety of definitions held by people withoutdisabilities.

Relation versus relationship

2011-10-25T07:07:00.000-07:00

Canyou P-L-E-A-S-E tell me when it is appropriate to use them term"relation" versus "relationship?" ...I typicallyuse the term "relation" with variables in stat/data analysis. I'd liketo be right, but I'm more interested in being accurate.

A couple of my relations, 6 years ago

Avery good question, especially because certain people—behaviorists, mostly—havemade up rules that defy good usage and elegance. First, the mistake they oftenmake is to say that “relations” should be used for the connection between twovariables. In behaviorism, of course, this is most commonly used in “functionalrelation.” These people can’t stand “functional relationship,” even though thisis actually a better form and doesn’t clang to people who know their English.These behaviorists think “relationship” belongs to the affiliations betweenpeople (e.g., “the child had a good relationship with his brother”).

Infact, a relationship has two meanings: personal affiliations (friendships,romantic link, etc.), the way two things are connected (including variables—e.g.,“the relationship between the predictor and the outcome” or “the correlationalrelationship between Variable X and Variable Y” or “the functional relationshipbetween the independent and the dependent variables”). Relation also describes thelink between people (e.g., relations between teachers and students should benurtured). You can see that this could also be “relationships between teachersand students….” So when discussing links between people, groups, or countriesand the way they behave towards each other (I’m quoting the BBC here), the twoterms are interchangeable. But in certain contexts “relations” is always used:diplomatic relations, race relations. Relations can also be usedinterchangeably with relatives, although that’s not as common in the U.S. as inBritish-English countries.

So,I’m afraid you’re not right about variables taking “relation,” although, as Isaid, many behaviorists would agree with you—and probably statisticians too.But if I had to pick two groups of people who like to talk fancy and whoconsider themselves precise but who slaughter the language, it would bebehaviorists and statisticians. Eighty percent of the time “relationship” willserve you well. Which one you choose depends on whose wincing you care mostabout!

New Part C Regulations: Much Ado About Nothing

2011-09-10T15:00:00.000-07:00

The finally arrived new Part C regulations have someinteresting features. I haven’t compared the old with the new; CEC is going todo that within the month. Some of the new regulations are noteworthy forpractitioners of the model described in Routines-BasedEarly Intervention, published by Brookes. Direct quotations from thenew-regs document are italicized.

The two disciplines. Thedefinition of multidisciplinary in §303.24 has been revised with respectto the individualized family service plan (IFSP) Team composition to requirethe parent and two or more individuals from separate disciplines or professionswith one of theseindividuals being the service coordinator.

An interesting interpretation of a discipline is theinclusion of service coordinator, which is actually a role or function. Butthis will alleviate the pressure on IFSP teams who have previously thought theyhad to find two people other than the service coordinator. The intent,originally, was to have different perspectives from the field. Now, when we’relucky enough to have a service coordinator with content knowledge about child development,family functioning, and disability, we’ll be fine. In states where servicecoordinators are limited in their content knowledge, there will theoreticallybe a loss. I can’t say, however, that I’ve noticed much of a gain by having twoadditional professionals from different disciplines. Evaluations have to berushed anyway, and they’re just for determining eligibility—not for diagnosis,so we might as well make the process as efficient as possible. A good change.

Scientifically based research. Scientifically based research has the meaning given the term insection 9101(37) of the Elementary and Secondary Education Act of 1965, asamended (ESEA).

Well, thanks. That’s pretty useless. You can, however, readthe definition at http://www.okhighered.org/itq/forms/2010-scientific.pdf(thanks to Oklahoma higher ed). Couldhave been clearer.

Transition. New§303.209(b)(1)(iii) provides that if a child is referred to the lead agency fewer than 45 days beforethat toddler’s third birthday, the lead agency is not required to conduct theinitial evaluation, assessment, or IFSP meeting, and if that child may beeligible for preschool services or other services under Part B of the Act, thelead agency, with the parental consent required under §303.414, must refer thetoddler to the SEA and appropriate LEA.

If this was already the regulation, I didn’t know about it.I assume it’s new. This definitely provides relief to the Part C program andmakes sense. We still can’t be sure, though, that a child with a third birthdayon June 1, for example, referred at the end of May won’t be made to wait untilAugust or September before anyone will provide help. A good change, nevertheless.

The 45 days. New §303.310(proposed §303.320(e)(1)) requires that, within 45 days after the lead agencyor early intervention service (EIS) provider receives a referral of a child, thescreening (if applicable), initial evaluation, initial assessments (of thechild and family), and the initialIFSP meeting for that child must be completed (45-day timeline).

When the clock stops has long been a contentious issue, withstates receiving conflicting messages from OSEP. Note that the regulation saysthe clock ends when the initial IFSP meeting is completed. Although this couldbe interpreted as the IFSP meeting for the first (i.e., initial) IFSP, it couldalso be interpreted as the first meeting about the IFSP. In our model, I haveargued that this could be the Routines-Based Interview, even if the signing ofthe IFSP happens later—that is, after the 45 days are over. The two problemswith my argument are, first, that, unless the RBI date is documented somewhere,no accountability is possible about meeting the 45 days. Second, it could delayservice delivery, which is the point of the 45-day requirement. I don’t buythis second argument, however, because many parents have told us that the RBIitself is very beneficial. A goodregulation, as long as it doesn’t get misinterpreted by states or the feds.

Abbreviation. “EIS” isthe long-standing, commonly accepted abbreviation used in the field of earlyintervention and we do not anticipate any confusion by the abbreviation’scontinued use in programs administered under Part C of the Act.

It is?

Purposes of early intervention. Two commenters recommended that, when describing the purpose of earlyintervention services in general, we retain the language that these servicesmust be designed to serve “the needsof the family related to enhancing the child’s development” that is in current§303.12(a)(1). The commenter stated thatmeeting family needs is a key component of an early intervention systemand should be addressed routinely in IFSP development, rather than only uponfamily request.

The originally proposed regs had included “as requested bythe family, the needs of the family.” In the final version “as requested by thefamily” was omitted to ensure that family needs should always be addressed,unless the family doesn’t want this. We shouldn’t wait for them to ask fortheir needs to be met. A good change.

Definition of early intervention services. One commenterrequested that we clarify in the definition of early intervention servicesthat EIS providers who work with infants and toddlers with disabilities andtheir families should focus their services on ensuring that family members andchildren have the tools needed to continue developing the skills identified inthe IFSP whenever a learning opportunity presents itself even when a teacher ortherapist is not present.

A great comment. It might even have been mine. If not, I’mclaiming it anyway. The feds weren’t swayed for the following reason:

However, in addition to thereasons stated, adding language to §303.13 as requested is not necessarybecause the definition of EIS provider in §303.12(b)(3) specifies that suchproviders are responsible for consulting with and training parents and othersconcerning the provision of early intervention services described in the IFSPof the infant or toddler with a disability. Additionally, this consultation and trainingwill provide family members with the tools to facilitate a child’s developmenteven when a teacher or therapist is not present.

They missed a goldenopportunity to discuss preparation for what happens between visits.

Types of earlyintervention services—family training, counseling, and home visits. One commenter recommended deleting the reference to “home visits” inthe title of this paragraph because the commenter considered home visits to bea method of providing a service rather than a service in and of itself… Section632(4)(E)(i) of the Act expressly states that early intervention services include familytraining, counseling, and home visits. Thus, removing the reference to home visits from §303.13(b)(3) would beinconsistent with the Act. .

No change was made. The discussion, however, shows that OSEPstill is unclear about how children learn and how services work. The paragraphfollowing the above discussion is as follows:

The language in§303.13(b)(3) does not mean that family training must occur in the home orinclude counseling. Section 303.13(b)(3)merely defines three separate early intervention services –- family training,counseling, and home visits -- that may be provided to assist the family of aninfant or toddler with a disability in understanding the special needs of thechild and enhancing the child’s development.

This suggests the other services, such as special instruction,OT, PT, and speech-language are not also services that may be provided toassist the family of an infant or toddler with a disability in understandingthe special needs of the child and enhancing the child’s development. Itimplies that the some services are for direct application to the child andothers are for helping the family. Not how I see it!

Furthermore, I always thought home-based was a setting butnot a service. You can’t like home visits in the service section of an IFSP,can you? I hope someone can straighten me out in a comment following this post.Unclear.

Sign language and cued sign services. The phrase “asused with respect to infants and toddlers with disabilities who are hearingimpaired” has not been included in the definition of sign language and cuedlanguage services in new §303.13(b)(12).

The discussion includes the point that it isn’t onlychildren who are hearing impaired who might benefit from signing. Well done.

Speech-language pathology services. Several commenters recommended adding such services as auditoryhabilitation and rehabilitation, dysphagia, auditory-verbal therapy, oropharyngeal, or feedingand swallowing services to the definition of speech-language pathologyservices in new §303.13(b)(15) (proposed §303.13(b)(12)).

No change was made because the definition in this section isnot intended to be exhaustive. Good! We already have too muchoverspecialization in early intervention, leading to fragmentation of servicesand professionals whose focus is too narrow. We also have certain subspecialty groupstrying to capture the market for certain types of children. Good nonchange.

Other services. Another commenter requested thatthe Department revise the language in this paragraph to indicate that any otherservices identified in the IFSP of an infant or toddler with a disability bebased on proven methods or evidence-based practices…. Discussion: Mirroring this standard,§303.344(d)(1) requires that each IFSP include a statement of the specificearly intervention services based on peer-reviewed research (to the extentpracticable) that are necessary to meet the unique needs for the child and thefamily to achieve the measurable results or outcomes identified in the IFSP.

This whole idea of services, either those identified as theregular ones in Part C or “other services,” being based on peer-reviewedresearch is laughable. As much as I’d like to advocate for this regulation, theservices used in Part C and the way they are implemented do not have asufficient research base anyway. But we’re not going to do away with them. So,to apply a higher standard to other services would be ridiculous. Furthermore,in the past 7 years or so, when the field started acting serious aboutevidence-based practices, we have become bogged down in debates about whichstudies are good enough to be included in analyses of EBPs and how many studiesfrom how many research groups need to be conducted to determine a practice isevidence based. And then we have the issue of gradations of evidence-based, becausewe’re loath to say a practice is or isn’t evidence based. And this discussionin the regs is about services, not even practices, and everything is hugelymore complicated when we have such a broad scope as a “specific earlyintervention service.” Correct nonchangebut the regs still don’t help us get rid of bogus treatments.

Services neither required nor funded under Part C. Section 303.344(e) provides for the IFSP Team to identify in the IFSPmedical and other services that the child or family needs or is receivingthrough other sources, but that are neither required nor funded under Part C ofthe Act.

This discussion about a rather pointless comment serves as agood reminder that these other services can be listed in the IFSP and they don’tcommit the Part C program to pay for them. Many states, especially whereeducation is the lead agency, shy away from (i.e., tell service coordinatorsnot to) list these services, in case the family thinks the program is going topay for them, as would happen on an IEP. Goodreminder.

Infant or toddler with a disability. : We have revised §303.21(a)(2)(ii) toadd “severe attachment disorders” to thelist of diagnosed conditions that have a high probability of resulting indevelopmental delay.

OK, but I think states still have the right to determine forthemselves who’s on their special list for diagnosed conditions. Severe attachmentdisorders was the only addition, among a number suggested. The list is ofexamples only, however, so I don’t think it really matters.

Multidisciplinary. Multidisciplinarywas defined in proposed §303.24, with respect to evaluation and assessment of a child, an IFSP Team, andIFSP development under subpart D of this part, as the involvement of twoor more individuals from separate disciplines or professions or one individualwho is qualified in more than one discipline or profession.

Back to this issue, but now focusing on how many people shouldbe there. Apparently, the transdisciplinary-approach haters rallied to commenton the regs, because a number of comments wanted to ensure the regs didn’tallow just one person who might be qualified in two areas (service coordinationand special instruction, for example?) to replace a group, which the commentersays is explicitly defined in Part B. Commenters requested that thedefinition be modified to ensure that multiple perspectives are included oneach IFSP Team and adequate representation is not hampered or constrained onany given IFSP Team by an individual who is qualified in more than one disciplineor profession. It’s atoss-up whether representation is more hampered in this situation or in onewhere two people have blinkers on, with respect to attending only to areas oftheir narrow training.

The discussion about evaluation and assessment includes thefollowing: With respect to IFSP Teammeetings, we believe it is important for the parent to be able to meet not onlywith the service coordinator (who may have conducted the evaluation andassessments), but also with another individual (whether that person is theservice provider or another evaluator) to obtain input from two or moreindividuals representing at least two disciplines and have revised §303.24accordingly.

They want two people there. For those states using medicalas one of the professions, this is not the intent of this regulation, unlessthe child has a chronic illness or something similar. This regulation doesn’taddress how a provider could meet with the family on an initial IFSP, before serviceshave been determined. I suppose the feds would say that then an evaluator wouldserve as the second person. In our model, I want states and teams to consider amost likely primary service provider (MLPSP).

Some commenters, including possibly me, wanted a referenceto transdisciplinary or interdisciplinary, but OSEP said, referencing specific team models in the regulatory definition of multidisciplinaryis not necessary.

Natural environments. Two other commenters recommendedthe definition indicate that a clinical setting could be the naturalenvironment, particularly when the service requires the use of specializedequipment that cannot be transported to the child’s home. One commenter expressed concern thatmandating services to be provided in settings where non-disabled children arepresent may suggest that the alternative is less than acceptable. Another commenter recommended that the definition of naturalenvironments require that services be provided within family routines andactivities and opposed identifying specific settings….

We expected clinic-based professionals to challenge thenatural-environments provision. Fortunately, the OSEP response was We do not believe that a clinic, hospital or service provider’s officeis a natural environment for an infant or toddler without a disability;therefore, such a setting would not be natural for an infant or toddler with adisability. Good nonchange.

Section 632(4)(G) ofthe Act provides that natural environments may include home and communitysettings. However, the reference to community settings was notincluded in the proposed regulations. “Community settings” was added back in. Good change.

Qualified personnel. Additionally, §303.344(g), whichprovides that an IFSP contain information about the service coordinator,requires that the service coordinator be selected from the profession mostimmediately relevant to the child’s or family’s needs or be a person who isotherwise qualified to carry out all applicable responsibilities under Part Cof the Act.

I don’t know that this is a change, but most servicecoordinators in dedicated-service-coordination states are not from theprofession most immediately relevant to the child’s or family’s needs, so let’shope they’re otherwise qualified to carry out all applicable responsibilities….The feds might have been thinking about service coordinators who are alsoproviders to the family (the blended model). But the second half of thedefinition of the qualification is a complete cop-out, just when we probablyneeded to raise the qualifications. That responsibility is probably correctlywith the states, but that means we’ll have to be vigilant about which statesactually make it possible for families to have properly qualified (not asdefined in the regs) service coordinators. Confusionand cop-out.

Paraprofessionals. The fedscontinue to allow paraprofessionals to “assist in the provision of earlyintervention services to infants and toddlers with disabilities.” They mentioncertification and supervision. It’s unclear to me whether a state could allowparaprofessionals to be the primary service providers or weekly home visitorsto a family. I have serious reservations about the suitability of paraprofessionalsserving in that role. Missedopportunity.

I have been through all 932 pages of the regs, and the itemsabove were the only ones worthy of mention. I might have missed other notables,so I hope readers will post comments below if they have other changes to pointout. Until someone points out something different to me, the most notablechange I notice is counting the service coordinator as one of the twoprofessionals.

Writing Outcomes or Writing Goals

2011-08-12T05:21:00.000-07:00

Are there times you write goals for a child that are not tied to specific routines? If so, can you give me an example?

Toileting for children who need to toilet at any time. They wouldn’t have actual toileting routines. People need to understand the vital importance of participation or engagement, in order for this question not to come up. Here’s the abstract to a good article by Jeanne Wilcox and Juliann Woods about the importance of participation for writing outcomes: http://lshss.asha.org/cgi/content/abstract/42/3/365. They focus on language, but the same argument can be applied to all areas of development.

We are still working from a mind set that we need to be writing goals based on provider concerns - even if the parent is not concerned or invested in the goal. We are basically saying that we should be telling the parents what they should be concerned about. I am not sure how to get past that.

Shouldn’t be allowed because it’s not family centered, as I explain below.

The basic issues are these:

1. How do we decide on an appropriate measurement if we do not break down the goal into smaller steps?

Would coming up with a breakdown of short-term objectives serve the same purpose as writing a measurement with the three criteria or should the list of short-term objectives be something in addition to the functional goal with measurement included?

The question is related to the seven steps for writing participation-based outcomes/goals, as described in the book Routines-Based Early Intervention. An example is below.

This question assumes that all skills are going to be taught in the steps in a task analysis, so the measurement becomes the accomplishment of step after step. This is an acceptable measurement method to supplement the criteria for outcome accomplishment. You see, the difference is between progress monitoring and the criteria for the END of the instruction—what answers the question How will we know when we got there—when to reassess, when to stop? The three criteria ask the questions, When is this overall skill (i.e., all the steps or a subset of the steps) needed (i.e., what routines), what level of performance is required (e.g., how many steps in the chain, what level of prompt, what frequency, what duration—whatever makes sense for the skill in context), and over what amount of time (which should be specified in any measurement system, even a task analysis one)? So it’s a false question to say it’s chaining versus our three criteria.

I am worried that those who don’t want to specify routines (a) don’t think of the necessity factor in outcomes (is it necessary?); they think more in terms of deficit—what can the child not do, regardless of context; and (b) think that professionals have to teach the child during routines, which would be difficult to do (instead of thinking that we need to be consulting with families so they can teach the child during routines).

2. How do we include professional opinion in goal-writing?

First, the rewording of the goal into a participation-based goal with three criteria is professional behavior. Second, professional opinion can go into the process of functional assessment, by the questions we ask families, the stars we highlight if we do an RBI, and the reminders of concerns we provide while the family is choosing outcomes/goals. But this requires a strong commitment to ethics, to ensure professionals are not talking parents into choosing outcomes they actually are not interested in or that are not actually functional. Third, professional input really comes into the strategies for intervention. It is a paradigm shift (sorry about the cliché) to let families make decisions about goals. Understanding whose child it is and that families need to be reinforced for the decisions they make about their children’s goals is the hallmark of a family-centered professional. Others are nice to families but don’t really trust them or care about the families’ priorities and long-term growth as parents; they are not truly family centered, even though they sometimes think they are God’s gift to families.

3. Does having a list of short-term objectives with the final objective being the end goal supercede the need to write the measurement piece?

This is partially addressed in my first answer. No, it doesn’t. If you want short-term objectives, here’s how it can work:

Joshua will participate in hanging out time and bath time by playing with a variety of toys. We will know he can do this when he plays with three toys in two hanging-out times and one bath time in a day for five consecutive days. [This is an example of a participation-based outcome with multiple criteria.]

Short-term objectives:

1. Joshua will play with two toys during one hanging-out time by October 1.

2. Joshua will play with two toys during one bath time by December 1.

3. Joshua will play with three toys during two hanging-out times by February 1.

4. Joshua will play with three toys during one bath time by April 1.

5. Joshua will play with three toys in two hanging-out times and one bath time in a day for five consecutive days by June 1.

If you have any pearls of wisdom that might help me find a way to navigate this I would really appreciate it. I fear I am just causing myself more confusion the more we go around on the subject.

Reread Chapter 7 in the RBEI book and look at the Goal Functionality Scale III.

New Discovery: Home Visits

2011-02-04T22:58:00.000-08:00

Home-visiting or "home visitation" programs have been discovered by the early childhood community and they're the new hot thing. Obama has called for support of such programs and they are proliferating and generally gaining a lot of national attention.

On February 16 and 17, the National Summit on Quality in Home Visiting Programs: Connecting Research to Policy and Practice will be held in Washington, DC (http://www.homevisitingsummit2011.org/). Where is Part C? Nowhere to be found among the confirmed speakers.

This has been true over the past 2 years, as these programs have been created and debated. Despite the fact that over 70% of the Part C children are receiving their most important service in the home, we are by and large not at the table with these Johnny Come Latelies.

To give credit where it's due, David Olds and his nurse home visiting model have been around for a long time, but they do not operate at nearly the scale of Part C home visits. Should we be at the table with these other programs or are we so fundamentally different that we're relieved to be excluded?

This is an important question the early intervention field needs to contend with. Amazingly, when the evidence base about home visiting programs is discussed, the conclusion is that it is ineffective. These findings primarily came out of the old Abecedarian Project and the Infant Health and Development Program, where these disadvantaged-family home visits were largely discredited, compared to intensive classroom-based programing.

But think of the different nature of those home visits from Part C home visits. Whereas disadvantaged-family homes visits often involve quite didactic interactions between trainers and parents, early intervention home visits, when done well, are designed to provide emotional, material, and informational support to families. The support is aimed in part at addressing specific, measurable family-chosen goals. I'm not trying to make Part C home visits sound better. Both types are designed to help with parenting.

So do we want early intervention to be associated with these increasingly popular home visitation initiatives? It seems peculiar for these programs not to learn from the history of over 25 years of early intervention home visits. But we also don't want the association to be so strong that we shy away from our special obligation to work on IFSP outcomes/goals.

It just seems peculiar to have a national summit on home visiting with no representation of Part C in it.

Toddler Groups

2010-12-15T03:52:00.000-08:00

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.

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

2010-12-14T19:17:00.000-08:00

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.”

MY RESPONSE

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.

WHAT TO WORK ON

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.

WHEN TO WORK ON GOALS

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.

SERVICES AND PLACEMENT

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.

RBI With Recent NICU Graduates

2010-12-05T19:11:00.000-08:00

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.

Pronouns Indicating Teamwork and Humility

2010-11-10T13:54:00.000-08:00

Occasional Posts on Language

I once worked with a graphics designer who had a couple of co-workers she routinely referred to as "my staff." Indeed, she was the team leader, but this use of the first person seemed self-aggrandizing. And I have subsequently found it in other middle managers in our field.

In early intervention and other human-service organizations, when we have at least three layers (e.g., boss, middle manager, workers), for the middle manager to talk about "my team" and "working for me" reveals (a) insensitivity to the fact that these people are also the boss's, (b) self-importance, and (c) unawareness of the organization or team. Better language is "our team" and "working for us."

In my experience, this problem is most commonly found in people who haven't supervised others before or very much.

Behavioral Consultation on Home Visits

2010-10-12T14:55:00.000-07:00

Home visits in this model are strong supports to families to help them make the most of the learning opportunities, as Dunst and Bruder would call them, that occur throughout the day. The Vanderbilt Home Visit Script is a beginning, but the real meat of the home visit is in the "behavioral consultation" that the home visitor provides.

My definition for this term, which has existed in school psychology and other professions using consultation, is specific to working with caregivers in early intervention: Collaborative problem solving and solution finding related to families' concerns for their child or other family members, including parents.

Behavioral consultation on child-level issues occurs in when discussing, on a home visit, progress on a child-level outcome or goal. Answers are expected to fall into three categories:

The child has not improved in performing the skill;

The child has improved; or

The child has mastered the skill.

Each of these leads the home visitor down a path of questions that include

Getting detailed descriptions from the family;

Asking for demonstration of child functioning, if necessary; and

Asking how previously discussed interventions are going.

Common consultative strategies in this approach are using

Ask-to-suggest (i.e., "Have you tried this? Have you tried that?");

Offering to demonstrate with the child;

Refining the skill the child is working on;

Tweaking implementation of the intervention;

Suggesting a change in how the routine is carried out;

Encouraging the family to persist with an intervention;

Upping the ante (i.e., changing the criterion when the child has mastered a skill); and

Constructing an Outcome x Routine matrix.

These home visits are usually highly focused and aimed directly at ensuring families have interventions they can use all the time between home visits, when child learning really happens. Sometimes families choose to talk about issues other than child skills, and sometimes the home visitor is using behavioral consultation on family-level issues.

When home visitors use behavioral consultation, they don't work with the child directly (although they might demonstrate interventions with the child), they don't take activities into the home (unless previously the family had requested them), and they don't spend all their time engaged in toy play with the child. The visit is structured around the IFSP outcomes or other topics the family wants to discuss. By the end of the visit, the family should have

interventions they have had a part in developing,

information, and

encouragement.

Behavioral consultation is described in Routines-Based Early Intervention, a book I wrote, published by Paul H. Brookes Publishing Co. (http://www.brookespublishing.com/).

Curriculum for Home Visiting

2010-07-01T19:37:00.000-07:00

Q: I would like to know what you would suggest as a good curriculum for us to use as providers. Many curriculums are on the market, but we need something that can be useful for sharing when doing activities and providing carry over suggestions to parents.

A: A curriculum is supposed to be what is taught to the learner. In early intervention, (a) home visiting is not just about "teaching" parents and (b) when they do want to be taught something, the content should come from (i) their individualized needs, not a curriculum; and (ii) the IFSP, if those needs are already reflected on there. In some cases, needs not on the IFSP should be put on there, if the family desires.

Many people confuse a curriculum with intervention suggestions. So your question might actually be about the intervention suggestions we make to parents. In our model, these come not from a book (e.g., curriculum) but from a process called Home-Based Behavioral Consultation. This is a collaborative, problem-solving process that marries the family's needs and resources (e.g., which routines they want help with and what they think is feasible) with the home visitor's expertise (i.e., strategies that address the specific need identified). This requires the home visitor to have knowledge about child development, family functioning, and behavioral interventions. It would be a great resource to take typical problems in everyday home routines and list various commonly suggested strategies, but I know of no such resource. So we are still left with relying on the training, experience, and collaboration of home visitors with families. Home visiting isn't an entry level position; it is sophisticated.

Having said all this, we do use the Measure of Engagement, Independence, and Social Relationships to monitor children's functioning in routines. This should not be used as a curriculum: It does not dictate what we do with families, but it helps those home visitors who don't think about the various components of child functioning within routines.

Perhaps the closest thing to a "curriculum" we use is the Routines-Based Interview, which is actually a process, not a product. But it is the tool for helping families decide what they want on the IFSP, which, as I mentioned earlier, is the list of things to work on--the definition of a curriculum.

Implementation II: Show Me the Research

2010-02-10T12:17:00.000-08:00

Question: We have a supervisor who wants to see the research that better outcomes are occurring for children with using this method of service delivery (referring to my routines-based early intervention in natural environments).

Answer: I would like to see the research that better outcomes are occurring for children who get the current method of service delivery.

One might argue that the change model should produce the evidence. That the onus isn't on the homeostatic model but on the one requiring effort and psychological unrest. Another way of looking at this we learned a long time ago with respect to the research basis for inclusion. The model with the backing of theory, rational thought, and moral certainty does not have the onus of proof. The atheoretical, irrational, and morally questionable (i.e., not empowering families and other caregivers adequately) model has the onus of proof.

Implementation I: Writing Outcomes for Family-Level Needs

2010-02-04T07:52:00.000-08:00

The next few blog entries will be about implementation issues that have arisen in one state I've been helping.

Question: Instead of writing 10 IFSP outcomes, some teachers [home visitors] are using [the daily contact log] to document concerns such as needing help finding day care, putting plastic on the windows, looking for a toddler bed, etc. The need/concern is documented, and the teacher follows up with the concern on the next visit.

Answer: These kinds of concerns are family needs, which are supposed to be part of early intervention and on the IFSP. What makes the askers of this question think that these needs shouldn't be outcomes? Do the have some child needs they also don't write outcomes for? Our accountability is at the level of outcomes, so we need important activities to be listed as outcomes, not hidden away in the child's record for which there is no accountability.

If the need came up during the Routines-Based Interview and the family selected it as an outcome, obviously it is written as an outcome. If a need comes up in the course of home visiting, it does not necessarily need to be added as an outcome. If much time and energy is going to be put on resolving the issue or if it becomes a big deal for the family, it should be added as an outcome, if the family chooses. Professionals should encourage not discourage this. Home visitors should be working on outcomes, so if something is not an outcome and they're spending much time on it, they are not doing what they should be doing. Similarly, if it's important to the family, we need to see that there is truly a goal to be accomplished, so an outcome gets written.

Preschool Services Need Attention

2009-09-04T05:10:00.000-07:00

It has become fashionable at early intervention/early childhood special education conferences to decry the supposed sorry state of affairs in Part C. In some places, criticism is warranted; in others, it's not. Many communities--the State of Missouri being one--are making significant strides towards excellent service delivery models.

Preschool services (Section 619 of Part B of IDE[I]A) have always been in a strange position. On the one hand, they receive much attention; on the other, they receive scant attention. They receive much attention in training in university programs for young children with disabilities, where much of the training is directed at preschool-aged children. In part, this emphasis is because of location: Students can be placed in classrooms for internships and student teaching, whereas placing students in home-based programs is much more problematic. Attention to preschool services is supposedly also revealed in conference presentations, where organizers and attendees alike are concerned about whether enough of the program is devoted to infants and toddlers and their families.

The scant attention I have noticed is in service delivery models.

Just how are preschool services organized?
What is the rationale?
How much are administrators paying to dosage issues?
Who are the targets of services?
What philosophies underpin services?
How much focus is on the influences of children's learning--children's learning opportunities?

These questions are related, and I will attempt to answer some of them. Others are for decision makers, practitioners, and families to consider, because my experience is that they often fail to consider them.

First, we can assume that, owing to what we now know about young brains and have long known about successful parenting, young children learn throughout the day better than they do in "lessons." This is related to the power of natural discriminative stimuli and to the difficulty young children, particularly those with developmental delays, have with generalization or "transfer."

Second, we can assume that what they are learning is far more than preschool behaviors (sitting, playing with play dough, negotiating with peers, etc.): They are still learning language, what their growing bodies can and cannot do, and how the world works, which is why learning opportunities exist throughout the day. This concept of alocated learning time is critical for understanding the difference between early childhood education and later education. The older children get, the more their learning can be concentrated into "school" (or Sunday school or piano lesson) time. In the preschool years, caregivers have the opportunity to teach throughout the day. This should make early childhood special educators think about their roles and opportunities.

Third, family systems theory, helpgiving theory, social support theory, and behavioral-ecological theory do not come to a grinding halt when the child turns three years of age. In Part C, there is some understanding that the whole of a child's waking hours is potential intervention time and that the environments in which the child finds him- or herself influence learning. Unfortunately, even though this understanding exist in theory, even in Part C it does not always translate into action. The situation is even worse in preschool, however, where service coordination is no longer a mandated service and where the (special) education mentality is pervasive.

If family systems theory were acknowledged, preschool services would be organized to provide emotional, material, and informational support to families, including the systematic assessment of their needs and accountability on the IEP (if that document must continue to be the driving document) for developing family-level goals and providing supports to meet those goals.
If helpgiving theory were acknowledged, preschool services would have an expanded view of family-centered practice, so they would attempt to meet families' needs for emotional, material, and informational support, rather than thinking that "parent participation" in school activities was most important.
If social support theory were acknowledged, preschool services would see the link between child learning and family well-being and family well-being (quality of life) and their social support, especially informal support. Early childhood special education would therefore spend at least a little time getting to know families' ecologies and helping families preserve and, if they desire, expand their informal-support networks.
If behavioral-ecological theory were acknowledged, preschool services would assess children's functioning throughout their typical day, through a family interview, and develop intervention plans that followed our knowledge of how young children learn. These plans would use children's interests and natural learning opportunities to teach them skills so they can participate successfully (i.e., be engaged) in their home, community, and school routines (activities).

Now let's discuss the number of hours that preschool services are provided to a child. If the child can go to school five mornings a week (e.g., 20 hours, allowing for a full 4 hours a morning instead of the measly 2.5 hours some preschool programs offer) or three full days a week (e.g., 15 hours, allowing for a full 8 hours), the school environment becomes a true learning environment. The child spends enough time there for learning opportunities to be distributed across time, and the child's "caregivers" during that time (i.e., teaching staff) spend enough time with the child that they become direct instructional or intervention agents themselves. This can be labeled the classroom model.

If these classrooms are self-contained (i.e., having only children with disabilities), they represent a dated approach that potentially violates moral and legal positions. If they are inclusive (i.e., at least half the children in each classroom have no disabilities), these classrooms are defensible and potentially excellent. This article is not about inclusion; it is about attention to children's learning opportunities and to their families.

Many preschool services are offered on a much leaner schedule, such as one to four 2.5-hour mornings a week, with the number of mornings being related to either the severity of the child's disability or the number of services the child has on the IEP. When a child is "at school" for such a small percentage of his or her waking time, we have to ask what the point of this service time should be. The child is transported in, sometimes by school bus, which is another whole discussion, sometimes by parents. Usually, the child is left "at school" for these short bursts of early childhood special education and related services. Family communication is limited to (a) notebooks, (b) intermittent home visits, or (c) discussions at arrival and departure, sometimes, with those families who do drop off and pick up their children. Often, that communication is about what the school people are working on, what the child did, and what the family can do to support the school's efforts. Sometimes, these short sessions at school are thought of as the times the child comes in for his or her therapies and special ed. Short times at school (i.e., fewer than 15 hours a week) can be thought of as the playgroup/clinic model.

Some preschool services are offered through itinerant services, which have the potential to acknowledge the theoretical bases I earlier described. Itinerant teachers can consult with a child's regular caregivers/teachers in child care or other classroom-based settings, such as Head Start. If the consultation is done well, using an individualized-within-routines approach and not a pull-out approach, this model of service delivery has the potential to expand intervention throughout the child's classroom day every day. Unfortunately, sometimes itinerant services are restricted to special education, with the therapies still happening in clinical types of settings at a school. If therapists can also travel to children's regular-early-childhood classroom settings and adopt a "consultative approach to direct services" (which is not as contradictory as it sounds), we really have the potential to provide meaningful intervention. There's still the family piece though.... This approach is labeled the itinerant model.

School districts fear that the itinerant model is too expensive, compared to keeping all the personnel in centralized locations and shipping the children in, in groups. For the reasons given above, this solution has to be considered pragmatic but atheoretical, if the playgroup/clinic model is adopted. Beginning steps for preschool administrators can include the following.

Become familiar with the literature on the theory and research related to the concepts described in this article, so decisions are made on intellectually and empirically defensible grounds.
Work towards converting the playgroup/clinic sessions into family support sessions. After all, because they consist of such short bursts, many families are presumably available to transport the children or to care for them when they're not "at school." Do not call this "school" time, because that has the connotation of teachers working directly with children, and these family support sessions will be much more than that.
Take all the FTEs currently devoted to preschool special ed and related services, acknowledging that some therapists might work also with older children, and divide that number into the number of children with IEPs. Consider this then to be potential caseloads, with one professional serving as the primary interventionist with that child and family in whatever location seems appropriate. This is a radical but highly commonsensical approach to resource distribution--and defensible on child-learning and service delivery grounds.
Expand itinerant services, once caseloads are reallocated to a primary service provider. Ensure this is done with both therapies and special education, not just the latter.

2009-05-11T17:54:00.000-07:00

What to Study

A colleague of mine was pondering what research question to ask next, which got me thinking about what I believe really needs to to be tackled.

If I were my colleague, I’d be curious about the actual amount of intervention children get—what we sometimes call the dosage question. Usually, this is measured in terms of the amount of time a child attends a program, but I’m interested in (a) how much intervention, typical or compensatory, does a child get from his natural caregivers and (b) how much program time is actually what Fisher, Berliner, et al. called “academic learning time” or true instruction. Part of my question is a political one: I simply don’t believe that only professional time counts. And I believe that a lot of professional time is incomplete teaching.

So what? First, if we could measure what children get from natural caregivers, we could count this as a buffer or asset that the child has. Second, if we could show that complete incidental teaching (setting up an engaging environment, following the child’s lead, eliciting elaboration, and ensuring there’s a consequence) is better than incomplete incidental teaching, which is better than nonelaborative responses, which is better than nonresponsive directives, we’d know more about the whole package of interventions children get and need.

Service Coordinators as Evaluators

2009-03-10T17:00:00.000-07:00

I need some insight and thought you can help. We are facing some challenges at the Early Intervention System in XXXX because of service provider shortages. We never seem to have enough service providers … We’ve been brainstorming alternatives because the way our system was conceptualized is that our service providers use some of their time to do initial child assessments before the IFSP meeting and I would prefer that they use their time to provide services!!!!

We have a group of Service Coordinators that have different educational backgrounds (ex., Social Workers, Pschology, Counseling, etc.) All of them have a Bachelor Degree and most have been working for the EI System for an average of 3 yrs. and it is my perception that they have the skills to carry out child assessments. Would it be appropriate to train Service Coordinators so that they can do the initial Curriculum Based Assessment? We use the HELP (Hawaii Early Learning Profile). I checked the Regulations and they basically talk about state licenses and certifications regarding providing services but I’m not sure if it also applies to the assessment process?????

Are your service coordinators just service coordinators, not providers? If so, by and large, they are not necessarily trained early interventionists; most importantly, sometimes they are not trained in child development or disabilities (see McWilliam, 2006). On the other hand, neither was I when I was doing child assessments as a home visitor. And the HELP does not require any kind of licensure. So my conclusion is that, if the service coordinator knows child development and disabilities, he or she can do the evaluation. You are talking about evaluation for eligibility, aren’t you? If so, remember they are just trying to answer the question in or out? If your state allows the HELP, then they’re not that particular about the exactitude of the evaluation, since the HELP isn’t norm referenced. So that’s another argument for allowing the SCs to do the evals, if they’re knowledgeable. The Part C regs do not prevent service coordinators or anyone else from doing the evals.

McWilliam, R. A. (2006). What happened to service coordination? Journal of Early Intervention, 28, 166-168.

Paraprofessionals in Early Intervention

2008-12-07T07:18:00.000-08:00

E-mail received from an early intervention leader in a progressive state, when it comes to quality services:

We are grappling with an issue of using PTAs/COTAs in the PSP model. Do you have some thought on the role these folks can or should play in a true PSP model? Specifically, we need to resolve for our system:

1. Can PTAs/COTAs serve as the Primary Service Provider and make the weekly home visits as long as their supervising PT/OT is participating in joint visits regularly?
OR
2. Would they not have the ability to “work across disciplines” as the PSP due to the limited scope and focus of their discipline?

It's not an easy question to answer. For once, putting aside the bureaucratic concerns about ways to save money, I come down on the expertise needed to make good decisions about what to do on home visits. I have created time allocation charts of how home visit times might be allocated, which can be ordered through researchcenter@siskin.org. These charts show that time might be spent in hands-on consultation, verbal consultation, greetings, and relationship building. What percentage of time in the visit is spent on each activity varies from family to family and visit to visit.

It takes good judgment with individual families to decide how a given home visit is going to shape up. Then add to that the options, shown in anothe graphic, also available from me, when a home visitor asks how progress is being made with a specific outcome. Here we see that the simple question "How's it going with [Outcome No. 1]?" can lead to an enormous number of follow-up questions and activities, resulting in offering to demonstrate, considering the outcome met, upping the ante (i.e., changing the criteria for completion, trying an outcomes-by-routine matrix, changing the intervention or routine, tweaking implementation of the intervention by the parents, or refining the parents' intervention skill.

Can a COTA or PTA handle these decisions, especially if they're outside the person's field. I'm not saying a regular OT or PT (or other fully licensed professional) would necessarily be that much better, but if we follow the guidelines that providers should have the highest credentials within their disciplines.... It's true that classroom teachers aren't held to as high a criterion (i.e., there are classroom paraprofessionals), but that's because more flexibility and decision making, not to mention consultative, skill is needed as a home visitor than as a classroom teacher.

Assistants fit the old model better than the primary-service-provider model. We need the most sophisticated professionals we can get. It's time to raise the bar and stop thinking that "something's better than nothing." Lisbeth Vincent, one of the pioneers in our field, said exactly this in 1986, when 99-457 was passed.

Having said that, I will point out that in certain parts of the country, paraprofessionals appear to be really valuable. They are often members of the same community as the families they serve, they often get close to the families, and they are good at informal support. It's hard to knock that grassroots kind of resource. Unfortunately, however, it goes only so far.

I come down on the side of increasing the quality of the workforce more than the breadth (quantity) or it.

Doctors' orders

2008-11-18T18:25:00.000-08:00

Hi Robin!

One of the barriers we continue to face with implementing evidenced-based practices is physician "orders" and information to families that their child needs a specific frequency of a specific therapy - with more being "required" the more significant the delay, disability or diagnosis. As we have worked in XXXXXXXX to teach practitioners about effective intervention, we are finding that while some or most understand, they are having trouble articulating the rationale and sticking with recommendations in the face of expectations and sometimes "demands" from families to provide what the physician has recommended or ordered. Can you point me to some articles, reports, research, etc. that we could used in our public awareness efforts with physicians and that providers could use with families to explain why we are recommending something different. It would be nice if we could come from strength - provide information that is compelling in and of itself - so providers don't feel that they have to "sell" their recommendations. Also, it is challenging to recommend something different in a way that doesn't put down the physician.

I don’t know of any materials that would directly help. As you might imagine, I deal with this all the time and here are the main messages I give:

It is “illegal” for physicians to dictate services, let alone intensity of services, upon diagnosing a child; according to IDEA, this is the responsibility of the team. Doctors respond to “illegal”!

We explain to parents that doctors base their recommendations on the diagnosis, as though all children with the same diagnosis had the same needs. “And of course your child is doing well, has awesome parents, and now has a team of early interventionists helping, so we’re not in a worst case scenario.”

What the doctor means is that your child needs at least this much INTERVENTION, but doctors don’t understand the difference between intervention and service. And actually your child deserves even more intervention than the doctor prescribed. Let’s do the math and add up all the intervention your child will get from you and his other primary caregivers. The job of the SERVICES is to help you make those interventions work.

Child care reflected on IFSP

2008-09-09T17:30:00.000-07:00

I have been grappling with the issue that the IFSP should reflect the child care hours a child in early intervention receives, in addition to the number of hours of official early intervention services (e.g., special instruction, family training, SLP, OT, PT, etc.). I thought the federal law specifically allowed for the listing of “services” paid for and unpaid for by the system, but it doesn’t. The IFSP must contain “a statement of specific early intervention services based on peer-reviewed research… necessary to meet the unique needs..., including the frequency, intensity, and method of delivering services.” Resources are mentioned in the law, of course, in the CPR section: “a statement of the family’s resources, priorities, and concerns….” So below I list places on the IFSP where child care and number of hours can be documented.

Ideally, every IFSP would document, in the natural environments section, how many hours a week the child was planned to (a) attend a child care center, (b) attend a family child care home, (c) receive child care from one primary nonparental child care provider (e.g., nanny/babysitter, family member). In the meantime, we might want to record it in one of the four places identified below. This would show everyone how much intervention the child care center is providing and probably not getting paid for, from early intervention funds.

Places on the IFSP Where Child Care Intensity Can Be Recorded

Concerns, priorities, and resources section

Section for documenting natural environments

Section for extra notes from the IFSP meeting

Strategies or action steps for outcomes/goals

(Thanks to Jacque Davis, Ph.D., for getting some background information on this for me.)

Toy Bags

2007-10-11T19:26:00.000-07:00

The following request for information came to me recently:

Hello I am emailing for advice and resources. I attended the seminar on routines based early intervention in XXXX.

I am a Director of an agency and we are discussing our roles as therapists and working towards shifting our thought process.

As we begin the shift of our staff "away" from bringing toys in - I was wondering if you had any resources or lists to help me with explaining the importance, and the role the therapy bag plays in the home? and the consequences? etc

any handouts? suggetions ? feedback?

example- parents WANT the providers who bring in the toy bags, not the ones who dont. "or" the therapists who "NEEDS" the items so they can have children learn skill or have they toys available

thank you for your help

Problems With the Toy Bag

There are two major problems with the toy bag. The first is that it sends a message to families that “your junk ain’t good enough.” Why else would we be bringing in other toys and materials. I recently conducted an RBI in which the mother told me that the home visitor brought toys that she already had in the home!

The second major problem, the really serious one, is that it implies that intervention occurs during the visit. If a home visitor gets down on the floor with the child and the toy bag an starts “working with” the child, it is not surprising that the parent would believe that the child is being taught. We have made the point in many places, including on this blog, that the purpose of weekly early intervention is not to teach children—that that is futile—but rather to provide caregivers with emotional, material, and informational support.

The persistent use of the toy bag thus leads to the attribution problem of parents’ attributing their children’s progress to weekly interactions with people outside the family instead of to ongoing interactions with regular caregivers. The consequences of parents’ making this erroneous attribution are obvious.

An indicator that the toy bag user him- or herself thinks that the intervention actually occurs during the visit is that they usually take the toys away at the end of the visit. If they believed that intervention is what happens between visits, they would leave the toys.

Another concern about the implication that intervention occurs during the visit is that so much of the visit is spent on triadic play among the home visitor, the child, and toys. Does anyone know of research that documents how much time families actually spend in such triadic play? I suspect it is a very small percentage of time.

So the staff in this program need to understand first how children learn (throughout days, not in lessons or sessions) and how services work (by supporting natural caregivers, not by working with the child weekly). Until they grasp those notions, they probably won’t understand what’s wrong with the toy bag.

Why do some parents want toy-bag-wielding home visitors? It’s because of the attribution problem. Once they are conditioned to believe that their child really needs direct, hands-on lessons with a teacher or sessions with a therapist, the empty-handed home visitor will look like a fisherman who forgot his pole, a carpenter without a saw, a plumber without a wrench—you get the idea. You probably also by now understand that early intervention is about teaching people to fish with their own poles, to make cabinets with their own saws, and to fix leaks with their own wrenches.

Some therapists say they need items. Hmmmm. What items are critical? Especially, what items are critical for supporting families to teach their children functional skills that the children need to participate in their routines? Surely nothing that comes out of a toy bag. After all, if the outcomes we’re working on are functional, that means we found out what the needs were in everyday contexts. We need to be working with the materials that are in those everyday contexts.

In addition to therapists or teachers saying they need items to do their home visiting job, other excuses for taking toy bags abound. One is that the toy bag items are for instruction; home stuff is for generalization. Another is that some homes have nothing (people in the U.S. actually say that with a straight face). Yet another is that parents want to see what their children might like. This is actually a reasonable reason to take toys—for children and families to try them out, but then leave them there for at least a week. Some fake interaction on a home visit doesn’t tell you whether the child will continue to be interested in the toy. These are mostly excuses that toy bag addicts make.

Yes, a number of experts in early intervention have identified the obsession with toy bags as an addiction! Some behaviors common to addicts will surface when toy bag addicts are told to stop taking them.

But program managers need to be prepared to ban toy bags, if they understand the points I’m making here. You can’t expect people to do something (or stop doing something) if you don’t tell them to do it (or stop doing it). The occasional bright home visitor will get it and abandon the toy bag as a result of training or reading or some other self-directed learning. But most addicts need to be told to stop.

The methadone treatment I suggest is a combination of the Routines-Based Interview and the Vanderbilt Home Visit Script. A future blog posting can address the VHVS, if there is interest. It was included in the training of the person who wrote me with this excellent question (at the beginning of this posting).

In conclusion then, (a) the staff need learn how children learn and how services work, (b) the program needs to ban toy bags (they are both symbolic and necessary for the propagation of atheoretical and nonempirical early intervention), and (d) the staff need to be trained to be support providers or consultants to the families. Only then will children get the amount and quality of early intervention they deserve, given the best available evidence.

What Kind of Strategies Should We Articulate on the Initial IFSP?

2007-09-03T14:15:00.000-07:00

What’s the Issue?

The issue in developing initial IFSPs is how detailed the strategies should be, considering we don’t know the child and family that well. In addition, many states are struggling to meet the 45-day limit, and the pressure to develop strategies can result in too much assessment too early in the process. At eligibility determination, for children with potential delays, the question to answer is in or out? Developing strategies requires answering the questions Why doesn’t the child perform the skill and What has the family already done? This entry addresses what the statute says about strategies on the IFSP, what kinds of guidelines states are providing, and what my recommendations are.

A related issue is, if strategies must be on the IFSP, according to State rules, what does it take to change them?

There is a question about whether strategies should be developed and inserted on the IFSP between outcome selection and the initiation of services. In states where strategies are required to be described on the form, this is the usual place in the process where that would happen.

Statute and Regulations
Although most states have a place for “strategies” or “action steps” on their recommended IFSP forms, in fact the law does not specify that such things are required on the IFSP. It says the following:

“(3) a statement of the measurable results or outcomes expected to be achieved for the infant or toddler and the family, including pre-literacy and language skills, as developmentally appropriate for the child, and the criteria, procedures, and timelines used to determine the degree to which progress toward achieving the results or outcomes is being made and whether modifications or revisions of the results or outcomes or services are necessary;

“(4) a statement of specific early intervention services based on peer-reviewed research, to the extent practicable, necessary to meet the unique needs of the infant or toddler and the family, including the frequency, intensity, and method of delivering services;

“(ii) Method means how a service is provided.”

“Procedures” and “method” can be location, model of service delivery (e.g., consultation, direct), and so on. Nowhere does the law stipulate that task analyses, specific activities, or even routines in which to intervene must be documented on the IFSP.

State Guidelines
If a form exists, with a space for documenting certain information, the rule or at least common wisdom is that that space must indeed contain information. Many states have therefore conditioned early interventionists, either by the form alone or by actual training, to insert strategies into the IFSP. For example, South Dakota implies that strategies must be on the IFSP, because it gives information about what to do when changing them ((http://www.doe.sd.gov/oess/Birthto3/word/APP_A_PAGE9.doc). A number of states imply that the IFSP must contain strategies by referring to linking “IFSP” and “strategies,” such as Florida’s policies: “Strategies on the IFSP indicate the activities that the family or caregivers will perform to support the child’s acquisition of basic skills needed to obtain the functional outcome and enhance development” ((http://www.doh.state.fl.us/AlternateSites/CMS-Kids/EarlySteps/EarlyStepsPolicy.pdf). Thes policies then do go on to refer to “initial strategies” that would be followed by “intervention activities and experiences that promote learning.” Vermont similarly discusses “IFSP strategies” (http://www.dcf.state.vt.us/cdd/pdfs/SPP_Part_C_12-02-05_Vermont_Final_R.pdf). Indiana discusses strategies that are “written into the IFSP” (http://www.in.gov/fssa/first_step/July2006_Best_Practice.html and http://www.firststepssoutheast.org/forms/bestpractices.pdf). Virginia similarly implies strategies on the IFSP but does acknowledge that “there may be more frequent changes in strategies as the Part C provider continues learning about the activity settings, routine…” (http://www.infantva.org/documents/pr-OrientationToPartC.pdf). Kentucky identifies assisting the team in developing strategies as a service coordination rule during the IFSP meeting (http://chfs.ky.gov/NR/rdonlyres/CA59E944-9947-415E-A83C-6545DB3BA09A/0/RES12PSCResponsibilitiesChecklist.pdf). Maine also mentions strategies in the context of this meeting (http://www.maine.gov/education/speced/cds/plan/cds_plan_submitted113005.pdf). Missouri, however, correctly points out, “Strategies/activities are optional” (http://dese.tekdevelopment.com/422.html).

Recommendations
Consider how much information we have about the child’s functioning at the conclusion of outcome selection. Theoretically, we know there are concerns (intake), we know the child is eligible, we know what the child’s performance is like during routines (assuming a decent needs assessment, such as a Routines-Based InterviewTM, has been conducted), and we know what the family wants as outcomes. What we probably do not know is (a) why the child is unable to do things the family has reported on during assessment and (b) what strategies the family has tried. For practical reasons—and in compliance with the federal law, for initial IFSPs, I recommend the following.

Eliminate strategies from the form, leave that space empty, or put in minimal information (e.g., “emotional, material, and informational support). Expecting evaluators to capture enough child-functioning information to recommend strategies is asking much of them, considering the 45-day rush. Let them conduct their functional assessments once the rush to get the child in services is over. The assessments will be more valid.
If it would be helpful to have further information, put in “consultation from ____.” Avoid “assessment from ____” to avoid having to get signed permission and having to write an assessment report.
Once services have begun, obtain the consultation to understand why the child needs help and to receive suggestions about intervention.
Develop strategies on the basis of input from any further assessment or consultation (i.e., those that occurred after the child was in services).
Change strategies as needed, without reconvening the IFSP team or calling official meetings.

Should Strategies Be Documented?
Probably, but not on the official document, which unnecessarily burdens the team trying to meet the 45-day deadline. Functional, family-centered, routines-based strategies could be manifold and dynamic, so capturing them on paper might be problematic. Remember, the law does not require them.

Old Blog Entries

2007-09-03T14:13:00.001-07:00

The following entries were copied from the previous blog, which went belly up.

· Deciding on the Primary Service Provider
Wednesday, June 20, 2007 at 3:15 PM CDT
In our model of early intervention in natural environments, we have developed the concept of the "most likely primary service provider" (MLPSP). This is the service provider who participates in the development of the initial IFSP, in situations where dedicated service coordinators are used. The purposes of designating an MLPSP are (a) to establish continuity between needs assessment and service provision and (b) to help the service coordinator (who might not have a background in intervention). Even if a community does not use the primary-service-provider (PSP) approach--also known as the transdisciplinary approach--it is useful to involve a "most likely service provider." This designation ("most likely") is used because, technically, no service provider is selected before outcomes have been decided. Theoretically, it's possible the ML(P)SP could be different, once outcomes have been established. Usually, this doesn't happen; the whole point is to have continuity, so you have to do a decent job of selecting the ML(P)SP.
The following question has come up: I have a question about assigning the most likely service provider so that they can participate from the "get-go" in the RBI...how do most state's select the person...especially if there are various options. really want to see our state get to this but do not know how the service coordinator determines this prior to the RBI and outcomes being selected.
In states where they have a history of independent vendors competing for kids it’s different from states where they have a history of cooperation, so it varies. In the former, I have helped states develop local interagency agreements about processes for making the decision, which might involve taking into consideration types of children, “openings,” taking turns, geography, individual-provider compatibility with the family (e.g., language spoken). If the competitors overlap in types of children and geography, then who has openings and taking turns becomes important. We have required the point of entry to document what they do with each referral, so, when an agency feels dissed, they can point to the data to show that they took turns, inquired about openings, made a decision based on personal compatibility, and so on.
It's a good question, and the answer lies in local interagency coordination, especially between the single point of entry or service coordination office and the providers. Having a transparent process and data about how the process is being implemented are the keys to implementation.
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· What's Functional About Blowing Bubbles?
Tuesday, May 29, 2007 at 5:46 AM CDT
The following question was recently posed to me:
I am a speech/language pathologist, working within poorer SES Latin communities. It is difficult to work on outcomes related to feeding, without materials (ie: bubbles, special spoons, cups, etc.). How do you propose this gets done? See, this is the piece I'm still puzzled about. I need to be given SOLID examples of providers in my "shoes" so to speak, who are utilizing this approach. For now, I still feel that in some aspects I need the "Therapy Bag". I don't know if you are given this type of feedback but I'd appreciate a response.
To a certain extent, I am teaching parents and caregivers in our FT (Family Training) Sessions; however, the Speech therapy sessons (ST), I still tend to use my own materials, as many o the families don't have the materials. However, I often give out small bubble tumblers (no charge) that cost say $2 and change in Target, so this way the families can practice "blowing bubbles" to improve speech production, if the outcome is "Johnny will say more words, to indicate his needs.
My response:
I think I see a fundamental issue in your questions--it's the definition of functionality. When you say, "It is difficult to work on outcomes related to feeding, without materials (ie: bubbles, special spoons, cups, etc.)," it's not clear that feeding itself is what's being worked on. In a functional approach, the special spoons or cups might indeed be used--assuming they would be left with the family, so the child could actually use them in daily feeding and drinking. Bubbles are another story! You can save your money, even though it’s nice of you to leave them in the homes. Bubble blowing is almost never a functional skill in early intervention and will not help “Johnny say more words.” Children do not need to blow bubbles to be able to eat or to talk. That’s a fact. Kids in early intervention are often taught bubble blowing and blowing through straws, although I have never come across these as functional needs.
The solid examples that might help are the strategies that would come from specific, measurable, functional outcomes. I will pull some feeding and language ones from real Routines-Based Interviews.
(Unfortunately, tables don't reproduce properly on blogsource. The next section was a table, with RBI Outcome, Measurable outcome, and Strategies as the column headings. There are four outcomes.)
RBI Outcome
Measurable outcome
Strategies
Miracle communicate with others in the family at play time
Miracle will participate in play time by communicating with others in the family. We will know she can do this when she says or signs five things to someone in the family at play time every day for three consecutive days
1. Assess Miracle’s interests
2. Teach parents to get Miracle engaged
3. Teach parents to join Miracle in what she is interested in
4. Teach parents to elicit words related to Miracle’s engagement (e.g., names of toys, actions, “more,” “finished,” “mine,” “yours”)
5. Have parents decide on 10 target words
6. Teach parents to emphasize these words when following Miracle’s cues at play time
Eat meals by mouth to be able to eat with the rest of the family; increase variety of foods
Miracle will participate in family meals by eating by mouth. We will know she can do this when she eats ½ cup of pureed food, ½ cup of soft foods, and ½ cup of chewable foods in 1 week for three consecutive weeks.
1. Assess Miracle’s tolerance for pureed foods—how much can she currently eat?
2. Decide on a rate of increase (e.g., increase by 1 tablespoon) and increase only when Miracle eats three consecutive meals at that criterion.
3. After ½ cup of pureed is achieved, introduce soft foods at the rate of 1 tablespoon at a time; follow the increase rate as above until she eats three consecutive meals of ½ cup of soft foods.
4. Follow Step 3 with chewable foods.
5. When switching from one consistency to the next, continue to give some meals with the previous consistencies.
6. Your job is to coach the family through these steps.
Communicate his needs (drink, don’t feel well, eat, more, play, TV, outside)
Child will participate in meals, indoor play, TV times, and outside play, by communicating. We will know he can do this when he makes 3 requests or answers 6 questions in each of the above situations (i.e., routines) on three consecutive days.
1. Teach parents to use incidental teaching, as described for Miracle in the first outcome—getting the child engaged, following the child’s lead, and eliciting elaboration.
2. On home visits, watch the parent doing this, giving data-based feedback, to increase the parent’s competence and confidence.
Eating with combination of textures; vegetables, fruits
Child will participate in meals by eating combinations of textures, including vegetables and fruits. We will know he can do this when he eats 1 cup with one soft and one chewable food during three meals in three days.
1. Assess with the parent the child’s food preferences for soft and chewable foods.
2. Teach the parent to shape up the eating behavior by gradually (over days) increasing the amount of mixed-texture food.
3. Teach the parents to keep track of how much of which kind of food the child eats.
Obviously, some more specific suggestions would enter into the parent-professional conversation, but these plans would keep the conversation focused on the needs the parent expressed.
I was being only somewhat facetious when I referred to the addiction to the toy or therapy bag. One of the ways we know it’s an addiction is because people (a) don’t believe it’s an addiction, thus proving them to be addicts; and (b) cannot see the fallacy in their arguments for continuing the use of the bag, thus operating “in denial.” To summarize the problems with the bag:
1. Most items are taken out of the home, thus preventing the child from learning from them;
2. Use of the bag reinforces in parents the idea that there is something magical about the professional-child interaction, when, in fact that interaction is not that important;
3. It implies that the family’s junk isn’t good enough; and
4. Joint toy play, which describes a lot of toy bag activities, constitutes a very small percentage of families’ natural interactions with the children, thus rendering it largely irrelevant.
I hope this helps a little. Remember that functional outcomes come from functional needs, which can only be assessed by asking the family about needs in daily routines. If you do that functional, family-centered needs assessment—the RBI—you will have functional things to work on with the family—a good long list of items. Your visits with the families will fly by.

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· 8 Problems With Some State Systems
Monday, April 16, 2007 at 7:52 AM CDT
1. Too many people involved in the IFSP development process and in service delivery (e.g., intake service coordinator, two or more evaluators, ongoing service coordinator, three or four providers--all these being different people)
2. No family outcomes on the IFSP!
3. Vague, incomplete child outcomes (e.g., two or three general outcomes, usually about movement and communication)
4. Disjointed providers--early interventionists on the IFSP who do not communicate with each other, usually because they are each employed by a different agency or are self-employed
5. Too much family time spent in receiving services, which is time that could be spent in interactions with the child, working, and so on
6. Overtesting of kids, especially those entering early intervention with an established condition (i.e., "medical diagnosis") who therefore do not need scores for determining eligibility
7. Misunderstanding of requirements for assessment of present level of performance (i.e., current level of functioning)--when do we need scores and when do we need descriptions?
8. Lack of family needs assessment (i.e., functional needs the child and family might have)
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· "Robin McWilliam says...": Service intensity
Friday, February 23, 2007 at 1:44 PM CST
At first, I used to be flattered when I heard I was being quoted. Now, I get nervous.
I occasionally hear that I am quoted by program administrators in a dispute with families about the amount of service the family should receive. Just today, for example, I spoke to an advocate who knew of a young child with apraxia and another with autism who had been told that Robin McWilliam says that one hour a week of early intervention is sufficient, or something to that effect.
First, in this case, the diagnoses of the children were apparently salient information. To some extent, this might be true, but we know that children with most diagnoses, including autism, are more alike other children than different from them. But some people (e.g., specialists, researchers, parents) have a lot to gain, in some cases literally (i.e., $$$), by emphasizing the diagnosis and the differences. This can lead to the establishment of separate programs, segregation of the children, false information to families, and syphoning of resources from other children and families. It can also lead to focused attention on discovery and treatment--a good thing. I do believe, however, that children and families have more to gain by emphasizing similarities with other children, including children without disabilities, than by emphasizing differences.
Second, the hours of service is really not what matters. It's the amount of intervention. In our work, we make this point over and over. Children should have the best quality intervention and should have the most they can get. The best quality intervention for young children means that it (a) is in the context where the child needs it; (b) promotes the child's engagement, independence, or social relationships; and (c) involves elaboration of the child's interest or engagement. They will get plenty of intervention because of (a): It should be woven throughout the fabric of the child's everyday life--or at least on those wefts where it's needed. Clearly, then, this intervention must come from the child's natural caregivers, who are usually parents and other caregivers (e.g., child care providers). Service is professional activity--the people who come in from outside the home or child care setting. It will no doubt be obvious that increasing the amount of time a professional shows up will have little effect on the quality or amount of intervention the child receives.
But perhaps it has some effect, and this is where the challenge of the child's disability might play a role. Providing many children with developmental support with the kind of incidental teaching I described above might not require a lot of professional time. If the child's behavior is under control, if the child's communication development is simply delayed, if the caregivers understand how to tweak their routines to help the child developmentally, and if the caregivers have the emotional and physical stamina to keep at it, a modest amount of support from a professional might be enough. "Enough" means that increases over a given amount of service would not result in a substantial increase in the amount of intervention.
I will soon post here guidelines for deciding on amounts of service. In the meantime, if you hear "Robin McWilliam says...," make sure it really is what I'm saying and not some convenient interpretation.
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· Where is the Family During Therapy?
Thursday, December 28, 2006 at 10:11 AM CST
In a broadcast of an often-repeated documentary about Treacher Collins syndrome, Juliana Wetmore's mother is driving Juliana to therapy. The first questions might be Why are they having to go to therapy rather than the therapists coming to the home? Did the family get a choice? But we'll move on to the more troubling questions. Juliana's mother says that Juliana likes speech therapy and physical therapy--they are like play time for her. Not everyone might agree, but I'm thinking this is sounding good so far. Juliana was still a toddler. But then her mother says that Juliana does really well in therapy but hasn't done those things for her. Red flags! We then see Juliana sitting at a little table across from a speech-language pathologist, who is getting her to sign and put puzzle pieces in the puzzle. It's good that she's getting functional communication: Juliana essentially has no mouth but does have intact use of her hands. A toddler sitting at a table might be developmentally weird, but in the grand scheme of things.... We see Juliana in physical therapy, which is focused on her walking--again, this is functional.
But here's the kicker: There's no sign of her mother anywhere during either therapy session. Putting 2 and 2 together...
(1) Julina's mother cannot get Juliana to do things that nonfamily members can +
(2) these things are done in a context that is only relevant for therapy (i.e., it is not where daily routines or significant events happen) +
(3) her mother is not present to learn how to elicit these behaviors in relevant contexts +
(4) Juliana is not old enough to be able to transfer the skills on her own (see No. 1 above as evidence).
(5) Therefore, this therapy is nonfunctional.Does it really matter that it is logically nonfunctional? After all, it is fun, and perhaps Juliana's mother feels that she has some control over her child's developmental progress because she takes her to therapy. But that's one of the problems. Her mother has been led to believe that Juliana is benefiting from this therapy. It is clear in the documentary that the parents do a lot for Juliana and her sister, which actually probably confuses the evaluation of the efficacy of therapy. Juliana is making progress, so everyone might be attributing this to the therapy. Research that Gloria Harbin and I have done on service utilization included this kind of attributional finding. My problem with leading parents to this attribution is that it is misleading them. Children of Juliana's age would be making progress because of the learning opportunities provided in the hundreds of interactions in her daily life, not because of isolated, decontextualized sessions with therapists, however fun and "functional" they might be. The reason we would know that the daily "incidental teaching" is working more than the therapy is that the mother has seen progress but has not seen Juliana do the things they are working on in therapy. One can only wonder how much better off Juliana would be if the well-meaning therapists concentrated on the mother rather than on Juliana.
More disturbing in the big picture is the fact that families see this otherwise inspiring documentary and get the wrong idea about how children learn and how therapy works.
On the other hand, an inspiring story appeared recently in the New York Times. The headline is "Parenting as Therapy for Child's Mental Disorders," by Benedict Carey. The report is about a successful parent education approach to treating children with ADHD. The family is central to therapy.
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· "Direct" versus "consulation"
Tuesday, December 12, 2006 at 10:08 PM CST
I have confused the field by teaching that the consultative model is effective, which has led to people putting "consultation" or "consultative" on the service sheets on IFSPs and IEPs. This has provoked reactions by some professionals and families alike that direct services are preferable to consultation. Clarification is needed.
When using an evidence-based, integrated approach to serving children in classroom programs, I recommend you define this as direct services. Such an approach would be individualized within routines or group activity (see www.IndividualizingInclusion.us), where visitors to the classroom (e.g., itinerant early interventionists or ECSE teachers or therapists) work in the classroom and do not pull children out. Their role is consultative in the sense that their major responsibility is to collaborate with the classroom staff to increase the likelihood that the staff will implement individualized interventions throughout the day. The visitor to the classroom is indeed a consultant. Yet, an integrated approach can be considered a direct service for two reasons: (a) the visitor to the classroom will have hands-on contact with children for the purpose of demonstration, and (b) an effective evidence-based approach should be reimbursed at a higher level than any other approach would be.
The problem has been that the terms "direct" and "consultative" have been applied to intensity instead of to model of service delivery, and direct services have been reimbursed at a higher rate. Therefore, "direct" is considered ongoing and frequent, and "consultative" is considered infrequent. However, integrated approaches should be frequent, to ensure that teachers have enough collaboration to help them be effective individualizers.
So, although the model is considered consultative, the bureaucratic designation should be direct, assuming this guidance is consistent with local or state definitions of these terms.
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· The RBI and Ecocultural Theory
Wednesday, November 29, 2006 at 8:48 AM CST
An anthropologist I highly respect, Tom Weisner (UCLA), and I have been engaged in parallel play. I have known his work for years, and we have met a couple of times. With Cindy Bernheimer, a former Chair of the DEC Research Committee, and other colleagues, Weisner has studied families from an ecocultural perspective. I strongly encourage you to read his work but especially
Weisner, T. S. (2002). Ecocultural understanding of children's developmental pathways. Human Development, 45, 275-281.The following points will show the parallels in our work.
1. Weisner describes ecocultural theory as being "based on the idea of locally rational action.... The 'local situation' consists of everyday routines and activities" (p. 277), and people use their schemas and what anthropologists call shared knowledge to make adaptations in their daily routines--adaptations that work for them and allow them to survive. These adaptations influence children's development.
2. Cultural pathways for children's development, according to Weisner, "are made up of everyday routines of life, and routines are made up of cultural activities (bedtime, playing video games, homework, watching TV..." (p. 276). Obviously, therefore, the Routines-Based Interview, which my colleagues and I developed in the 1980s (see McWilliam, 1992) is relevant for understanding children's cultural pathways.
3. Weisner points out that the single most important thing one can do to influence the development of an intact infant "would be to decide where on earth--in what human community--that infant is going to grow up" (p. 276). How families carry out their routines will vary individually but will have some commonalities within the region of the world, country, or city where they are situated. The cultural pathways for the infant are, to some extent, determined by how families in that place conduct their routines.
4. The behaviorist in me concurs strongly with Weisner's assertion that developmentalists should think about children "as already situated in some human community" (p. 277)--that would bring culture into developmental research. Context, also called the ecology, are vital for understanding children's development and behavior.
5. The Ecocultural Family Interview (EFI) was developed in the 1990s to collect data on children and families in their daily routines (Weisner, Bernheimer, & Coots, 1997), and the RBI was developed for more or less the same reason but for a clinical application--to give families a framework for selecting intervention goals. The EFI is "one way to enter children's and families' cultural pathways [by asking] parents and children directly about their daily routines and activities" (p. 277). Just like the RBI, "the EFI is an open-ended, semistructured conversation that covers a broad range of topics related to a family's daily routines" (p. 277). The latest published description of the RBI, for comparison, is in McWilliam, R. A. (2005). Assessing the resource needs of families in the context of early intervention. In M. J. Guralnick (Ed.), A developmental systems approach to early intervention (pp. 215-234). Baltimore, MD: Paul H. Brookes Publishing Co.Weisner, with the EFI, has had a similar experience to ours with the RBI: "Parents sometimes see this as a chance for a 'life review', or at least 'multiple-week review', encouraging them to reflect on what they are doing and where they are going" (p. 278). First, families have said about the RBI things like, "This was a life-changing experience." Second, the reflection on where they are going is consistent with the goal-planning purpose of the RBI.
6. Professionals who are used to assessment being entirely driven by the professional evaluator become concerned at the lack of apparent comprehensiveness of the RBI. Weisner points out that "there are no 'false negatives' in the EFI data" (p. 278), because the interviewer asks about important topics. That is also true in the RBI. That doesn't mean that every detail will be uncovered, but of course traditional structured assessment also covers only those items the developers thought to include on the test. But the RBI, like the EFI, is structured enough to ascertain the information for which the interview was designed. The EFI covers for each routine the script for the activity, feelings and motives, goals/values, people who are or should be involved, and the tasks to get done. The RBI covers for each routine what everyone is doing, what the child is doing, how the child is engaged, how independent the child is, what social-relationships behaviors the child displays, and how satisfied the parents are with the routine.
7. The EFI includes scores, which the RBI does only for satisfaction with home routines and goodness of fit of classroom routines. With the EFI, the interviewer scores items "describing the family routine and how it gets created and sustained" (p. 278). The UCLA researchers have attained reasonable interrater agreement on those scores. I have been contemplating a scoring system for the RBI, beyond the one per routine we currently have. It would add to the reliability of the longitudinal data.
8. The final serendipitous connection between Weisner's work and ours is about child engagement. Weisner writes, "Ecocultural theory is based on the idea that children's engagement in more sustainable routines and activities is good for children, and produces well-being, ...[which] consists of engaged participation in cultural activities deemed desirable by a cultural community... and the psychological experiences produced thereby" (p. 279). Our research on engagement has influenced the structure of the RBI, and what I have come to call "engagement theory" is central to our research, training, and service. It is consistent also with the World Health Organization's notion that "participation" (similar to engagement) is the critical dimension of successful functioning.
If our work and Weisner's are indeed as well connected as it appears, it is very gratifying for us to be in such worthy company. More importantly, from an epistemological, methodological, and conceptual standpoint, it is perhaps not coincidental that well-conceived practices that begin in ostensibly disconnected places, disciplines, and research groups will eventually find their "points of validation"--a term I'll use to claim that our RBI must be good if it's so similar to Weisner's EFI.
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· What the law says about where outcomes should come from
Wednesday, November 15, 2006 at 5:33 PM CST
IDEA does not specify where anticipated results or outcomes (i.e., individualized goals) on the IFSP should come from.I have been looking for guidance in the law about where individualized outcomes on the IFSP should come from. My reading of the statute provides no answer to this question. The outcomes do not have to come from the multidisciplinary assessment nor from the CPR. Unfortunately, however, links between the child assessment and services and between the family assessment and services are made. They should have made it clear that the outcomes come between assessment and services.
Here’s the part of 108-446 I’m referring to:
‘‘SEC. 636. INDIVIDUALIZED FAMILY SERVICE PLAN.
‘‘(a) ASSESSMENT AND PROGRAM DEVELOPMENT.—A statewide system described in section 633 shall provide, at a minimum, for each infant or toddler with a disability, and the infant’s or toddler’s family, to receive—
‘‘(1) a multidisciplinary assessment of the unique strengths and needs of the infant or toddler and the identification of services appropriate to meet such needs;
‘‘(2) a family-directed assessment of the resources, priorities, and concerns of the family and the identification of the
supports and services necessary to enhance the family’s capacity to meet the developmental needs of the infant or toddler; and
‘‘(3) a written individualized family service plan developed by a multidisciplinary team, including the parents, as required by subsection (e), including a description of the appropriate transition services for the infant or toddler.
‘‘(b) PERIODIC REVIEW.—The individualized family service plan shall be evaluated once a year and the family shall be provided a review of the plan at 6-month intervals (or more often where appropriate based on infant or toddler and family needs).
‘‘(c) PROMPTNESS AFTER ASSESSMENT.—The individualized family service plan shall be developed within a reasonable time after the assessment required by subsection (a)(1) is completed. With the parents’ consent, early intervention services may commence prior to the completion of the assessment.
‘‘(d) CONTENT OF PLAN.—The individualized family service plan shall be in writing and contain—
‘‘(1) a statement of the infant’s or toddler’s present levels of physical development, cognitive development, communication development, social or emotional development, and adaptive development, based on objective criteria;
‘‘(2) a statement of the family’s resources, priorities, and concerns relating to enhancing the development of the family’s infant or toddler with a disability;
‘‘(3) a statement of the measurable results or outcomes expected to be achieved for the infant or toddler and the family,
including pre-literacy and language skills, as developmentally appropriate for the child, and the criteria, procedures, and timelines used to determine the degree to which progress toward achieving the results or outcomes is being made and whether modifications or revisions of the results or outcomes or services are necessary;
‘‘(4) a statement of specific early intervention services based on peer-reviewed research, to the extent practicable, necessary to meet the unique needs of the infant or toddler and the family, including the frequency, intensity, and method of delivering services;
I’m looking at this now because I’m helping a number of states and programs figure out how to insert a routines-based needs assessment into their IFSP development process. In our legalistic, accountability-driven atmosphere, people want to know what’s required—what the law says. I knew the law didn’t mandate a functional needs assessment, but I wanted to make sure I knew about any actual or inferred links from the outcomes back to any earlier step (e.g., formal assessment for eligibility or the multidisciplinary assessment that all kids are offered). My recommendation to programs and states is, for children coming in under possible delay, either test them first and then do an RBI, which produces the outcomes (goals), or score a test during the RBI, if the child is highly likely to be delayed and if the test is pretty functional. For children coming in under established condition, just do an RBI, which produces information on current levels of functioning in the five domains, so you can count that as the multidisciplinary assessment (as long as you have indeed involved two people from different disciplines somewhere along the way) and it gives you the outcomes.
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· Three-tiered model applied to early intervention?
Friday, October 27, 2006 at 10:01 AM CDT
Could we incorporate prevention and response-to-intervention models into early intervention?
A doctoral student at the University of Wisconsin--Madison and I are writing a chapter for the next edition of Best Practices in School Psychology, in which we pose the possibility that the three-tier model should be applied to home visiting practices and possibly other practices in early intervention. The three-tier model is ubiquitous in school psychology now and is alluded to (perhaps even directly referred to) in IDEA 2004, with the response-to-intervention (RTI) language. The tiers are (1) universal or preventive services, (2) problem-focused services, and (3) highly specialized services. The expectation is that Level 1 is received by the vast majority of students, Level 2 by a small percentage of students (e.g., 5-15%), and Level 3 by a very small percentage (e.g., < 5%).
This doesn't fit perfectly into early intervention, because infants and toddlers don't get services unless something's wrong--or unless they are in child care. Preschoolers might be in some group care setting where they could receive preventive (AKA preventative) services. But let's focus this discussion on families receiving home-based early intervention, which is over 70% of the families in Part C. What's the universal intervention they receive?
Parenting in regular routines in the home and community. Where early intervention is different from services for school-aged children is that, without the specialized services (e.g., special education), school-aged children still get some service (i.e., regular education), whereas, without specialized services (i.e., early intervention), infants and toddlers get no service. But do they get nothing?
Of course not. They get parenting, which is the most effective intervention of all (see the NICHD Early Child Care research). But we cannot for legal and moral reasons not provide families with support when they are eligible for early intervention and want it. Therefore, my thought is that we enter the family's life at Level or Tier 2, but then the focus of that level of specialized services should be to support Level 1 interventions. This should address both child and family ultimate or distal outcomes. By that, I mean children should make progress in their functioning and families should increase their quality of life. In future posts, I'll elaborate on that connection, but the main point here is that the application of the three-tiered model in early intervention should possibly be to apply specialized services (Level 2) to enhance the effectiveness of interventions delivered by parents and other natural caregivers of the child (Level 1).
What about Level 3? Those are the few services that need to be employed to meet needs that this support-based approach cannot meet. Some of them will be child-level services, and some will be family-level services. The former would include medical or allied-health services such as orthopedics, audiology, or other medical specialties, but not OT, PT, and speech. Those developmental therapies would, like special instruction or early childhood special education, be used to enhance regular caregivers' capacity. There is no need for direct hands-on by the big four (OT, PT, SLP, ECSE). The family-level services that might be needed to supplement the support-based approach might be in the counseling arena, if the family needs professional-level counseling or therapy, or in the "social work" or "service coordination" arena, if the family needs more help in securing resources than even a good home visitor can manage.
Be careful, though. Home visitors who believe their job is purely related to children's performance might eschew family support and attempt to refer to Level 3 too early. This might be where the RTI approach should come in. Perhaps the system should require that some level of intervention be tried at Level 2, especially around the emotional needs of the family, before approving the use of Level 3. Families can, of course, privately gain access to any level of service they choose. To use this three-tier model effectively, Level 2 service providers need to be trained in the support-based approach, which would include training on when to refer and when not to.
The three-tier model is not a perfect fit for early intervention, but it does provide a framework for encouraging the use of natural family and community assets (Level 1), which is desperately needed because of the field's pernicious slide towards overspecialization.
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· DEC Conference
Sunday, October 22, 2006 at 10:49 PM CDT
The annual DEC conference in Little Rock was a good opportunity to catch up with old friends such as Don Bailey, Mary Beth Bruder, Gloria Harbin, Lee Ann Jung, Beth Rous, Sharon Walsh, and Barb Wolfe. I also had the chance to see briefly a number of other friends and former students. Here are some of my highlights from the conference, bearing in mind that I could be in only one place at a time, and had meetings during sessions.
· The keynote included a wise and pointed speech by my friend Mark Wolery on the topic of using recommending practices. It also included a hilarious movie assembled by Larry Edelman.
· Before the conference, Ann Turnbull ran the second meeting of the Family Community of Practice, which was the Family Summit at the first meeting in January. The focus of this meeting was how to get supports to families that they currently are not getting. A session later in the conference provided Ann the opportunity to tell others what is going on with this community of practice. In future entries, I will talk more about this issue and about two important innovations I have been thinking about: an application of the three-tier approach and learning from multisystemic therapy.
· A meeting with Heather Shrestha of Paul H. Brookes Publishing Company about a book Amy Casey and I have written on engagement. This book will come out in 2007.
· DEC is revising the Recommended Practices, and roundtables were held to get people's input into the issues addressed by each of the strands. My strand is "interdisciplinary models," which first needs to change its title. I doubt anyone realizes this is about working with teams comprised of people from different disciplines.
· Amy and I had two posters, one on the Engagement Classroom Study we are currently undertaking and one on the preliminary study we did on the Routines-Based Interview. Many people stopped by, and Amy handled the questions in her usual admirable way.
· I attended an introductory session by Robyn Ridgely on home visiting, which she handled deftly, including questions about whether talking to families about their outcomes was a fraudulent way of providing therapy.
The DEC conference is the best all-around forum for discussion of early intervention and early childhood special education. Most of the major players in the field serve their profession by going, there are plenty of sessions for practitioners, families can absorb much information and impart suggestions, and researchers continue to contribute.
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Welcome to Relocated Blog

2007-08-24T11:15:00.000-07:00

This blog addresses issues about the provision of early intervention supports for infants and toddlers with disabilities and their families. The posts will deal with methods for implementing early intervention in a family-centered, normalizing, and evidence-based manner. You can read about the model at www.VanderbiltChildrens.com/earlyintervention. This blog takes off where an initial one, at www.earlyintervention.blogsource.com left off; that blogging service is shutting down.