How to Impress Families

A former student has written to me with two related issues. First, one mother she works with said she was glad “Lori” was making home visits over the holidays, “Since I was a little concerned that E. was not connecting to you as much as [the speech-language pathologist and the occupational therapist].” Lori said this made her question whether she’s missing something in her approach. “Is it wrong for me to not have that strong connection and bond with the child that I would get if I spent more time in direction interaction with him?”

Second, Lori was working successfully with a family, until a speech-language pathologist was brought on. The mother started questioning Lori’s approach. Lori wrote, “She told me the SLP brought such great toys and worked at the table with the child, getting him to do so many things. That approach is less work for the family and more impressive to have the ‘professional’ come in and work with the child.

In both situations, the mothers appear to want child-centered therapy. They have been seduced by professionals who form strong attachments to the child (or vice versa) and who sit down and do direct, hands-on intervention with the child. Those appear to be ways to impress families. Here was my answer to Lori.

Your question is familiar but not easy to resolve. First, we have an ethical obligation to give families information, including the information that it’s not what a professional does on weekly visits that improves a child’s learning and development but what the natural caregivers do throughout the day. It is not being unprofessional to put down the other professionals’ approach (although you shouldn’t do it in a put-down way); it is being ethical. Second, your relationship with the child is pretty much irrelevant to the process. I’ve always said there are three reasons for putting your hands on the child, and one of them is to show you love the child. But that’s just something to help build the relationship with the parents. Again, the ethical thing is for you to explain to that parent that how the child feels about you is actually not important. You are there to make sure that the parent enjoys—and teaches—the child. Third, it sounds as though you are in a vendor, competitive environment where, possibly, you can’t lose families or don’t want bad things to get back to the referral source (the service coordinator?). This is unfortunate and one of the deadly things about the vendor system in early intervention, because, if you have given a family the information about how children learn and how services work, and they are still seduced by the child-centered approach, you should offer to back out. Usually, one of our rationales is that there are plenty of other families needing our help. But in your market, that might not be true. You can see that I believe we should (a) give families the truthful information, (b) not cave and do useless things, and (c) not cross the line from giving information to trying to convince. When parents argue for a more hands-on approach by the professional, one line I’ve used with some but not total success is, “Your child deserves so much more than that.”

Being family centered does not mean pretending that families know better than we do how early intervention works. Remember that families are easily seduced by quick fixes, technology, and magical thinking. It’s not very sexy for some families to think that the day-to-day interactions in ordinary activities of daily living, like playing, reading, going for a walk, hanging out, having meals, toileting, and so on, are the crucibles of teaching and learning. Our role can be the healer, such as you find in the medical world, or the coach—and think here of life coach or executive coach. Those coaches don’t do things FOR their clients: They prepare their clients to handle situations. Healers lay hands on the patient, while the family observes (and prays!). The healing looks mystical, mysterious, and is of course mythological. In early childhood, it also looks fun: The kid is having a blast with the toys and other gizmos the professional brings into the home. We can think about this bounty in one of two ways. First, we could get a 17-year-old babysitter to come with new and interesting stuff and we’d be doing just as much good. Second, we could turn early intervention into a sort of mobile Target, where we introduce fun objects to children in their homes. A third way of thinking might be: I have to get this kid to do stuff with me because I believe I am effective on my hourly visits, so I’m going to take in materials to get him or her interested in me. I haven’t even addressed the ludicrousness of then removing those objects at the end of the visit; that’s so obvious that it’s amazing parents don’t see said absurdity.

Families usually are doing their best for their children, so it’s a real shame when professionals undermine their work by altering their thinking about how children learn. As you can see, my thoughts don’t give you an easy solution, but I hope they keep you strong in doing the right thing and give you the freedom to walk away if the parents don’t like your approach. In my home-visiting program, where we see 150 families at any one time, we hardly ever have families wanting to “fire” us for not being more hands-on—and we have the same situation as you do: therapists using a radically different approach from ours.

My granddaughter, Tinsley, counting carrots to leave for  Santa's reindeer. Nothing to do with the post!

Out of Clinics Into Natural Environments

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

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

Here are some points about clinic-based services.

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

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

When Do You Demonstrate Something on a Home Visit?

It has always been my understanding that modeling for the parent is an appropriate first step, followed by giving the reins to the parent- am I missing something? 

 Modeling for the family is an appropriate SECOND step. First, we talk, then we offer to demonstrate. If, instead of modeling, we can talk the parent through the intervention, that's even better. But sometimes demonstration is called for.

One of parents' biggest complaints across the board continues to be too much “talk” and not enough modeling.

 When parents say there's too much talk and not enough action, this could be because they expect us to have our hands on the child (i.e., they have wrong expectations about what home visiting should be--not their fault) or because indeed the home visitor is too passive and doesn't get down to brass tacks. Many home visitors implementing the RBEI (or "Unified") model let the pendulum swing too far to the consultative end, because their natural tendency is to be the expert. If the pendulum has swung to an extreme, they simply are not being helpful enough. There are, in this world, some home visitors who simply can't, along with the parents, come up with some strategies for addressing a problem. Either they were so used to doing dumb activities (e.g., from the toy bag, from some curriculum) that, without that crutch, they don't know what to do or they just don't have ideas. 

 Most parents seem to learn best  from a visual demonstration by the service provider, followed by the coaching piece as the parent works with his/ her child.

 Most parents have probably not received top-notch family consultation, which would be the home visitor's talking the family through the intervention, with the family doing the intervention. It's like my fly-fishing guide. He did indeed show me how to cast, on land, with no fly on the end of the line, so I'd see the correct movement. But very quickly he put the rod in my hand and gave me feedback on my attempts. Once we were in the water, he NEVER cast the line, because he was afraid of catching a fish. If he'd caught a fish, he believed he would have made me feel bad. Not true, but that's the way fishing guides in New Zealand are conditioned. You can see the parallel with home visitors: We don't want kids doing well with us. So the majority of the support is giving feedback and telling the learner how to make corrections.

I'd put outright demonstration as something we resort to, not something we begin with. Also, don't assume that what families tell you is the best way to go. Under the principle of the uninformed consumer (from marketing), if a person hasn't tried X but has tried Y, she will say Y is better. Hence, we need to make sure families experience good family consultation.

Is an Ecomap a Prerequisite?

Some people think you have to complete an ecomap before conducting a successful Routines-Based Interview^TM. Although it might be helpful to do so, actually an ecomap isn’t a prerequisite to an RBI. The real value of the ecomap is during solution finding or problem solving in family consultation. Family consultation is the key ingredient in support-based home visits. When working with a family to find a solution for addressing an outcome, the early interventionist should ask the family to consider whether anyone in their support system, as depicted on an ecomap, might be able to help.

But to do an RBI, the only part of the ecomap you really need is the inside box: who lives in the home. 

In the RBI Certification Institute, we train people to complete an ecomap before the RBI, principally to imbue them with this extra skill. In service delivery, the ecomap can be done at an earlier visit than that in which the RBI is conducted. Some professionals complete it at the intake visit. It is possible although not desirable to have different people complete the ecomap and an RBI. As with all other parts of service delivery, by far the best solution is to have the same person or people involved all through intake, eligibility determination, IFSP development, and service delivery.

To repeat: It’s helpful but not necessary to have an ecomap completed before conducting an RBI.

Is There an Ideal Inclusion Proportion?

The Division for Early Childhood of CEC has a position paper on inclusion that includes the following statement:

“Ideally, the principle of natural proportions should guide the design of inclusive early childhood programs. The principle of natural proportions means the inclusion of children with disabilities in proportion to their presence in the general population."

(http://www.dec-sped.org/uploads/docs/about_dec/position_concept_papers/PositionStatement_Inclusion_Joint_updated_May2009.pdf)

The DEC guidance is a philosophical one. No research studies have systematically compared different proportions. About the only things that can be said from research are that (a) inclusion has resulted in increased social and functional skills for children with disabilities, compared to self-contained programs; (b) it has resulted in more altruism and “acceptance” (hard to measure) by children without disabilities, compared to programs with no children with disabilities; and (c) old studies of early childhood special ed settings that might or might not have included children without disabilities (i.e., reverse mainstream, special-ed-oriented classrooms) were of lower quality than were inclusive settings.

So what are ideal ratios? Philosophically, some people, like DEC, say natural proportions. Programmatically, some people like me prefer a setting where there are enough children with disabilities that all children benefit from the good things that come from early childhood special education (e.g., individualization, specialized information to teachers—from therapists or itinerant ECSE teachers, family-centered practices, effective instruction) and retain the good things that come from early childhood education (e.g., developmentally appropriate practice to promote play, emergent literacy and numeracy, and social-emotional development). This percentage of children with disabilities rarely should exceed 50% or it is in danger of becoming too focused on special ed. The key ingredients in an ideal program, then, are the two sets of examples I’ve just given. There is no ideal ratio.

Floortime and the Routines-Based Early Intervention Model

What about Greenspan's Floortime in the context of the Routines-Based Early Intervention model?

http://www.stanleygreenspan.com/

Floortime can be used in the context of Routines-Based Early Intervention (RBEI). Often, Floortime practitioners think it's the only thing they should be doing with families, so that would be inconsistent with our primary service provider (PSP) and family consultation approaches. The PSP needs to attend to all child and family needs and needs to use coaching practices (family consultation). Floortime can be what the PSP suggests to the family, for addressing social relationships (one of the three foundational outcomes in the RBEI model), rather like incidental teaching is what we suggest as an intervention method the family can learn.

As the RBEI model matures, I am more and more convinced we should be incorporating parenting strategies, such as talking and reading to the child, behavior management, and effective teaching. I would put Floortime in this category.

Philosophically, I come from a behavioral orientation, and Greenspan comes from a mental-health orientation, but there is more overlap than separation in our approaches.

(In the picture taken from Greenspan's website, I'd rather see the professional in the background and the parent interacting with the child, but this is presumably a publicity shot!)