Friday, July 31, 2020

Telepractice Checklists

For 5 months, implementers of the Routines-Based Model (RBM) have been noting how relatively easy the switch to virtual visits has been, especially for home visits. Because Routines-Based Home Visits have always been centered on collaboration with the caregiver, we simply switched from sitting in the living room together to talking via Zoom. The biggest difficulty has obviously been the small amount of time the home visitor might have been interacting directly with the child. I have always said there are three reasons to put your hands on a child:

  • ·       Assessment (seeing what a child might do with a certain strategy)
  • ·       Demonstration (showing the family what your strategy looks like)
  • ·       To show you love the child.

In telepractice, we can’t do these in the same way, with literal hands on, but “home visitors” have devised creative ways to have caregivers show what the child does (assessment) and to be explicit about their ideas (the equivalent of demonstration).

The RBM has always used performance checklists to (a) describe practices in the model, (b) serve as a platform for feedback in coaching, and (c) measure the fidelity to the model of a professional’s practice (Dunst & Raab, 2010; Marturana & Woods, 2012). We have therefore created the Routines-Based Telepractice Visit Checklist and the Telepractice Collaborative Consultation to Children’s Classrooms (CC2CC) Checklist. You can find these at www.eieio.ua.edu/materials under Consultative Service Delivery.

Routines-Based Telepractice Visit Checklist

We were able to use the Routines-Based Home Visit Checklist as the basis for this telepractice version. The new one has a section on establishing a technology connection. It also recognizes that the pandemic, the lockdown, early intervention delivered through telepractice, working from home, and so on, demand extra sensitivity and empathy from the home visitor.

We still review child goals, if that’s what the family wants to talk about, going over existing strategies the family has been using or developing new strategies. One of the hallmarks of the RBM is the collaborative approach with caregivers, which, with families, we call family consultation. We do not simply listen to a family’s report or concern and immediately give them suggestions: That would be an expert model, not a collaborative model. In telepractice visits, it’s the same: We ask many questions before venturing an idea.

If demonstration by the home visitor would be helpful, telepractice challenges us. On the checklist, we have added describing the strategy in detail to demonstration (Item 25). Whereas on a live visit, the home visitor might describe the strategy in fairly general terms, followed by, “Would you like me to show you what I’m talking about?” the virtual visit cannot rely on showing the family what you’re talking about. For example, the home visitor might say, after asking many questions to get context, “Have you considered sitting behind him on the floor and applying gentle pressure on his hips to stabilize him?” After the parent’s quizzical look, the home visitor says, “Would you like me to show you?” Now, in a telepractice visit, the home visitor might still suggest the pressure on the hips and, instead of offering to demonstrate, say, “Would you like me to be more specific?” If the parent says yes, the home visitor continues, “You can sit behind him, with him sitting between your legs. He should have things to do in front of him—toys he likes, for example. To help him be stable, you can put your hands at the tops of his legs, with gentle pressure. That should stabilize him. Over time, you can release that pressure, to give him opportunities to stabilize himself, using his core.” This can be accompanied by demonstrating on yourself, about the placement of hands, for example. Some home visitors are using dolls as props for demonstration.

Just like in-person home visits, when you conduct a visit virtually, you should have the Next-Steps Form, the ecomap, and the matrix. These can all be found at www.eieio.ua.edu/materials. These are the three key documents a home visitor using Routines-Based Home Visits has at every visit. In the virtual world, we still use them.

Just like in-person visits, virtual visits take advantage of the opportunity to provide emotional, material, and informational support, as needed. They also take advantage of the opportunity to attend to parenting basics, which, in our model, are talking to children, reading to children, playing with children, and teaching children. We say in the RBM that early intervention is a parenting program, not a rehabilitation or special education program.

Telepractice CC2CC Checklist

Visiting teachers, virtually, is a tricky business. Some classrooms are open to accommodate the needs for child care of essential workers. Our useless federal leadership is telling us contradictory and scienceless noninformation about how to meet the needs of children in classroom programs. This situation has revealed much about the strengths and weaknesses of governors, even within the two major parties. In our field, we have to recognize that some infants, toddlers, and preschoolers with disabilities are going to classrooms, and we early interventionists (I include in this term early childhood special educators and therapists) need to support their teachers, without visiting the classrooms in person.

Hence, we have developed the Telepractice CC2CC Checklist as a guide. I hope, in some programs, coaches are joining the visits to classrooms, and providing feedback, using the checklist. If not, visitors (i.e., “home visitors” going to child care, itinerant ECSEs) can check themselves.

Again, we did not have to make many changes to our CC2CC Checklist. The same issues discussed in virtual home visits are pertinent in classroom visits, so I won’t repeat them here. In in-person visits as well as in telepractice visits with teachers, we do want to include classroom-wide issues, such as the zone defense schedule, using incidental teaching, and using ideas from Reggio Emilia (see Item 31).

With both Routines-Based Telepractice Visits and Telepractice CC2CC, we should keep the following in mind.

  1.   Visits might be shorter because of distractions, interruptions, and videoconference fatigue.
  2.     Visits might seem disjointed and disorganize; give yourself a break—you have less control over the situation.
  3. Families might be distracted, uninterested in your visit, or inconsistent in their reports; give them a break—we don’t know everything they’re dealing with, although you should try to find out and understand.
  4. Some families might be thriving in this environment. They love being home with their kids and don’t want to be out with other people.
  5.   Teachers in classrooms are true front-line workers. I hope people put up signs saying “Heroes work here,” like they do at hospitals. These teachers are under more stress than usual. Maybe your work is to reassure them, give them a laugh, and maybe help them with some difficult situations.

I hope the checklists help. Thanks to Cami Stevenson for working on these checklists with me.

 

Dunst, C. J., & Raab, M. (2010). Practitioners’ self-evaluations of contrasting types of professional development. Journal of Early Intervention, 32, 239-254.

Marturana, E. R., & Woods, J. J. (2012). Technology-supported performance-based feedback for early intervention home visiting. Topics in Early Childhood Special Education, 32, 14-23.

 

Saturday, June 13, 2020

Black Lives Matter and the Routines-Based Model


Implementers of the Routines-BasedModel (RBM) around the world and members of The RAM Group stand with our brothers and sisters of color in decrying police brutality, discrimination, and both overt and implicit racism. We want to describe how the RBM is already designed to empower all families and how implementers of the model need to redouble our efforts to identify and combat injustice.

Black lives matter and so do other lives too easily marginalized. Here, we include all people who are treated with judgment and bias, including people who speak differently, look different, understand differently, act differently, and so on. 

To acknowledge the diversity of families, the first thing we do with families is construct an ecomap depicting their informal supports as well as their intermediate and formal supports. Each ecomap begins with a blank sheet of paper because every family is different. Families tell us who is in their lives and how frequently they communicate with them.

To develop a plan of support for children and families, we find out how families lead their lives and what they would like to be different. To assess needs, we don’t hold child and family functioning up to some given standard that might not conform to this family’s priorities or resources. We listen to what families do and want, without judgment. This procedure is the Routines-Based Interview (RBI).

The RBI ends with the family’s deciding on their goals for the child and family. Even for children in child care or preschool. Not only does the family decide on 10-12 goals; they put them in priority order of importance.

In providing supports to families, ideally in the home but also in other settings, the family sets the agenda for the visit, the family helps come up with the strategy, and the family decides what they will do with the child or for the family. In this model, professionals do not assume an authoritarian or “colonial” approach. We provide emotional support, material support, and informational support. But families make the decisions, helped by our information. These are Routines-Based Visits.

In the RBM, when professionals go to children’s classrooms, they really visit the teachers—to help them meet children’s needs throughout the week. Just like home visits. This Collaborative Consultation to Children’s Classrooms (CC2CC) includes rules about respecting whose turf you’re on. Classrooms often reflect the culture of the children and staff, and RBM implementers seek to understand this ecology. As with families, teachers tell early intervention (0-5) professionals what they need.

We have highlighted some of the ways the RBM respects each family’s and teacher’s culture, way of life, decisions, and priorities. The model supports families as they are; it does not try to change them—unless they want to change. Science, ethics, and common sense endorse this approach.

Now, we need to take new action. We need to do the following:
  1. Listen to ourselves as we speak to families and teachers—for signs of implicit racism;
  2. Listen to ourselves and our colleagues when we discuss children, families, and teachers, and put a stop to judgmental language;
  3. Listen for families’ or teachers’ reports about being treated unfairly and follow up to find out more, however uncomfortable that might be for us; and
  4. Speak up to perpetrators of racism, bias, and injustice or report them to their superiors.

Signed by[1]

Robin McWilliam, Nashville, Tennessee, and Tuscaloosa, Alabama, USA
Cami Stevenson, Portland, Oregon, USA
Sue Bainter, Lincoln, Nebraska, USA
Lisa Spurlock, Chattanooga, Tennessee, USA
David Munson, Billings, Montana, USA
Margarita Cañadas Perez, Valencia, Spain
Marisú Pedernera, Asunción, Paraguay
Pau García Grau, Valencia, Spain
Catalina Morales Murillo, Valencia, Spain
Denise Luscombe, Perth, Australia
Brooke Serpell, Melbourne, Australia
Ai-Wen Hwang, Taipei, Taiwan
Lily (Hua-Fang) Liao, Taipei, Taiwan
Rosa Fernández Valero, Spain
Lin-Ju Kang, Taoyuan, Taiwan
Valecia Davis, Jackson, Mississippi, USA
Cecília Aguiar, Lisbon, Portugal
Brandi Brown, Montgomery, Alabama, USA
Naomi Younggren, USA and Germany
Charity Yang, Taiwan
Sylwia Wrona, Cieszyn, Poland
Hong Hway Lim, Singapore
Stephen Carberry, Canberra, Australia
Becky Hoo, Singapore
Claudia Escorcia, Valencia, Spain
Hui-Ching (Jane) Su, Beitun, Taichung, Taiwan
Stacy Callender, Jackson, Mississippi, USA


[1] Signatures do not reflect endorsement by our employers

Saturday, May 2, 2020

Welcome to Early Intervention Services: Why Routines are Important







This video describes important elements of the Routines-Based Model. I have trained professionals from York Region both there and through our institutes.

Saturday, April 25, 2020

Eligibility Determination During Stay-at-Home Orders



child reading book
Photos from Unsplash

How can children with suspected delays be deemed eligible for Part C services if they cannot be tested? This post discusses our opportunities to focus our concept of early intervention on needs and prevention rather than on deficits and intervention. In normal times, states imposed a bottleneck to prevent too many children to enter early intervention and overwhelm the system. In the past few years, states have increased their eligibility bars and decreased the frequency of services. The first option has denied early intervention to children who might really benefit from it, such as children with mild autism, children with challenging behaviors, and children with environmental conditions putting them at risk for delays and eventual school failure—or prison. The second option has eroded the concepts of (a) a close relationship between the family and a primary service provider, sustained through weekly visits; (b) building the family’s capacity through the partnership for solution finding during the visit, followed by the family’s implementing their strategy and reflecting with their home visitor the next week; and (c) the primary service provider approach, with the family receiving weekly visits all right—but from people of different disciplines every week, leading to either conflicting messages or duplication of service.
Now, we cannot rely on those standardized tests to determine how delayed the child is, because we cannot test the child remotely. I do believe states and agencies can make do, and obtain family report about the child’s abilities. The problem is good test items are not necessarily functional. They are good test items because, when administered in a standardized way, they lead to an aggregate score, differentiating children along a continuum. The aggregate score is an important concept: How a child performs on an individual item is not important: The scores of all the items in a scale or a subscale are put together (i.e., aggregated) to see where the child scores. On norm-referenced tests, these can be compared to age norms, to determine how delayed a child is.

Families are not likely to be able to report a child’s performance on a nonfunctional test item. If it’s nonfunctional, it does not occur in everyday life, and therefore parents would have no idea how many blocks a child can stack in 45 seconds.

Perhaps we can take this opportunity to look at children’s functional profiles to determine whether early intervention is for them. I’d like to suggest a parent-completed tool, an interview, and a milestone checklist—the first to see how far behind on functioning, not test taking, the child is; the second to determine what the child’s and family’s needs are, to become the outcomes on an IFSP; and the third to see the extent to which the child has achieved milestones in routines.

Parent-Completed Tool for Functioning

Here, I describe the Measure of Engagement, Independence, and Social Relationships (McWilliam & Younggren, 2020), how to handle the difference between Internet and hand-written notes, helping families complete the MEISR, and how to interpret the profile to determine potential eligibility.

MEISR

The MEISR lists functional skills in 14 common home routines for children birth to three years of age. Figure 1 shows an example. Families rate their child’s abilities from not yet (1) to sometimes (2) to often or beyond this (3).


 
Figure 1. Sample MEISR, from Brookes webinar presentation

Handling Paper

Unfortunately, the MEISR is available only in paper version, so programs need to figure out ways to get the tool to families. They can obtain the MEISR at https://products.brookespublishing.com/Measure-of-Engagement-Independence-and-Social-Relationships-MEISR-Research-Edition-P1152.aspx. They can use snail mail or scanning to instruct families on how to complete the tool. Specifically, if they use snail mail, they will need to provide families with self-addressed stamped envelopes. This dated method is probably better used with a scanned copy of the form. Families can be instructed to (a) use Adobe to edit the scanned tool, to identify their score for each item; (b) use a pen or pencil and scan the response back or take pictures of the pages; or (c) tell their service coordinator what their responses are, via telephone.

Helping Families to Complete the MEISR

Some families might appreciate support in the scoring of the MEISR, so professionals will go through the tool with the family, with the professional recording the family’s score for each item. Again, this can be done with a shared screen or the family’s having a scanned copy of the MEISR in front of them.

 toddler playing wooden xylophone toy

Because the MEISR is comprised of functional items, it is not hard for families to record or report what their child does. Professionals can follow the guidelines in the MEISR Manual for establishing the basal and ceiling, so families do not have to answer all the questions. The guidelines are on the MEISR, so some families can follow them without any help.

Interpreting the Profile for Potential Eligibility

Now you have a completed MEISR, what do you do with this information. I recommend you calculate the percentage of items mastered for the child’s age. The directions for this calculation are on the tool and in the manual and are as described above. States can determine the cut-off for the percentage of total skills for the child’s age that they will use to make a child eligible. For example, one state might state that, if a child has mastered only 75% of the functional items up to his or her age, the child should be deemed eligible to receive Part C services. Another state, might set the criterion at 50%, meaning the child must have more significant functional delays. Because the RBM promotes prevention as well as intervention, we recommend as high a percentage as the state can manage.

The starting ages on the MEISR are not norm-referenced: They come from an examination of various tools and curricula, so they are not scientifically valid. The MEISR provides a profile of a child’s functioning, and we have included starting ages, to help professionals determine if the child is close to age-expected performance. But the MEISR cannot replace norm-referenced tests to determine delay. We propose the MEISR as a more functional but less precise method of determining eligibility when you cannot test children directly.

Interview to Determine Needs

A routines-based interview has been identified in many places as a viable needs assessment method, but THE Routines-Based Interview (RBI), as defined in the RBM, is particularly compelling. When people are trained to do the RBI to fidelity, the child outcomes are more functional (Boavida, Aguiar, & McWilliam, 2014; Boavida, Aguiar, McWilliam, & Correia, 2016). I recommend you conduct a Routines-Based Interview, if you’re trained to do so, or a routines-based conversation, if you’re not trained. You should be able to determine the child’s functioning in different routines, the family’s needs, and the outcomes/goals they want for their child and family.

Via technology, you can interview the family about their daily routines. This information will give you and the family ample information for them to decide on their outcomes/goals. These outcomes/goals can become the focus of tele-visits. To begin with, we need to know the child’s functioning in routines through the day.

Functioning

A child’s functioning in his or her routines is defined by the child’s engagement, independence, and social relationships. The extent to which the child can participate meaningfully (i.e., be engaged), be independent, and communicate and get along with others defines the child’s functioning.

Engagement
How meaningfully does the child participate at a given time of the day? For example, what’s the child ‘s participation like during hanging-out time? If the child reaches toys or other objects and keeps him or herself occupied during most of hanging-out time, the child is in good shape. If, on the other hand, the child doesn’t participate much, doesn’t stay involved very much, or participates at a lower level than we would expect, we would annotate these deficits with our method of “starring” iems. Virtually, starring items can happen by highlighting sections of notes or inserting asterisks.

Independence
How independently does the child function in this routine? What level of prompt or other assistance does the child need? Sometimes, children can function more independently than their caregivers let them, so we need to be sensitive to cultural and family concepts of how much a caregiver should help a child.

Social Relationships

Social relationships consist of communication and getting along with others, which are interrelated. How well does the child communicate during this routine and how well does he or she understand communication. How well does the child cooperate, play with, and otherwise interact with others in the routine? 
Together, engagement, independence, and social relationships (EISR) form the foundations of learning (McWilliam, 2008). In the RBM, they are assessed in context—in routines.

Family Needs

Asking families about their day-to-day activities evokes a number of family needs, especially when we ask them about whether they have enough time for themselves, their worries, and what they would like to change in their life. Some family needs are related to the child, such as having information about the child’s disability, learning sign language to help the child’s communication, or having information about resources to help the child. Other family needs are indirectly related to the child but meet the adults’ needs, such as furthering their education, working out, or having time with the partner. These family-level needs are important because of what, in the RBM, we call the two-bucket principle: A mother can fill her child’s bucket only to the exten that her bucket is full.

Goal Decision Making

The interview ends with the family’s making decisions, after reviewing what was discussed in the interview, about what they want to work on. The decide on 10-12 outcomes/goals and then put them into order of priority (i.e., importance). These functional child skills and family goals are then written to be measurable. Child goals have acquisition, generalization, and maintenance criteria.

Milestone Achievement

Families celebrate their children’s milestones. In our routines-based view of children’s and families’ functioning, we recognize that different routines produce different milestones. In the next few weeks, I will unveil a new milestone achievement chart to help families and early interventionists score children’s functioning.

Conclusion and Call to Action

We have heard that, during the stay-home order, states are

  • ·       Using the MEISR, the Carolina, or the AEPS to determine delays through clinical opinion;
  • ·       Developing an interim IFSP, expecting the formal evaluation to be late;
  • ·       Screening with the ASQ and ASQ-SE;
  • ·       Restricting eligibility to established conditions; and
  • ·       Using methods such as the MEISR or AEPS, to be confirmed with state-approved tools later.

 selective focus photography of girl holding her hair
We have heard that professionals have questions about how to conduct evaluations and assessments, how to determine COS ratings, and how therapists are to conduct evaluations. This blog post has addressed a number of these issues. Importantly, therapist-administered evaluations are not necessary to determine whether a child has a functional problem. By definition, if the problem is functional, a caregiver of the child in the relevant routine would know whether the child’s meaningful participation was compromised. Therapist would be needed to understand why the child was not engaged and what strategies might be employed to help the child.
States and agencies should not put the brakes on entry to Part C during the pandemic. Even more than normally, families need support. We can use functional assessment as suggested here to enroll children and their families. If necessary, we can confirm their delays later. Even better, we might learn that a functional assessment is actually a more authentic way of determining whether we can help them.

Boavida, T., Aguiar, C., & McWilliam, R. A. (2014). A training program to improve IFSP/IEP goals and objectives through the Routines-Based Interview. Topics in Early Childhood Special Education, 20(4), 200-211. doi:10.1177/0271121413494416
Boavida, T., Aguiar, C., McWilliam, R. A., & Correia, N. (2016). Effects of an in-service training program using the routines-based interview. Topics in Early Childhood Special Education, 36(2), 67-77.
McWilliam, R. A. (2008). The engagement construct. In R. A. McWilliam & A. M. Casey (Eds.), Engagement of every child in the preschool classroom (pp. 125-134). Baltimore, MD: Brookes.
McWilliam, R. A., & Younggren, N. (2020). Measure of Engagement, Independence, and Social Relationships. Baltimore, MD: Paul H. Brookes.