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!)

After the RBI: Actual Intervention

Problem

A colleague told me recently that my models were good for needs assessment but professioanals needed to know what to do during actual intervention. Ouch. The Routines-Based Interview (RBI) has become well known and implemented, but people stop there. They don’t go on to finish the book, so to speak. Here, I explain that it’s what happens after the RBI that’s really important—and that intervention is a huge part of my models, Routines-Based Early Intervention (RBEI) and the Engagement Classroom.

RBEI

The RBEI model (confusingly close to “RBI”) consists of five components: understanding the family ecology (ecomap development), family-centered needs assessment (RBI), integrated service delivery (primary service provider), support-based home visits (family consultation), and collaborative consultation to child care (individualized within routines). The ecomap and the RBI often go together. To master these is to master finding out what families’ real priorities are for their children and themselves, based on an in-depth exploration of functioning in everyday contexts. The result is a long list of goals designed to increase children’s meaning participation in their routines and to meet family-level needs. But that’s it. And yet that is the springboard for effective interventions. Therefore, in my way of thinking, the RBI is necessary but not sufficient. It is very hard, for example, to use good family consultation, also known as coaching, if you don’t have meaningful, functional things to discuss with the child’s caregivers such as parents and teachers. The RBI sets the stage and was always designed for that purpose; see the original book (now out of print, so good luck), Family-Centered Intervention Planning.

What the RBEI model has to offer after the RBI is a method for organizing service delivery (the primary service provider), a method for conducting home visits (family consultation), and a method for visiting children in their group-care settings (collaborative consultation). These methods are well articulated, they come with supporting materials (e.g., checklists), and they are being successfully implemented in numerous places around the world.

Engagement Classroom

The Engagement Classroom model is a package of practices also but for the running of a classroom. It doesn’t cover all the things a teacher has to consider. For example, it is designed to be used with almost any curriculum and with almost any developmentally appropriate approach. (Although currently I’m inspired by its application with the Reggio Emilia approach.) The Engagement Classroom model features (a) inclusion, (b) incidental teaching, (c) integrated specialized services, (d) functional needs assessment (i.e., the RBI), (e) the zone defense schedule, and (f) engagement data collection. Again, the purposes of the RBI in this model are to assess functional needs by looking at child behaviors in everyday contexts of the classroom (and home) and to produce a set of family-chosen goals pertaining to those needs. Once we have those goals, incidental teaching and integrated services (i.e., therapists and itinerant early childhood special educators) occur meaningfully. Everybody is on the same page, and the focus is on function—engagement, independence, and social relationships (EISR) in the routines of the child’s school day (and home time). The classroom has some organizational features to promote this functioning, such as children of all abilities, the organization of adults, and the organization of classroom space. Adults are trained to focus on EISR.

Price of Success

The success of the RBI has improved the development of intervention plans and has give professionals a tool for working closely with families in that process. The popularity of the interview has overshadowed the other parts of the RBEI and Engagement Classroom models, or perhaps mastery of the first course (i.e., the RBI) has been so filling that the main course has been forgotten about. The metaphor stops there, because a first course is optional, whereas we have found the RBI to be almost a prerequisite to the intervention parts of the models.