Wednesday, January 6, 2016


his post continues the 12 mental shifts I described in September—the mental shifts that have to occur to move from a clinical approach to a family-centered, functional approach. This time, the shift involves asking the question, Whose child is it anyway?
The question most often crops up when professionals and the family disagree. At least, it should crop up. The two disagreements are when families want to address something you don’t care about and when they don’t want to address something you do care about.

Families want to address something you don’t care about

Javier insisted his son, Carlos, should say please and thank you. Carlos could barely say mama and dada. The early interventionist thought there were much more functional words he should be learning next, such as more, yes, finished, eat, drink, and so on. She explained to Javier that these words could be useful in different routines and were generally easy for children to learn. She noticed, however, that Javier himself didn’t use them in playing or feeding Carlos but did model thank you and please. Then she remembered Whose child is it anyway? Not only is this a true and obvious statement but because Javier had this as a priority, he was motivated to work on it, so Carlos received the intervention frequently. Signing please and thank you do no harm and actually help Carlos learn about imitation, communication, and rituals—all important for learning and family routines.

What if Javier had wanted Carlos to use the toilet at 18 months? The early interventionist would have had an ethical obligation to provide Javier with information, which is another mantra of the Routines-BasedModel. We have an ethical obligation to provide families with information.

Families don’t want to address something you care about

Philomena is a physical therapist and is working with Rose and her family. Rose gets into a four-point position, on her hands and knees. She often then sits back on her ankles, but there’s no movement—no “creeping” on hands and knees, with the tummy off the floor. Philomena thinks this is important: It would help Rose learn about reciprocal movement and weight shifting, not to mention that it would be a more efficient way of moving than the commando crawl Rose did use. But Rose’s parents were politely lukewarm about creeping. They’d heard that many babies simply skip over creeping before learning to stand and eventually walk. Also, they didn’t like making Rose do things she didn’t want to do, and Rose had no interest in creeping, even with a towel slung under her belly and held up by an adult. Philomena incorrectly thought creeping was a prerequisite to walking; after all, it was next on the mobility developmental checklist. 

Then she remembered Whose child is it anyway? She’d given the parents information about weight shift and reciprocal movement, so she’d done her ethical duty. If the parents didn’t work on creeping, it wasn’t going to harm Rose. Even if Rose learned to move independently later than she would if she crept, so what? Early intervention doesn’t mean we have to push all skills to be learned as early as possible. If children or their caregivers aren’t interested, it’s futile to perseverate on the topic. 

A few weeks went by, when Rose’s mother said she wanted her to play more independently and for longer, so she could get dinner ready (the dreaded dinner preparation routine). Philomena worked with the mother to come up with solutions, and, on one visit, the mother said, “If it didn’t take her so long to get to her toys, she wouldn’t get fussy so quickly.” 

Philomena said, “How can we get her to be quicker? Or should we put the toys closer?”

“We need to get her moving better than that crawling she does.”

“We can certainly work on that, but that would require a grown-up with her, and you’re busy preparing dinner.”

“Maybe I can work on it when we’re just hanging out, playing in the living room,” said Rose’s mother.

“Is that a useful time for her to be able to move better?” asked Philomena.

“Yes, it’s the same issue. She can be more independent in her play.”
Asunción, Paraguay, where I recently spoke at the ORITEL Conference

This is an example of how, even when we acknowledge whose child it is, the skill might be addressed. It was only when Rose’s mother saw a functional need, for Rose to be engaged during dinner preparation, that the skill became a priority. After this conversation, perhaps even at another visit focused on play time, Philomena would have used family consultation (Mental Shift 12) to develop, with the mother, the specific intervention strategies.