Monday, March 23, 2020

Tele-Intervention and the Routines-Based Model


Home visits have been suspended during the Covid-19 pandemic, but early interventionists can still provide supports to families. I discuss here how the principles of the Routines-Based Model match the demands of distance service delivery, the definition of tele-intervention, the research behind telepractice, how to use telepractice for the Routines-Based Interview, and how to use tele-intervention for home visits.

 woman smiling holding glass mug sitting beside table with MacBook

How the Principles of the Routines-Based Model Match the Demands of Distance Service Delivery

The Routines-Based Model of Early Intervention (Birth to Five Years) is a method of providing supports to children with disabilities and their families that focuses on functioning in children and on meeting families’ needs. Numerous countries, states, and programs are implementing this evidence based model (see www.eieio.ua.edu and http://robinmcwilliam3.wixsite.com/ram-group). The following table shows important principles in the Routines-Based Model (RBM) and the demands of distance service delivery. The table shows that the RBM can be used to deliver useful tele-intervention and that tele-intervention can be used to apply the RBM.
Principles of the Routines-Based Model
Tele-Intervention Application
All the intervention occurs between visits
“Visits” build the family’s capacity to meet child and family needs
Family sets the agenda
The Next-Steps Form is virtually completed and reviewed during visits
Parents are competent adults
We collaborate to determine interventions parents will carry out
Family consultation is how we work with families
We ask many questions to help families arrive at solutions they want to implement
The two-bucket principle
The visit includes discussion of family outcomes/goals and other family needs
We provide support-based visits (McWilliam & Scott, 2001)
We provide emotional, material, and informational support

Definition

Early intervention has been delivered via tele-intervention for many years, especially in remote, rural areas (Davis, Hopkins, & Abrahams, 2012). We define tele-intervention as the provision of support to families via videoconferencing technology. Providers can use Zoom, Skype, FaceTime, or other methods of connecting with families via both video and audio. These platforms allow for both the interventionist and the family to be on camera. Zoom, Skype, and other platforms also allow for screen sharing, which might be helpful as early interventionists provide families with information.
Tele-intervention requires families to have Internet connection and a device for communicating via videoconference, such as a smart phone, a tablet, or a laptop. By definition, these devices have embedded cameras.

Research

Much of the research on telepractice has been conducted in providing early intervention to children who are deaf or hard of hearing. In a study of 48 children who were deaf or hard of hearing and their families, one group received telepractice and one group received traditional in-person home visits (Behl et al., 2017). Children in the telepractice group scored higher than children in the in-person group on some language scores, and the groups were equal in other language scores. Family measures did not differ. In the telepractice group, providers were more responsive, and families were more engaged.
In an evaluation of tele-intervention, parents rated their comfort with seven steps required to use the videoconferencing platforms:
“(1) turning on the computer,
(2) connecting the camera and microphone,
(3) connecting to the Internet,
(4) connecting to the VHV Project website,
(5) logging on to the website,
(6) starting the camera, and
(7) locking the microphone to talk.”
Parents' initial comfort with these technical skills was high and remained so. Conclusions from this study were that “virtual home visits” had pros and cons for different families and providers but that they “can be useful in accomplishing the mission of early intervention.” (Olsen, Fiechtl, & Rule, 2012).
In addition to tele-intervention with families, telecoaching can be successfully used to train early interventionists (Neely, Rispoli, Gerow, & Hong, 2016; Tomeny, 2020)

Routines-Based Interview

Service coordinators can conduct an RBI via a teleconferencing platform. The following table shows the main steps of the RBI and how they are accomplished via tele-intervention.
Major Steps of the RBI
How Tele-Intervention Applies
Ecomap development
Ask families the usual questions and draw the ecomap.
Once concluded, take a picture of it.
Save the picture.
Either share it with the family through Messenger, email, or another method or share your screen and show the family the saved ecomap.
Ask them about any changes, what they think of the ecomap, what will be done with it, and how it will be used.
RBI
Looking at parents, proceed from main concerns, through routines, all the way to the time, worry, and change questions. Take notes. If you take notes by hand, copy them and save them. If you take notes electronically, save them. If you type notes, highlight, bold, or in some other way indicate starred items.
Recap
Share the screen to show either your picture of your notes or your typed notes.
Recap the starred items
Goal decision making
Looking at parents, ask for the things they want to work on.
When they need it, share your screen, showing your notes.
Ask the family when you should move ahead.
After they have added some outcomes/goals, you, still sharing your screen, go through the notes until you have at least 10 outcomes/goals.
 woman sitting and holding white Acer laptop near brown wooden wall

Routines-Based Home Visits

Providers can similarly use tele-intervention for visits. I concentrate on home visits, because during the Covid-19 season, children’s classroom programs have been suspended. After discussing synchronous versus asynchronous visits, I address the essential stages of Routines-Based Home Visits: the agenda, reviewing progress, reviewing interventions, developing strategies, and planning for the next visit.

Synchronous Versus Asynchronous Visits

Visits can be in real time, in which the family turns on the device, and the early interventionist communicates with the family in real time. This method is most like a live home visit. A family can also record what goes on in one or more routines and share them, electronically, with their early interventionist, who then gives feedback. In the following sections, I assume synchronous (i.e., live) electronic visits, but, remember, you can communicate not IRL (in real life).

Agenda

Once connected, the early interventionist proceeds the same way she[1] would as if she were there in person. She gives the family an opportunity to talk about anything they want to talk about.

Focus of Visit

If the family has nothing in particular they want to talk about, the early interventionist refers to the bottom panel of the Next-Steps Form: what the focus of the next visit should be. This might be a child outcome/goal, so the early interventionist might say, “You said you wanted to talk today about Vinny’s standing independently. How’s that going?” The answers to this question could be “not much improvement,” “child is improving,” or “child can do it.” Each of these answers leads to questions the early interventionist can ask: See the family consultation flow chart at http://eieio.ua.edu/uploads/1/1/0/1/110192129/family_consultation_english.pdf.

Review Interventions

In this flow chart, we see “How’s intervention going?” This important question can lead to a number of adjustments: refine the skill to be tackled, tweak the implementation change the intervention or the routine, decide whether to change or persist, or try the matrix. Offering to demonstrate again is virtually (to coin a term) impossible via technology. Reviewing interventions include the other two actions: child demonstration and caregiver demonstration.
Child demonstration via technology occurs when the early interventionist observes what the child typically does. The caregiver might say, “I want you to see what he usually does.” This could be something good (i.e., an accomplishment) or something bad (i.e., something the child cannot do or does badly). It can be initiated by the caregiver, as in “I want you to see what he does.” Or it can be initiate by the early interventionist, as in “Would you mind showing me what he does?”
Caregiver demonstration via technology occurs when the early interventionist observes what the caregiver does to help the child. Again, this could be initiated by the caregiver, as in “I want you to see what I do.” Or it can be initiated by the early interventionist, as in “Would you mind showing me what you do?”

Develop Strategies

Strategy development with families via technology, using the RBM, is little different from doing so live. Early interventionists should follow the steps in the Routines-Based Home Visit Checklist and the Family Consultation flow chart. In case it hasn’t been obvious, life conversations, such as through Zoom, Skype, and WhatsApp are better than email or chats. Follow-up summaries by email, however, are extremely valuable (Barton, Kinder, Casey, & Artman, 2011; Tomeny, 2020).

Plan for Next Visit

As with a regular home visit, the tele-intervention visit should include what the caregiver will work on from now until the next visit and what the focus of the next visit should be: the right-hand and bottom panels of the Next-Steps Form. The early interventionist should scan, screen shot, or save the NSF and send it to the caregiver.

 two babies and woman sitting on sofa while holding baby and watching on tablet

Principles Revisited

Supporting families without visiting them seems anathema to early intervention in the U.S. Nevertheless, we realize that, in the RBM, it’s about providing emotional, material, and informational support to families. This support does not require us to be natural environments. We learned that in working with international implementation sites that could not see their way out of their clinics and rehab centers. It’s not where you support families: it’s how you support them. Therefore, get families online and support them by attending to the following principles:
Principles of the Routines-Based Model
All the intervention occurs between visits
Family sets the agenda
Parents are competent adults
Family consultation is how we work with families
The two-bucket principle
We provide support-based visits (McWilliam & Scott, 2001)

References

Barton, E. E., Kinder, K., Casey, A. M., & Artman, K. M. (2011). Finding your feedback fit: Strategies for designing and delivering performance feedback systems. Young Exceptional Children, 14, 29-46.
Behl, D. D., Blaiser, K., Cook, G., Barrett, T., Callow-Heusser, C., Brooks, B. M., . . . White, K. R. (2017). A multisite study evaluating the benefits of early intervention via telepractice. Infants & Young Children, 30, 147-161.
Davis, A., Hopkins, T., & Abrahams, Y. (2012). Maximizing the impact of telepractice through a multifaceted service delivery model at the Shepherd Centre, Australia. The volta review, 112, 383.
McWilliam, R. A., & Scott, S. (2001). A support approach to early intervention: A three-part framework. Infants & Young Children, 13, 55-66.
Neely, L., Rispoli, M., Gerow, S., & Hong, E. R. (2016). Preparing interventionists via telepractice in incidental teaching for children with autism. Journal of Behavioral Education, 25, 393-416.
Olsen, S., Fiechtl, B., & Rule, S. (2012). An evaluation of virtual home visits in early intervention: Feasibility of "virtual intervention". The volta review, 112, 267-281.
Tomeny, K. R. (2020). Telecoaching in early intervention: Supporting professionals and families of toddlers with or at risk for autism spectrum disorder. The University of Alabama, Tuscaloosa, AL.  
3/23/2020


[1] The feminine pronoun is used for convenience, recognizing early interventionists, like me, can be men.

7 comments:

  1. Robin, THANK YOU for this article. I've been waiting for your thoughts and you did not disappoint!

    One thought I have had is that collaborative Early Intervention teams that utilize the Primary Service Provider model are going to be the most successful.

    I believe some families will be overwhelmed by technology-based service delivery and I wonder what this will look like when there are multiple providers (specifically, those that haven't collaborated together before).

    I'd love to hear your thoughts on this!

    Johanna

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  3. Hello Robin. I hope this finds you safe and healthy. I agree with the comments above and would welcome a one-pager we could share with families and providers. Let me know how I can help.

    Best,
    Deborah

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  4. Robin,
    Thank you for sharing.

    I am also wondering about supporting families who may be overwhelmed by technology-based service delivery. How to put them at ease about this way of service delivery.

    In some cases, I can see this working very well with families and they may prefer this method of service delivery.

    Thoughts?
    Darla

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  5. Robin thank you very much. Currently in Spain this post is so useful, our situation is so difficult because all the people are at home (professionals and families, each one in their house, obviously), and that situation was just in one day, so the early childhood intervention services found the need to adapt it to the new home and routines situation.
    When I was reading your post, I was thinking about Spain moment and I have comen to feel pleasure being that your recommendations are near of our experience.

    Really Thanks

    Rosa Fernández

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  6. Hi Robin! It's Jeanne from Nebraska! I am doing my first home visit via Zoom tomorrow. THANK YOU for the article-as always-it was very helpful!!

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