More Direct Service Is Not Better: A Script

 

 

Need

Professionals feel pressure from families or other professionals to provide more direct, hands-on therapy than they currently provide. The Routines-Based Model actually promotes hands-on only for demonstration. How do we explain this?

Script

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• Children benefit from the most intervention they can receive.
• Who’s available to provide this intervention? Not weekly visitors. Instead, regular caregivers (e.g., adults in the family, teachers).
• Professionals therefore spend their precious weekly visits empowering caregivers with techniques they have acquired through their specialized training.
• The more professionals that families work with, the lower their family quality of life, so we use a primary service provider.
• We change primary service provider only when absolutely necessary (research shows the longer a family works with a provider, the more family centered the family perceives the service to be).
• When the primary service provider needs help, he or she gets help from team members with the relevant expertise.
• The primary service provider attends to all the child’s needs and the family’s needs, ensuring nothing falls between the cracks like it does in traditional multidisciplinary service delivery (different professionals visiting the caregiver regularly).
• We don’t pile on services to address each need. We add joint home visits (“consults”) when primary service providers and caregivers have questions needing extra expertise.
• Professionals use collaborative consultation to fit their expertise into caregivers’ routines; they don’t push their methods into caregivers’ lives.
• Caregivers now have the capacity to provide intervention to children throughout their awake time all through the week, so, children receive maximal learning opportunities.
• Increasing direct, hands-on therapy would not necessarily increase this intervention time; in fact, it would decrease it, because the family would think intervention occurred one hour a week instead of the 98 hours a week when they or other natural caregivers are with the child.
• We use this primary service provider, functional, family-centered approach because a professional should attend to the whole child and family in naturally occurring routines in life.
• Caregivers now have the capacity to provide intervention to children throughout their awake time all through the week, so, children receive maximal learning opportunities.

  

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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

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[1] Signatures do not reflect endorsement by our employers

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.

 

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.

 

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.

 

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

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