MENTAL SHIFT 2: WHOSE CHILD IS IT ANYWAY?

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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.

MENTAL SHIFT 1: ALL THE INTERVENTION OCCURS BETWEEN VISITS

In my August 23, 2015, post, “Routines-Based Practices to ReplaceCenter-Based Services,” I threatened to address 12 mental shifts that have to occur, to move from a clinical approach to a family-centered, functional approach. I wrote that the next 12 posts would each address one of the mental shifts but I posted two entries that weren’t on this list. So today’s is Mental Shift 1.

12 Mental Shifts

1.       All the intervention occurs between visits.

2.       Whose child is it anyway?

3.       Children are learning from their caregivers, whether you want them to or not.

4.       Anyone spending time with the child has the opportunity to teach the child.

5.       Passing judgment on parents or other caregivers is a self-fulfilling prophecy.

6.       Parent failings don’t exist; only professional ones.

7.       What matters is how children function in their everyday lives. Function = participation = engagement = learning.

8.       The rush to get ahead leads to failure in early intervention.

9.       It’s about getting children engaged, independent, and in social relationships.

10.   It’s about helping families feel confident in their competence with their children.

11.   Too many cooks spoil the broth.

12.   Teamwork can work through collaborative consultation.

Perhaps no phrase better describes the Routines-Based Model than All the intervention occurs between visits. It implies that intervention is what the child receives from his or her regular caregivers. Intervention is the steady dose of learning opportunities, as Bruder and Dunst called them, that children need in order to learn. Understanding that young children do not learn in single small lessons, provided perhaps once a week, is central to this idea. Children learn through repeated interactions with the environment, distributed over time. The environment is most commonly a more competent person, such as a parent or a sibling. These more competent people were who Vygotsky talked about as essential to a child’s zone of proximal development. 

Regular caregivers are those people who spend substantial time with the child, which will be addressed in Mental Shift 4, as you can see in the list.

If all the intervention occurs between visits, what should we do during the visit? Working directly with the child is mostly a waste of time, unless the child is old enough to transfer what happens in a visit to nonvisit time—say developmental age of 8 years or something. So home visits where the early interventionist is on the living room floor, going through activities with the child are pretty useless, especially if the parent is not involved—by the home visitor. A visit to a clinic, while the parent sits in the waiting room, observes through a window, or observes in the room, while the clinician “works with” the child, is similarly a wasted opportunity. A child going to a play group for a couple of hours a week might get to have fun with other children, which is great. But to call it early intervention, if the parents are really not gaining meaningful support (e.g., information), is misleading. Sometimes, professionals “work with” (don’t you love this expression when interacting with infants, toddler, and preschoolers?) children, while the parents meet, with or without a professional facilitator. That’s a waste of money. They should hire good babysitters instead of therapists or teachers, because that single-shot of professional time while the parents are busy elsewhere isn’t effective. The parent support might be, for those who like that kind of thing, as Glen Affleck discovered years ago (i.e., that support group meetings are not effective for everyone). 

What we should do during visits is support the family for the time we’re not there. Build their capacity. We’ll talk about that more in Mental Shift 10, and we’ll address nonparental caregivers in Mental Shift 4.

How do we build up caregivers’ capacity to be effective interventionists with the child? Through family consultation and collaborative consultation, which are forms of “coaching,” a term M’Lisa Shelden and Dathan Rush have arrogated to describe a nondirective, reflective, and respectful approach to teaming between professionals or between professionals and families. Key features of family consultation, as I’ve defined it, are

• Families determine the outcomes/goals.
• Professionals help determine why the child isn’t doing the skill yet and what interventions might work
• The professional making the visit uses other team members’ expertise, as needed.
• In working with families, the professional asks at least four context questions before the “ask-to-suggest,” which is “Have you ever tried _____?” The ask-to-suggest is a suggestion in the form of a question.
• The professional and the family discuss a potential solution, which is another name for an intervention.
• The professional offers to demonstrate or to watch the parent.
• The professional makes suggestions for modifications to what the parents do.
• The professional asks the parents to determine the feasibility of the intervention (“Do you think this will work?”). Families are encouraged to say no, if they have doubts.
• At the next visit, the professional asks how the intervention went.
• The quality of the relationship between the professional and the family is important for developing trust and honesty.

In later posts, I’ll discuss the key features of collaborative consultation to group care programs, such as day care and preschool. They’re similar.

If early interventionists working with children birth-6 would remember ALL THE INTERVENTION OCCURS BETWEEN VISITS, their time spent with the family and other caregivers would be effectual.

Sensory Integration Therapy and Decreasing Stereotypy

One of the disorders sensory integration (SI) therapy is said to help with is the decrease of behavioral excesses in children with autism. In a new single-subject experimental design to evaluate the efficacy of various SI techniques on reduction of stereotypic behaviors, a net swing, “deep pressure,” and a sensory diet consisting of “deep compression” via a therapy ball, “deep pressure” via heavy work activities, “meatball squeeze,” and joint compression were examined with three preschoolers with autism. 

Single-subject studies are truly experimental; the other truly experimental type of research is randomized control trials. Single-subject studies involve a small number of participants but many data on the dependent variable are collected over time. What you give up in the number of participants, you gain in the number of observations per participant. Furthermore, the controls on the independent variable (i.e., the treatment) are very tight. Finally, you can see the exact results of the difference between conditions—between baseline and treatment, for example.

The study is by Sniezyk and Zane and was published in March in Focus on Autism and Other DevelopmentalDisabilities, Volume 30, Number 1. The occupational therapists conducting the treatments had the freedom to determine what specific behaviors to target and what exact treatments to use. The study used rigorous inter-observer agreement procedures, to ensure the reliability of the data, and they measured the fidelity of the procedures to ensure the children really were receiving the SIT described by their therapists. Quoting the abstract, “The results showed that there was no causal relationship between the sensory procedures and improvements in the targeted dependent variables. Thus, SIT remains an unproven treatment for autism.”

The purpose of this post isn't simply to bash SIT, which is too easy, but rather to encourage the evidence-based treatments for reducing stereotypies. The National Professional Development Center on ASD has an excellent review of evidence-based practices.