MENTAL SHIFT 2: WHOSE CHILD IS IT ANYWAY?

T

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.

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.