Relation versus relationship

Can you P-L-E-A-S-E tell me when it is appropriate to use them term "relation" versus "relationship?" ...I typically use the term "relation" with variables in stat/data analysis. I'd like to be right, but I'm more interested in being accurate. 

A couple of my relations, 6 years ago

A very good question, especially because certain people—behaviorists, mostly—have made up rules that defy good usage and elegance. First, the mistake they often make is to say that “relations” should be used for the connection between two variables. In behaviorism, of course, this is most commonly used in “functional relation.” These people can’t stand “functional relationship,” even though this is actually a better form and doesn’t clang to people who know their English. These behaviorists think “relationship” belongs to the affiliations between people (e.g., “the child had a good relationship with his brother”).

In fact, a relationship has two meanings: personal affiliations (friendships, romantic link, etc.), the way two things are connected (including variables—e.g., “the relationship between the predictor and the outcome” or “the correlational relationship between Variable X and Variable Y” or “the functional relationship between the independent and the dependent variables”). Relation also describes the link between people (e.g., relations between teachers and students should be nurtured). You can see that this could also be “relationships between teachers and students….” So when discussing links between people, groups, or countries and the way they behave towards each other (I’m quoting the BBC here), the two terms are interchangeable. But in certain contexts “relations” is always used: diplomatic relations, race relations. Relations can also be used interchangeably with relatives, although that’s not as common in the U.S. as in British-English countries.

So, I’m afraid you’re not right about variables taking “relation,” although, as I said, many behaviorists would agree with you—and probably statisticians too. But if I had to pick two groups of people who like to talk fancy and who consider themselves precise but who slaughter the language, it would be behaviorists and statisticians. Eighty percent of the time “relationship” will serve you well. Which one you choose depends on whose wincing you care most about!

New Part C Regulations: Much Ado About Nothing

The finally arrived new Part C regulations have some interesting features. I haven’t compared the old with the new; CEC is going to do that within the month. Some of the new regulations are noteworthy for practitioners of the model described in Routines-Based Early Intervention, published by Brookes. Direct quotations from the new-regs document are italicized.

The two disciplines. The definition of multidisciplinary in §303.24 has been revised with respect to the individualized family service plan (IFSP) Team composition to require the parent and two or more individuals from separate disciplines or professions with one of these individuals being the service coordinator.

An interesting interpretation of a discipline is the inclusion of service coordinator, which is actually a role or function. But this will alleviate the pressure on IFSP teams who have previously thought they had to find two people other than the service coordinator. The intent, originally, was to have different perspectives from the field. Now, when we’re lucky enough to have a service coordinator with content knowledge about child development, family functioning, and disability, we’ll be fine. In states where service coordinators are limited in their content knowledge, there will theoretically be a loss. I can’t say, however, that I’ve noticed much of a gain by having two additional professionals from different disciplines. Evaluations have to be rushed anyway, and they’re just for determining eligibility—not for diagnosis, so we might as well make the process as efficient as possible. A good change.

Scientifically based research. Scientifically based research has the meaning given the term in section 9101(37) of the Elementary and Secondary Education Act of 1965, as amended (ESEA). 

Well, thanks. That’s pretty useless. You can, however, read the definition at http://www.okhighered.org/itq/forms/2010-scientific.pdf (thanks to Oklahoma higher ed). Could have been clearer.

Transition. New §303.209(b)(1)(iii) provides that if a child is referred to the lead agency fewer than 45 days before that toddler’s third birthday, the lead agency is not required to conduct the initial evaluation, assessment, or IFSP meeting, and if that child may be eligible for preschool services or other services under Part B of the Act, the lead agency, with the parental consent required under §303.414, must refer the toddler to the SEA and appropriate LEA.

If this was already the regulation, I didn’t know about it. I assume it’s new. This definitely provides relief to the Part C program and makes sense. We still can’t be sure, though, that a child with a third birthday on June 1, for example, referred at the end of May won’t be made to wait until August or September before anyone will provide help. A good change, nevertheless.

The 45 days. New §303.310 (proposed §303.320(e)(1)) requires that, within 45 days after the lead agency or early intervention service (EIS) provider receives a referral of a child, the screening (if applicable), initial evaluation, initial assessments (of the child and family), and the initial IFSP meeting for that child must be completed (45-day timeline).

When the clock stops has long been a contentious issue, with states receiving conflicting messages from OSEP. Note that the regulation says the clock ends when the initial IFSP meeting is completed. Although this could be interpreted as the IFSP meeting for the first (i.e., initial) IFSP, it could also be interpreted as the first meeting about the IFSP. In our model, I have argued that this could be the Routines-Based Interview, even if the signing of the IFSP happens later—that is, after the 45 days are over. The two problems with my argument are, first, that, unless the RBI date is documented somewhere, no accountability is possible about meeting the 45 days. Second, it could delay service delivery, which is the point of the 45-day requirement. I don’t buy this second argument, however, because many parents have told us that the RBI itself is very beneficial. A good regulation, as long as it doesn’t get misinterpreted by states or the feds.

Abbreviation. “EIS” is the long-standing, commonly accepted abbreviation used in the field of early intervention and we do not anticipate any confusion by the abbreviation’s continued use in programs administered under Part C of the Act.

It is?

Purposes of early intervention. Two commenters recommended that, when describing the purpose of early intervention services in general, we retain the language that these services must be designed to serve “the needs of the family related to enhancing the child’s development” that is in current §303.12(a)(1).  The commenter stated that meeting family needs is a key component of an early intervention system and should be addressed routinely in IFSP development, rather than only upon family request.

The originally proposed regs had included “as requested by the family, the needs of the family.” In the final version “as requested by the family” was omitted to ensure that family needs should always be addressed, unless the family doesn’t want this. We shouldn’t wait for them to ask for their needs to be met. A good change.

Definition of early intervention services. One commenter requested that we clarify in the definition of early intervention services that EIS providers who work with infants and toddlers with disabilities and their families should focus their services on ensuring that family members and children have the tools needed to continue developing the skills identified in the IFSP whenever a learning opportunity presents itself even when a teacher or therapist is not present. 

A great comment. It might even have been mine. If not, I’m claiming it anyway. The feds weren’t swayed for the following reason:

However, in addition to the reasons stated, adding language to §303.13 as requested is not necessary because the definition of EIS provider in §303.12(b)(3) specifies that such providers are responsible for consulting with and training parents and others concerning the provision of early intervention services described in the IFSP of the infant or toddler with a disability.  Additionally, this consultation and training will provide family members with the tools to facilitate a child’s development even when a teacher or therapist is not present.

They missed a golden opportunity to discuss preparation for what happens between visits.

Types of early intervention services—family training, counseling, and home visits. One commenter recommended deleting the reference to “home visits” in the title of this paragraph because the commenter considered home visits to be a method of providing a service rather than a service in and of itself… Section 632(4)(E)(i) of the Act expressly states that early intervention services include family training, counseling, and home visits.  Thus, removing the reference to home visits from §303.13(b)(3) would be inconsistent with the Act.  .

No change was made. The discussion, however, shows that OSEP still is unclear about how children learn and how services work. The paragraph following the above discussion is as follows:

The language in §303.13(b)(3) does not mean that family training must occur in the home or include counseling.  Section 303.13(b)(3) merely defines three separate early intervention services –- family training, counseling, and home visits -- that may be provided to assist the family of an infant or toddler with a disability in understanding the special needs of the child and enhancing the child’s development.

This suggests the other services, such as special instruction, OT, PT, and speech-language are not also services that may be provided to assist the family of an infant or toddler with a disability in understanding the special needs of the child and enhancing the child’s development. It implies that the some services are for direct application to the child and others are for helping the family. Not how I see it!

Furthermore, I always thought home-based was a setting but not a service. You can’t like home visits in the service section of an IFSP, can you? I hope someone can straighten me out in a comment following this post. Unclear.

Sign language and cued sign services. The phrase “as used with respect to infants and toddlers with disabilities who are hearing impaired” has not been included in the definition of sign language and cued language services in new §303.13(b)(12).

The discussion includes the point that it isn’t only children who are hearing impaired who might benefit from signing. Well done.

Speech-language pathology services. Several commenters recommended adding such services as auditory habilitation and rehabilitation, dysphagia, auditory-verbal therapy, oropharyngeal, or feeding and swallowing services to the definition of speech-language pathology services in new §303.13(b)(15) (proposed §303.13(b)(12)).

No change was made because the definition in this section is not intended to be exhaustive. Good! We already have too much overspecialization in early intervention, leading to fragmentation of services and professionals whose focus is too narrow. We also have certain subspecialty groups trying to capture the market for certain types of children. Good nonchange.

Other services. Another commenter requested that the Department revise the language in this paragraph to indicate that any other services identified in the IFSP of an infant or toddler with a disability be based on proven methods or evidence-based practices…. Discussion: Mirroring this standard, §303.344(d)(1) requires that each IFSP include a statement of the specific early intervention services based on peer-reviewed research (to the extent practicable) that are necessary to meet the unique needs for the child and the family to achieve the measurable results or outcomes identified in the IFSP.

This whole idea of services, either those identified as the regular ones in Part C or “other services,” being based on peer-reviewed research is laughable. As much as I’d like to advocate for this regulation, the services used in Part C and the way they are implemented do not have a sufficient research base anyway. But we’re not going to do away with them. So, to apply a higher standard to other services would be ridiculous. Furthermore, in the past 7 years or so, when the field started acting serious about evidence-based practices, we have become bogged down in debates about which studies are good enough to be included in analyses of EBPs and how many studies from how many research groups need to be conducted to determine a practice is evidence based. And then we have the issue of gradations of evidence-based, because we’re loath to say a practice is or isn’t evidence based. And this discussion in the regs is about services, not even practices, and everything is hugely more complicated when we have such a broad scope as a “specific early intervention service.” Correct nonchange but the regs still don’t help us get rid of bogus treatments.

Services neither required nor funded under Part C. Section 303.344(e) provides for the IFSP Team to identify in the IFSP medical and other services that the child or family needs or is receiving through other sources, but that are neither required nor funded under Part C of the Act. 

This discussion about a rather pointless comment serves as a good reminder that these other services can be listed in the IFSP and they don’t commit the Part C program to pay for them. Many states, especially where education is the lead agency, shy away from (i.e., tell service coordinators not to) list these services, in case the family thinks the program is going to pay for them, as would happen on an IEP. Good reminder.

Infant or toddler with a disability. :   We have revised §303.21(a)(2)(ii) to add  “severe attachment disorders” to the list of diagnosed conditions that have a high probability of resulting in developmental delay. 

OK, but I think states still have the right to determine for themselves who’s on their special list for diagnosed conditions. Severe attachment disorders was the only addition, among a number suggested. The list is of examples only, however, so I don’t think it really matters.

Multidisciplinary. Multidisciplinary was defined in proposed §303.24, with respect to evaluation and assessment of a child, an IFSP Team, and IFSP development under subpart D of this part, as the involvement of two or more individuals from separate disciplines or professions or one individual who is qualified in more than one discipline or profession.

Back to this issue, but now focusing on how many people should be there. Apparently, the transdisciplinary-approach haters rallied to comment on the regs, because a number of comments wanted to ensure the regs didn’t allow just one person who might be qualified in two areas (service coordination and special instruction, for example?) to replace a group, which the commenter says is explicitly defined in Part B. Commenters requested that the definition be modified to ensure that multiple perspectives are included on each IFSP Team and adequate representation is not hampered or constrained on any given IFSP Team by an individual who is qualified in more than one discipline or profession. It’s a toss-up whether representation is more hampered in this situation or in one where two people have blinkers on, with respect to attending only to areas of their narrow training.

The discussion about evaluation and assessment includes the following: With respect to IFSP Team meetings, we believe it is important for the parent to be able to meet not only with the service coordinator (who may have conducted the evaluation and assessments), but also with another individual (whether that person is the service provider or another evaluator) to obtain input from two or more individuals representing at least two disciplines and have revised §303.24 accordingly.

They want two people there. For those states using medical as one of the professions, this is not the intent of this regulation, unless the child has a chronic illness or something similar. This regulation doesn’t address how a provider could meet with the family on an initial IFSP, before services have been determined. I suppose the feds would say that then an evaluator would serve as the second person. In our model, I want states and teams to consider a most likely primary service provider (MLPSP).

Some commenters, including possibly me, wanted a reference to transdisciplinary or interdisciplinary, but OSEP said, referencing specific team models in the regulatory definition of multidisciplinary is not necessary.

Natural environments. Two other commenters recommended the definition indicate that a clinical setting could be the natural environment, particularly when the service requires the use of specialized equipment that cannot be transported to the child’s home.  One commenter expressed concern that mandating services to be provided in settings where non-disabled children are present may suggest that the alternative is less than acceptable.  Another commenter recommended that the definition of natural environments require that services be provided within family routines and activities and opposed identifying specific settings….

We expected clinic-based professionals to challenge the natural-environments provision. Fortunately, the OSEP response was We do not believe that a clinic, hospital or service provider’s office is a natural environment for an infant or toddler without a disability; therefore, such a setting would not be natural for an infant or toddler with a disability. Good nonchange.

Section 632(4)(G) of the Act provides that natural environments may include home and community settings.  However, the reference to community settings was not included in the proposed regulations.  “Community settings” was added back in. Good change.

Qualified personnel. Additionally, §303.344(g), which provides that an IFSP contain information about the service coordinator, requires that the service coordinator be selected from the profession most immediately relevant to the child’s or family’s needs or be a person who is otherwise qualified to carry out all applicable responsibilities under Part C of the Act.  

I don’t know that this is a change, but most service coordinators in dedicated-service-coordination states are not from the profession most immediately relevant to the child’s or family’s needs, so let’s hope they’re otherwise qualified to carry out all applicable responsibilities…. The feds might have been thinking about service coordinators who are also providers to the family (the blended model). But the second half of the definition of the qualification is a complete cop-out, just when we probably needed to raise the qualifications. That responsibility is probably correctly with the states, but that means we’ll have to be vigilant about which states actually make it possible for families to have properly qualified (not as defined in the regs) service coordinators. Confusion and cop-out.

Paraprofessionals. The feds continue to allow paraprofessionals to “assist in the provision of early intervention services to infants and toddlers with disabilities.” They mention certification and supervision. It’s unclear to me whether a state could allow paraprofessionals to be the primary service providers or weekly home visitors to a family. I have serious reservations about the suitability of paraprofessionals serving in that role. Missed opportunity.

I have been through all 932 pages of the regs, and the items above were the only ones worthy of mention. I might have missed other notables, so I hope readers will post comments below if they have other changes to point out. Until someone points out something different to me, the most notable change I notice is counting the service coordinator as one of the two professionals.

Writing Outcomes or Writing Goals

Are there times you write goals for a child that are not tied to specific routines? If so, can you give me an example?

Toileting for children who need to toilet at any time. They wouldn’t have actual toileting routines. People need to understand the vital importance of participation or engagement, in order for this question not to come up. Here’s the abstract to a good article by Jeanne Wilcox and Juliann Woods about the importance of participation for writing outcomes: http://lshss.asha.org/cgi/content/abstract/42/3/365. They focus on language, but the same argument can be applied to all areas of development.

We are still working from a mind set that we need to be writing goals based on provider concerns - even if the parent is not concerned or invested in the goal. We are basically saying that we should be telling the parents what they should be concerned about. I am not sure how to get past that.

Shouldn’t be allowed because it’s not family centered, as I explain below.

The basic issues are these:

1. How do we decide on an appropriate measurement if we do not break down the goal into smaller steps?

Would coming up with a breakdown of short-term objectives serve the same purpose as writing a measurement with the three criteria or should the list of short-term objectives be something in addition to the functional goal with measurement included?

The question is related to the seven steps for writing participation-based outcomes/goals, as described in the book Routines-Based Early Intervention. An example is below.

This question assumes that all skills are going to be taught in the steps in a task analysis, so the measurement becomes the accomplishment of step after step. This is an acceptable measurement method to supplement the criteria for outcome accomplishment. You see, the difference is between progress monitoring and the criteria for the END of the instruction—what answers the question How will we know when we got there—when to reassess, when to stop? The three criteria ask the questions, When is this overall skill (i.e., all the steps or a subset of the steps) needed (i.e., what routines), what level of performance is required (e.g., how many steps in the chain, what level of prompt, what frequency, what duration—whatever makes sense for the skill in context), and over what amount of time (which should be specified in any measurement system, even a task analysis one)? So it’s a false question to say it’s chaining versus our three criteria.

I am worried that those who don’t want to specify routines (a) don’t think of the necessity factor in outcomes (is it necessary?); they think more in terms of deficit—what can the child not do, regardless of context; and (b) think that professionals have to teach the child during routines, which would be difficult to do (instead of thinking that we need to be consulting with families so they can teach the child during routines).

2. How do we include professional opinion in goal-writing?

First, the rewording of the goal into a participation-based goal with three criteria is professional behavior. Second, professional opinion can go into the process of functional assessment, by the questions we ask families, the stars we highlight if we do an RBI, and the reminders of concerns we provide while the family is choosing outcomes/goals. But this requires a strong commitment to ethics, to ensure professionals are not talking parents into choosing outcomes they actually are not interested in or that are not actually functional. Third, professional input really comes into the strategies for intervention. It is a paradigm shift (sorry about the cliché) to let families make decisions about goals. Understanding whose child it is and that families need to be reinforced for the decisions they make about their children’s goals is the hallmark of a family-centered professional. Others are nice to families but don’t really trust them or care about the families’ priorities and long-term growth as parents; they are not truly family centered, even though they sometimes think they are God’s gift to families.

3. Does having a list of short-term objectives with the final objective being the end goal supercede the need to write the measurement piece?

This is partially addressed in my first answer. No, it doesn’t. If you want short-term objectives, here’s how it can work:

Joshua will participate in hanging out time and bath time by playing with a variety of toys. We will know he can do this when he plays with three toys in two hanging-out times and one bath time in a day for five consecutive days. [This is an example of a participation-based outcome with multiple criteria.]

Short-term objectives:

1. Joshua will play with two toys during one hanging-out time by October 1.

2. Joshua will play with two toys during one bath time by December 1.

3. Joshua will play with three toys during two hanging-out times by February 1.

4. Joshua will play with three toys during one bath time by April 1.

5. Joshua will play with three toys in two hanging-out times and one bath time in a day for five consecutive days by June 1.

If you have any pearls of wisdom that might help me find a way to navigate this I would really appreciate it. I fear I am just causing myself more confusion the more we go around on the subject.

Reread Chapter 7 in the RBEI book and look at the Goal Functionality Scale III.

New Discovery: Home Visits

Home-visiting or "home visitation" programs have been discovered by the early childhood community and they're the new hot thing. Obama has called for support of such programs and they are proliferating and generally gaining a lot of national attention.

On February 16 and 17, the National Summit on Quality in Home Visiting Programs: Connecting Research to Policy and Practice will be held in Washington, DC (http://www.homevisitingsummit2011.org/). Where is Part C? Nowhere to be found among the confirmed speakers.

This has been true over the past 2 years, as these programs have been created and debated. Despite the fact that over 70% of the Part C children are receiving their most important service in the home, we are by and large not at the table with these Johnny Come Latelies.

To give credit where it's due, David Olds and his nurse home visiting model have been around for a long time, but they do not operate at nearly the scale of Part C home visits. Should we be at the table with these other programs or are we so fundamentally different that we're relieved to be excluded?

This is an important question the early intervention field needs to contend with. Amazingly, when the evidence base about home visiting programs is discussed, the conclusion is that it is ineffective. These findings primarily came out of the old Abecedarian Project and the Infant Health and Development Program, where these disadvantaged-family home visits were largely discredited, compared to intensive classroom-based programing.

But think of the different nature of those home visits from Part C home visits. Whereas disadvantaged-family homes visits often involve quite didactic interactions between trainers and parents, early intervention home visits, when done well, are designed to provide emotional, material, and informational support to families. The support is aimed in part at addressing specific, measurable family-chosen goals. I'm not trying to make Part C home visits sound better. Both types are designed to help with parenting.

So do we want early intervention to be associated with these increasingly popular home visitation initiatives? It seems peculiar for these programs not to learn from the history of over 25 years of early intervention home visits. But we also don't want the association to be so strong that we shy away from our special obligation to work on IFSP outcomes/goals.

It just seems peculiar to have a national summit on home visiting with no representation of Part C in it.

Toddler Groups

I have recently been asked to comment on toddler groups. This was the situation:

I am currently part of a committee that includes staff from our Early Intervention Program and we have been given the charge to explore ways to provide integrated developmental groups for toddlers receiving services. To date this attempt has not proven successful due to a number of factors including low rate of reimbursement, ratios, and trying to come up with incentives for parents to pay to bring their toddlers to such a group.


There’s probably a good reason families have been reluctant to take their toddlers to a group: They don’t see the value, especially when taking the hassle of getting there into consideration. The argument that groups would give families more options would only be valid if it were an option they valued. Most states and local programs have considered them more from a logistical, staff convenience standpoint. A few staff can be at one location, and families can do the traveling, and we can “serve” multiple children at once. In addition to the potential spuriousness of the option argument, the assumption that peer interaction opportunities should be provided by the early intervention program should be questioned. First, toddlers don’t need to interact with peers; as you know, developmentally, the best we can expect in 2-year-olds is parallel play and attentional engagement with peers, with occasional bursts of associative play. Especially when the children might have developmental delays, the argument that it’s good for them to be in groups for a few hours a week is pretty weak.

The amount of time is another issue. We know that experiences in small amounts of time are less valuable for little kids than they are for adults, who can benefit from short (e.g., 1 hour) weekly sessions.

In some states, groups have been discouraged or even disallowed. In other states, people are using them as you describe. Still others have a hybrid, where toddlers get together a number of times a week (e.g., two to four) for short periods (e.g., 2 or 3 hours). Even at 4 days x 3 hours, this is 12 hours. No one knows whether this is long enough to have a meaningful effect, but we do know that it’s an inconvenience or even hardship for families to take their children on this kind of schedule. It makes it very difficult for working families, for example.

Is there a way you could make a group effective? If it were designed primarily for emotional, material, and informational support for families, it has a chance. I have published on taking a support-based approach to home visits with the same three types of support. At the group, families could spend time with each other, which some families really like. They could get information about the four things families typically want information about: child development, resources including services, their child’s disability, and, most important of all, what to do with their child (i.e., interventions). The materials support could come from equipment, toys, diapers, food, clothing, and so on, provided by both the program and some families themselves. If the group of families wanted to meet as a group, they could rotate who plays with the children in an adjacent room, ensuring appropriate ratios, furnishings, toys, and so on. If they wanted to make it more like a gaggle of parents talking while playing with their children, they could do that. As professionals or even other parents make suggestions about how to do something with a child, they can demonstrate with the child, but the hands-on with the child is for the purpose of supporting the family, not with a false premise of actually teaching the child at that time.

Why would families like this option? Perhaps to get out of the house and to meet other parents. They might also want to see how their child acts around other children, but we should be very careful not to insinuate that peer interactions before the age of three are necessary. If we take this preparing-for-the-next-environment to its logical conclusion, before you know it, we’ll be teaching babies to hold crayons, to sit on carpet squares, and to wash their hands, because that’s what they’ll have to do when they reach toddlerhood.

Therefore, you can see that I don’t believe child-directed groups are theoretically sound, effective, or a good use of resources.

How to Address Autism From a Natural-Environments Perspective: Talking to Parents

I address this thorny issue by showing you an adapted version (for confidentiality reasons) of some correspondence I had with a mother of a 3-year-old who was about to be diagnosed with autism. The parents were already thinking about what services might be appropriate for their child. It’s unfortunate that the way we provide early intervention and early childhood special education emphasizes type and amount of service rather than type and amount of support or intervention.

The mother described her child, whom I knew somewhat, as having challenging behaviors, poor expressive language—even gestural, self-stimulation, mild but extremely pervasive self-injurious behavior, apparent lack of pain sensation, poor direction following, rigidity, and failure to play with toys as intended. To me, behaviors related to engagement, independence, and social relationships are more important than the diagnosis. She had requested 10 hours a week of applied behavior analysis: “I want him to be able to get the services/help that will benefit him the most. I am afraid if he doesn’t start getting services [there it is again] it will be harder for him in the future.”

MY RESPONSE

In my opinion, 10 hours of traditional ABA would not be enough to address the problems you’ve described. He probably needs more hours of contingent learning (what ABA tries to do), spread out through the day, in the contexts where he needs to learn skills and behaviors. Discrete-trials training, which is what traditional ABA is, tends to be decontextualized and to have poor generalization to meaningful routines. But the principles of ABA (systematic reinforcement of desired behavior, stimulus control, data-based instruction) would probably be helpful for Kenny, regardless of diagnosis. He’s still a little kid, so applying methods for older children are at best inappropriate and ineffective and at worst robbing him of his childhood. But your description makes it clear he needs to be taught to play and function as a kid. If you think the autism diagnosis/label (only MDs and licensed psychologists can diagnose) would help Kenny get appropriate services, I can see why you’re anxious to explore that. I, however, wonder whether that’s true. It’s not services that make a difference, it’s intervention. Do you see the distinction I’m making? You probably want to specify the most effective interventions for him and then see what services can provide them, but note that parents don’t have the right to mandate methods (interventions) in the IEP world, whereas they can advocate for services. So my suggestion is to base your decision about what services you go after on the types of interventions they would apply. The law pretty much forces us to think backwards.

I have a picture of Kenny’s spending at least his school day and possibly much of his home time, if it’s not too disruptive to family life, where (a) there is a at least one clear goal for what he is being taught in each routine (i.e., activity or time of day); (b)where those goals increase his participation, engagement, independence, communication, or getting along with others; (c)where the rate of systematic incidental teaching is high; and (d) where one or two goals are addressed through precision teaching in context. This is doable but requires the team to be smart, organized, and creative and always respectful of Kenny’s developmental age and interests of his parents’ priorities.

Do you see then what I mean about the 10 hours of ABA not being enough? I have seen it used to teach discrete trials out of context; the child doesn’t learn to generalize the skills to nonteaching times; and the other adults in the child’s life can’t use the same techniques for a host of reasons. The child then displays great “gains” in highly particularized areas—those the discrete-trials training addressed (e.g., sorting colored objects into correct little trays), suggesting the method is highly effective. Meanwhile, the child’s engagement, independence, and social relationships might not have improved or even have deteriorated. So it all depends on how applied behavioral analysis is used. (Full disclosure: I am a behaviorist, with a degree from one of the most behavioral master’s programs in existence, and a teacher of board-certified behavior analysts.)

Forgive me for sounding as though I really know Kenny and his specific needs. I’m speaking on the basis of your description of him, what you say you want for him, and what I have seen with hundreds of other children with similar characteristics, whether they have the autism diagnosis or not.

The mother then asked me what specific interventions to request at the IEP meeting.

WHAT TO WORK ON

I received your message about specific interventions to request at the IEP meeting. To elaborate on what I said about more than the 10 hours a week of traditional ABA, it seems that Kenny needs to be working on engagement (this is a big issue in autistic-like behaviors and it is what a child should be doing instead of self-hitting or -biting), independence, and social relationships. Social relationships consist of communicating and getting along with others. I don’t know the specific goals Kenny might have but they should generally fall into these categories, because these categories are pretty much what is functional for young children, especially those with disabilities. Furthermore, they apply regardless of disability. I would say that they apply for Kenny. You all and the IEP team might need to get at the specifics. So that’s the deal about what to work on. Now let’s talk about when to work on them.

WHEN TO WORK ON GOALS

I don’t know Kenny’s classroom schedule but they are using the zone defense schedule, which tells me the day is broken into 15-minute increments, except possibly for nap time. So let’s assume Kenny is in the room for 3 hours before nap (i.e., 9-12) and 3 hours after nap (i.e., 2-5). That’s 24 fifteen-minute intervals or activities. In each of those, we should aim for about 4 incidental-teaching contacts and for a minimum of 5 minutes engagement. The 4 comes from research Amy Casey and I have done showing this is a feasible rate. The 5 minutes of engagement is equal to 33% of the time, which is low, according to numerous studies of ours, but might be ambitious for Kenny right now. Incidental teaching is a form of ABA in which an adult addresses engagement, independence, or social relationships—including specific goals on Kenny’s IEP—by getting him engaged, responding to his interest, eliciting more sophisticated behavior, and ensuring it was reinforcing. Engagement time can range from low-level engagement, such as doing things repetitively (but not perseveratively or “stimming”), up to high-level engagement, such as solving problems, communicating with language, or making something. Now let’s multiply: 4 incidental-teaching contacts x 24 activities or “routines” = 86 learning opportunities. In incidental teaching you count learning opportunities rather than trials, which is what you count in discrete-trial training or traditional ABA. A learning opportunity can involve one or more discrete trials, but they are in context, making each one more salient than a decontextualized “trial.” Multiplying engagement amounts, we would have 5 minutes x 24 routines = 120 minutes or 2 hours a day. Multiply this by 5 days and we have the same number of hours as 10 hours of ABA a week, but the engagement time is (a) in playful contexts—and Kenny’s still a little kid, (b) delivered by Kenny’s familiar caregivers (i.e., teachers), and (c) spent learning meaningful skills.

SERVICES AND PLACEMENT

Therefore, if I were you (I’d be exhausted), I would request continued classroom services at his current program, with systematic incidental teaching being used in each routine to address engagement, independence, and social relationships. That means that, before you talk about services, you need to make sure you have good functional goals that get at these areas of development. I believe you’ve completed the MEISR, which should help with goals. As for therapies, the best value they provide is guiding the teachers and you all (i.e., Kenny’s regular caregivers) about how to elicit the desired behaviors during incidental teaching. The OT would have ideas about how to elicit his self-help and maybe some fine motor skills. The SLP would have ideas about how to elicit his communication. But ultimately we need the teaching staff and you to own those intervention ideas so you can use them 24/7 so to speak. Therefore, you might not need a high intensity of these services. After all, how much information do the teaching staff and you all need, week in and week out. You don’t want the therapists working with Kenny directly, even though everyone says parents should try to get the most therapy possible; you want them working with the teachers, so Kenny gets even more intervention than he would if the therapists worked directly with Kenny. At the IEP meeting, the most you can really talk about is the frequency and intensity of different services, not the approach used: That’s beyond the purview of parents’ rights.

I hope this gives you something to go on. I’ve tried to give you as much information as possible while leaving room for you to determine the specific goals. You’ll notice that this approach involves individualizing intervention for Kenny, meeting him where he is, with his strengths and needs in specific routines, rather than thinking of him in terms of a specific disability or conglomeration of disabilities. I also want you to know that I’m not pushing his existing program over other settings, although I would “push” a normalized, developmentally appropriate setting over a clinical, decontextualized setting. It just so happens that his existing program provides the former.

The parents liked this approach: After all, they want the best help for Kenny, which does involve lots of intervention. It’s just that that intervention needs to be distributed throughout the day and has to be meaningful. We are going to document how many incidental-teaching episodes occur per routine and how many minutes of engagement per routine he has.

RBI With Recent NICU Graduates

Question: I work specifically with families that have babies coming out of the NICU. They most times are eligible based on an established condition due to being “at risk” for developmental delay. They don’t always have delays or the family doesn’t have concerns. In talking about our program at the initial visit we emphasize supporting them in their daily activities and routines, however during the interview everything is fine. This often results in a struggle to develop IFSP outcomes. I will say when there are clear concerns and issues it is much easier to develop routines based outcomes.

Answer: The two important things to remember are that this is a plan for the family, not just the child, and that it’s about what child skills come next. So, as you’re going through the day, make sure the interviewer is asking the parent about what would make that time of day easier or better for him or her, what the parent’s hours from Hell are, and what things the parent would like to be doing that he or she hasn’t been able to figure out. When asking about child engagement, independence, and social relationships, find out what the child is currently doing of course, which will be quite rudimentary for a child just out of the NICU. The questions then aren’t about what the child isn’t doing but what he or she will do next. This requires interviewers really to know their infant development. As options for what the child will learn to do in each routine get listed, they should be starred on the notes. As you know, these are then recapped, and the family is prompted to pick them as outcomes, if necessary. Between desires for what the parent wants to be doing and the myriad things the infant will learn to do, you should end up with a pretty meaty IFSP.

If you haven’t seen these books, they might be of interest: Working With Families of Young Children With Special Needs and Routines-Based Early Intervention. They both have chapters on the RBI.