Making Teams out of Individuals

Early intervention for infants and toddlers in some communities is almost devoid of teamwork, even though multiple people might be in the on-paper team for a child and family. The on-paper "team" is simply the list of people providing services. If those people come from different agencies or are sole providers and they each do their own thing, they aren't a true team.

In my book Routines-Based Early Intervention, I discuss virtual teams, which are very much like what M'Lisa Shelden and Dathan Rush call geographically based teams. See their books on the primary service provider and on coaching.

This is how it works: Professionals from different disciplines, often education/child development, OT, PT, and SLP, and different agencies agree to form a team that will use evidence-based practices and the primary-service-provider (PSP) approach. Any member of the team can serve as the PSP for a child and family. All members of the team agree to support each other. In Shelden and Rush's model, they actually attend meetings together. They sometimes go on joint home visits with the PSP. The secondary service providers don't make separate visits: That defeats the purposes of the PSP approach.

Azusa, Laurie, and Tania

Each team member bills back to his or her respective agency, insurance company, Medicaid, and so on for their services. They have an agreement with the service coordinators to have the referral go to the team, so the team, not the service coordinator, decides who the PSP will be.

The thorny question becomes who decides on the individual services, with frequency and intensity: the service coordinator or the team? Ideally, the team does, with the family, and they inform the service coordinator. In this ideal world, the service coordinator trusts the team because they're using a transdisciplinary model and therefore not piling on services. Technically, however, the service coordinator is responsible for completing the IFSP, so this arrangement can become a power issue.

The different agencies involved in the virtual team (perhaps as many as four) need to approve this approach, whereby their people are sometimes the primary and sometimes the secondary. It shouldn't be an issue, because they bill for every visit, regardless of role. In some places, though, you can't bill for each person's hour of service on joint home visits ("co-treats"--dreadful term; "co-visits"). Some people know how to be flexible with this approach, essentially ignoring the other person at billing time, whereas others are sticklers and have to agree to payment for half the time.

The virtual or geographically based team is a great way to restore teamwork to early intervention, but it requires individual professionals to take the initiative and get it done. It also requires service coordinators to cooperate and help.

The Real Spanish-Translation Confusion in the RBI

My last post was about translating “worry” and “change”: A bit of a nonissue, really. It turns out that wasn’t’ really the issue. The real issue was indeed a thorny one—the difference between “concerns” and “worry.” In Spanish, preocupación would typically be the word for both. You will see in a minute why the same word for both could be a problem.

When conducting the RBI with fidelity, the interviewer keeps track of concerns, usually by starring them (i.e., drawing a star or asterisk in the margin). We train interviewers to notice concerns, indicate them, and then refer to them during the recap. The recap is the quick reminder of the main points—or “concerns”—that came up during the interview. Therefore, the interviewer or note taker goes through the starred items (i.e., concerns) to help the family remember them when they decide on outcomes/goals. We don’t actually use the word “concerns” with families, which might be part of the answer to the question about translation. But first, let’s review when “worry” crops up in the RBI.

Immediately preceding the recap, in fact right after discussion of the last routine of the day, the interviewer asks the “worry and change” questions. The worry question is, “When you lie awake at night, what do you worry about?” You can see that, if the interviewer has just asked the parent what she worried about (¿Qué te preocupa?) and then the interviewer or note taker says he or she is going to review her preocupaciónes, the parent might well think, “I just told you what it was.” If the interviewers use the same word for worry and concern, it could be confusing for the parent.

The answer is don’t use preocupación to refer to the starred items. Even in English, as I mentioned earlier, it’s best not to use “concerns”: It sounds too heavy. In English, it’s better to say, “Now I’m going to go through the things that came up at each time of the day.” (Notice the avoidance of both “concerns” and “routines,” another potentially confusing word.) Therefore, in Spanish, it would be something like, “Ahora voy a enumerar las cosas que usted mencionó en cada momento del día.” 

Worry and Change RBI Questions in Spanish

One of our RBI certified trainers has an interpreter telling her that the worry and change questions have the same words/meaning in Spanish.  She has trouble presenting the questions because she doesn’t know how to distinguish between the two. 

Actually the questions are quite different in Spanish, as they are in English.  "When you lie awake at night, what do you worry about?" is


--Cuando te quedas despierta por la noche, ¿qué te preocupa? (There's a more formal version that interpreters would know.)

"If there's anything you could change in your life, what would it be?" is

--Si hay algo que podría cambiar en tu vida, qué sería?

Spanish speakers will recognize that the operative concept in the first question is preocupación, and in the second question it's cambio.

Some RBI Questions and Answers

Some RBI Questions and Answers

RBI trainers have asked three questions about conducting Routines-Based Interviews. First, how do you conduct an interview with both parents present?

Principles you should follow when interviewing both parents:

1.      Make eye contact with both parents when asking questions. Look at the person replying and not at the other person during the reply.

2. Accept both parents’ responses.

3. We’re not trying to get at the truth: We’re trying to get at whatever parents want us to know.

4. In routines where only one parent is present, ask only that parent about those routines.

5. The RBI isn’t worth fighting over.

This question usually arises when interviewers are afraid of conflicting answers, which are actually very rare. Nevertheless, people should know how to handle them.

During the ecomap, if one parent says he or she gets a lot of support from someone and the other parent says he or she doesn’t, draw both kinds of lines.

If the answer to “What happens next?” is different, tell the parents you’ll discuss both and tell them which one you want to ask about first. Remember, then, to ask about the other one right afterwards.

If the parents contradict each other about what happens in a routine, say, “It sounds like sometimes [this happens], and sometimes [that happens]. Right?”

In outcome/goal selection, write down both people’s ideas, if both are contributing. If one parent says that one is not important, ask the parent who suggested it whether it’s still important to him or her. If it is, write it down and say, “I’ll just write them all down and then you all can decide on the most important ones.”

During prioritizing, if the parents disagree, see if they can come to agreement. If not, say it doesn’t matter and get each parent’s priority order, separately. But don’t have two sets of outcomes/goals.

Apart from disagreement, a problem for some interviewers is lack of participation by one of the parents. That’s the parent’s choice. You should continue to look at both parents when asking questions. You can ask follow-up questions to only the parent who provided the first answer.

A common problem when interviewing both parents is time management, if both parents contribute much. Managing time is an essential skill in conducting the RBI, regardless of the number of parents. Interviewers will know that the solution is to skip some routines and, when the parent becomes repetitive, to interrupt as politely as possible.

In general, keep it simple. It’s just a conversation with a couple of parents about their family life and the child’s engagement, independence, and social relationships. Keep the five principles above in mind.

The second question is What about a grandparent who tries to take over? Specifically, the question was when the parent of the child was a teenager, but the issue can occur even for older mothers (or fathers).

Principles you should follow when interviewing two generations:

1. Figure out who runs the household and respect that person’s role.
2. Respect the parent’s response, regardless of his or her age or other characteristics (e.g., intellectual capacity).
3. Figure out who is the main caregiver and teacher of the child in each routine and pay more attention to that person, while keeping Principles 1 and 2 in mind.

It’s not easy to juggle these principles, and it’s simplistic to say that the parent’s point of view should always take precedence. If the grandparent has the power in the family or is the actual caregiver of the child in a given routine, you have to listen to that person’s perspective if you want the resulting plan to be meaningful.

Some of the same issues as interviewing two parents, discussed above, come up when interviewing any two people in a family. Again, remember that most two-generation interviews are free of conflict, but it is possible to have a domineering grandparent. Don’t alienate that person by trying to ignore him or her or to shift the balance of power too obviously.

Sometimes, the ongoing support person, such as the weekly home visitor, will find out that one or the other of the parties has a hidden agenda. For example, I’ve known parents who have told me, out of earshot of the grandparent, that their biggest goal is to get out from under the grandparent’s (their parent’s) thumb. Similarly, grandparents have sometimes taken me aside to tell me that they have serious reservations about the caregiving the parent provides. These have been goals that didn’t come up during the RBI. That’s OK. 

The RBI does not necessarily get what caregivers want: It is designed to get what they want to tell us, as we discuss daily routines.

Remember, when interviewing two-generation families with a domineering grandparent, the three purposes of the RBI:

1. To obtain a rich and thick description of child and family functioning;
2. To establish a positive relationship with the family (not just the parent); and
3. To leave with a meaty list of functional outcomes/goals.

Don’t overcomplicate these two-generation interviews. We’re not trying to resolve differences in an RBI. We’re just trying to achieve the three purposes just mentioned.

The third question is What do you do with Hispanic families who want to know why you’re asking so many questions? Be very careful about questions like this! People assume the RBI works differently for Anglo families from Latino families and from Native American families and so on. It’s a thin line between being culturally sensitive and stereotyping families.

Principles to follow in this regard are

1. Don’t discriminate against anyone on the basis of their cultural background by denying them access to the RBI;
2. As with all families, “read” them as you’re proceeding through the interview;
3. Most families of all cultures are eager to talk about their day to an expert who is really interested; and
4. The interviewer’s style is far more likely to make a family comfortable with the RBI than is the family’s cultural background.

The known characteristics of many Latino families can have an impact on the RBI. One cultural variable is respeto—the importance of children respecting their elders (Barker, Cook, & Borrego, 2010). It sometimes carries over to families’ beliefs that lay people should not question professionals. A well-conducted RBI should obviate this issue, however, because the professional is not providing information; he or she is seeking it. Respeto can sometimes account for parents’ saying what they think the professional wants to hear. The interviewer should not become distressed about that. Remember that we are trying to find out what parents want to tell us, not the Truth (capitalized on purpose).

A second Latino cultural variable is personalismo—the desire to get personally close to the professional (Barker et al., 2010). Parents might want you to hold their child or they might ask you about your own family. What a great problem! Let’s not assume that Latino cultural variables are all challenges. On the contrary: Anglos could learn from many of them. Self-disclosure: I was born in El Salvador, spent my early childhood in South America, my father’s family lived in South America continuously for 50 years in the 20^th century, and I speak Spanish (sort of). So I have some familiarity with Latino culture. Ironically, however, some doubters about the cultural validity of the RBI are themselves Hispanic, but that doesn’t legitimize their concerns. Their concerns might reflect their own awkwardness with asking detailed questions, which is one of the most common learning-curve problems when developing RBI competence, regardless of the culture of the professional or the interviewer. In Portugal, a Latin country, the RBI is well accepted as being not only culturally appropriate but actually a good match for families’ love of talking about their families. This brings up also the caution that not all Latinos are alike for two important reasons. One is that their countries of origin are distinct. Mexicans, Puerto Ricans, and Cubans, to name only three, do not like to be thought of as one culture. The second reason Latinos are not all the same is acculturation (Barker et al., 2010). Families differ in the extent to which they hold on to beliefs and ways of being from their country of origin versus taking on Anglo or American beliefs and ways of being. Barker and colleagues point out that families differ in the amount of acculturation stress they feel—how difficult or easy it is for them to adjust to life in the U.S. These variations within Latino families demonstrate why it’s important not to overgeneralize about their comfort with the RBI.

Another Latino cultural variable that can have an impact on the RBI is machismo—the idea that the man is in charge(Barker et al., 2010). The wise interviewer will try to ascertain if this is a strong dimension of the family being interviewed. If the father is present, some of the challenges discussed in the first two questions above need to be met. If the father is absent during the interviewer, the interviewer might question whether the father (or grandfather) will support the resulting outcomes/goals. It’s actually not as big a deal as you might think, because often with the machismo culture comes a willingness to let women take care of child rearing. Furthermore, marianismo, in which women are venerated as pure and noble (as in the Virgin Mary), is a cultural value that is often part of machismo. Although some Anglos might not be comfortable with these ideas, they actually don’t interfere with successful RBIs, if the interviewer is competent.

In sum, interviewers should be culturally sensitive but they should not see the RBI as a culturally restrictive tool. It should be considered universal. Latinos do not, as a group, have problems with detailed questions any more than Anglos do. It all depends on how you ask them.

Have fun interviewing couples, two-generation families, and Hispanics. They make interviews fun.

Barker, C. H., Cook, K. L., & Borrego, J. (2010). Addressing cultural variables in parent training programs with Latino families. Cognitive and Behavioral Practice, 17, 157-166.

Visible Learning

What works in education? Ah, but how well does it work? No, but how well compared to other things does it work? What are the most effective influences on achievement? What about all the things we wring our hands over that actually make trivial although positive differences (class size) or have no effect (learning styles)?

A work friend of mine, Teletha, put me on to "visible learning," John Hattie's meta-analysis of meta-analyses of effects on education for children and youth ages 4-20. I don't know whether Hattie has employed good criteria for the GIGO problem in meta-analysis, let alone meta-meta-analysis: garbage in, garbage out. This means that you don't want to include bad studies in your meta-analysis, so you have to have inclusion and exclusion criteria for the studies.

His point about a positive effect size is one that many researchers understand, but some policy makers might not (and some researchers don't understand, and some policy makers do): The purpose of an effect size is that it gives you a range of the magnitude of the effect and does not rely on a cut-off point, like the p value associated with the null hypothesis statistical test does. So I don't get too technical, perhaps you should look at this web page for an explanation of Hattie's logic: http://www.learningandteaching.info/teaching/what_works.htm.

He needs to be careful not to use .4 as a cut-off. Nevertheless, the point is well taken, especially when you understand the concept of standard deviations. Hattie has found that the mid-point of effects on educational achievement is .40 (40% of a pooled standard deviation), so effects less than that are relatively weak to the effects above that. And effects are on a continuum with a common metric, so you can tell how much more effective one variable is than another.

Now it's time to show you a couple of 15-minute videos of "visible learning." Part 1: http://www.youtube.com/watch?v=sng4p3Vsu7Y&feature=related. Part 2: http://www.youtube.com/watch?v=lS_AackYwEo&feature=related.

The RBI and Speech-Only Children

Why should we do a Routines-Based Interview for children whose only need is related to a speech or language delay? After all, the RBI is lengthy and addresses much more than the presenting problem. More efficient methods exist for identifying speech or language goals.

Four reasons explain why the RBI is a good practice to use with “speech-only” children. (This colloquial label violates the person-first rule and is used to acknowledge my familiarity with early-intervention team vernacular!)

1. Early intervention is supposed to be more than a rehabilitation or remediation service. The purposes of early intervention are to support the family and other natural caregivers in promoting the child’s development just to provide a service to tackle those things that have gone wrong. It is supposed to address all areas of child development and family functioning, including and especially parenting.

Speech-only children are developing in other areas beyond those identified as deficient or delayed. They are learning to play, to solve problems, to move, to handle increasingly small and complicated objects, to get along with others, and so on. The ticket into early intervention is admittedly an established condition or a delay, but, once in, the program has an obligation not to put on blinders and address only the deficits.

Whether the early intervention system should pay for services addressing typically developing areas of development is a matter of public policy. From child development and family systems perspectives, addressing nondeficit areas is appropriate even for single-deficit children. In child development, to promote children’s language, we know it is helpful to promote their overall engagement. In family systems, we know that family members have many opportunities to work on children’s speech and language throughout every day. Therefore, it is not inappropriate for public funds to be used for promoting skills other than the deficient ones.

Another developmental reason for taking a broader view to needs assessment (i.e., conducting an RBI) is that children with speech or language delays might have behavior problems. Research has documented these areas are associated with each other more often than would be expected by chance. Therefore, we should conduct needs assessments for speech-only children that assess engagement (i.e., appropriate behavior) across the day.

The last issue related to the purposes of early intervention is that speech-only children have parents and other family members who might need support. An effective way of finding out what kind of support they might need is to conduct an RBI. This procedure helps identify whether they need emotional support, material support, or informational support, whereas traditional speech or language assessments do not identify support needs adequately.

2. What’s the best way of addressing a child’s speech-language goals? The most effective and efficient method for providing interventions to young children is to embed interventions into everyday interactions, activities, and routines. To do this, the team of people designing the interventions (i.e., the family and professionals) need to know what happens currently in routines and what the desired behaviors are (even if they are primarily about speech or language). Understanding the concept of goodness of fit, when children have speech or language deficits that means that the demands for communication and social interaction in different routines and the abilities or interests of the child do not match well. In other words, meaningful participation in a routine might require the child to speak clearly and, if the child doesn’t yet have the ability to speak clearly, a functional problem ensues. Now we have three options: (a) change (i.e., teach) the child, (b) change the routine, or (c) change your expectations. This goodness-of-fit approach requires us to assess routines in a way best accomplished by the RBI.

3. Do we really want to discriminate against speech-only children and their families? The RBI is heartily endorsed by families, has been shown to be effective, and is valued by many early intervention programs around the world. To deny families with children with speech or language delays the opportunity to participate in an RBI is discriminating against them, therefore, on the basis of the child’s specific disability.

4. The RBI helps determine the functional needs that arise because of the child’s speech-language deficits. Often the existence of a delay is determined, appropriately, by a norm-referenced measure, so that a person can say with some confidence that the child’s reported or observed speech or language is behind what would be expected for a child of that age. What it does not tell us is how this impairment affects functioning. If it did not affect functioning—if the child lived on a desert island, being raised by friendly animals who did not have conventionalized communication (so we might have to rule out chimpanzees), the deficits might not be important. Who cares? So-called normal communication isn’t needed. But usually there is some functional impact of a speech or language impairment. In fact, often the functional impact is what precipitates a referral to early intervention. To obtain an environmental scan of the current and potential impact of the impairment, an RBI is ideal. It addresses the everyday contexts of the child’s life, which are more varied and challenging than life on a desert island.

Without everyday context, the documented deficits could become “speech” goals that have no relevance to specific times, people, places, or activities. Therefore, children can be working on their final-th sound (e.g., both, bath, Beth, cloth) completely devoid of a reason to be using this sound. Although decontextualized instruction can be used with older children, it is usually very difficult to use effectively with young children. But many therapists and teachers try.

The final issue about functionality is that speech goals, as distinct from language goals, are actually about speaking so as to be understood. People familiar with my model will recognize these as the controversial “artic” goals—where we wonder why so much attention goes into articulation therapy when articulation is not resolved until children are in elementary school. But of course I do recognize that families want to be able to understand children and that children want to be understood when they speak. All children go through artic training by their natural caregivers, but some children still have great difficulty making themselves understood. So understandability goals are very relevant. The RBI can help figure out who needs to understand the child, when, where, and about what. Further assessment, usually by a speech-language pathologist, can help identify what specific problems the child might have, such as a structural or tone problem, which might guide what the intervention options are.

So, when you wonder why you’re going to all the trouble of doing an RBI with the family of a speech-only child, remember it’s because early intervention is supposed to address the whole child, it’s the best way of identifying speech-language goals, it’s discriminatory to deny an RBI to any specific group of families, and it helps determine functional needs.

Parenting Website

Check out raisingchildren.net.au, a terrific website for parents and the professionals who work with them.