Routines-Based Practices to Replace Center-Based Services

In the next 12 posts, I shall describe shifts in thinking that have to occur to bring about family-centered, functional services—essentially the Routines-Based Model (RBM). Shifts in thinking are nothing without shifts in practice, so I will also mention practices that can either follow or precede thinking. The fact that the order is unimportant should be heeded. We know from Tom Guskey’s early work on attitudes towards mainstreaming that you can’t wait around for buy-in to occur. Sometimes, you have to employ the Nike principle to achieve buy-in.

In the U.S., we have come to take some practices for granted, such as the value of home visits. Yet, home- and community-based early intervention is not global. Even in the U.S., in some states, therapies are still provided in clinics, whereas “developmental therapy” (a term applied to either special instruction or family training) is almost always provided in the home or the child’s group-care facility.

Center-based services is a term I usually try to avoid, because “center” can apply to a classroom or an office. Here, I am using it to refer to an office; it’s what I usually call “clinic-based services.”

Administrators and advocates bemoaning practitioners’ use of passé methods as a failure to secure buy-in might be missing the boat. If you want people to do something, tell them to do it. It probably is true that to use the Routines-Based Model well, your heart has to be in it—you have to believe in this way of doing business. But the way to get there might not be to pump up the buy-in activities like communities of practice, publications, or posts. It might be to provide a structure for the practices you want.

Why do people practice early intervention the way they do? Most early interventionists didn’t pick up a book and follow the directions there. (If they wanted to, they could do worse than looking at Routines-Based Early Intervention, Engagement of Every Child in the Preschool Classroom, or Working With Families of Young Children With Special Needs.) Most people in the trenches are doing what their bosses or their colleagues told them was the way we do things around here.

In my 12 posts, I aim to highlight some assumptions undergirding “clinical” or professional-centered practices and to present some new assumptions. The overall paradigm shift (a term unfortunately overused), when all 12 aspects are attended to, is the adoption of a procedure for providing early intervention for children 0-6 and their families. This procedure involves treating families with informal respect, providing families with opportunities for meaningful decision making (e.g., the goals on the intervention plan), and meeting families’ needs even if indirectly related to the child; in other words, the procedure means being family centered. The 12 mental shifts required include rethinking professional roles with each other and with the family, rethinking authentic assessment and progress monitoring, rethinking goal selection, and rethinking the outcomes of early intervention.

The paradigm shift throws a spotlight on quality of supports. For too long, early intervention and, in the U.S., early childhood special education have focused on how children get in (eligibility), what services they get, and, in the past 10 years, how they are rated in three broad outcomes relative to their peers. Family outcomes have also been required. But attention to what exactly was going on in home visits, in visits to child care programs, and in preschool special ed has been lacking.

The first mental shift, coming in the next post, is All the intervention occurs between visits.

Real Alignment: Routines-Based Model and DEC Recommended Practices

Practices in the Routines-Based Model are directly aligned with just over half (53%) of the 2014 DEC Recommended Practices. They are indirectly aligned with a further quarter (26%) of the Recommended Practices. This model, therefore, is a useful vehicle for implementing most of the Recommended Practices.

The Routines-Based Model (RBM) is a way of providing early intervention and early childhood special education, focusing on naturally occurring routines, on family strengths, and on children’s engagement. Some of its well-known components are the Routines-Based Interview (RBI), the ecomap, the primary service provider, support-based home visits, collaborative consultation or integrated therapy, incidental teaching, and the zone defense schedule. The model provides guidance on both home- and classroom-based service delivery, serving children birth to 6 years of age and their families.

The DEC Recommended Practices (Division for Early Childhood, 2014) were developed to provide guidance to practitioners and families about the most effective ways to improve the learning outcomes and promote the development of young children, birth through five years of age, who have or are at-risk (sic) for developmental delays or disabilities. (p. 2)

My colleagues and I have been developing and refining the RBM since the 1980s, so some practices, such as the RBI, predate DEC Recommended Practices—even the original ones in 1991. All RBM components predate the current (i.e., 2014) Recommended Practices (McWilliam, 2010; McWilliam & Casey, 2008).

To determine the real alignment, not to be confused with wheel alignment, of the RBM with the Recommended Practices, I determined whether each of the latter was directly addressed by an RBM component, indirectly addressed by the RBM, or not addressed by the RBM. The Recommended Practices, which can be downloaded from http://www.dec-sped.org/recommendedpractices, are organized in eight topic areas.

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Leadership

Most of the recommended practices in this area are not linked to the RBM, which tends to emphasize practitioner-level practices. But our use of implementation science and our methods for program evaluation are linked to the practice related to collaboration with stakeholders on the collection and use of data (L12). Also, our use of the primary service provider (PSP) is directly linked to promoting the efficient and coordinated service delivery from multiple disciplines (L13). The model is indirectly linked with L3, L6, and L9.

Assessment

The RBM addresses needs assessment for program planning, monitoring child progress, and measuring child outcomes, so it is aligned with all but two of the assessment recommended practices (A1, A8). The major assessment tools in the RBM are the RBI (McWilliam, 2012); the Measure of Engagement, Independence, and Social Relationships (MEISR) (McWilliam & Younggren, in press); the Classroom MEISR (ClaMEISR) (McWilliam, 2014); the Children’s Engagement Questionnaire (McWilliam, 1991); and the STARE (Casey & McWilliam, 2007). All of these are directly linked to working as a team with the family (A2) but less so with other professionals. They are also directly linked to conducting assessments that include all areas of development (A4). The RBI and STARE are directly linked to using a variety of methods including observation and interviews (A6). The RBI, MEISR, and ClaMEISR are directly linked to obtaining information about the child’s skills in daily routines (A7), systematic ongoing assessment (A9), and assessment tools with enough sensitivity to detect child progress (A10). The model is indirectly linked to a further three recommended practices (A3, A5, A11).

Environment

The RBM is linked, mostly indirectly (E2, E4, E5, E6), to all the environment recommended practices. The Engagement Classroom Model, which in a previous form was known as the individualizing inclusion model (Wolery, 1997), along with support-based home visits and participation-based goals, directly addresses services and supports in natural and inclusive environments (E1). Family consultation addresses working with the family and other adults to promote children’s participation (E3).

Family

The RBM is linked to all but one family recommended practice (F8). The RBI and family consultation directly address building trusting and respectful partnerships with the family (F1). Support-based home visits are directly linked to four recommended practices. Along with our mantra that we have an ethical obligation to provide families with evidence-based information, they are directly linked to the practice that says almost exactly that (F2). Through family consultation, support-based home visits are directly linked to supporting family functioning and promoting family confidence and competence (F5). By incorporating the five parenting skills in our model, these home visits are directly linked to engaging the family in opportunities that support parent knowledge and skills (F6). The emotional-support component of the home visits is directly linked to being responsive to the family’s concerns, priorities, and resources (F3). The RBI is directly linked to creating outcomes and goals that address the family’s priorities (F4). The RBM is indirectly linked to two family recommended practices (F9, F10).

Instruction

The RBM is linked, mostly directly, to all the instruction recommended practices. All the assessment tools mentions earlier are directly linked to identifying each child’s strengths, preferences, and interests (INS1). The RBI is directly linked to identifying skills to target for instruction with the family (INS2), and, with incidental teaching, planning for and providing the level of support the child needs to participate in routines (INS4). Incidental teaching is also directly linked to embedding intervention within and across routines (INS5), using systematic instructional strategies to promote child engagement (INS6), and using explicit feedback and consequences (INS7). The STARE and goal attainment scaling are directly linked to gathering and using data to inform decisions (INS3). The focused RBI and our behavior-management strategies are directly linked to using functional assessment and related strategies for challenging behaviors (INS9). Participation-based goals are directly linked to implementing the frequency, intensity, and duration of instruction (INS10). Finally, family consultation is directly linked to using coaching or consultation strategies with primary caregivers (INS13). The RBM is indirectly linked to three instruction recommended practices (INS8, INS11, INS12).

Interaction

The RBM is directly linked, because it includes incidental teaching, to all the interaction recommended practices. With our focus on engagement, it is directly linked to promoting the child’s social development (INT2). Our focus on social relationships, along with incidental teaching, is directly linked to promoting the child’s communication development (INT3).

Teaming and Collaboration

The model is linked also to all the teaming and collaboration recommended practices, although not all directly. The PSP and associated joint home visits are directly linked to representing multiple disciplines (TC1) and working with families as a team to exchange information (TC2). The PSP is also directly linked to identifying one practitioner from the team who serves as the primary liaison (TC5). The RBM is indirectly linked to two other recommended practices (TC3, TC4).

Transition

The RBM is not linked to either of the transition recommended practices.

If the DEC Recommended Practices can be considered the most effective ways to help young children with disabilities and their families (I wish they included families in the outcomes of the practices, not just in the implementation of the practices), this real alignment validates the model. The model has other components that aren’t directly aligned with the recommended practices, and one fifth of the recommended practices aren’t addressed by the model. Nevertheless, the alignment is good enough to say that the RBM can keep early intervention 0-6 on the road and not in the ditch.