MENTAL SHIFT 4: ANYONE SPENDING TIME WITH THE CHILD HAS THE OPPORTUNITYTO TEACH THE CHILD

Children learn from those around them, but there must be a threshold amount of time. Or perhaps the time spent is correlated with the impact one can have on the child. The mental shift in this post is from thinking that intervention comes from people who spend short amounts of time and not from those who spend long amounts of time.

The work of Mary Beth Bruder, Carl Dunst, and Carol Trivette on "learning opportunities" has documented that ordinary routines in a child's life are where learning naturally happens. And the work of Tom Weisner and Cindy Bernheimer has shown that everyday routines are the chunks of time that families construct to make their lives work, and that these ecocultural niches are the context of child and family development.    

The discussion here is about substantial time. I've used 15 hours a week as an informal, unscientific criterion for deciding whether a caregiver should be included in a Routines-Based Interview (RBI). If the relationship between time spent and influence on child functioning is linear, those spending fewer than 15 hours a week can't be said to have no influence. The issue becomes one of efficiency. If the amount of influence is small, then it's not worth their time or ours to be interviewed. Families, however, can always have anyone they like at the RBI.

Who spends substantial time with the child? Almost always the custodial adults, such as parents. Custodial adults, therefore, are the parent figures in the child's life, so, from now on, I'll just call them "parents." Adults who are responsible for care of the child, perhaps while the parent is working, also spend substantial time with the child; these are child care providers or preschool teachers, for example. 

What about influential people who don't spend the requisite amount of time, such as grandparents. They can give children enjoyable times, new opportunities, special moments, and so on--all of which can create memories, if the child is old enough. But early intervention should focus on those adults who are around during the everyday routines: They have enough teaching opportunities distributed through the day that can make a difference. Furthermore, they're teaching when, where, and with whom the child needs the skills. By teaching in the moment, the child is learning to respond to the naturally occurring "discriminative stimuli." When someone walks in the room, the child learns to say hi. That's a lot better than repeating hi in multiple trials in an early intervention session with a professional. Children can learn context-specific behaviors that reinforce the adults in charge of those contexts, and here I'm talking about the short-time caregivers, such as visiting grandparents or early intervention professionals. The child can learn not to touch the ornaments at Grandma's house or to take his seat in the therapy room. The issue now is one of functionality. How do these help with the child's functioning in everyday routines? If they generalize, fine, but young children, especially if they have developmental disabilities, do not transfer well. If the adult also "transfers," then you get a bit more bang for your buck. For example, if an early intervention visit focuses on the parent interacting with the child, perhaps practicing how to teach the child something during a routine, the parent can then use the same task directions and prompts during regular life. Therefore, because the adult generalized his or her strategies from the short-time session to the long-time real life, the child has a chance of learning the skill.

In the Routines-Based Model, early intervention supports (i.e., services) are aimed at the long-time adults, usually parents and teachers. In future MENTAL SHIFT posts I'll discuss how we provide those supports.

MENTAL SHIFT 3: CHILDREN ARE LEARNING FROM THEIR CAREGIVERS, WHETHER YOU WANT THEM TO OR NOT

Continuing the mental shifts necessary to provide functional, family-capacity-building early intervention, here I discuss the fact that caregivers are teaching their children already. So what is the role of early intervention (birth-6)?

We are building on the foundation caregivers (parents and teachers) have already established with the child. As Vygotsky pointed out early in the 20th century, children learn from other people who do things at a little more advanced level than they do (i.e., in the zone of proximal development). Obviously, adults are way more advanced, but, when they're teaching children, they elicit behaviors that are minor advancements to the child's existing behaviors. If they're too advanced, the child doesn't learn them well. If they're not advanced enough, no learning occurs although the child might get in some practice. Similarly, when we work with adults, our best efforts should involve ideas for tweaking what the adults are already doing. This is for a different reason from why we work only in the child's ZPD. With adults, it's more about homeostasis: Adults tend to develop their ecocultural niches that are not terribly malleable.

As the research of Bruder and Dunst has shown, learning opportunities abound in families' lives. Some families make the most of these opportunities and others are possibly unaware of their impact on their children's learning and development. In research conducted through the NICHD, one of the best predictors of children's outcomes at age 16 years was the quality of mothering they children received when they were infants. This was also true for those infants in full-time child care. Parenting makes a difference.

As early interventionists, therefore, we don't go into homes with the assumption that we're going to train parents to teach their children. Rather, we know they are already teaching their children, and we're helping them figure out (a) why the child is or isn't doing something in the course of everyday routines, (b) what strategies can be added to the routines (i.e.,  things parents can do in their existing routines) to help the child participate more meaningfully or competently, and (c) whether or not those strategies worked. These are essentially the three stages of Sue Sheridan's conjoint behavioral consultation. Early intervention is indeed a consultative process--the good, collaborative consultation, not the bad, expert consultation.

When we realize that families have already created the "teaching space" in their routines, our job is easier, more relevant, and more acceptable to families. Furthermore, we're expanding the family's capacity to teach their children by reinforcing it and building upon it. When an early interventionist creates new routines (e.g., heaven forbid, play time on the floor with select toys), it doesn't acknowledge the family's existing ecocultural niche. It sends the opposite messages: either you're not teaching your child or what you're doing isn't good enough.

Families' belief systems about their parenting role vis à vis teaching the child or their sense of self-efficacy in that role can be a factor in what we do in early intervention, as the following table shows:

 

	Parents who don’t intentionally teach their child very much	Parents who intentionally teach their child a lot
Early intervention works directly with the child	Parents are reinforced in this belief; we need professionals to teach the child	Parents might believe what they do is not enough
Early intervention builds the family’s capacity	Parents become more aware of the teaching they do and increase the amount	Parents’ self-efficacy and confidence are increased, thus sustaining and even expanding their teaching

Implementation Stages

From the Encyclopedia of Social Work (http://socialwork.oxfordre.com/view/10.1093/acrefore/9780199975839.001.0001/acrefore-9780199975839-e-949)

I've posted a new vlog at www.mcwilliamconsulting.com on implementation stages for adopting the Routines-Based Model. You can also see it at https://youtu.be/5GeOgsxOoZY.

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.

The Age of Empathy

In the Harvard Business Review, Rita McGrath has written about the three great ages of management: execution, expertise, and empathy. The execution era was the one when the organization was a machine. The expertise era was the one when executives went from controlling others to coaching them. McGrath argues that we are now in an era when organizations look “to create complete and meaningful experiences”—era of empathy. 

Empathy extends to customers or consumers but also to employees. Implicit is the idea that management occurs through networks rather than through lines of command. What does this mean for human-service organizations? I propose that it has the following implications.

First, the CEO, president, or director, whatever the title of the top dog, coordinates and integrates decision making, rather than takes input and makes a decision. The sham of participatory decision making, which some CEOs don’t even know to claim, is that the subalterns participate in providing input but actually don’t participate in the decision. In integrated decision making, the team members (e.g., a “leadership” or “management” team) propose decisions and defend them. As decisions are discussed, (a) the team reaches a consensus, (b) the president concludes what the majority decision is, or (c) the president decides which decision is the most evidence based. Unfortunately, still, in many organizations, none of these factors leads to the decision.

Second, the director is more like an anthropologist than a director. He or she explores the culture and makes decisions that advance the service within the context of that culture. In one situation in which I found myself, the CEO paid attention to one cultural group, the board of directors, but not to other cultural groups: families (consumers), the community, and the staff. Self-preservation or COA (covering one’s posterior) is hardly a commendable trait. Today’s administrator should see what’s good for society, however large or small that might be, but I’m referring to the organization. The first priority should be the consumers (children and families), second should be the staff, and third should be community. The last priority should be the president and the board, but that takes possibly uncommon ethics, honor, and confidence. I’m optimistic enough to believe that if decisions are made from a place of empathy, the results will be good.

Third, the era of empathy suggests that organizations’ leaders should function transparently. A very few topics need to be handled discreetly, but a common problem is the director confiding in just one person, amazingly often the finance director. I know the temptation. In an administrative job I once had, I found myself in alliance with my budget person, often against my faculty. The budgetary pressures led to this unfortunate alliance, but I was operating as though we were still in the age of execution, where the budget person and I knew what was best and we exercised control over others. In the age of empathy, leaders should think first about how actions will affect others. 

Circular arguments abound in the leadership of nonprofit organizations, as they do whenever people have to make decisions about what’s best for someone else. In child custody cases, for example, judges make decisions about what’s “in the child’s best interest,” as though that were independent of the parents’ interests. An amazing lack of understanding about family systems theory. And judges rarely consult good research to help determine the child’s best interest. In organizations, CEOs and their sycophantic finance directors justify decisions similarly as being in the “best interest of the organization.” But when those decisions are made secretly, with false arguments to the board, and without empathy for consumers, staff, and the community, it’s difficult to agree they’re in the best interest of the organization.

Of course the easy argument is an economic one. Let’s cut out the thing that costs the most or returns the least, economically. Which is why a business mentality doesn’t work in the nonprofit or academic world. Because that thing might be the best thing going for the organization in terms of quality, reputation, or the overall well-being of the organization. If it is costly, then empathetic leaders (directors, deans, and board members) would realign resources to support that thing.

How is the theory of an “age of empathy” relevant in a leader’s feeling threatened by one or more faculty or staff members? Empathy is probably a convenient word beginning with e, to match execution and expertise. Those of us who grew up in the hippie or just-post-hippie era remember Leo Buscaglia, who wrote, “Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.” Do they teach this in MBA programs? An empathetic CEO is not going to be threatened by someone with heart, intelligence, and drive. Rather, he or she would embrace this person as a strong ally, would learn from this person (ah, but that takes humility!), and would seek this person’s counsel. 

Buenos Aires last week

In conclusion, the age of empathy might be here but some organization leaders aren’t. Board members would be well advised to understand that empathy (genuine, not a histrionic facsimile) is a valuable trait in a president. Presidents would be well advised to practice empathy, to appreciate that relinquishing pride, self-interest, and secrecy actually open up the organization to a state of well-being. Staff would be well advised to determine whether their leaders operate from a place of empathy and, if not, and if they can afford it, leave such a situation. Consumers would be well advised to make the same determination and, if not, make a fuss to the board or whoever controls the purse strings. The time of empathy in management in human services has arrived; it probably arrived a long time ago. We should perhaps now be paying attention to it.