MENTAL SHIFT 7: What matters is how children function in their everyday lives.

Function = participation = engagement = learning

Yes, children should learn about the world, learn to move, learn to speak, learn to manipulate objects, learn to solve problems, learn to get along with others, and learn to take care of themselves. The curriculum of early childhood is clear. It shows up in state early-childhood standards, in tests, in curricula, and in parents' expectations. The question is What's the best way for children to learn this material? Or perhaps the philosophical question is whether this curriculum is what we aim for, or is it the natural outgrowth of normal development? Maybe we just made it the curriculum, because it's what we saw happening in early childhood. The outcome.

This question has bigger implications than you might think. If it's what children "should" learn, then adults will move heaven and earth to teach children these skills. It also becomes the framework for assessment and individualized program planning, usually based on the child's deficits. If a child is behind in one or more of these areas, those become targets for intervention. This can lead to making the child do what he or she is no good at.

If the areas of learning I outlined above are the outcome rather than curriculum, then we know children learn the content at different paces and in different ways and sometimes not at all. We call that developmental disability. Interesting.

Now let's turn our attention to how children learn best. If we take a curricular approach to functioning, as I mentioned above, we might be tempted to take an academic approach; I use that term to refer to the "academy"--the school, with lessons and a fair amount of adult direction. If we take an outcome approach, we let learning happen, supposedly naturally, which sounds almost as frightening. The classic constructivist philosophy endorses this approach. If the child is a curious, active, intelligent being with a good environment, naturally occurring learning will be fine. But if the child has inherent difficulties in learning or a poor environment, we need to pay attention.

So what do we change? We can't cure the biophysical condition, including what's going on in the brain--at least not efficiently. Brain science does claim we can restructure brains, but--and here's the kicker: We do it by changing the environment. The environment is comprised of social, nonsocial, and temporal conditions around the child. Included in the social environment are the interactions the child has with adults or even other children--interactions that can enhance or impede learning. The nonsocial environment includes safe or unsafe spaces, things to play with (they don't have to be toys), places to move around in or on, and so on. The temporal environment has to do with the sequence of routines, which in some families is predictable and in others is not.

The quality of the child's environment for enhancing learning is what Bruder and Dunst have discussed in their work on learning opportunities.

Mental Shift 7 is about understanding that learning does happen in everyday routines. If a child is functioning in a routine, it means he or she is participating meaningfully, whether cuddling with the mother at wake-up time, eating independently at breakfast time, helping to get dressed at dressing time, putting on shoes at going-out time, pointing at trucks in the car ride, playing independently during dinner preparation, using words or signs at dinner time, playing with a parent during hanging-out time, putting a washcloth to the face at bath time, or turning pages in a book at bedtime. And I listed only one of a score of skills a child could display in each routine--and there are more routines than these. A child's day is full of learning opportunities--of opportunities to participate meaningfully. When a child is so participating, we say the child is engaged. And if the child is engaged, the child can learn. As Dunst, Trivette, and I wrote (on papyrus, I think) back in 1985, a child cannot learn if a child is not engaged.

We do want children to learn and we do want them to function in their environments. Fortunately, these two things go together, joined by participation and engagement.

MENTAL SHIFT 6: Parent Failings Don’t Exist; Only Professional Ones

Readers will scoff at the idea that adult family members with whom we work have no faults. I agree that most humans—in fact, those I appreciate the most—are flawed. But this way of thinking about parents—that they don’t have failings—the failings are ours—is a helpful one in early intervention for children with disabilities birth to five.

This post continues the list of mental shifts required to move from a clinical approach to a family-centered, functional approach. It continues the theme of Mental Shift 4 on the dangers of passing judgment on parents. 

What are some parent behaviors early interventionists might see that could lead some professionals to view them as failings?

1.      Ineffective behavior management.

2.      Unresponsiveness to the child.

3.      Inadequate care of the child.

4.      Unfriendly behavior towards the early interventionist.

5.      Substance abuse.

6.      Unhealthy personal habits.

7.      Constant conflict with others.

In the Routines-Based Model, we try to uncover why some of these things occur and what we can do to help. Some of them occur because parents don’t have another frame than the one they’re using for interacting with their child, caring for him or her, or their own eating and sleeping habits. In this case, one role of the early interventionist is to present options to families. When it comes to parenting behaviors, however, models close to the family’s demographic work better than models far from their demographic. And often the divide between parents and professionals is wide, in terms of race, ethnicity, educational level, income, and so on. 

When parents really are “failing,” as in inadequate care of the child, we need to follow our state guidelines for reporting, of course. But if it hasn’t reached that point, we need to develop our relationship with the family so we can be honest with them about what needs to change. When families know you have their best interest in mind (e.g., keeping the family together, ensuring the child gets what he or she needs), they will take what you have to say. If, however, they sense you’re passing judgment and pitting children against parents, they won’t take what you have to say.

Piper and Lola

When parents have their own issues, such as substance abuse, crazy relationships with food, and unhealthy habits generally, the early interventionist is in a difficult position. First, he or she has to consider whether the parent’s behaviors are putting the child at risk. Second, the professional needs to embrace the challenge of seizing the moment if the parent expresses a need related to one of these issues. For example, if the parent says, “I probably shouldn’t drink as much as I do,” the early interventionists should follow up with questions about whether the parent wants help drinking less and whether the parent feels the child is in danger when the parent is drinking. It’s impossible to script out what to do, because relationships differ, but the closer a professional gets to a parent, the more likely it is the parent will talk about these issues. 

When the issue is a so-called personality issue, such as the parent being constantly confrontational, again carpe diem. If the parent gives a bit of an opening, such as, “I don’t understand why everyone assumes I’m hostile,” the early interventionist could say, “Perhaps that’s because you end up yelling at people every time you talk to them.” If the professional has a good relationship with the parent, he or she might be able to say such a thing. If the relationship isn’t good, the statement would be considered hostile in itself. 

In general, professionals need to take responsibility for helping the family when they appear to be “failing.”

MENTAL SHIFT 5: Passing Judgment on Parents is a Self-FulfillingProphecy

Perhaps nothing characterizes a family-centered approach to early intervention more than being nonjudgmental. This characteristic is not just about early intervention of course: It is central to the idea of inclusion and acceptance.

Stockholm 2016

What behaviors or attitudes of parents might lead an early interventionist to pass judgment? The categories could be (a) parenting, (b) lifestyle, (c) so-called personality, and (d) implementation of interventions.

Parenting. Early intervention is essentially a parenting program, so, when parents engage in parenting behaviors that early interventionists might think are ineffective or even bad, it seems almost part of the job to do something about it. Ineffective parenting might be getting the timing wrong on reinforcing a child's behaviors, behavior management strategies that actually reinforce the behaviors parents don't want, or giving children tasks too difficult for the child's developmental level. Many other examples exist. "Bad" parenting might be things we know are not good for kids, either from research or from our own professional experience. These things might be corporal punishment, poor feeding, and providing the child with a physically unhealthy environment. One of the mantras of the Routines-Based Model is We have an ethical obligation to provide parents with information. If we see parents engaging in ineffective parenting and we have information that would help them meet their own goals, we should give the information to them. Meeting their own goals is important. For example, if the parents let the children graze all day, you might know this could cause a problem at meal time and, possibly, lead to obesity. Should you say anything? As always, begin with a question, such as, "Is it OK with you that he grazes all day?" If the parent gives an answer that essentially indicates yes, you can follow it up with, "Do you have any problems with his eating his meals?" If the parent says yes, you have the opening to provide information about the problems with grazing. If the parent says no, just be patient. An opening might come up later. It could be that the child causes a mess when grazing, for example. There's your opening.

Lifestyle. Parents in early intervention might lead their lives very differently from the early interventionist. They might be messy or neat freaks. They might spend all their time in front of the television or they might be constantly on the go. They might be loud and raucous or they might be quiet and withdrawn. They might be rich or they might be poor. Any deviance from the early interventionist's own way of life could lead to judgment on the part of the professional.

Personality. Parents might have behavior patterns in their interactions with others (i.e., a "personality") that's difficult for the early interventionist to deal with. Some parents are friendly, others are withdrawn. Some are sarcastic, others are sugar-sweet. Some are rough around the edges, others are cultured. Some are bitter, others are happy. This is where reframing is particularly helpful.

Withdrawn = thoughtful
Sarcastic = funny
Rough around the edges = down to earth
Bitter = cautious

Implementation of interventions. Perhaps nothing irks an early interventionist more than parents who don't implement interventions the professional thought the parent was going to implement. In the Routines-Based Model, we professionals take responsibility for that situation. We must not have arrived, jointly with the parent, at a feasible intervention. So we need to ask more questions, working with the parent to find out whether the parent really wants to work on that problem and, if so, what other solutions might work. By taking responsibility, we quickly avoid passing judgment on the parent.

Is it acceptable to pass judgment internally as long as I don't act on it? To some extent, acting nonjudgmental is what's important. By continuing to practice nonjudgmental behavior, the mind can follow: You will become less judgmental. On the other hand, if you harbor judgment about a parent, even if you don't say anything, the parent might sense it. The pursed lips, the lack of response, the tone of voice.... Parents are smart: They'll pick up on it. Understanding that we can't tell people how to think, we are left with guidance about how to speak and write about families, not to mention how we work with them. I'm reminded about the privilege I had of working at the Family, Infant and Preschool Program (FIPP) in Morganton, NC, in the mid-1980s, when Carl Dunst was the Director. The culture of the program was such that no one said negative things about families, even back at the office. Our peers would correct us if we used judgmental language, such as saying a parent was in denial.

The relationship with the parent gives you leeway. Our language is perceived as judgmental, in part because of how we say things but also because of a lack of trust. If the parent hasn't developed a good relationship with us and we say something--even just ask a question--the parent might think we're passing judgment. But if we're like a friend to the parent, the very same statement or question is perceived as a friendly, helpful gesture, because the parent trusts us. It's another reason to work always on building and maintaining a positive relationship with the family. Furthermore, if we really like the family, we are less likely to be judgmental, so the positive cycle of nonjudgmental behavior is enhanced.

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.