On a given day, you might have anywhere from 2-6 visits with families. If you step back and reflect, how do these visits typically work? There may be a similar way you begin or end your visits. You may find yourself conducting visits in the same parts of the home across visits or asking similar questions of families. Would you say that there is a “culture” to how you practice EI?

The article below challenged me to look at EI from a cultural point of view. We talk all the time about how individualized EI must be in order to be most effective, but the reality is that the way in which home visits are conducted is often similar across providers. Having a similar framework for visits doesn’t preclude individualizing; it seems to me that this could be fine line, though.  Visits could be conducted in such a similar, even predictable manner that the ability to individualize to child interests, family routines, or changing priorities becomes challenging. Or, having a similar, cultural framework across visits could provide the stability needed to allow the provider to individualize. Read on and see what you think.

Source: Brorson, K. (2007). The culture of a home visit in early intervention. Journal of Early Childhood Research. 3(1), 51-76. (PDF, New Window)

Research: What Do We Know?

Brorson (2007) conducted a qualitative study of one EI program to examine how services were delivered. Four families and seven service providers participated in the study. Families and providers participated in multiple videotaped observations of visits and multiple interviews. A review of program documents was also conducted. Results revealed information about the structure of a typical home visit, values and beliefs of providers, and program philosophy.

Typical Home Visit – Brorson noted that the typical home visit included eight parts: 1) planning,  2) greeting, 3) activities, 4) observation, 5) demonstration, 6) shared knowledge, 7) follow-up, and 8) scheduling.

Beliefs of Providers – Providers espoused a belief in collaborative, family-centered interactions with parents, but this was not seen in observations of visits, interviews, or in the reviewed documents. Instead, providers were observed to educate rather than reciprocally collaborate with parents.

Program Philosophy – Brorson described five assumptions that appeared to guide staff in the delivery of services. These assumptions were:

• Structured activities provide the frame for the visit and the means through which the family learns what to expect.
• The culture of a home visit is stable across families, providers, treatment techniques, etc. This stability is established by how the provider conducts visits, which tends to be similar across families though does allow for individualizing.
• Delivery of EI services “is in a constant state of change requiring therapists to become perpetual learners.” (p. 64)
• Providers play a leadership role during visits in educating families about the culture of visits.
• Providers have their own individual definitions of family-centeredness (rather than a shared understanding and implementation).

Because this study only focused on a single program and a small sample of families and providers, generalization is not really possible. However, insights learned from this study can be used by providers and program administrators to reflect on the culture of how EI is provided in their programs.

Practice: How Can You Use What You Know?

Yes, this article is older now, but I think that the insights learned in this small study are fascinating. Let’s think about these insights and how they might apply today:

Typical Home Visit – These 8 parts of a visit look very familiar to me, especially when I think of a more traditional model. When I compare these parts to more recent thinking related to caregiver coaching and collaboration, a few important pieces appear to be missing – the opportunity for the caregiver to be in the lead and practice using strategies with the child, reciprocal reflection and feedback, and joint planning for what happens between visits. Spending a few minutes reflecting on which of these parts and pieces of a visit typically happen on YOUR visit could help you identify your strengths and where you’d like to improve.

Beliefs of Providers – We all are pretty sure we understand family-centered practices, but do our understandings match with the literature? Do we practice what we preach? On your visits tomorrow, pay attention to how much you actually collaborate with the parent. Are you doing most of the talking and the work during the visit, or are you sharing the conversation and collaborating to support parent-child interaction?

Program Philosophy – If we accept that we play a leadership role with teaching families how to interact during visits, then that reminds us that families probably don’t start out knowing what they are supposed to do. Remember to take the time on your first few visits to help them learn how the process works. Educate them in the importance of their active participation and practice during and between visits. You may do this the same way across families, but does that mean that all visits should basically look the same? I don’t think so. Your methods may be similar, and your underlying philosophy maybe similar across families, but the activities of the visit should look different – if you are individualizing to child and family interests, environments, and priorities and joining family routines.

So here are the questions I’d like you to consider in the comments below:

Is it okay for your visits to basically work the same way across families? Why or why not?

If you espouse family-centered intervention beliefs, are you implementing them?

How would you describe the culture of visits in your program? In your individual practice? Does it match with Brorson’s findings? If not, how is it different?

Disclaimer – I’m a big believer in calling visits “intervention visits” rather than “home visits.” This reflects the evolution of practices in our field from focusing on the home as the location for EI to focusing on intervention, which can happen anywhere. I used “home visit” in this post to match the language used in the Brorson (2007) article, but in my happy little world, we’re moving away from that phrase to something more reflective of recommended practices. 🙂

The post Research to Practice Brief #6: Home Visiting Beliefs and Practices appeared first on Early Intervention Strategies for Success.

In your busy day, there’s often very little time to stop and really think about what you’re doing. Instead, you just “do” what needs to be done. In Virginia, and in many states, early interventionists (EIs) are working very hard to adopt coaching practices as a means of interacting with families. When you do stop to think about it, you may think, yes, I use coaching all the time. Or, you may think that you’re trying very hard to coach but find that some coaching strategies are easier to use than others. Research is emerging that is seeking to find out which coaching practices early interventionists are actually using. There are some interesting trends that may give you pause as you consider your own work with children and families.

Source: Salisbury, C., Cambray-Engstrom, E., & Woods, J. (2012). Providers’ reported and actual use of coaching strategies in natural environments. Topics in Early Childhood Special Education, 32(2), 88-98.

Research: What Do We Know?

Salisbury, Cambray-Engstrom, and Woods (2012) conducted a small study of six early interventionists in one state. These interventionists had been receiving professional development in the Family Guided Routines-based Intervention (FGRBI) approach for over two years.  The FGRBI approach describes a group of coaching strategies that include: conversation/information sharing, observation, problem-solving and planning, demonstration, joint interaction, caregiver practice with feedback, guided practice with feedback, and direct teaching. These strategies are used by EIs during visits with families to promote development during targeted routines and activities. To determine how much these providers were using the FGRBI coaching strategies, the authors coded 90 videos of intervention visits that occurred over a 4-month time frame. They also analyzed contact notes for each visit to determine whether there was a match between the coaching strategies described in the notes and those that were actually used.

Interestingly, the authors found that the coaching strategies used most were conversation and information sharing and engaging in joint interactions with the family. The strategy used least often across providers was problem-solving with the family, which was used in less than 1% of the intervals coded from the videos (researchers looked for these strategies to occur during each 30-second interval of time). About 20% of intervention visit time was spent with the provider interacting with the parent and child using strategies such as direct teaching, demonstration, caregiver/guided practice with feedback, and observation. Overall, providers used a range of coaching strategies but tended to under report the specific strategies they used when describing the visit in a contact note.

The authors noted that the practices the providers used most often were those that placed the flow of information from themselves to the parent, rather than placing the parent in more of a leadership role. This group of providers used coaching strategies more frequently than what has been reported in other studies, perhaps because this group had received extensive training. Even so, the use of the strategies was still limited, which the authors interpreted to mean that shifting to use caregiver coaching can be challenging, even for well-trained EIs.

Practice: How Can You Use What You Know?

Because the study sample was so small, we really can’t generalize these results to the larger EI population. However, a provider or a program can reflect on these results to see if there are similarities with their own experience. Here are a few ways you can use what you’ve learned:

Consider how much problem-solving you actually do with families – This is the most interesting finding to me and has been confirmed in a few other articles too. Families have also said that the most valuable thing that happens on EI visits is problem-solving with the provider. Yet, it appears that we don’t do it very often. On your next 3 visits, pay attention to how you respond when the parent mentions a problem. Do you immediately offer suggestions, or do you take the time to help the parent problem-solve a solution that works for her?

Consider sharing leadership during a visit – Who leads most of the activities of the visit? Who leads the interactions with the child – you or the parent? If you find that the answer to both of these questions is YOU most of the time, then use this insight as an opportunity to look for ways to share leadership. As often as possible, step back and let the parent lead, with you in a supportive role.

Be intentional in facilitating the parent’s practice (with the child), problem-solving, reflection, and feedback – Sharing leadership means that you are supporting the parent as she practices using  strategies with the child, reflects on the experience, gives and receives feedback, and problem-solves to plan for how to use the strategy between visits. Look for opportunities at EACH visit to use these specific coaching strategies because they directly support the parent’s learning.

Be sure you capture all that you do in the contact note – You’ve heard it before: if it’s not written down, it didn’t happen. You have limited time to get your notes done, but use that time to accurately capture the variety of coaching strategies you use. Be specific and use the language of coaching to describe your interactions with families.

Which coaching strategies do you think you use most frequently? Which do you need to target to use more often? 

What do you think contributes to how much problem-solving occurs during visits?

Share your insights and experiences in the comments below!

Want to know more about the FGRBI approach? Check out the FGRBI website for information, tools, and videos!

The post EI Research to Practice Brief #5: Which Coaching Strategies Do We Really Use? appeared first on Early Intervention Strategies for Success.

Where are your practices on the traditional vs. participation-based continuum?

Wherever you are on the continuum, take some time to examine the similarities and differences between the two interventions, reflect on your own practices, and plan for how to evolve your work to a more evidence-based approach. This brief provides a summary of research by Campbell & Sawyer (2007), who examined videotaped intervention visits to determine differences between traditional and participation-based intervention. One significant finding: parents and children are more engaged in general, and with each other, when intervention focused on the child’s participation in daily routines, rather than targeting missing skills. When parents and children are engaged, intervention is more likely to be meaningful, useful, and successful. Read on to learn more about how you can use participation-based intervention practices in your work with families.

Source: Campbell, P. H., & Sawyer, L. B. (2007). Supporting learning opportunities in natural settings through participation-based services  (PDF, New Window). Journal of Early Intervention, 29(4), 287-305.

Research: What Do We Know?

The authors of this study examined 50 videotapes of “typical” visits from early interventionists from a variety of disciplines. Videos were analyzed using the Natural Environments Rating Scale (NERS) and the Home Visiting Observation Form (HVOF) to determine differences between traditional and participation-based intervention. Traditional intervention included learning activities planned by the interventionist that targeted specific skills, with the interventionist working directly with the child. In contrast, participation-based intervention focused on helping the child participate in naturally occurring learning opportunities and teaching caregivers how to interact with their children using intervention strategies to support participation. Strategies were incorporated into family routines and activities because they provided the context for the child’s participation. A primary differences between the two types of intervention were what roles the interventionist and the caregiver played in the service. The authors provide a detailed table in the article comparing the two types of intervention (p. 290).

Based on the review of the videotaped visits, the authors concluded that more visits showed traditional practices (70%!) than participation-based practices, which is consistent with other EI literature. Despite what we know from the literature – that traditional practices are not most effective – they persist. When participation-based practices were used, children were more frequently rated as “very engaged” and the child or parent was more likely to be the leader of the activity. The interventionist acted more frequently as a facilitator with the parent-child-interventionist triad rather than providing more direct, child-focused intervention. Interventionists providing participation-based intervention engaged in more observation, used more modeling and verbal support, and focused more on the parent-child interaction. There was more caregiver involvement in general and more interaction with the child, with less time spent in a more passive role. In both types of intervention, materials in the home were used and play provided the context of triadic interactions between the parent, child, and provider. There was, however, a statistically significant difference between what occurred during traditional and participation-based intervention.

Practice: How Can You Use What You Know?

What practices can you start using to provide more participation-based intervention? Here are a few to get you started:

Videotape a few of visits – Use a similar method as was used in this study. Videotape a few visits (with parent permission) then compare your work with the table on pg 290 in the article. Reflect on whether your practices are more traditional or participation-based and why. This could be done individually, with a supervisor or mentor, or as a group staff development activity.

Step back and let them lead – Let go of your plan for the visit and let the parent and child lead. Try this with new families, or explain to a family you have a relationship with that you’d like to try something different. Keep the IFSP outcomes in mind and look for opportunities for learning and participation in whatever routine you find yourself in.

Spend more time actively observing – This was an important difference between the two approaches. Rather than “doing,” spend more time watching. Use what you learn from watching to provide guidance and support to help the parent adapt the routine so that the child can learn from it.

Focus on caregiver-child interactions – That’s where learning happens. Shift your focus from what you think YOU need to what the PARENT can learn to do.

Let go of assessment skills – What we learn at the assessment is important, but don’t let it be the guide for your intervention. Look at the bigger picture. How do children learn to use a pincer grasp in everyday life? Yes, the child isn’t standing in the middle of the floor for 5 seconds, so how can she learn this kind of balance while helping her dad rake leaves? Keep your eye on the prize – learning while participating in real life.

Where are you on the continuum? If your practices are more traditional, what’s your next step for becoming more participation-based? If you already focus on participation, what advice to you have for others?

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A new pediatric practice has just opened in your city and expressed an interest in meeting with staff from your EI program. This practice identifies itself as a “medical home” for children and you wonder, “What does that mean?” As far as you can tell, the physician and her staff are very interested in building a collaborative relationship with your program, individualizing care, and providing coordinated, family-centered services. You think, “Hmm, the way they operate sounds a lot like how WE operate…this could be the start of a great relationship!”

Clinical Report: What Do We Know?

According to a recently published clinical report in the journal of Pediatrics entitled, “Early Intervention, IDEA Part C Services, and the Medical Home: Collaboration for Best Practices and Best Outcomes,” the medical home process involves a way of providing family-centered primary medical care (Adams, Tapia, & the Council on Children with Disabilities, 2013). The authors of the article point out that the medical home process has much in common with the key components of early intervention, including focusing on early identification and referral of infants and toddlers with delays and disabilities, tracking of development, making sure that services are accessible to families and responsive to their needs, building community partnerships to boost coordination, and providing continuous monitoring to ensure that services are appropriate. Even the idea of the natural environment crosses both processes, with the physicians understanding that development happens during daily activities so intervention will be most effective when focused there. Both processes also use coaching to help families learn to meet their own needs and both require active participation from everyone to be successful.

Practice: How Can You Use What You Know?

The commonalities between the medical home process and early intervention are so important because, as the authors describe, both have been found to be effective in making long-term positive changes in children’s health and development. The authors of this article provide an overview of current evidence-based practices in EI, focusing on why services are provided in natural environments using coaching methods with families. This is important for physicians to understand so that they can help families know what to expect of early intervention and can assist families with monitoring the child’s services. Physicians are also some of our greatest referral sources so we want them to understand why we operate the way we do.

With this article in mind, here are a few practical strategies for how to use what you know:

Make time for your physician referral sources – If possible, schedule a meeting several times a year with the physicians in your area to talk about how EI works in your program, to plan for collaboration, etc. Be sure to take a treat or a token of thanks for their support!

Send a copy of this article to physicians in your area with a tea bag & a note – Send a nice note saying that you thought he/she might enjoy this article over a cup of tea. Offer to collaborate and invite the physician to call you with any questions or suggestions for how you can work together better.

Invite physicians to join an intervention visit or IFSP meeting – You might be surprised so extend the invitation. Reach out to a nearby medical school. I recently heard about a program in Northern VA where medical residents regularly join visits – how awesome is that! There is nothing like seeing intervention in action to help you understand how it works!

What strategies do you use to collaborate with physicians in your area? Have you worked with any physicians who use the medical home process? Share your ideas and experiences!

For more info on evidence-based practices that you can share with families and physicians, be sure to check out the archived webinar, “I Know It but Can’t Explain It: What the Evidence-Based Practices Are in EI” on our 2013 Talks on Tuesdays Recordings Page on the Virginia Early Intervention Professional Development Center site.

Reference:

Adams, R. C., Tapia, C. & The Council on Children with Disabilities. (2013, October). Early intervention, IDEA Part C services, and the medical home: Collaboration for best practice and best outcomes. Pediatrics, 132(4), e1073-e1088.

The post EI Research to Practice Brief #3 – Collaboration between EI and the Medical Home appeared first on Early Intervention Strategies for Success.

The practice of early intervention (EI) is always evolving and changing as new evidence comes to light about how to support children and families. This brief summarizes a research study that examined the behaviors of caregivers of young children with autism that were associated with higher levels of joint attention and language in children. It is followed by strategies you can use to evolve your practices based on the findings in the study.

Research: What Do We Know?

Siller, M., & Sigman, M. (2002). The behaviors of parents of children with autism predict the subsequent development of their children’s communication. Journal of Autism and Developmental Disabilities, 32(2), 77-89. (PDF, New Window)

Siller and Sigman examined whether or not particular caregiver communication behaviors would be associated with higher levels of language in children at later ages. Twenty-five children with autism were matched to samples of children with developmental delays or typical development in areas of mental age, language age, and years of maternal education. Each child’s social-communication was assessed at the beginning of the study and 1 year, 10 years, and 16 years later. Caregiver-child play interactions were observed and videotaped in a lab playroom. Specifically, the authors wanted to know: Will caregivers who spend a higher proportion of play engagement targeting objects that are already the focus of the child’s attention, trying to maintain the child’s ongoing activity, have children with more superior communication skills at later ages (p. 79)?

Findings

The strongest predictors of superior communication abilities in the children with autism were linked to caregiver’s verbal behaviors. Specifically, caregivers who synchronized what they said with the child’s focus of attention and used communication that was undemanding had children with the greatest gains in language development. Interestingly, how attentive children were to toys and how often caregivers talked with them was not predictive of communication gains; rather, it was how the caregiver communicated with the child that was more important.

Practice: How Can You Use What You Know?

These findings point to the importance of early interventionists helping families learn to communicate with their children in ways that are more naturalistic and less demanding (i.e., avoiding “say sand” or “what is this?” and instead “You’re poring the sand!” with emphasis on the important word “sand”). Interventionists can also help families synchronize what they say during play with what the child is doing – meaning that the caregiver talks about objects and activities that the child is already playing with or attending to.

This can be challenging when children have restricted interests or tend to play repetitively with toys or other objects (like opening and closing cabinet doors or spinning bowls on the floor). Rather than removing the child from the repetitive activity, the caregiver can join the child in the activity, narrating the play by giving words to what is happening and making the activity interactive. Using what the child is already doing can make it easier for him to engage, communicate and attend for longer periods of time. Learning in this manner is also interest-based, because the play context is one that the child has chosen.

Practical Strategies

I think that these findings are likely to be true for children who have language or other delays without having autism. Try out what you’ve learned on your next visit using these strategies:

Share these findings with parents – Talk about these key findings and help families reflect on them and think of ways to use them to help their children. Don’t assume that parents won’t understand.

Observe parent-child play and link what you see with these findings – Point out when play and communication are synchronized and when opportunities arise to do that. For example, if the child is spinning a bowl on the kitchen floor, coach the parent in how to take a turn spinning the bowl too and how to talk about it – “my turn!” or “ready, set, go!” when she or the child spins the bowl.

Use the child’s perseverative play rather than always discouraging it – We don’t want children to spin bowls all day long, but using that activity, which he enjoys, and turning it into an undemanding fun interaction can be a great context for learning.

Practice synchronization – This sounds complicated, but it’s really just about following the child’s lead, imitating what he does and says, taking turns, and building on his play. Keep the focus on what he’s doing, rather than on your own agenda, and use his play to help him learn what he needs to know.

Reflect on how you play with the child too – Listen to yourself and think about what you do. Practice implementing these findings too so that you can help families learn them. If you are modeling a more demanding approach, then step back and see how you can make changes as well.

What are your thoughts about these findings? How have you helped families be less demanding in their communication and be successful with engaging their children during play?

For more information and resources related to supporting infants and toddlers with autism spectrum disorders, visit the VA Early Intervention Professional Development Center’s topic page on Autism Spectrum Disorder or the free Autism 101: What Every Early Interventionist Needs to Know module.

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The practice of early intervention (EI) is always evolving and changing as new evidence comes to light about how to support children and families. This brief summarizes a research study that examined perceptions and experiences of EI providers as they implemented a new service delivery approach. It is followed by strategies you can use to evolve your practices based on the findings in the study.

Research: What Do We Know?

Salisbury, C. L., Woods, J., & Copeland, C. (2010). Provider perspectives on adopting and using collaborative consultation in natural environmentsts. Topics in Early Childhood Special Education, 30(3), 132-147. (PDF, New Window)

Salisbury, Woods, & Copeland (2010) conducted a case study of six early intervention (EI) providers as they adopted the collaborative consultation approach. Collaborative consultation focuses on increasing caregivers’ capacity to support the needs of their children using strategies such as modeling, coaching, joint problem solving, reflection and feedback, and prompting with children and families during natural routines. For more information about collaborative consultation, read Collaborative Consultation in Natural Environments: Strategies to Enhance Family-Centered Supports and Services (PDF, New Window) by Woods, Wilcox, Friedman, & Murch (2011).

This study included providers from the four most common EI disciplines: occupational therapy, physical therapy, speech language pathology, and developmental therapy (or special instruction). Information was gathered from the providers through a survey, interviews and focus groups to understand their perceptions about and experiences with adopting and using the collaborative consultation approach during their visits with families.

Findings

Five types of support were identified that affected providers’ abilities to learn about the approach and implement it in their work, including:

1. Reflection on one’s own practice
2. Viewing their work environment as a “learning community”
3. Having a broad definition of training
4. Having organizational support
5. Actual experience with the approach

Support at all levels of the organization was important, from the individual staff level up to the managerial and organizational levels.

Providers reported a commitment to adopting these valuable practices while also describing challenges. They found that it was easier to use these practices when families had specific requests for support, understood the approach and worked in the home. They also noted that using the approach was impacted negatively by other providers who had not adopted it (i.e., who were still using toy bags).  They noted that changing practices was hard for both the provider and the family when both were used to interacting using more traditional practices. Implementing these practices was successful when providers perceived that they had appropriate training, had time to practice using the approach, and received support from their team and their organization.

Practice: How Can You Use What You Know?

We know that changing intervention practices is closely tied to your perceptions about the change as well as the support you receive. It also takes lots of practice and reflection to compare what you know and have always done with what you are learning. Based on this article, keep these strategies in mind as you evolve your practice:

Be aware of your own attitudes – how you think drives what you do. Be open to change.

Understand that changing practices is challenging and success is more likely with appropriate support – Changing practices is a personal and an organizational issue. Providers need understanding and support at all levels.

Initiate a change in practice with new families – It might be easier to try out new practices with new families, rather than changing how you work with a family you have supported for a while using a different approach.

Explain your practices to families – Help families understand why you are using new strategies and how these strategies will help them and their child. You will likely learn alot from them about what is effective and how best to implement the new practices.

Reflect on your changing practices – Reflection needs to be an active process. Think about what you do on each visit, why you did it, and how you could improve it. Ask a peer to tag along and provide feedback. Videotape a visit then critique it. Reflect with your team and support each other as you discuss successes and challenges. Put reflection time on your staff meeting agenda and do it with every meeting.

Seek out training – Attend a conference or workshop. Participate in or lead a staff development activity. Read an article or book about the practice. Taking an online module or course. Find a more experienced mentor.

Create a learning environment – Supervisors need to make time for staff reflection, practice and training. Make the change a shared priority and encourage staff to learn from and with each other.

What other strategies have you used to change and grow your practices?

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