The Vision for Enhancing the Capacity of Families in Natural Environments

http://tactics.fsu.edu

Why are we here today?

Genuine commitment to high quality EI services

Frustration with current level of implementation

Curiosity about what and how others are doing

Interest in continuous improvement Recognition of importance of

administrative and supervisory support

Project EPIC Collaboration between KU and local EIP Questions included:

Level of implementation for high poverty families Barriers and facilitators to success Applicability of FGRBI in inner city

Results included: Fewer services were received consistently;

cancellations by providers equaled families EI was provider directed and not routines based Families liked the concept of RBI (but didn’t have

many opportunities) Providers concern about family participation was #1

barrier; Administrative support was #2 barrier

Objectives for This Morning

Describe and define various family centered approaches used in natural environments

Identify observable provider behaviors and key program indicators to assist in program development and staff supervision

Review the barriers to full implementation and share solutions

Top 10 List: Why is this so hard?

10. Intrinsic vs. Extrinsic Reinforcement 9. “Public” Practice – Visibility of Providers 8. Change 7. Knowing How and Believing it Should 6. Self Reflection and Evaluation 5. Collaboration 4. “Thinking” Creatively 3. Balance of Complex Interactions 2. Time 1. Diversity of Family Values and Expectations

Big Problem #1

Knowing what “it” is… Family Centered Services, Natural

Environments

Believing “it” is effective…Evidence, Attitudes

What are Family Centered Services?

Embraces the unique and lasting relationship between family members

Recognizes the family and their life as the context for assessment and intervention

Respects and adapts to the multiple and diverse responsibilities and roles of families

Provides adequate information and support for the family to make informed decisions and respect for their choices

Offers information and opportunities for participation in a timely, sensitive and individualized format

Recognizes importance of relationships between family and team as partners in the teaching and learning process

Why Talk About Family Centered Services?

EI with active parent programs identify improved child outcomes, greater family satisfaction (Brooks-Gunn 2002).

Family centered services are not consistently implemented despite support (Guralnick, 2002).

Day to day actualization of family centered practices is a major OSEP compliance citation (USDOE) and identified by program directors as a major struggle (Hughes, 2003).

Changing demographics provide constraints to current policies and procedures (Vacca, 2000).

Society (politics) espouses a more active parental role in education.

What is Early Intervention in Natural Environments?

More than moving to a new location and continuing toy bag or clinic practices

Easier to say than do… and despite rumors otherwise, it isn’t “just” done

Integrates child and family centered philosophies

Data supports use in both individual and group settings and by parents and paid caregivers

Examples include: JARs, ABI, ELO, FG-RBI, NLO Benefits child by enhancing functionality,

opportunities for practice, and motivation Decreases need for generalization training Saves time and energy for caregivers

Why Parent Mediated Interventions?

Natural environments legislation increases emphasis on parent participation.

Evidence supports success of parent implemented interventions.

Parents learn multiple strategies for varying goals with diverse children in a variety of cost-effective models.

Outcomes identified for children are positively impacted by parent implemented interventions.

Parents are satisfied with their participation.

More specifically… Multiple strategies

“Packages” of development and behavioral methods (EMT, Hanen)

ABA (prompts, cues, reinforcement) Sequences of facilitative interactions

Diverse children Communication and language delay Down syndrome and other DD Autism and “Challenging Behavior”

Cost-effective methods Group classes Modeling and instruction Video demonstrations and feedback Home-based problem solving

Child outcomes included…

Increased understanding and use of gestures, picture symbols, words and word combinations

Decreased use of maladaptive behaviors and increased use of communication replacement behaviors

Direction following Toilet training and other adaptive skills Self-feeding, increase in food intake Social interactions with siblings, peers

How Do NE Models Differ?

Context for instruction Everyday experiences, events and routines Therapy or planned special instruction

Activity type Child preferred & directed Adult planned & directed Blended

Delivery of instruction Natural learning opportunities Adult directed Parent mediated

Level 1 = Location

Level 2 = Activity

Level 3 = Learning Opportunity

(Dunst, 1997)

1

2

3

Playground

Slide

•Steps •Platform•Turntaking •Up/down, On/off•Problem solving•Sliding through

1

2

3

Child CharacteristicsPersonal Values, PreferencesFamily Characteristics and

StructureGeography, CommunityResourcesSupportsCosts (Personal, Time, Money)

InputsRoutines, Activities, Events,

Settings, Interactions

Outputs

Child Choice, Participation

Child CompetenceChild Quality of LifeFamily Well-BeingFamily SatisfactionFamily Quality of LifePsychological Costs

Interventions(Adapted from Dunst, 1999)

Child CharacteristicsPersonal Values, PreferencesFamily Characteristics and

StructureGeography, CommunityResourcesSupportsCosts (Personal, Time, Money)

(Adapted from Dunst, 1999)

InputsRoutines, Activities, Events,

Settings, Interactions

Big Problem #2

Knowing what and how to do it…. Working with families Being a consultant

Dyad

Make or Break Practices for Family Centered Services

Gathering and Giving – Reciprocal Information and Resource Sharing Process Explain why information is meaningful in everyday life Provide examples and developmental knowledge

Observing and Modeling – Individualized Interactions Watch what, how, & when parent interacts Show what strategies or behaviors are needed

Problem Solving and Decision Making - Supportive & Respectful Relationships Present alternatives for caregiver participation Integrate learning strategies for adults in process

Initial Contacts Establish partnership process

Everyone is an expert… and everyone is a learner

Initiate capability -vs- disability point of view Communicative competence as basis for

intervention Set the stage for proactive caregiver

participation Prepare caregivers for process; seek input for

plan Offer examples, opportunities, alternatives:

Assessment is a novel and frightening experience

Identifying Routines and Activities for Observation during Assessment

Discuss child and family preferred routines and activities prior to assessment visit

Suggest alternatives to the family to assist in their choice making

Survey the family for special interests or activities that will enhance their comfort in participation

Identify routines and materials that enable easy completion of assessment measure(s) identified for use by the team

Roles for the Family

More than a continuum of options for participation (Crais et al)

Multi-faceted and dynamic participation throughout the relationship (Woods & McCormick) Guide Team member Decision maker Contributor Observer and validator Problem solver Teacher

Observing routines Routine

Sequence Repetition Joint attention Positive, motivating

Child Anticipate Attend Initiate Respond Imitate Independently

participate

Careprovider Expect participation Respond, expand Use objects Read child’s cues Use intervention

strategies Encourage

Dyad Position, proximity Mutual attention Turn taking Positive affect Cues, repairs

Giving Information Remember the capability and proactive

participation planning Share strengths… “JP loves his snacks so that’s a great

opportunity for communication… using gestures and vocalizations. You’re right…he doesn’t have words, but there are many ways…”

Avoid all jargon Be concrete and give practical examples

that relate to family You told me you like to go to the playground…

Use a variety of adult learning strategies Visuals

Plan of ActionFamily’s Priority: Communicate using words everybody understands.

Specific Outcome: JP will use 5 new words (supported with gestures where needed) to gain attention and answer questions.

STRATEGIES WHO WHERE At music, computer and play time, encourage JP to imitate sounds, noises, words, and motor actions.

Ms. MaryMom & Kelly will share songs& computer time

Home and Childcare

While playing outside JP will be asked to choose between bikes, ball, and favorite sand toys.

Dad, Ms. Mary, Friends, Derek, Anne

Home and Childcare

Plan of ActionFamily’s Priority: Communicate using words everybody understands.

Specific Outcome: JP will use 5 new words (supported with gestures where needed) to gain attention and answer questions.

STRATEGIES WHO WHERE During activities in the community such as Church, softball, or errands, JP will name family, friends, and common objects with models

Dad, Mom, Kelly, Jennifer, Josh, Derek, friends

Community

activities, car, church

During caretaking routines (bathtime, meals, dressing, potty) JP will label choices when asked

Mom Home

Big Problem #3

Embracing the family’s perspectiveValues, Lifestyle, Roles, Responsibilities,

Believing families want to and can…

Scaffolding for Careproviders

Occurs within collaborative environment with acceptance of and respect for each other’s values, skills, and knowledge

Begins with skills/strategies the partner exhibits Relationship provides support for new ideas and skills

to develop and security for risk taking to occur Working within each other’s “zones of proximal

development” increases use of knowledge within practice

Use of adult learning strategies and systematic instruction enhances learning success for caregiver and professional

Adult Learners

Comfortable Environment

Respect for Values and Priorities

Effective Communication

History and Experiences

Contributions and Participation

Collaboration and Problem Solving

Applicability to Life and Functionality

Competing Commitments

For Learning to Occur For Learning to Occur EfficientlyEfficiently::

Child must engage with the environment

Child and caregiver must interact contingently with each other

Caregiver must mediate the physical and social environment for the child, thus linking the child’s engagement to the environment

Components of Triadic Support Hierarchy

PIWI Projects, Children’s Research Center, University of Illinois at Urbana-Campaign

Establish Supportive Environment

Enhance Caregiver Competence

Provide InformationFocus Attention

Model

Suggest

4 Steps for Problem Solving

Define the problemGenerate ideasChoose solutionsDevelop the plan

Questions to Enhance Problem Solving in Family Centered Services

What is the problem? Who is affected? How? What is the impact? What could happen if it is ignored? What could happen if it is addressed?

What are the facts? What is believed? When, where, how and who should join

in the problem solving process?

Problem Solving … continued

What has been tried? What worked? What didn’t? Any ideas why?

What other ideas should be considered? What should be tried first? What is an

alternate plan? Are resources available? Who will do what? When? How? How will we know if it works?

Increasing caregiver competence with strategies

Initial discussion with handouts Video of another parent using strategy in

a caregiving or play routine Discussion about pros and cons of the

strategy Practice together Video taping of caregiver using strategy

with opportunity to watch and critique Problem solving with data collected

weekly

Key learning strategies identified by caregivers

Problem solving weekly with clinician Initial video of other parent using

strategyDiscussion of pros and cons to make a

good match between strategy, outcome, routine and child interest

Time to talk about the data

What research says doesn’t work for generalization

Modeling (McBride & Peterson)Handouts (Fox & Dunlap)Group training without feedback

and follow-up (Strain et al)Facility based service delivery

(NAS report)

Our Data

Child change occurs at rate greater than anticipated from maturation

Family satisfaction is very highParents learn strategies within daily

routines and playParents report improved confidence

in ability to parent child with special needs

So what’s special about the model?

Systematic instruction increased acquisition rate of embedding by caregivers

Family members generalized strategy use across routine types and into community settings

Parents initiated identification of routines for intervention through problem solving with providers

Data collection by families was integral

Why is this so hard?National Perspectives on

Implementation of Natural Environments

DEC International ConferenceSan Diego – 12/6/2002

Panel

Judy Carta – Juniper Gardens Children’s Projects, KU- Kansas City

David Lindeman – University Center of Excellence, KU - Parsons

Christine Salisbury- Child and Family Development Center, University of Illinois-Chicago

Juliann Woods- Florida State University, Tallahassee

Inservice Personnel Preparation:

Problems and Solutions Problem: Moving from knowledge to

consistent implementation Solutions:

Develop “FC-NE” culture across team members and agencies supported by administrative policies

Provide time and funding for collaboration and coaching within team including FSC

Develop friendly communication formats and require it among team members including family

Infuse “FC-NE” into every agenda and initiative

Preservice Personnel Preparation:

Problems and Solutions Problem: Quality practicum opportunities

in NE with skilled EI Solutions:

Become a community provider on the matrix for families to choose – authentic training including the policies and paperwork

Use a consistent model with guidelines, systematic instruction, student expectations, video feedback, fidelity checklists

Establish relationships and help build programs through continuing ed., grant opportunities and $$ incentives

Grow your own – hire them – expect them to develop program further

Connect with the State agency Establish Department policies on FC-NE placements

Examples of Solutions…

Administrator identified NE as priority for hiring personnel and subsequent evaluations

Regional team defined PSPM for their region through stakeholder meetings… before the state did it for them!!

Team of SLPs are defining process for decision making on services for kids with ASD in NE using logic syntax as a part of their district performance standards

TA consultants infuse NE into every initiative, e.g. early literacy in NE – not another new state initiative… just expansion

Barriers Still Exist…

Payment disincentives for non-NE services Legislation aimed at accountability that

requires “time” in services- not quality Confusion between co-treatment,

consulting, coaching for re-imbursement Limited information and resources for

families on what NE is and isn’t and their roles….

Limited involvement in DEC

Inservice Personnel Preparation:

Problems and Solutions Problem: Moving from knowledge to

consistent implementation Solutions:

Develop “FC-NE” culture across team members and agencies supported by administrative policies

Provide time and funding for collaboration and coaching within team including FSC

Develop friendly communication formats and require it among team members including family

Infuse “FC-NE” into every agenda and initiative

Preservice Personnel Preparation:

Problems and Solutions Problem: Quality practicum opportunities

in NE with skilled EI Solutions:

Become a community provider on the matrix for families to choose – authentic training including the policies and paperwork

Use a consistent model with guidelines, systematic instruction, student expectations, video feedback, fidelity checklists

Establish relationships and help build programs through continuing ed., grant opportunities and $$ incentives

Grow your own – hire them – expect them to develop program further

Connect with the State agency Establish Department policies on FC-NE placements

Examples of Solutions…

Administrator identified NE as priority for hiring personnel and subsequent evaluations

Regional team defined PSPM for their region through stakeholder meetings… before the state did it for them!!

Team of SLPs are defining process for decision making on services for kids with ASD in NE using logic syntax as a part of their district performance standards

TA consultants infuse NE into every initiative, e.g. early literacy in NE – not another new state initiative… just expansion

Barriers Still Exist…

Payment disincentives for non-NE services Legislation aimed at accountability that

requires “time” in services- not quality Confusion between co-treatment,

consulting, coaching for re-imbursement Limited information and resources for

families on what NE is and isn’t and their roles….

Limited involvement in DEC