The Vision for Enhancing the Capacity of Families in Natural Environments

1. The Vision for Enhancing the Capacity of Families in Natural Environments http://tactics.fsu.edu

2. 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

3. 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

4. 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

5. 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

6. Big Problem #1 • Knowing what “it” is… Family Centered Services, Natural Environments • Believing “it” is effective… Evidence, Attitudes

7. 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

8. 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.

9. 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

10. 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.

11. 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

12. 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

13. 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

14. 1 Level 1 = Location Level 2 = Activity Level 3 = Learning Opportunity (Dunst, 1997) 2 3

15. Playground Slide •Steps •Platform •Turntaking •Up/down, On/off •Problem solving •Sliding through 1 2 3

16. Inputs Outputs Routines, Activities, Events, Settings, Interactions Child Characteristics Personal Values, Preferences Family Characteristics and Structure Geography, Community Resources Supports Costs (Personal, Time, Money) Child Choice, Participation Child Competence Child Quality of Life Family Well-Being Family Satisfaction Family Quality of Life Psychological Costs Interventions (Adapted from Dunst, 1999)

17. Inputs Routines, Activities, Events, Settings, Interactions Child Characteristics Personal Values, Preferences Family Characteristics and Structure Geography, Community Resources Supports Costs (Personal, Time, Money) (Adapted from Dunst, 1999)

18. Big Problem #2 • Knowing what and how to do it…. • Working with families • Being a consultant

19. Child Provider Dyad Careprovider

20. 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

21. 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

22. 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

23. 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

24. 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 Observing routines

25. 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

26. Plan of Action Family’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. STRATEGIESWHO WHERE

27. Plan of Action Family’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. STRATEGIESWHO WHERE

28. Big Problem #3 • Embracing the family’s perspective Values, Lifestyle, Roles, Responsibilities, • Believing families want to and can…

29. 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

30. 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 Adult Learners

31. For Learning to Occur Efficiently: • 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

32. Components of Triadic Support HierarchyPIWI Projects, Children’s Research Center, University of Illinois at Urbana-Campaign Establish Supportive Environment Enhance Caregiver Competence Provide Information Focus Attention Model Suggest

33. 4 Steps for Problem Solving • Define the problem • Generate ideas • Choose solutions • Develop the plan

34. 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?

35. 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?

36. 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

37. Key learning strategies identified by caregivers • Problem solving weekly with clinician • Initial video of other parent using strategy • Discussion of pros and cons to make a good match between strategy, outcome, routine and child interest • Time to talk about the data

38. 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)

39. Our Data • Child change occurs at rate greater than anticipated from maturation • Family satisfaction is very high • Parents learn strategies within daily routines and play • Parents report improved confidence in ability to parent child with special needs

40. 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

41. Why is this so hard? National Perspectives on Implementation of Natural Environments DEC International Conference San Diego – 12/6/2002

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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