Applying Interdisciplinary Evidence Based Research to Intervention Practices Paediatric Update Symposium ELLEN POPE, MS, OT UNIVERSITY OF KANSAS MEDICAL CENTER February 28, 2011

Parental Perspectives of Therapy Parental Perspectives of Therapy “Concerns exist regarding whether extensive therapy can send a message that the child is unacceptable as they are and needs “fixing up” “Concerns exist regarding whether extensive therapy can send a message that the child is unacceptable as they are and needs “fixing up” “The effect of much early intervention has been for me to focus on what Sean cannot do at the expense of celebrating and wondering at all that he has achieved.”

Traditional vs. New Paradigm  Treatment models  Expertise models  Deficit-based models  Service-based models  Professionally- centered models (Dunst, 2000) (Dunst, 2000)  Promotion models  Capacity-building models  Strengths-based models  Resource-based models  Family-centered models (Dunst, 2000) (Dunst, 2000)

But, why can’t I provide a traditional approach to therapy?  Laws and often times funders require that our practice is based on peer-reviewed research to the extent practicable.  This peer reviewed research supports changing our practice at least as often as we change our hairstyle……..:)

 It is probably not a good idea now.  If you haven’t changed your practice as often as you have changed your hairstyle, you are out of date! THIS HAIRSTYLE WAS A GOOD IDEA IN 1986 (Nicholson, 2009)

Look at the interdisciplinary research …  How do children learn? ( what do you know about this?)  How do adults learn? ( what do you know about this??)  Who are you working with in your therapy practice?

TRADITIONAL Treatment Models Focus on remediation of a disorder, problem, or disease, or its consequences

NEW Promotion Models Focus on promoting competence and positive functioning

Expertise Models Depend on professional expertise to solve problems for people

Capacity Building Models Provide opportunities for people to use existing abilities and develop new skills

Deficit-Based Models Focus on correcting a person’s weaknesses or problems

Strengths-Based Models Acknowledge the assets of people and help them use these assets to improve functioning

Service-Based Models Describe practices primarily in terms of professional services

Resource-Based Models Describe practices in terms of a wide variety of formal and informal supports within a community

Professionally-Centered Models View professionals as experts who determine the needs of a person from their own as opposed to the other person’s perspective

Family-Centered Models View professionals as agents of families and responsive to family desires and priorities

AGREED UPON MISSION AND KEY PRINCIPLES FOR PROVIDING EARLY INTERVENTION SERVICES IN NATURAL ENVIRONMENTS AGREED UPON MISSION AND KEY PRINCIPLES FOR PROVIDING EARLY INTERVENTION SERVICES IN NATURAL ENVIRONMENTS  Sponsored by the Office of Special Education Programs, US Department of Education  OSEP TA Community of Practice – Part C Settings (Hurth & Pletcher, 2007) (Hurth & Pletcher, 2007)

7 KEY PRINCIPLES (modified )  1. Children learn best through everyday experiences and interactions with familiar people in familiar contexts.  2. All families, with the necessary supports and resources, can enhance their children’s learning and development.  3. The primary role of a service provider in early intervention is to work with and support family members and caregivers in children’s lives.

7 KEY PRINCIPLES  4. The process must be dynamic and individualized to reflect child and family preferences, learning styles and cultural beliefs.  5. Outcomes must be functional and based on children’s and families’ needs and family- identified priorities  6. The family’s priorities, needs and interests are addressed most appropriately by a primary provider who represents and receives team and community support.

7 KEY PRINCIPLES 7. Interventions with young children and family members must be based on explicit principles, validated practices, best available research, and relevant laws and regulations 7. Interventions with young children and family members must be based on explicit principles, validated practices, best available research, and relevant laws and regulations

#1 Children learn best through everyday experiences and interactions with familiar people in familiar contexts Everyday experiences With familiar people In Familiar Contexts

Natural Learning Opportunities  Children’s learning opportunities that are interest-based and provide contexts for asset expression are more likely to optimize learning and development (Dunst, Bruder, et al., 2001; Dunst et al, 2000; Gallimore & Goldenberg, 1993; Gelman et al., 1991; Guberman, 1999; Nelson, 1999; Riksen-Walraven, 1978; Shelden & Rush, 2001)

Consider this…. “It’s important to remember that the amount of service is not what’s important, because all the child’s learning occurs between sessions.” (McWilliam, 1996) (McWilliam, 1996)

Frequency Issues  Two hours/week = 2% of total waking hours of a one year old child  Diapering, feeding, playing=each happen at least 2000 times by the child is one year of age  Just 20 everyday activities would equal 40,000 learning opportunities by age one. (Dunst, 2001)

Looks Like/ Doesn’t Look Like  Using toys and materials found in the home or community setting  Identifying activities the child and family like to do which build on their strengths and interests  Using toys, materials and other equipment the professional brings to the visit  Designing activities for a child that focus on skill deficits or are not functional or enjoyable

Principle #1 Looks Like: Using toys and materials found in the home or community setting  “But……..the family doesn’t have any toys in their house for Natalie to play with.”  “But……I can get Joey to do things with my toys that nobody else can get him to do.”  “But…..the family really likes it when I play with Ezra in the living room so they can prepare dinner in the kitchen.”  “But…..the family doesn’t have any routines.”  “But….all this family does is sit on the couch and watch tv”

#2 All families, with the necessary supports and resources, can enhance their children’s learning and development #2 All families, with the necessary supports and resources, can enhance their children’s learning and development All families With necessary supports & resources All families With necessary supports & resources

Looks Like Does NOT  Assuming all families have strengths and competencies; appreciating unique learning preferences of each adult  Basing expectations for families on characteristics such as race, ethnicity, education, or income

Looks Like Does NOT  Matching outcomes and intervention strategies to the families’ priorities, needs and interests, building on routines and activities they want and need to do  Viewing families as apathetic or exiting them from services because they miss appointments or don’t carry through on prescribed interventions

#3 The primary role of the service provider in early intervention is to:  Work with and support the family members and caregivers in a child’s life

Looks Like Does NOT  Valuing and understanding the provider’s role as a collaborative coach;  Focusing only on the child and assuming the family’s role is to be a passive observer of what the provider is doing “to” the child

Looks Like Does NOT  Pointing out children’s natural learning activities and discovering together the “incidental teaching” opportunities that families do naturally between the provider’s visits  Giving families activity sheets or curriculum work pages to do between visits and checking to see these were done

One approach…coaching as a style of adult interaction  We are working more as partners; side by side  Both partners have specific, valuable information  Both partners have unique skills  We are learning together  Just as a coach helps his or her players tap into their talents, so does the home visitor with the families

Coaching is...  An adult learning strategy in which the coach promotes the learner’s ability to reflect on his or her actions as a means to determine the effectiveness of an action or practice and develop a plan for refinement and use of the action in immediate and future situations. (Rush & Sheldon, 2004)

Uses of Coaching  Coaching is used to provide support and encouragement, refine existing practices, develop new skills, and promote continuous self-assessment and learning.

Coaching Principles  Assist the person in feeling successful by taking one small step at a time  Support the person in demonstrating new learning  Create an environment in which it is ok to fail as part of the process and to ask for help

Coaching Principles  Remind yourself.... You are not the person with the answers. You have astute observations, questions and reassuring support to offer that will help the family member feel able to propose new ideas and options.

Characteristics of Coaching  Joint Planning  Observation  Action/Practice  Reflection  Feedback

Functional Outcomes Probe Question Examples Functional Outcomes Probe Question Examples “What does your family want to see happen or changed as a result of intervention? “ What are the activities that your family would like to do that are difficult? “What kinds of things would you like “Joey” to do that would make life easier for you or more FUN for him?”

Example of a functional outcome “Kyle will help feed and water the dogs every morning and every evening”

#6 The family’s priorities needs and interests are addressed most appropriately by a primary provider who represents and receives team and community support  Primary Provider  Represents and receives team and community support

“children don’t come in pieces” Marion Wright Edelman

The more (decontextualized, skill-based) services the child and family received, the less satisfied they were with early intervention 96% of parents having one provider rated him/her as helpful 77% of parents having two providers rated them as helpful 69% of parents having three or more providers rated them helpful Dunst et. al 1998

Looks Like Does NOT  Having a primary provider, with necessary support from the team, maintain a focus on what is necessary to achieve functional outcomes  Having separate providers seeing the family at separate times and addressing narrowly defined, separate outcomes or issues

Looks Like Does NOT  Coaching or supporting the family to carry out the strategies and activities developed with the team members with the appropriate expertise  Providing services outside one’s scope of expertise or beyond one’s license or certification

Primary Coach Approach  All team members attend regular team meetings for the purpose of colleague-to- colleague coaching.  The team is comprised of all key disciplines (OT, PT, ST, ECSE)

How do you decide who will be the primary provider/coach?  What are the family’s and child’s outcomes?  Who has the knowledge and availability?  Who has rapport or a relationship with the family?

What do I do differently on Monday morning? What do I do differently on Monday morning?  Find the “Bright Spots” (Heath & Heath, 2010) What is already working? Where is it working well?  Explore the websites  Think reflectively: What is most important to the family? What are the participation issues? Are we writing functional, participation based outcomes?  Am I using the activities and routines of the family? Do I know the child’s interests? Do I use them In intervention? What are the child’s strengths?

Questions??? Thank you for your interest and participation!

Resources

Bibliography Bibliography Bridle, L. & Mann, G. Mixed Feelings – A Parental Perspective on Early Intervention. Supporting Not Controlling: Strategies for the New Millennium: Proceedings of the Early Childhood Intervention Australia National Conference, July 1-3, 2000, pp Campbell, P.H. (2004) Participation Based Services: Promoting children’s participation in natural settings. Young Exceptional Children, 8 (1) Dunst, C. J. (1995). Key characteristics and features of community-based family support programs. Chicago: Family Resource Coalition. Dunst, C. J. (1999). Placing parent education in conceptual and empirical context. Topics in Early Child- hood Special Education, 19, Dunst, C. J. (2000). Revisiting “Rethinking early intervention”. Topics in Early Childhood Special Education, 20, Dunst, C. J. (2000). Revisiting “Rethinking early intervention”. Topics in Early Childhood Special Education, 20, Dunst, C. J. (2004). An integrated framework for practicing early childhood intervention and family sup port. Perspectives in Education, 22(2), 1-16.

Bibliography Bibliography Dunst, C.., Bruder, M.B., Trivette, C.M., Hamby, D., Raab, M., & McLean M. (2001). Characteristics and consequences of everyday natural learning opportunities. Topics in Early childhood Special Education, 21, Dunst, C. J., & Trivette, C. M. (1996). Empowerment, Trivette, C. M., Dunst, C. J., & Hamby, D. W. (1996). Factors associated with perceived control appraisals in a family-centered early intervention program. Journal of Early Intervention, 20, Dunst, C. J. (1995). Key characteristics and features of community-based family support programs. Chicago: Family Resource Coalition. effective helpgiving practices and family-centered care. Pediatric Nursing, 22, , 343. Dunst, C. J., & Trivette, C. M. (1997). Early intervention with young at-risk children and their families. In R. Ammerman & M. Hersen (Eds.), Handbook of prevention and treatment with children and adoles- cents: Intervention in the real world (pp ). New York: Wiley.

Bibliography Bibliography Dunst, C. J., Trivette, C. M., & Deal, A. G. (Eds.). (1994). Supporting and strengthening families: Methods, strategies and practices. Cambridge, MA: Brook- line Books. Dunst, C., Trivette, C. & Cutspec, P. (2002a). Toward an operational definition of evidence-based practices. Centerscope, 1(1), Dunst, C., Trivette, C. & Cutspec, P. (2002b). An evidence-based approach to documenting the characteristics and consequences of early intervention practices. Centerscope, 1(2), 1-6. Dunst, C.J. & Trivette, C.M. (2009b). Using research evidence to inform and evaluate early intervention practices. Topics in Early Childhood Special Education. 29 )1), Hanft, B.E., $ Pilkington, K.O..(2000). Therapy in natural environments: the means or end goal for early intervention? Infants and Young Children, 12(4), 1-13 Hanft, B.E., Rush, D.D., & Shelden, M. L. (2004). Coaching Families and colleagues in early childhood. Baltimore: Brookes. Jung, L.A. (2003). More is better: Maximizing natural learning opportunities. Young Exceptional Children, 6(3), Law, M. (2000). Strategies for implementing evidence-based practice in early intervention. Infants and Young Children, 13, Shelden, M.L. & Rush, D.D. (2001). The Ten Myths about Providing Early Intervention Services in Natural Environments. Infants and young Children, 14(1): 1-13.

Bibliography Trivette, C. M., Dunst, C. J., & Hamby, D. W. (1996). Factors associated with perceived control appraisals in a family-centered early intervention program. Journal of Early Intervention, 20, Workgroup on Principles and Practices in Natural Environments (November, 2007) Mission and principles for providing services in natural environments. OSEP TA Community of Practice- Part C Settings.