Applying Interdisciplinary Evidence Applying Interdisciplinary Evidence Based Research to Intervention PracticesBased Research to Intervention Practices

Paediatric Update SymposiumPaediatric Update Symposium

ELLEN POPE, MS, OT ELLEN POPE, MS, OT UNIVERSITY OF KANSAS MEDICAL CENTERUNIVERSITY OF KANSAS MEDICAL CENTER

February 28, 2011February 28, 2011

Parental Perspectives of TherapyParental Perspectives of Therapy

““Concerns exist regarding whether extensive therapy Concerns exist regarding whether extensive therapy can send a message that the child is unacceptable as can send a message that the child is unacceptable as

they are and needs “fixing up”they are and needs “fixing up”““The effect of much early intervention has been for me to The effect of much early intervention has been for me to

focus on what Sean cannot do at the expense of focus on what Sean cannot do at the expense of celebrating and wondering at all that he has achieved.”celebrating and wondering at all that he has achieved.”

Traditional vs. New ParadigmTraditional vs. New Paradigm

Treatment modelsTreatment models Expertise modelsExpertise models Deficit-based Deficit-based

modelsmodels Service-based Service-based

modelsmodels Professionally-Professionally-

centered modelscentered models (Dunst, 2000)(Dunst, 2000)

Promotion models Promotion models Capacity-building Capacity-building

modelsmodels Strengths-based Strengths-based

modelsmodels Resource-based Resource-based

modelsmodels

Family-centered Family-centered modelsmodels

(Dunst, 2000)(Dunst, 2000)

But, why can’t I provide a traditional But, why can’t I provide a traditional approach to therapy?approach to therapy?

Laws and often times funders require that Laws and often times funders require that our practice is based on peer-reviewed our practice is based on peer-reviewed research to the extent practicable.research to the extent practicable.

This peer reviewed research supports This peer reviewed research supports changing our practice at least as often as changing our practice at least as often as we change our hairstyle……..:)we change our hairstyle……..:)

It is probably not a It is probably not a good idea now. good idea now.

If you haven’t If you haven’t changed your changed your practice as often as practice as often as you have changed you have changed your hairstyle, you your hairstyle, you are out of date!are out of date!

THIS HAIRSTYLE WAS A GOOD IDEA IN 1986 (Nicholson, 2009)

Look at the interdisciplinary researchLook at the interdisciplinary research…… How do children How do children

learn? (learn? (what do you know what do you know

about this?)about this?)

How do adults How do adults learn? (learn? (what do you know what do you know

about this??)about this??)

Who are you Who are you working with in working with in your therapy your therapy practice?practice?

TRADITIONALTRADITIONALTreatment ModelsTreatment Models

Focus on remediation of a Focus on remediation of a disorder, problem, or disease, disorder, problem, or disease, or its consequencesor its consequences

NEWNEWPromotion ModelsPromotion Models

Focus on promoting competence Focus on promoting competence and positive functioningand positive functioning

Expertise Models Expertise Models Depend on professional expertise to solve problems Depend on professional expertise to solve problems

for peoplefor people

Capacity Building ModelsCapacity Building ModelsProvide opportunities for people to use Provide opportunities for people to use existing abilities and develop new skillsexisting abilities and develop new skills

Deficit-Based ModelsDeficit-Based Models

Focus on correcting a person’s Focus on correcting a person’s weaknesses or problemsweaknesses or problems

Strengths-Based ModelsStrengths-Based Models

Acknowledge the assets of Acknowledge the assets of people and help them use these people and help them use these assets to improve functioningassets to improve functioning

Service-Based ModelsService-Based Models

Describe practices primarily in Describe practices primarily in terms of professional servicesterms of professional services

Resource-Based ModelsResource-Based Models

Describe practices in terms of a Describe practices in terms of a wide variety of formal and wide variety of formal and informal supports within a informal supports within a communitycommunity

Professionally-Centered Professionally-Centered ModelsModels

View professionals as experts View professionals as experts who determine the needs of a who determine the needs of a person from their own as person from their own as opposed to the other person’s opposed to the other person’s perspectiveperspective

Family-Centered ModelsFamily-Centered Models

View professionals as agents of View professionals as agents of families and responsive to families and responsive to family desires and prioritiesfamily desires and priorities

AGREED UPON MISSION AND KEY AGREED UPON MISSION AND KEY PRINCIPLES FOR PROVIDING EARLY PRINCIPLES FOR PROVIDING EARLY

INTERVENTION SERVICES IN NATURAL INTERVENTION SERVICES IN NATURAL ENVIRONMENTSENVIRONMENTS

Sponsored by the Office of Special Education Sponsored by the Office of Special Education Programs, US Department of EducationPrograms, US Department of Education

OSEP TA Community of Practice – Part C OSEP TA Community of Practice – Part C SettingsSettings

(Hurth & Pletcher, 2007)(Hurth & Pletcher, 2007)

7 KEY PRINCIPLES7 KEY PRINCIPLES(modified(modified))

1. Children learn best through everyday 1. Children learn best through everyday experiences and interactions with familiar people experiences and interactions with familiar people in familiar contexts.in familiar contexts.

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

3. The primary role of a service provider in early 3. The primary role of a service provider in early intervention is to work with and support family intervention is to work with and support family members and caregivers in children’s lives.members and caregivers in children’s lives.

7 KEY PRINCIPLES7 KEY PRINCIPLES

4. The process must be dynamic and 4. The process must be dynamic and individualized to reflect child and family individualized to reflect child and family preferences, learning styles and cultural beliefs.preferences, learning styles and cultural beliefs.

5. Outcomes must be functional and based on 5. Outcomes must be functional and based on children’s and families’ needs and family-children’s and families’ needs and family-identified prioritiesidentified priorities

6. The family’s priorities, needs and interests are 6. The family’s priorities, needs and interests are addressed most appropriately by a primary addressed most appropriately by a primary provider who represents and receives team and provider who represents and receives team and community support.community support.

7 KEY PRINCIPLES7 KEY PRINCIPLES

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

#1 Children learn best through #1 Children learn best through everyday experiences and everyday experiences and

interactions with familiar people interactions with familiar people in familiar contextsin familiar contexts

Everyday experiencesEveryday experiences

With familiar people With familiar people

In Familiar ContextsIn Familiar Contexts

Natural Learning Natural Learning OpportunitiesOpportunities

Children’s learning opportunities that Children’s learning opportunities that are interest-based and provide contexts are interest-based and provide contexts for asset expression are more likely to for asset expression are more likely to optimize learning and development optimize learning and development

(Dunst, Bruder, et al., 2001; Dunst et al, 2000; Gallimore & (Dunst, Bruder, et al., 2001; Dunst et al, 2000; Gallimore & Goldenberg, 1993; Gelman et al., 1991; Guberman, 1999; Goldenberg, 1993; Gelman et al., 1991; Guberman, 1999; Nelson, 1999; Riksen-Walraven, 1978; Shelden & Rush, 2001)Nelson, 1999; Riksen-Walraven, 1978; Shelden & Rush, 2001)

Consider this….Consider this….

““It’s important to remember that the It’s important to remember that the amount of service is not what’s amount of service is not what’s important, because important, because all the child’s all the child’s learning occurs learning occurs betweenbetween sessions.” sessions.”

(McWilliam, 1996)(McWilliam, 1996)

Frequency IssuesFrequency Issues

Two hours/week = 2% of total waking hours of a Two hours/week = 2% of total waking hours of a one year old childone year old child

Diapering, feeding, playing=each happen at Diapering, feeding, playing=each happen at least 2000 times by the child is one year of ageleast 2000 times by the child is one year of age

Just 20 everyday activities would equal 40,000 Just 20 everyday activities would equal 40,000 learning opportunities by age one.learning opportunities by age one.

(Dunst, 2001)(Dunst, 2001)

Looks Like/ Doesn’t Look Looks Like/ Doesn’t Look LikeLike

Using toys and materials found in the home Using toys and materials found in the home or community settingor community setting

Identifying activities the child and family like Identifying activities the child and family like to do which build on their strengths and to do which build on their strengths and interestsinterests

Using toys, materials Using toys, materials and other equipment and other equipment the professional the professional brings to the visitbrings to the visit

Designing activities Designing activities for a child that focus for a child that focus on skill deficits or are on skill deficits or are not functional or not functional or enjoyableenjoyable

Principle #1 Looks Like:Principle #1 Looks Like: Using toys and materials found in the Using toys and materials found in the

home or community settinghome or community setting ““But……..the family doesn’t have any toys in But……..the family doesn’t have any toys in

their house for Natalie to play with.”their house for Natalie to play with.” ““But……I can get Joey to do things with my toys But……I can get Joey to do things with my toys

that nobody else can get him to do.”that nobody else can get him to do.” ““But…..the family really likes it when I play with But…..the family really likes it when I play with

Ezra in the living room so they can prepare Ezra in the living room so they can prepare dinner in the kitchen.”dinner in the kitchen.”

““But…..the family doesn’t have any routines.”But…..the family doesn’t have any routines.” ““But….all this family does is sit on the couch and But….all this family does is sit on the couch and

watch tv”watch tv”

#2 All families, with the #2 All families, with the necessary supports and necessary supports and

resources, can enhance their resources, can enhance their children’s learning and children’s learning and

developmentdevelopment

AllAll families With necessary families With necessary supports & resourcessupports & resources

Looks Like Does NOTLooks Like Does NOT

Assuming all families Assuming all families have strengths and have strengths and competencies; competencies; appreciating unique appreciating unique learning preferences learning preferences of each adult of each adult

Basing expectations Basing expectations for families on for families on characteristics such characteristics such as race, ethnicity, as race, ethnicity, education, or incomeeducation, or income

Looks Like Does NOTLooks Like Does NOT

Matching outcomes Matching outcomes and intervention and intervention strategies to the strategies to the families’ priorities, families’ priorities, needs and interests, needs and interests, building on routines building on routines and activities they and activities they want and need to dowant and need to do

Viewing families as Viewing families as apathetic or exiting apathetic or exiting them from services them from services because they miss because they miss appointments or don’t appointments or don’t carry through on carry through on prescribed prescribed interventionsinterventions

#3 The primary role of the service #3 The primary role of the service provider in early intervention is to:provider in early intervention is to:

Work with and Work with and support the family support the family members and members and caregivers in a caregivers in a child’s lifechild’s life

Looks Like Does NOTLooks Like Does NOT

Valuing and Valuing and understanding the understanding the provider’s role as a provider’s role as a collaborative coach;collaborative coach;

Focusing only on the Focusing only on the child and assuming child and assuming the family’s role is to the family’s role is to be a passive observer be a passive observer of what the provider is of what the provider is doing “to” the childdoing “to” the child

Looks Like Does NOTLooks Like Does NOT

Pointing out children’s Pointing out children’s natural learning natural learning activities and activities and discovering together discovering together the “incidental the “incidental teaching” teaching” opportunities that opportunities that families do naturally families do naturally between the between the provider’s visitsprovider’s visits

Giving families activity Giving families activity sheets or curriculum sheets or curriculum work pages to do work pages to do between visits and between visits and checking to see these checking to see these were donewere done

One approach…coaching as a One approach…coaching as a style of adult interactionstyle of adult interaction

We are working more as partners; side by sideWe are working more as partners; side by side Both partners have specific, valuable informationBoth partners have specific, valuable information Both partners have unique skillsBoth partners have unique skills We are learning togetherWe are learning together Just as a coach helps his or her players tap into Just as a coach helps his or her players tap into

their talents, so does the home visitor with the their talents, so does the home visitor with the familiesfamilies

Coaching is...Coaching is...

An adult learning strategy in which the An adult learning strategy in which the coach promotes the learner’s ability to coach promotes the learner’s ability to reflect on his or her actions as a means to reflect on his or her actions as a means to determine the effectiveness of an action or determine the effectiveness of an action or practice and develop a plan for refinement practice and develop a plan for refinement and use of the action in immediate and and use of the action in immediate and future situations.future situations.

(Rush & Sheldon, 2004)(Rush & Sheldon, 2004)

Uses of CoachingUses of Coaching

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

Coaching PrinciplesCoaching Principles

Assist the person in feeling successful by Assist the person in feeling successful by taking one small step at a timetaking one small step at a time

Support the person in demonstrating new Support the person in demonstrating new learninglearning

Create an environment in which it is ok to Create an environment in which it is ok to fail as part of the process and to ask for fail as part of the process and to ask for helphelp

Coaching PrinciplesCoaching Principles

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

Characteristics of CoachingCharacteristics of Coaching

Joint PlanningJoint PlanningObservationObservationAction/PracticeAction/PracticeReflectionReflectionFeedbackFeedback

Functional Outcomes Probe Functional Outcomes Probe Question ExamplesQuestion Examples

““What does your family want to see happen What does your family want to see happen or changed as a result of intervention?or changed as a result of intervention?

“ “ What are the activities that your family What are the activities that your family would like to do that are difficult?would like to do that are difficult?

““What kinds of things would you like “Joey” What kinds of things would you like “Joey” to do that would make life easier for you to do that would make life easier for you

or more or more FUNFUN for him?” for him?”

Example of a functional Example of a functional outcomeoutcome

““Kyle will help feed and water the dogs Kyle will help feed and water the dogs every morning and every evening”every morning and every evening”

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

supportsupport

Primary ProviderPrimary Provider

Represents and receives team and Represents and receives team and community supportcommunity support

““children don’t come in children don’t come in pieces”pieces”

Marion Wright EdelmanMarion Wright Edelman

The more (decontextualized, skill-based) services the The more (decontextualized, skill-based) services the child and family received, the less satisfied they were child and family received, the less satisfied they were

with early intervention with early intervention

96% of parents having one 96% of parents having one provider rated him/her as helpful provider rated him/her as helpful

77% of parents having two 77% of parents having two providers rated them as helpful providers rated them as helpful 69% of parents having three or 69% of parents having three or

more providers rated them helpfulmore providers rated them helpfulDunst et. al 1998Dunst et. al 1998

Looks Like Does NOTLooks Like Does NOT

Having a primary Having a primary provider, with provider, with necessary support necessary support from the team, from the team, maintain a focus on maintain a focus on what is necessary to what is necessary to achieve functional achieve functional outcomesoutcomes

Having separate Having separate providers seeing the providers seeing the family at separate family at separate times and addressing times and addressing narrowly defined, narrowly defined, separate outcomes or separate outcomes or issuesissues

Looks Like Does NOTLooks Like Does NOT

Coaching or Coaching or supporting the family supporting the family to carry out the to carry out the strategies and strategies and activities developed activities developed with the team with the team members with the members with the appropriate expertiseappropriate expertise

Providing services Providing services outside one’s scope outside one’s scope of expertise or of expertise or beyond one’s license beyond one’s license or certificationor certification

Primary Coach ApproachPrimary Coach Approach

All team members attend regular team All team members attend regular team meetings for the purpose of colleague-to-meetings for the purpose of colleague-to-colleague coaching. colleague coaching.

The team is comprised of all key The team is comprised of all key

disciplines (OT, PT, ST, ECSE)disciplines (OT, PT, ST, ECSE)

How do you decide who will be the How do you decide who will be the primary provider/coach?primary provider/coach?

What are the family’s and child’s What are the family’s and child’s outcomes?outcomes?

Who has the knowledge and availability?Who has the knowledge and availability?

Who has rapport or a relationship with the Who has rapport or a relationship with the family?family?

What do I do differently on What do I do differently on Monday morning?Monday morning?

Find the “Bright Spots” (Heath & Heath, 2010) Find the “Bright Spots” (Heath & Heath, 2010) What is already working? Where is it working well?What is already working? Where is it working well?

Explore the websitesExplore the websites Think reflectively: What is most important to the Think reflectively: What is most important to the

family? What are the participation issues? Are we family? What are the participation issues? Are we writing functional , participation based outcomes? writing functional , participation based outcomes?

Am I using the activities and routines of the family? Am I using the activities and routines of the family? Do I know the child’s interests? Do I use them In Do I know the child’s interests? Do I use them In intervention? What are the child’s strengths? intervention? What are the child’s strengths?

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

participation!participation!

ResourcesResources

http://www.coachinginearlychildhood.orghttp://www.coachinginearlychildhood.org

http://www.disabilityisnatural.com

http://www.fippcase.orghttp://www.fippcase.org

http://www.poweroftheordinary.org

http://www.researchtopractice.info

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