High Quality Teambased Early Intervention Services for Infants

High Quality, Team-based Early Intervention Services for Infants and Toddlers March 24, 2011 Council Bluffs, Iowa Lynda Cook Pletcher lynda. pletcher@unc. edu

We are here today and over the next few months as early intervention teams to…. .

In our time together today and the next few months we will explore: Ø Current trends and approaches in use for providing EI services around the country Ø The roles and functions of a team during the Early intervention process Ø Practices of functional Ø Common underlying themes to these approaches assessment Ø Writing functional outcomes Ø Some of the agreed upon practices (implementation) of these approaches Ø Team responsibilities providing on on-going services

Quality teams have: Ø Common purpose Ø Agreed upon values and beliefs Ø Share common information Ø Share common tasks Ø Understand each others role and functions Ø Frequent and clear communication QT Ø Value and respect each member Ø Willingness to help one another Ø Share and support each others learning and growth Ø Focus on personal and team growth

Children AND families are the focus of Early Intervention services “Services that are designed to meet the developmental needs of each child eligible…. AND THE NEEDS OF THE FAMILY related to enhancing the child’s development. 303. 12(a) (1) The team’s broad purpose: to work with children and their families.

Early Intervention Services are: Ø Designed to meet the Ø Ø developmental needs of each eligible child Designed to meet the needs of the family related to enhancing the child’s development Are selected in collaboration with parents Are provided under public supervision by qualified personnel In conformity with the individual family service plan Ø Meet the standards of the state and federal regulations Ø To the maximum extent appropriate to the needs of the child, are provided in “natural environments” including the home and community settings in which child without disabilities participate Ø At no cost unless federal or state law provides for a system of payments by families including sliding fees (sec. 303. 12)

General role of All service providers Ø Consulting with parents, other service providers and representatives of community agencies Ø Training parents and others regarding the provision of early intervention services Ø Participating in the multidisciplinary team assessment of the child and family and in the development of integrated goals and outcomes for the IFSP QT Common Functions

Scenario 1 and 2 activity. How are the two “visits” different? What are things in each you “like” or dislike”? Which scenario seems more “like” us currently?

The statues and regulations tell us some information about Ø What services are provided under the law Ø General purpose of early intervention Ø Who can provide the services Ø States responsibility of oversight and monitoring Ø How services are paid for States can then choose their service delivery approach: the program design to support their services and the actual how and what those services look like in practice.

Changing landscape out there What was described in the late 1980’s and ’ 90’s in each state’s original grant application, which defined their system and the services, has evolved and changed over the years. Life has changed greatly in the same time period! Ø Federal & State surplus to state deficits Ø Infant health survival rates Ø Paper and pencil records to advanced technology Ø Changing insurance coverage Ø New research and better practices… just to name a few…. .

Its not that providers aren’t doing a good job with children and families… Its more that we are impacted by the constantly changing tides.

Some reasons states have given for now looking at changing or refining their service delivery approach according to their APR’s Ø Help with staff shortages Ø More effective services Ø Cost less? Ø More efficient processes Ø Research has caught up with practices Ø It’s the “right” thing to do Ø Matches our purpose and mission of Early intervention in a better way……. . Ø WHAT are your reasons?

The service delivery approach impacts: Ø State (regional) structures necessary to support the approach Ø The way the EI services are organized at the program or regional level Ø Teaming practices and team composition Ø What “it” looks and feels like/ doesn’t look like, to families (and to the providers) Ø Providers knowledge or training Ø Beliefs, values and demonstrated competencies

Names states identified as endorsing or using within their state (in 2010): Transdisciplinary team-primary service provider (8) Primary Service Provider (PSP) (7) Coaching-Primary service provider (5) RBI-with primary service provider (2) Family Centered services (3) Family centered/ Transdisciplinary teams (1) Team based service delivery (1) ERRAPP or ERAP (3) Direct Therapy/consultation (1) Consultative Team model (1) Independent provider model with a vendor system (1) Individualization of services (1) Multidisciplinary team (1)

More information about states Ø 5 states reported using a combination of approaches Ø 4 states reported a named approach in use now, but said they are moving towards a primary service provider model and 1 other said primary service provider/ coaching model Ø 23 states did not name a specific approach but many used words in their training or vision that are included in the various approaches (RBI, functional outcomes, consultation, teaming, coaching, natural learning environments. Ø Other terms mentioned were ECO mapping, relationship based activities, TACTICS and FACETS and floor time

Are we all speaking the same language? ? ? QT Common language

Adoption or Adaption Ø HUGE variation in the words states choose Ø States at various stages of exploring to implementing Ø Only a few states have tried to go “statewide” Ø States are doing multiple approaches Ø A few states have tied themselves to a one particular “developer” who does the training and support during implementation of pilot sites. Ø Some states are using the developer’s materials and doing their own thing- providing their own training and adapting various pieces with their own state name Ø Other states are using the “agreed upon principles and practices” and focusing on the commonalities. Ø States are working through issues first that appear to be in the way of adoption of an approach

“Unpack” some of the most frequently mentioned approaches or terms Ø Primary Coach Approach to Ø Ø Teaming (PSP with coaching FACINATE Ta. CITS, FACETS & FGRBI Everyday Routines and Activities, CMP Agreed upon Principles and Practices

People associated with the most frequently mentioned approaches Ø Family Centered Practices- Dunst, Trivette and Deal Ø Using Everyday Routines and Activities-Carl Dunst/ Mary Beth Bruder Ø Primary Coach Approach to teaming, PSP with Coaching- Rush, Shelden and Hanft Ø Routine Based Early Intervention and Family Centered Intervention in Natural Environments (FACINATE)-Robin Mc. William Ø Therapists as Collaborative Team Members and Family Guided Routine Based Interventions- Julianne Woods- (FACETS/Ta. CTICS and FGRIB)) Ø Co. P work approach neutral, Principles and Practices (Pletcher, Hurth, Lucas, Younggren et all) Ø Other names sharing information; Naomi Younggren, Bonnie Keilty, Pip Campbell, Lee Anne Jung QT Common Information

Primary Coach Approach to Teaming , PSP with Coaching Dathan Rush, M’Lisa Shelden and Barbara Hanft Ø Geographically located team Ø One person primary coach to family Ø Receives support (coaching) from other team members Ø Provides direct support to parents/ other caregivers using Ø Ø coaching techniques Natural learning environment practices Strengthens parents competence and confidence while promoting children’s learning and development Use of developmental enhancing strategies used throughout the families daily activities Respecting parents and other care provider as adult learners

For more information http: //www. coachinginearlychildhood. org/index. php Hanft, B. E. &Rush, D. D. & Shelden, M. L. (2004) Coaching families and colleagues in early childhood. Baltimore: Brookes Shelden, M. L. & Rush, D. D. (2010) “A primary coach approach to teaming and supporting families in early childhood intervention. In; Working with families of young children with special needs. R. A. Mc. William (ed) Guilford Press, NY.

Family Centered Intervention in NATural Environments (FACINATE)- Robin Mc. William Ø Understanding the family ecology (ECO mapping) Ø Functional Intervention Planning (RBI Routines based interview) Ø Integrated services- a primary service provider works with family, with backing from a team of professionals to address the IFSP outcomes with family Ø Consultation and joint home visits with the PSP when needed Ø Support based home visits with the Vanderbilt home visiting script to provide informational, emotional and material support Ø Collaborative child care Consultation Ø Functional child outcomes to increase engagement, independence and social relationships throughout everyday routines

For more information Ø http: //www. siskin. org/www/docs/112. 180 Ø R. A. Mc. William (2010) Routines-Based Early Intervention: Supporting Young Children and their Families. Brookes, MD. Ø R. A. Mc. William (2010) volume Ed. Working with Families of Young Children with Special Needs. Guilford Press, N. Y.

Family Guided Routines Based Intervention (FGRBI)- Julianne Woods Ø Introduction of natural environments and welcoming the family Ø Routine based assessment in natural environments (RBA) Ø Linking assessment to intervention- Contextually relevant Ø Ø outcomes tied to family routines and activities; embedding outcomes into natural occurring routines Involving care givers in teaching and learning Monitoring progress Collaborative teams working together with families Family guided, family focused

For more information and resources: Ø http: //fgrbi. fsu. edu/ Ø http: //tactics. fsu. edu

Using Everyday Routines and Activities (Carl Dunst and Mary Beth Bruder) Uses everyday family and community opportunities, experiences and events as the source of children’s learning Locations yield activity settings, the settings are rich in multiple learning opportunities Child engagement in enjoyable activities- interest based learning opportunities Contextually Mediated Practices (CMP)-child interest, everyday activity settings, increased learning opportunities and parent mediate child learning) Home visits assist families to identify and engage in these meaningful activities and meet their needs Family centered practices and effective helping practices used by professionals

More information: Ø http: //www. everydaylearning. info/index. php Ø http: //www. puckett. org/ Ø Dunst, C. J. , Raab, M. , Trivette, C. M. & Swanson, J. (2010) “Community-based everyday child learning opportunities” in R. A. Mc. William (Ed. )Working with families of young children with special needs. Guilford Press, NY.

Agreed upon Principles& Practices for Providing Early Intervention Services in Natural Environments Ø This is NOT an approach Ø A document the reflects consensus practices validated through Ø Ø several research, model demonstration and outreach projects funded over the past decade Practices are written to be approach neutral Suggests a flow of activities that need to occur during the EI process Not intended as a sequential or all inclusive checklist Practices can be used by any team member including the Service coordinator and family

Three documents in the set Ø http: //www. nectac. org/~pdfs/topics/families/Finalmissionandprinciples 3_ 11_08. pdf Mission and Key Principles Ø http: //www. nectac. org/~pdfs/topics/families/Principles_Looks. Like_Does nt. Look. Like 3_11_08. pdf Looks like/doesn’t look like Ø http: //www. nectac. org/~pdfs/topics/families/Agreed. Upon. Practices_Final Draft 2_01_08. pdf Agreed upon Practices Ø Members of the original workgroup: Susan Addison, Betsy Ayankoya, Mary Beth Bruder, Carl Dunst, Larry Edelman, Andy Gomm, Barbara Hanft, Cori Hill, Joicey Hurth, Grace Kelley, Anne Lucas, Robin Mc William, Stephanie Moss, Lynda Pletcher, Dathan Rush, M’Lisa Shelden, Judy Swett, Nora Thompson, Julianne Woods and Naomi Younggren.

All these “approaches” have common Foundational themes Ø Family Centered Authentic/Functional Practices Assessment Ø Relationship Based Ø Functional Outcomes activities Ø Adult learning Ø Natural Environments principles Ø Natural learning Ø Team based service opportunities, delivery activities Ø

These common themes impact our practices in many ways Ø How we interact with families and other team members Ø How we help child and adults learn Ø The way we provide help and support Ø How we do assessment Ø What we even write on the IFSP Ø How we provide ongoing services

The elephant in the team room: individual values and beliefs about… Ø How children learn best Ø Viewing disabilities Ø Role as a provider Ø Different types of families Ø Where “services” should be provided Ø How to do assessments/evaluation Ø Working with other professionals

Your values and beliefs will impact: Ø What you actually do and even say to families. Ø Your participation on your team. Ø How comfortable (or not) you are with any of the approaches? Ø How willing you may be to try specific practices? QT Shared values and beliefs

Activity: Mission and Key Principles. What do you and your team believe and value? Take 5 minutes and read over the “mission “ and 7 key principles. Use the pink or blue marker to highlight words that resonate with you Use the yellow or green marker to highlight words you feel more Cautious about Discuss as a team which words match what you believe and know about…. And which words you feel more uncomfortable about. Why?

Activity: Mission and Key Principles. What do you and your team believe and value? Take 10 minutes to read 1 of the key principles/ looks like doesn’t look like. Read all the descriptions of looks like doesn’t carefully! Use the same color marking strategy as you just used Discuss as a team does the principle feel any more comfortable now that you can see more description of practices? Are there areas you can see for personal or team improvement?

Team Based Service Delivery

Component Multidisciplinary Interdisciplinary Transdisciplinary Philosophy of Team Interaction Team members recognize the importance of contribution from several disciplines Team members are willing and able to share responsibility for services among disciplines Team members commit to teach, learn and work across disciplinary boundaries to plan and provide integrated services Family role Generally families meet with team members separately by discipline The family might be consider a team member. Families may work with whole team or team representative Families are always members of the team and determine their own team role QT Roles and tasks

Component Multidisciplinary Interdisciplinary Transdisciplinary Lines of Communication Typically informal. Members may not think they are part of a team Team meets regularly for case review, consultation etc. Meets regularly to share information and to teach and learn across disciplines; consultation and team building Staff Development Happens independently and within individual disciplines Frequently shared and held across disciplines Frequently occurs and is across disciplines. Viewed as critical to team development and role transitions. QT Roles and tasks

Component Multidisciplinary Interdisciplinary Transdisciplinary Assessment Process Members conduct separate assessments by disciplines. Members conduct assessments by disciplines and share results with one another Team participates in an “arena” assessment, observing and recording across disciplines IFSP Development Members develop separate plans for intervention with in their own disciplines Goals are developed by disciplines and shared with rest of team to form a single service plan Staff and family develop plan together based functional assessments information from the family and the child IFSP Implementation Implemented separately by disciplines and separate visits by discipline Still discipline specific but some times-co-visits when working on several outcomes/goals One person is the major implementer with the family and other members consult or teach the primary member

Activity: Team types Look over the team descriptions silently. When done look up to signal you are finished reading. 2. In a round robin- each member share honestly what they feel is best description of the current team. 3. Once each person has had a chance to comment talk about discuss openly some of the following. 4. Is that adequate to what we are hoping to provide to children and families; are their things we need to learn more about, things in our way; are their any conflicting values and beliefs? 1.

No disguising it- it’s still a cat…

Teaming in 1200 AD: Leaning a New Technology http: //www. youtube. com/watch? v=0 Cd 7 Bsp 3 d. Do

Video Demonstrates Coaching What did you see? Functional (Authentic) Assessment What did you see? Contextually mediated practice What did you see? QT Support one another to learn

Other methods for teams to become more Transdisciplinary Adopted from: Mc. Gonigel &Woodruff (1994) The Transdisciplinary team: A model for family-centered early intervention. In L. Johnson (Eds) Meeting Early intervention challenges: Issues from birth to three (pp. 95 -131). MD: Paul H. Brookes Ø Role Extension Ø Role Enrichment Ø Role Expansion Ø Role Exchange Ø Role Release Ø Role Support

The Early Intervention Journey: Large Steps in the Team Process Intake Initial visit(s) Evaluation and assessment IFSP Initial meeting Development of IFSP goals and functional outcomes On-going services Ongoing assessment and review of IFSP Exit -transition

Intake/acting on the referral Ø First opportunity to help families know more than just the name of your program Ø First opportunity for the team to get information from the family Ø Even this very first encounter should demonstrate your value and beliefs and purpose. Ø Who on the team does what? Ø What do you share with families? Ø How do you communicate information to other team members?

Some possible team tasks at intake Ø Contacting the family Ø Introducing yourself and the EI program Ø Listening to their concerns or reasons for referral Ø Verifying information Ø Answering questions Ø Setting up initial visit(s) Ø Sharing or mailing more information

Resources for this step Ø CO Brochure which clearly describes their Transdisciplinary team Ø Woods- Welcoming the family Ø Mc. William book Chapter 3 (Checklist) Ø Co. P Practices 1 -4 Ø Others you have….

Initial Visit: Some team tasks Ø Becoming acquainted and establish rapport Ø Clarifying family concerns, or reason for contacting EI Ø Getting to know the family and the child Ø Explaining the program Ø Listening Ø Collecting useful information- child and family Ø Going over necessary paper work Ø Discussing parental rights.

Initial visit(s) Ø Explaining and screening of the child (if needed) Ø Gathering information about family’s every day routines and activities Ø Gathering information about family supports and resources Ø Explaining and sharing information (again)-Answer questions Ø Explaining and coordinating the evaluation and assessment Ø Exploring involvement/roles of the family in the child’s evaluation and assessment and IFSP

Resources for initial visits Ø Robin’s text chapter 4/5 Ø Practices document pages 2 -5 Ø TACTICS handouts- Identifying Family activities… What families want to know about assessment, Getting to know your child Ø Handout- Questions for eliciting Family routines, interest and priorities Ø ECO mapping Ø Routine Based interview Ø Other methods things you have found and like

Evaluation and assessment are considered processes that have different purposes under Part C. (34 CFR 303. 322) Ø “Evaluation is defined as the procedures used by "appropriate qualified personnel to determine a child's initial and continuing eligibility", consistent with the state definition of infants and toddlers with disabilities' and includes determining the status of the child in each of the developmental areas (cognitive development, physical development, including vision and hearing, communication development, social or emotional development and adaptive development”. Ø Usually view as “tests, scores and percentage to establish delays in one or more areas of development. ”

Assessment Ø "Assessment means the ongoing procedures used by appropriate qualified personnel throughout the period of a child's eligibility under this part to identify - (i) the child's unique strengths and needs and the services appropriate to meet those needs; and (ii) the resources, priorities, and concerns of the family and the supports and services necessary to enhance the family's capacity to meet the developmental needs of their infant or toddler with a disability. Ø Assessment methods can include tests, but also includes observation, open or close ended questions, interviews with parents and other caregivers.

Functional or Authentic Assessment in EI Ø Methods and activities to really learn about the child (and family) Ø What the child can do, likes, is interested in, and how well he/she does it Ø What in the daily routines or activities is challenging to the child and family Ø Generate ideas to try and discover what support is necessary Ø MUST be done where the child is, and in the situations that parents want to address Ø Focus is on the child’s participation in family and community activities and routines

Can’t have functional Outcomes without functional assessment “A functional outcome must by definition come from a functional assessment. One cannot take a nonfunctional goal and turn it into a functional one by writing it differently. ” Mc. William (2010)

Resources on Functional Assessments Ø ECO Mapping - Chapter 4 Ø Needs Assessment chapter- 5/6 Facilitating a Ø Problem solving approach for Families- Ta. CTICS Ø Handout with family questions

The Early Intervention Journey: Large Team Steps in the Process Intake Initial visit(s) Evaluation and assessment IFSP Initial meeting Development of IFSP goals & functional outcomes On-going services For June: Ongoing assessment and review of IFSP Exit from EI- transition

In the next month your team should: Ø Choose an individual action and/ or whole team action/task. Ø That you want to improve your confidence competence (and enjoyment too) in becoming a quality team or team player. Ø Look back at first three steps in the team journey and the resources, or other ideas you may have from today. Ø Commit to trying something out with the team and with family. We will be discussing “progress” concerns, questions on our April call.

Some possible ideas? Ø Team develop a talking point script to tell families about the purpose of EI and how the team (which includes the family) works together Ø Choose one of the resources (i. e. eco mapping , questions to elicit family concerns, routines) and try with a family Ø Practice the RBI with a team member and receive coaching from them

Team work is like white water rafting! Ø Have a clear sense of where you are headed Ø Plot your course together Ø Check for rapids or rough spots before entering the water when possible Ø Good communication strategies and clear methods to communicate before you start Ø Define the roles Ø Use individual strengths http: //www. youtube. com/embed/Eml. FZk. GPHS 8

White water rafting is a lot like our teamwork Ø All wear life jackets Ø Choose paddles that fit Ø Get in the boat together Ø Balance one another Ø All paddle equally Ø When one tires- out, provide extra support Ø Be mentally prepared for things not going as planned Ø In a tough spot follow the directions of the boat leader quickly Ø Rescue person overboard immediately Ø The thrill is in the successful journey of the entire boat (team) so endurance is an absolute

Functional Outcomes Ø First appeared in Rehabilitation field (Activities for daily living) Ø Improve child’s ability to participate in activities that are relevant to the child and family Ø Use natural motivators (interests and enjoyment) Ø Require an understanding of family’s routines and or activities Ø Are not development domain specific Ø IFSP functional outcomes look very different from traditional service-driven outcomes

Coaching Ø A methodology defined as “an interactive process of observation, reflection, and action in a which a coach promotes directly or indirectly a learner’s ability to support a child’s participation in family and community contexts. ” Hanft, Rush and Shelden 2004 Ø In this approach the methodology of coaching is equally applied to the team members Ø One team member becomes the primary coach who works closest with the family and can be a team members of any discipline

Contextually Mediated Practices (CMP) Dunst et all Is an intervention approach involving: Ø Identification of the interest of the child and everyday community and family activities Ø Selection of the activities that provide the best opportunities for interest-based learning Ø Increasing child participation in the interest-based everyday learning opportunities Ø The use of different interactional techniques for supporting and encouraging child competency, exploration and mastery Ø Evaluation of the effectiveness of parent-mediated activities