Routines-Based Early Intervention: Supporting Young Children and Their Families - Tapa blanda

Robin McWilliam is the originator of the Routines-Based Model, implemented in 10 countries and many states in the U.S. He is a professor of special education at The University of Alabama, where he founded and directs the Evidence-based International Early Intervention Office (EIEIO). He is also the founder and leader of the RAM Group, an international community of practice fostering the Routines-Based Model. He has formerly been a professor of pediatrics at Vanderbilt University Medical Center, a senior scientist at the Frank Porter Graham Child Development Institute, and a professor of education at the University of North Carolina at Chapel Hill. Dr. McWilliam's research centers on infants, toddlers, and preschoolers with and without disabilities, with a specific focus on child engagement, service delivery models, and collaboration with families. He has provided consultation, training, and technical assistance across the United States and in some countries overseas on providing early intervention in natural environments and on the Engagement Classroom Model. His Routines-Based Interview (RBI) is a widely used method of assessing families' needs and developing individualized family service plan (IFSP) outcomes and individualized education program (IEP) goals.

Excerpted from Chapter 6 of Routines-Based Early Intervention: Supporting Young Children and Their Families, by R.A. McWilliam, Ph.D. Copyright© 2010 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

The purposes of assessment were described in Chapter 5, and the case has been made for an innovative method to determine a family's functional needs. Current standardized methods do not determine these needs. First, some method is needed to identify functional goals or outcomes, otherwise known as target behaviors. Functionality of child outcomes can be thought of as addressing participation or engagement needs, addressing independence needs, and addressing social-relationship needs. Throughout this book, the importance of these three domains is stressed. Second, family priorities need to be reflected in the IFSP. Third, outcomes should be broad enough to cover a variety of ways of displaying the target behavior yet narrow enough to know what is really being addressed. Fourth, the strategies or action steps should aim directly at the function problem. Strategies such as using oral-motor exercises might be employed to address an outcome related to eating and swallowing, but a more direct approach is to teach a child to chew and swallow. The rule is teach first. Fifth, the process for developing IFSPs needs to foster investment by caregivers other than the family, such as child care providers, in the outcomes. The Routines-Based Interview (RBI) is a method that addresses these five needs.

Confluence of Two Models

The RBI is central to two models that have become quite widespread in the past 10 years. It was first described in Family-Centered Intervention Planning: A Routines- Based Approach (McWilliam, 1992), which was written primarily for helping classroom-based staff to be family friendly. The premise was that planning with families in a way that addressed families' true concerns for their children, both at home and in the classroom, would help overcome the barrier of not seeing families for as long a time each week and on their home turf. Many of the principles from the co-ops where we tried out this and other practices have evolved into the individualizing inclusion model of classroom-based services (Wolery, 1997). That model hinges on the RBI as an assessment of the ecological congruence between a child's abilities and the classroom environment. This assessment leads directly to the development of the IFSP or individualized education program (IEP). Once a list of functional behaviors is identified, all services are provided in the classroom to ensure teamwork between classroom staff and specialists such as speech-language pathologists, itinerant special educators, occupational therapists, and physical therapists. The specialists' responsibility is to make their intervention suggestions fit into classroom routines, and teachers' responsibility is to embed those interventions into routines. The model hinges on functional outcomes or goals, which come from the RBI.

By now, it will be clear that the RBI is also central to the model of early intervention in natural environments. Again, the functionality of the child- and family-level outcomes in situations where the family is receiving home- and community-based services, including consultation to child care, makes the model of service delivery and the home and child care visits go more smoothly. As will be demonstrated throughout this book, the RBI is the linchpin for many of the other practices I recommend be employed in early intervention.

Research on the RBI

We recently completed the first study on the efficacy of using the RBI for IFSP development (McWilliam, Casey, & Sims, in 2009). Sixteen families were randomly assigned either to receive the RBI or to receive the business-as-usual IFSP development process. An RBI produced better outcomes than did the traditional approach to IFSP development. The families in the RBI group were more satisfied with the IFSP development process than were the families in the contrast group, and the contrast group had more variable responses. As expected, the number of outcomes was greater as a result of the RBI than as a result of the standard process. Finally, outcomes written as a result of the RBI were more functional than outcomes written as a result of the standard process.

What Are Routines?

In this model, routines are not activities the professional implements with the family. Instead, they are naturally occurring activities happening with some regularity, including caregiving events and simply hanging-out times. As reluctant as I might be to admit this, not everything happens in routines. Hence, at the beginning of the interview, we ask about major concerns first. In fact, conversations about routines do lead to many concerns beyond what happens in routines. Therefore, a Routines-Based Interview is not as circumscribed as might be thought. Another safeguard comes at the end of the interview, when the family is asked if anything else should be discussed.

Routines-Based Interview

In the original manual (McWilliam, 1992), five stages of the RBI were described. They are presented in the following sections.

Preparation of Families and Staff

If the child spends more than about 15 hours a week in child care, the child care provider should be included in the interview. If this person can be present at the same meeting as the family, the ideal situation is achieved. Often, however, caregivers and families are not free at the same time, in which case child care providers should be interviewed before the family. That allows the interviewer to convey what the child care provider has reported, and the family has all the information for making their decisions.

In preparing for the interview, the main point to convey to families and classroom staff is to think about what routines (times of day, everyday events and activities) they have and, for each one, consider the following points:

1. What the expectations are
2. What the child does
3. How well that routine is working for the family or, for classroom routines, for the Child

The Family Preparation Form (Harbin, 2005; McWilliam, 1992) is provided in Appendix 6.1 to help families get ready for the interview.

The other preparation points are logistical: where, when, who, and so forth. Families should be warned that the RBI lasts for 2 hours and that it is quite an intense conversation, so it works best if there are few distractions. This could include having someone else watch the child, if that is convenient for the family. This request is not made callously; the RBI is done only every 6 months and is quite different from a regular home visit. Some interviewers are self-conscious about making this request, but families appreciate being warned more than being sabotaged. Of course, some families are not able to make arrangements, which is fine.

The Interview

The interview is a semi structured interview that must contain the following critical features for it to be considered a "Routines-Based Interview (RBI)":

1. Main concerns. At the beginning of the interview, the family should be asked what their main concerns are, so these can be listed and elaborated upon as the conversation moves to the day-to-day life of the family. Often families' main concerns are about walking and talking. Traditionally, that is where the outcome/goal selection ended, with a walking outcome and a talking outcome—no other child target behaviors and no family-level outcomes/goals. So, whereas the answer to the main concerns question historically has led straight into outcome/goal development, in this approach it is merely the beginning, to determine what is on the family's mind.
   
   
2. Go through the day. As mentioned above, the structure of the interview is the family's progression through a typical day. To move from one time of day to another, the family is asked what happens next, rather than assuming what routines a family has and in what order they occur. During the discussion about each time of day, the interviewer attempts to find the answers to the following six questions:
   1. What everyone (both parents, siblings, other classroom children) is doing at that time
   2. What the child does
   3. The child's engagement
   4. The child's independence
   5. The child's social relationships
   6. The family's satisfaction with the routine

   The discussion is detailed enough for the interviewer to be able, figuratively, to paint a picture of the routine and to be able to determine what the family would like to happen differently at that time of the day. Depending on how much detail the parent gives in answer to an open-ended question such as, "What does breakfast time look like?", the interviewer might need to ask many detailed follow-up questions to be able to paint that picture. The goal is to find out what else the family would like to happen during that time of day—something that gets a star, as described next.
   

3. Star concerns. When the family mentions something a) not going well, b) they would like to be different, c) they think the child will be able to do next, or d) that raises a red flag for the interviewer, the interviewer makes a note of it and puts a star next to it. This helps with retrieval during the recap, described below. An example of something not going well might be the parent's saying, "She runs away every time I take her out of the car. That worries me to death." An example of something the parent would like to be different might be, "I'm not sure I have enough toys on the floor to entice him to crawl." An example of something the child might be able to do next might be, "She's doing really well when we go for a walk. It's a fun time. I guess the next skill will be for her to be able to step up and down at the curb with just one hand held." An example of a red flag might be, "Bedtime is no problem. I tell him he'll get a spanking if he doesn't lie there quietly." The parent might not think there is a problem, but the interviewer sees this as an opportunity to offer ideas for managing bedtime.
   
   
4. Satisfaction ratings. At the end of the discussion of every home routine, the interviewer asks for a judgment by the parent of how well that time of day is going—how happy the parent is with that time of day—on a scale of 1–5. If discussing school routines with a classroom teacher or child care provider, the concluding question is how well that time of day is working for the child—a goodness-of-fit question—on a scale of 1–5.
   
   
5. Worry and change questions. Once the whole day is completed or time is running out (e.g., 1.5 hours have elapsed), the family is asked two questions:
   1. When you lie awake at night, worrying, what is it you worry about?
   2. If there's anything you could change in your life, what would it be?
   
   
6. Recap. This is the summary of the important information emanating from the interview. It will include child-level needs, such as for the child to sit independently at different times of the day; child-related family needs, such as the family's wanting to learn a way to figure out a child's preferences at meals and playtimes; or family-level needs, such as the parents making time for each other without the child. The interviewer quickly goes through all the starred items. Nothing is written down at this point; this is just a summing up.
   
   
7. Family chooses outcomes. After the recap, the family is asked to start listing the things they would like to work on, including the three types of needs mentioned above. If necessary, the interviewer shows the family the notes, particularly the starred items.
   
   
8. Priority order. Once the family has finished selecting outcomes and goals, as long as there is a minimum of six of them, they are asked to number them in order of importance.

The Protocol for the Routines-Based Interview (McWilliam, 2009a), available from Siskin Children's Institute (http://www.siskinresearch.org), is a tool to help guide the interviewer through the process and to document what is said. Figure 6.2 provides common questions, in order. This list can be photocopied and used as a reference during the interview.

Outcome Writing

Once outcomes have been identified, the service coordinator needs to put the RBI outcomes on to the IFSP. The service coordinator consults with other team members about the wording of outcomes, although the parent's words are often enough. Writing functional IFSPs and IEPs is discussed in Chapter 7.

Strategies and Review

At the same time that the service coordinator consults with other team members about the wording of outcomes or goals as necessary, he or she also consults with them about strategies. Only one or two strategies are needed for each outcome at this early stage. It is unreasonable to expect that teaching plans, for example, can be developed without knowing more about the child's functioning. Reviews occur at least every 6 months, but should occur as often as needed.

To review the structure of the RBI, families report on their routines first, and child care providers or teachers report on classroom routines second. Team members other than the interviewer who might be present can ask questions and provide information during discussions of routines, but they do not have a separate decontextualized reporting time. All professionals withhold giving advice, because as soon as they do so it changes the dynamics. The family loses confidence and seeks reassurance about what they do during their routines. If the family does specifically ask for suggestions, the interviewer says, "That's a very good question. Let me write it down, and another team member or I will be sure to answer that for you later."

Interview Strategies

Conducting a good interview requires knowing child development, knowing family functioning, and having good people skills. This leads to appropriate questions within the structure presented above. The following interview behaviors are critical for the success of an RBI.

• Be natural and as informal as is appropriate.
• Put the parent at ease with this naturalness and informality.
• Look the parent in the eye when he or she is talking.
• Avoid the use of jargon; if the parent uses jargon, ask what he or she means.
• Nod and in other ways affirm what the parent is saying.
• From time to time, express admiration for what the parent does with his or her family.
• Express understanding about how the parent might feel (e.g., "I bet you feel really good about that," or "I bet that's really frustrating"); more safely, ask the parent how he or she feels.
• Place papers flat so the parent can see what is being written—distance notwithstanding.
• Find a point of personal contact and very briefly use "self-disclosure" (any behavior or verbalization that reveals personal information to the family about the professional) (Psychopathology Committee of the Group for the Advancement of Psychiatry, 2001) or "therapeutic use of self" (applying the accumulation of knowledge and techniques from professional education and training) (Edwards & Bess, 1998).
• If the parent cries, offer to stop the conversation.
• If the parent becomes emotional, either move on to another topic or ask if something else should be talked about.
• As much as possible, refrain from engaging in judgmental talk about the other parent, if only interviewing one parent.
• Ask about specific routines to move the interview along if it is taking a long time; the goal is to end in 90 minutes.
• Ask detailed questions at the beginning of the interview to show the parent the level of detail required.
• Keep the structure of the six questions per routine:
  1. What's everyone doing?
  2. What's this child doing?
  3. What's this child's engagement like?
  4. What's this child's independence like?
  5. What are this child's social relationships like?
  6. How satisfactory is this time of day (home) or how good a fit are this routine and the child (classroom)?

  Missed Questions

  No two interviewers will conduct an interview exactly the same way, despite the structure provided here, which is why this is called a semi structured interview. It is the follow-up questions that vary from one person to another. Inevitably, therefore, an observer might think that some questions were not asked. Correct! There is no way that all possible questions could be asked, but that is perfectly acceptable. In a way, this demonstrates the power of the process. Even with different interviewers who would ask different questions, 1) a list of functional outcomes is produced, 2) a huge amount of relevant information is discussed, and 3) a positive relationship is formed in a short time.

  The Most Common Concern Among Professionals

  Many professionals are concerned that families will not choose relevant things to work on or that they will have their priorities wrong. For example, when a family says that they want their child to stack eight blocks in 45 seconds, the interviewer may internally question why this is so important. First, this concern sometimes is related to a mismatch between what was found on the evaluation for eligibility and the outcomes or goals resulting from the RBI. Such a mismatch would perhaps reveal the different purposes of these assessments. The former is for determining status relative to normalcy. The latter is for determining needs for functioning in routines. Assessments conducted for different purposes can be expected to produce different ideas about what to work on. The model described here clearly puts more weight on routines-based needs than on test-based deficits.

  Second, confusion between eligibility for services and necessity of services is rampant in our field. Just because a child qualifies for speech-language pathology services, for example, does not mean that he or she needs them. In fact, there is no criterion for determining "need" for services in early intervention. It is all a matter of clinical judgment. Professionals should refrain as much as possible from using the term needing services. The alternative is to say that services would be helpful to meet needs, goals, or outcomes. Understandably, this is not a popular notion because of the fear that payers for services will adopt the notion to say that early intervention services are unneeded and therefore should not be paid for. But the specific point being made here is that qualification for a service should not be translated as necessity for a service.

  Third, just because a family does not identify a skill as a priority and an outcome, or goal, does not mean that no one will address it. Many learning opportunities are afforded to children beyond what is on their IFSPs or IEPs. For example, for a child who was determined to have delayed communication, the family may choose various eating, crawling, and toy-play outcomes and goals—but nothing about communication. Does this mean the team cannot work on language? No. As professionals work with the family about making the most of the natural learning opportunities that happen in every routine, to address their priorities, they encourage the family to talk to the child about what they are doing and to elicit communication related to eating, crawling, and toy play. So, professionals can relax when families do not select what they would have selected.

  Fourth, as families obtain more information, they might add skills that, at the time of the RBI, were not important. Early interventionists who worry about "critical periods" for intervening early can relax (there is a theme here), to some extent, because the idea of critical periods has largely been replaced by the more forgiving idea of "windows of opportunity" (Bailey, 2002): There are no times after which experiences are unhelpful, nothing is predetermined by a certain age, and one cannot measure a percentage of a given domain (e.g., a child's intelligence, a child's personality) as being determined by a certain age.

  Fifth, professionals do have the ethical obligation to provide families with any information they have, but when a child is first entering services they have not had a chance to convey that information. As time passes, families might learn about the importance of a skill they did not originally choose. Professionals need to be very careful about what they try to concern parents with, which leads to the sixth point: It is the parents' child, not the professional's child. Altogether, therefore, the list families produce at the end of the RBI will be a valid reflection of their functional needs.

  Sample Outcome Lists

  The following lists come from real interviews with families. Identifying details have been changed, but these examples show the apparent functionality of the outcomes, the level of specificity, and the extent of family outcomes. The purpose for each outcome and how it would appear on an IFSP or IEP, including criteria for measurability, are discussed in Chapter 7.

  Family Outcomes for Mary (Elliott's Mother)

  1. Elliott will move on stuff outside and inside (e.g., going up stairs).
  2. Elliott will play and walk on different textures outside.
  3. Family will find out why Elliott is eating no more than he is.
  4. Elliott will eat a variety of foods.
  5. Elliott will pick up foods with his fingers.
  6. Mary will keep Elliott engaged during church, so it is easier for her to attend church [note that the purpose is provided already in this outcome].
  7. Elliott will make choices at meals, dressing, and hanging-out times.

  Priorities for Kris (Joshua's Mother)

  1. Joshua will crawl, stand, and walk (moving independently).
  2. Joshua will use sign language, including yes, no, Mommy, and Daddy.
  3. Kris will connect with therapists.
  4. Joshua will gain weight.
  5. Joshua will play with toys in a coordinated way in the evening.
  6. Joshua will stay in his bed through the night.