Providing Early Intervention Services Using the Primary Service Provider Approach

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Providing Early Intervention Services Using the
Primary Service Provider Approach

• Team Member Roles
• and Considerations
• July 10, 2008

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Wisconsin Birth to 3 Wisline Teleconference

• Arianna Keil, WPDP
• Linda Tuchman, WPDP
• Michelle Davies, Birth to 3 RESource Portage
  Project

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Materials

• Power Point Presentation
• Early Intervention Team Information document
• List of references
• Available at WI Department of Health Services
  website http//dhs.wisconsin.gov/bdds/b3etn/2008/
  200807/index.htm

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Agenda

• Background
• Relationship-Based Intervention
• EI Service Delivery Models
• Transdisciplinary Model
• Primary Service Provider Approach
• Team Member Considerations
• Parents
• Therapists
• Educators
• Service Coordinators
• Physicians
• Administrators
• Discussion

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Relationship-Based Early Intervention What is it?

• Intervention that is primarily concerned with
  fostering growth-producing
• parent-practitioner and
• parent-child relationships.
• Kelly, 1999 Mahoney, Boyce, Fewell, Spiker, and
  Wheeden, 1998 Greenspan and Wieder, 1998
  Affleck, McGrade, McQueeney, and Allen, 1982,

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Relationship-Based Early Intervention What is it?

• Central focus on parent-child relationships and
  parent-professional relationships is a shift
• From deficit-based, child focused model
• To a strength-based, transactional model in which
  mutually satisfying parent-child interactions are
  supported by professionals
• Weston, Ivins, Heffron, and Sweet, 1997 Kelly
  and Barnard, 1999 Woolfson, 1999

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Relationship-Based Early InterventionWhy is it
important?

• Parent-child relationships form the foundation
  for a childs early development and intervention
  that supports these relationships can enhance
  childrens development.

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Relationship-Based Early InterventionWhy is it
important?

• Intervention effects on child development
  unlikely to occur unless parents increased their
  level of responsive behavior with their young
  children.
• Mahoney et al, 1998, 1999, 2004, 2005

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Relationship-Based Early InterventionWhat are
the implications for EI professionals?

• Practitioners use strategies that
• support parents in their relationships with their
  child as the vehicle for intervention.
• support parents competence and confidence to
  increase their childs learning and participation
  in daily life.
• Bruder and Dunst, 2000

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Relationship-Based Early Intervention

• Relationships
• Organizers of development
• Basis for all intervention
• Weston, 1997

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IDEAs Goals for EI

• 1. Enhance the development of I/T with
  disabilities to minimize their potential for
  developmental delay
• 2. Enhance the capacity of families to meet the
  special needs of their I/T with disabilities

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Relationship-Based Early Intervention

• Practitioners attend to not only what they do,
  but how they do it.

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What is the research evidence that
relationship-focused EI improves child and family
outcomes?

• The style of parent-child interaction plays a
  central role in developmental outcomes of the
  child
• Mahoney, Boyce, et al. (1998)
• Girolametto, Verbey, and Tannock (1994)
• Mahoney, Wiggers, and Lash (1998)
• Mahoney, Wheeden, and Perales (2004)
• Mahoney and Perales (2005)
• Solomon, Necheles, Ferch, and Bruckman (2004)

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What is the research evidence that
relationship-focused EI improves child and family
outcomes?

• Parent-Child Interactions Influence Family
  Outcomes
• Woolfson (1999)
• Hauser-Cram, Warfield, Shonkoff, Krauss, Sayer,
  and Upshur (2001)

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Skills Needed for Relationship-Based EI

• Expertise in child development
• Training in a specific discipline
• Interpersonal skills
• Edelman, 2004

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Relationship-Based Early Intervention,
Interpersonal Skills

• Skills Needed to Support Parent-Child
  Relationships Include Capacity to
• Listen
• Demonstrate Concern and Empathy
• Promote Reflection
• Observe and highlight the parent/child
  relationship
• Respect role boundaries
• Respond thoughtfully in emotionally intense
  interactions
• Understand, regulate, and use ones own feelings
• Gilkerson et al, 2005

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Other relationships crucial to effective EI
support and service delivery

• Practitioner - Practitioner
• Supervisor - Practitioner
• Organizational support for relationships

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Practitioner Practitioner Relationships, Key
Ingredients

• Building authentic relationships by being direct,
  honest and supportive
• Having consistent, predictable, regularly
  scheduled meetings
• Support from a supportive facilitator
• Poulsen Colem 1996

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Supervisor Practitioner Relationships

• Supervisory relationship ideally models the
  interpersonal interactions characterizing other
  relationships
• Can be supported through the approach of
  reflective supervision
• Thoughtful dialogue
• Active listening
• McCollem et al, 2001

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Organizational Support for Relationships

• A relationship-based organization is one in
  which quality relationships characterized by
  trust, support, and growth exist among and
  between staff, parents and children these
  relationships form the foundation for all the
  work thats done.
• Parlakian, 2001

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Organizational Support for Relationships

• Relationships are valued, not as a touch-feely
  nicety, but as a foundation for doing business.
• Parlakian, 2001

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Ways of Providing Relationship-Based EI

• Early Intervention Team Models
• Multidisciplinary Teams
• Interdisciplinary Teams
• Transdisciplinary Teams
• ERIC, 1989

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Multidisciplinary Teams

• Professionals from several disciplines work
  independently of one another
• Approach does not foster services and supports
  reflecting view of the child as integrated whole
• Can increase the burden of coordination and case
  management on family
• Linder, 1983

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Interdisciplinary Teams

• Include parents and professionals from several
  disciplines
• Have formal channels of communication (i.e., team
  meetings) to share information and discuss
  individual results
• Peterson, 1987

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Transdisciplinary Team

• Parents and professionals from several
  disciplines
• Goal To form team that crosses disciplinary
  boundaries
• Team members accept and accentuate each others
  strengths

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Staff Development on Transdisciplinary Teams

• Sharing general information
• Teaching others to make specific judgments
• Teaching others to perform specific actions

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Fundamental Beliefs Behind Transdisciplinary Model

• Childrens development is integrated and
  interactive.
• Children must be served within the context of a
  family.
• ERIC, 1989

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Transdisciplinary Service Delivery

• All team members share responsibility for
  development of service plan
• Service plan carried out by the family and one
  other team member (primary service provider)

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Why is this approach especially beneficial to
serving children with developmental disabilities
and their families?

• Building relationships with parents is of equal
  importance to the content of developmental
  interventions.
• Service fragmentation and family isolation occur
  when systems focus on deficits and fail to
  integrate services of various professionals.
• Parents of children with developmental
  disabilities are especially vulnerable in these
  environments because they may be receiving
  services of two or more different professionals
  or early interventionists.

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Primary Service Provider Considerations

• Designation of PSP
• Team decision
• Individualized for each family
• Carefully consider which team member offers the
  best match of expertise and relationship with the
  family
• Not based only on logistics (such as availability
  and cost)
• Team must communicate regularly to support one
  another and ensure maximum progress
• Woods, 2008

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Primary Service Provider Considerations

• All team members focus on the interactions
  between the caregiver and child, rather than
  direct service delivery to the child.
• Woods, 2008

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Implications of the Transdisciplinary Model for
Staff

• Commitment to supporting one another through
• Giving time and energy necessary to teach, learn,
  and work across traditional disciplinary
  boundaries
• Working toward making all decisions about the
  child and family by team consensus

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Implications of the Transdisciplinary Model for
Staff

• Commitment to supporting one another through
• Supporting the family and one other team member
  as the childs primary service provider
• Recognizing the family as the most important
  influence in the childs life and including them
  as equal team members

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Individual Team Member Considerations, Parents

• Must feel empowered and recognize the value of
  their contribution toward their childs
  development
• One example describing this approach to families
  from Nevada http//health2k.state.nv.us/BEIS/Provi
  dingServicesSupport2006ENG.pdf

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Individual Team Member Considerations, Speech and
Language Pathologists

• 2008 article on this issue in ASHA Leader,
  Providing Early Intervention Services in Natural
  Environments

http//www.asha.org/about/publications/leader-onli
ne/archives/2008/080325/f080325b.htm
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Individual Team Member Considerations, Speech and
Language Pathologists

• PSPA (Woods, 2008)
• One professional on the team is designated as
  the primary service provider (PSP) this model
  helps avoid fragmentation of services and
  frequent home visits from multiple professionals
  (e.g., audiologists, educators, occupational and
  physical therapists).
• With this approach, which involves role
  release and role extension, one professional
  is designated to provide services across
  disciplines, and the other professionals provide
  consultation to this designated primary provider.

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Individual Team Member Considerations, Speech and
Language Pathologists

• SLP may serve as either primary provider or
  consultant
• ASHA recommends a SLP as the primary provider if
  the childs main needs are communication or
  feeding and swallowing

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Individual Team Member Considerations, Speech and
Language Pathologists

• The designation of the PSP should be a team
  decision and individualized for each child and
  family.
• It is a viable model if it includes careful
  consideration of which team member offers the
  best match of expertise and relationship with the
  family, and is not based only on logistics, such
  as availability or cost.
• When using the PSP model, the team must
  communicate regularly to support one anotheras
  well as the child and familyto ensure maximum
  progress. Woods, 2008

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Supporting parents in communication strategies

• Increasing evidence supports parents as effective
  communication and play partners
• Kaiser et al, 2007 Mahoney et al, 2005

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Facilitating Learning for Caregivers

• Five adult learning strategies
• 1. Agree on learning priorities and roles
• 2. Join in rather than take over
• 3. Build on the caregivers strengths
• 4. The relationship does matter
• 5. Provide specific and meaningful feedback to
  enhance competence.
• Woods, 2008

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Individual Team Member Considerations, Physical
Therapists

• Maximizing Your Role in Early Intervention,
  publication from APTA website
• http//www.apta.org/AM/Template.cfm?Sectionsearc
  htemplateCM/HTMLDisplay.cfmContentID8534
• Most prevalent model in EI program across the
  country (Jeffries, 2002) is transdisciplinary,
  requiring role release
• Legal, ethical concerns about releasing
  aspects of their discipline
• Goal teach others activities not requiring the
  expertise of a therapist
• Important Family, other team members performing
  activities taught to them by therapist, only
  doing activities, not providing PT

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Individual Team Member Considerations, Physical
Therapists

• Primary Service Provider
• "One reason the primary service provider evolved
  is that young children should not have to
  tolerate the interaction with four or five
  different professionals every week. With a
  primary service provider, a child can develop a
  significant relationship with one provider who is
  collaborating with the other team members."  Toby
  Long, PT, PhD

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Individual Team Member Considerations, Physical
Therapists

• Primary Service Provider (Barbara Connolly, PT,
  EdD, FAPTA President of APTA's Section on
  Pediatrics)
• Physical therapists collaborate on a regular
  basis when teaching others on how to physically
  manage a child on a day-to-day basis.
• Example, a PT may not always be available when it
  is necessary to position or reposition a child
  during speech therapy, so the PT must demonstrate
  to the speech pathologist the appropriate ways to
  position the child during therapy. 
• Alternatively, a physical therapist might need to
  teach the child sucking/swallowing in order to
  give the child fluids or food during a session.
• Sucking/swallowing is not something exclusive to
  speech pathologists, as it also qualifies as an
  oral-motor skill and is part of the APTA Section
  on Pediatrics' "Competencies for Physical
  Therapists in Early Intervention" and is included
  in functional training in self-care and home
  management in the Guide to Physical Therapist
  Practice. 

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Individual Team Member Considerations, Physical
Therapists

• Empowering Parents (Barbara Connolly, PT, EdD,
  FAPTA President of APTA's Section on Pediatrics)
• Critical to the early intervention process
  because parents ultimately are the ones who will
  facilitate their child's progress.
• "Remember, this is the parents' child, not your
  own. We are not with the child 24 hours a day
  the parents are. It's our job to empower the
  parent. It's not your hands that make the
  difference, it's your brain that makes the
  difference.
• When a PT is successful in teaching the parent
  how to work with their child, the child is more
  likely to develop the necessary skills.

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Individual Team Member Considerations, Physical
Therapists

• The therapist needs to think about her role
  within a system of care. A system of care for
  children with disabilities is large and varied.
  It could include the family, the medical
  community, the education or early intervention
  system, the social service system,
  community-based resources such as libraries,
  parks, and activities. The providers of all these
  systems and activities could have skills to help
  the family reach their goals for their children
  and realize their dreams." Toby Long, PT, PhD

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Individual Team Member Considerations,
Occupational Therapists

• Side by Side Transdisciplinary Early
  Intervention in Natural Environments, AOTA
  publication, 2006
• http//www.aota.org/Pubs/OTP/1997-2007/Features/2
  006/f-040306.aspx
• We depart from therapist-directed interactions
  to a side-by-side collaboration with families,
  creating the agenda together. The outcome we seek
  under Part C is to support parents' capacity to
  captain their own ship and not become dependent
  on professionals for all decision making.
• Kristine Ovland Pilkington, OT

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Individual Team Member Considerations,
Occupational Therapists

• Supporting Parents
• Occupational therapy practitioners can bring
  their therapeutic use of self to all team and
  family interactions, coaching and guiding rather
  than directing and doing.
• Kristine Ovland Pilkington, OT

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Individual Team Member Considerations,
Occupational Therapists

• Team Interactions
• To become comfortable moving beyond traditional
  practice (i.e., teaching children new skills in a
  therapy session), we realize that our
  interactions with teammates and families must
  play a central role in our early intervention. As
  we interact with our teammates, so will they
  interact with each other and the families they
  support.
• Kristine Ovland Pilkington, OT

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Individual Team Member Considerations,
Occupational Therapists

• Transdisciplinary Services
• This model assumes that any given team member can
  incorporate basic things into his or her
  interventions that other members may have
  expertise about.
• Evaluation and planning are shared across
  disciplines and team members.
• This model does not assume that all team members
  can provide the same services, although some role
  release is expected.
• Team building, ongoing communication, and
  collaboration are required for this model to be
  successful.

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Individual Team Member Considerations,
Occupational Therapists

• Example of Transdisciplinary Services
• For example, if the educator is working on play,
  and the occupational therapist has concerns about
  the child using two hands, basic activities from
  the occupational therapist can be incorporated
  into those sessions.

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Individual Team Member Considerations, Educators
and Service Coordinators

• Division of Early Childhood, Recommended
  Practices (2005)
• Family-based practices
• Interdisciplinary models
• Transdisciplinary model recommended

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Individual Team Member Considerations, Educators
and Service Coordinators

• A critical value embedded in transdisciplinary
  practices is the exchange of competencies between
  team members.
• McWilliam, 2005

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Individual Team Member Considerations, Educators
and Service Coordinators

• Transdisciplinary Model
• Team members share responsibilities and
  information to the extent that one team member
  can assume the role of another
• Interventions focus on the whole child and
  family, are provided by a primary service
  provider
• McWilliam, 2005

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Individual Team Member Considerations, Educators
and Service Coordinators

• Transdisciplinary Model
• Specialists share knowledge and skills with PSP
  and parents
• Professionals provide guidance they trust
  regular caregivers to implement the interventions
  effectively
• McWilliam, 2005

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Other Team Member Considerations, Physicians

• Understanding approach and rationale behind it
  essential in creating appropriate expectations in
  parents
• One example describing this approach to
  physicians from Georgia http//health.state.ga.us/
  pdfs/familyhealth/FAQ20for20Physicians20-20Ser
  vice20Delivery20for20web.pdf

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Other Team Member Considerations, Administrators

• Understanding approach and rationale behind PSPA
  essential in supporting staff
• A Relationship-Based Approach to Early
  Intervention (Edelman, 2004)
• http//www.earlychildhoodconnections.org/files/rel
  ationship_based_approach.pdf

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Other Team Member Considerations, Administrators

• Societys commitment to ensuring healthy
  development of every child begins with the
  parent-child relationship, and requires that the
  broader institutions affecting the family stand
  alongside parents in their efforts to ensure the
  well-being of young children. Thompson, 2001

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Other Team Member Considerations, Administrators

• Importance of regular team meetings to support
  this method of service children and families
• Collaborative assessment, planning, service
  delivery, evaluation, decision making,
  problem-solving, and conflict resolution require
  strong, trusting committed relationships among
  the team members. Such relationships are built
  over time it is essential that transdisciplinary
  teams have regularly scheduled meetings to build
  their capacity to do the work at hand. Edelman,
  2004

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In Summary

• Relationship-based intervention approaches are
  generally effective in increasing parents
  responsiveness toward their children and
  improving outcomes in children with developmental
  challenges

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In Summary

• The Primary Provider Approach to service delivery
  is a relationship-focused approach designed to
  strengthen the connection between
• the professional and parent
• the parent and child
• so that parent interactions best promote the
  childs development.

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Discussion Time

• What would this approach mean for
• Your program?
• Individual team members within your program?
• Children and families served by your program?

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More Information on the Primary Service Provider
Approach to Service Delivery

• Fall 2008 Birth to 6 EVENTS newsletter
• Giving it Away
• Additional professional development activities in
  spring of 2009