A Collaborative Inservice Training Model for Early Development Providers

1. A Collaborative Inservice Training Model for Early Development Providers February 20, 2004 Mary Pat Moeller, Ph.D. Boys Town National Research Hospital

2. Presenting Issues • Geographically challenged state affecting access to services • Long-standing history of birth-3 services in public school programs • Limited availability of specialists to work with population of newly-identified D/HH infants • Advances in technology and concomitant need to update expertise • Practice shifts (primary service provider model; services coordination)

3. Collaborators: • Parent-Infant Team at Boys Town National Research Hospital • Parent-Infant Team at Omaha Hearing School • Part H Program (Co-leads: Dept of Education, Dept of Health & Human Services) • Nebraska Regional Programs for D/HH

4. Needs Assessment • Surveys and interviews revealed need for:-update on new technologies-strategies for working with families-family support methods-teamwork within primary service provider model-assessment and IFSP development • Most felt “comfortable” with development and communication

5. Needs: Post Hoc • Specific auditory development stages and strategies • Shifting from child-focus to relationship-focus • Process for determining priorities with families in communication and audition • Process for supporting/guiding families in decision making • Expectations for infants and families

6. Inservice Program Components

7. Laying a Foundation Why focus on relationships, not child skill development? Techniques: Lecture & Discussion

8. Envision “The Potential“ • Two hours/week = 2% of total waking hours for a toddler • Diapering, feeding, playing = each happen at least 2000 times before the first birthday • Just 20 everyday activities would equal 40,000 learning opportunities by age one (Dunst, 2001)

9. Review Research Findings • McBride & Peterson (1997) observed a child-focused dominance in 160 sessions • Too little focus on parent-child relationship • Mahoney, et al., (1998) – Interventions impact child development to the extent that parents are supported and encouraged to engage in responsive interactions with the child

10. Consider Outcomes Expectations • When identification is late, families have a “short stay” in the birth-3 program • Parents in this situation did not demonstrate independence or confidence in addressing goals • Implications: Parents benefit from “longer stay” in EICalderon, Bargones & Sidman, 1998

11. Consider Parental Expectations • Dromi & Ingber (1999) qualitative analysis of parental expectations for intervention (in Israel) Independent Decision-makers (N = 7)Well Socialized (N = 13) Full Collaborators (N=7)Relinquish Responsibility (N = 23) • How do our practices influence perceptions? Does one size fit all? 20 in Partnerships

12. Avoid Deficit Model -Attachment patterns of H/HH are similar to H/H - Deaf and hearing toddlers equally likely to perceive mothers as sensitive & emotionally responsive -Parents make adaptive & intuitive adjustments -We should not assume the need to focus on negative aspects of interaction Lederberg & Prezbindowski, 2000

13. Core Values & Beliefs • We are in the home to support care providers in developing competence and confidence in helping the infant learn • Each family is unique & we work to honor this diversity • The family is the expert on the child and the constant in the infant’s life • Families are equal team members

14. ABC’s of Family-Centered Intervention • Monday: Audition, Babies and Coping with Technology • Tuesday: Assessing Babies A-ZWhat parents want from EI • Wednesday: Signature behaviors for communication and auditionIFSP development • Thursday: Learning and coaching through daily routines • Friday: Cultural competence, partnerships and support for decision making

15. Beyond Lecture: Skill Building Activities • Hands-on interactive experiences • Expectations-shaping experiences • Videotape analysis • Provision of operating frameworks • Prompted practice • Group brainstorming application

16. Skill Building Activities (Cont) • Small groups: family case studies • Dialogue with parents/families & strategies for family support • Identifying “tools of trade”

17. “Hands On“ Interactive Experiences • Small groups rotate to learning stations: -identify problem with hearing aids/earmolds-identify parts of cochlear implant; -administer six sound test-listen to FM system-problem-oriented role play • Resource library – review unfamiliar curriculum and resources; share with group

18. Expectations Shaping • “Guess the audiogram” game • Simulations of hearing loss • Longitudinal observations of children • Experienced providers sharing challenges and rewards • Program observations

19. Videotape Analysis • Developmental examples to support learning of hierarchies and evaluation techniques • Longitudinal examples with discussion • Practice identifying target behaviors with “answer key” and “coach”

20. Early Communicative Functions (Intentions) • Behavioral RegulationUse communication to get others to do what I want or stop doing something-Request object/action-Protest object/action

21. Early Communicative Functions (Intentions) • Social Interaction-get adult to look at or notice me for affiliation purposes-request social routine-request comfort-call -greet-show off-request permission Heehee..let’s play more

22. Early Communicative Functions (Intentions) • Joint Attention- “Direct attention to share the focus”- Get the adult to look at or notice- Comment on object/action- Request information (wh? or rising intonation or facial expression) Wow..check that out Look..cool

23. Provision of Operating Frameworks • Examples: providing a structure for typical progression of a home visit • Providing a model for exploring communication matches

24. Rubric for a Home Visit Arlene Stredler-Brown, 2004

25. Sources of Input for Decision Making Family Values & Beliefs Parent to Parent Contact Content Sources Family Resources Family’s Evolving Goals & Needs Community Resources Collaborative Problem Solving Evaluation Findings Program Visits Profession-al input; Role models Sounding Boards

26. Prompted Practice • Guided practice with language sample analysis & criterion referenced checklists. • Linking developmental observations to ISFP goals. • Using family assessment tools with a partner: checking for “feel” of the tool. • Being a sounding board…parent expresses “X,” we answer “Y.”

27. Language Sample

28. Language Sample

29. Ways to Analyze Samples: • What strengths did you observe? • What objective measures can we make?Complexity (mean length of utterance)39/18 = 2.16 • % intelligible 11/17 = 64% • Mom’s response typesmeaning conveyedturn taking • Language functions • Language means

30. Goals Related to Improving Speech • L will discriminate and say the differences between words that differ in vowel perception and consonant perception • Parents and professionals will monitor L’s discrimination errors and address as needed • L. will increase speech intelligibility (through strengthening of auditory skills) • Parents will provide a variety of forms of feedback to L (parallel talk, expansions, etc.)

31. Group Brainstorming Application • Karen Rossi “Signature Behaviors” • Small groups assigned everyday task like diapering the baby • Determine how each signature behavior could be targeted in this natural context • Both communication and auditory behaviors targeted

32. Small Group Case Studies • Teams from same geographic area work together • Experienced providers join each team • Each group member brings case study to workshop, including areas of challenge • Workshop content applied to case studies; Periods of discussion

33. Dialogue with Families • Parent panel with diverse representation • Articles and web sites from parent perspectives explored • Small group discussion of resources for family support • Brainstorming additional resources

34. Avoiding Info Overload! IFSP, EHDI. MDT, dB, LRE, ENT, DSL, AV, BTE, CI, ASL, CS, MCE???…but I’m just a BABY

35. Tools of the Trade • Identifying key strategies • Taping examples • Observe and label • Discuss application in own setting

36. Child development Values & culture Potential impact of hearing loss Communication & language development Communication approaches & fluency Amplification and Listening Devices Assistive technology Expectations Specialized Knowledge & Skills Stredler-Brown, Gallegos,Moeller & Pittman, 2004

37. What is Coaching? • Coaching is a mindset for providing intervention and supports • It shifts the service delivery model from expert-driven to learner-focused • Focuses on supporting the people involved with the child across natural environments • Dynamic exchange of information based on learner’s skills and needs • Reciprocal process –series of conversations focused on mutually agreed outcomes

38. Coaching • Use an interactive process of observation and reflection in which the coach promotes the learner’s ability to support the child in being and doing… • Learner gains confidence and competence to implement strategies to increase the child’s learning opportunities and participation in daily life • Learner knows when the strategies are successful, can modify & can generalize to new situations and needs • Caregivers and interventionists are the “learners”

39. Coaching Techniques • Active, supporting listening • News commentator role – provision of objective, descriptive feedback-identifies what both parties are seeing-clarifies what is working-models how observation guides us-helps to pinpoint areas of strength & need

40. Coaching Techniques • Guided experiments – “I wonder what will happen if we….”-a process of using discovery to figure out what works…what strategies are a “good fit”-partners “try it out” and evaluate

41. Coaching Techniques • Model or demonstrate a skill, and test it out together • Jointly discover what is typical (can you show me?…How does that work for you?…You don’t typically…) • Recruit and accept parental interpretations, predictions and advice (you don’t think so…?)

42. Coaching Techniques • Caregiver in the driver’s seat…may take negotiation about roles • Use of synthesizing statements (summarizing, notetaking, commenting on what we are finding out that is important) • Acting as a sounding board

43. Regional Workshops • Structured as follow up to summer workshop • Based on regional needs assessment • Workshop + case management issues • Offered in regional sites throughout the state • Practical, interactive:-birth to 5 auditory learning -evaluation techniques-IFSP development • Enhanced understanding of learner needs • Ongoing training opportunities essential

44. Planned: Link newer providers with experienced providers On-site visits with demonstration & technical support Video, email and phone contacts throughout the year Actual: More experienced providers most willing Brainstorming helpful Email resource helpful Limited access to home visits Confidentiality issues Requirement? Mentoring Program

45. Successes: All parties gained insights that strengthened the system Increased access and capacity in state System of contacts to support service provision Improved training strategies Limitations: Turnover in trained staff (reassignments) Need for creative models for implementing mentoring “Ivory tower” perceptions Modality-related issues Outcomes

46. Summary • Learners profited from:-Content responsive to needs assessment-Experiential practice -Practical illustration of methods-Clear steps in processes-Learning experiences that shift paradigms & expectations-Follow up tailored to specific needs