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Caseloads and frequency of service in early intervention : a factor in the research to practice gap Maurice Burgess, Nathalie 2018-04

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 CASELOADS AND FREQUENCY OF SERVICE IN EARLY INTERVENTION: A FACTOR IN THE RESEARCH TO PRACTICE GAP by NATHALIE MAURICE BURGESS BCR, The University of Calgary, 2013 A GRADUATING PAPER SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER IN EDUCATION In THE FACULTY OF GRADUATE STUDIES Early Childhood Education We accept this paper as conforming to the required standard ……………………………………………………….. ……………………………………………………….. THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) April 2018 © Nathalie Maurice Burgess, 2018   ii  Abstract In my capstone project, I conduct a literature review on the topic of early intervention (EI) and caseloads (child/ren and their families) assigned to EI professionals. More specifically, I examine the literature concerned with how EI professionals manage their caseloads.  I am concerned that early interventionists have high caseloads and do not have time to implement early intervention best practice that is required to provide quality care, more specifically, meeting families’ priorities and supporting children’s growth and development.  Two theoretical frameworks, Vygotsky’s (1986) sociocultural theory and Bronfenbrenner’s (1994) ecological systems theory, guide this project.  I also include family centred practice, holistic approach, the transdisciplinary model, and provide evidence of their benefits to early intervention.  The literature reviewed in this project provides information to be used as the basis to which frequency of service and caseload numbers can be determined.  I include studies about early intervention best practice: adult skill building, functional assessment, natural learning environment, as well as other studies addressing frequency of service based on need.  I argue that to effectively implement these practices, adequate time -- hence manageable caseloads -- are required.  I connected research-to-practice through case scenarios.  In connecting this review of the literature to practice, I have prepared a workshop for early interventionists, especially those in leadership positions, regarding fundamental early intervention best practice principles that include connections to my own practice.  Based on the findings of this review, I recommend using early intervention best practice principles and service based on need as the foundational components of which discussions and decisions about caseload are made.      iii  Table of Contents Abstract……………………………………………………………………………………………ii Table of Contents…………………………………………………………………………………iii Acknowledgements………………………………………………………………………………..v CHAPTER 1: INTRODUCTION…………………………………………………………………1 Context, Personal Background, Rationale, and Importance………………………………1 Key Terms…………………………………………………………………………………4 Overview of the Theoretical Frameworks……………………………………………...…5  Approaches and Models……………………………………………………….…..7 Introduction to the Literature Review…………………………………………………….8 Purpose, Significance, and Guiding Questions……………………………………………9 Summary and Organization of the Project…………………………….…………………10 CHAPTER 2: LITERATURE REVIEW………………………………………………………...11 Sociocultural Theory……………………………………………………………….…….11 Bronfenbrenner’s Ecological Systems Theory………………………………….……….12 Approaches and Models………………………………………………………….………14 Review of the Literature…………………………………………………………………15 Family Centred Practice (FCP) and Early Intervention……………….…………16 Adult Skill Building…………………………..………………………….17 Holistic Approach and Early Intervention Practices ………………….…………19 Transdisciplinary (TD) Model and Early Intervention Practice…………………20 Functional Assessment: Meaningful Information Collected to Determine  Goals…………………………………………………………………………..…21 iiii  Natural Environment: The Location of Assessment and Intervention Visits…....22 Frequency of Service Based on Need……………………………………………24 CHAPTER 3:  CONNECTIONS TO PRACTICE…………………………………………...….28 Context and Background…………………………………………………………………28 The Connection between Early Intervention Best Practice Principles and Caseloads......29 Case Scenario #1…………………………………………………………………29 Case Scenario #2…………………………………………………………………32 Case Scenario #3…………………………………………………………………35 Case Scenario #4…………………………………………………………………38 Connections to Practice: A Workshop for Early Intervention Programs…………….…..39 CHAPTER 4:  CONCLUSIONS………………………………………………………………...42 Reflections and Concluding Thoughts…………………………………………………...42 Limitations and Recommendations for Future Study and Practice…………………...…44 References………………………………………………………………………………………..47 Appendices………………………………………………………………………………….……53 Appendix A………………………………………………………………………………54 Appendix B………………………………………………………………………………57       iiv  Acknowledgements I wish to express gratitude to my husband and best friend, Tony, for his support and understanding when I was not available to do many things as I pursued my dream; to all my friends and family for their patience and support over the last couple of years; and especially my mom, who has missed our frequent FaceTime discussions.  I promise they will occur more frequently.     I especially want to thank the families involved with early intervention that have honored me with their time by sharing their stories and inviting me into their homes.  The motivation and desire to want to do things better evolved from each journey and family encounter.  I also want to thank all the wonderful early interventionists with whom I have worked over the years, for taking the time to share their stories, their insights, ideas, and feedback that also inspired me to begin this journey.  They are truly wonderful ladies who are making a difference every day.  I extend my appreciation to previous and present management who embraced my ideas and who worked collaboratively with me to operationalize them.  A special thanks to Judy Evans who provided guidance and compassionate support when I first started my career as team leader and who always encouraged my ideas.  She always made sure that I was the voice for my ideas and insisted I represent them.  For that, I am so thankful.   Lastly, thanks to all the wonderful classmates who shared their experiences, wisdom, and time to make this educational endeavor so memorable and valuable, and to all the professors for their kindness and expertise, especially Dr. Mari Pighini for her unwavering support and guidance.  I particularly benefited from her experience and expertise as an early interventionist; they added meaning to my personal learning objectives.      1  CHAPTER 1: INTRODUCTION In my capstone project, I conduct a literature review on the topic of early intervention (EI) and caseloads (child/ren and their families) assigned to EI professionals. More specifically, I examine the literature concerned with how EI professionals manage their caseloads. Early intervention programs (EIP) support families who have a child or children birth to three years of age with a diagnosed disability or at risk for developmental delays (Keilty, 2010).  In this project, I specifically refer to EI services for children with developmental delays or disabilities that include vision, but not hearing-impaired children or deaf parents as per the parameters of the EI program where I work in Alberta, Canada.  There may be other caseload concerns for this population not addressed in this project.  At the same time, EI programs that extend their services to children age five or six may be included or referenced in this project.  As an EI team leader, I believe that it is very difficult to manage the complexity of needs of families while trying to do family centred and responsive care, active skill building of caregivers, and coaching with professionals supporting the family when visits occur every month.  The complexity of needs of families involved with EI are such that the families require responsive and individualized attention.  I intend to provide a link between theory and practice that supports EI services.  The service follows the recommended best practice of visiting families based on need which ultimately requires more frequent visits.   Context, Personal Background, Rationale, and Importance As the clinical team leader of an EI program, I support 15 early interventionists and make recommendations based on EI best practice.  I have been working on caseload management issues since 2011.  One of our challenges with implementing the service as outlined in our service delivery is that staff are unable to book a visit within a week of doing the functional 2  assessment that is used to determine goals and plan for intervention.  This impacts the flow and the overall effectiveness of the intake and planning process.  Furthermore, we have experienced an increase in referrals with families with children with complex needs seeking our service.  Examples of this include: Syrian refugees with minimal resources who are isolated (Theobald, 2017), unemployed parents, multiple children with diagnosed and/or query autism without needed supports and resources (source: observational and documentation based-information from file reviews).  Information about the complexities of the family and the overall needs of the children in terms of intensive home support is required, even if it is for a short duration of time.  In this role, I see myself as an advocate for both the families we serve and the team that I support.  I am passionate about supporting families in getting the service they need while ensuring that staff are engaged and supported with the resources required to provide quality care.      Working in the role as team leader for the past ten years, I have conducted file reviews, completed observations of practice during home visits, and had meetings with staff expressing concerns about their ability to support families as outlined in our service delivery model.  I also reflected on my personal experience working as an early interventionist visiting families in their home.  We continue to meet our target to see families within four weeks of referral (organizational expectation), but with increased referrals this has impacted the frequency of visits to families.  Most families qualify for weekly service as per the needs assessment we developed, but as caseloads grow to meet the above target the frequency of service is adjusted accordingly. Currently we visit families every four to six weeks, which I contend compromises the quality of service.  Referrals to the EI program where I work have increased by 220% from 3  407 (2007-2008 fiscal year) to 896 (2016-2017 fiscal year)1.  Caseloads have grown from approximately 30 to 60 per 1.0 full time employee.  Staff report feeling overwhelmed and concerned about not being able to provide service based on family need.  This has significant risk for quality care, decreased job satisfaction, and staff stress (Collister, Slauenwhite, Fraser, Swanson, & Fong, 2014).  In addition to the factual data showing frequency of service impacted by high caseloads is feedback from the receiver of our service.  For example, annual parent surveys included concerns about the frequency of visits and access to their early interventionists.   A few years ago, I had a revelation that all the issues presented by my colleagues came down to one common denominator: caseloads.  Robust research supporting the significance of EI for children with developmental delays or disabilities includes the work of authors like Bruder (2010), Keilty (2010), and Raver and Childress (2015). This quote taken from Raver and Childress’s (2015) book on family centred EI, summarizes it succinctly: “although early intervention cannot eliminate most disabilities, it can have a positive effect on the development of many young children and lessen the effect of the disability or delay on the child’s interactions and participation in everyday life” (p. 24).  To achieve this outcome, as well as others, such as supporting responsive relationships that foster healthy brain development and/or to help families manage the stress and challenges of raising a child with a delay or disability (Keilty, 2010), I believe we must implement EI best practice.  It is imperative that we get it right by providing quality service.  To do so, caregivers need to be supported with the necessary tools to be                                                           1 These are anecdotal comments derived from organization report information and names are protected for privacy and confidentiality.    4  successful, in a manner as outlined in this project, which includes ensuring staff have caseloads that enable them to provide service based on need.   The concerns above provided the basis for my inquiry.  In the next section, I present definitions of the terms that provide a context for understanding the content included in my capstone project. The terms are organized in alphabetical order.  Key Terms Adult skill-building: This strategy includes supporting parent capacity because parents have the greatest opportunity to influence a child’s development.  Adults support children’s learning by giving the child opportunity to practice their current skills and by encouraging them to do new things, something beyond their current level of functioning.  This is referred to as Vygotsky’s (1986) zone of proximal development (ZPD), introduced in Chapter 1 and defined in Chapter 2.  Best practice:  I refer to best practice throughout this project in terms of what Pletcher and Younggren (2013) described as: “interventions with young children and family members must be explicit principles, validated practices, best available research, and relevant laws and regulations” (p. 51).        Caseloads: “The term caseload refers to the number of families served by each home visitor” (Alberta Children’s Services, 2004, p. 27).  It includes the number of files for each child and his/her family that the early interventionist is responsible for supporting and providing service.   Early interventionist:  For this project, early interventionist includes all professionals who work for EI programs and who provide direct service to families.  It may include designated 5  professionals; for example, occupational therapists and non-regulated professionals including early childhood educators (McWilliam, 2010). Functional assessment: “Consists of two practices related to gathering information from families about their child and family supports and gathering information about the child’s functioning with the context of daily activities” (Ridgley, Snyder, McWilliam, & Davis, 2011, p. 314).   A functional assessment includes daily routines and activities as the context used to determine goals and priorities. Primary caregiver:  This includes the parent or any person who spends more than 15 hours a week with the child (McWilliam, 2010).  Parent, family, or caregiver are used interchangeably throughout this project to refer to the primary caregiver.      Quality care/service:  I refer to Buysse and Wesley’s (2006) definition: “conceptualized broadly, the definition of quality encompasses all aspects of children’s surroundings, care, education, and experiences that are beneficial to their development and well being” (p. 202).  Quality care is giving each family what they need, that is, responsive care, to ensure that families are supported and have the tools to assist their children to participate in a meaningful way at home and in the community.     Having defined key terms, I now turn to the theories, approaches, and model that inform my study. Overview of the Theoretical Background My capstone project draws on Vygotsky’s sociocultural theory and on Bronfenbrenner’s ecological systems theory, both grounded in social constructivism.  Vygotsky’s (1986) sociocultural theory posits that children progress through developmental stages in the context of social interactions influenced by the cultural context in which they live.  Vygotsky’s theory 6  supports the importance of the role of the parent discussed in this paper, including the zone of proximal development (ZPD) and the more knowledgeable other (MKO), as well as using the context to guide decisions made to support early childhood practices, in this case EI.  For example, rather than using universal curriculum a contextualized response to early childhood promotes the development of each child, in his/her community (Edwards, 2003).  Finally, Rogoff (1998) expanded the work of Vygotsky by describing three interacting influences on development, intrapersonal, interpersonal and contextual, discussed in more detail in Chapter 2.       The ecological systems theory of human development includes the relationship between several systems (microsystem, mesosystem, exosystem, microsystem, chronosystem) and their impact on development (Bronfenbrenner, 1994).  Bronfenbrenner identified the need to understand the complex system and all the variables impacting the child’s development.  He expanded his framework to include proximal processes, and also specifically distal processes, described in Chapter 2.  Sontag (1996) argued for the ecological systems theory to be used as a framework in early learning for children with disabilities to adequately include the role of the family and other environmental considerations.  This emphasized the importance for programs working with young children to include ways to gather information about all the possible variables impacting a child’s development into the assessment and intervention process.  These theories are important to my capstone project in that families need to be visited based on need. It takes time to understand and support the entire family with issues or concerns related to overall well being which may influence their ability to care for and concentrate on the intervention.   Vygotsky’s (1986) sociocultural theory and Bronfenbrenner’s (1994) ecological systems theory support the notion of the whole child by recognizing that the child’s development is influenced by the complexity of relationships among different systems and his/her cultural context.  One of 7  the social contexts that influences the child’s development is the child’s family, which is foundational to family centred practice (FCP), an approach discussed next.    Approaches and Models Family centred practice (FCP) is the overarching, umbrella term used to guide how early interventionists relate and work with families.  It includes the entire family and not just the receiver of service, in this case the child.  Fundamental to family centred care is the need to assist the family that is supporting the child (Dunst, 2002; Dunst, Trivette, & Hamby, 2007; Espe-Sherwindt, 2008; Pighini, Goelman, Buchanan, Schonert-Reichl, & Brynelsen, 2014).  I describe two benefits of FCP.  First, family well-being has a direct impact on the overall health of the child (Bailey et al., 2006; Gerlach, 2015).  Second, families prefer a FCP approach and report increased satisfaction with service (Pighini et al., 2014; Rodger, O’Keefe, Cook, & Jones, 2012).  The role of the primary caregiver is pivotal to the intervention process.  Therefore, in this capstone project I provide evidence supporting the idea or notion of active skill-building in terms of engagement, (Byington & Whitby, 2011; Dunst et al., 2007; Espe-Sherwindt, 2008), assisting parents with their needs (Garner, 2013), and everyday opportunities as the context for learning (McWilliam, 2012).   The study by Dunst et al. (2007) on helpgiving practices complements the discussion and provides an explanation of participatory practices to use with families involved in EI, as explained in Chapter 2.    A second model supporting this project is the holistic approach.  To understand the holistic approach, one must start with the term holistic.  In a document describing an early learning and child care curriculum for the province of Alberta, Canada, Makovichuk, Hewes, Lirette, and Thomas (2014) defined holistic as a term that “means that we always consider the whole child in our work-intricately entwined in relationships, in play, in learning, and the 8  environment” (p. 84).  Within the holistic approach, the term “holistic” means that all areas of a child’s development and overall well-being are considered versus compartmentalizing or working on one developmental domain at a time (Noddings, 2005).  Children in EI are supported by including and working with all variables that influence their development.  I include studies that found benefits to using a holistic approach and recommend it as preferred practice (Greenwood, 2006; Nadeem, Maslak, Chacko, & Hoagwood, 2010; Noddings, 2005).  Finally, I include the transdisciplinary (TD) approach to suggest how the team is organized to support the family.  The TD model is less intrusive, less confusing, and less stressful for families because they are not dealing with multiple people (King et al., 2009). Researchers who described and supported the TD model include Bell, Corfield, Davies, and Richardson (2009), King et al. (2009), and Fitzmaurice and Richmond (2017), reviewed in Chapter 2.       In the next section, I provide a brief overview of the literature on EI principles and frequency of service based on need to illustrate how they connect to the topic. Introduction to Literature Review While there are no explicit recommendations for frequency or dosage of service for EI service to be effective (Keilty, 2010), the literature reviewed in my capstone project provides information to be used as the basis on which frequency of service and caseload numbers can be determined.  I include studies about EI best practice, as well as other studies addressing frequency of service based on need (e.g. Palisano & Murr, 2009; Raikes et al., 2006).  In addition to the theoretical frameworks, approaches, and model cited above, I review the following topics.  First, I include literature supporting the use of a functional assessment in EI, which is how information is collected to plan and determine intervention with families (Gatmaitman & Brown, 2015; McWilliam, Casey, & Sims, 2009; Rigley et al., 2011).  Second, I expand on the concept 9  of a child’s natural environment, which supports early interventionists’ decision about the location of intervention (Dunst, Hamby, Trivette, Raab, & Bruder, 2000; IDEA, 2004).  I begin with some background to situate why natural environment is used in EI and a proposed definition.  In the United States, unlike Canada, there is federal legislation to support EI best practice.  The Individuals with Disabilities Education Improvement Act (IDEA) is US federal legislation informed by research.   Part C Infant and Toddler program of IDEA requires that service and support be provided in the child’s natural environment unless there is a valid reason it cannot, and family capacity building, discussed later, is the target of intervention (IDEA, 2004).  I include studies describing two pivotal components of natural environment: contextual learning supports development (Dunst, Bruder, & Espe-Sherwindt, 2014; Spagnola & Fiese, 2007), and generalization of skills (Hanft & Pilkington, 2000). Finally, I provide evidence from the research regarding service based on need that shows that intervention at greater frequency achieves better outcomes.  I include Aaron et al.’s (2014) study supporting one hour a week of service, and studies supporting weekly visits for shorter periods; for example, 10 visits to do active skill building (Carol, Bernard, & Dozier, 2016) or 12 visits as needed by the family with an emphasis on daily practice (Palisono & Murr, 2009).  I also include Wilkins et al.’s, (2010) study about parents feeling supported by more frequent contact, Raikes et al.’s (2006) study supporting frequent visits to assist parents with their needs, and studies considering the disability to determine frequency of service (Jung, 2003; Soto, Kiss, & Carter, 2016). Next, I outline the purpose and significance of this project, and articulate my guiding questions.  10  Purpose, Significance, and Guiding Questions The purpose of this capstone project is to gain a deeper awareness of how the extant literature identifies the need to have manageable caseloads to allow for greater frequency of service that supports quality intervention. The anticipated significance of this project is for EI leaders to acquire information that can be used to advocate for manageable caseloads that permit service provision based on need.  The main question guiding my capstone project is: What are the aspects identified in the extant literature that consider frequency of service and caseload numbers in relation to EI services, and more specifically, a) in relationship with meeting families’ priorities, and, b) in relationship with supporting children’s growth and development? Summary and Organization of the Project In Chapter 1, I introduced the topic of my project and added a definition of EI and other key terms, introduced the theoretical background and approaches and authors reviewed in the literature.  Finally, I stated the purpose, significance, and guiding questions for this capstone project.   In Chapter 2, I elaborate on the theoretical frameworks in relation to supporting families with their diverse and individual needs within a cultural context.  I share findings from research studies that demonstrate the benefits of short-term, intensive service, and fundamental EI principles that support the importance of providing service based on need.  In Chapter 3, I connect theories reviewed and extant literature with scenarios from my EI practice that support manageable caseload.  In Chapter 4, I provide a brief summary and reflection, highlight limitations of this capstone project, and identify next steps.    11  CHAPTER 2: LITERATURE REVIEW In Chapter 2, I elaborate on Vygotsky’s (1986) sociocultural perspective and Bronfenbrenner’s (1994) ecological systems theory.  Moreover, I expand on the holistic approach, family centred practice approach, and the transdisciplinary model in relation to supporting families with their diverse and individual needs within a cultural context.  Sociocultural Theory As previously introduced, Vygotsky’s (1986) sociocultural theory posits that children progress through developmental stages influenced by their cultural context and relationships with others.  It includes two important components: relationships and cultural context.  First, according to Vygotsky, the developmental process is led by interactions with others.  Vygotsky used the term zone of proximal development (ZPD) to describe the place in which more capable peers or adults support a child to do things that are slightly outside of this or her ability or current skill level.  According to Vygotsky, children learn when a MKO, for example, a supportive adult or peer, is responsive to what they are doing.  Bruner expanded the idea of MKO with the notion of scaffolding.  Wood, Bruner, and Ross (1976) explained it in terms of “the adult ‘controlling’ those elements of the task that are initially beyond the learner's capacity, thus permitting him to concentrate upon and complete only those elements that are within his range of competence” (p. 90).   Second, a significant contribution to early childhood education and development from Vygotsky’s (1986) work was that learning is contextualized and culturally influenced.  According to Vygotsky, child development is influenced by the cultural context in which a child lives.  To illustrate the importance of context, in a literature review outlining the significance of using Vygotsky’s social cultural perspective in early childhood education, Edwards (2003) 12  explained the following: “the development of intellectual ability in the young child was therefore considered a function of social interaction contextualized according to the particular cultural setting in which it occurred” (p. 225).  In sum, children learn through relationships, which are influenced through the cultural context where they live.  Rogoff (1998) further introduced three interconnected components to the sociocultural theory to explain influences on child development; the individual, relationships and social interactions with others, and the context or environment in which the child lives including community and institutional practices.  I explore in the next section the expansion of the sociocultural theory in terms of the different variables that influence and impact the learner as described in Bronfenbrenner’s ecological systems theory.          Bronfenbrenner’s Ecological Systems Theory As introduced in Chapter 1, Bronfenbrenner’s (1994) ecological systems theory outlined the relationship between the child, family and society and their impact on development.  The ecological systems theory provided a theoretical framework that consisted of multiple systems, described below, that accounts for the complexity of child influences. This is a viewpoint contrary to the developmental psychology model (Bronfenbrenner, 1994; Goelman & Guhn, 2011).  The psychological model uses tests to evaluate isolated skills including cognitive and social skills.  Test scores categorize children without considering environmental factors or other variables that impact a child’s development (Goelman & Guhn, 2011).  On the contrary, the ecological systems theory includes the following several interconnected systems that influence development:   1) The relationship between the child and family, peers, and school (microsystem). 13  2) The, relationship between microsystems; for example, the family and daycare (mesosystem). 3) Indirect influences; for example, the parent’s work (exosystem). 4) Norms and values that guide behaviors; for example, culture, religion and laws (microsystem), and, finally,  5) The timing of an event in the person’s life or events unique to a particular period; for example, a recession (chronosystem; Bronfenbrenner, 1994; Goelman & Guhn, 2011).   Bronfenbrenner stressed the significance of learning about and supporting the complex system impacting the child’s development. Of importance to EI is the term ‘proximal processes,’ that Bronfenbrenner used to explain the interactions between the immediate environment and its impact on human development.  Bronfenbrenner (1994) explained proximal processes as “processes of progressively more complex reciprocal interaction between an active, evolving biopsychological human organism and the persons, objects, and symbols in its immediate environment” (p. 38).  For proximal processes to be effective on a child’s development, Bronfenbrenner identified two conditions: regular interactions for extended periods and frequent interactions.   In EI proximal processes are supported when helping parents identify meaningful naturally occurring daily activities and routines that provide the frequency, variety, and intensity that children need to practice and learn new skills.           Sontag (1996) elaborated on the importance for education to shift towards understanding problems related to family functioning, including poverty or malnutrition, to adequately educate the child.  Furthermore, Sontag argued for the ecological systems theory to be used as a framework in early learning for children with disabilities to include the role of the family and other environmental considerations. The main posits of the ecological systems theory reinforced 14  the idea that children do not live in isolation but instead live under the influences of family, community, and society.  Approaches and Models In this section, I expand on family centred practice (FCP), the holistic approach, and the transdisciplinary (TD) model, introduced in Chapter 1.  I begin with the family centred practice.  There is robust research for family centred practice (FCP) which includes active parent involvement in early childhood intervention and the impact it has on child and family outcomes (e.g., Dunst et al.,2007; Espe-Sherwindt, 2008; Pighini et al., 2014).  If the family is struggling with basic needs (e.g., shelter or food) or other overall health issues (e.g., depression), the family needs to be supported so that they are ready and capable of caring for their child.  FCP includes relational and participatory behaviors, described later in the literature review that fosters a collaborative relationship between professional and caregiver (Dunst et al., 2007).  Characteristics of a FCP include respecting cultural values and beliefs, including family and child goals, acting in a kind and nonjudgmental manner, and family decision making (Dunst et al.,2007; Espe-Sherwindt, 2008; Pighini et al., 2014), which are essential to establishing a positive and trusting partnership.   The holistic approach encourages the natural way in which children discover and explore their environment.  The term ‘whole child’ is integral to the holistic approach.  In a Canadian document supporting early learning and early childhood, Franklin, McNinch, and Sherman (2013) included the concept of whole child as one of the principles, as per the next quote:  …this means that the cognitive, physical, social, spiritual, aesthetic, and emotional development of the child are all interrelated and must be taken into account in early 15  learning environments.  Early learning is strongly influenced by multiple and intertwined social, cultural, and linguistic contexts. (p. 6)  This definition highlights the importance of viewing a child’s development as the sum of all its parts, influenced by many variables, including the sociocultural and linguistic context.        The transdisciplinary (TD) approach was developed in the United States as an approach that embodies family centred principles (Fitzmaurice & Richmond, 2017) and is an example of a service model that uses a primary early interventionist to support the family, which is more conducive to helping establish a trusting relationship than perhaps the multidisciplinary approach.  A TD model is recommended as EI best practice.  In her work supporting children with neurological impairments, Limbrick (2011) suggested using the term ‘team around the child’ or ‘integrated approach’ as used in other countries to address fragmented service by bringing professionals together to plan interventions, as being synonymous with TD.  Similarly, in a study that examined early childhood best practice and challenges resulting from increased complexity of needs and dwindling resources, Bruder (2010) recommended a ‘collaborative team process’ as one of three top practices. The TD model includes using a primary service provider, one professional, who is supported by a team of professionals, in contrast to having multiple professionals visit the family as in a multidisciplinary or interdisciplinary approach (Bell et al., 2009; Fitzmaurice & Richmond, 2017).  A fundamental characteristic of the TD model is the sharing of expertise and building capacity among colleagues of other disciplines, referred to as role release (Fitzmaurice & Richmond, 2017).   Review of the Literature Having expanded on the theoretical framework, the approaches and model, I next present the findings from the literature reviews and studies pertaining to the benefits of fundamental EI 16  principles, followed by studies that demonstrated better outcomes when service was provided based on need.  Family Centred Practice and Early Intervention (EI) As previously introduced, the family centred practice (FCP) approach includes a recognition of the value and importance of the role of the family in terms of supporting the child’s overall well-being and development.  In a summary report of a qualitative study investigating early childhood and EI services to indigenous children and families in British Columbia, Gerlach (2015) found that there were health inequities and structural barriers to accessing services.  One strategy Gerlach recommended to facilitate access to service was support for caregivers with their primary needs (e.g., housing and access to food so that parents can take care of their children).  Earlier on, Bailey et al. (2006) had conducted a literature review of family outcomes involved with EI.  The researchers consulted many stakeholders; for example, parents, EI coordinators and professionals across the United States using the Early Childhood Outcomes (ECO) website, to get feedback regarding outcomes.  Bailey et al. used the feedback to refine and recommend five outcomes that EI programs can use to evaluate the effectiveness of service.  They are: (1) families understand their child’s strengths, abilities, and special needs, (2) families know their rights and advocate for their children, (3) families help their children develop and learn, (4) families have support systems, and (5) families access desired services, programs, and activities in their community.  Bailey’s (2006) position regarding the pivotal role of the family is further demonstrated by the following statement: “families play critical roles in their child’s development; helping families has direct implications for the extent to which children benefit from services” (p. 229).  These findings in these studies and review 17  have illustrated the importance of family support in addressing the needs of the child.  When the family struggles, so, too, will the child.  A second benefit to FCP is that families prefer a family centred approach and are more satisfied with service than they are with being told what to do without their input and preferences considered, reporting it to be helpful and beneficial to their care in EI.  For example, using a multiple case study approach involving 11 adults and 7 children regarding parents’ experiences with EI services, Pighini et al. (2014) identified the following themes: 1) FCP and home visits foster close relationships with service providers; 2) Parents valued the inclusion of other family members and the one to one relationship with the consultant; 3) Parents valued collaborative consultation the most when compared with being told what to do; 4) Parents valued active listening that helped them feel empowered; 5) Finally, they valued joint decision making and gaining a better understanding of their child’s development.  Pighini et al. found that FCP was participants’ preferred approach.  Furthermore, in a qualitative study investigating the Family Goal Setting tool (parents place cards with goal statements into a yes, no or maybe pile) involving EI families in Australia, Rodger et al. (2011) found that parents felt supported when family goals and needs were included and not just those of the child.  Families reported feeling empowered and increased satisfaction with service.   An important aspect of FCP is families working collaboratively with the caregiver to build their capacity and skills to support their child’s healthy development.  I will refer to this as adult skill building, an important component of EI practice.  Therefore, I elaborate in more detail in the next section.       Adult skill building.  Engagement is the first aspect of adult skill building, starting with treating the parent as expert.  In a literature review investigating empowering families during the 18  EI planning process, Byington and Whitby (2011) differentiated between ‘parent as expert’, a collaborative approach where the parent is treated as the expert of her/his child and ‘the professional as an expert’ in their respective field.  They concluded that treating the parent as an expert resulted in increased participation and engagement.  The issue of engagement is addressed by using what Carl Dunst, a researcher focusing on EI, termed participatory practices.  Dunst et al. (2007) identified two components of FCP: relational and participatory helpgiving practices.  Relational practices include using clinical skills to establish a relationship (e.g., active listening and empathy), which is found to be used more often and is easier to implement than participatory practices (Dunst et al., 2007).  Participatory helpgiving practices include action-oriented behaviors of family members to achieve their chosen goals and priorities.  Dunst et al. (2007) defined it as “practices that are individualized, flexible, and responsive to family concerns and priorities, and which involve informed choices and family involvement in achieving desired goals and outcomes” (p. 370).  Using a meta-analysis of family centred helpgiving practices from 47 studies, Dunst et al. found that participatory helpgiving practices resulted in positive family experience and positive family and child outcomes.   Likewise, in a literature review of family centred practice, Espe-Sherwindt (2008) attributed relational and participatory behaviors to it its success.  First, FCP helped establish a trusting relationship.  Second, it addressed the power imbalance by having parents make decisions and be agents of change.  In doing so, Espe-Sherwindt claimed that this lead to the positive outcomes for children and families she found characteristic of FCP.   A second component of building parent capacity is recognizing and supporting parents with their own issues that may impact their ability to care for their child, as Greenwood (2006) has identified.  Children and families exposed to, or living in, toxic environments need access to 19  EI services and child care support to prevent or mitigate the impact of toxic stress on children’s development (Garner, 2013).  For example, in a study examining toxic stress and its impact on early childhood, specifically healthy brain development, Garner (2013) discussed the negative impact adverse childhood experiences, household dysfunction and neglect had on children’s social emotional, cognitive and language skills. Garner recommended competent home visitor staff that can support the complexity of needs of child, family, and community.  Garner explained that this can be done by supporting nurturing relationships between child and parent and building parent capacity to manage stress and adverse events.  A third component of adult skill building is the opportunity to use every day routines and activities in between EI visits to maximize learning experiences.  In a study about preparing for home visits and the implementation of visits in EI, McWilliam (2012) discussed the issue of dosage by differentiating between the service visit which occurs for an hour once or twice a week, and intervention which is the time in between visits.  McWilliam explained that the key to successful home visits is the engagement of parents during the service visit to identify strategies to use during everyday learning opportunities (e.g., routines and family activities), and recommended the need for further research in this area.   In sum, the findings from studies in this section support the pivotal role of the parent and the need for programs to engage parents in the intervention process, thus pointing to the need for time invested and responsive planning in EI.      Holistic Approach and Early Intervention (EI) Practices As introduced earlier on in this chapter, the holistic approach provides a perspective of the child as a person influenced by many factors that include the family, environment, culture, socioeconomic status, and biological influences.  These factors need to be considered when 20  supporting the whole child.  The studies and literature reviews examined in this section have reported on the benefits of using a holistic approach; their findings include recommendations to use it as a practice with families and children.  For example, in a literature review evaluating educational and public policies, Nadeem et al. (2010) found that a holistic approach to social, emotional and academic needs of children led to better academic success and overall healthy development of children.  Similarly, in a literature review evaluating the curriculum used to meet the No Child Left Behind education policy in the United States, Noddings (2005) found fragmented curriculum design did not address the complexity of needs of children and families. Instead, Noddings recommended holistic treatment to educate the whole child to teach character development.  Greenwood’s (2006) literature review that examined the political and policy influences of Aboriginal early childhood programs in Canada also recommended off-reserve programs to include language, traditions, identity, and culture.  In sum, a holistic approach protects and celebrates identity while supporting overall health and well-being.    Transdisciplinary Model (TD) and Early Intervention (EI) Practice  A transdisciplinary (TD) model of service can be an effective and an efficient way of providing service to families.  For example, in a study describing the transition from using a multidisciplinary team approach in EI to a TD model over a three-year period, Bell at al. (2009) found significant attendance improvements, and decreased wait times for service despite an increase in caseloads without additional resources.  The authors attributed the results to increased efficiencies of existing resources.  For example, they described using play-based assessments and therapy groups led by nurses supported by professionals.  This meant that more children were seen during groups and it provided more time for professionals to complete individual visits with more complex cases.  Likewise, in a literature review of the TD model in EI, King et al. (2009) 21  found the following benefits of using a TD model.  First, it promotes a holistic approach that is optimal for children and their families.  Second, it is less confusing and less intrusive for families.  Parents do not have to schedule different appointments, establish relationships with different individuals and remember whom they must contact for different things.  Third, having to deal with one person is less stressful for families than dealing with many professionals.  Fourth, they reported that this approach leads to better care and outcomes for the child.  On the other hand, in an attempt to find evidence supporting the claim outlined in a 2013 Australian document regarding the TD model as evidence best practice used in EI for children with disabilities, Fitzmaurice and Richmond (2017) found limited research supporting the claim from their systematic review of eight studies.  They recommended more research to evaluate the effectiveness of using the TD model on developmental outcomes.  Nevertheless, the benefits from the first two studies support the use of a TD model in EI, particularly parents reporting that the TD model is less stressful (King et al., 2009) and increased efficiencies when used (Bell et al., 2009).         Next, I expand on functional assessment and natural environment as pivotal components of EI, followed by research supporting service based on need.  These components are likely to have an impact on caseloads and frequency of service, explained later in the implications for practice.   Functional Assessment:  Meaningful Information Collected to Determine Goals  Most programs adopt a model that may include screening and assessment to use with children and families, but how and why this is done is important to the planning and intervention process.  For instance, McWilliam et al. (2009) conducted a literature review and used preliminary data from an empirical study showing support for a functional assessment, the 22  Routine Based Interview (RBI). The RBI is a semi-structured interview used to gather and assess family needs by learning about everyday routines in the natural environment.  At the end of the discussion parents choose family and child goals related to daily activities and routines that are important to them, and the selected goals are the basis of the intervention plan.  McWilliam et al.  suggested that family centeredness and functional goals can address the issue of poorly established goals, which they claim are often included on service plans.  McWilliam et al. found that the RBI process resulted in greater satisfaction than when using scripted questions, the number of child and family outcomes was greater, and the goals were functional.   In a more recent literature review about quality individualized family service plans used with families in EI, Gatmaitan and Brown (2015) identified five components for practitioners and families to use as a guideline in the planning phase.  The five components described are functional assessment, functional outcome writing, linking functional outcomes to services, service integration, and progress monitoring.  Gatmaitan and Brown described characteristics of a functional assessment as an authentic assessment (e.g., observing the child in the natural environment, using informal or semi-structured interviews including the RBI to gather information about the child and family, creating an ecomap to understand family informal and formal support networks, and using effective communication strategies to establish a trusting relationship so caregivers feel safe to share their concerns).  Likewise, in an extensive literature review and using preliminary data from a pilot study investigating the quality of EI, Rigley et al. (2011) identified functional assessment as one of five components associated with quality family service plans.  In sum, the information gathered during a functional assessment can be used to develop meaningful goals selected by the parent that is also used for intervention planning.                            23  Natural Environment: The Location of Assessment and Intervention Visits Closely linked to the functional assessment is the natural environment in which the assessment and intervention occurs.  Three arguments support natural environments: inclusive practice that is a fundamental right for all children (UNICEF Canada, n.d), contextual learning that supports overall development (Hanft & Pilkington, 2000; Spagnola & Fiese, 2007), and generalization of skills (Hanft & Pilkington, 2000).  Robust research supporting inclusive practice exists.  This topic is beyond the scope of this project; therefore, I will elaborate on contextual learning and generalization of skills.   As discussed earlier, contextual learning supports overall development by using family routine in the natural environment.  In a literature review of evidence of the effectiveness of using family routines with families of young children, Spagnola and Fiese (2007) described family routines as repeated activities that involve two or more people, help maintain structure and provide the context for the development of children.  Spagnola and Fiese found that including routines and family rituals (e.g. graduation or birthdays) linked to improved vocabulary, enhanced social skills and academic success for children.  In other research, Dunst et al. (2014) used data from 124 caregivers from 22 states receiving EI service to investigate context and program effectiveness, and found that parent capacity building was significantly lower when services were provided entirely outside of their home.  In both studies, contextual learning attributed to parent engagement and implementation of strategies was used to improve child outcomes.   Finally, in EI generalization is referred to as the ability of parents and children to use what they learned from one context and apply it to other situations.  For example, in a study examining natural environment as an extension of FCP, Hanft and Pilkington (2000) conducted a 24  literature review exploring how service was provided in a natural setting.  They posited that how service was provided was as important as the location.  Hanft and Pilkington (2000) explained the following: “generalization of skills and behaviors, both of caregiver and child, are more likely to occur when there is no delineation between the intervention setting and natural environment” (p. 4).  They found viewing parent as expert, selecting parent goals and priorities, imbedding activities into existing routines, and using parent learning styles in the context of daily activities were characteristic of both natural environments and FCP used to promote child learning opportunities.        Frequency of Service Determined Based on Need  Determining frequency of service is a complex issue.  For instance, Aaron et al. (2014) conducted a qualitative study to investigate factors used to decide the intensity of service with families during the Individual Family Service Plan (IFSP) meeting, required by IDEA.  Factors they identified included insurance coverage and method of delivery influenced parent’s choice of frequency of service more so than parent participation and team support during the IFSP.  The authors indicated a concern with IDEA’s outlined expectations to provide FCP that includes family’s needs and child specific concerns in natural environments, yet it does not provide guidelines for frequency of service.  “Determination of intensity of EI services is a complex multifactor process and disparities in intensity of services may arise for a number of reasons” (Aaron et al., 2014, p. 344).  Despite the complex nature of determining frequency of service, the authors found that 57% of families recommended 240 minutes a month (e.g., one hour a week).  Similarly, in a literature review about the intensity of therapy service for children with developmental disabilities, Palisano and Murr (2009) found that it is dependent on the family context, goals and family priorities.  They identified five considerations: episode of therapy, 25  readiness for activity and participation, method of service delivery (e.g., direct therapy, groups or consultation), distinction between intensity of therapy and practice of activity in natural environments, and linking skill level and method of service delivery.  They discussed optimal dosage as one hour of therapy practice a week for three months (12 hours of practice) combined with 10 minutes of daily practice (105 hours of practice).  Another consideration when determining the frequency of service is what is required to support active adult skill building.  For example, Caron et al. (2016) conducted a qualitative study examining in-the moment-feedback and its impact on child outcomes of a 10-session home visitation program called Attachment and Biobehavioral Catch-up (ABC).  The goal of this program was to change child outcomes by changing parents’ behaviors. Caron et al. found that greater frequency and quality of vivo feedback, in-the-moment commenting, resulted in greater parent retention of strategies, decreased negative parent behavior, and predicted parent behavior change.    In other studies, parents report feeling supported by more frequent contact with professionals.  For example, Wilkins et al. (2010) used the Measure of Processes of Care (MPOC-56), a survey developed by King, Rosenbaum, and King, to collect information about the process of family centred care.  In this study the MPOC-56 was used to gather information from parents about their perceptions of family centre care for children 0 to 6 involved with EI for children with intellectual disability in Australia.   One of the findings from the 156 completed questionnaires was that family centred care was “perceived more favorably with more frequent contact by allied health professionals” (Wilkins et al., 2010, p. 716).  The highest results were in relation to feeling supported and respected by the professionals, interpersonal relationships resulting from frequent contact.       26  Deciding frequency of service appears to require a shift from using the severity of disability to asking questions based on need.  Jung (2003) conducted a literature review supporting the switch from centre-based services to natural environments as required by the 1997 IDEA revision.  Jung presented concerns regarding children receiving centred based therapy several times a week without maximizing everyday opportunities and supporting caregivers’ capacity.  According to Jung, the revised legislation required a switch from intense frequency of service based on the severity of the disability to asking two questions:  how often will the child’s intervention likely need to be changed?  And how often does the family need support to be comfortable in using intervention strategies?  Jung suggested that a single person could visit the family weekly to support their overall needs and invite other team members as needed for discipline-specific questions.   Jung also identified concerns with visiting too frequently (e.g., daily or multiple people visiting weekly), which may result in a lack of parent follow-through and confidence because the caregiver believes they do not have power to influence development.  However, in other studies the diagnosis is an important consideration when deciding the frequency of service.  There are some diagnoses that come with the recommendation for intense or high frequency of service to mitigate the risk of more pervasive problems and improve outcomes.  For example, in a recent article describing a new diagnosis category for children with suspected autism, Early Atypical Autism Spectrum Disorder (EA-ASD), Soto et al. (2016) explained the importance of recognizing the functional impairment of associated behaviors before a diagnosis is given as well as the need to qualify children for intense, evidence-based EI programs.    Finally, successful implementation of FCP, specifically supporting caregivers with their needs is pivotal to determining frequency of service.  For instance, Raikes et al. (2006) used data 27  from an existing Early Head Start study examining home visitation program conditions from 11 programs from both urban and rural areas of western, midwestern and eastern United States (US).  Early Head Start is an early childhood support program for low income families with children age birth to three and half. More specifically, “Early Head Start provides comprehensive family centered services within high-quality early learning environments that adhere to the research-based Head Start Program performance standards” (Administration for Children and Families, 2017, para. 2).  Raikes et al. looked at quantity of involvement, quality of engagement and the content of the visit (the extent to which the visit centered around child-related activities).  Funders in the US require Head Start programs to focus on child development.  Raikes et al. found that parents most at risk participated less in the program because visits that centered on child development did not address their top priority.  The authors recommended looking at ways to engage parents with multiple risk factors.  Overall, families that received more visits that included supporting parents’ needs reported better child outcomes.   In this chapter I completed a review of the literature, including different programs that show evidence for greater frequency of service, based on need as one major component. In Chapter 3, the next chapter, I will explore ideas supporting the implementation of service based on need that aligns with EI best practice discussed in this chapter.       28  CHAPTER 3: CONNECTIONS TO PRACTICE  In this chapter I draw from my professional experience, informed by the theoretical framework and literature reviewed, with aspects that consider frequency of service and caseload numbers in relation to EI services.  The courses taken throughout my master’s program have reaffirmed the value in the clinical changes we have been doing at my work in EI over the last several years, provide evidence to support their ongoing use, and offer new information to evaluate ideas and strategies.  At present, the issue is to ensure EI staff have manageable caseloads to effectively implement them.  I reiterate my belief that quality outcomes relate to the successful implementation of these practices.  So, in a culture emphasizing quality and outcomes, the issue of caseload deserves attention and needs the theoretical backing to support decisions.  In connecting with the guiding question for this project, I provide examples of things we have done to implement principles discussed in Chapter 2 as it relates to meeting families’ priorities and supporting children’s growth and development, along with examples of challenges that are directly related to caseload.    I conclude with information on a workshop prepared for early interventionists, especially individuals who are in leadership positions who make decisions about program design and allocate resources.      Context and Background I have already introduced in Chapter 1 how, as team leader for an EI program, I became convinced of the importance of supporting early interventionists with manageable caseloads to provide quality care to children and families.  Addressing the issue of caseload in EI, I realized that there was minimal information on the subject. Through the review of the literature, I became aware I was not alone in that discovery.  For example, in Keilty’s (2010) book about EI, he included the question “How often should interventions occur?” with the following response: 29  “currently, research provides little guidance on this topic” (p. 78).  He proceeded to recommend, like others in the literature reviewed (e.g., Aaron et al., 2014; Carol et al., 2016; Palisono & Murr, 2009), that the family and professional determine the frequency of service required to support the family.  When situating these posits within my professional context, the question remains, what is required to support families in EI?  Now informed by the previously cited findings of providing service based on individual family need, my answer is adequate time to implement proven EI best-practice principles as discussed in this project.   The Connection between Early Intervention (EI) Best Practice Principles and Caseloads The following are examples from my personal experience in my role as EI team leader.  I use these examples to illustrate the challenges with implementing best practice when caseloads are high, as experienced by early interventionists on my team.  These examples are the catalyst to my capstone project and inspiration behind the workshop I hope to share with professionals.  I have used pseudonyms for privacy and confidentiality purposes.  In this first example, the issue of effective implementation of an EI practice is compromised due to high caseloads.        Case Scenario #1 In 2013, I discovered the Routine-Based Interview (RBI) book and later attended a workshop by the author, Dr. Robin McWilliam.  I was convinced that the process was the answer to our challenge in finding a way to gather meaningful and contextual information from the family that could be used to develop family and child goals.  Prior to this, my program did not have a process to determine goals with the family.  Information was collected using a scripted family interview about developmental areas and routines and activities reflective of Western values.  That same year I introduced the RBI to the team.  I developed a small working group of early interventionists to develop a plan to integrate 30  it into our practice.  The first attempt included a modified version of the process that incorporated specific routines with examples of questions, bridging the transition for those who wanted to ensure specific developmental questions were included.  Completing file reviews during the pilot phase, it was evident by the wording of goals that merging questions to fit the process shifted the outcome to be developmental versus functional with few family goals.  My recommendation following the pilot was to implement the process exactly as intended.  I developed guidelines to support the learning and implementation of the process since formal training was not possible.  For example, we watched a video of its implementation by the author, followed by discussion, provided practice in small groups during team meetings, encouraged joint home visits to observe other staff, and made the RBI checklist available for self-reflection or to use on joint home visits to reflect on the behaviors for model fidelity.  It has been a few years since the RBI was integrated into practice.  I still see goals that are more developmental than functional.  When asking early interventionists about it, one issue they identified was not being able to book the follow-up visit within a week of doing the RBI.  This impacts the flow and the overall effectiveness of the intake and planning process.  For example, early interventionists describe the challenge with completing the goal selection and reviewing the intervention options when the follow-up visit occurs three to four weeks after the RBI.  “It’s as though they [parents] and I forgot what we discussed.  Either we need to take time to go back over the notes to make sense of things or we choose things that are not really connected to the meaningful discussion we had.  In many cases, the goals selected become skill based” (C. S., personal communication, May 2016).  In hearing 31  their struggles, I wonder at times is there an easier way.  I wonder would a checklist about routines used for goals be easier for staff?   In reflecting on this experience, I am reminded that ‘easier’ might not necessarily be ‘best’ practice.  Using checklists or developmental questions, while easier to implement, I believe creates a narrow vision and does not give the depth of information to support the whole child and his/her family.  First, I am reminded of the value in my decision to shift from a deficit-based approach to a flexible and responsive approach in which meaningful goals are selected with families, consistent with the findings by Hanft and Pilkington (2000).  Second, the decision to implement the RBI as designed versus compartmentalizing in terms of developmental domains fits with the holistic approach as discussed in Noddings’s (2005) study.  More specifically, using the RBI or something similar may avoid implementing fragmented curricula or processes that do not address the complexity of needs of children and families as found by Noddings in her study.  Third, my goal to use a functional assessment to gather information about meaningful family routines that are culturally relevant, as well as learn about all the possible variables impacting a child’s development, is suggested by Gatmaitman and Brown (2015) and earlier on, by both McWilliam et al. (2009) and Rigley et al. (2011) as preferred practice in EI.  In addition, this approach encompasses culture and contextual relationships, the main posits of Vygotsky’s (1986) sociocultural theory.   Furthermore, the RBI fits with Sontag’s (1996) suggestion to use the ecological system theory as a framework in early childhood to adequately include the family and gather information about other environmental influences impacting development.  Finally, The RBI promotes family centred practice by including family priorities that are culturally relevant, meaningful, and chosen by the family to be incorporated in the family service plan.  32  This addresses the issue of goals not being family centred because of how they are typically established as posited by Ridgley et al. (2011) and Rodger et al. (2012).   I am encouraged to continue to advocate for the RBI as a fundamental part of our service.  I hope to achieve what McWilliam et al. (2009) reported in their study findings: when done well, as per the process, the RBI results in greater satisfaction, the number of child and family outcomes are greater, and the goals are functional.  As demonstrated in this example, the caveat is that early interventionists need time to implement it effectively.   The next scenario demonstrates the pressure early interventionists feel when managing high caseloads, and its impact on decision making that ultimately impacts the family experience.         Case Scenario #2 Vicky, a mother of a child involved in our program, called to express frustration regarding the outcome of a recent visit with her early interventionist, Elaine, and support coach (e.g., speech language pathologist).  Vicky’s child has been referred to a multidisciplinary team to investigate autism.  This is difficult for her to accept because, as she stated, she does not want her child to “have” autism.  Nonetheless, the referral was made, and she plans to proceed with the appointment when it occurs.  Vicky recently had a conversation with two different professionals not involved with our program who indicated that they did not think her child has autism.  She shared the information with the professionals in her home, namely, the early interventionist and the speech language pathologist, and according to Vicky the conversation ensued was all about providing information to convince her otherwise.  The conversation with Vicky reflected her feelings of frustration, sadness, and hopelessness.  Vicky then shared that she was going to stop EI services.  I presented her with other options to explore (e.g., discuss with the 33  staff how she felt or change workers).  She agreed to talk to the staff.  When reflecting with the early interventionist, I asked what she thought attributed to the outcome.  She identified two things impacting the outcome.  First, Elaine indicated that she knew it was best to ask Vicky if she wanted to talk more about how she was feeling.  However, feeling pressure to optimize the visit with the professional who can discuss autism in more detail was looming.  Elaine also indicated that while she was aware of the parent-led agenda that we use, implementing it is challenging when there is always so much pressure to make decisions in the moment about what to concentrate on when you know you will not be able to see the family for another four or six weeks.  Second, the pre-planning visit as required by the process supporting the transdisciplinary model did not occur, which could have entailed a discussion about recent concerns or fears Vicky was having, as well as a plan to approach it, should it come up.  Elaine identified time to schedule the discussion as the reason it did not occur.                   When reflecting on this scenario, it is obvious to me that Vicky is struggling with the idea that her child may have autism.  This reaction is not surprising or unfamiliar in the work that we do, nor is it an obstacle to providing intervention to the family.  For example, we do not need a diagnosis to provide service.  However, the pressure comes with knowing that if the child has a diagnosis, they could qualify for other specialty services that are more intense than what we can provide. This resonates with Soto et al.’s (2016) recommendation in that children with autism need to qualify for intense, evidence based EI programs.  On the other hand, I have advocated for service based on need and not by disability, consistent with Jung’s (2003) recommendation about determining frequency of visits based on family need versus using severity of disability to determine frequency of service.  Rather, it is more important to ask questions like what Jung 34  suggested; for example, how often will the child’s intervention likely need to be changed, and how often does the family need support to be comfortable in using the intervention strategies?  I believe that in this example if Elaine could have decided service based on the response by asking these questions, she would be visiting the family more frequently, the pressure to choose what to focus on would be lessened, and future situations like this could be avoided.  In the moment, responsive care is more easily done when the worry about when the visit can occur is removed.         Second, in connecting with the example about parent experience, I resonate with Dunst et al.’s (2007) finding that parent confidence, competence, and enjoyment help parents feel empowered.  When parents feel empowered, they provide meaningful learning opportunities for children that are needed to meet child outcomes and achieve developmental goals. In this example, Vicky felt discouraged and powerless.  She was going to discontinue service, ending all opportunities to provide meaningful strategies adding to her skills, confidence, and competence to provide nurturing and positive experiences for her child.  I believe that this is an example where parent support and needs were the issue.  A solution might lie in giving her the opportunity to discuss her fears or concerns.  This takes time and requires frequent visits, as identified by Raikes et al. (2006).  I have seen this issue reflected in my numerous discussions with early interventionists who admitted to avoiding going in the parent’s direction on topics they know will take time, for two reasons: inability to follow-up on tasks and the inability to reschedule in a timely manner.           In the next case scenario, I present recent strategies that my team and I have to consider to address high caseloads without the possibility of receiving an increase in resources, including more early interventionists.  I highlight four strategies that I have reflected on deeply, and I continue to question their efficacy or impact on our service in terms of quality care.    35  Case Scenario #3 In the last year, the following strategies have been implemented or are currently in the process of being implemented at my work.  First, we tightened admission to the program, and now require all children without a diagnosis or confirmed developmental delays in two or more areas to complete screening before proceeding to the RBI.  The screens are mailed or emailed as preferred by the family.  If the family is unable to complete it on their own, in the case where English is the second language, we will use an interpreter to complete it with the family either by phone or in person.  Clerical staff members are responsible for following up with families within the timeframe identified.  After two unanswered or unresponsive phone calls to the family an “unable to contact” letter is sent.  This is followed by discharging the child within two weeks if there is no response from the family or referral source.  One thought is that parents who respond and complete this task might thereby be indicating their willingness and readiness to participate in our service.   Second, I developed a process for early interventionists to offer intervention groups to three or four families on caseload for a period of 6 weeks.  The initial intent was in response to families who wanted to learn in a group context and who wanted to be paired with families that have similar concerns.  The expectation was that it would be offered in a community setting where children and families go for early learning experiences, including parent link centers or libraries made possible by established partnerships to use their space.  It is now seen as a caseload management strategy, making it a mandatory practice that every early interventionist must do to see more families.  It is mostly offered 36  in a clinic setting because space is more readily available, which is easier for staff to arrange and set up.   Third, I had to revisit and reinforce the idea that visits to daycares or preschools for children on caseload needed a specific focus related to identified goals.  In some cases, staff were providing the service to children in the daycare setting because this is what the family requested, as the family was not available during the day or evening.  If this is the main reason for visiting the daycare, we no longer visit there.    The fourth strategy that we are working on is a readiness assessment for early interventionist to use during the first phone intake.  The intent is to help determine who is ready and wanting to be actively involved in the EI process so that we can reduce the time spent trying to connect with families or proceeding with a home visit when the family is not ready for service.      We made these recommendations and decisions with the desire, hope and intention for families to receive quality care and to support early interventionists.  However, throughout my master’s program I have become aware of what Duhn (2010) described as the ‘dominant discourse,’ equating quality care to service that is “measurable, manageable, and standardized” (p. 52).  I realized that the problem with this is that it often results in scripted processes and standardized curricula or program design that are not responsive to the cultural context or needs of the individuals served.  In this example, while it is possible that the strategies may have benefits or improve processes, they were created to address the issue of caseload, rather than in response to what is best for families and staff.  Furthermore, in doing so, this contradicts with fundamental FCP principles that embody helping families with their full range of needs, as discussed in Pighini et al. (2014).  Second, parent readiness may be a reason parents do not 37  complete the screens when referred to the program.  However, it may also be an indicator of other struggles experienced by the family for which support is needed.   Recognizing and supporting the entire family and not just the receiver of service, in this case the child, has significant implications for the child, as identified in the studies by Bailey et al. (2005), and later by Gerlach (2015).  I resonate with and believe that Bailey et al.’s (2005) quote exemplifies this point perfectly: “families play critical roles in their child’s development; helping families has direct implications for the extent to which children benefit from services” (p. 229).  Secondly, I believe that support for families will directly impact child outcomes, consistent with the findings of studies from Dunst (2002), Dunst et al. (2007), Espe-Sherwindt (2008), and Pighini et al. (2014) in terms of positive outcomes for children and families, and characteristic of FCP.  Therefore, it is imperative that the readiness assessment, including steps taken to determine who proceeds to the RBI or other processes, consider the full range of possibilities to ensure families needing service are not denied access due to process barriers.        Next, I reflected on the initial reasons used to make the decision not to provide service in the daycare.  First, we do not have the resources to establish and define the roles and responsibilities with the various programs.  Second, referrals to our program to support children in daycares would be significant, as seen by the ongoing gap for resources in daycares to support challenging behaviors.  Third, we see ourselves as a parent support program because parents have the greatest influence on development.  Finally, unlike the style of implementation in the U.S., we do not have the capacity to conduct the RBI with both the parent and early learning staff.  In sum, the decision was made because we do not have the capacity, not because this is best for the child.  This decision contradicts with Bronfenbrenner’s (1986) ecological systems theory, in that valuable support to a microsystem (in this case the daycare) and the relationship 38  between the child’s microsystems (family and daycare) pivotal to the child’s development, is ignored.  Also, this decision negates the benefits of supporting children in their natural environment, by using meaningful real-life situations to influence the child’s development as explored in the studies by Hanft and Pilkington (2000) and Spagnola and Fiese (2007).  This point, as well as the issue that children are unable to generalize what they learned from one setting to another (an aspect also highlighted in Hanft and Pilkington’s (2000) study) is something to consider when evaluating the intervention groups discussed in the above example.  In terms of development, children are influenced by the relationships they have with their caregivers, family members, peers, and community members (e.g., daycare staff).  Learning activities that are incorporated into routines and daily activities provide the frequency, variety and intensity needed to learn new skills.  This example speaks to Bronfenbrenner’s (1994) notions of distal processes and their influences on child development in that regular interactions for extended periods and frequent interactions are required for distal processes to be effective.  Therefore, it is important that daycare staff are supported in creating meaningful learning experiences for children with disabilities or developmental delays.  The next and final example demonstrates the positive outcomes observed by visiting weekly for a short period of time.          Case Scenario #4 During the summer, caseloads are often at their lowest because many families are discharged when scheduled to attend the early childhood program in the fall; as well, many families on caseload do not want service because of holiday plans.  Last summer, an early interventionist, Charlene, was able to schedule a couple of families for weekly visits for six to eight weeks.  During that time Charlene returned to the office with examples of parent participation (e.g., a family was implementing strategies discussed 39  and shared feedback that the strategies were working).  Charlene reported feeling confident in her ability to effectively support the families with their concerns and that the frequency of visits permitted using real life examples to coach or guide a parent through using a strategy.  Charlene reported that goals were achieved and progress was made.  Upon reflection, Charlene noted that this was less feasible during monthly visits that were spent catching up and sharing updates.  This example supports the pivotal role of the caregiver as an active participant to successful EI experiences, as identified by the findings of Byington and Whitby (2011), Dunst et al. (2007), and McWilliam (2012).  More specifically, the benefits of participatory helpgiving practices on child and family outcomes in terms of parent participation by actively implementing strategies, as advocated by Dunst et al. (2007), were experienced by Charlene in the example.   Finally, this example speaks to the benefits of real-time coaching during frequent visits for a short period of time, consistent with the finding of Carol et al.’s (2016) study.     Connections to Practice: A Workshop for Early Intervention (EI) Programs  The insights I have gained through the review of the literature and from my experience working as team leader consulting with early interventionists and hearing from families have led me to develop a PowerPoint presentation exploring the issue of caseloads (see Appendix A).  The workshop focuses on key elements to consider when making decisions about caseload.  As previously stated, it is a complex issue, one that does not have a quick or easy solution.  I attempt to explain this in the workshop, along with some guiding principles that leaders or administrators can use to make informed recommendations about caseload.       In Part 1, I introduce the topic including a definition of caseload, the purpose and significance in relation to my work as EI team leader, my guiding questions, and learning 40  objectives for the presentation.  Before proceeding, I ask participants to think of words to record on “post-its” that describe their practice principles used to support their service delivery.  In Part 2, I introduce the theoretical frameworks, Vygotsky’s (1986) sociocultural theory and Bronfenbrenner’s (1994) ecological systems theory.  Moreover, I present the approaches used for this project, family centred practice, the holistic approach, and the transdisciplinary model.  In Part 3, I introduce the comprehensive literature review undertaken for this capstone project.  I present core EI best practice principles and specific literature addressing the importance of service based on need.  To conclude this sharing of information, I ask participants to place the post-it notes with the words from the earlier exercise on a flip chart that includes the principles from Part 1 and Part 2, calling attention to similarities and importance of having principles to guide our practice.  I draw attention to a handout that summarizes key points discussed in Part 1 and Part 2 (see Appendix B).  In Part 4, I connect research and practice by sharing the case scenarios included in this project.  Before proceeding with my analysis for each scenario, I ask each participant to record thoughts and ideas stimulated by the examples regarding issues with respect to caseloads to engage in a discussion in Part 5 of the presentation. In Part 5, I present an overview of the limitations of this project and present a summary of key points in a pyramid that I propose could be used as a tool to guide and help make decisions about caseloads.  I invite participants to engage in a discussion on the following questions: 1) Has this presentation helped you understand the connection between EI best practice and caseload?  If yes, why and how?  If no, why not?  2) If you are unable to provide conditions, in this case, manageable caseloads, in which staff can do best practice, how will you decide the principles of practice?  How will you make decisions about caseload?  3) Any other thoughts or experiences that you want to share about how to support manageable caseloads to ensure quality care for families involved in EI?  41  To conclude the presentation, I share a video and some final thoughts regarding the significance of evaluating ideas against foundational EI best practice principles, in this case when making decisions about caseloads as related to quality care.  Finally, I thank participants for their attendance and their commitment to providing quality care to children and families and for advocating for the conditions that support early interventionists to achieve this goal.        In the final chapter, Chapter 4, I reflect on my original guiding questions regarding EI best practice principles, caseloads, and quality care, and share my concluding thoughts on the topic.        42  CHAPTER 4: CONCLUSIONS In this capstone project I have reviewed the extant literature providing a link between theory and the importance of visiting families more frequently to effectively implement EI best practice.  While I saw the complexity with the issue of caseloads over the last few years, by the end of my investigation, I was convinced that the issue of manageable caseloads for EI staff is not easily addressed.  Furthermore, I am convinced that it is pivotal to the quality of care families and children receive.  Because of the comprehensive literature review, I believe that the best practice principles discussed in this project serve as a foundational component upon which decisions about caseloads can be made.  I feel better informed about the importance of using EI principles and service based on need in order to advocate for caseloads that allow for their effective implementation.  In the following sections, I draw from the findings of my literature review, as well as the connections I have made to my practice to address my guiding question “What are the aspects identified in the extant literature that consider frequency of service and caseload numbers in relation to EI services?  More specifically, a) in relationship with meeting families’ priorities and b) in relationship with supporting children’s growth and development.”  I also consider the limitations of this project and possibilities for future study and practice in this area.                Reflections and Concluding Thoughts My capstone project has elaborated on the importance of providing EI best practice for children birth to three years of age with a diagnosed disability or two or more developmental delays, by offering service based on need, and I have suggested that these foundational principles be used to make decisions about caseloads.  In considering my question, my review of the literature has shown the significance of the following aspects or program characteristics: a) a 43  holistic approach considers the whole child, b) the value of using a family centred approach supports the entire family, c) active skill building of the parents because they are agents of change and have the greatest opportunity to influence development, d) a transdisciplinary model establishes a trusting relationship with a primary person while benefiting from the expertise of many professionals, e) a functional assessment identifies culturally relevant and meaningful family and child goals, f) visiting families in their home and community protests their right to belong and participate, and g) providing service based on need is responsive and individualized.  Each one of these topics, as supported in the literature review, has shown a direct impact on meeting families’ priorities, Part A of my guiding question: “What are the aspects identified in the extant literature that consider frequency of service and caseload numbers in relation to EI services? More specifically, a) In relationship with meeting families’ priorities?”  I believe that supporting the needs of the family and not just those of the child is often overlooked.  In some cases, while some programs may say they are family centred and supportive of parents’ needs, their actual policies and procedures contradicts practices to effectively guide parents because early interventionists are not given the time to implement what needs to be done.  I also believe it is imperative that those working in EI programs include components of service, as discussed in this project, by involving caregivers in a meaningful way.  I reiterate a statement I used earlier, when the family struggles, so, too, will the child.  Family capacity has a direct impact on child outcomes.  In regard to Part B of my guiding question, “b) in relationship with supporting children’s growth and development,” for each topic in the literature review there is at least one article that explicitly identified improved child outcomes supporting growth and development.  The topics and articles include family centred practice (e.g., Gerlach, 2015), adult skill building (e.g., Garner, 2013), holistic approach (e.g., Noddings, 2005), transdisciplinary model (e.g., King 44  et al., 2009), functional assessment (e.g., McWilliam et al., 2009), natural environment (e.g., Spagnola & Fiese, 2007), and frequency based on need (e.g., Raikes et al., 2006).  Second, the scenarios used in the connection to practice offered concrete examples of the impact of high caseloads and not having time to implement best practice effectively and confidently.   I believe time is a common denominator to implement these practices.  What I have tried to illustrate in this capstone project is that in order to make decisions about caseloads, as professionals in early childhood education and EI, we need to have a solid theoretical framework and EI research to recommend, advocate or make decisions about caseload.  For example, early interventionists can support the holistic needs of children when caseloads are such that they can provide service based on need, and given the time required to address the issues.  I have realized it is important to ask questions that evaluate practices or procedures against the things that we know will make a difference in EI.   Limitations and Recommendations for Future Study and Practice  In this capstone project, I argued for manageable caseloads to implement EI best practice principles.  Therefore, the scope of this project was limited in reference to topics related to foundational EI best practice that I believe are important.  I chose not to include child-focused intervention as a topic because of explicit teaching or direct therapy implied by this approach, which typically occurs primarily between the early interventionist or therapist and child without the parent.  I believe this undermines and interferes with the important role of the parent and adult skill building.  Drawing from my findings from this literature review and connections to practice, I believe that it is important that future study continues in order to examine explicit EI approaches that center around the pivotal role of the parent, resources, and conditions required to be successful, and show how these approaches have a direct impact on child outcomes.   45   A dearth of research exists that explicitly addresses the issue of caseload, and how to make decisions about it, specifically for EI practices (Keilty, 2010).  In my review of the literature, I did not discover any studies or literature reviews providing guidance on the topic of caseload.  As a result of this dearth and of the emphasis on outcomes and quality care, I believe this is an area that warrants attention and future investigation.   I suggest explicit investigation regarding caseloads and its impact on child and family outcomes involved with EI programs would provide valuable contributions to the field of early childhood.  I recognize that this would be a complex undertaking because there are so many variables and components that need to be considered when evaluating child and family outcomes when implementing the practices discussed in the project.  I also suggest that both the receiver of service, families -- including the voices of children -- and early interventionists, be included in the research.  I believe that each group of individuals has valuable information pertaining to caseloads and the implementation of EI best practices.  In doing so, I believe it would provide concrete ideas and insight that could be used to bridge the research to implementation gap.   When reflecting on the fact that there is little research specifically addressing the issue of caseloads in EI (Keilty, 2010), I wondered why this is the case.  Is it because countries like the United States that have federal legislation are given the resources needed to effectively implement EI best practice?  Therefore, the issue of caseload may not be an issue for them.   For example, while attending a training hosted by an EI program in Chattanooga, Tennessee, I had a discussion with the director about caseloads.  The director explained that when there were enough families waiting for service, the program administrators applied for funding to create a position and hire an early interventionist (Amy Jenkins, personal communication, April 2014).  46  This leads to my recommendation to investigate funding models and system structures that support the implementation of EI best practice.    My third and final recommendation relates to contextual relevance.  In my situation as a team leader advocating for manageable caseloads, providing a solid theoretical framework and findings from the literature review pertaining to the significance of implementing EI best practice, is valuable and relevant.  For example, drawing from the connections to practice, early interventionists at my program are not able to implement EI best practice principles, provide service based on individual family need, or responsive care as discussed in this project.  This may not be applicable to all EI programs; therefore, the content of this project may be limited to programs experiencing a similar situation, and future study for programs in different contexts may be required.  A recommendation for practice is to complete an analysis of the problem, in this case caseloads, to determine whether or not the underlying problem is related to the implementation of best-practice principles.  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The Journal of Child Psychology and Psychiatry, 17(2), 89-100.     54  APPENDIX A Presentation Slide 1 Presented by:Nathalie Maurice BurgessMED in Early Childhood Education Program, The University of British Columbia I begin with welcoming everyone to my presentation, “Caseloads and Frequency of Service in Early Intervention (EI), a factor in the Research to Practice Gap”.  This presentation is a part of my MED ECE Studies with UBC.  Intended for early interventionists, especially leaders and management that make decisions about caseloads, the allocation of resources, and service delivery recommendations.  Introduce what the literature revealed about caseloads and propose some ideas to use when addressing the issue of caseloads.    Slide 2 1. Part 1-Introduction2. Part 2-Theoretical Framework, Approaches and Model  3. Part 3-The Literature Review4. Part 4-Connections to Practice5. Part 5-Discussion and Questions for Reflection6. Concluding Thoughts This is the agenda for today’s workshop.  Read aloud agenda from the slide.     55  Slide 3  What inspired this project? Image Source: https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcTGchMMoyEIa34BhmEsT0PYcxfa91dv8c22BF8Wio7bEXs9VuC-TA“although early intervention cannot eliminate most disabilities, it can have a positive effect on the development of many young children and lessen the effect of the disability or delay on the child’s interactions and participation in everyday life”(Raver & Childress, 2015, p. 24) The purpose of my capstone project was to gain a deeper awareness on how the extant literature supports the need to have manageable caseloads to allow for greater frequency of service to ensure quality intervention. My hope for this presentation is for leaders to have information to advocate for manageable caseloads that permit service provision based on need, and to be equipped to advocate for the rights of children and families that we serve.  I highlight key points from my Capstone project (p. 1 to3).  For example; • Currently we visit families every 4 to 6 weeks, compromising the quality of service.   • Referrals to the EIP have increased by 220% from 407 (2007-2008 fiscal year) to 896 (2016-2017 fiscal year).   • Caseloads have grown from approximately 30 to 60 per 1.0 full time employee.   Slide 4  What are the aspects identified in the extant literature that consider frequency of service and caseload numbers in relation to early intervention services,  a) in relationship with meeting families’ priorities b) in relationship with supporting children’s growth and development. The main question guiding my capstone project is what are the aspects identified in the extant literature that consider frequency of service and caseload numbers in relation to EI services, and more specifically, a) in relationship with meeting families’ priorities, and, b) in relationship with supporting children’s growth and development.  56  Slide 5  explain the importance of a solid theoretical framework and early intervention best practice principles in terms of making decisions about caseload.   Identify non-negotiables to use to advocate for manageable caseloads.   Image Source: https://cdn.pixabay.com/photo/2016/05/25/13/21/target-1414788_960_720.png By the end of this presentation you will be able to explain the importance of having a solid theoretical framework and EI best practice principles in terms of making decisions about caseload and be able to identify what I like to refer to as non-negotiables to use to advocate for manageable caseloads.       Slide 6 “The term caseload refers to the number of families served by each home visitor”.(Alberta Children’s Services, 2004, p. 27) “The term caseload refers to the number of families served by each home visitor”.  (Alberta Children’s Services, 2004, p. 27).  It includes the number of files (child and his/her family) that the early interventionist is responsible for supporting and providing service to.        57  Slide 7 Image Source: https://cdn.pixabay.com/photo/2016/11/15/07/57/group-1825513_960_720.jpg:  Before proceeding, I ask participants to think of words they use to describe their principles of practice, then place them onto a post-it note. They can add more than one, adding each new word to a separate post it.  I give 5 minutes to complete the exercise.  Ask that they put them aside.  We will revisit them later.    Slide 8 Part 2: Theoretical FrameworkVygotsky’sSociocultural Theory Bronfenbrenner’sEcological Systems Theory  My capstone project draws on, Vygotsky’s (1986) sociocultural theory and Bronfenbrenner’s (1994) ecological systems theory, both grounded in social constructivism.  They support the way in which children learn and influences on development that are foundational to EI.  I begin with describing each theory in more detail in the next slides.  At this time, I draw attention to the handout [APPENDIX B].  It includes the main points that I will review in the theoretical framework and the literature review.      58  Slide 9  Vygotsky’s (1986) sociocultural theory posits that children progress through developmental stages in the context of social interactions.   Children learn through relationships in culturally relevant contexts  Vygotsky’s (1986) sociocultural theory posits-children progress through developmental stages influenced by their cultural context and relationships with others.  Includes two important components; relationships and cultural context. The developmental process is led by interactions with others.  I explain Vygotsky (1986) term zone of proximal development (ZPD) and the more knowledgeable other (MKO) - Wood, Bruner, and Ross’s (1976) notion of scaffolding.  I review Edwards (2003) work - the importance of Vygotsky’s sociocultural perspective in ECE. In sum, children learn through relationships influenced by the cultural context they live in.   Slide 10  Bronfenbrenner (1994)Image Source: https://upload.wikimedia.org/wikipedia/commons/9/9b/Bronfenbrenner%27s_Ecological_Theory_of_Development_%28English%29.jpg I explain the multiple systems as seen in the diagram, note this image does not include the chronosystem, that accounts for the complexity of child influences that was contrary to the developmental psychology (Bronfenbrenner, 1994; Goelman & Guhn, 2011).  I explain the importance and define the term proximal processes (Bronfenbrenner, 1994) and Sontag’s (1996) recommendation for the ecological systems theory to be used as a framework in early learning for children with disabilities to include the role of the family and other environmental considerations.   The ecological systems theory reinforces the idea that children do not live in isolation but rather are influenced and affected by their family, the community they live, and society.  59  Slide 11  I share Makovichuk, Hewes, Lirette, & Thomas’s (2014) definition of holistic and Noddings’s (2005) explanation-includes all areas of a child’s development versus compartmentalizing or working on one developmental domain at a time - supporting the natural way in which children discover and explore their environment and Franklin, McNinch, and Sherman’s (2013) definition of whole child.  Slide 12  I refer to FCP studies (Dunst, 2002; Dunst, Trivette, & Hamby, 2007; Espe-Sherwindt, 2008; Pighini, Goelman, Buchanan, Schonert‐ Reichl, & Brynelsen,, 2014) to explain and define what it is, its impact on child and family outcomes.  I present Dunst et al.’s (2007) relational and participatory behaviors.      60  Slide 13  Team around the child Integrated approach Collaborative team processThe TD model includes using a primary service provider, one professional, who is supported by a team of professionals in contrast to having multiple professionals visit the family as in a multidisciplinary or interdisciplinary approach (Bell et al., 2009; Fitzmaurice & Richmond, 2017).  I refer to studies from Fitzmaurice and Richmond’s (2017) and Bell, Corfield, Davies, & Richardson, (2009) to define and explain TD.  Often recommended as EI best practice.  I refer to Limbrick (2011) and Bruder’s (2010) studies referring to synonymous terms.   Slide 14 It takes time to understand and support the entire family with issues or concerns related to overall well being which may influence their ability to care for and concentrate on the intervention.    These theories support my proposed capstone project because to effectively work within these theoretical perspectives and approaches, families need to be visited more often than once a month.  It takes time to understand and support the entire family with issues or concerns related to overall well being which may influence their ability to care for and concentrate on the intervention.   Vygotsky’s (1986) sociocultural theory and Bronfenbrenner’s (1994) ecological systems theory support the notion of the whole child by recognizing that the child’s development is influenced by the complexity of relationships among different systems and his/her cultural context.      61  Slide 15 Part 3: Literature Review• Holistic Approach and Early Intervention• Family Centred Practice (FCP) and Early Intervention• Adult Skill Building • Transdisciplinary (TD) Model and Early Intervention • Functional Assessment:  Meaningful Information Collected to Determine Goals • Natural Environment: The Location of Assessment and Intervention Visits• Frequency of Service Determined Based on Need  In this section I review the literature findings from research studies pertaining to the benefits of fundamental EI principles, followed by studies that demonstrated better outcomes when service was provided based on need.     Slide 16 Image source: https://upload.wikimedia.org/wikipedia/commons/4/44/Wiki_pic_%281%29.jpgA holistic approach protects and celebrates identify while supporting overall health and well-being The holistic approach provides a perspective of the child as a person influenced by many factors that include the family, environment, culture, socioeconomic status, and biological influences.  These factors need to be considered when supporting the whole child.  I present findings from Nadeem, Maslak, Chacko, and Hoagwood (2010) related to better child outcomes, Noddings (2005) recommended holistic treatment to educate the whole child, and Greenwood’s (2006) recommended a holistic approach to address family needs      62  Slide 17 Image Source: https://cdn.pixabay.com/photo/2017/09/29/23/41/user-satisfaction-2800863_960_720.png Benefits:1. Helping families has a direct impact on overall health of the child2. Families prefer a FCP approach and report increase satisfaction with service“Families play critical roles in their child’s development; helping families has direct implications for the extent to which children benefit from services” (Bailey et al., 2006, p. 229).  FCP recognizes the value and importance of the role of the family in terms of supporting the child’s overall well-being and development.  I review findings from Gerlach (2015) -health inequities and structural barriers to accessing services; Bailey et al. (2006) -pivotal role of the family.  These studies demonstrate the importance of family support to effectively address the needs of the child.  When the family struggles, so too will the child.  I present studies showing that families prefer FCP, are more satisfied with service, reporting it to be helpful and beneficial to their care in EI, Pighini et al. (2014) and Rodger, O’Keefe, Cook, and Jones (2011).  Slide 18  Engagement ◦ parent as expert◦ Participatory helpgiving practices Supporting parents with their needs and priorities All the intervention occurs between visitsThe studies in this section support the pivotal role of the parent and the need for programs to actively engage parents in the intervention process.  This too, takes time and requires responsive planning.      An important aspect of FCP is working collaboratively with the caregiver to build their capacity and skills to support their child’s healthy development adult skill building.   I refer to findings from: Byington and Whitby (2011), Dunst et al. (2007) and Espe-Sherwindt (2008) regarding engagement.  Garner’s (2013) study regarding recognizing and supporting parents with their issues, building parent capacity to manage stress and adverse events, and McWilliam’s (2012) study to explain the difference between the service visit and intervention visits.  In sum, the studies in this section support the pivotal role of the parent and the need for programs to actively engage parents in the intervention process.  This too, takes times and requires responsive planning.      63  Slide 19 Image Source: https://upload.wikimedia.org/wikipedia/commons/b/ba/Working_Together_Teamwork_Puzzle_Concept.jpgAn efficient and effective way of providing service to families   I review to findings from Bell at al. (2009) and King et al. (2009) regarding efficiencies and an effective way to provide service to families in EI.  I mention will Fitzmaurice and Richmond (2017) finding and recommendation for more research to evaluate the effectiveness of using the TD model on developmental outcomes.         Slide 20 Image Source: https://c1.staticflickr.com/8/7469/16106024400_4fc6267a0f_b.jpg Most programs adopt a model that may include screening and assessment to use with children and families but how and why this is done is important to the planning and intervention process.   I review findings from McWilliam, Casey and Sims (2009)- specifically the RBI, Gatmaitan and Brown (2015) and Rigley, Synder, McWilliam, and Davis (2011) regarding functional goals and meaningful components a quality family service plans.  In sum, the information gathered during a functional assessment can be used to develop meaningful goals selected by the parent that is also used for intervention planning.                               64  Slide 21 • Inclusive • Contextual learning• Generalization of skillsHow service is provided is as important as the location (Hanft & Pilkington, 2000) Three arguments support natural environments; inclusive practice that is a fundamental right for all children (UNICEF Canada, n.d), contextual learning supports overall development, and generalization of skills.  There is robust research supporting inclusive practice which is beyond the scope of this project.  Therefore, I elaborate on the last two.  I present findings from Spagnola and Fiese (2007) and Dunst, Bruder, and Espe-Sherwindt (2014) regarding contextual learning, Hanft and Pilkington (2000) pertaining to generalization of skills.       Slide 22 “Determination of intensity of EI services is a complex multifactor process and disparities in intensity of services may arise for a number of reasons” (Aaron et al. 2014, p. 344) One hour a week Weekly visits for shorter periods 10 hours a week to do active skill building 12 visits with daily practice Frequent contact Parents feel supported Assists parents with their needs The disability Determining frequency of service is a complex issue.  I present findings from Aaron et al. (2014) supporting one hour a week of service, Caron, Bernard, and Dozier (2016) supporting weekly visits for a shorter period doing active skill building, Palisano and Murr (2009) supporting weekly visits for 12 weeks as needed by the family with an emphasis on daily practice, Raikes et al. (2006) and Wilkins et al. (2010) regarding parents feeling supported by more frequent contact, and Jung (2003) and Soto, Kiss, and Carter (2016) regarding the diagnosis as an important consideration when deciding the frequency of service.    65  Slide 23 Image Source: https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQm3Du45Xn5HsokhcpJ6t5XwYVkZ5-GR12dIfdSnI9-A-LISr9BNw Post flip chart paper around the room with the following headings: holistic approach, FCP, adult skill building, TD model, functional assessment, natural environment.  Before proceeding with the connections to practice, ask participants to take a minute to add their post-its from earlier to the EI component that fits best with the word they used to describe their practice.  Questions for discussion: What do you notice?  (e.g. I anticipate there will be lots of words used to mean the same thing).  The intent of this exercise is to have everyone think deeply about the practices they are using in their approach with families.    Slide 24 Part 4: Connections to Practice1. Case Scenario #1 –Implementation of the RBI2. Case Scenario #2-Vicky’s Experience3. Case Scenario #3-Strategies Implemented4. Case Scenario #4-Charlene’s Reflection  The following are examples from my personal experience in my role as EI team leader.  I use these examples to illustrate the challenges with implementing best practice when caseloads are high as experienced by my team.  These examples are the catalyst to my capstone project and inspiration behind this workshop.      Note: I have used pseudonyms for privacy and confidentiality purposes.   66  Slide 25  RBI ImplementationSource: Google Image I share Case Scenario #1-regarding the issue of effective implementation of an EI practice, compromised by high caseloads.  I review and explain the main points from Ch. 3 of my project related to this scenario:  shift from a deficit-based approach to a flexible and responsive approach in which meaningful goals are selected with families, RBI fits with the holistic approach, functional assessment gathers meaningful information re: family routines that are culturally relevant and preferred EI practice.  This approach encompasses culture and contextual relationships and includes the family and gather information about other environmental influences impacting development.    Slide 26  Vicky – a mom’s experience Too many families,With a wide range of needs, Not enough time! I share Case Scenario #2 which demonstrates the pressure early interventionists feel when managing high caseloads, and its impact on decision making that ultimately impacts the family experience.  I review and explain the main points from Ch. 3 of my project related to this scenario: pressure comes with knowing if a child has a diagnosis they could qualify for other specialty services more intense than what we can provide.  Parent support and needs were the issue.  This takes time and requires frequent visits.  I have seen this issue reflected in my numerous discussions with early interventionists who admitted to avoiding going in the parent’s direction on topics they know will take time for two reasons; inability to follow-up on tasks and the inability to reschedule in a timely manner.           Note: I created the image/quote box used in this slide, slide 26 & 27.   67  Slide 27  Strategies Implemented1. Screens required 2. Restricted support to daycare 3. Intervention groups4. Readiness assessment“Families play critical roles in their child’s development; helping families has direct implications for the extent to which children benefit from services” (Bailey et al., 2005, p. 229).  I share Case Scenario #3 –regarding recent strategies that my team and I considered to address high caseloads without an increase in resources.  I highlight four strategies: families need support with a wide variety of needs right from referral, readiness assessment and other processes need to consider the full range of possibilities to ensure families needing service are not denied access due to process barriers, provide service to daycare and other places children attend and build capacity of  daycare staff as related to this goals.    Slide 28 Charlene –an early interventionist’s reflectionImage Source: https://upload.wikimedia.org/wikipedia/commons/f/ff/What_is_mentoring_%2814805966275%29.jpg I share Case Scenario #4-demonstrates the positive outcomes observed by visiting weekly for a short period of time.   This example supports the notion of the pivotal role of the caregiver as an active participant to successful EI experiences, the benefits of participatory helpgiving practices on child and family outcomes in terms of parent participation by actively implementing strategies and speaks to the benefits of real time coaching during frequent visits for a short period of time.        68  Slide 29 Part 5: Discussion and Questions for ReflectionImage Source: https://cdn.pixabay.com/photo/2013/12/03/07/57/exchange-of-ideas-222788_960_720.jpg The courses taken throughout my master’s program has reaffirmed the value in the things we have been doing at my work in EI over the last several years, provides evidence to support their ongoing use, and offers new information to evaluate ideas and strategies.  The present issue is ensuring EI staff have manageable caseloads to effectively implement them.  I believe that quality outcomes are related to the successful implementation of these practices.  The issue of caseload deserves attention and needs the theoretical backing to support decisions about it.    Slide 30  Minimal research/information on the subject.  In Keilty’s (2010) book about EI, he included the question “How often interventions occur?” with the following response; “currently, research provides little guidance on this topic” (p. 78).  More research needed -caseloads and EI quality care and outcomes and pertaining to funding models that adequately support the implementation of EI best practice.   Contextual relevance is important.  The inability to implement EI best practice is specific to my context [read aloud the examples on the slide].  This may not apply to other EI programs.  Recommend -identify the issue related to the problem, in this case caseloads, then build an argument to address the issue.     69  Slide 31 Manageable caseloadsTime to effectively implement themService Based on NeedEarly Intervention Best PracticeCaseload Pyramid Decision Tool What I propose is to use a pyramid, which I named caseload pyramid decision tool, to engage in discussions about caseloads.  It includes summary points from my capstone project.  Maybe it can serve as a tool that participants can use to organize their thoughts and to advocate for manageable caseloads.   It helped me organize the key points in relation to the topic of caseload and frequency of service.   I elaborate on each one in more detail in the next few slides.    Slide 32 Early Intervention Best Practice First, as mentioned throughout this project, EI best practice principles are the foundation to which decisions about caseloads need to be made.  EIPs need to have a solid theoretical framework and research explicitly defining best practice research.  Always evaluate ideas against these key components.  If the object of service is to provide quality care, then EI practice principles are what I like to refer to as non-negotiables.  Which is why it is placed at the base of the pyramid.     Note: I created this pyramid using the power point smart art resource to represent my ideas.  It is not based on any particular model.    70  Slide 33 Service Based on Need An overarching theme is that the frequency of service be decided based on need to effectively implementation EI best practice.  We need to surrender to the fact that at this point, nor can I see there ever will be, a nice formula to define caseloads and frequency of service.  What was apparent from the literature in this capstone project is that individualized, responsive care based on need is the one way to effectively implement EI best practice.      Slide 34 This takes TIME.  Adequate TIME to:  Truly do family centred practiceSupport the whole child as with the holistic approachDo active skill building of the parentsWork as a collaborative team with a main person supporting the familyComplete meaningful assessments to develop child AND family goalsVisit families in their home and community settingsProvide service based needTime to effectively implement them An underlying theme to effectively implement EI best practice is time, directly linked to caseloads.     Adequate time implement the principles discussed in this capstone project.  For example, [read aloud the points from the slide].          71  Slide 35 Manageable caseloads And finally, time is allotted when early interventionists have manageable caseloads.    Slide 36 1) Has this presentation helped you understand the connection between early intervention best practice and caseload?  If yes, why and how.  If no, why not. 2) If you are unable to provide conditions, in this case manageable caseloads, in which staff can do best practice how will you decide the principles of practice?  How will you make decisions about caseload?  3) Any other thoughts or experiences that you want to share about how to support manageable caseloads to ensure quality care for families involved in early intervention?  Discussion I ask each table to take 10 minutes to discuss and record their response or thoughts to the above questions.  I ask each table to choose a recorder and a presenter, and to share one response/idea for each question.  I move to each table, asking them to share a different response/something new or in addition to what the previous group shared for each question, giving each group the opportunity to share an original idea or thought and to hopefully get through the ideas from the group.          72  Slide 37 Concluding thoughts(Center on the Developing Child at Harvard University, 2014) I play the above video.  Then share the following final comments: This video, building adult capabilities to improve child outcomes:  A theory of change, is an excellent summary of the importance of supporting adults with their full range of needs as well as the significance of adult skill building.  I believe this video touches on the topics discussed in this presentation.    For example;  • We live in environments of relationships- sociocultural theory • Children most at risk need everyone they interact with to build their capacity, resiliency and strength –ecological systems theory • The reason we are not having a greater impact on child outcomes is because we need to actively build the skills of the adults and focus on the development of adults, their skills and needs, this includes parents as well as daycare and preschool staff–this touches on FCP, adult skill building, holistic approach, service based on need, child’s natural environments.  More importantly, there are two very important questions; what could we do differently? And how does policy strengthen parent’s abilities to provide what children need?  Now informed by the previously discussed findings of providing service based on individual family need, I answer, adequate time to implement proven EI best practice principles as discussed in this project which begins with manageable caseloads!    I conclude by thanking participants for their attendance, their sharing of ideas and for contributing to the discussions.             73  Slide 38, 39, 40 and 41:  References   74       75  APPENDIX B Theoretical Framework Vygotsky’s Sociocultural Theory AND Bronfenbrenner’s Ecological Systems Theory  Children learn through relationships influenced by the cultural context they live in, AND Interconnected relationships between the child, family and society impacts development. Approaches and Models FAMILY CENTRED PRACTICE (FCP) Respects cultural values and beliefs, includes family and child goals, acts in a kind and nonjudgmental manner, and family decision making.  Support for the family that is supporting the child. Adult Skill Building  WHY:  Shift from professional led-expert model and therapy with the child to  active skill building and capacity building of caregivers. Caregivers have the greatest influence on the child’s development. All the intervention occurs between visits. WHAT:  Child-caregiver interactions, meaningful everyday opportunities and experiences, strength and interest-based learning.    HOW (method):  Coaching, collaborative consultation, and incidental teaching.  HOLISTIC APPROACH Supports the development of the whole child versus compartmentalizing or working on one developmental domain at a time.  TRANSDISCIPLINARY (TD) MODEL WHY:  Shift from multidisciplinary model–working in silo, multiple visits with various professional to working together, selecting the best person to support the family based on need and priorities.  WHAT:  Inclusive environments, contextual enviroment, and natural settings. HOW (method):  Primary coach model, primary service provider, and community connections.  Early Intervention Best Practice Functional Assessment  WHY:  Shift from deficit based -developmental checklists/screens used to determine goals to culturally relevant and meaningful goals to improve overall family functioning and increase child’s participation in daily routines and activities.  WHAT:  Family routines, daily activities, natural learning environment. HOW (method):  Routine Based Interview (RBI). Child’s Natural Environment  WHY:  Shift from clinic based –de-contextualized settings to places children without delays attend and live.   Every day learning opportunities. WHAT:  Home and community -inclusive environments, contextual and natural settings. HOW (method):  Contexually mediated practice, resource-based intervention, and routine-based home visits. Frequency of Service WHY:  Shift from frequency of visits determined by availability impacted by high caseloads when expected to absorb all referrals to the program to responsive care based on family need.   WHAT:  Frequency of service determined by family need. HOW (method):  Manageable caseloads so there is time to implement the above best practice principles, needs assessment, and professional and family choice based on identified need. How the team is organized to support the family? How to choose the location of intervention? How to work with the caregiver?  How to determine frequency of visits? How information is collected to determine goals and intervention?  76     

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