The Rest of The Story: The Changing Face of Early Intervention

About one year ago now, I started hearing some new buzz words swirling around the Early Intervention Program in my home state of Wisconsin–words like evidence-based practices and coaching, natural learning environments and primary provider. As a pediatric speech-language pathologist, I was a bit intrigued. Mostly though, I was rather annoyed and quite a bit skeptical. After all, I had been trained to look analytically at a child’s speech or language, come up with a plan to fix it, and implement that plan systematically and objectively. Suddenly, it seemed, I was being asked to take a step way back. To work through parents rather than through the child, and to train parents to be speech therapists. And I found it absurd to expect parents to learn in a few short months what I had learned in six years of higher education.

Because I’m the curious type, though, I started asking lots of questions and doing lots of research. I’ll be honest and say that my primary motivation was to prove that this approach was wrong. I dug through the research on speech and language outcomes for early intervention, looking for the “evidence” that was being touted about so loudly. I found research to support the clinician-directed ABA intervention and language facilitation in play with which I was very familiar and some research to show that parent-led intervention could improve child language and phonology as well. Yet I found not one large, well-controlled study that proved beyond a shadow of a doubt that this “new” approach—the one that called for coaching parents to responsively engage their children in the context of natural learning opportunities–was any better than what we were already doing.

A funny thing happened along the way, though. The more I read, the more I began to realize something else. In focusing so narrowly on speech sounds, vocabulary development, and two-word phrases, I was omitting a huge body of research about child development. I started to see that so much of what was being asked of us as early intervention professionals had less to do with speech and language outcomes per se, and more to do with infant and toddler mental health. I began reading research that suggested that most significant factor in a young child’s development was not the amount of time that child spent in therapy, but rather the degree to which that child’s parent was responsive and engaged. And I began to understand that my single biggest source of power as an early interventionist was not to be found in playing on the floor with the child myself, but in helping that child’s parents become more responsive and engaged with him.

This isn’t to say, of course, that I suddenly began to think that there was no value in interacting directly with a child. This is far from true. Interacting directly with children helps us to discover what does and does not work with that child and allows us to model strategies for parents. There is every place for this in our early intervention practices. But this past year, I began to understand that I needed to be much more intentional about when and how I interacted with children. I also needed to be much more careful about building up parent competence in enhancing their own child’s development, rather than giving the appearance that a child’s development was dependent on me. After all, as a weekly early intervention visitor, I was with that child less than 2% of all his waking hours. It seems so silly that I ever assumed that I was the agent of change in a young child’s life, but I did. This past year, it finally dawned on me that early intervention wasn’t about me and what I did with the child…it was about that child’s parents and what they did with him. And if I couldn’t effect change in that, I simply wasn’t doing my job.

One year later, I’ve realized that these evidence-based practices aren’t about me training parents to be speech-language therapists at all. Children under the age of three don’t need their parents to be speech therapists. They need them to be parents. I’m not being asked to give up my role. I’m being asked to take all the information I have about child development, mesh it with what I’ve learned about infant and toddler mental health, and find ways to intricately weave those practices into the fabric of that child’s relationship with his parents. I’m being asked to get into that child’s life, to know his daily routines—no matter what they are–and to work within those. I’m being asked to start where the parents are, not where the child is. It’s complicated, it’s complex, and it’s messy. And it’s my job.


Becca Jarzynski, M.S., CCC-SLP
is a pediatric speech-language pathologist in Wisconsin. Her blog, Child Talk, can be found at www.talkingkids.org and on facebook at facebook.com/ChildTalk.

Comments

  1. What a great article! You explained our changing role so clearly and that our job isn’t being diminished at all, it’s just evolving into something that allows us to be so much more effective in the life of a child. Thank you!

  2. Yep, takes a fair amount of experience in the Early Childhood arena before you finally start to realize that you have to get the parents involved in their child’s development. Otherwise you’re fighting an uphill battle that is extremely difficult to win! What is really frustrating is trying to work with the parents who either just don’t care or just don’t get it!

  3. Welcome to the world of true “family centered” intervention. It’s not new, lots of us have been collaborating and coaching parents for many, many years. You should check out the work of Dr. James MacDonald (“Play to Talk”) and the many Hannen Institute programs. I also recommend this recent blog entry written by one of the parents that I have worked with.
    http://blog.friendshipcircle.org/2011/04/14/5-steps-to-getting-started-with-play-therapy/ It is a clear and concise description of collaborative intervention with parents.

    And also, kids DO need their parents to be speech therapist – who else is going to coach and practice with them when you are not there? Speech and language development is not a trade secret. Teaching parents how to use that information is meaningful and effective ways is what your professional role should be.

  4. Ronny, I share your frustrations, as do many of my peers. Although I will also say that a large part of what I learned this year is how to work with families who don’t seem to ‘get it’ per se….to really start with where the the family is (even if it’s not where I think they should be) and help them learn to be engaged and responsive with their children in the context of activities they already do (even if it’s watching movies!) It’s not easy, but I think I’m starting to get it, and it is *so* wonderful to see the (even very small) gains these families make as families!

  5. CMFast….re: it not being new….true enough–I should have said “new to me!” :) I’m familiar with both MacDonald and Hanen– both are awesome! Also just took an ASHA course by Dr. Wilcox and it was fantastic in helping me wrap my head around all of this and what it means for EI. It should be required for every SLP who works in EI.

    To clarify my statement about parents needing to be speech therapists: Of course we need to teach them to integrate strategies into their day and to give away our knowledge…that’s my main point. What I meant by that statement was that I am starting to understand that we don’t always need them to do “speech therapy” with their kids in the traditional sense of “hey you have to sit on the floor and play with your child for an hour each day” type of “speech therapy.” Nor do we need them to, for example, be able to assess phonology like we do. Or think in terms of semantic relations. They don’t need to be able to assess children as precisely as we do. They just need to be able to learn to facilitate their own child’s development in ways that are important to them. Our job is to match *our* knowledge with their priorities and activities and give away the knowledge that would best help them facilitate their child’s development. In doing so, I believe we are helping them be better *parents*, not to teaching them to be speech therapists, per se. It’s a subtle distinction, and perhaps it only exists inside my head, but it was a important thought to me anyway! :)

  6. Erin McLeod says:

    Great Post Becca: Particularly in light of the research supporting early intervention, which will have major ramifications for our field. I have become responsible for 0-3 caseload in the last 2 years, and although wasn’t as skeptical as you were, a colleague of mine was, and I listened. I did alot of consulting and reading about attachment and, yes, communication is directly linked with both relationships/self-development and communication. I love what I do. And I expect that this new field will blossom. You captured the resistance really nicely, thank you for your honesty. I think it will take some time before our field as a whole travels that journey to stand where you do now.

  7. Excellent post! What I love most about EI is the parent interaction. Like you mentioned, Becca, we are only with our clients a small percentage of the time, which is why it’s so important to effectively teach and empower the parents. When I first inform parents that I strongly prefer that they participate in treatment, some are a little skeptical and apprehensive. I find they are also a little hesitant to model some of the treatment techniques at first. So, in addition to coaching and training, I also provide encouragement and counseling when needed. I often remind parents that even though I am the speech and language “expert”, they are the experts when it comes to their child. :)

  8. Jessica T says:

    I think your article is nicely written, but I am never going to be in support of a primary provider plan. I agree with many of your points, but how can we justify a primary provider plan for many of our families? I think it is our “job” to empower families. That means total flexibility on the part of the therapist. I get that, and I can do that. However, is empowering and supporting children and families really going to be done in this manner? I think natural learning environments and coaching are a huge part of success in 0-3. However, if the county I work in was on a primary provider plan, I would probably leave. I don’t feel comfortable going into a home and being the main contact for all services. I don’t want to leave, consult the pt, and then bring that back to the family. I think families deserve that direct contact with the pt. I think the primary provider plan is a way for our state to save money.

  9. Excellent article. I think parents are getting involved more and more with the advent of new technologies. The things that were therapies before are now games. For example, our SLP used to work really hard to get my son to do breath exercises. It was hard. Now, I found an app to do just that and it is fun and entertaining (Party Whistle).
    SLP’s for that matter all therapists should be knowing more about the daily lifes of the kids and understand where the kid is not independent and help them become independent by setting up programs.

    I also noticed you can teach lot of things with a single program rather than doing one for each (SLP/OT/ABA). ABA guys may be best equipped to handle the integration as they spend most of the time with the kid. I always bring my SLP notes and give it to the ABA.

    Check out some of the FREE apps that I found for my kids here.
    http://techinspecialed.com/2011/04/02/freediscounted-apps-autism-awareness-day/

  10. I did EI for years and always worked with the parents, educating them to their child’s needs and how they could support them. How is this a new thing? This is just new language to justify a decrease in direct services. Your 2% time of direct service will now be 1%. Even with parent training and guidance, it’s not enough. Kids need both. This is exactly what RTI is doing in the public schools….decreasing direct service. There are a lot of theories to support this but not a lot of hard evidence. There are also a lot of kids out there who are floundering with out the direct intensive services they require. Don’t jump on the bandwagon too soon. These trends tend to circle around. None of these ideas are new just recycled based on opinion and budgets. RTI was tried under another name in the 80ies and failed. Lots of kid fell through the cracks and it’s happening again.

  11. Great article. It seems a large amount of progress in children can be influenced by early intervention programs before they enter kindergarten. Thank you for describing the benefits of early intervention. Interesting read.

  12. I loved your article! I completely agree with you and I think that parental involvement in therapy is incredibly important and not just for early intervention children but for children of all ages. In my private practice, I couch parents to actively interact with their young children during therapy sessions (ages 0-3), not just for bonding and attachment purposes (I work with a large number of internationally adopted children) but also to ensure subsequent carryover and transfer of skills in a variety of settings (home, play ground etc) outside of therapy. For older children, I encourage the parents to observe the sessions (if it makes sense and does not adversely affect the child’s performance), so then the parents can apply similar strategies when working on homework tasks with their kids. I recently did a review of of client treatment data and saw that for a number of clients with similar type and level of impairment, the duration of treatment was shorter if their parents exhibited active involvement in their treatment and with homework activities.

  13. Nice and Dandy but... says:

    This should not be some epiphany of integrating parent involvement. Most kids in the public school programs are poor, have uneducated parents, or live in foster homes with absent caregivers who do not have the resources outside of school to “play” or have the time to learn how to be a SlP. Seriously. Ya, maybe if a child is from a two parent family that has income and can take their kids to a private practice will invest this kind of time and money.

    I work for the largest school district in my state and most kids in my program of 50+ live in foster homes or group homes, all but maybe 10. Many of the homes have multiple kids with other issues. The reality in my world and the population I work with is focusing on the school-based practices. We do not get follow through from the caregivers, and rarely does any of our teachings carry over into the home. Not to be the Debbie downer here, but it is my reality in the public schools setting.

    • I agree with the previous poster that many settings in which we work are certainly not idyllic and children in these settings lack parental involvement and carryover. However, there are other ways to implement carryover that do not involve parents. In addition to my private practice, I also have a hefty caseload in a psychiatric hospital which hosts an outpatient school program for children with severe emotional, behavioral, and psychiatric deficits. 90% of them are adopted, in foster care, have neglectful and/or absentee parents and about 50% have open division of youth and family services cases. So instead of the parents I involve: teachers, personal aids, and who ever else I can get my hands on. I even ask nurses and psychiatrists to observe my sessions and help out with speech and language carryover strategies. I had mental health specialists supervise speech homework in the “calm down area”. And guess what. It really works! The point is that it’s rough out there and we all wish we had idyllic circumstances to work with, but we can still make the best of it and still do a pretty good darn job with carryover if we put our creative minds to it.

    • Toby Stephan says:

      In my experience, reality is often what we make it out to be. If we say adamently that something is, it is; however, many times when I’ve taken a close look at what I presumed reality was, I realized reality to be much more complex with many more possibilities than I ever imagined.

  14. Roma Johnson says:

    Thank you for a wonderful article!!! It is taking awhile….but our early intervention SLP’s are beginning to understand the importance of what happens in the child’s every day life that makes a difference in language development, not what we “professionals” do in an hour a week. To that end, I have always felt that the parent/caregiver was the object of my intervention, not the child. Keep up the good work.

  15. Pam Cooper says:

    I just love what you wrote about our “new” roles and taking a more positive look at what we can do to help the parents who will then help their child! Bravo!