David SugdenUniversity of Leeds 

Cork November 17th

Ecological Intervention: From Planning to Implementing a Programme

Ecological Intervention:Step by Step Summary

Recognising a difficultyCollecting information to plan the

programmePlanning the ProgrammeImplementing the programme

Recognising a difficulty

Someone has suggested there is a problem.

Parent, family member, teacher, friend, child him/herself.

Decision to investigate the problem

Key Features of Ecological Intervention

Intervention outcomes are a function of the interaction of the child’s resources, the environmental context and the manner of presentation of tasks to be taught.

Or put another way

The difficulties do not solely reside in the child!

Bronfenbrenner Model

Ecological InterventionResources of the Child

Outcomes

Environment Manner of

in which Activity presentation

occurs

Child’s Resources

Accurate assessment of the child and the context in which s/he functions is essential.

The child’s wishes are key variables in the intervention process. This will usually include identifying functional tasks, choosing priorities, establishing targets for success and engaging in monitoring their own progress.

Resources of the childStandardised tests-MABC, BOT,EYMSC, othersDynamic assessment-observation by skilled

OT/PTCriterion referenced tests-various checklists

for teachers, parents and othersInterviews, child, teachers, parents, othersSchool reportsExclusionary criteria-C and DNon motor, co-occurring characteristics-

attention, personal and social, cognitive, other.

Resources of the childPOP

Profile

Objectives

Priorities

Targets, Objectives and Priorities

Setting Targets and Objectives-come from Collecting Information and should involve the child at all times.

Assigning PrioritiesOne causing most problemsOne with knock on effectsOne that is achievableQuick winsEnjoyment factor

Environmental contextFamily and home

School setting

Health services

Community support

Family and homeDaily life and routines

Family circumstances

Cultural values

Informed decisions in the family

School settingSchool policy on SENFormal proceduresResources in school Practices in schoolSupport practicesOutside help

Health servicesOTs and PTs and others

Mode of delivery

Waiting lists

What part the GP?

Community supportSports centres

Sports clubs

Community groups

Implementing Ecological Intervention

Two prerequisites for the approach

Participation through engineering the environment

Successful learning through good teaching

Ecological Intervention EI is a way of thinking and acting , an

approach, rather than a rigid package which must be delivered by a highly skilled professional in a specified way.

Our starting point is that intervention cannot be viewed as an add-on to normal daily life. Instead, intervention should be an integral part of daily living.

Different individuals playing different, but equally important, roles- child, parents, health professionals, teachers, others.

Participation and SuccessfulLearning

7 points for guidance

The Movement Coach Organising the context Working in a meaningful context Learning specific skills through task analysis,

task adaptation and expert scaffolding. Learning specific skills is not enough:

broadening the learning through generalisation

Instructions, practice and feedback Monitoring and evaluation

The Movement Coach

The person responsible for the organisation, delivery and monitoring of EI.

Need for central person to argue case and take responsibility

Plan of actionNegotiate with significant personsCoordinate with familiesWho is it-possibilities.

Organising the contextData on:

Child, targets s/he has setTargets others see as importantSupport systems and possibilitiesIndividuals and their roles

Meeting and firm commitmentScheduling and practiceCommunication and timetabling for actionLearning to move-moving to learn

relationship

Working in a meaningful context

Functional tasksRealistic and relevantEveryday activities-formal and informalActive movements

Teaching specific skills through task analysis, task adaptation and expert

scaffoldingAnalysingAdaptingStrengths –weaknessesExpert scaffoldingBike riding example

Choice of tasksFunctional activities- from assessment,

objectives and priorities. Very strong research evidence for this.

Group tasks for generalisation eg same body parts, same cognitive processes, similar demands but vary the detail. Helps ‘solving a movement problem’.

Specific tasks according to need. Eg handwriting, buttoning, bike riding.

Task adaptation and task Analysis

Task adaptation mainly function for participation.

Task analysis mainly for learning

Together they interact and achieve both participation and learning.

Task adaptation and task analysis

We are always keen to stress that it is always preferable to teach the functional activities holistically in a manner as close as possible to its naturalistic setting

However……..

Task Analysis

Break down the task into components

Each component has to be: achievable

a whole in itself-for motivation

easy to build into the overall task

Lead up Activities for Bike Riding-Gwent NHS

Standing on left holding bike and pushing the bike while steering.

Braking to verbal command and visual target. Steering in and out of cones and around corners. With brakes, getting on and off bike. ‘Scooting’ –sitting on bike with pedals removed on lowered

seat, walking the bike followed by raising of legs. ‘Scooting’ and steering and braking. With a handling belt, pedal with support repeating all of the

above stages. Prepare pedal for push off with belt. Push off and prepare second foot to move to pedal still with

belt. Once this can be accomplished remove belt but ‘shadow’

support. Once confident with this, start to make context

unpredictable with cones and moving others.

Task Adaptation

Change the context/environment- modify the pitch, numbers, rules.

Modify the ball, bats, etc., self help aids, shoes, shirts, pencils, rulers, lines, scissors.

Adapt the game, wall ball, jump rope etc.

Teaching specific skills is not enough: broadening the experience through

generalisation

Prior learning affecting new learning

Taking information, skills, knowledge learned in one context and using them in another

Performing new skills in a slightly different manner to ones learned

Generalisation

Continuum of ability to do this but in many populations who have atypical development, a lack of spontaneous generalisation is often a core characteristic.

GeneralisationWhat is required to generalise

The acquired knowledge, strategies, dispositions, abilities, information for a particular task

A recognition, automatically or consciously, that the new context requires the above.

The second bullet point is the one that often proves to be very problematic and particularly resistant to

improvement in children with atypical development

Generalisation

LEARNER

Outcomes

CONTEXT TASK

GeneralisationSo do we focus on:

Tasks? Type and range

Learners? Cognitivists and learner’s perception of

similarity

Contexts? Sociocultural perspectives and social

interactions in context

Facilitation of Transfer/Generalisation

Clinical/educational setting and practices

Variability of examples/practice in class of actions

(Task)

Importance of explicit task analysis (Learner)

Metacognitive strategies-explaining to each other, teaching of self regulation, monitoring (Learner)

Expert scaffolding (Context)

Practice in context (Context)

Example of handling the learning process

Instructions and practice Understanding the skill

Short and simple, move straight into task; pick out 1 or 2 major points the child needs to understand. Feedback the same. Cognitive awareness

Acquiring and refining the skillGradual progression to looking at errors and how to

correct. Cognitive awareness Automating and generalising

Dual tasks and different contexts/cognitive awareness

Freezing and releasing degrees of freedom

Early part of skill learning or early development-dfs are frozen. Eg painting a window; child throwing

As skill develops and/or learning progresses dfs are selectively released- still being controlled-to increase flexibility and adaptability.

Skilful therapist and teacher uses this when working with child

Physical disability?

Monitoring and Evaluation

Ongoing monitoringCheck with child-enjoyable-progressCheck with others-carryon? Adjustments?Realign targets and priorities?

Evaluating the whole programmeChilds viewMeeting of original targets-view of the teamTest dataOther data

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Case study Gary 7 yrs 8 months

Referred by health visitorBorn 6 weeks prematurelyConcerns since reception - fidgeting,

concentration, shouts out, clumsyExtra help in school - real problems holding a

pencil, handwriting “appalling”Good memory, conversation & computer skills

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GOALS:

Writing - parents choice but he agreed & set following goals for himself Sitting properly, holding paper,

g,l,p,q,z,R,S,V,Z Laces Ball gamesNot worked on but identified by child: Trying new things on the playground - a bit

scared Running - in races mostly win

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MABC total score

0

2

4

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8

10

12

14

16

Test 1 Test 2 Test 3 Test 4

3rd %ile

54th %ile

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Intervention methods Group –resource efficient, provides a peer

group, novice learner model 8 times over 2 weeks – 50 minutes Based on functional tasks identified by

applying criterion B Child & parent agree goals Task specific approach with use of motor

learning & cognitive strategies

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Results

Coordination improved –observation at camp Writing improved - sitting position, hand on

paper, mum says she can now understand writing in homework book.

Can now do own laces (occasionally come undone)

Ball skills - no change on MABC but improvement in football skills noted by parents, child and OT

Running & trying new things on the playground – he says no longer an issue

Other Work in Leeds

Supported for 4-5 years by Action Medical Research Longitudinal – 31 children – multiple assessments Periods of intervention, non intervention & monitoring Dilemmas:

We wanted to helpLong waiting lists-up to two yearsSpecific Professionals, PTs, OTs & others – high skill –

low contact timeOthers – Teachers & Parents – unknown skill/potential

– high contact time

Children in the Study31 children aged 7-9 yearsInitially teacher selectedChecked by MABC23 in lowest 5% - 8 in 5-15% on movement

ABC

Comply with DSMIV on exclusionary conditions

Questions

Can teachers and parents, with help, enact an effective intervention programme?

Can children with DCD be helped in this way?

Are there some children who require other forms of intervention

Procedures, Profiles and Programmes

Asked teachers for children with movement difficulties

Movement ABC Test and ChecklistKept 15% as well as originally planned 5%After 1st assessment individual profiles developed.Strengths, weaknesses and prioritiesEach week guidelines given to parents and

teachersAbilities to work on, activities and ways to present

(later)Principles from Ecological Intervention

(Henderson and Sugden 2007)

Sequence of events over project period

Assessment of total Group7 weeks No Intervention

Assessment of total GroupGroup 1 Teacher Intervention 7 weeks Group 2 Parent

Assessment of total GroupGroup 1 Parent Intervention 7 weeks Group 2 Teacher

Assessment of total Group7 weeks No intervention

Assessment of total Group

Monitoring

Monitored and assessed regularly for 2 years 26 followed through, testing plus interviews with parents

and teachers and children. Formed 3 group

14 stayed out of lowest 5%-10 out of lowest 15%8 variable- some (5)staying out as long as intervention

continuedThus 19 out of 26 improved as long as intervention is

present2 minor changes and 2 children stayed in lowest 5% -

no improvement

Movement ABC Test scores for Child 4

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Test 1 Test 2 Test 3 Test 4 Test 5 Test 6 Test 7 Test 8 Test 9

Movement ABC Test

Tota

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Movement ABC Test scores for Child 8

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Test 1 Test 2 Test 3 Test 4 Test 5 Test 6 Test 7 Test 8 Test 9

Movement ABC Test

Tota

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Movement ABC Test scores for Child 26

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Test 1 Test 2 Test 3 Test 4 Test 5 Test 6 Test 7 Test 8 Test 9

Movement ABC Test

Tota

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Answers to questionsTeachers and parents with help can

enact a programme of intervention for children with DCD

A majority of children with DCD can be helped in this way

Some children will need more specific intervention

Not possible as yet to predict which ones will stay out of category post intervention

Concluding Comments• Participation is essential for learning to take place. ‘Little and often’-amount of appropriate practice is the

major influencing variable. Clever use of professionals and significant others. Remember the problems never resides solely in the

child.

Final Thoughts Much of the definition and particularly intervention

success is in our control-optimistic model-we have seen this in many intervention studies.

Engineer the environment and deliver good therapy/teaching