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Vol. 11, No. 2, March 2008 YOUNG EXCEPTIONAL CHILDREN 29 YEC DOI: 10.1177/1096250607311933 http://yec.sagepub.com © 2008 Division for Early Childhood Bonnie Keilty, EdD The University of North Carolina at Charlotte Early Intervention Home-Visiting Principles in Practice: A Reflective Approach T he home is the most frequently used location for providing early intervention supports and services (U.S. Department of Education, 2006). However, practices to address child development outcomes have shifted from direct, hands-on “treatment” to supporting families through collaboration and consultation so that they can promote their child’s development by using identified intervention strategies effectively and confidently during their everyday activities (Bailey et al., 1998; Bruder, 2000; McWilliam, 2000a; Shelden & Rush, 2001). Routine activities, those everyday family experiences, provide rich opportunities for promoting child development. For example, mealtime might not only be a time for learning eating skills but can also provide opportunities to develop communication and socialization skills. Interventionists support families’ use of these routine activities as learning opportunities by embedding intervention strategies, individualized to the unique learning characteristics of the child into the routine activities. at Apollo Group - UOP on August 24, 2015 yec.sagepub.com Downloaded from

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Vol. 11, No. 2, March 2008 YOUNG EXCEPTIONAL CHILDREN 29

YEC

DOI: 10.1177/1096250607311933http://yec.sagepub.com

© 2008 Division for Early ChildhoodBonnie Keilty, EdDThe University of North Carolina at Charlotte

Early Intervention Home-VisitingPrinciples in Practice: A ReflectiveApproach

The home is the mostfrequently used locationfor providing earlyintervention supports and

services (U.S. Department ofEducation, 2006). However,practices to address childdevelopment outcomes have shiftedfrom direct, hands-on “treatment”to supporting families throughcollaboration and consultation sothat they can promote their child’sdevelopment by using identifiedintervention strategies effectivelyand confidently during theireveryday activities (Bailey et al.,1998; Bruder, 2000; McWilliam,2000a; Shelden & Rush, 2001).Routine activities, those everydayfamily experiences, provide richopportunities for promoting childdevelopment. For example,mealtime might not only be a timefor learning eating skills but canalso provide opportunities to developcommunication and socializationskills. Interventionists supportfamilies’ use of these routine activitiesas learning opportunities byembedding intervention strategies,individualized to the unique learningcharacteristics of the child into theroutine activities.

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The context of the early

intervention home visit is

the individual family’s

routine activities.

The shift in home visitingpractices is aligned with Division forEarly Childhood of the Council forExceptional Children recommendedpractices. Practices regardingchild-focused interventions includeconsidering the setting (i.e., routineactivity) in intervention design,ensuring strategies can be usedacross settings where children learn,and promoting child engagementwith other people and materials(Wolery, 2000). A recommendedpractice for interdisciplinary modelsis “team members focus onbetween-session time (i.e., build inactivities that can be carried outacross time and contexts)”(McWilliam, 2000b, p. 54).Although home visiting consultationpractices are endorsed, earlyinterventionists might have difficultyimplementing these practices,especially when they have beentrained to be more hands-on anddirected toward the child ratherthan the caregiver and child(Bruder, 2000; Shelden & Rush,2001). The purpose of this article isto guide early interventionists’reflections on their own home visitingpractices with respect torecommended practices. The practicesdiscussed are specific to the timesduring home visits when interventionis focused on child learning outcomes.There most likely will be other timeswhen the home visit focus is on otherfamily outcomes, where thesepractices might be modified to reflectthe different focus.

Critical Home VisitingComponents

Research and practice literaturehave identified four overarching

home visiting components tofacilitate child learning anddevelopment. Home visits should (a)occur within the context of thefamily’s routine activities, (b)promote child engagement, andbuild family capacity by (c) ensuringcaregiver engagement in the homevisit and (d) supporting caregiverconfidence and competence in theiruse of the intervention strategies(Bailey, 2001; Bailey et al., 1998;Brooks-Gunn, Berlin, & Fuligni,2000; Bruder, 2000; Dunst, 2000;Dunst, Bruder, et al., 2001; Kaiser& Hancock, 2003). Each of thesecomponents is discussed below, witheach section beginning with aquestion interventionists canconsider as they reflect on theirpractices.

Context

How are the family’s routineactivities used as the setting forhome visits?

The context of the earlyintervention home visit is theindividual family’s routine activities(Dunst, Bruder, et al., 2001;McWilliam, 2000a). These routineactivities may be specific events,such as reading books after lunch,or simply times of the day, such asbefore or after the child’s nap. Toidentify and use these routineactivities, interventionists and familymembers can discuss why homevisits occur during routine activities.The conversation might includethat all children, those withand without disabilities, learnbest within the routine activitieswhere they will use new skills,which also provides multipleopportunities throughout the dayand week to practice emerging

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competencies (Bronfenbrenner,1993). The concept that thecontextual characteristics ofdifferent routine activities shapechild participation may also bediscussed. For example, a childmight be able to sort or matchobjects when sitting down andplaying, but squatting and standingto match socks from the dryer cancreate a different challengerequiring different supports. Usingthe routine activities during thehome visit will ensure the strategiesfit those specific routine activitieswhere the strategies will be usedwhen the home visitor is notpresent (McWilliam, 2000a).Although interventionists might notbe available for all routineactivities where families willgeneralize the strategies, theinterventionist and family membersshould discuss the use of thestrategies within those routineactivities to make sure that thestrategies “fit” those activities toeffectively promote the child’sdevelopment.

The routine activities usedduring home visits are individualizedbased on the family’s interests andpriorities. These may be times thatthe family has specific concerns butcan also include times that areenjoyable or relaxed, such aswalking through their flower gardenor choosing clothes to wear asopportunities to learn colors.Families may feel that their child islearning throughout the day andmay not identify specific routineactivities. However, it may not beenough to use just any “typical”routine activity, such as eating,getting dressed, or playing together.Instead, interventionists and families

can collaborate to identify thoseroutine activities that make sensefor the individual family (Dunst,Hamby, Trivette, Raab, & Bruder,2000). Considerations inidentifying routine activities thatmake sense for the individualfamily include family values andpriorities (e.g., it is important tothe family that the child andsiblings play together), childinterests (e.g., the child likes towatch the construction vehiclesbuilding in their neighborhood),child needs (e.g., the child has ahard time transitioning to andparticipating in the bedtimeroutine), and/or restrictions on thefamily’s time (e.g., the family doesnot want to embed strategies aroundfollowing directions during weekdaybreakfast because of the hurriednature of the morning routine).

Finally, context includes thefamily’s customs and practices. Forexample, the family may beinterested in understanding the bestway to play interactive games withtheir infant. Instead of theinterventionist suggestingspecific songs and finger playsthe interventionist knows, theinterventionist can ask the parentsto identify those that are a part ofthe family’s culture, perhaps onesremembered from their childhood.Intervention strategies can then beintegrated into the family’s customsto promote child interaction andengagement.

Child Engagement

How does the home visit supportactive child participation in thefamily’s routine activities topromote child learning?

The routine activities used

during home visits are

individualized based on

the family’s interests and

priorities.

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The learning opportunitiesavailable in routine activities can becapitalized on when the child isengaged by participating in theroutine activity in developmentallyand individually appropriate ways(Dunst, 2000; Dunst, Bruder, et al.,2001; Dunst, Trivette, Humphries,Raab, & Roper, 2001).Considerations in creatingengagement include, but are notlimited to, active involvement,interest, and motivation to learn.A child is not engaged when he isbeing distracted from an activityhappening to him, such as whengiven a toy to play with while hisface is washed to provide oralmotor stimulation before eating.Interventionists and caregivers canbe creative and try to find ways toengage the child and opportunitiesfor child initiation during theactivity, two early features of self-determination (Erwin & Brown,2003). From the example above,engagement and initiative might bebuilt into the activity by having thechild “tell” the caregiver when heis ready to have his face washed orhold a face cloth and imitate facewashing while the caregiver iswashing his face.

Child interest either occursnaturally because the child isalready interested in the routineactivity, or interest is intentionallybuilt into a routine activity as partof intervention, considering theindividual child’s motivations(Dunst, Bruder, et al., 2001; Dunst,Trivette, et al., 2001). For example,whereas some children might bemotivated by singing, another childmight not become interested usingsuch an approach. The family andinterventionist can collaborate to

identify the child’s interests thatmight facilitate engagement andlearning.

A child is motivated to learnwhen the activity is designed to bejust enough of a challenge that thechild understands what is expectedand can figure out the aim of theactivity (Keilty & Freund, 2004).Adaptations can be made bymodifying materials or changingthe arrangement of the physicalenvironment and by usingresponsive caregiving strategies tosupport the child’s motivation totry to be successful (Campbell,2004).

Through interventionist andfamily collaboration, strategies topromote child engagement areidentified and tried to determinetheir effectiveness. If theengagement strategies do not seemto be working during the homevisit, other strategies should beattempted while the interventionistis available to problem solve withthe family. Although the familymay have many ways to engage thechild in routine activities, theinterventionist and family shouldensure the engagement strategiesare successful within the specificroutine activities where interventionstrategies are embedded.The family should not be leftwith only potential strategies thatmay or may not work or withinterventionist recommendationsthat the family keeps trying eventhough the child was notengaged when it was attemptedduring the home visit. Withoutthe strategies to promotechild engagement, caregiverdisengagement in future homevisits might result.

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Caregiver use of

intervention strategies

between home visits

begins with caregivers

feeling comfortable

engaging and

actively participating in

the home visit.

Caregiver Engagement

How is the caregiver activelyparticipating so that she or he canlearn specific intervention strategies?

Caregiver use of interventionstrategies between home visitsbegins with caregivers’ feelingcomfortable engaging and activelyparticipating in the home visit(Brooks-Gunn, et al., 2000;Roggman, Boyce, Cook, & Jump,2001). Wagner and colleagues(Wagner, Spiker, Linn, Gerlach-Downie, & Hernandez, 2003)identified five dimensions ofcaregiver engagement: presence,availability, involvement,application of support strategies,and exploration of additionalsupports. The extent to whichcaregivers are engaged can bedependent on the way the home visitis structured or other influences inthe family’s life.

Before caregiver engagement canbe facilitated, the interventionistmust understand the caregiver’sexpectations of early intervention.Caregivers may perceive earlyintervention to be comparable totraditional child-directed clinic orclassroom services. During homevisits, interventionists must be clearas they discuss, and consistent asthey practice, to support caregivers’understanding of their roles asappreciated, active participants.Interventionists and caregivers mightdiscuss what participation couldlook like. Different ways theinterventionist might participateinclude asking questions andlistening to the caregiver, explainingand demonstrating how to usecertain strategies, and providingfeedback to the caregiver. The

caregiver can participate in thehome visit by asking questions andclarifying statements, observing theinterventionist’s demonstrations,trying out the strategies, andproviding feedback to theinterventionist (Kaiser & Hancock,2003; Rush, Shelden, & Hanft,2003; Woods, Kashinath, &Goldstein, 2004). From thisconversation, consensus on whatearly intervention home visitinglooks like can be achieved.

Encouraging caregiverparticipation from the inception ofhome visits as well as at thebeginning of each home visit canconvey its importance. Providing afew “warm-up sessions” in theinitial home visits or a few minutesof the interventionist and child aloneat the beginning of each visit, wherethe caregiver passively watches or isnot in the room, can convey to thecaregiver that she or he does not reallyneed to be, nor is valued as, acollaborator in the home visit. Thiscan further reinforce a direct childtreatment model. Shifting from aninterventionist–child model to acaregiver–child with interventionistsupport model can be more difficultthan using the desired model fromthe beginning. Caregivers may alsobe confused about how toparticipate in home visits if someteam members are encouragingcaregiver participation and othersare not. Open communicationamong all team members, includingthe family, is critical to ensuringeveryone sees the value incollaborating with caregivers so theyfeel comfortable engaging in homevisits.

Home visits can be designedso that caregiver engagement is

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anticipated and necessary.Scheduling home visits during aroutine activity the caregiver sees asa learning opportunity can buildengagement because it is alignedwith the caregiver’s priorities. If thecaregiver appears disengaged, theinterventionist and caregiver candiscuss the purpose of home visiting,whether it is a good time for thevisit, and whether the visit should berescheduled if the caregiver cannotparticipate at the scheduled time.Another strategy is to ask thecaregiver what she or he is doinginstead of participating in the homevisit (i.e., the real routine activity ofthe moment) and whether thatroutine activity might be anopportunity to embed interventionstrategies.

If the caregiver is notparticipating in the visit, theinterventionist and caregiver cancollaborate to uncover possiblereasons for the caregiver’sreluctance. The family may havetime constraints of which the

interventionist is unaware, or thefamily may not truly understand orembrace the importance ofparticipation. The plan and resultinginterventions may not be meaningfulto the caregiver if they are notdesigned according to the family’strue goals. The caregiver may notfeel comfortable with the strategiesif they are difficult to embed intoroutine activities. Encouragingfamilies to discuss their concernsabout participating in home visitscan provide an opportunity toproblem solve. For example, theconversation may reveal that thehome visit is the only time thecaregiver can “take a break.” Withthis knowledge, the interventionistand caregiver can brainstormstrategies to address this need,including identifying informalsupports, such as family, friends,and neighborhood babysitters,as well as more formal sources ofsupport, such as respite services.The purpose of this conversation isto meet the caregiver’s prioritiesand open the door for activecaregiver participation inthe home visit.

Lack of caregiver engagementmay also result from pressing familyissues that interfere with thecaregiver’s attention. For example, acaregiver may be present for thevisit but busy coordinating thechild’s doctor’s appointments. Orthe caregiver may be involved in thevisit but seem very tired anddisinterested because she or he isoccupied with moving her or hisaging parents closer to home. Attimes such as these, there may needto be a shift from child-focusedvisits to family-focused visits inorder to support the family inaddressing these priorities.

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As mentioned previously, earlyinterventionists are not alwaystrained to work with families. Thismay result in interventionists’feeling uncomfortable engaging inconversations with families aboutcaregiver participation.Interventionist discomfort in thisconsultation role can negativelyinfluence caregiver participation, ascaregivers may sense theprofessional’s uncertainty with thesepractices. Interventionists can taketime to reflect on their own feelingsabout consulting with families. Theycan explore research and practicearticles on collaborating withfamilies, seek outside professionaldevelopment opportunities, and usesupervisory and peer mentors toexamine these concepts of practicedeeply. As interventionists gainmore knowledge of and competencein working with families, they willfeel more comfortable engaging inconversations necessary for an openand equal partnership with families.

Caregiver Competence andConfidence

How does the home visit ensure thecaregiver can accurately utilize theintervention strategies?

Caregivers can and do learnhow to use intervention strategies topromote their child’s learning anddevelopment effectively (e.g., Kaiser& Hancock, 2003; Mobayed,Collins, Strangis, Schuster, &Hemmeter, 2000; Woods et al.,2004). To facilitate caregiverconfidence and competence in usingrecommended interventionstrategies, home visits are designedin terms of both approach—howhome visits are implemented—andcontent—what strategies are

recommended. The literaturerecommends various approaches tofacilitate effective strategy use.These approaches usually comprisesome combination of discussionand explanation (verbal and/orwritten), modeling, and practicewith feedback (Dunst, Bruder, et al.,2001; McWilliam & Scott, 2001;Rush et al., 2003; Woods et al.,2004).

When specific strategies arediscussed, a rationale for how thestrategies will address the family’spriorities and outcomes can increasecaregiver “buy-in” to learn thestrategies. For example, a caregiverwho understands the link betweenoral motor techniques and thefamily’s goal of communicativecompetence is more likely to use thestrategies than a caregiver whoperceives the oral motor techniquesas “exercises to help strengthen thechild’s muscles.” Although somestrategies may only need to bediscussed with the caregiver, such asputting toys in the bathtub as asource for play and interaction,other strategies will need to bedemonstrated and practiced.Modeling provides an opportunityfor caregivers to observeinterventionists demonstratingstrategies within the routineactivities (Kaiser & Hancock, 2003).However, what might appear to bemodeling might really be direct childinstruction between the interventionistand the child, with the caregiverpresent but passively observing theintervention (e.g., sitting on the couchwatching; McBride & Peterson, 1997).For true modeling to occur, theinterventionist is activelydemonstrating the strategies with a fullexplanation of what she or he is doingand thinking about while engaged in

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a two-way conversation with thecaregiver. After modeling occurs,caregivers need the opportunity topractice and receive feedback on use ofthe strategies so that both theinterventionist and caregiver areconfident that the caregiver can use theintervention strategies accurately.

Ongoing, open communicationbetween caregiver andinterventionist is necessary to ensurethat the caregiver is trulycomfortable using the strategies.Interventionists can encouragecaregivers to ask questions andidentify possible reservations inusing the strategies so they can beaddressed. For example, aninterventionist might coach acaregiver in positioning the child onher or his lap, facing her or him,while swinging on their backyardswing, to promote interaction andincrease use of muscles. By readingthe caregiver’s cues and asking forfeedback, the interventionist mightdiscover that the caregiver feelsuncomfortable transitioning intothat position and feels unsteadyonce on the swing. Theinterventionist and caregiver cancollaborate to (a) identify new waysto get into the position and feelstable on the swing, (b) find otherways to promote learning andinteraction while on the swing,and/or (c) identify other routineactivities where the samecompetencies can be addressed, suchas when they are sitting on therocking chair on the porch.Receiving feedback on the strategiesattempted allows the interventionistto tailor the strategies to thecaregiver’s preferences and comfort.The approaches chosen to supportcaregiver strategy use will most

likely be different for eachindividual family depending on thechild’s characteristics and thecaregiver’s learning style. Theapproaches will also vary within thesame family depending on thecomplexity of the strategiesrecommended.

When discussing potentialintervention strategies, considerationis made as to whether the strategy isfunctionally relevant to the child’slife (e.g., does the strategy makesense based on the routineactivities?) and easy, or “doable,”for the caregiver to use in routineactivities (Dunst, Trivette, et al.,2001; McWilliam, 2000a).Interventionists can monitor thehome visit by asking, If theinterventionist is taken out of theroutine activity, can the strategiessuggested still occur? For example,if the interventionist is holding thechild while the caregiver is trying astrategy for putting on the child’sshoes, the strategy suggestedmight not work when theinterventionist is unavailable toassist. Home visitors can beattuned to what the routineactivities usually look like so thatthe caregiver can more easily usethe strategies in everyday life.

The amount of support neededto use recommended strategieseffectively, and the types andnumber of strategies perceived asreasonable, will vary for eachfamily. The interventionist andcaregiver can decide togetherthe frequency and intensity ofsupport needed, as well as thenumber and kinds of strategieswith which the caregiver feelscomfortable (Jung, 2003; Woodset al., 2004).

Ongoing, open

communication between

caregiver and

interventionist is necessary

to ensure that the

caregiver is truly

comfortable using the

strategies.

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Reflecting on HomeVisiting Practices

Early interventionists canenhance home visiting effectivenessby reflecting on their own practicesin accordance with therecommended practices aroundusing routine activities as theintervention context, facilitatingchild and caregiver engagement, andsupporting caregiver confidence and

competence in strategy use. TheHome Visiting Principles Checklist(Table 1) was designed to assist earlyinterventionists in this reflection.

The Home Visiting PrinciplesChecklist is divided into the fouroverarching components of homevisiting practices. The questionsunder each section correspond tothe defining concepts of eachcomponent discussed in this article.The checklist was developedthrough a review of early

Table 1Home Visiting Principles Checklist

Criteria Yes No

Context: How are the family’s routine activities used as the setting for home visits?Does the family understand why home visits occur during their routine activities? —— ——Does the home visit occur within the same routine activities where the caregiver will use the —— ——

strategies between home visits?Are the routine activities used in home visits identified by the caregiver as important opportunities for their child to learn? —— ——Are the routine activities used during home visits individualized to the specific family? Do the interventions

“fit” within the family’s interests, priorities, and context? —— ——Do the routine activities occur often enough so the child has repeated opportunities to practice new behaviors and skills? —— ——Are the family’s customs used in the interventions? —— ——Child engagement: How does the home visit support active child participation in the family’s

routine activities to promote child learning?Is the child interested in the routine activity? If not, has interest been built into the routine activity as part of intervention? —— ——Is the routine activity adapted so that the child can actively participate as expected for the individual child? —— ——Is the activity structured to be just enough of a challenge so the child is learning something new? —— ——Caregiver engagement: How is the caregiver actively participating so that she or he can learn specific

intervention strategies?Is active caregiver participation in home visits fully discussed with the caregiver? —— ——Does the caregiver understand her or his active participation in home visits is appreciated? —— ——Is the caregiver actively involved in home visits from the beginning of the (a) intervention program

and (b) each home visit? —— ——Are home visits designed so that it depends on caregiver engagement for home visits to occur? —— ——Is the level of caregiver engagement similar across team members? —— ——Caregiver competence and confidence: How does the home visit ensure the caregiver can accurately

utilize the intervention strategies?Are the intervention strategies demonstrated and fully explained to the caregiver according to caregiver characteristics? —— ——Does the caregiver have an opportunity to practice the strategies during home visits to provide and receive feedback? —— ——Are caregiver questions and reservations addressed by the interventionist? —— ——Can the strategies be implemented without the interventionist present? —— ——Is the right level of support (frequency and intensity) provided so the caregiver can accurately

learn the intervention strategies? —— ——Does the caregiver think the recommended intervention strategies and number of routine activities in which

to embed intervention strategies are reasonable? —— ——

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intervention research and practiceliterature and individual and groupprofessional development activitiesaround implementing home visitingpractices. The checklist was used inan early intervention home-visitingworkshop to guide discussion on thepractices observed in videotapedhome visits. In evaluations of theworkshop, participants reportedthat the checklist was very valuableto use as they reflected on their ownpractices.

The Home Visiting PrinciplesChecklist can be used periodicallyduring preservice practica orprofessional supervision andmentoring experiences. After anobserved home visit, theinterventionist and mentor can eachcomplete the checklist and use it as adiscussion guide. An action plan canthen be developed, identifying specificareas to strengthen and potentialstrategies for strengthening them.Interventionists, alone or inpartnership with a mentor, can alsouse the checklist to review possibleintervention aspects that can befurther considered when havingdifficulty partnering with a specificfamily. The checklist provides anopportunity for interventionists toconsider possible modifications thatmay contribute to the success oftheir home visits.

Setting Home VisitingExpectations

It should be noted that home visitsare only one part of the interventionprocess. There are multiple phasesprior to the initiation of home visitsthat can be used to organize theintervention team around

recommended home visiting practices.During team meetings or mentoringsessions, intervention teams can reflecton how they discuss early interventionwith families upon initial contact andways to tailor the discussionaccording to each family’sassumptions about early intervention(e.g., Does the family think earlyintervention is a place to receivephysical therapy sessions?). Focusingthe evaluation and assessment processon the family’s priorities and routineactivities, and child learning withinthose routine activities, can further setthe stage for home visiting. TheIndividualized Family Service Plan caninclude outcomes that are truly thefamily’s goals and functional withinthe family’s routine activities as wellas strategies that include familyparticipation. If the family has alreadybeen receiving early interventionsupports, understanding what homevisits have looked like in the past canfacilitate a conversation about thesimilarities and differences in homevisiting approaches.

Conclusion

Early intervention home-visitingpractices have shifted to aconsultation model where caregiversare supported in facilitating theirchild’s engagement and learning inthe routine activities of everydaylife. Interventionists can furtherenhance their work with familiesthrough reflection and considerationof their current practices in light ofthese recommended practices.

NoteYou may reach Bonnie Keilty by

e-mail at [email protected].

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