parents’ and service providers’ perceptions of the family goal setting tool: a pilot study

Parents’ and Service Providers’ Perceptions ofthe Family Goal Setting Tool: A Pilot StudySylvia Rodger*, Amy O’Keefe*, Madonna Cook� and Judy Jones�

*Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Qld,

Australia; �Department of Communities, Disability & Community Care Services, Housing & Homelessness, Brisbane, Qld,

Australia

Accepted for publication 12 October 2011

Background This qualitative study describes parents’ and

service providers’ experiences in using the Family Goal

Setting Tool (FGST). This article looks specifically at the

tool’s perceived clinical utility during annual, collabora-

tive goal setting.

Methods Participants included eight parents and ten

service providers involved in a Family and Early Child-

hood Service in Queensland, Australia. Participants

were interviewed individually (parents and one service

provider) or in a focus group (service providers). The

transcribed interviews were analysed using standard

content analysis techniques.

Results Four key themes emerged including: (i) the facili-

tation of goal setting, (ii) strengths-based focus, (iii) fam-

ily centred processes and (iv) family empowerment.

Conclusions Both parents’ and service providers’ were

positive about the FGST. Insights into barriers to holistic

goal setting and the clinical utility of the tool are

described. Further refinement of the tool and trial in a

range of early intervention contexts is required.

Keywords: early intervention, family centred practice,

goal setting, qualitative study

Introduction

Family centred practice

In recent years there has been a shift in the underlying

principles and practices utilized within early childhood

intervention frameworks. In many services, Family

Centred Practice (FCP) principles have been adopted in

service provision for children with special needs (Dunst

2002; Edwards et al. 2003; Dodd et al. 2009; Epley et al.

2010). The FCP is based upon the foundational under-

standing that effective service delivery for children

extends beyond individual child-based therapy, requir-

ing the child to be viewed within the context of the fam-

ily unit. Parents and service providers are viewed as

equal partners in the decision-making process of deter-

mining interventions and the direction of the child’s

care (Rosenbaum et al. 1998; Turnbull et al. 2000). As a

framework, FCP has influenced the design and imple-

mentation of services provided for young children with

disabilities in health care, early intervention, early child-

hood services, special and general education (Dempsey

& Keen 2008; Jeffries 2009).

Alongside FCP is the ‘strengths-based approach’,

which posits similar underlying philosophies regarding

the emphasis on collaborative partnerships between

families and service providers (Raghavendra et al. 2007;

Epley et al. 2010). In service delivery FCP and strengths-

based approaches reinforce that service provision is

developed around the family’s existing capacities, inher-

ent strengths, practices of living, family care and envi-

ronmental contexts in order to facilitate change that is

relevant and significant to the individual family (Allen

& Petr 1996; Moore 2005).

Family engagement in goal setting emphasizes oppor-

tunities for families to direct therapy interventions that

are uniquely meaningful to them (Case-Smith 2001; Sie-

bes et al. 2006; Nijhuis et al. 2008; Rodger & Keen 2010).

FCP highlights the important role of the family within

the child’s life, as parents are in a position to provide

‘expert’ insights into the competencies and needs of the

child, and should thereby have a role in goal setting

and prioritization (King et al. 2004). The underlying

requirement within these models of practice is that goal

setting is family driven as opposed to being therapist-

driven.

Journal of Applied Research in Intellectual Disabilities 2012

� 2012 Blackwell Publishing Ltd 10.1111/j.1468-3148.2011.00674.x

Published for the British Institute of Learning Disabilities

Although the principles of FCP are espoused, many

early intervention programmes fail to be truly family

centred in goal setting and treatment planning (Hanna

& Rodger 2002; Siebes et al. 2007; Thompson 1998;

Tomasello et al. 2010). Typically health professionals

define parent roles in the intervention process (MacK-

ean et al. 2005). Lawlor & Mattingly (1998) also sug-

gested that the ‘therapist as expert’ concept prevailed

in goal setting with families. MacKean et al. (2005) fur-

ther concluded that it is only when families have the

opportunity to decide the parameters of the family

therapist partnership and their level of involvement in

decision making that services can be truly family cen-

tred.

Current goal setting practices

To this end, a number of goal setting tools have been

adapted for use with children and their families (Pollock

et al. 2010). A recent literature review by Tam et al.

(2008) identified four tools that are most commonly used

in goal setting with children including: (i) The Canadian

Occupational Measure (COPM) (Law et al. 2005), (ii) The

Goal Attainment Scaling (GAS) (Kiresuk & Sherman

1968), (iii) The Perceived Efficacy and Goal Setting Sys-

tem (PEGS) (Missiuna et al. 2004) and (iv) The Pediatric

Activity Card Sort (PACS) (Mandich et al. 2004).

The use of the COPM in paediatric settings has

increased over recent years and is the most commonly

used tool when goal setting with children (Tam et al.

2008). The COPM is a well established occupational

therapy measure that is designed to detect client

changes in self-perception of occupational performance

over a period of time (Law et al. 2005). A second widely

used tool is GAS (Kiresuk & Sherman 1968), a criterion-

referenced goal setting and outcome measurement tool.

Studies have supported the validity and reliability of

GAS as an outcome measure in paediatrics, however,

other research has identified potential bias in the devel-

opment of goals and the assessment of goal achieve-

ment, as clinicians often devise and evaluate the goals

(King et al. 1998; Steenbeek et al. 2007, 2010; Tam et al.

2008).

A more recently developed tool, the PEGS (Missiuna

et al. 2004) is a goal setting tool that utilizes a card-sort-

ing method via which the child evaluates his or her

competence on a range of motor-based activities and

subsequently identifies therapy goals. The final tool, the

PACS, is similarly based upon the child sorting through

a range of activity cards and identifying activities that

are the most difficult for them. These selections then

become priorities for intervention (Mandich et al. 2004).

All four tools were designed to establish children’s

intervention goals. There are no existing tools that spe-

cifically address family goal setting with parents. This is

pertinent when children are young and have cognitive

impairments that impact their ability to participate inde-

pendently.

Family goal setting

At one of the Family and Early Childhood Service

(FECS) in Queensland, Australia, the difficulty of pro-

viding a streamlined goal setting process for families

within a multi-disciplinary team context was explored.

To be eligible for this early intervention service, fami-

lies must have a child aged up to 6 years who has, or

is at risk of, a significant global developmental delay,

or has a cognitive impairment. At least annually, the

key worker from the team meets with the parents to

determine family goals. The team found that parents

often have difficulty determining therapy goals, particu-

larly soon after their child is diagnosed when the issues

seem overwhelming. Furthermore, there was a need for

a more streamlined process that was not profession

specific.

As a result, a family goal setting tool (FGST) with

activity cards for use by all team members was devel-

oped by the final author to assist parents ⁄ carers to iden-

tify child and family early intervention goals. The aim

of this article is to describe the FGST and to determine

its clinical utility from the perspectives of parents and

team members. Hence the following research questions

were posed: ‘What are parents’ experiences of using the

card sort to identify annual goals for their Family and

Team Plan (FTP)?’ and ‘What are the team members’

experiences of using this tool with parents to determine

intervention goals?’

Materials and Methods

Design

A generic qualitative research design (Caelli et al. 2003)

was used to reveal a representation of families’ and

team members’ experiences using the FGST during

annual Family and Team Planning sessions. The project

received ethical clearance from Disability Services, a ser-

vice within Department of Communities (Queensland

Government) and one of The University of Queensland

Ethics Committees. Parents and team members provided

written consent prior to participation.

2 Journal of Applied Research in Intellectual Disabilities

� 2012 Blackwell Publishing Ltd

Participants

Participant group 1

The participants were a convenience sample consisting

of the parents and ⁄ or primary carers (n = 8, 67%)

recruited from the client base of a Family and Early

Childhood Service provided by Disability Services,

Department of Communities. These families were recruited

from those who engaged in annual goal-planning meet-

ings between February and July 2010 (N = 12). A service

staff member (not part of the research team) approached

eligible families after the annual FTP meeting in which

the FGST was utilized. Participant Information Sheets

and Consent Forms were provided. Consenting parents’

details were then provided to the research team who

were not members of the service team. Participants were

eight mothers from Australian ⁄ English backgrounds,

who were all engaged in home duties. Only one mother

worked part time, 14 h a week as a teacher (Parent 4).

The majority had completed high school or attended

university. (See Table 1).

Participant group 2

All ten members of the Family and Early Childhood Ser-

vice Team were invited to participate in a focus group

to discuss their perceptions of the utility of the FGST.

All had used the tool during the 6-month period of data

collection and consented to participate in the focus

group. One team member consented to participate in an

individual interview as she was unable to attend the

focus group. A training session on use of the FGST was

provided by the tool’s designer (JJ) prior to use with

families. Participants consisted of two occupational ther-

apists (OT), two speech and language pathologists (SLP),

one physiotherapist (PT), one psychologist (PSYC), two

social workers (SW) and two programme officers (PO).

(Programme officers hold a tertiary qualification in

health ⁄ education ⁄ social welfare and provide family, pro-

gramme and resource support.) All participants were

women and aged between 24 and 55 years old. Each

had been employed within the service team for at least

12 months at the time of the focus group, and had

between 3 and 27 years (mean = 14 years) experience in

working with children. Regarding participation in goal

setting meetings prior to use of the FGST, four service

providers had undertaken less than five meetings, three

between 10 and 20 meetings, and three more than 20

meetings. In terms of use of the FGST, service providers’

experience ranged between 1 and 6 times. Tab

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Instruments

The FGST used in the study was developed by the final

author (JJ) in 2009–2010 to aid in the process of devel-

oping annual FTPs with families. It was first used sys-

tematically during the first half of 2010 when this study

was undertaken. An audit of FTPs from 2005 to 2009

led to a list of 40–45 potential goals that could be

depicted as cards used in a sorting process. These were

then supplemented by additional goals based upon the

clinical knowledge and experience of the developer. A

number of these goals reflected the developer’s under-

standing of the potential impact of disability on family

life, relationships and well-being, and so targeted needs

beyond the child with the disability. In addition

inspired by research using the Measures of the Pro-

cesses of Care (MPOC) (King et al. 1995) parents’ needs

for provision of information were also addressed. It

was believed that although some goals were beyond the

scope of direct therapy services, identifying and dis-

cussing the range of issues at the heart of family con-

cerns provided the potential for facilitating problem

solving, prioritization for ‘within team’ social work and

psychology support and linkage with services and ser-

vice providers beyond the team. Cards were developed

to depict each goal (activity ⁄ skill ⁄ task ⁄ issue) and

included a written descriptor and an illustration using

Board Maker� (Mayer-Johnson, Pittsburgh, PA, USA)

Symbols (See Figure 1). A blank card with the title

‘something else’ was also included to ensure parents

were invited to add goals not encapsulated by the other

cards. Three coloured base plate cards labelled ‘yes’

(green), ‘no’ (red) and ‘maybe’ (orange) to aid the sort-

ing process and a suggested script, with summary card

to assist a consistent approach by service users, were

also included (See Figure 2). The cards were then circu-

lated within the team to identify gaps, determine poten-

tial areas of confusion or need for clarity, for comment

on the wording ⁄ symbols and to indicate any unneces-

sary goal cards. As a result, extra cards were added to

the tool leading to the final count of 78 cards (including

‘something else’). A number of graphics ⁄ words were

also changed to allow a clearer depiction of the card

theme or content. The 77 cards within the FGST were

classified according to seven domains namely: (i) infor-

mation, resources and support for parents ⁄ carers, (ii)

inclusion of child ⁄ family in community ⁄ participation,

(iii) social relational support, (iv) daily living skills, (v)

communication, (vi) gross motor ⁄ mobility and (vii) play

and early academic skills.

After a discussion regarding the purpose of the

Annual FTP families were provided with the option of

using the FGST to assist them in goal setting. Families

were presented with the cards and asked to place each

in one of three piles – ‘yes’, indicating they were inter-

ested in pursuing that activity ⁄ skill ⁄ issue ⁄ topic in the

short to medium term; ‘maybe’, indicating the activ-

ity ⁄ skill ⁄ issue ⁄ topic depicted on the card was a poten-

tial area of concern ⁄ interest that needed to be discussed

or re-considered in the future; and ‘no’, indicating they

were not interested or had no immediate desire ⁄ need to

pursue that particular goal. The blank ‘something else’

card was positioned as the last card in the pack. The

process of sorting the cards frequently led to discussionFigure 1 Depicts a selection of the FGST cards, as used in goal-

setting with families during the research trial.

Figure 2 Demonstrates the FGST cards being sorted into

appropriate yes ⁄ no piles, indicating if the goal is to be consid-

ered for inclusion in the Family and Team Plan.



and identification of parental concerns related to the

child’s performance of particular tasks or activities or

their needs in relation to accessing additional support

and information for the family. On completion of the

initial sort the ‘yes’ pile cards were discussed further

and families were assisted to prioritize their top 3–6

cards that represented activities ⁄ issues they wished to

work on during the year. Due to overlap within the card

content it was possible to combine individual cards into

an overall priority area (e.g. ‘family community outings’

and ‘using community facilities’ into ‘increased commu-

nity participation’). These cards became the focal point

for establishing early intervention goals. Non-priority

goals from the ‘yes’ pile were recorded as potential

future goals. The cards in the ‘maybe’ pile were dis-

cussed to clarify areas of potential concern or interest

and were sometimes re-allocated by parents to alterna-

tive piles. Goals remaining in the ‘maybe’ pile were also

recorded as potential ‘starting points’ for future goal set-

ting discussions. Once priorities were established, fami-

lies were immediately provided with a photocopy of the

goal cards chosen. Identified goals were later formalized

in a document recording each goal, the child’s ⁄ family’s

current skills ⁄ situation in relation to the goal, first steps

towards achieving the goal, and team members to be

involved.

Data collection ⁄ interviews

Semi-structured telephone interviews with parents or

carers were conducted by a research team member

(MC) (who was not a member of the FECS team but

worked in the service). These interviews were recorded

and transcribed verbatim. Interviews ranged from 30 to

45 min. A semi-structured interview schedule was

developed based on the literature and knowledge of

the goal setting process being piloted. The par-

ents ⁄ primary carers were supplied with a copy of the

interview questions prior to the interview. At the

beginning of the interview, consent and use of the

interview information was revised. Several demo-

graphic questions were addressed, namely the child’s

age and primary condition ⁄ diagnosis, length of involve-

ment with the service, household occupants; par-

ent’s ⁄ carer’s occupation, educational status and

cultural ⁄ ethnic background. The remaining questions

focused on the parents’ ⁄ carers’ experience of the pro-

cess of using the FGST, features of the cards, usefulness

of the tool in family goal setting, previous experiences

of goal setting without the cards and suggestions for

improvements with the cards themselves or with the

process. All transcripts were de-identified and partici-

pants provided with numeric codes.

Team members were engaged in a focus group dis-

cussion facilitated by research team members (SR,

AOK), which was audiotaped then transcribed verbatim

by a research team member. Thomas et al. (1995) sug-

gested that a major advantage of using the focus group

format is that it offers the chance to observe group

dynamics through social interaction that results in data

that are often deeper and richer, compared to those

obtained from one-on-one interviews. Hence, two

researchers facilitated the group with one documenting

observations and taking field notes while the other led

the discussion. Prior to the focus group, team members

completed a demographic information form providing

details regarding qualifications, experience working

within a family centred framework, and the number of

goal setting meetings participated in and use of the

FGST while goal setting with families. A focus group

protocol was developed to facilitate discussion about the

clinical utility of the FGST including the merits, limita-

tions and suggestions for modification. The protocol

specifically addressed overall impressions, process of

using the cards, nature and number of goals identified,

prioritization process and formal documentation of fam-

ily plans. Both interview protocols can be obtained from

the corresponding author.

Data analysis

The audiotaped interviews were transcribed verbatim

and de-identified by a second research team member

(AOK) and reviewed by the same two independent

researchers (AOK and SR). The use of these two coders

enabled triangulation and peer checking throughout.

This thereby enhanced confirmability and reduced

investigator bias within the analysis (Mays & Pope

1995). Although data saturation could not be conclusively

established due to time constraints, no new relevant

themes emerged during the eighth parent interview.

Conventional content analysis (Hsieh & Shannon

2005) using hand coding was employed. The transcripts

were reviewed by two research team members (AOK)

(SR) to obtain a sense of the whole and to derive codes.

Collaborative discussions ensued regarding the coding

structure with a very high level of consistency between

each researcher’s interpretations. The individual codes

(53) were grouped into clusters (9) which then formed

themes (4) regarding parents’ and service providers’

experiences of using the FGST. This occurred through a

process of ongoing discussion and consensus.



Results

Four key themes emerged consistently across both par-

ticipant groups, providing commonalities between the

service providers’ and families’ perspectives. These

themes included: (i) the facilitation of goal setting, (ii)

strengths-based focus, (iii) family centred processes, and

(iv) empowerment of families. Some additional consider-

ations are also described. These themes are detailed in

the following sections with supporting direct quotations

(in italics) from both parents’ and service providers’

experiences.

The facilitation of goal setting

All parents interviewed described the FGST as an aid to

annual collaborative goal setting. The tool was described

as ‘easier’ and ‘simplified’, making the goal setting pro-

cess more manageable for parents. As one parent noted:

‘You want them to be normal; you want them to be nor-

mal yesterday. So when you are faced with this over-

whelming amount of what do I want? Well I want

normality; well no we have to start with smaller steps.

To actually have it broken down into well is communica-

tion issues the problem? Is social issues(sic) the problem?

Is it toileting? Is keeping him safe the issue?... So actu-

ally to focus on the little steps makes the bigger picture

look not quite so scary’ (Parent 4).

All eight parents noted that the greater ease in goal

setting resulted from the cards acting as prompts due to

the array of choices ⁄ cues before them. Furthermore all

noted that the cards allowed them to consider previ-

ously un-recognized areas of intervention. Comments

from parents included:

‘...I really rely on visual things so for me to see it, its

better than trying to think of something – they were

good prompts for me to come up with ideas and then to

actually sort it as to areas to focus on’ (Parent 3).

‘Overall I think they (the cards) were pretty good… it

showed me pictures of things I hadn’t even thought of

myself. So I found them quite guiding and helpful in that

respect’ (Parent 6).

‘You know sometimes you’ll sit down to do something

and you won’t remember everything that is impor-

tant...But having the cards there, everything was…pretty

much covered’ (Parent 7).

This was further reflected in the service providers’

perspectives with one (PO) stating:

‘I found even those families where you have thought it

might be too simplistic, have found it a really useful

prompt. You know I’ve thought not that they are over-

whelmed, but maybe they wouldn’t have thought of the

scope that they could with the cards’.

Both parents and service providers noted that the pro-

cess of using the FGST reduced parents’ anxiety when

goal setting. One service provider (SLP) explained:

‘Because I must admit, in the past when we’ve told fami-

lies we have planning coming up they’re like ‘oh no’.

But seriously it’s like a big burden for them. It’s almost

like the goal setting is for our documentation and not

necessarily for them’ and’ It just takes the pressure off.

Because I know that families used to come sometimes to

those meetings and go ‘oh’. They hadn’t had the chance

to think through it and in this way they don’t have to’.

Over half the parents noted that it can be difficult to

identify goals in the context of the FTP. Using the

FGST reduced some of that pressure; ‘Sitting there

with people waiting for an answer for me, when I am

wracking my brain...Its stressful when you don’t actually

come up with anything useful and thinking about the peo-

ple sitting there waiting for me to think of something... I

found that it made it a bit easier’ (Parent 1).

The FGST also aided the service providers in goal set-

ting. It appeared to act as a prompt in promoting a more

multi-disciplinary focus when developing the FTP with

families. As one service provider (SLP) noted ‘I think

without the cards you tend to favour your own discipline. Not

that you mean to, it’s just where your thought processes lie’.

Another service provider (OT) stated, ‘I think on a positive

side there are choices available through the cards sort that I

don’t always think to offer parents when we are doing a Family

and Team Plan. So from that perspective it might tweak some

areas we hadn’t covered’. Service providers also recognized

that the tool was an aid to discussion with families; ‘...It

really gives you a chance to tease things out as well and if they

raise a lot of things that they are not sure of, it really gives you

the chance to investigate it a bit further’ (SLP).

Strengths-based focus

A particular theme that emerged from three of the eight

parent participants and more strongly by service provid-



ers was the strengths-based focus underpinning goal

setting which was aided by the use of the tool. When

framed appropriately, parents felt that the use of the ‘no

pile’ allowed a positive reflection of progress opposed

to sole identification of deficits or areas to improve. One

parent stated:

‘It was really worthwhile... that the no cards can be

because he’s already been there, he’s done that, it’s some-

thing he can do. And I think that because so much of

what we do with having a child with a disability is nega-

tive – I mean you look at their deficits, because that’s

what needs to be fixed. I mean you have to address the

deficits, but its so nice to every now and then reflect on

he can do this, look at where we have come from…. It’s

nice to say well this isn’t a problem anymore, how nice

is this’ (Parent 4).

In terms of the three parents who were positive about

the benefits of reflecting on the ‘no’ pile, there was a

range of children’s ages and length of involvement with

FECS from <6 months to more than 2 years. The benefit

of framing the ‘no’ pile in a positive manner was also

discussed by service providers, with one (SW) illustra-

tive comment being, ‘I found it useful...in the sense that the

strength was leaving the cards together and not saying ‘well

they don’t need feeding’ – and you know but just having

them there and saying ‘well they can do that now’’.

Family centred processes

Another emergent theme related to the provision of

family centred processes when using the FGST in goal

setting. Parents and service providers alluded to the

family centred nature of goal setting with the FGST.

Two sub-themes emerged, namely a more holistic

approach to family centred goal setting, and overcoming

barriers to holistic goal setting.

More holistic approach to family centred goal setting

From a service delivery point of view, the tool

appeared to promote a family centred rather than

child-centred approach to interventions, and more con-

sistent service provision by the team. From the fami-

lies’ perspective, this led to a more individualized and

family specific outcome as it provided more options

for families with varied needs. As service providers’

noted ‘It is family-directed rather than therapy-directed’

(PT), and ‘It’s a family and team plan, it’s not what you

think, it’s what they want’ (SW). Thereby the majority

(five of eight) of the parents noted that the use of the

FGST led to more family orientated goals with two

parents noting:

‘It covered more than just the baby, it covered services to

help us cope. Which again is one of the things that prob-

ably the cards led to a conversation of them advising me

of what services were available to help all of us rather

than just the baby‘ (Parent 1).

‘There was one (card) there on stress management, so we

talked about that which is not something that maybe

would have come up at any other time’ (Parent 3).

Of the parents interviewed, six out of eight reported

that the use of the FGST also resulted in an increased

knowledge of team services available to them:

‘It was good to know exactly what can maybe be offered

as opposed to just going in my with needs and what I

thought was best for my child. Yeah it was good to go

‘oh okay there might be something else we can look at’

(Parent 5).

The FGST was also noted to provide an opportunity

to connect absent partners or family members with the

goal setting process. It was noted during the focus

group that the majority of FTP meetings are attended by

mothers alone due to the father’s conflicting work

schedules etc. As one service provider (SLP) described

‘That probably is the bonus of using the system – is that they

can use it at home’. Just under half of the parents also

described the photocopied summary of goals chosen to

be particularly useful when partners or families are

unable to attend meetings. One parent said:

‘Because my parents are very involved in the care for my

child they like to know what goes on at the therapy ses-

sions and everything. So being able to physically show

them and go through the photocopy with them was great’

(Parent 6).

Overcoming barriers to holistic goal setting

The use of the FGST also provided an opportunity for

service providers to better meet the individual families’

needs in goal setting. This was particularly relevant for

families who were unsure of their child’s ⁄ family’s

needs, and those with poor literacy skills. In the past,

goal setting within the team has mostly been done in a



lengthy interview session. One service provider (SW)

noted ‘I went out to a family where there was limited literacy

skills....it was useful in that instance with the person, rather

than just going through words saying ‘what does that mean’

as we had the pictures’. Another service provider (OT)

explained her use of the FGST and which types of fami-

lies may benefit more from its use:

‘Those with literacy difficulties and also those with or

who have difficulties working out their child’s needs

because the cards actually stimulate their thoughts....And

I use it across the board with families that really struggle

with literacy and others who are quite intelligent par-

ents. And both of those categories I’ve used the cards

for....and they have used it’.

Furthermore the majority of the parents described the

cards as easy to understand with one noting ‘You could

see straight away what they were trying to tell me and they

were pretty straightforward. I can imagine if I had issues with

English they would be quite clear in what they were trying to

tell me’ (Parent 5).

Empowerment for families

In addition to the perceived strengths-based focus of the

tool, there were many references to how empowering the

tool was for parents. Five of the eight parents described

the FGST as an avenue of increasing ownership or inde-

pendence in the family goal setting process. The sense of

increased ownership appeared to be related to physically

being in control of sorting through the cards. As one par-

ent described ‘I thought it was helpful because you actually

got to hold the thing in your hand and have a look at it...So

the physical having to hold them and sort them I found to be

therapeutic for myself’ (Parent 6). A second parent noted

‘It was nice to have ownership of a nice pile of cards. It does

keep you focused on it as it’s your choice which cards you’re

taking’ (Parent 4). Within the focus group this aspect of

the process of using the FGST was illustrated by the fol-

lowing; ‘I think the difference in the previous method where

we had a piece of paper that we might have written on that

they might have been able to look at- but you’re actually giving

them the cards to sift through’ (SW).

Empowerment was also ensured for parents through

the reduced reliance on service providers when goal set-

ting. Thereby there was a sense of increased indepen-

dence. As one service provider (SLP) noted ‘In the past,

parents had difficulty coming up with any (goals). Often you

would just get ‘therapy’’. The same service provider

described that with the FGST, ‘Families can be a bit more

independent with actually working through the card sort... so

to some extent I think maybe they can be a bit more indepen-

dent’. And as a second service provider described ‘It

changes the dynamic in a positive way’. This was similarly

reflected in parent responses, with one parent stating:

‘I found using the cards – it was me choosing those

things as opposed to relying on a staff member to be able

to prompt and kind of say ‘what about this or that’. I

guess the cards are taking the place of the person throw-

ing up ideas and its making me identify with those

things more’(Parent 3).

Additional considerations

Although most of the feedback related to the use of the

FGST was positive, a few additional considerations

were raised. For example, service providers noted that

goal setting meetings potentially detracted from ‘ther-

apy-time’ with the child. This was also raised by one

parent who explained that the goal setting meeting fell

in her highest priority therapy session (Speech-Ther-

apy). However, overall this issue appeared to be related

more to the planning required for goal setting by the

service as a whole, as opposed to a result of using the

FGST.

A second potential issue was repetition or overlap of

content across the cards, which was raised both by ser-

vice providers and some parents (e.g. ‘taking turns’ and

‘playing with others’, or ‘coming for help’ and ‘telling

me what they want’). However, all the parents noted

that this did not detract from the process of goal setting,

with two parents noting ‘I found that there were a lot of

cards however all kids have different needs so it is to be

expected’ (Parent 2) and ‘There were a lot of cards but you

probably need the amount that they had so that everything is

covered in terms of where goal-setting can go’ (Parent 7).

The third consideration was related to the potential of

missing ‘need areas’ of individual families’ that are not

included in the cards of the FGST. Only one parent

and one service provider raised this, with the parent

relating:

‘Purely because you are looking through these cards and

flicking through – that anything I felt at the time, or

anything that I might have walked in thinking about

was gone because I was just sorting through and work-

ing out the cards and what pile I thought was relevant

to my child. And anything else I had before just, yeah,

disappeared’ (Parent 2).



However, the suggested script used by service provid-

ers prompted them to give families a choice about using

the cards at the outset by saying something like, ‘Would

you like to use the cards, or do you think you already

have a pretty clear idea of what goals you want us to

work on? This provided parents with a choice and for

those who used the FGST, the ‘something else’ card also

provided options for them to raise other issues.

Discussion

This study explored the experiences of parents and early

intervention service providers using the FGST during

annual family goal setting. The analysis identified four

overarching themes including the facilitation of goal set-

ting, a strengths-based approach, empowerment of fami-

lies and family centred processes. The tool was

perceived positively in providing a holistic approach to

family goal setting and overcoming previously acknowl-

edged barriers. These pilot results indicate that the

FGST is a valuable tool in goal setting from both par-

ents’ and service providers’ perspectives. However, due

to the uniqueness of the tool there is, as yet, no gold

standard for comparison in the literature. Thereby the

perceived benefits of the tool will be discussed, in rela-

tion to the underlying themes of FCP in early interven-

tion.

A key finding was that the FGST allowed parents a

greater sense of control and ownership over the goal

setting process. This concept of ‘parent empowerment’

is essential in promoting a collaborative partnership in

family centred services (Epley et al. 2010). Research

demonstrates that active involvement of parents (or par-

ents as drivers) in goal setting increases feelings of com-

petency and ownership, and views of equal partnership

with service providers (Oien et al. 2009; Broggi & Saba-

telli 2010). Furthermore, Rodger & Keen (2010) found

that high levels of family involvement in decision mak-

ing was associated with increased family satisfaction

and perceived provider competence. This sense of con-

trol also appeared to reduce the anxiety felt by some

parents when goal setting, as the FGST cards provided

prompts in determining family driven goals. Previously

this anxiety was fuelled by uncertainty in setting goals,

and caused some parents to question their chosen goal’s

appropriateness and suitability. Using the FGST was

perceived to increase parents’ confidence when choosing

individualized goals and communicating their meaning

to service providers. These findings coincide with

research suggesting that parents experience less stress

and have greater feelings of competency when services

are family centred (O’Neil et al. 2001; Law et al. 2003;

Broggi & Sabatelli 2010).

Furthermore, through the use of the FGST, parents

also consistently reported a greater knowledge of avail-

able services for the family as a whole, rather than just a

focus on their child’s needs. This finding reflects litera-

ture regarding parent and therapist evaluations of fam-

ily centred services using the MPOC (King et al. 1995).

Investigators have found that ‘general information pro-

vision’ is consistently scored lower by parents, including

information about the child’s disability, information

about therapy issues, financial costs and assistance and

the types of services available (Dyke et al. 2006; Nijhuis

et al. 2007; Wilkins et al. 2010). The provision of this

information is important in empowering parents in deci-

sion making and goal setting, while also alleviating

stresses related to uncertainty and lack of knowledge.

Researchers have found that limitations in information

exchange and provision are a consistent weak point in

FCP, and need to be addressed to increase service satis-

faction (Raghavendra et al. 2007). By prompting parents

and service providers to consider previously unrecog-

nized areas of intervention ⁄ support, the FGST addresses

this need for greater information provision. As a result,

parents and service providers indicated that the goals

set were more holistic and family centred. This was par-

ticularly related to recognizing that goal setting was

based within the context of the entire family, as opposed

to solely directed at child-based interventions. This

reflects the trend in FCP in early intervention in recog-

nizing that children cannot be adequately served with-

out considering the unique patterns of need of their

families (Allen & Petr 1996).

Another outcome of the study was the appreciation

of parents and service providers of the strengths-based

approach facilitated by the FGST. In the design of the

FGST a strengths-based focus was acknowledged as

underpinning the service delivery approach utilized by

the team. Although the no pile was considered to assist

parents to exclude goals that were not parents’ imme-

diate focus, it was not considered at the outset that this

pile might help parents reflect positively on their

child’s achievements to date. This had the effect of

empowering parents and helping them to be positive

and identify their child’s and families’ strengths and

achievements to date. The move from deficit-based

frameworks to a focus on family strengths supports the

parent-therapist relationship in this context. Kemp et al.

(2004) proposed that a key strategy in providing sup-

port to families is recognizing and celebrating small

positive changes or achievements in child development.



This was commented on by parents and service pro-

viders alike.

Service providers reported an improved capacity to

engage and involve families from different cultural and

language backgrounds through use of the FGST. Com-

munication and language have been found to be criti-

cally important cultural issues in occupational therapy

practice (Fitzgerald et al. 1997). They identified that one

of the most important features of intercultural communi-

cation was developing a means of articulating and rec-

onciling these differences, in a satisfying way for all

involved. The FGST demonstrated the potential to over-

come these barriers due to the picture card format. Fur-

thermore, Board Maker � is currently available in 44

different languages and has the capacity to alter facial

characteristics ⁄ complexion to increase the connection to

the user (Spectronics 2010). Thereby it demonstrates the

potential to overcome barriers related to communication

and literacy levels, by providing an accessible graphic

format. During the 6 months of data collection, no fami-

lies from culturally and linguistically diverse back-

grounds were engaged in annual goal setting. Hence,

the utility of the FGST with a range of cultural groups

and with those with limited literacy needs further explo-

ration.

The limitations of this study are largely related to the

restricted sample population. All study participants

were involved in the one community-based early inter-

vention service in Queensland, Australia and thereby

the results are limited to this context. In addition, it was

not possible to differentiate the impact of other con-

founding factors, including staff consistency in use of

the FGST and its influence on parent perceptions, differ-

ent approaches to goal setting by different service pro-

viders and parents’ past experiences of goal setting.

Furthermore, it is acknowledged that there may be bias

among parent participants who participated in this

study, who may have been those with stronger views

about the FGST.

The results of this pilot study provide encouragement

regarding the use of the FGST as it has only been used

for 6 months during which this study took place. A

whole 12-month cycle would be needed to see how use-

ful the FGST is in terms of goal appropriateness and

progress monitoring. However, research is required to

refine the tool and determine its utility in other family

centred, community-based early intervention services

and whether it could be used with outcome measure-

ments such as GAS (Kiresuk & Sherman 1968) to moni-

tor intervention progress. Future research also needs to

investigate the capacity of the tool to overcome lan-

guage, literacy and communication barriers when goal

setting with families with varied backgrounds.

Note

Corrections were made to pages 2, 3, 5, 6, 7 and 10

on 21 March 2012 year after first publication online on

6 January 2012. The errors have been corrected in this

version of the article.

Correspondence

Any correspondence should be directed to Sylvia Rod-

ger, Division of Occupational Therapy, School of Health

and Rehabilitation Sciences, The University of Queens-

land, Brisbane 4072, Qld, Australia (e-mail: s.rodger@

uq.edu.au).

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