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Early intervention for army families.

By Robin McWilliam, Ph.D. Director, Siskin Center for Child and Family Research, Siskin Children's Institute

With her husband stationed with the U.S. Army in Afghanistan, Ntombi Henderson was left alone to care for their 9-month-old baby, Boi. As if that wasn't hard enough for this Army wife, Ntombi was worried about their child's development. Boi wasn't sitting up or making the same kinds of sounds other babies make. Ntombi felt overwhelmed--and even worse, helpless. But the Army was prepared to help families like hers.

When Ntombi took Boi to the doctor for his shots, the physician referred her to early intervention--a service that could answer her questions about Boi's development. The Department of Defense provides support to families of infants and toddlers with disabilities, just like the Hendersons, through the Educational and Developmental Intervention Services (EDIS), specifically through Early Intervention Services (EIS). In this article, I discuss the Army's model of delivering these services, what it means to focus early intervention on "routines" and issues specific to military families.

These services gave Boi the help he needed and Ntombi the peace she wanted.

Model of Service Delivery

The Army employs possibly the best methods for helping families with infants and toddlers with disabilities in the world. The two dimensions to service delivery are development of each family's plan and how support is then provided. A number of reasons explain why the Army's method might be superior. One is that they have a centralized structure, where key leaders can implement a consistent set of practices across all Army early intervention locations. A second is that, within that structure, the Army has excellent leadership, especially in the form of Dr. Naomi Younggren (supported by Audrey Ardison, the Medical Command program manager) who has championed the implementation of evidence-based and recommended practices in this tight-knit, well-oiled but very spread-out agency. In the continental U.S., the Army Medical Command has nine sites. Outside the continental U.S., it has EDIS sites in Puerto Rico, Korea, Germany, Italy, Belgium, and The Netherlands. When Army families have a child requiring early intervention services, they are assigned to posts having those services. A third reason for the high quality of EDIS early intervention services is that well-qualified people are contracted or hired to work in the programs. These professionals are mostly early childhood special educators, speech-language pathologists, occupational therapists, and physical therapists. When a child is eligible for early intervention, the most important first step is to develop a plan for how these professionals will work with the family.

To develop a plan of action, known as an individualized family service plan, professionals need to determine what the real needs are, and they need to guide the family to choose "outcomes."

One of the areas I have worked with the Army most closely on is its method for assessing individualized needs of infants and toddlers with disabilities and their families. EDIS/EIS professionals are probably the most advanced users of the Routines-Based Interview (RBI), which was first described in a book I wrote in 1992. Dr. Younggren has become one of the foremost experts in the use of the RBI, and she has incorporated it into the method of developing individualized plans for children served by the Army.

The Routines-Based Interview is a semi-structured interview conducted by one or more early intervention professionals with the adult family members of a child who will receive early intervention. The interview runs through the family's day, with the family doing all the talking in response to the professionals' in-depth questions. As the family is talking, the professionals make note of problem areas the family discusses or they ask the family what they would like to happen differently at different times of the day. Unlike other "assessments" done with the child, this one evaluates a child's day-to-day functioning in real-life situations, and it includes the family's functioning. The family's functioning is just as important, because, according to family systems theory (and bucketsful of evidence), the well-being of one member of a family affects the well-being of other members of the family living in the same household.

At the end of the interview, the family, having just talked about their day-today life in great detail, chooses what they would like the team to work with them on. This results in a hefty set of outcomes--sometimes known as goals. Compared to planning that produces only two or three outcomes, this method produces 6 to 12 outcomes, which reflects a complete and thoughtful needs assessment. Having this many outcomes is not surprising, considering the assessment is done "routine" by "routine." So the list of outcomes incorporates more detailed child behaviors, more pieces of information families say they want, more goals for just the parents themselves, and it covers the whole day, instead of global child-level outcomes, just child development issues, and no specific context for the outcomes.

Once the family has used the interview to generate a list of outcomes or things to work on, the team, including the family, decides what services are needed to address these outcomes. This service decision making is another strong suit for EDIS/EIS. They emphasize the use of a primary service provider instead of piling on a slew of providers, as is sometimes done in other systems.

In Ntombi's situation, for example, EDIS can develop a plan with her and then send out one person from any of the specialty areas to be her "service coordinator" and primary service provider. That person would come to her home every week and give her information, including what to do with Boi. The home visitor would also give her information about resources such as other services or places and programs in the community, about the child's disability, and about child development. Very importantly, the home visitor would provide emotional support to Ntombi directly and would help Ntombi have time with and access to her own family and friends. The Army's early intervention professionals know that informal support networks are even more important than professionals and agencies, which are formal support systems. From time to time, another member of the team, representing a different specialty area, will accompany the regular home visitor to provide suggestions to Ntombi. In some cases, these other specialists make independent visits, but it is better for them to go with the regular home visitors, so the regular people are in a better position to help Ntombi carry out the other specialist's suggestions. The use of a primary service provider instead of a bunch of professionals going to the home all the time is a hallmark of excellent early intervention, even though some families and professionals might think that more frequent visits by more professionals is the way to go. The training and technical assistance I have provided to EDIS has been focused on a model of providing early intervention in natural environments being used more and more across the U.S. and further afield.

Routines-Based Early Intervention

Boi is learning throughout the day, which means that the fabric of day-today life is rich with learning opportunities for him. Who is with him throughout the day? Ntombi, not professionals. If he went to a child care program or what military installations call child development centers, his additional natural caregivers would be the teachers. Routines-based early intervention is therefore the provision of support to the child's natural caregivers so they can make the most of the learning opportunities they are already providing the child; they can turn those learning opportunities into "interventions" for the child. This is contrasted with session-based early intervention, which for years was focused on the actual home visit or therapy session as the time when the child was supposedly learning. With the routines-based approach, sessions are used to give the families (and child care teachers) the information, coaching, and encouragement to use all those hours of play, caregiving, and just hanging out as intervention opportunities. Families in the military have some issues that come up in both the Routines-Based Interview and in supporting them through home visits.

Issues Specific to Military Families

This year, I am working with EDIS professionals in the U.S. and overseas on the refinement of their already-excellent services. The issues they, unlike early interventionists working with non-military families, face include deployment and, often, being quite young parents. The deployment issues can be that only one parent is rearing the child or children, and single parenting is exhausting. The parent remaining with the children is also likely to worry about the safety of the deployed partner. Being in the Army for some families is itself a difficult situation, when they discover the hardships around raising a family and managing the time demands of the military.

Fortunately, the military has many resources for families, and of course health care and housing are provided. A tenet of early intervention is to marshal all the resources that might help meet families' outcomes. I am always impressed with the resilience of families of young children but I am equally moved by the stresses they are under when the child has developmental problems and parents are deployed. In terms of the quality of support available from early intervention, if you have an infant or toddler with disabilities, it's good to be in the Army. *

Robin McWilliams, Ph.D. is the Director of Siskin Center for Child and Family Research and the Siskin Childrens' Institute in Chattanooga, Tennessee. He is one of the nation's leading researchers in early intervention/early childhood special education (EI/ECSE). As director of the research center, he serves as the new Siskin Endowed Chair of Research in Early Childhood Education, Intervention and Development. Most recently, he was the director of the Center for Child Development at Vanderbilt Children's Hospital in Nashville. Dr. Robin received his Ph.D. in Education from the University of North Carolina at Chapel Hill.
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Title Annotation:United States Military Section
Author:McWilliam, Robin
Publication:The Exceptional Parent
Geographic Code:1USA
Date:Dec 1, 2009
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