what role does setting play?

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Parent involvement in early intervention: what role does setting play? a

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Yvonne Kellar-Guenther , Steven A. Rosenberg , Stephen R. Block & Cordelia C. Robinson

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d

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Colorado School of Public Health, University of Colorado, Aurora, CO, USA. b

Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA. c

School of Public Affairs, University of Colorado Denver, Denver, CO, USA. d

Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA. Published online: 29 Jul 2013.

To cite this article: Yvonne Kellar-Guenther, Steven A. Rosenberg, Stephen R. Block & Cordelia C. Robinson (2014) Parent involvement in early intervention: what role does setting play?, Early Years: An International Research Journal, 34:1, 81-93, DOI: 10.1080/09575146.2013.823382 To link to this article: http://dx.doi.org/10.1080/09575146.2013.823382

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Early Years, 2014 Vol. 34, No. 1, 81–93, http://dx.doi.org/10.1080/09575146.2013.823382

Parent involvement in early intervention: what role does setting play?


Yvonne Kellar-Guenthera*, Steven A. Rosenbergb, Stephen R. Blockc and Cordelia C. Robinsond a Colorado School of Public Health, University of Colorado, Aurora, CO, USA; bPsychiatry, University of Colorado School of Medicine, Aurora, CO, USA; cSchool of Public Affairs, University of Colorado Denver, Denver, CO, USA; dPediatrics, University of Colorado School of Medicine, Aurora, CO, USA

(Received 10 March 2013; final version received 5 July 2013) This study compared levels of parent involvement in early intervention services for children under three which were delivered in community settings (children’s homes and child care programs) and specialized settings (early intervention centers and provider offices) in the USA. Respondents reported the highest levels of parental involvement in the home. However, level of involvement in the home was not significantly higher than the provider’s office for parent attendance, quality and content of parent-provider communication, and effective instruction; level of provider communication and instruction to parents was not significantly higher in the home than in the early intervention center. Early intervention services in the child care setting were associated with the lowest levels of parent involvement. With the exception of child care, these results suggest that specialized and natural settings are associated with similar levels of parent involvement. Keywords: setting; early intervention; parental involvement

In the USA, early intervention services for children under three years of age must be delivered in natural environments whenever possible. Natural environments include places that are frequented by children who do not have disabilities, such as child care centers or children’s homes. Currently, the overwhelming majority of infants and toddlers (87.4%) receive early intervention services in their homes (Data Accountability Center 2010). The goal of providing services in the child’s natural setting is shared by early childhood interventionists in Europe (Carpenter, Schloesser, and Egerton 2009). The emphasis on natural environments is based on the belief that providing early intervention services in natural settings facilitates the child’s access to opportunities for learning that occur throughout the day (Swanson, Raab, and Dunst 2011) as well as providing opportunities for children to learn by interacting with typically developing peers (Bruder 2010; Sheldon and Rush 2001). It is also believed that early intervention in children’s homes will lead to familycentered care (Salisbury and Cushing 2013; Sheldon and Rush 2001) by facilitating *Corresponding author. Email: [email protected] Ó 2013 TACTYC


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greater parent involvement in therapeutic activities through their active participation in early intervention sessions (Whitehead, Jesien, and Ulanski 1988). Ideally, the caregiver should be talking with the provider, demonstrating techniques for the provider, and getting advice from the provider (Salisbury and Cushing 2013). It is believed that this approach facilitates productive intervention activities by tapping into materials and contexts that are part of the child and family’s daily life (Friedman, Woods, and Salisbury 2012; Hanft, Rush, and Sheldon 2004; Hughes and Peterson 2008) and increases the likelihood that parents and children will engage in therapeutic activities outside EI sessions (Bruder 2010; Hanft and Pilkington 2000). Parents are thought to be more likely to be physically present during service delivery when services are delivered in the home, since no travel for the family is required (Mott 1997; Shelley-Sireci and Racicot 2000). By contrast, attending sessions in a provider’s office may be difficult because traveling may be risky for a medically fragile infant (Mott 1997; Weiss 1993) and families may need to find child care for siblings (Kuchler-O’Shea, Kritikos, and Kahn 1999; Mott 1997; Wehman and Gilkerson 1999). Moreover, even when the appointment in the office setting is kept the parent might not stay for the intervention visit (McWillliam, Tocci, and Harbin 1995). Yet, it is also possible for parents to be ‘absent’ when early intervention services are delivered in the home because they can become distracted by siblings, television, or household chores; distractions that are minimized in a professional office setting (Mott 1997). Providers in a study by Fleming, Sawyer, and Campbell (2011) stated that it could be difficult to get caregivers involved in the early intervention visits in the home. They identified caregiver characteristics, the home environment, family life stressors, caregivers’ expectations and understanding of early intervention, and commitment and investment in early intervention services as factors that can increase or decrease parental involvement. While attendance is important, it is only one component of parental involvement (Ketelaar et al. 1998). Many providers believe family members are more involved when the intervention takes place in a natural setting vs. an early intervention center (Hanft and Pilkington 2000; Mahoney, Robinson, and Fewell 2001; Shelley-Sireci and Racicot 2000) because the natural setting is believed to enhance the quality of coaching or instruction that parents receive from providers. Natural settings are thought to facilitate the professional’s focus on what the caregiver is doing with the child, instead of simply focusing on the child (Hanft and Pilkington 2000). One of a few observational studies that have been done found parents’ involvement during home visits may be limited to observing the professionals working with their children (McBride and Peterson 1997). Moreover, Sawyer and Campbell (2009) found that providers had less strongly held beliefs about participation-based practices (e.g. role of provider teaching caregiver) than about other early intervention practices (e.g. professional collaboration) and for those in their study, about 40% continued to provide services the traditional way even after being trained on participation-based practices. About 94–95% of the providers in the observational part of the study delivered early intervention in the child’s home, 1–3% in an area close to the home, and 1% in the child care setting (Sawyer and Campbell 2009). In addition to parent participation, communication between parents and providers is also important for parental involvement. Open and clear communication and active listening promotes strong parent-professional relationships (Burton 1992;

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Kalyanpur and Rao 1991; McCurdy and Jones 2000; McWilliam, Tocci, and Harbin 1995; Popp and Wilcox 2012; Upshur 1991) while a lack of clear communication makes parents feel less involved in early intervention activities (Wehman and Gilkerson 1999). Lack of clear parent-provider communication is a common parent complaint (Wehman and Gilkerson 1999), but natural settings are believed to promote parent-provider communication (Hanft and Pilkington 2000; Weiss 1993). There is a rationale for believing that providing early intervention activities in natural settings will result in greater acceptance by parents of professional advice (Gajdosik and Campbell 1991; Hanft and Pilkington 2000), but this belief has not been fully tested. Research questions Using caregiver responses to interview questions, this study examined the effect of setting on five aspects of parent involvement in early intervention services: (a) parent attendance, (b) parent participation during the intervention visit, (c) communication between parent and provider, (d) provision of instruction to parents, and (e) parent use of instructional strategies. Methods Procedures Data were collected using interviews with the primary caregiver. The interviews were conducted by telephone, and required between 30 and 45 minutes to complete using a script approved by the Colorado Multiple Institutional Review Board. As Bailey, Hebbeler, Olmsted, Raspa, and Bruder (2008) point out, interviews often yield a higher response rate and allow a more thorough understanding of the phenomenon being studied than a survey and are less labor intensive and easier to use than direct observation for large studies. Interviews can also be tailored to fit the caregiver’s communication style and the interviewer can probe or provide additional information if a question is unclear. Extensive training procedures were designed to improve the validity of selfreport data (Del Boca and Noll 2000). For this study, data collection staff participated in one training session, followed by mock training calls, and weekly meetings with the supervisor. The first few calls were completed under the observation of the supervisor. Results were not used if the staff member had questions about the validity of the responses, such as if the participant was evidently distracted during the call. To increase the diversity of the sample, the interview survey and consent forms were translated into Spanish by a team of three: two individuals with advanced degrees in Spanish, and one Mexican-born native Spanish speaker. Both the interview survey and consent forms were administered in Spanish by staff who were fluent in Spanish. A total of 21 (22.8%) of the 92 interviews were conducted in Spanish. Participants and sample selection Service coordinators from the agency that funded early intervention services, in Denver, Colorado, USA, identified 191 households who qualified for this study on


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the basis of children (a) not older than 3.5 years of age, (b) who had received early intervention services for a period of at least six months, and (c) who had received at least one early intervention service within the previous six months. To protect their privacy, families were mailed a recruitment letter by the Colorado agency they worked with and asked to actively dissent if they were not interested in being part of the study; 15 families asked that their names not be passed on to the research team. Of the 176 names passed on to the research team, 30 could not be contacted within the time frame of the study reducing the sample to 146 families who consented to participate in the study, for a response rate of 76%. Of the 146 interview surveys, 5 interviews were not used because the interviewers felt the parents did not understand the questions or were distracted and not engaged during the interview. As a result, a total of 141 interviews were deemed usable for analysis. Of these, only 92 reported receiving services at least 80% of the time in a specific environment. Because we are looking at the effect of location on several outcome variables, it was decided that it was important that there was a predominant location in which services were delivered; 80% was deemed acceptable because a clear majority of the time families are receiving services in one location. The analyses were run on the data from these 92 families. Demographics of families For the 92 families who participated in this study, parents’ median education level was one to two years of education after high school. The families’ incomes averaged $35,000. Further demographic data are presented in Table 1. Demographics of the children For the 92 children, the mean age was 2.57 years at the time of the interview. These children received an average of 2.74 services during the six months prior to the interview. Table 2 shows the remaining demographic information for the children. Measures Items on the interview survey were adapted after items on NEILS (National Early Intervention Longitudinal Study). NEILS is a longitudinal study that follows families and children through their experiences in early intervention. The goal of NEILS is to gather characteristics of children and families, the services they receive, and the outcomes they experience (Hebbeler et al. 2007; SRI International 2013). The NEILS items that were used included family and child demographics, household characteristics, Individual Family Service Plans (IFSP) processes and early intervention services, and family services. While the NEILS’ IFSP items were organized by setting, the tool used in this study was organized by services received. This difference in procedure provided more specific information about parent experiences with service providers. The interview was piloted with 45 families prior to this study. These 45 families were not eligible to be part of the larger study. Instead, their responses were used to refine the interview. For this study, caregivers were first asked to provide demographic information. The primary care-provider was then asked to identify which therapy/therapies or service(s) the child had received at least three times during the

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Table 1. Demographics of families.


Sample used for analysis N = 92 Primary respondent to survey Child’s mother Child’s father Foster mother Grandmother Marital Status Married Not married Separated Divorced Widowed Language used for interviews English Spanish

N

%

78 5 6 3

84.8 5.4 6.5 3.3

68 15 6 5 2

73.9 16.3 6.5 5.4 2.2

71 21

77.2 22.8

Table 2. Demographics of Children. Sample used for analysis N = 92 Child’s sex Male Female Child’s ethnic group African American American Indian/Native American Caucasian Hispanic Mixed Child’s Eligibility for Early Intervention Services Categorical Eligibility Developmental delay Both categorical and developmental delay Missing data

N

%

52 40

56.5 43.5

13 4 27 39 9

14.1 4.3 29.3 42.5 9.8

9 17 66 0

9.8 18.5 71.7 0

past six months. The most common services were educational visits, speech, physical, and occupational therapies. Once the types of services were identified, families were asked to answer a standard set of questions about each service they had received. Families were told that they could skip any questions they were not comfortable answering; these were coded as ‘refused.’ These questions addressed (a) parent attendance, (b) parent participation during the intervention visit, (c) communication between the parent and provider, (d) provision of instruction to parents, and (e) the degree to which parents reported using instructional strategies. If the caregivers indicated that transdisciplinary services were received, they were also asked which services specifically were provided for their child by those providers and which other services they

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received from an individual discipline (e.g. speech therapy from a Speech Language Pathologist). Primary setting of service(s) For each early intervention service received in the previous six months, caregivers were asked to identify all the settings in which that service was delivered. The settings included home, early intervention center, provider’s office, child care settings, hospital, outpatient clinics, and other. If caregivers listed more than one setting per service, they were asked to indicate the primary setting. Hospital and outpatient clinic settings were dropped from the analyses for this study because few families received the bulk of their services in those settings. To determine the primary setting for all the services a family received, the primary settings for each service were tallied. Of the 92 families included in the analysis, 61 (66.3%) received 80% or more of their services in the home, 12 (13.0%) in the early intervention center, 9 (9.8%) in child care, and 10 (10.9%) in the provider’s office. Aspects of parent involvement Parent attendance To determine if parents attended the early intervention sessions, they were asked to indicate how often they had attended a particular service during the past six months using a response range of ‘every time’ (5) to ‘never’ (0). All the attendance responses were averaged across the services received. Parent participation during intervention visit Parents were asked how actively they participated in the sessions. Responses ranged from ‘did everything with my child’ (5) to ‘just watched’ (0). Parents’ responses were averaged across the services received. Communication between parent and provider Communication between parents and providers was assessed using four items. For each service the child received, the respondent was asked how often the parent and provider discussed how the child was doing in the service, what help the caregiver may have needed, how often the parent solicited the provider’s advice on how to talk or play with the child, and how often the parent requested advice about ways to help the child learn to be more self reliant. A composite communication variable was computed using these four items. The responses ranged from ‘every early intervention session’ (5) to ‘never’ (0). The responses for these four items were summed for each service and then averaged across the services received (Cronbach alpha = 0.86). Provision of instruction to parents Instruction was assessed with three items used in an earlier study (Rosenberg and Robinson 1988). Parents were asked how often the provider made suggestions to

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the parent about things she could do with the child, how often the provider showed the parent things she could do with the child, and how often the provider asked the parent to model an intervention that the provider had previously recommended. Responses ranged from ‘every time’ (5) to ‘never’ (0). A composite score was computed for the three items which was then averaged across the services received (Cronbach alpha = 0.67). Parent use of instructional strategies Caregivers were asked how often they used advice from the service provider. Parents were asked to report for each service the child received ‘How often have you used advice the service provider(s) has/have given you about (Child’s) needs and/or about how to help him/her?’ Responses ranged from ‘every time’ (5) to ‘never’ (0). All the advice-following responses were averaged over the number of services received.

Results To determine if the environment of early intervention services related to purported benefits, an analysis of variance (AOV) was computed for each of the five measures of parent involvement. Planned comparisons were not done because there is little empirical work to indicate what differences should be expected among the settings. The Dunnett test was chosen for post hoc analyses. Effect sizes are reported for the magnitude of differences between home and the other settings. Effect size is a numerical way of expressing the size of a reported relationship. Here effect sizes are reported in terms of Cohen’s d. The number of families in each setting and means and standard deviations for the five variables are presented in Table 3.

Parent attendance during the intervention Parent attendance was highest when intervention was delivered in the home (F = 45.66, df = 91, p = 0.00) but not statistically higher than parent attendance at a provider’s office. Attendance was significantly lower at the early intervention center and child care settings. The lowest level of parent attendance was when services were delivered in the child care setting; in fact parental attendance at child care settings was significantly lower than at the other settings. The effect sizes were large for the differences between home and child care, as well as between home and early intervention center (Table 4). Parent participation during the intervention visit Parent participation was significantly lower at child care settings than at home or at the early intervention center (F = 3.34, df = 86, p = 0.02), no other comparisons were statistically significant. The effect size shows that the largest difference in parent participation is between home and child care; there were modest or small differences for the other settings, with the EI center being associated with higher parent participation than home (Table 4).

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Table 3. Parent ratings of involvement by setting. Mean (SD)


Attendance (0–5) Participation (0–5) Communication (0–20) Instruction (0–15) Advice following (0–5)

Home (n = 61)

Child care (n = 9)

EI center (n = 12)

Provider’s office or Clinic (n = 10)

4.67 (0.64) 3.01 (1.23)

0.72 (0.67) 1.61 (0.74)

3.25 (1.91) 3.53 (1.34)

4.2 (1.32) 2.72 (1.24)

15.85 (3.84)

11.09 (3.54)

14.15 (3.21)

14.65 (4.48)

10.95 (2.48) 3.99 (0.87)

5.62 (1.80) 4.17 (0.64)

9.68 (2.63) 4.43 (0.68)

8.85 (1.82) 4.38 (0.81)

Table 4. Differences in parent involvement across settings. Mean difference (effect size) Attendance Home Participation Home Communication Home Instruction Home Advice following Home

Child care

EI center

Provider’s office or clinic

3.95⁄⁄(6.03)

1.42⁄⁄(1.00)

0.471(0.45)

1.40⁄(1.38)

.518(0.40)

0.298(0.24)

4.77⁄⁄(1.29)

1.71(0.48)

1.21(0.288)

5.23⁄⁄(2.46)

1.27(0.50)

2.09(0.97)

0.180( 0.24)

0.444(0.56)

0.389(0.46)

⁄

The mean difference is significant at the p < 0.05 level. The mean difference is significant at p < 0.01 level.

⁄⁄

Communication between parent and provider Communication between parent and provider differed significantly only between home and child care settings (F = 4.40, df = 91, p = 0.01). The effect size was large for the difference between home and child care; modest for the other settings (Table 4). Parents reported they talked most with the provider when services were delivered in the home and least when services were delivered at child care settings. The frequency with which parents solicited advice was highest at home but not statistically higher than parent and provider communication at early intervention centers or providers’ offices. Provision of instruction to parent The highest level of instruction to parents in the sessions occurred in the home setting (F = 7.48, df = 75, p = 0.00) the difference in level of instruction was statistically significant only between child care and home and the effect for the difference between home and child care, and home and office; medium for the early intervention center (Table 4).

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The degree to which parents used instructional strategies The level at which parents used instructional strategies from providers did not differ significantly for any of the settings (F = 1.41, df = 90, p = 0.25) and the effect size was modest for the differences between home and all other settings with home having the lowest rate of advice following (Table 4).

Additional analyses To better understand the relationship between the statistically significant indicators of parental involvement, we ran a series of correlations. For the caregivers in this study, higher attendance at the early intervention session was related to higher levels of parent participation in the session (r = 0.25, p = 0.02) and communication between the parent and provider (r = 0.38, p = 0.00). Higher levels of caregiver participation in the intervention session was also positively related to higher levels of communication between the parent and provider (r = 0.26, p = 0.01), and the provider giving instruction that was more specific to what the parent and child did together (r = 0.27, p = 0.02). Additionally, higher levels of communication between parent and provider were positively and strongly related to the provider giving instruction that was more specific to what the parent and child did together (r = 0.53, p = 0.00). Finally, higher levels of communication between parent and provider was related to higher levels of interventionists providing instruction to parents (r = 0.27, p = 0.01).

Discussion The goal of this study was to examine the impact of service settings – natural (home and child care) and specialized (early intervention center and provider office) – on parent involvement in early intervention activities. To our knowledge, this is the first study to have made direct comparisons of parent involvement across natural and specialty settings. The results of this study lend only limited support to the belief that natural settings provide unique advantages for children and families over specialty settings with regards to parent involvement. Study findings indicate that following the interventionist’s advice was unrelated to service setting. Children’s homes were associated with the highest levels on the other four of the parental involvement variables utilized in this study; however, this study’s findings suggest the benefits associated with service delivery in the home may not be substantially greater than those associated with service delivery in the provider’s office or early intervention center. This lack of difference may result from a failure of providers to use natural settings to maximum advantage (Fleming et al. 2011). This fits with literature stating that providers taking a more traditional approach will bring in materials to the home rather than use what is in the home (Campbell, Sawyer, and Muhlenhaupt 2009). Parents in our study reported that they were not significantly more or less likely to attend the early invention sessions in the home vs. the provider’s office. Additionally, parents’ participation during the intervention session and communication with providers did not differ between home, early intervention center, and provider’s office. Nor did parents report that providers significantly differ in involving the parent-child dyad when providing instructions about services in any of these


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three settings. This supports Sawyer and Campbell’s (2009) assertion that the provider’s beliefs about participation-based practices are more significant than where the services are delivered. The small difference between home and specialty setting may reflect the fact that homes come with distractions, including siblings, television, and phone calls that can make it hard for the parents to participate (Fleming et al. 2011). Only child care settings were associated with substantially lower levels of parental involvement. However, this is understandable as parents typically spend little time at child care settings. Of all the indicators, communication between parent and provider may be the best indicator of parental involvement in early intervention activities. Communication goes beyond just being in the same room. Communication requires the exchange of ideas and information. For our respondents, communication between the parent and provider was significantly and positively correlated with all the other parent involvement variables. This study suggests that communication, and by extension the parent-provider relationship, may be more critical to parent involvement than the venue for the services. It is important that there be face-to-face meetings between parents and providers. Mott (1997) argues that delivering services in someone’s home allows an opportunity for a deeper connection between the provider and family. Relational scholars (Bochner 1984; Miller and Steinberg 1975) argue that face-to-face interaction allows both parties to use nonverbal cues and artifacts to gain some insight into the other (Trenholm and Jensen 1996). Yet Salisbury and Cushing (2013) argue that just meeting face-to-face is not enough; providers need to work with and through the caregiver. They found that when providers used this approach vs. the providerled approach, provider and caregivers were engaged in a focused conversation about the session or the child twice as often (8%) as were adults in the provider-led condition (4%) and the provider focused on the caregiver twice as much as in the provider-led condition (22% vs. 12%). This increase in active engagement taps into some of the principles of effective practice for adult education including mutual respect and collaborative spirit (Brookfield 1988) and was not dependent on location in Salisbury and Cushing’s study (2013). Salisbury and Cushing’s (2013) study on instructional approach supports our view that the relationship between the provider and the family should take precedence over the setting where services are provided. Future research should address the predictors of a high quality parentprovider relationship and what role, if any, setting may play. Limitations and future directions There are several limitations to this study. First, the number of families who received services in settings other than the home was limited (n = 31, 33.7%). More specifically, few families received early intervention services in child care settings (n = 9, 9.78%), an environment that was shown to significantly differ from the other settings tested. Future studies may be strengthened by stratifying the sample of families in various service settings in order to ensure higher numbers for all types of environments. Second, this study was conducted in one urban community. Consequently, this work needs to be replicated in additional communities in order to determine whether the patterns of comparable parental involvement at home, early intervention center, and provider office will continue to be found in larger and more diverse samples.


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The finding regarding the low levels of parent involvement in the child care setting also warrants further exploration. The current reality is that many families with children who have disabilities require child care. Future studies may want to focus on how to ensure adequate parental involvement when early intervention services are delivered in child care settings. This study examined parent involvement in several common venues for early intervention services. However there were several other settings, including in-patient care and community-based activities that were also used by families in this study. Due to the low numbers of respondents who used those settings, it was not possible to examine parental involvement in those settings. Future research should look at parent involvement in the delivery of services in less commonly used settings. Future research should also look at the cost benefits of providing services in natural settings. Providing services in homes and other natural settings can be more costly than providing services in specialty settings (Kelso et al. 2009). In addition, total reliance on natural settings can exclude families from potentially useful programs that occur in clinical settings.

Conclusions The meaning and intent of the requirement that early intervention be delivered in natural settings has generated considerable interest. We believe that a major aspect of the underlying intent of the requirement was based upon an expectation that parent implementation and carryover of early intervention activities would be facilitated by provision of services in home and other community settings. These findings suggest that, with the exception of child care, setting may not be a powerful determinant of parent involvement. Our findings support the research being done that is looking at service delivery models that bring in parents as active partners in the early intervention regardless of setting (Popp and Wilcox 2012; Salisbury and Cushing, 2013). Additional ways of delivering services, such as videoconferencing should also be examined (Kelso et al. 2009). It will be important to conduct additional research on how to maximize the advantages of all settings in which early intervention is delivered.

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