Promoting Positive Behavioral Outcomes for Infants and Toddlers: An Evidence-Based Guide to Early Intervention [1st ed.] 9783030516130, 9783030516147

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Heather Agazzi Emily J. Shaffer-Hudkins Kathleen Hague Armstrong Holland Hayford

Promoting Positive Behavioral Outcomes for Infants and Toddlers An Evidence-Based Guide to Early Intervention

Promoting Positive Behavioral Outcomes for Infants and Toddlers

Heather Agazzi • Emily J. Shaffer-Hudkins Kathleen Hague Armstrong • Holland Hayford

Promoting Positive Behavioral Outcomes for Infants and Toddlers An Evidence-Based Guide to Early Intervention

Heather Agazzi Department of Pediatrics University of South Florida Tampa, FL, USA

Kathleen Hague Armstrong Department of Pediatrics University of South Florida Tampa, FL, USA

Emily J. Shaffer-Hudkins Department of Pediatrics University of South Florida Tampa, FL, USA

Holland Hayford University of South Florida Tampa, FL, USA

ISBN 978-3-030-51613-0    ISBN 978-3-030-51614-7 (eBook) https://doi.org/10.1007/978-3-030-51614-7 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To my husband, Siviero, and our children, Marina, Analynn, and Enzo. To my mother, Janice G. Curtiss. In loving memory of Janna Howard. –Heather Agazzi To my husband Michael and our boys Logan, Andrew, and Maxwell. –Emily Shaffer-Hudkins To the parents and teachers who have taught us so much. –Kathleen Armstrong To Dr. Agazzi, Dr. Shaffer-Hudkins, and Dr. Armstrong, thank you for allowing me to collaborate on this book. I have appreciated the opportunity to help support other providers in serving families. –Holland Hayford

Foreword

Even in the best of situations, raising children can be challenging, and for some families, the environmental and/or other stressors that they face make parenting even more demanding. Promoting Positive Behavioral Outcomes for Infants and Toddlers is designed as a toolkit for early intervention providers, to enable caregivers to guide their child towards a more successful future. Based upon evidence-­ based treatments for young children and our clinical experiences working with families, we offer interventionists a positive and systematic approach that actively involves and engages caregivers and helps them to be responsive and supportive to their client’s individual and changing needs. From birth through age 5, caregivers play the key role in providing the relationships and experiences needed for healthy and happy development. As children mature, many caregivers question their responses to their child’s growing independence and need for guidance and may be at a loss when their child engages in unsafe, inconsiderate, or aggressive behavior. Teaching children to manage their feelings, be kind to others, and to make choices for safe and appropriate behavior is critical to successful parenting. Helping caregivers through these hurdles is an important role for the early interventionist, who, through parent training, can make a significant difference in the everyday lives of children. Children with developmental delays/disabilities may present greater challenge to effective parenting, as caregivers may not be sure what their child understands or can be expected to do. Children who have experienced abuse and neglect, and their caregivers, more often engage in negative interactions with each other and are clearly families in need of support and guidance from the early interventionist. Foster caregivers may feel unprepared to meet the needs of children placed in their care, who may present with emotional and behavioral issues. In these cases, the early interventionist’s role becomes one of teacher, mentor, and coach. Parent training, guided by the latest knowledge of teaching and intervention methods and combined with the science of behavior, gives caregivers the means they need to provide their children with a safe and enriching environment. Each of the nine chapters address a different topic essential to successful early childhood development and early intervention. Chapters offer advice on engaging vii

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caregivers, working with diverse families, learning to problem-solve, developing individual treatment plans, incorporating evidence-based interventions into real world settings, tracking progress, and identifying/solving challenges and obstacles presenting during treatment. The content is designed to be user-friendly for a variety of early intervention providers, including pediatricians, psychiatrists, psychologists, social workers, therapists, teachers, and nurses, who may work in homes, clinics, community settings, or schools. We expect that this text will be effective in classrooms preparing providers to work with families. Lastly, we offer this book to early intervention providers who are champions for young children during those critical years that are so important to their future. Heather Agazzi Department of Pediatrics University of South Florida Tampa, FL, USA

Acknowledgment

This book is the embodiment of a lifelong dedication of an incredible clinician and mentor, Dr. Kathleen Armstrong, to supporting the unique needs of young children and their families. In turn, this book would not have been possible without her tireless efforts to understand the needs of typically developing children, as well as children with special needs. I, Heather Agazzi, would like to thank Dr. Armstrong, the founder of the HOT DOCS program, for developing a powerful intervention that serves diverse families. She taught me so much about working with families and provided me the opportunity to co-develop HOT DOCS and adapt it to Spanish. Dr. Armstrong’s mentorship and teaching legacy has developed many psychologists who are prepared to carry on her work. I would like to thank Dr. Emily Shaffer-Hudkins for lending her expertise and time to co-author this book. As the director of our Bay Area Early Steps program, she brings exceptional knowledge and experience for supporting diverse families in their natural environments. To Holland Hayford, thank you for sharing your vast knowledge and experience in applied behavior analysis and for stepping up to the plate when deadlines were short. Lastly, this book is dedicated the loving families who have put their trust in our hands as we developed a curriculum to best meet their needs. Please know we are forever grateful for allowing us into your lives and informing this text.

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Contents

1 Social-Emotional Development in Young Children and the Purpose of Early Intervention��������������������������������������������������������������     1 Early Childhood Development����������������������������������������������������������������     1 Motor Development ��������������������������������������������������������������������������������     2 Cognitive Development���������������������������������������������������������������������������     3 Communication and Language Development������������������������������������������     4 Social-Emotional Development ��������������������������������������������������������������     5 Context for Development: Environment and the Caregiver-­Child Dyad������������������������������������������������������������������������������     6 Impact of Early Childhood Social-Emotional Development on Long-Term Outcomes������������������������������������������������������������������������������     7 Need for Early Intervention ��������������������������������������������������������������������     8 Connecting Children with Early Intervention Programs ������������������������     9 Federal Early Intervention Program: Individuals with Disabilities Act, Part C������������������������������������������������������������������������������������������������    11 Basic Tenants of IDEA, Part C����������������������������������������������������������������    12 Eligibility for Part C Programs Across the USA ������������������������������������    12 Individualized Family Support Plans������������������������������������������������������    13 Transition from Part C to Part B��������������������������������������������������������������    14 Impact of Part C and Other Early Intervention Programs������������������������    15 Chapter Summary������������������������������������������������������������������������������������    16 References������������������������������������������������������������������������������������������������    16 2 Best Practices in Assessment and Intervention with Infants and Toddlers ��������������������������������������������������������������������������������������������   21 Early Childhood Assessment ������������������������������������������������������������������    21 Common Assessment Tools ��������������������������������������������������������������������    22 Requirements for Determination of Eligibility to Part C Programs��������    25 Best Practices for Early Intervention ������������������������������������������������������    26 Chapter Summary������������������������������������������������������������������������������������    32 References������������������������������������������������������������������������������������������������    32 xi

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3 A Routines-Based Approach to Early Intervention����������������������������    35 A Routines-Based Approach to Early Intervention���������������������������������    35 What Are Routines and Rituals?��������������������������������������������������������������    35 Importance of Routines for Development������������������������������������������������    36 How Does a Routines-Based Approach Fit with Early Intervention? ����    37 Evaluating Routines and Rituals��������������������������������������������������������������    38 Establishing Healthy Routines����������������������������������������������������������������    39 Helping Children Follow a Routine ��������������������������������������������������������    41 Using Routines As a Basis for Early Intervention Strategies������������������    42 Chapter Summary������������������������������������������������������������������������������������    42 Supplemental Materials ��������������������������������������������������������������������������    43 Strategies for Healthy Eating Behaviors����������������������������������������������    43 Creating a Mealtime Routine ��������������������������������������������������������������    43 Do’s and Don’t’s for Parents����������������������������������������������������������������    44 Specific Mealtime Interventions����������������������������������������������������������    45 Tips for Weight Gain����������������������������������������������������������������������������    46 Treatment Strategies for Sleep Problems��������������������������������������������    46 Creating a Bedtime Routine����������������������������������������������������������������    47 Do’s and Don’t’s for Parents����������������������������������������������������������������    47 Specific Sleep Interventions����������������������������������������������������������������    48 Separation Games that Help Support Sleep ����������������������������������������    50 References������������������������������������������������������������������������������������������������    51 4 Problem-Solving Behavior: The ABC’s of Behavior��������������������������    53 Overview of Behavior������������������������������������������������������������������������������    53 Operant Conditioning������������������������������������������������������������������������������    54 Function of Behavior ������������������������������������������������������������������������������    56 Problem-Solving Behavior: Helping Our Toddlers, Developing Our Children’s Skills ��������������������������������������������������������������������������������������    57 Case Examples Problem-Solving the Function of Behavior��������������������    58 Summary��������������������������������������������������������������������������������������������������    61 Supplemental Materials ��������������������������������������������������������������������������    62 Problem-Solving Chart: Practice Identifying the Function ����������������    62 References������������������������������������������������������������������������������������������������    62 5 Strategies to Prevent Problem Behavior������������������������������������������������   65 Understanding the Child’s Behavior��������������������������������������������������������    66 Prevention Strategies��������������������������������������������������������������������������������    67 Preventions Reduce Triggers ������������������������������������������������������������������    67 Preventions Clearly Prompt Desired Behavior����������������������������������������    69 Preventions Improve Transitions Between Activities������������������������������    70 Preventions Promote Independence and Practice Positive Exposures ����    73 Chapter Summary������������������������������������������������������������������������������������    74 References������������������������������������������������������������������������������������������������    75

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6 Techniques to Teach Children New Skills����������������������������������������������   79 Development of Children with Developmental Disabilities��������������������    79 Challenging Behavior Among Young Children���������������������������������������    80 Teaching New Skills����������������������������������������������������������������������������    81 Identifying New Skills ����������������������������������������������������������������������������    83 Teaching New Skills��������������������������������������������������������������������������������    83 Functional Communication Skills�����������������������������������������������������������    84 Teaching Gestures��������������������������������������������������������������������������������    84 Teaching American Sign Language ����������������������������������������������������    86 Teaching Words and Phrases����������������������������������������������������������������    87 Social-Emotional Skills ��������������������������������������������������������������������������    90 Preventions Pave the Way for Teaching Children New Skills ������������    93 Chapter Summary������������������������������������������������������������������������������������    94 Supplemental Materials ��������������������������������������������������������������������������    95 Problem-Solving Chart: Practice Planning New Responses����������������    95 References������������������������������������������������������������������������������������������������    95 7 Positive Discipline Skills��������������������������������������������������������������������������   99 Basics of Behavior Review����������������������������������������������������������������������    99 Planning New Responses ������������������������������������������������������������������������   100 Increasing Appropriate Child Behaviors: Positive Reinforcement����������   101 Social Reinforcers��������������������������������������������������������������������������������   102 Tangible Reinforcers����������������������������������������������������������������������������   103 Activity Reinforcer������������������������������������������������������������������������������   104 Token Reinforcers��������������������������������������������������������������������������������   106 Selecting Reinforcers ��������������������������������������������������������������������������   108 Decreasing Child Behavior Problems������������������������������������������������������   110 Extinction��������������������������������������������������������������������������������������������   110 Planned Ignoring����������������������������������������������������������������������������������   111 Validate and Redirect ��������������������������������������������������������������������������   112 Follow-Through ����������������������������������������������������������������������������������   112 Time Out from Positive Reinforcement ����������������������������������������������   113 Chapter Summary������������������������������������������������������������������������������������   116 Supplemental Materials ��������������������������������������������������������������������������   118 Teaching Compliance with Follow-Through ��������������������������������������   118 Time Out for Noncompliance��������������������������������������������������������������   119 References������������������������������������������������������������������������������������������������   120 8 Family-Centered Practices in Early Intervention��������������������������������  123 Family-Centered Practices ����������������������������������������������������������������������   123 Respect and Dignity����������������������������������������������������������������������������   124 Communication������������������������������������������������������������������������������������   125 Strengths-Based Practice ��������������������������������������������������������������������   126 Teamwork and Collaborative Practice ������������������������������������������������   126 Chapter Summary������������������������������������������������������������������������������������   129 References������������������������������������������������������������������������������������������������   130

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9 Helping Caregivers Manage Stress������������������������������������������������������   131 Caregiver Stress ��������������������������������������������������������������������������������������   131 Case Example of Caregiver Stress ����������������������������������������������������������   132 Problem-Solving Caregiver Stress ����������������������������������������������������������   133 Warning Signs of Stress ��������������������������������������������������������������������������   135 Preventions for Stress Management��������������������������������������������������������   136 Developing Healthy Routines��������������������������������������������������������������   136 Simplify Life and Manage Finances����������������������������������������������������   140 New Skills������������������������������������������������������������������������������������������������   140 Communication Skills��������������������������������������������������������������������������   141 New Responses����������������������������������������������������������������������������������������   142 Chapter Summary������������������������������������������������������������������������������������   143 References������������������������������������������������������������������������������������������������   144 Glossary of Terms������������������������������������������������������������������������������������������   147 Index����������������������������������������������������������������������������������������������������������������   151

About the Authors

Heather  Agazzi  Ph.D., M.S., ABPP, NCSP, is an Associate Professor at the University of South Florida in the Department of Pediatrics, Section Chief of Child Development, and an Infant Mental Health Mentor-Research/Faculty. Dr. Agazzi engages in extensive teaching of psychology for medical students, psychiatry fellows, pediatrics residents, and psychology interns in her role as the internship director of the USF Health Doctoral Internship in Professional Psychology. She is the Director of the HOT DOCS parent training program and a Parent-Child Interaction Therapy Level 1 Trainer. Dr. Agazzi’s clinical and research interests include behavioral parent training for young children with disruptive behavior disorders, autism spectrum disorders, and trauma exposures. Emily-Shaffer Hudkins  Ph.D., NCSP, is an Associate Professor at the University of South Florida, Department of Pediatrics. She is a licensed psychologist and the Director for the Bay Area Early Steps program, which provides developmental evaluation and early intervention and therapy to children from birth to 3 years of age in two local counties. Dr. Shaffer-Hudkins’ research and clinical interests relate to enhancing development and quality of life for young children with complex developmental delays or healthcare needs and their families. Holland Hayford  M.A., is a doctoral student at the University of South Florida’s School Psychology Program. She is a certified trainer in the HOT DOCS behavioral parent training program and has a graduate certificate in Positive Behavior Support. Holland’s clinical and research interests include behavioral parent training for children with disruptive behavior disorders as well as behavioral and mental health supports for children on the autism spectrum.

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About the Authors

Kathleen  Armstrong  Ph.D., NCSP, is Professor Emerita of Pediatrics at the University of South Florida, where she was recognized for her teaching of graduate and medical students by the Kosove Graduate Teaching and Service Award. Currently, Dr. Armstrong teaches psychology courses at Western Carolina University and helps with WCU’s development of a PSY D program. Dr. Armstrong is the coauthor of peer-reviewed publications, books, and training curricula focused on early childhood mental health and parent training. She is a licensed psychologist and Level 1 Trainer for Parent Child Interaction Therapy.

Chapter 1

Social-Emotional Development in Young Children and the Purpose of Early Intervention

Early Childhood Development In order to effectively facilitate early intervention strategies with families, early intervention providers must first understand the key aspects of child development as well as milestones across the developmental domains. In the first years of life, infants and toddlers acquire a vast array of developmental skills. Brain development at this stage is the fastest rate of any other time point in the lifespan, with brain volume increasing exponentially until around age 6 (Stiles & Jernigan, 2010). In addition, children experience significant growth in areas known as developmental domains. The Centers for Disease Control and Prevention or CDC (2019) identifies these developmental domains as (1) motor/movement, (2) cognitive, (3) language and communication, and (4) social-emotional. Motor development is defined as changes in the way we move our bodies over time (Lipkin, 2009). There are two categories of motor development; gross motor is the use of “large full-body movements,” while fine motor is the use of refined movements including “the pincer grasp of late infancy or throwing during the toddler and preschool years” (Lipkin, 2009). Cognitive development is defined as changes in the way we think over time (Bjorklund & Causey, 2017). Language/communication development is defined as the development of children’s speech patterns and understanding of verbal language. Language is divided into two components: (1) expressive, or forming spoken language, and (2) receptive, or understanding what is being said (Landy, 2009). Finally, social-emotional development is defined as the child’s ability to regulate emotions, express empathy, and interact with others (Landy, 2009). See Table 1.1 for an abbreviated version of the developmental milestones in early childhood as outlined by the CDC.

© Springer Nature Switzerland AG 2020 H. Agazzi et al., Promoting Positive Behavioral Outcomes for Infants and Toddlers, https://doi.org/10.1007/978-3-030-51614-7_1

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1  Social-Emotional Development in Young Children and the Purpose of Early…

Table 1.1  Brief review of CDC developmental milestones Child – 2 months Child − 4 months Child − 6 months Child − 1 year Child − 2 years Child − 3 years

Child − 4 years

Child − 5 years

Motor • Holds head up • Has smooth movements • Keeps head steady on own • Rolls over

Cognitive • Notices faces • Visually tracks things • Expresses emotions • Pays attention to faces • Shows • Sits on own curiosity • Stands with • Moves things support between hands • Rocks/crawls • Finds hidden • Walks with objects support • Uses objects • Takes steps or functionally stands • Sorts shapes • Kicks/throws • Finishes book objects phrases • Draws lines/ • Labels items circles • Plays • Runs easily make-believe • Pedals a tricycle • Completes • Walks up and small puzzles down stairs • Turns pages • Names some • Catches balls colors/ • Pours, cuts, numbers mashes food • Recalls stories • Copies letters • Uses a fork and • Counts 10 or more objects spoon • Prints letters • Uses the toilet or numbers independently

Communication • Coos • Turns head toward sounds • Babbles • Differentiates cries for needs • Makes letter sounds • Attends to name • Responds to simple requests

Social-Emotional • Smiles • Looks at caregiver • Imitates facial expressions

• Recognizes familiar people • Enjoys seeing self in mirror • Is nervous with strangers • Has preference for people • Displays more independence • Engages in parallel play • Shows affection • Takes turns • Displays range of emotions

• Knows names • Uses short sentences • Repeats words • Follows simple instructions • Names objects • Says first name/ age • Prefers playing • Knows some with children basic grammar • Sings songs from • Discusses interests memory • Speaks clearly • Says name and address

• Differentiates make-believe from reality

Motor Development Each developmental domain assumes a substantial role in early childhood development, and a child’s progress in each domain can be assessed through analysis of markers known as developmental milestones. Regarding developmental milestones for motor development, babies at 2 months of age should be able to hold their head up, although they may need some support to keep their head steady (CDC, 2019). They may try to push their bodies upward if they are lying on their stomachs. Babies at 2 months of age should display a higher competency in gross motor development (broad movements of the arms and legs). By 4 months of age, babies should be able to push themselves upward if lying down and hold their head steady without support. They should be able to bring their hands to their mouth, as well.

Cognitive Development

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Babies at 6 months of age will begin to show more independence with motor skills, particularly gross motor skills. They should be able to sit independently, although this skill will continue to be refined as the child approaches 1 year of age. Six-month-old babies should be able to roll back and forth and support their weight using their legs when standing (CDC, 2019). As the child reaches 1 year of age, they may begin attempting to stand or walk with or without support. Children at 2 years of age are able to walk on their own and may begin running. They may attempt to kick or throw toys, and they should be able to copy simple shapes such as a circle or line. It is around this age that children will most likely begin climbing on objects, as well. Climbing and running will become easier for the child as they reach age 3. More complicated motor skills such as walking up or down stairs should also see some improvement at age 3. As children continue to grow, their motor skills should become more refined. Four-year-old children should begin using tools to cut and pour, and they might explore functional uses of objects. Five-year-old children may begin using forks and spoons as their fine motor skills improve. It is around 4 or 5 years of age that children are expected to use the toilet independently.

Cognitive Development In the beginning stages of cognitive development, 2 month olds begin to visually track objects and pay closer attention to faces of caregivers. As babies reach 4 months of age, they should respond to others’ affection, express emotion verbally or nonverbally, and display improved hand-eye coordination (CDC, 2019). Six-month-­ old babies should be able to express curiosity regarding their surrounding environment, and 1-year-old children should be able to find objects hidden in simple ways, attend to an object when labeled, imitate gestures, and use objects for their intended functional purpose. Children at 2 years of age should be able to locate hidden objects, begin sorting shapes and colors, finish familiar phrases or songs, and label familiar items. Two-year-old children may also indicate a preference for one hand. It is also at this age that children should be able to follow simple directions. As they near age 3, children should be able to engage in pretend play, complete small puzzles, turn pages in a book, build towers of at least six blocks, and use objects with simple moving parts such as a door handle or toys with buttons. Children at 4 years of age should be able to identify at least some colors and numbers, and they should have a basic understanding of the concepts of counting and time. They may be able to use scissors with or without support, and they should display an improvement in their reading comprehension skills. Around age 5, children should have a basic understanding of common objects/ideas such as food and money. Their written skills should also see some improvement as they begin to print letters and draw more complex shapes and pictures. In addition, 5-year-old children should be able to count at least ten objects.

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Communication and Language Development Communication and language development can be seen in babies at 2 months, who should be able to make a variety of cooing or gurgling sounds (CDC, 2019). Two-­ month-­old babies should also attend to sounds in their environment by looking toward the sound or turning their head toward the sound. It is developmentally appropriate for 4-month-old babies to babble with expression, whether the babbling makes sense or not. Babies at 4 months of age should begin imitating sounds and words that they hear other people verbalize. Much of this imitation will result in very broad word approximations or babbling (e.g., gaga, dada, baba) that will become more refined as the child continues to grow. It is also around this time that babies should begin to differentiate their cries to reflect their different needs. Six-­ month-­old babies should attempt to respond to other people’s verbalizations by making sounds. These sounds may include certain vowel or consonant sounds as their ability to approximate words improves. In addition, children at this age should be able to respond or attend to their name being said. One-year-old babies should be able to say simple words as they continue to develop their vocabulary (e.g., bye, mama). They should express differences in emotion or tone when verbalizing sounds or words. They may also use a variety of simple gestures such as shaking their head or waving at others. Children at this age should be able to respond to simple requests from caregivers. At 2 years old, children should be able to point to objects or pictures when these items are labeled, and they should understand the names of familiar people and objects. Two-year-old children should be able to form short, simple sentences or phrases (e.g., I want juice). Their vocabulary should be around 200–300 words (Owens, 2016). They should also be able to follow simple instructions from caregivers. By the time children reach 3 years of age, they should have a basic understanding of vocabulary and be able to speak with others using simple sentences (CDC, 2019). Three-year-old children should use a variety of around 1000 words in conversations with other people, and their speech should be relatively easy to understand. In addition, they should be able to identify their first name, age, gender, and any friends that they may have. Four-year-old children should understand some “basic rules” of speech and grammar. They should be able to sing popular songs or recite rhymes that they hear, and they may engage in storytelling. At 5 years of age, children’s speech should be clear and understandable to others, including strangers. They should be able to use a variety of tenses in their speech, as well; their vocabulary should exceed 2000 words (Owens, 2016). Children at this age should be able to say their name and address when asked. Additional details regarding the development of communication and language skills can be found in Chap. 6.

Social-Emotional Development

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Social-Emotional Development Social-emotional development also begins at infancy and continues to be enhanced throughout childhood. Babies at 2 months of age should begin attending to other people, particularly their caregiver(s). Some self-soothing behaviors should begin at this age as well, such as sucking on the hands (CDC, 2019). At 4 months of age, babies should begin smiling at and playing with their caregiver(s). They should imitate other people’s movements and facial expressions. Six-month-old babies should be able to recognize familiar faces of adults and children and be able to differentiate familiar people from strangers. Although babies at this age enjoy playing with other people, they prefer spending time with their caregivers rather than other adults or children. Six-month-old babies should begin responding to the emotions expressed by other people, as well. They may also enjoy viewing themselves in a mirror. At 1 year of age, children may appear shy around strangers, and they may display an increased closeness to their caregiver(s). One-year-old babies may also become anxious in unfamiliar or stressful situations. They should display a preference for certain familiar objects and people. Children at this age will begin to engage more actively with their caregiver(s) by handing their caregiver(s) objects that they wish to use or engaging in certain verbal or physical behaviors in order to gain caregiver attention. One-year-old babies should be able to play some simple games with their caregiver(s), as well. At 2 years of age, children should continue to imitate people around them, particularly adults. Two-year-old children should begin to engage with other children more frequently, although much of their play will be parallel rather than collaborative (CDC, 2019). Children at this age should desire more independence in everyday activities, and they may display defiance in certain situations. At 3 years of age, children should display unprompted affection or concern for other people, especially friends. They should begin engaging in turn-taking with peers. Separation from caregivers should become easier at this age as children begin forming more meaningful relationships with same-age peers. Three-year-old children should demonstrate a basic understanding of their everyday routines, and they may express distress or frustration at having their routines disrupted. At 4 years old, children should attempt more new or unfamiliar things. They should be able to discuss their interests with others, and they should prefer playing with other children rather than by themselves. Four-year-old children may engage in a variety of pretend-play scenarios, but they may not be able to fully differentiate pretend-play from reality. By contrast, 5-year-old children should be able to differentiate imaginary situations from reality. Children at 5 years of age should identify with same-age peers and emulate the behavior of their peers. They may display a variety of interests or hobbies, and they should demonstrate an increased sense of independence. Developmentally appropriate 5-year-old children should also be more compliant with demands presented to them by adults. Additional information on social-­ emotional development in children can be found in Chap. 6.

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Based on the aforementioned developmental milestones, it is clear that early intervention plays a key role in regulating and enhancing childhood development. Specifically, early intervention can help promote appropriate social-emotional development in children. Children’s interactions with their caregivers, other adults, and peers can all have an impact on how they learn socially appropriate behaviors. Early interventionists must consider the context in which a child is developing, as well as the quality of the caregiver-child relationship.

 ontext for Development: Environment C and the Caregiver-­Child Dyad Development of young children occurs within the context of the people, interactions, and larger social-cultural factors surrounding them. The ecological framework of development outlines the many different, yet overlapping, contexts for development. Posed by Bronfenbrenner in 1994, this theory posits that child development is dynamically influenced by the people and environmental context around them (e.g., mesosystem), both at a close and distal level. This includes variables such as the interactions and opportunities they are exposed to at home and in the community. Since the original development of the ecological framework for development, researchers have underscored the importance of culture at all levels of the framework, not just the mesosystem (Bronfenbrenner, 1994). Culture, operationalized as “an ever-changing system composed of the daily practices of social communities (e.g., families, schools, neighborhoods, etc.) and the interpretation of those practices through language and communication,” is an intricate part of the everyday systems surrounding a child (Vélez-Agosto, Soto-Crespo, Vizcarrondo-­ Oppenheimer, Vega-Molina, & García Coll, 2017). Examples include beliefs in parental involvement in children’s education, role of grandparents in childrearing, and ways in which a family “partakes” in the community around them. Along with the child’s environment, early interventionists should consider the nature of the caregiver-child dyadic relationship between the caregiver and child. A positive caregiver-child dyad consists of parental warmth, effective behavior management, and support of the child’s independence (Prinzie, Stams, Deković, Reijntjes, & Belsky, 2009). Parental warmth is defined as the caregiver’s ability to demonstrate support for the child’s needs and desires in an effort to build the child’s sense of independence and self-worth (Baumrind, 1991). Effective behavior management entails the caregiver maintaining behavioral expectations that are developmentally appropriate for the child, in addition to providing supervision and corrective yet didactic feedback for the child’s noncompliance (Baumrind, 1991). Finally, support of the child’s independence, or autonomy support, is defined as the caregiver allowing the child to explore their environment and interests in a safe and productive manner (Prinzie et al., 2009). Together these factors help to create a positive caregiver-child dyadic relationship that fosters later success in the child’s

Impact of Early Childhood Social-Emotional Development on Long-Term Outcomes

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social-emotional growth, as well as the child’s growth across other developmental domains. Benefits of a positive caregiver-child dyadic relationship include an increase in children’s compliance with caregivers’ demands, an increase in the warmth of the parent-child relationship, increases in children’s social skills and empathy, an increase in children’s creativity, and a decrease in children’s perceived stress and emotional instability (Kochanska et al., 2010; Wilson & Durbin, 2012). Negative outcomes of a poor caregiver-child dyadic relationship include an increase in children’s behavior problems, decreased compliance with caregivers’ demands, the development of an antisocial affect in children, a potential increase in children’s aggression, an increase in children’s emotional instability, and an increase in children’s perceived stress (Kochanska et al., 2010). See Table 1.2 for an abridged summary of the effects of positive and negative caregiver-child dyadic relationships on children’s social-emotional development.

I mpact of Early Childhood Social-Emotional Development on Long-Term Outcomes Research indicates that 10–20% of young children experience problematic or “challenging” behaviors (Campbell, 1995). If these behaviors are not addressed during early childhood, children may experience a plethora of negative effects. Young children who demonstrate deficits in social-emotional skills are at an increased risk for mental health concerns, higher rates of juvenile and adult delinquency, higher school dropout rates, and lower levels of academic achievement (Brown, Copeland, Sucharew, & Kahn, 2012; Jones, Greenberg, & Crowley, 2015). These same negative outcomes can occur in children who engage in challenging behaviors. In addition, children with a history of challenging behaviors or with deficits in their social-emotional skills may experience difficulty navigating relationships with adults such as caregivers and teachers. As a result, negative interactions occur, and few positive relationships are formed. These potential aversive outcomes emphasize the importance of early intervention for children. Caregivers who have children with challenging behaviors are also at an increased risk for experiencing negative outcomes. Many caregivers who have children Table 1.2  Effects of positive and negative caregiver-child dyadic relationships Positive Parent-Child Dyadic Relationships • Increase child’s compliance • Increase warmth of relationships • Increase child’s empathy • Increase child’s social skills • Increase child’s imagination • Reduce child’s perceived stress • Increase child’s emotional stability

Negative Parent-Child Dyadic Relationships • Increase child’s problem behaviors • Development of antisocial affect • Potentially increase child aggression • Increase child’s perceived stress • Reduce child’s emotional stability

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d­ isplaying problematic behaviors have higher levels of parenting stress or stress related to caring for and raising their children (Plaza, Sevilla, Rico, & Murillo, 2017). Children’s challenging behaviors can also have a negative impact on caregivers’ mental health and relationships with others in the family and community (Webster-­Stratton & Spitzer, 1996). Early prevention and intervention have proven highly effective at reducing problematic or challenging behaviors and at reducing caregivers’ parenting stress (Dunlap et  al., 2006; Plaza et  al., 2017). Thus, early intervention positively affects not only the child but also the caregiver and family.

Need for Early Intervention Decades of research demonstrate the critical need for early intervention to address developmental delays and risks for delays. First, early intervention provides support to young children in order to address developmental and behavioral concerns before they become more severe (Karoly, Kilburn, & Cannon, 2006). Because of this, the use of early intervention decreases the intensity of services that the child may need over the longer term. Second, early intervention teaches children critical life skills that will help them be successful in school (Karoly et al., 2006). Many early intervention programs and strategies focus on school-readiness skills such as following directions, reading and writing, understanding mathematical processes, displaying appropriate social skills, and effectively regulating emotions. Third, early intervention leads to a higher probability of positive life outcomes as the child ages, such as graduating high school, attending college, and having a form of stable employment (Karoly et al., 2006). Finally, early intervention affects not only the children in treatment but also the caregivers and families of said children. Caregivers who engage in early intervention programs often report a reduction in their parenting stress as well as higher-quality, more positive relationships with their child (Karoly et al., 2006). Specifically, early intervention as it pertains to social-emotional development can have a significant impact on a child’s later success in both academic and career settings. Early intervention strategies can be used with children to enhance their social-emotional development and help prevent future negative outcomes in school, work, and relationships. Many programs emphasizing social-emotional intervention seek to improve relationship between the child and their caregiver(s), as well as relationships between the child and their peers (Case-Smith, 2013). In addition, early intervention strategies for social-emotional development can include modeling and role-playing-appropriate social-emotional skills with children. Children who receive early intervention services focusing on social-emotional development display more age-appropriate social skills, fewer aggressive behaviors, a better understanding of empathy, increased success in future academic and vocational settings, and higher-quality relationships with other people (Case-Smith, 2013). Due to this existing research outlining the benefits of early intervention, interventionists should integrate this type of support into patient care as soon as is feasible.

Connecting Children with Early Intervention Programs

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Early intervention is unique to patient care in many ways. It is often the first “outside” help that families of young children receive. Early intervention also occurs in the natural environment, meaning that services are delivered right in homes and daycares. Additionally, as outlined in the Individuals with Disabilities Education Act (IDEA), at-risk children ages birth to 3 have access to early intervention services referred to as the Part C program (IDEA, 2004). There is no income requirement for participating in the Part C program, and thus, early interventionists serve families from all socioeconomic statuses. The Part C program can provide various services to at-risk children, including supports for motor, cognitive, language/communication, and social-emotional development. Finally, early intervention is heavily focused on a coaching model and routines-based approach. Research has demonstrated that early intervention has the greatest impact for children birth–3 when caregivers are actively engaged in the treatment and implementing processes (Mahoney & Perales, 2005). Essentially, early intervention providers have the challenging task of teaching families about strategies that will fit into their routine. These specific concepts will be discussed further in Chapters 2 and 3.

Connecting Children with Early Intervention Programs In the USA and many other industrialized countries, there are numerous programs and resources available to support the development of infants and young children. Early intervention programs typically focus on one or more of the following: developmental assessment or monitoring, support and skill building for parents or future parents, and direct therapy or intervention to promote a child’s development. While specific types of early intervention programs vary across states and local communities, certain resources are nationally funded and regulated and implemented in all parts of the country. The largest and likely most well-known national early intervention program is IDEA Part C, which is discussed in further detail below. Other national programs that are focused on developmental monitoring and/or supports during the early childhood years include Healthy Families America, The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, and Healthy Start. Both Healthy Families and MIECHV utilize a preventive approach in which in-­ home visits are provided to caregivers in order to give them individualized supports and skills needed to promote healthy parenting and child well-being and minimize risk for abuse and/or neglect. No early intervention service is intended to be a stand-­ alone program; rather, interagency partnerships across healthcare, education, and social supports create the wraparound care that is most beneficial for young children and their families (National Early Childhood Technical Assistance Center, 2011). Even though there are often several local early childhood resources available in most communities across the country, programs may be underutilized in general or often underutilized or not accessed by many families that are the most in need or at-risk. Services and resources are also scarcer in rural areas. For instance, population statistics show that although approximately 5–8% of young children birth to 3

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exhibit a significant developmental delay resulting in the need for direct therapy or early intervention, the national Part C program serves approximately 3.25% of the population in this age group (Lazara, 2018). Connecting families and young children that need either prevention or early intervention services poses several considerations and challenges. All states in the USA designate a lead agency to administer Child Find, a legal mandate that requires public school districts to find children with disabilities and developmental delays that may need special education services. While Child Find covers any child aged birth to 21 years of age, many children with developmental delays are not identified prior to entering Kindergarten (Boyle et  al., 2011). Numerous national programs have been developed to provide parents, childcare providers, and family members information on developmental milestones, warning signs for various developmental conditions, and steps to take if concerned about a child’s development. Such programs include those by the CDC (Learn the Signs, Act Early; WIC Developmental Milestone Checklist Program) and the US Department of Health and Human Services (USDHHS; Birth to 5: Watch Me Thrive!). With so many resources for public education, community screening, why are so many young children and families still not accessing early interventions services? Although ongoing Child Find efforts are made by early intervention agencies and programs, historically outreach is limited to and difficult in at-risk, high-needs populations including families living in poverty or very low socioeconomic environments, families of minority racial and ethnic groups, and children involved with the child welfare system in dependency care. While young children raised in such contexts are often at great risk for developmental delays, research shows that these subpopulations are among the lowest to utilize developmental screening and early intervention supports (Corr, Santos, & Fowler, 2016). Pediatricians are the primary point of contact for caregivers that have a concern regarding their infant or toddler’s development (Raspa et al., 2015). The use of standardized developmental screening measures leads to much higher rates of detection of delays in infants and toddlers and subsequently higher rates of necessary early intervention. Without routine screening at pediatrician well visits, over two-thirds of children aging birth to 5 may still be missed for developmental concerns requiring intervention (Guevara et al., 2013). The rate at which pediatricians routinely screen for developmental delays has increased more than twofold over the past 15 years. In 2002, less than 25% of pediatrician practices utilized a formal developmental screening tool at infant and toddler well visits (Hirai, Kogan, Kandasamy, Reuland, & Bethell, 2018). As of 2012, more than half of pediatric practices utilize routine screening. Wide-ranging barriers limit the degree to which rates of screening in primary pediatric care remain relatively low, with the most prevalent concerns including time constraints, lack of familiarity with developmental screening tools, and limited knowledge for where to refer parents in the result of a positive screening concern. However, when pediatric clinics implement standardized screening via parent-completed questionnaires such as the Ages and Stages Questionnaire (Bricker et  al., 1999) or Parents’ Evaluation of Developmental Status (Glascoe,

Federal Early Intervention Program: Individuals with Disabilities Act, Part C

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1998), physicians are able to identify developmental concerns more accurately and earlier in development (King-Dowling, Rodriguez, Missiuna, & Cairney, 2016). In addition, pediatricians utilizing a standardized screening questionnaire report that their well visits are more efficient and that appropriate follow-up is easier (King-­ Dowling et al., 2016). Access to early intervention programs may also be limited due to the fact that, unlike K-12 education, services are voluntary and caregivers can choose at any point whether to refer their young child for assessment and/or continue in the intervention process. This impacts the degree to which at-risk caregivers (e.g., those with lower education, living in poverty, trauma backgrounds) get connected with such resources for their children. Social disparities have been identified in regard to likelihood of receiving early intervention services, including reduced likelihood for black children to receive physical therapy services and lower intensity of physical and occupational therapy for children with public insurance (Khetani, Richardson, & McManus, 2017). These findings highlight the need to continue working to increase awareness of developmental disability and available services in all communities.

 ederal Early Intervention Program: Individuals F with Disabilities Act, Part C In the USA, Public Law 99-457 was passed to amend the Individuals with Disabilities Education Act (IDEA) in 1986 to extend the rights and protections of school-aged children with disabilities to infants and toddlers who meet eligibility criteria (e.g., demonstrated developmental delays and/or conditions which put a child at-risk for later difficulties). This landmark legislation, IDEA Part C, helped ensure infants and toddlers with developmental delays and/or disabilities were able to access services designed to meet their needs as soon as possible. Much of the momentum for passing this legislation was not only to maximize the development of young children but also to reduce special education costs by reducing the need for so many supports and services to children with developmental delays during K-12  years (National Center for Education Evaluation, 2011). Since the initial passing of this legislative mandate, all states within the USA have implemented an early intervention program to provide developmental screening, assessment, monitoring, and services for children up to age 3. Within the USA, individual states vary considerably in the way early intervention services are provided to families according to the number of professionals working with a family, frequency of services, and the components emphasized in intervention plans. However, all federally and state funded early intervention programs are regulated by specific guidelines, such as provision of services in a child’s natural environment. These guiding principles are described in further detail in Chap. 2.

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Basic Tenants of IDEA, Part C Some of the key tenants of all IDEA Part C programs include (1) provision of services in a child’s natural environment, (2) utilization of a coaching or caregiver-­ child facilitation model (vs. direct therapy with the child only), and (3) routines-based intervention (Workgroup on Principles and Practices in Natural Environments, 2018). Provision of service in a child’s natural environment (i.e., home, childcare center, community settings they visit during the day) is one of the most unique facets of the Part C program. This tenant is based on decades of research that demonstrates children learn best within the context of their everyday environments with the caregivers with whom they are most familiar. In addition, natural environments provide opportunities for children with disabilities and developmental delays to participate in the same settings as typically developing peers. Unlike older children and adults, young children have difficulty generalizing skills across settings; thus, learning through participation in the everyday, enjoyable activities within a child’s typical setting maximizes the potential for developmental growth (Dunst, Bruder, Trivette, & Hamby, 2006). Implementation of early intervention services via a coaching model is another unique aspect of Part C programming. A primary purpose of early intervention is to empower parents and caregivers to understand ways in which they can promote their child’s development in everyday interactions as well as advocate for their child’s special needs both early in life and as they develop. When early intervention providers approach their role as one in which they move alongside the parent rather than lead the interaction, the appropriate focus is placed on the most important relationship in the therapeutic process – that of the parent and the child. Finally, the use of routines-based intervention is a key aspect of early intervention with young children and families. Although play-based activities often comprise the majority of traditional early intervention and therapy with young children, play is just one of the many daily routines in a child and family’s life. Routines-­ based intervention not only capitalizes on the hundreds of natural learning opportunities that occur throughout the day but also greatly increases the likelihood that caregivers will follow-through with strategies to enhance young children’s development (McWilliam, 2010). More specific elements to early intervention service delivery and examples of each key tenant will be discussed in Chap. 2.

Eligibility for Part C Programs Across the USA Nationally, IDEA Part C programs serve approximately 390,000 children under age 3 (Lazara, 2018). Part C mandates the eligibility of children experiencing a developmental delay as well as those with established physical or mental conditions that are likely to lead to delay. These conditions often include sensory impairments (vision, hearing), chromosomal abnormalities, neurological conditions, and

Individualized Family Support Plans

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d­ isorders resulting from prenatal substance exposure such as fetal alcohol syndrome. States use various forms of norm-based developmental assessment to determine children’s developmental profiles, and states vary widely in their criteria for a developmental delay and subsequent Part C eligibility (Early Childhood Technical Assistance Center, 2015). Most states operationalize a delay as a certain percentage or standard deviation below the mean based on a child’s specific age. The most common criteria used is a delay of 25% (2 standard deviations) below the mean in one developmental domain or 20% (1.5 standard deviations) below the mean in two or more areas of development. Although established rules and eligibility criteria are decided at the state level, an important part of the Part C evaluation process for infants and toddlers includes the informed clinical opinion of the professionals performing the assessments. Various child and family-specific factors such as social-­ emotional concerns, quality of motor movement, and/or impact of prior trauma may not be well elucidated on standardized developmental assessments and practitioners and the IFSP team must have the ability to determine eligibility and service needs in such cases (Lucas & Shaw, 2012). Per IDEA legislation, children with physical and/or mental conditions that have a high probability of resulting in developmental delay are also eligible for the Part C program. Some states provide guidance and set parameters to this form of eligibility with a list of conditions, typically developed in collaboration with a panel of pediatric physicians and other healthcare professionals (Office of Special Education Programs, 2011). Common conditions include Down syndrome, autism spectrum disorder, sensory impairments including hearing or vision loss (depending on severity), and extremely low birth weight, among many others.

Individualized Family Support Plans An Individualized Family Support (or Service) Plan (IFSP) is the guiding document for a child and family’s process through any Part C program. Individualized Family Support Plans are a family-based and team-based approach to assessment and service delivery. Different from an Individualized Education Plan (IEP) utilized in the school-aged population, IFSPs are based on the foundation that intervention for young children is maximized in the context of supporting their family and caregivers. IFSPs are developed by a team that includes the parent, family service coordinator, licensed or certified early intervention provider(s), and other relevant professionals or family members. The goal of the IFSP is to facilitate family decision-­making about the supports they would like for their child (McCormick, 2014). The IFSP documents a child and family’s steps through the Part C program, beginning with intake and family assessment, through ongoing service plan and transition. Per IDEA, the IFSP includes, but is not limited to, information on parent’s priorities and concerns, family and child history and present status, child’s strengths and interests, developmental assessment results, and goals and intervention plan and timeline. Goals on the IFSP are family-friendly and are accompanied

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by strategies that can be readily implemented by caregivers during daily routines with their child. For instance, strategies may address ways to promote a child’s language development during mealtimes together or ways to encourage independent motor movement such as climbing or cruising while outside at a playground. Consistency and quality of IFSPs vary considerably across states and within local programs (Gatmaitan & Brown, 2016). The IFSP should reflect the key principles of early intervention by focusing on family and child strengths, including goals integrated across developmental domains, and strategies embedded into family’s everyday contexts rather than isolated therapeutic activities. Qualitative reviews of IFSPs from across the USA demonstrate that many times IFSPs do not readily reflect these key principles and instead utilize more traditional therapeutic plan of care structure and terminology (Gatmaitan & Brown, 2016). Five key components to IFSP quality have been identified as (a) functional assessment, (b) functional outcome writing, (c) linking functional outcomes to service decisions, (d) integrating service delivery, and (e) monitoring progress (Ridgley, Snyder, McWilliam, & Davis, 2011). By including each of these components, the IFSP documents best practices for data-driven, family-centered service delivery. These principles for IFSP development will be examined further in Chap. 2 in relation to development and delivery of quality early intervention.

Transition from Part C to Part B At the time of a child’s third birthday, if developmental delay is still evident and families choose to continue participating in services, many children will transition to receive services in their local school district. A separate section of IDEA legislation, Part B, outlines educational guidelines for children with developmental delays and disabilities ages 3–21 (National Center for Education Evaluation, 2011). Preschool special education is considered an extension of early intervention serving children ages 3 to 5 prior to their entrance in Kindergarten and is typically delivered in a school setting (Danaher, 2011). If a child is receiving early intervention services through a Part C program, transition planning begins well before the child’s third birthday and includes parent education on Part B, developmental assessment of child’s skills, and development of an Individualized Education Plan (IEP) if a child is determined eligible for services. Although IDEA Part B legislation pertains to all children ages 3–21, for purposes of comparison between early intervention for children birth to 2 vs. 3 to Kindergarten age, the term Part B will be used to refer only to services for children ages 3 and 4. There are several distinct differences between Part C and Part B programs, including location of services, shift in focus from child and family to child-specific, duration, and intensity of services, and types of service (National Center for Hearing Assessment and Management, 2016). As described earlier, Part C services are rendered in the child’s natural environment including homes, childcare centers, and various community locations. Part B services are typically rendered in the local

Impact of Part C and Other Early Intervention Programs

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school district classrooms but must abide by the least restrictive environment, meaning that the child remains with peers without disabilities to the extent possible. The guiding documents (IFSP vs. IEP) for both programs also differ in that the IFSP is family-driven and includes background information regarding the child’s family, and family outcomes and priorities are used to inform goals for the child’s development; in contrast, the IEP outlines special education and related services based on a child’s functional and academic needs, with the main goal to allow children to participate as much as possible in general education settings. One of the most significant distinctions between the two programs is in regard to the duration and intensity of services. Most children enrolled in Part C programs receive one or a few hours at most of early intervention services. This aligns with the service delivery model of Part C whereby providers serve to facilitate naturally occurring developmental opportunities between caregiver and child. Once children transition to Part B, many attend a classroom setting for multiple hours each week. For many families this aspect to transition can be the most difficult adjustment, both logistically and emotionally; however, outcomes research demonstrates that the vast majority of children adjust well following transition from Part C to B and that families are satisfied with the developmental supports provided to their child as well (Hughes & Valle-­ Riestra, 2012). Finally, the system of payment for each program differs; Part C services are mandated to be supplemented through the use of public or private insurance and/or family fees, while Part B services are provided at public expense through the state and local education agencies.

Impact of Part C and Other Early Intervention Programs The goal of early intervention is to not only positively impact a child’s development but ultimately to give caregivers and families the strongest start possible in the child’s first years of life by helping them understand positive parenting practices, the importance of healthy attachment, basics of child development, and how to promote their own child’s well-being. In addition, early intervention is designed to help caregivers become lifelong advocates for their child as they navigate academic, social, and community settings together (Dunst & Espe-Sherwindt, 2016). Overall, statistics show that early intervention programs are highly impactful. Services have been shown to improve outcomes for infants and toddlers across all developmental domains (Landa, Holman, O’Neill, & Stuart, 2011). In regard to child outcomes, 46% of children who receive EI and had been at risk of needing special education services do not need special education at kindergarten age. In regard to family satisfaction and family advocacy, the vast majority of families (90%) report that participation in a Part C program improves their ability to help their children develop and learn (Bailey et al., 2005). Programs targeted at youth with special needs during the first 3 years of life are also by far the most economically efficient. James Heckman, a well-known economist, demonstrated via large-scale population statistics that society saves more than

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1  Social-Emotional Development in Young Children and the Purpose of Early…

$7 for every $1 invested in early childhood intervention programs (Heckman, 2008). Long-term outcomes include reduced need for special education services and remedial adult training programs, which are much more expensive to support per individual, as well as increased high school graduation rates (Jimerson, Reschly, & Hess, 2008).

Chapter Summary This chapter provided an overview of developmental milestones in infants and toddlers, with a focus on social-emotional development, the foundation for many other developmental skills. The prevalence of social-emotional problems and relation to later development provides a strong rationale for focusing on this aspect of development in the early years of life. This chapter also reviewed the general purpose of early intervention and synthesized the wealth of supporting literature for intervening in the birth to 5 population. Finally, a summary of various early intervention services and programs was given, with a more detailed overview of the federal early intervention programs, IDEA Parts B and C.

References Bailey, D. B., Hebbeler, K., Spiker, D., Scarborough, A., Mallik, S., & Nelson, L. (2005). Thirty-­ six-­month outcomes for families of children who have disabilities and participated in early intervention. Pediatrics, 116(6), 1346–1352. Baumrind, D. (1991). The influence of parenting style on adolescent competence and substance use. The Journal of Early Adolescence, 11(1), 56–95. Bjorklund, D. F., & Causey, K. B. (2017). Children's thinking: Cognitive development and individual differences. Thousand Oaks, CA: Sage Publications. Boyle, C. A., Boulet, S., Schieve, L. A., Cohen, R. A., Blumberg, S. J., Yeargin-Allsopp, M., et al. (2011). Trends in the prevalence of developmental disabilities in US children, 1997–2008. Pediatrics, 127(6), 1034–1042. Bricker, D., Squires, J., Mounts, L., Potter, L., Nickel, R., Twombly, E., et al. (1999). Ages and stages questionnaire. In. Baltimore: Brookes Publishing. Bronfenbrenner, U. (1994). Ecological models of human development. Readings on the Development of Children, 2(1), 37–43. Brown, C. M., Copeland, K. A., Sucharew, H., & Kahn, R. S. (2012). Social-emotional problems in preschool-aged children: Opportunities for prevention and early intervention. Archives of Pediatrics and Adolescent Medicine, 166(10), 926–932. Campbell, S. B. (1995). Behavior problems in preschool children: A review of recent research. Journal of Child Psychology and Psychiatry, 36(1), 113–149. Case-Smith, J. (2013). Systematic review of interventions to promote social–emotional development in young children with or at risk for disability. American Journal of Occupational Therapy, 67(4), 395–404. CDC. (2019). CDC’s developmental milestones. Retrieved from https://www.cdc.gov/ncbddd/ actearly/milestones/index.html

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Corr, C., Santos, R. M., & Fowler, S. A. (2016). The components of early intervention services for families living in poverty: A review of the literature. Topics in Early Childhood Special Education, 36(1), 55–64. Danaher, J. (2011). Eligibility policies and practices for young children under Part B of IDEA. National Early Childhood Technical Assistance Center (NECTAC). Dunlap, G., Strain, P. S., Fox, L., Carta, J. J., Conroy, M., Smith, B. J., et al. (2006). Prevention and intervention with young children’s challenging behavior: Perspectives regarding current knowledge. Behavioral Disorders, 32(1), 29–45. Dunst, C. J., Bruder, M. B., Trivette, C. M., & Hamby, D. W. (2006). Everyday activity settings, natural learning environments, and early intervention practices. Journal of Policy and Practice in Intellectual Disabilities, 3(1), 3–10. Dunst, C. J., & Espe-Sherwindt, M. (2016). Family-centered practices in early childhood intervention. In Handbook of early childhood special education (pp. 37–55). New York: Springer. Early Childhood Technical Assistance Center. (2015). States’ and territories’ definition of/criteria for Part C IDEA eligibility. Retrieved from https://ectacenter.org/~pdfs/topics/earlyid/partc_ elig_table.pdf Gatmaitan, M., & Brown, T. (2016). Quality in individualized family service plans: Guidelines for practitioners, programs, and families. Young Exceptional Children, 19(2), 14–32. Glascoe, F. P. (1998). Collaborating with parents: Using Parents’ evaluation of developmental status to detect and address developmental and behavioral problems. Nolensville, TN: Ellsworth & Vandermeer Press. Guevara, J.  P., Gerdes, M., Localio, R., Huang, Y.  V., Pinto-Martin, J., Minkovitz, C.  S., et  al. (2013). Effectiveness of developmental screening in an urban setting. Pediatrics, 131(1), 30–37. Heckman, J. J. (2008). Schools, skills, and synapses. Economic Inquiry, 46(3), 289–324. Hirai, A. H., Kogan, M. D., Kandasamy, V., Reuland, C., & Bethell, C. (2018). Prevalence and variation of developmental screening and surveillance in early childhood. JAMA Pediatrics, 172(9), 857–866. Hughes, M. T., & Valle-Riestra, D. M. (2012). Early childhood special education: Insights from educators and families. International Journal of Education, 4(2), 59. Individuals with Disabilities Education Act, 20 U.S.C. § 1400 (2004). Jimerson, S. R., Reschly, A. L., & Hess, R. (2008). Best practices in increasing the likelihood of high school completion. Best Practices in School Psychology, 4, 1085–1097. Jones, D.  E., Greenberg, M., & Crowley, M. (2015). Early social-emotional functioning and public health: The relationship between kindergarten social competence and future wellness. American Journal of Public Health, 105(11), 2283–2290. Karoly, L.  A., Kilburn, M.  R., & Cannon, J.  S. (2006). Early childhood interventions: Proven results, future promise. Santa Monica, CA: Rand Corporation. Khetani, M. A., Richardson, Z., & McManus, B. M. (2017). Social disparities in early intervention service use and provider-reported outcomes. Journal of Developmental and Behavioral Pediatrics, 38(7), 501. King-Dowling, S., Rodriguez, M., Missiuna, C., & Cairney, J. (2016). Validity of the ages and stages questionnaire to detect risk of developmental coordination disorder in preschoolers. Child: Care, Health and Development, 42(2), 188–194. Kochanska, G., Woodard, J., Kim, S., Koenig, J. L., Yoon, J. E., & Barry, R. A. (2010). Positive socialization mechanisms in secure and insecure parent–child dyads: Two longitudinal studies. Journal of Child Psychology and Psychiatry, 51(9), 998–1009. Landa, R. J., Holman, K. C., O’Neill, A. H., & Stuart, E. A. (2011). Intervention targeting development of socially synchronous engagement in toddlers with autism spectrum disorder: A randomized controlled trial. Journal of Child Psychology and Psychiatry, 52(1), 13–21. Landy, S. (2009). Understanding early brain development and temperament. In Pathways to competence: Encouraging healthy social and emotional development in young children (2nd ed., pp. 3–84). Baltimore: Brookes Publishing.

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Lazara, A. (2018). Part C infant and toddler program federal appropriations and national child count 1987–2018. Retrieved from http://ectacenter.org/partc/partcdata.asp Lipkin, P. H. (2009). Motor development and dysfunction. In W. B. Carey, A. C. Crocker, E. R. Elias, W. L. Coleman, & H. M. Feldman (Eds.), Developmental-behavioral pediatrics (4th ed., pp. 643–652). Philadelphia: Elsevier Health Sciences. Lucas, A., & Shaw, E. (2012). Informed clinical opinion. NECTAC notes No. 28. Chapel Hill: The University of North Carolina, FPG Child Development Institute, National Early Childhood Technical Assistance Center. Mahoney, G., & Perales, F. (2005). Relationship-focused early intervention with children with pervasive developmental disorders and other disabilities: A comparative study. Journal of Developmental and Behavioral Pediatrics, 26(2), 77–85. McCormick, L. (2014). Assessment and planning: The individualized family service plan and individualized education program. Teaching Young Children with Disabilities in Natural Environments, 47–74. McWilliam, R. (2010). Routines-based early intervention: Supporting young children and their families. Baltimore: Brookes Publishing. National Center for Education Evaluation. (2011). National assessment of IDEA overview Retrieved from https://ies.ed.gov/ncee/pubs/20114026/pdf/20114026.pdf National Center for Hearing Assessment and Management. (2016). Eligibility and service delivery policies: Differences between IDEA Part C and IDEA Part B: A comparison chart. Retrieved from http://www.infanthearing.org/earlyintervention/docs/aspect-idea-part-c-and-idea-part-b. pdf National Early Childhood Technical Assistance Center. (2011). The importance of early intervention for infants and toddlers and their families. Retrieved from https://ectacenter.org/~pdfs/ pubs/importanceofearlyintervention.pdf Office of Special Education Programs. (2011). Part C of the Individuals with Disabilities Education Act: Final regulations nonregulatory guidance. Retrieved from https://sites.ed.gov/idea/files/ original_Final_Regulations-_Part_C-DOC-ALL.pdf Owens, R. (2016). Language development: An introduction. Boston: Pearson. Plaza, J. C., Sevilla, M. D. G., Rico, G. M., & Murillo, C. P. M. (2017). Parenting stress and coping strategies in mothers of children receiving early intervention services. Journal of Child and Family Studies, 26(11), 3192–3202. Prinzie, P., Stams, G.  J. J., Deković, M., Reijntjes, A.  H., & Belsky, J. (2009). The relations between parents’ big five personality factors and parenting: A meta-analytic review. Journal of Personality and Social Psychology, 97(2), 351. Raspa, M., Levis, D. M., Kish-Doto, J., Wallace, I., Rice, C., Barger, B., et al. (2015). Examining parents’ experiences and information needs regarding early identification of developmental delays: Qualitative research to inform a public health campaign. Journal of Developmental and Behavioral Pediatrics: JDBP, 36(8), 575. Ridgley, R., Snyder, P. A., McWilliam, R., & Davis, J. E. (2011). Development and initial validation of a professional development intervention to enhance the quality of individualized family service plans. Infants & Young Children, 24(4), 309–328. Stiles, J., & Jernigan, T. L. (2010). The basics of brain development. Neuropsychology Review, 20(4), 327–348. Vélez-Agosto, N.  M., Soto-Crespo, J.  G., Vizcarrondo-Oppenheimer, M., Vega-Molina, S., & García Coll, C. (2017). Bronfenbrenner’s bioecological theory revision: Moving culture from the macro into the micro. Perspectives on Psychological Science, 12(5), 900–910. Webster-Stratton, C., & Spitzer, A. (1996). Parenting a young child with conduct problems. In Advances in clinical child psychology (pp. 1–62). New York: Springer.

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Wilson, S., & Durbin, C.  E. (2012). Dyadic parent-child interaction during early childhood: Contributions of parental and child personality traits. Journal of Personality, 80(5), 1313–1338. Workgroup on Principles and Practices in Natural Environments. (2018). OSEP TA community of practice: Part C settings- Seven key principles: Looks like/doesn’t look like. Retrieved from http://www.ectacenter.org/~pdfs/topics/families/Principles_LooksLike_ DoesntLookLike3_11_08.pdf

Chapter 2

Best Practices in Assessment and Intervention with Infants and Toddlers

Early Childhood Assessment Factors Specific to Assessment of Young Children  In the first years of life, infants and toddlers acquire a vast array of developmental skills as outlined in Chap. 1. Early interventionists may use a variety of assessments to evaluate children’s competency and performance in regard to these developmental skills. When assessing infants and toddlers, early interventionists should consider several factors that could potentially affect the administration of and scores on assessments. First, the activity level of the child can affect the administration and scoring of the testing instrument. Children who display hyperactivity may have difficulty concentrating on completing assessment tasks, especially timed tasks and tasks that may take longer to complete. They may not pay attention to a task’s instructions, and as a result they will perform the task incorrectly. Early interventionists should consider the child’s attention span during assessment. In addition, children may engage in challenging behaviors or tantrums during the assessment process. These behaviors could be an attempt to avoid the assessment process, to leave an aversive place or situation, or to gain attention from caregivers or other individuals. Children who display challenging or disruptive behaviors may refuse to complete assessment tasks or may intentionally complete tasks incorrectly. They may require additional behavioral management in order to finish the assessment. Factors such as children’s activity level and challenging behaviors are just some of the many age-related variables that can affect an early interventionist’s assessment. In addition, children may engage in more problematic behaviors if they have not received sufficient sleep or food prior to the evaluation. In order to control for these factors, the early interventionist should consult with the family prior to administering the assessment to gain insight regarding the child’s focus, behavior, and energy level, as well as any other factors that the family may discuss.

© Springer Nature Switzerland AG 2020 H. Agazzi et al., Promoting Positive Behavioral Outcomes for Infants and Toddlers, https://doi.org/10.1007/978-3-030-51614-7_2

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Family Involvement in Assessment  In addition to preparing for child factors that may affect the administration of or scores on an assessment, early interventionists should also seek family involvement throughout the assessment process. Engaging families can help interventionists obtain additional information about the child that may not be gathered from the assessment alone. Such information can include the child’s medical history, past experiences with medications, and a general history of the family’s physical and mental health. Cultural values of families should also be taken into consideration, as different cultures have different expectations regarding developmental milestones. Interventionists can also ask caregivers about their children’s behaviors at home as well as in daycare or school settings. Finally, family members can provide insight into how the child’s behavior, communication, and other developmental competencies affect the overall functioning of the home. Involving families in early childhood assessment can also allow interventionists to evaluate the quality of the caregiver-child relationship through observation of interactions between the child and their family. In addition, involving families can lead to ongoing consultation throughout the assessment process. Thus, it is critical that families be involved at all stages of the assessment process.

Common Assessment Tools Norm-Referenced  When selecting assessment tools for children, early interventionists should consider the use of norm-referenced assessments. In norm-­referenced assessments, an individual’s scores are compared to the performance of a group of peers possessing similar characteristics to the individual for which the assessment is scored (Urbina, 2014). Norms themselves are defined as “typical” behavior exhibited by certain groups of individuals. Norm-referenced tests are the most commonly used assessments in interpreting a child’s abilities in a variety of domains (Urbina, 2014). However, it is important to note that many of these assessments do not provide explicit recommendations for which type of intervention may be most beneficial given a child’s score (Magyar, Pandolfi, & Peterson, 2007). Norm-referenced tests are used to identify areas of difficulty or delay in the child in order for early interventionists to determine their next steps in providing support to the child and their family. Criterion-Referenced  Early interventionists should also consider use of criterion-­ referenced assessments. In criterion-referenced assessments, an individual’s scores are compared to a predetermined standard of performance or competence (Urbina, 2014). In many cases, criterion-referenced tests are scored on a range of values. For example, if a child hypothetically scores above a 90 on a criterion-referenced test, they might be considered proficient. By contrast, if a child hypothetically scores below a 70 on a criterion-referenced test, they might be considered below their expected level of performance. Each assessment has its own set of scoring standards which must be valid and reliable in nature.

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Broadband Assessments  Assessments that are classified as broadbrand seek to identify general disabilities or conditions in children, such as learning disabilities, motor skills, language development, and other general areas of growth and functioning (Glascoe, 2007). Broadband assessments can be either norm-referenced or criterion-referenced. These assessments help identify areas of strength for children as well as areas where additional support or intervention may be needed. Common examples of broadband assessments include the Battelle Developmental Inventory-­ Second Edition or the BDI-2 (Newborg, 2005), the Bayley Scales of Infant and Toddler Development-Fourth Edition (Bayley & Alward, 2019), the Mullen Scales of Early Learning (Shank, 2011), the Vineland Adaptive Behavior Scales-Third Edition (Sparrow, Cicchetti, & Saulnier, 2016), and the Adaptive Behavior Assessment System-Third Edition or ABAS-3 (Harrison & Raineri, 2008). Below is a table outlining key features of these selected broadband assessments (Table 2.1). Narrowband Assessments  In contrast to broadband assessments, narrowband assessments seek to identify more specific conditions or disabilities in children, such as autism spectrum disorder (ASD) or attention-deficit/hyperactivity disorder (ADHD), as well as motor or language delays (Glascoe, 2007). Like broadband assessments, narrowband assessments can be either norm-referenced or criterion-­ referenced. Common examples of narrowband assessments include the Autism Diagnostic Observation Schedule-Second Edition or ADOS-2 (Lord et al., 2012), the Peabody Developmental Motor Scales-Second Edition or PDMS-2 (Folio & Fewell, 2000), the Preschool Language Scales-Fifth Edition or PLS-5 (Zimmerman, Steiner, & Pond, 2011), and the Eyberg Child Behavior Inventory or ECBI (Eyberg, Sutter, & Pincus, 1999). Below is a table outlining key features of these selected broadband assessments (Table 2.2). Table 2.1  Example broadband assessments Assessment Name Battelle Dev. Inventory, 2nd Ed. (BDI-2)

Referencing Description of Assessment Norm-­ Five scales (cognitive, referenced communication, motor, personal-­ social, adaptive) Available in Spanish Norm-­ Five scales (cognitive, language, Bayley Scales of Infant motor, social-emotional, adaptive) and Toddler Dev., 4th Ed. referenced (Bayley-4) Mullen Scales of Early Norm-­ Five scales (gross motor, fine motor, Learning referenced visual reception, expressive language, receptive language) Assesses school readiness Norm-­ Three domains (communication, daily Vineland Adaptive living skills, socialization) Behavior Scales, 3rd Ed. referenced Has parent/teacher forms (Vineland-3) Norm-­ Three adaptive domains (conceptual, Adaptive Behavior social, practical) Assessment System, 3rd referenced Available in several languages Ed. (ABAS-3)

Age Range 0–7 years, 11 months

16 days – 42 months 0–5 years, 8 months

0–90 years

0–89 years

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Progress Monitoring/Ipsative Assessment  Progress monitoring helps determine the existence of a disability or delay as well as determine what type of eligibility the child might receive. Early interventionists can also use ipsative assessments to monitor the child’s progress in targeted developmental domains after an intervention has been introduced. Progress monitoring helps early interventionists decide if the selected intervention is effective at helping the child or if the intervention needs to be modified or changed. Early interventionists can use the data they collect as part of progress monitoring to make visual representations of the child’s progress over time. One group of progress monitoring tools that has been proven to be reliable and valid is the Individual Growth and Development Indicators or IGDIs (Greenwood, Carta, & McConnell, 2011). This group consists of evidence-based assessments that span across the developmental domains, including the Early Problem-Solving Indicator, the Early Communication Indicator, the Early Movement Indicator, and the Early Social Indicator (Hughes-Belding, Luze, & Choi, 2019). Details pertaining to progress monitoring tools are outlined below (Table 2.3.). Another evidence-based progress monitoring assessment tool is the Hawaii Early Learning Profile or HELP (Parks, 1992/2013). This tool is specific to children from birth to age 3 and analyzes a wide array of developmental skills and behaviors. The major domains of the HELP include cognitive, language, gross motor, fine motor, social-emotional, and self-help. Like the IGDI tools, the HELP has been proven to be reliable and valid in its evaluation of developmental domains (Li, Gooden, & Toland, 2019). The HELP also analyzes children’s behavior and skills across settings and can be utilized along with many early development assessment tools. When using a progress monitoring tool, it is important that a goal-level of performance be established (Greenwood et  al., 2011). Goals should be decided upon through collaboration of all members of the intervention team. If possible, the child’s family or primary caregivers should also be consulted regarding the goals for intervention. Initial goals should be simple and then grow more difficult as the child becomes proficient in, or masters, easier tasks (Greenwood et  al., 2011). For Table 2.2  Example narrowband assessments Assessment Name Autism Diagnostic Obs. Schedule, 2nd Ed. (ADOS-2) Peabody Dev. Motor Scales, 2nd Ed. (PDMS-2)

Referencing Norm-­ referenced

Description of Assessment Assesses for autism etiology Available in several languages

Age Range 12 months – adulthood

Norm-­ referenced

0–5 years

Preschool Lang. Scales, 5th Ed. (PLS-5)

Norm-­ referenced

Eyberg Child Behavior Inventory (ECBI)

Norm-­ Referenced

Three composite scores (gross motor, fine motor, total motor) Measures reflexes, visual-­ motor integration, etc. Evaluates play behaviors Targets phonemes/words Available in Spanish Allows caregiver to evaluate child’s behavior Available in Spanish

0–7 years

2–16 years

Requirements for Determination of Eligibility to Part C Programs

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e­ xample, if a 3-year-old child is using single words rather than phrases to communicate his needs, the early interventionist could set an initial goal of three independent two-word phrases during a 1-hour time period (i.e., during a therapy or intervention session). When the child masters this criterion, the early interventionist could then raise the number of two-word phrases before moving on to three-word phrases or short sentences. Early interventionists can individualize goals to align with the child’s strengths and areas of needed support. Analyzing progress monitoring data will help the early interventionist decide if the child has met mastery criteria or whether further support is needed.

 equirements for Determination of Eligibility to Part C R Programs Determination of a child’s eligibility for the Part C program requires completion of an assessment by a multidisciplinary team of evaluators. Typically, this team consists of two to three professionals across disciplines including early childhood education, physical therapy, occupational therapy, speech therapy, and other related disciplines (e.g., nursing, social work, psychology). Using a team approach to assessment ensures focus on the whole child as professionals from multiple backgrounds with varying expertise contribute to the development of the Individualized Family Support Plan (IFSP). In addition, the assessment tools used must include a focus on all five domains of development. Most states require the use of a specific norm-referenced assessment that covers all developmental domains (e.g., motor, cognitive, language, self-help, social) such as the BDI-2 or Bayley-4, with the option for evaluation teams to include other measures as well in order to gather all relevant information needed to make a determination of eligibility (Office of Special Education Programs, 2011). Specific eligibility criteria are determined at the state level and were reviewed in Chap. 1. Developmental assessment data are then used in conjunction with other information shared by the family and IFSP team to develop the intervention plan. Table 2.3  Summary of IGDI progress monitoring tools Name Early Communication Indicator (ECI) Early Movement Indicator (EMI) Early Social Indicator (ESI) Early Problem-Solving Indicator (EPSI)

Developmental Domain Key Skills Language/ Gestures, vocalizations, single words, communication multiple words Motor Transition in position, grounded/vertical locomotion, throwing/rolling, catching Social-emotional Attending to faces, non-verbal social gestures, child-initiated physical contact, vocalizations Executive functioning/ Looking at objects/surroundings, problem-solving understanding the function of objects, finding solutions to problems

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Using Assessment Data to Inform Intervention Plans for Young Children  When communicating assessment results to family members, early interventionists should highlight the child’s strengths in addition to discussing areas in which the child may need further support (Gatmaitan & Lyons, 2013). This practice is particularly helpful when disclosing difficult news to caregivers, such as the fact that their child has a developmental disability. It is important to show the family where their child’s scores fall in comparison to the normative sample so that they understand the extent of the gap between their child’s skillset and the skillset of typical same-age peers. Bringing visual supports, including graphs or charts, can be useful in communicating this information to caregivers. Other types of assessment information from observations or interviews should also be discussed at this time. Finally, early interventionists should use jargon-free language when disseminating assessment results, as using dense vocabulary and acronyms can overwhelm caregivers. Just as the child’s family should be considered during the assessment process, the child’s family should also be considered when creating intervention plans. Some caregivers may need professional guidance or support while implementing intervention strategies with their children. Other caregivers may be resistant to use certain interventions with their children. This resistance could be due to a lack of time or resources on the caregiver’s part, a lack of confidence, or a fear of some potentially negative repercussions of the intervention. Hence, it is important that the child’s family be actively involved in the intervention process so that they are motivated to implement the intervention with fidelity. Early interventionists should also consider the family context and priorities when designing an intervention plan. For example, one family may strongly value a child saying “please” when requesting an object or activity, and another family may prefer if the child simply says, “I want the truck.” Because the primary goal of an intervention plan is to assist the family in determining which supports and services would best fit their child’s needs, early interventionists must remember these families’ cultural values, religious beliefs, and intervention priorities (Gatmaitan & Brown, 2016). Keeping these factors in mind will lead to a more successful intervention plan.

Best Practices for Early Intervention Understanding the Family’s Perspective  For many families, early intervention is the first or among the first forms of outside help they receive. Although early intervention calls for the process of assessment and intervention to be family-friendly, caregivers are nevertheless experiencing exposure to a new system for their child and family, often filled with unfamiliar people, processes, and jargon. Furthermore, considering that one of the key guiding principles of early intervention is use of the natural environment, hosting early intervention providers into one’s home may be a somewhat uncomfortable step for families to take in order to receive assistance with their child’s developmental delays. Seeing these aspects of early intervention

Best Practices for Early Intervention

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through the family’s eyes can help providers be more attuned to helping caregivers feel comfortable by emphasizing the important role that parents play in promoting development. In addition, acknowledging the family’s perspectives can enhance the collaborative relationship with early intervention providers, as well as the focus on using naturally occurring routines and home environments. This focus on natural home environments may reduce the undue pressure that parents may feel to “prepare” their home or routine for visits. In addition to becoming familiar with the nuances of early intervention, parents are often working through the numerous emotions that accompany recognition and acceptance of their child’s developmental delay. Young children come into early intervention programs through a variety of pathways. Some children may have a prediagnosed or established complex condition that has already resulted in formation of a multidisciplinary support team and numerous conversations with parents about accompanying developmental sequelae. Other children may have an identified developmental delay by a health or childcare professional that parents have not yet acknowledged or understood themselves. Families face a wide range of emotions as they move through the process of developmental assessment and early intervention, and they also cope in diverse ways (Ulrich & Bauer, 2003). A family’s cultural background often plays a role in coping and acceptance as well. Some cultures do not recognize developmental delay, or delays and/or disorders are seen as a punishment and lead to potential social isolation if shared with other family members or community members. It is important that providers seek to understand each family’s values and background to the best of their abilities, keeping in mind that each family has unique circumstances. There are numerous ways that providers can support families as they learn to adapt to navigating the world on behalf of their child with development delays. Some of these include being self-aware of potential biases and beliefs about family backgrounds and about child development, listening to concerns and withholding judgment, and being encouraging yet realistic regarding intervention goals and progress (Crawford & Weber, 2014). Coaching and Facilitating the Caregiver-Child Relationship  Social learning theory posits that we learn the most and the best from those with whom we have the greatest connection (Bandura & Walters, 1977). Thus, young children learn best from their caregivers. There are several relationships that develop within the context of early intervention, including the provider-caregiver, provider-child, and caregiver-­ child, but the caregiver-child relationship is central, and this dyad should be the focus of early intervention. Many early intervention providers enter the field due to experience and/or passion and enjoyment for working with infants and toddlers. However, providers may downplay or overlook the reality that much of the work of early intervention is adult-focused – that is, coaching and working with the caregivers of infants and toddlers. The quote “there is no such thing as an infant…without maternal care one would find no infant” (Winnicott, 1960) speaks to the core of infant-caregiver attachment, in that a baby can truly only exist with someone to care for them at all times. Early

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childhood researchers have identified three key building blocks for healthy caregiver-­ infant attachment: sensitive responsiveness, affective warmth, and engagement (Guralnick & Bruder, 2019). From the moment of birth, or some would say even the prenatal period, these components develop by responding contingently to babies’ cues, narrating activities, and focusing on babies’ interests and attention. Early intervention professionals should explicitly identify these building blocks for parents and then find ways to both enhance attachment and use attachment to promote young children’s development. Several key components to coaching in early intervention that are generally consistent across the literature base are outlined in Table  2.4 (Friedman, Woods, & Salisbury, 2012; Gatmaitan & Lyons, 2013). Over the course of the early intervention relationships, some aspects of the coaching process may be more heavily emphasized than others. For instance, when establishing rapport or when new developmental skills or strategies become the focus of EI sessions, a provider may rely more heavily on directing and demonstrating for the caregiver. Alternatively, if caregivers report that strategies are not effective, a provider may observe behaviors and interactions for more of a session to better understand the family’s dynamics and routines as it relates to opportunities for enhancing the child’s development. Natural Environment  The research on evidence-based practice for enhancing development, well-being, and overall health in youth and young adults is vast. Yet we cannot assume that what is effective for these older age groups can also be extended to what is best for infants and young children. Early intervention has been proven to be highly effective in regard to both short- and long-term outcomes but only when delivered via certain guiding principles and parameters that we know are effective for the young developing brain. One of these key principles includes the fact that infant and toddlers depend on experiential learning within their natural, everyday environment (Zwaigenbaum et al., 2015). Although both legislative policy on early intervention programming as well as guidance from the early childhood literature base have highlighted the importance of this for years, the implementation of experiential learning opportunities within a child’s natural surroundings has become a more standard practice over the past two decades (Crawford & Weber, 2014).

Table 2.4  Core components of early intervention coaching Observation and Data Gathering Use active listening Observe typical interactions and family dynamics

Direct Demonstration and Teaching Show techniques and strategies to address IFSP goals and overall development Explicit review of how techniques are useful

Practice and Problem-Solving Feedback and Reflection Examine activities and Facilitate follow-­ through in between strategies together sessions Engage caregiver in Identify what provider will help with Give feedback for future implementation (handouts, reminders) practice of skills

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A quite common misperception to services rendered in the natural environment is that the “where” of the intervention sessions is the key to making services more effective. Thus, early intervention providers may in essence implement a more direct therapy approach that doesn’t emphasize the critical focus on the caregiver-­ child nor does it employ a coaching model. Early intervention providers must not assume that because the service occurs in the family’s home or the childcare facility, they are compliant with natural environment guidelines for Part C services. In reality, best practice must merge natural environment, coaching, and routines-based intervention into a holistic and quite different approach than traditional therapy. Recommended practice in natural environments involves using toys and other items found in the child’s home or childcare. Although this can pose challenges in situations where very few to little items are available in a home setting, families must be empowered to know that the interactions that occur between caregiver-child around a toy or item are far more impactful on a child’s learning than the items themselves. Routines-Based Intervention  Interventions to promote development and enhance the caregiver-child relationship can be highly effective when they occur within the context of everyday caregiving routines. Embedding interventions into the natural “happenings” within a family’s day increases the learning opportunities and also the likelihood that the intervention(s) will occur. While play is a key component of a child’s day, caregivers do not spend the majority of their day playing on the floor with their child. Rather, playful interactions between caregiver and child throughout the day, along with more traditional special playtime together in short intervals, are a practical and natural way to approach intervention planning. Playful interactions include being very present in the moment, narrating actions and feelings, letting a child lead, and shaping and prompting developmental skills in a fun and encouraging way. These caregiver-child interactions have recently been termed as “serve and return” by Harvard researchers and have powerful connections to early brain development (Center on the Developing Child, 2019). These interactions can be used to promote any area of development and can be used within any routine. Often EI providers focus on very common routines such as mealtimes, bath time, dressing, and bedtime, but routines can include a vast array of other daily occurrences for the child and family including picking up and/or dropping off older siblings to school, riding in the car, getting the mail, feeding the family pet, making phone calls to other family members, diaper changes, and many other activities. Identifying ways to promote development within these routines involves open questioning, active listening, and creativity on the part of the early intervention provider as well as a collaborative partnership with caregivers, as there must be adequate buy-in for caregivers to mindfully capitalize on these moments throughout each day. The ability for early intervention providers to assist families in setting up functional routines and implement routines-based intervention is one of the most challenging yet most important components of effective services. Thus, we have dedicated an entire chapter (e.g., Chap. 3) in this book that provides a more detailed framework for using routines as a part of early intervention and illustrates examples of implementation of routines-based intervention.

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Setting the Stage  Given the uniqueness of the early intervention service delivery model as compared to a traditional, medical model for therapy, it is critical that families are introduced to and reminded of the purpose of early intervention services from the time of referral all the way through the first and subsequent intervention sessions. Providers often note that some families embrace the opportunity to discuss various family routines during sessions while others do not. However, the degree to which the scope and purpose of services are understood by caregivers appears to make a significant difference in caregivers’ willingness to ask questions (Campbell & Sawyer, 2009). Pediatricians remain the primary referral source for Part C programs nationwide, and the degree of understanding of early intervention services across the pediatric medical community varies considerably (Crawford & Weber, 2014). Thus, caregivers whose children are referred for services may have different expectations for what services will entail. Ideally, families will have heard a consistent message regarding the coaching and routines-based model of early intervention from the point of referral moving forward. Providers can continue to set the stage for a successful partnership by incorporating discussion of the developmental and caregiver education model of early intervention into the first few sessions. In addition, direct conversation regarding the roles of the provider and the caregiver is essential so that families fully understand that they are truly the primary interventionist for their child. Many early intervention professionals struggle with what they perceive as lack of involvement or follow-­ through by caregivers over the course of time when in reality the appropriate setup and initial conversations about what makes early intervention effective have not taken place (Crawford & Weber, 2014). Considering that many providers serve young children in childcare centers and preschool, setting the stage with the administration of a facility and with individual classroom teachers and providers is also critical and can pose unique challenges (Wilcox & Woods, 2011). There are several different considerations for establishing rapport when rendering services in a center. Just as when working with families, providers should respect the guiding philosophies and principles of the center and remember that they are a visitor to the existing structure and culture within the facility. One quite effective way to develop buy-in from the staff is to pay attention to their priorities in addition to the intervention goal(s) for the child. Helping them problem-solve challenges that are most prevalent in their everyday roles can go a long way in regard to forming a partnership for the long term. Given the busy caretaking and learning routines within childcare classrooms, providers should also find brief opportunities to communicate directly with the provider(s) as they manage several infants and/or toddlers at one time. Early interventionists can also empower parents to talk with their child’s center or school regarding the importance and benefits of the Part C service delivery model for enhancing development. Multidisciplinary Teaming and Consultation in Early Intervention  A multidisciplinary teaming approach is best practice for the provision of early childhood services. In many states a team-based primary service provider (PSP) approach is used, in which one early intervention professional of a certain discipline is ­identified

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as the primary provider working with a child and his or her caregivers, and professionals of other disciplines support the PSP via consultations (Shelden & Rush, 2013). The PSP is chosen based on the prioritized needs of the child and family. The national organizations of many disciplines participating in early intervention, including the American Occupational Therapy Association, American SpeechLanguage-Hearing Association, and the Division for Early Childhood of the Council for Exceptional Children, all recommend a team-based service delivery model when working with infants and toddlers (Shelden & Rush, 2013). Although one important reason for shifting to a team-based PSP model is to save Part C dollars, the model has other benefits, including (a) reduced burden on the family to “host” providers and coordinate multiple therapeutic visits each week, (b) emphasis on routines-based intervention that incorporates all areas of development vs. domain-specific strategies, and (c) opportunity for early intervention providers to “transfer skills” among one another as well as the family via consultation sessions (McWilliam, 2010). Previous research has shown that intensity of early intervention services per week is actually negatively correlated with family well-being, with factors such as struggles to manage appointments, interruption to daily routines, and handling conflicting information from multiple providers all noted by families as contributing to higher levels of stress (Dunst, Hamby, & Brookfield, 2007). In order for the teaming model to be successful, service providers must understand and support their role in connection with the others on the team and be comfortable with some degree of “role release” (Guralnick & Bruder, 2019). Family-Centered Early Intervention  As with any type of professional work with children and families, treatments and interventions are only as effective as the degree to which they are family-centered. This includes consideration of individual strengths, needs, risk factors, and cultural and family values. The need for cross-­ cultural understanding is of critical importance for early intervention providers considering that more than half of the children under age 5 in the USA are from racial and ethnic minority backgrounds (Child Trends, 2018). In addition, the societal structures and systems related to conception, birth, and childrearing has changed dramatically over the past two decades and no doubt will continue to evolve. Examples of evolving factors include increased survival rates of very premature infants, increased numbers of children in part-time or full-time childcare during the day, and more multiple births associated with advances in reproductive medicine, among numerous other changes. Thus, the environment for infants, young children, and their caregivers looks quite different from the state of the early intervention field that many providers remember entering years ago (Ensher & Clark, 2011). It is the responsibility of early intervention professionals to remain abreast of these changes and adapt their work to consider and accommodate these new factors in order to effectively work with families. Specific guidance on individualizing early intervention treatment plans to ensure supports are child- and family-centered is provided in Chap. 8.

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Chapter Summary This chapter provided information on some of the factors specific to developmental assessment in young children, as this differs from assessment of older children in many ways. Management of behavior and attention levels and involvement of caregivers in the assessment process are key considerations for early childhood assessment. Normative assessment processes and specific examples of tools were outlined to help readers understand how children may become eligible for early intervention. In addition, the importance of progress monitoring to establish individualized goals, assess gains, and evaluate the effectiveness of intervention was discussed. Simple progress monitoring tools for use in early intervention practice were reviewed. This chapter also highlighted best practices in working with infants and toddlers and their caregivers. These include engagement of caregivers as the primary agents of change for their young child, facilitation of the parent-child relationship via coaching, and implementation of routines-based intervention and learning through play.

References Bandura, A., & Walters, R.  H. (1977). Social learning theory (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall. Bayley, N., & Alward, G. P. (2019). Bayley scales of infant and toddler development-fourth edition administration manual. In. Bloomington, MN: NCS Pearson. Campbell, P. H., & Sawyer, L. B. (2009). Changing early intervention providers’ home visiting skills through participation in professional development. Topics in Early Childhood Special Education, 28(4), 219–234. Center on the Developing Child, H.  U. (2019). Five steps for brain-building serve and return. Retrieved from https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wpcontent/ uploads/2017/06/HCDC_ServeReturn_for_Parents_Caregivers_2019.pdf Child Trends. (2018). Racial and ethnic composition of the child population. Retrieved from https://www.childtrends.org/indicators/racial-and-ethnic-composition-of-the-child-population Crawford, M. J., & Weber, B. (2014). Early intervention every day: Embedding activities in daily routines for young children and their families. Baltimore: Brookes Publishing. Dunst, C. J., Hamby, D. W., & Brookfield, J. (2007). Modeling the effects of early childhood intervention variables on parent and family well-being. Journal of Applied Quantitative Methods, 2(3), 268–288. Ensher, G. L., & Clark, D. A. (2011). Relationship-centered practices in early childhood: Working with families, infants, and young children at risk (1st ed.). Baltimore: Brookes Publishing. Eyberg, S., Sutter, J., & Pincus, D. (1999). Eyberg child behavior inventory and Sutter-Eyberg student behavior inventory-revised. In J. Meikamp & S. C. Whiston (Eds.), ECBI. Lutz, FL: PAR inc. Folio, M. R., & Fewell, R. R. (2000). Peabody developmental motor scales examiner's manual (2nd ed.). Austin, TX: Pro-Ed. Friedman, M., Woods, J., & Salisbury, C. (2012). Caregiver coaching strategies for early intervention providers: Moving toward operational definitions. Infants & Young Children, 25(1), 62–82. Gatmaitan, M., & Brown, T. (2016). Quality in individualized family service plans: Guidelines for practitioners, programs, and families. Young Exceptional Children, 19(2), 14–32.

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Gatmaitan, M., & Lyons, A. (2013). Early intervention specialist program: Coaching manual. Unpublished training document. Retrieved from http://ohioeicommunityofpractice.weebly. com/uploads/1/8/6/0/18607188/ksu_coaching_manual.pdf Glascoe, F. P. (2007). Developmental and behavioral screening. In Handbook of intellectual and developmental disabilities (pp. 353–371). New York: Springer. Greenwood, C. R., Carta, J. J., & McConnell, S. (2011). Advances in measurement for universal screening and individual progress monitoring of young children. Journal of Early Intervention, 33(4), 254–267. Guralnick, M. J., & Bruder, M. B. (2019). Early intervention. In Handbook of intellectual disabilities (pp. 717–741). New York: Springer. Harrison, P.  L., & Raineri, G. (2008). Best practices in the assessment of adaptive behavior. Bethseda, MD: National Association of School Psychologists. Hughes-Belding, K., Luze, G. J., & Choi, J.-Y. (2019). Convergent validity of infant/toddler developmental progress monitoring tools. Child & Youth Care Forum, 48(4), 493–511. Li, Z., Gooden, C., & Toland, M.  D. (2019). Reliability and validity evidence for the Hawaii Early Learning Profile, birth-3 years(1), 62. Retrieved from http://ezproxy.lib.usf.edu/ login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edsbl&AN=RN61897792 2&site=eds-live Lord, C., Rutter, M., DiLavorne, P. C., Risi, S., Gotham, K., & Bishop, S. L. (2012). Autism diagnostic observation schedule, second edition (ADOS-2) manual (part I): Modules 1–4. Torrance, CA: Western Psychological Services. Magyar, C.  I., Pandolfi, V., & Peterson, C.  R. (2007). Psychoeducational assessment. In J.  W. Jacobson, J. A. Mulick, & J. Rojahn (Eds.), Handbook of intellectual and developmental disabilities (pp. 333–351). New York: Springer Publishing Company. McWilliam, R. (2010). Routines-based early intervention: Supporting young children and their families. Baltimore: Brookes Publishing. Newborg, J. (2005). Battelle Developmental Inventory−second edition. Itasca, IL: Riverside. Office of Special Education Programs. (2011). Part C of the Individuals with Disabilities Education Act: Final regulations nonregulatory guidance. Retrieved from https://sites.ed.gov/idea/files/ original_Final_Regulations-_Part_C-DOC-ALL.pdf Parks, S. (1992/2013). HELP® strands. Palo Alto, CA: VORT Corporation. Shank, L. (2011). Mullen scales of early learning. In J. S. Kreutzer, J. DeLuca, & B. Caplan (Eds.), Encyclopedia of clinical neuropsychology (pp. 1669–1671). New York: Springer. Shelden, M. L. L., & Rush, D. D. (2013). The early intervention teaming handbook: The primary service provider approach. Baltimore: Brookes Publishing. Sparrow, S.  S., Cicchetti, D.  V., & Saulnier, C.  A. (2016). Vineland adaptive behavior scales, (Vineland-3). San Antonio, TX: Psychological Corporation. Ulrich, M.  E., & Bauer, A.  M. (2003). Levels of awareness: A closer look at communication between parents and professionals. Teaching Exceptional Children, 35(6), 20–23. Urbina, S. (2014). Essentials of psychological testing. Hoboken, NJ: Wiley. Wilcox, M. J., & Woods, J. (2011). Participation as a basis for developing early intervention outcomes. Language, Speech, and Hearing Services in Schools, 42(3), 365–378. Winnicott, D. W. (1960). The theory of the parent-infant relationship. The International Journal of Psycho-Analysis, 41, 585–595. Zimmerman, I. L., Steiner, V. G., & Pond, R. E. (2011). Preschool language scales. In T. McKnight & K. L. Shapley (Eds.), PLS-5 (5th ed.). London: Pearson. Zwaigenbaum, L., Bauman, M.  L., Choueiri, R., Kasari, C., Carter, A., Granpeesheh, D., et  al. (2015). Early intervention for children with autism spectrum disorder under 3 years of age: Recommendations for practice and research. Pediatrics, 136, 60–81.

Chapter 3

A Routines-Based Approach to Early Intervention

A Routines-Based Approach to Early Intervention Routines, or the pattern and predictable events of a child and family’s day, serve as the ‘backdrop’ for a child’s interactions with the world around them. Routines are a key factor to consider before, and in conjunction with, all behavioral interventions for young children. Without a healthy and orderly daily foundation for a child’s development, even the best laid plans for improving behavior will be ineffective. Just as the first chapter detailed the numerous environmental factors that impact children’s development and behavior, the general order to a child’s day can also relate to success or struggles with their behavior. This chapter highlights a critical area that early interventionists must first attend to in order to experience success with subsequent behavioral intervention strategies.

What Are Routines and Rituals? The terms “routine” and “ritual” are sometimes used interchangeably. While these terms are related, they have different meanings and offer distinct insight into understanding a child and family’s typical day. Routines are essentially the activities that make up the general structure to our day. They are repeated throughout the week and thus have a sense of predictability. Most families have several routines (morning routine, after-school routine, bedtime routine), some of which they may actively plan and be aware of (i.e., “intentional routines”), and others that may not even be viewed as a “routine” but have a clear pattern each day. With young children, routines generally fall into the categories of caregiving and play (Jennings, Hanline, & Woods, 2012). Caregiving routines include activities such as diapering, dressing, and mealtimes, while play routines include outdoor play, evening play before bedtime, etc. © Springer Nature Switzerland AG 2020 H. Agazzi et al., Promoting Positive Behavioral Outcomes for Infants and Toddlers, https://doi.org/10.1007/978-3-030-51614-7_3

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Within each routine, there are a set of activities or behaviors referred to as rituals. Rituals are the special activities that help us navigate through a routine. For instance, the routine of grooming a young child after bath may include the following steps, or rituals: drying off with a towel, putting on lotion, diapering, getting dressed, combing hair, and then getting a big hug from mom. For young children, rituals may take on an emotional component because they provide a sense of comfort and control. If the routine example of grooming after bath is followed but mom forgets the ritual of giving a hug, many a parent can testify to the toddler tears that may occur! Little ones tend to thrive on rituals as they provide a sense of predictability that toddlers crave. However, caregivers must continuously evaluate whether various rituals are (a) necessary for the routine that is occurring, (b) functional in that they make life easier, and (c) gradually being shaped over time to promote children’s independence. Each of these considerations will be discussed further later in this chapter.

Importance of Routines for Development The predictability that routines provide help to regulate caregiver and child behavior, reduce stress, and ultimately allow for a home or classroom to run more smoothly. Routines are one of the environmental foundations that support healthy development in young children (Spagnola & Fiese, 2007). Talk with any preschool teacher and you will most certainly hear about the need for predictability and routine for a well-run classroom! Having planned times in which a family unit comes together contributes to the stable and nurturing environment that is critical for young children (Spagnola & Fiese, 2007). Research across the past few decades consistently supports the empirical link between predictability and healthy development and functioning, particularly with regard to social-emotional functioning, language acquisition and cognitive skills. Among a sample of over 8000 preschool children, increased participation by parent and child in five common routine activities at home (i.e., family dinner, reading, playtime, storytelling, and singing) was linked to higher social-emotional health and literacy (Ely, Gleason, MacGibbon, & Zaretsky, 2001; Gleason & Weintraub, 1976; Hart & Risley, 1995; Muniz, Silver, & Stein, 2014). These findings highlight that in essence, family routines help to create a stable living environment and give little ones the sense of security and organization they need to thrive toward developmental milestones. An additional routine that is strongly linked to positive development and behavior is the bedtime/sleep routine. A multitude of studies show that a healthy bedtime routine promotes good sleep which is essential for optimal health and functioning (Meltzer & Crabtree, 2015; Weissbluth, 2003). Without a functional bedtime routine, young children suffer from too little or poor-quality sleep, which compromises development and leads to higher incidence of challenging behavior (Gregory & Sadeh, 2012). Recent research also highlights the long-term benefits of childhood routines. Adults who experienced predictable sleep schedules and mealtimes as well as consistent participation in family and community activities during childhood

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demonstrated better time management and attention to tasks later in life (Malatras, Israel, Sokolowski, & Ryan, 2016). The researchers stress that routines not only provide a more secure sense of home life but also teach children self-regulation and self-discipline, which are key skills for later responsibilities in adulthood. Disruption of routines may cause anxiety, dysregulation, and for little ones, challenging behavior to occur. Most caregivers can recall a classic disruption to routine that occurs when first bringing home their newborn baby. All of a sudden, the established patterns caregivers had for eating, sleeping, and spending their free time are turned upside down! This example brings to light the importance of consistency in our lives and the angst that can arise when routines and patterns of the day are not in place. In fact, biology plays a role in the importance, if not necessity, of routines. Good routines help to regulate our body’s “clock” or natural circadian rhythm, a roughly 24-hour cycle that tells the body when to do basic functions such as sleep, eat, and other physiological processes by responding to light and darkness. Similar to the “optimal times” to sleep and wake, circadian rhythm also relates to our daily activities due to its regulation of neurochemicals and hormone functions (Smolensky & Lamberg, 2015). Without these basic functions under control, both physical and emotional functioning are often compromised over the course of development. In young children, this can mean negative implications for developmental progression as well. A recent study found that shorter sleep duration in young children was associated with increased future risk of emotional disorder symptoms in boys and girls, as well as an association between reduced sleep and behavioral disorder symptoms in boys (Ranum et al., 2019).

 ow Does a Routines-Based Approach Fit H with Early Intervention? Helping families and other caregivers to reflect on current routines and establish healthy routines that will promote development is truly at the core of a family-­ centered, early intervention approach. Children typically receive one to 2 hours per week of early intervention home-visiting services in their natural environments (e.g., home or childcare). Children with complex medical or developmental needs may have a higher frequency of services. For most children, however, the home visitation sessions serve a very small percentage of their everyday routines. In fact, 1 hour per week of early intervention is actually only ~5% of the total wake hours for a child during a typical week. That is a small amount of time in comparison to all of the hours that each child and family will function outside of their early intervention support. Thus, routines-based intervention becomes a very logical approach in order to maximize the impact of services. Traditionally, early intervention has largely consisted of providers engaging young children in developmental play activities, with parents observing and practicing these interactions. While play is an excellent tool for teaching children new

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concepts and improving parent-child attachment (discussed further in Chap. 6), the reality is that most parents and caregivers do not spend the majority of the time they are with their children on the floor playing together. The routine activities of each day substantiate a larger majority of caregiving and time spent with children. Often times when we think of routines, some of the first concepts or mental pictures that come to mind are mealtime, bath time, and bedtime. Certainly, these are essential and frequently occurring routines within the day. However, early interventionists can think more broadly about what constitutes a routine in order for interventions to more accurately reflect the many patterns within a child and caregiver’s day together (e.g., picking brother up from school, checking the mail, feeding the dog, etc.). Each of these repeated activities provide many natural learning opportunities within them to promote developmental milestones in the domains of language, social-emotional, cognition, self-care, and motor skills. Thus, routines become the core of ongoing early intervention in order for strategies to translate into everyday life for a child and family.

Evaluating Routines and Rituals The true purpose of routines is not to simply have predictability but, more importantly, to make one’s life simpler, help the day run smoothly, and help children learn new skills and thrive. Early interventionists can help families reflect on their own routines and rituals and identify activities and times that are going well, as well as the most important parts of the day to modify in order to enhance their child’s development. When thinking about personal routines, providers must be mindful that routines are family-driven, not professional-driven. Each family has a unique set of patterns and rituals to their daily life, and the provider’s first task is to become familiar with these. Use of a routines-based interview (RBI) provides an excellent starting point. McWilliam (2010) outlines basic elements to conducting an RBI, typically done in a semi-structured format with caregivers. First, the family is asked about their main concerns for their child’s development. The interviewer then guides the family through a discussion of the progression of a typical day. A connection is made between each basic routine and the child’s engagement, independence, and social relationships. In the RBI protocol, the early interventionist is guided to ask the following questions asked about each routine: What does this look like? Where is everyone? What is your child doing? What is everyone else doing? How much does your child do for him/herself? What does your child’s communication like? How is your child interacting with others at this time? On a scale of 1–5, how well do you feel this time of day goes for you?

This discussion is meant to help guide the family in reflecting on well-­functioning parts of the day, connect routines and rituals to their child’s behavior, and then prioritize aspects of the day that should be modified in order to help inform an intervention plan (McWilliam, 2010). At the conclusion of the interview, the early

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interventionist will have (1) a list of functional outcomes, (2) a vast amount of relevant information, and (3) a positive start to rapport development with the caregiver. As an example, the following lists shows the useful information gathered through an RBI. Family outcomes for Myriah (Jadyen’s mother) 1 . Jayden will walk inside the house without falling down. 2. Jayden will put on his t-shirt independently and pull up his pants. 3. Jayden will wash his body with a washrag during bath time. 4. Jayden will stand still as Myriah puts on lotion after bath time. 5. Myriah will communicate frustration or disapproval to Jayden without yelling. As outlined earlier in the chapter, each ritual within a routine should be evaluated according to whether it is (a) necessary for the routine that is occurring, (b) making life easier, and (c) promoting a child’s independence. Consider the example presented previously of the rituals that could be part of a child’s grooming after bath routine. If after completing an RBI with this family, perhaps the parents shared that this routine is not going well (i.e., a “1” on the scale of 1 to 5 question) and that the child refuses the ritual or step of putting on lotion, as well as does not assist with getting dressed. These questions have helped to pinpoint two rituals within the routine that now may be the focus for subsequent intervention strategies. Without this specific information about the breakdown within a family’s routine, early interventionists can essentially “miss the boat” and work to implement strategies that don’t match the deficit or need. For instance, if a provider hears from a family that the overall routine of grooming after bath is difficult and doesn’t gather further details, they may suggest that the parents use verbal prompts before each step to help their child follow along. However, for this family’s situation, the verbal prompts may not be appropriate, as we still do not know the reason why the child is refusing to put on lotion, as well as what the child needs to be taught in regard to dressing skills. This example highlights the importance for early interventionists to take the time needed to assess for and evaluate daily routines.

Establishing Healthy Routines Many caregivers perceive routines to be difficult to both establish and maintain. The thought of “scheduling” daily life can often seem more like a chore than a helpful strategy to improve their child’s behavior and overall family functioning. Early interventionists can talk with parents about how routines and rituals not only make life easier for young children, but they can also help adults reduce stress and ease into parenthood. The early stages of parenting can be overwhelming, and finding ways to make life predictable and functional can be a great coping mechanism. In addition, routines may take time to fully establish and integrate into a young family’s lifestyle. Researchers found that parents of young babies reported fewer predictable routines than parents of preschool-age children (Fiese, Hooker, Kotary, &

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Schwagler, 1993). Parents of infants also reported less emotional investment in their family’s routines and rituals. During the first months of life, parenting is intensely focused on maintaining the patterns of feeding and sleeping. It may be that routines outside of these activities are more apparent and significant to parents as they head into the toddler years. It is important to remember that each family has individual priorities and values that require every routine to look a little different. In their “Essentials for Parenting Toddlers and Preschoolers,” the Centers for Disease Control and Prevention (CDC) offer a helpful example of how the routine of a 3-year-old child may differ across three different families, based on whether the child attends childcare or preschool, ages of other siblings, and other factors (Centers for Disease Control and Prevention, 2017). All three routines align with the basic recommendations for sleep and media viewing among young children but vary based on the family makeup and priorities. For instance, one child has an earlier wake up time at 6:30 AM and a short breakfast routine in order to get to daycare in time but eats dinner with his family in the evening and is in bed by 7:30  PM.  In contrast, another child doesn’t wake up until 8:00 AM and eats together with his mom and little brother every morning. However, during the evening, family mealtimes aren’t as consistent. This child goes to bed around 8:30 PM each night. The purpose of this comparison is not to pinpoint the right “timing” of activities for these young children or even the right manner in which to have a routine such as a mealtime. Rather, these case examples show that the routines across families have differences, but at the core, when basic principles are followed, and consistency and quality caregiving is present, these individualized routines all work. When helping families to establish functional routines, providers can start by examining the basic flow to their day, finding first what is going well and relates to appropriate behavior from their child, and then targeting areas that are consistently harder for that family. Early interventionists should be mindful of important guidelines by organizations such as the National Sleep Foundation or American Academy of Pediatrics (AAP). For instance, currently the AAP’s statement on media for young children is that “for children younger than 2 years, evidence for benefits of media is still limited, adult interaction with the child during media use is crucial, and there continues to be evidence of harm from excessive digital media use” (Radesky et al., 2016). In addition, providers should be aware of what other research supports in regard to healthy routines for young children. As summarized earlier, recent studies have shown the following types of routines to be most significant for optimizing social-emotional development: mealtimes as a family, appropriate bed/ wake times, nurturing interactions that involve uninterrupted attention to a child, and shared reading, singing, and story times (Gregory & Sadeh, 2012; Hart & Risley, 1995; Muniz et al., 2014; Spagnola & Fiese, 2007). Early interventionists can help families balance these findings with their own family priorities, values, and desired outcomes for their child in order to develop individualized routines. Sometimes, even something as simple as encouraging a parent to take a special ritual (e.g., stuffed animal or special prayer) from their own childhood and implement it within a routine with their child can engage that caregiver in a meaningful way

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Helping Children Follow a Routine

and promote the parent-child relationship. Specific strategies for helping families establish a healthy sleep and mealtime routine are provided as supplements to use with families at the end of this chapter.

Helping Children Follow a Routine The ability to follow new routines or adapt to changes to routine should be considered a skill that often needs to be explicitly taught to young children. In Chap. 5 on preventing challenging behavior, we will more closely examine strategies meant to teach routines via tools such as visual schedules. Caregivers and early intervention providers must be mindful that routines and the rituals within them need to be taught, rather than expected. Young children learn best from repeated practice with visual supports to aid their understanding. Visual schedules can be used for displaying routines that are the most important or difficult to follow each day. Figure 3.1 is an example of a visual schedule of the morning routine that is developmentally appropriate for a preschool age child. Photographs are typically more developmentally appropriate for a young child than clip art or other picture representations. More specifics on developing and implementing visual schedules is provided later in this text. Another key to helping children follow a routine is to plan for them to gradually become more independent with aspects of each routine. Early interventionists can provide parents with developmental guidance on what can be expected as their child continues to develop. Young children strive for a feeling of independence, and encouraging them to participate more in routines can help those times of day go more smoothly while also teaching important self-care skills like hand-washing, dressing, and communicating their wants and needs. Often times, teaching these skills requires considerable patience and attention from caregivers. But with time and practice, a child ends up learning to do more skills independently and Morning Schedule Eat breakfast

Put on shoes.

Put on backpack

Get in the car.

Fig. 3.1  Preschooler visual schedule with clip art

Put oncoat.

Have a good day!

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participate with less resistance due to routines providing the consistency and self-­ autonomy they are seeking. As with many behavioral preventions and interventions, providers can help parents see the longer-term picture that the effort and attention paid to routines now is setting the stage for better interactions and reduced behavior challenges to come.

Using Routines As a Basis for Early Intervention Strategies Early interventionists are trained to readily identify “routine-based” strategies that promote children’s development. Routines-based intervention is at the core of the IDEA, Part C model described in Chap. 1. This approach emphasizes the role of the family in change and helps to increase the amount of learning opportunities that occur within what a family is already doing (Crawford & Weber, 2014). Routine-­ based strategies can essentially include countless types of activities, such as giving a prompt to prepare a child for bath time, teaching turn-taking during ball play, or helping a child attend to a book with their caregiver. Essentially, all routines that involve a caregiver and child offer the potential for learning. Many times, caregivers go through the flow of the day without considering the teaching and prompting that can occur in seemingly ordinary moments. While the focus of this book is on behavioral development (e.g., social-emotional development), let’s consider for a moment how one simple childhood routine – hand-washing – hits on all areas of development. Within this routine, a child can learn self-care skills (cleaning their hands), sequencing skills (following the steps of hand-washing), gross motor skills (stepping on the stool at the sink), fine motor skills (turning on the water), communication skills (on/off, hot/cold), and social skills (looking at himself and mom in the mirror). This example is meant to highlight the infinite teaching possibilities within routines and rituals that are already occurring. This concept can be applied to teaching social-emotional skills as well. Think for a moment about how many opportunities can be embedded into a child’s daily routine to teach and practice turn-taking. You may already have three to five examples come to mind!

Chapter Summary The task of early intervention providers is to match learning opportunities within the context of daytime routines to the desired developmental and behavioral outcomes for a child. Essentially, the focus on routines for improving behavior can be twofold. First, some routines simply need to be modified or structured more in order to be functional and lead to pro-social skill development. For instance, if a family’s bedtime routine has too many rituals that prolong the time leading up to the child sleeping, an early interventionist may begin by helping parents eliminate certain rituals such as kissing every stuffed animal before getting in bed. This would reduce

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the bedtime routine and ensure adequate sleep hours. A second focus on routines is to identify how various preventions and interventions can be incorporated into daily schedules to help move the family toward the desired outcome(s) for their child. In the example of turn-taking above, mealtimes, playtime with peers at childcare, and reading a book during the bedtime routine may all be identified as opportunities for teaching a particular skill. In summary, home visiting in early intervention requires that providers consider to how to help the family achieve their goals within the context of natural, daytime routines. Within this context, children will have the most opportunities to learn desired skills and caregivers will be equipped with the information they need to promote their child’s development.

Supplemental Materials Strategies for Healthy Eating Behaviors Age Newborns 2–4 months 5–6 months

Typical development of feeding skills Hand-to-mouth activity, play or mouth fingers and hands Expects feeding at regular intervals, visual recognition of nipple or bottle Begins finger feeding, plays with spoon, choking on breast or bottle is rare, one sip at a time from a cup, ability to swallow pureed food 7–8 months Feeds self a cracker, may hold bottle independently 9 months Uses two hands to hold cup/bottle, more precise feeding, reaches for spoon and may insert in mouth 12 months Finger feeds independently, holds and lifts cup with some spillage, brings spoon to mouth but inverts spoon before mouth, fills spoon poorly Preschool Can eat independently, can ask for preferred foods, is still developing taste buds and preferences School age Begins to make food choices outside of the home environment at school, friends’ houses, etc. Teenage Can prepare food for self Information adapted from DOH Publication Number 961–158

Creating a Mealtime Routine • Develop a structured mealtime routine. • Teach your child the importance of sitting at the table during meals, no food or drinks should be allowed anywhere else in the house. • Have children participate in meal preparation or setting table. • Things to consider:

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1. Caregivers must role model appropriate mealtime behaviors for children (e.g., sitting down at the table, turning off all distractions, eating healthy foods, using manners). 2. Post your routine on the refrigerator or wall to help you and your child stay on schedule. 3. Begin by prompting your child 15 minutes before the routine will begin. 4. Kids take more time to eat than adults so take your time eating your meal and enjoy sitting a few minutes at the table before cleaning up. 5. Offer children foods from all the food groups at meals. 6. Buy plenty of fruits and vegetables to offer at snack times as well as mealtimes. 7. Bake, broil, steam, or grill your food. Don’t fry. 8. Young children are messy eaters and should not be forced to be neat. Use newspapers under their chair as they acquire the skills to eat neatly. 9. Mealtimes should be no longer than 30 minutes. For children who do not want to remain seated at the table, set a timer and demand that they stay at the table for 10 minutes. Over time, increase the time spent at the table so that it is sufficient to consume a full meal.

Do’s and Don’t’s for Parents • DO develop a plan/script for how you are going to cope with crying or refusal/ avoidance behaviors. 1. Remember to redirect your child to the table and say, It is time to eat. 2. First we eat, and then we play. • DO share your plan with all caregivers. Mealtime routines are most effective when followed consistently by all caregivers in all settings (weekdays/weekends, home/Grandma’s house). • DO control your own stress and frustration at mealtime. Children recognize and reflect caregivers’ moods, especially in fearful situations. • DON’T allow your child to depend on a bottle or sippy cups with milk for their primary source of calories if your pediatrician has indicated that the child can transition to a solid food diet. • DON’T take phone calls during meals. Phone calls can be returned after meals. • DON’T give in to pleas to eat more preferred ‘junk foods’ like crackers, cereal, or pizza at every meal. Children need to eat balanced diets that consist of fruits and vegetables, meat and beans, grains, and dairy. Giving in to avoid a power struggle seems logical but has negative long-term effects. Children quickly learn behaviors to avoid eating non-preferred foods and use them more often and more forcefully over time. • DO encourage your child to try a food even if they previously tried the item and did not like it. Children’s taste buds change as they age so you will want to try and reintroduce foods every 3–5 months. Even if they do not eat the whole serving right away, encourage them to try one bite.

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• DON’T reinforce your child if he/she gets out of his seat. If child leaves the table: 1. Return child to the table immediately. 2. Do not provide positive reinforcement by hugging, soothing, or attention (even direct eye contact can be attention). • DO limit sugar (refined sugar). This includes pastries, ice cream, cookies, candies, snack bars, soda, fruit juice drinks, and sports drinks. Offer fruit for snacks and desserts. Fruit juice offers no nutritional benefit and should not be given to infants younger than 6 months of age (American Academy of Pediatrics, 2005). Speak to the pediatrician about recommendations for fruit juice consumption. • DO limit potato chips and other fried snacks.

Specific Mealtime Interventions Functions of Behavior • Your child is positively reinforced for crying or having a tantrum by gaining your attention (both positive and negative attention are reinforcing) and by avoiding eating. Incentives • As soon as your child sits at the table, reinforce him/her for following directions. Throughout the meal, be sure to praise your child for trying foods, doing “good eating,” and using manners. Expect Extinction Bursts • Children’s behavior often gets worse when caregivers change the way they respond. When you begin using these strategies, expect your child’s behavior to get worse before it gets better. If your child’s challenging behavior escalates, stay calm and stick to your plan. Complete Ignoring • Do not provide attention for whining or crying at the table. If they spit food out, gag, or vomit, involve them in the clean-up process and do not give them attention for the inappropriate behavior.

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Tips for Weight Gain If your child is having trouble gaining weight, here are some tips for hiding extra calories: 1. Add 2–4 tablespoons powdered milk to 1 cup milk. Mix into puddings, potatoes, soups, ground meats, vegetables, or cooked cereal. 2. Carnation instant breakfast can be added to milk or pureed fruit to make milk shakes. 3. Blend eggs into milkshakes or other drinks. Eggs can also be added to hamburger meat, soups, and casseroles. 4. Add oil, butter, or margarine to casseroles, sandwiches, soups, vegetables, cooked cereal. 5. Mix dried fruits and nuts into cereals or desserts. 6. Serve peanut butter on toast, fruit or crackers. 7. Use ice cream in milkshakes. 8. Provide 3 meals and 3 snacks per day. 9. No water or juice when child is thirsty, give the child milk or some type of milkshake/carnation instant breakfast/ensure.

Treatment Strategies for Sleep Problems Age Newborn 0–3 months Infant 4–12 months Toddler 1–2 years Preschool 3–5 years School age 6–12 years Teenager 13–18 years Adult 18–60 years

Basic sleep requirements 14–17 hours per day, waking every 2–3 hours for feedings 12–16 hours per day, including naps 11–14 hours per day, including naps 10–13 hours per day, including naps 9–12 hours per night, typically no longer taking naps during the day 8–10 hours per night 7–9 or more hours per night

Information adapted from American Academy of Sleep Medicine revised guidelines 2016

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Creating a Bedtime Routine • • • •

Create a structured but relaxed bedtime routine Teach your child to go to bed Don’t put them in bed after they finally fall asleep Things to consider: 1. Begin by prompting your child 15 minutes before the routine will begin 2. Post your routine on bedroom door or wall to help you and your child stay on schedule 3. Younger children may need pictures or visuals of routine activities 4. Start with calming activities such as brushing teeth, washing face, putting on PJ’s, reading a story 5. Limit routine to 15–20 minutes

Do’s and Don’t’s for Parents • DO develop a plan/script for how you are going to cope with crying or pleading at night (especially related to fears). 1. Find books to read with your child about common nighttime fears. 2. Conduct bedroom checks for “The Boogeyman.” Add a “search” of your child’s room into your bedtime routine, use a flashlight as your tool. Be careful not to allow your search to become a game. It is a calming, reassuring activity, not an exciting race. • DO share your plan with all caregivers. Bedtime routines are most effective when followed consistently by all caregivers in all settings (weekdays/weekends, home/Grandma’s house). • DO control your own stress and frustration at bedtime. Children recognize and reflect caregivers’ moods, especially in fearful situations. • DON’T allow your child to depend on a bottle to fall asleep or have a bottle in the middle of the night after 4 months of age. Falling asleep while feeding from a bottle is risky for children’s health and development. • DO provide your child with a sleep aid, such as a nightlight, flashlight, toy, or blanket to provide comfort and reduce fears. • DON’T allow bedrooms to be play-zones. Bedrooms should be sleep-only zones. Reduce over stimulating bedrooms that have lots of toys or clothes in sight and walls with high intensity colors. • DON’T give in to pleas to postpone bedtime. Giving in to avoid a power struggle seems logical but has negative long-term effects. Children quickly learn which of their behaviors will successfully postpone bedtime and use them more often and more forcefully each night.

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• DON’T reinforce your child if he/she gets out of bed. If child leaves bed or bedroom to escape sleep: 1. Return child to bed immediately. 2. Do not provide positive reinforcement by hugging, soothing, or attending to their behavior (even direct eye contact can be attention). 3. If child has been frightened, only comfort in his/her bed, not yours.

Specific Sleep Interventions Functions of Behavior • Your child is positively reinforced for crying or having a tantrum by gaining your attention (both positive and negative attention are reinforcing) and by avoiding going to or staying in bed. Cautions • Briefly check on your child if his/her crying is different, prolonged, or intense to ensure safety. Incentives • As soon as your child wakes up in the morning, provide reinforcement for staying in bed and not crying. Simply offering enthusiastic verbal praise may help improve bedtime behavior, I am so proud you stayed in your bed all night! You are such a big boy! Expect Extinction Bursts • Children’s behavior often gets worse when caregivers change the way they respond. When you begin using these strategies, expect your child’s behavior to get worse before it gets better. If your child’s challenging behavior escalates, remain calm and stick to your plan. Complete Ignoring • Put your child to bed following bedtime routine. • When your child cries after being put to bed and during the night, do not respond.

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Gradual Ignoring • Put your child to bed following the bedtime routine. • If your child cries after being put to bed or during the night, immediately check on him/her. • Begin spending less time with your child each time you enter his/her bedroom to comfort. For example, if you had been spending an average of 30 minutes with your child, reduce that time to 25 minutes. • Once the preset attending time is up, leave the child and do not return. If the child falls back to sleep and awaken again, repeat the process. • Over time, reduce the amount of time you spend with your child during these attending periods. Bedtime Pass • Use an index card as a pass giving the child permission for one out-of-bed experience per night. • Child surrenders pass to caregiver after using it. • Pass used for specific activity only (bathroom visit, drink, etc.) • All other crying, complaining, and escaping behaviors are ignored, and the child is immediately returned to bed. • For severe behaviors, several passes per night and reduce the number of passes over time. Brief Checks • Put your child to bed following the bedtime routine. • If child cries after being put to bed or awakens during the night crying, briefly check on your child every 5–10 minutes until he/she stops crying. • During these checks, do not give extended attention to your child. Simply give your child a pat on the back or head, position the child’s blankets, or say “goodnight.” Leave the room. • Over time, as your child begins to sleep longer, increase the time between checks. Gradual Withdrawal of Caregiver • • • • •

Prior to beginning this program, put a bed for yourself in your child’s room. Put your child to bed following the bedtime routine. If your child cries, lie down on your bed and pretend to be asleep. While you are pretending to be asleep, ignore the child’s crying. Once your child has fallen asleep, leave the room.

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• If your child cries during the night, return to the child’s room and your bed there. Pretend to be asleep and ignore the child’s crying. Again, leave when the child falls back to sleep. • After 1 week, return to sleeping in your own room and ignore your child’s crying.

Separation Games that Help Support Sleep Because sleep can create fears about being left alone, playing separation games during the daytime help both caregivers and child become comfortable with the process. 1. Playing disappearing games with objects is easier than having a favorite person disappear. Start with what is not so emotionally charged for the child. Hide favorite toys under sofa cushions, under tables, around the room threshold, and so on. Then encourage the child to find “Big Bird.” You can hide and retrieve objects or make the game more elaborate by hiding the toy, then take the child outside the room for a few seconds with you, then run back to find the toy. 2. Spray away. For children that fear the “monsters” in the dark, use a spray water bottle to ritualize spraying the monsters out of the room. 3. Play peek-a-boo around comers of rooms, from under blankets, and behind furniture. Play games that move from one room to another, like rolling a ball and chasing it into the next room or playa “magic carpet” ride, pulling the child on a beach towel from one place to another in the house. Create spaces to crawl through, like a big box. 4. Make a “goodbye” book with pictures of mom, dad, and child, including mom waving “goodbye,” coming home, and the like. Use the book to read to the child. The caregivers can give it to him when they leave him at the babysitter’s or at day care. 5. Many caregivers slip out the door to avoid goodbyes. Let the child see caregivers get ready to leave. Ritualize the goodbye so that the child can predict the routine. When leaving him/her with the babysitter, take some extra time so that it’s not a rushed time. The caregivers should be sure to have a reunion when they return, offering a hug and a kiss. The caregivers may practice saying goodbye and leaving for short periods of time while they do a brief chore (e.g., 5 minutes), gradually increasing the time that they are away. 6. Leave a “transitional object” (stuffed animal, keys, blanket) with him/her when the caregivers leave. The caregivers should carry this object with them and their child when going places to attach special meaning to it. It becomes a symbol that they will come back.

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References Centers for Disease Control and Prevention. (2017). Essentials for parenting toddlers and preschoolers: Examples of family routines. Retrieved from cdc.gov/parents/essentials/structure/ buildingblocks-family.html Crawford, M. J., & Weber, B. (2014). Early intervention every day! Embedding activities in daily routines for young children and their families. Baltimore: Brooks Publishing. Ely, R., Gleason, J.  B., MacGibbon, A., & Zaretsky, E. (2001). Attention to language: Lessons learned at the dinner table. Social Development, 10(3), 355–373. https://doi. org/10.1111/1467-9507.00170 Fiese, B.  H., Hooker, K.  A., Kotary, L., & Schwagler, J. (1993). Family rituals in the early stages of parenthood. Journal of Marriage and the Family, 55(3), 633–642. https://doi. org/10.2307/353344 Gleason, J. B., & Weintraub, S. (1976). The acquisition of routines in child language. Language in Society, 5(2), 129–136. Gregory, A.  M., & Sadeh, A. (2012). Sleep, emotional and behavioral difficulties in children and adolescents. Sleep Medicine Reviews, 16(2), 129–136. https://doi.org/10.1016/j. smrv.2011.03.007 Hart, B., & Risley, T.  R. (1995). Meaningful differences in the everyday experience of young American children. Baltimore: Paul H Brookes Publishing. Jennings, D., Hanline, M.  F., & Woods, J. (2012). Using routines-based interventions in early childhood special education. Dimensions of Early Childhood, 40(2), 13–22. Malatras, J.  W., Israel, A.  C., Sokolowski, K.  L., & Ryan, J. (2016). First things first: Family activities and routines, time management, and attention. Journal of Applied Developmental Psychology, 47, 23–29. https://doi.org/10.1016/j.appdev.2016.09.006 McWilliam, R. A. (2010). Routines-based early intervention: Supporting young children and their families. Baltimore: Brookes Publishing. Meltzer, L. J., & Crabtree, V. M. (2015). Pediatric sleep problems: A clinician’s guide to behavioral interventions. Washington, DC: American Psychological Association. Muniz, E. I., Silver, E. J., & Stein, R. E. K. (2014). Family routines and social-emotional school readiness among preschool-age children. Journal of Developmental and Behavioral Pediatrics, 35(2), 93–99. https://doi.org/10.1097/Dbp.0000000000000021 Radesky, J., Christakis, D., Hill, D., Ameenuddin, N., Chassiakos, Y. R., Cross, C., et al. (2016). Media and young minds. Pediatrics, 138(5), ARTN e20162591. https://doi.org/10.1542/ peds.2016-2591 Ranum, B. M., Wichstrom, L., Pallesen, S., Falch-Madsen, J., Halse, M., & Steinsbekk, S. (2019). Association between objectively measured sleep duration and symptoms of psychiatric disorders in middle childhood. JAMA Network Open, 2(12), e1918281. https://doi.org/10.1001/ jamanetworkopen.2019.18281 Smolensky, M., & Lamberg, L. (2015). The body clock guide to better health: How to use your body's natural clock to fight illness and achieve maximum health. New York: Henry Holt and Company. Spagnola, M., & Fiese, B. H. (2007). Family routines and rituals: A context for development in the lives of young children. Infants & Young Children, 20(4), 284–299. https://doi.org/10.1097/01. IYC.0000290352.32170.5a Weissbluth, M. (2003). Healthy sleep habits, happy child: A step-by-step program for a good night's sleep. New York: The Random House Publishing Group.

Chapter 4

Problem-Solving Behavior: The ABC’s of Behavior

Overview of Behavior According to the Merriam-Webster Dictionary, behavior is defined by (1) the way in which someone conducts themselves or behaves; (2) the manner of conducting, which includes anything the organism does involving action and response to stimulation as well as the response of an individual, group or species to its environment; and (3) the way in which something functions or operates (Heuristic, n.d.). Put more simply, behavior is anything we do and is observable and measurable by others. Furthermore, as first described by Skinner (1938), behavior is movement of an organism which can always be observed within the context of the natural environment (Skinner, 1938). Skinner’s theory of operant conditioning, also known as behavioral analysis, used both the stimulus and reinforcement to shape (teach) desired behavior, and he coined the terms stimulus, response, and reinforcement in his laboratory experiments (Skinner, 1938). Behavioral analysis has made great contributions to educational, therapeutic, and business settings to manage challenging behavior and conflicts and to improve learning and productivity (Skinner, 1953). Several therapeutic approaches and the field of Applied Behavior Analysis (ABA) are based upon the work of Skinner and subsequent colleagues and are used to help people with disabilities including autism spectrum disorder (ASD) and other behavioral health challenges achieve a better quality of life (Morris, Smith, & Altus, 2005). Finally, B. F. Skinner’s legacy extended to the study of environment-infant interactions and attachment (Gerwitz & Pelaeznogueras, 1992). Antecedents, Behavior, and Consequences  In current terminology, the stimulus is referred to as the antecedent, the response as the behavior, and the reinforcement as the consequence, hence the acronym ABC’s of behavior (Cooper, Heron, & Heward, 2001; Dyer, 2013). The antecedent refers to the action, event, or circumstance that occurred before the behavior and might have contributed to the behavior. We might describe these as setting events or triggers, such as the presence of another person, the time of day, the current activity, or even a change in daily routine. Simply © Springer Nature Switzerland AG 2020 H. Agazzi et al., Promoting Positive Behavioral Outcomes for Infants and Toddlers, https://doi.org/10.1007/978-3-030-51614-7_4

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stated, answering simple questions of who, what, where, and when can help identify the antecedent or triggering event (Armstrong, Agazzi, Childres, & Lilly, 2012; Williams, Armstrong, Bradley-Klug, & Curtiss, 2010). For example, during a grocery shopping trip, a child notices his or her favorite candy at the checkout line and starts screaming for candy. The antecedent or triggering events to the behavior could include the time of day of the shopping trip, the proximity of the candy, waiting in line, other shoppers around the family, etc. The behavior refers to what the individual is doing and can be observed and described by others. Using the above example, the child notices the candy and begins screaming at his caregiver for candy and starts kicking the shopping cart. The screaming and kicking escalate, until the caregiver finally gives the child the candy. The child’s behavior is recognizable by others and can be defined in concrete terms such as screaming, kicking, falling on the floor, etc. The consequence refers to what happens following the behavior. The consequence is not necessarily negative or a punishment, so for clarity and to prevent confusion, this term was labeled as reactions by Agazzi, Childres, and Armstrong (2017) in their parent training program Helping Our Toddler’s, Developing Our Children’s Skills (HOT DOCS), further described later in this chapter. For example, if the screaming child described above is given candy, he or she may quiet down. Thus, the consequence or the parent’s reaction to the child reinforces or encourages the child’s misbehavior. And, if the child quiets down and enjoys the candy, the parent feels relieved, and therefore giving into the child’s demands is reinforced by the consequence (the child’s response). In this instance, we might conclude that the child learned that screaming results in getting candy, and the parent learned that giving in to their child’s misbehavior results in momentary reprieve from the noise and embarrassment.

Operant Conditioning According to operant conditioning theory, learning occurs when an association is made between a behavior and its consequence (Cooper et al., 2001). Thus, when a desired consequence or reward follows a behavior, it increases the likelihood that the behavior will occur again in the future. In the above example, the child got the candy he or she wanted and thus is more likely to engage in the challenging behavior in the future. Likewise, the parent was relieved when he or she gave in to the child’s demands and is also more likely to give in to the child in future situations. Behaviors followed by adverse consequences or punishments, on the other hand, are less likely to happen again. In the above example, if the parent had continued to ignore the child and continued checking out of the store, the child would eventually calm down and would be less likely in the future to demand candy. The adverse consequence in this case would be loss of parent’s attention, and no candy. Note that the parent in this instance who ignored the misbehavior would be rewarded by a less

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demanding child in the future. But indeed, ignoring child disruptive behavior in public settings is difficult for most caregivers, even those with strong parenting skills! Operant learning also considers the timing of consequences/reactions to the target behavior in shaping and teaching new behaviors. For example, the more immediate and consistent the reward, the more powerful it becomes (Cooper et al., 2001). A parent who immediately praises their child for sitting quietly in the grocery cart is likely to see that behavior repeated in future shopping trips. A parent who commends their child for asking in a polite voice for candy and lets him or her choose a treat is also likely to witness that polite behavior in the future, versus the screaming and kicking described in the example above. Note that the timing and frequency of the reinforcement becomes more complicated once an individual has acquired a new behavior but in learning new skills immediate and consistent reinforcement work best. Other terms that are used in operant conditioning (e.g., learning theory) include shaping and chaining. Shaping is a process which rewards closer approximations to the desired behavior, and chaining refers to breaking down a task into smaller steps and then teaching and linking the steps (Cooper et al., 2001; Skinner, 1938, 1953). Teaching a young child to tie a shoe could involve breaking the task down, teaching each step in the process, and praising successes until child masters shoe tying. Finally, consequences including reinforcement and punishment are the tools that are used to shape or modify behavior. Reinforcement includes any response following the behavior that increases the probability of the individual performing that behavior in the future. Punishment is any response following the behavior that decreases the likelihood of that behavior in the future. This is also referred to as conditioning. Conditioning refers to learning involving the formation, strengthening, or weakening of an association between a stimulus and a response (Cooper et al., 2001; Skinner, 1938, 1953). For example, if a child enjoys playing games on the tablet, his parent might allow more tablet time after the child helps with simple chores (e.g., pick up shoes and toys). This is also referred to as positive reinforcement, if earning extra tablet time increases the child’s willingness to complete chores. Negative reinforcement refers to the removal of a consequence that the individual does not desire, in order to reinforce desired behavior. For example, if a parent wants her child to help with chores, and the child does not like the parent nagging, the child helps with chores, and parent stops nagging. An adult example of the power of negative reinforcement would be slowing down when driving on the interstate in order to avoid a speed trap (and subsequent ticket and driver license points). Positive punishment is a response that decreases undesired behaviors when it follows the behavior. For example, a child refuses to stop playing and clean up his or her toys. The parents may try to reduce this behavior by making the child do even more chores around the house besides cleaning up toys if the child does not stop playing. Negative punishment, using the same example, would have parents remove the toys and put them out of reach, thus decreasing the noncompliance, if the child does not stop playing and help clean up (Prince, 2013).

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Function of Behavior Furthermore, from a behavior analysis lens, every behavior has a purpose, which expresses the person’s desires, feelings, and preferences. When we refer to the function of the behavior, we are talking about the reason that the behavior occurs (Cooper et al., 2001). In young children, the function of behavior is frequently thought to be a form of communication (Agazzi et al., 2017; Neidert, Rooker, Bayles, & Miller, 2013). Careful observation of child behavior can help adults understand what children are attempting to communicate and develop interventions to make communication more successful for them. The possible functions of behavior are described as (1) access to something, such as attention from a parent, or obtaining a desired object or activity; (2) escape from something, such as social interaction, or perhaps avoiding a demanding task or discomfort; and, (3) seeking sensory input, such as visual or kinesthetic stimulation that may feel good to the individual child. Behaviors that might express these functions include asking, yelling, grabbing, tantrums, aggression, or self-injury, and frequently young children repeat these behaviors in order to access what they desire or wish to avoid, especially if the behavior has worked for them in the past (Armstrong, Ogg, Sundman-Wheat, & Walsh, 2013; Kerr & Nelson, 2010). In cases of very young children or those with limited communication skills, challenging behavior is thought to serve a communication function or expression of their wants and needs and may be addressed using positive behavior support strategies (PBS; Fox & Duda, 2008). Note that when describing behaviors to, it is important to do so in an objective manner. That means that value-laden descriptions such as good or bad be avoided when discussing challenging behavior. Multiple observers will add value to the description of the behavior, as well as multiple times spent observing and recording the behavior. In psychology, this is sometimes referred to as the topography of a behavior, or the operational definition of behavior (Cooper et al., 2001), and is simply a way of stating objectively what the child did and what was observed. The function of the behavior, on the other hand, tends to be much more subjective, as it is an attempt to explain why the behavior happened. Notably, behavior may have more than one function. Functional Behavior Assessment (FBA) is a process of gathering information from a variety of sources to develop a hypothesis regarding why a child is displaying challenging behaviors in order to develop appropriate interventions (Tobin, 2001; Umbreit, Ferro, Liaupsin, & Lane, 2007). The function of the behavior must be assessed in terms of a child’s context/environment. This means determining what happens before the problem behavior occurs (i.e., antecedents that can lead to or exacerbate the problem behavior) and what happens after the problem behavior occurs (consequences that may be maintaining the behavior), and this is sometimes referred to as the ABC’s of behavior (Fader, 2019). Maintaining consequences are either positive reinforcement, such as attention or access to a preferred activity ­following the behavior, or negative reinforcement, such as behavior that results in avoiding activities which might be painful.

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Problem-Solving Behavior: Helping Our Toddlers, Developing Our Children’s Skills The Helping Our Toddlers, Developing Our Children’s Skills (HOT DOCS; Agazzi et al., 2017) behavioral parent training program teaches a set of practical parenting strategies founded in behavior analysis and positive behavior supports. The overarching aim of the HOT DOCS program is to improve the lives of young children with behavioral problems, including children with DD, and their caregivers by preventing problem behaviors and teaching new social-emotional and communication skills (Armstrong et al., 2012; Williams et al., 2010). The HOT DOCS Problem-Solving Chart (see Table 4.1.) is a tool that is used to help adult caregivers determine the function of challenging behavior, by providing a visual scheme. By accurately describing the behavior within the context of triggers (antecedents) and reactions (consequences), the caregiver can easily identify the function of child behavior, and whether the function helps the child obtain something (e.g., attention, an object, an activity) or escape something (e.g., difficult demands, pain). To simplify function, HOT DOCS uses the terms to “get” or “get out of” something. The problem-solving process is complete when there is enough information to develop a hypothesis or summary statement describing the function or purpose of the problem behavior. In order to complete the chart, caregivers and early childhood professionals respond to the questions in Table 4.1. The first step is to describe the behaviors of concern in operational terms, meaning, it is very clear what the child did to someone who did not observe or hear the behavior. This means that vague terms like “temper tantrum” or “aggression” are replaced with descriptions like “screamed, cried and rolled on the floor” and “hit his sibling.” Next, the triggers should be explored by answer a series of “Wh” questions. Then, reactions by other people in the environment can be identified. Finally, the function of behavior can be hypothesized based on the information collected in the top row of the HOT DOCS Problem-Solving Chart. Once the function is determined, attention can turn to the bottom row of the HOT DOCS Problem-Solving Chart. This method Table 4.1  HOT DOCS Problem-Solving Chart Triggers Describe events just before the behavior: · Where was the child? · What was the child doing? · Who else was present? · What were they doing? Preventions

Behaviors Specifically describe the behavior: · What did the child do? · What did you see or hear? Function: to ‘get’ or ‘get out of’

Reactions What happened following the problem behavior? · How did others react? · What actions occurred? · What happened in the room?

New skills

New responses

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guides caregivers in developing interventions that will likely both prevent problem behavior and teach the child new skills that are more suitable and age appropriate behavior. Alternative models to problem-solving behavior are available. For example, all data sources may be summarized using a Functional Assessment Matrix (Umbreit et al., 2007), from which a hypothesis may be developed to explain why the challenging behavior occurred. The Functional Assessment Matrix analyzes information collected by organizing it into cells. For example, if much of the information falls into the intersection of cells labeled “Obtain” and “Tangibles or Activities,” then it is possible that the function of behavior is to get tangibles or access activities. This information is then used to create a behavior intervention plan designed to decrease the challenging behavior and increase positive, prosocial behavior through manipulating antecedents and/or consequences of the behavior that align to function of behavior (Alberto & Troutman, 2013; Duda, 2011; Williams et  al., 2010). Interventions designed to teach a more appropriate behavior by replacing the problem behavior, e.g., preventions and new skills, will be discussed in detail in Chaps. 5 and 6. The next section presents simple case studies to demonstrate how one might determine the function of behavior using operant principles and the HOT DOCS Problem-Solving Chart.

Case Examples Problem-Solving the Function of Behavior Example 1:  Jake removes his clothes and tantrums on workday mornings. Mother helps Jake dress for preschool and then goes on to get dressed herself for work. When Jake’s mother leaves his room to get ready for work, he throws himself on the floor and pulls off his clothing while whining and crying. By the time mother is ready to go out the door, Jake is completely undressed and distressed. Mother is of course frustrated and worried that she will be late for work. Jake continues to resist her efforts to get him ready and out the door. Every morning is stressful for both. Jake cries all the way to preschool and must be carried into his classroom. Jake often misses breakfast at school because he is late or so distressed. The antecedent for this behavior is the morning routine. Mother is busy getting ready and not giving Jake attention that he likely desires. Jake may also be hungry as he does not eat until he arrives at school. The response or consequence for Jake’s behavior is that he receives mother’s attention, albeit because she must wrestle him to get him to school, and is so distressed when he gets there, which he misses breakfast. The function here may be both escape and attention. Jake may not want to go to preschool and may desire more time with his mother in the morning. Or perhaps Jake is hungry or bored, because he has nothing to do while his mother gets ready for her day. To figure out the function, mother will likely need to step back, observe his behaviors, and analyze the antecedents of the morning routine and consequences

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Table 4.2  Jake’s Problem-Solving Chart Triggers Morning routine; Jake is home with mother Mother wakes and dresses Jake and leaves his room

Preventions

Behaviors Jake whines and cries, throws himself to floor, undresses. Function: • Get his mother’s attention? • Get a playmate before school? • Avoid going to school? • Communicate hunger? New skills

Reactions Mother tells him to stop; carries him to the car; tells Jake to calm down; Jake arrives late to school and misses breakfast

New responses

Note. The top part of the chart is highlighted to indicate the focus is to first identify the function of a child’s behavior. Once function is identified, the bottom part of the chart will become useful for identifying strategies to replace problem behaviors

related to Jake’s behavior, especially her reactions. She also may wish to enlist the aid of Jake’s teacher, to find strategies that would help him (Table 4.2). Example 2:  When Hannah is told to clean up her toys before bedtime, she begins to tantrum. Hannah screams no, throws her toys, and falls on the floor. Sometimes she bangs her head on the floor, and her parent will hold her to prevent Hannah from banging her head. It has taken as much as a half hour to calm Hannah down, and then she may help her parent clean up the toys. Parent expresses that she is very stressed over this situation. The antecedent to this behavior is likely the time of the evening, as well as the bedtime routine. Hannah may be especially overtired or grumpy, as is her parent. The response to her behavior is that her parent gives her attention, perhaps not positive, and Hannah avoids going to bed for an extra half hour. Thus, the parent’s response serves to reinforce the problem behavior. This appears to be a function of escape, because Hannah does not want to stop playing and may not want to go to bed. It may be that Hannah also enjoys the extra attention that she gets from her parent to prevent head banging, as well as assistance in cleanup. Once again, parents will need to carefully observe her behaviors, within the context of the antecedents and consequences, to come up with a strategy to increase her cooperation and make the bedtime routine more enjoyable for all. Hannah may respond more positively if she is given an advance warning that play time is ending, extra attention and praise when she does cooperate with cleanup, a small reward such as a sticker for assisting, and a positive bedtime activity with her parent such as reading a book together (Table 4.3). Example 3:  Richie is a 4-year-old boy with developmental delays.

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Table 4.3  Hannah’s Problem-Solving Chart Triggers Bedtime; Hannah prompted to clean up toys.

Preventions

Behaviors Hannah screams no, throws her toys and falls on the floor. Function: • Avoid clean up? • Avoid bedtime routine? • Get her mother’s attention? • Get physical touch? New skills

Reactions Parent holds Hannah to prevent head banging. Parent holds Hannah and makes calming sounds until Hannah calms; parent cleans up toys

New responses

Note. The top part of the chart is highlighted to indicate the focus is to first identify the function of a child’s behavior. Once function is identified, the bottom part of the chart will become useful for identifying strategies to replace problem behaviors

During free-play at centers, Richie has been hitting other children at preschool (not hard) and laughs after he does that. Richie also grabs other children’s toys and runs off laughing or knocks over what they might be building. His classmates frequently tell him no or report his behavior to the teacher. Nobody wants to play with Richie anymore. Richie spends much of his day being reprimanded by his teacher and is taken to the time out chair. Richie does not stay in the time out chair and returns to disrupt his classmates. Other parents are complaining because they have heard about Richie’s behavior. The antecedent in this case may be that Richie sees other children playing and sees them with toys he desires. The consequence or reactions to his behavior are many and appear to reinforce his challenging behaviors. The children pay more attention to him – even though it does not appear to be positive attention. The teacher pays more attention to him and spends more time with him, trying to discipline him. Here, the function is probably attention. Richie wants the attention of his classmates and perhaps even his teacher, which may be the function of his challenging behaviors. Also, Richie does not yet have the words or play behaviors to join with his peers, so he needs to learn more appropriate communication and play behaviors. His teacher will need to carefully observe Richie, think about his challenging behaviors in the context of antecedents and consequences, and come up with a plan to help him interact more appropriately. This may include increasing her attention and use of praise when Richie does follow directions and approaches his peers in a positive manner. She will likely need to teach Richie how to complete time out, if that consequence is necessary and successful in curbing his aggressive behaviors (Table 4.4). In each of the three case presentations, observing the child and writing down the events that immediately precede an occurrence of problem behavior, describing the

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Table 4.4  Richie’s Problem-Solving Chart Triggers Behaviors Preschool classroom; many Richie hits peers and laughs; peers and teachers are present; takes their toys; knocks over playing alone during centers. their toys.

Preventions

Function: • Get peer attention? • Join a peer during play? • Get teacher attention? New skills

Reactions Teacher reprimands Richie; teacher sends Richie to time out.

New responses

Note. The top part of the chart is highlighted to indicate the focus is to first identify the function of a child’s behavior. Once function is identified, the bottom part of the chart will become useful for identifying strategies to replace problem behaviors

problem behavior using concrete terms, and writing down the events that follow the problem behavior are critical to determining the function of the behavior and to develop the intervention plan (Christ, 2008). This information can be jotted down on index cards and kept for later analysis using the HOT DOCS Problem Solving Chart (Agazzi et al., 2017; Armstrong et al., 2012).

Summary Early intervention professionals can assist caregivers with understanding the function of child behavior (get something or get out of something) by identifying triggers to child behavior and reactions that maintain child behavior. Within the context of triggers (antecedents) and reactions (consequences), the caregiver can more easily identify whether the function helps the child obtain something (e.g., attention, an object, an activity) or escape something (e.g., difficult demands, pain). The HOT DOCS Problem-Solving Chart is a visual tool to guide caregivers in this process. The problem-solving process is complete when there is enough information to develop a hypothesis or summary statement describing the function or purpose of the problem behavior. This method guides caregivers in developing interventions that will likely both prevent problem behavior and teach the child new skills so they can engage in age-appropriate behavior. A blank HOT DOCS Problem-Solving Chart is provided as a supplement at the end of this chapter to guide families through their own problem-solving.

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Supplemental Materials

Problem-Solving Chart: Practice Identifying the Function Example 1 Triggers

Behavior

Reactions

Function:

Example 2 Triggers

Behavior

Reactions

Function:

References Agazzi, H., Childres, J., & Armstrong, K. (2017). Helping our toddlers, developing our children’s skills-third edition revised (3rd ed.). Tampa, FL: Department of Pediatrics, University of South Florida. Alberto, P. A., & Troutman, A. C. (2013). Applied behavior analysis for teachers (9th ed.). Upper Saddle River, NJ: Pearson.

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Armstrong, K., Agazzi, H., Childres, J., & Lilly, C. (2012). Helping our toddlers: developing our children’s skills. Tampa, FL: Department of Pediatrics, University of South Florida. Armstrong, K., Ogg, J., Sundman-Wheat, A., & Walsh, A. (2013). Evidence-based interventions for children with challenging behavior. New York: Springer. Christ, T. (2008). Best practices in problem analysis. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology V (pp. 159–176). Bethesda, MD: National Association of School Psychologists. Cooper, J. O., Heron, T. E., & Heward, W. L. (2001). Applied behavior analysis (2nd ed.). Upper Saddle River, NJ: Prentice-Hall, Inc. Duda, M. A. (2011). Do’s and don’ts of functional assessment. In G. Flick (Ed.), Understanding and managing emotional and behavior disorders in the classroom. Boston: Pearson. Dyer, K. (2013). Antecedent-behavior-consequence (A-B-C) analysis. In F.  R. Volkmar (Ed.), Encyclopedia of autism spectrum disorders. New York: Springer. Fader, S. (2019). Understanding the antecedent behavior consequence. Retrieved from https://www. betterhelp.com/advice/behavior/understanding-the-antecedent-behavior-consequence-model/ Fox, L., & Duda, M. (2008). What are children trying to tell us?: Assessing the function of their behavior. Center on the Social and Emotional Foundations for Early Learning. Retrieved from https://www.csefel.vanderbilt.edu/briefs/wwb9.pdf Gerwitz, J., & Pelaeznogueras, M. (1992). B.  F. Skinner’s legacy to human infant behavior and development. American Psychologist, 47(11), 1411–1422. https://doi. org/10.1037/0003-066x.47.11.1411 Heuristic. (n.d.). Merriam-Webster’s online dictionary. Retrieved from https://www.merriam-webster.com/ Kerr, M. M., & Nelson, M. C. (2010). Strategies for addressing behavior problem is the classroom. Upper Saddle, NJ: Pearson. Morris, E. K., Smith, N. G., & Altus, D. E. (2005). B.F. Skinner’s contributions to applied behavior analysis. The Behavior Analysist, 28(2), 99–131. Neidert, P. L., Rooker, G. W., Bayles, M. W., & Miller, J. R. (2013). Functional analysis of problem behavior. In D. D. Reed & J. K. Luiselli (Eds.), Handbook of crisis intervention and developmental disabilities: Issues in clinical child psychology (pp. 147–167). New York: Springer. Prince, K. (2013). The difference between positive/negative reinforcement and positive/negative punishment. Retrieved from https://www.bcotb.com/ the-difference-between-positivenegative-reinforcement-and-positivenegative-punishment Skinner, B.  F. (1938). The behavior of organisms: An experimental analysis. New  York: Appleton-Century. Skinner, B.  F. (1953). Science and human behavior. New  York: The Free Press, Simon and Schuster. Tobin, T. J. (2001). Parents’ guide to functional assessment. Educational and Community Supports, University of Oregon, 3(1). Umbreit, J., Ferro, J. B., Liaupsin, C. J., & Lane, K. L. (2007). Functional behavioral assessment and function-based intervention: An effective, practical approach. Upper Saddle, NJ: Pearson. Williams, J., Armstrong, K., Bradley-Klug, K. L., & Curtiss, H. (2010). HOT DOCS: A parenting intervention to prevent and address challenging behavior in young children. Journal of Early Childhood and Infant Psychology, 6, 1–20.

Chapter 5

Strategies to Prevent Problem Behavior

“An ounce of prevention is worth a pound of cure” is a familiar phrase to many of us. This sound piece of advice actually dates back to the 1700s, when Benjamin Franklin used it to warn about the need for coordinated fire prevention efforts at that time (Independence Hall Association, 2020). The importance of preventative efforts across many facets of society continues to be relevant today, evidenced by the development of prevention science utilized in education, health, and mental health (National Sleep Foundation, 2018). The idea behind prevention science is that preventing or reducing problems is much more effective than addressing issues once they are established. Likewise, when considering individual child behavior problems, preventions may be a more effective way to motivate children to engage in appropriate behaviors rather than resorting to problem behaviors, leading to better relationships with caregivers and more successful child outcomes. As discussed in Chap. 4, behavior may be viewed within the context of antecedents and consequences (reinforcement and punishment; (Cooper, Heron, & Heward, 2001; Prince, 2013). The antecedent is thought to trigger the behavior, meaning that the social or physical environment occurring just before the behavior occurs contributes to the expression of the behavior (Armstrong, Ogg, Sundman-Wheat, & Walsh, 2013). Following data collection from multiple observations of the behavior, including triggers, reactions, and function of behavior, preventions can be devised with the goal of reducing or eliminating problem behavior. This chapter will present research-based strategies which are proven to reduce challenging behaviors and help children learn important skills such as listening and following directions, functional communication, transitioning between activities, and mastering adaptive skills. As a first step in this process, careful observation of the child’s behavior will help caregivers gain a better understanding of the child’s strengths and needs, likes and dislikes, and motivators (Green, 2016). This process is sometimes referred to as a functional assessment (Ala'i-Rosales et al., 2019).

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Understanding the Child’s Behavior The first step in reducing or eliminating challenging behaviors is to understand the child’s behavior and especially patterns of behavior. For example, challenging behavior in young children may be viewed as a communication attempt. If this is the case, then caregivers may determine what the child is attempting to communicate by observing and documenting the behavior. In turn, this will help them to identify a replacement skill for the child to communicate his/her wants in a functional manner and reduces the child’s need to use challenging behavior to get needs met (Chazin & Ledford, 2016). Child preferences such as play activities, foods, or social interactions are important motivators that may be determined by observing a child when they are comfortable and calm. Preferences may also be noted by noticing what makes the child smile or seem happy. These motivators are sometimes referred to as functions of behavior. The function of a behavior is thought to stimulate the child’s behavior toward a goal. Knowing what the child wants gives caregivers ideas as to how to teach and reward new behaviors and skills. For example, adult attention may be a very powerful motivator for some children. Others may wish to escape from certain situations, people, or demands. Sometimes, children may even be motivated by sensory stimulation. Hypothesizing what the child wants to avoid or what upsets him/ her also gives the caregiver or professional clues about how to adapt their interaction style or the environment in order to help the child. Observing child strengths (e.g., agility, cooperation, willingness to follow directions and rules, communication skills) as well as child weaknesses (e.g., inattention and distractibility, irritability, communication delays) offers caregivers and professionals clues as to what skills to build upon and what new skills need to be taught (Donaldson & Austin, 2017). The behavior that we want to change is often referred to as the “target behavior,” while the behavior or new skill to be taught is termed the “replacement behavior” (Williams, Armstrong, Bradley-Klug, & Curtiss, 2010). After carefully observing and documenting the child’s behavior across contexts and with different people, the caregiver and/or professional will better understand what sets the child’s behavior in motion. To review briefly, this is referred to as the antecedent or trigger and includes anything else that happens just before the behavior occurs such as where the child is, what he/she is doing, where the adult is, and what he/she is doing (Agazzi, Childres, & Armstrong, 2017). Antecedent-based strategies become especially powerful when implemented in natural settings, such as home, community, and school environments. These strategies have been shown to reduce behavior problems in young children at risk for developing emotional disorders (Park & Scott, 2009). Furthermore, classroom teachers reported that antecedent-­based strategies were effective, acceptable and easy to implement (Park & Scott, 2009). Once the behavior is better understood, caregivers and/or providers will want to think about what prevention strategies they might put into place to prevent the behavior from occurring, as well as what new skills they would like to teach the child.

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Table 5.1  HOT DOCS Problem-Solving Chart Triggers Describe events just before the behavior: • Where was the child? • What was the child doing? • Who else was present? • What were they doing? Preventions • Ensure sleep and physical activity • Clear, calm directions • Use verbal and gestural prompts • Predictable routines • Visual schedules • Social stories • Use timers • Offer choices • First-then boards

Behaviors Specifically describe the behavior: • What did the child do? • What did you see or hear? Function: To “get” or “get out of” New skills

Reactions What happened following the problem behavior? • How did others react? • What actions occurred? • What happened in the room?

New responses

Prevention Strategies Prevention strategies are another term for antecedent-based strategies and refer to ways that the environment can be modified, or caregiver actions can be changed, to improve child behavior or make it less extreme. Prevention strategies should be implemented before a problem behavior occurs, so that it lessens the need for the behavior to occur. Preventions include the following components: (1) reduce triggers, (2) clearly prompt desired behaviors, (3) promote independence and allow for practice with positive exposures, and (4) improve transitions between activities. Table 5.1 contains a list of prevention strategies that will be discussed in this chapter. New skills and new responses will be discussed in later chapters. All strategies must be individualized to the child, with consideration of his/her behavioral and developmental functioning. Each of these categories is discussed next, with a case example presented.

Preventions Reduce Triggers Predictable Routines  Consistent routines are critical in establishing a feeling of predictability and serve to regulate child behavior (Wildenger, McIntyre, Fiese, & Eckert, 2008). Stable routines have been found to reduce stress for children challenged by poverty and single-parent homes (Spagnola & Fiese, 2007b). For example, children with consistent and organized bedtime routines are healthier and less

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likely to experience sleep problems and consequent disruptive or irritable behavior during waking hours (National Sleep Foundation, 2018). Overall, children’s health is improved when predictable sleep routines are maintained and reinforced (Armstrong, 2009). Predictable family mealtimes have been shown to improve child health and well-being (Fiese, 2008). Both consistent bedtime and mealtime routines are associated with competence in social and pre-academic skills for children enrolled in Head Start programs (Spagnola & Fiese, 2007a). Functional routines are extremely important in teaching children with developmental delays and disabilities, like autism spectrum disorder (ASD), more functional skills (Rodger & Umaibalan, 2011). For example, children with ASD have difficulty understanding pragmatic language, so they need consistent cues to help them understand what is happening around them and what is expected of them. Many children with ASD also have sensory processing challenges, which further create discomfort in their interpretation of sensory input surrounding them. Finally, children with ASD may have difficulty organizing their thoughts and translating these thoughts into actions. Predictable routines help them understand their world better and, thus, support more independence in daily activities for children with developmental problems. The consistent implementation of routines helps to facilitate skill acquisition, communication, and social interactions. Daily activities such as sleeping, dressing, eating, and playing can all be enhanced by teaching and reinforcing consistent routines in those domains. For children who are young or those with language delays, directions should be stated in simple terms the child understands and paired with hand gestures in effort to improve child compliance. Many children find it easier to follow routines where pictures are used to demonstrate the steps within that routine. Providing advanced notice of the beginning and end of an activity also helps children participate in and complete routines successfully. Finally, a key strategy to motivating children to follow a routine is to offer a preferred activity once the routine is completed (Agazzi et al., 2017). Environmental Adaptations  Slight changes in the child’s environment can be used to promote engagement, show children what to do, and help them to develop social/emotional competencies, as well as to prevent challenging behaviors (Hemmeter, Ostrosky, & Corso, 2012). These adaptations are frequently referred to as positive behavior supports and have been used to help children participate in home, school, and other environments (Fox, Dunlap, & Cushing, 2002). In a study with over 700 toddlers at risk for problem behavior and their low-income parents, positive behavior supports were found to reduce or prevent problem behavior (Dishion et al., 2008). Specifically, Hancock and Carter (2016) discussed strategies used in high-quality, supportive classroom environments to promote young children’s social and emotional development and prevent and address challenging behavior. The environmental strategies recommended included having adequate materials available, defining play centers, offering a balanced schedule, planning structured transitions, and individualizing instruction for children needing extra support (Hancock & Carter, 2016).

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Environmental preventions to ensure child safety are referred to as “baby-­ proofing,” or protections put into place to prevent injuries or even deaths (National Safety Council, 2020). Covering electrical outlets, installing child-proof locks, placing gates in doorways or stairwells, building fencing, using only cordless window products, and installing pool alarm systems are some options to make homes safer. All medications should be kept in child-proof containers and maintained out of the child’s reach. To protect children from damaging high-tech equipment or valuable items (e.g., vases, picture frames) and from hurting themselves, place the equipment out of the child’s reach or secure it to hold it in place. Color coding is one way to designate safe areas for play or permission to access to certain objects. These preventions not only protect children (and expensive equipment) from harm but also teach children to respect boundaries. Caregivers and professionals can encourage independence in daily routines through the use of environmental preventions like having defined areas in the home for play, homework, meals, or dressing. Designating a place for each family member at the dinner table helps children know where to sit during mealtimes. Storing children’s toys in designated crates will help children remember where their favorite objects are and later help them learn to clean up their toys. Adaptive equipment such as Velcro fasteners to help with dressing, or special cups to help with drinking, gives children with delays tools to manage everyday items successfully and promotes independence (Williams et al., 2010).

Preventions Clearly Prompt Desired Behavior A number of prevention strategies may help caregivers communicate more effectively with their child, including giving clear directions, gaining the child’s attention before interacting, using simple language, and pairing words with gestures or pictures (Agazzi et  al., 2017; Armstrong, Agazzi, Childres, & Lilly, 2012; Williams et  al., 2010). Each of these strategies is discussed in more detail in this section, beginning with giving clear directions. Giving Clear Directions  Understanding how to give clear directions that children understand is essential to improving child compliance. To give clear directions caregivers must ensure the (1) directions are specific, (2) developmentally appropriate, (3) stated positively, and (4) given one at a time. Specific directions mean that the adult tells the child exactly what he/she is expected to do, such as “Please keep your hands to yourself.” Developmentally appropriate directions include tasks which the child is able to do easily. For example, a 3-year-old child is unlikely to be able to tie their shoes but may be able to put their shoes on their feet. As such, the caregiver would state to the child, “Put your shoes on.” Stating a direction positively means that the caregiver tells the child what is expected of them, rather than what they should not do. So instead of saying “stop running,” the caregiver might say “walk beside me.” Giving one direction at a time helps young children and children with

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attention problems remember what they have been told to do and, thus, helps them to be more successful. Rather than saying “clean up your toys and put the toy box in your room,” one might say “put the Legos in the box.” Prior to giving the next direction, the child should receive a labeled praise for compliance with the first direction, “Good listening!” Gaining a Child’s Attention  Gaining the child’s attention before giving directions or starting a conversation ensures the child is listening. Rather than calling out across the room, it is important to move near the child. Caregivers and professionals should position their body at the child’s level and make sure that they have the child’s eye contact prior to beginning the discussion. It is important to create a pleasant interaction by conveying warmth such as through the use of a smile and, if the child enjoys touch, a gentle touch on their arm. This could also be a great time to use a clear and simple direction, such as “Look at Mommy,” and praise them once they do it. Caregivers should also be prompted to use a calm voice and role model appropriate facial expressions that match the emotion in their words. Using simple language that the child understands is critical to communication. Depending upon the child’s communication level, words may be paired with gestures or pictures, to get the point across. For example, using the sign for “all done,” while asking a child if they have finished their meal, helps to improve understanding and gives the child an appropriate way to respond, rather than using challenging behavior. Pictures (always paired with words) are also an effective way to help a child who is preverbal communicate. When children engage in prosocial communication, they should be praised for their efforts, and rewarding a child with a physical or stimulatory activity will likely make them want to please caregivers again in the future (Agazzi et al., 2017).

Preventions Improve Transitions Between Activities For many children, moving from one activity to the next creates confusion and frustration, which frequently results in challenging behavior. Prevention strategies, when applied effectively, can help children make smooth transitions and results in more independent behavior. Notably, many preschool teachers consider a child’s ability to make transitions between activities independently as one of the essential skills for success in kindergarten (Ostrosky, Jung, Hemmeter, & Thomas, 2008). Strategies to support transitions include verbal reminders and warnings, visual supports, visual schedules, first-then boards, and social stories. Each will be briefly addressed in turn. Verbal Prompts  Verbal reminders and warnings are issued between activities and help children prepare to leave one activity and move to the next. For example, a caregiver might say “5 more minutes before we leave for school” or might use a timer to signal the transition, again letting the child know that when the timer goes

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off, he must move to the next activity. This warning helps children anticipate what will be happening next in their life and, as such, prepares them to transition successfully. Visual Supports  Visual supports have been studied extensively in interventions for children with developmental delays/disabilities including ASD and language delays. According to Meadan, Ostrosky, Triplett, Michna, and Fettig (2011), visual supports may be used across environments (home, school, community), and with individual or groups of children. Different methods may be used to create the supports that include gestures, real objects, pictures, photos, or words, as well as combinations of the aforementioned methods. For example, a schedule of events during the day will help to ease transitions for many children. Visual supports may be used to help children follow steps in a new skill, such as brushing their teeth. Pictures can be made available to nonverbal children to help them communicate wants and needs, such as food, drink, play, and all done, often eliminating the need for challenging behavior (Armstrong et al., 2012). A note to caregivers and professionals regarding visual supports is to always pair the visual cue with spoken language, to help in the transition to spoken language. Visual supports to promote development will be further covered in the next section on functional communication. Visual schedules may use a combination of pictures and words to lay out a child’s day or steps within an expected routine. For example, most teachers will have a visual schedule posted to show children the daily activities that they will be participating in and, similar to visual supports, may point to the activities while describing the day. Skills such as dressing for school could also be listed in order on a visual schedule, which is then posted in a prominent place. Note that visual schedules must be reviewed frequently, for children to learn to follow them. And of course, as with any activity used to help children manage transitions, ample praise and rewards following the desired behavior will help children master expectations. Another type of visual support is a first-then board. The first-then board uses pictures as visual prompts to help a child anticipate one activity and the next and is often used to help children complete tasks they do not enjoy. For example, the first-­ then board would present a picture of a child taking cough medicine and then playing with a favorite toy. The non-preferred activity is followed by a preferred activity to help the child visualize the progression of events and complete the non-desired task (e.g., take cough medicine). As with other picture supports mentioned earlier in this chapter, caregivers should always say the word(s) aloud, when showing the first-then picture to the child, in order to build language skills. For very young children or those with language delays, actual objects may be used instead of pictures to communicate activity. Functional Communication Training  According to the American Speech-­ Language-­Hearing Association (ASHA), functional communication skills are forms of behavior that express needs, wants, feelings, and preferences that others can understand. When individuals learn functional communication skills, they can express themselves without resorting to challenging behavior or experiencing

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c­ommunication breakdown (ASHA, 2019). Functional communication has been used successfully to support communicative competence of children and adults with a wide range of complex needs (Beukelman & Mirenda, 2011). Functional communication can vary in its expression and may include movements, gestures, vocalizations, visual supports, or output from augmentative and alternative devices. This method of communicating must be practical, constantly available, and able to meet the specific needs of the child, as well as understandable by the caregiver (ASHA, 2019). Functional communication strategies were used to teach six preschool children with delays to request teacher attention, teacher assistance, and preferred materials during small-group classroom activities. Not only were the children able to use the functional communication strategies successfully, but they showed a decrease in problem behavior (Hanley, Heal, Tiger, & Ingvarsson, 2007). The approach was later evaluated and coined as the Preschool Life Skills (PLS) Program and found that the children not only improved but maintained their skills taught using this approach (Luczynski & Hanley, 2013). The Picture Exchange Communication System (PECS) was developed by speech therapists Andy Bondy and Lori Frost in 1995 to teach functional communication skills to young children with ASD. Since 1995, PECS has been applied worldwide with individuals with communication challenges (Bondy & Frost, 1995). PECS begins by teaching the individual to give a picture of a desired object or action to a communication partner, who immediately honors the exchange. PECS later goes on to teach children how to construct sentences, answer questions, make comments using pictures, and share emotions (Meadan et  al., 2011; Sharma et  al., 2019; Warren, Veenstra-VanderWeele, Stone, Bruzek, & Nahmias, 2011). Over 250 studies have been completed since inception of this program in support of this approach, a few of which are briefly reviewed below. In 1998, Schwartz, Garfinkle and Bauer documented the use of PECS in two studies teaching functional communication skills to young children with disabilities. They found that the children were able to learn to use PECS quickly and efficiently and that the children’s use of functional communication skills generalized to other settings (Schwartz, Garfinkle, & Bauer, 1998). In a meta-analysis, it was concluded that PECS was a promising intervention practice based upon the extant empirical literature for PECS, especially for preschool children and those with ASD (Ganz, Davis, Lund, Goodwyn, & Simpson, 2012; Warren et  al., 2011). Lastly, Warren et al. (2011) completed a review article on treatments for children with ASD and reported that PECS, when included as part of an intensive early intervention package, was effective in improving communication and reducing challenging behavior. Contemporary research on functional communication training focuses on the use of technology in helping individuals to interact successfully, including sharing emotions. In one study, an iPad was used as a speech-generating device in teaching nonverbal preschool children to make requests. It was found that using the iPad was equal to using more traditional pictures (Agius & Vance, 2016). Sharma and his

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colleagues (2019) used an Android app with emoji technology to help children with ASD communicate emotions to family members. Given the rapid development of technology as well as children’s awareness and competency using technology, its use to address educational and therapeutic challenges seems inevitable (Agius & Vance, 2016; Sharma et al., 2019). For example, researchers are studying how toddlers perceive and use words, how caregivers affect the outcomes for language therapies, and how to improve communication between children with and without developmental disabilities, utilizing technology such as a communication board with symbols and pictures and smartphone applications.

 reventions Promote Independence and Practice P Positive Exposures Choice  Offering choices to children helps them to indicate their preference for items, persons, or activities. Much of the research on choice-making has been conducted with children who have disabilities, but some studies demonstrate the effectiveness of this prevention with children without disabilities as well. Children who benefit most directly from this intervention are those who display problem behaviors to escape participation in activities or those avoiding materials that they find relatively unappealing, undesirable, or difficult (Dunlap & Liso, 2004). When a choice is offered in a way that meets children’s needs, it enhances motivation, learning, and well-being and also promotes a child’s development of independence (Katz & Assor, 2007). Choices can be offered in countless settings and activities, including meals, chores, classroom centers, routines, and play. Types of choices may include choosing materials during an activity, choosing which activity will come next, choosing a friend to sit with at lunch, and choosing clothing, food, or beverages. Depending on the child’s communication level, choices may be offered verbally (“Do you want juice or milk?”), by using actual objects (showing the child a juice box and milk carton and asking the question) or by using picture representations, such as a menu board of pictures (actual photos or drawings of the milk and juice cartons) from which the child can make his or her selection. Choices may be offered within and between activities. Evidence suggests that choice-making is effective in preventing behavior problems because it offers the individual some control or power over the environment. This control, in turn, motivates her or him to participate and remain engaged longer (Penne State Extension, 2018). Furthermore, giving children choices helps prepare them for independence in later life. Of course, the key to using choice effectively with children is deciding in advance what choices to offer them and limiting the choices to 2 or 3 (Armstrong et al., 2012). Further, caregivers must be okay with the choices their children make so it is important that they consider this in advance of giving the child options and not pose an option for which they are unprepared to

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follow through (e.g., play with messy toys or sleep in the caregiver’s bed). Examples of choices for young children include: “Would you like me to read to you or would you rather read it yourself?” “Would you like to nap on the couch or your bed?” “Would you like to use crayons or paint today?” “Would you like a peanut butter sandwich or a cheese sandwich?” In their meta-analysis of single-subject research studies using choice-making as an intervention, providing choice opportunities resulted in clinically significant reductions in the number of occurrences of problem behavior (Shogren, Faggella-­ Luby, Bae, & Wehmeyer, 2004). Task behavior for boys with ASD improved when choices were offered between activities or between materials (Ulke-Kurkcuoglu & Kircaali-Iftar, 2010). The use of choice has also demonstrated positive effects in helping children with ASD be successful in circle time within inclusive classrooms (Barton, Reichow, Wolery, & Chen, 2011). Role-Playing  Role-playing is a strategy used to teach children new skills through play in a safe environment. Role-playing allows children to act out scenarios and practice skills they will need to face difficult or new situations, such as going to the dentist or riding a school bus. Role-playing helps children build their self-­confidence, develop problem-solving skills, enhance their communication skills, and manage their emotions. For example, a child who may be facing an uncomfortable procedure, like a blood draw, might first role-play with his/her caregiver at home, using a play doctor kit, and take turns being the doctor and patient. Caregivers would rehearse this skill many times with their child prior to the real event. Visual supports can also be incorporated into the rehearsal to lay out the sequence of events or the steps the child would need to take to be successful. Small steps toward progress need to be reinforced by verbal praises and potentially tangible rewards for more difficult tasks.

Chapter Summary This chapter provided an overview of evidence-based practices used to prevent or reduce problem behaviors and improve behavioral and communication skills, as well as increase independence in young children with or without disabilities. We have long recognized that preventing or reducing problems in young children is much more effective than addressing issues once they are established and often unmanageable (Melmed, 2015). Behavioral practices have contributed to the methodology employed for prevention practices, including use of the functional assessment, function-based treatments, antecedent control, and applications of other behavioral principles (Williams et al., 2010). These strategies have been shown to inhibit challenging behavior in young children and promote better outcomes. Notably, any behavior change strategy must consider first of all, the caregiving

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relationship; the individual child’s wants, preferences, strengths, and needs; the context surrounding the child and family; and ability of the caregivers to implement recommended strategies. As the technology revolution unfolds, integration of new applications and devices will likely contribute to these interventions and their outcomes.

References Agazzi, H., Childres, J., & Armstrong, K. (2017). Helping our toddlers, developing our children’s skills-third edition revised (3rd ed.). Tampa, FL: Department of Pediatrics, University of South Florida. Agius, M. M., & Vance, M. (2016). A comparison of PECS and iPad to teach requesting to pre-­ schoolers with autistic spectrum disorders. Augmentative and Alternative Communication, 32(1), 58–68. https://doi.org/10.3109/07434618.2015.1108363 Ala'i-Rosales, S., Cihon, J. H., Currier, T. D. R., Ferguson, J. L., Leaf, J. B., Leaf, R., et al. (2019). The big four: Functional assessment research informs preventative behavior analysis. Behavior Analysis in Practice, 12(1), 222–234. https://doi.org/10.1007/s40617-018-00291-9 Armstrong, K. (2009). The young and the restless: A pediatrician's guide to managing sleep problems. Contemporary Pediatrics, 26(3), 28–39. Armstrong, K., Agazzi, H., Childres, J., & Lilly, C. (2012). Helping our toddlers: developing our children’s skills. Tampa, FL: Department of Pediatrics, University of South Florida. Armstrong, K., Ogg, J., Sundman-Wheat, A., & Walsh, A. (2013). Evidence-based interventions for children with challenging behavior. New York: Springer. ASHA. (2019). Retrieved from http://www.asha.org Barton, E.  E., Reichow, B., Wolery, M., & Chen, C.-I. (2011). We can all participate! Circle time for children with autism. Young Exceptional Children, 14(2), 1–21. https://doi. org/10.1177/109625061093681 Beukelman, D. R., & Mirenda, P. (2011). Augmentative and alternative communication: Supporting children and adults with complex communication needs (4th ed.). Baltimore: Brooke. Bondy, A. S., & Frost, L. (1995). The picture exchange communication system. In 1995 National Conference on Autism, (pp 117–120). Chazin, K. T., & Ledford, J.R. (2016). Challenging behavior as communication. In Evidence based instructional practices for young children with autism and other disabilities. Cooper, J. O., Heron, T. E., & Heward, W. L. (2001). Applied behavior analysis (2nd ed.). Upper Saddle River, NJ: Prentice-Hall. Dishion, T. J., Shaw, D., Connell, A., Gardner, F., Weaver, C., & Wilson, M. (2008). The family check-up with high-risk indigent families: Preventing problem behavior by increasing parents’ positive behavior support in early childhood. Child Development, 79(5), 1395–1414. https:// doi.org/10.1111/j.1467-8624.2008.01195.x Donaldson, J. M., & Austin, J. L. (2017). Environmental and social factors in preventing, assessing, and treating problem behavior in young children. Applied Behavior Analysis, 4(1), 9–16. https://doi.org/10.1177/237273221668394 Dunlap, G., & Liso, D. (2004). Using choice and preference to promote improved behavior. Center on the Social and Emotional Foundations for Early Learning. Retrieved from http://www.csefel.vanderbilt.edu/briefs/wwb14.pdf Fiese, B.  H. (2008). Reclaiming the family table: Mealtimes and child health and wellbeing. Society for Research in Child Development, 22(4), 1–20. Fox, L., Dunlap, G., & Cushing, L. (2002). Early intervention, positive behavior support, and transition to school. Journal of Emotional and Behavioral Disorders, 10(3), 149–157. https://doi. org/10.1177/10634266020100030301

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Ganz, J. B., Davis, J. L., Lund, E. M., Goodwyn, F. D., & Simpson, R. L. (2012). Meta-analysis of PECS with individuals with ASD: Investigation of targeted versus non-targeted outcomes, participant characteristics, and implementation phase. Research in Developmental Disabilities, 33(2), 406–418. https://doi.org/10.1016/j.ridd.2011.09.023 Green, J. (2016). Observation: The key to understanding your child. Retrieved from http://www. naeyc/our-work/families/observation-key-to-understanding-your-child Hancock, C. L., & Carter, D. R. (2016). Building environments that encourage positive behavior: The preschool behavior self-assessment. Young Children, 71(1), 66–73. Hanley, G. P., Heal, N. A., Tiger, J. H., & Ingvarsson, E. T. (2007). Evaluation of a classwide teaching program for developing preschool life skills. Journal of Applied Behavior Analysis, 40(2), 277–300. https://doi.org/10.1901/jaba.2007.57-06 Hemmeter, M. L., Ostrosky, M. M., & Corso, R. M. (2012). Prevention and addressing challenging behavior: Common questions and practical strategies. Division for Early Childhood, 15(2), 32–46. https://doi.org/10.1177/1096250611427350 Independence Hall Association. (2020). In Case of Fire. Philadelphia: In case of fire. Retrieved from https://www.ushistory.org/franklin/philadelphia/fire.htm Katz, I., & Assor, A. (2007). When choice motivates and when it does not. Educational Psychology Review, 19(4), 429–442. https://doi.org/10.1007/s10648-006-9027-y Luczynski, K. C., & Hanley, G. P. (2013). Prevention of problem behavior by teaching functional communication and self-control skills to preschoolers. Journal of Applied Behavior Analysis, 46(2), 355–368. https://doi.org/10.1002/jaba.44 Meadan, H., Ostrosky, M., Triplett, B., Michna, A., & Fettig, A. (2011). Using visual supports with young children with autism spectrum disorder. Teaching Exceptional Children, 43. https://doi. org/10.1177/004005991104300603 Melmed, M. (2015). How to prevent mental health problems? Begin at the beginning with infants and toddlers. Retrieved from https://www.zerotothree.org/resources/117-how-to-prevent-mental-health-problems-begin-at-the-beginning-with-infants-and-toddlers National Safety Council. (2020). Childproofing your home. Retrieved from https://www.nsc.org/ home-safety/safety-topics/child-safety/childproofing National Sleep Foundation. (2018). Children and sleep. Retrieved from http://www.sleepfoundation.org/articles/children-and-sleep Ostrosky, M. M., Jung, E. Y., Hemmeter, M. L., & Thomas, D. (2008). Helping children understand routines and classroom schedules. What works brief series, No. 3. Retrieved from http:// csefel.uiuc.edu Park, K.  L., & Scott, T.  M. (2009). Antecedent-based interventions for young children at risk for emotional and behavioral disorders. Behavioral Disorders, 34(4), 196–211. https://doi. org/10.1177/019874290903400402 Penne State Extension. (2018). Giving Children Choices. Retrieved from http://bkc-od-media. vmhost.psu.edu/documents/tips0309.pdf Prince, K. (2013). The difference between positive/negative reinforcement and positive/negative punishment. Retrieved from https://www.bcotb.com/ the-difference-between-positivenegative-reinforcement-and-positivenegative-punishment Rodger, S., & Umaibalan, V. (2011). The routines and rituals of families of typically developing children compared with families of children with autism spectrum disorder: An exploratory study. British Journal of Occupational Therapy, 74(1), 20–26. https://doi.org/10.427 6/030802211x12947686093567 Schwartz, I. S., Garfinkle, A. N., & Bauer, J. (1998). The picture exchange communication system: Communicative outcomes for young children with disabilities. Topics in Early Childhood Special Education, 18(3), 144–159. https://doi.org/10.1177/027112149801800305 Sharma, P., Upadhaya, M. D., Twanabasu, A., Barroso, J., Khanal, S. R., & Paredes, H. (2019). Express your feelings: An interactive application for autistic patients. In M.  Antona & C.  Stephanidis (Eds.), Universal access in human-computer interaction. Multimodality and assistive environments. Champaign, IL: Springer.

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Shogren, K. A., Faggella-Luby, M. N., Bae, S. J., & Wehmeyer, M. L. (2004). The effect of choice-­ making as an intervention for problem behavior: A meta-analysis. Journal of Positive Behavior Interventions, 6(4), 228–237. https://doi.org/10.1177/10983007040060040401 Spagnola, M., & Fiese, B. H. (2007a). Family routines and rituals: A context for development in the lives of young children. Infants & Young Children, 20(4), 284–299. https://doi.org/10.1097/01. IYC.0000290352.32170.5a Spagnola, M., & Fiese, B.  H. (2007b). Routines and rituals: Opportunities for participation in family health. Otjr-Occupation Participation and Health, 27, 41s–49s. https://doi.org/10.117 7/15394492070270s106 Ulke-Kurkcuoglu, B., & Kircaali-Iftar, G. (2010). A comparison of the effects of providing activity and material choice to children with autism spectrum disorders. Journal of Applied Behavior Analysis, 43(4), 717–721. https://doi.org/10.1901/jaba.2010.43-717 Warren, Z., Veenstra-VanderWeele, J., Stone, W., Bruzek, J. L., & Nahmias, A. S. (2011). Therapies for children with autism. Comparative effectiveness review No. 26. Retrieved from http://www. effectivehealthcare.ahrq.gov/reports/final.cfm Wildenger, L. K., McIntyre, L. L., Fiese, B. H., & Eckert, T. L. (2008). Children’s daily routines during kindergarten transition. Early Childhood Education Journal, 36(1), 69–74. https://doi. org/10.1007/s10643-008-0255-2 Williams, J., Armstrong, K., Bradley-Klug, K. L., & Curtiss, H. (2010). HOT DOCS: A parenting intervention to prevent and address challenging behavior in young children. Journal of Early Childhood and Infant Psychology, 6, 1–20.

Chapter 6

Techniques to Teach Children New Skills

Chapter 1 provided a review of the dramatic development in young children’s abilities that occur during the first years of life. This developmental process has been conceptualized as transactional in nature, meaning that biological factors as well as interactions between the child, the caregiver, and the environment greatly influence the child’s developmental outcomes at any given time (Sameroff & Chandler, 1975). Caregiver style is greatly influenced as a result of the cumulative effect of these bi-­ directional interactions. To oversimplify the complexity of this developmental process, when a young child’s social and communicative behavior can be interpreted by the caregiver, the caregiver is able to meet the child’s needs and both child and caregiver are satisfied. Over many such exchanges, language and social-emotional development is influenced as the child and caregiver’s interactions become more predictable and habitual throughout daily routines (Prizant & Wetherby, 1990).

Development of Children with Developmental Disabilities Most children with developmental disabilities (DD) experience significant delays in their acquisition of these early life social-emotional and communication skills (Carson, Klee, Perry, Donaghy, & Muskina, 1997). Children with autism spectrum disorder, one such developmental disability, present with marked impairments in their ability to engage in social communicative behaviors. This includes delays in skills like making eye contact, joint attention, engaging in reciprocal interactions, and using conventional gestures to communicate (Colgan et  al., 2006; Wetherby et al., 2004; Yoder, Stone, Walden, & Malesa, 2009). Young children with ASD may present with more pronounced deficits than their peers with other DDs, but they benefit from similar early intervention approaches involving modeling, prompting, repeated practice, and feedback (e.g., reinforcement) on their performance (National Autism Center, 2015).

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Among children with DD, the absence of or delay in achieving communication milestones can lead to frustration for child and caregiver alike. For example, children with DD may have difficulty responding clearly to parental wooing, and in turn, parents can feel confused and over time become disengaged, or in extreme cases, emotionally unavailable to their children (Greenspan, 1984). Frustrated children are more at-risk for disruptive behavior which in some cases involves extreme tantrums, physical aggression, self-injury, and destruction of property. These behaviors are dangerous to the child and their caregivers and also limit their ability to participate in community settings (Reeve & Carr, 2000). Such behaviors also interfere with participation in early intervention treatments such as speech and language, occupational, and physical therapies (Jacobson, 1982). Therefore, teaching children key social-emotional and communication skills to prevent and reduce challenging behaviors is a priority for early interventionists, parent advocacy groups, and researchers in the field of DD (Kaiser & Hester, 1997; National Autism Center, 2015).

Challenging Behavior Among Young Children A sizeable body of literature describes the ways in which child behavior effectively changes adult behavior (Emery, Binkoff, Houts, & Carr, 1983). More specifically, caregivers often inadvertently reinforce child problem behaviors by providing attention or some tangible item in order to stop the child’s misbehaviors. Over time, caregivers become increasingly more likely to respond to child misbehavior with positive reinforcement, a process that was coined as “coercion” (Patterson, 1980). Children learn to coerce their parents to provide a preferred response (e.g., a positive reinforcement) through frequent display of challenging behaviors. Unfortunately, these maladaptive child behaviors often escalate over time (Patterson, 1980). Table 6.1 illustrates the coercive cycle, while a mother and her young child are waiting in the check-out line at the grocery store. In this case illustration, Jaxon’s behavior was positively reinforced by getting the chocolates, and his mother’s behavior was also reinforced, albeit negative Table 6.1  Coercive Cycle Jaxon is a 24-month-old boy with speech and cognitive delays. He is sitting in the grocery cart, while his mother unloads the groceries for check-out. He reaches toward the candy display for a bag of chocolates and starts to whine. At first, his mother ignores his request and continues to unload her groceries. Jaxon becomes inpatient and frustrated and starts to whine more loudly while reaching for the chocolates. The store is full and another woman is in cue behind Jaxon and his mother waiting to check out. Jaxon’s mother looks at him and says, “No chocolates today, we’ll eat lunch when we get home.” Jaxon responds by starting to cry and again reaches for the chocolates. While Jaxon’s mother tries to ignore his protests, his cry eventually turns to a scream and he kicks and punches at his mother. The mother pleads with Jaxon to calm down, but he is now in a full-blown temper tantrum and other adults in the store stare at the mother-­ child pair. Jaxon’s mother finally decides to give him the chocolates, and he calms down as she opens the bag and feels relieved from the humiliation.

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reinforcement, by extinguishing the aversive interchange with her son as well as the stares from other adults. Over time, these interchanges are shortened as the child learns to coerce adult behavior more quickly by increasing the intensity or frequency of their misbehavior (Reeve & Carr, 2000). To put it bluntly, by engaging in more disruptive behaviors, children learn to get the adult to “cave in” to their demand. The cumulative effect of these exchanges strains the parent-child relationship and places the child at-risk for social-emotional, behavioral, and educational problems in the future (Patterson, 1980).

Teaching New Skills It is within this context of parent-child interactions that early intervention providers can coach families in the acquisition of new social-emotional and communication skills. In teaching strategies to promote functional social-emotional and communication skills, we allow children to access preferred items by making an appropriate verbal or gestural request. In turn, this may reduce the child’s need to engage in increasingly challenging behavior to secure adult attention. By teaching caregivers these strategies, we improve the quality and quantity of positive parent-child interactions critical to promoting healthy relationships and for the attainment of developmental milestones. Using the HOT DOCS Problem-Solving Chart in Table 6.2, early intervention providers and caregivers are guided to conceptualize the “new skills” a child needs to learn to replace their “problem” behaviors. These new skills are selected based upon an understanding of the function of the child’s behavior as discussed in Chap. 4. As a brief reminder, the goal of understanding the function of behavior is to help the child use more appropriate behaviors to get his or her needs met (e.g., to get or get out of something). Teaching opportunities for new skills can be arranged throughout the child’s daily routines so they are natural learning opportunities that Table 6.2  HOT DOCS Problem-Solving Chart Triggers Describe events just before the behavior: • Where was the child? • What was the child doing? • Who else was present? • What were they doing?

Behaviors Specifically describe the behavior: • What did the child do? • What did you see or hear? Function: to ‘get’ or ‘get out of’

Reactions What happened following the problem behavior? • How did others react? • What actions occurred? • What happened in the room?

Preventions

New skills

New responses

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are most likely to “stick” with the child. Early intervention providers will assist caregivers with identifying teachable moments when children are most amenable to learning new skills. When children are calm and happy, they are ready to learn new skills. When they are engaged in challenging behavior, little learning is likely to take place. Also, helping caregivers understand that teachable moments are also those in which the caregiver is well-rested, relaxed, and can be patient with their child. Teaching new skills requires a lot of prompting, rehearsal, and reinforcement, so even when caregivers are well-rested it is hard work. In the case of Jaxon (discussed in Table  6.1.), when Jaxon initially started to whine and reach for chocolates in the store, the goal would be to teach the caregiver to prompt Jaxon to make an appropriate request (e.g., with a gesture or words) and then reinforce this request by giving him a small snack. In doing so, Jaxon learns that he can access what he wants (e.g., chocolate or a similar small snack) by using an appropriate behavior (e.g., requesting), one that is more functional and reduces the likelihood of problem behavior. It is important that Jaxon is reinforced with the desired object initially, even if it is giving him a chocolate or equivalent, because this increases the likelihood that he will engage in this same appropriate requesting behavior in the future. Once Jaxon knows how to make an effective request for preferred items, the caregiver can offer an alternate item with similar appeal as a chocolate but more acceptable to the caregiver (e.g., fruit chew). New skills are taught during daily life routines as these are natural opportunities for teaching and they occur with high frequency. Through repeated practice in real-­ life scenarios with their caregivers, children are most likely to acquire new skills to effectively communicate their wants and needs. As children learn to communicate more effectively, their caregivers can better understand their needs and respond to them quickly. While caregivers may not be able to satisfy their child’s every want and need, they learn to use these teachable moments to redirect their child to an available choice. In this way, caregivers and children accumulate more positive exchanges that serve to strengthen the social-emotional relationship and prevent behavior problems. Before moving forward, ponder this quote by Tom Herner, a past President of the National Association of State Directors of Special Education (Herner, 1998): If a child does not know how to write, we teach. If a child does not know how to read, we teach. If a child does not know how to multiply, we teach. If a child does not know how to behave, we… This quote illustrates that our first response to misbehavior is often to discipline children rather than to teach them how we would like for them to behave. Adults also generally view social skills and challenging behaviors as being completely separate from academic skills like reading or writing, yet we know that children learn all skills through a process involving modeling, practice, and reinforcement (Cooper, Heron, & Heward, 1987). In cases of misbehavior, if caregivers quickly focus on disciplinary consequences such as time out, taking away toys, or even spanking, they end up spending much less energy noticing and teaching prosocial behaviors, and children may receive more attention for misbehavior.

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This chapter will now present early intervention strategies to teach children “new skills” as taught in the HOT DOCS curriculum (Armstrong, Agazzi, Childres, & Lilly, 2011). First, we present strategies to improve early childhood communication. Then, we share strategies to promote social-emotional skill development. These strategies are aimed at assisting caregivers to enhance children’s learning and development through everyday learning opportunities. Consistent with federal mandates and inclusive practices, these strategies can be implemented in natural environments by caregivers and focus on increasing functional communication and social skills during teachable moments.

Identifying New Skills Before moving into specific skills, early intervention providers can assist caregivers with a step-by-step plan for identifying and teaching their children the skills they need to learn. This process can begin with an informal observation of caregiver-­ child interactions, paying careful attention to the child’s strengths and weaknesses as well as the caregiver’s skills. Then the early intervention provider can work with the caregiver to set goals for the dyad. A good way to start this conversation is, “What would you like for your child to do?” Caregivers will be most likely to follow a plan they help create, so involving them in the identification of key skills is very important. Next, assist the caregiver with prioritizing and selecting the goals, paying careful attention to keystone behaviors or foundational skills that will generalize across settings and increase the future probability of prosocial behavior (Barnett, Bauer, Ehrhardt, Lentz, & Stollar, 1996). A good example of a keystone behavior is teaching a child to request more, either through a sign or vocalization. When a child can make a simple, effective request for more of something they want, they are more likely to use this skill in place of challenging behavior to access a variety of preferred items in the future.

Teaching New Skills The next step is to break down the skill into small steps, sometimes referred to as chaining. Some skills will naturally involve fewer steps than others (i.e., teaching a child to request more versus teaching a child to put on shoes independently). Once the steps have been simplified into small steps, the process of teaching each step should incorporate multiple learning modalities like modeling, hand-over-hand assistance, and opportunity to practice with constructive feedback and reinforcement (Cooper et al., 1987). While teaching new skills, early intervention providers should be mindful to encourage caregivers to use their newly acquired parenting skills, including Giving Clear Directions, Using a Calm Voice, and Specific Praise. When possible, teach caregivers to incorporate the use of preventions as discussed

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Table 6.3  Steps for Teaching New Skills • Observe current skills • Set goals (short and long term) • Break down skills into smaller steps sometimes called “chaining” • Teach each step using: ∘∘ Demonstration of skill ∘∘ Use clear directions ∘∘ Use a calm voice ∘∘ Use specific praise ∘∘ Use visual supports and other prevention strategies

in detail Chap. 5. Visual supports or other preventions can be especially helpful for young children or children with language delays, and they may come in handy when teaching new skills. Finally, be mindful that children have very short attentions pans, so teaching may be best in short bursts so that interactions remain fun for the caregiver and the child (Table 6.3).

Functional Communication Skills Teaching Gestures Nonverbal gestures are an essential component of human communication and emerge in infancy. Teaching children to use gestures increases their ability to send clear messages to their caregivers. In turn, caregivers can meet their child’s needs whether they are for social interaction or access to a preferred item. Early interventionists can clarify for caregivers that teaching children to use nonverbal communication strategies does not prevent children from acquiring spoken language; on the contrary, they serve as a bridge to spoken language as the develops verbal language skills (Fitzpatrick, Stevens, Garritty, & Moher, 2013; Kopchick, Rombach, & Smilovitz, 1975). Many children and their caregivers will have developed some means of gestural communication. Gestures can range in complexity from reaching for an item to waving goodbye. Gestures are a foundational pre-language skill and can be taught and reinforced during teachable moments throughout the daily routine (Linder, 1990; Ozcaliskan & Goldin-Meadow, 2005). Early interventionist professionals can guide caregivers on how to embed gestures during daily family routines like feeding and dressing as well as during play-based activities like sorting shapes. Finding those teachable moments when child attention is piqued will be helpful. Gestures that facilitate a child’s ability to make effective requests are particularly important and are an appropriate target of early intervention. For example, to teach a child to request objects with a reach or a point, consider placing preferred toys slightly out of the child’s reach and then prompt the child to use a gesture to get to the desired

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Table 6.4  Teach Gestures 1. Place two toys slightly out of child’s reach 2. Prompt child while pointing to toys, “Do you want this toy or this one? Show me.” 3. Wait 5 seconds for child response 4. If child responds, skip to step 8 5. If no response, repeat prompt while demonstrating the gesture to child 6. If child responds, skip to step 8 7. If no response, provide hand-over-hand assistance to achieve an approximation of the gesture. 8. Give child toy and provide specific praise, “Nice job pointing to the car!”

toy. Early interventionists should demonstrate for caregivers how to model pointing at the two toys while saying, “Do you want this toy or this one? Show me.” Emphasizing key aspects of the modeled behavior, in this case a gesture, can increase the likelihood that the child will imitate the model (Linder, 1990). Early intervention providers can model for caregivers how to emphasize the words this toy or this one by a short pause in between the words as well as speaking those words with more intensity. At the same time, the emphasis on the spoken words is accompanied by the gesture of pointing, which can also be emphasized with increased physical intensity. By emphasizing aspects of the situation, caregivers can draw child attention to the behavior to be imitated (Cooper et al., 1987). After prompting the child, it is important to teach caregivers to wait about 5 seconds to give the child an opportunity to respond. If the child responds with a gesture (e.g., reaches) indicating their preferred toy, offer specific praise, “Nice job reaching for the car!” If the child does not respond, the caregiver should be instructed to repeat the verbal prompt and the physical gesture. Again, provide specific praise if the child responds. If the child is unable to respond in 5  seconds, the caregiver can be instructed to provide hand-over-hand assistance to the child to achieve an approximation of the reach gesture. Even an approximation of reaching would satisfy. Once the child demonstrates the skill, with or without adult assistance, reinforce the child’s attempt with specific praise, “Nice job reaching for the cars!” Table 6.4 outlines the steps to teach a child to gesture. Rehearsing New Skills  In order for a child to master a newly learned skill, they need many opportunities to practice the skill during daily routines paired with feedback on their behavior (Cooper et al., 1987). The above example is just one of many opportunities a child may have to practice pointing or reaching to indicate choice of objects. Throughout the day, there are a myriad of opportunities for children to make choices, such as which snack they want to eat, which drink they prefer to drink, or which TV program they want to watch. These are all great opportunities to teach a child to make gestural requests. For example, the same steps could be applied during snack time to facilitate a child’s ability to request a preferred food. Encourage caregivers to select a couple of appropriate snacks and then present them to the child, one in each hand, while emphasizing the keywords and the physical gesture of showing the different foods. For example, “Do you want carrots or crackers?” Initially, a reach toward the preferred food would be an acceptable response

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and should be reinforced with verbal praise and access to the food. As the child demonstrates mastery of reaching for a preferred item, they can be taught to engage in a more sophisticated request like a direct point. Visual supports can be used as well by placing photos of snack food options on a table for the child to see. The caregiver would then prompt the child to point to a picture of a preferred food through modeling the behavior combined with a verbal prompt like, “Point to the food you would like to eat?” Again, the steps in Table 6.4 can be followed until the child achieves the skill. Offer Choices  Children have a natural desire to become independent, even when they cannot do tasks completely by themselves. Providing children with opportunities to make choices bolsters social behaviors and task-related behaviors and has proven to be a very effective teaching strategy with young children (Bambara, Koger, Katzer, & Davenport, 1995; Jolivette, Wehby, Canale, & Massey, 2001). A rule of thumb is to provide two choices, as too many may overwhelm children and lead to power struggles. Further, when trying to teach a child to gesture to indicate their choice, having appealing options will increase their desire to make a communicative request.

Teaching American Sign Language American Sign Language, a sophisticated language used by many North Americans who are deaf or hard of hearing, transforms spoken words into a series of hand movements combined with facial expressions and body postures (Wilcox & Shaffer, 2006). While traditionally viewed as a language for people who are deaf or hard of hearing, young children with communication delays can be taught to use many basic ASL signs. In fact, there are several ASL signs that augment typically developing children’s ability to communicate their daily wants and needs before they are developmentally ready to use spoken words (see Table 6.5). Caregivers can learn to role model signs for their children throughout daytime routines as an adjunct to spoken language. Signs for the words more, help, eat, drink, done, sleep, change, bath, play, banana, water, book, please, potty, and thank you are good first signs because these are high frequency words for young children. To teach children these signs caregivers need to use them all day throughout natural routines. Many of these sign words like can be used across routines. For example, the sign for more can be used at meals to request more food or drink, during play routines to request Table 6.5  High Frequency Words Young Children Can Learn to Sign Eat Drink Banana Water

Help Sleep Bath Play

TV Book Thank you Please

More Potty All done Mom/Dad

Note. A simple Google search will yield many sites that teach the signs for these words

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Table 6.6  Teaching a Child to Sign More 1. Prompt child while demonstrating the sign, “Do you want more juice?” 2. Wait 5 seconds for child response 3. If child responds, skip to step 7 4. If no response, repeat prompt while demonstrating the sign to child 5. If child responds, skip to step 7 6. If no response, provide hand-over-hand assistance to achieve an approximation of the sign. 7. Give child more juice and provide specific praise, “Great job signing more!”

more time with a toy and while on the playground to request more time in a swing. Early intervention providers can download the sign movements from the internet and provide handouts to caregivers. Many Internet resources teach commonly used signs for young children and provide visual instructions on how to make the signs. Prompting Signs  Some children may require some physical teaching and prompting before they can use a sign independently for functional communication. The same steps used to teach children to gesture also apply to teaching children to sign. Remind caregivers to start by prompting the child to communicate. In this case, the caregiver might be encouraged to start the prompt with, “Do you want more juice?” while simultaneously signing more. Again, children should be given about 5 seconds to process the information before the caregiver repeats the prompt. This step can be repeated if needed, and ultimately the caregiver can be instructed to provide physical assistance with the gesture if needed. Be mindful to help caregivers follow through with a specific praise, “Great job signing more!” even if the child requires physical assistance while also giving the child more juice (Table 6.6).

Teaching Words and Phrases As gestures and signs equip young children to use functional communication, they will be less frustrated and less likely to engage in challenging behaviors. When children are calm and getting their needs met, they can be taught keywords or phrases to combine with gestures. As speech and language skills develop, children will progress from vocalizations that are approximations of words to clearly articulated words and simple phrases. Early intervention providers should encourage caregivers to be good role models of spoken language by articulating their words clearly and slowly. It may be necessary to demonstrate for caregivers how to speak to very young child. A few key strategies will facilitate children’s ability to process and imitate speech skills. First, be sure to have the child’s attention by getting down at their level and making eye contact. Further, consider using as few words as needed to get the message across. Young children have limited attention spans, especially for challenging tasks like processing language skills. They may only be able to remember a few words at a time. For example, “Use your words!” is a great phrase to prompt a child when they pull a caregiver’s hand or tap their body. This

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phrase is brief and clear, telling the child exactly what to do. Also, consider using visual supports to assist the child with building their communication skills. Start with objects for very young children, whereas photos, pictures, and even text paired with photos may be used with older children. For example, if a child pulls his father’s hand toward the toy box, encourage the father to pull out two preferred objects, label each one, and then prompt the child to use words by saying, “Use your words. You want the train or ball?” Keeping the phrase clear and simple is paramount to facilitating understanding for young children. Reassure caregivers that it is okay if there are minor grammatical markings or word omissions in the phrase. As a child’s receptive language skills improve, caregivers can increase the complexity of their own statements and prompts, as well as use other visual supports like a choice board. Teaching Calm Voice  Young children with DD frequently whine when making requests or trying to gain caregiver attention because it is very effective for them. Whining is so annoying to adults that they have a very hard time ignoring it and they often give in to the child’s demands while the child is whining. Whining is problematic because it often escalates into a full-blown temper tantrum if caregivers are unable to redirect the child’s behavior. In general, pleading with children, coaxing them, or making threats usually only escalates whining. A direct strategy to teach children to use a calm voice is to encourage caregivers to role model calm voice. It can be particularly difficult for caregivers to remain calm when children are whining so it can be helpful for early intervention professionals to demonstrate how to control tone of voice when working families as well as provide caregivers with strategies to calm down when their emotions escalate. Remind caregivers that children learn by watching their own parents, so controlling their temper and tone will model the new skills they want their children to be using. When children are whining, redirection and planned ignoring tend to be the most effective techniques for reducing these challenging behaviors. While these skills will be reviewed in detail in Chap. 7, planned ignoring involves removing all attention from the whining behavior. Redirection involves prompting the child to use an appropriate response that is incompatible with whining. For example, early intervention professionals can model redirection for caregivers with verbal prompts like, “Use a big girl voice”, “Calm voice”, or “I don’t understand you.” These prompts can be paired with hand gestures and/or visual supports to facilitate communication when appropriate. Consider the following vignette where Zoe, a 3-year-old girl with a speech delay brings a new toy to her mother to get help opening the box (Table 6.7). In this vignette, Zoe initially attempted to use gestural communication (e.g., handing her mother a box) to get her needs met, but perhaps not understanding the developmental appropriateness of the behavior, Zoe’s mother ignored the request and prompted Zoe to open the box by herself followed by prompting her daughter to say “please.” By this time, Zoe was either not able or willing to say please due to her increasing frustration. Zoe repeated the gestural request many times and started to whine and cry. Zoe’s challenging behaviors escalated and her mother ultimately voiced her disapproval. In this example, Zoe received ample attention for inappropriate behaviors (e.g., whining, hitting the box). Eventually, Zoe’s mother opened

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Table 6.7  Prompting a Calm Voice Zoe’s mother is sitting on the living room floor with Zoe and her 6-month-old baby brother. Zoe places a box in front of her mother and gestures for mother to open it while whining mildly. Mother refuses to help and prompts Zoe to open the box independently. Zoe begins to whine more intensely and gestures again for help. Zoe’s behavior quickly escalates to a cry while hitting the box and looking at her mother in an attempt to get help. Zoe’s mother responds by saying, “open it!” in a sarcastic tone of voice. Zoe continues to cry and tries to open the box unsuccessfully. Zoe’s mother then prompts Zoe to say “please.” Zoe then picks up the box and hands it to her mother to get assistance while crying and screaming and hitting the box. Mother escalates the coercive situation by raising her voice and using a sarcastic tone, “No, no, I don’t like this behavior!” but opens the box for Zoe.

the box and Zoe calmed herself down and gained access to the toy. The coercion cycle is nicely illustrated here as both Zoe and her mother escalate their behaviors until one person gives in, in this case Zoe’s mother. Zoe’s mother wants Zoe to learn to use a calm voice with words (e.g., please) to make a request. Zoe’s mother needs to learn to prompt the behavior she wants to teach Zoe and praise Zoe for approximations of the skill. Zoe could have been praised for using a gesture to communicate (e.g., bringing the box over) and then prompted to use a calm voice to request help or say please. If Zoe was unable to say these words, mother could prompt an equivalent sign and even provide hand-over-hand assistance with the sign as needed. If Zoe engaged in challenging behaviors, Zoe’s mother would be prompted to redirect her to use a big girl voice or coached on how to use planned ignoring until Zoe calmed down, new skills which will be presented in Chap. 7 (Table 6.8). Table 6.8  Zoe’s Problem-Solving Chart Triggers Describe events just before the behavior: • Zoe is in the living room with mother and baby brother • Zoe is interested in a box • Mother is watching the children play

Behaviors Specifically describe the behavior: • Zoe puts box in front of mother, points to it, whines, escalates to crying and jumping in place, she hits the box, picks it up and hands it to her mother Function: Get the box opened Preventions New skills • Prompt Zoe to say • Zoe makes an appropriate request by signing “please”, or sign, “please” or saying, “please” in a calm • Use first-then voice statement, “First sign please, then I’ll open the box” • Give clear directions to use a calm voice • Model the calm voice for Zoe during the prompt

Reactions What happened following the problem behavior? • Mother scoffs, ignores Zoe’s request and says, “you open it!” Mother continues to scoff and say, “say please!” • After a minute, mother opens the box for Zoe while verbally reprimanding the inappropriate behaviors. New responses • Mother uses a specific labeled praise, “thanks for using a calm voice/ gesture” • If Zoe does not use appropriate behavior, mother redirects Zoe with calm voice and physical assistance to sign “please” if necessary; mother ignores Zoe until she is calm and then redirects Zoe to new skill

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Social-Emotional Skills Social learning theory emphasizes the important role caregivers play in teaching children about feelings and emotional regulation throughout daily routines and social interactions. Children learn social-emotional skills through direct observation and/or instruction of real social situations, including the observation of rewards and punishments of others’ social behaviors. Thus, when caregivers model maladaptive emotional regulation behaviors, children will learn and imitate their caregivers, especially if these behaviors are associated with desirable outcomes. It may be necessary to help caregivers reflect upon and self-evaluate the types of social-emotional behaviors they model for children. Once caregivers are self-aware of their own behavior, they can take the steps necessary to role model more adaptive social-­ emotional behaviors, as well as begin to prompt these behaviors in their children. Next, we review how to teach young children critical social-emotional skills to help regulate their interactions with caregivers, teachers, and peers, including using feeling words, taking turns, sharing, waiting, and following directions. These skills will improve caregiver-child interactions and peer-peer interactions and also prepare children for success in school. Teach Feeling Words  Teaching children to recognize and label feelings helps them to regulate their behavior, and to use feelings words rather than problem behaviors to express themselves. Since early intervention occurs in the context of daily routines, caregivers can be taught to talk aloud about what they are doing and how it makes them feel to create natural learning opportunities to observe emotion expression. Caregivers can also teach feeling words by labeling their child’s feelings and describing for them why they may feel this way. For example, “You feel frustrated because it is time to put the toys away. It is hard to clean up!” Visual supports showing child-like faces of different emotions can be useful for augmenting instruction. Consider a series of cue cards with key emotions (e.g., happy, excited, sad, frustrated, mad, calm) that can be laminated and placed on a small key ring for easy use around the home as well as taken on errands for use in public. In the same manner, caregivers can use daily life routines to also teach their children empathy for others’ emotions, a skill that may not come easily for all children. Caregivers can play a key role in teaching children to be empathetic toward others. For example, caregivers teach children empathy for others by showing them how to know when someone else is distressed (e.g., “Your baby sister is crying, she must be uncomfortable”), how to comfort others (e.g., “Watch me give baby sister her pacifier to help her calm down”), and how to apologize when they have hurt someone else’s feelings (e.g., “I am sorry I raised my voice at you, I know that hurts you!”). Teach Waiting  Learning to wait is a difficult task for young children who do not share the adult perspective on “sense of time.” For the most part, young children live in the present and waiting to play with a toy, sitting through a meal, or sitting quietly

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in church is challenging for even the most mellow child. However, learning to wait is an important skill needed for success in most social situations and especially needed in school. Preventions are the key to success when teaching children to wait. Using preventions like timers, visual schedules, first-then boards, and Giving Clear Directions can facilitate the acquisition of this skill. Preventions are easy to incorporate into real routines, and they can be practiced throughout the day (e.g., caregiver cleans up dishes or makes a short phone call) as a way to prepare for more difficult waiting scenarios (e.g., running errands or doctor offices). To start, guide caregivers to teach their child to wait for a brief interval, say 1 minute, so they can make a quick phone call or go to the bathroom. Early intervention professionals can help caregivers think about which prevention strategies might be helpful for this activity, such as setting a timer, giving the child a clear direction on what to do while they wait (e.g., first play with blocks alone, then daddy will come play), or using a visual support that shows the child what to expect during the routine. Once the waiting activity has begun, prompt caregivers to give specific praise to the child for waiting. At first, the praise should occur more frequently during the wait interval, say every 20 seconds or so. As the child becomes better at waiting, they will require less frequent praise to stay on task, and they will be able to wait for longer intervals. Caregivers will be able to complete their chores and run errands without constantly correcting their child’s problem behaviors (Table 6.9). Having predictable routines and clear boundaries also help children learn to wait. When children have to wait in public, like at the doctor’s office or the grocery store, the busy bag discussed in Chap. 5 is a strategy that can make the waiting time more bearable. Children who are occupied with activities have less difficulty waiting. Caregivers should be instructed to engage their child with the busy bag, talking to them about the toys inside and playing alongside them. In addition, the caregiver

Table 6.9  Teach Waiting 1. Choose a brief activity to teach waiting (e.g., brief phone call) 2. Consider the use of any preventions (e.g., timer, visual supports) 3. Give child a clear direction to wait, “First play with blocks alone, then daddy will come play” and set the timer 4. If the child starts to play, praise them and walk away to make a brief pretend phone call to practice this skill 5. If the child follows the caregiver, they should be redirected to the play area and reminded of what to do. Repeat this step as necessary 6. Provide the child with frequent praise as they are learning to wait, “Great job waiting while daddy makes a phone call! I’ll be there soon” 7. When the timer rings, be sure to approach the child quickly and provide specific praise and a few minutes of direct attention, “Great job waiting, now I can play with you!”

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should provide frequent specific praise for appropriate public behavior (e.g., “Nice job playing quietly when waiting for the doctor!”). Teach Sharing and Taking Turns  Learning to share and take turns is difficult for young children because they are not yet able to take another’s perspective and are naturally very self-centered. In the young child’s mind, everything is mine. Turn-­ taking and sharing are key social skills that help children to develop and maintain peer relationships. Children can first learn to take turns during daily play routines with their caregivers, and after practicing at home they can be expected to start to apply the skills with same-age peers. Early intervention professionals should encourage caregivers to utilize toys and activities that are very appealing to their child to maintain their attention. In teaching a child to take a turn, they are also learning to wait. Caregivers can rely on a number of preventions to help communicate turn-taking expectations. For example, a visual that says my turn and your turn with corresponding pictures can be utilized to prompt the child. A timer can be used to signal the transition between turns and when it is time to give up a turn, caregivers should use clear directions (e.g., “It is my turn to put the block in the box, so please hand me the block”) and follow up with specific praise for compliance. When children are not successful with taking turns, validate their feelings (e.g., “It is difficult to share the toy, but you can do it!”), and redirect them to hand off the toy, followed by specific praise for compliance. This skill may require frequent rehearsal and even hand-over-hand assistance at times. Small play groups with same-age peers provide a great opportunity for adults to teach children turn-taking and sharing. It is best to schedule brief play intervals with no more than five children so that caregivers can provide close supervision, modeling, and feedback to the children as they navigate these new social learning experiences. Caregivers should be mindful to describe what the children are doing and label the feelings associated with that behavior. For example, “You made your friend happy when you shared your toy!” or “See how sad your friend is when you do not share your toy.” Caregivers use supervision as a prevention by monitoring children closely and redirecting their behavior and diverting their attention before any trouble begins. Teach Following Directions  As with learning to take turns and share, following directions may take time for a young child. Children learn how to follow directions when caregivers set clear expectations, model these expectations, and help children follow through on the task at hand. Following directions is a life skill, critical for success in school and other varied contexts (e.g., sports, extracurricular activities, peer relations). Daily routines are ripe with opportunity to follow directions making this skill an appropriate target for early intervention activities. Caregivers need some basic instruction on a few key tips for teaching children to follow directions. First, teach caregivers to move close to the child before giving a direction. Giving directions from across the room is less direct and does not always allow for eye contact. Be sure the caregiver moves down to the child’s level and gain’s his/her eye

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Table 6.10  Follow Through for Directions 1. Move close to the child, make eye contact 2. Give a clear direction, “It’s bath time, please walk to the bathroom” 3. Wait 5 seconds for compliance, provide specific praise, “Great listening!” 4. If the child non-complies, give a warning, “You can walk to the bathroom by yourself or mommy will help you!” 5. Wait 5 seconds for compliance, provide specific praise, “Great listening!” 6. If the child non-complies, gently provide physical assistance to walk to the bathroom and say, “OK, mommy will help you!” Move quickly to the bathroom and provide specific praise as soon as the child begins to comply with the direction

contact before giving a direction. Next, assist caregivers with making a clear direction that is developmentally appropriate. This means simply stating the expectation in vocabulary with which the child is familiar; stating one direction at a time; and avoiding inconclusive directions that are difficult to follow (e.g., “clean up this mess!”). After a child complies with a direction, he/she should be praised specifically for compliance (e.g., “Good listening!”). Early intervention providers should emphasize for caregivers the importance of praising the child for listening or minding. When children disobey, it is important that caregivers learn to use follow through, a parenting technique that involves graduated prompting to ensure a child follows a direction and prevents the child from escaping the direction. Follow through involves restating the original command in the form of a warning and then, if the child continues to non-comply, gently directing the child with hand-over-hand assistance to comply. Follow through always ends with praise for compliance, even if the adult provided physical assistance. See Table 6.10. for a quick glance of the steps to teach follow through for directions. These steps will be reviewed in greater detail in Chap. 7.

Preventions Pave the Way for Teaching Children New Skills Visual supports and schedules, as discussed in Chap. 5, ease difficult transitions from preferred to less preferred activities and support young children to make good choices. Teach caregivers how to ease difficult transitions through the use of preventions. For example, it is difficult for many children to transition from playing with toys to dinner time. In this case, prompting the child with a visual schedule well in advance of the dinner would be useful. Use the schedule to show which activities remain for the day (e.g., bath time, brush teeth, read story, go to bed). Set a timer and prompt the child of the remaining time to play. Provide verbal warnings and set a timer to signal the transition from playtime to dinner time. When the timer rings, support the child to follow through with the direction as needed.

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Chapter Summary In summary, promoting functional communication skills among young children with DD increases their ability to communicate wants and needs and their skills in accessing preferred activities and interactions, thereby reducing the need to engage in challenging behaviors. Similarly, teaching social-emotional skills like waiting, taking turns, and following directions makes daily routines more pleasant and also prepares children for success in interpersonal relations and success in school. Table 6.11 is a HOT DOCS Problem-Solving Chart which outlines the new skills young children commonly need to learn to replace challenging behavior, as well as the preventions that promote the acquisition of new skills. To teach new skills, the early intervention team should observe the child during daily routines and consider which skills the child needs. Caregivers need to play a key role in determining which skills to teach their children, as they are their child’s primary teacher and will be responsible for providing practice opportunities throughout the week. Next, the team can set goals, and break the skills down into smaller steps. To teach the new skills, consider the child’s interests and motivation to learn and how to maximize learning opportunities (e.g., teaching a child to learn to request more when they are hungry). Remember to praise small steps toward the new skills and provide physical assistance, including follow through, when necessary. At the end of this chapter, a blank HOT DOCS Problem-Solving chart is provided as supplemental material.

Table 6.11  HOT DOCS Problem-Solving Chart Triggers Describe events just before the behavior: • Where was the child? • What was the child doing? • Who else was present? • What were they doing? Preventions • Give clear directions • Visual schedule • Prompts • Social story • Warning time: Timers • Natural endings • First-then boards • Offer choices • Busy bags • Use calm voice

Behaviors Specifically describe the behavior: • What did the child do? • What did you see or hear? Function: to “get” or “get out of” New skills • Functional communication skills -- Gestures -- Words/phrases -- Signs -- Making choices -- Use calm voice • Social emotional skills -- Feeling words -- Waiting -- Taking turns -- Sharing -- Following directions

Reactions What happened following the problem behavior? • How did others react? • What actions occurred? • What happened in the room? New responses

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Early intervention providers can use this blank chart to personalize a family’s problem-­solving experience. Encourage caregivers to be patient, as each child will progress at their own rate, and some children will require more practice and constructive feedback than others. As children develop, we expand their skill sets by modeling increasingly difficult social behaviors within reach of their current development. Caregivers are encouraged to practice their new skills on a daily basis as well, and early intervention providers will need to check in with caregivers to problem-­solve any difficulties as well as celebrate their successes. Lastly, early intervention professionals are role models for caregivers and should use the skills they teach with caregivers like providing clear directions, praising caregiver efforts, and helping caregivers to problem-solve and monitor their progress.

Supplemental Materials Problem-Solving Chart: Practice Planning New Responses Triggers

Behavior

Reactions

New Skills

New Responses

Function: Preventions

References Armstrong, K., Agazzi, H., Childres, J., & Lilly, C. (2011). Helping our toddlers, developing our children’s skills (HOT DOCS). (Revised 2nd ed. Tampa, FL: Department of Pediatrics, Division of Pediatric Neurobehavioral Health, University of South Florida.

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Bambara, L. M., Koger, F., Katzer, T., & Davenport, T. A. (1995). Embedding choice in the context of daily routines: An experimental case study. The Journal of the Association for Persons With Severe Handicaps, 20(3), 185–195. https://doi.org/10.1177/154079699502000303 Barnett, D. W., Bauer, A. M., Ehrhardt, K. E., Lentz, F. E., & Stollar, S. A. (1996). Keystone targets for change: Planning tor widespread positive consequences. School Psychology Quarterly, 11(2), 95–117. https://doi.org/10.1037/H0088923 Carson, D.  K., Klee, T., Perry, C.  K., Donaghy, T., & Muskina, G. (1997). Measures of language proficiency as predictors of behavioral difficulties, social and cognitive development in 2-year-old children. Perceptual and Motor Skills, 84(3), 923–930. https://doi.org/10.2466/ pms.1997.84.3.923 Colgan, S. E., Lanter, E., McComish, C., Watson, L. R., Crais, E. R., & Baranek, G. T. (2006). Analysis of social interaction gestures in infants with autism. Child Neuropsychology, 12(4–5), 307–319. https://doi.org/10.1080/09297040600701360 Cooper, J. O., Heron, T. E., & Heward, W. L. (1987). Applied behavior analysis. Upper Saddle River, NJ: Prentice-Hall, Inc. Emery, R. E., Binkoff, J. A., Houts, A. C., & Carr, E. G. (1983). Children as independent variables – Some clinical implications of child-effects. Behavior Therapy, 14(3), 398–412. https:// doi.org/10.1016/S0005-7894(83)80102-6 Fitzpatrick, E.  M., Stevens, A., Garritty, C., & Moher, D. (2013). The effects of sign language on spoken language acquisition in children with hearing loss: A systematic review protocol. Systematic Reviews, 2, 108–108. https://doi.org/10.1186/2046-4053-2-108 Greenspan, S. (1984). Fostering emotional and social development in infants with disabilities. Zero to Three, 8, 8–18. Herner, T. (1998). Counterpoint. National Association of State Directors of Education. Jacobson, J. W. (1982). Problem behavior and psychiatric impairment within a developmentally disabled population II: Behavior severity. Applied Research in Mental Retardation, 3(4), 369–381. https://doi.org/10.1016/S0270-3092(82)80004-0 Jolivette, K., Wehby, J. H., Canale, J., & Massey, N. G. (2001). Effects of choice-making opportunities on the behavior of students with emotional and behavioral disorders. Behavioral Disorders, 26(2), 131–145. Kaiser, A. P., & Hester, P. P. (1997). Prevention of conduct disorder through early intervention: A social-communicative perspective. Behavioral Disorders, 22, 117–130. Kopchick, G. A., Rombach, D. W., & Smilovitz, R. (1975). Total communication environment in an institution. Mental Retardation, 13(3), 22–23. Linder, T. (1990). Transdisciplinary play-based assessment: A functional approach to working with young children. Baltimore: Paul H. Brookes Publishing Co. National Autism Center. (2015). Findings and conclusions: National standards project phase 2. Retrieved from http://www.autismdiagnostics.com/assets/Resources/NSP2.pdf Ozcaliskan, S., & Goldin-Meadow, S. (2005). Gesture is at the cutting edge of early language development. Cognition, 96(3), B101–B113. https://doi.org/10.1016/j.cognition. 2005.01.001 Patterson, G. R. (1980). Mothers: The unacknowledged victims. Monographs of the Society for Research in Child Development, 45(5, Serial No. 186). Prizant, B. M., & Wetherby, A. M. (1990). Toward an integrated view of early language and communication development and socioemotional development. Topics in Language Disorders, 10(4), 1–16. Reeve, C. E., & Carr, E. G. (2000). Prevention of severe behavior problems in children with developmental disorders. Journal of Positive Behavior Interventions, 2, 144–160. Sameroff, A., & Chandler, M. (1975). Reproductive risk and the continuum of caretaking causality. In F. Horowitz (Ed.), Review of child development research (Vol. 4). Chicago: University of Chicago Press.

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Wetherby, A. M., Woods, J., Allen, L., Cleary, J., Dickinson, H., & Lord, C. (2004). Early indicators of autism spectrum disorders in the second year of life. Journal of Autism and Developmental Disorders, 34(5), 473–493. https://doi.org/10.1007/s10803-004-2544-y Wilcox, S., & Shaffer, B. (2006). Modality in American sign language. In W. Frawley (Ed.), The expression of modality (pp. 207–237). New York: Mouton de Gruyter. Yoder, P., Stone, W. L., Walden, T., & Malesa, E. (2009). Predicting social impairment and ASD diagnosis in younger siblings of children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 39(10), 1381–1391. https://doi.org/10.1007/s10803-009-0753-0

Chapter 7

Positive Discipline Skills

Basics of Behavior Review To effectively teach children new skills requires continual effort. Therefore, to reinforce how young children learn, we will first briefly review the basics of behavior covered in Chap. 4. It is important for early intervention providers and caregivers to remember that all behavior is functional or purposeful (Skinner, 1953). So why do children continue to use misbehavior even when you know their caregivers have taught them new skills? The short answer is because it works for them! And why do some children engage in unusual behaviors like eating Play-Doh and spinning around in circles? The short answer here is self-reinforcement. Some children may find pleasure in eating Play-Doh due to its salty flavor and its bright attractive colors. Spinning provides a feeling of dizziness that some children find pleasurable. Even unusual behaviors like these serve some function (e.g., self-reinforcement) to the child. Children never behave in a vacuum; rather, they engage in behaviors that meet their needs. Children with DD and disruptive behaviors are determined and efficient, meaning they use behaviors requiring the least amount of effort to get their needs met as quickly as possible. Even if children are punished for misbehavior (e.g., a lecture on bad choices), if they repeat the same behavior, it means that some part of the experience is reinforcing to the child (e.g., undivided parental attention). Therefore, reconsidering the function of a child’s behavior is necessary if a child continues to engage in misbehavior. Behaviors that result in desired outcomes are likely to be repeated in the future, whereas behaviors with undesirable outcomes are unlikely to be repeated for very long. Consider this example. Each week you work hard at your job, and at the end of the week, you receive a paycheck for your efforts. If you stopped receiving paychecks, how long would you continue to work at the same job? Not very long! When misbehavior persists, early intervention providers and caregivers alike can use the HOT DOCS problem-solving chart to systematically evaluate what type of © Springer Nature Switzerland AG 2020 H. Agazzi et al., Promoting Positive Behavioral Outcomes for Infants and Toddlers, https://doi.org/10.1007/978-3-030-51614-7_7

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reaction a child receives for misbehavior and identify the function of the child’s behavior (e.g., self-reinforcement, get something, or get out of something). The next step is to plan new caregiver responses that will reduce misbehavior and increase appropriate behavior that allows the child to get their needs met. Consider the case example in Table 7.1. of a toddler misbehaving during a dressing routine and identify the function of her behavior. In this case, what is the function of Kylie’s behavior? Do you think Kylie wants to “escape” the dressing routine, or does Kylie “want attention” from her mother? Figure X shows that Kylie’s misbehavior gained her access to mother’s attention and resulted in her avoiding getting dressed. Jennifer’s vague directions (“Let’s get dressed!”) and reactions (e.g., laughs and chasing her) encouraged Kylie to continue to run away during the dressing routine. Kylie needs to learn some new skills (e.g., follow direction to get dressed, ask for parent attention), and Jennifer needs to teach Kylie to comply with the dressing routine and ask for parental attention through new caregiver responses listed in Table 7.2. The main tenant of behavioral theory is to manipulate antecedents and consequences (e.g., reinforcement and punishment) as a primary means of changing and shaping behavior (Skinner, 1953). In Chap. 4 we reviewed consequences that shape and change child behavior, including specific praise when children engage in a new skill, planned ignoring to deal with minor child misbehaviors, and follow-through as a method for teaching children to follow directions. In the current chapter, we cover these strategies and others in greater detail. Early intervention providers will learn effective parenting strategies that caregivers can use to reinforce child learning. As such, we now turn our attention to new caregiver responses to reinforce children’s learning and how to employ these strategies during day-to-day routines.

Planning New Responses Even after children have learned new functional communication and social skills, they make choices about how to behave in each situation, namely, use the new skill or revert to old problem behaviors. Caregiver responses to child behaviors influence their decision-making on whether they will repeat a behavior. Caregivers want to be sure to reinforce behaviors with which they are comfortable being repeated in the Table 7.1  Reinforcing Misbehavior during a Dressing Routine Kylie is 33-month-old girl with speech delays and challenging behavior. She runs around the living room while her mother is trying to get her dressed. Her mother, Jennifer, says, “Let’s get dressed,” and Kylie runs away from her mother and laughs. Jennifer laughs with Kylie and proceeds to chase her, turning the dressing routine into a game of chase. Jennifer catches Kylie and holds her on her lap to physically dress her while offering Kylie some juice for completing the dressing routine. Kylie begins to whine, cry, and arch her back and eventually wiggles out of her mother’s lap and onto the floor. Jennifer again laughs and says, “I’m going to get you!” Kylie hides behind a chair and Jennifer goes to find her. Kylie does not get dressed.

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Table 7.2  Kylie’s Problem-Solving Chart Triggers • Mother gives a vague direction, “Let’s get dressed!”

Preventions • Use a clear direction, “Kylie put on your dress!” • Give Kylie a warning that it’s almost time to get dressed • Use a visual support to signal the transition (e.g., first-then board)

Behaviors • Kylie runs away and laughs • Kylie whines, cries, arches back Function: Kylie gets positive attention and avoids getting dressed! New skills • Kylie stands still and while mother dresses her • Kylie asks to play chase

Reactions • Mother chases Kylie and laughs • Mom holds Kylie and offers her juice

New responses • Mother ignores any misbehavior and redirects Kylie to get dressed • Mother uses follow-through • Mother praises Kylie for getting dressed • Mother repeats a first-then statement: “First you get dressed, then we play chase!”

future. The goal is to help children make the connection that appropriate behaviors result in desired outcomes and problem behaviors stop resulting in desired outcomes. The key to making sure a child understands the connection between their own behavior and caregiver reactions is that caregivers learn to respond immediately and consistently to child behaviors. This means that every time a child runs away from a caregiver command, the caregiver responds with a consistent technique. Early intervention providers must be mindful of this principle when working with caregivers and evaluate each caregivers’ commitment to implementing new responses consistently. If caregivers are not consistent, child behavior will not improve. This typically leads to caregiver frustration and abandonment of the strategies as ineffective. Thus, caregiver buys in, and motivation to change is critical to the successful implementation of discipline strategies.

I ncreasing Appropriate Child Behaviors: Positive Reinforcement When children use appropriate behaviors to get their needs met, caregivers want to respond with something the child views as rewarding. This is called reinforcement, more specifically, positive reinforcement. Positive reinforcement refers to the introduction of a stimulus (e.g., positive meaning to introduce or present) that increases the likelihood of future behavior. There are many ways to use positive reinforcement. For example, providing a specific praise when a child shares a toy with their sibling and giving a child a cookie upon completion of their dinner meal are both examples of positive reinforcement. The key is that the child finds the stimulus

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rewarding and for each child this may vary slightly. Broadly speaking, examples of rewards or positive reinforcement options include verbal praise, physical affection, tangible items, special time with caregivers, and access to desired activities. Positive reinforcement can be extremely effective with young children, yet we know that it is underutilized by caregivers and preschool teachers as a tool for shaping desired behaviors (Lampi, Fenty, & Beaunae, 2005; Mesa, Lewis-Palmer, & Reinke, 2005). Positive reinforcement should always be contingent upon child behavior and occur immediately after the behavior so that the child connects his/her behavior to a predictable consequence. Further, when learning new ways of behaving, children need repeated practice and exposure to the reinforcing consequence. Early intervention providers should teach caregivers to create opportunities for children to practice desired behaviors during daily routines so they have positive experiences connecting consequences to their actions. Caregivers too benefit from practice opportunities to incorporate the new response style into their parenting repertoire. We now turn to a discussion of specific examples of positive reinforcers that have proven successful at changing behavior in young children.

Social Reinforcers Verbal Praise  Providing children with verbal praise regarding appropriate behavior is an underutilized, yet highly effective social reinforcement strategy for shaping behavior (Cooper, Heron, & Heward, 1987; Strain & Joseph, 2004). Behavioral and educational scientists have studied the influence of praise on academic and nonacademic behavior for decades (Gunter & Denny, 1998; Lampi et al., 2005; Sutherland & Wehby, 2001a, 2001b). Verbal praise compliments a child on his or her behavior. There are two kinds of praise that early intervention providers should be aware of: (1) labeled praise, a specific praise regarding child behavior, “I like it when you play quietly with the dolls!” and (2) unlabeled praise, a nonspecific praise of behavior, “Good!”, “That’s awesome!”, and “Good boy!” Labeled praise is more effective than unlabeled praise because it tells the child exactly what the caregiver likes. Labeled praises can also be combined with nonverbal gestures that communicate positive evaluation like a high five, thumbs up, or a smile that accompanies a verbal statement (Hall, Lund, & Jackson, 1968). Gestures, such as these, can add enthusiasm and affect to the spoken message. Going back to the basic tenant of behaviorism, when adults give children positive attention for good behavior, children often increase that good behavior in order to get more positive attention. Labeled praise is an excellent new response for caregivers because it increases the behavior it describes, increases child self-esteem, and when combined with other effective parenting strategies leads to more positive caregiver-child relationships (Barlow, Johnston, Kendrick, Polnay, & Stewart-Brown, 2006; Lampi et  al., 2005; Mesa et al., 2005; Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2009; Webster-Stratton & Reid, 2010). Table 7.3. provides examples of how to create great labeled praises that include a positive evaluation word/word phrase and a specific behavior. Early

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intervention providers can use this table as a guide and ask caregivers to create some of their own praise stems and child behaviors they can praise during daily routines. Physical Contact and Proximity  Close proximity and physical contact are two additional examples of social reinforcers that influence the likelihood of future child behaviors (Burnett, 2001; Cooper et al., 1987; Feldman, 2003; Lampi et al., 2005). Proximity involves walking near the child and remaining close while the child is expected to engage in a particular behavior. Physical contact involves giving a child a pat on the back, a hug, a kiss, or some other touch that demonstrates approval. These strategies have proven to increase the power of verbal praise when delivered in a way the child finds acceptable (Burnett, 2001; Feldman, 2003). By using proximity, a caregiver can also influence how a child behaves in the future by gaining child attention. Getting down on the child’s level and making eye contact is a good first step in gaining their attention. Proximity also communicates a certain immediacy and importance as opposed to speaking to a child from across the room where one can barely make eye contact. Further, if the child needs physical assistance to complete a certain task, the caregiver will be more readily able to provide such support. Finally, when using proximity, a caregiver is better positioned to provide immediate physical contacts to reinforce desired behaviors. In summary, verbal praise is an effective social reinforcer for teaching children to engage in desired behaviors. Verbal praise increases in power when combined with physical contacts and proximity and does not demand much time or effort on behalf of caregivers. These strategies can also be combined with other forms of reinforcement discussed later in this chapter. In addition, praise is most effective when it is specific rather than nonspecific. A final note on praise is that children should hear at least three positive statements to every one reprimand/correction (Fredrickson & Losada, 2005; Shores, Gunter, & Jack, 1993).

Tangible Reinforcers Tangible reinforcers can be objects or activities that increase the likelihood of a behavior when the reinforcer is presented immediately after the presentation of that behavior (Cooper et al., 1987). Commonly used tangible reinforcers include stickers, marbles, trinkets, and small toys. Tangible reinforcers or rewards are commonly Table 7.3 Creating Labeled Praises

Great

Praise stem I love the way… Nice job… Thank you for… Great job… Excellent…

Child behavior You ate your dinner! Using gentle hands with your toys! Holding my hand in the parking lot! Listening! Sharing your toys with brother!

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used with very young children in the form of a prize box in the preschool classroom or a sticker box at the doctor’s office. For example, access to a sticker is contingent upon cooperative behavior from the child during the doctor’s exam. Early intervention providers must keep in mind that young children with DDs will need a comprehensive package of supports to be cooperative in situations like the doctor’s office or dentist office or to sit through a 1-hour religious service. These activities invoke feelings of fear and boredom in little children who have not yet developed the cognitive skills to cope with these emotions for extended times. This can lead to unwanted challenging behaviors. Caregivers will need to plan for such routine outings in advance considering what types of behaviors they can reasonably expect from their children, how to support those behaviors through planned preventions (e.g., visual supports, social stories, first-then boards, busy bag), and how to respond to child behaviors using new caregiver responses. The key to helping young children with DD make it through difficult and boring events is to use preventions and not rely solely on the promise of a reward (e.g., use preventions and new responses). Let’s consider a case example of a 35-month-old boy with a history of speech delay who presents to a phlebotomy lab to have his blood drawn. In this case, preventions were used in combination with a tangible reinforcer and verbal praise to reward cooperative behavior during a blood draw (Table 7.4). In this case example, Ana spent a great deal of time preparing her child for what could have been a very difficult trip to the phlebotomy lab. However, the experience was positive for Jake and his mother for several reasons. First, Ana described what to expect using a visual support (e.g., pictures and text; see Fig. 7.1.) to which Jake could relate. Second, Ana also noted that she would be happy with Jake for cooperating and that he would receive a small toy backhoe at the end of the visit. Finally, Ana supported Jake’s behavior throughout the experience by utilizing preventions, a calm voice and verbal distraction during the procedure, and once the procedure finished, she gave him verbal and physical praise as well as the tangible reinforcer. In this example, Ana successfully combined many new caregiver skills discussed in this book to support her son through a difficult medical procedure.

Activity Reinforcer An activity reinforcer is a privilege such as baking cookies with a caregiver, playing a favorite game, going to the library, or going to visit a special friend or family member. An activity reinforcer can be particularly useful in situations where it is inappropriate to use tangible items or food reinforcers or where the cost of the reinforcer may be an issue (Cooper et al., 1987; Hall & Hall, 1980). Young children love to have the undivided attention of their caregivers, and, thus, activity reinforcers like playing with a preferred toy or a special game one-on-one with the parent can be a very effective reinforcement. In the case example of Kylie (Table  7.1.), she was highly motivated to play chase (e.g., a potential activity reinforcer) with her mother. Kylie’s mother could have offered to play chase with Kylie after she put her clothes

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Table 7.4  Combining Preventions and New Responses Jake is a 35-month-old boy whose pediatrician ordered blood work to test his immune response to a previously administered vaccine. Jake is frequently sick, and his pediatrician believes he may need a booster vaccine, and the only way to be certain is draw blood and conduct lab analyses. Jake is too young to understand these details, and his parents are worried about how they will keep him still while the phlebotomist sticks his skin. Jake’s early interventionist suggested the family create a visual support to teach Jake what to expect when getting his blood drawn. Jake’s mother, Ana, made a brief picture schedule that described the steps involved in drawing blood and incorporated pictures of Jake and his pediatrician so that he would relate to the images. Ana was honest in the visual support about the potential discomfort Jake would feel when the needle went into the skin. She also included a candy reinforcement after the blood draw. Two weeks prior to the blood draw, Ana began reviewing the visual support with Jake daily. When Ana told Jake the doctor needed the blood to see how strong he was, Jake said, “to see mighty machines?” Jake was interested in construction vehicles and likened his own strength to that of a vehicle. Ana took advantage of this, and each time she went through the visual support she said, “the doctor wants to test your mighty machines in your body!” On the day of the blood draw, Ana was quite nervous but tried to hide her feelings from her son. When Jake was called back to the phlebotomy room, Ana reviewed the visual support with Jake one more time. She used a calm voice and told Jake to sit still on her lap and she wrapped her arms around him as the nurse went to work. The nurse stuck Jake and he never moved. Ana was pleasantly surprised! She quickly began talking to Jake about all the mighty machines coming out of his body and into the tube. Jake sat and listened to his mother describe the vehicles and remained still and entertained by his mother’s talk until the end of the procedure. A short minute later, the needle was out and Ana gave Jake a small toy backhoe as promised along with a big hug and labeled praise. Fig. 7.1  Trip to the doctor visual support

Mommy takes me to the doctor.

It pinches just a bit!

The doctors keep me healthy.

Today, they check my blood.

Mommy will I get a special toy! hold me.

on by using a clearly stated first-then statement (think preventions!), and the original function of Kylie’s behavior (gain parent attention via play) would have been satisfied by the consequence. Early intervention providers can help caregivers identify activity reinforcers that are typically accessible within the home environment

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and do not require travel or have an associated cost. Older children can be motivated by gaining access to activities they find pleasurable like riding a bike or going to the park (Armstrong, Agazzi, Childres, & Lilly, 2011).

Token Reinforcers Tokens are used within a token economy, a well-established behavior change system based on the systematic reinforcement of desired behaviors (Jones & Kazdin, 1975; McLaughlin, 1982; O'Leary & Becker, 1967; Shapiro, McGonigle, & Ollendick, 1980; Sullivan & O'Leary, 1990). Tokens are offered to children after the child engages in a prosocial behavior and therefore serve as an interim reinforcer. The token can then be exchanged in the future for a backup reinforcer or reward (Armstrong et al., 2011; Cooper et al., 1987). Token economies can be applied to preschool-age children with a basic understanding of numeracy but are not appropriate for very young children who would have a hard time waiting for the backup reinforcer. There are three key components of a token economy. First, the behaviors to be reinforced must be clearly defined. Second, an exchange system needs to be selected and this is referred to as a token. Third, the backup reinforcers or rewards must be selected and given some token value. While a token economy can be easy to use, it does require some initial set up, and for it to be successful, caregivers must be committed to implementing it with consistency (e.g., maintenance over time). First, when selecting behaviors to target in a token economy, the general rules include (1) selecting only measurable and observable behaviors, (2) specifying what constitutes task completion, and (3) beginning with a small number of behaviors or new skills, including some that will be easy for the child to accomplish and result in early success for the child (Cooper et al., 1987; Heward, Dardig, & Rossett, 1979). A variety of behaviors are appropriate for a token economy including following instructions the first time they are given, putting away toys or personal belongings when asked, and holding hands when walking in the store. Tokens are a nice reinforcement for public outings because they can be given to the child immediately after a behavior, when other forms of tangible reinforcement may not be easily accessed. Second, an exchange system must be selected so that tokens can be dispensed. This may include tally marks or smiley faces, stickers placed on a paper, or holes punched on a card, in which case it is clear how the child will receive the token. If objects like tickets or poker chips are used, the child should have some special container for storing the tokens before they are exchanged. A little cup with a lid works well for objects, and a small envelope or folder can work for storing tickets. Lastly, the backup reinforcers or rewards must be selected and the ratio of exchange determined. Naturally occurring activities and events can be used as backup reinforcers. For example, tokens can be used to access more time on electronic devices, to play a special game with caregivers, or to earn more time to play outside. If naturally occurring activities do not work, then backup items not usually

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present can be used (e.g., special edible treats, books, small toys, or movies). It is important that the backup reinforcers are not abundantly available to the child during daily routines, or else they will not serve as motivators to the child. A ratio of exchange must be planned, and at least initially, it is important for the ratio between number of tokens earned and the cost of backup reinforcers to be low so that the young child can experience many successes. Over time, the ratio will need to be adjusted to maintain its effect on child behavior. If a child earns few tokens, only a few will be available to spend, and this may not allow the child to select desired rewards. On the contrary, if a child earns many tokens, it is possible the child will be able to exchange some of them for a reward and still have plenty left to use in the future. If savings become too great, the child may not have to engage in a behavior to gain access to future reinforcers. Once children demonstrate mastery with the new skill being targeted, caregivers can start to fade the reinforcement ratio to reduce the likelihood of saving too many tokens. Alternatively, the cost of reinforcers can be increased (Cooper et  al., 1987). Additionally, caregivers can begin to introduce a new behavior to reinforce with the token economy, while fading out the token economy altogether for behaviors now emitted at a high frequency. Let’s consider a case example of a token economy used to reinforce sharing and taking turns among two preschool-aged children (Table 7.5).

Table 7.5  Case Presentation of Token Economy for Two Preschool-Aged Children Curtiss (a 37-month-old boy with challenging behavior) and his sister Alexis (4-year-old) are very close in age and often compete over the same toys when playing at home. Their mother, Leanne, swears that Curtiss only wants a toy the minute his sister picks it up. Even when sitting down to play with toys like trains or dolls, where there are many options, the children fight over the same toy. Leanne noticed that Alexis would often give in to Curtiss’ demands because he would scream, cry, and sometimes use aggression to get what he wanted. After speaking with her pediatrician, Leanne decided to use a token economy to motivate the children to share and take turns with toys. She named the tokens “kindness stones” and told her children each time they shared one of their toys or they took turns with the same toy, they would earn a decorative vase stone. Leanne helped the children identify rewards that could be earned at the end of the day (three stones = extra TV time, a small candy, or a game with mom) and the end of the week (ten stones = go out for ice cream, go to the park, or popcorn at the Target cafe). Before starting the token economy, Leanne spent 1 day modeling taking turns and sharing for her children during daily play routines. The children learned quickly and soon started imitating their mother. In the beginning, Leanne reinforced each act of sharing or taking turns to promote success and create a “kindness” momentum. Within 2 weeks, the children were often sharing and taking turns with toys. They also asked frequently to count their stones to see how many they needed to earn their next reward. After 3 weeks, Leanne reduced the frequency with which she handed out stones for sharing and taking turns, instead offering labeled praises most of the time. If the children asked for a stone when she gave a labeled praise, she politely told them that she would determine when they earned the stones. Leanne was so pleased with the success of the token economy that once the children had mastered sharing and taking turns with their toys, she incorporated “putting shoes in the shoe cabinet” and “washing hands before dinner” to the token economy and faded out sharing/turn-taking. She introduced these new skills by following the same procedures described above.

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In this example, Leanne used a token economy with her preschool-aged children to teach very important social skills, namely, taking turns and sharing toys. As a reminder, these social skills are not easy for young children who due to their age are often very egocentric. The token economy worked so well for Leanne and her family that she continued to use it to teach her children other important daily life skills. A few concluding remarks are worthy of mention when considering use of the token economy. At least initially, implementing a token economy requires a bit of planning and materials. It may feel cumbersome to some caregivers to find the time to devote toward initial planning. Early intervention providers may help caregivers with the planning process to ensure they create a sustainable and developmentally appropriate system for their child. Additionally, while the token economy is an effective behavior system to reinforce new skills in children, it must be utilized consistently to be effective. Further, the ratio of exchange may need to be adjusted over time such that initially the learner earns enough tokens (frequent reinforcement) to exchange for desired backup reinforcers, and over time the cost of backup items can be increased, or the frequency with which tokens are delivered can be reduced. Finally, it is important to select backup reinforcers that are appealing for each child, and this may vary between children living within the same family. Next, we briefly review how to select appropriate reinforcers before turning our discussion to new responses for caregivers when children revert to problem behaviors.

Selecting Reinforcers For a behavior change program to work, an appropriate reinforcer needs to be identified. Caregivers can usually identify potential reinforcers easily because they know their child’s preferences. At any rate, there are a few tenets early intervention practitioners should be aware of when it comes to reinforcers. First, one basic way to determine a potential reinforcer is to ask the child what they prefer (Cooper et al., 1987). For young children with DD, it may be necessary to show pictures or objects that represent the reinforcer to facilitate communication. And what a child chooses as a reinforcer may only be true under certain conditions. For example, a child might choose watching TV as a reinforcer, but what they meant was watching the cartoon Jake and the Neverland Pirates. If this cartoon is not on, TV may not be reinforcing. The DVR or Netflix can assist with making sure the preferred programming is available at all times. At any rate, creating a menu of reinforcers may ease the caregiver’s burden of selecting the right reinforcer (see Table 7.6. for a sample reinforcement menu; Quick, 2014). Early intervention providers should keep in mind that what a child identifies as a reinforcer at one time might not function as a reinforcer at other times. First, if a reinforcer is available and not contingent upon any specific behavior in one setting, say cookies at grandmother’s house, it is unlikely that the reinforcer will be useful

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Table 7.6  Reinforcement Menu • Read a story • Extra screen time • Small edible treat • Pick a game to play with parent • Bake a treat • Go for a bike ride

• Go to the park • Listen to music and dance • Play hide-and-seek with parent • Go out to eat • Color with parent • Get a new toy

at motivating child behavior in that setting. Second, as children age and their interests change, so does their preference for reinforcement (Cooper et al., 1987; Quick, 2014). As children mature, another way to identify potential reinforcers is to observe how they spend their free time. Note whether a child is drawn toward a certain toy during indoor play or prefers to play outdoor games and which activities they do for the longest duration. In choosing reinforcers, practitioners can encourage caregivers to just try out a reinforcer and see if it works while trying to keep in mind the child’s age, interest level, and activity level as guides. A brief discussion of food reinforcers is worthy of mention before we turn our attention to responding to problem behaviors. Food, especially sweet and salty treats, can be very powerful reinforcers because they do not have to undergo any type of conditioning process, as such they are called “primary reinforcers” (Cooper et  al., 1987). Food is automatically reinforcing for people, and it has been used extensively in applied settings to shape a host of behaviors with success (Hursh & Bauman, 1987). Another benefit to food reinforcers is that they can be delivered in very small quantities (e.g., one jelly bean, one piece of cereal), and once they are consumed, they are gone. Food reinforcers should always be paired with secondary reinforcers such as labeled praise and social interaction. That way, once the behavior becomes strengthened, the food reinforcer can be faded while the praise and social interaction are maintained. Since children are highly motivated by sweet treats, the Premack’s Principle (e.g., “Grandma’s Law”; Premack, 1959) states that a high-frequency behavior is contingent upon a low-frequency behavior: “First you eat your vegetables, then you can have a cookie!” Many people worry that offering food to children for good behavior is akin to dog training or will teach children bad habits. Others worry, and rightly so, that food reinforcers are not the right choice given the childhood obesity epidemic (Ogden, Carroll, Kit, & Flegal, 2014). However, the quantity of food reinforcement should be so small that it is highly unlikely that it would lead to any adverse health event. At any rate, early intervention practitioners should be aware that food reinforcers are only one of many options for shaping behavior. If caregivers have strong aversions to using food as a reinforcer or if you are working with a client with weight problems, help the family identify reinforcers that are socially and culturally appropriate, and never coax them to use any reinforcer with their child.

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Decreasing Child Behavior Problems Despite the best of parenting efforts to teach and reinforce appropriate behaviors, there will be times when children revert to problem behaviors. Perhaps they are tired, hungry, irritable, or just “being a kid” which means not always thinking through the consequences of their actions. Early intervention practitioners want to be sure that children are not inadvertently receiving some reinforcement when engaging in challenging behaviors. Further, they want to be sure that the child has learned the appropriate skills he/she should be using instead of the problem behavior. The following behavioral management techniques should only be used once the early intervention team has identified, taught, modeled, and reinforced a new skill to be used as a replacement for problem behavior (Armstrong et al., 2011). The following techniques are most effective at decreasing or eliminating problem behaviors when used simultaneously with a plan to reinforce appropriate behaviors. As with reinforcement techniques, the following techniques must be applied consistently and immediately to be effective. The most effective method of stopping problem behavior is to extinguish it, meaning that it no longer receives reinforcement, which is very difficult to implement under the pressures of daily life circumstances. Now we turn our attention to non-punishment procedures for addressing disruptive child behaviors.

Extinction One method to reduce the occurrence of behavior is to withhold reinforcement. This is a non-punishment technique commonly referred to as extinction. Extinction has been well-studied across settings (e.g., homes, schools, institutions) and for a variety of behaviors ranging from mild misbehavior to severe aggression (Hall, Grinstead, Collier, & Hall, 1980; Harris, Wolf, & Baer, 1964; Rekers & Lovaas, 1974). The success of extinction depends upon identification of the reinforcer and then withholding that reinforcement. It does not require any additional verbal or physical prompts or the use of any aversive procedures. While it sounds like a simple process, it can be very difficult to use in applied early intervention settings due to children’s resistance during its implementation (Rickert & Johnson, 1988). Many parents have a hard time ignoring child behavior for the time needed to complete the procedure and see positive results (Whaley & Mallott, 1968). Positive reinforcement, or the presentation of a stimulus immediately after a behavior that increases the likelihood of this behavior in the future, was presented earlier as a means for increasing desirable child behaviors (Armstrong et al., 2011). Challenging child behaviors are also maintained by positive reinforcement. For example, when a child cries after he has been put to bed and his parents return to the bedroom to console him, he is receiving positive reinforcement in the form of parent attention, and he is likely to cry again the following night. Or, when a child cries for

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a candy at the grocery store check-out line and his mother gives him the candy, he has also received positive reinforcement in the form of a tangible treat and will likely use this behavior again in the future. A behavior maintained by positive reinforcement can be placed on extinction by no longer providing the reinforcement after the behavior is emitted. So, in the examples above, an extinction procedure would involve not going back into the child’s room at night and not buying the child candy at the check-out line. While extinction is a very effective practice and usually results in very quick declines in challenging behavior, as previously noted, in practice parents report low acceptance of extinction due to child resistance. Graduated extinction is a modified form of extinction that may be better received by caregivers and is most associated with sleep training in young children. A graduated extinction approach to sleep training is often referred to as the Ferber Method, named after the pediatrician Richard Ferber (Ferber, 1985). In the Ferber Method, the caregiver ignores their child’s sleep protest for short periods and then can briefly check in with the child. Over time, the caregiver allows more and more time to pass before going in to check on the child. As such, many caregivers report this strategy is easier to implement (Whaley & Mallott, 1968). While extinction and graduated extinction are both vulnerable to an “extinction burst,” the extinction burst may be more persistent with graduated extinction approaches. An extinction burst is a spike in child challenging behavior in protest to the caregiver’s new response. It is important that caregivers understand an extinction burst is a normal child reaction to this approach so they do not give up on extinction techniques before they see results. If the challenging behaviors continue to be extinguished, they ultimately will diminish as the child learns that the behavior no longer achieves the desired response (e.g., parent attention; Perle, 2016).

Planned Ignoring Planned ignoring involves the application of extinction for minor child misbehaviors that are not aggressive or destructive, such as whining, sulking, pouting, and making faces (Armstrong, Lilly, & Curtiss, 2006; Lydon, Healy, O’Reilly, & McCoy, 2013). Planned ignoring usually involves the child in the process, whereas with extinction, the caregiver would select a behavior to change and then plan to remove all reinforcement for that behavior. While in extinction, there is no element of time involved, planned ignoring occurs in the context of time (Cooper et  al., 1987). In planned ignoring, the caregiver selects a target behavior, usually a minor attention-seeking behavior (e.g., whining), and then explains to the child that whining is no longer an acceptable way of getting parental attention because it is within the child’s ability to use a gesture, sign, or word to get attention (be sure they have learned these new skills!). Then, the parent should model the acceptable ways to get attention and role-play with the child when the child is calm. From this point forward, when the child demonstrates acceptable means for getting attention (e.g., gestures, words, or signs), the caregiver immediately gives social attention and a labeled

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praise. When the child uses unacceptable means to get attention, the caregiver removes attention for a brief period of time until an acceptable behavior is demonstrated. Once an acceptable behavior is emitted, reinforcement resumes. With planned ignoring, it is assumed that the “time in” setting is reinforcing for the child (Gable, Hester, Rock, & Hughes, 2009; Hester, Hendrickson, & Gable, 2009; Madsen, Becker, & Thomas, 1968). Some of the benefits to planned ignoring include its quick application, its convenience, and its non-intrusiveness as a time out procedure (Cooper et al., 1987).

Validate and Redirect An alternative to planned ignoring, validate, and redirect involves purposefully acknowledging the child’s feelings and then moving on to ignore the problem behavior while redirecting the child to an appropriate behavior (Armstrong et al., 2011). This technique lets a child know they are understood and respected but still prompts them to use the appropriate behavior to get their needs met. It works well for minor misbehaviors such as whining, sulking, pouting, or noncompliance. For example, if a child whines and withholds a toy from his sibling, his caregiver might validate his feelings and redirect him to share by stating, “I know it’s tough to share your toys. It’s Gavin’s turn to play with the ball, and then you will have another turn. Please hand the toy to Gavin.” In this way, the child’s feelings are acknowledged, but he is redirected to use a more appropriate behavior instead of waiting for him to decide when to share. The appropriate behavior can be thought of as the “positive opposite” or what you want the child to do (Armstrong et al., 2011). When the child follows the redirection, he receives immediate social attention and labeled praise for making a good choice. When the child does not follow the redirection, caregivers can consider the use of follow-through for noncompliance.

Follow-Through Follow-through is an ideal technique for making sure children follow clear directions. Remember, clear directions tell a child exactly what they should do. They are simple, brief, and stated at the child’s developmental level. In the above example, “Please give Gavin the toy” is a clear direction because it tells the child what to do in a few words that are easy to understand. Follow-through combines redirection and correction and considers a child’s natural desire for independence (Armstrong et al., 2011). In effect, a child is diverted from making a poor choice, offered an opportunity to follow directions, gently guided to follow the direction if needed, and then praised for cooperation. This method is more teaching-oriented compared to other disciplinary consequences that involve reprimands, removal of privileges, or time out because it tells the child what is expected and then guides them to follow

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Table 7.7  Teach Following Directions with Follow-Through 1. Move close to the child and make eye contact. 2. Give a clear direction, “Please give Gavin the toy.” 3. Wait 5 seconds for compliance, provide specific praise, “Great listening!” 4. If the child non-complies, give a warning, “You can give Gavin the toy by yourself or mommy will help you!” 5. Wait 5 seconds for compliance, provide specific praise, “Great listening!” 6. If the child non-complies, gently provide physical assistance to hand the toy over and say, “OK, mommy will help you!” Move to provide hand-over-hand assistance and provide specific praise for any child effort to comply with the direction.

that expectation. With follow-through, a child is never rewarded for noncompliance. Follow-through involves restating the original command in the form of a warning and then, if they still non-comply, gently directing the child through the direction with physical assistance. Follow-through always ends with praise for compliance, even if the adult provided physical assistance. See Table 7.7. for the steps to follow through. At the end of this chapter, supplemental handouts are provided for early intervention providers to copy and disseminate when teaching follow-through and time out.

Time Out from Positive Reinforcement Time out from positive reinforcement, or simply put time out, is time away from rewarding stimuli for a specified time contingent upon some misbehavior (Brantner & Doherty, 1983; Cooper et al., 1987). It is defined as the contrast between “time in” and “time out” environments, and when used properly the strategy only needs to be in place for short periods of time to change child behavior (Anderson & King, 1974; Eyberg, 1988; Jones & Downing, 1991; Sanders, Markie-Dadds, Tully, & Bor, 2000; Webster-Stratton & Reid, 2010). Time out is used as one of many strategies in the most well-studied and nationally recognized behavioral parent training programs for treating disruptive behavior disorders in young children (e.g., Triple P, Parent-Child Interaction Therapy, Incredible Years; Eyberg, 1988; Sanders et  al., 2000; Webster-Stratton, 1981). Some of the advantages of time out include providing children with an opportunity to calm down and regain self-control, allowing parents to stay in control and feel less angry because they have a plan to address challenging behavior, and not reinforcing or modeling aggression as does spanking children for misbehavior (Morawska & Sanders, 2006). When to Use Time Out  Time out is an effective form of discipline when a child has not complied with a caregiver direction or when the child is behaving in a manner judged to be unsafe to self or others. For example, time out may be used when a child is given a clear command and has not complied with the command or if the child is throwing a toy around in a way that is judged to be unsafe and refuses to obey a caregiver instruction to put the toy down. Similarly, if a child is aggressive

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toward a peer or an adult, time out may be used. Time out is not appropriate for behaviors like sulking, pouting, or irritability and hyperactivity. Similarly, time out is not appropriate for situations when a child is feeling distressed or scared. Further, time out may not be appropriate for very young children with developmental delays or for young children with autism spectrum disorder when the function of their behavior is to escape or avoid an interaction. Consider follow-through as a response to noncompliance with these special populations. In general, Anderson and King (1974) described three situations in which time out is an appropriate discipline strategy: (1) safety (e.g., child repeatedly runs away from parent in public places; (2) high-intensity behaviors (e.g., physical aggression); and (3) when the use of positive reinforcers is not working, like when the child’s behavior is reinforced by another family member. Effective Use of Time Out  Time out must be used consistently and the procedures must be applied correctly for the strategy to be effective. Also, time out is a skill that must be taught so that children understand the consequence and when it will be applied. One of the first steps is to decide which behaviors always result in time out. Again, remember that time out is most effective for noncompliance with caregiver instructions and destructive or aggressive behaviors. Choose a location for time out. When selecting a time out location, try to find a place that is free of distractions, toys, TV, and social attention. Good locations for time out can include a kitchen corner, the hallway, a step, chair, bench, or an area of the floor marked off with tape. To make time out portable, caregivers can use a cloth or towel that can be carried in a bag or purse; this can be helpful if timeout is needed in a community location (e.g., grocery store or playground). Early intervention providers need to clarify that the time out location should not be exciting or scary for the child, and spaces like playrooms, closets, or dark rooms should not be utilized. The duration of time out can be as brief as 1 minute or as long as 3 minutes. Younger children with DD may need to start with very brief time out periods to learn the skill successfully. Longer periods are not more effective than shorter periods, and short time intervals are generally recommended (Benjamin, Mazzarins, & Kupfersmid, 1983; McGuffin, 1991; Pendergrass, 1971). Importantly, caregivers should determine the release from time out, not the child. Contingent release from time out when the child is quiet for a specified period (e.g., 5 seconds after the 1 minute of time out) typically results in better outcomes than when the child determines their own release (Bean & Roberts, 1981), even if the child says he/she is ready to follow the caregiver instruction. Finally, all child misbehavior in the time out chair must be ignored. If caregivers redirect, chastise, or acknowledge child comments during time out, it becomes a time in situation wherein the child receives parent attention, and this must be avoided. Even if requests to use the restroom must be ignored, most children can wait 1–3 minutes to go to the bathroom, and if they have an accident in time out, this too should be ignored, and then the child can be engaged in clean up once the time out is completed. Table 7.8. lists some common time out problems with tips and solutions for correcting these behaviors. It is important to note that children should be explicitly taught the time out procedure prior to its use in order to avoid some of

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Table 7.8  Time Out Problems, Tips, and Solutions Time out problems Child makes hurtful comments; asks to go to the potty; apologizes for misbehavior Child won’t sit in the chair Child leaves the time out chair/area Other child interacts with child while in time out Child has multiple settings where time out is used

Tips and solutions Ignore child; refrain from eye contact, facial expressions, and verbalizations Teach and practice time out when child is not upset, praise child for sitting until finished Stop timer and silently redirect child to the time out location. Restart the timer Other child goes to time out in different location, this should be covered when teaching time out Use a portable towel, blanket, or mat to mark the time out spot wherever the child misbehaves

these problems, as well as to help them adjust to its use. Let’s turn our attention to how to teach time out to young children. Teach Time Out to a Child  To teach the time out process, caregivers must choose a time when their child is calm and open to learning a new skill. Early intervention providers may want to consider the use of a time out visual support to facilitate understanding in young children with DD. Encourage caregivers to teach time out to their child using a doll/stuffed animal or even an older sibling. Explain to the child and demonstrate the entire time out process during a preferred play activity like stacking blocks. During the demonstration, role-play all possible scenarios by giving a doll/stuffed animal simple clear commands combined with physical gestures such as “hand me that block” or “put the block on here.” During the first command, have the doll comply with caregiver instructions quickly, and then explain to the child that the doll is making a good choice to listen so quickly. Next, give another simple clear direction, yet this time only have the doll comply after a warning. Before the warning, be sure to point out that the doll is not listening so you will provide a warning and give the doll another chance to comply with caregiver instructions. This way, the child will learn the association between each behavior and its consequence. Provide a final simple clear direction to the doll, and this time have the doll completely ignore the direction and the warning. Explain to the child that the doll is not listening and that time out will be the consequence for not listening. Then place the doll in time out, pointing out that the doll must stay seated on the chair quietly before returning to play. During this demonstration, be sure to define the boundaries of time out so that the child understands where they need to position their bodies and explain that if they get out of time out before they are told, they will be redirected to time out and the timer will start over. See Table 7.9. for the time out steps for noncompliance which can be used for a demonstration with a young child. Using time out for aggression is a very similar process, except that no direction has been given. Rules and expectations regarding aggression should be discussed ahead of time, and the child should be frequently reminded about the exact behaviors that will result in a time out. Aggressive behaviors include hitting, pushing,

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Table 7.9  Time Out for Noncompliance 1.  Give a clear direction to the child 2.  Allow 5 seconds for the child to comply • If compliant, praise and continue activity • If noncompliant, provide a warning 3.  Allow 5 seconds for the child to comply • If compliant, praise and continue activity • If noncompliant, lead to time out location 4.  Set a timer, 1–3 minutes, depending on age and development 5.  Time out ends 6. Tell the child they have been sitting quietly and ask if they are ready to follow the original Clear Direction • If they indicate yes, prompt them to follow the command and praise • If they indicate no, use follow-through and assist them with completion of command

spitting, kicking, as well as destructive behaviors like breaking or throwing toys and objects. After teaching the expectations regarding appropriate social interaction skills, any instance of aggression is immediately followed with time out. Once the child completes the time out, he/she should be prompted to apologize if appropriate or repair the damage. If they refuse to apologize or repair the damage, the time out can be restarted, and this process starts over. A few final comments about time out are worth mentioning. Time out is an effective strategy for decreasing challenging behaviors. It can be quickly used to deescalate difficult situations across contexts. Time out can be very difficult caregivers to implement with fidelity and often results in the child being released before they complete the time or the caregiver giving the child a lecture or other attention while they are in time out. Also, time out does not teach children new social skills; therefore, it is important to consider whether or not a child needs to learn a new skill to help them be more successful the next time they are in a difficult social situation. Early intervention providers can guide caregivers to carefully consider whether or not their child knows how to follow a specific direction, and if the answer is no or it is unclear, it is best to use a teaching approach like follow-through.

Chapter Summary Caregiver responses have a strong influence on child behavior. Therefore, it is important that early intervention providers understand this relationship and teach caregivers about the events that predict and maintain challenging child behaviors. To develop a supportive behavior plan, it is critical that caregivers also understand the function of challenging behavior. Behaviors are not repeated unless they serve a function for the child. Early intervention providers can help caregivers assess whether a child has a more appropriate skill that could serve the same function as the challenging behavior, and, if not, develop a plan to teach the child the new skill.

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However, even if a child has a more appropriate skill, they may continue to engage in problem behavior if it is more effective and efficient than using the new skill. Caregivers must be self-aware of their responses to child problem behaviors to ensure they are not accidentally reinforcing problematic behaviors. Early intervention providers are ideally positioned to teach caregivers how to implement these strategies throughout day-to-day routines to support child behavior and promote healthy families. At this point, we have reviewed all components of the HOT DOCS Problem-Solving Chart (see Table 7.10.), and this visual tool can be used with caregivers to create an individualized plan of care.

Table 7.10  Completed HOT DOCS Problem-Solving Chart Triggers Describe events just before the behavior: • Where was the child? • What was the child doing? • Who else was present? • What were they doing? Preventions • Give clear directions • Visual schedule • Prompts • Social story • Warning time: timers • Natural endings • First-then boards • Offer choices • Busy bags • Use calm voice

Behaviors Specifically describe the behavior: • What did the child do? • What did you see or hear? Function: to “get” or “get out of”

Reactions What happened following the problem behavior? • How did others react? • What actions occurred? • What happened in the room?

New skills • Functional communication skills -- Gestures -- Words/phrases -- Signs -- Making choices -- Use calm voice • Social emotional skills -- Feeling words -- Waiting -- Taking turns -- Sharing -- Following directions

New responses Is the behavior something the child should do MORE often (e.g., appropriate behavior)? • Reinforce, reward Is the behavior something the child should LESS often (e.g., challenging behavior)? • Ignore, redirect, correct, follow through, time out

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Supplemental Materials Teaching Compliance with Follow-Through Teaching Compliance with Follow Through For younger children using follow through for directions is very effective in teaching compliance IF you follow the same sequence every time you give a command. DIRECT COMMAND: Please hand me the _________

WAIT 5 SECONDS Remain silent, don’t say anything else

Obeys: THANK YOU FOR LISTENING!

Disobeys/Dawdles: REPEAT DIRECT COMMAND Please hand me the ________ WAIT 5 SECONDS

Disobeys: Can you hand me the ___ by yourself or do you need me to help you?

WAIT 5 SECONDS You must need help. I’ll help you!

Praise the child even if they resist: Good listening!

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Time Out for Noncompliance Time Out for Non-Compliance DIRECT COMMAND: Please put your feet on the floor.

WAIT 5 SECONDS Remain silent, don’t say anything else

Obeys: THANK YOU FOR LISTENING!

Disobeys/Dawdles: CHAIR WARNING If you don’t put your feet on the floor, you’ll have to sit on the time out chair.

Disobeys: You didn’t do what I told you to do so you have to sit on the time out chair. Take child to chair quickly. Don’t say anything else.

Stay here until I say you can get off. (~ 3 minutes + 5 quiet seconds) Stays on chair: You are sitting quietly. Are you ready to put your feet on the floor? If yes, lead child back to the task. Give enthusiastic LABELED PRAISE for compliance.

Gets off chair: You got off the chair before I said you could. I will take you back to the chair. Return to the time out chair.

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References Anderson, K.  A., & King, H.  E. (1974). Time-out reconsidered. Journal of Instructional Psychology, 1(2), 11–17. Armstrong, K., Agazzi, H., Childres, J., & Lilly, C. (2011). Helping our toddlers, developing our children’s skills (HOT DOCS). (revised 2nd ed.). University of South Florida, Department of Pediatrics, Division of Pediatric Neurobehavioral Health. Tampa, FL. Armstrong, K., Lilly, C., & Curtiss, H. (2006). Helping our toddlers, developing our children’s skills (HOT DOCS). Participant manual. University of South Florida, Department of Pediatrics, Division of Child Development. Tampa, FL. Barlow, J., Johnston, I., Kendrick, D., Polnay, L., & Stewart-Brown, S. (2006). Individual and group-­ based parenting programmes for the treatment of physical child abuse and neglect. Cochrane Database of Systematic Reviews, 3, ARTNCD005463. https://doi.org/10.1002/14651858. CD005463.pub2 Bean, A. W., & Roberts, M. W. (1981). The effect of time-out release contingencies on changes in child noncompliance. Journal of Abnormal Child Psychology, 9(1), 95. Benjamin, R., Mazzarins, H., & Kupfersmid, J. (1983). The effect of time-out (TO) duration on assaultiveness in psychiatrically hospitalized children. Aggressive Behavior, 9, 21–27. Brantner, J. P., & Doherty, M. A. (1983). A review of timeout: A conceptual and methodological analysis. In S. Axelrod & J. Apshe (Eds.), The effects of punishment on human behavior (pp. 87–132). New York: Academic Press. Burnett, P. (2001). Elementary students’ preferences for teacher praise. Journal of Classroom Interaction, 36, 16–23. Cooper, J. O., Heron, T. E., & Heward, W. L. (1987). Applied behavior analysis. Upper Saddle River: Prentice-Hall, Inc.. Eyberg, S. (1988). Parent-child interaction therapy: Integration of traditional and behavioral concerns. Child and Family Behavior Therapy, 10(1), 33–46. https://doi.org/10.1300/ J019v10n01_04 Feldman, S. (2003). The place for praise. Teaching PreK-8, 5(6). Ferber, R. (1985). Solve your child's sleep problems. New York: Simon & Schuster. Fredrickson, B. L., & Losada, M. F. (2005). Positive affect and the complex dynamics of human flourishing. American Psychologist, 60(7), 678–686. https://doi.org/10.1037/0003-066x.60.7.678 Gable, R. A., Hester, P. H., Rock, M. L., & Hughes, K. G. (2009). Back to basics: Rules, praise, ignoring, and reprimands revisited. Intervention in School and Clinic, 44(4), 195–205. Gunter, P. L., & Denny, R. K. (1998). Trends and issues in research regarding academic instruction of students with emotional and behavioral disorders. Behavioral Disorders, 24(1), 44–50. Hall, M. C., Grinstead, J., Collier, H., & Hall, R. V. (1980). Responsive parenting: A preventative program which incorporates parents training parents. Education and Treatment of Children, 3, 239–259. Hall, R. V., & Hall, M. C. (1980). How to select reinforcers. Austin, TX: Pro-Ed. Hall, R. V., Lund, D., & Jackson, D. (1968). Effects of teacher attention on study behavior. Journal of Applied Behavior Analysis, 1, 1–12. Harris, F. R., Wolf, M. M., & Baer, D. M. (1964). Effects of adult social reinforcement on child behavior. Young Children, 20, 8–17. Hester, P. P., Hendrickson, J. M., & Gable, R. A. (2009). Forty years later — The value of praise, ignoring, and rules for preschoolers at risk for behavior disorders. Education and Treatment of Children, 32(4), 513–535. Heward, W. L., Dardig, J. C., & Rossett, A. (1979). Working with parents of handicapped children. Columbus, OH: Charles E. Merrill. Hursh, S. R., & Bauman, R. A. (1987). The behavioral analysis of demand. In L. Green & J. H. Kagel (Eds.), Advances in Behavioral economics (Vol. 1, pp. 117–165). Norwood, NJ: Ablex.

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Strain, P.  S., & Joseph, G.  E. (2004). A not so good job with “good job”: A response to Kohn 2001. Journal of Positive Behavior Interventions, 6(1), 55–59. https://doi.org/10.117 7/10983007040060010801 Sullivan, M. A., & O'Leary, S. G. (1990). Maintenance following reward and cost token programs. Behavior Therapy, 21, 139–149. https://doi.org/10.1016/S0005-7894(05)80195-9 Sutherland, K. S., & Wehby, J. H. (2001a). The effect of self-evaluation on teaching behavior in classrooms for students with emotional and behavioral disorders. Journal of Special Education, 35(3), 161–171. https://doi.org/10.1177/002246690103500306 Sutherland, K. S., & Wehby, J. H. (2001b). Exploring the relationship between increased opportunities to respond to academic requests and the academic and behavioral outcomes of ­students with EBD – a review. Remedial and Special Education, 22(2), 113–121. https://doi. org/10.1177/074193250102200205 Webster-Stratton, C. H. (1981). Videotape modeling: A method of parent education. Journal of Clinical Child Psychology, 10(2), 93. Webster-Stratton, C.  H., & Reid, M.  J. (2010). The incredible years program for children from infancy to pre-adolescence: Prevention and treatment of behavior problems. Clinical Handbook of Assessing and Treating Conduct Problems in Youth, 117–138. https://doi. org/10.1007/978-1-4419-6297-3_5 Whaley, D. L., & Mallott, R. W. (1968). Elementary principles of behavior. Englewood Cliffs, NJ: Prentice-Hall.

Chapter 8

Family-Centered Practices in Early Intervention

Family-Centered Practices Caregivers are at the core of any successful treatment plan used for early intervention to support healthy childhood development. Engaging caregivers and enhancing their skills will help them to address their child’s needs at home and in the community (Bruder, 2010; Dunst, Trivette, & Hamby, 2007). As such, early intervention providers must have a clear understanding of best practices in early intervention, as well as the core components of which embrace family-centered practices to meet the needs of diverse families. Early intervention providers must also provide for inclusion in natural environments, be driven by teamwork and collaborative practice, and utilize evidence-based practice in treatment planning. Each of these practices will be described in more detail in the sections below. The support for family-centered practice was first documented about 30 years ago in studies with hospitalized children. In some cases, parents were allowed to stay with their children in the hospital, while in others, children stayed by themselves. The children whose parents stayed with them during hospitalization needed less medical intervention and responded more positively to hospital treatments. In addition, their care was better managed by their caregivers once they returned home. Similarly, in the world of early intervention, children with developmental delays and disabilities have been found to respond better to treatment when interventions are provided by their parents and other key caregivers, within their everyday routines and familiar settings (Bruder, 2010; Dunst et al., 2007). Family-centered practice aims to build caregivers’ knowledge and skills, so that those individuals closest and most important to the child will have the greatest impact as possible on the child’s learning and development (Dunst & Trivette, 2009; Karaasian & Mahoney, 2015). The four core principles of family-centered practice are (1) respect and dignity, (2) communication, (3) strength-building, and (4) collaboration across all providers (Baas, 2012). The implementation of family-centered practice will require some initial time investment, such as building relationships, modifying treatment © Springer Nature Switzerland AG 2020 H. Agazzi et al., Promoting Positive Behavioral Outcomes for Infants and Toddlers, https://doi.org/10.1007/978-3-030-51614-7_8

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approaches, and teaching caregivers the strategies they need, but it results in many benefits, including: • • • • •

Improved intervention decision-making based on strong information gathering A greater knowledge of the family’s and child’s strengths and their areas to grow Better adherence to the intervention when it is developed collaboratively Fewer miscommunications and more effective problem-solving Greater satisfaction with services (Baas, 2012; Everhart, Haskell, & Khan, 2019)

Respect and Dignity As an early intervention provider working with families of infants and toddlers, one must consider how to provide services that are culturally and ethnically sensitive. What are the implications of culture on developing strong relationships with families? How will a family’s culture shape their understanding of their child’s needs, the goals they set, and their dreams for the child’s future? While early interventionists are not expected to be experts on every different cultural background they encounter, it is important to avoid stereotyping families based on work with other families from similar cultural, religious, or ethnic backgrounds. In family-centered planning, each family is unique regardless of their affiliation with a specific race or religion. At any rate, having some knowledge of core belief systems in diverse cultural groups will prepare the early interventionist for the early stages of home visiting, wherein building rapport is often the primary focus. Early intervention providers want to show respect and dignity for families by considering the following variables in the home environment: • • • • • • •

Family make up and caregiver roles Language(s) spoken Developmental expectations and appropriate stimulation Family access to basic resources Caregiver support Child-rearing practices Health practices

Having some basic understanding of these variables will allow the early intervention provider to prepare for their first meeting with the family and treat each family member with respect. For example, knowing the family’s primary language is critical to ensure a translator is available if needed or if handouts and paperwork are available in the preferred language. Also, knowing who the primary caregiver is or if there are extended caregivers in the home who also have a primary caregiving role can be helpful during the initial visit to ensure the early interventionist includes all key stakeholders in the intervention plan. As part of family-centered planning, early intervention providers listen to and honor family perspectives and choices, even when they may differ from the

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dominant culture. Children learn in the context of their family, so families should be viewed as the central influence on the child’s learning and development (Bruder, 2010). Early interventionists must come to understand family characteristics including culture, values, beliefs, and knowledge in order to successfully engage the caregivers in the early intervention plan. In the early stages of building rapport, early interventionists can explore family characteristics by asking simple questions like: 1 . What are your hopes for your child? 2. How do you understand your child’s special needs? 3. What do you expect from early intervention? 4. What matters most to you now? In asking these questions, early interventionists give families the opportunity to share what they value, what they know, what they want to learn, and what they expect from the home visitor. Further, the early interventionist can take this information and use it to integrate cultural competency and responsiveness into all aspects of the design and implementation of the early intervention plan. For example, a value common to many Hispanic and African-American families is a strong family bond and commitment to extended family members (Ensher & Clark, 2011). Therefore, when working with families from these backgrounds, the early interventionist should be mindful of this value and honor family requests to include other caregivers in the intervention plan. At the same time, with family-centered planning, this value cannot be assumed to be true of all individuals who identify as African-­ American or Hispanic. The point is that the early interventionist makes it a point to see each family as unique and takes the time to explore this uniqueness with each family. This type of rapport building will be the foundation to strong communication over the course of the early intervention plan. Building a strong relationship with the family is just as important as the early interventionist’s technical skills in promoting development among children with a disability or developmental delay (Dunst et al., 2007; Dunst & Trivette, 2009).

Communication In family-centered practice, communication should be honest and flow between all parties. Early intervention programs and providers share complete information with families in ways that are useful and affirming. Care is taken to avoid biased comments (e.g., the child has delays in speech because he is an only child and stays at home with his mother). Communications are provided in the family’s preferred language when possible, and interpreters are called upon when needed. Families receive timely communication, and communication is presented accurately and completely so that families can make informed decisions about their child’s care. Access to information empowers caregivers to feel more prepared, less helpless, and more in control (October, Fisher, Feudtner, & Hinds, 2014). Early intervention programs make families aware of family resource centers and parent liaisons who

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have experienced the trials and tribulations of raising a child with special needs and understand the early intervention system. Sometimes speaking to another caregiver who can relate to the family’s personal experience, share a sense of struggle, and hope for the future makes a world of difference for caregivers who are learning to navigate early intervention and raising a child with special needs.

Strengths-Based Practice Inherent in these values is the recognition of and focus upon the family’s strengths, which are utilized to help caregivers build their own network of resources to support their child’s progress. Each child and his or her family are unique, meaning that providers must learn what they can about the family in order to best serve them and optimize intervention. When given the necessary supports and resources, all families can promote their children’s learning and development. Strengths-based practices support families to make decisions for themselves with the resources they have available. Early interventionists help families to identify options, weigh the pros and cons of different choices, and support families throughout decision-making by evaluating outcomes. Strengths-based practices focuses on capacity-building by recognizing family assets and talents and helping family members to use these talents to enhance child development and family functioning (Dunst et al., 2007; Dunst & Trivette, 2009). Similarly, from a strengths-based practice lens, the early interventionist highlights what each child can do and identifies emerging skills within the child’s development, rather than what the child is not able to do. From the community perspective, the early interventionist highlights resources the community might contribute toward implementation of the family-centered early intervention plan and makes efforts to connect the family to these resources. Increasingly, early interventionists are encountering families with complex needs. All families, especially families of children with developmental disabilities/ delays, are faced with a host of factors that can affect the individual caregiver, the child, or the family unit. These factors include social support, health and mental health issues, stressful employment, unemployment, divorce and separation, finances and poverty, and family/community violence. These factors, compounded by the extra duties surrounding raising a child with special needs, can place families at risk for poor coping and have an adverse impact on the well-being of infants and young children (Agorastos, Pervanidou, Chrousos, & Baker, 2019).

Teamwork and Collaborative Practice Teamwork and collaboration are key features underlying successful family-centered practice and, by extension, early intervention practice. This means that caregivers and providers form a team around the child’s needs in order to share information,

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communicate well, and develop strategies to assist the child (Shelden & Rush, 2010). Within this model, one key provider is typically identified, who is often the early intervention specialist. This individual must have a sound knowledge base and a skillset in evidence-based early intervention practice, so that they can assist and teach the family strategies. One must be an effective communicator in order to offer insights, teach skills, and train other team members. An optimal skill set for this key provider would include a solid foundation in early child development, expertise in evidence-based strategies, and teaching and coaching competencies. Further, the skilled early interventionist must remember that family values form a key consideration in determining if a behavior is problematic or not. Our ideas on the acceptability of behavior and responses to behavior are shaped by many variables like our personal experiences and education, the expectations our caregivers had for us, and what is deemed appropriate in our larger community and culture (Heieneman, Childs, & Sergay, 2006). Team Problem-Solving  One strategy that may be used with the caregivers and the intervention team to develop a family-centered intervention plan is the HOT DOCS Problem-Solving Chart (see Table 8.1). This tool enables the caregivers to identify their concerns, problem-solve with the team, and develop strategies to use in intervention. The caregiver begins by describing the child’s behavior or current level of Table 8.1  Oscar’s Problem-Solving Chart Triggers • Oscar is in a playgroup with five peers • First activity in the morning • One child has a truck • Parents are sitting off to the side of the room, visiting with each other and drinking coffee

Behavior • Oscar sees a truck • Pushes the child • Scratches the child • Grabs the truck • Leaves the area to play with the truck Function:  Get toy Preventions New skills • Oscar shares • Caregiver practices sharing with caregiver with Oscar during home • Oscar asks for a routines turn • Caregiver uses a timer to signal • Oscar learns to turn-taking and transition wait for his turn • Caregiver allows Oscar to bring a special toy to show the group • Oscar shares toys with peer • Caregiver supervises more • Oscar is able to closely during playgroup transition to • Caregiver models sharing with new activity children during playgroup • Caregiver prompts Oscar to share a toy • Caregiver prompts Oscar to use his words to ask for a turn

Reactions • Child moves away from Oscar and Oscar plays with toy • Child cries/fusses and caregiver either: ∘∘ Scolds Oscar ∘∘ Takes toy away from Oscar and returns it to the child

New reactions • When Oscar performs any of the new skills, the caregiver says: Thank you for sharing, using your words, etc. • If Oscar snatches the toy, the caregiver redirects Oscar to return toy to his peer and prompts Oscar to use a new skill

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performance. Along with the team, they identify triggers, reactions, and the function of the child’s behavior. Once the function of behavior is identified, the team can then develop an early intervention plan through the development of preventions, new skills for the child, and new responses for caregivers to promote the child’s use of prosocial behaviors and skills. Then, the team can develop a plan to monitor the child’s response to the intervention plan. Decisions as to how to determine mastery of new skills are also developed at this time, as well as how the team will proceed if the plan is unsuccessful. The caregiver(s) should be central to this team problem-­ solving approach within the context of family-centered planning. Caregivers’ wishes, concerns, and values drive the early intervention plan, and the early intervention professional supports and respects the caregiver’s decisions. Crafting Child and Family Outcomes  Both child and family outcomes must be included within the individualized treatment plan. New skills refer to the replacement behaviors needed by the child to function more successfully. For example, rather than yelling, a child may need to learn to ask for “more.” Preventions refer to environmental supports which can be used to promote more independent and/or appropriate behavior. One example of a prevention would be to give clearly stated directions, so for a child learning to use the word “more,” caregivers would prompt the child to sign or say “more” when appropriate. New responses refer to caregivers’ responses to the child’s behavior that strengthen new skills. New responses include both labeled praise, such as “thank you for using your words” when the child demonstrates the new skill, and redirection when the child does not respond in an acceptable manner. Of note, in some cultural groups, there is a strong belief that children should do what their told and should not have to be praised for appropriate behavior. Early intervention providers may need to spend time exploring this belief with clients. In the context of developing new skills, young children will be more likely to use new skills if they receive positive reinforcement for using the skill. Thus, when trying to teach young children to behave in new ways, it is especially important for them to hear praise; however, as the child masters the new skills, caregivers can learn to fade the ratio of positive reinforcement to a level that is more in line with their cultural beliefs. Table 8.1 displays a family-centered intervention developed for Oscar by his caregivers and early intervention team members, to help him learn to share and take turns with his peers. Oscar is a 3-year-old Hispanic boy who is an only child and who has never been to daycare or participated in a group setting with peers. Oscar stays at home with his mother and paternal grandmother, while his father works long hours in a lawn care service. Oscar has mild speech delays but can use two-­ word phrases now. Parents would like to enroll Oscar in a preschool; however, they are concerned about his interactions with his peers in their small community, as Oscar can be quite aggressive with peers when his mother takes him to play at the community center. Oscar’s mother reports avoiding the community center at times because she is embarrassed by Oscar’s behavior and speech delay. Oscar’s grandmother believes he will learn the skills and that his mother is too worried about his

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development. Given that Oscar’s mother would ultimately like him to attend preschool, the early interventionist asks his mother how she would feel about going to the community center with Oscar so they can observe his social play. Oscar’s mother agrees that it would be a good idea to let someone else observe her son’s behavior. They talk to the grandmother as a team to see if she agrees with the plan, and she agrees that it would be good so that the early interventionist can calm the mother’s worries. The interventionist observes Oscar in a playgroup situation in the community center and notes that he moves towards peers when he sees a toy that he wants, snatches the toy, moves away, and plays alone. This behavior occurs approximately every 5  minutes. Caregivers typically respond to Oscar by either redirecting his behavior or scolding him, and the other children avoid him. The early interventionist shares this information with Oscar’s mother and grandmother using the top portion of the HOT DOCS Problem-Solving Chart in Table 8.1. Both his grandmother and mother agree that the chart is an accurate depiction of Oscar’s behavior during free play with same-age peers. Oscar’s grandmother acknowledges that she is surprised by the frequency of his behavior and did not realize that she sometimes missed times when Oscar took a toy from a peer as she was chatting with friends. She says Oscar will learn how to share eventually but reports an increase in motivation to teach him this skill more actively. By this age, most children are learning to share and take turns; however, Oscar is still having difficulty with these concepts. Oscar’s early intervention team will come together to develop an intervention plan that is guided by his family’s values and goals while holding the guiding principles of person-centered planning in mind. If this intervention plan is successful, Oscar will demonstrate the ability to engage in simple sharing and turn-taking, and his parents will feel more confident in his readiness to enroll in preschool.

Chapter Summary This chapter began with careful consideration of the four guiding principles in family-­centered practice. A common theme to these principles is effective communication, which will be the foundation for a strong relationship between the family and the early intervention provider. This relationship is contingent upon the early interventionist’s ability to be culturally competent and responsive to the complex needs of families with children with disabilities and developmental delays. The early interventionist carefully considers how to show respect and hold the family’s dignity in mind during interactions. Further, the early intervention provider presents themselves as a collaborator on the team and engages the family in problem-solving through a collaborative team framework while emphasizing a strengths-based approach to intervention planning. Person-centered planning is central to positive behavior outcomes for young children, as it is well-established that when intervention plans have value to the client and family, they are more likely to result in

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positive outcomes (Heieneman et  al., 2006). Addressing child behavior involves careful consideration of the values, perspectives, and beliefs of the child’s caregiving community. When we intervene, we hold the guiding principles in mind to best support diverse families.

References Agorastos, A., Pervanidou, P., Chrousos, G. P., & Baker, D. G. (2019). Developmental trajectories of early life stress and trauma: A narrative review on neurobiological aspects beyond stress system dysregulation. Frontiers in Psychiatry, 10, 118. https://doi.org/10.3389/fpsyt.2019.00118 Baas, L. S. (2012). Patient- and family-centered care. Heart & Lung, 41, 534–535. Retrieved from Retrieved from http://www.heartandlung.org/article/S0147-9563(12)00309-3/fulltext Bruder, M. B. (2010). Early childhood intervention: A promise to children and families for their future. Exceptional Children, 76(3), 339–355. https://doi.org/10.1177/001440291007600306 Dunst, C. J., & Trivette, C. M. (2009). Capacity-building family-systems intervention practices. Journal of Family Social Work, 12(2), 119–143. https://doi.org/10.1080/10522150802713322 Dunst, C. J., Trivette, C. M., & Hamby, D. W. (2007). Meta-analysis of family-centered help giving practices research. Mental Retardation and Developmental Disabilities Research Reviews, 13(4), 370–378. https://doi.org/10.1002/mrdd.20176 Ensher, G. L., & Clark, D. A. (2011). Diversity in context: What difference does a difference make for a child? In G. L. Ensher & D. A. Clark (Eds.), Relationship-centered practices in early childhood: Working with families, infants, & young children at risk (pp. 73–98). Baltimore, MD: Paul H. Brookes Publishing Co. Everhart, J. L., Haskell, H., & Khan, A. (2019). Patient- and family-centered care: Leveraging best practices to improve the Care of Hospitalized Children. Pediatric Clinics of North America, 66(4), 775–789. https://doi.org/10.1016/j.pcl.2019.03.005 Heieneman, M., Childs, K., & Sergay, J. (2006). Parenting with positive behavior support: A practical guide to resolving your child’s difficult behavior. Baltimore, MD: Paul H. Brookes Publishing Co. Karaasian, O., & Mahoney, G. (2015). Mediational analyses of the effects of responsive teaching on the developmental functioning of preschool children with disabilities. Journal of Early Intervention, 37(4), 286–299. October, T. W., Fisher, K. R., Feudtner, C., & Hinds, P. S. (2014). The parent perspective: “Being a Good Parent” when making critical decisions in the PICU. Pediatric Critical Care Medicine, 15(4), 291–298. https://doi.org/10.1097/pcc.0000000000000076 Shelden, M. L., & Rush, D. D. (2010). A primary-coach approach to teaming and supporting families in early childhood intervention. In R. A. McWilliam (Ed.), Working with families of young children with special needs. New York: Guilford Press.

Chapter 9

Helping Caregivers Manage Stress

Caregiver Stress Raising children with developmental disabilities poses multiple challenges beyond those associated with parenting a neurotypical child (Baker et al., 2003; Baker & Blacher, 2002; Baker, Blacher, Crnic, & Edelbrock, 2002; Hauser-Cram et al., 2001; Liu, Zhai, & Gao, 2020). Caregivers of children with DD have the added duties of scheduling specialty care visits with medical providers and therapists, working with their child’s daycare or school to provide needed behavioral supports and/or academic accommodations, managing financial resources to cover needed services, and managing time to get to appointments and meetings, all on top of traditional child-­ rearing duties. While many caregivers develop positive strategies to cope with these responsibilities, they can be overwhelming at times, and study after study documents heightened stress among caregivers of children with DD (Baker et al., 2002; Baker et al., 2003; Baker & Blacher, 2002; Crnic, Friedrich, & Greenberg, 1983a; Crnic & Greenberg, 1987; Crnic, Greenberg, Ragozin, Robinson, & Basham, 1983b; Hauser-Cram et al., 2001). Caregivers of children with DD and comorbid disruptive behavior disorders report the highest stress levels, and this effect holds when factors like social support, family size, and socioeconomic status are controlled (Hastings, 2002; Liu et al., 2020; Medina, Rios, Aleman-Tovar, & Burke, 2020; Quine & Pahl, 1991; Sloper, Knussen, Turner, & Cunningham, 1991). Among these caregivers, stress levels tend to fluctuate based on the child’s stage of development and the associated caregiver demands, with the early childhood years, the onset of adolescence, and the transition to adulthood associated with highest stress (Baker et al., 2002; Blacher, 2001; Kraemer & Blacher, 2001; Wikler, 1986). Some researchers have also found that severity of behavior problems, not child cognition, better explains the high levels of caregiver stress (Donenberg & Baker, 1993; Floyd & Gallagher, 1997). Thus, when developmental status varies between groups, elevated parental stress is more common among caregivers of children with more severe behavior problems (Beck, Hastings, Daley, & Stevenson, 2004). © Springer Nature Switzerland AG 2020 H. Agazzi et al., Promoting Positive Behavioral Outcomes for Infants and Toddlers, https://doi.org/10.1007/978-3-030-51614-7_9

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The relationship between child behavior problems and caregiver stress continues to be explored as researchers search for clues to causality (Park & Johnston, 2020). Much work remains to be done regarding parenting variables (e.g., social support, mental health, parenting style) and child characteristics (e.g., severity of behavior problem, disability status, adaptive functioning) to fully understand these relations. In the disability literature, caregiver behavior has been implicated in the development and maintenance of child behavior problems through the lens of operant conditioning (Oliver, 1995; Park & Johnston, 2020). Namely, parents who have high stress levels are likely to engage in parenting behaviors that increase or maintain challenging child behaviors over time. While further research is needed to elucidate the degree to which parent stress impacts child behaviors and whether there are protective factors that may moderate the relationship (e.g., parent SES, mental health), there is a transactional relationship between child behavior and parenting stress (Baker et  al., 2003; Park & Johnston, 2020). This implies an interaction between child and parent where both individuals are constantly responding and adapting to one another and the environment. Therefore, caregivers benefit from early intervention techniques that teach them to address challenging child behaviors and learn positive strategies to cope with the many demands of life and parenthood.

Case Example of Caregiver Stress To illustrate parenting stress, consider the following case example (see Table 9.1.). This case presents a day in the life of Richard, who is a husband, a father, a son, and an employee. Richard, like many caregivers, wears multiple hats and has many life responsibilities. In this case example, Richard is experiencing many common life events that cause stress. Caring for aging parents with chronic health conditions places additional caregiving duties, above and beyond those associated with caring for young children. Aging parents often need assistance with daily life tasks like scheduling and attending medical appointments, taking medications, managing finances, and finding transportation. While Richard’s wife stays at home to care for their young Table 9.1  Case Study of Caregiver Stress Richard is a 37-year-old male, who is married and has a 2-year-old son with developmental delays and challenging behavior. Richard’s mother lives in a neighboring town. In the past year, Richard has experienced the following life events: • Richard’s father passed away. • Richard’s mother was her husband’s caregiver during his lengthy illness, and caring for her husband adversely affected her own health. • Since his father’s death, Richard has stopped smoking. • Richard’s wife is a stay-at-home mom and helps her mother-in-law with daily chores and errands. • Richard works overtime to support his family and mother. • Richard and his wife may be expecting another child.

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child, the additional daily chores of helping her mother-in-law are an added burden for her and for her husband. Richard lost his father, and now he works longer hours to provide financial assistance to his mother, who now has her own health problems. Richard has one day off from work a week, working 10-hour shifts as a technician at the local hospital. At his wife’s request, Richard recently stopped smoking cigarettes, but he has replaced this habit with overeating. This unhealthy behavior has caused him to gain an extra 25 pounds to his already slightly overweight body frame. One night, Richard comes home from work exhausted and lies on the couch while his wife prepares dinner. After about 30 minutes, his wife comes into the living room and wakes him up for dinner, requesting that he go get their son Pat and bring him to the table. Pat is in his bedroom watching Blue’s Clues when Richard comes in and abruptly turns off the TV. He picks up Pat to take him to the dinner table. Pat immediately starts to whine and say “Blue’s Clues!”, but Richard tells him it is time for dinner and walks toward the kitchen. Patrick escalates his whining to a scream and begins to cry. He waves his arms and kicks his legs to get out of his father’s embrace. Richard threatens Pat with a spanking if Pat continues to kick and Pat kicks harder. Richard swats Pat on the bottom and straps him into his high chair while Pat continues to protest. Richard then yells, “Calm down Pat or no more Blue’s Clues for you!” Katie walks over to serve Pat his dinner, and Pat immediately throws it on the floor. Richard screams at Pat and gives him a few more swats on the legs. Katie tries to calm her husband down while cleaning up the spilled food. Richard tells Katie to bring Pat another plate of food and then tries to force feed Pat. Katie asks Richard to calm down and let Pat eat on his own but Richard says, “He cannot waste food like that. He must eat! You have to stop babying him!” Pat continues to cry while his father tries to spoon food in his mouth and Katie continues to plead with Richard to back off. Finally, Richard takes Pat out of his chair and puts him in his bedroom and returns to the table to eat his own dinner. Katie has her head in her hands and says, “I’m late this month….”

Problem-Solving Caregiver Stress We can conceptualize this family interaction by using the HOT DOCS Problem-­ Solving Chart in Table 9.2. First, let us consider the antecedent variables that serve as triggers for Richard’s behaviors. Richard is very tired because he has been working extra shifts to cover finances, and his wife wakes him from a much-needed nap. Richard is dealing with cumulative stress and would benefit from stress-relief activities but likely would find it impossible to create the time given his busy schedule. Early intervention providers are challenged to help caregivers identify stress-relief strategies that can be implemented within their natural daily routines. Richard, for example, might enjoy listening to relaxing music on his drive home from work, taking a short walk when he arrives home and then getting a shower to transition himself into a more relaxing mood for the evening. Given Pat’s young age, Katie may consider feeding Pat earlier in the evening and then creating a play time for the three

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Table 9.2  Richard’s problem-solving chart Triggers • Katie wakes Richard • Katie asks Richard to get

Pat for dinner • Pat resists Richard and whines, cries, and kicks

Preventions

Behaviors • Richard grabs Pat and

brings him to the kitchen

• Yells and threatens then

Reactions • Pat is quiet • Katie stops nagging Richard

spanks Pat

• Yells at Katie • “Forces” Pat to eat • Sends Pat to bedroom Function: Get out of stressful family interactions

New skills

New responses

of them that involves toys as opposed to television viewing. Then Pat could go to bed early and the caregivers could spend some time together talking about their days over a meal. New skills, or replacement behaviors, are determined by evaluating the function of Richard’s behavior. In this example, while Richard tried to bring his son to a family dinner, it ended in Pat being sent to his bedroom. Richard would benefit from new communication skills, as would Pat, as father and son escalated the degree of aggressive communication to vocalize their needs. Finally, new responses for Richard may include validating himself for using new skills, validating his wife for the caregiving work she had done all day long, and communicating with his wife about their worries, disagreements, and their daily successes. In this way, family interactions would be less stressful which aligns with the function of Richard’s maladaptive behaviors (Table 9.3). Early intervention professionals can also utilize this chart when working with caregivers to see the relationship between life stressors, caregiver behaviors, and the consequences that maintain their behaviors and the behaviors of those around them. It serves as a problem-solving tool to identify preventions that soften triggers to stress (e.g., antecedents), determine new caregiver skills that are positive and effective, as well as determine new caregiver responses. It may also facilitate a conversation about how stress fluctuates from day-to-day and in the context of different life events. Early intervention providers can normalize caregiver stress and stress responses, as everyone is exposed to a host of stressful events associated with daily life (e.g., car line, traffic, arranging childcare, meeting deadlines, school projects, etc.) and individual ability to cope with stressful events differs. Even positive life events like marriage or having family in town can increase stress. Helping caregivers see the impact of stress on their relationships, health, and ability to function is the first challenge prior to identifying lifestyle changes (e.g., preventions) that may reduce or at least help caregivers manage stress.

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Table 9.3  Family Problem-Solving Chart Triggers • Katie has been home with Pat all day • Katie is tired from helping mother-in-law • Katie might be pregnant • Katie wakes Richard • Katie asks Richard to get Pat for dinner • Pat resists Richard and whines, cries, and kicks Preventions • Ensure adequate sleep for family • Increase daily physical activity for Richard • Ensure good nutrition for family and move Patrick’s dinner time earlier in the evening • Caregivers engage in daily self-care

Behaviors • Richard grabs Pat and brings him to the kitchen • Yells and threatens then spanks Pat • Yells at Katie • “Forces” Pat to eat • Sends Pat to bedroom Function: Get out of stressful family interactions New skills • Richard and Katie can use strong communication skills: first-then statements, calm voice, ask for help, I-messages • Redirect Patrick if he resists and then use follow-through for directions

Reactions • Pat is quiet • Katie stops nagging Richard

New responses • Caregivers can validate one another’s efforts to use good communication and use effective parenting strategies • Caregivers can use humor to get through difficult family routines

Warning Signs of Stress A discussion of the warning signs of stress is worth discussing as the human body is hardwired to cope with stress. Caregivers need to understand that stress is a normal psychological and physical reaction to life’s daily demands. Human bodies are enabled with a stress alarm that signals the body to release hormones and raise blood pressure and heart rate when confronted with stressors or threats. These physiological alarms signal a “fight-or-flight” response, and once the threat is removed, the body should return to normal. However, the complexities of modern life often render this impossible, leaving bodies in a heightened state of alarm and making stress management activities critical to returning to a calmer, relaxed state (Mayo Clinic, 2017). Table 9.4 lists many of the warning signs that someone is under stress. These symptoms can be thought of as red flags, alerting the individual that they are having a hard time coping with stressful life events. These symptoms often overlap, and rarely do they occur in neat categories as they are presented in the table. If these events are not better managed, the individual is at heightened risk for physical and/ or emotional breakdowns. Early intervention professionals are encouraged to share this table with families to assist them in identifying their own symptoms of stress. While this chapter explores strategies to help caregivers of children with DD manage stress, some families will need to seek out professional medical advice if their symptoms do not improve. Always refer caregivers to their primary care physician if their symptoms seem too severe, life threatening, or threatening to the lives of

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Table 9.4  Warning Signs of Stress Physical Headaches Stomachaches Chronic fatigue Heart palpitations Weight gain/loss Trembling

Emotional Anxiety Nervousness Excessive worry Anger Depression Fearful

Behavioral Crying Nervous habits Sleep problems Over-reacting Increased eating or drinking Smoking

Mental Poor concentration Poor memory Confusion Mind racing Going blank Indecision

their children. It may be a sign that they need more intensive psychiatric treatment, in addition to stress management.

Preventions for Stress Management Parents are the first and most important models for their children. Children learn skills that their parents teach them like learning to put their dishes away and cleaning up their toys. Children also learn by watching their caregivers during daily life routines, and sometimes caregivers may teach their children problem behaviors. In the case example of Richard, a very stressed father models several maladaptive behaviors like yelling, using physical force, and spanking his child. To be better role models, caregivers must evaluate their behaviors and consider healthier alternatives to dealing with stress and daily life hassles. Preventions, or lifestyle changes that reduce or manage stress, increase one’s ability to cope with life hassles in an adaptive manner. Preventions are centered on developing healthy routines including things like adequate sleep, nutrition, physical activity and selfawareness, as well as learning to simplify our schedules and commitments. The following section provides an overview of some health-promoting behaviors that all adults benefit from. While early intervention providers are not expected to be wellness coaches, they can help caregivers evaluate the degree to which their daily routines support them in their role as caregiver. Help them identify ways to promote their own self-care so that they are better positioned to deal with the demands of raising a child with DD.

Developing Healthy Routines The business of modern life poses many barriers to developing healthy routines around exercise, nutrition, and sleep. Many caregivers work very long hours leaving little time for fresh food shopping, planned exercise, adequate sleep, and daily self-­ care. Caregivers typically prioritize their children’s needs over their own, even though their needs are central to a strong, healthy family.

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Sleep Routines  Quality sleep is extremely important for optimal functioning. While people used to believe that sleep was a passive state, science now tells us that the brain is actively working on important functions like growth, memory, muscle development, and restoration (Roban, 2016). The average child ages 4  months through 6 years needs 11–12 hours of uninterrupted sleep per night, and most adults need between 7–9  hours of sleep a night for optimal functioning (Roban, 2016). Children who get sufficient sleep have stronger cognitive skills which means better memory and reasoning skills and greater academic success. Similarly, adults who get sufficient sleep are more able to focus, control their emotions, and problem-­ solve (Kempton, 2016). On the contrary, children and adults who are sleep deprived are often emotionally labile, have difficulty focusing, and are more at risk for temper tantrums (e.g., children) and maladaptive behavior (e.g., children and adults). Early intervention providers can assist caregivers with evaluating family sleep routines and the impact of sleep routines on child and caregiver behaviors and introduce sleep hygiene strategies (see sleep strategies reviewed in Chap. 3 for child-focused sleep strategies). Early intervention providers can direct caregivers to web-based sleep resources available through the Mayo Clinic, the Centers for Disease Control and Prevention, and the American Sleep Association. In general, adults want to consider how to schedule adequate time to sleep (7–9 hours a night), and sleep-promoting nighttime routines. Routines that support relaxing activities (e.g., meditation, reading, taking a bath) and avoid high-intensity or stressful activities (e.g., watching violent programming) are encouraged, as well as avoiding caffeine, alcohol, and foods that are difficult to digest. This often means putting cell phones and tablets away from the bedside to charge and on silent so they do not interfere with quality sleep. Nutrition  Early intervention providers may also help families evaluate their nutritional choices. High-quality nutrition fuels the body and brain to perform optimally and also helps individuals achieve a healthy weight (Mozaffarian, Hao, Rimm, Willett, & Hu, 2011). Most people have heard that a diet rich in high-quality foods that are unrefined and minimally processed is best. This would include foods like fruits and vegetables, whole grains, healthy fats, and healthy sources of protein. Lower-quality foods are typically highly processed or high in sugar and fat. Sugar-­ sweetened beverages, often high in caffeine, are a great example of a low-quality food that is universally available. While most early intervention providers are not working with clients in the role of a nutritionist, they can still help families evaluate their health-promoting behaviors related to food and drink choices, set health-­ promoting goals, or refer them to dietary services as needed. Physical Activity  Children and adults benefit from exercise. Regular physical activity is associated with many positive health benefits. Physical activity is particularly important for the development and maintenance of healthy bones, muscles, and joints; to help control weight gain and reduce body fat; and to prevent or delay the development of high blood pressure (Centers for Disease Control and Prevention, 2015a). It can also help to increase flexibility, balance, and endurance (Centers for

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Disease Control and Prevention, 2015a). Additionally, research has found a positive association between physical activity and engagement in health-related behaviors (i.e., increased consumption of fruits and vegetables, decreased use of recreational drugs; Centers for Disease Control and Prevention, 2015a). The Centers for Disease Control and Prevention is an excellent resource for physical activity guidelines for children and adults. Very young children are constantly in motion given their natural curiosity to explore the world and very short attention spans. It is important for children to have time to run and play outside as well. Current recommendations suggest that younger children engage in 60 minutes a day of suitable activities like climbing on a playground, running in the yard, or learning to ride a bike (Centers for Disease Control and Prevention, 2015c). Some children with developmental disabilities may have motor impairments or specific health needs that prevent them from safely engaging in certain activities, so early intervention providers may refer caregivers to the pediatrician before enrolling a young child in a particular sport. The CDC suggested that adults engage in two types of physical activity each week: aerobic conditioning and muscle-strengthening activities. Specifically, according to 2008 Physical Activity Guidelines for Americans, adults need at least 150 minutes of moderate aerobic activity (e.g., brisk walking, leisure bike ride) or 75 minutes of vigorous aerobic activity (e.g., jogging/running, swimming, biking quickly) as well as 2 days of strength training that targets all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms; (Centers for Disease Control and Prevention, 2015b). For some adults, it may be difficult to find the time or the energy to engage in physical activity, especially given the heavy responsibilities of raising a child with developmental disabilities. Early intervention providers may assist caregivers with finding ways to embed more exercise into daily routines. They should be mindful to start small so that caregivers do not become overwhelmed with the additional activity. For example, they can help caregivers to identify activities that may get them moving alongside their child like teaching their child to ride a bike, or going on a family walk while pushing the child in the stroller. Play intervals are often short and occur daily and may be an ideal way to develop some health-­ promoting physical activities. Early intervention providers may also suggest strategies to promote activity outside the home (e.g., parking further away from the store entry) and while at work (e.g., taking the stairs, taking a walk during lunch break) as a way to embed more physical activity within routines without finding additional time. Very busy caregivers with demanding work schedules may consider ways to increase physical activity on the weekends when they do not have to work or taking turns taking a short walk around the block after the children go to bed. There is no easy solution, and each family must identify small ways to commit to health-­ promoting activities that will reduce stress, increase health, and support them to engage in adaptive parenting. Mindfulness and Self-Awareness  Mindfulness has become a buzz word in mental health, religious and spiritual communities, fitness gurus, and other interest groups like yoga practitioners. Mindfulness is a basic ability to be self-aware of the moment,

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aware of where we are and what we are doing, without being overly judgmental or reactive to the events surrounding us. Mindfulness involves stepping back from our thoughts about what has just happened or what may happen in the future and just being in the moment. Mindfulness can occur during meditation or prayer, or even during daytime routines like walking between places or doing a yoga practice. While mindfulness may sound like a fancy term or a special thing that other people do, it is not and all people can learn to engage in brief mindfulness activities that calm the brain and the body, reduce stress, enhance performance, and gain insight into our own mind and increase our attention to the well-being of others (Hayes, Strosahl, & Wilson, 2012). Mindfulness activities are a gateway to self-awareness and can be performed in brief intervals over the course of a day or week. Early intervention providers can share the benefits of mindfulness techniques with caregivers and may help caregivers identify small steps to incorporating mindfulness practices as a form of self-care and prevention, so caregivers of children with DD are prepared to handle the demands of daily life. Table 9.5 provides a simple mindfulness activity (e.g., progressive muscle relaxation) that can be performed while sitting in a chair. This technique incorporates deep breathing, muscle relaxation, and thinking about the moment to reduce stress and bring calm and relaxation to the body. Early intervention providers are encouraged to try mindfulness activities themselves, before sharing them with clients as the benefits are universal for all people. If caregivers find that time is a barrier to mindfulness, help them identify ways to incorporate these strategies into their daily routines. For example, a few deep breaths at a very long traffic light, while waiting at a doctor’s office, on lunch break, or when rolling into bed at night. Mindfulness does not have to be one more responsibility, it can be a moment that adults anticipate because it is simple, intuitive, and time-limited, and it brings an immediate sense of calm and relief. Table 9.5  Five Minutes of Mindfulness 1. Find a seat. Wherever you are sitting – a chair, the floor, a bench – find a spot that gives you stability. 2. Notice your arms and legs. If you are seated in a chair, let your feet touch the ground. If seated on the ground, try and cross your legs and feel the support of the ground. Put your hands on your upper legs and feel them rest comfortably. Not too far forward or too near the torso. 3. Try to sit up straight. Find a comfortable position where the spine is not too stiff but comfortable. Let the shoulders drop and the neck relax. 4. Drop the chin slightly and gaze downward. Look down toward the ground by lowering the eyelids. If you need to close your eyes than do so, but it is not necessary. Otherwise, find a spot and look at it without focusing on its details. 5. Breathe in and out. Feel your breath coming in and out. If you find yourself getting stuck on thoughts or judgments about past events or worrying about the future, go back to the breath and focus on deep inhalations and long, slow exhalations. Feel the air fill up the rib cage and then slowly leave the body. Try to take 10–20 nice deep breaths and then check in to see where your thoughts are. If you have wandered to judgments or worry, return your attention to your breath.

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Simplify Life and Manage Finances Simplify Daily Schedules  Many families simply find that they have too much to do. They become overscheduled with daily work and parenting demands, running errands, children’s extracurricular activities, religious activities and medical/developmental therapies. A first step in reducing stress is to be self-aware of the unnecessary commitments and then prioritize responsibilities. Caregivers may need assistance with prioritizing demands and reassurance that it is okay to reduce the number of commitments they make. For example, now may not be the time to sit on community boards or to volunteer many hours at the local shelter; however, when their young child is older, there may be more opportunity to engage in such activities. Children also need time to engage in free play, and if their routines are too busy, they do not get this time. Many children engage in daily therapies to address their needs so adding on extracurricular activities may not be appropriate. Families need down time in the home so that they have time to cultivate healthy routines and engage in key preventions that promote health and reduce caregiver stress. Manage Finances  Responsible money management is critical to creating a harmonious home. Raising a child is expensive, and raising children with DD may result in additional costs associated with medical treatments, therapies, and specialized childcare or educational instruction. While early intervention providers do not provide financial services, it is an area for families to consider when trying to reduce their stress. Better financial planning, including setting a budget, tracking purchases, and paying down debt will help to reduce the stress that comes with overspending. Many communities have nonprofit agencies that provide debt relief counseling or assist with tax preparation for families who need assistance. Early intervention providers may consider keeping a list of such resources to share with families in need.

New Skills Caregivers need to learn new skills to cope with the daily stressors of life. Raising a child is full of challenges and daily hassles which can greatly strain the caregiver-­ child relationship as well as other relationships. Caregivers want what is best for their child but can struggle with feelings of inadequacy, frustration, and exhaustion due to the demands of the job. Early intervention providers can support caregivers to be self-aware of their successes and evaluate their stressors to identify positive coping mechanisms. Early intervention providers should keep in mind that raising a child with DD and challenging behavior can be particularly difficult, and caregivers of these children are at heightened risk for stress, mental health problems, marital strains, and life dissatisfaction. Caregivers will benefit from learning communication skills to promote healthy relationships including the use of listening skills, I-messages, and anger management techniques.

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Communication Skills Positive communication skills are key replacement skills. Learning to communicate with children, spouses, parents, teachers, daycare providers, and early intervention providers is extremely important. While many books and web-based resources are available to teach adults better communication skills, early intervention providers can teach caregivers a few simple strategies that can greatly impact daily interactions. Skills such as listening, validating others, and using I-messages can help adults communicate their needs more effectively, get needed help, as well as recognize the needs of others. Listening Skills  Listening is hard, especially with daily distractions like cell phones, TVs, and children who need and demand caregiver attention. Early intervention providers can help caregivers learn to listen by role-modeling good listening skills themselves. Engaging in key behaviors like maintaining eye contact, being attentive, active acknowledgement (e.g., a head nod or simple “uh huh”), keeping an open mind (e.g., thinking about the speaker’s message without judgment or generating solutions), and remaining quiet until the speaker finishes. Once the speaker finishes, it may be appropriate to reflect the message back (e.g., “So you are tired and frustrated because you’ve been awake all night with your toddler.”) and validate the other person’s feelings (e.g., “I understand your frustration, it’s difficult to be a strong mom when you have not had any sleep). Listening skills can have a strong impact on relationships as individuals like to be heard and understood. Parents of children with DD often feel and become isolated due to the burden of going in public with their child, and the early intervention provider may be one of the only people who lend a listening ear. I-Messages  Another effective communication strategy is to teach caregivers to use I-messages. I-messages serve as a means for mutual problem-solving with spouses or other caregivers. I-messages involve three parts: (1) a feeling word, (2) what caused the feeling, and (3) what could happen to make things right (Gordon & Edwards, 1995). In the case example of Richard, he could have used an I-message to communicate to his wife Katie his frustrations about the long commute home (e.g., “I feel really frustrated because I sat in one hour of traffic and I would like to go for a quiet walk to clear my head before dinner.”) An understanding spouse would recognize her partner’s need for a short break before he begins his nighttime responsibilities as husband and father. Adults need a social support system, someone with whom they can communicate their frustrations and worries. For people in marriages or partnerships, this person is typically the spouse/partner. Early intervention providers should consider whether single caregivers with whom they work have a social support system, as they are at heighted risk for chronic stress and associated poor health outcomes (Cairney, Boyle, Offord, & Racine, 2003). If they do not have a social support system, consider ways to connect them with family members or friends, as well as other parents

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of children with DD either through support groups, social media groups, or local advocacy agencies. Anger Management  Everyone feels angry sometimes, but how we cope and express these strong feelings is critical. Remember, parents are the first and strongest models for their children. If children watch their caregivers engage in aggressive acts feeling angry, they are most likely to see these behaviors as normal expressions of a strong emotion. While people may believe lashing out or hitting a pillow helps them relieve strong emotions, it is not true; rather it teaches a maladaptive behavioral pattern. Learning how to appropriately manage angry emotions is critical. The first step in anger management is to recognize one’s own triggers for angry emotions. To do so, caregivers must learn to pause when confronted with situations that create strong angry feelings. This pause gives the individual to think about what just happened and how to best address it without a strong, or worse, an aggressive reaction. Pausing for a few seconds, minutes, or even hours will help the individual process the event and the emotions they are experiencing. Recognizing the bodily reactions to these emotions is key because these are typically our body’s cues or early warning signs that we need to step back from a situation and calm down, prior to doing or saying something that will be regretted later. Once one is aware of triggers to powerful angry emotions, they can try to use calming techniques like deep breathing, counting to ten, or even walking away from the situation. These techniques give the individual time to reduce the initial powerful emotions, avoid aggressive reactions, and think more clearly about effective responses that result in the best outcomes. Finally, help clients understand that it is okay to disagree with others, as long as they do it in a way that does not harm or belittle others. Encourage clients to think about how they communicate their message through word selection and body language. Remind clients to use I-messages when communicating stressful events. Positive communication skills and a willingness to share emotions, listen to others, and problem-solve difficult situations will go a long way toward reducing stress in the home and increasing cohesion and mutual respect. This leads to fewer arguments and an overall happier home. When clients are really struggling with anger management strategies, early intervention providers should be award of community resources that can provide more intense supports.

New Responses Just as we teach caregivers new responses to child behaviors, we also teach them new responses to use with themselves. Stress is a normal part of daily life. Stressors are present in the home, community, and in the workplace. News media is constantly updating consumers with stressful stories. Since we cannot escape the stressors associated with life and there is no pause button for caregiver stress, we must learn to cope with stressors through adaptive behaviors (e.g., new skills). Early

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intervention providers can encourage caregivers to use new responses on themselves and with their spouses/partners, helping them to identify ways to praise and acknowledge their own successes, even if they are small. For example, self-­ affirmation for preparing a healthy breakfast, taking their child out for a walk, or even remaining calm during a difficult temper tantrum can help reinforce small successes and motivate caregivers to keep trying to use new skills. Encourage caregivers to also find opportunities to praise and recognize the support of other adults in their lives, as this recognition can go a long way toward improving relationships and maintaining helpful behaviors of the other person. Early intervention providers can also role-model the use of these skills for caregivers by praising caregivers for attending sessions, doing homework or even coming to an appointment on time. Another new response to the constant tasks and challenges of raising a child is to use humor. Encourage caregivers to take a step back, evaluate their expectations and how they may be misaligned with how a particular situation unfolded, and acknowledge that it is okay. Never in history have parents been perfect in every situation. Use humor to cope with the parenting experiences that do not go so well! It will lighten the gravity of the situation and give the caregiver a break from self-criticism.

Chapter Summary When times are hard and caregiver stress is high, it’s important to remind caregivers to validate their feelings and return their focus to preventions and new skills as means for coping with daily life hassles and stress. Remember that raising a child is a very difficult job and all caregivers struggle with feeling overwhelmed from time to time. Encourage caregivers to engage in self-reflection on family routines like sleep, nutrition, and exercise, as well as their efforts to communicate effectively and manage anger appropriately. Encourage caregivers to solve problems together rather than dwelling on them, and that it is okay to disagree as long as the discussions are supportive and respectful of one another. Remind caregivers to take care of one another and not be afraid to ask for help from their partner, extended family members, or friends who have a stake in their lives. In parenting, as with many other parts of life, finding a balance is key. Remember the airplane oxygen mask rule, first secure your own mask, and then assist small children with their own mask. A caregiver needs to engage in self-care activities in order to provide high-quality care for their children. For caregivers of children with DD, who report the highest levels of caregiver stress and mental health problems, self-care is critical. Early intervention providers may also consider ways to connect families of children with disabilities to case management and respite care services in their communities. These services can provide a needed break or another ear to listen. In all cases, if caregiver symptoms of stress persist, refer them to their primary care physician for further evaluation and treatment.

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Glossary of Terms

Applied Behavior Analysis (ABA) The science of applying experimentally derived principles of behavior to improve socially significant behavior. ABA defines behavior in observable, measurable terms, within the context of environment, antecedents, and consequences. Antecedents  Events that occur immediately before a behavior, in HOT DOCS terminology these are referred to as triggers. Autism Spectrum Disorder (ASD)  A neurodevelopmental disorder that is marked by persistent deficits in social communication and social interaction across multiple contexts and the presence of restricted, repetitive patterns of behavior, interests, or activities. Busy Bags  A prevention strategy that consists of portable, preferred toys and activities that are used to keep children engaged during wait times. Broad-Band Assessments Assessments which identify general conditions and abilities in children. Caregiver-Child Dyad  Relationship between the caregiver and child. Choices A prevention strategy that is used to provide children with alternative selections. Communication and Language Development Area of growth that relates to a child’s development of words and sentences, ability to respond to others’ attempts to communicate, and expression of wants and needs. Cognitive Development  Area of growth that relates to a child’s executive functioning such as tracking objects, identifying and recognizing the function of objects, and developing repertoires of academic skills (i.e., colors, numbers, shapes). Consequences  Outcomes or reactions that happen immediately after a behavior and may strengthen or weaken behavior, in HOT DOCS terminology these are referred to as reactions. Criterion-Referenced Assessments  Assessments in which an individual’s scores are compared to predetermined cutoff points. Developmental Delay  The difference between a child’s actual level of functioning and expected level of functioning. © Springer Nature Switzerland AG 2020 H. Agazzi et al., Promoting Positive Behavioral Outcomes for Infants and Toddlers, https://doi.org/10.1007/978-3-030-51614-7

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Glossary of Terms

Developmental Domains Areas of growth (motor, cognitive, communication, social-emotional, etc.) that continue to improve and become more complex over time. Early Steps  Is Florida’s early intervention program for children ages birth to 3 years and their families. Early Steps is funded through the Individuals with Disabilities Education Act (IDEA). See “IDEA Part C” for more information. Empathy  Considering other’s perspective and validating those feelings. Expressive Language  Spoken language or expression of wants and needs. Extinction Burst  A short-term increase in the frequency and intensity of a behavior due to a lack of reinforcement, commonly seen during planned ignoring. Fine Motor A subcategory of motor development that involves more refined or complex movements such as using a fork, tying shoelaces, drawing with a crayon or pencil, etc. First-Then  A prevention strategy that consists of a description of what needs to be accomplished first, before the reinforcement is available. Function of Behavior  The underlying purpose or meaning of a behavior. Generalization  The tendency to perform a learned behavior in settings other than where learning occurred. Gross Motor  A subcategory of motor development that involves large movements such as walking, jumping, lifting arms, throwing objects, etc. “I-message”  A communication skill that involves making first person statements beginning with “I feel angry when…” rather than blaming the other person. IDEA (Individuals with Disabilities Education Act)  A federal act requiring all states to provide individually appropriate educational services for students with identified disabilities. IDEA Part C The section of IDEA that pertains to early intervention services available to eligible children from birth through 3 years of age and their families. IEP (Individualized Education Program)  A document that outlines individualized goals and objectives to be achieved by students ages 3–21 years receiving special education services through the public school system. IFSP (Individualized Family Support Plan)  A document that outlines individualized goals and objectives to be achieved by the infant or toddler receiving early intervention services and his/her family. Ipsative Assessment (Progress Monitoring)  Assessments which help determine an intervention’s effectiveness in treating the concern it is meant to target. Just for Me Story  A prevention strategy that consists of a story developed for a child outlining expected behaviors, feelings, and consequences, including how others will feel. Modeling  Imitation learning, the tendency for individuals to first observe and later imitate the behaviors of others. Motor Development  Area of growth that relates to a child’s movements, posture, and physical engagement with objects in a variety of ways. Narrow-Band Assessments Assessments which identify specific concerns and abilities in children.

Glossary of Terms

149

Natural Ending A prevention strategy that consists of a taking into account the conclusion of one activity before transitioning to the next. Natural Learning Opportunity  Favorable opportunities to promote learning during daily routines. Negative Reinforcement  Behaviors motivated by removal of or escape from an aversive situation are said to be negatively reinforced. For example, a child screams when mother vacuums, so mother stops vacuuming. Screaming is negatively reinforced because it stops the aversive event. The child is more likely to scream in the future when faced with aversive events. Norm-Referenced Assessments  Assessments in which an individual’s scores are compared to the scores of a group of similar peers. Operant Conditioning A set of scientific principles explaining how behavior is acquired or reduced, also referred to as learning theory. Planned Ignoring  Intentionally not paying attention to undesired behavior, while making sure to pay attention to more desired behaviors. Positive Reinforcement  Behaviors motivated by attention, approval, or acquisition are said to be positively reinforced. For example, a child praised by his/her mother immediately after performing a task receives positive reinforcement. The child is therefore more likely to repeat that task in the future. Premack’s Principle A scientific principle associated with operant conditioning that uses highly reinforcing activities to motivate less preferred activities. First-­ then is a prevention strategy that incorporates the Premack’s Principle. Preventions  Strategies that act to preclude challenging behavior by toning down triggers. Progressive Relaxation  A method used to promote muscle relaxation by using a combination of classical and operant conditioning techniques to tense and relax muscles. Progressive relaxation has proven physical and mental health benefits. Prompts  A prevention strategy that consists of cues (visual, auditory, or physical) that promote a given response. Punishment  An aversive consequence following behavior that is intended to stop the behavior or make it less likely to happen again in the future. Examples of punishment include taking away items or privileges, yelling, or spanking. Reactions  HOT DOCS terminology for consequences or events that occur immediately after a behavior. Receptive Language  Understanding messages communicated by others. Redirection Directing the child toward a desired behavior through distraction, prompting, and gentle guidance as needed. Reinforcement  Any consequence following behavior that increases the likelihood of that behavior happening again in the future. Ritual  A group of specific behaviors that occur during a routine. Routine  A schedule of events that regularly occur each day and help to regulate behaviors. Shaping  A systematic procedure used to teach new skills by reinforcing successive approximations toward the desired goal. Sleep Hygiene  Conditions and practices to promote healthy and restorative sleep.

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Glossary of Terms

Social Learning Theory  A set of scientific principles explaining the role that imitation plays in the development of social skills, also referred to as observational learning theory. People will imitate live or media models under certain sets of circumstances. Social Stories A copyrighted prevention strategy first developed to teach social skills to children with ASD through a structured story format which describes what to do in situations that are confusing or difficult. In HOT DOCS these are referred to as Just for Me Stories. Successive Approximations  Steps toward goals that are systematically reinforced as they come closer and closer toward accomplishing the goal. Teachable Moments  Periods of time when a child is most available to learn a new skill. Time Out  A procedure whereby all attention is briefly removed from the child due to enduring instances of noncompliant or aggressive behavior. Time out is effective for use with children ages 3–12, motivated by attention. Triggers  HOT DOCS terminology for antecedents or events that occur immediately before a behavior. Visual Supports  Prevention strategies that provide children with a more concrete understanding of the environment and/or another way to communicate their wants or needs.

Index

A Activity reinforcer, 104, 106 Adverse consequence, 54 American Academy of Pediatrics (AAP), 40 American Sign Language, 86 American Speech-Language-Hearing Association (ASHA), 71 Anger management, 142 Antecedent-based strategies, 66 Applied behavior analysis (ABA), 53 Autism spectrum disorder (ASD), 53, 68 B Bedtime routine, 47 Behavioral analysis, 53 Behavior analysis, 56 Brain development, 1 Broadband assessments, 23 C Caregiver-child dyadic relationship, 6, 7 Caregiver-child facilitation model, 12 Caregiver-child interactions, 83 Caregiver-child relationship, 29 Caregivers manage stress, 134 Caregiver stress case study, 132 child behaviors, 132 daily work and parenting demands, 140 DD and comorbid, 131 developmental disabilities, 131 fight-or-flight, 135 intervention professionals, 134

money management, 140 overweight body frame, 133 problem-solving chart, 134 responsibilities, 132 stress-relief activities, 133 unhealthy behavior, 133 warning signs, 135 Caregiver style, 79 Centers for Disease Control and Prevention (CDC), 138 Challenging behavior, 54 caregivers, 82 daily life routines, 82 disruptive behaviors, 81 misbehavior, 82 parent-child interactions, 81 social-emotional and communication skills, 81 Child behavior antecedent-based strategies, 66 caregivers and professionals, 69 challenging behavior, 66 daily activities, 68 environmental adaptations, 68 problems, 132 Choice-making, 73 Clear directions caregivers, 69 child’s communication level, 70 Coercive cycle, 80 Cognitive development, 3 Common assessment tools broadbrand assessments, 23 criterion-referenced assessments, 22 narrowband assessments, 23 norm-referenced tests, 22

© Springer Nature Switzerland AG 2020 H. Agazzi et al., Promoting Positive Behavioral Outcomes for Infants and Toddlers, https://doi.org/10.1007/978-3-030-51614-7

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Index

152 Communication and language development, 4 babbling, 4 conversations, 4 vowel/consonant sounds, 4 Communication skills, 100, 141 Consistent routines, 67 Criterion-referenced tests, 22 D Developmental assessment data, 25 Developmental disabilities (DD) experience, 79 child problem behaviors, 80 communication, 80 disruptive behavior, 80 Disruptive behaviors, 99 E Early childhood assessment assessment process, 21 family involvement, 22 problematic behaviors, 21 Early childhood development brain development, 1 CDC developmental milestones, 2 motor development, 1 Early childhood social-emotional development caregivers, 7 challenging behaviors, 8 prevention and intervention, 8 social-emotional skills, 7 Early intervention, 1, 9, 28, 29, 123–126, 128, 129 coaching, 27, 28 emotions, 27 family’s perspectives, 27 problem-solve challenges, 30 routines based intervention, 29 service delivery model, 30 working, 27 Early intervention programs, 8, 11, 15 national programs, 9, 10 pediatricians, 10 population statistics, 9 social disparities, 11 types, 9 Early intervention services, 12 Ecological framework, 6 Environmental preventions, 69 Evidence-based progress monitoring assessment tool, 24 Extinction, 110

F Family-centered early intervention, 31 Family-centered planning, 128 Family-centered practice, 123, 129 aims, 123 benefits, 124 caregivers, 128, 129 child and family outcomes, 128 communication, 125, 126 dignity, 125 principles, 123 problem-solve, 127 respects, 124 teamwork/collaboration, 126, 127 Family problem-solving chart, 135 Federal early intervention program child’s natural environment, 11 landmark legislation, 11 legislative mandate, 11 Follow-through, 112, 113, 118–119 Food reinforcement, 109 Function of behavior, 56 positive reinforcement, 56 Functional Assessment Matrix, 58 Functional Behavior Assessment (FBA), 56 Functional communication skills caregiver, 85 emphasis, 85 gestures, 84 intervention, 85 modeled behavior, 85 nonverbal gestures, 84 offer choices, 86 rehearsing, 85 teachable moments, 84 Functional communication strategies, 72 Functional communication training, 72 Functional routines, 68 G Graduated extinction, 111 H Hannah’s Problem-Solving Chart, 60 Healthy eating behaviors, 43 Helping Our Toddler’s, Developing Our Children’s Skills (HOT DOCS), 54 curriculum, 83 problem-solving chart, 57, 58, 61, 67, 81, 82, 99, 117, 129

Index I IDEA legislation, 13 IDEA Part B legislation, 14 IDEA Part C programs, 12 IGDI progress monitoring tools, 25 Individualized Education Plan (IEP), 13, 14 Individualized family support (or service) plan (IFSP) components, 14 consistency and quality, 14 documents, 13 legislation, 14 principles, 14 J Jake’s Problem-Solving Chart, 59 Jaxon’s behavior, 80 K Kylie’s problem-solving chart, 101 L Language/communication development, 1 Listening skills, 141 Long-term outcomes, 16 M Maladaptive behavior, 137 Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, 9 Mealtime interventions, 45 Mealtime routine, 43–44 Merriam-Webster Dictionary, 53 Meta-analysis, 74 Mindfulness, 138, 139 Motor development, 1 developmental milestones, 2 motor skills, 3 Multidisciplinary teaming approach, 30 Mutual problem-solving, 141 N Narrowband assessments, 23, 24 Natural environment, 29, 123 Nonverbal gestures, 84 Norm-referenced tests, 22

153 O Operant conditioning theory, 54 consequences/reactions, 55 positive punishment, 55 reinforcement, 55 Oscar’s Problem-Solving Chart, 127 P Parental warmth, 6 Part C program, 9, 12, 15 assessment information, 26 communicating assessment, 26 early childhood education, 25 intervention plan, 26 Part C service delivery model, 30 Physical Activity Guidelines for Americans, 138 Picture Exchange Communication System (PECS), 72 Planned ignoring, 111, 112 Positive caregiver-child dyadic relationship, 7 Positive punishment, 55 Positive reinforcement, 110 child behaviors, 101, 102, 110 time out, 113 Predictability, 36 Preschool special education, 14 Preschooler visual schedule, 41 Prevention science, 65 Prevention strategies, 67 Preventions promote independence choices, 73 settings and activities, 73 Primary reinforcers, 109 Problem-solving behavior, 58 antecedent, 53 HOT DOCS, 57 noise and embarrassment, 54 organism, 53 Problem-solving process, 57 Problem-solving tool, 134 Progress monitoring tool, 24 Public Law 99-457, 11 Punishment, 55 R Reinforcement menu, 109 Reinforcement techniques, 110 Reinforcing misbehavior, 100 Replacement behavior, 66 Rewards, 55 Richie’s behavior, 60 Richie’s Problem-Solving Chart, 61

Index

154 Role-playing, 74 Routine-based strategies, 42 Routines-based approach behavioral disorder symptoms, 37 challenging behavior, 41 childhood, 36 disruption, 37 dressing skills, 39 early intervention, 37 environmental factors, 35 evaluation, 38 factor, 35 family functioning, 39 functions, 37 parent-child relationship, 41 predictability, 36 preschool teacher, 36 repeated activities, 38 rituals, 35, 36 social-emotional functioning, 36 social-emotional skills, 42 visual schedules, 41 Routines-based intervention, 12, 29 Routines-based interview (RBI), 38 S Separation games, 50 Skinner’s theory, 53 Sleep interventions, 48–50 Social-emotional development, 5–7, 16 cognitive development, 3 communication and language development, 4 early childhood development, 1 early intervention, 8, 15 IDEA, 11, 12 IFSPs, 13 motor development, 2 social-emotional development, 5, 8 Social-emotional skills, 89 intervention professionals, 91 teach feeling words, 90 teach sharing, 92 teach waiting, 91 Social learning experiences, 92 Social learning theory, 27, 89 Social reinforcement, 102 physical contact, 103 praises, 103 proximity, 103 Social skills, 100 Social support system, 141 Strengths-based practices, 126 Stress management CDC, 138

children problem behaviors, 136 healthy routines, 136 intervention, 137 preventions, 136 quality sleep, 137 regular physical activity, 137 T Tangible reinforcers, 103–105 Teach caregivers, 93 Teach following directions, 92 caregivers, 92 visual supports and schedules, 93 Teach waiting, 91 Teaching American sign language caregivers, 86 communication, 88 functional communication, 87 gestural communication, 88 keywords/phrases, 87 sign, 87 visual supports, 88 Teaching new skills, 84 steps, 84 visual supports, 84 Time out, 113 discipline strategy, 114 noncompliance, 115, 116 teach child, 115 tips/problems/solutions, 115 use, 114 Token reinforcers, 106 components, 106 exchange system, 106 preschool-aged children, 107, 108 rewards, 106, 107 rules, 106 Treatment strategies, sleep problems, 46–47 V Validate and redirect, 112 Value-laden descriptions, 56 Verbal reminders and warnings, 70 Verbal warnings, 93 Vineland Adaptive Behavior Scales-Third Edition, 23 Visual schedules, 71 Visual supports, 71, 105 Z Zoe’s Problem-Solving Chart, 90