EI Talk: A Blog for Early
Childhood Professionals

IDEA defines the natural environment as “the home and community settings in which children without disabilities participate.”  In other words, a natural environment is anywhere a child would go in her regular day whether or not she had a disability.  Providers often think of natural environments as home or childcare, but the grocery store, park, library, or shopping mall are also good examples of natural environments.  When IDEA was first implemented the makers of the law and the regulations that guide the law’s implementation meant for natural environments to mean more than location. 

Delivering services and supports in an environment means that we must consider environment as the “the aggregate of social and cultural conditions that influence the life of an individual or community.”  (Webster).  Thus our services and supports to the families we serve must take into account all the things that influence the life of an individual:

• their social interactions and expectations,
• their cultural influences and priorities, and
• the routines and activities that are accomplished throughout the day.

Intervention planning considers these elements by partnering with families to determine appropriate and meaningful learning opportunities that reflect the family’s life style, priorities, concerns, and resources.

Two key components that are often missed in discussions about services in the natural environment are the concept of naturally occurring learning opportunities and the goal of participation in family routines.  Children learn best through meaningful interaction and engagement within a familiar context, such as daily routines.   Naturally occurring learning opportunities are the experiences that happen throughout a child’s day that allow for learning to occur in a natural, familiar context.  Embedding strategies into naturally occurring learning opportunities increases opportunities for practice and, thus, maximizes learning.  In addition, natural environment services focus on participation rather than the remediation of deficits.  Increasing participation in daily routines increases the child’s engagement and interaction, which serves to help maximize learning. 

Consider the following two scenarios.  The IFSP team has written an outcome for a child to begin to identify colors.  In order to meet this outcome, the provider sees the child at home.  During the session, the provider sets up a small table and uses little animal figures to help the child identify colors.  After the animal game, the provider and child play a special iPad game that uses sounds and animation to learn colors.  The child’s older sister becomes very interested in the iPad, so the provider allows her to join in so the younger child will learn to take turns during play.  At the end of the session, the provider tells the mother that they can play similar games using the toys in his bedroom.    

In the second scenario, the provider meets the mother and child at the grocery store.  The mother has been very distracted during sessions lately and mentioned having “so much to do next week” several times during the last session.  The provider agreed to meet mom at the grocery store around the corner from the child’s home.  As they walked through the produce section, the provider and mother talked about ways to help the child learn colors.  The provider suggested that mom pick up two vegetables (carrots and cucumbers) and ask the child to point to the one that is green.  They repeated this several more times as the mother gathered the vegetables for that night’s dinner salad.  As they traveled to the cereal aisle, the provider asked the mom if she could think of a game to play on that aisle.  Mom looked at her shopping list and saw “Cheerios,” so she asked her child to point to the yellow box.  They continued to repeat similar strategies on different aisles throughout the session.  As they were leaving the provider reminded mom that they can play similar games at home as she puts the groceries away. 

Both scenarios address the IFSP outcome of learning colors.  But, which of these two scenarios is reflective of true NE service?  The first scenario takes place at the home and includes a developmentally appropriate game to teach the child colors.  The provider uses family involvement by incorporating the sister and gives mom an activity to work on over the next week.  The problem with this scenario is that it is unlikely to occur naturally.  It is unlikely the toddler will sit at a small table on his own to participate in a learning game.  In addition, the provider will take the animal figures and iPad with her when she leaves and the child will wait a full week before he sees those items again.  The provider did give the mom an activity to work on, but it wasn’t in a naturally occurring way either.  This scenario also does not address participation in family routines.  How does this activity help the family’s daily life? 

The second scenario takes place at the grocery store because mom’s schedule was too busy for the session to occur at home.  The provider worked with the mom to identify and deliver strategies to help the child learn the colors.  The mom is able to practice and gains confidence throughout the session, making it more likely that she will repeat the activity on the next grocery trip.  Because grocery shopping is something this family does often, this scenario will occur again naturally and, from the sound of it, frequently.  The provider also suggested a way to continue the learning activity when the family gets home.  In addition, the mother and provider worked together to come up with strategies.  Most of the intervention occurred through interactions between the child and mother.  The provider used her expertise and knowledge of development to guide the mother to a developmentally appropriate game to learn colors.  Lastly, the child was able to participate in the grocery shopping routine.  He wasn’t just along for the ride as mom hurried through her day. He was actively engaged in the activity and the learning opportunities were increased. 

What are some methods you have used to identify Naturally Occurring Learning Opportunities (NOLO) with the families you serve? 

Listed below are some resources that are helpful in identifying Naturally Occurring Learning Opportunities:

FIPP CASETools: Checklists for Promoting Parent-Mediated Everyday Learning Opportunities—this can be downloaded from FIPP.  It is a structured way to help providers identify with families NOLO.  There is also an article about this in CASEinPoint by Dunst and Swanson. http://www.fipp.org/Collateral/casetools/casetools_vol2_no1.pdf

The ECTA center has several helpful resources to explain more about what contemporary early intervention practice considers intervention in the natural environment.  http://ectacenter.org/~pdfs/topics/families/Principles_LooksLike_DoesntLookLike3_11_08.pdf

•        Key Principles and Practices for Providing Early Intervention Services in Natural Environments:

o   Mission and Key Principles for Providing Early Intervention Services in Natural Environments

o   Seven Key Principles: Looks Like/Doesn’t Look like

o   Agreed upon Practices for Providing Early Intervention Services in Natural Environments

McWilliam RA (2000).  It’s only natural to have early intervention in the environments where it’s needed.  Young Exceptional Children Monograph Series No 2:  Natural Environments and Inclusion, 17-26.

Woods J (2004). Enhancing services in natural environments. NECTAC Conference Call. retrieved on August 30, 2013 from:  http://ectacenter.org/~calls/2004/partcsettings/woods.asp.

— Jamie Holloway

Kinesiotape’s popularity is increasing with therapists, athletes, and the general public.  Kinesiotape was once known only to orthopedic physical therapists who applied the tape skillfully for specific uses it is now available to the general public at any running or sports store.  There are many on-line resources such as YouTube videos available demonstrating the uses and application of kinesiotape to solve everything from shin splints to tempomandibular joint pain.  Although popular the use of kinesiotape in adults and athletes has not been proven to be effective. ¹ The use of kinesiotape with children, especially those with developmental disabilities or delays has not even been studied.

So is there a case to use kinesiotape in EI?

Kinesiotape is often used to promote alignment either with children with torticollis or decreased abdominal control.  The research, based on few small population studies, indicates that kinesiotape may be beneficial for use with children with  torticollis to reduce the asymmetrical position of their head ².  The tape can be applied to relax (or inhibit) the tight sternocleidomastoid muscle (SCM).  Alternately tape can be applied to encourage contraction (or facilitation) of the weaker or lengthened opposite lateral flexor muscles.

Applying tape to young children can be challenging for parents and therapists, for that reason it is often used as an adjunct to an intervention, applied by the therapist with instruction to the family on removing it.  When used for children whose muscles have adequate range of motion the “facilitation” technique can help cue kids through tactile pressure to activate the SCM.  The tape serves as a tactile reminder to maintain proper alignment.

Example of facilitating the lengthened SCM: image from  http://ot4kids.co.uk/kinesio-taping/benefits

Children with decreased abdominal control and decreased muscular endurance, are more likely to have trunk deviations affecting their sitting balance and overall stability.  While there have not been any large pediatric population studies examining the benefit of using kinesiotape for abdominal control it is commonly applied by therapists.  Studies that have examined the effect of kinesiotape on sitting posture in children with cerebral palsy have been inconclusive.  Ssimssek and Mazzone found improvements in sitting posture and improved arm movements^3,4, although Footer⁵  found no benefit.  Children need adequate abdominal strength and need to maintain the abdominal contraction to independently roll, sit, crawl and walk efficiently.  Kinesiotape can act as a tactile reminder to contract the abdominals and prevent any deviations in trunk alignment.  Taping techniques to encourage use of the abdominals is easily replicated by parents once they are instructed.

The use of kinesiotape in young children demands research and clear data collection from those of us who are using it in practice.

Do you use kinesiotape in your practice?
• What techniques do you use or what do you find beneficial or useless about it?
• How are you collecting data to determine its effectiveness?

References

1.  Morris D, Jones D, Ryan H, Ryan CG. (2012). The clinical effects of Kinesio(®) Tex taping: A systematic review. Physiotherapy Theory and  Practice, 259-270.
2. Ohman A. The immediate effect of kinesiology taping on muscular imbalance for infants with congenital muscular torticollis. Physical Medicine and Rehabilitation, 4:504-508.
3. ŞŞimşşek TT, Türkücüoğğlu B, Çokal N, Üstünbaşş G, and ŞŞimşşek İE. (2011). The effects of Kinesio® taping on sitting posture, functional independence and gross motor function in children with cerebral palsy. Disability and Rehabilitation, 33 : 2058-2063.
4. Mazzone S, Serafini A, Iosa M, Aliberti MN, Gobbetti T, Paolucci S, Morelli D. (2011). Functional taping applied to upper limb of children with hemiplegic cerebral palsy: a pilot study, 42(6):249-53.
5. Footer CB. (2006). The effects of therapeutic taping on gross motor function in children with cerebral palsy. Pediatric Physical Therapy, 18: 245-52.

– Erin Wentzell

We have all said it and written it a million times:  Your baby needs Tummy Time every day!  But do we ever take the time to explain what that means or why it’s important?  Maybe if we took the time to explain to caregivers the benefits of Tummy Time, they would understand the need to create opportunities to promote Tummy Time.

What are the benefits of Tummy Time and what are the essential suggestions we should be giving caregivers to promote the use of Tummy Time, throughout the day?

Tummy Time can be more than just a position, it can be an activity to engage with a child and develop necessary strength and developmental skills.  When Tummy Time incorporates active play it gives parents the opportunity to work on head control, eye contact, shoulder girdle strength, vocalizations, engagement, and social interaction.  Playing while on the tummy develops initial upper extremity weight shifting skills, strength of the upper back and trunk muscles, postural control, and   proprioception.  It also helps the baby to dissociate his head from his trunk and use the muscles around his eyes.  Although initially Tummy Time is a passive position, we must encourage caregivers to actively engage with the infant. Suggest to the caregiver to sing songs while the child is laying on their chest in the morning in bed or play peek-a-boo with a blanket on the floor or knock over cups or any other fun age-appropriate activity that engages the child while on their tummy.

Check out these sites for more ideas about Tummy Time. Remember to personalize these guidelines to include active play games for the caregiver and the child.

• Children’s Hospital of Atlanta:  Tummy Time Tools (in 7 languages)   http://www.choa.org/childrens-hospital-services/orthopaedics/programs-services/orthotics-and-prosthetics/Tummy-Time-tools
• Pathways.org:  5 Essential Tummy Time Moves (in Spanish and English)  http://pathways.org/awareness/healthcare-professionals/talking-about-Tummy-Time#.Uf52HpLOuuk
• Check out the video for more ideas of Tummy Time Moves:  http://www.youtube.com/watch?v=M3rCtW9DMD4

—

Erin Wentzell PT, DPT, PCS

Families who receive early intervention services participate in the development of the Individualized Family Support Plan (IFSP).  The IFSP is the document that describes the family’s resources, priorities, and concerns and identifies the support plan for the family.  The outcomes on the IFSP determine the focus of the support plan as well as services that will help meet the needs of the family and child.  Similar to other benchmarks, the outcomes on the IFSP need to be objective and measurable and time specific.  They also must describe how the child’s participation in activities and routines will be enhanced.  Outcomes are more than skill development goals.  Outcomes must clearly indicate what the child is expected to do or would like to do.

Let’s set up two examples of outcome writing.

Johnny is a two-and-a-half year old boy who is having difficulty communicating his wants and needs.  His family would really like him to talk more.  Sometimes his parents have to go through a whole litany of foods to find out what he would like to eat.  Johnny’s parents told the IFSP team that it would make meal time more fun if he could only tell us what he wants!

To help the family with their concern the IFSP team developed a variety of outcomes that they thought would be appropriate.

1. In 3 months, Johnny will use a gesture or word to make a choice between two food items during breakfast and lunch each day.
2. In 3 months, Johnny will label 10 pictures of food correctly for 7/10 trials.
3. In 6 months, Johnny will increase his vocabulary by saying 15 new words.
4. In 6 months, Johnny will use a single word to request his cup throughout the day when he is thirsty.

Which of these outcomes do you think best meets the needs of the family?  Why?

Let’s look at these outcomes closely to see which ones are examples of outcomes to include on the IFSP.

1. This outcome gives a time frame (3 months) for when the outcome is expected to be met and clearly states who the outcome is about (Johnny).  This outcome is measurable in that Johnny will need to perform this skill consistently during 2 meals each day. When Johnny meets this outcome, it will be helpful for his family because they will know what he wants to eat.
2. This outcome is time specific, child-focused, and measurable.  Let’s look closer at the “measurability” piece of this outcome.  Labeling 10 pictures of foods correctly for 7/10 trials is certainly an objective measure, but how likely is it that Johnny’s parents only want him to use words 70% of the time?  When we examine the helpfulness of this outcome, we see that it is lacking here as well.  Naming 10 pictures of foods is unlikely to be helpful to the family because it lacks context.  It does not address Johnny’s ability to communicate that he wants a certain food, only to name a picture of a food
3. This outcome also gives a time frame (6 months) and clearly states that Johnny is the person the outcome is about.  This outcome is measureable–We know Johnny will have met this outcome when he has 15 new words.  However, this outcome may or may not be helpful for the family.  Johnny’s new words could be anything from animals to names of family member’s.  Also, Johnny could achieve this outcome without ever learning to use his words to communicate his wants and needs.  While this outcome is measurable and gives a specific time frame, it is not very helpful for the family and would not help Johnny increase participation in routines.
4. Like outcome #1, this outcome meets our criteria for a good outcome.  It is measurable (Johnny will use a single word to request his cup when he is thirsty.  This would be helpful for the family because they would no longer have to guess if Johnny is thirsty or hungry or neither.  We know that we expect Johnny to meet this outcome in the next 6 months.  This outcome reflects Johnny learning in a natural context.

Writing IFSP outcomes can be challenging.  Teams want to write them in family friendly language and in plain terms, so everyone will know what the outcome is and why it is important to the family and when it should be reached.  Writing good outcomes takes practice.  There are a few hints that you may find helpful when your team creates outcomes with families:

• Who (usually the child, may be the family or caregiver, NEVER the interventionist)
• Will do what (the desired behavior)
• How measured (objective criteria)
• Under what conditions (are modifications, adaptations, accommodations needed)
• In what routines/activities
• When (time frame)

Click this link to the ECTA Center for more resources on writing outcomes.

http://ectacenter.org/topics/families/famresources.asp

Jamie Holloway, PT, DPT, PCS