ROUGHLY EDITED COPY
EHDI - STOPHER
‘Providers’ Use of Coaching Behaviors in Telepractice’
March 9, 2015
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> Okay, we're going to move on to the second session. I'll be walking around handing out some evaluation forms. Make sure you get those back to me at the end of the session. That'd be great.
> Do we have sound? How's that? Can you hear me okay? Okay...my name is Arlene StredlerBrown. Nice to see you, nice to be here, in Kentucky. And...I'm talking about telepractice. And I guess I want to know, because I talked to Jane Seton yesterday and decided this would be a great way to start this talk. If you think about inperson therapy, traditionally sitting there in a family's home or in a clinic, and think about how the provider does their work. In the context of being familycentered.
So, now we get this new way of doing therapy and it's conducting therapy remotely, through telepractice. Same familycentered work. How do the providers do their work? How do the providers act familycentered?
So...if we do a comparison, which I'm going to walk you through by the time a half hour goes by, one situation showed that providers were more familycentered than did other. Do you think it would be inperson or telepractice? So, just think for a minute, then I'll do a show of hands here. Do you think providers are more familycentered in telepractice? That was a majority. So, I won't have the other group hold up their hand.
My study was an exploratory study, I had no hypothesis, I had some ideas, but...I just finished my dissertation on February 20th. So...someone said, you're still a student. I said, no, I'm not. And thank you. And I decided to study telepractice for a couple reasons.
One is, when I was Director of the Colorado Home Intervention Program a long time ago, probably 15 years ago, I tried to get the School for the Deaf to implement telepractice and...the reason was kids all around the state of Colorado, you know, the big mountain range, right in the middle of it? Kids all around that state didn't get the same frequency of therapy or maybe the same experienced therapists as kids in the Denver, Boulder, Fort Collins, Colorado Springs area. While your states may not have big mountain ranges in the middle of them, except for Rhode Island, I think everyone has a rural component in their state.
So, telepractice was of interest and those of you who have dabbled in telepractice and how many of you would that be? Okay...less than half. Might realize that things have changed in 15 years. The costs, the equipment, the software, the hardware, the bandwidth. So...telepractice has become more accepted, more familiar, and, I decided, in my dissertation, that I wanted to study telepractice. At the same time, and I won't go into this at all, NIH has funded a study at the University of Colorado to look at child outcomes of telepractice versus inperson therapy.
Enough said about that, but the good news was, it got funded, so I decided I wouldn't do my dissertation on that topic, but rather, I'd do my dissertation on another topic that I worked with for years and years, which has been being familycentered. Teaching parents how to, I haven't used a PC in so long, makes me nervous. Once I switched to a Mac, I made the switch.
So, being familycentered, I'm not going into a long definition of it, although, I was just talking with a pediatrician from Colorado that said, I bet if you poll everyone in this room, you'd come up with as many interpretations of familycentered practice.
But let's say for context, if part C includes active parent involvement, it includes looking at what the family's needs are, priorities and then, the reason I have this highlighted, this is the question I spent if the professionals will identify and enhance family members capabilities and family members competencies by working with the family members. And Kathy, thank you, for your recent CNN opportunity, I took this quote right from you. We really are in the business of empowering parents to be effective language teachers for the children. And because I was a doctoral student, I have references and citations ad nauseum for you to look at.
What behaviors [ ] am I going to study? I went, again, to the literature. There's lots. I think there's 23 behaviors here. My statistician on my committee said, you have a small study, pick four. That's about as much as you can pick and get some kind of good statistical findings. So, I picked the four, wait, this isn't the updated, come back, I want them back. Someone get the proctor, this is not the one I uploaded this morning. This is not the presentation I uploaded in the speaker room this morning? He said he replaced the one that was there with the one I have on my flash drive, can I plug that in? It's dated 3/8. That's the one! Thank you. Thank you, whoever it was who ran out to get him.
Okay...so, I don't need this. So, I picked the four that are checked and in red. I chose to look at, does the provider observe the parent? Does the provider explain a skill and teach it to the parent? Does the provider give feedback to the parent about what the parent did with the child? I'll explain these in a minute. So, of all the 23 behaviors, I picked those four.
I know from the literature, you probably know from your practice, it's hard to do familycentered early intervention. Ma'am these are some of the reasons you didn't learn how to do it. The parent really wants you to work with their child, there's all kinds of reasons it's hard to do familycentered early intervention. This quote is 1996. He said learning the skills to become a familycentered practitioner can be confusing for newbies and seasoned practitioners. First, you have to unlearn traditional therapeutic techniques working with the child and then prescriptively move from descriptive, hierarchical techniques towards coaching relationships. The therapist's role is to coach the parent.
So...I wanted to ask, among other things, but for today, I picked these questions, do you use more FCEI behaviors as a practitioner when you do telepractice? And if you use more of one of these behaviors, of the four I picked, do you use more of the others? Are there any other associations that are statistically evident and if telepractice can be shown to be a good thing, if it can, then we might change our system like insurance might pay for it. Among other things. Providers can have new training opportunities around FCEI, parents might learn how to do the work we want them to do with their children more effectively and maybe the kids will do better because all the research says that you really work with the parents, the outcomes for the kids are better than if you work with the child for an hour a week. Or three hours a week.
So...I looked at, and I'm not going to go through any of the outcomes of this, but just to set the stage, I studied characteristics of providers. I looked at what discipline are they in, speech path, audiology, how long have they been working, certification, how long had you been working in early intervention and telepractice. There are interesting findings, but I'm not going to discuss that in this talk.
And then the dependent variables, so what did these providers do? Just to be clear on the four behaviors, observation, the caregiver interacts with the child, while the interventionist observes without offering any feedback or suggestions. And this still isn't the most current slide, which is really baffling me. Really baffling me. But anyway...again, from Kathy's recent article, the therapists rely more on the parents to act as teachers. It makes sense, if the parent's really working with their child, we'd observe love. Which is why I chose that behavior to study.
Then I looked at direct instruction, the idea of teaching parents and here's an example from one of my videos that I watched, where the therapist said, so...she's talking to the parent. Go over to the sink, you can make a whole routine about turning on the water and saying, wash, wash, wash your hands. That's one of those little routines that you do 1,000 times a day. When your child is starting to hear, it'll be one of those little chants he does and maybe he will saywawawa and he's sort of saying wash your hands. I get in the habit of doing that now.
That's instructing the parent about a technique they should be using in a routine. Happens frequently.
Parent practice with feedback, working with the therapists, the provider is watching the parent and then telling the parent how they did. This is from one of the videos, as she's vocalizing more, you're doing a great job of modeling for her and waiting. A short bit of feedback. That was good pause time, you're doing an excellent job of saying Mama has this and this, what do you want? Giving her the models for it and then waiting. A good amount of pause time. That's an example of that behavior and the fourth behavior was giving feedback to the parent about the child this time.
For instance, that was awesome, she did it that time! She stuck the article in, this was great. So...those are my four behaviors. I looked at 16 videos. 16 providers, one video each, therapy was delivered in the telepractice condition.
I created my own coding protocol, there's my own story to that. None of the great ones out there did anyone use more than once or twice. So, I decided, I'll create my own too. I wanted something with just my four behaviors and some of the great ones out there coded ten, fourteen behaviors and I just, the sixteen providers, it was too many behaviors.
I looked at what happened in 30second intervals, very standard for other studies. I did two things, this is important in the results. I looked at the predominant behavior in the 30second interval. Which of the things happened for the most seconds. I coded it another way, this isn't in the literature at all, I don't understand why. I coded what everyone did at any time in a 30second interval. Sometimes two of the behaviors happened, sometimes three, occasionally all four. Feedback can be short, right? Or you can be observing and putting a little bit of feedback to the parent and continue observing. So...I think that's a more powerful and true way of looking at what we're doing.
All the kids were deaf and hard of hearing, they were all birth to 36 months of age. They all spoke English and I welcomed any communication approach. And...100% of my providers were implementing listening and spoken language. I tried. All over this country. I contacted 23 agencies to find people who were using sign or simultaneous communication through telepractice. I didn't find one. I don't understand. But...this is what I found.
I need to go so much faster. So, I'm going to skip a few things. Here was a relationship between two of the four behaviors. This is feedback to the parent about the parent. This is feedback to the parent about the child. They kind of went handinhand. If you didn't have much feedback to the parent, you didn't have much feedback to the child. You were doing something other than reporting back to the parent about their behaviors or their child's. If you had a moderate amount of feedback to the parent, you had a moderate amount of feedback to the child. Thank you.
And this is curious. If you had a whole lot of feedback to the parent, these four providers had very little feedback about the child. I just think that's kind of curious.
And I think it can be addressed in a training situation easily. But here's what I want to get through, I'll just march you through it here. This isn't a statistical part of my study, but an important part. How different are providers when they deliver therapy in telepractice. That's what I studied. Compared to when therapy is delivered facetoface. That's what other people studied. I took what other people did, I compared my findings with my people to it. Okay? Different groups.
So, let's look at observation.
If you look at these five studies in the reference section, observation in person, facetoface therapy was used 36% of the time in facetoface therapy. One study was 6%, one was 36%, other studies had different percentages. If I only looked at the predominant behavior in any 30second interval in telepractice, observation was used way more. Way more. I'm curious about all behaviors that occur in any 30second interval and then the number was diluted a little bit. Lots of other things happened. And the comparison goes on. I'll get to implications in a minute.
Direct instruction, teaching the parent what to do. One study, they used direct instruction in person, 19%. If you looked at the 16 in my study, 12% of the time, predominant was used. Didn't quite match that, I found that interesting. If you look at giving feedback to the parent, in facetoface therapy, the person editing my dissertation didn't believe that. She changed it to 36%. No, inperson therapy, therapists, in four different studies, gave less than 1% of feedback to the parent about what the parent did and of those four studies, 66% was the most. In telepractice, 3% and 10% if you look at all occurrences. May not have been the primary behavior used, but used a lot more than if you counted in all positions.
I think that's a really valuable behavior. I think it's really important to give feedback to the parents and it doesn't happen much in person, it happens a whole lot more in telepractice, is it enough? That's a question beyond the scope of what I'm going to talk to you about, but what I hope you're all thinking and then, if you look at feedback to the parent about the child, again, three studies this time, in person, from not at all, to less than 1%. Barely at all..36% in in person therapy. In telepractice, in the predominant position, in the 30second interval, it was occurring 6.5% of the time. If you looked at it occurring at all, it was 12% of the time, I'm thrilled with these findings. That's what being familycentered is all about.
So, if we look at implications here I'm going to ask a few questions for you to think about. In a fullday workshop we can explore it in much more detail. Observation is used a lot. What was it? 79% or something like that? That's good. The interventionist is not working with the child. They're really kind of, well, let me just say, they're not working with the child. But if they're not doing, giving feedback to the parent or they're not instructing, observation is good for some reasons, but I'm sort of saying is it too much of a good thing? Are they observing just too much, if there isn't feedback and instruction to go along with that observation.
The one statistical finding I showed you. Feedback to parent about themselves and feedback to parent about the child are associated statistically.
These three behaviors, instruction and feedback, thank you, to the parent about the parent or to the parent about the child, they have been in sort of similar amounts. You know, 10%, 14%, 6%, bless you. Interesting.
If you were designing a training program and some of you are, and I have to, once again, thank all of you who were here, who helped me to get kids, providers for the study, thank you, couldn't have done it without you. Do you think, if you're designing a training program that you would design it to have equal amounts of these three behaviors? Do you think one should happen more than the other? Just curious. I'd be interested in another study. If we can look at which provider behaviors improve child outcomes. That was far beyond the intent of my study, but I'm curious about that. And...which provider behaviors are maybe associated with parent satisfaction with the intervention.
Coaching practices very popular in familycentered intervention. I'm thinking it's not happening with any regularity. What I gave you, my percentages were means of the 16 providers. I didn't go into it, but the data is there if you look this up on the website. You'll see the range. One provider had observation in every 30second interval. Other things too, but observation was the predominant behavior in every 30second interval. I think it's interesting.
Again, if you designed a training program, how much observation? How much direct instruction to be determined? Regarding familycentered early intervention programs. I think that telepractice might be the next frontier for becoming familycentered. We keep trying, we keep talking about it, how do you change practice? And I was talking with Jean and Betsy last night at dinner and they commented that once, and Marge Edwards too, once you do therapy in telepractice and change some of the ways that you interact with families, it kind of carries over to your inperson therapy. So we're really glad we're studying this at the University of Colorado now, before telepractice becomes so widespread that it impact everyone's facetoface therapy. Kind of like newborn screening, right? You had to study it before it was universal.