2.
Family-Centered families is not, however,
Practices Even though
experts in early intervention
early on called for a family-
centered approach, the shift
away from child-centered or
even professional- centered
practices has been protracted
(Bailey, Winton, Rouse, &
Turnbull, 1990; Dunst &
Trivette, 1987). The pervasive
influence of special education
on the field of early
intervention (Smith et al.,
2002) and Medicaid
reimbursement for therapy
services (McWilliam, Young, &
Harville, 1996) might have
contributed to early
interventionists’ providing
direct, hands-on services to
children, rather than working
with the family. Family
centeredness consists of
several elements: having
positive relationships with
the family, meeting families’
needs, and giving families
meaningful decision-making
opportunities (McWilliam,
2010b). In a qualitative study
of early interventionists
whose families were extremely
supportive, McWilliam, Tocci,
and Harbin (1998) found that
the early intervention
professionals were positive,
responsive, oriented to the
whole family, friendly, and
sensitive (McWilliam et al.,
1998). Turnbull et al. (2007),
however, have argued that
being nice to families is
insufficient; their needs must
be met. Specifically, they
pointed out that the required
early intervention services of
family training, counseling,
social work, and psychology
were underused. Support to
confined to specific services.
Existing services from
“developmental therapists”
or generalist home visitors,
who are often educators by
training, can invoke family-
centered practices (Bruder &
Dunst, 2005). Although having
positive relationships might
not be sufficient, it is
necessary. Meeting families’
needs beyond the development
of the child sometimes comes
under the purview of service
coordination. Where service
coordination is performed as a
separate activity from service
provision (i.e., “dedicated”
service coordination),
caseloads are often high, and
service coordinators function
primarily as case managers
(Bruder & Dunst, 2006; Harbin,
Bruder, Mazzarella, Gabbard, &
Reynolds, 2001; McWilliam,
2006). Service coordinators’
ability to devote time to
helping meet families’ needs
is thereby limited. These
needs range from basic needs
such as housing, clothes,
food, and diapers to self-
actualization needs such as
finishing highschool
education, time alone, and
finding a job (Maslow, 1943).
The routines-based interview
has been described as one tool
early interventionists use to
determine families’ needs for
resources (McWilliam, 2005) as
well as for the child’s skill
attainment (McWilliam, 2011).
It also is a method for giving
families the opportunity to
make meaningful decisions,
because it includes families’
choosing their outcomes/goals.
Fundamental to family-centered
 practices is the belief that
families and other caregivers
intervene with their children
between visits from a
professional. Dunst
(2007)wrote, “The … approach
to early intervention … is
consistent with the intent of
the IDEA early intervention
program that places primary
emphasis on strengthening
parents’ capacity to promote
their children’s learning and
development” (p. 162).
Routines-based interventions,
discussed in a subsequent
section, are a primary
approach that can be used with
families. Its premise is that
families have many
opportunities to teach their
children throughout the week,
whereas home visiting or
clinic-based professionals
have usually 1 h a week
(Bailey, Aytch, Odom, Symons,
& Wolery, 1999). Because
professionals are working with
families to enhance their
ability to work with the
children, work with children
birth to three has focused on
the coaching of parents.
3.Coaching
The term “coaching” has gained
in popularity in early
intervention largely because of
the writings and presentations
of Shelden and Rush (Hanft,
Rush, & Shelden, 2004; Rush &
Shelden, 2005; Shelden & Rush,
2010). They have defined
coaching as “An adult learning
strategy in which the coach
promotes the learner’s ability
to reflect on his or her actions
as a means to determine the
effectiveness of an action or
practice and develop a plan for
refinement and use of the action
in immediate and future
situations” (Rush & Shelden,
2005, p. 3). Although Kemp and
Turnbull (2014) have criticized
coaching with parents as being
inconsistently defined and
lacking in evidence, Friedman,
Woods, and Salisbury (2012) have
actually defined coaching in
terms of 12 strategies they have
observed in speechlanguage
pathologists participating in a
study on family-guided routines-
based intervention. The
ingredients of coaching included
a child-focus, conversation and
information sharing, caregiver
practice with feedback,
demonstration, direct teaching,
early intervention, guided
practice with feedback,
individualized family support
plan, joint interaction,
observation, and problem
solving/reflection. Clearly, not
all of these mirror the
collaborative nature of working
with families; rather, it was an
exhaustive list of the
activities observed, with some
being more family-centered than
others. The way professionals
interact with parents of infants
and toddlers during intervention
sessions is still a notable
feature of early intervention,
whether called coaching,
partnering (Espe- Sherwindt,
1990), or consultation
(McWilliam, 2010a). The
principles of working with
families in a “coaching” way
include professionals’ use of
adult learning principles, a
collaborative consultation
approach (versus expert
consultation), and joint problem
solving or solution finding
(Dunst & Trivette, 2009;
McWilliam, 2010a; Sheridan,
Kratochwill, & Bergen, 1996).
This approach is contrasted with
early interventionists’
assessing what families need,
giving them directions (perhaps
smoothed over as suggestions or
recommendations), and returning
to see how much they have
followed through. That model is
known as expert consultation. By
taking a more reflective tactic,
professionals may build
families’ autonomy and self-
confidence (Boud, Keogh, &
Walker, 2013).
4.Responsive Teaching
What is the optimal way for
adults to interact with very
young children to promote their
engagement and learning? The
evidence points to a responsive
method. This was first brought
to the attention of early
intervention with Hart and
Risley’s (1975) incidental
teaching of language, in which
objects likely to interest the
child were placed out of reach,
to elicit the child’s preverbal
request, such as pointing and
making noises. R.A. McWilliam 79
The adult then prompted
verbalizations or approximations
of such. Over time, incidental
teaching has been applied beyond
language to all areas of
development (Casey & McWilliam,
2008; Casey, McWilliam, & Sims,
2012). It has also been used
with young children with autism
(McGee & Daly, 2007; McGee,
Morrier, & Daly, 1999). Mahoney
and colleagues have appropriated
the term responsive teaching for
his model, which emphasizes
attending to and imitating the
child’s behaviors and
discourages active elicitation
of other behaviors, including
more sophisticated forms of the
behavior (Karaaslan, Diken, &
Mahoney, 2013; Mahoney, Perales,
Wiggers, & Herman, 2006).
Modeling of behaviors, however,
is permitted in this model,
because that is considered a
somewhat passive prompt. The
model promotes reciprocity,
contingency, nondirectiveness,
affect, and interactive match
(Karaaslan et al., 2013). In a
randomized control trial in
Turkey (Karaaslan et al.),
responsive teaching was more
effective than a control
condition in terms of maternal
responsiveness and children’s
pivotal behaviors (attention,
initiation), although the
families in the experimental
group received 3 h of services a
week more than families in the
control group. A characteristic
of Mahoney’s (2006) responsive
teaching, contingency, matches
to some extent one of the most
strongly evidence-based
practices in early intervention:
responsecontingent interactions
(Dunst et al., 2007; Dunst &
Kassow, 2008; Dunst, Raab,
Hawks, Wilson, & Parkey, 2007).
Contingent responsiveness
involves the systematic
application of an adultdelivered
stimulus, for the purpose of
reinforcing the behavior, when
the child produces a desired
behavior. Reinforcement, by
definition, means it is
contingent, and it increases the
likelihood of future
occurrences, including
potentially the rate and
strength of the behavior. In a
review of 22 studies, verbal
comments, imitating children’s
vocalizations, and predetermined
nonverbal sounds were all found
to be effective in increasing
infant vocalizations, when used
contingently, but imitation had
the biggest effect (Dunst,
Gorman, & Hamby, 2010). Dunst
and colleagues have synthesized
the research on infant
contingency learning and
developed learning games for
this learning (e.g., means-end,
control over the environment)
(Dunst & Trivette, 2008).
Notably, they also conducted a
synthesis of research on
caregiver responsiveness. The
most effective characteristics
were caregiver behavior attuned
to children’s signals and
intents to interact, caregiver
responsiveness that is prompt
and appropriate to the child’s
behavior, and interactions that
are synchronous and mutually
reinforcing. It is perhaps
significant that both a
constructivist and a behaviorist
approach lead to the same
conclusion: that adults should
be sensitive to their
children’s cues and should
respond to those cues to promote
learning. Although
nondirectiveness is a feature of
responsive teaching, in fact,
directiveness might not be the
opposite of responsiveness. In a
cluster analysis of teachers,
based on their teaching styles,
responsiveness and directiveness
were seen to coexist; that is,
an adult can be both responsive
and directive within a teaching
episode (de Kruif, McWilliam,
Ridley, & Wakely, 2000). It is
the balance of the two that
might need to be individualized
for the child. At its simplest,
adult interactions can be
classified along the two
dimensions as (a) highly
responsive and highly directive,
(b) highly responsive and
nondirective, (c) unresponsive
and highly directive, and (d)
unresponsive and nondirective.
Current thinking is that there
might be a place for (a),
because some children need
direction, as long as it is in
the context of something they
are interested in (i.e., it is
also responsive) (McWilliam,
Scarborough, & Kim, 2003). Style
(b) represents the Mahoney
(Mahoney et al., 2006) approach.
Style (c) represents the sort of
directive teaching, out of
context, that the literature
does not support. Style (d)
similarly would not be endorsed.
5.Routines-Based
Interventions Where do
adults carry out these
interactions with children? They
implement responsive teaching in
everyday routines, whether in
the home or in the classroom.
Attention to the location and
timing of caregivers’
interactions with children has 5
Birth to Three: Early
Intervention 80 evolved because
of the increased realization
that these routines, rather than
the formal service delivery
times, are when learning
opportunities are available
(Dunst et al., 2001; Dunst,
Raab, Trivette, & Swanson,
2010). Like coaching,
definitions of “routine” vary.
Dunst and colleagues (Dunst,
Hamby, Trivette, Raab, & Bruder,
2000) conducted a confirmatory
factor analysis of home and
family activities to arrive at
11 categories, several having
routine as part of the title
(e.g., Family Routines,
Parenting Routines, Child
Routines). McWilliam (2010a)
defined routines as times of the
day, identified by families. In
a measure in which families
report children’s functioning
in their child’s day, McWilliam
and Younggren (in press) present
13 routines: waking up, meals,
dressing, toileting/diaper
change, outings, play time with
others, play time alone, nap,
bath, hanging out/books/TV,
grocery shopping, outdoors, and
bedtime. A review of
interventions occurring in
natural learning environments
judged practices as contextually
versus noncontextually based,
child versus adult directed, and
practitioner versus
nonpractitioner implemented
(Dunst, Trivette, Humphries,
Raab, & Roper, 2001).
Noncontextual practitioner-
implemented practices have
“increasingly been emphasized”
(p. 48). Blended practices are
described as a mix of child- and
adult-initiated activities, as
the authors found in the
literature on embedding goals
and objectives in the context of
child-adult interactions. The
authors point out that even in
the naturalenvironments
provision of the law, the
implication is that
practitioners will implement
interventions with the child in
natural environments. Dunst et
al. note that this direct,
hands-on approach has three
problems. First, the context
might no longer be natural, if
the practitioner works with the
child out of context with the
natural learning environment.
Second, the amount of time spent
working with the child in the
absence of parent participation
is so small in the child’s week
that it is unlikely to have any
impact. Third, no studies, in
2001, had shown the efficacy of
Part C services [authors’
emphasis] in natural
environments. Therefore, the
point of working in the context
of natural routines highlights
the phrase in the context of.
This work does not mean working
with the child during those
routines (Hanft & Pilkington,
2000); it means working with the
family (or teacher, in classroom
programs) about child and family
functioning in natural routines.
This subtle but important
difference has had implications
for another variation on this
practice: embedded
interventions. The concept of
embedding intervention on
children’s individual goals and
objectives in routine, planned,
or childinitiated activities was
described by Bricker and Cripe
(1992) as activity-based
intervention. It was
subsequently defined as
something parents could do as
the opportunities arose in
“meaningful” activities, which
were not articulated (Cripe &
Venn, 1997). The locus of
embedding then was considered to
be daily routines (Fox, Dunlap,
& Cushing, 2002; Woods,
Kashinath, & Goldstein, 2004).
In the face of much
decontextualized intervention
for children with ASD (Bellini,
Peters, Benner, & Hopf, 2007),
it is noteworthy that embedding
intervention in daily routines
has been supported for infants
and toddlers who are at risk for
ASD (Woods & Wetherby, 2003).
McBride and Schwartz (2003)
provide an overview of the
considerable amount of research
supporting the efficacy of
embedding instruction into
ongoing activities. These
authors point out that embedded
instruction is sometimes
considered “naturalistic
instruction.” When naturalistic
interventions are organized to
ensure that they are frequent,
context based, and following the
child’s interest, they are
likely to be effective. When
“naturalistic intervention” is
used to describe a haphazard
rate with undocumented quality
of implementation (i.e.,
informal fostering of
children’s learning), its
likely efficacy comes under
question (Wolery, personal
communication, February 17,
2012).
6.Service Coordination
IDEA requires that service
coordination be offered to every
family receiving Part C
services. The service
coordinator is responsible for
ensuring the IFSP is developed,
reviewed, updated, R.A.
McWilliam 81 and closed. He or
she helps the family find
resources to meet their IFSP
outcomes (i.e., goals), whether
provided by the system or not.
That is, unlike the individual
education program (IEP), the
IFSP lists services required by
law (assuming appropriateness
for the child) and other
resources, such as a parents’
morning-out program, a library
story hour, or a program offered
through the Y. The service
coordinator is the individual at
the point of a potentially
controversial decision: the
frequency and intensity of
services. In the development of
the IFSP, services are to be
decided once IFSP outcomes have
been determined. This is
sometimes violated, with the
“team” deciding on services
and the service providers (e.g.,
therapists) writing discipline-
specific outcomes (Jung &
McWilliam, 2005). The frequency
and intensity of each service is
required on the IFSP. If a
primary service provider
approach is being followed, one
professional’s service will be
frequent (e.g., hourly per
week), with other
professionals’ service less
frequent (e.g., hourly every 3
months or 240 min a year). If a
multidisciplinary approach is
being followed, two or more
services will be listed at the
same frequency and intensity
(e.g., hourly per week). If the
family or a professional on the
team insists on higher frequency
than the service coordinator
recommends, that service
coordinator now has a
potentially difficult situation.
If he or she can provide a
strong rationale for the primary
service provider approach (e.g.,
it is intervention time that
matters, and that is not
correlated with service time)
and is confident about the
decision, all is well. If not,
either the service coordinator
capitulates or the family (or
advocating professional) is left
unhappy. This critical point in
service delivery requires virile
administrative support in both
service coordination policy and
in managerial support of the
service coordinator. The
rationale for dedicated service
coordination is twofold, to
restrict the mindless piling on
of services (McWilliam, 2011)
and to have a person separate
from the providers, so the
family can speak freely about
any concerns they have about
services. In a study of families
of infants and toddlers enrolled
in Part C, the dedicated and
independent model, where service
coordinators were from a
different agency from the
providers, was associated with
fewer services and less frequent
contact compared to two other
models: service coordination
that was dedicated but not
independent and blended service
coordination (Bruder & Dunst,
2006). Considering the piling on
of services that sometimes
occurs, as mentioned earlier, it
is unclear whether fewer
services are a good or a bad
outcome. How service
coordination is managed is up to
the states. A review of policy
infrastructures supporting
service coordination identified
three dimensions of the
infrastructure: the
responsibilities of the service
coordinator, the IFSP, and
policies facilitating a
comprehensive and coordinated
services system (Harbin et al.,
2004). Most states were found
not to have a sufficient
infrastructure, but these data
were collected at the turn of
the century. Park and Turnbull
(2003) wrote that service
integration was affected by
interpersonal (e.g., openness,
sharing information, showing
empathy) and structural factors
(e.g., funding streams,
duplication of services,
documentation system). The
family-centered practices
described earlier apply to
service coordination as well as
to service provision. In fact,
the more service coordinators
adhere to a family-centered
model, the more satisfied
families are with their service
(Romer & Umbreit, 1998). Bruder
and Dunst (2008), who have
undertaken the most complete
research on service
coordination, found that family-
centered practices were the
strongest predictor of whether
service coordinators performed
the services the researchers had
identified as important. Blended
service coordination was
associated with more
implementation of the services
than was dedicated service
coordination. One of the key
services provided by service
coordinators is preparing the
family for the transition from
Part C to Part B: preschool
services. Some states have
adopted a vendor model, in which
“dedicated” service
coordinators find independent or
agency-affiliated professionals
to staff the IFSP team
(McWilliam, 2011). In these
environments, professionals are
competing for the early
intervention business. A by-
product is lack of
accountability through
supervision or 5 Birth to Three:
Early Intervention 82 practice
guidelines, especially for
professionals who do not report
to supervisors. This situation
has become quite pervasive in
the delivery of services to
children with autism, with
independent service providers
accountable only for providing
the hours stipulated on the IFSP
but not for the quality or type
of service they provide. Many
occupational, physical, and
speech therapists working with
any children in early
intervention have similar
freedom, which makes the
promotion of evidence-based
practices or the implementation
of a model challenging.
7.Transition to
Preschool Most children in
Part C services go on to be
served by their local school
systems’ early childhood
special education program
(Hebbeler et al., 2007). This
transition on or near the
child’s third birthday, which
is required by IDEA (with an
option to continue the IFSP),
can be justified only in terms
of history (preschool grants had
been given to schools for years
before Part H, now Part C, was
legislated), politics (state
education departments wanted the
funds), and beliefs (that school
systems were conceptually and
practically equipped to provide
developmentally appropriate
preschool services). In
presenting a unified theory of
practice, Odom and Wolery (2003)
listed three practices for
“developmentally instigative
adults” (p. 166) to enhance
transitions across programs: s
Assessing the demands of the
next setting and teaching needed
skills (Le Ager & Shapiro, 1995)
s Preparing personnel and/or
family for transition to next
setting (Wilson, Allen, &
Pfalzer, 1996) s Interagency
agreement to smooth transitions
(Rosenkoetter, Whaley, & Hains,
2001, p. 166) The transition
from home-based supports to
preschool services, which is
pervasive at age 3 in the USA,
makes parents anxious. In a
study of family perceptions of
transitions in early
intervention, 43 % of families
said they were uncomfortable
with this transition, but
parents were grateful to be
entering their children in
preschool (Lovett & Haring,
2003). Interestingly, parents
liked having more service at 10
h a week of preschool versus 1 h
a week in birth-to-3 services.
If the 1 h a week was
interventionist driven, then the
families might have been
correct. But again this is an
example of confusing service
time with intervention time.
Almost 25 years ago, concerns
families expressed about
transition planning were about
transfer of parents’
friendships with professionals
to new people, changes in
service delivery (e.g., shift
from family-focused to
childfocused services),
discrepancies in eligibility,
and variations in labeling and
concerns about social
acceptability (Hains,
Rosenkoetter, & Fowler, 1991).
In a study of the role of
independent therapy providers in
the transition to preschool, the
most commonly reported
strategies for participating in
the transition were working with
families, attending meetings,
and communicating with receiving
therapists (Myers, 2007).
Barriers were identified as lack
of time and low support from
service coordinators. The low
support from service
coordinators was mostly not
putting therapists on the
intervention plan at the rate
therapists thought appropriate.
All child and family transitions
should be planned for, but the
age 3 one is especially rough
(Fowler, Hains, & Rosenkoetter,
1990). First, the infant-toddler
service system is very different
from the preschool service
system. Second, families have to
make the transition when they
are still figuring out the
accommodations needed because of
having a child with special
needs. Third, they might have to
break off close relationships
they have formed with their
early intervention
professionals. By no means are
these seven practices the only
recommended ones in early
intervention for children birth
to 3 (Division for Early
Childhood, 2014), but they
represent the major activities
of this critical program of
supports. The future of early
intervention rests on
consideration of four aspects.