Preliminary Evaluation of the Implementation of a Routines-Based Early Childhood Intervention Model in Australia

Abstract

The aim of the current pilot study was to evaluate the implementation of a routines-based early childhood intervention (RBECI) model by Australian Early Childhood Intervention (ECI) professionals. The RBECI model consisted of four key components: (a) Routines-Based Interviews (RBIs), (b) participation-based goals, (c) home visits, and (d) community consultations. Five ECI professionals and nine families were recruited from an Australian ECI service. Professionals’ ability to implement the model was assessed immediately before and 6 months after receiving training in the model. Individual in-depth interviews elicited professionals’ perspectives on implementing the model. Results revealed that professionals’ knowledge, understanding, confidence, and home visiting skills increased from pre- to post-intervention, but community consultation skills did not. There were limitations in the quality of RBIs and participation-based goals produced. Overall, professionals were positive about the implementation of the model. The findings provide support for the adoption of the RBECI model in ECI more broadly.

Keywords

evaluation evidence-based practices intervention strategies preparation personnel

In Australia, 22% of children are developmentally vulnerable on one or more domains including physical health and well-being, social competence, emotional maturity, language, and cognition prior to entering school (Australian Centre for Community Child Health, 2012). Children who experience a developmental delay or disability need additional supports and services during their early childhood years (from birth to 6 years old; Department of Education and Early Childhood Development, 2010), which can be accessed through early childhood intervention (ECI) services (Kemp & Hayes, 2005; Sukkar, 2013). ECI professionals in Australia provide specialist teaching and therapeutic interventions that are delivered in a variety of modalities, including home visiting and consultation to the community (e.g., child care and preschool). Similar to elsewhere around the world, the ECI field in Australia has moved toward a transdisciplinary key worker (KW) model, where intervention is embedded within daily routines that occur in the natural environment (Sukkar, 2013). However, the processes involved in ECI professionals’ implementation of routines-based models of ECI, and corresponding key stakeholders’ perspectives, remain unknown.

The ECI literature reveals a clear consensus regarding the benefits of embedding learning opportunities in activities and routines that occur in the family and community environment (e.g., Bruder, 2010; Dunst et al., 2001). Routines are defined as any naturally occurring activities that are undertaken often enough to become a meaningful part of the child’s everyday life (e.g., getting dressed, mealtimes; McWilliam, 2010). The explicit sequence of routine events provides repeated opportunities for the acquisition and refinement of skills (Cheslock & Kahn, 2011). Moreover, the regularity in which routines occur over extended time periods allows for the consequences of behavior to be realized by the child (Bronfenbrenner, 1999). Embedding intervention within routines thus allows for the transfer of skills across activities, which traditional one-on-one therapy does not (Bruder, 2010).

Families are central to their children’s development and, by extension, to early intervention’s program efforts (Bruder, 2000; McWilliam, 2010). Given the emphasis on family-centered practice and context-mediated learning opportunities, it is the role of ECI professionals to work collaboratively with families and use coaching techniques to increase parental confidence and competence to maximize their child’s learning opportunities (Rush, Shelden, & Hanft, 2003). Parents are more likely to provide development-enhancing learning opportunities when they feel empowered about their parenting capabilities (Dunst & Trivette, 1996), and their ability to do things on their own, without the need for ongoing ECI professional support (Turnbull, Turbiville, & Turnbull, 2000).

Routines-Based Early Intervention (RBEI) is a recently developed model based on the principles of providing children with naturally occurring learning opportunities, and the role of families as partners in the delivery of intervention and supports (McWilliam, 2010). This model emphasizes functional outcomes, specifically children’s engagement, independence, social relationships, and quality of life for families. It incorporates five key components, each accompanied by one major practice: (a) understanding the family ecology (ecomap development), (b) functional family-centered intervention plans (Routines-Based Interviews [RBIs] and participation-based outcomes), (c) integrated service delivery (primary service provider), (d) support-based home visits (family consultation), and (e) collaborative consultation to child care (individualized within routines). Although these components are widely accepted as “good practice” in ECI, they have varying levels of empirical evidence behind them. The ecomap, which sets the beginning of the implementation of the RBEI model, is a graphic representation of the family’s informal, formal, and intermediate supports, providing ECI professionals with an understanding of the family ecology and the level of support and resources available to the family (Jung, 2010; McWilliam, 2010). Ecomaps have been demonstrated to be an effective interview tool across a number of disciplines, including social work (e.g., Hartman, 1995) and psychology (e.g., Horton & Bucy, 2000), and have been suggested to be a useful tool to use in ECI (e.g., Jung, 2010; McCormick, Stricklin, Nowak, & Rous, 2008).

Next, a RBI is conducted with the family (or child care provider if a child is in care for more than 15 hr per week). The RBI is a semi-structured interview that gathers information about a child and family’s daily routines to develop functional goals, to assess child and family functioning, and to create a positive relationship between the ECI professional and the family (McWilliam, 2010; McWilliam, Casey, & Sims, 2009). Although the implementation of the RBI has become widespread in the United States (McWilliam et al., 2009), there is some discrepancy between the face validity and the empirical validity of this practice. Only two studies to date have examined the efficacy of conducting an RBI for the development of an individual family service plan (IFSP), compared with traditional IFSP development procedures. In a preliminary study by McWilliam and colleagues (2009), 16 families received either the RBI to inform the IFSP or the standard IFSP development process that had been previously implemented (i.e., no RBI was conducted). Results indicated greater family satisfaction with the IFSP development process, a greater number of outcomes, and more functional outcomes were produced when RBIs were implemented, compared with the standard IFSP development process. Similarly, Boavida, Aguiar, and McWilliam (2014) found that the quality of goals and objectives on IFSPs written by 80 professionals increased by more than three standard deviations after receiving training to conduct RBIs. These studies provide initial support for the value of the RBI in assisting ECI planning with families such as the development of functional IFSPs. However, further research needs to be conducted to replicate findings, thus enlarging the evidence base for the RBI.

The third component of the RBEI model involves having one primary service provider (i.e., an ECI professional referred to as a Key Worker in Australia) provide support, resources, and information to the child and family during regular home visits and community consultations (McWilliam, 2010; Sukkar, 2013). Each primary service provider is supported by a team of other professionals from a variety of disciplines (e.g., allied health and education) who provide additional services to the child and family as required. This transdisciplinary approach has been identified as necessary for intervention (Bruder, 2000; Sloper, 1999) due to its presumed benefits, such as it better meets families’ needs (Sloper & Turner, 1992), it is a more comprehensive and efficient intervention service (Hanson & Bruder, 2001; King et al., 2009), as well as being less intrusive of the family’s life (Foley, 1990). Although the transdisciplinary approach is widely adopted by ECI programs, the benefits require more extensive empirical basis (King et al., 2009).

Support-based home visiting is the fourth component of the RBEI model, the purpose of which is to provide emotional, material, and informational supports to families (McWilliam, 2010). Commonly used in support-based home visiting are ECI professionals’ coaching strategies, such as modeling, listening, performance feedback, and problem solving, which are central to family and child learning and interaction (Kaiser & Hancock, 2003; Rush et al., 2003; Woods, Wilcox, Friedman, & Murch, 2011). Quality implementation of coaching strategies facilitates a triadic interaction (ECI professional−child−families), whereby the ECI professional works with the child’s family to enhance the families’ capacity and skills to promote the child’s learning and development within naturally occurring activities (Rush & Shelden, 2006a; Rush et al., 2003; Shelden & Rush, 2010). Recent research (Salisbury, Cambray-Engstrom, & Woods, 2012; Salisbury, Woods, & Copeland, 2010) has revealed that although ECI professionals utilize a range of coaching practices in home visiting, they underestimate their use. Furthermore, ECI professionals report feeling more confident implementing coaching practices and less concerned about home visits after receiving training, reflective practice, and problem solving regarding implementation issues. In the investigation of home visiting as a whole within a routines-based model, to date, only one study has examined its effectiveness in comparison with traditional home visiting (THV). In a randomized control study conducted by Hwang, Choa, and Liu (2013), 31 families with children aged between 5 and 30 months with or at risk of developmental delay received either the RBEI or the THV for a 6-month period. The RBEI involved a trained home visitor conducting an RBI, coaching and collaborating with families to set functional child goals, and designing intervention strategies that were embedded within family routines. Conversely, for the THV group, a home visitor used a curriculum-based developmental evaluation to plan the intervention, instructed families to choose developmental goals, and selected intervention strategies for families to use. Children’s outcomes were assessed at five time points (baseline, pre-intervention, mid-term intervention, post-intervention, and follow-up), and goal achievements were measured at two time points (mid-term intervention and post-intervention). Results indicated that the RBEI was more effective than THV in promoting children’s functional outcomes and attaining family selected child goals. However, there was no significant difference between intervention groups in developmental domains. Although Hwang and colleagues’ (2013) study provided support for ECI based around routines over THV, it was limited in that it only examined child goals and outcomes and excluded goals and outcomes related to the family. Furthermore, families did not receive intervention in community-based settings.

The final component in the RBEI model involves ECI professionals providing collaborative consultation to caregivers within community settings, such as child care providers or preschool teachers. The rationale for providing community consultation is that caregivers within the community have the potential to have a positive impact on a child’s developmental outcomes and skill acquisition due to the amount of time they may spend with a child (McWilliam, 2010). Furthermore, community consultations help facilitate a child’s inclusion within their community, specifically in community settings comprised mostly of children without a disability. Similar to the implementation of home visits, it is recommended that ECI professionals utilize coaching practices when conducting community consultations (Rush & Shelden, 2011). McWilliam (1996, as cited in McWilliam, 2010) compared several methods for ECI professionals to provide early intervention in child care settings. Over a 2-year period with 80 young children, six methods were examined: (a) one-on-one pull out, (b) small-group pull out, (c) one-on-one in classroom, (d) group activity, (e) individualized within routines, and (f) pure consultation. Results indicated that the individualized within routines method was the optimal method to use; it taught preschool teachers to embed intervention into the child’s routine, which meant that intervention was occurring between visits from the ECI professional. Furthermore, this method allowed for the reciprocal learning process between the teacher and the ECI professional to collaboratively determine how to make the intervention work within the child’s routines in their community. Although research has provided evidence for the use of coaching practices in ECI (e.g., Fox, Hemmeter, Snyder, Binder, & Clarke, 2011; Knoche et al., 2012), relatively little empirical evidence exists regarding ECI professionals’ coaching of caregivers in community-based settings as a complementary component of a routines-based intervention approach.

In sum, although the RBEI model offers a coherently developed set of components, its implementation as a whole is yet to be empirically examined. Indeed, it is thought that the efficacy of the various RBEI components is enhanced when they are used in conjunction with one another (Boavida et al., 2014; McWilliam, 2010). Finally, ECI professionals’ perspectives regarding the implementation of the RBEI model have not been investigated for purposes of face validity. Therefore, the present study sought to address these gaps in the literature and to answer three key questions: (a) Following training, how well in terms of skills, knowledge, and confidence do ECI professionals implement a routines-based early childhood intervention (RBECI; this terminology is used to differentiate from McWilliam’s RBEI model and to emphasize that our model focuses on early childhood, i.e., from birth to 6 years old) as a model (i.e., RBIs, participation-based goals, home and community consultations) with families? (b) Is there a relationship between the quality of the RBIs and the functionality of the participation-based goals? and (c) What are ECI professionals’ perspectives on implementing the RBECI model of practice?

Method

Participants

A convenience sample was utilized to recruit five Key Workers (KWs) from a community-based intervention service for children with disabilities and developmental delays, and their families located in Melbourne, Australia. All KWs had previously received training in, and were committed to, the adoption of family-centered practice. They were invited to participate in this study to build on their knowledge and skills regarding routines-based intervention. KWs were females aged between 23 and 37 years (M = 28.80, SD = 5.12 years) whose qualifications included undergraduate qualifications in speech pathology (n = 2), occupational therapy (n = 2), and a post-graduate qualification in special education (n = 1). KWs’ ECI years of experience ranged from 1 to 5 years (n = 3), 5 to 10 years (n = 1), and 15 to 20 years (n = 1). Three of the KWs worked full-time in ECI and two worked part-time (4 and 3 days per week, respectively). Ten families who were new to the intervention service provider in 2013 agreed to participate; however, 1 family dropped out of the study. Eight mothers and one father aged between 29 and 38 years (M = 38.76, SD = 5.50 years) participated. In all, 56% of parents were born in Australia, 22% in Europe, and 22% in Asia. The majority of parents were married (77.8%) and more than half (55.6%) were employed outside of the home for an average of 3 days per week. Parents’ education levels were diverse: no high school diploma (n = 1), high school diploma (n = 3), polytechnic certificate or diploma (n = 3), trade apprenticeship (n = 1), and undergraduate degree (n = 1). Of their children receiving services, 4 were males and 5 were females aged between 27 and 60 months (M = 42.89, SD = 9.06 months). The primary diagnoses of these children included autism spectrum disorder (n = 6), global developmental delay (n = 2), and Down syndrome (n = 1).

Design

The current mixed-methods study was quasi-experimental, within-subjects design. The pre-test–post-test design examined change in KWs’ knowledge, understanding, confidence, home visiting, and community consultations skills, as a result of the implementation of the RBECI model of practice. The quality of RBIs and participation-based goals produced during the intervention were assessed. Qualitative interviews elicited KWs’ perceptions on implementing the model.

Measures

Details regarding each of the measures, time of completion, and respondents are shown in Table 1. KWs and families completed a Demographic Questionnaire to ascertain information regarding KW, child, and family characteristics.

Table 1.

Measures, Time of Completion, and Respondents.

Measures	Time of completion	Respondent
Demographic Questionnaire	Pre-RBECI implementation of intervention	KWs, families
Knowledge and Understanding Assessment		KWs
Confidence Scale		KWs
Support-Based Home Visiting Scale		KWs
Coaching Practices Rating Scale		KWs
RBI Implementation Checklist	During RBECI implementation of intervention	Researchers
Goal Functionality Scale III		Researchers
Knowledge and Understanding Assessment	Post-RBECI implementation of intervention	KWs
Confidence Scale		KWs
Support-Based Home Visiting Scale		KWs
Coaching Practices Rating Scale		KWs

Note. RBECI = routines-based early childhood intervention model; RBI = Routines-Based Interview; KWs = Key Workers.

The Knowledge and Understanding Assessment was developed for the present study based on test questions devised by McWilliam (2010) regarding routines-based intervention. The 23 multiple-choice questions measured KWs’ knowledge and understanding of the RBECI model. Each correct answer was awarded one point; hence, scores could range between 0 and 23. Reliability and validity indices were not possible to obtain, given the small sample size. However, two judges who were registered psychologists and knowledgeable in routines-based intervention determined the correspondence between items and questions devised by McWilliam individually and then together via joint discussion. KWs’ understanding and knowledge of the RBECI model in the home and community settings were also assessed through two visual analogue scales (Hayes & Patterson, 1921). KW’s were required to mark along a 10 cm axis that ranged on a continuum from I know nothing to very knowledgeable, and marks were converted to a numerical value ranging from 0 to 10.

The Confidence Scale comprised of two visual analogue scales that measured KWs’ confidence in implementing the RBECI model during home and community consultations. KWs were required to mark along a 10 cm axis ranging from not confident at all to extremely confident, and marks were converted to a numerical value ranging from 0 to 10. Visual analogue scales have been established as a valid and reliable technique for measuring subjective experience in a variety of clinical and research applications (see McCormack, de L. Horne, & Sheather, 1988 for a review).

The Support-Based Home Visiting Scale adapted from the Support-Based Home Visiting Checklist (McWilliam, 2010) assessed KWs’ home visiting skills within the past 3 months. The 33-item self-report scale measured the extent to which KWs provided support to families in the home in four areas (i.e., emotional support, the visit, the script, and behavioral consultation) on a 5-point Likert-type scale from 0 (no opportunity) to 5 (all of the time). This measure was used due to its strong suitability to the support approach used in home visits in the RBECI model compared with other home visiting scales (McWilliam, 2010).

The Coaching Practices Rating Scale (Rush & Shelden, 2011) was completed by KWs and examined their community consultation skills within the past 3 months. The 14-item self-report scale measured KWs use and adherence to coaching practices during community consultations on a 6-point Likert-type scale from 0 (no opportunity) to 5 (all of the time). A high degree of internal reliability (α = .96) and construct validity was obtained for the scale (Rush & Shelden, 2006b).

The RBI Implementation Checklist (McWilliam, 2010) is the only measure currently available to evaluate KWs’ adherence to essential steps for conducting an RBI. All of the RBIs were audiotaped and transcribed verbatim, and they ranged from 79.02 to 193.97 min (M = 117.08, SD = 34.82 min) in duration. The first two authors of this article read the interviews and independently completed the RBI Implementation Checklist for each interview. The 36 items on the checklist focused on whether the interviewer asked questions for each routine about what the whole family is doing at the time; what the child’s engagement, social relationships, and independence are like; the family’s satisfaction with the routines; and the family’s concerns and priorities. Questions about the interviewer’s manner (e.g., affect, affirming behavior, listening techniques) were also assessed. Each of the 36-items were marked as observed (+, 3 points), partially observed (±, 2 points), or not observed (−, 0 points). However, the first item could not be rated as it refers to steps taken by the interviewer to prepare the family for the RBI at least 1 day earlier, which was not audiotaped. Thus, a score for the remaining 35 items were aggregated as a percentage, with the goal to obtain 85% or above. Any discrepancies in scoring were resolved, and the codes assigned by the principal coder (second author of this article) were used in all analyses. Inter-rater reliability calculated as agreements / (agreements + disagreements) was 91.17%.

The Goal Functionality Scale III (McWilliam, 2010) has been used in prior research to analyze the quality of participation-based goals (e.g., Boavida et al., 2014). It was independently completed by the first two authors of this article who rated each goal on the families’ individual family support service plan (IFSSP). The seven-item scale calculated seven dimensions (i.e., participation, specificity, necessity, acquisition criterion, generalization criterion, meaningfulness, and time frame criterion), on a 4-point Likert-type scale from 1 (not at all) to 4 (very much). Any discrepancies in ratings were resolved, and the ratings assigned by the principal coder (second author of this article) were used in all analyses. Inter-rater reliability calculated as agreements / (agreements + disagreements) was 95.32%.

Qualitative Methodology

To examine KWs’ perspectives on implementing the RBECI model of practice, individual in-depth interviews were conducted with each of the KWs by the first author of this article. Due to the KWs’ caseloads and difficulties in scheduling the interviews, the interviews were conducted approximately 3 months after the completion of the post-intervention assessment and lasted between 22.40 and 45.07 min (M = 33.77, SD = 8.78 min). The interviews commenced with an overview of the purpose of the interview, followed by a broad open-ended question regarding KWs’ experiences (Kvale, 1996) with the implementation of the RBECI model. Follow-up questions were asked to ascertain KWs’ perspectives about the individual components of the RBECI model (i.e., RBIs, participation-based goals, home and community consultations) and to clarify participants’ responses if necessary. For example, “How did you find the goal setting in light of the RBI?” “How did the home visits go from your perspective?” and “Has the RBECI model had any impact on community consultations?”

Procedure

Following approval from the University Human Research Ethics Committee, KWs were invited to participate in the study. Subsequently, each KW invited two families to participate on the basis that they were new to the intervention service provider and had not attended an ECI service provider previously. Once formal consent was obtained, KWs and families completed a Demographic Questionnaire. Next, a pre-assessment of KWs’ ability to implement the RBECI model was conducted followed by a 2-day training workshop. The RBECI model was then introduced with families for 6 months, at the end of which a post-assessment of model implementation by KWs was conducted.

Training of KWs to implement the RBECI model

KWs participated in a 2-day workshop on the RBECI model of practice, facilitated by two registered psychologists from the intervention service provider who were experienced in training, consultation, and ECI and had liaised with a routines-based intervention expert in designing the workshop. Table 2 presents the content of the workshop and the teaching methods used for each day of the workshop. Teaching methods used in the workshop included presentations, role-plays, use of DVDs for modeling, and practice completing each of the measures. All workshop content and teaching methods adopted adult learning principles (Knowles, 1973).

Table 2.

RBECI Model Training Workshop Content and Teaching Methods.

Session	Content	Teaching methods
Day 1	RBI	DVD demonstration, group reflection on DVD, RBI Implementation Checklist practice, role-plays, presentation
	Participation-based goals	Presentation, DVD demonstration, Goal Functionality Scale III practice, group work
Day 2	Support-based home visit	Presentation, DVD demonstration, Support-Based Home Visiting Scale practice, discussion, role-plays, group reflection
	Community consultation	Presentation, discussion, Coaching Practices Rating Scale practice, role-plays, group reflection

Note. RBECI = routines-based early childhood intervention model; RBI = Routines-Based Interview.

Implementation of the RBECI model

Following the workshop, each KW individually conducted one RBI with two families, followed by the development of goals for the IFSSP. One KW implemented these practices with one family only due to a family dropping out of the study. Note that the information related to child and family outcomes were also collected as part of another study.

KWs participated in seven group reflective practice sessions held approximately every 3 weeks following training. These sessions were run by the two registered psychologists who facilitated the RBECI workshop. The purpose of these sessions was to give KWs the opportunity to reflect on their own practice according to the RBECI model and to provide them with supervisor feedback. Reflective practice sessions involved direct observation (i.e., listening to audio-recordings of the RBIs and observing excerpts from home visits) and check-in-based performance feedback regarding the implementation of the RBI, participation-based goals, home visits, and community consultations.

Data Management and Analysis

Descriptive statistics, followed by paired-sample t tests were used to assess differences in KWs’ skills, knowledge, and confidence pre- and post-implementation of the RBECI model. Descriptive statistics were analyzed to examine the quality of the RBIs and participation-based goals, followed by Kendall’s correlation coefficient that assessed the relationship between the quality of the RBIs and the functionality of the participation-based goals. All of the in-depth interviews were audiotaped and transcribed verbatim by a professional transcriber, and the second author of this article cross-checked the written transcripts with the audiotapes for reliability purposes. Thematic analysis was used to systematically explore participants’ comments about their experiences with the implementation of the RBECI model. This process of locating common patterns within a data set (Gifford, 1998) commenced with the first two authors of this article independently reading and coding all of the participants’ comments into tentative categories. The authors then met and compared categories and engaged in discussion about the common experiences expressed by the KWs. There was high overlap in individual interpretations and consensus was reached on all categories, resulting in a shared analytical framework being developed (Patton, 2001). The reliability of the findings was addressed by having the third author of this article read the interviews and the final themes. No changes to the themes were made.

Results

Differences in KWs’ Skills Following Implementation of the RBECI Model of Practice

Descriptive statistics are provided in Table 3 for each of the measures used to assess KWs’ knowledge and understanding, confidence, and self-reported use of home visiting and community consultation skills at pre- and post-intervention. Two-tailed paired-samples t tests were conducted to determine whether a significant difference existed between pre- and post-intervention on the Knowledge and Understanding Assessment, Confidence Scale, Support-Based Home Visiting Scale, and Coaching Practices Rating Scale. There was a significant improvement from pre-to post-intervention for all outcome measures, except for the Coaching Practices Rating Scale.

Table 3.

Contrast of KWs’ Knowledge and Understanding, Confidence, Home Visiting and Community Consultation Skills From Pre- to Post-Intervention.

	Pre-intervention		Post-intervention					95% CI
Measures	M	SD	M	SD	t(4)	p	Cohen’s d	Lower	Upper
Knowledge and Understanding Assessment	24.35	2.67	39.00	1.77	−9.15	.001	−4.09	0.86	6.80
Confidence Scale (Home)	2.80	1.39	8.50	0.92	−12.34	<.001	−5.52	1.24	9.09
Confidence Scale (Community)	2.00	1.27	7.10	1.70	−6.63	.003	−2.97	0.54	5.01
Support-Based Home Visiting Scale	112.20	7.29	137.30	4.74	−7.76	.001	−3.47	0.69	5.80
Emotional support	22.00	1.41	26.80	1.30	−4.15	.014	−1.85	0.00	3.29
The visit	29.80	1.64	38.40	0.55	−12.68	<.001	−5.67	1.28	9.33
The script	26.00	2.12	31.00	2.00	−9.13	.001	−4.08	0.86	6.78
Behavioral consultation	34.40	4.62	41.10	2.41	−3.72	.02	−1.66	0.00	3.00
Coaching Practices Rating Scale	42.00	6.82	47.40	9.86	−1.32	.26	−0.59	0.00	1.50

Note. KWs = Key Workers; CI = confidence interval.

Quality of RBIs and Participation-Based Goals

To assess the quality of the RBIs and participation-based goals, descriptive statistics on their respective measures were obtained. The mean total percentage across all nine RBI Implementation Checklists was 81.60% (SD = 10.37%), compared with the recommended minimum of 85% by McWilliam (2010). Frequencies for each question on the RBI Implementation Checklist across all nine RBIs were examined. Due to one KW only conducting one RBI (due to a family dropping out of the study), it was deemed more appropriate to examine frequencies across all RBIs, as opposed to the average scores each KW received for the RBIs they conducted. Notably, follow-up questions related to social relationships (Item 10) were not observed in any of the RBIs. Moreover, follow-up questions to gain an understanding of functioning (Item 6) and asking what the parent would like to see next in the routine (Item 21; if there were no problems in the routine) were frequently not observed or were only partially observed (i.e., only asked for some of the routines discussed). However, the following items were observed in all of the RBIs: have a good conversational flow (Item 4); ask follow-up questions that were developmentally appropriate (Item 11); ask for a rating of each routine (Item 14); use good affect (Item 17); avoid unnecessary questions (Item 23); act in a non-judgmental way (Item 24); allow the family to state their own opinions, concerns, and so on (Item 27); and summarizing concerns (Item 30).

Frequencies for each of the questions on the Goal Functionality Scale III across the 66 goals that were produced on the IFSSPs by all KWs and families were examined (see Table 4). KWs scored a mean of 3.12 (SD = 0.24) out of a possible 4, for each question on the Goal Functionality Scale III. Notably, goals frequently did not include an acquisition criterion, a meaningful acquisition criterion, and a generalization criterion. Conversely, all goals emphasized the child’s participation in a routine. Kendall’s correlation coefficient was computed to assess the relationship between the RBI scores and goal functionality scores. There was a non-significant correlation between the two variables, τ = .25, p = .35.

Table 4.

Frequencies of Scores on the Goal Functionality Scale III.

	Frequencies
Questions	Not at all	Somewhat	Much	Very much
1. Emphasize the child’s participation in a routine (i.e., activity)?	0 (0.00)	0 (0.00)	0 (0.00)	66 (100.00)
2. State specifically (i.e., in an observable and measurable manner) what the child will do?	1 (1.52)	0 (0.00)	0 (0.00)	65 (98.48)
3. Address a skill that is either necessary or useful for participation in home, “school,” or community routines?	0 (0.00)	0 (0.00)	2 (3.03)	64 (96.97)
4. State an acquisition criterion (i.e., an indicator of when the child can do the skill)?	14 (21.21)	12 (18.18)	3 (4.55)	37 (56.06)
5. Have a meaningful acquisition criterion (i.e., one that shows improvement in functional behavior)?	28 (42.42)	3 (4.55)	6 (9.09)	29 (43.94)
6. Have a generalization criterion (i.e., using the skill across routines, people, places, materials, etc.)?	49 (66.67)	9 (13.64)	0 (0.00)	8 (12.12)
7. Have a criterion for the time frame?	19 (28.79)	2 (3.03)	11 (16.66)	34 (51.51)

Note. Percentages appear in parentheses.

KWs’ Perspectives on Implementing the RBECI Model of Practice

Four main themes emerged from the interviews with the KWs related to their perspectives on implementing the RBECI model of practice: (a) the breadth of information elicited during the RBIs, (b) the functionality of participation-based goals, (c) the positive impact of embedding intervention within routines on home visits and community consultations, and (d) the length of time taken to commence “intervention.” Each of these themes will be discussed in turn.

The breadth of information elicited during the RBIs

KWs were overwhelmingly positive regarding the usefulness of the RBIs. Specifically, they indicated that the RBIs elicited a broader scope of information that may not have been acquired using previous methods (e.g., screening assessment). For example, one KW indicated that the RBI elicited “. . . a lot more information than just talking about the different skills [of the child].” Another KW stated that they “. . . definitely got a lot more information about how things are currently looking during the day for the family.” Furthermore, the RBI highlighted aspects of daily routines that were not working well for families:

. . . I don’t know whether dressing would have come up as a high priority for them unless I had gone through right from the beginning of their day what was happening. Because the big things for them were more around . . . his diagnosis and I think we probably would have got a lot more stuck on that and not found out the other things that were difficult for them.

Although RBIs were viewed as a very useful tool, KWs expressed concerns regarding the time involved in conducting them. The completion of the RBIs was lengthy, taking one long session (i.e., more than 3 hr) or two sessions to complete:

. . . Well initially, the first one I did, took I think 3 hours, 3 and a half hours . . . It took a long time and I was exhausted. In hindsight, I would have done it over 2 sessions . . . I didn’t realize it would take so long.

The RBIs were particularly lengthy for families with multiple members:

. . . It’s not something you can do very quickly. It’s quite detailed, especially when you’re wanting to find out what everyone in the family is doing and if you’ve got a family of 5 that’s a lot of people and if there’s another child in the family who also has special needs or a disability then it’s even longer.

KWs also reported issues with the amount of time spent writing up the RBI, to provide a copy to the families at their next home visit. One KW indicated, “. . . the write-up takes forever . . . It’s just finding the time to type it up.” KWs’ perception was that time spent completing paperwork meant less contact time with the family, indicating competing priorities for KWs and possibly the limited financial resources available to complete important ECI tasks.

The functionality of participation-based goals

KWs were able to produce more functional participation-based goals within the child and families’ routines as a result of the information obtained during the RBI compared with previously used assessment tools. One KW expressed that

. . . Setting goals was pretty good because it kind of moved seamlessly from getting that list of goals at the end of the RBI into writing the IFSSP. It was quite easy and then in terms of the intervention, I think it was good to be working on something that’s within their routines as opposed to taking them out and trying to work on like a specific skill.

A different KW indicated that “. . . the goals that you come up with as a result of the RBI are just so much more . . . useful and meaningful.” Furthermore, KWs found that a number of family goals were produced as a result of the RBI, which they viewed as a positive addition to the support they provided to families. One KW stated “. . . I’m pleased we’re doing family outcomes now—I think that’s a really good addition, definitely.” KWs, however, noted that some families only wanted to work on family goals, “. . . housing, relationships, everything else is a priority for the family, and you can’t get to the underlying developmental side of things.” This led to frustration for KWs who felt that the child required intervention embedded within routines, but they were unable to do so because it was not a priority for the family. As a KW remarked,

. . . Most of my service has been looking at early enrolment into school, well that doesn’t fit into a routine, . . . but it is the family’s priority . . . It’s pointless talking about the crazy bath time [routine] when all mum’s thinking about is, is she going to go to school?

The positive impact of embedding intervention within routines on home visits and community consultations

KWs reported that having clear goals embedded within routines when conducting community consultations in child care/preschool gave more purpose to visits:

. . . We have such a focus now that you don’t just duck out to a preschool and do an observation for an hour for the sake of it, there’s a focus behind the visit. You might be observing to see where in the routine you could get this goal happening.

Furthermore, focusing on routines simplified discussions with early childhood educators about intervention. As a KW commented about one child,

. . . There were a lot of routines that weren’t going so well within the child care, particularly around sleep time, any kind of mat time, and lining up outside, so having that clear kind of framework to go through with the child care around what areas they wanted to improve on was useful.

During home visits, KWs found that embedding intervention within routines made attaining goals easier for families.

. . . This is where I think it’s been amazing, because you’re not asking the family to do it [intervention] all day. You’re only focusing on this one routine and they see the success. It flows through to the rest of the day.

As a result, families quickly came to understand the value of embedding intervention into routines. For example,

. . . Now when I talk about working on things [goals] being really embedded in their daily routine . . . mum is a lot more open and receptive to it because I think she understands the importance of embedding it in their daily routine and making sure that it’s not just that sort of one off and that there is consistency across settings.

KWs expressed concern, however, that they were only able to work predominantly either in the home or in the child care/preschool due to time constraints, funding, and the families’ goals. KWs indicated that “. . . it would be nice if we had time to go see them at preschool and at home” and that “. . . additional funding may help so that KWs can conduct both home visits and community consultations.”

The length of time taken to commence “intervention.”

The final theme that emerged was the length of time taken to commence “intervention” with families. KWs discussed that parents were frustrated with the process of the RBECI model, particularly in regards to the initial associated paperwork. One KW indicated that “. . . we know it [the time initially invested] pays off, but there are times when you can sense the family is itching to get going.” Another KW said that

. . . We got to a point where she [the mother] just felt like all we were doing was talking and we weren’t actually doing anything for the family. You could see she was like, “What are you here for? You’re not actually helping.” We had certain things that we had to get through, all this paperwork that we had to do and the RBI stuff on top of that. It was a couple of months before I could come up with any strategies that she felt would be helpful . . . She didn’t want me to sit down and explore her feelings, she wanted some quick fixes and I felt the pressure and I needed a couple of runs on the board before we could really sit down and talk about things.

To appease the family and ensure they continued in ECI, KWs indicated that they provided intervention strategies to the family prior to completing the RBI. One KW stated that “. . . we started working on a goal because it was the only way that I could keep her (the mother).”

Discussion

The current study is the first to provide a preliminary evaluation of the implementation of the RBECI model of practice by Australian ECI practitioners. Overall, the findings provide support for the various components of the model (i.e., RBIs, participation-based goals, home and community consultations) to be implemented together. Specifically, KWs’ knowledge, understanding, and confidence regarding the RBECI model of practice increased from pre- to post-intervention. Furthermore, KWs’ average score attained on the RBI Implementation Checklist almost reached the recommended minimum of 85% (McWilliam, 2010). Although KWs demonstrated some clear strengths in their collaborative and positive interactional styles with families, they omitted or frequently omitted questions about the child’s social relationships, the child’s functioning, and what parents would like to see next in the routines when there were no problems. Future training should emphasize the importance of focusing on the assessment of children’s social development in everyday routines, given its centrality to overall child and family functioning and thus development of effective interventions (National Scientific Council on the Developing Child, 2004).

Overall, functional participation-based goals were developed by KWs, as evidenced in the high average score obtained on each question on the Goal Functionality Scale III. However, almost half of all goals produced did not include a meaningful acquisition criterion, which is critical in establishing whether the child has shown improvement in functional behavior and thus acquired the skill (McWilliam, 2010). Furthermore, a generalization criterion was frequently omitted from the goals, which is paramount in ensuring the skill is demonstrated and mastered across routines, people, and places at the level the family wants (McWilliam, 2010). Our findings are similar to those reported by Boavida et al. (2014) who found that even after receiving extensive training that focused on developing high quality goals and objectives on individualized plans through the RBI, professionals scored lower on the generalization criterion and meaningful acquisition criterion than other criteria. In all, reasons behind KWs’ omission of the generalization criterion and meaningful acquisition criterion are unclear, and thus warrant further investigation.

In the current study, no relationship was found between the quality of the RBIs and the functionality of participation-based goals. This finding is surprising considering that prior research has demonstrated an improvement in the quality of goals on IFSPs when RBIs have been implemented with fidelity compared with goals developed when no RBIs were implemented (Boavida et al., 2014; McWilliam et al., 2009). Furthermore, KWs in the current study perceived the goals that were produced as a result of the information acquired during the RBI to be more functional than goals produced using other methods, such as screening assessments. The presence of an outlier in the RBI scores in the current study and the small sample size may have contributed to this non-significant finding (Field, 2009). However, KWs may have required more extensive training, practice, and feedback regarding conducting the RBIs and developing participation-based goals. Professionals in the study by Boavida et al. (2014) received two sessions on the RBI: one session focused on analyzing a video-recorded example of an RBI, and the other session focused entirely on practicing RBI skills in a role-play. In addition, they received a session that partly focused on writing functional goals and objectives. Finally, individual feedback was provided to professionals on an RBI and functional goals 3 months after the initial training sessions. In comparison, KWs in the current study received one training session that included discussion and practice regarding conducting an RBI and writing functional goals and seven group reflective feedback sessions over a 6-month period.

One notable finding regarding the participation-based goals produced on the IFSSPs was that there were a similar number of child-centered (n = 36) and family-centered (n = 30) goals. This indicates that the family-centered philosophy was adhered to, as KWs encompassed the family’s, as well as the child’s priorities in the intervention (Bruder, 2000). This is important to ensure that the family feels supported in facilitating the changes they want for themselves and their child (Bruder, 2000; Shelden & Rush, 2010).

Home visiting skills significantly improved following the implementation of the training on the RBECI model of practice. This finding supports previous research indicating that ECI professionals implemented home visits, in terms of coaching strategies, to a high standard when professional development and support was provided (Salisbury et al., 2012). However, it must be noted that home visiting skills were measured via a self-report rating scale, and therefore, KWs may have overreported their skills. Alternative measures, such as observations, would provide a more accurate reflection of home visiting skills (Salisbury et al., 2012; Salisbury et al., 2010).

In contrast to home visiting skills, community consultation skills did not improve from pre- to post-implementation of the RBECI. At post-intervention, KWs were attaining scores just more than half of what they potentially could have on the Coaching Practices Rating Scale, indicating that they were not using and adhering to coaching practices. One possible explanation for this finding could be the lack of opportunity two of the five KWs had to conduct community consultations. One child did not attend child care or preschool and one family did not identify support in the community as a priority for them. Regardless, when these two KWs were excluded from the analysis, there was still no significant improvement in community consultation skills from pre- to post-intervention. A more likely explanation for lack of improvement in community consultation skills is that the RBECI training course that the KWs participated in prior to the implementation of the intervention focused more heavily on the RBI, participation-based goals, and home visiting. Furthermore, limited time was spent during reflective practice sessions discussing consultations conducted in community settings. Taken together, the results indicate that targeted training and supervision is required to improve KWs’ community consultation skills.

Interestingly, despite KWs’ community consultation skills showing no improvement from pre- to post-implementation of the RBECI model, their confidence in conducting the RBECI in community settings increased over this period. This suggests that although the training and feedback that KWs received during the intervention period did not significantly improve their self-reported consultation skills while visiting child care and preschool settings, they did increase their confidence in implementing the RBECI model during consultations. KWs reported during the in-depth interviews that having clear routines-based goals assisted them in their consultations with early childhood educators, which may have made them feel more confident implementing RBECI practices in community settings.

Limited funding and resources for conducting home visits and community consultations and the possible impact on KWs’ performance emerged as a concern for KWs during the in-depth interviews. In the state of Victoria in Australia (where this study was conducted), families in ECI are only funded for approximately one visit (i.e., 1 hr) per fortnight. This is in contrast to the United States where the National Early Intervention Longitudinal Study (NEILS) reported that families received on average 1 to 2 hr per week of face-to-face service during their first 6 months of ECI (Hebbeler et al., 2007). Thus, the findings from the current pilot study may not be generalizable to countries where funding for ECI is more available. Further research is required to elucidate the amount of funding that is required to achieve quality routines-based ECI.

Limitations and Suggestions for Future Research

Several methodological limitations must be acknowledged in the present study.

Sample size was small that precluded representation from a range of KWs with a wider range of demographics (e.g., profession and years of experience in ECI), and thus the performance of more sophisticated data analyses. Thus, it would be beneficial for future research to examine the implementation of the RBECI model of practice on a larger sample size. It would also be beneficial to examine the RBECI implementation across different service providers, to examine if cross-community variability occurs (Guralnick, 2005). The psychometric properties of the measures used in the current study were limited, thus research needs to be conducted to find support for the use of these measures in future studies. The current study did not include a follow-up to ascertain whether the findings were maintained over time. In the future, it would be advantageous for the implementation of the RBECI model to be examined in a longitudinal study.

Although this study examined KWs’ experience in the implementation of the RBECI model, previous research (Mattern, 2015) has indicated that the experiences and beliefs regarding the implementation of evidence-based practices in early intervention differ between ECI participant groups (i.e., families, early childhood educators, and early intervention service providers). It would therefore be beneficial to also gain the perspectives of families, early childhood educators, and service providers regarding the implementation of the RBECI model of practice.

Conclusion

The current study demonstrated that ECI professionals are able to effectively acquire knowledge and skills regarding the use of routines-based interventions in their daily practice. It also provided preliminary support for the RBECI model to be implemented on a larger scale. However, the study highlighted the need for further training, coaching, and supervision of KWs to improve the ability associated with the effective implementation of the RBECI model, especially in terms of community consultation skills. Furthermore, KWs are instrumental in promoting families’ awareness of the time frame and rationales around the processes involved with the RBECI model to increase their confidence in the model. In effect, these improvements in implementation are likely to have positive developmental outcomes for children receiving ECI, as well as positive implications for their families. Finally, the current study highlighted that strong agency leadership in the form of commitment to quality and improvement is critical to successful implementation of interventions at a service-wide level. In this regard, ECI leaders’ acknowledgment of a system-based approach, whereby program components, processes, and child and family outcomes are clearly specified, is paramount to enabling effective ECI programs.

Footnotes

Acknowledgements

The authors would like to thank all of the ECI professionals and families who participated in the study. We would also like to thank Dr. Robin McWilliam for his comments regarding the design of the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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