Supporting Families and Caregivers in Everyday Routines Incorporating intervention into daily life can enhance a child’s development. Early-intervention clinicians are key to teaching parents and other caregivers how to provide opportunities for children to practice and expand language abilities as they play, get dressed, eat, and take part in other daily activities. The charge of early intervention ... Features
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Features  |   September 01, 2011
Supporting Families and Caregivers in Everyday Routines
Author Notes
  • Melissa A. Cheslock, MS, CCC-SLP, provides services to infants and toddlers with a range of developmental needs and their families at the Hand in Hand Early Intervention Program of the United Cerebral Palsy Center of Greater Birmingham (Alabama). She is a member of Special Interest Group 12, Augmentative and Alternative Communication. Contact her at mcheslock@ucpbham.com.
    Melissa A. Cheslock, MS, CCC-SLP, provides services to infants and toddlers with a range of developmental needs and their families at the Hand in Hand Early Intervention Program of the United Cerebral Palsy Center of Greater Birmingham (Alabama). She is a member of Special Interest Group 12, Augmentative and Alternative Communication. Contact her at mcheslock@ucpbham.com.×
  • Sally J. Kahn, MS, CCC-SLP, is a clinician at the Hand in Hand Early Intervention Program of the United Cerebral Palsy Center of Greater Birmingham (Alabama). Contact her at skahn@ucpbham.com.
    Sally J. Kahn, MS, CCC-SLP, is a clinician at the Hand in Hand Early Intervention Program of the United Cerebral Palsy Center of Greater Birmingham (Alabama). Contact her at skahn@ucpbham.com.×
Article Information
Special Populations / Early Identification & Intervention / School-Based Settings / Attention, Memory & Executive Functions / Features
Features   |   September 01, 2011
Supporting Families and Caregivers in Everyday Routines
The ASHA Leader, September 2011, Vol. 16, 10-13. doi:10.1044/leader.FTR1.16112011.10
The ASHA Leader, September 2011, Vol. 16, 10-13. doi:10.1044/leader.FTR1.16112011.10
Incorporating intervention into daily life can enhance a child’s development. Early-intervention clinicians are key to teaching parents and other caregivers how to provide opportunities for children to practice and expand language abilities as they play, get dressed, eat, and take part in other daily activities.
The charge of early intervention is to provide supports to help families and caregivers enhance their children’s learning and development through everyday enrichment opportunities (IDEA, 2004). Children are thus able to practice skills throughout the day, every day, in meaningful ways.
A contextualized approach to intervention builds on interactions between children and family members to achieve outcomes. Services are provided in the child’s natural environment and are focused on enhancing the family and caregiver’s ability to support their child’s development (IDEA, 2004).
Although most clinicians provide services in the natural environment as outlined in the Individuals With Disabilities Education Act (IDEA), services often lack the integration of the family and caregiver’s typical routines. As a result, intervention becomes decontextualized and limited in opportunities for meaningful experiences.
To provide supports to families and caregivers effectively, it is important to subscribe to a core set of evidence-based practices that provide the foundation of early intervention services. These foundational principles constitute a consensus of a variety of professional organizations, including ASHA, and are reflected in the family of documents on the roles and responsibilities of speech-language pathologists in early intervention (ASHA, 2008; search “early intervention” at ASHA’s Practice Policy). A clinical forum and an article, “Guiding Principles and Clinical Applications for Speech-Language Pathology Practice in Early Intervention,” based on these principles, appears in a recent issue of Language, Speech, and Hearing Services in Schools.
Services are family-centered. Services address each family’s strengths, needs, priorities, and concerns, all of which are different for each family based on its unique culture and circumstances.
Services focus on the entire family, not just on the child’s needs. Inherent in this principle is the belief that families and caregivers, with appropriate supports and resources, play an important role in enhancing their children’s development. Family members are the most stable, influential, and valuable people in a child’s life (Iovannone, Dunlap, Huber, & Kincaid, 2003) and all families have strengths, in varying degrees, to assist their child in learning. Families are diverse and include both immediate and extended family members. Caregivers may be family members, but they also may be valued members of the family’s community, including, for example, a teacher, nanny, or babysitter.
Evidence of the effectiveness of parents and caregivers implementing supports in daily routines is growing. Studies in which the clinician trains and coaches caregivers to implement supports have revealed positive effects on child language and communication outcomes (Roberts & Kaiser, 2011) and a decrease in parental stress over the need to find extra time in which to conduct treatment (Kashinath, Woods, & Goldstein, 2006). In general, with appropriate clinician support and scaffolding, caregiver intervention is as effective in obtaining communication outcomes as clinician-implemented intervention (Romski, Sevcik, Adamson, Cheslock, & Smith, 2007).
When given the choice, most families and caregivers choose to participate actively in their child’s intervention plan (Crais, Roy, & Free, 2006). Services then become more collaborative and SLPs serve to support and consult with families and caregivers to achieve outcomes throughout daily routines.
Services are developmentally supportive and promote children’s participation in natural environments. Services that are developmentally supportive offer children authentic learning experiences to support functional communication development throughout everyday routines specific to the family, as well as interactive participation appropriate to the child’s age, developmental level, strengths, needs, and family priorities (ASHA, 2008).
According to IDEA (2004), natural environments for children who have or are at risk for disabilities are the same as those of typical same-aged peers who have no disabilities. A child’s primary natural environment is usually the home, but it also may include community settings such as a park, grocery store, or early-learning childcare program.
Providing services in a child’s environment extends beyond location alone to include typical events that occur throughout the day, such as caregiving routines (e.g., dressing, feeding, and bathing) and play routines (e.g., building with blocks, rolling a ball, or playing on a swing set). Intervention in natural environments, conducted by the family and caregivers, provides realistic social contexts and offers multiple opportunities for successful communication and learning throughout the child’s day.
Services are comprehensive, collaborative, and team-based. An SLP is one clinician among several professionals on a team, with the child and family at the center, and provides unique insights related to communication development.
A comprehensive team-based approach is recommended because eligible children may have or be at risk for having delayed development in a variety of areas that require consultation from a number of professionals. Families and caregivers, who know their children best, can also offer valuable insight and knowledge.
Although there are multiple service delivery models for teams to follow, their common goal is to support families in their ability to enhance their child’s development. Models that best meet this goal are collaborative, such as interdisciplinary or transdisciplinary models, and stress the importance of communication among team members, family involvement, and embedded intervention within natural environments.
Identifying Routines
In supporting families and caregivers to enhance their child’s development, clinicians must make certain that the families and caregivers understand the concept of routines so they are able to identify them as contexts for learning.
In a Project INTEGRATE document, Robin McWilliam (2001) defined routines as “not necessarily things that happen routinely. They are simply times of day.” They are outcome-oriented and typically have a clear sequence of events. For example, the outcome of a morning dressing routine is simply being dressed, and would include the sequence of picking out clothes, taking off pajamas, getting dressed, and then putting away the pajamas. It is within these sequences that opportunities for communication and learning can occur.
Described another way, routines are a mix of structured and unstructured life experiences relative to each individual family (Dunst, Hamby, Trivette, Raab, & Bruder, 2000). A structured activity might be going to story time at the library, whereas an unstructured activity could be swimming in an inflatable pool. Activities occurring often enough to become a meaningful part of the child’s everyday life then become routines. These routines, which are repetitive and predictable, provide a framework in which to embed intervention.
Routines within early-learning programs are typically structured or semi-structured, and may include circle time with songs and story, art, free play, and lunch. Regardless of the type or level of structure, all routines have potential to provide positive learning opportunities for communication.
Assessment
Comprehensive assessment in early intervention provides a thorough representation of a child’s functional behavior during daily routines. The SLP plays an important role in conjunction with other team members to identify communication strengths and needs within the comprehensive assessment, and to help the family identify routines in which to embed intervention goals.
Formal measures may include standardized tests or questionnaires that identify specific communication strengths and needs, whereas informal measures may include interviews and observation of the family and caregiver’s existing routines. Informal measures reveal more valuable information about the family’s routines and the child’s participation level in those routines, and give a more complete picture of the child’s overall functioning.
During the interview, it is important to learn about family priorities and concerns and to explain the value of embedding intervention goals during routines. When families and caregivers understand this value as well as their vital role in their child’s development, they are more likely to take an active role.
An informal interview also should determine caregiver perceptions and expectations for the child’s participation in priority routines and reveal challenging aspects of the routines. For example, having the child participate in mealtime by verbally requesting food items is often an expectation. Helping families and caregivers determine barriers to the child’s mealtime participation can be an excellent starting point for intervention.
Following the interview, observing the caregiver or family members reveals their unique style of interaction and helps the SLP to determine the success of the routine and alterations that could provide more potential for increased communication and child participation (Wilcox & Woods, 2011).
Routines of the day vary for each child and family. It is important only that the routines are meaningful and occur often enough that they are predictable for children to anticipate their role of participation (Family-Guided Routines-Based Intervention, 2004). Routines are simply the vehicles—based on family priorities and needs identified through the interview— through which the child learns new skills and improves upon skills already established.
Intervention often begins with routines that are highly preferred and motivating for the child. However, helping families and caregivers identify more challenging routines also is essential. Children may learn new skills during highly preferred routines and practice existing skills during more challenging routines. Regardless of the routine, opportunities are available for the child to participate communicatively.
Enhancing Communication Participation Through Routines
Supporting families and caregivers throughout their everyday routines is a dynamic process of SLPs sharing their unique knowledge and skills, making practical suggestions, identifying communication opportunities, and teaching appropriate strategies. This support entails building on family and caregiver strengths while making positive suggestions and problem-solving with the family and team.
No matter the environment, be it home or a community setting, the goal remains—more successful communication participation of the child in daily routines. Once priority routines are identified and observed, the SLP helps the family or caregiver determine ways to embed communication opportunities to meet already established outcomes within the many sequences of their daily routines.
Embedding opportunities to participate in everyday routines is an evidence-based practice recognized as an important component of services for young children (Bronfenbrenner, 1992; Dunst, 2006; Wilcox & Woods, 2011). Empowering families and caregivers to implement intervention themselves builds on this practice and allows for more frequent and genuine learning experiences and generalization of newly learned skills. Children learn more and make developmental gains with repeated learning opportunities in meaningful daily activities (Rapport, McWilliam, & Smith, 2004).
Simply participating in routines with opportunities for communication does not ensure the desired outcomes are achieved; specific, individualized strategies to support children in learning must be implemented. SLPs use a variety of early-learning strategies—including environmental arrangement, parallel talk, visual support, responsive feedback, expansions, choice-making, and time delay—that support language acquisition and help children expand on existing language abilities during appropriate opportunities.
For example, a child in daycare demonstrates behavior problems that inhibit his ability to participate successfully during small-group play. The SLP observes that the behavior may be caused by the child’s inability to communicate his wants during that routine effectively and suggests giving the child toy choices. Helping the caregiver to reframe the child’s behaviors by offering positive strategies is essential for establishing rapport and developing trust with the caregiver (Case-Smith & Holland, 2009).
SLPs need to share their unique knowledge of these strategies with families and caregivers by modeling and coaching. In doing so, the SLP supports and strengthens parent and caregiver confidence and competence to provide the child with everyday learning opportunities.
The SLP models the implementation of specific strategies with a child to provide concrete examples and then steps back to allow for caregiver practice. The interventionist then coaches the family member or caregiver through the interaction, offering positive suggestions and feedback when necessary. This teaching process should occur in multiple environments and with multiple caregivers, when possible, to encourage generalization and maintenance of learned strategies into other routines (Kaiser & Hancock, 2003). Following coaching, it is important to review what worked and did not work and plan next steps.
Supporting families and caregivers in embedding intervention goals within their daily routines is a flexible and adaptable process. As the child’s communication participation in a routine increases, family and caregiver expectations for the child also typically increase. In addition, more learning opportunities often become available for a child as participation in a routine increases.
Ongoing communication and collaboration between the family and SLP, as well as with the rest of the team, are essential. Progress should be monitored with families and caregivers, and expectations for children’s participation should be frequently revisited to ensure progress.
Case Study: Helping a Preschooler Through Transition Times

Mason’s family entered an early intervention program when he was 18 months old to address significant delays in his receptive and expressive language as well as concerns about social interactions at daycare. His teachers wanted to help Mason but were already stretched attending to a full classroom of children ages 3 and younger.

Mason’s visits were scheduled at daycare with feedback provided to his family through follow- up phone calls. The SLP used Mason’s natural environment—daycare—and everyday classroom routines as a context for services. This approach allowed for more cohesive services and addressed teacher concerns. Discovering ways to encourage participation, increase communication opportunities, and decrease stress for the teacher were priorities for both family and caregivers.

At her first visit to the daycare, the SLP explained that Mason’s family was most concerned with his ability to participate and learn in the classroom. She explained that intervention would occur in routines of the day and that she would serve as a support to increase Mason’s participation in the classroom. Because Mason’s teacher was most concerned with his ability to transition from the playground to the classroom, they decided to choose that routine (clean-up and lining up at the door) to begin intervention.

The teacher explained the typical sequence of the routine (clean-up song, picking up outside toys, and lining up at the door) as well as her expectations for the children. She noted that instead of cleaning up his toys, Mason appeared to ignore the teachers and would often have a tantrum when it was time to go back inside.

By observing Mason during the transition, the SLP noted that he was not processing the auditory signal (“clean-up song”) that cued the other children to clean up, a behavior that his teachers viewed as “ignoring.” She also noted that the next routine—snack—was reinforcing for Mason as he calmed down rather quickly back inside the classroom.

The SLP shared her observations with Mason’s teacher and offered some strategies, such as visual support, to help the routine go more smoothly. The SLP explained that using visual supports may enhance Mason’s understanding of auditory input, thereby helping him to attend to communication better and follow classroom directions.

At her next visit, the SLP brought picture symbols for clean-up and snack and a “first-then” picture board to facilitate the transition process. She explained how the pictures, when paired with the routine, would become meaningful for Mason. During outside play, the SLP demonstrated use of the picture symbol for “clean-up” and then, along with the teacher, helped Mason to clean up the outside toys.

Once inside, the SLP demonstrated pairing the picture symbol for “snack” with the snack routine. She explained that once Mason was accustomed to the picture symbols, they could incorporate them into a “first-then” picture board to help Mason understand the transition. The SLP left the picture symbols and “first-then” picture board with the teacher for everyday practice.

During the following visit, Mason’s teacher demonstrated use of the strategies. The SLP provided input and recommendations when necessary. They also discussed the potential for use of the picture symbols and “first-then” board in other difficult transitions.

This scenario demonstrates successful intervention using everyday routines in a natural environment. Through discussion with Mason’s teacher, the SLP determined a specific routine of concern. The SLP offered a specific strategy (first-then visual support picture board) for increasing participation, and explained how to implement it (modeling, then coaching the teacher until she felt comfortable implementing the strategy herself). They were able to collaborate to discover new ways for Mason to participate and, in turn, gain new opportunities for learning.

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FROM THIS ISSUE
September 2011
Volume 16, Issue 11