Who gets coached? A qualitative inquiry into community clinicians' decisions to use caregiver coaching

Examining the Family-Centeredness of Speech-Language Pathologists Working With Children Who Use Augmentative and Alternative Communication

PURPOSE

Family-professional partnerships are important for youth learning to use aided augmentative and alternative communication (AAC). This study examined the family-oriented beliefs and practices of speech-language pathologists (SLPs) working with preschool and school-aged children learning to use aided AAC (aged 3-21 years), specifically during the COVID-19 pandemic.

METHOD

Participants were 25 SLPs who participated in an individual semistructured interview. Qualitative analysis was used to identify and describe groups of SLPs based on commonalities and differences in their beliefs and practices working with families. The characteristics of SLPs in each group was also explored descriptively (e.g., race/ethnicity, work setting, caseload).

RESULTS

SLPs clustered into three groups based on their beliefs and practices: (a) professionally centered, (b) family-allied, and (c) family-focused. SLPs varied across these groups in how they planned services, offered training/coaching, communicated, shared resources, offered emotional support, and adapted to and with different families.

CONCLUSIONS

Findings indicate the need to support greater family-centeredness in AAC services by building on the strengths of SLPs in the field. Promoting strong family-professional partnerships could in turn improve outcomes for students who use AAC.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25044125.

Possible unintended consequences of pediatric clinician strategies for communicating about social-emotional and developmental concerns in diverse young children

INTRODUCTION

Screening to promote social-emotional well-being in toddlers has positive effects on long-term health and functioning. Communication about social-emotional well-being can be challenging for primary care clinicians for various reasons including lack of time, training and expertise, resource constraints, and cognitive burden. Therefore, we explored clinicians' perspectives on identifying and communicating with caregivers about social-emotional risk in toddlers.

METHOD

In 2021, semistructured interviews were conducted with pediatric clinicians (N = 20) practicing in Federally Qualified Health Centers in a single metropolitan area. Most participants identified as female (n = 15; 75%), white non-Hispanic/Latino (n = 14; 70%), and were Doctors of Medicine or Osteopathic Medicine (n = 14; 70%). Thematic analysis was conducted on audio-recorded interview transcripts.

RESULTS

Clinicians used various approaches to identify social-emotional concerns which were sometimes difficult to distinguish from other developmental concerns. The clinician-caregiver relationship guided identification and communication practices and cut-across themes. Themes include: starting with caregivers' concerns, communicating concerns with data and sensitivity, navigating labels, culture, and stigma, and limiting communication based on family capacity and interest.

DISCUSSION

Prioritizing the clinician-caregiver relationship is consistent with best practice and family-centered care. Yet, the dearth of standardized decision support may undermine clinician confidence and impede timely conversations about social-emotional concerns. An evidence-based approach with developmentally based culturally informed quantitative tools and standardized decision supports could help ensure equitable management and decision making about young children's social and emotional well-being and development. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

It's our job to bridge the gap: Perspectives of bilingual autism providers on heritage language care

LAY ABSTRACT

In the United States, many people have heritage languages they speak in their homes other than English, such as Chinese or Spanish. Autistic children whose families speak different languages could benefit from support and teaching in their heritage languages. Still, caregivers have reported that it is challenging to do so. Many autism professionals make suggestions that are not based on research. To date, researchers have not examined the perspectives of the small group of bilingual professionals in the United States who provide bilingual support for autistic children. Therefore, this study explored how bilingual autism providers in the United States talked about their work, bilingualism, and the impacts their bilingual work has on autistic children and families. The bilingual providers in this study reported many positive outcomes for autistic children when they can learn and use their heritage languages and some negative outcomes when providers cannot communicate in the same language. Recommendations from this study highlight the need to recruit more bilingual providers in the field of autism.

A mixed-methods evaluation of organization and individual factors influencing provider intentions to use caregiver coaching in community-based early intervention

BACKGROUND

Most psycho-social interventions contain multiple components. Practitioners often vary in their implementation of different intervention components. Caregiver coaching is a multicomponent intervention for young autistic children that is highly effective but poorly implemented in community-based early intervention (EI). Previous research has shown that EI providers' intentions, and the determinants of their intentions, to implement caregiver coaching vary across components. Organizational culture and climate likely influence these psychological determinants of intention by affecting beliefs that underlie attitudes, norms, and self-efficacy to implement an intervention. Research in this area is limited, which limits the development of theoretically driven, multilevel implementation strategies to support multi-component interventions. This mixed methods study evaluated the relationships among organizational leadership, culture and climate, attitudes, norms, self-efficacy, and EI providers' intentions to implement the components of caregiver coaching.

METHODS

We surveyed 264 EI providers from 37 agencies regarding their intentions and determinants of intentions to use caregiver coaching. We also asked questions about the organizational culture, climate, and leadership in their agencies related to caregiver coaching. We used multilevel structural equation models to estimate associations among intentions, psychological determinants of intentions (attitudes, descriptive norms, injunctive norms, and self-efficacy), and organizational factors (implementation climate and leadership). We conducted qualitative interviews with 36 providers, stratified by strength of intentions to use coaching. We used mixed-methods analysis to gain an in-depth understanding of the organization and individual-level factors.

RESULTS

The associations among intentions, psychological determinants of intentions, and organizational factors varied across core components of caregiver coaching. Qualitative interviews elucidated how providers describe the importance of each component. For example, providers' attitudes toward coaching caregivers and their perceptions of caregivers' expectations for service were particularly salient themes related to their use of caregiver coaching.

CONCLUSION

Results highlight the importance of multi-level strategies that strategically target individual intervention components as well as organization-level and individual-level constructs. This approach holds promise for improving the implementation of complex, multicomponent, psychosocial interventions in community-based service systems.

Validity of the Toddler Autism Symptom Inventory in Non-Hispanic White and Black Toddlers

Racial disparities exist in autism diagnosis, and yet, the development of most diagnostic tools has not explicitly examined measurement equity between racial and ethnic groups. We examined the validity of the Toddler Autism Symptom Inventory (TASI), a semi-structured interview developed for diagnosis of toddlers, in non-Hispanic Black/African American and non-Hispanic White children. After controlling for group differences in socio-economic status, no differences in diagnosis, age at diagnosis, mean developmental level, or autism severity were found. TASI ROC curves for both groups, in the overall sample, and in samples stratified by SES, showed high AUC values. Validity of two cutoff scores was acceptable. Lack of significant differences in TASI score or responses to individual items suggests similar symptomatology. These results provide early support for the use of the TASI in diagnostic evaluations of Black and White children.

A Comparison of Maternal and Clinician Perception of Communication in Autistic Toddlers

PURPOSE

Parent instruction in communication facilitation strategies for autistic toddlers relies on assumptions that parents interpret child behaviors in alignment with clinician definitions of communication. The purpose of this study was to identify features of child behaviors that are predictive of alignment in identification of child communication between clinical researchers and mothers of young autistic children.

METHOD

Participants were 33 mothers and their autistic children between 18 and 48 months of age. Mothers' and clinical researchers' perceptions of child communication were assessed using a procedure in which mothers and clinical researchers each independently identified child communication in the same ten 1-min video clips of each mother's child. Endorsed communicative acts were coded for the presence of conventional forms (e.g., vocalization) and potentially communicative forms (e.g., body movement). Multilevel binomial regressions, fit with Bayesian inference, were conducted to predict classification of maternal endorsements of child communication based on the presence of conventional and potentially communicative forms as either an aligned act (i.e., act endorsed by mother and clinical researcher as communicative) or a unique maternal endorsement (i.e., act endorsed by mother but not clinical researcher).

RESULTS

The presence of vocalization, verbalization, and gesture each significantly predicted increased likelihood of alignment; the presence of eye contact did not. Although repetitive and sensory behaviors significantly increased the likelihood of unique maternal endorsement, affect shifts and body movements each significantly reduced the likelihood of unique maternal endorsement, and hand activity was not significantly predictive of unique maternal endorsement.

CONCLUSIONS

Misalignment in mothers' and clinical researchers' identification of communication may be in part due to mothers' endorsement of behavioral forms that are not traditionally classified as part of a child's communication repertoire. Findings emphasize the need to work toward designing communication interventions that consider the ways in which clinicians and parents of autistic children each bring their own interpretive frameworks to the early intervention experience.

Clinician Intentions to use the Components of Parent Coaching Within Community Early Intervention Systems

PURPOSE

Parent coaching is a complex, psychosocial intervention with multiple core components. Clinicians' use of these core components may be influenced by distinct factors; no research has examined whether clinician perceptions of parent coaching vary across core coaching components. This study aimed to examine the extent to which clinicians working with families of young autistic children in publicly funded early intervention intend to use core parent coaching components, and to examine how closely psychological factors relate to providers' intentions to use each component.

METHODS

Using the Theory of Planned Behavior as a framework, this study compared the strength of clinicians' intentions across five core parent coaching components: collaboration with parents, delivering the intervention within daily routines, demonstrating the intervention, providing in-vivo feedback, and reflection and problem solving. We examined the associations between intentions and psychological determinants of intentions (i.e., attitudes, norms, and self-efficacy) for each component.

RESULTS

Clinicians' average intentions varied by core component, with strongest intentions for demonstrating the intervention strategy for a parent. The associations between intentions and psychological determinants also varied by core component. Attitudes, injunctive norms, and self-efficacy, but not descriptive norms, significantly related to clinicians' intentions to use collaboration and daily routines, whereas attitudes and descriptive norms, but not injunctive norms and self-efficacy, significantly related to clinicians' intentions to use feedback and reflection and problem solving.

CONCLUSION

These results suggest that implementation strategies should be tailored to the specific intervention component to be most efficient and effective. The results also provide examples of potentially malleable factors that implementation strategies can strategically target.

Overcoming tensions between family-centered care and fidelity within Early Intervention implementation research

LAY ABSTRACT

Early Intervention systems provide therapeutic services to families of young children birth to 3 years with developmental delays and are considered a natural access point to services for young children and their families. Research studies in the autism field have been interested in training providers to deliver evidence-based practices in Early Intervention systems to increase access to services for young children with an increased likelihood of being autistic. However, research has often overlooked that Early Intervention systems prioritize family-centered care, an approach to working with families that honors and respects their values and choices and that provides supports to strengthen family functioning. This commentary points out that family-centered care deserves greater attention in research being done in Early Intervention systems. We describe how family-centered care may shape how interventions are delivered, and discuss directions for future research to evaluate the impact of family-centered care alongside intervention delivery.

Factors that influence clinical decisions about offering parent coaching for autistic youth served within the Medicaid system

Background

Parent coaching is an evidence-based practice for young autistic children, but it is underutilized in lower-resourced community settings like the Medicaid system (Straiton et al., 2021b). Clinicians often struggle to implement parent coaching with low-income and marginalized families (Tomczuk et al., 2022), but little is known about which factors influence clinician decision making processes about providing parent coaching to this population.

Methods

This qualitative analysis used the framework method and thematic analysis. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework (Aarons et al., 2011) to identify factors in the clinical decision-making process that community providers use when offering parent coaching to families of Medicaid-enrolled autistic children. Interviews with 13 providers and a focus group with 13 providers were analyzed.

Results

The following themes emerged: 1) Policies drive provider task priorities and affect competing demands; 2) Providers are more likely to use parent coaching when agency leaders monitor parent coaching benchmarks, though this is rarely done; 3) Logistical factors like scheduling and treatment location affect perceived feasibility of using parent coaching; 4) Previous experience or coursework in parent coaching and/or family systems supports the quality of parent coaching implementation; 5) Provider perceptions of "parent readiness" are initially indicated by overt expressions of parent interest.

Conclusions

In the absence of outer-context and inner-context policies, providers have more decision-making power to offer parent coaching based on their own judgements and preferences, which may result in fewer families being offered parent coaching and increased bias related to which families are offered this service. State-, agency-, and clinician-level recommendations are provided for increasing equitable provision of this evidence-based practice for autism.

Barriers and facilitators for obtaining support services among underserved families with an autistic child: A systematic qualitative review

LAY ABSTRACT

Families from underrepresented ethnic or racial groups and those with limited financial resources could experience more difficulty in accessing support services for their autistic child due to certain types of barriers. We searched academic journals, websites, and other sources for studies which looked at what barriers might be present for such families and what might help families access support services for their autistic child. The search found 18 studies. Results from each study were examined and coded into themes. Parents reported that accessibility, diversity of support services, and stigma influenced their experiences with support services. We discuss what these findings might mean for future research and for service delivery.

Implementation strategy mapping methods to improve autism intervention use in community settings: a study protocol

Background

Implementation strategies are purported to facilitate adoption and use of evidence-based practices (EBPs) across settings. The use of tailored implementation strategies may be particularly effective, as they are selected with the explicit purpose of addressing setting-specific implementation determinants. However, methods to select and tailor implementation strategies, including in community settings, remain understudied. This project will identify and describe implementation strategy mapping methods (ISMMs) from extant peer-reviewed literature and pilot test a method to match implementation strategies with determinants in low-resourced community mental health (CMH) agencies that deliver services to children on the autism spectrum.

Methods

Aim 1: A scoping review, following PRISMA guidelines, will be conducted to identify implementation strategy mapping methods (ISMMs) utilized in child mental health settings. Data extraction will identify and describe each ISMM, including identifying methodological and procedural steps, analyzing the frequency of ISMM use, and identifying outcomes measured in eligible ISMM studies.

Aim 2: Using scoping review findings, select and pilot test one ISMM within five community mental health agencies in Michigan that provide services to autistic children. We will recruit five directors/agency leaders, supervisors, and direct providers at each of the eligible agencies (expected N = 25). A sequential explanatory (QUAN➔ QUAL) mixed methods design will be used. Participants will complete a demographics and client survey, as well as a needs assessment to identify implementation determinants. The impact of the ISMM on organizational readiness for change (from pre- to post-ISMM), as well as implementation outcomes of the ISMM (feasibility, acceptability, appropriateness, usability), will be examined. Semi-structured interviews will elicit stakeholder perspectives on the mapping method.

Discussion

The current project aims to advance our knowledge of methods for selecting, tailoring, and mapping implementation strategies to address context-specific determinants to implementation. Additionally, this project will contribute to growing science found at the intersection of implementation science and autism research by utilizing the implementation determinants framework, the CFIR, to guide data collection, analysis, and interpretation of findings. Finally, these findings may support future EBP implementation efforts within low-resourced communities, with the ultimate goal of increasing equity in access to EBPs for autistic children.

Involving Caregivers of Autistic Toddlers in Early Intervention: Common Practice or Exception to the Norm?

PURPOSE

Family-centered practice (FCP) is a core component of early intervention (EI) associated with improved child and family outcomes, but little is known about community-based speech-language pathologists' (SLPs') inclusion of families in EI. Many caregivers of autistic children experience caregiving-related stress, making these intervention principles especially critical to the provision of optimal services. This study aimed to characterize EI SLPs' use of FCP coaching strategies and the quality of caregiver-SLP relationships.

METHOD

Participants included 25 families with an autistic toddler and their EI SLP. One intervention session for each SLP-family dyad was recorded and coded for the SLP's use of FCP coaching strategies. Caregivers and SLPs completed surveys about their working alliance, caregiver perceptions of family-centered care, and SLPs' approach to FCP.

RESULTS

SLPs primarily use child-directed strategies without caregiver involvement. When involving caregivers, SLPs infrequently use coaching strategies that are important for caregiver learning and collaboration (e.g., joint planning and guided practice with feedback). However, caregivers perceived their child's services to be highly family-centered, and caregivers and SLPs rated their working alliance to be of high quality.

CONCLUSIONS

The presence of strong caregiver-SLP working alliances alongside infrequent usage of effective coaching strategies indicates that SLPs may engage caregivers in ways that are perceived to be highly collaborative but are not optimal for caregiver involvement in all aspects of their child's services (goal setting and implementation of intervention). Consideration of family preferences and SLP beliefs about FCP will inform ways to disseminate FCPs needed to optimize families' capacities to support their child's development.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20113550.