Coaching in Context Process

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interventions: Coaching (a type of parent-mediated intervention) and Context-therapy. The .... providing home-based care for children with complex disabilities and ASD (Darrah et al., 2011; ..... 313); significant messages expressed ..... Brainstorming: Quantity, originality and creativity are promoted; criticism is ruled out;.
Coaching in Context Process Maximizing Participation in Every Activities of those who have Autism Spectrum Disorder and other disabilities

















Marie-Christine Potvin Liliane Savard Patricia A Prelock April 2018









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Table of Contents Introduction Chapter 1. Coaching in Context Process Empirical Evidence Chapter 2. Required Skills Set and Learning Resources Chapter 3. Goal Setting and Progress Tracking Chapter 4. Description of the Coaching in Context Process Quick Guides 1. Coaching 2. Motivational Interviewing TM 2. Goal Setting and Scaling 5. Focus on Strengths and Environment 7. Creative Problem SolvingTM Appendices Appendix A - Characteristics of Assessment Tools Appendix B - Goal Attainment Scaling Template Appendix C – Brainstorming Appendix D – Sample Visit Note References

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Authors’ Biography: Marie-Christine Potvin, Ph.D., OTR/L is and Associate Professor at Thomas Jefferson University. Dr. Potvin’s research focuses on understanding the barriers to, and enhancing the participation of individuals with autism spectrum disorder (ASD) with the intent to positively affect their quality of life. Liliane Savard, PT, DPT, PCS is a pediatric physical therapist with 20 years of experience working with children and their families in a variety of settings. She has a developed an expertise in working with children with ASD. Her research focuses on motor learning in those with ASD to promote participation, communication and community inclusion. Patricia A. Prelock, Ph.D., CCC-SLP, BCS-CL is Dean of the College of Nursing and Health Sciences, Professor of Communication Sciences & Disorders and Professor of Pediatrics in the College of Medicine at the University of Vermont. Dr. Prelock’s research focus is the nature and treatment of ASD, specifically addressing issues of social cognition including theory of mind. Her intervention approaches are community-based, family centered, collaborative and culturally responsive.

Contributors:

Tammy L. Murray, DOT, M.Ed., OTR/L is a school based occupational therapist in the Worcester Public Schools and an Adjunct professor at Assumption College in Worcester, Massachusetts. Interests include: researching school participation particularly with children with autism and family/community centered care and handwriting legibility as it relates to academic success within the natural environment. Dr. Murray has 24 years of clinical experience serving children and families in diverse settings. Gillian A. Rai, DOT, M.Ed., OTR/L is an Assistant Professor and Director of the Doctorate in Occupational Therapy at George Washington University. Interests include studying the sensory aspects environments and its impact on occupational performance, particularly with families and individuals with ASD as well as Family Centered Care (and Community centered OT. Dr. Rai has more than 20 years of combined experience in academia and clinical OT practice in the US and abroad serving children and families in many diverse settings. Alexis St. Croix, CCC-SLP is a speech-language pathologist at Visiting Nurse Association of Chittenden and Grand Isle in Vermont. When she was a graduate student at the University of Vermont, she spearheaded the writing of the early draft of this intervention manual.

Acknowledgements:

University of Vermont, undergraduate and graduate students: Holly Bodony, Alex Cohen, Emily Slentz, Danielle Spaulding, Maura Stonberg, and Alice Symington.

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Introduction This manual describes a culturally responsive process developed to enhance the functioning in everyday activities of individuals with autism spectrum disorder (ASD) in achieving goals that they or their family members have self-selected. Although the manual is focused on individuals with ASD, the process can be used with individuals who have a variety of disabilities, and their families. The intervention process, named the CinC Process, combines two primary interventions: Coaching (a type of parent-mediated intervention) and Context-therapy. The CinC Process begins with identification of family-driven goals and continues with familyselected strategies to realize progress toward these goals. The selected strategies prioritize modifying the task and environmental demands of an activity, rather than skill remediation. The word family is used in this process to refer to a child or youth with ASD, their siblings and their parents or caregivers, or an adult with ASD who may choose to include friends and/or family members. Children, youth and young adults with ASD may experience challenges across all activity and participation domains within the International Classifications of Functioning, Disability and Health such as self-care, interpersonal relationships and learning (World Health Organization, 2001). Individuals with ASD, including those who have a measured intellectual quotient in the average to above average range, experience challenges with activities of daily living and postsecondary education, and are frequently under-employed (Cimera & Cowan, 2009; Shattuck et al., 2012; Sikora, Vora, Coury & Rosenberg, 2012). Furthermore, a preponderance of evidence suggests that those with ASD participate in fewer different-types of recreational activities, with a narrower range of other people, and closer to home than their same-aged peers (Potvin, Prelock, Snider & Savard, 2014). The most common barriers to recreational participation are not necessarily impairments in skills but rather attitudes, physical environment, transportation, policies, and lack of support from staff and service providers (Anaby et al., 2013). In fact, remediating skills of children with ASD without consideration of contextual issues typically leads to poor skill generalization in other settings or tasks (Dunn, Cox, Foster, Mische-Lawson, & Tanquary, 2012). Thus, intervention that accommodates a person’s impairments and modifies the environment and task demands of the activity yields faster, greater, and more meaningful changes than intervention focused on skill remediation alone (Dunn at al., 2012; Law et al., 2011; Potvin et al., 2014). The CinC Process is designed to address such participation challenges by having the person with ASD and/or their family members identify goals that are important to them, then addressing these goals through a process of coaching in context. This manual includes information that allows clinicians to learn about, and use, the CinC process in their own work. Chapter 1 provides an overview of the intervention process and a summary of empirical evidence that supports it. Chapter 2 provides a description of the necessary skill set for successful implementation of the CinC Process. Chapter 3 describes Goal Attainment Scaling, an integral part of this process. Finally, Chapter 4 provides a detailed description of the CinC process. The chapters are followed by brief summaries of the key facets of the approach referred to as ‘Quick Guides’. In addition, information about various tools, assessments, and forms that may be used within this process can be found in the Appendices. Potvin, Savard & Prelock (Revised April 2018)

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Chapter 1 CinC Process Empirical Evidence Introduction CinC Process Overview The CinC process includes a Goal-Setting visit and intervention visits (see textbox). The process Initial Visit (Goal-setting) described in this manual combines the • Family-selected occupational fundamentals of two existing interventions with goals emerging empirical evidence: coaching, a type of • GAS rubric created parent-mediated intervention, and context therapy (Darrah et al., 2011; Graham, Rodger & Intervention Visits Ziviani, 2014). Within coaching, it makes draw 1. Connect from Motivational InterviewingTM. The • Family rate goals’ attainment intervention strategies that are central to this • Action plan review process, and their current empirical evidence are described in this chapter. 2. Brainstorm • Brainstorm possible strategy Coaching a Parent-mediated Intervention to make progress toward goals Parent-mediated interventions include those interventions delivered by a parent to support the 3. Plan overall functioning of a child. Parents are most • Family select strategies to try often provided training by a clinician to gain the until next visit knowledge and skills to become the mediator of the • Interventionist provides intervention, however, a coaching approach can resources or training when also be used in parent-mediated intervention. family identifies the need Parent-mediated interventions have been most often used to support the social communication and social interaction of children with ASD with strong support for parents’ effectiveness in doing so (McConachie & Diggle, 2007). Research suggests this type of intervention is also effective in increasing parents’ responsiveness to their child’s social communication behavior (Delaney & Kaiser, 2001; Moes & Frea, 2002). For example, parents use responsive interactions to facilitate their child’s social emotional development (Mahoney & Perales, 2003), respond sensitively to their child’s attempts at interaction, and interpret their child’s actions as meaningful (Alfred Green, & Adams, 2004). More recently, a randomized controlled trial examining the effectiveness of parent mediated social communication revealed a decrease in autism severity among other improvements following one year of intervention (Pickles et al., 2016). Parents reported that they learn interventions strategies best when they are actively involved and have opportunities to attempt the strategy in the presence of the therapist (Glennon, 2016). The literature described in this paragraph focused on the training of parents, however, the principles of parent mediated intervention can also be used with youth and adults with ASD themselves.

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Coaching is a form of parent-mediated intervention with extensive empirical evidence of effectiveness for children with ASD (McConachie & Diggle, 2007). While many parent-mediated interventions focus on the training of parents in specific skills, in a coaching approach, skills training is not the focus but may be incorporated as needed (Dunn et al., 2012). The intention of coaching is to provide supportive guidance to the family. Coaching techniques can be useful with both children and adults with ASD, particularly when used within natural context (Simpson, 2015). Coaching provides a process for meaningfully engaging the family. It has been found that coaching significantly enhances the occupational performance and participation of children and adolescents with ASD (Simpson, 2015). When using a coaching approach, family-identified goals are essential. Participation in home and community environments increase when family priorities are embraced and the child's development is supported (Schaaf et al., 2015). Coaching has been found to yield moderate positive change in improving parent-child interaction (Kessler & Graham, 2015). Coaching has also been found to significantly increased participation in the everyday life activities of those with ASD (Case-Smith, 2013; Dunn et al., 2012; Dunst et al., 2006; Dunst et al., 2007; Graham, Rodger, & Ziviani, 2013). A specific coaching approach, called Occupational Performance Coaching (OPC), was developed by Graham (2010) to specifically address the need of achieving everyday functioning goals. OPC is a family-centered, strengths-based approach that promotes collaboration and relationship building between parents and interventionists to develop problem-solving skills (Graham, 2010; Graham et al., 2014). OPC focuses on creating an egalitarian relationship between the parent and the interventionist (Graham et al., 2014). Direct instruction by the interventionist is minimized to encourage parents’ perceptions of competence in their child’s care, and to increase their capacity to problem-solve independently (Graham et al., 2014). The interventionist may provide evidence-based information and strategies when necessary, but OPC is not primarily an instructional or educational intervention approach (Graham et al., 2014). The interventionist provides emotional support and guidance to promote parent and caregiver reflection and problem solving to attain the family and child’s goals (Graham et al., 2014). OPC was designed specifically for parents of children with disabilities, but like other coaching approaches, it can also be used with individuals with ASD themselves. OPC and the coaching approach proposed within the CinC Process appear to be very similar, however, OPC does not, at present, have an intervention manual. There is initial positive evidence suggesting that OPC is effective to use with parents of children with disabilities (Graham, 2010; Graham et al., 2013; Hui, Snider & Couture, 2016). Parents generalized the skills gained from the OPC process for sustained improvements in other areas of functioning (Graham et al., 2013). OPC was shown to be effective in assisting parents to achieve outcomes that promoted increased participation for themselves and their children, while leading to improvements in parental self-competence and confidence (Graham et al., 2013). Mothers of children with ASD, intellectual disability, and children with unspecified diagnoses report positive overall experiences with OPC (Graham et al., 2014). OPC was viewed Potvin, Savard & Prelock (Revised April 2018)

CINC PROCESS 7 as valuable, and as resulting in positive impacts on family dynamics and on parental feelings of self-competence (Graham et al., 2014). Parents reported learning specific strategies to support their children’s performance, becoming more aware of their own knowledge and skills, and gaining insight into their own, and their child’s preferences, resulting in less stressful and more successful interactions during challenging situations (Graham et al., 2014). To be effective coaches, interventionists’ implementing the CinC Process need to have a working understanding of Motivational Interviewing and how to create a Therapeutic Alliance with families. Motivational interviewing is a strategy that uses conversation to promote behavioral change in a manner that is supportive and empowers the person contemplating the change. It addresses the person’s feelings and thoughts including any feelings of ambivalence, and it supports selfefficacy (Miller & Rollnick, 2013). This strategy was originally developed for the treatment of addiction, however, it has been shown to be an effective family-based intervention to promote other behavioral changes, including in children and teenagers who are obese (Pakpour, Gellert, Dombrowski, & Fridlund, 2015; Taylor et al., 2015; Broccoli et al., 2016). Since the achievement of goals often requires changes in behavior, interventionists using the CinC Process to support person with ASD in identifying their own goals may find motivational interviewing techniques especially useful. The key aspects of motivational interviewing are described by Erickson and colleagues (2005) and Miller and Rollnick (2013). Interventionists express empathy through skillful reflective listening, with ambivalence being recognized as a normal component of a change process. The interventionist facilitates client self-discovery of the discrepancy between his or her behavior and goals or values. This is used to generate the rationale for change. The interventionist recognizes that resistance to change is not opposition. The client is supported in finding his own answers and solutions. The interventionist conveys his own belief in the person’s ability to change. The client is responsible for choosing and implementing the changes. Context Therapy Context therapy focuses on improving functional abilities of a person by changing the parameters of the task or the environment, rather than attempting to remediate the overarching impairment in the individual (Darrah et al., 2011). Context therapy is a strengthsbased approach that includes a series of strategies for modifying the environment and activity demands and has been found to be effective in improving the participation of children with cerebral palsy (Law et al., 2011) and those with ASD around daily routines (Dunn et al., 2012). Participation in daily routines and everyday activities is targeted within the context of the child’s natural environment through a partnership between the family and interventionist (Darrah et al., 2011). Solutions are structured to support the child’s level of participation by optimizing the child’s strengths and decreasing environmental barriers including physical, social and attitudinal barriers in the immediate and community environments (Darrah et al., 2011). Family involvement and self-direction are essential components in all aspects of assessment, intervention and goal setting. Context therapy does not determine the specific process used by

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interventionists when working with families. Dunn and colleagues (2012) suggested that coaching be the approach used with Context Therapy as a guide to the interactions between the interventionist and the family. Context therapy as a manualized intervention is relatively new, but the concept of improving participation in children with disabilities through modifications of the environment and task has existed for some time (Darrah et al., 2011). Law and colleagues (2011) found positive outcomes in a randomized control trial of a group of children with cerebral palsy (CP) who received either a child-focused intervention (control group) or context-focused intervention (intervention group) over a 6-month period. Results showed that the context-focused intervention was as effective as the traditional strategies often used in occupational and physical therapy to remediate impairment (Law et al., 2011). Empirical evidence supports the use of CT to reduce challenges in participation, and to increase parental self-competence and confidence in providing home-based care for children with complex disabilities and ASD (Darrah et al., 2011; Dunn et al., 2012). Dunn and colleagues (2012) found that parents felt more competent and children with ASD experienced significantly increased participation in everyday activities following CT with parent coaching. The study used a repeated pretest-posttest design to measure the effectiveness of reflective guidance during family daily routines (Dunn et al., 2012). Conclusion The intervention process described in this manual adopts coaching to facilitate family involvement, while using the basic tenets of Context Therapy to identify and modify environmental and task barriers. The culturally responsive process is family driven and structured to facilitate family identification of goals, and to allow exploration of family-based strengths and solutions. Interventionists are encouraged to learn more about coaching and context therapy, and the other aspects of this process, through the resources provided in Chapter 2. The overarching goal of combining these two interventions is to provide support and facilitate information exchange and reflection within a structured process that is focused on the youth and young adult’s strengths to increase participation and self-sufficiency in the individual with ASD and/or their family. Steps to guide provision of the CinC Process to enhance participation are thoroughly described in the Chapters 3 and 4.

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2 Chapter 2 Required Skills Set and Learning Resources Introduction The CinC Process is an inter-professional approach that combines knowledge and skills that are traditionally used by a variety of health professionals. Thus, most clinicians using this intervention will bring strengths, but also want to deepen their skill set with other aspects of this process. Consequently, interventionists are encouraged to acquire the knowledge and skills that they are lacking by learning about the different aspects of the process using the resources provided below as a starting point. 1. Family-Driven Practice: Family-directed practice involves families having the primary decision making role in all aspects of care including setting goals and designing, implementing, and evaluating their child’s intervention plan (National Federation of Families for Children’s Mental Health, 2008). It reflects a practice in which the locus of control is solely within the family (Spencer, Blau & Mallery, 2010). Family-driven care emerged in the mental health field but its applicability is broader (Spencer, Blau & Mallery, 2010). In the CinC Process, family driven practice is exemplified by the role of the interventionist as a coach who facilitates a structured process in collaboration with the family. Family-Driven Care Guiding Principles: To learn from your client about their perception of your family-centeredness, consider using the Measure of Processes of Care (https://canchild.ca/en/resources/47-measure-ofprocesses-of-care) List of resources about family-driven practice: http://reclaimingfutures.org/members/sites/default/files/main_documents/Resources_for_ Movement_to_Family.pdf 2. Cultural Responsive Practice: Interventionists must be aware of their own cultural, personal and emotional characteristics and biases before and during the intervention to engage in an effective coaching process. To self-assess your current level of cultural competence, consider completing the Cultural and Linguistic Competence Health Practitioner Assessment (www.clchpa.org) To learn about various aspects of culturally responsive practice in health care visit the Dimensions of Culture website (www.dimensionsofculture.com) and Think Cultural Health (www.thinkculturalhealth.hhs.gov). Finally, the self-pace training modules developed by Mental Health in Multicultural Australia will allow you to strengthen your culturally

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responsive practices (www.mhima.org.au/framework/framework-for-workers/overviewfor-workers). 3. Coaching: Training in coaching principles is highly recommended, such as coaching for health care professionals, wellness coaching, or motivational interviewing. A starting place is the book entitled The Early Childhood Coaching Handbook written by Rush and Sheldon (2011) 4. Motivational Interviewing: There are numerous resources to gain depth of knowledge and skills about motivational interviewing. The resources below are a starting point for those using the CinC Process Introduction to Motivational Interviewing: www.youtube.com/watch?v=s3MCJZ7OGRk Motivational Interviewing -Core clinician skills: www.youtube.com/watch?v=-zEpwxJlRQI Motivational interviewing -Introducing DARN-C: www.youtube.com/watch?v=Pwu99NIGiXU 5. Context Therapy: The interventionist should be well versed in the core principles of context therapy. This approach is thoroughly described in the article by Darrah and colleagues (2011) whose reference is included in the reference list. 6. Characteristics of Individuals with ASD: Extensive research studies and innumerable articles, books and websites have been written to describe the array of characteristics of individuals who have ASD. The two resources below provide in-depth, research-based, information about these characteristics. Ashland University Autism Internet Modules: Linking research to real life. These internet modules provide information about the specific learning characteristics of individuals with autism. These learning resources are free, and can be accessed by creating an account through the link located in the upper left corner of the page. http://www.autisminternetmodules.org/ Autism Speaks Video Library. These resources are free with registration, and provide a wide range of research-based information about developmental characteristics, assessment and treatment, and resources for individuals with autism spectrum disorders and their families. https://www.autismspeaks.org/what-autism/video-glossary 7. ASD-Specific Strategies: Interventionists should have a wide range of knowledge about strategies found to be empirically efficacious with individuals with ASD. Such strategies that may be especially useful with CinC are summarized below. Comic Strip Conversations: Using simple drawings, Comic Strip Conversations (CSC) are visual representations intended to improve understanding and comprehension of a social Potvin, Savard & Prelock (Revised April 2018)

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context including both verbal and nonverbal communication. Illustrating actions, what is said and potential thoughts, CSC can help a child with autism visually process a problematic situation and identify positive solutions. Comic strip conversations use eight conversation skill related symbols and a color system to distinguish the emotional content of the conversation, and are beneficial in supporting present, past or future experiences and situations. Additional Information: http://www.autism.org.uk/about/strategies/social-stories-comicstrips.aspx Learning Module: http://www.autisminternetmodules.org/mod_view.php?nav_id=1147 Peer Mediation: Peer Mediation involves using a peer of similar age to provide academic and/or social support to a child with a disability. In peer-mediated interventions, peers are trained to model, prompt, and reinforce academic, social and other target behaviors. They are supported by educators and others, who also provide consistent instructional and social opportunities for the students to interact. Peer mediated interventions support students with disabilities in developing independence, communication, relational, and social skills and have been shown to benefit students with a range of disabilities and varying degree of need as well as the peers involved in the intervention. Additional Information: http://afirm.fpg.unc.edu/node/2 Learning Module: http://www.autisminternetmodules.org/mod_intro.php?mod_id=13 Pivotal Response Training: Pivotal Response Training (PRT) is a play based intervention that uses a developmental approach and applied behavior analysis (ABA) methods to target the core deficits of autism. PRT focuses on developing four “pivotal” skills or behaviors through: motivation to respond, responsivity to multiple cues, self-management, and self-initiation. These areas are considered pivotal because when targeted, they generate significant improvements in other, largely untargeted, developmental and/or behavioral areas related to response and function. Pivotal Response Training emphasizes parent involvement as primary interventionists. In addition to creating teaching sessions, PRT integrates methods into existing routines occurring within the natural environment and uses natural reinforcement, child choice and turn taking, and provides opportunities to practice target behaviors. Pivotal Response Training has been successfully implemented across settings by an array of individuals, such as parents, peers, siblings, and professionals. More Information: www.autismspeaks.org/what-autism/treatment/pivotal-responsetherapy-prt Learning Module: http://www.autisminternetmodules.org/mod_intro.php?mod_id=41

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Prompting: A prompt is a supplemental cue or stimulus, or a set of procedures, provided to increase the probability of generating the desired response (and decreasing an incorrect response) when acquiring new skills. Children with autism often benefit from direct instruction to learn a variety of communicative, behavioral, social, cognitive, and adaptive skills. Prompts can be physical, gestural, verbal, visual, modeled, or positional. A hierarchy of prompts can be used to teach target behaviors or skills (Prelock & McCauley, 2012). It is important to remember that individuals may respond differently to the same prompt, therefore, prompt types and level selection should be individualized to the characteristics and needs of each learner with Autism. Additional Information: http://autismpdc.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/Prompting_Steps-Least.pdf Learning Module: http://www.autisminternetmodules.org/mod_intro.php?mod_id=43 Rules and Routines: Children with autism often experience difficulty with regard to attention, interpreting social cues, organizing and sequencing, transitioning, independent initiation, and unstructured or unpredictable environments and events. Developing and explicitly teaching rules and routines help students with autism participate in and better understand the expectations in different settings they experience throughout the day and the variable expectations within those contexts. Rules are statements that define acceptable behavior in specific environments or situations and routines highlight the steps necessary to complete specific actions or tasks. Rules should be concrete, positive, consistent, observable and begin with a set of broad of expectations and develop in complexity as understanding occurs. Developing, teaching, and practicing routines can decrease anxiety and promote successful participation in multiple environments, and explicit teaching of routines has been shown to be advantageous in the development of functional skills. Visual supports, or other organizational methods, can be used to increase accessibility and enhance instruction. Eventually teaching elements of flexibility and tolerance for unexpected events or changes should be included into the routine. More Information: http://www.autisminternetmodules.org/mod_view.php?nav_id=731 Learning Module: http://www.autisminternetmodules.org/mod_intro.php?mod_id=64 Self-Management: Self-management is the ability to independently regulate one’s behavior through self-monitoring, reflection, modification, and/or reinforcement. Through selfmonitoring, children with autism are taught to monitor their behavior, record performance, and receive reinforcement when they demonstrate the pre-established behavioral task. A self-management system is implemented first by arranging the system through: identifying

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and describing the target behavior, establishing reinforcers, developing a data collection system, and selecting a self-monitoring recording device. The child is taught to use the system through explicit teaching of the target behavior, to discriminate between correct and incorrect behaviors, and to use the self-recording method. Once the system is fully implemented, independent engagement of self-management strategies is encouraged. Selfmanagement is a valuable foundational skill as well as a tool to develop other skills. It also helps to reduce challenging or unwanted behaviors. The ability to engage in selfmanagement fosters independence and self-determination. Additionally, it increases performance as well as responsiveness to the environment and the probability that a response will elicit natural reinforcers. Self-management interventions can be used to support skill development in all areas, adaptive, behavioral, social, cognitive, and communicative, and in variable contexts. Additional Information: http://www.iidc.indiana.edu/pages/Dont-Forget-About-Self-Management Learning Module: http://www.autisminternetmodules.org/mod_intro.php?mod_id=76 Social StoriesTM: Social StoriesTM are individually designed and written stories that describe a social situation often in regard to a challenging future situation, with the intention of providing direct access to relevant social information. A Social StoryTM should be written from either a first or third person perspective and contain simple descriptive sentences and positive language. Social stories generally include a description of where and when a situation occurs, the individuals involved, what is occurring and why, and suggestions for “expected behaviors” (Prelock & McCauley, 2012, p. 313); significant messages expressed within the text are often reinforced with additional visual (or auditory) supports. Social StoriesTM are considered a popular intervention strategy and have been used in various service delivery models to promote a range of positive social, communicative and behavioral functions in individuals with autism, as well as to facilitate access to educational and social opportunities. Additional Information: http://carolgraysocialstories.com/social-stories/what-is-it/ Learning Module: www.autisminternetmodules.org/mod_view.php?nav_id=1149; http://carolgraysocialstories.com/social-stories/social-story-sampler/ Video Modeling: Video modeling involves the creation and use of a video to teach a new behavior or skill, or improve existing behaviors or skills such as taking turns in a conversation or game, greeting peers, or performing self-care tasks. Video modeling can also be used to replace or eliminate challenging behavior. There are several types of videobased interventions that fall in the broad category of “video modeling”: true video modeling, video self-modeling, point-of-view video modeling, and video prompting. In

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general, video modeling involves an individual (adults, peers, animated characters, etc.) being recorded while performing a target behavior(s). The video is played for the person with autism prior to each teaching session or possible occurrence of a behavior, and then he or she is prompted to engage in the target behavior. Video self-modeling or self-observation consists of recording the individual performing the target behavior. Inappropriate or other erroneous behaviors are generally edited from the video. Point-of-view video modeling involves using a task-analysis to perform the sequence of steps from the perspective or “eye level” of the target individual. Video prompting shows the sequence of behavior in multiple segments, stopping the video after each clip so the individual has the opportunity to practice the target behavior(s). Video modeling may be especially appealing for students with autism who often have an interest in video. In addition, it can be incorporated with other methods such as applied behavioral analysis (ABA), Social StoriesTM and/or visual supports. Additional Information: www.autisminternetmodules.org/mod_view.php?nav_id=1407 Learning Module: http://www.autisminternetmodules.org/mod_intro.php?mod_id=30 Visual Supports/Schedule: A visual cue or support is a picture, image, item, word, or graphic representation used to prompt a child concerning a task, routine, expectation or behavioral response, and support the child’s ability to anticipate, understand, and engage in events. A considerable range of visual supports exist including pictures, gestures, written words, icons, objects, schedules, timelines, scripts, environmental arrangement, and organization systems, etc. Visual supports help a child with autism keep track of and move through daily activities, access the curriculum, learn tasks and information more quickly, and improve independence and task completion. Visual supports may serve as scripts for social situations, supplement verbal instruction, make auditory information visual, foster a greater understanding of expectations, support understanding of time and sequences, as well as the ability to adapt and adjust to changes in the environment. Furthermore, the use of visual supports has demonstrated decreases in behaviors associated with task completion such as anxiety, aggression, and frustration. Visual supports can be utilized in numerous environments and support engagement in an array of tasks. They facilitate an individual with autism’s ability to navigate task complexity and activity details, and extent should be individualized. Additional Information: www.autismspeaks.org/docs/sciencedocs/atn/visual_supports.pdf Learning Module: http://www.autisminternetmodules.org/mod_intro.php?mod_id=2

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Chapter 3 Goal Setting and Progress Tracking A critical aspect of, and the first step in, the CinC Process is the identification of family driven goals. These goals may be related to recreational activities or other domains of participation that the family would like to target. It is imperative that the family selects the goals, as family goal selection increases family participation and implementation of selected strategies (Potvin et al., 2014; Østensjø, Øien, & Fallang, 2009). Some families may readily have goals they want to target. Others may need a structured process to identify their own participation goals. The Canadian Occupational Performance Measure (COPM) is one instrument used to help families identify goals, and that may be useful within the CinC Process. Other tools allowing a family to reflect on different aspects of participation and useful in identifying goals are described in Appendix A, Characteristics of Assessment Tools. The Canadian Occupational Performance Measure (COPM) is a client centered standardized tool used to detect changes in a client’s self-perception of performance in specific domains of participation. These areas are self-care, productivity, and leisure (Law, Baptiste, McColl, Opzoomer Polatajko & Pollock, 1990). The COPM uses a five-step, semi-structured interview and a structured scoring format to help families identify meaningful participation goals based on a self-rated level of importance, current performance level, and perceived satisfaction in the task (Law et al., 1990). The COPM is based on the core belief that the individual’s involvement and incorporation of their unique characteristics are fundamental to the therapeutic process (Law et al., 1990). To learn how to use the COPM, visit the following website: http://www.thecopm.ca/learn/. Once goals are established, the CinC Process suggests that the interventionist use an established method to quantitatively measure progress toward the families’ self-selected goals. Goal Attainment Scaling (GAS) is research-based approach developed and Common Errors with GAS: revised by Kiresuk and Sherman (1968; • Overly generalized goals 1994) used to quantify goals and measure • Overly technical goals progress. GAS is helpful in measuring • Multiple variables change individual goals, evaluating functional • Unequal scale intervals goals, and promoting cooperative and • Clinically irrelevant client-centered goal setting (McDougall & • Unrealistic scale levels King, 2007). Clinicians from a variety of • Use of different verb tenses fields have used GAS to evaluate the • Redundant/incomplete scale levels efficacy of therapy and to help guide the • Baseline set at an inappropriate level planning process for children with • Blank scale levels (McDougall & King, 2007) developmental, physical, and

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communication needs (McDougall & King, 2007). Goals in GAS must meet six basic criteria which are described in Table 1. Then, a 5-point scale is created to identify the predicted level of attainment and the expected outcomes for each client identified goal. Each point on the scale is set at clinically equal intervals to ensure accurate collection of data. Use of a scoring scale can alleviate confusion when tracking progress, and can provide clinically relevant information for eligibility and planning purposes (McDougall & King, 2007). Quick Guide 2 provides additional information about GAS and Appendix B, Goal and Scale/Rubric Worksheet, provides a sample GAS table. Some recommendations to help guide GAS are detailed below. Table 1. GAS Goals’ Six Basic Criteria (McDougall & King, 2007) Basic Criteria Examples & Suggestions 1) Relevant to the Individual 1) Use the COPM for goal identification 2) Easily Understandable 2) • Phrased in the present tense • “The child can…” • Written with clear language and • “The child will discriminate between…” concrete behavioral terms • “The child will sit with…” • All items describe an observable behavior 3) Measurable 3) Select only one variable to measure change such as time, distance, level of assistance. Include the number of trial a child is allowed. Be specific about the context 4) Behavioral in Nature 4) Specify an observable behavior written in concrete terms. 5) Attainable and Realistic 5) Goal is clinically meaningful and achievable 6) With a Specified Time Frame for 6) Set a due date Completion

Potvin, Savard & Prelock (Revised April 2018)

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Chapter 4 Description of the Coaching in Context Process The intervention begins with the family identifying domains of participation that are most important to them (i.e., the goals set in Chapter 3). These will become the targets of the intervention. Focusing on the family’s priorities is a central component of this family driven and culturally responsive parent-mediated intervention. Family-determined goals can be elicited in a variety of ways. The approach and tools discussed in Chapter 3 and in Appendix A are recommended for use with this intervention process. Once goals are identified and scaled so that progress can be tracked (see Chapter 3), the family and interventionist identify the best setting in which to engage in the intervention process of Connect, Brainstorm and Plan. The Connect and Brainstorming components of the intervention process can occur in any location, including clinical settings and telehealth. However, the nature of context-based intervention requires that strategies be trialed and implemented, during the Plan phase, in the most natural setting possible. The setting may be the family’s home, neighborhood playground, local gym, or any other location where the goal would naturally take place so that strategies can be tried in context. A family may be able or chose to trial strategies on their own or with the support of their interventionist. CinC Session “at-a-Glance” A qualified interventionist will lead each session in o Connect collaboration with the family. Each session will last § Goal(s) attainment approximately 60 minutes and consist of the following rating three components: Connect, Brainstorm and Plan. These § Action plan review three components of intervention parallel the steps of § Identify bridges and Creative Problem Solving (Quick Guide 6). It is barriers recommended that the session occur on a weekly, every o Brainstorm other week or monthly basis depending on the natural § Family driven: opportunity for the family to implement the plan between Individual or group sessions. For example, if a goal is related to a child’s § Focus on strengths and context participation on a soccer team that meets twice a week, o Plan weekly CinC sessions would be appropriate. On the other § Family select hand, if a goal is related to participation in a community strategies to be activity that occurs once a month, monthly CinC sessions implemented would likely be preferable. § Family determine if they need the Each goal should be targeted until consistent goal interventionist to attainment. However, the interventionist and family are provide resources or encouraged to revisit goals that have not been attained training to accomplish after 4-6 sessions. Consistent goal attainment is defined as the plan reaching a rating of 0 for two consecutive data points (McDougall & King, 2007).

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Connect The interventionist and family discuss progress 5 Whys made toward the goal and the efficacy of the last Plan (see “Know-How” CinC Session at-a-glance) in a manner that is in line with steps 1 and 2 of Creative Problem Solving (Quick Guide 6). 1. Write the specific The interventionist and family may find the use of visuals challenge (i.e., written plan, written notes, concept mapping, etc.) to 2. Ask (and write down) be useful during this and the other components of the CinC why the challenge Process. Assessment of progress is done through occurred collaborative analysis of the aspects of the plan that were 3. Repeat step 2 up to five times to identify five implemented since the last session. To ensure a consistent potential causes (e.g., and predictable planning process, the interventionist why else?) and/or reviews the previous week’s plan with the family. The causes of the causes interventionist engages the family in an explicit, rather than already identified (e.g., generalized, review of the previous plan and the particular what caused that?) aspects that the parent identified as working well or those that require modification. The interventionist uses reflective Resource: Mind Tools questioning to elicit the family’s thoughts about causes of challenges and successes encountered in implementing the plan (Quick Guide 3). For example, through reflective questioning, conduct an analysis of the demands of the task or of the environment, and identify potential barriers and bridges to success. In addition to reflective questioning, the interventionist may use the 5 Whys also called Root Cause Analysis to elicit a reflection from the family about the potential causes of the challenges/successes and the relationship between the causes (Zidel, 2006In keeping with context therapy, the interventionist encourages the family to consider the characteristics of the task and the environment in which the strategies were implemented in their attempt to understand the underlying causes of challenges. During this part of the intervention session, the Coaching Skills interventionist uses a range of coaching skills (Quick Guide “Know-How” 1). The interventionist provides emotional support through active listening, empathizing, and responsive and • Listen actively encouraging feedback. The interventionist may reinforce • Empathize parent achievements and efforts with encouraging • Be Responsive feedback. The interventionist may reframe parents’ • Be Egalitarian perceptions through paraphrasing, or offering alternative • Encourage interpretations of performance to help parents develop • Reframe techniques, perspectives, and new learning to support their • Probe child’s performance (Graham, 2010). The interventionist uses open-ended comments to encourage discussion and Resource: Quick Guide 1 celebrate small successes and progress made. The interventionist should not be critical of or use a judgmental Potvin, Savard & Prelock (Revised April 2018)

CINC PROCESS 19 tone of voice toward any family members. To remain consistent with the context-based principles of the intervention, the focus should not be on remediating the child’s challenges, but rather should be on what changes can maximize the child’s strengths and abilities and increased participation. Brainstorm: The interventionist and the family use a Visual Brainstorming Options Creative Problem-Solving (Quick Guide 6) during this part of the session. The parents, with the support of the • Easel pad interventionist, brainstorm strategies that may result in • Laptop + Projector progress toward the goal(s). The parent is encouraged • Laptop + Television to list a variety of ideas or proposed solutions • Google Doc with 2 portable addressing the identified barriers in the environment or devices (e.g., laptop, tablet) the task, while focusing on maximizing the child’s • ‘Cloud’ Mind Mapping Tool intrinsic strengths (Quick Guide 4). During the brainstorming phase, divergent and creative ideas are generated and recorded for all to see (i.e., written on Brainstorming large paper or typed in a document that all participants 5 Whys can see). It will likely be helpful to maintain a runninglist of brainstormed strategies from one session to the • Individual next so that each session can build on the previous one • Group (Templates are provided in Appendix C and D). If • Stepladder Technique comments about the feasibility of any proposed • Brainwriting strategy are made, they are noted but without • Crawford’s Slip Writing dismissing the strategy. Only later are these strategies Method analyzed for practicality, appropriateness, and • Round-Robin likelihood to be effective. • During this stage, efforts are made to generate a range of possible strategies. All family members who want to be involved are asked to contribute strategies. Depending on family dynamics and preferences, the strategies can be generated by all family members together ‘popcorn’-style or individually by family members then shared with the group. The interventionist may use reflective questioning to guide illicit ideas from a family. For example, an interventionist may ask what strategies have worked for other goals or what strategies have worked at school. During the brainstorming, the interventionist may mention evidence-based strategies unfamiliar to the family that may be useful to achieve the goal. The interventionist may also find it useful to share a written list, such as the one provided in Chapter 2 with the family. The interventionist will minimize the amount of strategies that he or she suggests in favor of providing guidance to facilitate greater competency and independence of the family members. Plan: During this stage the family selects, prioritizes, and refines the strategies brainstormed during the previous step with the interventionist’s support. The intent is to develop a plan that the family can implement in the absence of the interventionist to help the individual with ASD

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make progress toward the goal. Like the previous step, Brainstorm, this step is family-driven with the interventionist facilitating the process. The interventionist may ask the family guiding questions such as... “What is realistic for you to try until our next visit?” “What strategies do you think are most likely to work?” “Which strategies would you like to have more information about?” “What barriers might you encounter in implementing the strategy?” Through this process, the family generates a feasible action plan that is intended to foster progress toward goal attainment. The interventionist captures this plan in writing and provides a copy to the family. The session ends with the family restating the action plan, ensuring that everyone has agreed to the same course of action. Allowing the parent to summarize the plan at the conclusion of the session provides further opportunities for reflection. It also provides an open forum for discussion of aspects of the intervention that may be in conflict with the parent’s beliefs, values, or overall goals. Necessary resources, material preparation, and informal training will be identified by the family. The interventionist will provide such resources, material, or training as needed. At times, the family may want the strategies attempted in a natural environment during the session through observation, modeling, and trialing (Quick Guide 5). The interventionist may observe the parent during an interaction for later reflection, or the parent can observe the interventionist as they model a specific strategy. The process for observing, modeling, and trialing begins with the interventionist and parent jointly discussing what strategies they are going to try, and why (Rush & Shelden, 2011). The interventionist and parent may want to identify a specific target for the parent to observe during the modeling activity. Any adaptations that the interventionist applies are explained to the parent during the modeling, or immediately afterward. The interventionist and parent then discuss what worked well, and what could have been done differently. This discussion may include how the interventionist’s actions and model differ from the parent during the same situation, and how the parent may implement strategies when working independently. Parents are invited to attempt the strategy while the interventionist observes. Again, the parent and interventionist reflect on how the activity worked, or may work when the parent tries it independently (Rush & Shelden, 2011). Observation, modeling, and trialing may occur as part of a CinC session, or as an additional session through the action plan.

Potvin, Savard & Prelock (Revised April 2018)

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Quick Guide 1: COACHING Coaching is an empirically based family-centered approach that takes place in natural environments, and reflects the interests of families and children (Dunn, Cox, Foster, MischeLawson & Tanquary, 2009). Principles of Coaching: • Promote parent and caregiver learning and engagement through an interactive and reciprocal process • Build a trusting relationship, choose relationship over control • Provide emotional support, information exchange, and a structured process which are key features of the coaching process • Identify the current obstacles that are limiting the child in specific environments • Guide the family to identify resources and solutions within the family or community • Use a process of joint discussion, problem-solving, and reciprocal reflection • Increase parents’ ability to identify effective supports for their child to implement independently • Use during everyday activities and routines to facilitate learning across a variety of settings that are meaningful to the child and family • Increase parental competency by allowing the family and child to participate more fully in meaningful, everyday activities • Use ongoing and evolving reflection to generate solutions and continued learning from insights revealed in the process (Dunn et al, 2009). Reflective Questioning: Reflective questioning, as a component of coaching, helps families identify intrinsic strengths and alternative actions through thoughtful analysis and reflection. The interventionist listens with an open mind while using specific questions to facilitate the parent’s evaluation of the situation and exploration of alternatives options. Careful reflection can encourage the parent to engage in ongoing examination, and feedback can help to build on existing knowledge and skills to achieve the desired outcomes (Dunn et al., 2009). The basic tenets of reflective questioning along with a description of various types of feedback are described below. Types of Reflective Questions (Dunn et al., 2009): • Awareness: “What do you know about…”, “What happened when you…” • Analysis: “How does that compare to what you did before?”, “What do you think will happen if you…?” • Alternatives: “What might make it work better for you next time?”, “What else could you have done?” • Action: “What do you plan to do?”, “What supports do you need to take that step?”

22 CINC PROCESS

Types of Reflective Feedback (Rush & Shelden, 2011): • Informative feedback: The coach shares knowledge or expertise in an encouraging, empathetic and respectful manner. Feedback should be directly related to observation, action, reflection, or direct questions. • Affirmative feedback: The coach demonstrates active listening and provides objective, and non-judgmental affirmation of the situation. • Evaluative feedback: The coach provides an evaluation, or assessment of the observed behavior or action. • Directive feedback: The coach directs what to do. Generally, directive feedback is inconsistent with coaching practices.

Potvin, Savard & Prelock (Revised April 2018)

CINC PROCESS 23 Quick Guide 2: MOTIVATIONAL INTERVIEWINGTM Motivational Interviewing (MI) is a process to accompany a person in their journey for change. The parts steps of the process (i.e., Engaging, Focusing, Evoking and Planning) as described by Miller and Rollnick (2013) are summarized in this Quick Guide. Family trialing strategies as part of the CinC process often requires that they explore some sort of changes. Consequently, MI is a helpful approach to have in your bag of tools as you implement the CinC process. Engaging: Use reflective listening and empathy to establish a trusting relationship. “Engaging” is most helpful as part of CinC Process titled, Connecting, however “Engaging Core Skills” can be used throughout CinC Process. Engaging Core skills & Examples Roadblocks to avoid 1. Open questions “What would you like your Using an “expert” stance or any (They encourage the person child to do?” or “What would power difference to talk) you like to be able to do” 2. Affirming statements “It took a lot of courage to…” Assessing, questioning & (They promote self-efficacy) probing 3. Reflecting statements “You felt judged when….” Telling people what to do or (They refer to what a person is providing solutions thinking or feeling) “… takes energy. You avoid it. Disagreeing and judging 4. Summarizing You wish…” Agreeing and praising statements (They combine statements made by client into a summary)



Focusing: Set a clear focus for the session. The clinician may choose to reflect specific aspects of the conversation and ignore others to help focus on the priorities at hand. Within the CinC Process this focus can be a specific goal or a specific aspect of a goal. Miller and Rollnick (2013) recommend the following steps to obtaining and providing information: Elicit: Clarify information needs and gaps: “What do you know about…?” Ask permission to share information: “Would you like to know about…?” Provide: Prioritize information, be clear and support autonomy Elicit: Ask for the person’s understanding and reflect the reactions you see.

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Evoking: This refers to the clinician using questions and reflective statements to encourage or “evoke” change talk. The expression of ambivalence from the parent or client is progress from perceiving no reason for change. Not truly perceiving a need to change, or being ambivalent about change, will hinder a family member to fully engage in the CinC Process. Ambivalence comes with anxiety and fears. The interventionist recognizing change talk in a family member (i.e., verbal expression that they are contemplating change) is the first step to attempting to evoke and explore change. Preparatory Change Talk Examples 1. Desire: “What do you hope our work will accomplish?” “I want to…” “How do you want your life to be different?” 2. Ability: “If you…, how could you….” “I could…”, “I am able to…” “How confident are you that you could…” 3. Reasons: “You probably have considered reasons to keep things the Discuss pros and cons way they are and a few reasons to make a change. What are some of these reasons?” 4. Need: “How important is it for you to….?” “I need to…”, “I have to…” “What do you feel is most important for you?” Evoking Tools to Elicit Change Talk: The “importance” ruler: “On a scale of 0-10, how important would you say it is for you to…?” The follow-up question is the useful question to generate change talk: “Why are you at 6 and not at 2?”, “What would increase the importance of…?” The “confidence” ruler: “On a scale of 0-10, how confident are you that you can….?” The follow up questions might help evoke change talk. For example: “What would need to change for your rating to go up?”, “Why is your rating 4 and not 1?” Planning: Commitment, Activation and Action Steps (CATS) language signals readiness that the family member is ready to transition to planning. For example: “I am going to do this”, “I am ready to…”, “I brought my gym shoes to work”. Some people may not be ready to make a plan at the end of a session, although as part of the CinC Process this is desired, following a family member’s readiness is also key to the success of the process. When a family member does not show a readiness to plan, going back to the evoking or engaging might be better for them. When guiding a person through making a change plan, Miller and Rollnick (2013) recommend being specific and using measurable achievements, for which this CinC Process recommends Goal Attainment Scaling. Confirming the goal and summarizing the plan made will ensure that both the interventionist and the family member are in agreement.

Potvin, Savard & Prelock (Revised April 2018)

CINC PROCESS 25 QUICK GUIDE 3: Goal Setting and Scaling The interventionist initiates a collaborative process to guide the family toward identifying and refining goals that are self-identified. It is recommended that the Canadian Occupational Performance Measure (Law et al., 1990) be used to identify goals, and Goal Attainment Scaling (McDougall & King, 2007) be used for operationalizing the goal and to create a scale to track progress toward the goals. Reflection questioning and probing questions may be used by the interventionist to assist the family in identifying goals that are important to them. GAS Goal and Rubric should be: • Family-driven • Relevant to the individual • Measurable In general, the scale must meet the following basic requirements: Criteria Criteria Met Criteria Not Met Change between levels is clinically meaningful Approximately equal intervals between levels Time period is set for goal achievement Scale reflects single variable of change (Adapted from the GAS manual; McDougall & King, 2007) Each level of the scale must meet the following basic requirements: Criteria Criteria Met Criteria Not Met Written in concrete behavioral terms Specify an observable behavior Written in the present tense Be achievable or realistically possible (Adapted from the GAS manual; McDougall & King, 2007) Common errors include: overly generalized goals, multiple variable changes, unequal scale intervals, clinically irrelevant scale levels, redundant or incomplete scale levels, inappropriate baseline, and use of multiple tenses when writing the goal (McDougall & King, 2007).

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Quick Guide 4: Focus on Strengths & Environment Create and update a list of the child and family’s strengths and support resources or ‘bridges’ to success. Include physical, social, emotional, cognitive, attentional and motivational aspects. Identify the task’s characteristics. Do not limit analysis of the necessary steps to the traditional or developmental way of performing the specific task. Accept all possible strategies to bring the child closer to their goal, even if this means using an atypical movement pattern. Look for creative and alternative solutions. Identify the characteristics of the environment that may facilitate or present a barrier to the successful completion of the goal. Look at physical accessibility, availability of assistance, and attitudes and practices of people within the environment. Discuss parent’s perception of child readiness for the task or goal. Child readiness is based on child characteristics, task demands, and environmental factors (Darrah et al., 2011). The parent and interventionist also consider other child’s characteristics such as motivation, attention, and cognition when encouraging new behaviors.

Potvin, Savard & Prelock (Revised April 2018)

CINC PROCESS 27 Quick Guide 5: Creative Problem-Solving Creative Problem Solving (CPS) is a structured process that promotes creative and alternative solutions to challenges through open discussion (Mitchell & Kowalik, 1999). Although CPS can be applied individually, collaboration allows for the formation of diverse ideas that may contribute to effective and unique solutions. Collaborative teaming is thus an essential component to using CPS. CPS Principles Brainstorming: Quantity, originality and creativity are promoted; criticism is ruled out; strategies for improvement are sought; adaptation and flexibility are supported Divergent Thinking: Accept all ideas deferring judgment; seek cohesion of ideas Convergent Thinking: Be deliberate & explicit; develop affirmative judgments; keep the overall goals in mind Matching the CPS Steps to the CinC Phases of Intervention CinC CONNECT 1. Identify the Bridges and Barriers • What is happening now? What is not occurring that should be? • What have you already tried? What good can be identified in the current situation? 2. Collect Data: Deepen your understanding • Brainstorm the key facets associated with the situation • Who, or what is involved? • What are some possible causes? • When, how, and where does the challenge occur? • What other problems are caused by this challenge? • What else would you like to know? Where might you find that information?



CinC BRAINSTORMING 3. Strategies Finding • Generate lots of strategies • Consider creative, unusual, or atypical possibilities • Write down ALL ideas CinC PLAN 4. Solution Finding • Choose the ideas that promote the most interest • Rate the ideas in order of usefulness, acceptability, and accessibility • Rewrite the ideas that have been identified as potential solutions 5. Create an Action Plan • Clearly state the task using terms that the parent can access • State who will implement, when it will begin and end, and identify points at which to assess achievement (Mitchell & Kowalik, 1999).



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Appendix A Tools That May be Used to Support Families in Identifying Goals and Barriers to Making Progress Toward These Goals

Aspects Tools Measured Focus on Youth’s Participation CAPE/PAC - Recreation

CPQ Life-H PACS PEGS

Dimensions Measured

Number of Items Respondent (Time to Complete) (Age of Child)

- Diversity 55 items Child - Intensity (60 min.) (6 to 18 years) - “With whom” - “Where” - Enjoyment - Preferences



- ADL - Education - IADL - Social participation - Play - Leisure

- Diversity 44 items - Intensity - Independence - Child enjoyment - Parent satisfaction



Parent (4 to 6 years)



- Nutrition - Fitness - Personal care - Communication - Housing - Mobility - Responsibilities - Interpersonal relationships - Community life - Education - Recreation

- Independence - Assistance - Satisfaction



Parent (birth to 14 years)



- Personal care - Diversity - School/productivity - Intensity - Hobbies/social activities - Sports



- Fine motor tasks







75 items (25 min.)

- Perceived physical 24 items

Potvin, Savard & Prelock (Revised April 2018)



Child (5 to 14 years)

Parent or

CINC PROCESS 29

PEM-CY

- Gross motor tasks competence - Goal setting

(10 min.)

teacher Child (5 to 8 years)

- Participation: home school & community - Environmental barriers to participation













- Diversity - Frequency - Involvement - Desire for change

Focus on Family Participation FLAP - Family leisure - Diversity - Intensity - Duration HPAS - Maternal - Intensity participation in leisure activities LPP - ADL - Satisfaction with - IADL performance - Social participation - Efficiency - Family life - Leisure - Work - Wellbeing Focus on Environmental Factors Impacting Participation CASE - Physical, social, and - Degree of impact attitudinal barriers at home, school, and in the community CHIEF - Accessibility - Frequency of the - Accommodation barrier - Resource availability - Magnitude of the - Social support barrier - Equality ECEQ - Physical environment - Presence/absence - Social support of factor

Parent of child (5 to 17 years)

42 items



Parent and child

8 items

Mother

23 items (10 min.)

Parent

18 items (5 min)



Parent

25 items



Parent

51 items

Parent

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ERQ



- Attitudes

- Importance to family



- Environmental factors at home school, and community

- Presence/absence 35 items



Parent (4 to 6 years)

Key. CAPE/PAC: Children’s Assessment of Participation and Enjoyment/Preference for Activities of Children (King et al., 2004); CPQ: Children’s Participation Questionnaire (Rosenberg, Jarus & Bart, 2010); Life-H: Assessment of Life Habits (Noreau et al., 2007); PACS: Pediatric Activity Card Sort (Mandich, Polatajko, Miller & Baum, 2004); PEGS: Perceived Efficacy and Goal Setting System (Missiuna, Pollock, Law, Walter & Cavey, 2006); PEM-CY: Participation and Environment Measure, Children and Youth version (Coster et al., 2012); FLAP: Family Leisure Activity Profile (Zabriskie & McCormick, 2003); HPAS: Health Promoting Activities Scale (Bourke-Taylor, Law, Howie & Pallant, 2012); LPP: Life Participation for Parents (Fingerhut, 2009); CASE: Child and Adolescent Scale of Enjoyment (McCauley at al., 2012); CHIEF: Craig Hospital Inventory of Environmental Factors (Whiteneck, Harrison-Felix, Mellick, Brooks, Chalifue & Gerhart, 2004); ECEQ: European Child Environment Questionnaire (Colver et al., 2001); ERQ: Environmental Restriction Questionnaire (Rosenberg, Ratzon, Jarus & Bart, 2010).

Potvin, Savard & Prelock (Revised April 2018)

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Appendix B Goal Attainment Scaling Template Goal 1: Scale for Goal 1: Interval Scale in2= Much More than Expected in1= More than Expected 0=Expected -1=Less than Expected -2=Current Level (Baseline) Goal 2: Scale for Goal 2: Interval Scale in2= Much More than Expected in1= More than Expected 0=Expected -1=Less than Expected -2=Current Level (Baseline)

Description:

Description:

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Interventionist: Who is present? Location of visit: Goal(s) Targeted: Visit # for Each Goal: Barriers Idea/solution

Appendix C Brainstorming-Phase Template





1



2

Date of visit: 3



4

Bridges

Barrier Bridge Discussion



Result





































































































Potvin, Savard & Prelock (Revised April 2018)



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Appendix D Visit Note Template Interventionist: Who is present? Location of visit: Goal(s) Targeted: Visit # for Each Goal: Connect: Goal #: _______ Previous Action Plans/ Strategies

1











2





Number or % opportunity Attempted 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

1. 2. 3. 4. Comments:



Number or % opportunity Attempted 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

1. 2. 3. 4. Comments: Goal #: _______ Previous Action Plans/ Strategies







Date of visit: 3

Is brainstorming about this need? (Yes or No)

Not Fully at all 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5





Helpful











Brainstorming need? (Yes or No)

Not Fully at all 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5



4

Helpful













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References Alfred, C., Green, J., & Adams, C. (2004). A new social communication intervention for children with autism: Pilot randomized controlled treatment study suggesting effectiveness. Journal of Child Psychology and Psychiatry, 40, 1-11. Broccoli, S., Davoli, A. M., Bonvicini, L., ... Rossi, P., G. (2016). Motivational interviewing to treat overweight children: 24-month follow-up of a randomized controlled trial. Pediatrics, 137(1), 1-10. Bourke-Taylor, H., Law, M., Howie, L., & Pallant, J. F. (2012). Initial development of the health promoting activities scale to measure the leisure participation of mothers of children with disabilities. American Journal of Occupational Therapy, 66(1), e1-e10. Case-Smith, J. (2013). Systematic reviews of the effectiveness of interventions used in occupational therapy early childhood services. American Journal of Occupational Therapy, 67, 379-382. Cimera, R. E., & Cowan, R. J. (2009). The costs of services and employment outcomes achieved by adults with autism in the US. Autism, 13(3), 285-302. Colver, A. F., Dickinson, H. O., Parkinson, K., Arnaud, C., Beckund, E., Fauconnier, J., … Thyen, U. (2001). Access of children with cerebral palsy to the physical, social and attitudinal environment they need: A cross-sectional European study. Disability and Rehabilitation, 33(1), 28-35. Coster, W., Law, M., Bedell, G., Khetani, M., Cousins, M., & Teplicky, R. (2012). Development of the participation and environment measure for children and youth: Conceptual basis. Disability & Rehabilitation, 34(3), 238-246. Darrah, J., Law, M. C., Pollock, N., Wilson, B., Russell, D. J., Walter, S. D., & Galupp, B. (2011). Context therapy: A new intervention approach for children with cerebral palsy. Developmental Medicine & Child Neurology, 53, 615-620. doi: 10.1111/j.14698749.2011.03959.x Delaney, E. M., & Kaiser, A. P. (2001). The effects of teaching parents blended communication and behavior support strategies. Behavioral Disorders, 26, 93-116. Dunn, W., Cox, J., Foster, L., Mische-Lawson, L. & Tanquary, J. (2009). Impact of an integrated intervention on parental competence and children’s participation for children with autism. University of Kansas Department of Occupational Therapy Education. School of Health Professions, University of Kansas Medical Center. Retrieved from: http://kcart.ku.edu/events/beyond_diagnosis_2011/presentations/CommConDunn%20KCARt%202011.pdf Dunn, W., Cox, J., Foster, L., Mische-Lawson, L. & Tanquary, J. (2012). Impact of a contextual intervention on child participation and parent competence among children with autism spectrum disorders: A pretest-posttest repeated-measures design. American Journal of Occupational Therapy, 66(5), 520-8. Dunst, C. (2006). Parent-mediated everyday child learning opportunities: I. Foundations and Operationalization. CASE in Point, 2, 2.

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CINC PROCESS 35 Dunst, C. J., Trivette, M. C.& Hamby, D. W. (2007). Meta-Analysis of family centred help giving practices research. Mental Retardation and Developmental Disabilities Research Reviews, 13, 370 – 378. Erickson, S. J., Gerstle, M., & Feldstein, S. W. (2005). Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings: A review. Archives of Pediatrics, 159, 1173-1180. Fingerhut, P. E. (2009). Measuring Outcomes of Family-Centered Intervention: Development of the Life Participation for Parents (LPP). Physical & Occupational Therapy in Pediatrics, 29(2), 113-128. Glennon, T. J. (2016). Survey of college personnel: Preparedness to serve students with autism spectrum disorder. American Journal of Occupational Therapy, 70, 7002260010. Graham, F. (2010). Occupational performance coaching: A contemporary approach for working with parents of children with occupational challenges (Unpublished doctoral dissertation). University of Queensland, Australia. Graham, F., Rodger, S., & Ziviani, J. (2013). Effectiveness of occupational performance coaching in improving children’s and mothers’ performance and mothers’ self-competence. American Journal of Occupational Therapy, 61(1), 10-18. Graham, F., Rodger, S., & Ziviani, J. (2014). Mothers’ experiences of engaging in occupational performance coaching. British Journal of Occupational Therapy, 77(4), 189-197. Kessler, D., & Graham, F. (2015). The use of coaching in occupational therapy: An integrative review. Australian Occupational Therapy Journal, 62(3), 160-176. doi:10.1111/14401630.12175 King, G., Law, M., King, S., Hurley, P., Rosenbaum, P., Hanna, S., … Young, N. (2004). Children’s Assessment of Participation and Enjoyment and Preferences for Activities of Children. San Antonio, TX: PsychCorp. Kiresuk, T., & Sherman, R. (1968). Goal attainment scaling: A general method of evaluating comprehensive mental health programs. Community Mental Health Journal, 4, 443–453. Kiresuk, T. J., Smith, A., & Cardillo, J. E. (1994). Goal attainment scaling: Applications, theory and measurement. Hillsdale, NJ: Erlbaum. Law, M.C., Darrah, J., Pollock, N., Wilson, B., Russell, D. J., Walter, S.D., Rosenbaum, P., & Galuppi, B. (2011). Focus on function: a cluster, randomized controlled trial comparing child- versus context-focused intervention for young children with cerebral palsy. Developmental Medicine and Child Neurology, 53, 621-629. Law, M., Baptiste, S., McColl, M., Opzoomer, A., Polatajko, H., & Pollock, N. (1990). The Canadian occupational performance measure: an outcome measure for occupational therapy. Canadian Journal of Occupational Therapy, 57(2), 82-87. Mandich, A., Polatajko, H. J., Miller, L., & Baum, C. (2004). Paediatric Activity Card Sort. CAOT Publications ACE. Mahoney, G., & Perales, F. (2003). Using relationship-focused intervention to enhance the social-emotional functioning of young children with autism spectrum disorders. Topics in Early Childhood Special Education, 23, 77-89. Missiuna, C., Pollock, N., Law, M., Walter, S., & Cavey, N. (2006). Examination of the Perceived Efficacy and Goal Setting System (PEGS) with children with disabilities, their parents, and teachers. American Journal of Occupational Therapy, 60 (2), 204-214.

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Mitchell, W. & Kowalik, T. (1999). Creative Problem Solving, 3rd ed. SUNY-Binghamton Press. Retrieved from: http://www.roe11.k12.il.us/GES%20Stuff/Day%204/Process/Creative%20Problem%20So lving/CPS-Mitchell%20&%20Kowalik.pdf McCauley, S. R., Wilde, E., A., Anderson, V. A., Bedell, G., Beers, S. R., Campbell, T. F., … Yeates, K. O. (2012). Recommendations for the use of common outcome measures in pediatric traumatic brain injury. Research Journal of Neurotrauma, 29 (4), 678-705. doi:10.1089/neu.2011.1838. McConachie, H., & Diggle, T, (2007). Parent implemented early intervention for young children with autism spectrum disorder: a systematic review. Journal of Evaluation in Clinical Practice, 13(1), 120-129. McDougall, J. & King, G. (2007). Goal attainment scaling: Description, utility and applications in pediatric therapy services, 2nd ed. Retrieved from: http://elearning.canchild.ca/dcd_pt_workshop/assets/planning-interventionsgoals/goal-attainment-scaling.pdf Miller WR, Rollnick S. Motivational Interviewing: Helping People Change 3rd Edition. New York, NY: The Guilford Press; 2013. Moes, D. R., & Frea, W. D. (2002). Contextualized behavioral support in early intervention for children with autism and their families. Journal of Autism and Developmental Disorders, 32, 519-533. National Autism Center (2009). National standards project. Retrieved from www.nationalautismcenter.org National Autism Center (2015). National Standards Project, Phase 2: Addressing the need for evidence-based practice guidelines for ASD. (www.nationalautismcenter.org) National Federation of Families for Children’s Mental Health (2008). Working definition of family-driven care. Retrieved from http://www.ffcmh.org/sites/default/files/Family%20Driven%20Care%20Definition.pdf National Professional Development Center on Autism Spectrum Disorders (2013). Evidencebased practice briefs. Retrieved from http://autismpdc.fpg.unc.edu/content/briefs Noreau, L., Lepage, C., Boissiere, CL., Picard, R., Fougeyrollas, P., … Nadeay, L. (2007). Measuring participation in children with disabilities using the Assessment of Life Habits. Developmental Medicine & Child Neurology, 49, 666–671. Østensjø, S., Øien, I., & Fallang, B. (2008). Goal-oriented rehabilitation of preschoolers with cerebral palsy—a multi-case study of combined use of the Canadian Occupational Performance Measure (COPM) and the Goal Attainment Scaling (GAS). Developmental Neurorehabilitation, 11(4), 252-259. Pakpour, A. H., Gellert, P., Dombrowski, S., & Fridlund, B. (2015). Motivational interviewing with parents for obesity: An RCT. Pediatrics, 135(3), e644-e652. Pickles, A., LeCouteur, A.L., Leadbitter, K., Salomone, E., Cole-Fletcher, R. Tobin, H., . . . Green, J. (2016). Parent-mediated social communication therapy for young children with autism (PACT): Long term follow-up of a randomised controlled trial. The Lancet, (published on line Oct. 25, 2026; http://dx.doi.org/10.1016/S0140-6736(16)31229-6) Potvin, M.-C., Prelock, P. A., Snider, L., & Savard, L. (2014). Promoting recreational engagement. In F. Volkmar (Ed), Handbook of Autism Spectrum Disorders. New York: Springer. Potvin, Savard & Prelock (Revised April 2018)

CINC PROCESS 37 Rosenberg, L., Jarus, T., & Bart, O. (2010). Development and initial validation of the Child Participation Questionnaire, CPQ. Disability and Rehabilitation, 31(1), 46-56. Rush D., & Shelden, M.-L. (2011). The early childhood coaching handbook. Baltimore: Paul H. Brookes Publishing Co. Schaaf, R. C., Cohn, E. S., Burke, J., Dumont, R., Miller, A., & Mailloux, Z. (2015). Linking sensory factors to participation: Establishing intervention goals with parents for children with autism spectrum disorder. American Journal of Occupational Therapy, 69, 6905185005. Shattuck, P. T., Narendorf, S. C., Cooper, B., Sterzing, P. R., Wagner, M., & Taylor, J. L. (2012). Postsecondary education and employment among youth with an autism spectrum disorder. Pediatrics, 1042-1049. Sikora, D. M., Vora, P., Coury, D. L., & Rosenberg, D. (2012). Attention-Deficit/Hyperactivity Disorder Symptoms, Adaptive Functioning, and Quality of Life in Children with Autism Spectrum Disorder. Pediatrics, 130(s2), s91-s97. Simpson, D. (2015). Coaching as a family-centred, occupational therapy intervention for autism: A literature review. Journal of Occupational Therapy, Schools & Early Intervention, 8:2, 109-125. Spencer, S. A., Blau, G. M., & Mallery, C. J. (2010). Family-driven care in America: More than a good idea. Journal of Canadian Academy of Child and Adolescent Psychiatry, 19(3), 176181. Taylor, R. W., Cox, A., Knight, L., Brown, D. A., Meredith-Jones, K., Haszard, J. J., Dawson, A. M., Taylor, B. J., & Williams, S. M. (2015). A tailored family-based obesity intervention: a randomized trial. Pediatrics, 136(2), 281-289. Whiteneck, G. G., Harrison-Felix, C. L., Mellick, D. C., Brooks, C. A., Charlifue, S. B., & Gerhart, K. A. (2004). Quantifying environmental factors: A measure of physical attitudinal, service, productivity, and policy barriers. Archives of Physical Medicine and Rehabilitation, 85, 1324-1335. World Health Organization (2001). International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland. Zidel, T. G. (2006) A lean toolbox: Using lean principles and techniques in healthcare. Quality Toolbox. Retrieved from: http://services.medicine.uab.edu/publicdocuments/anesthesiology/jc0923art1.pdf