Serving Children in Natural Environments

The changes and the challenges

 We have both been in an established practice for many years. Then we each became involved with Early Intervention through Golden Gate Regional Center at different times. Early Intervention in California is called California Early Start and it is managed through the California Department of Developmental Services which contracts with private not-for-profit corporations called Regional Centers throughout the state for the responsibility of assessment, planning and service for the population from birth to 3 years of age.
When we first heard the term "natural environment" and thought about the dramatic changes that we envisioned and thought would be necessary, we panicked! Do we have to change the location of assessments from the professional office to the child's home? At each child's home? Do we have to do the assessment and provide each child therapy in each child's home or day care, no longer seeing children in our profession offices? Do we have to incorporate typically developing children into our office routines? How can this all be accomplished without disruption? How can we continue to professionally serve multiple children with delays and disabilities under this new requirement? And will our professional business survive? What really is a "natural environment?"
The use of natural environment is written into Part C of Individuals with Disabilities Education Act (IDEA), which states "to the maximum extent appropriate to the needs of the child, early intervention services must be provided in natural environments, including the home and community settings in which children without disabilities participate." ( Sec. 303.12) Natural environments are defined as "settings that are natural or normal for the child's age peers who have no disabilities." (Sec. 303.18) The only exception to the rule reads that "a setting other than a natural environment [may be] determined by the parent and the individualized family service plan team only when early intervention cannot be achieved satisfactorily for the infant or toddler in a natural environment." This is not a suggestion or a recommendation, it is the federal law.

What to do now? What changes to make? How to include natural environments into our assessment and therapies and how to include our assessments and therapies into natural environments? With further inquiry, we found that "natural environment" is not a location and it is not a structure or a therapy. It is a philosophy. It is a way of doing things. It is a way of incorporating into the assessment and into the therapy items, methods and situations that the child naturally has or uses or encounters on a regular bases where ever she or he is during the day. In addition, this should occur in a location that the child participates in on as a part of their daily routine. We had to collaborate with community agencies to offer locations for therapies that included "typically developing children or "non-identified" children. Some of the partnerships were developed with Golden Gate Regional Center, Institute of Human and Social Development (IHSD) of San Mateo County, and Our Second Home a community center in San Mateo County. These agencies also shared similar value in offering inclusive playgroups to the families that they naturally work with.
The first challenge was to incorporate "natural" type activities [usual daily activities] into the assessment process. Home visits are offered to the parents. Some parents prefer office visits or meeting elsewhere for the assessment. Parents are asked to provide a few of the child's typical toys, some books and some typical snacks. These items are used as necessary in order to stimulate typical behavior, non-verbal communication with the parent, receptive language, expressive language and pragmatics. Much can be observed using these techniques.

The next challenge was to incorporate "natural" type activities [usual daily activities] into the Playgroups that Jasna Cowan offers to families . Some of that was already being accomplished. More was added to encourage language around daily routines of that individual child: meal times, nap times, and play activites.

For example, The child can carry out activites with a doll, such as feeding, washing and/or bathing the doll; taking about each activity while doing it and encouraging the child to respond. The doll is then wiped with a towel and "all done" is encouraged. Time is spent reading a book to the baby (doll), a nap is suggested (in small bed) and "night-night" is encouraged.

Sometimes various stations are set up using cue cards to inform parents of the language startegies being emphasized, so the parent can do the activity and encourage the use the key words with the child as the activity is being done.

Following directions and vocalization is also encouraged during "free play" activity. This could be playing with cars and trucks, drawing at a table or climbing and sliding in the "gym" area. Do you want to jump? Where? Do you want a new crayon? Which one? Do you want another ball? The blue one or the red one? The children and their family member (often mothers - fathers, nannies and grandparents are also encouraged to attend) are in the group class for 1 hour and 30 minutes.Two important aspects of therapy: 1. We use a family-centered approach. The play groups always include and involve at least one parent or family member in the therapy and in structured class activities which are similar to activities that the child and family do every day. We provide playgroups in locations where other typically developing children naturally gather such as at a Head Start office or school. We also offer playgroups and individual therapy in the family's home and/or community parks and libraries. Currently we have a moble speech therapy recreational vehicle that can go anywhere in the family's community and provide a mobile, natural environment experience. We did not want to limit the therapy only to the specific identified delay, but to relate the therapy to the various activities which the family and child usually do during their time together. We discuss practical strategies and practical practices under practical situations which both the child and the parent typically encounter. 2. Goals are developed for each child and also goals are developed for each participating parent or family member. Yes, positive reinforcement activity is taught and positive reinforcement activity goals are developed for family members as appropriate.Next, "natural" type activities outside of the class were incorporated, about once a month, to a community outing. Some of these outings can include, going to a store, to the local mall, going to a local park, accessing the local library, to a restaurant, to the zoo or to see animals, following directions, listening to others, talking to others, waiting for a response, and being in areas where other children, "typically developing" children, are present. All of this is in hopes that if and when the chid does not need speech therapy any longer the families will continue to access community locations to promote language and real experiences.
Short-term group activities are planned in these environments. Some examples of these activities are: Play dates for members of the group at a home or at a park; walking through a department store or a shopping mall; looking at and talking about and labeling what is seen; eating a snack at or near one of those places; sitting on a bench; visiting a library and reading and sharing books; and going to a pond and feeding the ducks and looking at and talking about what is seen and what is happening. Even when riding in a car, a family member can sing and talk to and with the child toward the agreed upon goal. Getting the child's attention, receptive language skills, responses by non-verbal gestures, imitative skills, expressive language skills, signs, and social and pragmatic communicative skills are practiced and rehearsed. For all the situations above, we use the techniques that are described in the articles about receptive language in ADVANCE March 8, 2010, July 26, 2010, and especially of July 27, 2011.

Contact with "typically developing"peers was also needed. How can we incorporate "typically developing" peers into our group structure, or even outside of the class? Looking about the community, we found several organizations that provided classes and structure for children from birth to 3years of age. These places ranged from daycares to preschools to Early Head Start to county screening programs. Forming a partnership with one or more of these seemed to be the most efficient way to accomplish the goal.
A working partnership was recently formed with the local Head Start program in which Early Head Start children are able to join the groups 2 to 3 times a month for speech and/or social involvement. Some groups are held at the Head Start location, others are at the speech group location. A non-profit was formed for this purpose. The non-profit helps any child attend a group by offering a sliding scale or scholarship. Funds are raised by doing workshops in the community.

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Now the speech-language group classes include up to three children identified as having a receptive and/or an expressive language delay and at least one, up to three, children who are not identified as having any delay, plus the parents or family members. Classes are structured as above with the first 15 minutes of the 1 ½-hour class time devoted to welcoming, introductions and explaining the class structure and methods. Issues of parent concern and challenging behaviors are also discussed as appropriate. We rely upon leader guided team based interaction. We encourage parent/family member- child bonding. We point out various interaction styles and suggest both verbal and non-verbal ways to redirect behavior and to encourage positive, not negative or disruptive activity. We encourage that the family member and the child both learn non-verbal skills, gestures, pragmatic skills, communicative-social skills.

When some parents in the community hear about the group classes, they become so interested that they ask whether their child can join the group without even having been screened or referred due to a delay. Some parents of 3-5 year-old children want a group formed for their children, too. One very interesting finding was that over time we found that not all "typically developing" children are actually developing typically. Some of the children have unrecognized or undiagnosed delays or behavior issues, similar to which may be found in the typical distribution of the population. At times it is carefully suggested that these children get screened and assessed if necessary to see if they qualify for therapy.

We are continuingly incorporating the concerns of parents and adding new situations into our program, both in the group classes and also in the visits to community settings. As we go forward we intend to continue to evolve and make adjustments as needed in order to continue to serve children through early intervention.

Jasna Cowan is a bilingual speech-language pathologist and John D. Michael is a pediatrician on a multidisciplinary team at Golden Gate Regional Center.

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