The Importance of Activities and Routines to a ...jeffline.jefferson.edu/cfsrp/tlc/caregiver/materials/Handout...Learning about activities and routines allows ... strategies involving

Campbell/TnT-IES Participation Based Services January 2010 Page 1 of 27

CAREGIVER ASSESSMENT OF ACTIVITIES AND ROUTINES Learning about activities and routines allows providers to work with caregivers to:

� Help children participate successfully in activities or routines that may currently be challenging;

� Embed intervention strategies, including adaptations and AT, into activities/routines so that children have multiple learning opportunities; and

� Identify the best ways for caregivers to learn strategies to promote their children’s development.

The Importance of Activities and Routines to a Participation-Based Intervention Approach

The chart below contrasts traditional child-focused intervention with participation-based approaches. In child focused intervention, teachers and therapists design or create activities to provide opportunities for a child to practice or learn an identified developmental skill. For example, an occupational therapist may structure an activity so that trucks and other vehicle toys are involved so that the child may practice a skill of pushing objects. In participation- based services, the emphasis is on: a) children’s successful participation in identified activity(ies) or routine(s); and b) embedding of intervention strategies into the activities or routines. For example, a speech and language pathologist may work with a caregiver around issues involved in having the child learn to chew and swallow a variety of foods thereby helping a child to participate successfully in mealtime. Or, opportunities to communicate particular words may be embedded into bathtime or riding in a car or other caregiver-identified activities/routines. When implementing participation-based services, developmental information is insufficient and information about participation in activities/routines must also be obtained. Traditional Child-Focused

Intervention Participation-Based Intervention

Approaches Context of Intervention Provider-designed activity

(selected by the provider) Typical family activity or routine selected by the caregiver with the provider

Length of Intervention

Length of home visit – typically an hour

Multiple hours infused throughout the week by providing learning opportunities in typically occurring activities/routines


Traditional Child-Focused Intervention

Participation-Based Intervention Approaches

Person implementing the intervention

Provider – during the home visit and caregiver through follow-up or home instructions

Caregiver(s) designated by the family and taught to use intervention strategies by the provider

Outcomes & Goal Statements

Child skill focused such as “ would like him to use words to communicate needs” or “He will hold toys with the tips of his fingers, transfer them from hand to hand, and retrieve them when hidden under a blanket or when dropped out of sight.”

Participation-based such as “participate during mealtimes by using words to request particular foods, ask for more, or indicate “done” or “participate in toy play with his mother by manipulating small objects, transferring them from hand to hand, and retrieving them when hidden or dropped.”

Types of intervention provided with child

Typically skill-building strategies involving direct interaction with the child; may include adaptations & AT

Adaptations, AT, multiple opportunities for practice using skills, opportunities for learning new skills – both contrived and incidental

Using the Caregiver Assessment Instrument

Providers learn about activities/routines in a variety of ways including informal conversations where caregivers describe a typical day to more formal strategies such as checklists or questionnaires. Obtaining information through conversations requires providers to be skilled in interviewing, listening, and structuring discussions to get needed information. Checklists or questionnaires, if completed separately and without the provider present, may not provide opportunities for caregivers to elaborate or talk more about the activity or for providers to ask further probing questions to learn more about what occurs or what the caregiver would like to see happen. The best way to find out about activities/routines is by interviewing caregivers, using follow-up questions and probes to learn as much as possible about situations such as:

� how successfully a child participates in the activity/routine � the ease with which the activity/routine is conducted � what the caregiver expects from the child � how the caregiver helps the child during the activity/routine � how much the child and caregiver enjoy the routine � any strategies the caregiver has used so that the child can participate or to make

the activity/routine enjoyable or manageable � how often the activity/routine is done

Generally, the Caregiver Assessment instrument may be administered in about 20-30 minutes. The depth of information that a provider may obtain is dependent on (a) available time; and (b) skills as an interviewer. If the Caregiver Assessment is used as a questionnaire and is filled out independently by the caregiver or by the provider reading the answers to the caregiver and then the caregiver answering each item, the information will be obtained quickly (i.e., will not require a lot of time) and is likely to be so superficial as to be ineffective as a source of information for programming. The point of the instrument is NOT to obtain “factual” information about going well or not or satisfaction or not but to gain an understanding of how these activities/routines “look.” This is especially important for providers since they are not able to be physically present to


observe every family activity/routine. For example, few providers are able to make Sunday visits to church, accompany the family when visiting relatives at night, or be present at bedtime. Information gained through the Caregiver Assessment should be as “rich” and complete as what a provider would have observed should observation have been possible.

Guidelines for Talking With Caregivers When interviewing caregivers, the ways in which the conversation is directed will influence what is learned. The use of a structured interview ensures that all major activities/routines will be covered in a discussion and allows caregivers to talk about the routine/activity while permitting providers to ask further questions to obtain a better understanding about what is occurring in each activity or routine. Being able to have as full an understanding as possible about what an activity or routine “looks like” is important since few providers have an opportunity to easily observe every family activity or routine. For example, providers are unlikely to be able to observe bedtime or accompany caregivers on visits to relatives or friends, to church, or to dinner at a restaurant. Providers who interview caregivers successfully can get a picture of what happens in various activities or routines without having to directly observe. There are many ways in which the Caregiver Assessment of Activities and Routines may be incorporated into a structured interview. Below are several examples of how to use the form as a basis for caregiver conversations. However, providers who are experienced in using open-ended questions, probes, or other types of interview techniques may use the form in other ways that may better fit their interview styles and experiences.

Example of One Way to Use the Caregiver Assessment of Activities and Routines Interview

What Provider Says -- What Provider Writes -- Ask the caregiver to tell you about a typical day – what happens from the time they get up in the morning until they go to bed.

As the caregiver discusses each routine on the questionnaire, write notes in the middle space on the form, then follow up by asking for ratings of the child’s performance and mark the correct box.

Using the form as a guideline, ask the caregiver about activities/routines that were not mentioned. For example, “you talked about putting ____ to bed at night but you didn’t mention bathtime. When does ___ usually get a bath and how does this work?”

Using probe questions, the provider makes sure that descriptions of activities/routines are completed for each category and that caregivers have made ratings about the child’s performance.

Ask caregivers if there are other activities/routines they would like to talk about and find out about the caregiver’s satisfaction with the child’s performance.

List these activities/routines in the blank boxes and indicate the caregiver’s rating of the child’s performance; write any information under the comments section.

In some instances, it is helpful to know how satisfied the caregiver may be with the child’s performance to determine how important this activity/routine may be for the caregiver. The caregiver can be asked as a follow-up about their satisfaction.

Indicate the satisfaction rating on the form.


What Provider Says -- What Provider Writes -- Functional Skills: 4 overall skill areas impact on children’s performance in activities/routines. Ask caregivers to talk about the child’s performance of each of these functional skills and identify where they may negatively limit the child’s performance. The caregiver’s satisfaction with the child’s performance can also be asked. If children have limitations in any of these areas, those limitations may impact on several activities/routines. This information can be used to think about adaptations (to bypass skill limitations) or creating opportunities for the child to practice or learn to use these skills.

Fill in the caregiver’s rating and describe any key points about the skill. Satisfaction ratings may be completed if this is an area that is asked about.

Summarize and end the interview by reviewing information and indicating any activities/routines that are not going well. These will be those where the child’s performance does not meet expectations. List all of the activities/routines identified in this way and ask the caregiver to describe what this would look like if it were going well. Follow-up questions may probe what has been tried, how well it worked (did not work), etc. The purpose is to fully understand what happens so that this activity/routine can be improved through adaptations/AT.

Some caregivers may not have activities/routines where the child’s performance does not meet expectations. Leave the form blank in these instances. Write descriptions of what the caregiver would like to see happen. (This information can be used to develop the GAS for this activity/routine and to measure progress in the child’s participation.)

Summarize those activities/routines that are successful for the caregiver/child. Ask any needed follow-up questions to understand why these go well (e.g., child enjoys riding in the car; loves music that caregiver plays during breakfast). This information will be used to help select one or more activities/routines in which to embed learning opportunities.

Add in any notations about why the activity/routine is enjoyable and * the activity/routine that will be used to develop the Caregiver-Child Interaction Plan.

.


Example of a 2nd Way to Use the Caregiver Assessment of Activities and Routines What Provider Says -- What Provider Writes -- Ask the caregiver to tell you about what happens with the child and caregiver during bath time. The goal is to understand what a typical bath time looks like. Ask any needed follow-up or probe questions to get full understanding of the routine – “you talked about ___ sitting in the bath tub in a bath seat, but tell me how he helps with washing?” “When bath time is going on, do you use this as a time for playing in the tub?” “What kinds of toys does ___ like to play with?” “What happens when you wash his hair?” When the caregiver has discussed the routine, ask them to rate the child’s performance.

As the caregiver discusses bath time, write notes in the middle space on the form, then follow up by asking for ratings of the child’s performance and mark the correct box.

Using the form as a guideline, ask the caregiver about each activity and routine listed on the form. You can ask the caregiver by the order of items on the form or vary the order, making sure that all areas are asked about. In each instance, use follow-up questions or probes so that you understand what each routine looks like for this caregiver/child and summarize/end the discussion of each activity/routine by asking for their ratings of the child’s performance.

Using probe questions, the provider makes sure that written descriptions of activities/routines are completed for each category and marks the form for the caregiver rating of the child’s performance.

Ask caregivers if there are other activities/routines they would like to talk about and find out about the caregiver’s satisfaction with the child’s performance.

List these activities/routines in the blank boxes and indicate the caregiver’s rating of the child’s performance; write any information under the comments section.

It may be helpful to know how satisfied the caregiver may be with the child’s performance to determine the importance of this activity/routine for the caregiver. All activities/routines may be reviewed – “you talked about mealtimes and said that ____’s performance sometimes met your expectations. How satisfied are you with how this routine is going?” Or, ask satisfaction ratings at the end of the discussion about each activity or routine.

Indicate the satisfaction rating on the form.

Functional Skills: 4 overall skill areas impact on children’s performance in activities/routines. Ask caregivers to talk about the child’s performance of each of these areas and identify where they may negatively limit the child’s performance. The caregiver’s satisfaction with the child’s

Fill in the caregiver’s rating and describe any key points about the skill. Satisfaction ratings may be completed if this is used.


What Provider Says -- What Provider Writes -- performance can also be asked. If children have limitations in any of these areas, those limitations may impact on several activities/routines. Information can be used to think about adaptations (to bypass skill limitations) or creating learning opportunities. Summarize and end the interview by reviewing information and indicating any activities/routines that are not going well. These will be those where the child’s performance does not meet expectations. List all of the activities/routines identified in this way and ask the caregiver to describe what each would look like if it were going well. Follow-up questions may probe what has been tried, how well it worked (did not work), etc. The purpose is to understand what happens so that this activity/routine can be improved through adaptations/AT.

Some caregivers may not have activities/routines where the child’s performance does not meet expectations. Leave the form blank in these instances. Write descriptions of what the caregiver would like to see happen. (This information can be used to develop the GAS for this activity/routine and to measure progress in the child’s participation.)

Summarize those activities/routines that are successful for the caregiver/child. Ask any needed follow-up questions to understand why these go well (e.g., child enjoys riding in the car; loves music that caregiver plays during breakfast). This information will be used to help select one or more activities/routines in which to embed learning opportunities.

Add in any notations about why the activity/routine is enjoyable and * the activity/routine that will be used to develop the Caregiver-Child Interaction Plan.

COMPLETED CAREGIVER ASSESSMENT

The assessment on the next pages was completed with the caregiver of a 17 month old. Limitations in functional skills of use of arms and hands and mobility. These limitations influenced his participation in some but not all activities and routines. Caregiver-selected activities/routines become potential targets for intervention in order to reduce caregiving demands by increasing child participation. Caregiver-selected activities/routines that are enjoyable become a context in which strategies for improving functional skills (or other developmental skills) by be embedded.

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Car

egiv

er A

sses

smen

t of

Act

ivit

ies

and

Rou

tine

s

Dat

e: 4

/7/0

8

Ch

ild’s

nam

e: P

G

Age

: 17

m

Com

plet

ed A

s: G

uid

ed I

nte

rvie

w w

ith

SG

mot

her

)

Prov

ider

Nam

e: L

LB__

D

IRE

CTI

ON

S F

OR

TH

E C

AR

EG

IVE

R A

SS

ES

SM

EN

T A

S A

N IN

TER

VIE

W/C

ON

VE

RSA

TIO

N:

1.A

sk t

he

care

give

r op

en e

nde

d qu

esti

ons

abou

t ea

ch a

ctiv

ity/

rou

tine

. Fo

r ex

ampl

e, s

tart

by

sayi

ng

“tel

l me

abou

t ba

thti

me

and

how

yo

ur

child

par

tici

pate

s du

rin

g ba

thti

me.

” Fo

llow

-up

by a

skin

g ad

diti

onal

qu

esti

ons

so t

hat

you

gai

n a

n u

nde

rsta

ndi

ng,

a p

ictu

re, o

f w

hat

th

e ro

uti

ne

or a

ctiv

ity

look

s lik

e. T

hen

ask

th

e ca

regi

ver

to r

ate

the

child

’s p

arti

cipa

tion

in t

erm

s of

th

e ca

regi

ver’

s ex

pect

atio

ns

(e.g

., ex

ceed

s, m

eets

, occ

asio

nal

ly m

eets

, doe

s no

t m

eet)

. If

you

wis

h, y

ou m

ay a

sk t

he

care

give

r ab

out

how

sat

isfie

d th

ey a

re w

ith

h

ow t

he

acti

vity

/rou

tin

e is

goi

ng.

For

som

e ca

regi

vers

, th

is h

elps

th

em t

o de

cide

th

e ro

uti

ne o

n w

hic

h t

hey

may

wan

t to

focu

s.

2.A

sk t

he

care

give

r to

rat

e th

eir

child

’s u

se o

f fu

nct

ion

al s

kills

(e.g

., so

cial

izin

g, c

omm

uni

cati

ng)

wit

hin

act

ivit

ies/

rou

tine

s an

d th

eir

sati

sfac

tion

wit

h t

he

child

’s a

bilit

ies.

You

are

not

try

ing

to fi

nd

out

abou

t th

e ch

ild’s

def

icit

(e.g

., sp

eech

) bu

t ra

ther

th

e ex

ten

t to

w

hic

h p

robl

ems

wit

h s

peec

h in

terf

ere

wit

h a

ch

ild’s

par

tici

pati

on.

3.Id

enti

fy a

ny

rou

tine

s w

hic

h m

ay n

ot b

e go

ing

wel

l (so

th

at y

ou c

an h

elp

care

give

rs m

ake

them

go

bett

er);

Iden

tify

rou

tin

es t

hat

are

po

siti

ve fo

r ca

regi

vers

/ch

ildre

n a

s th

ese

will

pro

vide

a c

onte

xt in

wh

ich

to

show

car

egiv

ers

how

to

teac

h t

hei

r ch

ildre

n id

enti

fied

skill

s.

E

XPE

CTA

TIO

NS

SATI

SFA

CTI

ON

R

OU

TIN

E/A

CTI

VIT

Y

Exceeds

Meets

Occasionally Meets

Does not meet

C

OM

ME

NTS

Very

Is OK

Somewhat

Not

Did Not Ask

BA

THTI

ME

Sit

tin

g in

tu

b is

pro

blem

; Slid

es

un

der

seat

bel

t; d

oes

not

hol

d h

im

wel

l en

ough

. En

joys

pla

y w

ith

tu

b to

ys.

MO

RN

ING

RO

UTI

NE

(g

etti

ng

up,

get

tin

g dr

esse

d, e

tc.)

I dr

ess

him

in t

he

mor

nin

g –

no

tim

e an

d h

e ca

n h

elp

but

it t

akes

to

o lo

ng.

He

wak

es u

p h

appy

an

d re

ady

to g

o.

BE

DTI

ME

(get

tin

g re

ady

for

bed,

goi

ng

to

bed,

sle

epin

g)

Wat

ches

vid

eo a

nd

then

we

read

a

book

in h

is r

ocki

ng

chai

r; h

e en

joys

bot

h o

f th

ese

acti

viti

es a

nd

falls

asl

eep

easi

ly.

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E

XPE

CTA

TIO

NS

SATI

SFA

CTI

ON

R

OU

TIN

E/A

CTI

VIT

Y

Exceeds

Meets

Occasionally Meets

Does not meet

C

OM

ME

NTS

Very

Is OK

Somewhat

Not

Did Not Ask

ME

ALT

IME

S (a

ppet

ite,

le

vel o

f ass

ista

nce

)

Doe

s n

ot fi

nge

r or

spo

on fe

ed; c

an

hel

p a

littl

e w

ith

cu

p; c

hew

s ok

bu

t n

ot b

ig p

iece

s; E

ats

wit

h u

s an

d ca

n s

tay

in h

igh

chai

r u

nti

l ev

eryo

ne

is d

one.

PLA

YTIM

E (I

ndo

or

Play

)

Can

’t pl

ay b

y se

lf w

ith

toy

s. C

an

wat

ch v

ideo

or

TV if

pro

pped

in

sitt

ing;

has

so

mu

ch t

rou

ble

mov

ing

arm

s &

han

ds t

hat

eve

n

big

toys

nee

d as

sist

ance

.

STO

RY

TIM

E

Li

kes

bein

g re

ad t

o an

d tr

ies

to

turn

pag

es b

ut

has

diff

icu

ltie

s ev

en w

ith

car

dboa

rd b

ooks

.

OU

TDO

OR

PLA

Y (r

idin

g a

bike

, pla

yin

g ou

tsid

e, p

layi

ng

on

play

grou

nd

equ

ipm

ent,

sw

imm

ing)

He

is b

est

at s

wim

min

g –

love

s th

e w

ater

, can

be

prop

ped

in k

iddi

e po

ol o

r I

hol

d h

im; c

an’t

do a

ny

ridi

ng

toy

– ca

n’t

hol

d on

. We

hav

e n

ot t

ried

pla

ygro

un

d eq

uip

men

t.

He

mig

ht

like

san

dbox

if I

cou

ld

figu

re o

ut

how

to

prop

him

up

and

hav

e h

is h

ands

rea

ch t

he

san

d.

AT

HO

ME

CH

OR

ES

(c

lean

ing,

pre

pari

ng

mea

ls, w

atch

ing

TV,

cari

ng

for

pets

, etc

.)

He

enjo

ys T

V –

esp

ecia

lly S

esam

e,

Bar

ney

, etc

. or

child

ren

’s m

ovie

s (D

isn

ey).

Too

litt

le t

o h

elp

wit

h

oth

er c

hor

es.

LEA

VIN

G T

HE

HO

US

E

He

enjo

ys g

oin

g ou

t; D

oes

take

lo

nge

r to

get

him

rea

dy t

o go

ou

t;

Doe

s n

ot h

elp

at a

ll bu

t do

es n

ot

fuss

.

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E

XPE

CTA

TIO

NS

SATI

SFA

CTI

ON

R

OU

TIN

E/A

CTI

VIT

Y

Exceeds

Meets

Occasionally Meets

Does not meet

C

OM

ME

NTS

Very

Is OK

Somewhat

Not

Did Not Ask

TRA

VE

L TI

ME

(rid

ing

in a

car

, bu

s, w

alki

ng,

et

c.)

He

enjo

ys r

idin

g in

car

. Is

har

d to

ca

rry

him

to

car,

pu

t in

sea

t, e

tc.

but

once

in c

ar s

eat,

sit

s w

ell a

nd

enjo

ys t

he

ride

.

RU

NN

ING

ER

RA

ND

S

(gro

cery

sto

re,

mal

l/st

ore

shop

pin

g,

ban

kin

g,

was

h/c

lean

ers)

I ca

n o

nly

go

one

plac

e at

a t

ime

if h

e is

wit

h m

e. T

oo m

uch

tim

e an

d ef

fort

to

get

him

ou

t of

th

e ca

r, in

a

stro

ller,

etc

. & g

etti

ng

too

hea

vy

to c

arry

. Fo

r m

ult

iple

err

ands

, I

leav

e h

im a

t h

ome.

OU

TIN

GS

(vis

it a

fr

ien

d/re

lati

ve, e

at a

t a

rest

aura

nt/

fast

food

, go

to

mu

seu

ms,

am

use

men

t pa

rks,

zoo

, et

c.)

Goi

ng

out

is n

o pr

oble

m –

vis

its,

ea

tin

g in

res

tau

ran

ts, e

tc. a

re

thin

gs h

e re

ally

en

joys

. S

omet

imes

th

e eq

uip

men

t is

a

prob

lem

or

he

has

to

be h

eld.

In

re

stau

ran

ts, h

e si

ts in

str

olle

r be

cau

se c

ann

ot s

it w

ell e

nou

gh in

m

ost

hig

hch

airs

.

USE

OF

FUN

CTI

ON

AL

SKIL

LS I

N R

OU

TIN

ES/

AC

TIV

ITIE

S S

OC

IALI

ZIN

G (

e.g.

, in

tera

ctin

g w

ith

pee

rs

and

adu

lts)

Ver

y so

cial

– s

mile

s, g

ets

peop

le’s

at

ten

tion

, mak

es n

oise

s; b

ut

in

child

car

e, m

ay o

nly

pla

y w

ith

ad

ult

–

CO

MM

UN

ICA

TIN

G

wit

h p

eers

an

d ad

ult

s

Mak

es a

lot

of n

oise

s bu

t do

es n

ot

hav

e w

ords

; Har

d to

kn

ow w

hat

h

e is

try

ing

to g

et a

cros

s

GE

TTIN

G A

RO

UN

D

(mob

ility

at

hom

e/co

mm

un

ity)

This

is b

ecom

ing

bigg

er p

robl

em

as h

e ge

ts o

lder

/big

ger.

Can

not

w

alk

yet

or r

eally

cra

wl w

ell;

nee

ds

to b

e ca

rrie

d a

lot;

in c

hild

car

e is

to

tally

car

ried

.

Cam

pbel

l/Tn

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arti

cipa

tion

Bas

ed S

ervi

ces

Jan

uar

y 20

10

Page

10

of 2

7

E

XPE

CTA

TIO

NS

SATI

SFA

CTI

ON

R

OU

TIN

E/A

CTI

VIT

Y

Exceeds

Meets

Occasionally Meets

Does not meet

C

OM

ME

NTS

Very

Is OK

Somewhat

Not

Did Not Ask

US

ING

HA

ND

S &

A

RM

S fo

r fu

nct

ion

al

task

s (e

.g.,

ran

ge o

f m

otio

n, h

oldi

ng

obje

cts,

man

ipu

lati

on)

He

can

bat

at

toys

if s

usp

ende

d bu

t ca

nn

ot g

rasp

an

yth

ing;

can

ba

ng,

pu

sh b

ig o

bjec

ts s

omet

imes

. A

lso

mak

es o

ther

th

ings

har

d –

eati

ng,

bat

hin

g, d

ress

ing,

etc

. N

eeds

hel

p w

ith

eve

ryth

ing

Use

bla

nks

to a

dd a

ctiv

itie

s or

rou

tine

s no

t in

clud

ed in

cat

egor

ies

Bas

ed o

n yo

ur a

nsw

ers

abov

e, li

st t

he r

outi

nes/

acti

viti

es t

hat

do n

ot m

eet

your

exp

ecta

tion

s.

RO

UTI

NE

/AC

TIV

ITY

Wha

t w

ould

you

like

to

see

happ

enin

g: W

hat

wou

ld t

he c

hild

be

doin

g? W

hat

wou

ld y

ou o

r ot

her

fam

ily m

embe

rs b

e do

ing?

Wha

t st

rate

gies

hav

e yo

u tr

ied?

1.M

ealt

imes

W

ould

like

to

see

PG s

it n

ext

to m

e or

his

dad

du

rin

g di

nn

er a

nd

try

to fe

ed h

imse

lf ei

ther

wit

h h

is

finge

rs o

r sp

oon

or

both

an

d to

eat

a w

ider

var

iety

of f

oods

oth

er t

han

jun

ior

food

s or

food

th

at I

ble

nd

or g

rin

d.

2.Ph

ysic

al A

ctiv

itie

s A

lot

of t

he

oth

er m

oth

ers

sit

outs

ide

wit

h t

hei

r ch

ildre

n w

hile

th

ey p

lay

in t

he

yard

. I w

ould

like

to

be

able

to

do t

his

an

d w

ould

like

to

see

PG p

layi

ng

wit

h o

ther

ch

ildre

n li

ke o

n a

rid

ing

car

or in

a

san

dbox

.

Cam

pbel

l/Tn

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arti

cipa

tion

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ed S

ervi

ces

Jan

uar

y 20

10

Page

11

of 2

7

RO

UTI

NE

/AC

TIV

ITY

Wha

t w

ould

you

like

to

see

happ

enin

g: W

hat

wou

ld t

he c

hild

be

doin

g? W

hat

wou

ld y

ou o

r ot

her

fam

ily m

embe

rs b

e do

ing?

Wha

t st

rate

gies

hav

e yo

u tr

ied?

3.Pl

ayin

g w

ith

Fam

ily

Mem

bers

(C

areg

iver

)

PG is

an

on

ly c

hild

bu

t w

e vi

sit

my

sist

er(s

) qu

ite

a bi

t an

d bo

th o

f th

em h

ave

child

ren

– o

ne

4 an

d on

e 3

and

5. I

wou

ld li

ke t

o be

abl

e to

tak

e h

im t

o m

y si

ster

s an

d se

e h

im p

layi

ng

wit

h h

is c

ousi

ns

and

at

hom

e to

pla

y w

ith

me

or h

is d

ad w

ith

toy

s w

ith

out

our

hav

ing

to d

o ev

eryt

hin

g w

hile

he

just

wat

ches

.

Bas

ed o

n yo

ur a

nsw

ers

abov

e, li

st t

he r

outi

nes/

acti

viti

es t

hat

are

enjo

yabl

e fo

r yo

ur f

amily

and

chi

ld.

RO

UTI

NE

/AC

TIV

ITY

1.E

veni

ng R

outi

ne

He

espe

cial

ly e

njo

ys b

ein

g re

ad t

o an

d w

atch

ing

an e

ven

ing

DV

D t

o u

nw

ind

from

th

e da

y.

2.Le

avin

g th

e H

ouse

&

Out

ings

E

njo

ys g

oin

g in

th

e ca

r, o

n v

isit

s to

my

sist

ers,

par

ents

, an

d to

pla

ces

like

the

zoo

or C

hild

ren

’s

mu

seu

m.

We

ofte

n g

o to

th

e pa

rk, z

oo, e

tc. w

ith

my

sist

ers

and

thei

r ch

ildre

n a

nd

as lo

ng

as h

e ca

n b

e in

his

str

olle

r, e

very

thin

g go

es w

ell a

lth

ough

he

part

icip

ates

pri

mar

ily b

y w

atch

ing/

look

ing.

3.

Wat

chin

g TV

, lis

teni

ng t

o st

orie

s H

e re

ally

en

joys

th

e ch

ildre

n’s

sh

ows

if th

ey h

ave

a lo

t of

mu

sic

and

acti

vity

. M

any

DV

D s

how

s ar

e al

so o

nes

he

likes

. H

e “s

ings

alo

ng”

an

d is

ver

y en

gage

d. H

e is

att

enti

ve w

hen

bei

ng

read

to,

m

akes

noi

ses

wh

en a

sked

qu

esti

ons

abou

t fa

mili

ar s

tori

es, a

nd

trie

s to

tu

rn b

ook

page

s.

Add

itio

nal C

omm

ents

: Fu

nct

ion

al s

kills

of u

sin

g h

ands

an

d ar

ms

and

gett

ing

arou

nd

curr

entl

y lim

it P

G’s

par

tici

pati

on in

som

e ac

tivi

ties

an

d ro

uti

nes

. As

expe

ctat

ion

s ch

ange

as

he

gets

old

er, t

hes

e lim

itat

ion

s m

ay e

ven

furt

her

inte

rfer

e w

ith

par

tici

pati

on.

Wh

ile h

e co

mm

un

icat

es s

uffi

cien

tly

wit

h fa

mily

an

d ch

ild c

are

pers

onn

el a

t th

is t

ime,

his

lack

of w

ords

may

eve

ntu

ally

bec

ome

mor

e of

a c

hal

len

ge fo

r pa

rtic

ipat

ion

an

d m

ay in

fluen

ce h

is a

bilit

y to

par

tici

pate

an

d so

cial

ize

wit

h o

ther

ch

ildre

n.

Page 12 of 27


USING CAREGIVER ASSESSMENT RESULTS FOR DECISION-MAKING ABOUT CHILD

INTERVENTION OPPORTUNITIES

Two general types of intervention categories are identified through the caregiver assessment:

� Activities/Routines Not Going Well � Activities/Routines that Caregivers Enjoy with their Children

Activities/routines in both of these categories may be contexts in which children may participate, learn, or practice. Figure 1 diagrams the ways in which information from the caregiver assessment is combined with developmental performance information to figure out which activity/routine categories (well/not well) may be selected as contexts for programming.

Activities/Routines Not Going Well Children’s skills or behavior may influence the ease by which caregivers carry out activities and routines. Bathtime, for example, may be especially challenging when a child is unable to sit easily in the tub or does not like water. Families may stop doing certain activities because the child’s participation is so challenging. Sometimes, when professionals ask a simple question such as “are there things that you used to do before your child came into your family, that you are no longer able to do?” they are surprised by the number of activities that caregivers have given up because of not being able to accommodate the child. EI professionals can play a valuable role in helping caregivers continue activities they would like to (or need to) do and to make family routines go as smoothly as possible. Improving activities/routines helps make a caregiver’s life less stressful even though these improvements may not necessarily directly address a child’s skill deficits. Improving a child’s participation in activities or routines that do not go well has the benefit of not only making the activity/routine be more pleasurable and less stressful but also of making the activity/routine go well enough that it may become a future context for teaching and learning. Activities/routines that are problematic may not be optimal situations in which to embed teaching and learning strategies. When activities/routines are not going well, most caregivers cannot wait for the child to learn a whole new skill that may be necessary for optimal participation. For example, a child care teacher cannot wait for a child who is unable to hold utensils, writing tools, etc. to learn to grasp in order for child care routines such as snack or lunch to go well, or for a child to participate in child care activities such as art or inside or outside play that require manipulation of materials. In situations that do not go well and where a child’s increased participation is needed to enhance the activity or routine, adaptation interventions, including AT, should be tried before using strategies designed to help a child learn a new skill.

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13

of 2

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10

Page

13

of 2

7

Car

egiv

er A

sses

smen

t: A

ctiv

ities

, Rou

tines

, P

riorit

ies,

Stre

ngth

s

Chi

ld A

bilit

ies

and

Ski

ll P

erfo

rman

ce (O

bser

vatio

n,

Dev

elop

men

tal s

kill-

base

d as

sess

men

t)

Not

Goi

ng W

ell

Goi

ng W

ell

Per

form

s W

ell

Def

icit

or D

elay

in

Per

form

ance

Do

Not

hing

Con

text

for L

earn

ing

and

Pra

ctic

e O

ppor

tuni

ties

Embe

d S

trate

gies

fo

r Lea

rnin

g an

d P

ract

icin

g S

kills

Teac

h C

areg

iver

s To

:C

reat

e or

pro

vide

mul

tiple

op

portu

nitie

s fo

r Par

ticip

atio

n,

Lear

ning

, & P

ract

ice

with

in D

aily

Ac

tiviti

es/R

outin

es

AN

DU

se C

hild

Inte

rven

tion

Stra

tegi

es

Med

iate

/Fix

with

A

dapt

atio

ns, A

T,

Env

ironm

enta

l In

terv

entio

ns

Page 14 of 27


Interventions using activities/routines that are not going well need to:

� Create immediate – or as immediate as possible – CHANGE � Create change using uncomplicated and easy-to-implement interventions � Provide opportunities for children to participate successfully � Enable caregivers to carry out the activity/routine easily and efficiently � Reduce or minimize caregiving demands.

A majority of the intervention strategies that “fix” activities/routines that are going poorly include environmental modifications, adaptations, and assistive technology (AT). These types of interventions are directed toward making environmental changes (e.g., changing a room arrangement; using equipment for an individual child) and using adaptations that allow a child to participate as independently as possible using materials or aids that do not involve adult assistance. For example, if a child can’t paint at the easels during art at child care because of poor standing balance, strategies such as making an adjustment in the easel height so that the child can sit to paint or using a stander so that a lot of balance is not required allow the child to be independent even though standing balance is not improved. Similarly, adaptations for eating utensils, writing tools, books, toys, or other materials can allow a child to participate without adult assistance even when the child has limited skills. Activities/routines that are not going well are NOT an optimal context in which to:

� Teach a new skill that a child is not presently able to do or able to do easily or independently (without excessive prompts);

� Embed opportunities for the child to practice something the child is able to do but not do well enough to be efficient, competent, or accurate.

Activities/Routines Caregivers Enjoy with Their Children

Many people have written about the importance of using family activities/routines as sources of natural opportunities for teaching children with disabilities. Activities/routines that are identified as a context(s) for child learning opportunities should only include those that are enjoyable for the child and caregiver and in which the child is easily engaged. If bath time, riding in a car, going to the library, or visiting grandma, are things that a caregiver and child enjoy doing, then these are appropriate activities/routines in which to embed opportunities for the child to practice or learn a specific skill. Interventions using activities/routines that caregivers enjoy with their children need to:

� Embed opportunities for a child to practice an existing skill that needs to be performed more fluently, efficiently, quickly, consistently etc. OR

� Embed opportunities for a child to learn a new skill – actually do a skill that is not easily within the child’s repertoire with or without specific intervention;

� Embed specific (differentiated) intervention strategies that allow a child to demonstrate/perform a new skill that the child is unable to perform

� Result in child practice or learning; � Embed opportunities for practice or new skill learning in ways that caregivers can

implement easily (i.e., are not complicated or too “artificial” and that don’t

Page 15 of 27


significantly detract from the efficiency, enjoyment, or other characteristics of the activity/routine;

� Enable caregivers to and children to continue to enjoy the activity/routine. Together, the caregiver and EI provider decide what activity/routine to use as a source of opportunities for learning and what skill(s) will be targeted. The family’s evening routine may include book reading before bed, an activity that may provide opportunities for using hands and arms, listening, or verbally or non-verbally identifying objects, colors, or other basic concepts. The caregiver and EI provider together decide what skills are important to be practiced or learned , then the EI provider decides strategies to be used and teaches these to the caregiver, optimally within the selected activity or routine. In this example, the EI provider is unlikely to be able to make a home visit during bedtime, however, the provider and the caregiver could practice bookreading with the child at another time during the day such as nap time. The provider would ask the caregiver to read to the child the same way s/he might when the child is getting ready to go to bed. Then, the provider and caregiver would identify strategies the caregiver might use to help the child acquire or practice the targeted skill. For example, the provider might demonstrate for the caregiver how to use facilitation to help the child reach and point or turn pages of the book and then have the caregiver use the facilitation with the child and verify the caregiver’s correct use (i.e., reinforce the caregiver for using this strategy well) or provide suggestions about how caregiver use might be improved. Some situations where a child is learning a new skill(s) within the context of an activity or routine may involve the use of both teaching strategies (such as facilitation, hand-over-hand guidance, systematic reinforcement) and adaptation interventions. For example, in the above example, the provider might help the caregiver to select cardboard-paged books with simple pictures spaced far enough apart for the child to successfully point or fasten page turners made of cardboard or another material onto the book pages so that the child can turn the pages without adult assistance. Adaptations should always be considered even when “special” therapeutic or educational strategies will be taught to caregivers. These simple modifications, for example, in material or the overall activity may make the activity/routine easier to use as a context for teaching and learning a new skill.

DEVELOPING INTERVENTION DESIGNED TO “FIX” PROBLEMMATIC ACTIVITIES OR ROUTINES

The age of a child and, therefore, typical developmental expectations as well as the child’s degree of disability/delay influence the extent to which caregivers experience activities/routines that are problematic. For example, few participation expectations are generally present when children are under the age of a year. Caregivers don’t expect infants to participate in morning routines, for example, or bathing but may have expectations about participation in play or travel time. Not every caregiver identifies an activity/routine as going poorly. However, when activities/routines are identified, providers should help design strategies that will work quickly to make the identified activity/routine more manageable and easy to carry out. In improving or fixing an activity/routine that is going poorly, providers help families to be raise their children more easily (with fewer caregiver demands) and increase children’s

Page 16 of 27


opportunities for incidental learning. When a child screams constantly when, for example, riding in the car, not only is the routine challenging for the caregiver (i.e., the driver), but any opportunities for playing, watching outside, or even napping during the ride are eliminated. The diagram below illustrates the process for identifying potential interventions to improve activities/routines that are not going well.

Environmental AccommodationsAdapt Room Set-UpAdapt/Select EquipmentEquipment/Adaptations for Positioning

Adapt ScheduleSelect or Adapt ActivityAdapt MaterialsAdapt Requirements or InstructionsHave Another Child Help --

Peer Assistance/TutoringCooperative Learning

Have an Individual Child Do Something DifferentHave an Adult Help a Child Do the ActivityHave an Individual Child Do Something Outside

of the Room (with an Adult)

Facilitating Children’s Participation and Learning

Page 17 of 27


Designing strategies to improve an activity/routine includes the following components: � Caregiver-identification of an activity/routine which is not going well and for

which the CCIP will be developed and adaptation/AT interventions will be used. � Completing an analysis of the activity

o Identifying which steps of the activity are a problem o Figuring out adaptations or assistive technology to try o Deciding what the adult (usually the caregiver) will do during the

activity/routine o Outlining what the child will be expected to do

� Teaching the caregiver how to implement adaptations/AT or other types of intervention

� Regularly reviewing the effectiveness of the intervention and trying other adaptations, AT, or child interventions if the ones initially planned are no longer effective.

Activity Analysis: The Caregiver-Child Interaction Plan (CCIP)

An analysis of the activity/routine is completed jointly by the caregiver and the provider to identify which aspects are really a problem and to then plan interventions. The plan is developed using discussion between the caregiver and the provider or through observation by the provider while the caregiver performs the activity/routine. Developing the CCIP takes between 20-30 minutes. The framework includes:

Steps Problem? Adaptation/AT What Caregiver Will Do

What Child Will Do

Steps of the Activity/Routine: Watch the caregiver do the routine/activity with the child and write down the steps. If you are unable to observe the activity/routine, then spend some time talking to the caregiver to discuss how the activity/routine takes place and write the steps on the CCIP. For example, for bathtime, the steps might be 1) place the child on the bed, remove clothing, go to the bathroom, run the water in the tub, place child in tub, etc. Every routine or activity has a beginning and an end. In this example, the beginning may be getting undressed and the end may be getting into P.J.’s or into bed/crib. Different caregivers may have different ways of doing an activity/routine so the steps may differ from person to person. Identifying the steps of an activity/routine seems to be the most difficult part of completing the CCIP. Use the Participation-Based Services Step-By-Step Resource Guide to find examples of activities/routines that have been broken into steps and to see if the steps written on the CCIP are really naturally occurring activity steps. Problem? Think about the steps and decide whether each step is or is not a problem. Adaptation/AT: Frequently adaptations or AT can be used to address a particular problem. For example, if washing the body is a problem, a child may be able to help or wash independently (dependent on age) by using a bath mitt instead of a washcloth. For each problem step, describe one or more adaptations/AT that might be tried. The

Page 18 of 27


Participation-Based Services Step-By-Step Resource Guide includes suggestions for adaptations/AT matched to the 12 routines (e.g., bathtime, mealtime, etc.) on the Caregiver Assessment. What the Caregiver Will Do: For each step, describe what the adult will do to help. This help may include verbal directions/reinforcement, physical guidance, placement of objects, time delay, or other child intervention strategies. What the Child Will do: Again, for each step, describe the expectations for the child. What do the adult(s) (provider and caregiver) expect that the child will be able to do (e.g., in this example, sit, wash self, or play with toys).

Tips for Writing the CCIP REMEMBER TO FOCUS ON THE STEPS (A LIST) OF AN ACTIVITY/ROUTINE AS IT

TYPCALLY OCCURS

� This does not mean directions for the caregiver (e.g., mother will lift child onto changing table; dad puts child into bumbo seat) but means the actual steps of the activity – i.e., 1) child crawls to bedroom, 2) lifted onto changing table; 3) placed onto back; ETC.)

� This is not home program instructions (e.g., during diapering, place John on back, give him a toy to play with, etc. does not mean what the child will do). This is not what the provider wants another adult or the child to do.

� It is a description of an activity/routine as it typically occurs without any intervention, structure, etc. manipulation, changing around, etc.

IDENTIFY WHETHER EACH INDIVIDUAL STEP IS OR IS NOT A PROBLEM

� When an activity/routine is not going well, individually identifying problem steps makes the “solution” easier to identify, find, or create. Only solutions need to be found for steps that are problems.

FIND ADAPTATIONS/AT TO MAKE THE IDENTIFIED PROBLEM STEP “GO WELL”

� When individual steps are identified as problems, adaptations or AT may frequently be used so that the step is no longer a problem

� Adaptations or AT are various solutions that come about by using special devices or materials, rearranging the environment, finding positioning, changing the way in which directions given to a child, using visual schedules, etc.

IDENTIFY EXPECTATIONS. WRITE DOWN WHAT THE CAREGIVER AND CHILD

WILL DO

� When an activity/routine is not going well, adaptations/AT should reduce what the caregiver needs to do. For example, in bathtime, a bath seat means that the adult does not need to hold the child in the tub.

� Adaptations/AT should also improve the child’s participation (use bath mitt to help wash self rather than hold washcloth independently)

Teaching and Reviewing with the Caregiver: Implementing the CCIP

The CCIP is a plan for the strategies that will be tried to improve an activity/routine that is not going well (or plan for embedding when activities/routines are going well).

Page 19 of 27


� The plan is implemented by the caregiver every day or whenever the

activity/routine occurs. � The provider supports the caregiver’s implementation by:

o Teaching the caregiver to use the adaptations/AT within the targeted activity/routine;

o Asking how the plan is working; o Reviewing to make sure the plan is revised when timely to do so (e.g.,

the number of supports may be reduced because less adaptation is needed; or planned adaptations are not working and others need to be tried); and

o Providing feedback, encouragement, etc. as the plan is implemented over time.

Various teaching strategies may be used to help caregivers learn to use adaptations/AT within an activity/routine that is not going well. Providers may not be able to observe the caregiver actually doing the routine but can engage in regular discussion and problem-solving to make sure that things are improving and to gage the caregivers’ expectation and degree of satisfaction.

Example Of A CCIP For Activity/Routine Not Going Well

PG’s caregiver completed the Caregiver Assessment of Activities and Routines and identified functional skills of getting around and using arms and hands as not meeting expectations and listed 3 routines as not going well. Mealtimes Would like to see PG sit next to me or his dad during dinner and

try to feed himself either with his fingers or spoon or both and to eat a wider variety of foods other than junior foods or food that I blend or grind.

Physical Activities A lot of the other mothers sit outside with their children while they play in the yard. I would like to be able to do this and would like to see PG playing with other children like on a riding car or in a sandbox.

Playing with Family Members (Caregiver)

PG is an only child but we visit my sister(s) quite a bit and both of them have children – one 4 and one 3 and 5. I would like to be able to take him to my sisters and see him playing with his cousins and at home to play with me or his dad with toys without our having to do everything while he just watches.

The caregiver and provided talked and PG’s mother decided to focus first on physical activities. In this situation, the provider was able to be outside in the yard with PG and his caregiver and to observe what the activity included. The provider and caregiver talked and developed the CCIP.

Page 20 of 27


Caregiver-Child Interaction Plan (CCIP)

(This plan and the analysis of effectiveness are to be completed by the early interventionist and caregiver together)

Routine/Activity: ___ÉâàwÉÉÜ ÑÄtç ______Location (if outside the home) ___ltÜwr__ Date: _rGBDGBCKr

Is this routine going well? Yes No (circle one) Focus: Routine or Creating Opportunities (circle one)

What I would like to see happen during this routine: \ ãÉâÄw Ä|~x àÉ á|à Éâàá|wx ã|à{ cZ tÇw Éà{xÜ ÅÉà{xÜá tÇw v{|ÄwÜxÇ tÇw {täx {|Å ux tuÄx àÉ ÑÄtç t Ä|ààÄx |ÇwxÑxÇwxÇàÄç ã|à{ Éà{xÜ v{|ÄwÜxÇ yÉÜ xäxÇ á{ÉÜà ÑxÜ|Éwá Éy à|Åx A What is the current situation? \y ãx zÉ Éâàá|wx? {x x|à{xÜ {tá àÉ á|à |Ç à{x áàÜÉÄÄxÜ ã|à{ Åx ÉÜ ÉÇ Åç ÄtÑ ã{|Äx \ àtÄ~A \y \ ãtÇà {|Å àÉ ÑÄtç? \ {täx àÉ {ÉÄw {|Å ÉÇ xäxÜçà{|Çz |Ç à{x ÑÄtç áàÜâvàâÜxA \ {täx àÜ|xw àÉ ÑÜÉÑ {|Å âÑ |Ç á|àà|Çz uâà {x ytÄÄá ÉäxÜ tÇw vtÇËà ÜxtÄÄç {ÉÄw tÇç Éy à{x àÉçá tÇçãtçA

Steps in the Routine

Problem(y/n)

Adaptations that will be used

What I will do What my child is expected to do

Go outside N I carry PG outside and generally bring his stroller

Help while I am carrying him by holding up his head or trying to grab onto my clothes.

Ask him what he wants to try

Y Picture noodle with pictures of sandbox, swing, sit and watch, go inside, etc so PG can choose

Hold PG on my lap or put him in stroller and give him the noodle and ask “what would you like to do?”

Point to the picture of what he would like to do

Put PG in stroller or put him on some play equipment

Y Sit in yard in inner tube so won’t fall over; adapted Little Tykes swing seat so can swing independently; sit in corner of sandbox or try cutting out a wastebasket to make a little chair for him to be in the corner of the sandbox

Place him in the equipment needed for whichever activity he selects

Sit and watch the other children with mom, play on swing, in the sandbox for a short period of time (under 15 minutes) but longer if he wishes.

Let him pick something else he might want to try

Y Picture noodle with pictures of sandbox, swing, sit and watch, go inside, etc. so PG can choose

Give him the noodle and ask “what would you like to do now”

Point to the picture of what he would like to do

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Problem(y/n)

Adaptations that will be used

What I will do What my child is expected to do

Put him in 2nd

choice activity Y Sit in yard in inner tube

so won’t fall over; adapted Little Tykes swing seat so can swing independently; sit in corner of sandbox or try cutting out a wastebasket to make a little chair for him to be in the corner of the sandbox

Place him in the equipment needed for whichever activity he selects


Continue choicemaking, activity sequence until it is time to go inside

Y Continue to use choice noodle for choices & positioning to enable participation

Allow him to use noodle to make choices; place him in equipment needed for whichever activity he selects


Go Inside N Carry PG inside when we are done playing with other children

Be carried inside – helping by holding on, holding head, etc.

Note: If the routine is not going well, planning focuses on completing the routine; if the routine is going well, planning focuses on embedding learning opportunities within the routine

EMBEDDING ADAPTATIONS/AT INTO ACTIVITIES/ROUTINES

Both families and EI providers are likely to focus on developmental skills that infants and toddlers may need to learn. Caregivers may identify talking or walking or behaving better or eating independently. Many of these skills are functional –meaning that they are essential to children’s abilities to interact with their physical and social worlds and caregivers will have reported their perceptions about the extent to which children’s overall functional skills meet caregiver expectations and satisfaction. Opportunities for children to acquire developmental/functional skills are present in activities/routines that are going well and can occur systematically when opportunities are planned. There are two basic types of learning opportunities: (a) planned; (b) incidental. In planned learning opportunities, a specific opportunity to perform a particular skill is created. Children learn when multiple opportunities are provided – within one activity/routine or within many different activities/routines. Making a written plan helps the caregiver, child care provider, or adult who is with the child during the activity/routine know what to do, when to provide learning opportunities, and what types of opportunities to provide to help children to demonstrate a particular skill. Planned learning opportunities include 3 general types:

1. Practice: Skill performance without adult assistance (child is able to do something without any more help than another child of the same chronological age but needs opportunities to practice for the skill to become integrated)

2. New Learning with Adaptations/AT: Skill performance using an adaptation or AT intervention and no more adult assistance than another child of the same chronological age; AND

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3. New Learning with Adult-Provided Intervention: Skill performance with the support of specially-designed instructional strategies such as antecedent arrangements, prompts and supports, or consequences.

Incidental learning refers to opportunities that are naturally available (not specifically designed) within the activities and routines in which children participate. Incidental learning best occurs when children are interested and engaged and participating in an activity/routine. The CCIP may also be used to design planned learning opportunities and to help identify child intervention strategies to be embedded within the activity/routine learning opportunities. The same components as used to plan for improving activities/routines that are not going well are included:

� Caregiver-identification of an enjoyable activity/routine for which the CCIP will be developed and in which instructional strategies will be embedded

� Completing an analysis of the activity o Identifying which steps of the activity are a problem (should be few to none

for an activity/routine that is enjoyable and going well.] o Figuring out adaptations or assistive technology to try, as necessary o Deciding what the adult (usually the caregiver) will do during the

activity/routine including the learning opportunities to be provided and interventions to be embedded

o Outlining what the child will be expected to do � Teaching the caregiver how to implement learning opportunities/instructional

supports � Regularly reviewing the effectiveness of the intervention and trying other

adaptations, AT, or child interventions if the ones initially planned are no longer effective.

Example Of A CCIP For An Enjoyable Activity/Routine In Which Learning

Opportunities will be Provided and Specially-Designed Interventions Embedded

PG’s caregiver completed the Caregiver Assessment of Activities and Routines and identified functional skills of getting around and using arms and hands as not meeting expectations and listed 3 enjoyable activities/routines. Evening Routine He especially enjoys being read to and watching an evening DVD to

unwind from the day.

Leaving the House & Outings

Enjoys going in the car, on visits to my sisters, parents, and to places like the zoo or Children’s museum. We often go to the park, zoo, etc. with my sisters and their children and as long as he can be in his stroller, everything goes well although he participates primarily by watching/looking.

Watching TV, listening to stories

He really enjoys the children’s shows if they have a lot of music and activity. Many DVD shows are also ones he likes. He “sings along” and is very engaged. He is attentive when being read to, makes noises when asked questions about familiar stories, and tries to turn book pages.

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PG’s provider and caregiver discussed how to create opportunities for him to use his arms and hands within the context of reading stories (Evening Routine or other times during the day) as well as to think of possibilities to create opportunities for getting around. Ideas for learning arm and hand learning opportunities were generated: reach toward the pictures, reach to turn pages of book (or to help turn pages), use of book props – figures on sticks or puppets to use during the story by moving arms, etc. The provider and caregiver also discussed strategies that might be incorporated into the activity to help increase use of movement such as hand-over-hand to point to pictures, etc. A CCIP was then created to embed these learning opportunities and strategies into book reading activities.

Caregiver-Child Interaction Plan (CCIP)

(This plan and the analysis of effectiveness are to be completed by the early interventionist and caregiver together)

Routine/Activity: __fàÉÜç extw|Çz __Location (if outside the home) _____Date: GBDHBCCJrrrr

Is this routine going well? Yes No (circle one Focus: Routine or Creating Opportunities (circle one)

What I would like to see happen during this routine: \à ãÉâÄw ux zÜxtà |y {x vÉâÄw áxÄxvà uÉÉ~á tÇw tvàâtÄÄç àâÜÇ à{x Ñtzxá ã{|Äx {x |á ux|Çz Üxtw àÉA What is the current situation? [x |á ÇÉà tuÄx àÉ àxÄÄ âá ã{|v{ uÉÉ~ {x ãÉâÄw Ä|~x tÇw vtÇÇÉà ÑÉ|Çà ãxÄÄ ã|à{ {|á y|ÇzxÜá uâà vtÇ áÉÜà Éy ÑÉ|Çà ã|à{ t y|áàxw {tÇw |Ç à{x Ü|z{à w|Üxvà|ÉÇ |y tá~xw t Öâxáà|ÉÇA


Problem(y/n)

Adaptations that could be used

What will the adult do What will the child do

Show him the schedule board with pictures of bath, reading, and bed and take his hand and point to reading. Say "this is next.” Encourage him to be able to point to the different pictures on his own.

Allow his arm/hand to be moved; Look at the picture. Eventually move his arm himself so that his hand is on the picture.

Begin reading by deciding what story to read

Y

Create a schedule to help the child transition.

Let the child pick out the book using a choice making device – picture board or switch.

Show him the communication board with pictures of covers of 3 books; Ask which book he would like to read; Watch his eyes to see where he looks; Encourage him to touch the book cover, then take his hand and have him touch the cover where he is looking.

Look at a book picture and move his arm to touch the picture independently or with help.

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Problem(y/n)



Use a 2 or 3 position switch (or 2 or 3 switches) with voice output so that he can hit a switch and make a choice of book. Wait for him to hit the switch and if he does not, follow his gaze and help him activate the correct switch.

Hit the switch independently or with help

Go to reading area

Y

Scooter for moving.Stabilize your child while

they walk by tying magazines or newspapers around their legs.

Build a Scoot-a-bout so the child can independently move from one place to another.

Have the child hold on to a hula hoop to increase stability.

Try a variety of ways of helping the child to move independently (depending on the child’s abilities).

Move independently from the bathroom/bedroom area to the family room.

Sit Y

Provide a child sized bench to sit on.

Make a barrel seat for your child to sit on.

Position your child using bolsters.

Put a box underneath the feet for support.

Identify a variety of options for ways the child may sit comfortably while reading.

Sit with sufficient support to be able to move arms and with sufficient comfort to sit for the length of the book.

Turn pages of book

Y

Use Slant board to prop book up so child/adult can see

Use communication picture board or voice-output switch so child can say when to turn the page

Use something attached to the book pages (felt pieces) or separate pages with daps of hot glue in order to allow the child to turn pages

Try a variety of strategies to stabilize the book and to make it easily viewed by the child. Modify the activity or material (book) so that the child may turn pages.

Turn pages of the book

Read the book N Make sure book is large so that child can touch picture.

Program a switch to help with reading words in repetitive stories

Encourage vocalization (reading along) of objects and story in bookEncourage child to move arm to touch named picture

Vocalize along with repeated words (e.g., “dog”); Look at and touch picture when named (e.g., “find the dog; where is the dog?”)

Put book away

N Put book on low shelf or in bin so that child may easily return book

Tell the child to put the book away

Put the book away

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Problem(y/n)



Go to next activity

Y Create a schedule to help the child transition.

Mobility aid (scooter, etc.)

Show the child/ask the child to indicate bed on the schedule board.Use mobility aid to go to bedroom

Go to bedroom/bed.

Note: If the routine is not going well, planning focuses on completing the routine; if the routine is going well, planning focuses on embedding learning opportunities within the routine

Caregiver Teaching and Generalization Across Activities/Routines

The CCIP is a starting point for embedding learning opportunities, adaptations/AT, and specially-designed child intervention strategies into activities/routines. Once the caregiver is comfortable with creating learning opportunities and using the child interventions, expansions can occur informally or with planning to extend embedding to multiple activities/routines. For PG, the diagram below was used to plan the extension of learning opportunities for mobility and use of arms and hands to other activities besides reading books at night. The 12 basic activities/routines are listed as:

� circles (situations where embedding will be extended); � diamonds (situations where embedding is likely never to occur); and � numbers to indicate the approximate order of the routines/activities into which

opportunities and strategies will be extended.

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A embedding plan was also designed to identify the activities/routines into which learning opportunities would be embedded in the future as well as to list the possible number of learning opportunities to be provided. As can be seen, there are a possible 75 learning opportunities that can be provided per day for PG to reach and use his arms and hands. The sheet includes the same information as the web but allows the actual implementation to be planned and documented. When this plan is fully implemented, more than 500 possible learning opportunities are available in a week’s time.

Tracking Sheet Embedding in Family Activities & Routines

Date: ___GBEEBCK________________ Child’s name: _______cZ_____

Provider Name: ___________U________ Caregiver Name:________`á ____________

ROUTINE/ACTIVITY

Exp

ecte

d #

Le

arn

ing

Opp

ortu

nit

ies

Ord

er o

f Im

plem

enta

tion

Dat

e Im

plem

ente

d

What Will Adult Do?

BATHTIME

15 5 Hold our washcloth and toys for PG to

reach towards when seated in bath seat

MORNING ROUTINE (getting up, getting dressed, etc.) 0

BEDTIME (getting ready for bed, going to bed, sleeping) 20 1 4/22/08

Create opportunities to: reach toward: books to choose, pictures in books, pictures when named, pictures for

comprehension; to turn pages; grasp or bat page turners

MEALTIMES (appetite, level of assistance)

15 2 4/30/08 Create opportunities to reach toward spoon, desired food, cup, etc.

PLAYTIME (Indoor Play) 0

STORY TIME 10 3 5/12/08

Create opportunities to: reach toward: books to choose, pictures in books, pictures when named, pictures for

comprehension; to turn pages; grasp or bat page turners

OUTDOOR PLAY (riding a bike, playing outside, playing on playground equipment, swimming)

0

AT HOME CHORES (cleaning, preparing meals, watching TV, caring for pets, etc.)

0

LEAVING THE HOUSE 5 4

Create opportunities to reach toward coat, hat and then assist in putting

on; to caregiver to be picked up TRAVEL TIME (riding in a car, bus; walking, etc.)

0

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ROUTINE/ACTIVITY

Exp

ecte

d #

Le

arn

ing

Opp

ortu

nit

ies

Ord

er o

f Im

plem

enta

tion

Dat

e Im

plem

ente

d

What Will Adult Do?

RUNNING ERRANDS (grocery store, mall/store shopping, banking, wash/cleaners)

0

OUTINGS (visit a friend/relative, eat at a restaurant/fast food, go to museums, amusement parks, zoo)

10 6

Create opportunities for reaching that match context – reach toward

animals, reach toward ---- or reach toward and touch

TOTAL 75

Documents

The Importance of Activities and Routines to a ...jeffline.jefferson.edu/cfsrp/tlc/caregiver/materials/Handout...Learning about activities and routines allows ... strategies involving