Parent-mediated interventions

Louis is a ten-year-old with additional needs whose family is experiencing disadvantage. Louis has been displaying significant behavioural issues at home and at school. Social worker Irma has been working with Louis to help him understand and process his emotions, which she has identified as contributing to his behavioural outbursts. She has been doing this face-to-face, however, recently Louis and his mother, Dominica, have moved residence to live with a relative due to financial issues, and they are now too far away for Irma to provide services face-to-face.

Irma has tried continuing her sessions with Louis via videocall, but found that he quickly becomes distracted and even leaves the room partway through the session. Because of this, Irma decides it may be appropriate to switch her approach to a parent-mediated intervention for Louis’s behaviour issues. After reviewing the case notes and consulting with her supervisor, Irma has a discussion with Dominica about the parent-mediated approach. Dominica is very willing to try the approach, but notes that financial stress may impact her ability to apply strategies. They agree to undertake the approach on a trial basis.

• Step 1: Identify target skill
  Based on her understanding of the literature on behaviour management, Irma suggests that a good target skill for Louis to develop could be the ability to express when his mood is becoming heightened, so that those around him can respond to de-escalate the situation before a behavioural outburst eventuates. Dominica also feels this would be a fantastic outcome to achieve. Irma, Dominica and Louis workshop the idea and express the target behaviour in concrete terms: “When Louis notices that he’s becoming frustrated, he will tell someone he’s with ‘I need to take a break’, and if prompted, give them a SUDS (Subjective Units of Distress Scale) rating out of 10.”
• Step 2: Identify target strategy
  Dominica and Irma decide that Dominica can be effective in supporting Louis’s development of this skill through prompting him regularly. They involve Louis in the discussion and together they identify that this is particularly important in certain situations like getting ready for school in the morning and after dinner in the evenings, because Louis is more likely to get agitated at these times and is also less likely to remember to apply the target behaviour (expressing his heightened mood).
• Step 3: Create parent-friendly procedures
  Because of everything else going on in her life, Dominica identifies that she will need help to apply the strategy. Irma helps design a number of measures to help her with this. She prepares a ‘poster’ featuring the identified skill for Louis and the support strategy that Irma should apply, including vivid colours to catch the eye, for the family to post in a prominent position (such as the fridge door). She helps Dominica identify key times of day when she might apply the prompting strategy, based on Dominica’s routines. She also holds a videocall session with Dominica to go through setting up regular reminders on Dominica’s phone to apply the strategy of checking in with Louis.
• Step 4: Teach the parent
  Although the strategy itself is relatively simple, Dominica and Irma identify that the wording is important if it’s to help de-escalate Louis’s mood. They also acknowledge that Dominica tends to get ‘worked up’ herself when Louis’s mood escalates, so she needs to develop her self-management skills. Dominica and Irma hold weekly practice sessions where Dominica describes recent experiences of trying to apply the strategy with Louis, and Irma also presents some role-play scenarios for Dominica to rehearse her approach.
• Step 5: Coach the parent to mastery
  Louis agrees to participate in a weekly videocall with Irma, alongside Dominica. Although these can sometimes devolve into arguments between Louis and Dominica, Irma uses this as an opportunity to coach Dominica in the use of the strategy. After eight weeks, Irma notes that Dominica is significantly more patient with Louis’s outbursts, and Louis is reliably expressing his frustration through words, even having adapted the wording to suit him (“You’re pushing me to 7 out of 10 right now”). In consultation with her supervisor, Irma decides that the family can apply the skill and supporting strategy consistently, so moves on to identifying a new skill to target, while continuing to check in regularly on how they’re going with the expressing frustration skill.

An early intervention Key Worker, Jo, has taken on a newly enrolled family – Mari and her parents Elle and Robin. Mari has a developmental delay and her family is keen to support her cognitive, language and social development. The family has expressed a strong preference for telepractice due to busy work schedules and the need to care for two other children with additional needs. Because Mari is only three, Jo believes that a parent-mediated intervention is the best approach in this case. She discusses this option with Elle and Robin over the phone and they agree that this would be beneficial.

• Step 1: Identify target skill
  Jo discusses current needs and concerns with Elle and Robin. She discovers that Mari is speaking only one or two words, and although she makes a range of other noises they’re not intelligible as words. Together they decide that a worthwhile aim would be to increase the amount of words that Mari uses. Based on the family’s observations, they agree that good areas to focus on would be words around mealtimes like “eat,” “more” and “ta” (please/thank you). Jo helps them put this in concrete terms as “at mealtimes, Mari will say words recognisable as “eat”, “more” and “ta” in a way that corresponds to their meaning.”
• Step 2: Identify target strategy
  Jo’s expertise in early intervention leads her to believe that Mari’s parents can support her use of this skill by using these words in a particular way themselves. She suggests to Elle and Robin that she can teach them a routine involving identifying situations where each word is relevant, making good eye contact with Mari, saying the word in a loud, clear voice while emphasising the articulation with their lips, and waiting expectantly for Mari to make a response. They identify another strategy based on recognising Mari’s attempts at communication, asking if she means the word they suspect and saying the word while waiting expectantly for her to say it.
• Step 3: Create parent-friendly procedures
  In consultation with Elle and Robin, Jo has chosen to target mealtimes for this parent-mediated intervention because it fits best with the family’s routines – Mari usually has at least one parent’s attention for about 20-30 minutes at mealtime, so it is realistic for them to try to apply the strategy within this window. It’s also relatively structured so it’s easier for Elle and Robin to recognise the situations when they should be using the strategy.
• Step 4: Teach the parent(s)
  Based on her previous experience, Jo recognises that the strategy identified can feel unnatural to parents who aren’t familiar with interacting with young children in this way. To make the procedure more parent-friendly, she collects a list of supporting materials including video demonstrations available on YouTube and a brief pictorial guide that can be viewed on a smartphone.
  Jo sets up a series of weekly videocall sessions where she guides Elle and Robin through the approach. She continuously reminds them of the two relevant strategies and explains each step. She gives them opportunities to roleplay with her.
• Step 5: Coach the parent(s) to mastery
  Jo asks the family to film one mealtime (or more) per week. She discusses with them how they can do this on their smartphones. Because the video needs to capture the whole breakfast table, they find a position where the phone can be propped up on a nearby bookcase at eye-level. They use a system where the recording is then uploaded to Google Drive because the file is too large for the family’s email system. Jo reviews the video then holds a videocall with both parents to discuss. She provides positive feedback on multiple features of how they interacted with Mari in the video. She also provides one or two suggestions for things that they could use to enhance their use of the strategy they’re applying.
  After four weeks of focusing exclusively on this procedure, Jo feels confident that Elle and Robin have mastered the strategy to help Mari learn the target language skill. Because it may take a while for Mari to master the skill, the family agrees with Jo that they can add in another target skill and support strategy to work on while they continue their focus on “eat, “more” and “ta” at mealtimes. Jo initiates the process for the new skill back at Step 1: Identify target skill.