Kaiser, Ann P. PhD; Hancock, Terry B. PhD
PARENTS ARE their children's first and most enduring teachers. In the course of normal development, parents support their children's language, social, and academic development (Hart & Risley, 1995). There is systematic evidence over the last 30 years that teaching parents specific strategies to support their children's development can be effective. Beginning in the late 1960s, researchers have reported positive effects of parents' implementation of behavior management strategies with children who have conduct disorders (Dumas, 1989; Webster-Stratton & Hammond, 1990), mental retardation (Kaiser, Hemmeter, & Hester, 1996), and autism (Schreibman, Kaneke, & Koegel, 1991), as well as children who have been labeled at-risk because of poverty (Wahler, 1980) and children who are developing typically but present a range of difficult behaviors (Kazdin, Esveldt-Dawson, French, & Unis, 1987). A variety of training methods, including directly training individual parents in behavioral procedures, teaching parents in groups, and using written manuals with limited direct consultation, have been shown to be effective in changing parent and child behavior (Kaiser, Hemmeter, Ostrosky, Alpert, & Hancock, 1995; Kovitz, 1976; Wahler, Cartor, Fleischman, & Lambert, 1993; Webster-Stratton, 1992). Parents of developmentally delayed and high-risk infants have been taught to increase systematically their responsiveness and consistency in reading infants' behavior cues with resulting improvements in the children's very early social communication (Barnard, 1997; Seifer, Clark, & Sameroff, 1991). Finally, parents have learned to implement a range of naturalistic language intervention strategies successfully (Hemmeter & Kaiser, 1994).
In spite of this evidence, interventions to teach parents specific skills to support child development have been controversial in the area of early intervention (Mahoney et al., l999). Several arguments against teaching parents strategies for early intervention have been proposed: (a) parents should not be asked to abandon their primary role as a parent in order to be their child's teacher (Turnbull & Turnbull, 1990); (b) children's development is best served by providing family-centered services that support parents and address the needs they identify as most critical (Dunst & Leet, 1987); and (c) it is stigmatizing to parents when professionals presume that parents do not have sufficient skills to support the development of their children with disabilities (Greene, 1999). While there is theoretical and empirical evidence that clearly supports a family-systems approach to early intervention (Dunst, 1999), there is no empirical evidence indicating that teaching parents strategies to support their children's development necessarily conflicts with a family-centered approach to early intervention (Kaiser et al., 1996).
Given the considerable empirical data indicating that teaching parents more effective interaction strategies can improve developmental outcomes and decrease problem behavior, we have chosen to focus on the conditions for optimizing parent teaching when professionals choose this approach. First, we discuss when teaching parents new strategies for supporting the development of their children is a good idea. Next, we outline the skills that parent educators need in order to be effective teachers of adults. Then, we provide specific strategies parent educators should consider in planning for effective interventions with parents. Lastly, we discuss a model for preparing professionals to teach parents. Throughout this article, we draw on empirical and anecdotal examples from our ongoing research on teaching parents strategies for naturalistic language teaching.
Since 1983, the authors have been engaged in research on naturalistic strategies for supporting early communication in young children with developmental disabilities. Our approach, milieu teaching, involves teaching children new communication forms in the context of everyday conversation. Child interests and activities set the occasion for teaching. The adult models new language, expands child's utterances, and gives meaningful communicative feedback to the child's attempts to communicate. In addition, the adult uses (eg modeling, manding and modeling, time delays, and incidental teaching) to prompt functional production of new communication forms by the child (see Delaney & Kaiser, 2001; Hemmeter & Kaiser, l994; Kaiser, l998; Kaiser, Hancock, & Nietfeld, 2000). Because this approach is designed to be used in conversations and in everyday interactions, it is ideally suited for parents to use to support their children's communication development.
We have examined applications of milieu teaching by therapists, parents, and classroom teachers, but our research has focused primarily on examining changes in child communication skills resulting from parent-implemented milieu teaching and related naturalistic communication approaches (Delaney & Kaiser, 2001; Kaiser, 1993; Kaiser et al., 2000). We have also conducted studies addressing strategies for training professionals to work with parents (Hester, Kaiser, Alpert, & Whiteman, 1996; Kaiser, Hester, Alpert, & Whiteman, 1995). In the course of conducting these studies, we have trained more than 40 special educators, psychologists, social workers, and speech pathologists who have then taught over 200 parents in our programs. Participants involved in these studies have included preschool children (ages 2½ to 6) with a wide range of disabilities (language delays, global developmental delays, behavior problems, mental retardation, autism), and their mothers, fathers, grandparents, and nannies from a wide range of economic and educational backgrounds. Typical parents in our research have been mothers with slightly more than a high school education who work full time and who have two children.
To date, approximately, 94% of the families who began the parent-implemented milieu teaching program with us have completed it. Of those parents who completed the intervention, almost all (97%) reached criterion levels of performance during teaching sessions while the parent interventionist was present. Parents generalized some of their newly trained skills to interactions at home, although there has been variability in the extent to which skills were generalized and maintained over time and settings (Kaiser et al., 1995; Kaiser, Hancock, & Hester, 1998). About 90% of the participating children have shown generalization and maintenance of newly learned language skills when observed at home. More than half of those children have demonstrated significant gains on global measures of language development immediately after the intervention and at follow-up points up to 6 month later (Hemmeter & Kaiser, 1994; Kaiser et al., 1995; Kaiser et al., 1998; Kaiser et al., 2000).
Our current research has two foci. First, we are studying the effects of combining therapist-implemented and parent-implemented Enhanced Milieu Teaching (EMT) to maximize child communication development across settings and time with preschool children who have mental retardation (Kaiser, Hancock, Solomon, Windsor, & Howard, 2000). Second, we are examining the preventive effects of teaching low-income parents of preschoolers with language delays and behavior problems to support their children's communication and social skills (Delaney & Kaiser, 2001; Hancock, Kaiser, & Delaney, in press).
Table 1 provides an overview of the goals we teach adults and the rationale for each goal in terms of supporting children's communication. Our experience in teaching parents derives from systematic implementation of a manualized intervention; the target of the intervention is to increase children's functional communication in everyday interactions. Our interactions with parents go beyond teaching them a communication intervention. They include consultation about their children's educational goals and programs, facilitating children's entry into school, and accessing resources in the community to support families and children.
WHEN TEACHING PARENTS IS A GOOD IDEA
All parents can learn new and effective strategies for supporting their child's development, but not every parent is ready or willing to learn new strategies at a particular point in time. Table 2 indicates when parent teaching is likely to be successful. First, parents must choose to participate. In making a choice, parents set their own priorities and make a commitment to learning new skills. Second, parents must consider being involved in learning new skills important for their children's development. Third, they must have sufficient time and energy, as well as logistical support (e.g., transportation, child care) to make a relatively long-term commitment to learning and producing new skills with their children. Although parent teaching programs vary in length, many take 10 or more sessions to teach new skills. It is important for parents to know the exact amount of time that will be required before they make a commitment to participate. Parent teaching is likely to be especially effective when the parents' engagement in the program is supported by other family members and close friends. Teaching parents in groups can provide support that is both functional and social and this support will enhance parent participation and learning (Kaiser et al., 1995).
Parent teaching is a good idea when certain conditions exist for their children who will be the targets of the teaching efforts. If children are highly likely to benefit from the parents' newly learned skills and this benefit can be shown through empirical evidence, parents are more likely to participate. When children have specific developmental needs that can be addressed through parent-implemented intervention and parents understand these needs, parents will perceive their participation to be highly important. While parent-implemented interventions can improve the parent-child relationship and increase parent responsiveness to the child (Delaney & Kaiser, 2001), it is easier for parents to begin a parent-teaching program when their children are already responsive to parent overtures and they enjoy spending time with their children.
Finally, parent teaching is a good idea when the adults who will serve as parent educators value parents as co-participants in the training process and work to set collaborative goals with the parents for themselves, the child, and the family. As we discuss in the remainder of this article, parent teaching is a good idea only when the adults serving as teachers have real expertise in the intervention procedures they will teach parents (e.g., supporting children's communication development), are skilled in teaching parents, and are open to feedback from and dialogue with parents about the teaching process, its goals, and outcomes.
WHAT PARENT EDUCATORS NEED TO KNOW
The role of the parent educator is complex and challenging. It is different from other professional roles such as teacher or case manager, although it may include aspects of these roles. Figure 1 shows the minimal set of skills required for parent educators to be effective in teaching parents new strategies to support their children's development. The skills can be grouped into three general areas: (a) skills in doing the intervention with children, (b) skills in teaching parents to do the intervention, and c) skills in managing the parent teaching process. At the core of these skills is the parent educators' fluency in the specific intervention they will teach parents. Fluency requires mastery of the specific child intervention procedures, understanding of the conceptual basis of the intervention and its core assumptions, and the ability to present information about the intervention in a way that is understood by the parents and is applicable to the individual children. Parent educators must be able to implement the intervention with children, to instruct parents in performing the intervention, and to troubleshoot with parents in their use of it, in order to provide specific feedback, coaching, and guidance toward effective implementation.
For example, when a parent educator teaches a mother to implement Enhanced Milieu Teaching (EMT) with her 3-year-old child with a significant language delay, the educator must first be able to implement the EMT procedures effectively with the target child. The parent educator's skill and experience in the EMT intervention allows her to model the procedures with the child, provides the practical knowledge about the types of adaptations that may be required for this child to learn, and establishes with the parent the credibility of both the EMT procedures and the parent educator. In addition to experience in implementing EMT, the parent educator must: (a) have conceptual knowledge of the procedures so that she can talk to the parent about the rationale for each aspect of the teaching protocol, (b) place the intervention in the framework of the child's current developmental characteristics, (c) relate the parent's behavior to the goals of the intervention and the family's goals for the child and themselves, and (d) answer the parent's questions. These skills link the parent educator's ability to perform the intervention directly to her skills in teaching the parent to implement the intervention.
Strategies for teaching parents are summarized in the box “Strategies for Teaching Parents.” Teaching parents requires skills that are different from those required to teach children; however, there are important points of overlap. Creating a safe learning environment requires establishing rapport with the parent and acknowledging the unique situation of the adult learner. In the Milieu Teaching Project, we speak frankly with parents about the challenges of being an adult learner, and we often report our own experiences in learning new language teaching skills. We encourage parents to talk with other parents who have gone through the program, and we share stories of other parents' challenges and successes. By focusing on their children's needs and creating support for the children's development, we place parents' learning of new skills in the context of their goals for their children and their families. The rationale for each parent behavior is presented in terms of the opportunity it offers for child learning. For example, expanding children's utterances gives the children the opportunity to learn elaborated language when their cognition and attention are already focused on a specific event; expansions take advantage of children's momentary readiness to learn new information.
Individual teaching sessions with parents are planned to make efficient use of the time and to tailor the presentation of information and the practice of new techniques to fit the parent's specific needs and skills. Some general principles for teaching parents are applied consistently across the individualized sessions. First, we teach using concrete positive examples of the desired behavior. Parent educators model the specific skill, show videotapes of the parent doing the skill or other parents with similar children performing the strategy. Scripted examples, cartoons or photos with key words, and videotapes of the procedures are given to the parents to take with them. The principles of responsive interaction (Weiss, 1981) that are core to EMT are used in teaching parent educators to: (a) listen carefully to what the parent says; (b) respond to the content, affect, and timing of the parent's communication; (c) balance turns in conversations; (d) teach in response to the parent's behavior and communication; (e) give positive, descriptive feedback; and (f) ask for clarification when the parent's behavior or communication is unclear.
In teaching new information, we first teach the principle (e.g., balance turns in conversations), then the specific applications (e.g., limiting parent talk, pausing to give the child a turn, nonverbal mirroring). We illustrate the principle with positive examples from the parent and child's videotaped sessions. We model with the child and then ask the parent to role play with the parent educator and practice with the child. Because the goal of this training is use of the EMT procedures at home and in everyday interactions with the child, we teach with generalization and maintenance as outcome goals. The parent is asked to generate examples of times when she can use each procedure at home and to keep notes about her use of the procedures between training sessions. The “What Happened Notes” are the anchor for conversations between the parent educator and the parent about the adaptations of EMT that are needed to make the procedures effective in teaching new communication skills at home.
Parent educators must have skills in coaching and giving parents feedback in their use of the target skills being taught. Coaching supports the parents in being immediately successful in implementing the newly learned skills. Parent educators provide assistance to parents while still staying in the background of the parent-child practice interactions. For example, the parent educator may quietly prompt the parent through a milieu teaching episode or remind the parent to praise and describe the child's behavior while the parent plays with the child. In order to coach effectively and give differential feedback about the parent's use of the procedures, the parent educator must know each step of the intervention procedures and be able to troubleshoot the parent's application of the procedures while watching the parent-child interaction. Beginning parent educators may need to analyze videotapes of parents practicing the intervention outside the teaching sessions with parents. Coaching is most effective when parent educators offer suggestions while parents are practicing; however, this requires mastery and fluency in the intervention and skill in tactfully providing precise information to parents. Using an implementation checklist that provides a step-by-step analysis of the intervention will help parent educators focus on parents' performance and give feedback for correct implementation (see Table 3 for an example of an EMT checklist). Sharing the implementation checklist with parents can sometimes help them in both understanding the intervention procedures and in viewing parent educators' feedback as systematic and rational.
Feedback to parents must be individualized to fit their skill in the intervention, their learning style, their education and reading levels, and the level of rapport and comfort between parents and parent educators. Most feedback should be positive, encouraging, and specifically descriptive rather than general. Feedback at the beginning of a session emphasizes what parents have learned in previous sessions and children's progress. Feedback during a teaching session occurs during and after parents practice with their children. Most feedback is verbal descriptions of what parents are doing correctly; however, summary level feedback using graphs, completed implementation checklists, or short written progress notes also are provided. Pre- and post-training videotapes, transcriptions of parent-child interactions, and graphs and test data showing child's progress provide parents with permanent products indicating their learning and the effects of their learning on their children's behavior and development. Some parents are not comfortable receiving praise and direct positive feedback. Reviewing videotapes can be an excellent teaching activity that provides many opportunities for positive feedback to parents, but not all parents enjoy seeing themselves on videotape. Parent educators may ask parents what forms of feedback they prefer, but they must also be attentive to parents' responses and make adjustments immediately to insure that the process of receiving feedback is positive for individual parents.
PLANNING IS KEY TO SUCCESSFUL PARENT EDUCATION
Successful parent education requires planning and preparation for individual sessions and for the series of teaching sessions. Goal setting during an initial meeting defines the tasks for parents and parent educators. Timelines and teaching formats are addressed during the first session so that parents know how many teaching sessions will occur, how long each session will last, and what will occur in each session. The responsibilities of parent educators and parents are discussed and a written summary of the timeline, the goals, and responsibilities of the participants are provided. For example, the parent agrees: (a) to come to the 20 EMT training sessions, (b) lasting about 45 minutes each, (c) scheduled for 2:30 p.m. on Tuesdays, (d) at her daughter's child care, and (e) to notify the parent educator at least 4 hours in advance if she needs to cancel the session. The parent educator agrees: (a) to provide 20 sessions of training, (b) at the time noted, (c) to bring the materials needed for each session, (d) to provide written summaries of the child progress after the training is completed, and (e) to call the parent each week to discuss implementation of the procedures at home.
For each session, parent educators prepare a lesson plan, an implementation checklist, and a parent feedback form. Parent educators set up the room before parents arrive so that their time together is focused exclusively on learning the intervention. In a typical EMT parent teaching session, about 15 minutes is devoted to reviewing child and parent's progress and introducing new information. Role playing or viewing videotapes may be used to provide concrete examples of the new information. The parent is invited to ask questions, report progress at home or modify the proposed agenda to fit her concerns. Typically, the target child is not present during this parent teaching period. The child joins the parent for a period of practicing the new skills. The parent educator may model new strategies with the child, or the parent and child may spend the entire 15 to 20 minutes interacting while the parent practices the new strategies. Parent-child interactions are videotaped for review by the parent educator after the session. The parent educator coaches and gives brief feedback while the parent and child interact. During the last 10 to 15 minutes of the session, the parent is invited to reflect and evaluate the practice session. The parent educator provides information in response to parent comment and concerns and additional feedback about the parent's implementation of the procedures. A few minutes are spent planning for interactions at home and brief homework assignments may be made. Time is set for a follow-up phone consultation later in the week. Sessions always end with summary level positive feedback to the parent about her behavior and her child's progress.
Efficient and effective parent teaching requires outside preparation in addition to the time spent with parents. It is typical to spend more than twice as much time in preparation for teaching parents as is spent on the actual instruction with parents. If videotapes of the parent-child interaction have been made, the parent educator will code or systematically review those tapes to assess parent progress in learning the new skills and child progress resulting from the parent's implementation of the intervention procedures. Parent behavior must be evaluated in reference to specific criterion behaviors indicative of learning the intervention. Based on this assessment of progress, the goals for the next session will be determined and the materials needed to meet these goals will be selected. Parents are given materials that might include videotape samples, transcriptions of the parent-child interaction, handouts summarizing new information, homework to promote generalization, role playing activities, and selection of toys or activities to be used in the parent-child interaction. When parents are having particular difficulty with some aspect of the intervention (e.g., completing milieu teaching episodes correctly or modeling talk exactly at the child's target level), the parent educator may need to analyze parent performance very carefully and create an error analysis and focused teaching plan to help the parent learn the specific skill. Reviewing parents' notes from their use of the intervention strategies at home (e.g. “What Happened Notes”) also help the parent educator understand and address any difficulties parents may be having.
Keeping systematic clinical notes on each session, observing parent and child progress, noting parent concerns and successes, and reviewing these notes prior to each session, helps the parent educator stay focused on the needs of a particular family. Individualization of the education process should occur throughout the sessions based on parent feedback and on the parent educator's continuing assessment of the teaching/learning process. Forms for brief written feedback at the end of each session and more substantive feedback at the mid and end points of the training should supplement the parent educator's ongoing evaluations.
Preparing Parent Educators
Professionals from a variety of disciplines serve as parent educators, but few programs prepare professionals as parent educators. The box “Overview of Professional Preparation for Teaching Parents” provides a comprehensive overview of a professional training program to prepare parent educators. Most parent educators will not have access to such comprehensive preparation and will need to craft their own training by blending their disciplinary preparation with an apprenticeship in parent education.
Parent educators must be able to place the skills they propose to teach parents in the context of children's development and families' goals. Disciplinary preparation focuses on the development of young children, and effective intervention training in family-centered support is foundational to becoming a parent educator. In addition, parent educators need knowledge of and experience in applying the specific child intervention strategies they will teach parents. Demonstrations of this knowledge should be didactic (e.g., showing competency in written and oral examinations covering the intervention procedures, the theoretical basis, and the rationale for using these procedures with children) and practical (e.g., meeting performance criteria in actually using the intervention with young children). Simply put, parent educators cannot teach what they do not know, and demonstrating their didactic and pragmatic knowledge is essential preparation for teaching parents
Parent educators need specific training in the process of parent teaching which includes: (a) working collaboratively with parents in a learning context, (b) setting goals and selecting strategies for parent education, (c) teaching specific intervention skills, (d) coaching, and giving feedback, (e) evaluating parent and child progress, and (f) teaching for generalization and maintenance. The skills outlined in Figure 1 and the principles summarized in the box “Strategies for Teaching Parents” must be acquired.
Parent education is a clinical skill and, thus, apprenticeship type training that includes pratica and supervision is recommended. In preparing parent educators, we have developed a sequence for training that includes: (a) demonstrating criterion-level knowledge about the content of the intervention, (b) demonstrating criterion levels on behavioral coding for observations of parents who are implementing the intervention, (c) practicing the intervention with at least two different children until performance criteria are met, (d) co-teaching at least two parents with an experienced parent educator, and (e) closely supervised parent teaching with at least two more parents. We emphasize behavioral coding of the intervention because this helps new parent educators learn the intervention at a high level of precision and because it teaches them to watch and analyze parent behavior as a basis for giving exact feedback and coaching to the parent. New parent educators are videotaped working with children and receive the same kind of feedback that they will later be giving parents so that they have the experience of being an adult learning a new skill with children. We also videotape new parent educators while they work with parents and give them specific feedback on their strategies for (a) building rapport with parents through responsive interaction strategies, (b) accuracy of new information and responses to parent questions, (c) use of positive examples for teaching new skills, and (d) strategies for coaching and providing feedback to parents.
Typically, professionals who come with solid disciplinary knowledge and good parent communication skills require about 9 months of training in an apprentice/mentoring relationship before they are ready to teach parents a specific intervention independently. Even experienced parent educators benefit from the use of manualized intervention protocols and participation in a supervised clinical working group. Unique challenges arise with families, and consultation with a more experienced parent educator and collaboration with other parent educators provide ongoing professional support. Supervised training in an apprenticeship model is intensive and time consuming; however, it is likely to lead to high levels of skill in teaching parents, the desired developmental outcomes for children, and positive evaluations of the teaching/learning process by parents.
While these guidelines for effective practice with parents have been drawn from empirical data and anecdotal examples from our ongoing research on teaching parents naturalistic language intervention strategies, the principles outlined in this article are still applicable in an early intervention community program setting. In a research context where the work is driven by a specific study protocol, these principles may be applied more intensively and precisely than is necessary in a community setting. The principles themselves though are extremely important to consider any time an adult (the interventionist) is working with another adult (the parent) to effectively support the optimal development of a child with special needs. While delivering services in children's natural environments can be challenging for interventionists working in families' homes, the skills outlined in this article should help support the efforts of parent educators in delivering those interventions. Early intervention program administrators can use information from this article as a guide for the kind of supports that are important to provide interventionists working with parents. While it may not be realistic for interventionists to spend as much planning time as is necessary to deliver a precise research protocol, community program administrators can communicate the importance of planning by allowing parent educators time in their weekly schedule for preparation. It would also be important for parent educators who work in the field to have professional ongoing support by partnering with someone else in the program who works with parents or with a parent educator from another early intervention program in the same community. This partnering would provide the important ongoing support needed for professionals as they develop the skills necessary to work effectively with parents.
During the last 15 years, we have systematically evaluated parents' perceptions of their participation in parent-implemented milieu teaching. These evaluations occur at the end of training and 6 months after the training is completed. Uniformly, parents tell us that their child made progress in the intervention, that they enjoyed learning new skills, and that they would recommend the program to other parents (Delaney & Kaiser, 2001; Hemmeter & Kaiser, l994; Kaiser et al., 2000). Parents' positive evaluations and data on child progress indicate that well-prepared parent educators can teach parents strategies to promote their children's development in ways that also acknowledge and support the unique talents and situations of individual parents.
Strategies for Teaching Parents
* Create a safe and supportive environment for learning
* Set goals for the child and for the parent collaboratively with parent
* Focus on the child and the child's development first, changing parent behavior second
* Apply principles of responsive interaction in interactions with parent: listen, respond, balance turns Teach to parent: behavior and communication, praise, omit negative feedback, ask for clarification
* Plan content and activities of individual sessions and the sequence of sessions to insure mastery of key behaviors
* Teach both the behavioral principle and the specific application; provide multiple examples
* Teach by using concrete, positive examples; provide supporting materials to illustrate examples
* Include practice in implementing the procedures with the child in each session
* Coach and give specific feedback to support parent during practice with child
* Teach for generalization and maintenance; when possible teach across settings, involve other caregivers, provide booster sessions
* Adjust teaching style, teaching methods, criterion performance levels of parent and child, and feedback to the individual parent
* Invite formal and informal feedback from parent at frequent intervals
Overview of Professional Preparation for Teaching Parents
* Core courses in discipline (e.g., special education, speech/language, physical therapy)
* Child development 0–8, including atypical development
* Family processes and ecology, including parenting children with disabilities, and the influence of parents on development
* Instructional strategies for young children
* Human developmental counseling for adults and families
* Applied behavior analysis, including principles of behavior change, data collection, and analysis
* Assessment and intervention with children 0–3, 4–8 (two or more experiences; with emphasis on one-to-one teaching)
* Specialty practicum with target population and disciplinary focus (e.g., language intervention with toddlers who have SLI; language intervention with preschoolers who have autism)
* Working with parents of young children during assessment, home visits, early intervention, classroom, or program participation; IFSP/IEP process
* This practicum emphasizes family-centered services; communication with parents across contexts, responsive listening, and arranging functional support for families
Apprenticeship in Parent Teaching
* Content of intervention
* Strategies for teaching parents the specific content of the intervention
* Practice intervention with child to criterion levels with feedback and coaching
* Observe and support ongoing child and parent intervention
* Collect data from intervention sessions
* Co-train with an experienced parent educator
* Coaching, feedback, and supervision during co-training; ideally feedback will be data based (implementation of parent teaching procedures, parent change, child change)
* Supervised teaching with at least two additional families
* Support and supervision during first year of independent teaching (data, coaching and feedback as needed, planning and problem solving with professional peers)
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