TO SUPPORT the implementation of Individuals with Disabilities Education Act Part C services (IDEA, 2004), the Division for Early Childhood (DEC, 2014) identifies coaching as an evidence-based strategy that can be used by early interventionists to engage families as decision makers and participants in their children's intervention. Although there is broad consensus that caregiver-implemented interventions are effective (Akamoglu & Meadan, 2018; Roberts & Kaiser, 2011), research in this area continues to be challenged by varying definitions of coaching and the component practices used in caregiver coaching (Biel et al., 2019, in press; Kemp & Turnbull, 2014; Meadan, Snodgrass, Palomo, Amenta, & Halle, 2017). The definition of a caregiver also varies across studies (e.g., Biel et al., 2019, in press; Windsor, Woods, Kaiser, Snyder, & Salisbury, 2019); therefore, for the purposes of this article, caregivers are defined as immediate or extended adult family members who have consistent interactions with the child in everyday activities.
Kemp and Turnbull (2014) highlighted differences across coaching approaches by exploring a continuum of coaching practices in early intervention (EI). On one end of the continuum, researchers defined coaching as a way to help caregivers learn to use specified intervention strategies with their children through a directive process led by the provider, similar to traditional parent training approaches. The provider was viewed as the “expert,” making intervention decisions for the family and teaching the caregiver strategies they believed were best for the child. At the other end of the continuum, coaching was defined as building family capacity to enhance child's development through a collaborative process, including the family and the provider working together. In a family capacity-building framework, providers support caregivers in identifying their goals and priorities for the child while also learning about, reflecting upon, and choosing which supports to use with their child (Swanson, Raab, & Dunst, 2011; Windsor et al., 2019).
A unique aspect of the family capacity-building framework is the focus on the caregiver's sense of confidence and competence in supporting their child. Providers support caregivers in knowing how to increase or decrease supports as the child grows and learns, how to adapt strategies to new contexts and as challenges arise, and how to share this information with other important family members who can also implement the intervention (Salisbury et al., 2017). Problem solving and reflection are two coaching strategies that are part of many family capacity-building coaching approaches and are often used to build a caregiver's confidence and competence in intervention planning and implementation (e.g., Brown & Woods, 2015; Schertz, Odom, Bagget, & Sideris, 2018). Although used frequently, these strategies are not well defined in EI research and, as such, are difficult to compare and replicate when examining caregiver-implemented interventions for young children. In this article, we examined how often and in what ways problem solving and reflection were used in caregiver-implemented intervention studies and how these strategies may be further defined to clarify implementation procedures in research on family capacity-building approaches.
CAREGIVER COACHING IN EI
As the evidence base for caregiver coaching was being developed, research on adult learning and professional development practices served as a guide for the development of caregiver coaching approaches in EI (Bransford, Brown, & Cocking, 2000; Trivette, Dunst, Hamby, & O'Herin, 2009). The National Research Council (NRC) published a research synthesis on adult learning called How People Learn leading to three main recommendations for designing and conducting adult learning experiences, which are often cited in descriptions of caregiver coaching (Bransford et al., 2000). First, adults learn best when their current knowledge is used to support their understanding of new information. By identifying what the learner already knows, an instructor can design programs to support continued learning, focusing on the foundational content as needed. The second recommendation was to build the learner's content knowledge, relating new content to a conceptual framework, which supports the learner's ability to retrieve, use, and generalize content to new situations. Finally, the third NRC recommendation incorporated elements of both problem solving and reflection. Adult learners must be able to monitor their understanding of content and identify situations in which they need additional information. They should be taught how to set learning goals and reflect upon their application of content and progress made.
Trivette et al. (2009) furthered these recommendations after conducting a research synthesis of 79 professional development studies, all of which included a method of adult learning and a randomized controlled trial or a nonequivalent comparison group design. Based on the NRC's recommendations for adult learning, a sequence of six adult learning characteristics were identified across studies, including the following: (a) introduction, (b) illustration, (c) practice, (d) evaluation, (e) reflection, and (f) mastery (Bransford et al., 2000). Results of the synthesis revealed that all six characteristics led to positive outcomes for adult learners, with outcomes being even stronger when a combination of the characteristics were used as well as opportunities for learners to take an active role in applying and evaluating their newly acquired knowledge and skills.
Most empirical studies on caregiver coaching in EI follow the recommendations of the adult learning literature, using a combination of coaching strategies rather than a single or specific instructional approach. Commonly used caregiver coaching strategies in EI include (a) joint planning, (b) information sharing, (c) observation, (d) direct teaching, (e) demonstration or modeling, (f) practice, (g) feedback, (h) problem solving, and (i) reflection (Brown & Woods, 2015; Friedman, Woods, & Salisbury, 2012; Kemp & Turnbull, 2014; Roberts & Kaiser, 2015; Rush & Shelden, 2011; Wright & Kaiser, 2017). Table 1 provides definitions of the different coaching strategies frequently included in studies of EI caregiver-implemented interventions (Friedman et al., 2012; Kemp & Turnbull, 2014).
PROBLEM SOLVING AND REFLECTION AS COACHING STRATEGIES
In the research synthesis by Trivette et al. (2009), the two adult learning characteristics with the strongest effects were evaluation and reflection. Evaluation was defined as a “process of evaluating the consequence or outcome of the application of the material, knowledge, or practice,” and reflection was defined as the “self-assessment of acquisition of knowledge and skills as a basis for identifying next steps in the learning process” (Trivette et al., 2009, p. 3). These two characteristics, which share features of the problem solving and reflection coaching strategies in EI, had the largest effects on adult acquisition of skills across studies reviewed. As such, opportunities for problem solving and reflection may also be critical for caregivers' acquisition of intervention skills and progress in meeting their children's developmental needs.
In EI, problem solving and reflection are two caregiver coaching strategies cited as important for building caregiver competency, confidence, and capacity to support the child's learning in the natural environment (Woods & Brown, 2011). Both strategies encourage the use of metacognition, and it has been suggested that adults can improve their own problem solving and reflection skills through practice and coaching (Anderson, 1993; Dewey, 1933; Siller et al., 2018). During caregiver coaching sessions, problem solving typically occurs when the provider and the caregiver identify problems related to intervention implementation and discuss strategies for improving interactions, strategy use, or child development (Friedman et al., 2012; Kemp & Turnbull, 2014). Reflection includes self-evaluation or self-assessment, with providers and caregivers identifying what went well or what was challenging during an experience and the associated beliefs or emotions related to that experience (Friedman et al., 2012; Kemp & Turnbull, 2014). It is thought that the two strategies build off each other with opportunities for problem solving potentially leading to opportunities for reflection and vice versa.
Very little research in EI has specifically and systematically examined the use of problem solving and reflection during caregiver coaching sessions. Caregivers who received coaching from providers often reported that they found problem solving and reflection to be helpful to their learning of intervention strategies with their children, but providers expressed difficulties in facilitating problem solving and reflective conversations with caregivers (Salisbury et al., 2017). Despite these difficulties, providers reported problem solving and reflection strategies to be beneficial and useful in caregiver coaching: “Letting the parent problem-solve [and] reflect ... forced me to sit back and give the parents more independence” (Salisbury et al., 2017, p. 7). Providers also found reflection advantageous for supporting “brainstorming and building a trusting relationship” with caregivers (Salisbury et al., 2017, p. 7).
The difficulties noted by providers may be a result of the limited and variable definitions of problem solving and reflection in the field as well as inadequate descriptions of how these types of conversations can be facilitated with caregivers during coaching sessions. Furthermore, it may be that not all caregiver coaching approaches include problem solving and reflection as specific coaching strategies, and this variability across approaches and definitions of caregiver coaching may limit access to strategies that can enhance the caregiver's application and generalization of the intervention strategies. Because there is not a widely agreed upon definition or set of required strategies for caregiver coaching in EI, researchers are limited in their ability to compare coaching approaches and practices to determine which are effective with whom and under what conditions. By first explicitly defining problem solving and reflection and then evaluating their effects on caregivers, researchers and professional development providers can better support providers in recognizing when, how, and why problem solving and reflection should be used to fully support caregiver independence as well as a collaborative, family-centered, provider–caregiver relationship.
PURPOSE OF THE REVIEW
The need for explicit definitions of coaching approaches and strategies is well documented (Barton & Fettig, 2013; Friedman et al., 2012; Kemp & Turnbull, 2014). In this scoping review, we further the work of Kemp and Turnbull (2014) by examining the definitions of caregiver coaching in EI as well as the inclusion and definitions of problem solving and reflection coaching strategies across coaching approaches. Scoping reviews focus on broad research questions, allowing researchers to summarize the current literature base, identify gaps, and inform policy, practice, and future research on the reviewed topic (Armstrong, Hall, Doyle, & Waters, 2011; Tricco et al., 2016). Our goal was to develop recommendations for refining definitions of caregiver coaching, problem solving, and reflection while also encouraging continued research on these topics. The review addressed the following research questions:
- How did studies define caregiver coaching, and what were the common characteristics of studies that evaluated EI caregiver coaching approaches?
- How prevalent were problem solving and reflection coaching strategies in studies that evaluated EI caregiver coaching approaches?
- How were problem solving and reflection coaching strategies defined in studies that evaluated EI caregiver coaching approaches?
Literature search strategy
Given there are no standardized guidelines for reporting scoping reviews (Tricco et al., 2016), the procedures for the current review were based on (a) the methodological framework proposed by Arksey and O'Malley (2005), (b) the PRISMA guidelines (Shamseer et al., 2015), and (c) a previous review of second-generation caregiver coaching literature conducted by Kemp and Turnbull (2014). The Kemp and Turnbull (2014) review served as the starting point for this review, and those articles (n = 8) were automatically included. A search of peer-reviewed literature published from January 2013 to June 2018 was conducted to identify articles published since 2012.
Multiple searches were completed in the following academic databases: ERIC ProQuest, PsychINFO, PubMed, and Web of Science. The search was limited to journals published in English. Search terms included early intervention OR early childhood AND coaching OR training AND caregiver OR parent. A total of 3,924 articles met the initial online search criteria. A hand search of the reference sections of articles was performed to identify additional studies. Journals dedicated to EI and early childhood were also reviewed to identify any studies missed in the database searches (Infants & Young Children, Topics in Early Childhood Special Education, and Journal of Early Intervention). Finally, studies included in published systematic reviews or meta-analyses related to EI were reviewed to ensure that the search was fully inclusive (e.g., Bradshaw, Steiner, Genoux, & Koegel, 2015; Meadan et al., 2017). The additional search procedures increased the final article count to 3,935. An initial screening of the titles and abstracts of all articles was conducted to rule out those not related to the topic of the review or duplicates of another article found in a different database.
Articles were included in the review if (a) participants were EI providers, caregivers, and at least one child with or at risk for developmental delays or disabilities aged 36 months or younger; (b) the study included caregiver coaching provided in the family's home; (c) the article described a coaching or parent training intervention that related to at least one EI discipline (e.g., speech–language pathology, occupational therapy, physical therapy, behavioral therapy, early childhood education, etc.); (d) the study was peer-reviewed and published between 2013 and 2018 (Kemp & Turnbull, 2014). Studies were excluded if they did not provide descriptions of caregiver coaching procedures or were nonempirical, describing caregiver coaching without any measure or data collection. Based on these criteria, 31 studies in addition to the eight studies from the Kemp and Turnbull (2014) review were included and reviewed (n = 39; Figure 1).
All 39 articles were coded using a comprehensive coding manual. Information extracted from articles was entered into a Microsoft Excel document and later summarized into tables. Each article was coded for the following: (a) study design; (b) use of the term “coaching”; (c) definitions of caregiver coaching; (d) child, caregiver, and coach attributes; (e) context of the coaching; (f) the inclusion of nine coaching strategies; and (g) definitions of problem solving and reflection. The nine coaching strategies in the coding scheme were identified on the basis of the work of current researchers who have examined theories of coaching and coaching implementation across various settings and populations of children in EI (Friedman et al., 2012; Kemp & Turnbull, 2014; Rush, Shelden, & Hanft, 2003; Stoner, Meadan, & Angell, 2013; Woods, 2013; Woods, Wilcox, Friedman, & Murch, 2011). A specific definition of each coaching strategy was based upon the original work of Friedman et al. (2012) and was then revised using additional details from Kemp and Turnbull (2014). The intent was to define each strategy in measurable and observable terms that could be differentiated from other strategies.
Article coding was completed by the authors, as well as trained undergraduate and graduate students in communication sciences and disorders. Coder training procedures began with an introduction to caregiver coaching by independently reading the Friedman et al. (2012) and Kemp and Turnbull (2014) articles on specific coaching strategies. Next, each coder met with one of the authors to discuss the content of the articles and the nine coaching strategies included in the article coding scheme. After reviewing each coaching strategy and identifying examples of each, one of the authors and the student sat side by side and coded two articles not included in the review, discussing any disagreements until consensus was met. Training articles included studies on coaching practices with teachers in a classroom setting or in homes with parents of children older than 3 years, all of whom did not meet eligibility for inclusion in the current review. Coder training continued with independent coding, followed by discussion for five additional training articles. Coders met an average of 80% agreement on at least three training articles before coding articles in the review.
During the first round of coding, all articles were double-coded by two independent coders, resulting in 83% (range = 53%–100%) reliability. Coders met weekly to discuss articles coded, and reliability measures were conducted throughout the coding process to ensure that reliability levels remained consistent. When disagreements in coding were noted, a second round of coding was conducted by a third coder to examine the disagreements. Based on the first, second, and third coders' findings, the coding team came to consensus on the appropriate final codes.
Content analysis for definitions
After coding each article, quoted definitions of caregiver coaching, problem solving, and reflection from individual articles were examined using methods of inductive content analysis (Cavanagh, 1997; Cho & Lee, 2014; Kondracki, Wellman, & Amundson, 2002). Codes and coding categories were directly drawn from the definitions and descriptions presented in articles. All quoted definitions and descriptions from each article were uploaded to QSR International's NVivo 12 Pro (2018), a qualitative analysis computer software package.
Before beginning the coding process, the first author read all article quotes in NVivo for familiarization. Next, using a constant comparative process, the first author began the initial coding process, developing codes based on the information provided in descriptions and definitions (Taylor & Bogdan, 1998). Initial coding resulted in total of 21, 8, and 17 codes for caregiver coaching, problem solving, and reflection quotes, respectively. The first and second authors then identified patterns across the initial codes and collapsed any codes that overlapped, resulting in a total of 9, 10, and 10 categories and subcategories for caregiver coaching, problem solving, and reflection, respectively. All four authors reviewed the collapsed codes and resulting categories. Using their clinical and research expertise in caregiver coaching and theories of adult learning, the team concluded on final coding categories (Table 2). The first and second authors then recoded all article quotes using the final coding scheme. Each article quote was coded as a single unit and coded with more than one subcode within main codes as appropriate.
The first and second authors independently coded 100% of all caregiver coaching, problem solving, and reflection quotes included in the reviewed articles, resulting in 90%, 89%, and 89% reliability, respectively. Reliability was calculated by taking the number of subcode agreements divided by the total number of subcodes coded for the unit and then multiplying by 100. An agreement was defined as both coders coding the same code for the same unit, or article quote. All disagreements were further analyzed by returning to the original article and reevaluating the definitions provided. Based on the reanalysis, the first and second authors came to a final decision on the appropriate code to include. The third and fourth authors reviewed the final coding to check for consistency and overall agreement with coding outcomes.
Study design and demographics
Of the 39 articles (Table 3), study designs included randomized controlled trials (n = 23), nonrandomized group designs (n = 2), single case designs (n = 11), and case study designs (n = 2). One article described two studies, which included a randomized controlled trial and a single case design (Welterlin, Turner-Brown, Harris, Mesibov, & Delmolino, 2012). The number of caregiver–child dyads in studies ranged from 1 to 757, resulting in a total of 3,709 caregivers and 3,701 children (Table 4). Mothers were the primary caregivers participating in the studies, with 13 studies reporting both male and female caregiver participants. Nine articles did not state the parental role or gender of the caregiver. The average age of caregivers in the current review was 32 years. Caregiver education ranged from some high school to graduate degrees, and family income ranged from “low income” to greater than $100,000 per year. Twelve articles listed the primary language(s) spoken by families and seven required caregivers to be proficient in a specific language but did not report the primary language(s) spoken in the home. A majority of the studies included child participants with diagnosed disorders (n = 27), including autism spectrum disorder, Down syndrome, speech–language disorders, and fragile X. A total of 12 studies included only children at risk. Six studies included a combination of children with diagnosed disabilities and children at risk.
The descriptions of coaches across the articles were limited. A total of 16 articles did not report the total number of coaches in the study, 33 did not report information on the coaches' years of experience in the field, and 13 did not report information on coaches' educational background. Of the articles that did provide information on experience and education, years of experience in the field ranged from 1 to 15 years, and most coaches had a bachelor's degree or higher. Three articles reported coaches having less than a bachelor's degree. The number of coaches in individual studies ranged from 1 to 114, and most studies included coaches who were considered therapists, interventionists, or clinicians (n = 26). Other studies included coaches who were researchers (n = 3) or graduate students studying a field related to EI (n = 9). Sixteen articles mentioned the language used by coaches during sessions with four studies specifically coaching in the family's preferred language.
Caregiver coaching strategies
Coaching strategies included in caregiver coaching approaches often varied across the articles in the current review (Table 3). The strategies included in most caregiver coaching approaches were direct teaching (95%, n = 37); practice (92%, n = 36); and feedback (82%, n = 32). The use of direct teaching varied across studies, ranging from content being provided to caregivers through a formal workshop with handouts or a manual (Brock, Kochanska, O'Hara, & Grekin, 2015; Shapiro, Kilburn, & Hardin, 2014) to more informal settings such as the family's home, with content delivered before, during, or after practice opportunities with the child (Brown & Woods, 2015; Guttentag et al., 2014). The procedures used to provide practice and feedback were fairly consistent; caregivers were typically given opportunities to practice using target strategies with their children or through role-play with other adults. Feedback was often provided verbally, either within or immediately following a practice opportunity, or at a later time through written or video review feedback. Demonstration and modeling were also included in several caregiver coaching approaches, with 79% (n = 31) providing demonstrations or models of intervention strategies through video or provider models.
Coaching strategies that were less frequent across caregiver coaching approaches included information sharing (38%, n = 15), joint planning (44%, n = 17), and observation (56%, n = 22). Joint planning topics varied and were limited in descriptions. For example, Hackworth et al. (2017) had providers assist caregivers as they planned when and where to use target intervention strategies, but it is unclear whether the planning was for the current session or for practice between coaching sessions. Brown and Woods (2015) specifically had providers include caregivers in the intervention plans for the current session and also supported the caregiver in planning how to continue using strategies between sessions.
Problem solving and reflection
Problem solving and reflection were not included in the majority of studies evaluated. Specifically, problem solving was included in 33% (n = 13) of studies, and reflection was included in 41% (n = 16). Descriptions of strategies or methods for facilitating problem solving and reflection were limited. Of the studies that included both problem solving and reflection as coaching strategies (23%, n = 9), all but one (Schertz et al., 2018) also included both practice and feedback as defined in Table 1. Of the 11 studies including problem solving (10%, n = 4) or reflection (18%, n = 7) but not both, eight included practice and feedback, two included practice with no feedback (Aboud, Singla, Nahil, & Borisova, 2013; Rivard, Terroux, & Mercier, 2014), and one did not specify practice or feedback (Blauw-Hospers, Dirks, Hulshof, Bos, & Hadders-Algra, 2011). When further examining the combinations of coaching strategies, studies that included problem solving and/or reflection had on average a combination of seven of the nine coaching strategies included within their coaching approach. The studies that did not include problem solving or reflection had an average combination of only four different coaching strategies in their coaching approach.
After identifying the number of studies that included problem solving and reflection as caregiver coaching strategies, content analysis procedures were used to further evaluate definitions and descriptions of caregiver coaching, problem solving, and reflection. A total of 23 articles provided definitions or descriptions of caregiver coaching (n = 14), problem solving (n = 8), or reflection (n = 16), and were therefore evaluated using content analysis procedures (Tables 5 and 6).
Definitions of caregiver coaching
Although 24 articles used the term “coaching” to describe their caregiver education program, only 14 provided definitions of caregiver coaching that could be coded using content analysis procedures (Table 5). Coding categories for definitions and descriptions of caregiver coaching included the following: (a) Characteristics, (b) Specific Coaching Strategies, (c) Caregiver Roles in Coaching, (d) References Cited, and (e) Mentioned Only. Four articles cited sources when describing coaching practices (McDuffie et al., 2016; Salisbury & Copland, 2013; Siller, Swanson, Gerber, Hutman, & Sigman, 2014; Wright & Kaiser, 2017). Sources cited included Friedman et al. (2012; n = 2), Kemp and Turnbull (2014; n = 1), Trivette et al. (2009; n = 1), and Woods & Brown (2011; n = 1). Ten articles mentioned caregiver coaching without providing any further description or definitions of the coaching process.
Twelve articles included some type of description related to the characteristics of caregiver coaching. This coding category included four subcategories: (1) Collaborative (n = 6), Family-guided (n = 3), Strategy and Skill Focused (n = 11), and Process (n = 8). Often times, codes were explicitly included in article definitions and descriptions. For example, “Collaborative” and “Family-guided” were terms used to describe specific caregiver coaching practices (Brown & Woods, 2015; Wetherby et al., 2014). Wright and Kaiser (2017) mentioned a “shared process,” suggesting that coaching practices had a collaborative component. Description suggesting caregiver coaching was focused on caregiver strategy use or building caregiver skills that included explicit mentions of coaching being used to support caregivers in using interventions and identifying the impact of the intervention on the child (Brown & Woods, 2015; Hackworth et al., (2017); Ingersoll, Wainer, Berger, Pickard, & Bonter, 2016; Wetherby et al., 2014; Wright & Kaiser, 2017). The process of caregiver coaching was defined by some researchers as being a 4-step process (Wetherby et al., 2014), a structured or cyclic process (Siller et al., 2014; Wright & Kaiser, 2017), or a process that carries over information learned in group trainings to home settings (Hackworth et al., (2017)).
Specific coaching strategies
Although all 39 articles in the review included specific coaching strategies within their coaching approach, only 10 articles explicitly identified the specific coaching strategies as part of their caregiver coaching descriptions or definitions. One article (Salisbury & Copeland, 2013) mentioned specific coaching strategies without providing further detail related to the characteristics of coaching or the caregiver's role in the coaching process.
Caregiver roles in coaching
Five articles described the caregiver role as part of the description or definition of caregiver coaching. Roles included caregivers being involved in intervention planning and implementation (Blauw-Hospers et al., 2011; Brown & Woods, 2015; Siller et al., 2014), and decision makers in identifying next steps for their child (Blauw-Hospers et al., 2011; Brown & Woods, 2015; Wright & Kaiser, 2017).
Definitions of problem solving
A total of 13 studies included problem solving as a coaching strategy but only eight provided further description of how problem solving was used to support caregivers (Table 6). Coding categories included the following: (a) Characteristics, (b) Questions, (c) New Ideas, (d) References Cited, and (e) Mentioned Only. Only one article (McDuffie et al., 2016) cited an outside source when describing problem solving and that source was Friedman et al. (2012).
The Characteristic coding category included four subcategories: (1) Collaborative, (2) Process, (3) Timing, and (4) Purpose. Four articles described the characteristics of problem solving with each describing problem solving as collaborative (Brown & Woods, 2015; McDuffie et al., 2013; McDuffie et al., 2016; Vismara, Young, & Rogers, 2012). Only one article described both the timing and purpose of problem solving (Brown & Woods, 2015), stating that problem solving was conducted “within each routine and across sessions to build the parents' capacity to embed strategies” (p. 53). Vismara et al. (2012) described only the purpose of problem solving, mentioning the use of questioning to “encourage parent evaluation about the strategies practiced and what to try next” (p. 4). No articles provided information regarding the process of problem solving.
Three articles mentioned questions that were used to support caregiver problem solving (Schertz et al., 2018; Siller et al., 2014; Vismara et al., 2012). Schertz et al. (2018) mentioned that questions were used to “elicit parents' new ideas” (p. 858). Siller et al. (2014) and Vismara et al. (2012) provided specific examples of problem-solving questions.
Five articles described problem solving as supporting caregivers in identifying new ideas to move forward with intervention (Bagner et al., 2016; Brown & Woods, 2015; Salisbury & Copland, 2013; Schertz et al., 2018; Vismara et al., 2012). For example, Brown and Woods (2015) that stated “collaborative problem solving occurred to ... identify new routines or strategies to try” (p. 53), and Salisbury and Copeland (2013) mentioned using problem solving to discuss “how to embed and generalize skills to other settings outside the home” (p. 70). Schertz et al. (2018) specifically mentioned using questions to probe “new ideas” (p. 858), and Vismara et al., (2012) provided an example of a question that may support caregivers in identifying new ideas: “what would you try differently the next time the two of you attempt this activity?” (p. 4).
Definitions of reflection
Sixteen articles included reflection as a coaching strategy, and all provided further description (Table 6). Coding categories for descriptions of reflection included the following: (a) Characteristics, (b) Questions, (c) Mode, (d) References Cited, and (e) Mentioned Only. Only one article (McDuffie et al., 2016) referenced an outside source in their description of reflection and that source was Friedman et al. (2012).
Similar to the problem-solving definitions, subcategories for the Characteristics code included (a) Collaborative, (b) Process, (c) Timing, and (d) Purpose. Only one article described the process of reflection (Vismara et al., 2012), and two described the timing (Moore, Barton, & Chironis, 2014; Vismara et al., 2012). Six articles described reflection as being conducted collaboratively with the caregiver (Landry et al., 2012; McDuffie et al., 2013, 2016; Moore et al., 2014; Vismara et al., 2012; Wetherby et al., 2014). Nine articles described the purpose of using reflection as a coaching strategy. Six described reflection as supporting caregiver self-analysis (Guttentag et al., (2014); Meadan et al., 2016; Moore et al., 2014; Schertz et al., 2018; Siller et al., 2014; Vismara et al., 2012). Others mentioned that reflection was used to review the session (n = 4; Moore et al., 2014; Rivard et al., 2014; Roberts & Kaiser, 2015; Schertz et al., 2018) and support caregiver practice (n = 3; Brown & Woods, 2015; Moore et al., 2014; Siller et al., 2014).
Seven articles mentioned using questions to support caregiver reflection. Questions focused on what was working for the family (n = 4; Dempsey, Kelly-Vance, & Ryalls, 2013; Moore et al., 2014; Schertz et al., 2018; Vismara et al., 2012) and what was challenging (n = 4; Moore et al., 2014; Rivard et al., 2014; Schertz et al., 2018; Vismara et al., 2012). One article specifically mentioned using open-ended questions (Wright & Kaiser, 2017) and one article only mentioned using questions without any further description or examples of questions posed (Ingersoll et al., (2016)).
Seven articles described the modes used to facilitate reflection in caregivers. Five studies used video reviews (Guttentag et al., (2014); Landry et al., 2012; Moore et al., 2014; Schertz et al., 2018; Siller et al., 2014), two studies used forms or checklists (Ingersoll et al., (2016); Meadan et al., 2016), and one study used reflective journals (Siller et al., 2014). Three studies included opportunities for reflection in coaching sessions delivered remotely through telepractice (McDuffie et al., 2013, 2016; Meadan et al., 2016; Vismara et al., 2012).
Overlap of definitions
Five articles were noted to have overlap of problem solving and reflection descriptions and definitions (Brown & Woods, 2015; Landry et al., 2012; McDuffie et al., 2013; Schertz et al., 2018; Vismara et al., 2012). The overlap of definitions made it difficult to differentiate between characteristics and processes related specifically to problem solving versus reflection.
This scoping review evaluated 39 peer-reviewed, empirical studies, identifying specific coaching strategies within EI caregiver coaching approaches published between 2011 and 2018. Problem solving and reflection, the primary focus of this review, were two specific coaching strategies that were infrequently included in the approaches, and of the studies that did include these strategies, limited definitions and descriptions of the strategies were provided. This finding is important as problem solving and reflection are often identified as important adult learning strategies that facilitate caregiver competence and confidence (Brown & Woods, 2015; Schertz et al., 2018). In the following paragraphs, recommendations are provided for refining definitions of caregiver coaching, problem solving, and reflection, and conducting future research on this topic.
Defining caregiver coaching
A total of 30 articles used the term “coaching” to describe caregiver education procedures but only 14 provided definitions or descriptions of their coaching approach. This finding is consistent with previous review of Kemp and Turnbull (2014) and illustrates that researchers have not yet changed their practices to include specificity in defining this broad term. The limited descriptions and operational definitions of the coaching process hinder replication of research, preventing researchers from comparing and refining coaching practices across studies. Furthermore, minimal descriptions of coaching characteristics and processes, as well as the educational background of those implementing coaching likely contribute to providers' confusion as to what constitutes coaching, how coaching practices should look in the field, and the educational experiences needed to coach caregivers with fidelity (Salisbury et al., 2017).
Working with caregivers collaboratively and targeting effective caregiver use of intervention strategies were the most common themes among descriptions of caregiver coaching in the articles reviewed. However, this information alone is not enough to support providers and enable replication in future studies. Specific information regarding the characteristics of caregiver coaching is needed. For example, researchers must define what is meant by “collaborative.” Wright and Kaiser (2017) described their coaching approach as being collaborative and when describing the caregiver role in coaching, caregivers were “decision makers” but there were no descriptions of when and how these decisions took place, or what the provider did to coach the caregivers to become a decision maker. In contrast, Brown and Woods (2015) described their coaching approach as collaborative, describing caregivers as decision makers when they were involved in intervention planning. Wetherby et al. (2014) also described a collaborative coaching approach but did not specifically mention the caregiver's role. It may be that all three studies included caregivers as decision makers who were involved in the intervention planning and implementation process, but details to confirm their roles could not be discerned from the article text alone.
Explicit descriptions of the intentional coaching process were also missing from many caregiver coaching definitions and descriptions. Some researchers described the process as being structured (Siller et al., 2014; Wetherby et al., 2014), cyclic (Wright & Kaiser, 2017), or based on information learned in group trainings (Hackworth et al., (2017)). The sequencing of coaching strategies and when specific coaching strategies were or were not used was not clear. Exploring the intentional process of coaching and the sequencing of coaching strategies may help the field identify when specific coaching strategies can be most effective (Bransford et al., 2000). For instance, problem solving may work best when implemented after direct teaching and demonstration, prior to a caregiver practice opportunity. In addition, following a practice opportunity with reflection may support the caregiver in evaluating progress and areas for improvement, leading to yet another opportunity for problem solving. As noted in the results, practice and feedback were two coaching strategies often identified in approaches that also included both problem solving and reflection. This may suggest that practice and feedback support metacognitive learning opportunities and are potentially the primary topics of problem solving and reflection. By explicitly describing the coaching process, researchers can further examine the best way to sequence caregiver coaching strategies during home visit sessions and compare this sequencing to caregiver and child outcomes (Barton & Fettig, 2013; Kemp & Turnbull, 2014). This information may also support professional development instructors or coaches who offer feedback to providers in the field (Salisbury, Woods, & Copeland, 2010).
Defining and delineating problem solving and reflection
Despite research showing the importance of problem solving and reflection for adult learning (Bransford et al., 2000; Trivette et al., 2009), these two coaching strategies were delineated in fewer than half of the caregiver coaching approaches reviewed. The field has limited information on how these strategies are or can be used with caregivers, and even less on the impact these strategies have on caregivers' intervention implementation. Most coaching approaches are evaluated as a package of multiple coaching strategies, making it difficult to identify which coaching strategies have the greatest impact on child intervention outcomes or which strategies may be used to extend interactions and support caregiver confidence. The first step toward better understanding problem solving and reflection as coaching strategies is to operationally define each within specific studies. This may be difficult as it was noted that some articles in the review had descriptions of problem solving and reflection that overlapped. For the purpose of this review, problem solving focused on identifying problems, potential solutions, and opportunities for future practice, and reflection focused on evaluating what went well, what was challenging, and any thoughts or feelings related to intervention progress (Table 1).
Based on the findings from the current review, identifying the specific purpose of problem solving and reflection may strengthen definitions and support providers in using these coaching strategies appropriately and effectively. For example, is problem solving and reflection meant to support caregiver intervention implementation, child developmental progress, caregiver sense of self-efficacy, or other positive outcomes? Problem solving and reflection may also be useful for strengthening the provider–caregiver relationship and building feelings of trust (Salisbury et al., 2017), or increasing caregivers' confidence in their intervention implementation abilities. As such, researchers are encouraged to operationally define not only individual coaching strategies, such as problem solving and reflection, but also the purpose of each strategy, allowing the field to recognize why and how strategies are used and when they might be implemented during a home visit session.
Question types and topics
Multiple studies discussed using questions to support both problem solving and reflection in caregivers. However, only two studies provided specific examples of questions used to support problem solving and reflection, with questions focusing on recalling intervention goals, summarizing what worked and did not work, and discussing what the caregiver could try differently in future sessions (Siller et al., 2014; Vismara et al., 2012). Although not explicitly stated, in most caregiver coaching approaches reviewed, reflective questions seemed to revolve around “what worked” and “what was challenging.” Identifying questions that go beyond these topics may be necessary to support caregivers in acknowledging their confidence and biases toward an intervention, understanding why an intervention worked or did not work, and recognizing when to modify an intervention to continue making progress. Examples of questions and topics discussed in studies may be important for replicating coaching strategy use in future research and the field and determining which types of questions have the most significant impact on caregiver and child outcomes.
Frequency, duration, and fading
At this point, it is unclear how often and how long providers and caregivers should engage in problem solving and reflection during a single home visit session. With further research on this topic, the field may find the timing of problem solving and reflection changes as caregivers become more confident and comfortable implementing interventions with their child. In contrast, researchers may find the frequency and duration remains consistent across time for some caregivers due to their continued learning of new intervention strategies. Additional research will help the field determine when and how providers can fade supports, encouraging the caregiver to take the lead and have a more independent role in problem solving and reflection. Opportunities for caregiver-led problem solving and reflection may ultimately build the caregivers' capacity to provide interventions that meet their child's developmental needs across multiple routines and settings.
Consideration of culture and mode
The family's cultural background, and the mode or format of problem solving and reflection may also be important when considering operational definitions. Few studies provided information regarding the families' first language and whether coaching sessions were conducted in their preferred language. Little information regarding the specific demographics of the participants (e.g., education or ethnicity) could be identified in several studies, resulting in further questions about the applicability of coaching for diverse populations. Details about the mode or format of coaching were limited as well. Many articles mentioned opportunities for reflection through checklists, forms, journals, video reviews, conversation, or a mixture of one or more of these modes. Problem solving appeared to be primarily conducted through conversation, although modes of problem solving were not explicitly stated in any of the studies.
Each mode of problem solving and reflection required the use of language for thinking, writing, or conversing, and as such, the use of a family's preferred language may be critical for supporting caregivers in evaluating and reflecting on their own practices. Research on problem solving and reflection across families with different cultural backgrounds may support providers in aligning coaching practices to meet the diverse needs of the families served in the field. Furthermore, examining how problem solving and reflection change on the basis of the specific mode used, or the family's cultural background and primary language, may help the field better understand problem solving and reflection as coaching strategies as well as the overall coaching process. For example, some caregivers may problem solve and reflect differently when they do so in writing or after watching a self-video versus problem solving or reflecting in conversation with the provider after a live practice opportunity. The same may be true for caregivers who are encouraged to reflect while receiving coaching remotely via telepractice versus in person. Some caregivers may respond better to one mode compared with another depending on their cultural background, and caregivers who are new to EI and coaching may need structured forms or checklists to support their early problem solving and reflection skills, eventually requiring less support as they build their intervention skills (Collin, Karsenti, & Komis, 2013; Schön, 1987).
Although many researchers and professional development providers include problem solving and reflection strategies within their coaching approaches, this scoping review appears to be one of the first to examine problem solving and reflection as specific coaching practices in EI caregiver coaching. Research on adult learning and professional development identified multiple factors that are important for knowledge application, including the ability to evaluate when, where, why, and how intervention strategies can be used, and how to develop a plan for moving forward and transferring learning to other contexts and expectations (National Academies of Sciences, Engineering, and Medicine [NASEM], 2018). Comparing these influential factors with the voices of caregivers who have experienced caregiver coaching illustrates the potential of these strategies to build caregiver capacity within EI programs (Salisbury et al., 2017).
Future research examining how problem solving and reflection are facilitated by providers during coaching sessions and how these strategies lead to caregiver understanding of intervention concepts is warranted. Explicit research on these coaching strategies across diverse providers and families will allow the field to further define problem solving and reflection, identify how and when these strategies should be implemented during sessions, and then ultimately examine the effects these strategies have on caregivers and children in EI. Defining problem solving and reflection—as well as delineating purpose, context, frequency of use, mode, and dosage—will help situate caregiver coaching approaches within capacity-building frameworks and allow for comparisons of adult learning strategies within caregiver-implemented interventions. With explicit and operationalized definitions of caregiver coaching, problem solving, reflection, and other coaching strategies, researchers can continue building on previous studies and expanding understanding of caregiver coaching in EI. This will ultimately increase the evidence base for coaching interventions and providers' confidence implementing coaching practices in the field.
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