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Early Interventionists' Ratings of Family-Centered Practices in Natural Environments

Tomeny, Kimberly R. PhD; García-Grau, Pau PhD; McWilliam, R. A. PhD

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doi: 10.1097/IYC.0000000000000203
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PART C SERVICES UNDER the Individuals with Disabilities Education Act (IDEA, 2004) are designed to support infants and toddlers with or at risk for disabilities and their families. Legislative guidelines for early intervention in the United States require professionals to deliver services in children's natural environments to provide a developmentally appropriate context for learning for very young children and their regular caregivers (IDEA, 2004). Natural environments are defined as “settings that are natural or typical for a same-aged infant or toddler without a disability” (IDEA, 2004) and can include places such as the child's home or community settings (e.g., childcare programs, stores, parks). Caregivers consist of people who spend a significant amount of time (e.g., ≥15 hr per week) looking after the child, including, but not limited to, parents, guardians, grandparents, and childcare providers. Part C of IDEA (2004), along with recommended practices put forth by the Division for Early Childhood (DEC, 2014), stresses the need to build family capacity when working with young children with or at risk for disabilities. Such guidelines and recommended practices indicate what early intervention services should look like for infants and toddlers and their families.

Over the past 30 years, researchers and experts have repeatedly emphasized the importance of family-centered practice in early intervention (e.g., Bailey et al., 1986; Bruder, 2000; Bruder et al., 2019; Dunst, Johnson, Trivette, & Hamby, 1991; McWilliam, 2010b; Thompson et al., 1997; Trivette, Dunst, & Hamby, 2010). For example, more than a decade ago, members of the Workgroup on Principles and Practices in Natural Environments (2008) emphasized the critical role of families in making decisions and supporting their children's development and, in turn, the role of the professional to support families as a whole rather than children alone. Despite the consistent messages surrounding family-centeredness, research suggests that many professionals continue to deliver child-centered services and lack clarity in their understanding of a collaborative, family-centered approach to intervention in natural environments to build capacity in caregivers, revealing gaps that remain in early intervention service delivery (Campbell & Sawyer, 2009; Dunst, Bruder, & Espe-Sherwindt, 2014; Fleming, Sawyer, & Campbell, 2011; Sawyer & Campbell, 2017).


As Woods, Wilcox, Friedman, and Murch (2011) highlight, the legislative requirements for the provision of early intervention services in natural environments emphasized changes not only in location (e.g., from clinical settings to families' homes) but in approaches to service delivery as well. This shift from a child-centered to a family-centered approach focuses on caregivers' interactions with their children and uses families' typical routines as a meaningful context for learning (Dunst, Bruder, Trivette, & Hamby, 2006; Woods & Brown, 2011). Daily routines, such as mealtimes or diaper changes, serve as natural, recurring opportunities for caregivers to foster child engagement and learning within the family's everyday activities (McWilliam, 2010a; Woods et al., 2011). Even though families' daily routines consist of ample opportunities to promote child development, research suggests that the way in which people conceptualize natural environments influences their perceptions of day-to-day child learning opportunities (Dunst, Bruder, Trivette, & Hamby, 2005). For example, Dunst et al. (2005) surveyed 1,000 parents of children younger than 3 years in early intervention. Results showed that parents reported a greater number of child learning opportunities when the survey emphasized child participation in everyday activities rather than early interventionists' implementation in everyday activities, demonstrating limitations when natural environments are conceptualized solely as locations for professional service delivery (Dunst et al., 2005). Another study examined 75 caregivers' and early interventionists' perspectives via focus groups, and results showed that although caregivers were more likely to understand the concept of natural environments as an opportunity for child learning, early interventionists primarily thought of natural environments as a location (Campbell, Sawyer, & Muhlenhaupt, 2009). This discrepancy demonstrates the potential for problems in understanding and subsequent delivery of services in early intervention. The findings from these studies highlight the significance and ramifications of the ways in which early interventionists interpret natural environments and understand recommendations for service delivery in early intervention. Findings also suggest a lack of understanding regarding how to use existing opportunities in natural environments to support child learning.

Rather than considering natural environments solely as a location, the concept of natural environments in early intervention should emphasize child learning opportunities embedded within families' existing daily routines (Dunst et al., 2006; Dunst, Trivette, Humphries, Raab, & Roper, 2001; McWilliam, 2000a; Woods & Brown, 2011). When early intervention services emphasize families' everyday routines as a platform for learning, children and families are more likely to demonstrate positive outcomes (Dunst et al., 2006; Kashinath, Woods, & Goldstein, 2006; Woods, Kashinath, & Goldstein, 2004). For example, Hwang, Chao, and Liu (2013) conducted a randomized controlled trial with 31 families of infants and toddlers in early intervention in Taiwan, comparing routines-based early intervention with traditional home visits, whereby professionals are more prescriptive, are less collaborative, and provide direct or curriculum-based instruction (e.g., predetermined areas of focus) to children or families. Results indicated that children in both groups showed developmental improvements, but the routines-based early intervention visits were more effective at increasing the functionality of outcomes and at achieving outcomes chosen by the families than the traditional home visits (Hwang et al., 2013). Routines-based early intervention in natural environments provides opportunities to target functional goals within the family's typical, existing activities, building caregiver capacity and supporting child learning (McWilliam, 2010a; McWilliam & Scott, 2001).


To help build family capacity, early interventionists should collaborate with caregivers to determine family priorities and provide opportunities for joint problem-solving (Friedman, Woods, & Salisbury, 2012; McWilliam, 2010b). Approaches such as family consultation (e.g., McWilliam, 2016a), collaborative consultation (e.g., Salisbury, Woods, & Copeland, 2010; Woods et al., 2011), coaching (e.g., Brown, 2016; Friedman et al., 2012; Rush & Shelden, 2011; Snyder, Hemmeter, & Fox, 2015), and family capacity building (Dunst et al., 2014; Dunst, Howse, Embler, & Hamby, 2018) are commonly used in the early intervention literature to refer to the process of collaborating with caregivers. Even though these terms differ slightly in their implementation, they consist of many similarities and are often used interchangeably in the community. Consistent with McWilliam's (2010a,2016a) writings, we use the term family consultation to encompass these approaches of fostering collaboration between professionals and caregivers.

Adult learning principles sit at the foundation of family consultation and other coaching approaches to working with families in early intervention (Donovan, Bransford, & Pellegrin, 2000; Friedman et al., 2012; Knowles, Holton, & Swanson, 2012; McWilliam, 2015,2016a; Rush & Shelden, 2011). As mentioned previously, family consultation is similar to approaches such as coaching, collaborative consultation, and family capacity building but differs in its specific practices such as discussion within routines, emphasis on child functioning, and use of the Intervention Matrix, all of which are components of the Routines-Based Model (RBM; McWilliam, 2010a,2016b). According to McWilliam (2016a), family consultation helps empower the family, supporting the notion that “...all the intervention occurs between professionals' visits” (p. 161). When using family consultation in the RBM, the early interventionist gathers information regarding child functioning, the family's everyday routines, and the caregiver's perspective on potential strategies from caregivers rather than simply telling them what to do. This information-gathering process promotes a family-centered approach to intervention and serves to foster a collaborative partnership between the adults (McWilliam, 2016a).

Research shows that early interventionists can, in fact, demonstrate the ability to implement family consultation or similar approaches with caregivers in their natural environments (e.g., Campbell & Coletti, 2013; Friedman et al., 2012; Salisbury, Cambray-Engstrom, & Woods, 2012). For example, following training on specific practices (e.g., demonstration with narrative, caregiver practice with feedback, guided practice, conversation and information sharing, problem-oriented reflection), early interventionists were able to carry out such practices when working with families of young children in early intervention (Campbell & Coletti, 2013). In a case study of six early interventionists, researchers examined early interventionists' use of coaching practices during home visits and found that they implemented such practices more frequently than findings from previous research (Salisbury et al., 2012). Another study showed that both caregivers and early interventionists expressed positive reports of their experiences with a coaching approach in everyday routines (Salisbury et al., 2018). Despite the promise for implementation of family-centered approaches in early intervention and reports of positive experiences, studies have shown professionals' continued use of traditional, child-centered services (e.g., Campbell & Sawyer, 2007,2009), and early interventionists have reported challenges to collaborating with caregivers (e.g., Krick Oborn & Johnson, 2015; Salisbury et al., 2010,2018). Such findings demonstrate the need for continued research on early interventionists' practices with caregivers to further understand their implementation of recommended practices during home visits.


Even though various models and approaches to early intervention exist, they consist of similar components based on the recommended practices highlighted earlier. Specifically, the RBM supports families in their everyday routines and natural environments through intervention planning via the Routines-Based Interview (RBI; McWilliam, 2010a,2012) and delivery of services via family consultation (McWilliam, 2010a). In the RBM, functional goals are created in partnership with the family to support the child's successful participation in everyday routines, and home visits emphasize collaborative problem-solving (also known as solution finding) with the family to identify and generate strategies and ideas for working toward these goals (McWilliam, 2010a). The present study focuses on components of the RBM, which are the methods for putting recommended practices into practice.


For many years, early intervention researchers have used tools to examine differences between early interventionists' perspectives of their own practices and their perspectives of ideal practices to better understand the research-to-practice gap (e.g., Bailey, Buysse, Edmondson, & Smith, 1992; Bjoörck-Åkesson & Granlund 1995; Crais, Roy, & Free, 2006; McWilliam, Snyder, Harbin, Porter, & Munn, 2000; Pereira & Serrano, 2014; Rantala, Uotinen, & McWilliam, 2009). We have labeled these measures discrepancy tools (e.g., García-Grau, Martínez-Rico, McWilliam, & Grau-Sevilla, 2019; Maxwell, McWilliam, Hemmeter, Ault, & Schuster, 2001). Items in discrepancy tools consist of descriptors associated with each item, ranging from nonrecommended practice to recommended practice. When completing a discrepancy tool, raters choose the descriptor that aligns most closely with their typical practices as well as the descriptor that aligns most closely with what they consider to be ideal practices.

In the early 1990s, Bailey et al. (1992) used a discrepancy tool to examine 180 early interventionists' perceptions of typical and ideal practices surrounding family involvement in services. Early interventionists' ratings of typical practice significantly differed from their ratings of ideal practice such that they rated their typical practices much lower than their ideal practices (Bailey et al., 1992). Even though the ideal ratings were in alignment with recommended practice in early intervention, these results demonstrated a gap between family-centered recommendations and actual practice in the community. Because researchers conducted this study shortly after changes to early intervention services emphasizing family-centeredness through Public Law 99-457 (1986), it is unsurprising that early interventionists' typical practices were not yet in alignment with recommended practice.

Very limited recent research exists comparing early interventionists' reports of typical and ideal practices, particularly in the United States. A decade ago, Rantala et al. (2009) conducted a study examining early interventionists' typical and ideal practices in Finland and the United States using the Families in Natural Environments Scale of Service Evaluation (FINESSE; McWilliam, 2000b). Early interventionists in the United States reported typical practices that were closer to recommended practice than those reported by early interventionists in Finland. However, early interventionists in Finland rated ideal practices that were closer to recommended practice than those rated by early interventionists in the United States.

In addition, a recent study of early intervention practices in Spain, which had a similar paradigm shift toward family-centeredness as the United States, examined typical and ideal practices of 250 early interventionists using the FINESSE II (McWilliam, 2011), a revised version of the original FINESSE (García-Grau, Martinez-Rico, McWilliam, & Cañadas Pérez, 2019). Results showed that early interventionists rated their typical practices lower than ideal practices, indicating a gap between recommended practice and reported implementation in the field (García-Grau, Martinez-Rico, McWilliam, & Cañadas Pérez, 2019), similar to previously shown gaps between typical and ideal practices (Bailey et al., 1992; McWilliam et al., 2000; Rantala et al., 2009).

Discrepancy tools play an important role in supporting the implementation of specific practices or a particular model in early intervention. Early intervention systems can use discrepancy tools for the purpose of organizational change, program evaluation, and evaluation of the quality of family-centeredness, as well as to identify professionals' ideal practices during this implementation process. During implementation of family-centered practices in Spain, discrepancy tools were used to evaluate the quality of professionals' practices (García-Grau, Martinez-Rico, McWilliam, & Cañadas Pérez, 2019; García-Grau, Martínez-Rico, McWilliam, & Grau-Sevilla, 2019). García-Grau, Martínez-Rico, McWilliam, and Grau-Sevilla (2019) analyzed the difficulty of specific practices, and results highlighted more difficult practices, such as allowing the family to set the agenda for the visit and identifying family supports, as well as easier practices, such as working with families in a family-centered way and organizing needs assessment by functional areas. By using a discrepancy tool during an implementation process, systems and programs can further understand the current state of programs, identify professionals' views of practices they value, and determine areas where professionals might need additional support.

The gap between reported typical and ideal practices in early intervention over the years demonstrates early interventionists' awareness of recommended family-centered practices but lack of full implementation in the community. This discrepancy could perhaps reflect professionals' beliefs about their roles in early intervention as well, providing a deeper understanding of implementation (or lack thereof) of family-centered practices. Unsurprisingly, studies have shown a relationship between early interventionists' beliefs and practices. For example, Campbell and Sawyer (2009) found that early interventionists who used recommended practices during home visits reported beliefs that were in closer alignment with recommended practice than by early interventionists who used traditional practices. On the other hand, Fleming et al. (2011) found that regardless of whether early interventionists used traditional practices or recommended practices, their beliefs were in alignment with recommended practices, showing their overall understanding of what practices should look like but a disconnect for some in their actual implementation. Meadan, Douglas, Kammes, and Schraml-Block (2018) found that even though early interventionists reported beliefs highlighting the importance of coaching practices and reported frequent use of such practices, the average scores for use of practices were lower than those for the importance of coaching practices. As Meadan et al. (2018) note, the challenges associated with translating knowledge to practice could explain why this discrepancy exists.

The mixed research findings related to early interventionists' beliefs and practices, as well as the paucity of more recent research on typical and ideal practices (particularly in the United States), emphasize the need for additional research in this area. Through the use of an implementation science framework (Fixsen, Blase, Metz, & Van Dyke, 2013), we can further understand how these three constructs play a role in today's early intervention system.


The purpose of the present study was to provide a description of reported quality and beliefs of early intervention practices in one southern state before beginning statewide implementation of the RBM. We planned to use these data to understand early interventionists' perspectives of their practices, without yet having gone through specific training in the RBM, revealing potential gaps between their views of typical and ideal practices. Such information allows those in charge of professional development to gauge where the state is collectively before beginning statewide training and to tailor supports accordingly. In the present study, we aimed to (a) describe typical practices, ideal practices, and family consultation beliefs of participating early interventionists; (b) analyze the influence of professional and contextual study variables on the scores on typical practices, ideal practices, and family consultation beliefs; and (c) examine the mediating effect of family consultation beliefs in the relationship between beliefs (ideal practices) and the professionals' usual performance (typical practices). We expected to see a large discrepancy between ratings of typical and ideal practices, with lower typical scores than ideal scores. We also expected ratings of family consultation beliefs to be in alignment with ideal practices but not with the predicted low ratings of typical practice.



Participants consisted of 99 early interventionists working for the Part C system in a southern state of the United States. Participants represented early interventionists across disciplines, and they worked in districts throughout the state. Professionals reporting “other” disciplines that did not fall into the categories of special education, early childhood/child development, speech–language pathology, physical therapy, occupational therapy, or social work were grouped together. This group was composed of psychologists, service coordinators, special instructors, and family and human development specialists. Participants' years of experience ranged from 1 to 37 years (M = 13.06, SD = 8.84) and ages ranged from 23 to 71 years (M = 46.18, SD = 12.45). Table 1 provides participants' demographic information.

Table 1. - Characteristics of Participants
n %
Service coordinator 18 18.2
Special instructor 18 18.2
Speech–language pathologist 14 14.1
Physical therapist 7 7.1
Occupational therapist 10 10.1
Administrator 3 3
Other 1 1
More than one role 28 28.3
Total 99 100.0
Special education 10 10.1
Early childhood/child development 13 13.1
Speech–language pathology 18 18.2
Physical therapy 7 7.1
Occupational therapy 9 9.1
Social work 4 4
Other 22 22.2
More than one discipline 16 16.2
Total 99 100.0
Early Intervention staff 61 61.6
Contract/vendor 38 38.4
Total 99 100.0


We used the Expanded FINESSE (McWilliam & Resua, 2017a), a revised version of the FINESSE-II (McWilliam, 2011), to determine early interventionists' ratings of typical and ideal home-visiting practices. The questionnaire consists of 25 discrepancy items with descriptors of practices on a scale of 1–7. The lowest ratings represent child-centered practices, and the highest ratings represent recommended practices in early intervention (i.e., family-centered and routines-based practices in natural environments). These recommended practices are articulated by components of the RBM described previously. For each of these items, participants chose a rating that best described their typical practice and also chose a rating that best described what they considered to be ideal practice. If a discrepancy existed between typical and ideal practices for a particular item, participants were asked to describe the reason behind this discrepancy. The internal consistency of the scores was high (α = .87) in the original version of the FINESSE (McWilliam, 2000b).

The second tool we used, the Family Consultation Beliefs Scale (FCBS; McWilliam & Resua, 2017b), consists of six items measuring early interventionists' beliefs about their roles specific to family consultation. Participants rated their family consultation beliefs on a 6-point Likert scale from 1 = strongly disagree to 6 = strongly agree. This instrument was developed for the current study to understand early interventionists' beliefs about their practices and thus psychometric properties have not previously been published.

The two measures described earlier were paired with a six-item demographic questionnaire. The demographic items gathered information related to discipline, role in early intervention, districts served, type of employment, age, and years of experience.


We recruited participants using an e-mail distribution list for employees of the state's Part C early intervention system, consisting of 450 employees across disciplines (e.g., special instruction, speech–language pathology, physical therapy, occupational therapy, service coordination, administration). The recruitment e-mail included a link to an electronic questionnaire via Qualtrics. Eligible participants received an initial e-mail and two reminder e-mails (one 3 weeks after the initial email and another 3 weeks after that).

Data analysis

The Statistical Package for Social Sciences (SPSS) Version 22.0 was used to conduct descriptive and correlational analyses among the variables of the study. To analyze the influence of the variables on the scores in typical practices, ideal practices, and family consultation beliefs, we used Mann–Whitney and Kruskal–Wallis nonparametric tests, which were performed with variables with two and three or more groups, respectively. The reason for using nonparametric tests was the violation of the assumption of homogeneity of variance and that some of the groups had a small number of participants. Effect sizes were reported, in addition to p values. Partial eta squared (ηp2) was calculated for the Kruskal–Wallis test (with reference values of .01, .06, and .14 for small, medium, and large effect sizes, respectively), and rank-biserial correlation (rrc) was used for the Mann–Whitney test (with correlations of .10, .30, and .50 as small, medium, and large effect sizes). Bonferroni correction was used for multiple comparisons in post hoc tests in order to reduce Type I error. This correction divides the α (.05) by the number of tests performed (number of comparisons). Finally, the plug-in PROCESS macro (Hayes, 2012) for SPSS was employed to run a simple mediation model with typical practices, ideal practices, and family consultation beliefs. The model tested in this study considered ideal practices (X) as a predictor of typical practices (Y), both directly and indirectly through family consultation beliefs (M), the mediator variable (Hayes, 2012). The direct and indirect effects using path analyses are based on logistic regression. We used the bootstrap method for bias-corrected confidence estimates (MacKinnon, Lockwood, & Williams, 2004) with a 95% confidence interval and 5,000 bootstrap samples (Preacher & Hayes, 2004). The sample size adequacy was calculated post hoc using G*Power 3 (Faul, Erdfelder, Lang, & Buchner, 2007) with a desired α of .05, a medium effect size, and a sample size of N = 99. The statistical power for our N was 1 − β = .94, F(2, 96) = 3.09, p < .05, f2 = 0.15, with two predictors, indicating the adequacy of the sample size for the analysis.


Reliability analyses showed good internal consistency of the scores on typical practices, ideal practices, and family consultation beliefs (α = .91, .79, and .65, respectively). Table 2 shows the descriptive statistics at the item level for both typical and ideal practices on the FINESSE. In addition, it includes a Cohen's d calculation to determine the size of the difference between typical and ideal practices. We used the usual reference of 0.2, 0.5, and 0.8 for small, medium and large effect size, respectively.

Table 2. - Comparison of Item-Level Typical and Ideal Practices
Items Typical Practice (1–7) Ideal Practice (1–7)
n M SD Min Max n M SD Min Max d
1. Written program descriptions (brochures, flyers, etc.) 83 4.83 1.69 1 7 83 5.82 1.44 1 7 0.73
2. Initial referral call 78 5.77 1.35 3 7 80 6.2 1.11 3 7 0.42
3. Family ecology 83 6.43 1.20 1 7 82 6.57 1.02 3 7 0.09
4. Supports 82 6.00 1.55 1 7 82 6.59 1.01 1 7 0.32
5. Needs assessment 86 6.35 1.09 1 7 86 6.67 0.73 3 7 0.38
6. Family needs 85 6.39 0.89 4 7 85 6.72 0.78 2 7 0.40
7. Satisfaction with home routines 77 5.51 1.02 3 7 77 6.14 1.06 2 7 0.57
8. Individualized outcomes/goals 91 5.51 1.39 1 7 90 6.21 0.95 3 7 0.55
9. Specificity of outcomes/goals 90 4.92 1.49 1 7 89 5.9 1.40 1 7 0.73
10. Service decisions 87 5.06 1.79 1 7 87 5.71 1.61 1 7 0.42
11. Transdisciplinarity of home-based early intervention 95 4.37 1.83 1 7 94 5.4 1.65 1 7 0.60
12. Home-visiting practices 98 5.77 1.41 1 7 97 6.42 1.25 1 7 0.59
13. Home visit agenda 98 5.71 1.38 2 7 96 6.32 1.17 2 7 0.54
14. Adult learning and consultation/coaching 94 6.39 1.05 2 7 93 6.76 0.80 2 7 0.40
15. Family consultation 96 5.78 1.13 3 7 95 6.35 0.86 4 7 0.53
16. Demonstrations for caregivers 98 6.27 1.19 3 7 97 6.78 0.56 4 7 0.47
17. Community-visiting practices 87 6.07 1.34 3 7 87 6.8 0.55 4 7 0.59
18. Working with families 98 6.6 0.77 4 7 95 6.88 0.41 5 7 0.42
19. Focus of child-level assessment and intervention 97 6.48 1.01 3 7 97 6.82 0.66 3 7 0.42
20. Location of sessions by specialists typical practice 96 6.98 0.14 6 7 95 6.98 0.14 6 7
21. Materials 96 5.88 1.33 1 7 95 6.45 0.95 3 7 0.51
22. Working with the child 96 5.63 1.01 3 7 97 6.37 0.82 4 7 0.70
23. Opportunity for practice 97 6.18 1.04 3 7 97 6.76 0.66 3 7 0.63
24. Caregiver reflection 98 6.14 1.13 3 7 97 6.7 0.68 4 7 0.53
25. Collaborative/joint problem-solving 97 6.39 0.97 3 7 97 6.84 0.49 4 7 0.51
FINESSE average score 5.90 0.68 6.45 0.52 0.50

On average, typical practices (M = 5.90, SD = 0.68) were rated slightly lower than ideal practices (M = 6.45, SD = 0.52), and family consultation beliefs (M = 4.96, SD = 0.62) showed that professionals agreed with the statements, as indicated by the closest descriptor on family consultation beliefs (fifth descriptor). For analysis purposes, we removed the only participant in the “other” group from the role variable because the professional did not report additional information for us to recode this participant into another category. Results of the Kruskal–Wallis and Mann–Whitney tests for FINESSE typical practices, ideal practices, and family consultation beliefs with background variables showed that scores on family consultation beliefs did not show differences in employment or role but showed noteworthy differences in discipline (Table 3). Post hoc comparisons showed that “other” scored higher than the rest of the disciplines. This difference was statistically significant after Bonferroni correction from special education (p < .01; d = 1.83), early childhood/child development (p < .01; d = 1.75), and speech–language pathology (p < .01; d = 1.41). Typical practices did not have statistically significant variation in scores for role and discipline. In terms of employment, however, early intervention staff members scored higher in typical practices than did contract employees. Finally, ideal practices showed statistically significant differences in all study variables. Nonparametric paired comparisons (Dunn's post hoc comparisons) showed statistically significant differences after Bonferroni correction in professionals' roles, between physical therapists and service coordinators (p = .003; d = 1.72). Discipline differences were found in ideal practices in most of the uncorrected comparisons but only statistically significant after Bonferroni correction between physical therapy and special education (p = .003; d = 1.89), with special educators reporting higher ideal practice scores. In addition, correlations showed that there was a positive relationship among typical practices, ideal practices, and family consultation beliefs and that professional experience and age were not related to the scores of any of the three outcomes (see Table 3).

Table 3. - Results of Kruskal–Wallis and Mann–Whitney Tests Among Typical and Ideal Practices, Family Consultation Beliefs, and the Study Variables
Typical Practices Ideal Practices Family Consultation Beliefs
M (SD) Mean Rank H (df) pp 2) M (SD) Mean Rank H (df) pp 2) M (SD) Mean Rank H (df) pp 2)
SC 6.06
38.97 4.28
42.61 13.43
41.58 3.87
SI 6.05
40.17 6.58
40.44 4.98
SLP 5.81
31.89 6.34
31.25 4.80
PT 5.94
33.57 6.10
17.43 4.88
OT 5.61
26 6.10
27.05 5.00
Administrator 5.72
39.67 6.84
53.33 5.22
Special education 6.08
46.6 2.34
53.1 14.38
32.5 22.09
EC/CD 5.98
44.19 6.37
36.08 4.78
Speech–language pathology 5.84
40.69 6.42
40.67 4.79
Physical therapy 5.89
39.21 6.12
20.5 5.07
Occupational therapy 5.62
32.22 6.07
32.72 4.94
Social work 6.06
46 6.82
62.63 4.50
Other 5.92
43.84 6.57
48.43 5.48
M (SD) Mean Rank U (df) p (r rb) M (SD) Mean Rank U (df) p (r rb) M (SD) Mean Rank U (df) p (r rb)
Employment Staff 6.00
55.15 1,473
56.16 1,535
53.28 1,359
Contract/vendor 5.75
41.74 6.26
40.11 4.86
Note. EC/CD = early childhood/child development; OT = occupational therapist; PT = physical therapist; SC = service coordinator; SI = special instructor; SLP = speech–language pathologist. Effect sizes for employment are calculated using rank-biserial correlation (rrb).

Not surprisingly, early interventionists' age and experience were related to each other (r = .58) but were not associated with the dependent variables. Typical practices showed noteworthy correlations with ideal practices (r = .52) and family consultation beliefs (r = .33).

Because of correlations among the variables, we performed a mediation analysis, following the theoretical model of ideal practices predicting typical practices, mediated by family consultation beliefs. As shown in Figure 1, we found a statistically significant positive relationship between ideal practices and typical practices, path c': b = .69, t(96) = 6.06, p < .001, 95% CI [0.46, 0.91]. We also found that ideal practices were positively related to family consultation beliefs, path a: b = .26, t(97) = 2.23, p = .03, 95% CI [0.03, 0.49], and that family consultation beliefs also predicted the outcome typical practices, path b: b = .25, t(96) = 2.58, p = .01, 95% CI [0.06, 0.43]. In addition, the ideal–typical practices relationship shrank upon the addition of the mediator, family consultation beliefs, path c: b = .62, t(96) = 5.52, p < .001, 95% CI [0.40, 0.85]. These results indicated a partial mediation effect of family consultation beliefs, where the influence of ideal practices on typical practices decreased but was still statistically significant when family consultation beliefs were considered. Finally, the indirect effect was statistically significant, as indicated by the confidence intervals not crossing zero.

Figure 1.
Figure 1.:
Results of the mediation model.


Results from the present study demonstrate that early interventionists rated their typical practices relatively high, and these ratings aligned closely with their ratings of ideal practices. Even though we expected to see a large discrepancy between typical and ideal practices, ratings of typical practices were only slightly lower than ratings of ideal practices. Such findings differ from previous early intervention research using discrepancy tools (e.g., Bailey et al., 1992; García-Grau, Martinez-Rico, McWilliam, & Cañadas Pérez, 2019; Rantala et al., 2009), which has shown significant differences between early interventionists' reports of typical and ideal practices. Results from this study also revealed that early interventionists generally agreed with statements about family consultation beliefs that aligned with recommended practice. These findings partially support our second hypothesis that ratings of family consultation beliefs would be aligned with recommended practices but not aligned with ratings of typical practice. Rather, we found a statistically significant positive relationship between typical and ideal practices, and early interventionists' family consultation beliefs predicted their reports of typical practices.

Typical and ideal practices

We describe three possible explanations for the close alignment between typical and ideal ratings in the present study: (a) Early interventionists actually use recommended practices during their home visits with families as reported; (b) early interventionists reported typical practice that they use in the most ideal situations with particular families on their caseloads; or (c) the Dunning–Kruger effect plays a role in early interventionists' ability to accurately evaluate their own practices (Dunning, 2011; Kruger & Dunning, 1999). The first explanation could be possible owing to an increased awareness in the field about recommended practices (e.g., DEC, 2014; Mattern, 2015; Yang, Hossain, & Sitharthan, 2013). With an increased emphasis on family-centeredness in natural environments and on professional development in early intervention over the years, it is quite possible that early interventionists' home-visiting practices are somewhat close to ideal. The second explanation could be an artifact of early interventionists' using ideal practices with certain families on their caseloads (i.e., families with whom family-centered practice comes more easily or naturally) as a referent for typical practice rather than considering their typical practice across a variety of families, particularly those with whom family-centered practice proves more challenging for early interventionists. Even though family-centered practice should be implemented across all families in early intervention, early interventionists might find that it comes more easily with some families than with others. The present study did not examine family-centered practice relative to different families, but potential differences in practice across families could have possibly played a role in early interventionists' questionnaire responses.

On the other hand, these data are self-reported, so the third explanation could show the potential application of the Dunning–Kruger effect (i.e., one's inability to assess one's own inabilities) in early intervention. According to the Dunning–Kruger effect, a person with little competence or experience in an area is likely to exhibit high levels of confidence in that area, demonstrating a mismatch between the level of competence and confidence: The less knowledgeable the person, the more confident (Dunning, 2011; Kruger & Dunning, 1999). As competence and knowledge increase, confidence decreases, with the individual now realizing how little he or she knows. With continued knowledge gain, confidence begins to rise again—this time appropriately. This phenomenon describes a natural learning pattern that occurs when lacking and acquiring certain skills. It is possible that the Dunning–Kruger effect comes into play in early intervention, as early interventionists' lack of knowledge and skills in a particular area where training is still needed leads to their overestimation of their abilities in that specific skill. In this particular study, the Dunning–Kruger effect could possibly play a role in early interventionists' high self-ratings of their typical practices.

Working with the child

When examining ratings of specific practices on the item level, results showed a large discrepancy between ratings of typical and ideal practices only with the item, Working With the Child. This finding is noteworthy, because this item specifically describes the early interventionist's interactions with the child and the caregiver during the home visit. Early interventionists' typical ratings (M = 5.63) on this item aligned more closely with the descriptor: The early interventionist and the caregiver take turns interacting with the child, but their ideal ratings (M = 6.37) aligned more closely with the descriptor: The early interventionist coaches the caregiver, and the caregiver primarily interacts directly with the child. As mentioned previously, experts in early intervention call for early interventionists to collaborate with caregivers via approaches such as family consultation (McWilliam, 2016a) to address family priorities and ultimately build family capacity (Friedman et al., 2012; McWilliam, 2010b). This approach differs significantly from working directly with the child and requires an understanding of adult learning principles to effectively support the caregiver rather than only support the child. The discrepancy between typical and ideal practices on this item demonstrates an awareness that what early interventionists typically do is not necessarily reflective of recommended practice. This underscores a need for further training and coaching in models encompassing specific family consultation practices, such as the RBM, to reduce the gap between awareness and actual practices.

Difficulty in understanding how to be family centered or carry out family consultation practices arises when publications of principles or general guidelines exist without articulating specific, observable, and measurable practices. With clearly defined practices, ongoing coaching and performance-based feedback can be used to support early childhood professionals' translation of new knowledge into practice (Friedman et al., 2012; Marturana & Woods, 2012; Rush & Shelden, 2011). Findings from the current study provide state leaders and those leading the statewide training in the RBM with information about the way early interventionists tend to approach service delivery, specifically in relation to working with children and caregivers. The discrepancy between typical and ideal practices on the item Working With the Child demonstrates an area where early interventionists need extra support to improve their overall implementation of recommended practice. Even though these results are specific to one particular state, we recommend all early intervention leaders be mindful of possible discrepancies so they can ultimately support the use of best practice in the field. Training and coaching in the RBM specifically address this gap, providing early interventionists with specific practices that could be observed and measured via fidelity checks during the application and feedback phase.

Family consultation beliefs

Results demonstrated that early interventionists were in general agreement with family consultation beliefs. Although no significant differences in employment or role were found, a statistically significant difference in discipline was found. The “other” group scored significantly higher than special education, early childhood/child development, and speech–language pathology. McWilliam and Bailey (1994) also found speech–language pathologists to be less likely to use integrated services and, in contrast, found special educators to use more integrated services. Early interventionists' family consultation beliefs also predicted their reports of typical practices, similar to Campbell and Sawyer's (2009) belief–practice findings. Despite mixed findings in previous early intervention research, it comes as little surprise that early interventionists' beliefs about their roles predicted their reported use of typical practices. By examining early interventionists' beliefs and identifying their relationship with typical practices, we can better understand how beliefs might play a role in implementation of certain practices. This information can be particularly useful when initiating change in a program or state related to particular practices or a specific model; addressing beliefs might be necessary for adoption and implementation of the new practices or model.


We were interested in determining whether early interventionists' demographic information played a role in their reported typical practices, ideal practices, and family consultation beliefs. Early interventionists' years of experience and age were not statistically significantly related to their reports of typical practices, ideal practices, or family consultation beliefs. Such findings demonstrate the possibility that as early intervention has evolved in the United States over time, we are finally at a point where we have general consensus about what early intervention should look like. In other words, it is possible that we are no longer under a transformative period where professionals who were initially trained in a direct therapy approach need to shift to a family-centered approach. On the other hand, if the Dunning–Kruger effect does, in fact, play a role in early interventionists' self-reported practices, we might not have evolved as much as these findings suggest. Early interventionists might be reporting typical practices that they, in fact, do not practice. The discrepancy tool makes it quite clear that higher scores are preferred practices, so a response bias might exist, where respondents rate themselves higher than they actually practice.

Results of the present study also showed that early intervention staff (i.e., early interventionists employed directly by programs) had significantly higher scores on typical practices than of contracted employees. One possible explanation for this phenomenon is that programs have more control or oversight over their own staff members as opposed to those who do contract work. In addition, it is possible that contracted employees have other full-time jobs in schools or centers, where family-centered practice is not necessarily emphasized to the same extent as in early intervention. In thinking about how each state's Part C system is set up, it is important to consider these findings and the possible implications of staff versus contract employees' use of specific family-centered practices.

Limitations and future directions

Participants in the present study were limited to early interventionists in one southern state to examine the current home-visiting practices in that particular state. Even though responses represented all of the state's districts, we cannot necessarily generalize our findings to Part C systems in other states. Future research should examine early interventionists' ratings of their practices across the United States to establish an understanding of home-visiting practices at the national level and determine whether differences exist across differing states. Each state's Part C system varies from the amount of funding received to requirements for level of training for early interventionists. Thus, examining home-visiting practices at both the state and national levels is important for a complete understanding of the implementation of Part C services in the United States.

Because this study examined only self-reported practices and did not examine early interventionists' actual practices using observational methods, we cannot determine whether early interventionists' reported typical practices reflect their actual practices and we can only hypothesize possible explanations for such high ratings of typical and ideal practices. As mentioned previously, early interventionists might actually use recommended home-visiting practices as reported, might consider ideal situations with specific families when reporting practices, or might overestimate their use of recommended home-visiting practices. Future research should compare reported practices via self-report with actual practices via observation across a range of families to determine whether a discrepancy exists between what early interventionists report they do and what they actually do. This would allow us to see whether the Dunning–Kruger effect exists in early intervention.

In conclusion, the results of this study provide a description of reported home-visiting practices and beliefs in one state's Part C system as they embark upon adoption of a particular family-centered model for early intervention, the RBM. Such information provides researchers and program leaders with an understanding of how to measure baseline conditions in an implementation process. Even though early interventionists rated typical and ideal practices generally high, questions remain as to whether their self-reported typical practices reflect their actual typical practices. Continued research on typical and ideal practices will provide additional information on the current state of home-visiting practices across the country to continue to promote and ensure the implementation of family-centered practices in early intervention.


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      early intervention; family centered; infants; natural environments; Part C; professional development; routines; toddlers

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