Promoting parent-therapist collaboration in intensive behavioural intervention programs : exploring estrategies to improve teamwork

This qualitative study investigated senior level staff (Senior Therapists), front-line staff (Instructor Therapists), and parent perspectives on parent-therapist collaboration within Intensive Behavioural Intervention settings. Two senior staff interviews, two parent interviews, and a focus group with therapists were conducted to examine how parents and therapists currently interact within IBI settings, parent and therapist expectations of each other, factors that promote and barriers that impede parent-therapist collaboration, and how parent-therapist collaboration might be improved. A constant comparative analysis by question within and across cases revealed five prominent themes of 'Role Definition', 'Perspective-taking/Empathy', 'Trust', 'Open Communication', and 'Consistency'. Additional similarities and differences were discovered between parent and therapist perspectives such as the need for clear parentprofessional boundaries, the importance of maintaining client privacy, and respect. Implications of the findings and suggestions for future research are discussed. Promoting Collaboration 3 Promoting Parent-Therapist Collaboration in Intensive Behavioural Intervention Programs: Exploring Strategies to Improve Teamwork Intensive behavioural intervention (IBI) plays an important role in the lives of families of young children with autism. As part of this treatment approach, the child, parents, and therapist form a necessary triumvirate. The perspective of each member should be considered during the development and evaluation of treatment. Parents of children with autism and Instructor Therapists (ITs), who provide one-on-one training, are expected to aid in the acquisition, generalization, and maintenance of skills taught to these children (Solish & Perry, 2008; Spann, Kohler, & Soensken, 2003). Minimal research however, has been conducted in which both parents and therapists are consulted to examine the expectations each have of one another, how collaboration is promoted, and how this relationship can be improved for the benefit of the parents, therapist, and child. Collaboration is defined as a way of working together to achieve a common goal (Dinnebeil, Hale, & Rule, 1999) which involves a partnership or relationship that reflects high levels of mutual respect, openness, trust, and shared responsibility. Adopting a collaborative approach to behaviour support entails designing and implementing treatments with those who have the most regular direct contact with the child, those who are most familiar with the child's background, and those who are most highly motivated to be involved in the intervention process (Dunlap & Fox, 2007). Such a partnership requires a " . clear and strong commitment by both parties, a shared vision, trust and open communication, mutual respect, and an understanding of each party's circumstances and roles" (Lucyshyn, Dunlap, & Albin, 2002, p. 161). For young children with autism participating in early intervention services, parenttherapist collaboration is an essential component of effective treatment and service delivery Promoting Collaboration 4 (Case, 2001; Dunlap & Fox, 2007; Nevas & Farber, 1999). Collaborative efforts have the potential to result in enduring behaviour change, improved quality of life for the child and his/her family, higher levels of parental satisfaction, and improved parenting strategies (BrookmanFrazee, Stahmer, Baker-Ericze'n, & Tsai, 2006; Marshall & Mirenda, 2002; Spann, Kohler, & Soensken, 2003). Lack of collaboration and poor communication can result in parents feeling as if their concerns are being ignored, parents and professionals not following through with scheduled tasks, parents and professionals having difficulty expressing their concerns to one another, and both having difficulty evaluating each others' participation (Hanna & Rodger, 2002). When it comes to the level of parental involvement in programming and the promotion of generalization of gains made in therapy for children with autism, frustration arises when parents and therapists do not communicate their needs and expectations. It is as a result of this disconnect between parents and professionals/paraprofessionals that a re-examination of the role and expectations of parents, as well as the support that they require, needs to occur. To begin to do so, the current study was designed to gain qualitative insight into how parents and therapists interact, how collaboration is promoted between the two, and how current practices might be improved, in order to inform future training opportunities for therapists and parents, IBI policy, and day-to-day transfer of skills from therapy to home and community settings. Presently there is not much research that describes how parents and therapists interact within IBI settings and whether this interaction is beneficial to clients, parents, or therapists. The goal of this research was therefore to investigate relationships between parents of children with autism who have received or are currently receiving IBI services and Instructor Therapists (ITs) to establish a framework for understanding and evaluating parent-therapist dynamics. Past Promoting Collaboration 5 research examining parent perspectives on special education suggests there is a mismatch between parental expectations of teachers and the requirements of professional practice which values objective involvement (Hess, Molina, & Kozleski, 2006). Parent perspectives have been routinely examined (Dunlap & Fox, 2007; Petr & Barney, 1993; Renty & Roeyers, 2005; Thompson, 1998; Whitaker, 2002), but few studies have investigated the views of therapists (Able-Boone, Goodwin, Sandall, Gordon & Martin, 1992; Sperry, Whaley, Shaw, & Brame, 1999) and, to the researchers' knowledge, no study has examined both perspectives in a joint discussion. Unfortunately, due to issues that are taken up in the discussion, a joint discussion was not possible for this study. The implications of this and recommendations for future attempts to have a joint discussion are considered. By interviewing parents and therapists in interactive focus group settings, participants were provided an opportunity to share their experiences in an accepting environment, with individuals who valued their opinions (Andonian, 2008; Brotherson, 1994; Morgan, 1993). Investigating the way in which parent-therapist relationships function (i.e., what works and what does not work) is also important for informing future research on parent training programs, therapist training, and how to promote collaboration between the two. Because significant discrepancies between parents' and educators' expectations could be detrimental to the child, it is important to assess whether incompatible ideas exist between these two groups (Ivey, 2004). Future research can then expand on the information obtained in these focus groups to evaluate current practice and to develop programs informed by the parent-therapist perspective. Information gathered from a supervisory level (Senior Therapists), front-line staff (ITs), and parents, who have had a variety experiences with IBI, represents a unique and comprehensive Promoting Collaboration 6 start to optimizing service delivery by incorporating the perspectives of the primary stakeholders in the intervention process for a child with autism. Children with autism are more likely to have better adult outcomes if they are provided the opportunity to master functional daily living skills in a variety of environments (Carothers & Taylor, 2004). To work toward the maintenance and generalization of skills learned in therapy, it is crucial that parents and therapists communicate on a regular basis. To begin to address this gap in service provision, research is needed to better understand what factors influence parenttherapist relationships and what both parties would like to see improved. Literature Review Intensive Behavioural Intervention (IBI), founded on the principles of Applied Behaviour Analysis (ABA), has been adopted as the treatment of choice for children with autism (Eikeseth, Smith, Jahr, & Eldevik, 2007; McEachin, Smith, & Lovaas, 1993; Remington et aI., 2007). Numerous studies have demonstrated its effectiveness in teaching new skills and reducing maladaptive behaviours in young children with autism (Lovaas, 1987; Sallows & Graupner, 2005). The focus of research is now expanding to investigate the specific components of early intervention that are most effective and the level of family involvement that can positively enhance programming. Additional research about the family's role in IBI, however, is still needed (Solish & Perry, 2008). IBI teams typically consist of a Supervisor/Senior Therapist, a lead therapist and one or more other Instructor Therapists (ITs). ITs are the front-line workers who work directly with the child and implement the programs developed by the supervisory team. The Supervisor/Senior Therapist works in conjunction with a Clinical Supervisor who oversees the program and reports back to a Clinical Director. Individual programs are developed and monitored by the Senior Promoting Collaboration 7 Therapist and a consulting Clinical Supervisor/Psychologist who reports back to a Clinical Director. The hierarchical structure ofthis program provides a complex environment for researchers to examine. How each level relates to one another and how each individual understands and fulfills his or her role in this hierarchy can have important implications for service delivery. Information about parent involvement and parent-professional collaboration is beneficial for service providers and staff and is necessary to improve the services provided for the benefit of the child and the family. It was therefore essential that steps be taken to seek out the perspectives of parents and therapists. Parent Perspective Families of children with autism face numerous challenges. Plienis, Robbins, and Dunlap (1988