Together Time was adapted to be a complementary component to PACT’s successful Growing Together program, the only supported parenting program in Maryland for parents and caregivers who are intellectually disabled and have children under age three. Together Time enhanced Growing Together by teaching specific parenting skills and fostering healthy relationships through 10 weeks of center-based groups and home-based teaching sessions.
Adaptations to the Together Time program included:
- Handouts formated for parents with reduced literacy skills
- Handouts and activities to be used in a 1:1 home based session with therapist and parent-child dyad for practice and transition of skills in a real life context.
- Inclusion of additional assessments of parent skills including the Allen Cognitive Level Screen; NCAST
The parent group consisted of seven mothers (the primary caregivers in all the families) ranging in age from 22-35. All participants were African-American mothers. Their intellectual disability diagnoses included learning disabilities and mild-moderate cognitive impairment (two of the families also had mental health issues). Their children were between the ages of one and three. One child was typically-developing, four required therapy services to address their developmental needs (speech, occupational or physical therapy) and one child was receiving behavior management services. Each parent-child received 10 hour-long Group Sessions that met weekly to introduce relationship building activities through daily routines, five Home Visits that reinforced the Group Sessions, and two Individual Assessment sessions (pre- and post- group participation.)
Group and individual sessions were designed and implemented by a licensed occupational therapist. Growing Together’s program coordinator and home-based parent educator were trained in the “Together Time” intervention and assisted in implementing group sessions in the center, and individual sessions in the home. The parent educator observed the Occupational Therapist during home-based individual sessions with two families each week. The parent educator then implemented the home-based individual sessions with a third family each week.
The following program components were provided:
- 10 Group Sessions on topics related to bedtime, bath time, meal time, dressing and play time (included all 6 families)
- 6 NCAST Assessments and Structured Interviews (one with each family) before the intervention
- 4 Post-Test NCAST and ACLS-5 Assessments after the intervention (1 family declined participation and 1 family was absent from group)
- 30 Home Visits. One with each family per topic (bedtime, bath time, meal time, dressing and play time) for 10 weeks
In order to determine the success of this program, several evaluation components were implemented under this grant including the use of a standardized assessment tool, Nursing Child Assessment Satellite Training (NCAST), the Allen Cognitive Level Screen-5 (ACLS-5), skilled clinical observations and interview/ parent report for each mother.
The Allen Cognitive Level Screen-5 (ACLS-5) is a leather lacing activity used to obtain a quick measure of global cognitive processing capacities, learning potential, and performance abilities and to detect unrecognized or suspected problems related to functional cognition. The screen consists of learning three visual-motor tasks (leather-lacing stitches) with increasingly complex activity demands. Completion of the three tasks requires that the person attend to, understand, and use sensory and motor cues from the material objects (leather, lace, and needles), the administrator’s verbal and demonstrated instructions and cues, and feedback from motor actions while making the stitches. The scores obtained are interpreted using the Allen Cognitive Scale of levels and modes of performance.
Four of the six mothers included in this group agreed to participate in the ACLS. Following completion of the “Together Time” program, all four mothers scored within the 4.1- 4.3 level indicating an ability to function independently in highly predictable routines and environments with the expectation that when change or challenge is introduced, assistance is needed for functioning.
The NCAST Teaching Scale is an evidenced-based intervention and research tool for parent-child interaction. It is a reliable and valid means of observing and rating caregiver-child interaction for the purpose of assessing strengths and areas needing improvement. Parent-child “dyads” were videotaped before and after completing the “Together Time” program. Caregivers were asked to choose a simple, but novel, activity they could teach to their child for no more than five minutes. These interactions were videotaped and then scored based on the following observation categories.
Caregivers were scored on: sensitivity to cues; response to child distress; social-emotional growth fostering; and cognitive growth fostering. Children were scored on: clarity of cues and responsiveness to caregivers.
A combined total of caregiver and child skills is also reported. A numerical score is derived based on the observation of behaviors check-list. NCAST identifies dyads that fall below the bottom 10% distribution of scores as a clinically relevant category and labels them “worrisome cases.” NCAST recommends further evaluation and intervention with this group.
All six families included in this program scored below the bottom 10th percentile (most worrisome category) distribution on the pre- test administration of NCAST when compared to their same ages, race and educational level peers. These low scores indicate low levels of mutually adaptive interactions. An improvement was noted in the post test administration, with five of the six dyad’s moving out of the
“most worrisome” category. All children included in the “Together Time” program scored within the average category in the pre and post test scores.
More detailed information was gathered using clinical observations during both group and individual sessions. There were several common challenges observed over the course of the “Together Time” Program. These challenges included difficulty implementing all steps needed to successfully teach their child a task, particularly describing the task, and materials and praising successes and partial successes. For example, in the context of teaching her child how to build a tower of 2-3 wooden blocks, one mother simply placed blocks and a cup in front of her child and said, “do it.” Following a brief period of the child mouthing the blocks in exploration and placing the blocks in and out of the cup, the mother stated “he’s done.” As a group, the mothers frequently used short commanding language and allowed very little deviation from task specific behavior. Examples of the type of teaching language used by mothers included “do it” “pay attention” and “come on.” Most mothers requested that their children point to pictures, build with blocks, lace beads or color with crayons with repetition of greater than five times during the teaching task. Very few mothers used the testing materials to play silly games, make funny noises or generally capture and keep their children’s interest in play. Interactions were primarily focused on completing the stated objective (i.e. stack three blocks, color a picture, point to and name body parts in a book). When children demonstrated difficulty performing the task immediately, parents frequently completed the task themselves or forced their children to complete the task by using hand-over-hand assistance. The greatest challenge noted was that none of the seven mothers in either the pre-test or post-test evaluation used any physical affection toward their children by touching or making soothing gestures.
The group did demonstrate several improvements and strengths over the course of the “Together Time” program. Mothers demonstrated strengths in engaging their children in play activities by establishing eye contact, making alerting noises of comments such as “hey,” “look at me,” or “pay attention”. Across all dyads, mothers demonstrated improved patience, and there were no examples of negative comments toward or about the children, no rough handling, and no yelling nor hitting in the post-test evaluations. Interactions during post-test evaluations included a greater number of joyful and playful interactions than during pre-test evaluations where this type of interaction was notably absent.
Upon the conclusion of “Together Time”, it was noticed that parents and children began to build an environment of safety and trust, and parents practiced skills for engaging their children in developmentally appropriate daily play activities. For example, mothers were observed teasing their children less, and positioning their children so that they could maintain eye contact and reach and manipulate toys. Parents more consistently allowed their children to play with testing materials and attempt tasks before stepping in.
The NCAST and ACLS were able to demonstrate precise areas of strengths and challenges within each dyad. Overall, mothers demonstrated competency on familiar and highly practiced routines of caring for their children. Through repetitious practice across 10 group sessions, the mothers were able to identify and adopt strategies to support their interactions in less familiar play based daily activities. Mothers were able to verbalize the use of practiced strategies for interaction such as creating a structure to the activity with rules for play and safety, use of engagement strategies such as voice inflection and choice making, or making the activity harder or easier so that their children would keep trying to learn.
Mothers demonstrated the greatest success in learning how to make rules and recognize how to keep play and learning safe. The mothers showed beginning skills in learning how to change the activities to keep learning fun. The NCAST scores showed that all of the mothers made improvements in how they interacted with their children. Mothers were better able to use language for describing, praising and teaching, and changed how they positioned themselves so that they maintained eye contact and were more engaged. Parents also did a better job choosing toys and play activities that created better interactions with their children.
The information gathered from this pilot project and the assessment and evaluation tools employed showed that:
- There is a need for programming that utilizes repetition and feedback, and is individualized based on parents’ strengths and needs.
- There is a need for an experienced facilitator with knowledge of learning theory and development to provide staff training.
- The demographic group that demonstrates greatest success and participation in this type of group are mothers with stable housing who are committed to attendance for home and group sessions.
- This model does not work as well with mothers who have a dual diagnoses of mental health issues and an intellectual disability.
- Mothers benefit from the combined approach of group sessions followed by 1:1 home based sessions for skill practice within the context of their everyday environment.
- Mothers benefit from peer social groups.
- Relationships and interaction styles can be positively impacted through this short-term, intensive support program.
- There is a need for a greater focus on the use of physical affection and soothing touch.
- There is a need for a greater focus on the use of language and communication styles.
- There is a need to expand each everyday activity to allow greater time to practice and integrate skills.
Allen, C. K., Austin, S.L., David, S. K., Earhart, C. A., McCraith, D. B, & Riska-Williams, L. (2007). Manual for the Allen cognitive level screen-5 (ACLS-5) and Large Allen cognitive level screen-5 (LACLS-5). Camarillo, CA: ACLS and LACLS Committee.
Sumner, G. & Spietz, A. (1994) NCAST Caregiver/Parent-Child Interaction Teaching Manual. Seattle: NCAST Publications, University of Washington, School of Nursing.