Communicating With Intention: Therapist and Parent Perspectives on Family-Centered Care in Early Intervention

Abstract

Importance: Responsive communication is critical to ensuring family-centered care in early intervention (EI). The Intentional Relationship Model (IRM) offers a framework for examining therapist–parent communication and offers strategies for supporting therapist responsiveness.

Objective: To explore family-centered care and therapists’ communication in EI using the IRM.

Design: Prospective descriptive study.

Setting: Illinois EI program.

Participants: Convenience sample of 101 therapists and 19 parents enrolled in an EI program. Therapist disciplines included developmental (n = 24), occupational (n = 32), physical (n = 17), and speech (n = 28) therapy.

Outcomes and Measures: Demographic questionnaire, Early Interventionist Self-Efficacy Scale, Early Intervention Parenting Self-Efficacy Scale, Measure of Processes of Care (MPOC)–Short Form, MPOC–Service Provider, Clinical Assessment of Modes (CAM), and Clinical Assessment of Suboptimal Interaction–Short Form (CASI–SF).

Results: Therapists used family-centered practices specific to relationship building more frequently than information sharing (especially sharing of general information). Therapists used the empathizing, encouraging, and instructing modes most frequently in their interactions with families. Participants’ scores on the MPOC, CAM, and CASI–SF were significantly correlated.

Conclusions and Relevance: Therapist–parent interactions were aligned with family-centered care. Opportunities for practitioners were identified in (1) sharing specific and general information and (2) expanding the use of collaborating, problem-solving, and advocating modes.

What This Article Adds: In this study, we explored how the IRM can inform family-centered practices in EI through examination of therapists’ interpersonal competency and therapeutic mode use.

This study identifies opportunities for practitioners to use the Intentional Relationship Model (IRM) to inform family-centered practices in early intervention.

Therapists’ responsiveness in a therapeutic relationship is critical to promoting parent engagement in pediatric rehabilitation (D’Arrigo et al., 2017, 2019). Families value technical and interpersonal skills in therapists (James & Chard, 2010), and therapists’ relational competencies may be more significant determinants of families’ perception of the quality of care than their technical competency (Bamm & Rosenbaum, 2008; MacKean et al., 2005). Therapists’ communication and interpersonal approaches have been recognized as essential to the delivery of family-centered care (Hodgetts et al., 2013) and integrated into existing measures of family-centeredness, such as the Measure of Processes of Care (MPOC; Cunningham & Rosenbaum, 2014). Research has suggested that therapists more frequently rely on strategies that support relationship building (e.g., showing interpersonal sensitivity, providing respectful and supportive care) than on those associated with sharing of specific (e.g., written reports on the child’s progress) or general (e.g., community resources) information (Almasri et al., 2018; Cunningham & Rosenbaum, 2014; McManus et al., 2020). Similar trends in communication have been reported for in-person and telepractice interactions (McCarthy et al., 2021).

Information sharing between therapists and families in early intervention (EI) has been reported to occur through conversation, modeling, and joint interaction with the child (Barton & Fettig, 2013; Colyvas et al., 2010; Friedman et al., 2012; Salisbury et al., 2010). Problem-solving, reflection, and practice with feedback are reported to be infrequent even when services are consistent with family-centered principles (Barton & Fettig, 2013; Colyvas et al., 2010; Friedman et al., 2012; Salisbury et al., 2010). For example, Friedman et al. (2012) found that family–therapist interactions were often one sided (with therapists offering recommendations or responding to questions without follow-up), and problem solving has been shown to occur in less than 1% of family–therapist interactions (Salisbury et al., 2010).

A significant push has been made toward increasing information sharing and family capacity-building practices in EI using coaching (Rush & Shelden, 2019; Woods et al., 2018). Although coaching has been accepted in EI, the literature on therapists’ adherence to coaching principles and outcomes specific to parent capacity remains limited (Ward et al., 2020). With increased emphasis on collaborative communication approaches in EI, research examining current trends in therapist–parent communication is warranted.

Intentional Relationship Model

The Intentional Relationship Model (IRM; Taylor, 2020) is the primary guiding model for the therapeutic use of self in occupational therapy and offers a framework for examining interpersonal aspects of clinical practice (Solman & Clouston, 2016). The IRM proposes that to remain client and family centered, practitioners must be competent in using the six therapeutic modes: (1) advocating, (2) collaborating, (3) encouraging, (4) empathizing, (5) instructing, and (6) problem solving (Taylor, 2020; Table 1). The model recognizes that each mode can be delivered through verbal and nonverbal means and stresses the importance of intentional, congruent, and flexible communication guided by the client’s preferences and needs (Taylor, 2020). The Clinical Assessment of Modes (CAM; Fan & Taylor, 2016) and the Clinical Assessment of Sub-optimal Interaction (CASI; Popova & Taylor, 2019) were developed to evaluate therapists’ communication as defined by the IRM. In adult rehabilitation, Wong et al. (2020) found that therapists more frequently reported using empathizing, instructing, and encouraging modes than collaborating, problem-solving, and advocating modes. Therapists’ use of therapeutic communication in pediatric settings has not been investigated to date and could offer insight into opportunities for advancing family-centered communication.

Table 1.

Therapeutic Communication Modes According to the Intentional Relationship Model (Taylor, 2020)

Model Definition	Application in Early Intervention
Advocating: Supporting the client’s awareness of their rights and access to resources and services	• Ensuring the parent’s awareness of their (and their child’s) full rights and protections under the Individuals With Disabilities Education Act of 1990, Part C (Pub. L. 101-476) • Supporting the child’s access to available services and supports through the EI and in the community
Collaborating: Supporting the client’s autonomy and independence in the decision-making process	• Supporting the parent’s goals for treatment • Providing the child with opportunities to make independent choices and following the child’s lead
Empathizing: Understanding and validating the client’s physical, psychological, and emotional needs	• Listening to the parent’s concerns and asking enrichment questions • Striving to understand the child’s lived experience through observation
Encouraging: Fostering hope and providing positive reinforcement	• Supporting the parent’s hope for the best outcomes • Providing social praise or a reward to the child
Instructing: Providing education, structure, and feedback on the client’s performance	• Teaching the parent strategies for engaging the child • Setting limits and clear expectations to support the child’s participation in an activity
Problem-solving: Facilitating analytical reasoning, using strategic questioning, and outlining the options available to the client	• Discussing with the parent the best possible steps and actions to support positive child outcomes • Asking the child strategic questions to promote their ability to problem-solve through play

Note. EI = early intervention.

Our primary objective was to describe the interpersonal aspects of family-centered care in EI using the IRM. We explored therapists’ and parents’ perspectives on therapists’ use of family-centered practices, therapeutic communication, and suboptimal interaction. We also examined the association between these factors and therapists’ and parents’ EI self-efficacy.

Method

This exploratory, prospective study was approved by the institutional review board at the University of Illinois at Chicago. The study had a cross-sectional design.

Procedures

Participants were recruited by means of a snowball sampling approach through word of mouth, state organizations, online groups, and support networks specific to EI and pediatric rehabilitation. Participants completed electronic informed consent and study surveys digitally using REDCap (Vanderbilt University, Nashville, TN). Participants received a $5.00 gift card upon full survey completion.

Participants

Therapists and parents (age ≥18 yr) enrolled in EI in Illinois were invited to participate in the study. Therapists had to (1) be licensed or certified as a developmental, occupational, physical, or speech therapist and (2) have at least three families active on their EI caseload. Parents had to be present during regularly scheduled EI appointments for a child who was (1) younger than 36 mo and (2) receiving services from at least one EI therapist.

Measures

Participants’ background information was collected using a demographic questionnaire and included information specific to professional and personal experience in EI.

Early Interventionist Self-Efficacy Scale and Early Intervention Parenting Self-Efficacy Scale

The Early Interventionist Self-Efficacy Scale (EISES; Lamorey & Wilcox, 2005) and the Early Intervention Parenting Self-Efficacy Scale (EIPSES; Guimond et al., 2008) are self-report measures of therapists’ and parents’ EI self-efficacy. The 15-item EISES and the 14-item EIPSES are rated on a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree). EISES Items 3, 5, 9, 11, and 15 and EIPSES Items 3, 5, 6, 8, 10, 11, 13, and 14 are reverse scored. The EISES and the EIPSES demonstrated appropriate internal consistency (Cronbach’s αs = .78 and .80, respectively), and internal validity was supported by exploratory factor analysis (Guimond et al., 2008; Lamorey & Wilcox, 2005).

Measure of Processes of Care

The MPOC is a measure of family-centered practice in pediatrics. A 27-item therapist version of the MPOC (MPOC–Service Provider [MPOC–SP]; Woodside et al., 2001) and a 20-item short-form version of the parent MPOC–20 (King et al., 2004) were used. The MPOC–SP and MPOC–20 are rated on a 7-point scale ranging from 1 (never) to 7 (to a great extent). Participants may mark an item as not applicable. The MPOC–SP includes four domains: Showing Interpersonal Sensitivity (10 items), Treating People Respectfully (9 items), Providing General Information (5 items), and Communicating Specific Information (3 items). The MPOC–20 includes five domains: Respectful and Supportive Care (5 items), Enabling and Partnership (3 items), Coordinated and Comprehensive Care (4 items), Providing General Information (5 items), and Providing Specific Information (3 items). The MPOC–SP and MPOC–20 have demonstrated excellent psychometric properties in pediatric settings (Cunningham & Rosenbaum, 2014), including evidence of appropriate internal consistency for the MPOC–SP (Cronbach’s α ≥ .76; Woodside et al., 2001) and MPOC–20 (Cronbach’s α ≥ .63; King et al., 2004).

Clinical Assessment of Modes

The CAM (Fan & Taylor, 2016) is a measure of therapeutic communication. Therapist and parent versions of the CAM were used. The CAM consists of 30 items that are rated on a 4-point scale ranging from 0 (never) to 3 (frequently). The CAM has six subscales: Advocating, Collaborating, Encouraging, Empathizing, Instructing, and Problem-Solving. Participants may mark an item as not applicable. The CAM demonstrated appropriate psychometric properties based on the evidence from Rasch analysis in adult inpatient (Fan & Taylor, 2016) and pediatric outpatient (Popova et al., 2019) settings, including evidence of appropriate internal consistency (Cronbach’s α > .70) and interrater reliability (interclass correlation coefficient [ICC] > .50) in outpatient pediatric settings (Popova et al., 2019).

Clinical Assessment of Suboptimal Interaction–Short Form

The CASI–Short Form (CASI–SF) is a measure of the therapist’s use of suboptimal interactions that may compromise the therapeutic relationship. Therapist and parent versions of the CASI–SF were used. The CASI–SF consists of 15 items that are rated on a 4-point scale ranging from 0 (never) to 3 (frequently). Participants may mark an item as not applicable. The CASI–SF demonstrated appropriate psychometric properties based on the evidence from Rasch analysis and evidence of appropriate internal consistency (Cronbach’s α = .89) and interrater reliability (ICC = .77) in the outpatient pediatric setting (Popova et al., 2019).

Data Analysis

Descriptive data were examined for trends in participants’ self-report. Associations between variables were evaluated using Pearson correlations with p < .05. Correlation coefficients were evaluated according to the following criteria: <.20, very weak; .20–.39, weak; .40–.59, moderate; .60–.79, strong; and >.80, very strong (Akoglu, 2018). Participants with missing data were omitted from the statistical analyses.

Results

A total of 124 therapists and 23 parents consented to participate in the study. Of that sample, 101 (81.5%) therapists and 19 (82.6%) parents completed the surveys in full (Table 2).

Table 2.

Participants’ Background Characteristics

Variable	n (%)
Variable	Therapists (n = 101)	Parents (n = 19)
Gender
Female	100 (99.0)	18 (94.7)
Male	1 (1.0)	1 (5.3)
Race/ethnicity
American Indian or Alaska Native	1 (1.0)	0 (0.0)
Asian	3 (3.0)	1 (5.3)
Black or African-American	2 (2.0)	2 (10.5)
Hispanic or Latino	6 (5.9)	7 (36.8)
White or Caucasian	86 (85.1)	8 (42.1)
Other	3 (3.0)	1 (5.3)
Education
High school diploma	0 (0.0)	5 (26.3)
Bachelor’s	13 (12.9)	9 (47.3)
Master’s	75 (74.2)	4 (21.1)
Professional doctorate	13 (12.9)	1 (5.3)
Annual household income, $
Decline to state	11 (10.9)	4 (21.1)
<21,000	0 (0.0)	2 (10.5)
21,000–40,000	7 (6.9)	1 (5.3)
41,000–60,000	16 (15.8)	2 (10.5)
61,000–80,000	16 (15.8)	1 (5.3)
81,000–100,000	12 (11.9)	4 (21.1)
>100,000	39 (38.7)	5 (26.2)
Employment
Full time	74 (73.3)	6 (31.6)
Part time	27 (26.7)	6 (31.6)
Unemployed	0 (0.0)	5 (26.3)
Other	0 (0.0)	2 (10.5)

Therapists’ Background

Therapists’ age ranged from 24 to 72 yr (M = 38.07, SD = 11.31). Disciplines included developmental (n = 24), occupational (n = 32), physical (n = 17), and speech (n = 28) therapy. The majority of therapists practiced full time (n = 74) and held an EI evaluator credential (n = 64). Therapists had between 3 and 40 (M = 14.26, SD = 11.11) families on their caseload.

The majority of therapists reported more than 25 hr of training in family-centered care (n = 53) and were not familiar with the IRM (n = 78). The number of therapists reporting no training in therapeutic communication (n = 27) was similar to that of those reporting more than 25 hr of training (n = 28). The number of years in practice was significantly correlated with training in family-centered care (r = .447) and training in therapeutic communication (r = .245). Training in family-centered care was significantly correlated with training in therapeutic communication (r = .274).

Parents’ Background

Parents’ age ranged from 26 to 45 yr (M = 33.47, SD = 4.90), and the children’s age ranged from 2 to 35 mo (M = 24.95, SD = 9.10). The majority of families were enrolled in EI for the first time (n = 15) and received services at home (n = 17). The length of services ranged from 2 to 30 mo (M = 13.79, SD = 7.98).

Therapists’ Use of Family-Centered Practices and Communication

Participants’ scores on the EISES or EIPSES, MPOC–SP or MPOC–20, CAM, and CASI–SF are presented in Table 3. Participants reported high levels of EI self-efficacy. The MPOC–SP and MPOC–20 scores were higher on the domains specific to relationship building than those specific to information sharing. Communication of general information was rated the lowest by both groups. Participants reported a high frequency of therapeutic communication and a low frequency of suboptimal interactions. Therapists reported that they most frequently used the empathizing and encouraging modes, followed by the instructing, collaborating, problem-solving, and advocating modes. Parents reported that the therapists most frequently used the instructing, empathizing, and encouraging modes, followed by the collaborating, problem-solving, and advocating modes.

Table 3.

Therapist and Parent Report of Self-Efficacy, Family-Centered Care, and Therapist’s Communication in Early Intervention

Variable	M (SD), Range
Variable	Therapist (n = 101)	Parent (n = 19)
EISES/EIPSES	5.23 (0.62), 3–7	5.66 (0.48), 4–7
MPOC–SP
Treating People Respectfully	5.95 (0.77), 3–7	—
Showing Interpersonal Sensitivity	5.34 (0.90), 3–7	—
Communicating Specific Information	5.02 (1.39), 2–7	—
Providing General Information	3.97 (1.54), 1–7	—
MPOC–20
Respectful and Supportive Care	—	5.91 (1.25), 2–7
Coordinated and Comprehensive Care	—	5.87 (1.27), 2–7
Enabling and Partnership	—	5.4 (1.59), 2–7
Providing Specific Information	—	3.92 (1.69), 1–7
Providing General Information	—	3.55 (1.64), 1–6
CAM
Empathizing	2.76 (0.27), 2–3	2.72 (0.35), 2–3
Encouraging	2.73 (0.37), 1–3	2.71 (0.27), 2–3
Instructing	2.65 (0.34), 2–3	2.75 (0.21), 2–3
Collaborating	2.59 (0.42), 1–3	2.66 (0.42), 2–3
Problem-Solving	2.51 (0.47), 1–3	2.66 (0.34), 2–3
Advocating	1.94 (0.61), 0–3	1.6 (0.62), 0–2
Total	2.53 (0.33), 1–3	2.52 (0.26), 2–3
CASI–SF	0.77 (0.42), 0–2	0.25 (0.35), 0–1

Note. Dashes indicate that the score is not available. CAM = Clinical Assessment of Modes; CASI–SF = Clinical Assessment of Suboptimal Interaction–Short Form; EISES = Early Interventionist Self-Efficacy Scale; EIPSES = Early Intervention Parenting Self-Efficacy Scale; MPOC–SP = Measure of Processes of Care–Service Provider; MPOC–20 = Measure of Processes of Care–20.

Self-Efficacy, Family-Centered Care, and Communication

Therapist Perspective

Weak positive correlations were found between (1) number of years in practice and scores on three MPOC–SP domains (Showing Interpersonal Sensitivity, r = .275, p < .001; Treating People Respectfully, r = .316, p < .001; and Communicating Specific Information, r = .232, p < .05) and (2) therapists’ EI self-efficacy and scores on three MPOC–SP domains (Showing Interpersonal Sensitivity, r = .204, p < .05; Treating People Respectfully, r = .359, p < .001; and Providing General Information, r = .208, p < .05).

The number of years in practice had a weak positive correlation with therapists’ overall mode use and the six mode subscales, with rs ranging from .194 to .389 (p < .05). The overall CAM (r = .239, p < .05) and the Collaborating (r = .217, p < .05), Empathizing (r = .223, p < .05), Encouraging (r = .226, p < .05), and Instructing (r = .258, p < .001) subscales had a weak positive correlation with therapists’ EI self-efficacy. Therapists’ suboptimal interaction had a weak negative correlation with the number of years the therapist had spent in practice (r = −.252, p < .001) and therapists’ EI self-efficacy (r = −.313, p < .001).

Associations between MPOC–SP, CAM, and CASI–SF are presented in Table 4. Therapists’ overall CAM, and the six mode subscales, had a weak to moderate positive correlation with the four MPOC–SP domains (Showing Interpersonal Sensitivity, Treating People Respectfully, Providing General Information, and Communicating Specific Information). The CASI–SF had a weak negative correlation with two of the four MPOC–SP domains (Treating People Respectfully and Providing Specific Information).

Table 4.

Associations Between Family-Centered Practices and Therapists’ Communication

Variable	MPOC–SP				MPOC–20
Variable	Showing Interpersonal Sensitivity	Treating People Respectfully	Providing General Information	Communicating Specific Information	Enabling and Partnership	Coordinated and Comprehensive Care	Respectful and Supportive Care	Providing General Information	Providing Specific Information
CAM	.683**	.604**	.425**	.550**	.706**	.778**	.787**	—	—
Advocating	.516**	.374**	.410**	.353**	.745**	.661**	.576*	.511*	—
Collaborating	.552**	.586**	.432**	.428**	—	—	.496*	—	—
Empathizing	.390**	.365**	.226*	.394**	—	—	—	—	—
Encouraging	.552**	.609**	.362**	.375**	.508*	.577*	.544*	—	—
Instructing	.593**	.468**	.272**	.574**	.588*	.654**	.668**	—	.531*
Problem-Solving	.606**	.489**	.250*	.486**	.679**	.699**	.736**	—	.581*
CASI–SF	—	−.344**	—	−.213*	−.602*	−.650**	−.609**	—	—

Note: Dashes indicate correlations significant at p > .05. CAM = Clinical Assessment of Modes; CASI–SF = Clinical Assessment of Suboptimal Interaction–Short Form; MPOC–SP = Measure of Processes of Care–Service Provider; MPOC–20 = Measure of Processes of Care–20.

p < .05.

p < .01.

Parent Perspective

There were no significant correlations between parent-reported parent factors (length of EI services; EIPSES) and therapist factors (MPOC–SP, CAM, or CASI–SF) with p > .05. Associations between MPOC–20, CAM, and CASI–SF are presented in Table 4. Three domains of the MPOC–20 (Enabling and Partnership, Coordinated and Comprehensive Care, and Respectful and Supportive Care) had a moderate negative correlation with the CASI–SF and a strong to moderate positive correlation with the overall CAM and the Advocating, Encouraging, Instructing, and Problem-Solving subscales. The Respectful and Supportive Care domain also had a moderate positive correlation with the Collaborating subscale. The Providing General Information domain had a moderate positive correlation with the Advocating subscale, and the Providing Specific Information domain had a moderate positive correlation with the Instructing and Problem-Solving subscales.

Discussion

Participants reported that therapists consistently used family-centered practices and therapeutic communication in EI, and suboptimal interactions between therapists and parents were infrequent. Consistent with previous research, therapists more frequently relied on relationship-building practices than capacity-building practices. Empathizing, encouraging, and instructing modes were reported more frequently than collaborating, problem-solving, and advocating modes. We hypothesize that, although therapists practice in a family-centered manner, they are not using the full range of family-centered communication strategies.

Previous research has found that therapists may be more confident than competent in using family-centered practices in EI (Bruder & Dunst, 2015; Bruder et al., 2011). The literature has consistently called for additional professional training (Bruder & Dunst, 2005; Campbell et al., 2009; Campbell & Sawyer, 2009) and development of cross-disciplinary competencies for EI teams (Bruder et al., 2019). An opportunity exists for occupational therapy practitioners to support interprofessional training initiatives on interpersonal communication using their knowledge of therapeutic use of self and the IRM.

Family-Centered Care and Therapists’ Communication in Early Intervention

Consistent with the strengths-based approach encompassed in family-centered care, therapists most frequently used the empathizing and encouraging modes in practice. Frequent use of the instructing mode further suggests that therapists incorporate information sharing. However, these interactions may not have the full capacity-building potential necessary for family empowerment that could be achieved by using the collaborating, problem-solving, and advocating modes. This finding supports previously published findings that therapists may overrely on direct instruction and underrely on problem-solving approaches (Barton & Fettig, 2013; Colyvas et al., 2010; Friedman et al., 2012; Salisbury et al., 2010; Sawyer & Campbell, 2012). Missed opportunities to shift power within the therapeutic relationship to the parent using collaborating, problem-solving, and advocating modes may be contributing to the challenges in translating family-centered theory into practice (Bamm & Rosenbaum, 2008; Bruder, 2010; Fingerhut et al., 2013; Kuo et al., 2012).

Significant associations were found between therapists’ mode use and frequency of family-centered practices, underscoring the critical importance of flexible and multimodal communication. The empathizing mode was one of the most frequently used modes, but it had the weakest association with family-centered practices, as reported by therapists and parents. Although empathic communication is critical for establishing a therapeutic relationship, therapists do not rely solely on the empathizing mode to ensure family-centered care. Future research should further investigate the role of empathic communication in family-centered care and professional education opportunities that support therapists’ capacity to communicate in a multimodal manner.

Limitations

Limitations to this study include convenience sampling that relied on participants’ self-report via electronic surveys. Our findings may be limited to the perspectives of therapists and parents who were active members of online communities and may not be generalizable to a wider population of providers and families in EI. Moreover, therapist and parent samples were not paired, limiting the conclusions that can be drawn when comparing the two perspectives. Last, the small sample of parents limits the strength and generalizability of findings. Future research should examine family-centered practices and communication with a paired-samples design and consider how therapist– parent interactions may change over time in response to family needs.

Implications for Occupational Therapy Practice

An opportunity exists for ongoing professional development related to therapists’ competency to remain flexible, intentional, and multimodal in their communication. Practitioners and educators are called to integrate a stronger emphasis on family-centered practices that ensure:

sharing of specific and general information with families throughout the intervention process and

flexible communication that incorporates collaborating, problem-solving, and advocating modes.

Conclusion

The IRM may offer a promising approach to expanding existing knowledge of family-centered practices in EI. Family-centered care is a standard of practice in pediatrics, and interventions that ensure parent engagement (i.e., caregiver education, training, and coaching) are associated with positive therapy outcomes (Clark & Kingsley, 2020; Gronski & Doherty, 2020; Kingsley & Mailloux, 2013). Yet evidence on therapists’ capacity to effectively implement family-centered principles, such as coaching, remains limited (Ward et al., 2020). The IRM recognizes that the interpersonal dynamics within the therapist–parent–child triad have the power to enable or inhibit parent and child participation in therapy (Taylor, 2020). Distinguishing between different communication modes can help therapists implement the full breadth of family-centered practices in pediatrics. We call on therapists to be more intentional in their sharing of specific and general information with families in EI and use of the collaborating, problem-solving, and advocating modes.

Footnotes

Acknowledgments

We acknowledge Michelle Bulanda, Joy Hammel, and Mary Khetani for their contributions to this study’s design.

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