Activating parents in early intervention: The role of relationship in functional and family gains

Including parents of children with a disability in early intervention programs has been widely advocated by multiple health professional disciplines. Within these interventions a substantial body of research supports the positive influence of the parent-child relationship on developmental outcomes. Programs that upskill parents, reflect family context and focus on increased participation in broader community and social settings are now considered best practice. Such programs have good face validity, with recent studies showing parents strongly endorsing the sharing of skills and strategies, allowing them to extend the child’s learning to multiple situations including within the family and wider community. Despite this evidence, successful widespread implementation of relationally-based programs has been difficult to achieve. Working directly with parents can include challenges beyond simply introducing strategies and having them apply these outside therapy sessions. It requires therapists to work in a context where parents may be struggling with feelings of incompetence and experiencing high levels of individual and relational stress that are often associated with parenting a child with a disability. Developing therapy goals that reflect family imperatives can also present challenges as therapists and parents may be driven by objectives derived from developmental checklists rather than contextual, family-prioitised goals. This thesis investigated the efficacy of a manualised program designed by the candidate (PCRI-EI; parent child relationally informed – early intervention) in addressing these challenges in an early childhood development clinic that delivers multidisciplinary services to children with disabilities. A preliminary case study showed promising changes for the family, in reduced stress and improved sense of competency for the parents, as well as positive impacts on functional outcomes for the child. Parents reported improvements in family engagement in community activities as well as in their own ability to more broadly understand their child’s challenges. A subsequent qualitative study investigated the experience of therapists as they made the transition to a relationally-based practice. Feedback from therapists indicated the systematic approach embedded in the protocol combined with reflective supervision built their competence and confidence in working collaboratively with families. At the same time, they reported being better able to generate therapeutic goals that preferenced family context and priorities over therapist-driven developmental aims. Changes in parents’ stress, psychological well-being and sense of competence, was investigated in a third study. Findings showed notable reductions in stress levels over time particularly those generated by parents’ conceptualisation of their child as difficult. Increased parental wellbeing and sense of competency were also reported. These changes were consistent across diagnostic categories. The final component of the thesis investigated impacts of PCRI-EI on the child’s functional capacity. Significant and marked increases in functioning were observed across time. The gains did not differ by diagnosis and parental feedback indicated family context was prioritised and valued. These improvements were generalised throughout social, community and educational settings. Taken together these findings indicate that through the combination of a manualised therapy model and ongoing reflective supervision, PCRI-EI supports the implementation of relationally-based, family-centred practices. PCRI-EI appears to provide the how-to component. The absence of which seems to have inhibited the widespread adoption of such programs in early intervention. Given the exploratory nature of the thesis these conclusions require further investigation. Nonetheless, they suggest successfully engaging parents in early intervention requires a systematic approach embedded in the practices of the organisation. The role of the therapist in supporting parents build the skills to work in this context is critical. Achieving that change in therapists’ capacity involves a similarly methodical approach that integrates professional development, reflective supervision and an appreciation of the professional identity challenges the changed way of working may present. This combination of factors does not appear to have been addressed in previous investigations around establishing relationally-based practices in early childhood interventions.