Preparing The Family to Partner With the School
The second step in the process of integration is to prepare the family to engage in a partnership with the school. The importance of families and schools working together has been very well documented as a key factor in the educational success of children. When addressing the needs of children with health problems, this partnership becomes even more critical.
Given the enormous challenges these children face in school and the limited capacity that schools often have in addressing complex medical conditions, collaborating with the school can be a difficult and frustrating process for families. The challenges often are magnified in low-income communities in which the culture of the school is highly incongruent with the culture of the surrounding neighborhoods.
Parents typically are required to serve as strong advocates for their child, but this may result in family-school relationship patterns that are adversarial and mutually coercive. Families need to understand school ecology, including the mission of schools, and public regulations that direct school policy. They need to learn about the culture of the schools in their community, as well as the resources and limitations of the schools to address complex health problems. Furthermore, it is important for families to know about resources in the community that can assist with school transitions.
Providing families with a framework for engaging in collaborative problem solving with educators also is critical to effective integration. In successful home-school relationships, parents and educators are cleaners, co-teachers, and co-decision makers. Parents respect the authority of teachers in the school domain, and teachers respect the authority of parents in the home domain. Both parties are actively involved in educating themselves and supporting each other in learning useful strategies for nurturing the child’s cognitive, social, and emotional development.
Preparing Schools to Partner with the Family and Healthcare System
As families are being prepared to partner with schools, educational professionals need to be oriented about how to collaborate effectively with families to address the complex health needs of the child. Although some families have or are able to develop, strategies for initiating a fruitful family-school partnership, it is typically the responsibility of school professionals to set the tone and create the context for a mutually supportive family-school collaboration.
To facilitate this process with children who have health problems, it is important for educators to understand the medical condition, the challenges to the child and family in coping with this condition, and the cognitive, social, and emotional needs of the child in the school context. Furthermore, teachers need to understand the significance of effective family-school collaboration and strategies for engaging families in effective partnerships to address the challenges these children face in school. To assist children and families in coping with medical problems, school professionals need to work effectively with health providers. Unfortunately, school personnel generally lack training and experience in collaborating with healthcare professionals.
Differences between the school and healthcare system with regard to mission, culture, regulations governing practice, models of practice, and language can serve as obstacles to effective communication across systems. As a result of these barriers, school and healthcare professionals often fail to communicate, depriving children of the benefits of collaboration and leaving parents in the challenging position of being the spokesperson for each group. School professionals often need encouragement and guidance to initiate collaboration and to engage in effective partnerships with healthcare providers.
Engaging the Family, School, and Health System in a Collaborative Process
Once all the systems involved with the child have been prepared, the actual consultative process can begin. This step offers the greatest challenge for professionals in promoting effective school integration. Collab-oration across systems is required to design, implement, and evaluate specific strategies to promote the child’s cognitive and social competence in school. Conjoint behavioral consultation is a highly useful model for guiding the collaborative, problem-solving process that can facilitate effective integration.
Conjoint Behavioral Consultation
Behavioral consultation is a wen-n: searched and well-developed process that focuses on solving student problems indirectly by providing consultation to individuals who are direct service providers. Behavioral consultation typically incorporates a functional behavioral assessment framework for conceptualizing and designing interventions to treat a wide range of school-based problems, including academic, behavioral, and social problems. This consultation method involves a series of interviews with intervention participants to identify problems, collect and analyze functional assessment data, design an intervention plan, implement the intervention, and evaluate outcomes. Although behavioral consultation generally is an effective approach for improving children’s adaptation in schools, this set of procedures traditionally has focused primarily on providing consultation to school professionals alone.
By so doing, the process may fail to capitalize on contributions that families can make in collaboration with educators to address children’s educational needs. Including families in the process has the potential to improve the effectiveness of behavioral consultation. Recognizing the limitations of scope and setting of the behavioral consultation model, Sheridan et al. further developed this model so that it includes families and school professionals in the collaborative consultation process. Integrating ecological systems theory with the principles of behavioral psychology into the conceptual framework, con-joint behavioral consultation incorporates the input of multiple informants in the family and school systems to understand the meaning and function of child behavior in each system.
Furthermore, this approach seeks to elucidate how behaviors and processes occurring in one system have an impact on functioning in the other system. Extensive research on CBC has been conducted over the past decade. Sheridan, Eagle, Cowan, and Mickelson reported the outcomes of 4 years of investigation in which CBC had been used to address a wide variety of problems. The reported CBC cases reflected consultation with 57 students, 53 parents, and 56 teachers. All of the cases involved collaborative consultation between school professionals and families. Students enrolled in this study were referred by school personnel for academic and/or behavioral problems.
The results of their analyses found overall effect sizes across cases to range from 0.83 to 1.36, suggesting strong effects on CBC. Furthermore, their findings indicated that CBC was highly acceptable to participating parents and teachers. CBC was designed to facilitate partnerships among other systems, in addition to the family and school, including the healthcare system and other community systems. With children who have health conditions, CBC necessarily involves the integration of the family, school, and healthcare system in the problem-solving process. A brief outline of the steps involved in CBC is provided here. Readers interested in a comprehensive description of the model and process are referred to as the manual written by Sheridan et al.
Stages of Conjoint Behavioral Consultation
Like behavioral consultation, CBC is divided into 4 stages. In the problem identification stage, the consultant and consultee work together to identify the key problem to be targeted. However, because multiple systems are involved in the problem identification process, the assessment is much broader than that in behavioral consultation.
For example, CRC usually includes a family assessment. The family assessment uses both interview and direct observation methods to determine family perspectives about presenting problems and to understand relationship patterns. During the interview, the consultant explores the family history and learns about parent-child and sibling interactions.
The problem identification process often includes an interview with the target child, as well as the completion of self-report measures. The assessment should also include a functional assessment of behavior conducted in school and/or home settings. The purpose of the functional assessment is to identify factors contributing to the emergence and maintenance of problems with cognitive, social, and emotional adaptation. This information can be highly useful in designing interventions tailored to address the specific needs of children and the challenges of families and school professionals.
The CBC Problem Identification Interview is Designed to Address six Goals
- Establish working relationships among families, school professionals, and health providers
- Specify the targets for intervention
- Identify antecedent, situational, and consequent conditions for the targeted problems as pan of a functional assessment
- Determine the severity of the problems
- Identify the goals of intervention
- Establish procedures for collecting baseline information.
The inclusion of family members, school personnel, and healthcare professionals in the CBC process requires that the consultant be skilled in working effectively with individuals from each of these systems and in facilitating communications across systems. The problem analysis stage of CBC involves an examination of baseline ecological and functional assessment data to design strategies that promote adaptive functioning within systems and that address the hypothesized functions of behavior. Intervention design should involve individuals from each system in the integration process.
It is important for each stakeholder group, including the child and caregivers, school personnel, and healthcare professionals, to contribute to an interpretation of the assessment data and to share perspectives about the social validity of potential intervention plans. Social validity refers to stakeholder views about the appropriateness and acceptability of the goals, strategies, and intended outcomes of intervention.
Intervention plans should reflect the priorities and values of participants from each system in order to increase the likelihood of intervention adherence and effectiveness. The next step of CBC is treatment implementation. During this phase, the consultant ensures that participants in the intervention process understand their roles and receive the orientation needed to perform their responsibilities competently. Intervention integrity, which refers to the extent to which intervention strategies are implemented as designed, is a critical component of this phase.
Strategies to Improve Integrity Might Include
- Providing systematic training to participants
- Pre-paring written scripts to guide the implementation process
- Using self-monitoring strategies to assist participants in directing their own work
- Arranging for a consultant or peer to observe intervention sessions then offering feedback to participants
. In the final stage, treatment evaluation, the consultant and participants review outcome data to determine the extent to which the integration process is effective in achieving specified goals. Evaluation is conceived as both a formative and summative process. Outcome data are collected formative during the course of school integration so that adjustments can be made along the way.
Also, outcomes are examined summatively after a designated time period to determine whether goals have been attained and whether a revision of the integration plan is needed. Furthermore, the social validity of the intervention needs to be evaluated by determining the extent to which functioning has been ‘normalized” and the degree to which participants perceive the intervention to be acceptable.
APPLYING CBC TO INTEGRATING STUDENTS WITH HEALTH PROBLEMS
The CBC model provides a framework for:
- Aligning the family and healthcare systems to facilitate the integration of cute children with health problems into school
- Integrating systems are into the problem-solving process.
Although this framework and set of meth-ods generally have been demonstrated to be effective, the process is primarily problem-focused and oriented toward deficit reduction. A limitation of this approach is that it may fail to acknowledge and build on the strengths of the child and assets in the family, school, and healthcare systems, which may be highly useful in designing strategies to prevent further health risks and promote resilience in the school context. Thus, we recommend an adaptation of CBC that incorporates problem-focused and strength-based approaches to the assessment of interventions.
In the initial “problem/asset identification phase,” the consultant collaborates with intervention stakeholders to identify both problems encountered by the child in multiple settings and assets of the child, family, school, and healthcare providers to promote adaptation across settings. During the intervention planning phase, child and system assets are used strategically to address problem areas.
Furthermore, strategies are developed to build child assets and to strengthen the systems to enable the child to become more resilient. Next, prevention strategies are implemented simultaneously with intervention approaches, so that problems get resolved while the child and the systems that support him or her are becoming increasingly stronger and more resilient. The outcomes of both prevention and intervention efforts are evaluated formatively so that strategies can be adjusted during the change process. The following case illustrates a strength-based application of the CBC model.
Case of Jackson
Jackson, 11 years of age, was hospitalized after sustaining a moderate to a severe closed head injury during a bike accident. After a 48-hour stabilization period, he was transferred to the neurorehabilitation unit of a children’s hospital. Upon review of records, a neuropsychologist noted that, prior to the accident, Jackson had the above-average cognitive ability and was performing at an above-average level in reading and at an average level in all other academic subjects. School records revealed a history of minor difficulties paying attention, following directions, and completing homework, although he had never been diagnosed with ADHD.
The parents reported that he was a sensitive child who was prone to worry. There was no evidence of depression or significant conduct problems prior to the injury. A brief neuropsychological evaluation performed 7 days after the accident revealed an estimated Wechsler Intelligence Scale for Children—Ill Verbal IQ in the above-average range and a Performance IQ in the borderline range.
Significant problems with visual-spatial memory, visual-motor integration, and fine motor functioning were appar-ern. Further evidence of right-hemisphere involvement was suggested by relative weaknesses on fine motor tasks involving the left versus the right hand. Performance on a continuous performance task and reports from hospital staff suggested significant problems with attention span and impulse control.
Also, on two occasions, Jackson displayed temper out-bursts with hospital staff when he could not have his way. Reports from his parents revealed that Jackson had two close friends in the neighborhood and that he had well-developed art skills. During the early period of recovery, he demonstrated little interest in drawing and resisted efforts to engage him in an activity.
Jackson lived in a two-parent family with an 8-year-old brother and 6-year-old sister. Both parents worked full-time, and the children were placed in daycare after school until a parent arrived to pick them up in the late afternoon. Although both parents reported a close relationship with Jackson, the father worked long hours, leaving link time for him to spend with his son. The mother assumed primary responsibility for school and homework issues and household chores.
She admitted that Jackson was challenging to parent and often argumentative at home. Jackson and his brother often fought; the relationship with the sister was generally cooperative. During a family interview in the first week of hospitalization, the parents were very upset and expressed guilt that their failure to supervise Jackson’s neighborhood activities closely may have contributed to the accident. To address Step 1 of preintegration, the consulting psychologist provided supportive counseling and conducted a family assessment with Jackson’s present.
Several subsequent meetings with the family were also conducted. During one of these meetings, the consultant and the neuropsychologist met with the family to discuss the nature of the head injury, its short-term effects, and the expected course of recovery, including the range of prognoses. The consultant assisted family members in understanding the information and formulating questions about their concerns. The psychologist emphasized the importance of strengthening parent-child relationships as the first step of intervention. The parents were assisted in engaging Jackson in a dialogue about projects they could work on together during the hospitalization. They were encouraged to modify their work schedules to become more available to the child during this period.
The consultant carefully observed the parents as they worked together and intervened to promote better communication and more adaptive problem-solving. Toward the end of the hospitalization, the psychologist met with the parents and child to discuss potential challenges Jackson might encounter upon re-entry to school, thereby addressing Step 2 of preintegration. The challenges included increased problems with writing assignments, such as seatwork, homework, and tests; difficulty paying attention and listening to instruction in class and problems with anger control.
Assets of the child and the resources of the school that would enable Jackson to ad-dress school challenges were identified. Jackson and his parents ex-pressed a lack of trust toward the current teacher but indicated that the teacher from the previous year had a strong relationship with Jackson. Also, one of Jackson’s best friends was in his class or most of the day.
The parents were informed about Jackson’s educational rights as a child with a handicapping condition and a disability. With parent permission, the consultant contacted the principal and described Jackson’s condition and the challenges he would likely encounter upon return to school. The consultant provided the principal with written information about Jackson and requested that his teachers be briefed about his condition and its likely impact on school functioning. In addition, the consultant spoke with the principal about the need to involve the district’s Department of Special Services to assist in the process of disability determination.
A meeting at the school was scheduled for the parents, key school personnel, including the teacher from the previous year, and the hospital consultant. At the family—school meeting the consultant’s initial goal was to establish the basis for a strong partnership involving the family, school, and healthcare team. Next, the psychologist facilitated a discussion to identify both potential child concerns in school and potential assets, as part of the problem/ asset identification process.
The psychologist described the findings of functional assessments of behavior during listening and seatwork tasks performed in the hospital, which revealed that the primary function of Jackson’s behavior during these activities was task avoidance. As a transition into the intervention planning phase, the psychologist highlighted the critical need to establish strong attachments for the child across all systems of functioning.
The parents described some of the strategies they had been using in the hospital to strengthen their relationship with Jackson, which included spending time playing board and card games with him. School professionals were encouraged to think of ways to relate effectively with Jackson upon his return to school. Pro-viding opportunities for Jackson to meet with last year’s teacher and to receive assistance from his close friend in the class were discussed.
The school team and parents were then encouraged to consider accommodation strategies for assisting Jackson to listen to classroom instruction and to work on assigned written work, taking into account that his behavior during these activities was primarily designed to avoid demands. Strategies that included allowing Jackson a choice of work activities, reducing the duration of high-demand activities, and providing positive reinforcement contingent on paying attention and attaining realistic goals for productivity were discussed.
Also, during the meeting, the family and school team agreed that Jackson should receive occupational therapy, and a schedule for providing this service was negotiated. An important goal of occupational therapy was to assist him in regaining interest in art activities. Furthermore, strategies to assist with attention in class and anger control were discussed. During the meeting, the roles of each member of the school and healthcare teams, as well as those of the parents and child, were specified to assist with intervention implementation.
For purposes of outcome evaluation, formative and summative out-comes were to be assessed by portfolio methods involving the review of tests, quizzes, seatwork, and homework teacher reports of child behavior and social skills child report of anxiety and self-esteem and peer reports of social acceptability. A written, individualized education plan that included target problems, assets and resources, intervention goals, strategies of intervention, outcome measures, and periods for reviewing outcome data was prepared.
The family and school team met on a bi-monthly basis for the initial 6 months to review progress and modify the intervention plan. Both parents were strongly encouraged to attend these meetings. The consultant attended the 2-month follow-up meeting and stayed in contact with the family and school team via telephone after that.
Fully integrating children with health problems into the fabric of the school can be a challenging process for the family, school professionals, and healthcare team. We recommend a four-step integration process based on principles of ecological systems theory and functional behavioral assessment. The first three steps are designed to prepare the family, school team, and healthcare team for integration and the fourth step focuses on coordinating these systems to plan, implement, and evaluate strategies of integration.
CBC provides a highly useful framework for achieving the fourth step in the process. A hallmark of the CBC approach is to involve stakeholders from all salient systems in the child’s life in the process of designing, implementing, and evaluating the intervention program. Interventions are designed to enable the child to function more competently within each system and to promote collaborative working relationships among family members and professionals from the school and healthcare systems.
In implementing CBC, we recommend an approach that integrates a strength-based, asset-building approach with one focused on deficit reduction and problem-solving. In this way, efforts to build resilience and to prevent further health risks can be incorporated with strategies to address emerging challenges and problems.