We are pleased to welcome Shubha Kashinath, PhD, CCC-SLP, as our guest host
for the SLP chat tonight, Monday, November 17, 2003 at 9:00pm EST. She will
be addressing the topic of SLP services in natural environments

Dr. Kashinath is the Project Coordinator for Family Guided Routines Based
Intervention (FGRBI).  FGRBI is a field initiated research project funded by
the Office of Special Education Programs, U.S. Department of Education. This
project is focused on developing and validating a family-guided routines-based
intervention model that meets the legislative mandates and the recommended
practices of the field with empirical data to support the model components.
The project will conduct a series of single subject studies of family-guided
routines-based intervention (FG-RBI) in collaboration with local community
programs to assure "real world" results and applications, in order to develop
a better understanding of the factors that contribute to natural environments
intervention and how to translate the information into procedures that will be
effective, efficient, and non-intrusive for families.

Dr. Kashinath has experience as a speech-language pathologist providing home-
based intervention services to families and children with disabilities in Florida,
California and Arizona. Her research interests include studying outcomes of family-
centered intervention practices with families and children with developmental
disabilities, especially those with Pervasive Developmental Disabilities (PDD).
She is currently involved in providing routines-based intervention services to
children and families and in training interventionists to provide effective early
intervention services for children with special needs.

Dr. Kashinath has provided us with a list of resources which may be found below
the chat transcript.

<Robin> Welcome!  We are chatting tonight with Shubha Kashinath, PhD, CCC-SLP, about SLP Services
          in Natural Environments.
<Robin> Shubha, please start with an overview of SLP services in natural environments
<Shubha_Kashinath> Thanks for having me here tonight.  Let's see- for the past 6 years, I have
          been involved 100% in providing speech therapy services in natural environments.  That is,
          as per Part C of the IDEA, early intervention is supposed to occur for children under the
          age of three in naturally occuring settings- such as home, daycare or childcare settings. 
          This means, that in addition to serving young children, SLPs have to take on a more
          consultative role and meet the needs of families and caregivers as well...
<Shubha_Kashinath> i have had different roles in this process, ranging from providing the
          intervention, to teaching caregivers how to support their child's communication, training
          other SLPs and early interventionists, and conducting research on it's effectiveness.
<Robin> What does the current research reveal?
<Shubha_Kashinath> Current research about how young children learn language has always supported
          intervention in natural environments.  This is because typically developing children
          learn language and social skills primarily in interactions with their primary caregivers
          and their family- so it makes sense for us to support communication for young children
          with disabilities in the same settings.
<Shubha_Kashinath> More specifically, parent-implemented interventions - i.e., when you teach
          parents to teach their young children has had a lot of research support.  However, there
          are some challenges as well.
<Robin> Is it then less effective to do therapy in an office?
<Shubha_Kashinath> Robin, I have to say that it is less effective to do therapy in an office.
          Because when you teach children in an office, you then have to deal with ensuring that
          the child's skills generalize to the real world setting- i.e., with his/her family.
<Shubha_Kashinath> But when you work in the natural environment, you are teaching a child skills
          where he/she needs to use it- so, it makes it more naturalistic and developmentally
          appropriate for the caregiver and child. Not to mention how motivating some daily
          routines are.
<AdrienneFSU> Any specific types of disabilities?
<Shubha_Kashinath> Yes- Adrienne.. at FSU, we have had a range of kids and families.  We have
          worked with children with severe cognitive impairments, Down syndrome, autism,
          developmental disorders and severe motor delays.
<cathi> Is it much like EIP?
<Shubha_Kashinath> Cathi- it is a lot like EIP-- in fact, in the really young ones, I think
          quality early intervention includes communication, social, and cognitive therapy all
          rolled in one!
<wendy> How many times a week you give therapy for kids?
<Shubha_Kashinath> Wendy- About how offen I visit families- it ranges from 1-2 visits per week,
          depending on how often the families' are authorized to get intervention.
<lstranger> Can you be more specific as to what daily routines you are teaching to and how
          that is accomplished in a 1x per week therapy delivering situation?
<Shubha_Kashinath> Lstranger- your question about daily routines is excellent.  Our goal is not
          to create routines for the family, but to work on each child's goals within what is
          happening naturally at home.  So, on any home visit, I may see between 8-10 routines.
<Shubha_Kashinath> Some examples include- singing, snack, diapering, getting juice, music related
          routines, reading books.  Things that families do with children on a day-to-day basis.
<cathi> How do you help with these daily routines?  What is your part/role?
<Shubha_Kashinath> Cathy- my role is to observe the routine for a few minutes, identify how we
          can embed the child's communication goal in the routine, and teach mom how to do it using
          as many different teaching methods as possible.  Let me give you an example.
<cathi> sure
<Shubha_Kashinath> I work with a family who's child is beginning to sign and has started using
          the sign for more.  Now, when I visit, I see he really likes to have a snack.  So I tell
          mom- see what happens if you wait and give him a chance to ask for more.
<cathi> ohhh, I see
<Shubha_Kashinath> Then I coach her to give the boy a prompt to use the sign more.  And he gets
          a snack when he does it or after mom has given him a chance to try.  So, my role is not
          to be hand's on with the child and get him talking to ME all the time..
<Shubha_Kashinath> But my role is to support the parent's ability to communicate with their child. 
          After all, I am only in their life temporarily and they are with each other 24-7.
<lstranger> What are your feelings about using sign language or picture exchange to augment a
          little one's minimal verbal skills?
<Shubha_Kashinath> Lstranger- I think a whole language approach is great! I often use signs and
          pictures to augument communication.
<linda> With the little ones who only have a few signs or words, I find it difficult to move them
          to other communicative functions beyond requesting.  Any ideas?
<Shubha_Kashinath> Linda - I often face that challenge.  One way that helps move kids on to other
          communicative functions like social interaction and joint attention is to engage them in
          social games- simple tickle games, chase, peekaboo etc., where what they are requesting.
<linda> ...but then, how do you move them to other functions after that?
<Shubha_Kashinath> Linda- I think moving children onto social interaction and joint attention has
          to happen one routine at a time.  Introducing routines other than those where they are
          primarily requesting for something they want- such as social games, such as pretend play,
<Shubha_Kashinath> Songs, community activities is a start.  I will be happy to mail you some
          references later.
<Lbs> Do you feel that it is more working with the parents rather than directly with the child?
<Shubha_Kashinath> Lbs- When I started working with parents, what I did feel was that I didn't
          have enough coursework or experience working with adults.  All through grad school, you
          are taught to work with children (or adults) with disabilities.
<Shubha_Kashinath> But when you are with a family, what you need to know is how to teach other
          adults. And we don't get enough of that adult learning stuff.
<alicia> I know what you mean by not recieving enough adult learning.  I am currently a student
           and I feel like we are primarily focused on children.
<cathi> Do you work hand in hand with other disiplines like OT or PTs?
<Shubha_Kashinath> Yes, I work with OTs and PTs all the time.  When you think about it, routines
          like hand-washing or eating or getting dressed involve gross and fine motor skills, so
          often we all work together to embed goals in a routine--- BUT...
<Shubha_Kashinath> We try to be careful to not burden the family with too many strategies and
<lstranger> What can you say in relation to working with kiddos in their day care setting as the
          natural environment?
<Shubha_Kashinath> Lstranger- I think you have an excellent question.  Now-a-days, we live in a
          society where both caregivers often work.. so if the child is in daycare all the time-
          then, that's the natural environment for the child.
<lstranger> But when a child is in daycare and service is delivered there - how can I
          (considering the time constraints in my schedule) relay this teaching to the parent too?
<Shubha_Kashinath> We have used technology to our benefit here.  One of our familes runs a
          demanding insurance business and I send them emails after my visit updating them on what
          I did (keeping confidentiality of course).  Sending home notes, phone calls etc. work
          for most people.
<alicia> Wouldn't you have to conduct an assessment of your clients to plan appropriate
          intervention for them?  Are there other strategies used if you were NOT to conduct the
          assessment yourself?
<Shubha_Kashinath> Yes, you do have to conduct an assessment. I think if you had to see a child
          on your caseload who you hadn't seen for an assessment, then an informal observation of
          the child and family in their preferred daily routines is a good place to start to gather
<cathi> Do you do the assessments on these children?
<Shubha_Kashinath> Yes, I do assessments as well within daily routines. It takes on a different
          form compared to standardized assessments, but there are some excellent curriculum based
          measures, such as Carolina, Hawaii, AEPS, etc.  I will add them on to the reference list.
<linda> I like the Hawaii as well, more therapy friendly than a Rosetti I think.
<Shubha_Kashinath> Linda, I agree.
<lstranger> I often use a standardized measure to "qualify" the child for services but with the
          little ones I rarely get good goal information from that measure...observation in their
          environment is very beneficial.
<Robin> What is the optimum number of visits per week, Shubha?
<Shubha_Kashinath> It depends on when I got the authorization.  Some kids like kids with Downs
          Syndrome I see from when they are 6-7 months till they turn three.  It depends on what
          they are authorized to get.  I see some kids only once a month.
<cathi> Depends on what they are authorized to get? ...by insurance?
<Shubha_Kashinath> Based on what we know and what the law says.  So, embedding intervention in
          routines is a means of providing early intervention within which you can use many
          different types of strategies.
<Shubha_Kashinath> Also Cathi- most of this is authorized under Part C, so it is paid for by IDEA.
<AdrienneFSU> Is this routine based therapy a type or means of early intervention?  Or is there a
          different way to distinguish this from traditional forms of "early intervention program"?
<Shubha_Kashinath> Routines based intervention, intervention in natural environments and early
          intervention in theory, should refer to the same thing.
<alicia> Would the number of visits depend on the level of need of the child?
<Shubha_Kashinath> Yes Alicia.
<Shubha_Kashinath> The key point is not how much YOU can see them.. but what you do in your time
          with the family, so that they can be providing the child with opportunities to
          communicate when you are not around.  SO in some ways- intervention happens a lot
          between visits...
<wendy> Do kids ever receive therapy every day?
<Shubha_Kashinath> I have not in Florida seen everyday visits.  Once or twice a week.
<cathi> So, when you go out to a house, do you go hand in hand with a PT or just know what the
          PT's goals are and reinforce as you do your thing?
<Shubha_Kashinath> Cathi- we start the process with each family with a team meeting where the
          parent is in charge and together we identify routines that will work (logistically, those
          that are motivating for the child) and then talk about each one's goals (PT, OT, SLP).
<Emily_K> Does most of your therapy center on facilitating communication or do you also try to
          incorporate improvement of fine motor or perspective taking skills?
<Shubha_Kashinath> Depending on the child's need, we work hand on hand with the PT, or use a
          trans-disciplinary model and work on the PT's strategies while making sure we check in           
          with each other regularly.
<linda> Do you find that much of what you do is modeling, since these kids don't say enough to
          use techniques like expanding or recasting? Are there other techniques for these limited
          verbal kids?
<Shubha_Kashinath> Linda, I use modeling the least. Other evidence based strategies include time
          delay or waiting, environmental arrangement, contingent imitation, turn-taking,
          contextual support, prompting, etc.
<linda> ..but if you are the only one talking, and the kid will only request...it all just FEELS
          like modeling.  I'm talking about kids with less than  words.  Late talkers and the "too
          old to be late talkers" group.
<Shubha_Kashinath> Most of our research has been on facilitating communication, although, like i
          said before, it is hard not to work on fine motor or other cogniitive skills especially
          in a daily routine.
<lstranger> What about the 2 1/2 year old with verbal skills but very poor intelligibility - any
          artic or phonological therapy?
<Shubha_Kashinath> I think there is a lot of potential for artic and phonological therapy to be
          embedded in functioanl routines.. I have not had many kids though who I have had to do
<lstranger> How would one embed artic or phonological therapy into a functional routine?...Please
          give an example.
<Shubha_Kashinath> Lstranger... consider a bath-time routine.  What if at bath-time, mom and you
          could choose to include toys that started with a particular sound.. like say fish,
          flowers, phone, feather, etc.  Then the child can have multiple turns to say those words
          as he plays and all you had to do was a little planning around what to include in his
          environment.. just an example that came to mind immediately.
<alicia> I like that idea.
<Shubha_Kashinath> So, see- even simple routines can be great.  Think about a trip to McDonald's..
          what are some things the child has to do to eat a meal?  What are some things you can get
          the parent to do to get the child to communicate?
<Emily_K> You could also do the same sort of activity but incorporate other senses into it by
          having the child touch or smell the objects to get a better schema.
<Shubha_Kashinath> Emily- great idea.
<fibita> Have you ever incorporated signing into therapy?  Also, what do you view as one of the
          greatest misconceptions parents might have about an approach that works well?
<Shubha_Kashinath> Fibita- I have incorporated signing in my therapy and the biggest fear for
          parents is that we are giving up on speech.  As long as you share with them that signing
          doesn't automatically mean no speech, I have found parents to accept it.
<lstranger> I like that idea - at what age do you think a child could respond to pictures vs
          objects in artic therapy?
<Shubha_Kashinath> Lstranger>- I think kids responding to pictures has more to do with their
          level of symbolic understanding than with age.  I would start with objects, then pair
          objects with a picture and slowly move to only pictures after the child understands that
          the picture represents the object.
<Emily_K> That sounds like a good fading technique.
<Shubha_Kashinath> We don't want to tell all these families to change their snack routine and do
          it like you would have snack in your house. Try think about how you can embed the child's
          goals within each different routine.
<lstranger> I have bags of toy/objects that represent different early developing sounds - like
          a /b/ bag and a/m/ bag that I use a lot in home based therapy.  The items are purchased
          at thrift stores.
<cathi> great ideas
<Shubha_Kashinath> Lstranger... I hesitate to take bags of toys to families.  When you look
          around in the family's home, are there objects laying around you can use instead? 
          Natural environments means good bye to the toy-bags!
<alicia> Also, if you are using toys the child is familiar with you would probably be more
          likely to get a positive response from the child such as the toys he plays with on a
          daily basis.
<Lbs> About saying bye to toy bags...I job shadowed an SLP who brought her own toys and the kids
          were more responsive to the new toys that they didn't have.
<Shubha_Kashinath> Lbs... what we are telling the parent then is that it is our special toys
          that make your child talk.  What happens when the SLP leaves?
<lstranger> Good point 
<Lbs> okay...What about this...the SLP I shadowed had birthday blow horns to help the child form
          lips and blow softly...and suckers and candy to help child work on moving the tongue...
          is that different than bringing in your own toys?
<Shubha_Kashinath> Lbs.. if suckers and candy are available in the home, then they would work
<lstranger> What about handouts for parent information?
Shubha_Kashinath> I would tailor handouts based on how parents learn. See if there are a lot of
          magazines lying around.. does this look like a parent who reads a lot? Then maybe give
          them a one-pager about your strategies.  If not, a cue card on the refrigerator to remind
          them may work as well.
<Emily_K> Shubha, do you have any suggestions about how to incorporate a family member who is
          a little more hesitant to participate than others?
<Shubha_Kashinath> Emily- great question.  I have had many families who sit back and don't get
          active at first.  My first line of attack is to tell myself maybe I didn't make it clear
          what the expectations are.  Because the family is probably familar with a medical model
          where they take their child to someone and watch and wait.  Other strategies are ask the
          parent what routine they are having problems with, ask them to take a turn with you,
          talk through the child and tell them how much they enjoy participating.
<Robin> Shubha, are there any other important points about working in natural environments that
          you would like to share with us?
<Shubha_Kashinath> Robin, I think the most important point for us to remember in working in
          natural environments is how to join in with the family vs. taking over the family's
          routines.  WE DO NOT want to create routines for families or change them drastically.
<Shubha_Kashinath> What we want to do is to help them teach their child no matter how they choose
          to live.  For example, snack may occur at a table for some families, may be on the run
          for others, and may be very short for others.
<AdrienneFSU> Shuba, I like how you observe everything in the environment to determine styles
          and strategies for interventions.
<lstranger> I see your point - it is less about telling the parent what to do and more about
          showing them what they are already doing or how to tweak what they are doing to enhance
<Robin> Well, its getting late!  Thank you, Shubha, for joining us tonight and sharing your
<cathi> Thank you Shubha
<alicia> Yes, thank you very much
<Emily_K> Thanks!
<wendy> Bye
<lstranger> Thanks for my first chat experience!
<Shubha_Kashinath> Thanks for having me.  This has been fun.  Good luck!


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