The Visit in Practice

Excerpted from Chapter 2 of The Visit: Observation, Reflection, Synthesis for Training and Relationship Building by Annette Axtmann, Ed.D., & Annegret Dettwiler, Ed.D.

Copyright © 2005 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

This section depicts the Visit in practice through the story of a single mother and her 5-month-old son, Hugo, who were living in a resident shelter for homeless mothers and their children. This example illustrates the power of the Visit to inform a service system by illuminating the strengths of a mother and her baby — in particular, a baby who has an undiagnosed physical delay. Portions of the Visit are described to illustrate what a direct care practitioner and supervisor may uncover through observation, reflection, and synthesis.

CONDUCTING THE VISIT WITH HUGO

Hugo will attend a child care center while his mother, Violet, participates in a drug treatment program. The Visit is conducted in the shelter’s infant/toddler child care room at the shelter one day before Hugo is to begin receiving services. The homeless shelter’s director arranged administration of the Visit because she believes that homeless mothers are so focused on survival that caring for their children can become a secondary concern. As for the participation of Hugo’s direct care practitioner in the Visit process, the director of the homeless shelter noted that ongoing professional development benefits children receiving services. Hugo’s direct care practitioner, Nancy, has a high school diploma and very little training in infant development and practice.

Meeting

The direct care practitioner and her supervisor (Jane, the head teacher for the shelter’s infant/toddler room) are waiting in the infant/toddler room when Violet enters, carrying Hugo in her arms. The supervisor voices her observation in the moment: “Hugo is clinging to you while he tries to understand us. He certainly knows who his Mommy is.” Violet smiles and says, “We’re buddies.” Jane asks Violet to decide how the Visit will begin; she can choose between the tasks for Hugo and the reflective parent interview. Violet demurs. The supervisor says, “You choose. You’re in charge here.” Violet chooses to give Hugo the tasks first and then engage in the interview.

Hugo’s responses to the tasks vary greatly. When Jane pulls him to sit, Hugo’s head lags almost painfully, and he does not help the supervisor on the second try. However, the observation of another competency task demonstrates this mother’s relationship with her son.

Hugo lies on his back on the floor. His mother has been asked to sit behind him. Hugo waves his arms and legs gently in the air. The supervisor asks Violet to ring a bell. She rings it lightly two times. Hugo stops waving his arms and legs, and as he stills completely, Violet lets out a soft gasp of amazement. She nods and says, “Yes, he heard it.” Then Jane asks Violet to call Hugo’s name. When Violet does this, Hugo immediately turns his entire body around so that he can see his mother. She extends her arms toward him as he looks at her and almost rolls over, straining his entire body around and toward her.

Next, Violet and Jane sit in rocking chairs, facing one another for the reflective parent interview. Violet has placed Hugo on his tummy on a blanket on the floor. Jane asks Nancy to sit beside him, “to be on his level.” Nancy secures a few toys and sits down next to Hugo. After a long and comfortable pause, Violet begins to tell their story. She says that she had been on drugs through 7 months of her pregnancy. When asked about Hugo’s special needs, Violet says she is very concerned about the tremors Hugo exhibits, especially during sleep. Violet believes that no one in the shelter is interested in the tremors, although they concern her greatly. When asked how she responds to these tremors, Violet tells Jane that she lifts Hugo up and holds him tightly against her chest so he knows that someone is there for him. Violet also wonders about Hugo’s eyes because he rubs them a great deal.

The team members thank Violet for sharing with them. They tell Violet they will write her a letter summarizing the meeting.

Co-Review

The co-review is led by questions posed by the supervisor to the direct care practitioner. As the supervisor and direct care practitioner in this case remember and restate what they learned during their meeting with the family, they synthesize the information provided during the reflective interview with their direct observations evidencing a strong attachment between Hugo and Violet. Hugo’s overall use of his motor system was cause for concern, demonstrated by his marked head lag in the pull-to-sit task. In contrast, a task with red rings had revealed Hugo’s ability to coordinate his visual and motor systems and, perhaps most important, to remember — hence, his cognitive strength. For instance, the team observed while Jane extended some small red rings toward Hugo’s left hand as he lay on his back. When the rings touched his hand, Hugo grasped and held on to them. Jane guided his hand and the rings to his mouth. Then, Hugo shook the rings and brought them back to his mouth independently.

Thus, the team’s nonjudgmental observations indicated a lack of coordination among Hugo’s social, emotional, cognitive, and motor systems. When compared with other children in his age range, as noted on the Developmental Characteristics Chart (available in this book), Hugo demonstrated severe motor developmental delay. His interactions with his mother and with the team indicated that his social, emotional, and cognitive systems were functioning well, and although his motor behavior was slow, it did improve in the context of social interactions (i.e., when his mother called his name).

Parent Letter

The parent letter grew out of the team members’ synthesized picture of the child and his parent. The letter reported Hugo’s social and emotional competencies and was illustrated with observations of interactions between Hugo and his mother as well as between Hugo, the supervisor, and the direct care practitioner. The letter emphasized Violet’s loving contribution to Hugo’s development. It suggested that Violet and Nancy, as Hugo’s direct caregivers, encourage Hugo’s motor development daily. The letter reassured Violet that Hugo’s direct care and other practitioners would observe vigilantly for tremors, especially while Hugo slept. Jane and Nancy would work with Violet to understand the significance of these involuntary movements and would discuss seeking a neurological evaluation if all participants deemed it necessary. Jane and Nancy would also observe Hugo when he rubbed his eyes; they would report to Violet what happened while and just before he did this.

The letter was guided by the team’s strong insight that Violet truly cared for Hugo. She was a perceptive advocate for ways to help him develop as fully as possible.

Portions of the letter written for Violet follow:

Hugo is developing well with regard to his ability to think and solve problems. For example, as he coordinated his eyes and head to follow the ball, he seemed to ask, “Where is it going?” . . . He talks by cooing and moving his entire body. He heard your voice as you sat behind him and turned his body all the way around to see you. In this and other ways, Hugo demonstrated his strong attachment to you. This tells us he trusts you and is beginning to trust others.

As noted, we observed Hugo’s physical ability to coordinate his eyes and body. Moving his body and lifting his head seem difficult for him. Suggestions for helping him in this area include dressing him in as few items of clothing as possible, positioning him on his belly on the floor, and encouraging him to move his body as much as possible. Toys or your face should be placed in front of Hugo’s eyes when he’s lying on his belly so that he has to lift his head to see them and hence work on his head control and trunk control.

Nancy will observe when he rubs his eyes; she will also observe him when he sleeps. If a tremor (shaking or startle-like movement) is observed, Nancy will lift Hugo from the crib and hold him securely so that he can feel her body, just as you described to us during the reflective parent interview. As you said, this will help Hugo to know that someone is there for him. We are glad you showed us how you hold him and how you feed him his bottle.

Parent’s Response

In this situation, the parent’s response was secured by the director of the homeless shelter, who was not in the infant/toddler child care room at any time during the visit. The director accompanied Violet as she carried Hugo into the residential section of the shelter. The director reported that when Violet entered the room where she and Hugo stayed with the other families, she burst out, “It was great! I learned so much — it made me want to know more about Hugo, his development!”

Direct Care Practitioner’s Experience

A few days later, Jane obtained Nancy’s evaluation of the meeting. The supervisor said, “Let’s reflect on your experience during Hugo’s visit. Did you learn anything special about Hugo and his mother and about infant development, in general?” Nancy replied,

I learned a lot by watching you. I learned how to observe how Hugo was supposed to be and how he actually was. I found out more about his prenatal development that helped us understand him. The practitioner team was on target as to his developmental delay. He stayed the same. Unfortunately, we did not get to refer him for further evaluation by a neurological pediatrician before he left the shelter. I used my copy of the letter we wrote for his mother with the entire staff.

Evidently, the direct care practitioner had made herself fully available to learn during the meeting with Hugo and Violet and during the co-review that immediately followed. Nancy began to see Violet as someone she needed to listen to and work with in caring for Hugo and to realize the value of careful observation. As Nancy worked with other children and parents on a daily basis, perhaps she began to synthesize her observations of parent–child interactions and her observations of the child’s response to everyday tasks with what she knew of the child’s history. Certainly, she was better prepared for conferences with her supervisor, for staff meetings, and for subsequent implementations of the Visit with other families. Nancy’s sense of herself as a professional is evident in her evaluation of her experience with her supervisor, Hugo, and Violet. She seemed confident and pleased about presenting Hugo’s case in a staff meeting, illustrating her findings with a copy of the letter she and her supervisor had written for Hugo’s mother.

HOW THE VISIT IS INTEGRAL TO THE SERVICE SYSTEM

Gradel, Thompson, and Sheehan (1981) presented research demonstrating that parent reports can be reliable, and Anastasiow and Harel (1993) stressed the value of identifying behaviors that suggest a baby is at early developmental risk. Hugo’s story is notable because it shows how conducting the Visit can uncover a parent’s and a child’s strengths as well as identify behaviors that suggest early developmental risk. Use of the Visit can set in motion timely and cost-effective efforts by a direct care practitioner and supervisor who work together within the same program. As a team, they are capable of activating the larger interrelated service systems. Thus, the Visit provides crucial training for direct care practitioners, changes how service systems view and work with families, and promotes the informed relationships that are basic to efficient practice.