Project TEAM: A group intervention to teach transition age

youth with developmental disabilities to problem solve physical and social

environmental barriers to participation

Jessica M Kramer, PhD, OTR/L, Associate ProfessorAriel Schwartz, OTR/L, PhD candidateDepartment of Occupational Therapy

Boston University

FINANCIAL DISCLOSUREAACPDM 72nd Annual MeetingOctober 9-13, 2018

Speaker Name: Jessica Kramer, I-Ting Hwang, Ariel Schwartz

I have no financial relationships to disclose.

I will not discuss off label use and/or investigational use in my presentation.

Agenda

• Project TEAM • Theoretical Foundations• Intervention Description• The “Game Plan”

• Research Evidence• Case Study• Implementation Strategies & Challenges• Q & A

Learning Objectives

• Learning objective 1: Describe how the Game Plan problem solving approach can facilitate the participation of transition age youth with DD and cognitive impairments.

• Learning objective 2: Describe the theoretical tenets underlying Project TEAM.

• Learning objective 3: Describe the preliminary evidence supporting the potential efficacy of Project TEAM to increase participation of transition age youth.

• Learning objective 4: Identify strategies and resources to support the implementation of Project TEAM in attendee’s practice context.

@ProjectTEAMBU

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Funding Acknowledgements

NIDILRR Grant #90IF0032-01-00NIH K12 HD055931

Why Focus on Transition Age Youth?

• Critical period of development • Post-secondary and/or vocational exploration

• Greater involvement in IEP• Self-directed planning

• Impending change in service delivery systems• IDEA (provided by school) to ADA (requested by user)

• Post-secondary and/or vocational exploration

Common approach to thinking about disability and participation

Physical Impairments and Disabilities

• Difficulties moving around

• Difficulties using hands to work with things

Sensory Impairments and Disabilities

• Difficulties hearing• Difficulties seeing• Difficulties communicating

with others

Cognitive Impairments and Disabilities

• Difficulties with attention and memory

• Difficulties understanding• Difficulties communicating

with others

Difficulties doing activities at school, work, and the community

8

Environmental approach to thinking about disability & participation

Physical Impairments and Disabilities

• Difficulties moving around

• Difficulties using hands to work with things

Sensory Impairments and Disabilities

• Difficulties hearing• Difficulties seeing• Difficulties communicating

with others

Cognitive Impairments and Disabilities

• Difficulties with attention and memory

• Difficulties understanding• Difficulties communicating

with others

• Stairs• Small materials• Tight spaces

• Confusing materials• Talking too fast• Rigid rules for task completion

• Noisy environments• Low lighting• Lack of translators

Environmental Barriers

Difficulties doing activities at school, work, and the community9

Environmental approach to resolving participation challenges

Physical Impairments and Disabilities

• Difficulties moving around

• Difficulties using hands to work with things

Sensory Impairments and Disabilities

• Difficulties hearing• Difficulties seeing• Difficulties communicating

with others

Cognitive Impairments and Disabilities

• Difficulties with attention and memory

• Difficulties understanding• Difficulties communicating

with others

• Ramps, elevators, and curb cuts

• Specialized technology• Spacious rooms and

hallways

• Directions written in clear language with pictures

• Speaking at a slower pace• Providing extra time or breaks

• One person talks at a time• Individualized lighting• Translators • Materials in braille

Environmental Supports

Able to do activities at school, work, and the community10

Project TEAM

• Project TEAM will prepare youth with disabilities to:• Systematically identify environmental barriers and supports• Generate modification strategies• Request reasonable accommodations

• The long term outcome of Project TEAM is to facilitate participation in valued life situations

Project TEAM: How is it different?

• Project TEAM is:• Focused on the young person.• Designed to be cognitively accessible.• Focused only on the environment.• Is explicitly rights based.

Project TEAM: Multi- Component Intervention

Group Curriculum

E-Peer Mentoring

Community-Based Trip

PAR Development

https://www.youtube.com/watch?v=MDNJLIiJZbM

Project TEAM Best Practices

15

Best practices informing

design

Best practices informing

delivery

Project TEAM:Teens making Environment and Activity Modifications

A 12-week manualized group intervention

Cognitive-Behavioral TechniquesYouths internalize a self-monitoring process

“Game Plan: Goal/Plan/Do/Check” using self-talk questions.

Resulting benefits:Shifts attributions about participation difficulties

from personal impairment to the environment.Facilitates generalization of training concepts to

everyday life, enabling youth to identify & resolve environmental barriers.

Universal Design for LearningConcepts are associated with symbols and

introduced using multiple modalities such as videos, games, and direct instruction.

Resulting benefits:Learning activities can be modified and graded

for optimal receipt to facilitate learning. The same content can be delivered to youth of

varying ages, abilities, and life experiences.

Experiential Learning ApproachYouth master new content and gain skills through group discussion, investigative learning activities,

field trips, and personal reflection.Resulting benefits:Youth immediately apply new concepts to real-life

experiences to achieve a personal activity goal. Youth make decisions and solve problems in

matters that are directly relevant to their lives, increasing self-determination.

Peer Support & Social LearningYouth acquire new skills and insights by

attending sessions and field trips with peers who share similar life experiences.

Resulting benefits:Creates a safe environment where youth work

together to identify solutions to environmental barriers, increasing self-efficacy.

Youth develop meaningful relationships that expand their social networks and support participation.

Project TEAM Goal Setting

Goal Setting• Youth identified, with support from family & facilitator • What activity at school, work, or in the community:

• Do I want to start doing?• Do I want to do more often?• Do I want to do more independently?• Do with different people?

Goal Level Description +2Much more than expected

For the second college tour, directs and tells adults how to help her plan and attend the tour.

+1More than expected

With support from adults other than parents, attends two college tours.

Expected Outcome With support from adults other than parents, tours a collegeBaseline Has not toured a college.-2Much less than expected

Refusal to tour or visit college classroom despite having a plan and support.

Project TEAM Group Curriculum

Group Curriculum

• Co-facilitated by licensed professional & disability advocate• 8 modules

• Each module is 2 meetings.• Each module completed in a week

• 12 weeks• Weeks 1-5

• Meet weekly• Weeks 7-12

• Meet every other week• Supported, individualized community based trip in off weeks

Content OverviewModule Content

1. Introduction to the Training: Who Am I and What Do I Want To Do?

2. Introduction to the Environment: What is it?

3. Identifying Environmental Barriers and Supports: What helps me or makes it hard for me?

4. Working around Barriers: Identifying Modification Strategies

5. Thinking through Strategies

6. Your Rights: Laws about Access & Environmental Changes

7. Communication: Asking for Change

8. Checking the Game Plan: Did I Reach My Goal?

All modules contain:• Icebreaker: Fun game to encourage

interaction• Discussion: Trainees share ideas or

experiences with each other to orient to a new concept

• Teaching time: Didactic activities- usually supported by ppts or video

• Learning activity: Game that requires trainees to use new concepts

• Personal goal: learning about the next step of the game plan & using with goals.

• Wrap up: Checking learning + Self Check quiz• Practice: Applying new concepts at home

Facilitator Manual

• The facilitator manual includes:• Estimated times for each activity• List of materials needed for each activity• List of modifications that can be made to

each activity to ensure accessibility• Activity Core Components to ensure the

activity is delivered in the intended manner• A suggested ‘script’ to use to explain or

introduce the concept or activity

Facilitating Success in Project TEAM• Core Components: Ways of interacting with trainees to

maintain engagement, support understanding, and ensure trainees have the opportunity to express their knowledge.

Kramer, J. (2015). Identifying and evaluating the therapeutic strategies used during a manualized self- advocacy intervention for transition-age youth. OTJR: Occupation, Participation, and Health, 35 (1), 23-33. doi: 10.1177/1539449214564146

Project TEAM E- Peer Mentoring

24

E- Peer Mentoring Protocol

• Eight peer mentoring calls:• Weeks 1-5: Weekly• Weeks 6-12: Bi-weekly• Telephone or Skype• All calls follow the same structure (objectives)

• Face-to-face contact:• First and last Project TEAM group session• Community-based outing

Instrumental Peer Mentoring Protocol

• Support provided by the peer mentor is focused on building skills:• Recognizing environmental supports and barriers• Requesting modifications• Attaining participation goals

• The mentoring relationship and positive connection facilitates increased knowledge and skills

E-Mentoring Themes E-Mentoring

Call Call Themes

1 Going out with friends

2 Going shopping

3 Going to a restaurant

4 Being outside in nature

5 Doing things at school

6 Working at a job

7 Traveling

8 Personal Participation Goal

https://www.123rf.com/photo_25662114_fast-food-restaurant--cartoon-illustration-of-a-fast-food-restaurant-and-cityscape-in-the-background.html

https://www.123rf.com/photo_6807595_travel-suitcase-with-stickers-eps-8.html

http://www.freepik.com/free-vectors/nature

Call Objectives

Objectives/Agenda for each call:1) Mentor and Mentee get to know each other by talking about the

weekly theme2) Help with personal participation goal3) Review the Game Plan and content from recent group session4) Apply the Game Plan to the weekly theme5) Questions, Homework reminders, & Goodbye

E-Peer Mentoring Script

Peer Mentor Supporter

Graduate OT students• Before call: Review script with mentors • During call: Provide 1:1 support

• Some mentors had indirect supervision• After call: Provide feedback • Do not directly interact with mentee

Training and Commitment • Initial orientation to Project TEAM• Weekly planning with research team • Ongoing supervision of peer mentor

Project TEAM Community Based Trip

31

Community Based Trip

• Co-Facilitator, peer mentor, and peer support participation in goal activity.

• Structured, 5-step support process based on the Game Plan.

Levin, M., Kramer, J. M. (2015). Key elements supporting goal attainment for transition-age young adults: A case study illustration from Project TEAM. Inclusion, 3(3), 145-161. doi: 10.1352/2326-6988-3.3.145

Project TEAM “Game Plan”

33

What is the Game Plan?

• A problem-solving process • Can be used for any activity goal• Based on disability rights

• A focus on environment barriers, not impairments• Includes disability rights laws that

support requests for changes• Four steps: Goal, Plan, Do, and Check• Each step has a ‘self-talk’ question

Game Plan OverviewStep Base Self-Talk Question Symbol First First Base Goal “What activity would I like to do?” Bulls eye with

arrow

Second Second Base –Plan Step 1

“What parts of the environment help me or make it hard for me?”

Thumbs up and down

Second Base –Plan Step 2

“What strategy can I use to change the environment?”

Thought bubble

Second Base –Plan Step 3

“Would using this strategy change the activity for other people?”

Other people

Third Third Base Do “Who do I talk to about making this change?” Person with talk bubble

Home Home Check “Can I do this activity now?” Check

Exposing Youth to Professional Language

• Environment• Strengths• Difficulties • Supports• Barriers• Advocacy• Accommodations

Teaching the Game Plan

What is the Game Plan Worksheet?• Guides trainees through the

Game Plan steps• Uses words and images• Each Project TEAM module

teaches knowledge necessary for the next step

• Youth complete one step of the Game Plan worksheet at the end of each module

GoalWhat activity would I like to do?

Motion: Shoulder shrug, asking questionSymbol: Bullseye with arrow

First Base Goal

Plan Step 1What parts of the environment help me or make it hard for me?

Motion and Symbol: Thumbs up and down

People• Includes adults and friends that you talk to or

interact with during activities.

Services & Organizations• Includes schools, clubs, religious groups, offices,

governments, businesses, and other groups that are in charge of organizing activities or events for people.

Rules• Includes directions about how activities should be

completed.• Includes the amount of time given to complete

activities.

Signs & Information• Includes all things that give people the facts they

need to do things or find things, like maps, symbols, lists, websites, brochures, or announcements.

Light, Sound & Smell• Includes sensations such as how bright something

is, how loud something is, or the scent/odor of something.

Plan Step 2What strategy can I use to change the environment?

Motion: Pointing to head in thinking motionSymbol: Thought bubble

Plan Ahead

Before you start an activity, think about how you will do the activity.

Get the things you need before you start an activity.

Use Technology or ThingsUse technology or things in different ways to do an

activity.Use new technology or things to do an activity.

Change SpacesChange the size, shape, and arrangement of indoor

spaces, outdoor spaces, entrances and exits, or ground. Change the amount or type of light, sound, or smell in

the space.Do the activity in a different place.

Change the RulesChange the way you do an activity by changing the

rules, amount of time, or order of steps.

Ask Someone For HelpFind people who can give you information or help you

solve a problem. Change the type or amount of help you get from other

people during an activity.

Teach Others About Abilities & Needs

Tell other people what you can do. Tell other people about the type and amount of help you

need to do an activity.Teach other people about your disability.

Second Base: Plan Step 2

Second Base: Plan Step 2

Plan Step 3Would using this strategy change the activity for other people?

Motion: Gesturing/pointing to othersSymbol: Other people

Second Base: Plan Step 3

Second Base: Plan Step 3

Second Base: Plan Step 3

DoWho do I talk to about making this change?

Motion: hand making talking motionSymbol: Person talking with talk bubble

Third Base: Do

Asking for Change Script

CheckCan I do this activity now?

Motion: make a check with fingerSymbol: Check

Home: Check

Project TEAM Research Evidence

65

Research Question and Design

Research Question Design

What is the effect of Project TEAM on participation goal attainment, knowledge, problem solving, self-determination, and self –efficacy?

Matched comparison group

ParticipantsProject TEAM

(n = 47)Goal Setting

(n = 35)

Age M(range)

17y 6 mo 17y 6mo

% Male 59.6% 60%

% Non-white 25.5% 34.3%

% Intellectual disability* 67.4% 37.1%

* p = .008

Methods: Procedures

• Project TEAM’s 12- week curriculum• Individualized goal setting with one community based trip• Manual driven curriculum: 2x week, 2 hours each meeting

• Fidelity: mean=86.7%, range: 73.3–94%• Electronic peer mentoring protocol: 8 sessions

• Goal setting only• Individualized goal setting• Two reminders over a 12 week period

• Fidelity= 100%

• Measurements at Initial, Outcome (12 weeks), 6-week Follow-Up• Instrument Battery: GAS, Project TEAM Knowledge & Problem Solving Test,

AIR Self-Determination Scale, Modified Disability Self-Efficacy Scale

Methods: Analysis

• Missing Data: • Individual items: Imputed using median of responses at that time period• Sum scores (attrition): Carry forward

• Linear mixed effects model• Fixed effects: Time, Group• Random effects: Participants• Tukey’s multiple comparison to explore EMD for all group x time interactions

• GAS• GAS T-Scores (mean = 50, goal attainment): Independent t- tests • Participation goal attainment: Chi-square, Fisher’s exact test

Results: Between Group Differences

Instrument

Between Group Differences

Outcome 6- Week Follow UpKnowledge

Problem Solving

Self-Determination(youth-reported)Self-Determination(parent-reported)Self-Efficacy (self- reported)

Results: Within Group Differences

Instrument

Within Group Differences

Project TEAM Goal SettingKnowledge IO

IFUProblem Solving IO

IFUIFU

Self-Determination(youth-reported)

IO

Self-Determination(parent-reported)

IOIFU

Self-Efficacy (self- reported)

Results: Goal Attainment

Instrument

Between Group Differences

Outcome 6- Week Follow UpGAS T-Score N/A

Participation Goal Attainment

Discussion

• Project TEAM had significantly better outcomes for youth’s participation goals

• Project TEAM may unique enhance youth’s compression, internalization, and generalization of knowledge and problem solving to everyday life.

• Parents only reported sustained changes in self-determination after Project TEAM.

• Self-efficacy is domain specific, and our measure may not have effectively assessed the self-efficacy domains targeted by Project TEAM.

Limitations

• Lack of randomization• Unequal distribution of IQ between groups

• Bias• No masked assessor• Data imputation

Research Question and Design

Research Question Design

Can peer mentors with IDD implement an e-peer mentoring protocol with fidelity?Can youth with IDD engage in an e-peer mentoring program?How do mentors and mentees with IDD engage in and perceive their relationship?

Program EvaluationRetrospective Analysis

Qualitative Study

Research Study

• Implemented Project TEAM in:• Boston area: 5 cohorts• Detroit area: 2 cohorts

• Implemented in community based settings:• 4 schools (High School/Transition programs)• 3 community service agencies

• 42 total mentor/mentee dyads

Mentor Characteristics n= 9Age M= 22.6 yrs

(Range 17- 35)Gender

Male 4Female 5

Number of peer mentoring relationships M= 4.67 (Range 1-11)

DiagnosisDown Syndrome 4Cerebral Palsy 2Dubowitz Syndrome 1Muscular Dystrophy 1Anxiety/Depression 1

Intellectual Disability 5

Mentee Characteristics (n =42) Number PercentageGender

Male 26 61.9Female 16 38.1

RaceAsian 5 11.9Black or African American 2 4.8White 31 73.8Others 4 9.5

Intellectual disability**Yes 27 64.3No 15 35.7

Reading levelBelow grade level 35 83.3At grade level 7 16.7

80

Data Collection • Audio recorded all peer

mentoring calls• Documented all job

accommodations• Peer mentor reflections after

each cohort• Analysis of audio recorded calls

and mentor reflections

Feasibility ResultsTransition-age youth with I/DD are able to participate in Project TEAM’s electronic peer mentoring

• Call attendance rate was 87% • Mentees engaged in conversation in 94% of opportunities

72%

22%

6% Not engaged

Engaged

Highlyengaged

Reference: Kramer, Ryan, Moore, & Schwartz, 2017

Feasibility Results

Peer mentors with I/DD achieve Project TEAM’s electronic peer-mentoring objectives:

• 87% of instrumental objectives met• Objectives significantly more likely to be met when mentors used supports

Reference: Kramer, Ryan, Moore, & Schwartz, 2017

What do mentees talk about during calls?

0102030405060708090

Facts Related toIntervention

Content

Facts NotRelated to

InterventionContent

PositiveEmotions

NegativeEmotions

Perc

enta

ge

StrongModerateWeak

Reference: Ryan, Kramer, & Cohn, 2017

• What mentees talk about during the call may impact the strength of connection in the mentor/mentee relationship

How do mentors respond to mentees during calls?

0

5

10

15

20

25

30

35

Advice Empathy Self-disclosure

Perc

enta

ge

StrongModerateWeak

Share personal info

• Mentors support mentees when they respond• Mentors in the strongest relationship:

• Provide more advice• Share the most personal information

Reference: Ryan, Kramer, & Cohn, 2017

Peer Mentors’ Perceived Roles: Teacher and FriendProfessional• “I gained an understanding of what it is like to have a job and be

responsible for maintaining a strong work ethic.” Teacher•“Someone who guides the mentee during Project TEAM to help them

understand what they need to do to be independent in changing their environment.”

Friend• “It is always helpful to get personal…The conversation is much more

open and relaxed, and it tends to help the [mentee] think outside of the box.”

Reference: Schwartz & Kramer, 2017

Mentor’s Approach to Cultivate a Supportive Environment

Actions• “I told her my own personal experiences…I also ask[ed] questions…to

make sure she understands…”

Dispositions• “In the heart I was positive, but in my mind I wasn’t…Having

accountability (it was my job) and hold myself to it.”

Reference: Schwartz & Kramer, 2017

Project TEAM Case study

87

Case Example: Dave’s Goal Listen to hard rock or metal music out in the community

Goal: What activity would I like to do?

• Dave loves listening to rock and heavy metal

• Usually goes with parents to blues concerts

• A rock concert would be his first experience listening to this music in person

Going out with friends and without parents to a rock concert became Dave’s activity goal

Dave’s Goal Attainment Scale Goal Level Description +2 Attends musical concerts/shows with a friend on one

occasion.+1 Attends musical concerts/shows with support on more

than one occasion.

0 Expected Outcome

Attends musical concerts/shows with support on one occasion.

Baseline Infrequently attends non-preferred musical concerts/shows with parents.

-2 Refuses to attend musical concerts/shows offered in the community despite having plans and support in place.

Plan Step 1: What parts of the environment help me or make it hard for me?

Supports Barriers

People People

Technology Rules

Inside Places Outside placesSigns and information

Plan Step 2: What strategy can I use to change the environment?

• To initially gather information, Dave used the strategies:• Plan ahead • Use technology• Ask someone for help

• In response to environmental barriers, Dave used strategies:• Change the rules

Plan Step 3: Would using this strategy change the activity for other people?

Who is involved in this activity or making this change?• Peer mentor• Others attending concert• Concert employees

• Would my peer mentor have more or less fun if I change the rules?• Would changing the rules make the concert less fun for others? • Would changing the rules make it harder for the concert employees

to do their jobs? • Would other concert attendees have less fun if I change the rules?

Do: Who do I talk to about this change?

• Concert venue manager or employees

Check: Am I able to do this activity now?

• By the completion of Project TEAM, Dave planned and participated in a rock concert

• By his 6-week outcome, Dave attended a second concert with a peer and support from his parents

He achieved a greater than expected frequency of attendance in the goal activity

Dave’s Goal Attainment Scale

Goal Level Description +2 Attends musical concerts/shows with a friend on one

occasion.+1 Attends musical concerts/shows with support on more

than one occasion.0 Expected Outcome

Attends musical concerts/shows with support on one occasion.

Baseline Infrequently attends non-preferred musical concerts/shows with parents.

-2 Refuses to attend musical concerts/shows offered in the community despite having plans and support in place.

Break out activity – apply it!

• Now think about a transition-age youth who you are working with• Work with a partner to choose one youth to use as a case• Fill out Game Plan Worksheets and discuss the environmental

barriers, supports, and strategies to be considered• One person can act as the coach asking the Game Plan Questions• The other person acts as the youth

Project TEAMImplementation Q & A

98

Reflection – Personal Goal Setting

• What was it like to take the focus off of the impairment, and instead to think about the environment?

• Can you envision any challenges to using this problem-solving model with youth?

Reflection – Applying this Problem-Solving Model

• What barriers do the youth you work with typically face? What are the most common supports available?

• What strategies do you think would be helpful for youth to use to change their own environment?

@ProjectTEAMBU

@bu_yell

LEARN MORE ABOUT US!

http://sites.bu.edu/yell/