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Published for the British Institute of Learning Disabilities

Journal of Applied Research in Intellectual Disabilities 2012, 25, 360371

Parents and Service Providers Perceptions of


the Family Goal Setting Tool: A Pilot Study
Sylvia Rodger*, Amy OKeefe*, Madonna Cook and Judy Jones
*Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Qld,
Australia; Department of Communities, Disability & Community Care Services, Housing & Homelessness, Brisbane, Qld,
Australia

Accepted for publication

12 October 2011

Background This qualitative study describes parents and


service providers experiences in using the Family Goal
Setting Tool (FGST). This article looks specifically at the
tools perceived clinical utility during annual, collaborative goal setting.
Methods Participants included eight parents and ten
service providers involved in a Family and Early Childhood Service in Queensland, Australia. Participants
were interviewed individually (parents and one service
provider) or in a focus group (service providers). The
transcribed interviews were analysed using standard
content analysis techniques.

Introduction
Family centred practice
In recent years there has been a shift in the underlying
principles and practices utilized within early childhood
intervention frameworks. In many services, Family
Centred Practice (FCP) principles have been adopted in
service provision for children with special needs (Dunst
2002; Edwards et al. 2003; Dodd et al. 2009; Epley et al.
2010). The FCP is based upon the foundational understanding that effective service delivery for children
extends beyond individual child-based therapy, requiring the child to be viewed within the context of the family unit. Parents and service providers are viewed as
equal partners in the decision-making process of determining interventions and the direction of the childs
care (Rosenbaum et al. 1998; Turnbull et al. 2000). As a
framework, FCP has influenced the design and implementation of services provided for young children with
disabilities in health care, early intervention, early childhood services, special and general education (Dempsey
& Keen 2008; Jeffries 2009).
 2012 Blackwell Publishing Ltd

Results Four key themes emerged including: (i) the facilitation of goal setting, (ii) strengths-based focus, (iii) family centred processes and (iv) family empowerment.
Conclusions Both parents and service providers were
positive about the FGST. Insights into barriers to holistic
goal setting and the clinical utility of the tool are
described. Further refinement of the tool and trial in a
range of early intervention contexts is required.
Keywords: early intervention, family centred practice,
goal setting, qualitative study

Alongside FCP is the strengths-based approach,


which posits similar underlying philosophies regarding
the emphasis on collaborative partnerships between
families and service providers (Raghavendra et al. 2007;
Epley et al. 2010). In service delivery FCP and strengthsbased approaches reinforce that service provision is
developed around the familys existing capacities, inherent strengths, practices of living, family care and environmental contexts in order to facilitate change that is
relevant and significant to the individual family (Allen
& Petr 1996; Moore 2005).
Family engagement in goal setting emphasizes opportunities for families to direct therapy interventions that
are uniquely meaningful to them (Case-Smith 2001; Siebes et al. 2006; Nijhuis et al. 2008; Rodger & Keen 2010).
FCP highlights the important role of the family within
the childs life, as parents are in a position to provide
expert insights into the competencies and needs of the
child, and should thereby have a role in goal setting
and prioritization (King et al. 2004). The underlying
requirement within these models of practice is that goal
setting is family driven as opposed to being therapistdriven.
10.1111/j.1468-3148.2011.00674.x

Journal of Applied Research in Intellectual Disabilities 361

Although the principles of FCP are espoused, many


early intervention programmes fail to be truly family
centred in goal setting and treatment planning (Hanna
& Rodger 2002; Siebes et al. 2007; Thompson 1998;
Tomasello et al. 2010). Typically health professionals
define parent roles in the intervention process (MacKean et al. 2005). Lawlor & Mattingly (1998) also suggested that the therapist as expert concept prevailed
in goal setting with families. MacKean et al. (2005) further concluded that it is only when families have the
opportunity to decide the parameters of the family
therapist partnership and their level of involvement in
decision making that services can be truly family centred.

Current goal setting practices


To this end, a number of goal setting tools have been
adapted for use with children and their families (Pollock
et al. 2010). A recent literature review by Tam et al.
(2008) identified four tools that are most commonly used
in goal setting with children including: (i) The Canadian
Occupational Measure (COPM) (Law et al. 2005), (ii) The
Goal Attainment Scaling (GAS) (Kiresuk & Sherman
1968), (iii) The Perceived Efficacy and Goal Setting System (PEGS) (Missiuna et al. 2004) and (iv) The Pediatric
Activity Card Sort (PACS) (Mandich et al. 2004).
The use of the COPM in paediatric settings has
increased over recent years and is the most commonly
used tool when goal setting with children (Tam et al.
2008). The COPM is a well established occupational
therapy measure that is designed to detect client
changes in self-perception of occupational performance
over a period of time (Law et al. 2005). A second widely
used tool is GAS (Kiresuk & Sherman 1968), a criterionreferenced goal setting and outcome measurement tool.
Studies have supported the validity and reliability of
GAS as an outcome measure in paediatrics, however,
other research has identified potential bias in the development of goals and the assessment of goal achievement, as clinicians often devise and evaluate the goals
(King et al. 1998; Steenbeek et al. 2007, 2010; Tam et al.
2008).
A more recently developed tool, the PEGS (Missiuna
et al. 2004) is a goal setting tool that utilizes a card-sorting method via which the child evaluates his or her
competence on a range of motor-based activities and
subsequently identifies therapy goals. The final tool, the
PACS, is similarly based upon the child sorting through
a range of activity cards and identifying activities that
are the most difficult for them. These selections then
 2012 Blackwell Publishing Ltd, 25, 360371

become priorities for intervention (Mandich et al. 2004).


All four tools were designed to establish childrens
intervention goals. There are no existing tools that specifically address family goal setting with parents. This is
pertinent when children are young and have cognitive
impairments that impact their ability to participate independently.

Family goal setting


At one of the Family and Early Childhood Service
(FECS) in Queensland, Australia, the difficulty of providing a streamlined goal setting process for families
within a multi-disciplinary team context was explored.
To be eligible for this early intervention service, families must have a child aged up to 6 years who has, or
is at risk of, a significant global developmental delay,
or has a cognitive impairment. At least annually, the
key worker from the team meets with the parents to
determine family goals. The team found that parents
often have difficulty determining therapy goals, particularly soon after their child is diagnosed when the issues
seem overwhelming. Furthermore, there was a need for
a more streamlined process that was not profession
specific.
As a result, a family goal setting tool (FGST) with
activity cards for use by all team members was developed by the final author to assist parents carers to identify child and family early intervention goals. The aim
of this article is to describe the FGST and to determine
its clinical utility from the perspectives of parents and
team members. Hence the following research questions
were posed: What are parents experiences of using the
card sort to identify annual goals for their Family and
Team Plan (FTP)? and What are the team members
experiences of using this tool with parents to determine
intervention goals?

Materials and Methods


Design
A generic qualitative research design (Caelli et al. 2003)
was used to reveal a representation of families and
team members experiences using the FGST during
annual Family and Team Planning sessions. The project
received ethical clearance from Disability Services, a service within Department of Communities (Queensland
Government) and one of The University of Queensland
Ethics Committees. Parents and team members provided
written consent prior to participation.

High school graduated from years 12


Disability support
Yes

High school left prior to graduation


Carer
Yes

Post graduate study


Transport modeller

Parent 8 More than 2 years

Parent 7 <6 months

Spastic quadriplegic
cerebral palsy
Down Syndrome and
heart condition

High school graduated


from years 12
High school left prior
to graduation
High school left prior to
graduation

Yes
Down Syndrome

Parent 4 More than 2 years


Parent 5 Between 6 and 12
months
Parent 6 Approx 2 years

Parent 3 More than 2 years

Joiner

Senior public servant


University degree
Field service consultant TAFE Diploma

High school graduated from years 12

High school left prior to graduation


Auctioneer Valuer
Parent 2 More than 2 years

Length of involvement Childs diagnosis and other


with FECS team
health conditions

Table 1 Demographic details of parent participants (N = 8)

All ten members of the Family and Early Childhood Service Team were invited to participate in a focus group
to discuss their perceptions of the utility of the FGST.
All had used the tool during the 6-month period of data
collection and consented to participate in the focus
group. One team member consented to participate in an
individual interview as she was unable to attend the
focus group. A training session on use of the FGST was
provided by the tools designer (JJ) prior to use with
families. Participants consisted of two occupational therapists (OT), two speech and language pathologists (SLP),
one physiotherapist (PT), one psychologist (PSYC), two
social workers (SW) and two programme officers (PO).
(Programme officers hold a tertiary qualification in
health education social welfare and provide family, programme and resource support.) All participants were
women and aged between 24 and 55 years old. Each
had been employed within the service team for at least
12 months at the time of the focus group, and had
between 3 and 27 years (mean = 14 years) experience in
working with children. Regarding participation in goal
setting meetings prior to use of the FGST, four service
providers had undertaken less than five meetings, three
between 10 and 20 meetings, and three more than 20
meetings. In terms of use of the FGST, service providers
experience ranged between 1 and 6 times.

Highest level of education

Participant group 2

Unemployed

Living with Partners occupation


a partner

The participants were a convenience sample consisting


of the parents and or primary carers (n = 8, 67%)
recruited from the client base of a Family and Early
Childhood Service provided by Disability Services,
Department of Communities. These families were recruited
from those who engaged in annual goal-planning meetings between February and July 2010 (N = 12). A service
staff member (not part of the research team) approached
eligible families after the annual FTP meeting in which
the FGST was utilized. Participant Information Sheets
and Consent Forms were provided. Consenting parents
details were then provided to the research team who
were not members of the service team. Participants were
eight mothers from Australian English backgrounds,
who were all engaged in home duties. Only one mother
worked part time, 14 h a week as a teacher (Parent 4).
The majority had completed high school or attended
university. (See Table 1).

Tracheal Stenosis and mild University degree


Yes
developmental delay
Down Syndrome
High school graduated
Yes
from years 12
Down Syndrome
High school graduated from Yes
years 12
PDD NOS
Post graduate study
Yes
PraderWilli Syndrome
University degree
Yes

Participant group 1

Parent 1 <6 months

Partners highest level of education

Participants

High school left prior to graduation

362 Journal of Applied Research in Intellectual Disabilities

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Journal of Applied Research in Intellectual Disabilities 363

Instruments
The FGST used in the study was developed by the final
author (JJ) in 20092010 to aid in the process of developing annual FTPs with families. It was first used systematically during the first half of 2010 when this study
was undertaken. An audit of FTPs from 2005 to 2009
led to a list of 4045 potential goals that could be
depicted as cards used in a sorting process. These were
then supplemented by additional goals based upon the
clinical knowledge and experience of the developer. A
number of these goals reflected the developers understanding of the potential impact of disability on family
life, relationships and well-being, and so targeted needs
beyond the child with the disability. In addition
inspired by research using the Measures of the Processes of Care (MPOC) (King et al. 1995) parents needs
for provision of information were also addressed. It
was believed that although some goals were beyond the
scope of direct therapy services, identifying and discussing the range of issues at the heart of family concerns provided the potential for facilitating problem
solving, prioritization for within team social work and
psychology support and linkage with services and service providers beyond the team. Cards were developed
to depict each goal (activity skill task issue) and
included a written descriptor and an illustration using
Board Maker (Mayer-Johnson, Pittsburgh, PA, USA)
Symbols (See Figure 1). A blank card with the title
something else was also included to ensure parents
were invited to add goals not encapsulated by the other
cards. Three coloured base plate cards labelled yes

Figure 1 Depicts a selection of the FGST cards, as used in goalsetting with families during the research trial.
 2012 Blackwell Publishing Ltd, 25, 360371

Figure 2 Demonstrates the FGST cards being sorted into


appropriate yes no piles, indicating if the goal is to be considered for inclusion in the Family and Team Plan.

(green), no (red) and maybe (orange) to aid the sorting process and a suggested script, with summary card
to assist a consistent approach by service users, were
also included (See Figure 2). The cards were then circulated within the team to identify gaps, determine potential areas of confusion or need for clarity, for comment
on the wording symbols and to indicate any unnecessary goal cards. As a result, extra cards were added to
the tool leading to the final count of 78 cards (including
something else). A number of graphics words were
also changed to allow a clearer depiction of the card
theme or content. The 77 cards within the FGST were
classified according to seven domains namely: (i) information, resources and support for parents carers, (ii)
inclusion of child family in community participation,
(iii) social relational support, (iv) daily living skills, (v)
communication, (vi) gross motor mobility and (vii) play
and early academic skills.
After a discussion regarding the purpose of the
Annual FTP families were provided with the option of
using the FGST to assist them in goal setting. Families
were presented with the cards and asked to place each
in one of three piles yes, indicating they were interested in pursuing that activity skill issue topic in the
short to medium term; maybe, indicating the activity skill issue topic depicted on the card was a potential area of concern interest that needed to be discussed
or re-considered in the future; and no, indicating they
were not interested or had no immediate desire need to
pursue that particular goal. The blank something else
card was positioned as the last card in the pack. The
process of sorting the cards frequently led to discussion

364 Journal of Applied Research in Intellectual Disabilities

and identification of parental concerns related to the


childs performance of particular tasks or activities or
their needs in relation to accessing additional support
and information for the family. On completion of the
initial sort the yes pile cards were discussed further
and families were assisted to prioritize their top 36
cards that represented activities issues they wished to
work on during the year. Due to overlap within the card
content it was possible to combine individual cards into
an overall priority area (e.g. family community outings
and using community facilities into increased community participation). These cards became the focal point
for establishing early intervention goals. Non-priority
goals from the yes pile were recorded as potential
future goals. The cards in the maybe pile were discussed to clarify areas of potential concern or interest
and were sometimes re-allocated by parents to alternative piles. Goals remaining in the maybe pile were also
recorded as potential starting points for future goal setting discussions. Once priorities were established, families were immediately provided with a photocopy of the
goal cards chosen. Identified goals were later formalized
in a document recording each goal, the childs familys
current skills situation in relation to the goal, first steps
towards achieving the goal, and team members to be
involved.

process. All transcripts were de-identified and participants provided with numeric codes.
Team members were engaged in a focus group discussion facilitated by research team members (SR,
AOK), which was audiotaped then transcribed verbatim
by a research team member. Thomas et al. (1995) suggested that a major advantage of using the focus group
format is that it offers the chance to observe group
dynamics through social interaction that results in data
that are often deeper and richer, compared to those
obtained from one-on-one interviews. Hence, two
researchers facilitated the group with one documenting
observations and taking field notes while the other led
the discussion. Prior to the focus group, team members
completed a demographic information form providing
details regarding qualifications, experience working
within a family centred framework, and the number of
goal setting meetings participated in and use of the
FGST while goal setting with families. A focus group
protocol was developed to facilitate discussion about the
clinical utility of the FGST including the merits, limitations and suggestions for modification. The protocol
specifically addressed overall impressions, process of
using the cards, nature and number of goals identified,
prioritization process and formal documentation of family plans. Both interview protocols can be obtained from
the corresponding author.

Data collection interviews


Semi-structured telephone interviews with parents or
carers were conducted by a research team member
(MC) (who was not a member of the FECS team but
worked in the service). These interviews were recorded
and transcribed verbatim. Interviews ranged from 30 to
45 min. A semi-structured interview schedule was
developed based on the literature and knowledge of
the goal setting process being piloted. The parents primary carers were supplied with a copy of the
interview questions prior to the interview. At the
beginning of the interview, consent and use of the
interview information was revised. Several demographic questions were addressed, namely the childs
age and primary condition diagnosis, length of involvement with the service, household occupants; parents carers occupation, educational status and
cultural ethnic background. The remaining questions
focused on the parents carers experience of the process of using the FGST, features of the cards, usefulness
of the tool in family goal setting, previous experiences
of goal setting without the cards and suggestions for
improvements with the cards themselves or with the

Data analysis
The audiotaped interviews were transcribed verbatim
and de-identified by a second research team member
(AOK) and reviewed by the same two independent
researchers (AOK and SR). The use of these two coders
enabled triangulation and peer checking throughout.
This thereby enhanced confirmability and reduced
investigator bias within the analysis (Mays & Pope
1995). Although data saturation could not be conclusively
established due to time constraints, no new relevant
themes emerged during the eighth parent interview.
Conventional content analysis (Hsieh & Shannon
2005) using hand coding was employed. The transcripts
were reviewed by two research team members (AOK)
(SR) to obtain a sense of the whole and to derive codes.
Collaborative discussions ensued regarding the coding
structure with a very high level of consistency between
each researchers interpretations. The individual codes
(53) were grouped into clusters (9) which then formed
themes (4) regarding parents and service providers
experiences of using the FGST. This occurred through a
process of ongoing discussion and consensus.
 2012 Blackwell Publishing Ltd, 25, 360371

Journal of Applied Research in Intellectual Disabilities 365

Results
Four key themes emerged consistently across both participant groups, providing commonalities between the
service providers and families perspectives. These
themes included: (i) the facilitation of goal setting, (ii)
strengths-based focus, (iii) family centred processes, and
(iv) empowerment of families. Some additional considerations are also described. These themes are detailed in
the following sections with supporting direct quotations
(in italics) from both parents and service providers
experiences.

The facilitation of goal setting


All parents interviewed described the FGST as an aid to
annual collaborative goal setting. The tool was described
as easier and simplified, making the goal setting process more manageable for parents. As one parent noted:
You want them to be normal; you want them to be normal yesterday. So when you are faced with this overwhelming amount of what do I want? Well I want
normality; well no we have to start with smaller steps.
To actually have it broken down into well is communication issues the problem? Is social issues(sic) the problem?
Is it toileting? Is keeping him safe the issue?... So actually to focus on the little steps makes the bigger picture
look not quite so scary (Parent 4).
All eight parents noted that the greater ease in goal
setting resulted from the cards acting as prompts due to
the array of choices cues before them. Furthermore all
noted that the cards allowed them to consider previously un-recognized areas of intervention. Comments
from parents included:
...I really rely on visual things so for me to see it, its
better than trying to think of something they were
good prompts for me to come up with ideas and then to
actually sort it as to areas to focus on (Parent 3).
Overall I think they (the cards) were pretty good it
showed me pictures of things I hadnt even thought of
myself. So I found them quite guiding and helpful in that
respect (Parent 6).
You know sometimes youll sit down to do something
and you wont remember everything that is important...But having the cards there, everything waspretty
much covered (Parent 7).
 2012 Blackwell Publishing Ltd, 25, 360371

This was further reflected in the service providers


perspectives with one (PO) stating:
I found even those families where you have thought it
might be too simplistic, have found it a really useful
prompt. You know Ive thought not that they are overwhelmed, but maybe they wouldnt have thought of the
scope that they could with the cards.
Both parents and service providers noted that the process of using the FGST reduced parents anxiety when
goal setting. One service provider (SLP) explained:
Because I must admit, in the past when weve told families we have planning coming up theyre like oh no.
But seriously its like a big burden for them. Its almost
like the goal setting is for our documentation and not
necessarily for them and It just takes the pressure off.
Because I know that families used to come sometimes to
those meetings and go oh. They hadnt had the chance
to think through it and in this way they dont have to.
Over half the parents noted that it can be difficult to
identify goals in the context of the FTP. Using the
FGST reduced some of that pressure; Sitting there
with people waiting for an answer for me, when I am
wracking my brain...Its stressful when you dont actually
come up with anything useful and thinking about the people sitting there waiting for me to think of something... I
found that it made it a bit easier (Parent 1).
The FGST also aided the service providers in goal setting. It appeared to act as a prompt in promoting a more
multi-disciplinary focus when developing the FTP with
families. As one service provider (SLP) noted I think
without the cards you tend to favour your own discipline. Not
that you mean to, its just where your thought processes lie.
Another service provider (OT) stated, I think on a positive
side there are choices available through the cards sort that I
dont always think to offer parents when we are doing a Family
and Team Plan. So from that perspective it might tweak some
areas we hadnt covered. Service providers also recognized
that the tool was an aid to discussion with families; ...It
really gives you a chance to tease things out as well and if they
raise a lot of things that they are not sure of, it really gives you
the chance to investigate it a bit further (SLP).

Strengths-based focus
A particular theme that emerged from three of the eight
parent participants and more strongly by service provid-

366 Journal of Applied Research in Intellectual Disabilities

ers was the strengths-based focus underpinning goal


setting which was aided by the use of the tool. When
framed appropriately, parents felt that the use of the no
pile allowed a positive reflection of progress opposed
to sole identification of deficits or areas to improve. One
parent stated:
It was really worthwhile... that the no cards can be
because hes already been there, hes done that, its something he can do. And I think that because so much of
what we do with having a child with a disability is negative I mean you look at their deficits, because thats
what needs to be fixed. I mean you have to address the
deficits, but its so nice to every now and then reflect on
he can do this, look at where we have come from. Its
nice to say well this isnt a problem anymore, how nice
is this (Parent 4).
In terms of the three parents who were positive about
the benefits of reflecting on the no pile, there was a
range of childrens ages and length of involvement with
FECS from <6 months to more than 2 years. The benefit
of framing the no pile in a positive manner was also
discussed by service providers, with one (SW) illustrative comment being, I found it useful...in the sense that the
strength was leaving the cards together and not saying well
they dont need feeding and you know but just having
them there and saying well they can do that now.

Family centred processes


Another emergent theme related to the provision of
family centred processes when using the FGST in goal
setting. Parents and service providers alluded to the
family centred nature of goal setting with the FGST.
Two sub-themes emerged, namely a more holistic
approach to family centred goal setting, and overcoming
barriers to holistic goal setting.

More holistic approach to family centred goal setting


From a service delivery point of view, the tool
appeared to promote a family centred rather than
child-centred approach to interventions, and more consistent service provision by the team. From the families perspective, this led to a more individualized and
family specific outcome as it provided more options
for families with varied needs. As service providers
noted It is family-directed rather than therapy-directed
(PT), and Its a family and team plan, its not what you
think, its what they want (SW). Thereby the majority

(five of eight) of the parents noted that the use of the


FGST led to more family orientated goals with two
parents noting:
It covered more than just the baby, it covered services to
help us cope. Which again is one of the things that probably the cards led to a conversation of them advising me
of what services were available to help all of us rather
than just the baby (Parent 1).
There was one (card) there on stress management, so we
talked about that which is not something that maybe
would have come up at any other time (Parent 3).
Of the parents interviewed, six out of eight reported
that the use of the FGST also resulted in an increased
knowledge of team services available to them:
It was good to know exactly what can maybe be offered
as opposed to just going in my with needs and what I
thought was best for my child. Yeah it was good to go
oh okay there might be something else we can look at
(Parent 5).
The FGST was also noted to provide an opportunity
to connect absent partners or family members with the
goal setting process. It was noted during the focus
group that the majority of FTP meetings are attended by
mothers alone due to the fathers conflicting work
schedules etc. As one service provider (SLP) described
That probably is the bonus of using the system is that they
can use it at home. Just under half of the parents also
described the photocopied summary of goals chosen to
be particularly useful when partners or families are
unable to attend meetings. One parent said:
Because my parents are very involved in the care for my
child they like to know what goes on at the therapy sessions and everything. So being able to physically show
them and go through the photocopy with them was great
(Parent 6).

Overcoming barriers to holistic goal setting


The use of the FGST also provided an opportunity for
service providers to better meet the individual families
needs in goal setting. This was particularly relevant for
families who were unsure of their childs familys
needs, and those with poor literacy skills. In the past,
goal setting within the team has mostly been done in a
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Journal of Applied Research in Intellectual Disabilities 367

lengthy interview session. One service provider (SW)


noted I went out to a family where there was limited literacy
skills....it was useful in that instance with the person, rather
than just going through words saying what does that mean
as we had the pictures. Another service provider (OT)
explained her use of the FGST and which types of families may benefit more from its use:
Those with literacy difficulties and also those with or
who have difficulties working out their childs needs
because the cards actually stimulate their thoughts....And
I use it across the board with families that really struggle
with literacy and others who are quite intelligent parents. And both of those categories Ive used the cards
for....and they have used it.
Furthermore the majority of the parents described the
cards as easy to understand with one noting You could
see straight away what they were trying to tell me and they
were pretty straightforward. I can imagine if I had issues with
English they would be quite clear in what they were trying to
tell me (Parent 5).

Empowerment for families


In addition to the perceived strengths-based focus of the
tool, there were many references to how empowering the
tool was for parents. Five of the eight parents described
the FGST as an avenue of increasing ownership or independence in the family goal setting process. The sense of
increased ownership appeared to be related to physically
being in control of sorting through the cards. As one parent described I thought it was helpful because you actually
got to hold the thing in your hand and have a look at it...So
the physical having to hold them and sort them I found to be
therapeutic for myself (Parent 6). A second parent noted
It was nice to have ownership of a nice pile of cards. It does
keep you focused on it as its your choice which cards youre
taking (Parent 4). Within the focus group this aspect of
the process of using the FGST was illustrated by the following; I think the difference in the previous method where
we had a piece of paper that we might have written on that
they might have been able to look at- but youre actually giving
them the cards to sift through (SW).
Empowerment was also ensured for parents through
the reduced reliance on service providers when goal setting. Thereby there was a sense of increased independence. As one service provider (SLP) noted In the past,
parents had difficulty coming up with any (goals). Often you
would just get therapy. The same service provider
described that with the FGST, Families can be a bit more
 2012 Blackwell Publishing Ltd, 25, 360371

independent with actually working through the card sort... so


to some extent I think maybe they can be a bit more independent. And as a second service provider described It
changes the dynamic in a positive way. This was similarly
reflected in parent responses, with one parent stating:
I found using the cards it was me choosing those
things as opposed to relying on a staff member to be able
to prompt and kind of say what about this or that. I
guess the cards are taking the place of the person throwing up ideas and its making me identify with those
things more(Parent 3).

Additional considerations
Although most of the feedback related to the use of the
FGST was positive, a few additional considerations
were raised. For example, service providers noted that
goal setting meetings potentially detracted from therapy-time with the child. This was also raised by one
parent who explained that the goal setting meeting fell
in her highest priority therapy session (Speech-Therapy). However, overall this issue appeared to be related
more to the planning required for goal setting by the
service as a whole, as opposed to a result of using the
FGST.
A second potential issue was repetition or overlap of
content across the cards, which was raised both by service providers and some parents (e.g. taking turns and
playing with others, or coming for help and telling
me what they want). However, all the parents noted
that this did not detract from the process of goal setting,
with two parents noting I found that there were a lot of
cards however all kids have different needs so it is to be
expected (Parent 2) and There were a lot of cards but you
probably need the amount that they had so that everything is
covered in terms of where goal-setting can go (Parent 7).
The third consideration was related to the potential of
missing need areas of individual families that are not
included in the cards of the FGST. Only one parent
and one service provider raised this, with the parent
relating:
Purely because you are looking through these cards and
flicking through that anything I felt at the time, or
anything that I might have walked in thinking about
was gone because I was just sorting through and working out the cards and what pile I thought was relevant
to my child. And anything else I had before just, yeah,
disappeared (Parent 2).

368 Journal of Applied Research in Intellectual Disabilities

However, the suggested script used by service providers prompted them to give families a choice about using
the cards at the outset by saying something like, Would
you like to use the cards, or do you think you already
have a pretty clear idea of what goals you want us to
work on? This provided parents with a choice and for
those who used the FGST, the something else card also
provided options for them to raise other issues.

Discussion
This study explored the experiences of parents and early
intervention service providers using the FGST during
annual family goal setting. The analysis identified four
overarching themes including the facilitation of goal setting, a strengths-based approach, empowerment of families and family centred processes. The tool was
perceived positively in providing a holistic approach to
family goal setting and overcoming previously acknowledged barriers. These pilot results indicate that the
FGST is a valuable tool in goal setting from both parents and service providers perspectives. However, due
to the uniqueness of the tool there is, as yet, no gold
standard for comparison in the literature. Thereby the
perceived benefits of the tool will be discussed, in relation to the underlying themes of FCP in early intervention.
A key finding was that the FGST allowed parents a
greater sense of control and ownership over the goal
setting process. This concept of parent empowerment
is essential in promoting a collaborative partnership in
family centred services (Epley et al. 2010). Research
demonstrates that active involvement of parents (or parents as drivers) in goal setting increases feelings of competency and ownership, and views of equal partnership
with service providers (Oien et al. 2009; Broggi & Sabatelli 2010). Furthermore, Rodger & Keen (2010) found
that high levels of family involvement in decision making was associated with increased family satisfaction
and perceived provider competence. This sense of control also appeared to reduce the anxiety felt by some
parents when goal setting, as the FGST cards provided
prompts in determining family driven goals. Previously
this anxiety was fuelled by uncertainty in setting goals,
and caused some parents to question their chosen goals
appropriateness and suitability. Using the FGST was
perceived to increase parents confidence when choosing
individualized goals and communicating their meaning
to service providers. These findings coincide with
research suggesting that parents experience less stress
and have greater feelings of competency when services

are family centred (ONeil et al. 2001; Law et al. 2003;


Broggi & Sabatelli 2010).
Furthermore, through the use of the FGST, parents
also consistently reported a greater knowledge of available services for the family as a whole, rather than just a
focus on their childs needs. This finding reflects literature regarding parent and therapist evaluations of family centred services using the MPOC (King et al. 1995).
Investigators have found that general information provision is consistently scored lower by parents, including
information about the childs disability, information
about therapy issues, financial costs and assistance and
the types of services available (Dyke et al. 2006; Nijhuis
et al. 2007; Wilkins et al. 2010). The provision of this
information is important in empowering parents in decision making and goal setting, while also alleviating
stresses related to uncertainty and lack of knowledge.
Researchers have found that limitations in information
exchange and provision are a consistent weak point in
FCP, and need to be addressed to increase service satisfaction (Raghavendra et al. 2007). By prompting parents
and service providers to consider previously unrecognized areas of intervention support, the FGST addresses
this need for greater information provision. As a result,
parents and service providers indicated that the goals
set were more holistic and family centred. This was particularly related to recognizing that goal setting was
based within the context of the entire family, as opposed
to solely directed at child-based interventions. This
reflects the trend in FCP in early intervention in recognizing that children cannot be adequately served without considering the unique patterns of need of their
families (Allen & Petr 1996).
Another outcome of the study was the appreciation
of parents and service providers of the strengths-based
approach facilitated by the FGST. In the design of the
FGST a strengths-based focus was acknowledged as
underpinning the service delivery approach utilized by
the team. Although the no pile was considered to assist
parents to exclude goals that were not parents immediate focus, it was not considered at the outset that this
pile might help parents reflect positively on their
childs achievements to date. This had the effect of
empowering parents and helping them to be positive
and identify their childs and families strengths and
achievements to date. The move from deficit-based
frameworks to a focus on family strengths supports the
parent-therapist relationship in this context. Kemp et al.
(2004) proposed that a key strategy in providing support to families is recognizing and celebrating small
positive changes or achievements in child development.
 2012 Blackwell Publishing Ltd, 25, 360371

Journal of Applied Research in Intellectual Disabilities 369

This was commented on by parents and service providers alike.


Service providers reported an improved capacity to
engage and involve families from different cultural and
language backgrounds through use of the FGST. Communication and language have been found to be critically important cultural issues in occupational therapy
practice (Fitzgerald et al. 1997). They identified that one
of the most important features of intercultural communication was developing a means of articulating and reconciling these differences, in a satisfying way for all
involved. The FGST demonstrated the potential to overcome these barriers due to the picture card format. Furthermore, Board Maker  is currently available in 44
different languages and has the capacity to alter facial
characteristics complexion to increase the connection to
the user (Spectronics 2010). Thereby it demonstrates the
potential to overcome barriers related to communication
and literacy levels, by providing an accessible graphic
format. During the 6 months of data collection, no families from culturally and linguistically diverse backgrounds were engaged in annual goal setting. Hence,
the utility of the FGST with a range of cultural groups
and with those with limited literacy needs further exploration.
The limitations of this study are largely related to the
restricted sample population. All study participants
were involved in the one community-based early intervention service in Queensland, Australia and thereby
the results are limited to this context. In addition, it was
not possible to differentiate the impact of other confounding factors, including staff consistency in use of
the FGST and its influence on parent perceptions, different approaches to goal setting by different service providers and parents past experiences of goal setting.
Furthermore, it is acknowledged that there may be bias
among parent participants who participated in this
study, who may have been those with stronger views
about the FGST.
The results of this pilot study provide encouragement
regarding the use of the FGST as it has only been used
for 6 months during which this study took place. A
whole 12-month cycle would be needed to see how useful the FGST is in terms of goal appropriateness and
progress monitoring. However, research is required to
refine the tool and determine its utility in other family
centred, community-based early intervention services
and whether it could be used with outcome measurements such as GAS (Kiresuk & Sherman 1968) to monitor intervention progress. Future research also needs to
investigate the capacity of the tool to overcome lan 2012 Blackwell Publishing Ltd, 25, 360371

guage, literacy and communication barriers when goal


setting with families with varied backgrounds.

Note
Corrections were made to pages 2, 3, 5, 6, 7 and 10
on 21 March 2012 year after first publication online on
6 January 2012. The errors have been corrected in this
version of the article.

Correspondence
Any correspondence should be directed to Sylvia Rodger, Division of Occupational Therapy, School of Health
and Rehabilitation Sciences, The University of Queensland, Brisbane 4072, Qld, Australia (e-mail: s.rodger@
uq.edu.au).

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