Using PICCOLO in Virtual Home Visits—Q&A from Brookes Coffee Chat

Q. How can I better engage a family with limited resources in virtual home visits?

All families have some resources, and home visitors can help families identify what they have to support their children’s development. Ask parents what they do have, but remember that young children learn from all their experiences, so you can be helping parents by asking about their regular everyday routines, chores that have to be done regularly, and school requirements for other children in the home—these are great opportunities to think about involving younger children. Be sure to ask openended questions about what they have been doing recently to engage their children in something fun and interesting, what they’ve enjoyed doing together in the past that they could try again, how they could adapt what they wish they could do so they can do it, activity ideas they’ve heard from other people they know at home with young children, and maybe even what they would do if they had 10 minutes to themselves without their children needing them. Listen well to identify their ideas and help them pick some things to try before you meet again. If you can meet online, help them pick an activity to try during your meeting so you can coach, inform, and encourage them.

Q. What kind of questions should I be asking my parents? Due to the pandemic things have changed. How can we can keep the visit going longer. What are examples of reflective questions?

Ask open-ended questions, follow-up questions, and reflective questions. Google “Motivational Interviewing” OARS. OARS stands for: Open-ended questions, Affirmations, Reflections, and Summaries. Open-ended questions are those that don’t have a right or wrong answer and could have many answers, “How have things changed for your family since this happened?” Affirmations are positive comments about what is going well, even something very simple, “That’s great that you’ve been trying to keep your regular routines going for your kids.” Reflections are comments on the meaning and emotions that you are hearing from parents, “I noticed you sounded concerned when you said you were not going to the playground—what concerns you?” Summarizing, “So you’ve found ways to keep your kids busy and happy, but you haven’t been going to the playground, and you are wondering about other ways your kids can get exercise—is that right?”

Q. Should we be concerned about family confidentiality in virtual visits? Is it safe to use Zoom?
Yes, you should be concerned and protect family confidentiality. Each meeting with a family should be scheduled separately rather than using the same link for multiple visits. When you set up a Zoom meeting with a family, be sure to send the password to the family with the Zoom link. Tell parents not to share their link or password. Also, use the waiting room feature where you let them into the meeting after they sign into Zoom. These features prevent others from hacking into your home visit. If you record a virtual visit on Zoom or another platform, please remember that recordings of family members are always confidential, just as they would be if video-recorded another way. You should get permission from the family and make sure that the video recording is password protected on a password protected device, used only for the intended purpose, and deleted immediately after use.


Q. How is the family’s confidentiality protected when recording with a virtual meeting platform that is not HIPAA compliant?
Programs that require HIPAA compliance may purchase Zoom for Healthcare, https://zoom.us/healthcare, or another HIPAA compliant platform for online video meetings.


Q. How do we record parent-child interactions or the whole home visit during a Zoom meeting?
In Zoom, it’s easy because there is a “record” button right on the bottom (or top) of the main screen where you see everyone’s faces. Click on it and it starts recording. Click again later and it stops. Other video meeting platforms can also be recorded. Usually, only the host can record an online meeting. To see both the family and the home visitor in your recording–for example, for later HOVRS scoring, click on Gallery View. To see only the family in your recording—for example for later PICCOLO scoring, click on Speaker View and mute yourself during the parent-child activity you and the parent planned to do for the observation. For PICCOLO observations, guide the family to identify pictures or a picture book they could talk about, pretend play toys, other sharable toys with parts, or whatever the family has that the child finds fun and interesting.

Q. Can you talk more about phone PICCOLO? What would it look like in a virtual home visit by phone?
PICCOLO was validated from recordings of parent-child interactions. If your program is using PICCOLO only for reporting, then you must observe parent-child interactions to use PICCOLO. If you are using PICCOLO to increase parent support of their child’s development, however, you can use it effectively by phone. For any PICCOLO observation, begin planning the observation in a previous home visit. Send the parent, by email or mail, a list of the the PICCOLO items in “29 Things Parents Do That Predict School Readiness.” Explain the purpose of the PICCOLO observation is to identify things they are already doing that are preparing their child to succeed in school. Point out to them a couple of the things you have previously observed them do during home visits. It is possible to mail a set of standard toys to each family, but it is also possible to have parents use what they already have. Guide the parent to find things to use for playing together with their child. Include (a) things to talk about (e.g., picture books, photographs), (b) things for pretending (e.g., kitchen or picnic toys, plastic cups or containers, empty food containers, plastic spoons and forks), and (c) things with parts to share (e.g., building blocks, beads, farm set, small cars, plastic cups or containers that nest or stack).


Q. How can you tell what the child’s response is if they are very young and can’t talk yet?
If you are trying to do a PICCOLO by phone, you will need to be asking the parent what they are doing, how the child is responding, what the child is doing, and what the parent thinks their vocalizations mean. These are valuable observations for providing positive feedback to parents as part of effective home visiting practice. PICCOLO was not validated for use with just audio, however, so the scores should not be used as reported data if validity is a concern. Any suggestions for families who don’t want to talk on the phone due to too many kids at home? If they simply don’t want a virtual home visit by phone, we have to respect that. Some people hate talking on the phone at all. If they find a phone call difficult because they are overwhelmed with having all their kids at home all day every day, we can help. So, try to find another time when they are willing to talk, then focus on ways to make their life with all the kids at home easier, not on program paperwork or telling them what to do. They are telling you that they are overwhelmed, so if you tell them, “just do this great activity from our curriculum to support the development of ___,” they may never answer the phone again when you call. Here are some things to try:

• Set up a time when the kids are busy with something else, before they get up in the morning or
  after they go to bed at night.
• Talk to the parent about what they’ve tried that keeps their kids busy and happy.
• Ask questions about what they’ve done in the past.
• For each activity they mention, ask what worked and didn’t work and how they might change it
  to work better.
• Ask them to pick just one to try again and see if it works any better. Ask them when they will try
  it. Let them know you’ll ask about it by text.
• Text them later to ask how it went.

Q. Do you have a suggestion for when phone service is not great, and you only hear parent-child interaction every few words. Will this then not be a good way to do PICCOLO with the family?
You might ask them if there is a time of day or a place in the home where they get better signal. Or you might try again another time. But if you can’t see them, and you can’t really hear them either, then you will not be able to observe their interactions with PICCOLO or anything else.


Q. How we can get families to participate during calls?
Getting families engaged is critical for any home visit but even more necessary in virtual visits online or by phone. Explain clearly to parents that home visits are designed to help parents better support their children’s early development, so there cannot be a real home visit without their participation. Then focus on what the family wants and what they are interested in. What are the parent’s goals for the child and for their family? In most programs, home visitors set goals with each family when they come into the program, but this is a good time to review those goals together again, ask if they have changed, and guide parents to find ways to take steps toward those goals. Ask what they already do with each other that they enjoy and will continue to do, what they want their child to learn to do, what they have to do anyway that they could engage their child in with them. Take notes on their ideas and reflect on them. Then ask which idea they want to try first, when they would have time to do it, what materials they will need, what might get in the way and how they could prevent that, and how they will tell if they want to try it more than once.

Q. What is PICCOLO?
The PICCOLO, available from Brookes Publishing, is an observational measure of parenting behaviors in four domains: affection, responsiveness, encouragement, and teaching. PICCOLO stands for Parenting Interactions with Children: Checklist of Observations Linked to Outcomes, a measure of 29 observable developmentally supportive parenting interactions that was validated based on observations and data from over 2,000 low-income families. It was designed to be useful for home visitors who want to adapt to each parent’s strengths, provide specific descriptive feedback, and track progress. The PICCOLO can be used from ages 4 months through 5 years. Many of our suggestions for using PICCOLO will apply to whatever observational parenting measure your program uses, such as the DANCE or the CHEEERS. PICCOLO helps practitioners observe a wide range of parenting behaviors that help children develop over time—an approach known as developmental parenting. Parenting strengths—what the parent already believes is important to do and is comfortable doing with his or her child—are a valuable resource for increasing the developmental support available to young children.


Q. Can you complete PICCOLO with the observations seen throughout different activities or visits? Or does it have to be done with only one activity observation?
If you are doing a PICCOLO observation for data collection, PICCOLO was developed to be observed and scored in one 10-minute observation of the parent and child playing together. We recommend having varied materials available for the interaction. However, once you are proficient at using the PICCOLO and can see the behaviors measured by PICCOLO, we recommend using the handout “29 Things Parents Do That Predict School Readiness,” the items from the PICCOLO, on most home visits. The goal is to identify what parents are doing well and let them know what they are doing well, how their child reacts when they do that behavior, and why the behavior is good for child development/school readiness. PICCOLO was validated based on a 10-minute observations. For valid scores, all observations should be the same duration. During 10 minutes, a parent and child may do multiple activities.


Q. My greatest concern is our HV are having trouble seeing the PCI during our ZOOM home visits.
For effective home visits using an online video meeting platform, such as Zoom, it is important to work with the parent to place their device—laptop, tablet, or phone—in a place where the parent, the child, and whatever they are doing together is visible on the screen. On Zoom, select “speaker view” and click on the “record” button to begin recording the observation. After 10 minutes (or sooner if the child does not want to play anymore), click on the record button again to end the recording.


Q. Is it possible to observe a whole PICCOLO in 5 minutes?
We recommend a 10-minute observation but you can observe many positive behaviors in less time. For babies, a 5-minute observation may a lot of time for sustained interaction. Observe for as long as the parent and child are comfortable. Remember to provide positive feedback on what the parent did well. Do not focus on what they did not do.

PICCOLO was originally validated on 10-minute videos, but we have shorted our training videos to 5 minutes to provide quicker feedback and offer more opportunities to practice scoring. The total scores from the 5 and 10 minute versions rarely differ enough to affect reliability. Our research shows that a 5- 10-minute PICCOLO observation can predict children’s development years later, for example from PICCOLO at age 2 to reading and math scores at age 11.


Q. How frequently are PICCOLO observations conducted?
We recommend doing a full PICCOLO observation at least 2 times during a program year. To demonstrate growth in parenting skills, measure PICCOLO after enrollment as soon as a child is at least 4 months old and again at a later time point. Many programs use it more frequently. Some home visitors use PICCOLO informally in many of their home visits to provide frequent feedback to parents about what they are already doing that is supporting their children’s development.


Q. How can programs use PICCOLO scores to track growth in families for program outcomes?
Improving parent-child interaction is a primary goal of most home visiting programs, and PICCOLO is a way to measure progress toward this goal. Many programs use PICCOLO as an outcome measure. Programs use various ways of recording and comparing scores. Excel can calculate differences in scores from and can display these changes in graphs. It is widely available, easy to learn, and most questions you will have can be answered by a quick Google search. A parent’s PICCOLO scores are entered in the spreadsheet, and graphs of progress can be produced. If a later score is higher than an earlier score, that is progress. An increase in a PICCOLO domain of 2-3 points is roughly equivalent to an increase of a standard deviation, which is considered meaningful.


Q. Can I use PICCOLO with other outcome measures?
PICCOLO can be used with other measures. For example, we recommend regular use of PICCOLO along with the ASQ to help guide home visit planning. If your other measure is also a parent-child interaction measure, you may want to choose just one measure (PICCOLO has strong psychometric properties).


Q. What coaching techniques would you suggest using with the parent who communicates with her child by a barrage of questions such as “What color is that?” “What shape is that?”
Always provide positive feedback that describes the parent’s positive behavior in relation to the child’s response and development. For example, you could say, “You ask your child a lot of questions, and when your child can answer your questions, you are helping them practice the language and cognitive skills they are developing.” And you can add more information, “Sometimes when we ask a lot of hard questions, kids get frustrated and stop answering, but when we keep questions easy and fun, they usually try to answer.”


Q. Can you do a PICCOLO with multiple children in the home?
You can do a PICCOLO with each child, one at a time. We would recommend doing these multiple observations on separate home visits to avoid overwhelming the family.


Q. Can we bridge PICCOLO to a developmental parenting curriculum, such as Parents as Teachers?
PICCOLO shows you what a parent’s strengths are for supporting their child’s early development. Knowing those strengths can help you and the parent select activities together that are a good fit for the parent’s strengths, the child’s development, and what the family already does and has. Some home visitors use their curriculum’s table of contents or another list of age-appropriate activities to guide this joint planning with parents, but more experienced home visitors can simply brainstorm ideas with a parent for experiences that will help their child reach the goals the parent has for their child.


Q. Where can we get training on developmental parenting, PICCOLO, HOVRS, or virtual home visiting? Where can I find out more about HOVRS and PICCOLO training or virtual training?
Email me at LoriRoggman@gmail.com for our training information. We are now scheduling virtual training webinars on developmental parenting, PICCOLO and HOVRS.

We offer training for making virtual home visits. Many of you have already become our new experts on virtual home visiting. Some families and programs intend to continue virtual home visits in the future when there is family illness or bad weather.


Q. How can I get a copy of HOVRS 3?
We provide the latest version of the Home Visit Rating Scales (HOVRS) only to people we have trained (see previous question). You can get a copy of the original version, HOVRS-1, in the appendix of Developmental Parenting, but the new one is easier to use and better for professional development.

Q. Should we use resources with more pictures and less writing for parents to see the meaning of interacting with their child?
Yes, photos and drawings and videos are great ways to communicate. For parents with limited literacy skills, visual information is essential. Photos, drawings, and videos can be used in online visits by screen sharing. In phone visits, they can be emailed or mailed to a family ahead of time. Adults, however, learn best through direct experience, by actually doing things with their child that they enjoy enough to want to do again. This is why planning together is so critical for effective home visits. Demonstrating the “right way” to play with a child by “modeling” rarely changes the parent’s behavior, especially for parents who are stressed or who lack self-confidence. In fact, for parents like that, a home visitor modeling their great skills with children can do harm by undermining a parent’s self-confidence. We find that when home visitors use a lot of modeling, families drop out sooner. Often, home visitors use modeling when they have not had good training in skills for engaging the parent with the child.


Q. What about the ASQ in virtual online or phone visits?
We have been guiding parents to do ASQs without the home visitor present. It’s been in online visits, but the same ideas might work with just the phone. We are not experts on the ASQ, but we have been using it in virtual home visits over the last year. Here are the steps we use.

1. Identify the correct ASQ form for the age of the child.
2. List the materials needed for the questions on that form. Think of things families might have in their homes that could be used for the same question, action, or skill. (It is helpful to brainstorm with other home visitors.)
3. By phone or online meeting, help the caregiver identify materials in the home that they can use for the ASQ questions for the age of the child.
4. Mail, text, or email a JPEG image of the correct ASQ form, or email a link to ASQ Family Access
5. By phone or online meeting, guide the caregiver through the questions and record them on your own form. Ask detailed questions when you need to know more about what the child can do. For questions that simply cannot be answered, mark them as unanswered.
6. Use an ASQ calculator that takes unanswered questions into account.
7. Look for additional ASQ products.
8. Get additional guidance for using ASQ in virtual home visits from a resource page with a recorded webinar and a special release of questionnaire files to text to families for support during interview administration (families who may not have internet access to do the questionnaire online):Using ASQ in a Virtual Enviornment