Preschool Teachers’ Perceptions and Use of Naturalistic Developmental Behavioral Intervention Strategies: An Explanatory Sequential Mixed Methods Investigation

Abstract

Preschool classrooms serve children of varying abilities, including those who may benefit from social communication intervention. Research supports the use of naturalistic developmental behavioral interventions (NDBI) to effectively increase social communication skills of young children. Yet, little is known about preschool teachers’ perspectives on and use of NDBI strategies. The purpose of this explanatory sequential mixed methods study was to integrate data from classroom observation, teacher self-report, and qualitative interviews to understand training and support needs for increasing implementation of NDBIs in a preschool classroom context. Eight preschool teachers provided a recording of an intervention session, self-reported their use of NDBI strategies, and participated in an interview to discuss their experiences. Results indicate preschool teacher participants perceive NDBI strategies favorably, although they may need targeted support understanding and using NDBI strategies. We discuss implications for practice that may support increased use of NDBIs by preschool teachers.

Naturalistic developmental behavioral intervention (NDBI) refers to a group of manualized early interventions that integrate developmental and behavioral approaches within natural contexts to support the development of young autistic children (Schreibman et al., 2015). NDBIs have a relatively strong evidence base supporting positive outcomes in young children in areas of social communication, language, play skills, social engagement, and cognition (Sandbank et al., 2020; Tiede & Walton, 2019). Manualized NDBI models (e.g., Project ImPACT, Pivotal Response Training, Enhanced Milieu Teaching, etc.) share overlapping features and instructional strategies, but also have unique features and emphases which distinguish them from each other (Frost et al., 2020). Researchers have identified common NDBI treatment elements and developed a fidelity tool (i.e., NDBI-Fi) to measure their implementation across models (Frost et al., 2020). These common NDBI strategies included being face-to-face and on the child’s level, following the child’s lead, modeling language, positive affect and animation, responding to the child’s attempts to communicate, using communicative temptations, and the frequency and quality of direct teaching episodes. Describing core features or strategies of NDBIs, rather than separate named and manualized programs, may facilitate communication and shared understanding of NDBIs in community contexts where manualized NDBIs are unfamiliar. Here, we focus on NDBI implementation in preschool classrooms. Fifty-five percent of children aged 3–5 years in the United States are enrolled in preschools (National Center for Education Statistics, 2022), making this an important first-line service context for all children, including those who did not receive Part C early intervention services prior to the age of 3.

NDBI Strategies within Preschool Classrooms

Although NDBIs were developed for children with social communication delays, NDBI strategies are largely consistent with developmentally appropriate practice in early childhood general education and recommended practices in early childhood special education endorsed by professional early childhood societies to support the development of all children. For example, the National Association for the Education of Young Children’s (NAEYC) developmentally appropriate practices focus on understanding the principles of child development to enhance learning through child-led play (NAEYC 2022), which broadly aligns with NDBI development-enhancing strategies (e.g., positive affect and animation and following the child’s lead). Also, the Division for Early Childhood’s (DEC) Recommended Practices in early intervention/early childhood special education guide preschool teachers to implement instructional practices to improve learning outcomes: “Practitioners use systematic instructional strategies with fidelity to teach skills and to promote child engagement and learning” (DEC, 2014, p. 12). However, these practitioner guidelines do not provide preschool teachers with specific strategies to implement, and there is variability in teachers’ use and perceived value of DEC Recommended Practices (Bruder et al., 2020). Little is known about whether preschool teachers implement common NDBI strategies and how they perceive NDBIs to align with their current practices. It is important to investigate perceptions and use of NDBI strategies in the context of preschools as this work may have implications for informing training and advancing the adoption and implementation of NDBI at scale.

Previous Research

NDBIs are not yet implemented on a wide scale and perceptions of their use is limited and varies across intervention settings and professions (D’Agostino et al., 2022). Recent literature suggests that community programs, like preschools, can provide intervention services to children with disabilities using NDBI programs (Odom et al., 2021; Siller et al., 2021). Research on specific group NDBI models implemented in community settings like Classroom Pivotal Response Teaching (Suhrheinrich et al., 2020) and group Early Start Denver Model is emerging (Zitter et al., 2022). Findings suggest high feasibility and acceptability by teachers following training. However, the literature also suggests several barriers to training community-based NDBI implementers (particularly those in group and school-based settings), including challenges adapting to a school-based setting (e.g., multiple students, structured classroom routines), implementing in concert with other instructional practices, and lack of training in foundational principles of NDBI (Stahmer et al., 2012). Perhaps due to these barriers, teachers may struggle to implement some components of NDBI with high fidelity while implementing other components successfully (Suhrheinrich et al., 2013; Suhrheinrich et al., 2020). Fidelity of implementation, including use and quality of strategy implementation, has been associated with children’s skill acquisition (Zitter et al., 2021), suggesting a need for understanding how to support high fidelity implementation in classrooms. Research suggests the importance of the “fit” of evidence-based practices in community settings (Suhrheinrich et al., 2020) and highlights the need to explore the acceptability of NDBI strategies from the perspectives of preschool teachers. Recent studies provide some evidence that preschool teachers are accepting of NDBI strategies (D’Agostino et al., 2023; Zitter et al., 2023). Yet, the extent to which preschool teachers may implement some common NDBI strategies in the absence of structured training is unknown and has the potential to inform targeted implementation and dissemination efforts.

Further, research focused on broader NDBI implementation within early intervention programs, serving children birth through three years and their families, is also emerging. For example, early interventionists providing community-based treatment to autistic toddlers (15 to 36 months of age) in inclusive childcare settings perceived NDBI strategies as effective for all toddlers, not just autistic toddlers (Maye et al., 2019). This finding is not surprising as NDBI strategies overlap with those included in national accreditation and standards of care of childcare settings (e.g., NAEYC Early Learning Program Accreditation Standards and Assessment Items, 2018). On the other hand, a recent survey of behavior analysts revealed that respondents had limited understanding of NDBI practices, only a few had received formal training in named NDBI models, and few believed them to be effective or appropriate for the field (Hampton & Sandbank, 2022). Yet, at the same time, use of several individual NDBI strategies were reported at high rates, including incidental teaching, responding to attempts to communicate, and modeling language. In a similar study conducted with early interventionists, providers self-reported consistent use of several NDBI strategies, particularly those with a developmental focus (Pickard et al., 2021). Taken together, these studies suggest that while formal dissemination of packaged NDBIs is limited, practitioners from a variety of training backgrounds implement at least some NDBI strategies in community practice settings. A limitation of this body of research is that it has relied on self-report ratings; as such, it is unclear whether ratings reflect true behavior or response bias (e.g., lack of familiarity with NDBI terminology, social desirability bias).

The aforementioned studies provide valuable information regarding the scaling up of NDBI implementation across disciplines, yet perspectives on common NDBI strategies from other key early intervention groups – including preschool teachers – are missing. Moreover, while previous research has relied on self-report ratings, extant research has not compared self-report ratings of NDBI strategies to observed use nor explained these findings with qualitative data. To address this gap, we collected in-depth data from a small sample of preschool teachers, including video of an intervention session and self-reported ratings of NDBI strategy use which were used to develop tailored semi-structured interviews with each teacher.

Purpose and Research Questions

Given that NDBI strategies appear to align with established best practice of preschool teachers, we were interested in the extent to which they use NDBI strategies with children with identified social communication goals. Further, we sought to explore teachers’ reported and observed use of NDBI strategies in an effort to further contextualize our findings and generate nuanced information about teachers’ understanding of NDBI strategies relative to their routine teaching practices. We hope that a greater understanding of preschool teacher’s perceptions, use, and training experiences around NDBI will facilitate future research supporting increased implementation of NDBI strategies within preschool classrooms. This explanatory sequential mixed methods investigation was designed to address the following research questions:

1. What NDBI strategies do preschool teachers use and when and how do they implement them?

2. What would support preschool teachers in increasing implementation of NDBI strategies?

Methods

Recruitment

Following approval by the Institutional Review Board, an informational flyer was distributed via email by the first author to early childhood administrators across two states (one Midwest and one Mountain West). Contact information of early childhood administrators was available online for each state. Early childhood administrators were emailed twice and asked to forward the informational flyer to preschool teachers within their district or organization. Interested preschool teachers who provided informed consent (n = 26) were contacted by the first author and directed to send an informational flyer to all families in their class. It is unknown exactly how many of the 26 preschool teachers sent the informational flyer to families. A total of 15 families across 8 different teachers subsequently consented to participate. All 8 preschool teachers were notified via email by the first author that a family from their class completed the consent form. If more than one family from a classroom consented, the teacher was asked to choose one to video-record based on the child’s likelihood of attendance and confirmation that the child had a social communication goal on their IEP.

Participants and Settings

Participants included eight preschool teachers and eight of their students who were children with an identified disability and individualized education program (IEP). Preschool teachers were all women, ages 25–46 (M = 36). Preschool teachers identified as White or European (n = 7) or other (n = 1; did not describe). Preschool teachers’ ethnic identities included not Latinx or Hispanic (n = 7) and Latinx or Hispanic (n = 1). Most preschool teachers held a master’s degree (n = 5), and the remaining held a bachelor’s degree (n = 3). Preschool teacher participants reported 2–18 years of professional experience working with young children with disabilities (M = 9 years). They were employed across two states in Head Start and/or state funded preschool programs. Half of the teachers identified their role as general education preschool teacher (n = 4) and the other half as early childhood special education teacher (n = 4). Preschool teachers represented eight different classrooms, and the settings were described as inclusive (n = 4; mix of typically developing children and children with identified disabilities) or self-contained (n = 4; all or a vast majority children with identified disabilities). Preschool-age children (three to five years old) included in this study had an active IEP that contained at least one goal or objective focused on social communication (e.g., requests, following directions, turn-taking, greetings, asking questions, answering questions, expressing like or dislike, conversation, etc.). Children’s eligibility labels included early childhood developmental delay, autism, and speech and language impairment.

Design

This study used an explanatory sequential mixed methods design, which involved the collection and analysis of multiple sources of quantitative data followed by the collection and analysis of qualitative data to expand on the first-phase quantitative results (see Figure 1; Cresswell & Plano Clark, 2018). Specifically, two sources of quantitative data (Phase 1) were used to guide the collection of qualitative data (Phase 2), consistent with connected integration or building of mixed data. Quantitative and qualitative data were subsequently connected via merged integration. An explanatory sequential mixed methods design was chosen to use the qualitative phase to understand and explain results of the video observation and survey data collected in the quantitative phase.

Figure 1.

Explanatory Sequential Mixed Methods Data Collection and Integration Design

Quantitative Phase

Video Data Collection.

Preschool teacher participants recorded a 10-min session with the child participant during a typically occurring routine or activity of their choice that targeted the child’s social communication goal. Preschool teacher participants were sent a link to a secure Box folder to upload the recorded session and were asked not to watch the recording.

Video Data Analysis.

All recorded sessions were coded using the NDBI-Fi Common Items Manual (see Frost et al., 2020). The second author, who developed the instrument and demonstrated reliability in the initial validation paper, coded all videos. The NDBI-Fi is an 8-item observational rating scheme that measures the implementation of common intervention elements across NDBIs, with items assessing a combination of frequency and quality of strategy use. The NDBI-Fi has demonstrated promising validity and inter-rater reliability (Frost et al., 2020; Sone et al., 2021). NDBI-Fi scores range from 1 to 5 for each of the 8 items with a total of 40 points possible. An average rating score is calculated by dividing the points earned by points possible and multiplying by 5. An average score could range from 1 to 5, with a higher score indicating greater consistency and quality use of NDBI strategies. Consistent with scoring conventions across NDBI, we considered a score of 4 or higher (or 80%) to be indicative of “high fidelity” use of NDBI strategies. To facilitate comparison, NDBI average scores were converted to the same scale as the self-rating (overall percentage, see below), by dividing by 5 and multiplying by 100.

Survey Data Collection.

A survey was administered online via Qualtrics following submission of the recorded session (see Supplemental Material). All surveys were completed within 24 hours of video uploading. The survey was developed by the authors based on the NDBI-Fi and previous surveys in the literature (Hampton & Sandbank, 2020; Pickard et al., 2021). The survey included four sections to gather information from preschool teacher participants on the following areas: (1) demographic information, (2) relevant knowledge and training, (3) demographic information on the participating child, and (4) self-ratings of NDBI technique use based on recorded session. Two experts in applied behavior analysis and early childhood special education evaluated the survey and provided feedback on the wording of demographics questions, organization of questions, and strategies addressed.

Knowledge and Training.

First, preschool teacher participants were asked to rate their familiarity with the term ‘naturalistic developmental behavioral intervention (NDBI)’. The response choices for this question included, not familiar at all, slightly familiar, moderately familiar, and very familiar. If a preschool teacher participant chose a response that indicated any level of familiarity (i.e., anything response other than not familiar at all), they were asked to briefly describe NDBI in their own words. Next, preschool teacher participants were asked to indicate their level of instruction (i.e., never, once, more than once, I am proficient in this area) for the developmental sequence of play, language, speech sounds, social communication, direct teaching episodes, and principles of applied behavior analysis (ABA).

Child Demographics.

Child demographic questions included age, IEP eligibility, and social communication goal(s) based on their IEP.

Self-Ratings of NDBI Technique Use.

NDBI techniques included the eight common elements as identified by Frost and colleagues (2020). Preschool teacher participants were asked to read each NDBI technique description carefully, think back to the session they had recorded, and rate their use from memory on a 10-point scale ranging from 0% to 100% of the time (e.g., 0%−9%; 10%−19%, etc.). Descriptions of NDBI techniques were taken from the NDBI-Fi manual (Frost et al., 2020). An option to provide comments was presented after each NDBI technique self-rating.

Analysis of Survey Data.

Responses were analyzed using descriptive statistics. Likert-type scaled items were analyzed to calculate means. An average range was calculated to represent an overall self-rating of NDBI strategy use for each preschool teacher participant. Open responses were reviewed independently by both authors and discussed to inform semi-structured interview question development.

Connected Integration: Using quantitative data to guide qualitative data collection

The first point of integration in this explanatory sequential design involved connecting the results from the initial quantitative phase to plan the follow-up qualitative data collection phase (i.e., interview protocol, described below). Rated video observations (NDBI-Fi scores) and self-report ratings were directly compared and used to inform the development of semi-structured interview questions for each preschool teacher participant, consistent with building mixed data through connected integration (Fetters et al., 2013). We considered both the consistency between an individual’s observed and self-report ratings and the overall level of scores (e.g., high use or low use of strategies), in addition to contextual factors described in open-ended response boxes when developing each teacher’s tailored interview guide. Video clips and ratings were also used and referenced during the interviews to facilitate discussion around specific results that needed to be further explained. Video clips were chosen collaboratively by the authors to gain additional information from teachers, particularly when their self-rating and observed use were discrepant (e.g., high observed use, but low self-rating, or vice versa).

Qualitative Phase

Semi-Structured Interviews.

Each preschool teacher participant was interviewed via Zoom by the first author an average of 9 days (range = 4–17 days) after video submission and survey completion. Longer latency for some interviews was due to the school’s holiday break schedule. Participants were sent an electronic document with an overview of NDBI and a list of common strategies with definitions (from Frost et al., 2020) to reference ahead of time. Interviews were semi-structured and included questions on the following topics: (a) training experiences and clarifying questions based on survey responses, (b) feasibility of NDBI strategy implementation, (c) the overall fit of NDBI strategies into their classroom context, (d) individualized questions based on their self-ratings of NDBI strategy use, (e) individualized open-ended questions based on a 1-min clip of their recorded session that was played during the interview, (f) recommendations for support or training to implement NDBI strategies, (g) expansion or revision of the NDBI definition they provided on the survey, and (h) participants were given the opportunity to share or ask anything else. Follow-up questions were asked as needed.

Analysis of Interviews.

Interviews were recorded and transcribed using Zoom. Transcripts were reviewed and verified by the first author. The first author served as the primary (“lone wolf”) coder and the second author audited 37.5% (n = 3) of interview transcripts and participated in the analysis (Saldaña, 2021). After reading all the transcripts, the first author used the method of structural coding to label passages with terms related to the research questions (Saldaña, 2021). Specifically, structural codes were applied to describe teachers’ explanation of their observed and self-reported use of NDBI strategies, context of use, barriers and facilitatory to implementation, and training experiences and recommendations for professional development. The first and second author met to discuss and refine the codes until consensus was reached and a code book with descriptions and examples of each code was developed. Codes were applied to three of the interviews and audited by the second author to refine the codebook before it was used to code the remaining transcripts. To further understand context of NDBI strategy implementation, frequencies were determined based on the number of individual participants who endorsed (i.e., positively or negatively) each preschool activity or routine. Study authors collaboratively developed themes and interpreted qualitative results by reviewing the qualitative data independently and discussing in meetings.

Merged Integration of Quantitative and Qualitative Data

Following the completion of the qualitative data collection, we integrated the connected quantitative and qualitative results to develop meta-inferences and develop a deeper understanding of our research questions. We used joint displays at this point of integration to analyze the data, which involved comparing quantitative and qualitative results and presenting them together in tabular form (Fetters, 2020; Haynes-Brown & Fetters, 2021). Joint displays were co-developed and iteratively refined by the study authors.

Results

Reported Use and Observed Use of NDBI Strategies

Preschool teacher participants’ average self-report and observed NDBI-Fi scores, along with quotations from qualitative interviews organized by response type (i.e., higher user vs. lower user), are presented in a joint display (Table 1). On average, preschool teacher participants’ NDBI-Fi score was the highest (4.0–4.25) on using positive affect and animation, pace and frequency of direct teaching episodes, and responding to attempts to communicate. Preschool teacher participants received mid-range scores (3.5–3.75) on quality of direct teaching opportunities, following the child’s lead, and modeling appropriate language and the lowest average scores on using communicative temptations (1.25) and being face-to-face on the child’s level (2.875). For the majority of NDBI strategies, preschool teacher participants’ average self-report ratings were lower than the average NDBI-Fi scores. Table 2 presents a joint display of illustrative quotes from preschool teacher participant’s reflections of their NDBI strategy use, organized by different teacher response styles at the item level (i.e., higher observed score and lower self-report; lower observed and higher self-report; similar observed and self-report scores). Pseudonyms were used in Table 2 for preschool teacher participants. Half of the preschool teacher participants self-rated their use of NDBI strategies lower compared to their NDBI-Fi score, two teachers self-rated their use of NDBI strategies higher than their observed use, and two teachers rated themselves similarly to their observed use (see Table 2).

Table 1.

Joint Display Presenting Average NDBI-Fi Scores by Strategy Alongside Teacher Reflections.

NDBI-Fi item	NDBI-Fi average score	Self-report average range	Illustrative quotes from teachers’ reflection on self-reported use
			Lower user	Higher user
Face-to-face and on the child’s level	2.875 (57.5%) range = 2–4 SD = .83	53.5–62.5%	“I’m definitely on the child’s level.” “So, I’m still kind of in his line of sight. I’m still kind of on his level of playing. I wasn’t sure if that was part of this, or if it was just being on their level was kind of what you’re trying to get to. But with him, I’m playing with him, I’m on his level and prompting, but I mainly kind of watched his reactions to the other students.”	“Okay I was face to face on child’s level.”
Following the child’s lead	3.625 (72.5%) range = 1–5 SD = 1.5	74.75–83.75%	“I think I was trying to follow his lead. I think hewas pretty much done with the card, so I think I had a stack next to it that I originally planned on having him go through, but I think he was kind of losing some of his attention.”	“If I follow the child’s lead, wow there’s so much learning that happens because the kids don’t realize that they’re learning they’re just happy because they’re doing something that’s interesting to them.”
Positive affect and animation	4.0 (80%) range = 2–5 SD = 1.2	64.75–73.75%	“I try to still kind of be positive and happy and inquisitive, but I don’t quite…I don’t know. Sometimes for certain students I’ll be that super high energy and then for other students that almost kind of throws them off.”	“And motivating fun songs, and I think that affect and animation is really important. You know, singing and happy and joining in all the actions.”
Modeling appropriate language	3.75 (75%) range = 2–5 SD = 1.0	47–53.75%	“I guess I could have done a lot more like modeling. I just answered for [child’s name] sometimes.”	“There was a lot of language there. She wasn’t saying very much, but I was modeling for her.”
Responding to attempts to communicate	4.25 (85%) range = 3–5 SD = .71	66–75%	No relevant quotes as only one teacher received a low score and expressed that they did respond to attempts to communicate.	“The one I saw the most was just like theresponding to communication because that’s kind of a goal of mine.”
Using communicative temptations	1.25 (25%) range = 1–2 SD = .46	30.75–37.50%	“I’m not sure what using communicative temptations is.” “It wasn’t that I wasn’t like, oh I’m not going to do this one, it was probably I think it just didn’t come as easily to me.”	N/A: No higher users for this item
Pace and frequency of direct teaching opportunities	4.125 (82.5%) range = 2–5 SD = 1.1	37–43.75%	“I’d say direct teachings probably the area that I probably do it, but that’s the part that I’m most iffy with.”	“For pace and frequency of the direct teaching, I’ve worked with him many times before, so I kind of knew and understood what he was capable of.”
Quality of direct teaching opportunities	3.5 (70%) range = 2–5 SD = 1.3	55.40–63.50%	“We do meet them where they’re at but it’s not as easy to get these end ones in [direct teaching opportunities] during that free time.”	“It was developmentally appropriate, and the opportunities were pretty clear. It was motivating and did support the language. I would repeat or model that and then he’d say it and I would repeat. So, I think I was pretty natural. And there’s the social aspect of engaging with the puzzle together, so it was good reinforcement.”

Table 2.

Joint Display of Reported vs Observed NDBI Strategy Use by Teacher

Response type, teacher, and context	Ratings		Qualitative findings from interviews
	Overall NDBI-Fi score (%)	Self-report*
Response type: Higher observed score, lower self-report
Jaime: General education, inclusion, play time with small group of children	4.25 (85%)	16.33–21.50%	During interviews, teachers from this group indicated lower self-efficacy implementing NDBI strategies in their classrooms.
Nadia: General education, inclusion, play time with small group of children	2.75 (55%)	28.20–34.50%
Mona: Special education, self-contained, play time one-on-one	4.00 (80%)	56.75–65.75%
Natalie: Special education, self-contained, small and large group activity	3.38 (67.60%)	32.63–40.50%
Response type: Lower observed, higher self-report
Mia: Special education, self-contained, one-on-one activity	2.38 (47.50%)	88.50–97.50%	These teachers had 15 or more years of experience and reported more training and higher levels of competency in using NDBI strategies. These teachers may have more confidence in their abilities resulting in higher self-report.
Kym: General education, inclusion, play time	2.75 (55%)	58.75–67.75%
Response type: Similar observed and self-report
Jovi: General education, inclusion, small group activity	3.88 (77.60%)	67.5–76.5%	Both sessions were more teacher-directed activities that the teachers shared they have implemented before. Teachers may have a better awareness of their use of strategies during familiar activities.
Ellen: Special education, self-contained, one-on-one activity	4.00 (80%)	80.50–89.50%

^*average self-reported range

Context of NDBI Strategy Implementation

Preschool teachers were asked to describe how NDBI strategies fit into their typical classroom activities and routines. Table 3 lists and defines the preschool classroom activities and routines described by teachers and displays frequencies of qualitative results and illustrative quotations. Overall, teachers perceived that NDBI strategies fit into all their typical classroom activities and routines. Choice/play time, small group, large group, and snack were activities/routines most discussed by teachers. Several teachers described choice/play time and large group as activities that lend themselves well to NDBI strategy implementation while some teachers described barriers. Choice/play time is a child-directed time, so one teacher noted that it is not always easy to implement more adult-directed strategies like communicative temptations and direct teaching opportunities. On the other hand, large group is an adult-directed activity and a few teachers mentioned having trouble responding to the needs and initiations of multiple children at once. The use of NDBI strategies during outdoor recess and motor/gym time varied among teachers. Relatively few teachers discussed arrival activities and one-on-one times as these are not activities/routines that typically occur in all preschool classrooms.

Table 3.

Context of NBDI Strategy Implementation

Activity or routine	Description	Number of teachers
		Positive endorsement	Negative endorsement	Illustrative quotes
Snack or mealtime	Children and adults eat snack or a meal together at a table or multiple tables.	8	0	“I feel like the actual snack is a pretty good learning opportunity.”
Small group	Adult-directed activities, other than play, with small (6 or less) groups of children.	8	0	“So, we do small group every day. I have an associate teacher and she’ll take half the kids and I take half the kids so right now we each have six, which is, I think, the perfect number. Because at small group, I can sit there and do some more direct teaching. They might be counting with the beads or patterning, and I’m like, Oh, what did you do with those beads? Tell me about it. Or, How did you sort those items?”
Choice/play time	Child-directed play time when children choose where and what to play with.	8	1	“So, the free playtime is the most obvious because they can kind of go wherever in the classroom they want.” “The supporting correct response we do and meeting them where they’re at. But yeah, it’s not as easy to get these end ones [communicative temptations and direct teaching opportunities] in during that free time.”
Large group	Adult-directed circle time or music and movement with whole class.	8	2	“Direct teaching, you know, once again, is kind of hard, because you’re working with a lot of kids so trying to like balance all of that. But I think you have, you know, some good opportunities to kind of hit on them.”
Through-out the day	All routines and activities that occur throughout the preschool day.	5	0	“But really so I would say every area. I think you have the ability to do all of these throughout the day.”
Outdoor recess/ indoor motor room or gym	Whole class plays outdoors or in large motor room/gym.	5	3	“We do have the core board in the motor room so kids can, you know, for swinging them they can request more. We can say, “ready set go” and then we use those visuals. And then we have a new playground, and I know our speech therapist was trying to get a large core board put out there because it’s just sometimes tricky to take the devices out there.” “I feel like I don’t get a lot of these because I feel like when they’re outside, they’re wanting to see somebody other than the 16 children that are in their class. So, when my kids are outside, they are on the playground with three other classrooms. They’re done seeing our face and they want to interact with somebody else.”
One-on-one	Structured one-on-one adult directed instruction occurring in the classroom or another space.	4	0	“So, I would say I’m best at this kind of one-on-one but in sensory type situations, because I can usually hold their engagement for much longer.”
Arrival	When children enter the classroom, they have routines/activities to complete and/or specific toys to play with.	2	0	“During our morning greeting time, we definitely hit on a lot of these.”

Facilitators and Barriers to NDBI Implementation

During interviews, preschool teachers were asked about their general use of NDBI strategies within their classrooms. Teachers perceived several barriers and facilitators to NDBI implementation (see Table 4 for themes, descriptions, and illustrative quotations). We identified themes at the child level (i.e., child characteristics), teacher level (i.e., perceived effectiveness, feasibility of NDBI strategy implementation, effort and time, self-efficacy, alignment with philosophy), classroom level (i.e., teacher-child ratio, classroom structure, support staff or co-teachers), and school level (i.e., supportive colleagues, impacts of the COVID-19 pandemic). Responses were relatively consistent across participants, such that each theme was discussed by five or more teachers.

Table 4.

Teacher Reported Facilitators and Barriers to NDBI Implementation

Theme	Description	Illustrative quote describing facilitator	Illustrative quote describing barrier
Perceived effectiveness	Beliefs about whether NDBI strategies are effective.	“I think all of them lend themselves to be very helpful in the classroom you just got to find the right opportunity to use them to be most beneficial.”	N/A: No teachers described NDBI strategies as ineffective.
Feasibility of NDBI strategy implementation	Feasibility (i.e., usability, practicality, ease, possibility; or lack thereof) of implementing NDBI strategies.	“You know, it’s easy to implement in the gen ed classroom. It’s easy to do on a regular basis we just don’t realize we’re doing it.”	“In my morning group I have to say it sometimes… I don’t want to be a troublemaker, so to speak, in there [inclusion class] where I’m eliciting children to maybe have some of those more significant behavioral outbursts because there has been some pushback of kids being in there.”
Alignment with philosophy	Whether NDBI strategies align with teachers’ philosophy or curriculum.	“A lot the things listed [NDBI strategies] are things that I learned in early childhood education.”	“No, because with HighScope everything that is out should be accessible to them so even stuff that I have on my desk. Even if I push it back, it’s supposed to be accessible to them. So, this one’s [communicative temptations] harder with the HighScope curriculum.”
Child characteristics	Characteristics of children that support or hinder NDBI implementation (e.g., skill, motivation, new student needing to learn routine, etc.).	“Most of the students that I have in the classroom, like I said, are communicating effectively at some level. You know, either verbally or with picture cards or something like that. Their behavior is pretty minimal most of the time.”	“I don’t use the temptations that much because [child’s name] does have a little bit of a temper. So, sometimes hiding stuff from him will trigger him and get him really wound up. But sometimes I’ll say, What one what one?”
Effort and time	Effort (e.g., planning, collaboration) and time required for NDBI implementation.	“So, a little time chiseled out from their planning time or something like that even once a month would be really, I think, helpful to build that relationship.”	“Which requires advanced planning and as a teacher, I’m sure you know, we have a million things to do and never enough time, so it’s not at the front of my dashboard.”
Self-efficacy	Confidence or lack of confidence implementing NDBI strategies.	“It depends on the day. Some days I feel like, yeah of course I can do these things, I’m feeling really good.”	“I don’t know if it’s me not being comfortable with it, but the… what was it? The animation. I mean, I am but not, like I said, like the other people.”
Support staff or co-teachers	The skill level of support staff or co-teachers and the availability of additional support.	“[Teacher’s instructional coach] has been super helpful because she brings in you know, the first then charts and it’s like well that’s a weight off my shoulders.”	“And it’s also hard when you don’t have a lot of hands. You know, when you’re kind of short staffed and you have a lot of kids and you’re trying to get through a lot of stuff. That makes a really big difference.”
Classroom structure	Features of the classroom structure (e.g., presence of child-led time, teacher-directed structure).	“We are, you know, we do provide that structure and routine that the students need, but we are a child play based program so we do follow the child’s lead and try to use what interests them in our instruction.”	“The blended class is a little bit more teacher directed and more seat work. More projects that are more teacher directed. It looks more like a kindergarten. So, there’s less time that I can really follow the child’s lead. I still can do the communication and those kinds of things, you know. A couple of them have their communication boards there, and I can respond with them. But it’s more teacher directed, and so it’s harder.”
Supportive colleagues	Attitudes, beliefs, and support of colleagues (e.g., other teachers, support staff, ancillary staff, admin, etc.).	“You know she’s very supportive about us trying to teach them to use some of these and have them fit into their classroom more appropriately.”	“So, most of the teachers here are great, but some of them still are working on that buy-in.”
Teacher-child ratio	Number of children in the classroom relative to the number of teachers and support staff.	“What we do to make it more feasible is I have some kids, half the class, go to the motor room and the other half in the classroom. So that way, we might only have three to four kids in the room, so we can do a lot more direct support with them.”	“I’ll be honest, it’s hard with 16 kids doing it.”
Impacts of COVID-19 pandemic	Impacts of the COVID-19 pandemic, including staffing shortages, new protocols (e.g., cleaning, masks, pre-packaged food), absences, lack of consistency, and lack of exposure to routines outside the home.	N/A: No teachers described the COVID-19 Pandemic as a facilitator	“Sometimes we have kids out for two weeks and then they come back and it’s like teaching them the first day of school again. So this year, in particular, has been more challenging to use some of these things consistently because it’s just so up and down.”

Note. N/A = not applicable

Reported Training Experiences and Familiarity with NDBI

Table 5 presents a joint display of survey results describing participants’ reported training alongside relevant qualitative data from semi-structured interviews. On average, preschool teacher participants reported more training experience with direct teaching episodes and the developmental sequence of play and language and less training experience with the developmental sequence of social communication and speech sounds. Teachers reported that relevant training experiences took place in pre-service higher education undergraduate and graduate courses and in-service training opportunities varied across participants.

Table 5.

Joint Display Representing Reported Training Experiences

Quantitative data from survey	Qualitative data from semi-structured interview
	Undergraduate/graduate training
	“You get the basics-what they should be saying at what age and just the generic overview of the speech, but not a ton unless you seek it out yourself.”
	“My master’s degree was in early childhood special education, so I received some training through that. A lot of it was about embedding goals into your natural routine, visual schedules, and creating appropriate goals.”
	“I didn’t really have many classes, like, for my bachelor’s degree on students with special needs that I can recall. I don’t think I had any. I do have my master’s degree, so I had, I think, two classes for my master’s degree, but I don’t think they prepared me.”
	Inservice training
	“I came to the district I am in now, I’ve been here seven years, and they’ve offered a lot of training.”
	“We’ve had some trainings through my work here and there, but I don’t think anyone can prepare you for one specific child.”
	“Now that I’m working as a teacher, not anything has been added to that.”
	“You get the basics of what they should be saying at what age and just the generic overview of the speech but not a ton unless you seek it out yourself, so I’ve sought out more.”
	“I went through some training when I got hired here, so I would say overall it’s really been a combination of like formal training and real-world experience kind of melding themselves together.”

Two teachers were not familiar with the term NDBI, but most of the preschool teacher participants reported being slightly (n = 5) or moderately (n = 1) familiar with the term. Yet, when asked to provide a definition of the term via the electronic survey, responses were vague. Respondents emphasized interventions “embedded activities into daily routines” or “naturally occurring setting(s)” to “increase certain behaviors” and “help students reach their behavior goals,” with little description of how this is accomplished. Following the interview, when asked if they would change or add anything to their definition, preschool teachers expressed increased familiarity alongside new insights. Some teachers described the importance of being intentional about embedding teaching naturally: “It does happen naturally, but there’s a lot more thought and structure that goes into it behind the scenes.” Others realized they were already implementing some of the strategies despite being unfamiliar with the term NDBI: “I actually found when I was reading through the handout you gave [description of NDBI and each common strategy], we have training in this, but we call it something different. Nobody has ever told me the specific name that you have.”

Teacher-Recommended Professional Development Methods and Supports to Increase NDBI Implementation

Preschool teachers were asked to describe the types of training and supports that would help them increase their use of NDBI strategies. Table 6 displays a list of teacher-recommended professional development methods and supports with examples and illustrative quotes. Preschool teachers described a variety of methods they thought would be useful, ranging from common professional development practices to ongoing work with trainers (i.e., coaching), to work with peers and colleagues. Some preschool teachers also described supports that would be beneficial, including troubleshooting specific challenges to NDBI strategy implementation and support for collaboration with colleagues.

Table 6.

Teacher-Recommended Professional Development Methods and Supports to Increase NDBI Implementation

Type of professional development or support	Examples	Illustrative quote
Knowledge-level professional development (PD)	Learning about NDBI strategies; workshop with make and takes; watching video examples; activities and handouts; ongoing PD sessions	“I feel like maybe continuing education. Just like reminders of these [NDBI strategies] every year of like, Hey, we’re sending these out. I think would be really nice.”
Coaching	Coach provides feedback and instruction on how to use NDBI strategies	“I really think that coaching over multiple days is more useful than just like a one-day training. Because you can go to this training and learn this great information then it’s like, Okay. Now how do you put it into practice?”
Observing other classrooms	Observing other classrooms that use NDBI strategies with fidelity	“I would benefit, I feel like, from going and visiting other classrooms where they are doing this really well and just seeing how they put it in practice.”
Self-assessment	Video reflection; self-rating	“This. You know, any chance that you can go back and look at your own teaching. I think that would be, you know, ideal being able to self-reflect and think about well, This is what I was trying to do. Did it work?”
Peer support	Peer observation and feedback; discussion with peers	“I learn a lot from other teachers because, you know, you’re in your classroom and you’re like, Okay, am I doing it? Is this correct? You don’t have somebody in the room watching you all the time saying, Oh yeah, good job! You did it! So, having that dialogue with other teachers and talking about these [NDBI strategies] and saying well, “How do you do it? How does it work in your classroom?”
Support for troubleshooting challenges	Support for challenges like child characteristics, ratio, and context	“I guess how to set it up so everyone’s getting that direct support and using all these areas that are important.”
Support for collaboration	Time to collaborate and learn from and with co-teachers and support staff	“I really think time to relationship build with the teacher, so they understand what I’m doing, why I’m doing it, and how it’s helpful. You know we’re all hanging on by a thread most days, you know, especially this year. So, a little time chiseled out from their planning time or something like that even once a month would be really, I think, helpful to build that relationship so they had a higher level of understanding and maybe a little more openness.”

Discussion

This mixed-methods study aimed to explore preschool teachers’ perception and use of NDBI strategies to support NDBI implementation efforts. The current study is notable in that it involved self-report and video data and incorporated quantitative and qualitative data from surveys and interviews to gain a deeper understanding of the role and potential of NDBI strategies within preschool classrooms. Previous NDBI research has focused on caregivers, ABA practitioners, and birth to three providers. This study offers insight into the adoption and implementation of NDBI among preschool teachers who play an integral role in providing intervention to young children with disabilities.

An encouraging finding was that preschool teacher participants implemented three of the eight common NDBI strategies (i.e., positive affect and animation, responding to attempts to communicate, and pace and frequency of direct teaching opportunities) with high quality/consistency (i.e., score of 4 or higher on the NDBI-Fi). Yet, NDBI-Fi average score results revealed that only three teachers implemented NDBI strategies with quality/consistency overall. We also found that preschool teacher participants rarely used communicative temptations and expressed a need for support in this area. Face-to-face and on the child’s level and following the child’s lead were also strategies that preschool teachers implemented with lower fidelity, perhaps due to constraints that come with working in a group environment. Further, we found that preschool teachers did implement direct teaching opportunities on average 5–10 times in 10 minutes, yet the opportunities were rarely child-initiated, and the quality was generally poor (i.e., average score of 3.5; range = 2–5).

Collecting self-report ratings and scoring video recordings with the NDBI-Fi allowed us to make comparisons between perceived and observed NDBI strategy use. We found that preschool teacher participants’ average self-report only aligned with average observed use of two NDBI strategies (i.e., face-to-face and on the child’s level and following the child’s lead), neither of which were implemented with high quality. We also found that only two of the eight preschool teacher participants’ self-report were similar to their observed use of NDBI strategies, while four preschool teachers rated their use lower than observed, and two rated their use higher. Response styles (e.g., higher quality/consistency observed and lower self-report) did not appear to align with teacher factors like role (i.e., special education or general education), experience, context (i.e., inclusion or self-contained), or activity (e.g., play time, small group, large group). These finding indicate that preschool teachers may not have a clear understanding of NDBI strategies and their ability to implement them. Yet, with such a small sample size, this finding may not generalize.

These findings also have implications for the design and interpretation of intervention trials, particularly as an emphasis on implementation in community settings increases. Our findings suggest that children are receiving exposure to some NDBI strategies as part of “usual care,” although implementation was found to be limited and often low quality across strategies. While obtaining information about teacher implementation via self-report is an expedient way to collect this data, our findings suggest it may not be particularly accurate.

In addition to our findings around NDBI strategy use, we also found that preschool teachers reported less training experience in the developmental sequences of language, social communication, and speech sounds. This is concerning as these are the main developmental domains that NDBI strategies target and an understanding of their development is critical for effective implementation. In addition, findings reveal that familiar and consistent terms and definitions may promote NDBI adoption and implementation. During interviews, some teachers noted that they gained a better understanding of NDBI strategies over the course of the study, and that in fact they did use some techniques but perhaps did not recognize the terminology or have full awareness of how they were implementing them. As we look toward dissemination efforts, this suggests that jargon-free, shared definitions of common elements may support teachers in linking their current practices with NDBI techniques.

Implications for Practice

Preschool teachers shared barriers and facilitators to implementing NDBI strategies and recommended professional development and supports to facilitate NDBI strategy implementation. Preschool teachers expressed that NDBI strategies can be implemented throughout the day across typically occurring routines and activities, yet some may be more feasible than others. NDBI strategies are predominantly child-led and designed to be implemented within naturally occurring routines and activities, in alignment with DEC Recommended Practices (2014). Our findings reveal that although NDBI strategies aligned with preschool teachers’ philosophy, there were existing barriers to implementation. Specifically, some teachers noted that following the child’s lead and implementing communicative temptations was not as easy during adult-directed activities with larger groups of students and some curricula (i.e., HighScope) seemed to prevent teachers from using communicative temptations as limiting access to toys was viewed as contradictory to the set curriculum. Preschool teachers may require more individualized professional development and supports to adapt or tailor NDBI strategies for a classroom context.

Several teacher-recommended professional development methods and supports were noted across participants, including knowledge-level professional development and coaching with support for troubleshooting challenges. Practice-based coaching is an effective in-service professional development model that utilizes coaching to support implementation of evidence-based practices like NDBI strategies (Snyder et al., 2015). Practice-based coaching also aligns with other recommendations made by our participants including support for collaboration, self-assessment involving video reflection, and peer support. Practice-based coaching can include video-based self-reflection and feedback, which are empirically supported practices (McLeod et al., 2019; Zan & Donegan-Ritter, 2014), as well as group coaching that allows for peer collaboration (Fettig & Artman-Meeker, 2016). Additionally, participants described the importance of supportive colleagues and noted the skill level of support staff and co-teachers may also impact NDBI implementation. Since attitudes and beliefs are a cited barrier to adopting practices, like supporting children with disabilities in an inclusive preschool environment (Barton & Smith, 2015), teaming and collaboration efforts should be central (DEC, 2014). Hence, a team approach to practice-based coaching may be important in educational settings.

Many of the facilitators and barriers that our participants reported were consistent with the literature, such as some teachers lacking confidence implementing NDBI strategies. Prior research indicates that preschool teachers do not feel well-prepared to teach children with disabilities (Chadwell et al., 2020). Our findings support the need for targeted professional development to support preschool teachers’ competence and confidence. Also, effort and time and teacher-child ratio are factors that can support or hinder the use of evidence-based practices (Wilson & Landa, 2019). Systemic changes in policies and resource allocations could support NDBI strategy implementation within preschool classrooms. In addition, impacts due to the COVID-19 pandemic were cited as barriers to implementing NDBI strategies. This study took place during the second full school year following the initial shutdown in March of 2020. Since then, preschool teachers have faced the demands of implementing many different protocols to continue quality programming. Preschool teachers met increased workload, challenges to adult and child interactions (e.g., attendance, masks, restrictions on sharing objects), and staff shortages, which impacted their ability to implement practices like NDBI strategies (Crawford et al., 2021). It is imperative that administrators recognize and respond to the needs of preschool teachers to support their well-being, and in turn, the provision of services to young children with disabilities in their classrooms.

Limitations and Future Research Directions

This work was exploratory in nature and presented with several limitations. First, we sampled a small number of preschool teachers from two states. While we collected rich data using mixed methods, our sample is not necessarily representative of all preschool teachers and perspectives may not generalize broadly. Another reason findings may not be generalizable is the teachers who participated within this study were highly educated (i.e., held a bachelor’s or master’s degree), which is not required across many regions of the United States. While it is a strength that we were able to collect video observations in addition to self-report, these observations represented only a small sample of behavior with one child during a teacher-selected activity and may not be representative of their usual behavior or practice overall. The time lapse between recording the video and the semi-structured interview may have affected teachers’ qualitative responses and should be considered when interpreting these findings. However, we addressed this in two ways. First, teachers were probed about some of their specific survey responses and shown clips from their own videos, which we hoped would support them in considering that context-specific interaction. Second, the interview included more generalized and contextual information (i.e., non-specific to the video observation) which would have been unaffected by the lapse in time. Another limitation is that interrater reliability for NDBI-Fi ratings were not collected; however, all scores were coded by a single, expert rater. Future research should consider a multi-method investigation using a larger, more representative sample of teachers and more thorough observations to gain a more robust understanding of preschool teachers’ usual educational practices. In addition, supplementing surveys with brief video examples or case vignettes may help communicate across disciplines. Validated self-report instruments were not available to answer our proposed research questions. However, the development of such tools would facilitate future research in this area. In addition, asking specifically about the salience or importance of barriers and facilitators may also strengthen our understanding of how to support preschool teachers in implementing new practices.

Conclusion

This study provides meaningful insight into NDBI adoption and implementation within preschool classrooms. Our preliminary evidence suggests preschool teachers perceive NDBI strategies favorably, although they may need targeted support in understanding and using NDBI strategies. We found that some NDBI strategies may translate particularly well to a classroom setting, yet others may be more challenging to implement in certain group contexts and common classroom activities. As NDBI researchers begin to focus more on dissemination efforts, our research suggests that collaborative, team approaches to practice-based coaching may be helpful in supporting preschool teachers to implement NDBI in classroom settings with high fidelity.