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 Article of Interest - Early Childhood

Early Intervention For Children with Disabilities
by Mary Beth Bruder, Ph.D., University of Connecticut School of Medicine, Child and Family Studies
For more articles on disabilities and special ed visit www.bridges4kids.org


Early childhood is an important time in any student's life. For children with disabilities, the early years are critical for a number of reasons. First, the earlier a child is identified as having a developmental delay or disability, the greater the likelihood that the child will benefit from intervention strategies designed to compensate for the child's needs. Second, families benefit from the support given to them through the intervention process. Third, schools and communities benefit from a decrease in costs because more children come to school ready to learn.

As a field, early childhood intervention has been defined as the provision of educational or therapeutic services to children under the age of eight. Legislatively, "early intervention" is used to describe the years birth to three while the term "Early Childhood Special Education," or "Preschool Special Education" has been used to describe the period of preschool years (3-5). For purpose of ease, this chapter will utilize Sigel's (1972) definition of early childhood intervention as a description of services provided to children from birth to age five under the Individuals with Disabilities Education Act (Part H for infants and toddlers; Part B for 3 to 5 year olds).

Who Receives Early Childhood Intervention

Early childhood intervention service providers have identified of at least three separate groups of children who warrant early childhood intervention: 1) children at established risk who are diagnosed with conditions known to result in disability or delay (e.g., genetic conditions); 2) children at biological risk because of prenatal, perinatal or postnatal histories suggesting increased vulnerability to disability or delay (e.g., prematurity or birth trauma); and 3) children at environmental risk because of conditions in their surroundings which might result in disability or delay (e.g., poverty). While children with established conditions are usually recognized during the first weeks of life, children at risk for delay or disabilities can be identified at any time between the age of birth and five. It has been estimated that 30% of these children from "at-risk" groups subsequently demonstrate delays in development.

One concern for both early childhood intervention programs and families is the lack of conformity for eligibility criteria for services across age groups and states. Under current legislation, services for infants and toddlers can be made available to a broad range of children, and each state can determine its own eligibility criteria. This criteria can also differ from preschool services under Part B both across and within states. Thus, efforts to identify eligible children and their families are somewhat idiosyncratic to each state and locality.

Historical Perspective on Early Childhood Intervention

The history of early childhood intervention spans multiple disciplines and fields of study. For example, the child development literature has provided early childhood intervention a theoretical focus which has evolved from the transactional model of development. At one time child development theory was polarized into two competing schools of thought: a biologically based view of development, versus one that stressed behavioral and environmental factors. The transactional developmental theory represents a synthesis of the two theories: it emphasizes the interactive nature of child development. The transactional model of development recognizes the fact that the interaction between the child and the environment is a continual process in which neither the child's status, nor the environmental effects on that status, can be separately addressed. This developmental model suggests that the environment can be used to modify a child's biological limitations, and conversely, a deficient environment can lead to delays in a child's development. This focus has greatly influenced both early childhood intervention strategies and early childhood intervention service models; most notably on the emphasis placed on a child's relationship with his caregiver.

The Maternal and Child Health field has emphasized the role of government in designing and supporting practices to promote the well being of children. The Children's Bureau, which was established by Congress in 1912, collected data on such issues as institutional care, mental retardation and the care of crippled children. The Social Security Act, which was enacted in 1935, established Maternal and Child Health Services, as well as services for crippled children. Lastly, the Social Security Act amendments in 1965 included Medicaid services for children. In particular, the Early and Periodic Screening Diagnosis and Treatment (EPSDT) program was initiated for all children under age 21 who qualified for Medicaid. EPSDT was funded to assist in the early identification and treatment of children's health and developmental needs.

The field of early childhood education was also an important contributor to current early childhood intervention service models. Initially, early childhood programs were developed to serve poor children, and to some extent, the parents of poor children. The concept of kindergarten was established in the early 1800's by proponents such as Friedrich Froebel in Germany. The first public school kindergarten program was established in the United States in 1872. At the turn of the century, half of all kindergartens in the U.S. were operated by public school systems, although the major focus was on the potential benefits of such programs for children who were poor.

The concept of preschool or nursery school was firmly established in the early 1900's, and as with kindergarten, the concept was developed in Europe. In England, the MacMillan sisters began nursery schools to provide for the emotional and physical well-being of poor children. In Rome, Maria Montessori also established early education programs for poor children. She had initially worked with children who were mentally retarded and used educational practices which emphasized learning through active involvement with the environment.

Both the Depression and World War II resulted in the government providing assistance to expand early education (both day programs and kindergarten) opportunities for young children, primarily as a support for working mothers. However, early childhood programs remained stagnant until the 1960ís.

The largest government funded early childhood program, Head Start, was established in 1965. Head Start began as a compensatory program for low income four and five year-old children. The program provided comprehensive early childhood services focusing on health, education, social services, and parent involvement. This program has been expanded to serve infants and toddlers.

Most recently, the federal Family Support Act (1988) and the Child Care and Development Block Grant (1991) recognized the importance of early care and education programs. States are authorized to coordinate such programs to ensure accessibility by families in need of child care, Head Start and other children's services. Rather than draw a distinction between nursery school, compensatory programs and child care, proponents have recently recommended the development of integrated systems of early care and education. However, fragmentation and dwindling resources continue to hamper efforts to both build capacity and enhance the quality of early childhood education so that all children may benefit from such programs.

Lastly, the field of special education contributed to the development of early childhood intervention through its emphasis on remedial and compensatory services and instructional techniques. Special education history began in the late 1700's in France with the story of Victor, a child who had grown up with wolves. Jean-Marc Itard developed and provided an intensive education program to teach Victor (who was known as the "Wild Boy of Aveyron") language and behavior skills. After this success, a student of Itard, Edourd Sequin, developed a physiological method of education for children with disabilities. This method emphasized the importance of early education and the use of detailed assessment information with which to develop a remediation plan. Unfortunately, the techniques used by Itard and Sequin were not universally adopted, and the preferred treatment for people with disabilities until the 1960's in both Europe and the United States was institutionalization and segregation from society.

During the Kennedy Administration, the government became more involved in providing services to children with disabilities. This commitment was formalized by Congress in 1966 when the Section for Exceptional Children was expanded to the Bureau of Education for the Handicapped within the U.S. Office of Education. A number of legislative initiatives also began in this era, including the 1968 Handicapped Children's Early Education Assistance Act. The act provided federal funds to support model demonstration programs to educate infants and preschool-aged children with disabilities. This impetus began to raise awareness about the importance of early childhood intervention and an early childhood branch was developed in the Office of Special Education and Rehabilitation Services within the U.S. Department of Education. It wasn't until 1986, however, that a federal mandate was established to make special education services available to all eligible children with disabilities. This mandate was established as P.L. 99-457 which was a set of amendments to PL. 94-142, the Education of All Handicapped Children Act (later renamed the Individuals with Disabilities Education Act or IDEA).

P.L. 99-457 added to IDEA a number of significant components specific to children under age five. First, services for eligible young children (age 3-5) were mandated under the provisions of free, appropriate public education (Part B of P.L. 94-142). Second, these amendments created incentives for states to develop an early intervention entitlement program for children age birth through two (Part H). Through IDEA's Part H, Congress identified an "urgent and substantial need" to enhance the development of infants and toddlers with disabilities, to minimize the likelihood of institutionalization and the need of special education services after this group reaches school age, and to enhance the capacity of families to meet the special needs of their infants and toddlers with handicaps (Education of the Handicapped Act Amendments of 1986, Section 671). To meet this need, federal financial help was made available to the states to develop programs to delivery interagency, multidisciplinary services for all eligible children. The past ten years represents a time when statewide systems have been designed, implemented, and refined. As of 1996, all states and territories were participating in Part H services.

The Effectiveness of Early Childhood Intervention

There are more than fifty years of research to support the effectiveness of intervention for infants and young children with disabilities. In the 1930's, a series of studies were completed on the impact of the environment on young children who were described as mentally retarded. In the first study, two children from an orphanage were placed in an institution for persons with mental retardation because of a lack of space in the orphanage. In the institution, they received attention from women who were labeled mentally deficient. The stimulation provided by these women over a two year period resulted in a significant rise in the intelligence quotient of the children. This finding provided the impetus for a second study which placed 13 more children from the orphanage on a ward with adolescent women who were mentally retarded. These women became surrogate mothers. Each woman was assigned one child to care for, after being given limited training on how to care and play with the children. A comparison group of 12 children remained in the orphanage where they didn't receive individualized attention. After a period of time (18 to 36 months), the children who were assigned the surrogate mothers had a mean gain of 27.5 I.Q. points, and the children in the orphanage showed a mean loss of 26.2 points. Follow-up completed 25 years later documented long term gains in the treatment group. There were significant differences in quality of life indices such as marriages, educational level (all of the experimental group had completed 12th grade), and employment. In contrast, the orphanage group had a mean educational level of third grade, one member had died, and four were institutionalized. All but one of the seven non-institutionalized adults were working as unskilled laborers.

Research conducted in the late 1950's also strengthened the concept of early childhood intervention. Dr. Samuel Kirk (1958) measured the effects of preschool experience on 43 children who were mentally retarded in comparison to 38 children who did not have preschool experiences. The children who received early childhood intervention demonstrated an I.Q. gain of between 10 and 30 points while the comparison group showed losses in I.Q. scores.

Other studies during this era documented the effects of the environment on development. Comparisons were made between infants who grew up in sensory deprived environments as opposed to infants who received stimulation. The infants who were sensory deprived had substantial decreases in their health, as well as mental capacity. One study followed up and looked at a group of such infants at ages 10 to 14, finding that the children who were raised in a sterile environment demonstrated deficiencies across all developmental and behavioral domains.

A number of studies conducted in the 1960's investigated the effects of early childhood intervention on children from low-income backgrounds. After a much publicized study which questioned the effectiveness of Head, a number of other studies applied more rigorous methodology to study the effects of early childhood intervention on preschool age children. These later studies documented positive effects in gains in I.Q., and socioemotional development and fewer later placements in Special Education among well run or model programs. One of the most comprehensive studies of this nature was conducted on the Perry Preschool Project which served low-income children. This study has followed enrolled children into adulthood, and significant differences were found between these children and a control group of children on quality of life indicators such as employment and incarceration. Similar findings have also been documented in other well controlled studies.

Many reviews of early childhood intervention literature involve scores of studies completed during recent years. While many problems have been identified in regard to methodological limitations within these data (e.g., lack of control groups; narrowly defined outcome measures), it is still a universally held belief that early childhood intervention is effective. Most recently, it has been suggested that studies should expand their impact by systematizing designs and improving methodology to more specifically on both input and outcome variables. For example, it has been suggested that studies on early childhood intervention effectiveness incorporate analyses which allow for greater application of a systems approach. This approach has been articulated by Guralnick and it includes a focus on (1) child and family characteristics, (2) program features, and (3) goals and objectives.

Two recently completed longitudinal efficacy studies have incorporated this perspective into their methodology. The Early Intervention Collaborative Study has followed a group of 190 infants and their families who received services within 29 community-based programs in Massachusetts and New Hampshire. Results suggested that developmental change in the participating children was influenced by gestational age and health characteristics, as well as the severity of the child's psychomotor impairment at entry. Different correlates of adaptive change were demonstrated both within and among subsamples of children, but also within and among mothers and fathers. Another longitudinal intervention study, the Infant Health and Development Program was a multi-site, randomized project which included low birthweight premature infants. The intervention infants received three years of home visits, child care, medical care, and parent groups. Results at age three showed that intervention infants scored higher on tests of mental ability than control infants who only received health related services.

Characteristics of Early Childhood Intervention

Early childhood intervention services and programs are different from services for school age children in a number of ways. These differences include the heterogeneous characteristics of the children served, the developmental nature of intervention goals, and the need for a flexible intervention schedule and service delivery approach. These characteristics, as delineated by Bailey, are on Table 1. In particular, the role of the family in early childhood intervention, the need for a team based model of service delivery, and the intervention context are unique to early childhood intervention. Following is an overview of these three characteristics.

Family Centered Orientation

Every child is a member of a family (however it defines itself) and has a right to a home and a secure relationship with an adult or adults. These adults create a family unit and have ultimate responsibility for caregiving, supporting the child's development, and for enhancing the quality of the child's life. The caregiving family must be seen as the constant in the child's life, and the primary unit for service delivery. Early childhood interventionists must respect the individual families they serve and the decisions of these families in directing their children's early childhood intervention programs.

Parents of young children with disabilities rarely take on this parenting role with any amount of preparation for the special challenges they will face. Rather, the early days, weeks and months of parental responsibility may be spent in a blur of visits to the hospital, physician's office and special clinics with little or no opportunity to adapt to the significant change which has taken place in their lives. While most parents report an increase in the level of stress they perceive after the birth of a child, the parents of an infant with disabilities must deal with unanticipated pressures and responsibilities that can make the parenting role appear to be overwhelming.

It has been suggested that the primary goal of early childhood intervention should be to facilitate the parents' awareness of, and adaptation to, their primary role of parenting a child with disabilities. One key to accomplishing this goal is to recognize the ongoing stress of parents and assist them to identify and recruit support networks. Support should be both formal (e.g., assistance with insurance and financial needs; identification of respite services; training on medical equipment) and informal (e.g., identifying existing community resources; facilitating family involvement within the school). The overriding premise of such support is that it must be individually matched to the needs of the family, and the use of such strategies should be directed by the family. By changing the focus from child change to parent-family adaptation, both programs and parents have seen beneficial results.

Family-centered care. Family-centered care is the name of a set of beliefs, attitudes, and principles which have been applied to the care of children with special health care needs and their caregiving families. The philosophy of family-centered care is based on the promise that the family is the enduring and central force in the life of a child, and has a large impact on his/her development and well-being.

In order to work effectively with infants and young children with disabilities, early childhood interventionists must become aware of each caregiving family's priorities, concerns, and resources. Furthermore, staff must be able to communicate with the family in order to establish collaborative goals for the child, and to design appropriate interventions which can be delivered in the context of the family. A family-centered approach to providing services to children and families is thus dependent on a relationship between early childhood interventionists and families which is based on mutual trust and respect.

Just as the population of children who are considered to have special needs is not a homogeneous group, neither are the children's families. The early childhood intervention professional serving young children with disabilities will no doubt work with a diversity of families who vary by background and economic conditions, as well as by family structure.

In addition, the early childhood interventionist must become more sensitive to the cultural background of the enrolled families. This important variable contributes to the composition and operation of a family system. The families of infants and toddlers in the early childhood intervention system represent all the facets of American society and cultural backgrounds. The basic cultural components that must be considered as professionals interface with families include language, communication style, religious beliefs, values, customs, food preference and taboos: any one of these factors may affect the family's perception of disabilities. Professionals who work in early childhood intervention must have the ability to understand the similarities and differences between their own cultural beliefs and values and those of the families they serve. The influence of cultural norms can be more significant than the influence of a specific intervention. Early childhood intervention must develop sensitivity to the unique role these parameters play in each family system. Each family will bring unique resources to the task of parenting their child with special needs, and each family will identify unique needs which must be addressed through early childhood intervention.

Early Childhood Intervention Teams

While infants and young children with disabilities may require the combined expertise of numerous professionals providing specialized services, the coordination of both people and services is frequently overwhelming. For example, personnel having medical expertise, therapeutic expertise, educational/developmental expertise and social service expertise traditionally have been involved in the provision of services to infants and young children with disabilities and their families. Each of these service providers may represent a different professional discipline and a different philosophical model of service delivery. In fact, each discipline has it own training sequence (some require undergraduate, while others require graduate degrees), licensing and/or certification requirements (most of which do not require age specialization for young children), and treatment modality (e.g. occupational therapists may focus on sensori-integration techniques). In addition, many disciplines have their own professional organization which encompass the needs of persons across the entire life span, unlike organizations focused on a single age group (e.g., NAEYC). Nonetheless, as services for young children with disabilities continue to grow, so too does the need for professionals. Table 2 contains an overview of the professional disciplines most typically involved in services for young children with disabilities and their families.

In order to improve the efficiency of the individuals providing early childhood intervention, it has been suggested that services be delivered through a team approach. A group of people become a team when their purpose and function are derived from a common philosophy with shared goals. The types of teams that typically function within service delivery models for young children with disabilities have been identified as multidisciplinary, interdisciplinary and transdisciplinary.

The transdisciplinary approach originally was conceived as a framework for professionals to share important information and skills with primary caregivers. This approach integrates a child's developmental needs across the major developmental domains. The transdisciplinary approach involves a greater degree of collaboration than other service models and, for this reason, may be difficult to implement. It has been identified as ideal for the design and delivery of services for infants and young children with disabilities receiving early childhood intervention.

A transdisciplinary approach requires the team members to share roles and systematically cross discipline boundaries. The primary purpose of the approach is to pool and integrate the expertise of team members so that more efficient and comprehensive assessment and intervention services may be provided. The communication style in this type of team involves continuous give and take between all members (especially the parents) on a regular, planned basis. Professionals from different disciplines teach, learn and work together to accomplish a common set of intervention goals for a child and his or her family. The role differentiation between disciplines is defined by the needs of the situation, as opposed to discipline-specific characteristics. Assessment, intervention, and evaluation are carried out jointly by designated members of the team. Other characteristics of the transdisciplinary approach are joint team effort and joint staff development to insure continuous skill development among members.

In the transdisciplinary approach, the child's program is primarily implemented by a single person or a few persons with ongoing assistance provided by team members from the various disciplines. In most early childhood intervention programs, it is the teacher and program assistants who take on the primary service delivery role. It is also appropriate for this role to be assumed by a special education teacher who may provide services within the early childhood program on a regular basis. Related service support staff, most commonly therapists, often serve as consultants to the teachers. In this way, the child's therapy, as well as other needs, are integrated into the daily routine of the classroom. This strategy facilitates the delivery of appropriate interventions across developmental domains, as opposed to having a specific speech group, fine motor group, gross motor group, etc. This does not mean that therapists stop providing direct services to children. In reality, in order for therapists to be effective, they need to maintain direct contact with the child with a disability.

Although collaborative, transdisciplinary service delivery teams appear simple in concept, implementation of this strategy can be difficult because of the differences between it and the more familiar, structured, discipline specific intervention structures. In particular, the time commitment required to implement a collaborative team model effectively across all individuals may be difficult for some early childhood intervention programs.

Early Childhood Intervention Environments

A variety of factors influence the decision about the optimum service setting for an infant or young child with disabilities. These include the location of the intervention program (i.e., urban vs. rural), the program's space allocation, the needs of the child, the transportation resources of the family and program, and the preference of the family. Early childhood intervention can be provided in a hospital setting, a child care setting (a center, family day care home, or baby sitter's house), the home, and community. Not all services have to be provided at the same location; the settings may change over time as the needs of the family and child change. Clearly, there is no standard setting in which to provide early childhood intervention. No matter where the intervention services occur, the intervention techniques and services (including assistive technology) must be transferable within all of the settings in which the child and family participate.

Many times, families are restricted from participating in community activities and everyday routines if their child has a disability. Early childhood interventionists should help the family identify the natural community environments in which the family would like to participate (shopping, church, library, etc.). Intervention routines should be used to empower the family to participate in as many of these natural environments as they wish.

Children with disabilities benefit from participating in group settings with children without disabilities; in fact, this practice, termed "inclusion," has been cited as a quality indicator of early childhood and early childhood intervention services. Support for the practice of inclusive early childhood intervention services was derived from a conceptual base that emphasizes the social/ethical, educational, and legal reasons for the integration of young children with disabilities with young children without disabilities. As a result, both families and professionals have articulated the importance of providing interventions to young children with disabilities within group settings that also serve young children without disabilities. In particular, a number of interrelated service delivery developments support the expansion of early childhood intervention into natural group environments. They will each be summarized.

First, families have become increasingly vocal about their expectations for their children with disabilities. It has been well documented that parents of young children with disabilities want their children to have the opportunity to receive services in the mainstream. These parents have also suggested that one of the most important outcomes of special education should be the development of friendships between their children and children without disabilities. Special educators, as well as other service providers for children with disabilities, are responding to expectations like these by revamping special education curricula to focus on the facilitation of social competence and friendships between children with and without disabilities. A collateral finding in this research has been that parents of young children without disabilities who have participated in inclusive preschool programs have reported positive attitudes toward this practice.

Second, there has been an increasing demand for child care services for young children. More than 11 million preschool children attend early care or school programs. This is not surprising since statistics show that 53% of women with an infant under the age of one were in the labor force and, therefore in need of ongoing child care. This large number includes women who have children with disabilities.

In order to meet this growing need, it has been suggested that early childhood intervention programs collaborate with child care programs and deliver services within those settings. Model demonstration projects have provided evidence for this model, providing that appropriate supports are in place. In particular, training resources are needed to increase the availability and access to child care programs to families with children with disabilities.

Third, Part H of IDEA (now re-authorized as a part of P.L. 102-119, IDEA) has emphasized the rights of eligible infants, toddlers, and preschool aged children to receive early childhood intervention services within natural environments, such as the home or in environments in which typical children participate. The definitions under Part H further clarify that, when group settings are used for intervention, the infant or toddler with a disability should be placed in groups with same-aged peers without disabilities, such as play groups, day care centers, or whatever typical group settings exists for infants and toddlers without disabilities.

Fourth, the Americans with Disabilities Act, (P.L. 101-336), prohibits discrimination against individuals with disabilities by state and local governments (Title II) and public accommodations (Title III). All state and local government operated services for children such as child care centers, pre-schools, park and recreations services, library services, etc. cannot exclude from participation in or deny the benefits of their services, programs or activities, or otherwise discriminate against a child with disabilities (P.L. 101-336, Sec. 202).

Last, young children aged three to five who are eligible for special education and related services have the right to receive these services in inclusive environments through two memorandums which were issued by the Office of Special Education and Rehabilitation Services, US. Department of Education. These memos reinforce the child's right to both part-time and full-time placement in programs which serve preschool children who do not have disabilities. Use of both private and public programs (such as Head Start) for typical children and as special education placements for children with disabilities is one strategy which has been identified to ensure a least restrictive setting.

These reasons, in combination, underscore to the need to expand inclusionary educational services to young children with disabilities and their families. The Division for Early Childhood, Council for Exceptional Children has released a position statement supporting inclusion for young children with disabilities; this is found on Table 3.

Service Elements in Early Childhood Intervention

Current practices in early childhood intervention are dictated to a large extent by federal and state regulations. Part H of IDEA contains a listing of services which can be made available to eligible infants and toddlers; these are on Table 4. Part B of IDEA dictates the services available to eligible preschool-aged children (the same as for children ages 5-21). These services are delivered in a variety of ways, depending on the unique needs of the child. Following are descriptions of service elements included in the early childhood intervention process.

Identification of Eligible Children and Assessment Models

Assessment is the process of gathering information in order to make a decision. Assessment is an important component of early childhood intervention, yet traditional assessment models (discipline specific, in a novel setting with contrived activities, conducted by a stranger) prove inadequate when working with infants and young children with disabilities. Effective early childhood intervention assessment protocols rely on a sensitivity to the age of the child as well as the nature of his delay or disability.

It has been noted that early childhood assessment offers a unique opportunity to facilitate parent participation and partnership in the intervention process. Parents are most knowledgeable about their children, and children are most comfortable with their parents. A comprehensive assessment process includes the gathering of information about a wide range of a child's abilities, and parents have the most extensive information in such areas as motivation, interactive abilities, learning style and tolerance for learning. Lastly, if assessment is viewed as an integral part of intervention, then parent participation in assessment introduces the parent as an equal partner in facilitating their child's development.

Assessment instruments include a variety of standardized and criterion references instruments which provide information across the traditional areas of development including cognition, fine and gross motor development, receptive and expressive communication development, social-emotional development and self help. Additional professionals representing different professional disciplines may utilize specific assessments which focus on specific developmental areas. It is most important that the instruments that are used match the intended outcomes of the assessment purpose. In early childhood intervention, three separate assessment purposes have been identified: screening, eligibility for services, program planning.

Screening is the process through which children are identified as having a possible developmental need or delay, and therefore require additional assessment. The major goal of developmental screening is to reduce the time that elapses before intervention begins. In order for screening to be effective, it must be accurate, comprehensive and cost effective. Screening can occur through a variety of methods. These can include parent interviews, observations of the child, or the use of a specific instrument or checklist. However, because of wide range and variations in normal development and behavior during the early years, infants and young children are difficult to screen. Parent involvement in the screening process may alleviate some of these difficulties. One technique which has been used to do this is the parent completed screening questionnaire.

Eligibility. A second purpose of assessment is for diagnostic or eligibility purposes. Usually this assessment is comprehensive, and includes a variety of measures (sometimes using standardized tools) and professionals with discipline specific expertise. When diagnosing the nature and extent of a child's disability, it is important that this assessment provides a foundation for more finely tuned assessment procedures which may follow. And, as with screening, parents should participate in the assessment.

Recent recommendations in regard to diagnostic assessment include a focus on the process as opposed to just the product of assessment. One method in which to do this is by using a Play Based Assessment protocol. This protocol supports the observation of a child in a play based situation which allows him to demonstrate his behavioral repertoire. Parents are an integral part of this play based assessment, and it should occur in a natural environment. Professionals from different disciplines can jointly collect information about specific development areas, as well as the interaction and integration of these areas within the child. An integrated assessment report is then completed by the participating professionals, including input from the family.

Program Planning. A third purpose of assessment is to determine intervention outcomes, goals, objectives and strategies. Assessments conducted for program planning should use a variety of instruments and discipline-specific professionals, as needed. It is most important that the family be an active participant in the assessment to ensure the validity of the outcomes or goals.

An important part of assessing for program planning is an inventory of the sequences of skills needed by the child to participate in a variety of natural environments. This strategy is called an ecological inventory, and it allows information to be gathered which has relevance to enhancing the child and family's quality of life.

The IFSP and IEP Process

The Individualized Family Service Plan (IFSP) and Individualized Education Plan (IEP) are intended to be planning documents, which shape and guide the day to day provision of early childhood intervention services. The IFSP is required for the provision of early intervention services for eligible infants and toddlers (aged birth to three) and their families. Table 5 contains the requirements which must be included in an IFSP and those that must be in an IEP. The IEP is used for special education services delivered to eligible children aged three and older. The IEP does not require a statement of the family's resources priorities and concerns, nor does it require a service coordinator and a transition plan. The requirement within the IFSP for the statement of the natural intervention environments is replaced by a statement on the extent of a child's regular classroom participation for preschool age children.

While the content of both the IFSP and IEP seem somewhat similar, the concept is different. The IFSP relies very much on a family-centered and community-based orientation to service delivery, while the IEP is more grounded in a public school based model of service delivery. Many states are trying to remedy this philosophical discrepancy by using IFSPs for both early childhood intervention and preschool special education. This practice is supported by the U.S. Office of Special Education Programs in regard to compliance to the regulations of IDEA.

It has been suggested that the IFSP and IEP contain individualized outcomes, goals and intervention strategies that are functional and embedded within daily activities and routines and delivered in accordance to the families' wishes. One way to articulate these outcomes is to utilize the Individualized Curricula Sequencing Model. This type of planning utilizes the many naturally occurring events and opportunities that exist in a young child's life as "intervention opportunities." When this method is used, the IFSP or IEP can be developed according to the family's (or other environmental) routines and priorities. The IFSP or IEP should incorporate specific intervention strategies within the activities utilizing adaptations as necessary. These adaptations should be focused on empowering the child to participate in all of the activities and routines in the environment.

Curriculum for Early Childhood Intervention

Curriculum provides a basis for the intervention which is delivered to children and their families. In particular, curriculum addresses the content of the intervention, the teaching/learning strategies and the means for assessing intervention. The designation of "best practice" in curricula for infants and young children with disabilities has been evolving for a period of years with input coming from theories of normal child development and from research with both typical and atypical children and their families.

Child curricula reflect a developmental focus. This is not surprising, since most eligibility criteria for early childhood intervention emphasize the discrepancy between a child's chronological age and developmental abilities. In fact, the most widely used descriptor of early childhood curriculum is Developmentally Appropriate Practice. This approach refers to a set of guidelines established to articulate appropriate practices for the early education of young children. Two core beliefs within these guidelines are age appropriateness and individual appropriateness. Within early childhood intervention, curriculum models that emphasize Developmentally Appropriate Practices are usually insufficient without the adoption of adaptations and teaching techniques individually tailored to a child's needs.

Other important practices which must be kept in mind when organizing and delivering curricula for an infant or young child are the use of intervention objectives (usually done in conjunction with the IFSP/IEP) and systematic instruction. Basically, objectives represent learning expectations, and are based on a child's strengths, needs, and preferences. Objectives differ from goals or outcomes in that they separate the goal into smaller components. Each objective should be written so that there is little or no doubt of the intervention target.

Principles of systematic instruction include the use of antecedents and consequences. Antecedents include prompts such as cues, signals, or other methods of gaining the child's attention; consequences include reinforces (individual for each child and as natural as possible) or correction procedures. There are a variety of instructional systems which can be used to enhance a child's learning. These include incidental teaching, time delay, mand-model, systematic commenting, and milieu teaching.

Interventionists do not have to sacrifice structure in order to provide a responsive learning environment. It is possible, and often advisable, to implement systematic instructional procedures within a responsive learning environment. The key to utilizing these procedures in naturalistic teaching situations lies in tailoring intervention to the needs of each child, using the least intrusive strategies to promote the learning of skills, and embedding instruction within developmentally appropriate routines and activities such as play.

Evaluation of Early Childhood Intervention

One element which must be highlighted within early childhood intervention programs is program evaluation. As previously described, the efficacy of early childhood intervention programs has received much attention during recent years. The result of such scrutiny has been an increased awareness of the importance of evaluation as it relates to the improvement and expansion of the early childhood intervention service system.

Early childhood intervention programs that serve infants and young children with disabilities and their families must consider a number of issues when designing evaluation plans. First and foremost is the heterogeneity of the population. This factor may limit the types and scope of variables which can be measured across the group of program participants. The second factor relates to the first. Few standardized tools are available which either meet the diverse developmental needs of the population, or allow for small rates of growth over time. A third factor to consider when planning an evaluation are the inherent methodological limitations that may compromise evaluation efforts within the group of severely disabled. These limitations may include subject characteristics which affect both the internal and external validity of the plans, sample or group size, the lack of rigorous designs, misuse of statistical procedures, and the lack of detail about both independent and dependent variables.

In order to remedy these inherent problems, it has been suggested that evaluation in early childhood intervention programs be multidimensional. For the enrolled child, the measurement and outcome procedures should match the specific goals of the interventions for which they are designed. This could include information which reflects the children's attainment of goals such as increases in interactional competence, contingency awareness or engagement with the environment. In addition, programs should measure the outcomes of various family variables such as independent resource management or recruitment of support networks. Last, the program should measure aspects of the environment, including staff status. All measures should be conducted on both a formative (during program operation) and a summative (at the completion of services) schedule.

One often overlooked, yet vital aspect of the program evaluation process is an assessment of the intervention environment. The Early Childhood Environment Rating Scale has been developed to assess the quality of center-based environments for young children. This scales is organized around basic categories and include some of these content areas: furnishings, routines, learning activities, interaction, program structure and adult needs. This type of environmental assessment provides immediate feedback about the nature and the quality of the environment, which in turn has a direct impact on the quality of early childhood intervention services.

A comprehensive evaluation plan should represent the scope of the most important features of intervention: the child, the family and the program. Without this critical feedback on all of these interlocking components, early childhood intervention services can never fully meet the individual needs of children and toddlers with disabilities and their families.

Transition

The importance of transition has been addressed in state and federal legislation, federal funding initiatives, and professional literature. A successful transition is a series of well planned steps that result in the placement of the child and family into another setting. Successful transitions are a primary goal of early childhood intervention. Needless to say, the type of planning and practices that are employed can influence the success of transition and satisfaction with the transition process.

Within the field of early childhood intervention transition is defined as "the process of moving from one program to another, or from one service delivery mode to another." Others have emphasized the dynamic process of transition, as children with disabilities and their families will have repeated moves among different service providers, programs and agencies, as the child ages. While formal program transition for young children with disabilities typically occur at age three (into preschool) and age five (into kindergarten), transition between services, providers, and programs also can occur throughout these early years. Part H of IDEA, the provision of early childhood intervention services, increases the potential number of transitions. For example, transition can begin from some children at the moment of birth, if it is determined that their health status requires transfer to a special care nursery.

According to Wolery, transition should fulfill four goals: a) to ensure continuity of services; b) to minimize disruptions to the family system by facilitating adaptation to change; c) to ensure that children are prepared to function in the receiving program; and d) to fulfill the legal requirements of P.L. 99-457. In order to achieve these goals, it is necessary to plan for transition. The responsibility for transition planning should be shared across the sending and receiving program, and involve families. Transition procedures should assist families and their children and promote collaboration between the program staff and families who comprise the transition team.

Future Issues in Early Childhood Intervention

Identification and Expansion of Learning Opportunities for Children. The ecological model of learning and development suggests that behavior exists, and is best understood, contextually. In order to facilitate learning, it is reasonable to suggest that infants and young children have access to environments that provide developmental enhancing opportunities. Recent research on the identification of learning opportunities has found that the every day settings that children and families participate in provide the contexts of learning. They include the experiences and opportunities given children as part of daily living, child and family routines, family rituals, family and community celebrations and traditions, etc., that are either planned or happen serendipitously.

A recent study on activity settings as sources of childrenís learning opportunities has identified the value of using family identified activity settings for intervention. One hundred twenty-four families in eight states (who were carefully recruited so that they were diverse in terms of their cultural, ethnic, and social economic backgrounds; parent and child ages {birth to six}; child diagnosis and severity of disability; and place of residence) first identified the activity settings constituting their family and community life and then identified the kinds of child behavior and learning opportunities occurring in the contexts of these settings. Findings indicate that the young children in this sample experience learning opportunities, on average, in about 15 different home locations and 23 different community locations. These locations, in turn, supported 87 and 76 home and community activity settings, respectively, which supported an average of 113 and 106 learning opportunities in the childís home and community. Consequently, an individual child can be expected to experience some 200 or more learning opportunities in the context of his/her family and community life beyond those provided as part of a childís involvement in an early intervention or preschool program. For example, a kitchen table is a place that supports a child in such activities as listening to others talk, "asking" for a drink, learning to eat with a spoon, playing with toys, "drawing" with crayons, and so forth. The most important findings of this study is that all children, regardless of their disability or severity of delay experience multiple kinds of activity settings and learning opportunities, and these should be measured as both opportunity factors to enhance development, and intervention outcomes when facilitating a childís learning through participation in the setting.

Competent Personnel. The trend toward more inclusive, coordinated, comprehensive, family-centered services within the context of the community as embodied in the provisions of P.L 99-457 has required a reconceptualization of the early interventionist from direct service provider to indirect service provider, with a flexibility to assume multiple roles. Buysse and Wesley (1993) suggested a two-fold shift in roles for early interventionists. First, the move toward family-centered services requires a reconceptualization of role to one that focuses on the involvement of the family in active decision-making about the planning, implementation, and evaluation of services for their child. Second, the ecological perspective that views the child and family as members of the larger community (e.g., childcare) supports more indirect service delivery roles (e.g., collaboration, consultation, technical assistance, and training).

In examining the current status of training programs for professionals in early childhood intervention, criticism has been leveled at the type of preservice training available to both undergraduate and graduate students. Each professional discipline area has its own training sequence (some require graduate degrees, others require undergraduate degrees) and there is no guarantee that graduates will have any exposure to young children and their families. Compounding these differences in training are differing philosophical and treatment options that affect the delivery of services within a discipline specific area such as motor therapy or a specific etiology such as children with autism or children with cerebral palsy. These challenges are compounded by a lack of professional standards specific to those providing intervention across professional disciplines. For example, allied health professionals receive licensure that allows them to treat people across the life span, while educators may have certificates that can be categorical by level of disability of age span or not. In particular, specialty standards for infants and toddlers with disabilities are virtually nonexistent.

In an effort to remedy this situation, specific training recommendations have been made for those professional disciplines involved in the delivery of early intervention. These recommendations include both discipline specific skills in both infancy, early childhood development and families, as well as interdisciplinary and interagency skills necessary for the implementation of early intervention. For example, all disciplines should have thorough knowledge of child development, identification and assessment strategies, intervention techniques, family systems, and effective communication, relationship building and helpgiving skills. These skills would also include being able to function as a team by sharing and utilizing other memberís expertise for both assessment and program planning. Additionally, all disciplines should have a working knowledge of interagency coordination and service integration strategies as required by Part H of IDEA. The most promising strategy for doing this is through interdisciplinary or interprofessional models of training. It must be noted that many of these skills will require supervised practical application in order to insure the trainee has acquired competence in these areas. Personnel is one component of effective programs that must be addressed in order to provide all children the opportunity to learn and become competent.

Evidence Based Recommended Practices. The field of early childhood intervention for children with disabilities has empirical evidence supporting effective practices that facilitate child competence. The Division of Early Childhood, Council for Exceptional Children is currently updating early intervention recommended practices to provide effectiveness evidence in the areas of: child focused services; family focused services; cultural and linguistic competence; technological applications; learning environments; interdisciplinary models; policy and procedures; personnel and systems change maintenance and leadership. These guidelines will be outcome driven and should facilitate effective program models of intervention.

One area of recommended practices for early intervention programs that has already been extensively studied is the use of family-centered practices. These practices include treating families with dignity and respect; being culturally and socioeconomically sensitive to family diversity; providing choices to families in relation to their priorities and concerns; fully disclosing information to families so they can make decisions; focusing on a range of informal, community resources as sources of parenting and family supports; are asset and strengths based; employ helpgiving practices that are empowering and competency-enhancing. A considerable literature has been amassed on the individual and collective use of these practices to add value to early intervention. These practices can be ascribed to both program services and practitioner helpgiving behavior. The implementation of such practices provide opportunity factors for children and families, while a lack of such practices has proven a risk factor.

Assistive Technology. The use of assistive technology as a tool for children with disabilities is an area receiving attention. IDEA lists assistive technology as both an early intervention service and a special education service. Assistive technology may be termed either "low tech," such as velcro strips or paintbrushes with extended handles. High technology devices include computers, CD-ROM, input devices such as switches, adapted keyboards, graphic tablets and output devices such as speech synthesizers. Additionally, a range of seating and mobility devices are also considered assistive technology. Other research in this area has supported the fact that assistive technology can be used to facilitate learning in young children with disabilities. It has been suggested that a greater emphasis on assistive technology be incorporated into early childhood intervention since technology expands a child's options and independence.

In addition, medical assistive devices are a necessity for many children with complex health care needs. These devices replace or augment inadequate bodily function. These devices include respiratory technology assistance (e.g., oxygen supplementation, mechanical ventilation, positive airway pressure devices), surveillance devices (e.g., cardiorespiratory monitors, pulse oximeters), nutritive assistive devices (e.g., tube-feedings, ostomies), intravenous therapy (e.g., nutrition, medication infusion), and kidney dialysis. The field of early childhood intervention must be prepared to use any technology necessary to enhance a child's development.

Collaborative Service Models. Early childhood intervention requires that many agencies work together to develop joint activities focused on the development of collaborative, service models. A logical extension to this requirement for services for young children with disabilities would be the design of collaborative service models to encompass the early care and education needs of all young children. The challenge would be to identify the various agencies, professionals and payment sources currently involved in the provision of such services. While interagency and cross disciplinary collaboration would be the first step toward building collaborative service models, the ultimate goal would be a seamless system of service delivery which fluctuates around a family and child's needs as opposed to artificially imposed program limitations reflective of agency and funding constraints.

There are many benefits to collaborative service delivery models. Most importantly is more efficient and effective use of service providers and funding streams across agencies resulting in improved service delivery. These models also result in a reduction in service duplication. Collaborative models enable parents and service providers to efficiently locate and manage the necessary services required by the family. Lastly, collaborative models eliminate the need for formal transitions, as services are integrated, comprehensive and longitudinal.

Unfortunately, the development of collaborative early childhood service systems remains an elusive goal for many states. This is not surprising considering that the service delivery system is composed of independent agencies, institutions and organizations, and each provides a specific service or function. As a result, each participating service agency provider has its own orientation toward the service system, thus creating the need for transition points for families and their children.

A collaborative model would not, however, negate the need for the practices and processes cited in this chapter. Many of the practices reflect effective service delivery principles which will, in fact, facilitate the movement of children and families within a seamless, collaborative service model. The challenge facing the field is to redefine service priorities to support families and their children as they make choices in service delivery reflective of their needs.

Conclusion

Early childhood intervention is a dynamic field focused on the enhancement of a child's abilities and development, and the support of a child's family to enable them to adapt to their child's ongoing needs. The issues facing eligible young children and their families are complex, demanding a commitment by early childhood interventionists to build comprehensive coordinated community service systems. These systems must be flexible, responsive and family-centered in order to provide the best start possible to infants and young children with disabilities.
 

http://www.worldbank.org/children/nino/basico/Beth.htm

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