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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 1960’s.
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 children’s
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
child’s 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 child’s 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
child’s 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 member’s 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.
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