District of Columbia Office of State Superintentent of Education

Strong Start Early Intervention Service Guideline was developed under contract number: CW18477 awarded to Georgetown University Center for Child and Human Development from the District of Columbia Early Intervention Program, Division of Early Learning, Office of the State Superintendent of Education.

Division of Early Learning Strong Start, DC Early Intervention Comprehensive System of Personnel Development

T A B L E O F C O N T E N T S

Introduction

4 Purpose of the Service Guideline4 Use of the Service Guideline4 Organization of the Guideline

Child Development

5 Importance of Early Development5 Developmental Domains6 Common Risk Factors for Developmental Delay or Disability

Approaches to Intervention.

7 Principles of Early Intervention8 Essential Elements of Early Intervention11 Strong Start Approach to Service Delivery

The Early Intervention Process in the District ofColumbia: Considerations at Each Stage of the Process

13 Segment 1: Referral14 Segment 2: Service Coordination 16 Segment 3: Eligibility Evaluation and Determination 19 Segment 4: IFSP Meeting and Plan (IFSP)Development28 Segment 5: Delivery of Early Intervention Services32 Segment 6: IFSP Review33 Segment 7: Transition

36 References

38 Appendix

38 Appendix A40 Appendix B

35 Summary

4

IntroductionPurpose of the Service Guideline

The Strong Start Early Intervention Service Guideline provides early intervention service professionals an overview of best practices for early identification, program planning, and intervention for infants and toddlers with developmental delays or disabilities in the District of Columbia. This service guideline is based on the best evidence available. It can be used to help the early intervention team (families and early intervention providers) to make decisions about appropriate assessments and intervention strategies to be used with young children with developmental delays or disabilities.

Use of the Service Guideline

The information in this document is compiled from a review of the literature and discussion among service providers in the field on what is considered contemporary early intervention for children with delays or disabilities and their families. This Service Guideline is the District of Columbia’s interpretation of its responsibility under the Infants and Toddlers with Disabilities Program (Part C) of the Individuals with Disabilities Education Act (IDEA) and in accordance with the mission of Strong Start, the District of Columbia’s Early Intervention program.

Early Intervention is an individualized program of services and supports to children, their families, and caregivers. The guidelines presented in this document should be tailored to the individual child and family. The decision to follow any particular recommendation should be made by the family and the provider based on the circumstances of the individual child and the family.

The primary reasons for developing a service guideline for young children who have developmental delays and disabilities are to:

• Provide an informational resource for professionals;

• Encourage consistency in service delivery across providers; and

• Enhance quality improvement in early intervention services.

Organization of the Guideline

Strong Start Early Intervention Service Guideline describes child development and common risk factors that may impact development and delineates considerations for service providers and families at each of the seven (7) steps in the Strong Start early intervention process: Referral, Service Coordinator, Evaluation, Individualized Family Service Plan (IFSP) Development, Early Intervention Services, IFSP Review, and Transition.

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Child DevelopmentImportance of Early Development

The brain develops at its fastest rate during the first three years of a child’s life (Center for the Developing Child, 2010). The first three years is also a time when the brain is most sensitive to information, experiences or interventions that impact a person’s function (Wachs, Georgieff, Cusick, & McEwen, 2013). The Individuals with Disabilities Education Act (IDEA), Part C was created to respond to the science that indicated that enriching a child’s development during the first three years and supporting their caregivers’ ability to meet their needs positively influences a child’s ability to participate in family life and, as they grow, to succeed in school.

Developmental Domains

Early intervention services as described by Part C of IDEA are designed to meet the developmental needs of an infant or toddler as identified in the individualized family service plan (IFSP). We assess a child’s development in one or more of the following developmental areas: physical, cognition, communication, social and emotional, or adaptive. Although we often assess these areas separately, it is important to keep in mind that these areas develop at the same time, they are interdependent, and they develop in the context of social relationships in familiar and community environments. For example, infants learning to crawl discover new objects in their world which stimulates not only their physical development but their cognition and communication as caregivers label new objects and the caregiver and child share these interactions.

Table 1 Description of Developmental Domains

Domain Description*

PhysicalUse of the small and large muscles of the body for play, self-help skills, and learning (fine and gross motor skills). This domain also includes growth measurements such as weight and height and vision and hearing status.

CognitionThinking and problem solving skills a child uses to receive, process, understand, and apply information

Communication The understanding of (receptive) and sharing of (expressive) thoughts and feelings using gestures, voice or other methods.

Social and EmotionalUnderstanding and expression of feelings for a sense of self and relating to others. Healthy social-emotional development includes the ability to form and sustain positive relation-ships as well as experience, manage and express emotions.

AdaptiveAlso called self-help or personal care skills, these are the skills a child develops to complete activities of daily living such as feeding, dressing, using the bathroom, brushing teeth, etc.

* Adapted from Colman, J.G. (2006). The Early Intervention Dictionary

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Common Risk Factors for Developmental Delay or Disability

According to the Early Childhood Technical Assistance (ECTA) Center, approximately 351,000 children under three years of age received early intervention services under IDEA, Part C in 2015. According to the Centers for Disease Control and Prevention (2013), 15% of the child population (ages 3-17 years) has one or more developmental disabilities. In 2015 over 1,800 children were referred to Strong Start for concerns about developmental delay or disability. There are biological and environmental factors that can put an infant, toddler, or young child at risk for delay or disability (Center for the Developing Child, 2010; Walker et al., 2011; Shonkoff, Garner, et al., 2012). These factors can affect a child’s ability to learn, communicate, engage with others, help themselves, and move.

Table 2 Common Risk Factors

Biological Environmental

y Premature birth

y Low birth weight

y Exposure to environmental toxins or harmful agents before or after birth

y Conditions1

y Genetic Disorders (Down syndrome, Fragile X, Noonan syndrome, tuberous sclerosis)

y Metabolic Disorders (Inborn errors of metabolism, peroxisomal disorders)

y Pre-Natal Exposures (Fetal alcohol spectrum disorder, TORCH, congenital CMV)

y Sensory Impairments (Vision loss, hearing loss)

y Motor Impairments (Arthrogryposis, Torticollis, Muscular dystrophies)

y Neurologic Disorders (Cerebral palsy, spina bifida, seizures)

y Sociocommunicative Disorders (Autism spectrum disorder, reactive attachment disorder)

y Other Medically Related Disorders (Cancer, hypothyroidism, plagiocephaly, lead intoxication, failure to thrive)

y Acquired Trauma Related Disorders (Traumatic brain injury)

Factors in a child’s environment can affect a young child’s development. These include

y Physical, sexual, emotional abuse

y Exposure to violence

y Maternal depression

y Neglect

y Poverty

y Poor nutrition

y Substance Abuse

1 Children with many of these conditions are automatically eligible for early intervention in the District of Columbia. For a complete list of

diagnosed conditions that make a child automatically eligible for early intervention in the District of Columbia, see the DC Early Intervention

Diagnosed Condition List (http://learningei.org/documents/Eligibility_April_2014.pdf) and Segment

3: Eligibility Evaluation and Determination.

7

Approaches to InterventionEarly intervention strategies for infants and toddlers with developmental concerns include a variety of methods and approaches. Interventions focus on the child’s needs by embedding strategies into naturally occurring learning opportunities. Providing services in these natural environments are considered best practice in early intervention.

Family members and other caregivers are critical to establish meaningful outcomes and intervention strategies with their Early Intervention (EI) provider team members. The focus of intervention for children with delays and disabilities is to promote function and participation. Statewide early intervention systems are required to measure and report the progress of children receiving early intervention in three specific child outcomes (Early Childhood Technical Assistance Center, 2014).

1. Social relationships, which includes getting along and relating well with other children and adults;

2. Use of knowledge and skills, which refers to thinking, reasoning, problem-solving and early literacy and math skills; and

3. Taking actions to meet needs, which includes movement, feeding, dressing, self-care, and following rules related to health and safety.

Early intervention services are provided to children and their families in ways that help families maximize their children’s development, consistent with federal law:

y Within the family’s natural environments (the home, child care and community routines, activities and settings in which children without disabilities participate);

y With the active participation of the family;

y In the language or mode of communication used by the family; and

y With respect for the family’s culture, beliefs, and values.

Principles of Early Intervention

The District of Columbia Early Intervention Program, Strong Start, supports and complies with the federal law and regulations that require early intervention services to be family centered, community-based, and provided in the natural environment, to the maximum extent appropriate. A naturalistic approach to intervention is preferred because interventions in the child’s natural environment have been found to be more successful in increasing spontaneous skill development and generalization than intervention provided in other settings (Dunst, Bruder, Trivette & Handby, 2006).

According to the Workgroup on Principles and Practices in Natural Environments (2008) there are seven principles that guide the delivery of early intervention services within the natural environment and meet the IDEA requirements to provide family-centered, community-based, evidence-based early intervention services:

1. Infants and toddlers learn best through everyday experiences and interactions with familiar people in familiar contexts.

2. All families, with the necessary supports and resources, can enhance their children’s learning and development.

3. The primary role of a service provider in early intervention is to work with and support family members and caregivers in children’s lives.

4. The early intervention process, from initial contact through transition, must be dynamic and individualized to reflect the child’s and family members’ preferences, learning styles, and cultural beliefs.

5. IFSP outcomes must be functional and based on children’s and families’ needs and family-identified priorities.

6. The family’s priorities, needs, and interests are addressed most appropriately by a primary provider who represents and receives team and community support.

7. Interventions with young children and family members must be based on explicit principles, validated practices, best available research, and relevant laws and regulations.

8

Essential Elements of Early Intervention

To implement these seven principles, there are five essential elements of early intervention.

1. Family-Centered Care

2. Natural Environments

3. Team-Based Services

4. Individualization of Services

5. Evidence-Based Practice (EBP)

Family-Centered Care

True partnership with the family is necessary for successful early intervention practice. Respect and acknowledgement of the unique aspects of a family and their strengths, preferences, and priorities are the foundation of service delivery. Family-centered practice as outlined in the principles of early intervention:

y Acknowledges the family as primary teachers and as the constant in the child’s life;

y Builds on family strengths;

y Honors cultural diversity and family traditions;

y Recognizes the importance of community-based services;

y Promotes an individualized developmental approach;

y Encourages family-to-family peer support;

y Supports children and families during transitions;

y Develops policies, practices, and systems that are family-friendly and family-centered in all settings; and

y Celebrates successes.

What children are expected to do in their families and communities as they develop is often related to the traditions and cultural expectations of their families. When working with families, it is important to understand the developmental expectations of their cultures in relation to acquiring developmental skills such as feeding, sitting, walking, talking, dressing, bathing, etc. Important cultural or family traditions should also be included when creating program plans or providing interventions for families. Additionally, understanding the cultures and preferred languages of the families of children receiving early intervention services is important for differentiating delays from cultural expectations and constructing strategies for intervention that respect the families’ beliefs and expectations.

Natural Environments

Natural environments are more than places. The critical component of early intervention practice is to embed services and supports into naturally occurring learning opportunities. Natural environments are settings where the child, family, and care providers participate in everyday routines and activities that are important to them and serve as important learning opportunities. Early intervention providers support families to promote functional participation in these activities. A provider coaching a mother to use techniques to help her son pick up and hold a spoon, fill it with yogurt and get it to his mouth during breakfast in the kitchen at their home so that he can learn to feed himself and enjoy a meal with his family is an example of providing interventions in a natural environment. Interventions within the context of a naturally occurring learning activity create opportunities for children to learn and practice skills that promote participation, build relationships; and get their needs and wants met.

9

Table 3 Natural Learning Enviroments

Location Activity Setting Learning Opportunity

Kitchen Eating breakfast Utensil useConversationSitting

Grocery store Weekly food shopping LabelingMatchingStrengthening

Child care Pretend play at play kitchen Turn takingSharingMaking choices

Coordinted and Collaborative Team-Based Services

Infants, toddlers, and young children receiving early intervention often have complex needs requiring services or supports from a variety of providers to meet their IFSP outcomes and improve participation. Some children also need or benefit from services and supports from community agencies and organizations beyond the early intervention program. IDEA, Part C, requires that services and supports are comprehensive, coordinated, and community-based. This requires that all providers (from the EI system or other community-based providers) and the family communicate, collaborate, and function as a team to implement a comprehensive plan. Team members must (Giancreco, Suter, & Graf, 2011)

y Be grounded in collaborative teamwork based on shared purposes and goals;

y Engage in tasks they are trained, qualified, and competent to perform;

y Be complementary and synergistic to one another;

y Base recommendations, suggestions, and intervention strategies on evidence based practices; and

y Focus recommendations, suggestions, and strategies on promoting participation in activities and routines as preferred by the family.

Teaming in Early Intervention

y Share information y Develop program plans together

y All team members contribute to the IFSP outcomes y Share strategies among team members

Primary Service Provider (PSP)

The primary service provider (PSP) provides early intervention services to the child and family with consultation, support, and/or coaching from other team members. The PSP works directly with the family and consults and collaborates with other team members on a regular basis. Any member of the team can be a primary service provider. Rush and Shelden (2013) recommend that teams consider the characteristics of the parent/family, child, environment, and practitioner when

deciding on which team member would be the PSP. For more information about this model of early intervention service delivery, see Early Childhood Technical Assistance Center (ECTA), EI Service Delivery Approaches (http://bit.ly/2n2qXE1).

PSP Works directly with family. Receives coaching support

from team members.

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Coaching Interaction Style for Service Delivery

Adult learning approaches support the family members or caregivers in promoting the development of the child’s ability to participate in expected routines of their day. Caregiver competence and confidence ensures that children will have many opportunities in natural learning activities throughout the day to practice the skills needed to meet outcomes. The Coaching Interaction Style by Rush & Shelden (2011) is the approach service providers are trained to use in Strong Start. The family or caregiver is supported to reflect on their actions to determine if an action or practice is effective and how to refine or use their actions to continue to promote the child’s participation (Rush & Shelden, 2004). Intervention strategies are planned together with the family or caregiver and refined through practice and reflection.

Individualization of Services

All families and children have different needs, even if they have similar conditions or situations. Culture, expectations, and events all influence what the priorities and needs are for families and children receiving early intervention services. Teams must create program plans that reflect those individual priorities and needs. As the priorities and needs of the family change, those changes need to be reflected in the program plan, and in the services and supports provided. Team members must be flexible, creative, and collaborative in determining the outcomes, services, and intervention strategies necessary to meet the family and child’s changing needs. Segment 4: The IFSP Meeting provides key information about creating outcomes as a team.

Evidence-Based Practice (EBP)

Providing evidence-based services is the thoughtful process of determining and using interventions with children and their families that are supported by research and professional expertise, and fit with a family’s beliefs, expectations, and values. Evidence-based practice includes critical thinking to synthesize information not only as it applies to individual intervention strategies, but also as to how those strategies are applied. For example, the requirement that services and supports are provided in the natural environment is based on evidence that children learn best, and have the most opportunity to practice skills to function and participate in places where children naturally learn. Teams making program plans determine intervention strategies to meet the child and family outcomes based on a combination of what is supported by research, professional expertise, and what is most acceptable to meet the individual needs of the family.

Professional Expertise

best evidence

family beliefs, values,

expectations

EBP

11

Strong Start Approach to Service Delivery

Strong Start, the DC Early Intervention Program, incorporates the principles and elements of early intervention to meet the individual needs of eligible children and their families. Strong Start believes that developmental growth is nurtured through relationships. Strong Start reflects and values the importance of parent and child, family-to-family, family and community, and family and provider relationships. Strong Start Services:

y Support families in meeting the needs of their children;

y Support the development of relationships among families, their children, their communities, and people who provide early intervention services;

y Regard families as team members; and

y Implement the IFSP that is developed based on the child’s individualized needs as well as the family’s concerns, priorities, and resources.

Team members who provide early intervention services:

y Are committed to provide integrated, coordinated services in collaboration with each other;

y Share responsibility and accountability for how the plan is implemented with the family;

y Are qualified as delineated by federal and state regulations; and

y Follow professional codes of conduct and as appropriate state licensing requirements.

Early Intervention includes but is not limited to:

y Promoting a positive parent-child relationship;

y Identifying activities and daily routines that are natural learning opportunities for the child;

y Coaching the family to promote the child’s acquisition of a variety of skills;

y Sharing knowledge of child development with families;

y Coordinating the intervention activities that are provided within the EI team;

y Networking and consulting with community providers based on the family’s needs; and

y Working directly with the child when appropriate.

12

The Early Intervention Process in DC: Considerations at Each Stage of the Process Strong Start, the DC Early Intervention Program, is a district-wide, comprehensive, coordinated system that provides early intervention services for infants and toddlers with disabilities and developmental delays and their families.

The federal, Individuals with Disabilities Education Act (IDEA), Part C, along with the District of Columbia Public Law 1-2-119, mandate that infants and toddlers with disabilities and their families receive coordinated services early. These services must be flexible, culturally responsive, and most importantly, meet the needs of the child and the family.

The Strong Start Program serves as the single point of entry for infants and toddlers in Washington, DC whose families have concerns about their development. Appendix A contains a diagram of the services provided by DC Strong Start from the Point of Entry through Transition.

There are seven steps in the early intervention process in the District of Columbia. This section outlines considerations for serving children with developmental delays or disabilities at each step in the DC Early Intervention process. For details of the Strong Start process see the Strong Start Road Map, http://osse.dc.gov/publication/strong-start-road-map.

Examples of children and their families are used throughout the segments to highlight factors the EI team should consider when making decisions at each of the seven (7) steps of the Strong Start process.

Example 1: Anton X. Anton is a 19-month old boy who was referred to Strong Start by his pediatrician. After conducting a screening using the Ages and Stages Questionnaire-3, the pediatrician was concerned about Anton’s language development. Anton also had a history of multiple ear infections which added to the physician’s concern. Anton’s mother, Mrs. X., also related that she and her husband are concerned about his language development and behavior.

Example 2: Kaila G. Kaila is 15 months old. She attends an Early Head Start program. She lives with her mother, Ms. G., in transitional housing. Ms. G is described as having cognitive limitations. Kaila’s teachers at the Early Head Start program think that an evaluation of Kaila’s development is needed to understand her delays and support her development in eating, social participation, cognition, and language development.

Example 3: Walter S. Walter is a 2 year-old boy whose parents, Mr. and Mrs. S. are wondering whether he has autism. They are not clear what this might mean for Walter and how it will impact his ability to make friends and to attend the same preschool as his sister when he turns 3. Both of his parents work outside the home. His father is a finance manager and his mother is a computer programmer. He has a 4 year-old sister who is doing well and attends preschool.

Segment 1: Referral

Referrals can be made by anyone who is concerned about a child’s development. A pediatrician, nurse, or social worker, for example, can make a referral directly to Strong Start by phone, fax or mail. A family may contact Strong Start directly and refer their own child. An intake specialist at the Strong Start administrative office receives the referral and contacts the child’s family. The intake specialist notes whether or not there are initial concerns about the child’s development or if the child has an existing health condition that may impact development. The intake specialist will collect any previous developmental or medical documentation and note areas of concern. Once the information is obtained, the early intervention process continues to the eligibility determination process.

EXAMPLE 1: Anton X. A call came into Strong Start from Anton X’s pediatrician. After conducting a screening using the Ages and Stages Questionnaire-3 (ASQ-3) the pediatrician was concerned about Anton’s language development. Anton also had a history of multiple ear infections which added to the physician’s concern. The physician’s office faxed the intake form to DC Strong Start along with supporting documents, such as the results of a recent hearing test and findings from the ASQ-3. The intake specialist, Myra C., noted that the child was 19 months old and the family’s primary concerns were in language development, his behavior, and talking. Myra transferred the information to the service coordinator, Jasmine C., to find an evaluation site/provider/company (which ever you feel comfortable with) to conduct the eligibility evaluation”.

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EXAMPLE 2: Kaila G. DC Strong Start received a referral from Lisa T., a social worker at an Early Head Start program Kaila attends. After completing an Ages & Stages Questionnaire-3 (ASQ-3) with the parent, reviewing the teachers’ findings on a developmental screening she conducted, and talking to Kaila’s mother, the Early Head Start team noted concerns in the areas of social, emotional, adaptive, and communication skills and decided to help Ms. G. (Kaila’s mother) with a referral to Strong Start. The intake specialist, Tamara N., noted the areas of concern and the reports from the developmental screenings and transferred the information to a service coordinator, Latasha M., to meet with Ms. G. and Kaila. After meeting with the family, Latasha M. will find an evaluation site/provider/company (which ever you feel comfortable with) to conduct the eligibility evaluation.

Example 3: Walter S. Walter’s parents, Mr. and Mrs. S., called DC Strong Start and talked to the intake specialist, Jamika K. Mrs. S. discussed the family’s concerns about Walter’s temper tantrums, sleep problems, delays in communication skills, and rigid play skills. Mrs. S. had the pediatrician’s report with the results of his developmental screening that included the Parents’ Evaluation of Developmental Status (PEDS) and the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R), indicating concerns in the areas of communication, and social and emotional development. The family and pediatrician would like to follow up on concerns of Walter. S possible being diagnosed with autism spectrum disorder due to previous concerns expressed. Jamika K., the intake specialist, made arrangements to get the physician’s reports and screening test results, and passed the information to a service coordinator, Dameon H., to find an evaluation site/provider/company (which ever you feel comfortable with) to conduct the eligibility evaluation.

Segment 2: Service Coordination

Each family is assigned a service coordinator (SC) who contacts the family to explain the program, gathers some demographic information, and conducts a family interview to help identify their concerns, priorities, and resources. When gathering this information with families, the Service Coordinator collects the following information:

y Description of the family;

y Visual map of resources and family supports;

y Where the child spends his or her day;

y Background and medical information;

y What routines the child and family participate in;

y What activities the family enjoys the most;

y What other routines the family would like to establish; and

y The difficulties or barriers the child may be experiencing in participating in routines, or the difficulties the family is experiencing because of the child’s needs in areas such as moving, communicating, relating to others, thinking and problem solving. Routines can include home routines such as sleeping, dressing, bathing, diapering/toileting, feeding, getting in and out of the home, etc., or community-based activities such as visiting relatives, going to child care, grocery shopping, or going to the library or restaurants.

The service coordinator conducts the family interview prior to the evaluation using the Routines Based Interview (RBI). This interview gathers all of this information through a structured conversation and is voluntary on the part of the family. It begins with visually mapping the family and their supports an eco map. An eco map is a visual representation or drawing of who is caring for the child and the informal and formal supports a family has. A conversation is then used to understand the strengths and challenges in a typical day and to identify a list of concerns. The list of concerns is put in priority order by the family and shared with the evaluation team. If the child is eligible, this list becomes the basis of the IFSP. For more information about the eco map, RBI, see Robin McWilliam http://bit.ly/2lZ52fX or the ECTA Center, Family Assessment page http://ectacenter.org/topics/families/famassess.asp

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Example 2: Kaila G. The SC, Latasha M., contacted the family and conducted a family assessment using the RBI with Kaila’s mother, Ms. G. Through the RBI, Latasha found out that Ms. G has some resources she finds helpful including the transition housing program staff, her friends at the program, the Early Head Start program teachers and staff, Kaila’s doctors, and Kaila’s health insurance staff. Latasha determined that Ms. G was not particularly concerned about Kaila’s development but did want support to help Kaila go to sleep easier and to eat more. Ms. G. describes Kaila’s strength as being smart. She also describes Kaila as “fussy”, especially at night. Ms. G. is able to carry Kaila most places or use a stroller and it’s been easy to get on and off the Metro and buses. This is how they get to and from the Early Head Start program. They eat meals with the other families in the transitional housing program and Ms. G. helps prepare some of those meals with other parents at the program. Kalia watches the food preparation from a seat but does not talk or help. She says Kaila usually won’t eat the food but does like mashed potatoes or yogurt. Ms. G. feeds Kaila from her own plate. Kaila sits on Ms. G’s lap during meals at the community meal table. Ms. G complained that the building where she is living can be noisy at night when she is trying to put Kaila to sleep. They sleep in the same room with Kaila in her crib and Ms. G in a bed. She describes her room as very clean, with everything is in its place, which is very important to Ms. G. Ms. G wants to leave the transitional housing program in one year and have a job and her own apartment. She loves the Early Head Start program because of the support from the social workers and other parents going through the same thing as she is with housing and employment. Ms. G. would like Kaila to walk and talk soon and have nice toys for her second birthday. Latasha scheduled an eligibility evaluation with a physical therapist and speech therapist from Infant and Toddler Services. The evaluation will be completed at the Early Head Start program as requested by Ms. G.

Example 3: Walter S. The Strong Start SC, Dameon H., contacted Mr. and Mrs. S. and gathered some information about the family using the RBI. TThey consider their extended family on both sides as resources, but indicated that they all live in Baltimore. They also consider a few neighbors with children the same age as resources and the day care for their daughter. Mrs. S. explained Walter spends his day with her. They visit family and run errands on the weekends. Mr. S. travels a great deal for his work but is usually home on the weekends. Morning routines are easy, Mr. S. drops off Walter’s 4 year old sister at preschool many mornings, but sometimes Mrs. S. does. The days Mrs. S. drops off Walter’s sister at preschool Walter will sit in his car seat and he enjoys the ride if he has a toy car with him and is allowed to remain in his pajamas. Dressing takes a long time and usually results in arguments, tantrums, and biting. After breakfast Walter will play with his cars. Sometimes Mrs. S. and Walter watch Thomas the Tank Engine or other television show together for about 30-60 minutes. He gets dressed shortly before lunch. Walter does not like to change clothes once he is in them. Mrs. S. gives him a warning during play or television that they will get dressed and reminds him several times. He will walk to his room but scream “no” and try to keep his shirt on when his mother tries to remove it. Mrs. S. tries to change his diaper, undress and dress him quickly to minimize the screaming. Once dressing is done, Walter usually calms down if allowed to play with his cars again. Dressing is Mrs. S.’s main area of concern and priority. Mr. S. likes to put the children to bed on the weekends but bedtime has become a long negotiation with Walter screaming during dressing and refusing to stay in his crib once placed there. They want to convert his crib to a toddler bed because they are fearful he will climb out, and he jumps and screams so hard that they are afraid the crib is unsafe. Bedtime is Mr. S’s. priority and main concern. Mr. and Mrs. S. both want to see Walter able to use the toilet, go to sleep easily, dress without an argument and attend preschool when he turns three next year. Dameon scheduled an eligibility evaluation with a speech-language pathologist and occupational therapist from X and O Therapy Services and shared the RBI information with that team.

Example 1: Anton X. The SC, Jasmine, contacted the family and spoke to Anton’s mother, Mrs. X. Jasmine conducted the family assessment using the RBI and found out that Mrs. X. wanted support to help Anton to pay attention and to talk more. She is especially concerned about Anton when she has to go shopping as Anton often has temper tantrums. The family has a car but during the week Mrs. X. and Anton often use the bus to go shopping. Mrs. X. reports that she considers Anton’s gross motor skills a strength because he moves “a lot.” Once Anton started to walking, his family said he seemed to be constantly in motion. Mrs. X said that she feeds Anton his meals in his high chair to prevent him from getting up during mealtime and “running around.” Anton is cared for by his mother during the day. Mrs. X. is a nurse who works on the weekends while Anton is home with Dad. They consider their jobs, health insurance, their extended family and their church as valuable resources. Mrs. and Mr. X. are hoping to enroll Anton in a preschool program when he turns two. Both parents are getting a bit frustrated as Anton seems to be getting more difficult to manage and they just don’t know what to do. According to the referral information received from the pediatrician Anton walked independently at about 16 months of age. Jasmine set up and eligibility evaluation with a speech language pathologist and occupational therapist and shared the RBI information with that team. Anton seems to be getting more difficult to manage and they just don’t know what to do.

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Segment 3: Eligibility Evaluation and Determination

A child may be automatically eligible if he or she meets the requirements (see below). One evaluation team member with expertise in the area of concerns indicated in the referral or from the Routines Based Interview will complete an assessment to determine the child’s level of performance.

Eligibility

Children are determined eligible in the following ways

1. Diagnosed Physical or Mental Condition with a High Probability of Developmental Delay:

A child is determined eligible if the child has a diagnosed condition as listed on the DC Early Intervention Diagnosed Conditions List (2014). (http://learningei.org/documents/Eligibility_April_2014.pdf ) These conditions have a high probability of resulting in a developmental delay.

2. A Developmental Delay

A child may be found eligible if he or she has at least 25% delay in two or more or a 50% delay in one or more of the 5 developmental domains (cognitive, communication, social or emotional, adaptive, or physical) as measured and verified by appropriate diagnostic instruments and procedures. (Note: If the delay is in the physical domain, the evaluators will indicate whether the delay is in the fine or gross motor area or both. Communication delay must be determined by both the receptive or expressive language areas).

3. Clinical Opinion of Atypical Development or Behavior (Informed Clinical Opinion)

In some instance, a child’s age, significant illness, or required adaptation for a child to perform the items on the evaluation may affect the results. When this is the case, an informed clinical opinion from one of the evaluators may be used to substantiate the equivalent delay of 25% in two or more areas, or 50% in one or more areas of development. The evaluator must provide a summary statement in the evaluation report with their name and credentials. The informed clinical opinion must include:

• The concern(s);

• Possible reason the results are not accurately reflected; and

• How the challenges affect the child’s participation in his or her daily routine

• Why the family would benefit from Strong Start, DC Early Intervention Program

Developmental Delay

To determine if a child has a developmental delay, early childhood intervention providers use standardized evaluation tools to compare the child’s development to their peers across 5 domains of development: social/emotional, cognitive, adaptive, communication, motor.

Evaluation Tools

Many tools have been published to determine if a child is developing as expected for his or her age or is demonstrating a delay in any of the five developmental domains. Some tools are designed to gather information across all the developmental domains (social/emotional, cognitive, adaptive, communication, motor) and other tools gather information in one specific domain of development. Strong Start, DC Early Intervention provides an Approved Assessment Instruments list of acceptable tools used for these purposes. If you have a question about a tool you want to use, ask Strong Start for latest copy of this list (it is updated frequently).

Examples of the common tools used by the elgibility teams to determine delay in all domains:

y Battelle Developmental Inventory, Second Edition (BDI-2)

y Developmental Assessment of Young Children, Second Edition (DACY-2)

y Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III)

y Transdiscplinary Play-Based Assessment, Second Edition (TPBA2)

Tools used with children who were born prematurely should be carefully considered. For children who are born

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prematurely, or prior to 37 weeks gestation, it is important to correct for how prematurely born the child is. Some tools are designed to be used and allow for correction of prematurity while others do not. For example, it is expected that correction for prematurity is done when using the BDI-2 but not with the DACY-2. Providers using these tools should have the proper training and be familiar with the exminer’s manual to make the best decsions on tool selection for children born prematurely.

Eligibility Determination

Eligiblilty is determined by the Strong Start, DC Early Intervention evaluation team. They consider the RBI information, exisiting health or developmental conditions, the results of the multidisciplinary evaluation, and information from the referral source.

For procedures about eligibility determination, see the practice manual for the Service Coordinator Appendix A: Point of Entry Services to Transition. The information from the evaluation and the decisions about elgibility are recorded in the DC EIP Strong Start Tracker by the Service Coordinator.

If it is determined that the child is not eligible, the family is informed and the Service Coordinator gives information about what other community-based programs are available to them to promote development in the areas of concern and that were a priority on the Routines Based Interview (RBI). For example, to support communication and early literacy, library programs and music classes would be helpful. Play group through Strong Start is another community-based option. The Strong Start Center Directory is a good place to begin to find community-based resources (http://bit.ly/2lZc83Y).

If a child is determined eligible, the family is informed and an assessment of the child’s performance level using the Assessment, Evaluation & Programming System, II (AEPS II) is completed as required.

Following eligibility determination, an eligibility meeting is held with the family that is scheduled by the Service Coordinator to either discuss community options, or if eligible, develop the Individualized Family Service Plan (see Segment 4) .

Example 1: Anton X. The eligibility evaluation was a team effort with the occupational therapist Estelle, Speech-Language Pathologist, Carrie and Ms. X. The RBI conducted by the SC Jasmine found that hat Anton’s routines included waking and coming downstairs by himself to greet his mother. He eats breakfast with his parents before his father leaves for work. He is home with his mother and 1 day/week they attend a neighborhood play group and they also try to walk to a local playground at least 3 times a week. They also try to go to neighborhood events such as toddler reading hour at the library. The family has dinner together and Anton starts his bed time routine after the dishes are done and he has a bath. He also takes a short nap in the afternoon. Although Anton’s growth is good and he eats quite a bit, he has a very limited diet. He prefers soft foods and will tantrum if one of his preferred foods is not available during meals. He also continues to demand a bottle prior to bed each night. Anton’s family describes him as a fun loving, busy little guy. He loves to run around at the playground and he really enjoys watching videos and playing on his father’s tablet. His bed time routine can be challenging. He takes a while to settle down. But he sleeps through the night. When he awakens he is ready to ‘go’! He can be very difficult to understand and he gets very frustrated when he tries to make his needs known. Also, he will tantrum when quiet time is expected. This is happening more often. Another concern for his family is that Anton wants to run down the grocery store aisle rather than sit in the grocery cart. Talking and behaving are the priorities for Ms. and Mr. X. Based on the family concerns from the RBI of tantrums, talking, attention and being ready for preschool, Estelle and Carrie used to use the BDI-2 to determine eligibility. They also observed Anton play and eat a snack at home with his mother, Ms. X. Estelle and Carrie found that Anton has strengths in his non-verbal cognitive skills and social-emotional development. When observing Anton during play by himself in the toy room, they saw that he preferred to move from one toy to another, seeming to have a short attention span. Even when encouraged to sit and play by his mother, he got up and dashed about. He did show a 25% delay in his gross motor development and a 50% delay in expressive language and a 10% delay in receptive language. They recommended Anton be found eligible for early intervention and an Assessment, Evaluation and Programming System II (AEPS-II) assessment was completed with the information gathered during the eligibility evaluation to further determine his needs for program planning. The team also recommended linkages back to his pediatrician for referrals to specialists to determine if further assessment of hearing should be completed because of his multiple ear infections. Carrie and Estelle encouraged Ms. X. to continue attending the play group as well as the library reading program. They contacted the SC Jasmine to schedule the eligibility meeting.

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Example 2: Kaila G. The physical therapist, Eileen S. and speech-language pathologist, Tory L., reviewed the RBI and referral information. They conducted the eligibility evaluation at the Early Head Start program with Ms. G and social worker from the program. Kaila has trouble separating from her mother (crying, wanting to be held) when Ms. G. drops her off. It takes quite a bit to help Kaila calm down during the morning routine of washing hands, changing diapers and eating breakfast. The evaluation team watched Kaila during some of her morning routine at the Early Head Start program. Kaila refused to sit at the table with the other children unless her primary teacher sat with her. She does not usually eat more than a bite of the breakfast and did not on the day evaluated. After breakfast she clung to her teacher. She sat on her teacher’s lap during morning greeting time. When Kaila sits on the floor, her teachers reported that Kaila’s usually sits in a W posture. When the teachers or her mother have her sit with her legs out in front of her or crossed, she has a hard time keeping her balance. Kaila crawled to the play areas, preferring the kitchen area. She liked to mouth the plastic food and bang on the pots and dishes. The teachers report that snack is similar to breakfast and that during outside time, Kaila prefers to sit in the stroller near a teacher on the playground.

Ms. G. noted to the team that she wanted Kaila to talk more like the other children. Ms. G. talked about their afterschool routines and said that they have a snack together on the way home; Kaila likes crackers or cookies that she can suck on until they are soft. They get back to their building and talk with the other parents and play in the small common room. Kaila likes to look at books while sitting on the floor. After dinner they play a little more and Ms. G. washes Kaila, puts her in her pajamas, and lays out her clothes for the next day. She says that Kaila cries when placed in her crib and she has to walk her or rock her to sleep before she puts her down for the night. This takes at least an hour. Many times during the night Kaila will wake up and Ms. G. gives her a bottle or pacifier to go back to sleep.

To gather more developmental information, the evaluation team used the Bayley Scales of Infant and Toddler Development, 3rd Edition. Currently we only use the Bayley for transition (youngest age 2 year 4 months). Since Kaila was born 6 weeks prematurely, this tool allowed for correction for her prematurity. Kaila was timid and appeared scared by loud noises and separating from familiar adults for interaction with the evaluators. Using bubbles helped to warm her up for moving around and participating in the testing. Her scores indicated that Kaila had at least a 25% delay in the communication, adaptive, motor and social/emotional areas even when considering her level of prematurity. Her cognitive was not quite 25% delayed, but of concern, especially since her delayed fine motor skills may have affected her cognitive scores. The evaluators, Eileen and Tory, were also both concerned about low muscle tone and the quality and slow pace of Kaila’s movement patterns, including those around her mouth, lips and tongue, which were making speaking and eating difficult. They noted the impact the delays in development were having on routines at home and at the Early Head Start program. They recommended that Kaila be found eligible for early intervention and an Assessment, Evaluation and Programming System II (AEPS II) assessment was completed to further determine her needs for program planning.

The team also recommended a linkage back to the pediatrician to determine if the bleeding in Kaila’s brain at the time of her premature birth was having an impact on her motor and oral motor abilities. Eileen and Tory discussed the evaluation with her SC . Eileen and Tory discussed ideas about some adaptive seating and utensils for classroom routines and meals may be helpful for Kaila to participate better in those routines at home and at school. Tory also recommended identifying a communication system (sign, pictures, gestures) that would work at home and school to increase communication. Eileen and Tory recommended a consult with a team psychologist to support recommendations in the area of social emotional development for her mother and teachers. These options were informally discussed in preparation for the IFSP meeting.

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Example 3: Walter S. Considering the RBI and referral information, the speech-language pathologist, Katie W., and an occupational therapist, Erin R. conducted a multidisciplinary eligibility evaluation at the family’s home using the Bayley Scales of Infant and Toddler Development, 3rd Edition. Strong Start only uses this assessment for transition. Walter did not make eye contact with the evaluators or go near them but did stay close to his mother and turned to her when she called his name. When Katie and Erin tried to engage him in a play activity he would watch them but not participate. When Mrs. S. interacted with him, he would try the activity. The team asked Mrs. S. to try some of the items at the beginning of the evaluation and eventually Walter engaged in some of them. When he did not want to engage in the activity he would turn and play with his cars which were on the floor. When Katie and Erin tried to play with his cars he would scoop them up and move away from them or he would scream. His screaming became louder and more frequent as the testing went on. Walter repeated some words and said “No” and “Mama” spontaneously. The team noted that Walter had low muscle tone (hypotonia) and difficulty coordinating his movements during the evaluation. His age equivalent scores in three developmental areas assessed with Bayley at the age of 2 years were as follows: cognition 18 months, expressive language 12 months, receptive language 16 months, gross motor 16 months and fine motor 18 months. The evaluation team used the Vineland Adaptive Behavior Scales, 2nd Edition to determine his developmental level in adaptive skills and social interactions. Based on parent report, Walter’s adaptive behavior is at the 15 month level and his social skills are at 12 month level. The evaluators recommended that Walter be found eligible for early intervention because of 25% delays in cognition, language, gross and fine motor development, a 50% delay in social skills and at least a 25% delay in adaptive skills. The eligibility team completed the Assessment, Evaluation and Programming System II (AEPS II) with the evaluation findings and Ms. S. They asked his SC to schedule an eligibility meeting. Because of Walter’s atypical interaction skills the team also recommended further evaluation using the Autism Diagnostic Observation Schedule-2 (ADOS-2) to determine if Walter has autism spectrum disorder.

Segment 4: Individualized Family Service Plan Meeting and Plan Development

The Individualized Family Service Plan (IFSP) is developed once the child is determined eligible for early intervention.

Outcomes that reflect the family priorities, which were discussed and listed during the Routines Based Interview:

y Strategies that the team agrees would help the child and family meet the outcomes; and

y Services necessary to build the capacity of the family and to help them and their child meet the outcomes.

1. Emphasize the positive, not the negative;

2. Use action words, not passive;

3. Are jargon free, using family-generated and family-friendly language;

4. Reflects the information gathered through the evaluation or on-going assessment; and

5. The measureable criteria are appropriate for the outcome.

Outcomes are created from the list of things to work on from the RBI and tailored in the IFSP meeting by the team based on new information since the last meeting and the evaluation information. The following steps are used to create participation-based outcomes (McWilliam, 2006).

y Choose the first priority from the list generated from the RBI or any new priority concern

y Determine the routines at home or community this affects (lunch, bath time, circle time, shopping)

y Write “(NAME) will participate in (ROUTINE)”

y Next, write “by____________”

y Add a criterion that will let the team including the family understand when the child or family has met the outcome

y Determine the time frame

[NAME] will participate in [ROUTINE] by_____________ [STATEMENT OF MEASUREMENT]

Participation-based outcomes can be family oriented or child oriented as show in Table 2.

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Table 4 Participation-Based Outcome Statements

Family-Oriented Outcomes indicate the: Child-Oriented Outcomes

y Family’s desire to acquire new knowledge or skills y Parent/caregiver as the actor y Focus of the outcome is on the parent’s/caregiver’s

ability to promote the child’s participation in activity settings

y Family priority

Ms. Nazir will read a picture book to Natalia before bed each night for 5 nights in a row

y Relate to the child’s participation within an existing or desired activity, setting or routine

y Target the interests of the child y Are a family priority

Natalie will participate in meal time by finger feeding ½ of her food at each meal 5 days in a row

Example 1: Anton X. Considering the family concerns and priorities from the RBI (talking, behaving, limited diet), Anton’s strengths (social, happy, movement, understanding, and tablet use), his present levels of development, the impact and limitations of his communication delays on participation during excursions and when demands are placed on him, the team (Ms. X., Jasmine, Estelle & Carrie) developed the following outcomes:

1. Anton will participate in meal time by choosing one new food to try during at least one meal each day by using gestures or verbalizations for 7 days in a row.

2. Anton will participate in play time by using three signs accompanied by verbalizations: more, Mother (mommy, mum, etc.), Father (Dad, Daddy, etc.) during play time at home or during playgroup each day for 2 weeks

3. Anton will participate in bed time by falling asleep by himself in 30 minutes after he is placed in bed awake but drowsy following bath, story, lullaby each night for 7 nights in a row.

4. Anton will participate in grocery shopping by picking five food products off the shelf (See Segment 5 for assistive technology considerations: iPad for matching groceries, signs/gestures)

Example 2: Kaila G. The team (Eileen, Tory, Latasha, Ms. G. and Kaila’s teacher) considered Ms. G.’s concerns and priorities (talking like other children, eating better, getting to sleep more easily, walking), Kaila’s present levels of development, Kaila’s strengths including her attachment to her mother, and the impact of her motor, oral motor, social and emotional, communication and adaptive delays on participation at school and at home. The team developed the following outcomes:

1. Kaila will participate in reading time at home in the evening with her mother by choosing from two books when presented by pointing each night for 5 nights.

2. Kaila will participate in snack/lunch by walking to the sink with the other children at the EHS program to wash her hands before snack and lunch for 5 school days.

3. Kaila will partipate in meal time by hand feed/finger feed herself 10 bites of food at lunch and dinner for 5 days in a row.

4. Ms. G. will follow a bedtime routine with Kaila by bathing, dressing, singing to Kaila at the same time every night for 5 ngihts in a row.

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Example 3: Walter S. The team (Katie, Erin, Dameon, and Mrs. S.) considered the concerns and priorities Mr. and Mrs. S. discussed during the RBI (sleep routines, tantrums, dressing, playing), Walter’s strengths (plays well by himself, likes cars, attachment to his family, likes to ride in the car), the information on the family routines and expectations, Walter’s present levels of development (delays in communication, adaptive skills and social-emotional development) and pending evaluations for ASD. Because the S. felt that their concerns were overwhelming them after the evaluation results were shared, they wanted to focus on Walter’s dressing and sleep routines the most. Based on all this information, the team came up with the following outcomes.

1. Walter will participate in going to the bathroom by walking to the bathroom by himself and sitting on the toilet with a parent’s help for at least one minute in morning and afternoon at home or at the store for 5 days in a row.

2. Walter wil participate in bedtime by falling asleep playing with his cars or car books with the night light on within one hour when placed in the bed by his father by the time the family goes on their next vacation in August.

3. Walter will participate in the dressing/undressing night time routine by helping to remove his pants and shirt with his mother or father’s help and push his arms and legs into his pajamas each night for 5 nights in a row by his vacation in August.

Assistive Technology (AT)

Assistive technology is considered when creating outcomes and used to support a child to meet the outcomes on the IFSP. AT could also be used to adapt the environment to be less stressful or challenging for the child. Assistive technology is any device, service, strategy, or practice that is used to reduce the problems faced by people with disabilities (Cook & Polgar, 2008). Assistive technology can be low tech (pencil and paper, picture communication board) to high tech (power-drive wheelchair, computerized communication system, etc.). Under IDEA, Part C, all teams must consider if assistive technology devices and services are required for a child to meet outcomes.

Considerations for Assistive Technology

For information about AT decision-making see the Assistive Technology Program for the District of Columbia (ATPDC) (202-547-0918 or http://www.atpdc.org) or the following resources:

y Early Childhood Technical Assistance Center: Assistive Technology http://ectacenter.org/topics/atech/atech.asp

y Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) http://www.resnaprojects.org

y Tots ‘nTech Research Institute http://tnt.asu.edu

Generally, the team should consider:

y Who will be involved in making decisions about the AT and following up with the family;

y What contexts and environments will the AT be used

y What are the preferences of the family or caregivers regarding AT and their knowledge of AT, their comfort in using AT, and the type and extent of training they may need;

y A plan for trying AT and taking data to determine usefulness;

y A plan for determining costs and payment, ordering/obtaining the AT, and tracking use or making modifications; and

y How the AT and AT services will be documented on the IFSP.

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Example 1: Anton X. The team discussed that one reason Anton may tantrum is because he is easily frustrated when he is not understood. The team thought a simple AAC device that will help him communicate may lessen his frustration. Because his family reported that he liked using the tablet and was able to point to a wide variety of common pictures, the family and team decided to teach the X.s and Anton to use a variety of language ‘apps’. Carrie, the SLP, met with Anton’s parents one evening when they were both available and downloaded a variety of apps that will encourage labeling of objects and can be used for matching. They also downloaded some that also produce a verbal response. Mr. and Ms. X. were very excited to start using these apps with Anton and Anton seemed as excited and ready to try them out. The next week Mr. X. emailed Carrie to report that over the weekend Anton and he went to McDonalds and Anton used his tablet to “order” Chicken McNuggets!

Example 2: Kaila G. Assistive technology considerations for Kaila included the picture strategies her mother, Ms. G. used to meet the bedtime routine outcome. The team, led by the speech-language pathologist, explored augmentative communication and decided on a gesture or sign based set of strategies with some pictures placed in the classroom and at home for daily routines. This seemed to be the easiest strategy for the family and the EHS program.

Example 3: Walter S. Assistive technology considerations for Walter included the picture schedule for his dressing and sleep routines as well as homemade picture books about dressing and sleep. The speech-language pathologist helped the team explore other forms of augmentative communication including a tablet computer but the pictures pared with words worked best for now and allowed Walter to point and approximate words and understanding the warnings his mother gave him about the dressing routines.

Determining Services and Team Members: General Guidelines for Decision-Making

Services are determined by the outcomes that address the family priorities, child and family strengths, and child and family needs for participation as determined in the IFSP. Infants and toddlers with developmental delays and disabilities require team members with expertise to meet their outcomes. As discussed in the Elements of Early Intervention, teamwork is key to determining and providing services under the IFSP.The make-up of the team is based on the needs of the child and family. There are only two team members that are required in the early intervention process: the child’s family (the primary team member) and the EI service coordinator. Other team members are determined by the concern, priorties, needs of the child and family, and the IFSP outcomes.

According to IDEA, Part C (http://idea.ed.gov/part-c/statutes#statute-1364) early intervention services’ mean developmental services that:

y are provided under public supervision; y are provided at no cost except where Federal or State law provides for a system of payments by families, including a

schedule of sliding fees; and y are designed to meet the developmental needs of an infant or toddler with a disability, as identified by the

individualized family service plan team, in any one or more of the following areas:

y physical development;

y cognitive development;

y communication development;

y social or emotional development; or

y adaptive development.

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These services could include (but are not limited to):

y Assistive technology devices and assistive technology services;

y Early identification, screening, and assessment services;

y Family training, counseling, and home visits;

y Health services necessary to enable the infant or toddler to benefit from the other early intervention services;

y Medical services only for diagnostic or evaluation purposes;

y Occupational therapy;

y Pediatrician and other physician care;

y Physical therapy;

y Psychological services;

y Service coordination services;

y Social work services;

y Special instruction;

y Speech-language pathology and audiology services, and sign language and cued language services;

y Transportation and related costs that are necessary to enable an infant or toddler and the infant’s or toddler’s family to receive another service; and

y Vision services.

IDEA further defines the professional providers who could be members of the IFSP team, but are not limited to the following:

y Audiologists

y Family therapists

y Nurses

y Occupational therapists

y Orientation and mobility specialists

y Pediatricians and other physicians

y Physical therapists

y Psychologists

y Registered dieticians

y Social workers

y Special educators

y Speech-language pathologists and audiologists

y Vision specialists

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Many of the professional associations for these service provider professions have guidance on providing services in early intervention (some resources require membership to access)

Table 5 Professional Associations Early Intevention Guidance

Professional Association Early Intervention Guidance

American Speech-Language-Hearing Association (ASHA)

Early Intervention

http://www.asha.org/slp/clinical/EarlyIntervention/

American Occupational Therapy Association (AOTA)

Early Intervention- Early Childhood

http://www.aota.org/practice/children-youth/early-intervention.aspx

Academy for Certification of Vision Rehabilitation & Education Professionals (ACVREP)

Certified Orientation and Mobility Specialist Scope of Practice

https://www.acvrep.org/certifications/coms-scope

American Physical Therapy Association (APTA), Section on Pediatrics

Early Intervention Special Interest Group Resources

http://pediatricapta.org/special-interest-groups/sigs.cfm?SIG=EI

Division of Early Childhood, Council for Exceptional Children

Recommended Practices in Early Intervention/ Early Childhood Special Education http://www.dec-sped.org/#!dec-recommended-practices/t8p3w

National Association of Social Workers (NASW)

Practice & Professional Development http://www.naswdc.org/practice/default.asp

National Association of Special Education Teachers (NASET)

Early Intervention http://www.naset.org/earlyintervention2.0.html

Decisions about what team members are needed to meet the outcomes are decided once the outcomes are created. The most likely primary service provider (MLPSP) is deterimed by the evaluation or current provider team. There is a rubric for determining the MLPSP Team member has the expertise to support the family to meet the outcomes called the Worksheet for Selecting the Most Likely Primary Service Provider http://fipp.org/static/media/uploads/casetools/casetool_vol6_no3.pdf (Rush & Shelden, 2012). The team considers family and child factors, the natural learning environments that will be used, knowledge and expertise needed by the service provider, and then factors such as family beliefs and values, distances traveled by providers, and availability among other things are considered.

Decisions regarding service delivery type, method, frequency and intensity should be made after careful consideration of several factors. Factors to consider include the following (adapted from Hebbler, Malik & Taylor, 2010):

• Complexity of IFSP outcomes

• Needs and complexity of the child for learning new skills

• Needs and complexity of the family-stressors, current level of confidence in their knowledge and skill in supporting their child, culture and language, social supports, preferences for learning new skills

• Number of environments the child is required to participate in

• Family and/or caregiver availability for level of service including daily and family routines of the child

• Child’s age

• If applicable, previous intervention type, frequency, and intensity including successes and barriers

y Available evidence about the frequency and intensity recommendation of any individual interventions strategies being considered

y Expertise of the providers

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Considerations for supporting families around behavior: The term behavior management has come to mean different things to different audiences. In early intervention, this term is NOT specific to Applied Behavior Analysis (ABA) Therapy or other specific interventions. Rather, behavior management is the use of strategies such as redirection, positive reinforcement, encouragement, patience, and modeling and reinforcing appropriate behavior to prevent challenging behaviors from occurring, escalating, or to minimize the intensity of those behaviors. Many service providers have expertise in these and other simple strategies to consider before using more intense, frequent, and structured interventions. Service Coordinators and Service Providers need to consider this information as they read the following examples. Examples of specific strategies continue through the next segment.

A Note about Behavior

Families with young children with disabilities or delays often ask for support in helping their child behave. Children with developmental disabilities or delays are often frustrated when they are learning new skills or meeting expectations. Like all of us, they often need a little help. Since the 1960s a common method to change behavior has been to apply the principles of behavior management. Behavior management uses techniques that build on how we learn. The term behavior management is often used but also confused with other supports such as behavior modification or behavior analysis or conditioning. Here are some clarification of terms used in the examples and in early intervention.

Behavior management is often used to describe strategies that prevent an undesirable behavior (i.e. temper tantrum) from escalating. Common caregiving strategies like redirection, positive reinforcement, encouragement, patience, and modeling are examples of simple behavior management strategies. Most early intervention providers were trained in these types of management strategies and use them throughout their work with children to promote positive behaviors. Teachers are highly skilled at using these methods as they will help keep order in a classroom, help children pay attention to the learning activities, and prevent children from talking off task. Rearranging the room or establishing a bedtime routine are other caregiving strategies that help families manage a child’s behavior.

Some children who have difficulty learning perhaps because they have a significant disability may need a more structured type of behavior management program, often referred to as behavior modification. Behavior modification strategies often require the parent or interventionist to keep documentation on how often the child demonstrates the behavior. Interventionists will also identify the antecedent that precipitates the behavior (A), the behavior (B), and the consequences (C) or what happens after the child demonstrates the behavior. Identifying the antecedents and the consequences often help parents and interventionists to make changes that prevent the behavior from occurring. For example if you know that you will break your diet if you eat a piece of chocolate, chances are you may not take that first bite. If a child gets distracted by the TV and won’t eat if the TV is on during meal time, a common suggestion to modify that behavior would be to turn off the TV. Interventionists also suggest ideas to families to change their response (consequence) to a child. We often suggest to ignore the undesirable behavior and praise the desirable.

Applied behavior analysis (ABA) has become a popular strategy for children with autism or intellectual disabilities. These are not new strategies. Recent research, however, has shown that ABA is effective in promoting specific skills in children with autism. ABA is a multi-tiered system of support that uses different levels of support to promote engagement, incorporate teaching strategies, and provide services to improve skills. Many interventionists have become trained in the use of ABA. Some children may benefit from ABA strategies provided by a certified ABA provider. Making this recommendation should be team decision based on the specific needs of the child and priorities of the family.

There are many other terms used to help people decrease undesirable behavior and promote desirable behavior. Some that are more commonly used are discrete trial training (DTT), positive behavioral support (PBS), cognitive behavioral therapy (CBT), direct instruction (DI), precision teaching (PT), etc.

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In the case examples throughout these Guideline, we give examples of behavior management strategies.

Example 1: Anton X. The team considered the factors for determining service type, method and frequency. The IFSP outcomes were not complex and were embedded into the routines of the child and family’s day that they were most concerned about. Anton does need more practice talking and making his needs known in a reliable, consistent manner. Because his frustration can escalate to a tantrum the family would like strategies to prevent this from happening, to redirect him if it does, or other strategies to help him to express himself and improve his behavior if redirecting doesn’t help. The family is confident in their ability to follow-through with instructions but would like support. The family would like to check in with at least one provider each week to make sure they are on track with the practice. Their preference is one week at the home and at least once weekly during a community outing, especially the grocery store. Given these factors, the team decided that the primary service provider would be speech-langauge pathologist. The occupational therapist would provide a short episode of services to support the family’s ability to help Anton self calm. They anticipate that if given support initially that provider directed service could be decreased over time. Considering all of these factors, the Family, Service Coordinator and Service Providers decided the following services, frequency, intensity and setting would best support the family on reaching the outcomes in the IFSP (see Anton X’s example in the next segment for specific strategies)

Service Type Service Description Setting

(PSP) Speech-language pathology (SLP) with experience in child caregiving and behavior management (distraction, positive reinforcement, modeling, etc), augmentative communication, and assistive technology

Sessions-1 individualFrequency- 2x weekly Intensity- 60 min

Once per week at Anton’s home during a meal and once weekly in a community activity.

Occupational therapy (OT) with expertise in sensory processing difficulties to teach strategies on controlling Anton’s ‘engine’, promoting feeding and strengthening oral-motor skills for eating and talking

Sessions – 1 individualFrequency- weekly consult for 1 month and then decrease as appropriate Intensity- 45 min

Home- with mother to coach mother and Anton in calming activities that can be incorporated throughout the day to prevent escalation of behavior.

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Example 2: Kaila G. The team considered the factors for determining service type, method and frequency. The IFSP outcomes were not complex, but the family situation and Ms. G.’s need for repetition for learning and understanding required more support without being overwhelming. Intervention strategies were embedded into the routines of the child and family’s day that they were most concerned about. Kaila’s delay in communication is fairly significant and there are concerns about her social emotional skills. She needs a soft, slow patient approach and support for her teachers as well as her mother. Considering all of these factors, the Family, Service Coordinator and Service Providers decided the speech-language pathologist was the best primary provider but because of the intensity of the needs at this time for both the parent and the child, a special instructor would support the family and the child care providers. See the chart below for all the services, frequency, intensity and setting would best support the family on reaching the outcomes in the IFSP (see Kaila G.’s example in the next segment for specific strategies)

Service Type Service Description Setting

(PSP) Speech-language pathology (SLP) with experience in behavior management, augmentative communication, and assistive technology

Sessions-1 individualFrequency- 2x weekly Intensity- 60 min

Two times per week: y Once at home during meal or bedtime

routines and y Once during nap or meal routines

at school.

Special Instructor who has expertise to support parents with cognitive disabilities and promotion of social emotional development

Sessions – 1 individualFrequency- 1X weekIntensity- 45 min

One time per week y In the classroom to coach teachers

in strategies to support participating in classroom learning routines (circle time, reading), meals, nap routines and support social/ emotional skills.

y Communicate with Kaila’s mother and ask her to participate at school when she is able and

y Establish a communication system to explain strategies with her.

Physical therapist Sessions-1 individual (consult)

Frequency-1 monthly Intensity- 45 min ConsultThis can be done through a video call with other team members after the PT reviews a video of Kaila

Once every month to advise team on strategies to improve walking in classroom and promotion of self-help skills

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Example 3: Walter S. The team considered the factors for determining service type, method and frequency. The IFSP outcomes were not complex, but urgent for the family because of the stress the tantrums caused at bed and dressing times. The family members were eager to try the activities and felt they wanted to keep the number of people in the house to a minimum as this added to the tantrums and routine disruptions for Walter. Intervention strategies were embedded into the sleep and dressing routines. Because of the urgency and intensity of Walter and the familiy’s needs to meet the outcomes, the Family, Service Coordinator and Service Providers decided the following services, frequency, intensity and setting would best support the family on reaching the outcomes in the IFSP (see Walter S.’s example in the next segment for specific strategies)

Service Type Service Description Setting

(PSP) Special Instructor (SI) who has expertise in behavior strategies such as identifying antecedents, and consequencing, supporting families to be consistent in providing positive reinforcement, behavioral shaping, extinction, etc.

Sessions-1 individual

Frequency- 1x weekly

Intensity- 60 min

Once weekly at home during dressing time (morning or evening)

Psychologist to help establish a behavior plan and consult with SI and SLP as needed to maintain behavior plan

One consultation session initially

At home, consult with team members as needed by phone, electronically, or in-person

Speech-language pathologist with expertise in augmentative and alternative communication

Sessions – 1 individual (consult)

Frequency- 1X month

Intensity- 45 min

Home one time per month to consult with family and special instructor on the communication system (picture schedule and others) and strategies to support more verbal communication.

Segment 5: Delivery of Early Intervention Services

Early intervention contemporary practice tells us that our purpose is to build the capacity of the family to promote skill development, remediate impairments, and to encourage participation. We also help families integrate assistive technology and other supports to compensate for impairments that are barriers to participation. As the team develops the child and family outcomes, and how to best support the child and family, they should consider the following:

y Natural environments (place, routine, learning opportunities) y Amount/type of practice required y Specific intervention strategies to be used

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Providing Services in Natural Environments

Young children learn as they engage with their environment during their everyday experiences. New skills are learned best within a familiar context that allows for ample opportunities for practice. Any intervention approach that is selected should take into account how young children learn. There are many models of early intervention (See Appendix for a description) that may be considered. Although slightly different it is clear that all these practices:

y focus on the child performing activities within the context in which the skill is required;

y require the child to actively participate;

y incorporate meaningful, functional age and developmentally appropriate skills; and

y require interventionists to collaborate with families.

Amount and Type of Practice

The team considers the amount and type of practice needed for the child to improve their function and best meet their outcomes. The literature on how children learn skills has identified five concepts related to practice that are important to be aware of when developing an intervention plan specific to promote skill development. Table 6 applies these principles of practice to early intervention. Table 6 Principles of Practice in Early Intervention

Table 6 Principles of Practice in Early Intervention1

Practice Specificity

Practice should take place under conditions that are comparable to the conditions that the skill will be used in

y Intervention occurs in natural environment settings where skill is to be performed

y Intervention occurs within daily routines (context) where skill is to be performed

Amount of Practice

Repetition is necessary y Embedding strategies within naturally occurring

routines allows for frequent practice opportunities throughout a child’s day

Length of Practice Sessions

Shorter, active practice sessions with longer rest breaks improve performance of skills

y Embedding strategies within naturally occurring routines allows for many short opportunities to practice several times throughout the day

Practice Variability

Changing skill demands leads to better retention of skills than constant practice in the same manner

y Opportunities to practice same skill within context of multiple routines (e.g., making choices—during mealtimes, playtimes, bath time, dressing, etc.)

y Opportunities to practice skill in different ways (e.g., learning to drink from a cup using difference cups available)

1 Description in Table 6 based on Gordon & Magill, 2012

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Intervention Strategies

There are many intervention strategies used to promote development and function in children. The selection of intervention strategies should be determined by the provider in collaboration with the family based on the best evidence available, family preferences, and provider experience. Table 5 describes considerations for the service provider when choosing specific intervention strategies for children with developmental delay or disabilities to meet the IFSP outcomes and promote participation.

Table 7 Considerations in Choosing Interventions2

Intervention Considerations

Alter Context y Select a context (location, routine, learning activity) where the child can perform within

their skills and abilities y Change the context to promote the skill and apply to more than one context

Adapt y Adapt the context and task demands to support performance y Enhance contextual features to provide cues so the tasks become more possible to

perform or challenging to promote development

Compensate

y Use of assistive technology, adaptive equipment, augmentative and alternative communication to allow a child to perform a skill when he or she has yet to master a skill or is not capable.

y Can be used to promote communication or prevent further impairment or disability as these strategies are often used to bypass a barrier to the performance of a desired outcome

Prevent

y Prevent occurrence of maladaptive performance y Anticipate problems and change course of events to have better outcomes y Prevent the development of secondary impairments or disabilities in children with known

difficulties

Promote/Create y Create situations that promote more adaptable performance in context y Enrich contextual/task experience to improve performance y Make best use of environment to enhance performance

Remediate/ Establish y Identify skills and barriers to performance y Design intervention to improve skills or abilities

2 Adapted from New York State Clinical Practice Guideline: Motor Disorders

http://www.health.ny.gov/community/infants_children/early_intervention/ docs/guidelines_motor_disorders_assessment_and_intervention.pdf

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Traditionally, most service providers use their expertise to remediate impairments or establish developmental skills or adaptive behaviors; there are; however, there are a variety of purposes to consider when deciding on an intervention plan. The goals of the intervention strategies are to promote a child’s ability for social interaction, parent-child interaction, communication, self-care, play, and mobility. Adaptation, prevention and anticipation of problems and barriers, altering the environment to promote success, and compensation with assistive technology are all important foci of service delivery. A service provider may choose more than one or shift focus as needs and priorities change.

When choosing evidence based intervention strategies, providers and families should consider the following:

• Is the intervention likely to accomplish the outcomes of intervention plan?

• Are there any potentially harmful consequences or side effects associated with this intervention?

• What positive effects of the intervention would we hope to see?

• Has the intervention been validated scientifically with carefully designed research studies of young children who have developmental delay or the same health or developmental condition?

• Can this intervention be integrated into the child’s current environment?

• What is the time commitment for the family/caregiver and provider? Is it realistic?

• Does the parent or caregiver find the strategy acceptable?

• Is there a cost to the family?

• What are the pros and cons of this intervention? What do other parents and professionals say about it (both pros and cons)?

• Does the provider of the intervention have knowledge or experience using the strategy for issues associated with developmental delay or the same health or developmental condition?

Coaching

DC Strong Start requires early intervention providers to use a coaching interaction with family members, child care providers, Head Start teachers, and other caregivers. in strategies to promote a child’s development and to accomplish the IFSP outcomes. Coaching is an adult learning strategy that builds capacity of family members or care givers to promote the development of the child. Coaching promotes competency and mastery of skills.

Providers who use a coaching as an interaction style focus their efforts on building the adult’s confidence and competence in promoting the child’s development. The adult could be a family member, a child care provider, a pre-school teacher depending on what outcome is being promoted and where the intervention is provided.

Because the intent of early intervention is to build the capacity of caregivers, providers will not use separate, special, “therapy” rooms for service provision nor will they isolate the child from the activities that are naturally occurring.

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Segment 6: IFSP Review

The purpose of the IFSP review is for the whole team (family and/or caregivers, service providers, service coordinator) to determine 1) the degree to which progress toward the IFSP outcomes is being made and 2) whether modifications or revisions to the IFSP are needed. The review is required at least every six months. At the one year mark, it is considered the annual review or annual IFSP.

Prior to the six month or annual IFSP review meeting the intervention team, including the family, will determine the progress bycomparing progress to the outcome measures and any AEPS results.

Table 8: IFSP Review Progress Monitoring and Updates

Progress Monitoring Concerns, Priorities, Routines, Resources

Six Month Review y Progress on outcomes y AEPS results

y Updates to the prior RBI and eco map

Annual Review

y Progress on outcomes y AEPS results y Eligiblity Evaluation standardized

assessment results

y New RBI and eco map

Progress and assessment results are provided, shared, and discussed with the family and the service coordinator prior to review meetings. Any data documenting changes in skill performance, outcome performance, and use of AT will be provided to the service coordinator. During the review meeting, the team, including the family, will discuss the following to determine if outcomes and/or services need to be modified or changed:

y Updated information about the family and child including priorities, concerns, strengths/ needs, routines, preferences, interests, and activities the child is expected to participate in;

y Any new circumstances for the child and family are discussed (changes in health, child care/early education, transportation, home life/living situation, routines);

y Any future child or family events that the child may be participating in that impact mobility, play, self-help, learning or transportation; and

y Child’s progress according to the caregivers and providers on IFSP outcomes.

Example 1: Anton X. At Anton’s 6 month review (Anton is now 25 months of age) his family was pleased with his progress in communicating. He was able to transition from using the apps on an tablet to using some single words to ask for different foods during meals and for some familiar activities during playtime at the playground and the playgroup. The tablet is still used when he is getting frustrated or searching for the words he wants to use and he still enjoys using it during community outings, especially grocery shopping. The bedtime routine has proven more difficult for Anton’s family. He will go through the routine and get in bed but gets up several times and has a difficult time falling asleep. Anton’s family would like to focus on bed time and identifying animal sounds and other pictures in books like the other children in his playgroup and at the library.

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Example 2: Kaila G. At the time of Kaila’s 6 month review (Kaila is now 21 months of age) her mother and teacher think she had made progress in her daily routines. Her mother reports that she is sleeping better; her teacher reports that she seems more engaged during circle time and both report that during meals she will use gestures and smiles to indicate what she wants. She is now able to feed herself with the adapted spoon and bowl but relies on using her hands/fingers for most of the meal. Kaila eats at least one portion of one type of food during meals at the Early Head Start program and at home but intake continues to be a concern. She does not take at least 10 bites. Her pediatrician has added a calorie booster drink to her diet. She is able to make a few signs, point and say partial words for “more, done, no and Mom”. Her mother is pleased with her progress but is afraid that this “IFSP review” means that the services will end soon. The team reassures her mother the review will not end the services for Kaila but set new outcomes. The teachers continue to want support around Kaila’s communication as they expected her to make more progress than they have seen. They have also grown more concerned about Kaila’s ability to participate in art activities and playing with toys with push buttons. Both are difficult for her to do with her hands. Both Ms. G. and the teachers want to focus on her communication skills and the teachers want to address activities that require fine motor skills over the next six months.

Example 3. Walter S. At the 6 month review, Walter (Walter is now 30 months of age) had a diagnosis of ASD. His parents shared that the dressing at bed and going to the bathroom were much better. Walter liked the picture schedule and the S’s. enhanced it to include other household routines including getting into the car to visit family. The bedtime routine has been less successful. The family transitioned to a toddler bed with sides and if his sister joins him at night, he will stay in the bed but this is presenting new challenges for his sister’s sleep and Walter learning to sleep independently. The other challenge the S’s discussed is his possible transition to his sister’s preschool when he turns three. Mrs. S. talked to the administration and they are willing to try to integrate Walter into the school but have little experience with children with ASD. This is a priority for the family. The team decided to include these concerns into the transition planning and new outcomes on his IFSP. The team also discussed what supports could be brought to the preschool as well as to Walter to make his 3 year old transition smooth and successful. His services type and frequency/intensity were updated with the new IFSP outcomes and included increased frequency and intensity for speech-language services to help with the transition (1 time per week individual)

Segment 7: Transition

Children transition out of early intervention because of family preference, age, or the family moves out of state. For a full description on transition in early childhood in the District of Columbia, see the District of Columbia Office of the State Superintendent of Education, Early Childhood Transition Guidelines http://bit.ly/2lZibpi.

As the child approaches his or her 3rd birthday, the service coordinator will start the process of transition with the family. The service coordinator will consider the following when developing options that the family may want to explore.

Extend IFSP Option

Children who are receiving early intervention from the Strong Start program and are eligible for Part B services (special education and related services) may choose to continue with the early intervention program until age 4 or entrance into preschool. The team, including the family, will develop/update an IFSP that also includes pre-literacy and numeracy skills and receive the appropriate services as determined by the IFSP’s outcomes. For more information about this option, see the Office of the State Superintendent, Specialized Education Policies and Regulations http://bit.ly/2miBUD3.

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Timeline for Transition in Strong Start

Considerations for Transition

y Parent preferences for preschool or learning program

y Child’s interests and preferences for learning, play, and physical activity

y The results of the special education and related services eligibility evaluation done through Early Stages http://www.earlystagesdc.org/

y Progress on IFSP outcomes

y The services, supports, and program expectations of the options available to the child

y Assistive technology needs

y Transportation options and needs (getting on/off bus, adapted car seat, wheelchair ties, etc.)

2 YEARSPart C:

Transition Discussions with Family Begin. Part B:

Refer children to Part C as necessary.

2 YEARS 6.5 MONTHSPart C:

Notify LEA and SEA of all children potentially eligible for B. Provide Part B with child’s Early Intervention Record.

Part B: Document referral.

Review, document receipt of child’s Early Intervention Record.

2 YEARS 7 MONTHSPart C:

Convene a Transition Conference. Part B:

Attend Transition Conference, obtain consent to evaluate.

2 YEARS 8 MONTHS - 2 YEARS 11 MONTHSPart C:

Upon invitation from LEA, attend child’s initial IEP meeting.Part B:

Continue with evaluation, eligibility and IEP processes.

3 YEARSPart C:

Child exits from Part C services or IFSP is revised under extended IFSP option.

Part B: Student’s IEP has developed and services in

Part B program begin.

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Example1: Anton X is now 2.6 years and is ready to begin the transition out of Part C. When he turned two, his parents enrolled him in a 5 day per week child care center and his mother started to work full time at a health clinic. Anton has been very happy at the child care center and the center has tried very hard to accommodate for his needs. When he entered the center he was receiving speech and language services and OT support. The OT consults on occasion with his parents and the child care center regarding behavior management and incorporating some fun sensory processing activities into learning activities. These strategies help keep his behavior regulated. The Xs. are quite happy with this center and would prefer Anton to stay there rather than moving on to the public school. When evaluated by the Part B 619 preschool child find program (Early Stages), Anton continued to show delays particularly in communication and social skills and was found to be eligible to receive Part B 619 services and supports under the category of developmental delay . During the transition meeting a variety of programs including a school-based preschool program were described to the Xs. The extended IFSP option was also discussed during the transition meeting and the team decided that Anton would continue on with the IFSP, receiving services from the SLP, Carrie, at the child care center as well as with his parents. The OT is also available if called. The team also thought that an education provider (Special Instructor) could meet with the teacher to ensure that she feels comfortable with Anton in the class and she is including him in all learning activities. Anton’s bedtime routine incorporates reading. Carrie, the SLP and the Special Instructor will recommend several books that incorporate literacy learning for the Xs to consider.

Example 2: Kaila G. Kaila is now over 2.5 years and her service coordinator, Tina S., has been helping Ms. G. plan for when Kaila turns three years old. Ms. G. has a part time job and Kaila has remained in her Early Head Start program, receiving her early intervention services in the classroom and sometimes at home. They live in an apartment now as part of the DC transitional housing program and the DC Developmental Disabilities Services (DDS) administration that Ms. G. qualifies for because of her intellectual disability. The DDS services include service coordination for Ms. G. and they are coordinating with Tina S. Kaila was referred to Early Stages for special education eligibility determination. Kaila qualified for special education, IDEA, Part B services and an Individualized Education Program (IEP) was completed and placement for a small class size preschool was recommended and explained. Tina S. and Ms. G.’s DDS service coordinator visited the preschool recommended and talked to the teacher. Ms. G. liked the preschool placement offered and the Head Start team agreed that it was a better place for Kaila to receive services and prepare for kindergarten, which is important to Ms. G. Ms. G. agreed to have Kaila transition to preschool and follow the IEP. Plans are underway to support Kaila and Ms. G. for this transition in a few months. Ms. G. has also benefitted from the home visiting program, Play and Learning Strategies (PALS), that she has been receiving. She would like this to continue. The Transition plan included a referral to the Home Instruction for Parents of Preschool Youngsters (HIPPY) program which is for 3-5 year olds. The HIPPY program will begin when Kaila turns three.

Example 3: Walter S.: The S’s liked the idea of extending Walter’s IFSP to include the transition to the same pre-school with his sister and if he qualifies for special education. They chose the extended IFSP option. Walter has an appointment with Early Stages in one week to make that determination. They wanted their son to have the same experience as his sister and getting both children to the same school was important to them as a family. The Ss are hoping the transition is successful enough that he will be able to stay in the preschool with supports until he is ready to go to kindergarten. IFSP outcomes around his transition to preschool including a smooth morning routine were incorporated at his IFSP review. Revisiting his communication system to increase his ability to express his needs and wants is also underway with the family and will be discussed with the preschool teachers if he is eligible to continue with the IFSP after age three. The family also wants a focus on his play with other children.

SummaryEarly intervention is an important program to support the development of infants, toddlers and young children to fully participate in their daily lives by promoting the competence and confidence of their family and caregivers. In order to be effective in this endeavor, early intervention service providers must work together, be dedicated to communication and coordination, and make evidence-based plans and decisions with families.

These guidelines provide foundational information to service providers of Strong Start, the District of Columbia’s Early Intervention Program. Additional information to support the steps in early intervention is available at the Office of the State Superintendent of Education, Division of Early Learning, DC Early Intervention Program (http://bit.ly/2lZ15Ip) and the Georgetown University Early Childhood Intervention Professional Development Center (http://leariningei.org)

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y ISC: y Obtains consent to evaluate/

assess; contacts MCO y Provides and explains rights; y Obtains written parent

consent for release of information (referral and transition consent forms, if appropriate);

y Coordinates with Evaluation site to schedule evaluation and provides PWN.

y Introduces the philosophy and concepts of EI, including routine based interview

y Identifies parental concerns and priorities for their child and family; Identifies family resources, including cost participation.

ISC makes contact with family to verify concerns and determines interest in proceeding.

YESNO

Intake / Family Assessment

y ISC schedules appointment and meets with family either in person or by phone, depending on the family’s choice and:

y Explains the program, using talking points/ begins AEPS Family Report interview

y Determines with family if they wish to have child evaluated and assessed.

y CF/I y Supports ISC in sending

information to family and outlining how to re- contact program if future concerns;

y Assists with parental consent and communicates with referral source regarding parent’s decision.

CF/I assist ISC as needed to correspond, locate resources, and follow up.

CF/I compiles referral information, Intake Supervisor identifies an Initial SC (ISC) and forwards information to ISC for initial contact with family.

Child Find/Intake receives referral, collects information on referral source’s reason(s) for referral and results of screening or assessment, from outside source.

Appendix A: POINT OF ENTRY SERVICES TO TRANSITION (USE MOST RECECENT)

Identification and Referral

If NOT eligible, ISC meets with family and evaluator and links with appropriate community resources and how to re-contact program if there are concerns in future.

ISC informs EI Supervisor of eligible child and Supervisor identifies a Dedicated SC (DSC) & ISC schedules and invites to IFSP

Evaluation Team (including family)

y Conducts evaluation and assessment

y Gathers AEPS information y Shares preliminary findings

regarding child with family y Submits eligibility

recommendation to the ISC for final eligibility determination

If Eligible ISC explains eligibility to family

ISC

y ISC gathers existing history, developmental and medical information.

y Determines if child automatically eligible (diagnosed condition);

y Works with evaluation sites to determine necessary evaluation and assessment to identify child’s developmental status and unique needs in each developmental area (Established risk or Developmental Delay)

y Provides written prior notice; y Provides and explains rights. y Prepares family for evaluation

and assessment.

Child Evaluation and Assessment

YESNO

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Dedicated Service Coordinator (DSC) assumes responsibility for guiding family and their multidisciplinary team

DSC:

y Develops transition plan; y Obtains consent for release

of information to appropriate entity;

y Ensures LEA invitation; y Provides prior written notice/

rights and coordinates timely transition conference;

y Ensures implementation of transition plan to ensure smooth transition.

DSC

y Provides transition follow up; y Provides prior notice/rights

to discontinue services; y Closes child record.

AEPS completed every six months.

DSC coordinates ongoing service provision and ensures timely IFSP reviews and annual IFSP meeting to develop new IFSP if child still eligible.

DSC ensures that service providers implement timely IFSP services.

ISC coordinates with evaluation team, family & DSC, schedules IFSP meeting, provides participants with Prior Written Notice (PWN) and prepares family for meeting.

IFSP team meets to develop IFSP including:

y Reviewing parents’ priorities and concerns;

y Establishing functional/measurable outcomes; identifying strategies; Identifying necessary services and timelines for initiating services and providers with MCO/fee/Ins support.

ISC obtains parents’ consent for IFSP services (signing IFSP)

For those services where consent is not provided, ISC provides and explains parental rights (including information on complaints/ mediation process); provides prior notice to not provide these services and how to re-contact program in future.

IFSP Development

ISC uploads IFSP & referral form

Consent provided for some or all

Service Delivery and Transition

Consent not provided

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APPENDIX BModel Description References

Activity-Based Motor Intervention

Building on research related to motor learning, Activity-Based Motor Intervention emphasizes learning motor skills that increase participation in daily routines. Through the use of structured practice and repetition of functional actions, motor skills are taught, facilitated, and used within a relevant and functional context. This model integrates impairment focused interventions.

(Valvano & Rapport 2006)

Activity Based Intervention (ABI)

Also called naturalistic instruction, the emphasis of Activity- Based Intervention is within an activity, routine, and context, but the target of intervention is the child, promoting skill development of the child. This is particularly relevant for group learning situations such as pre-school or child care.

(Pretti-Frontczak& Bricker 2004)

Contextually Mediated Practices (CMP)

CMP uses context or natural learning opportunities to promote child’s acquisition of new skills, competence, or knowledge. This model uses everyday family and community activities as the sources or “context” for learning.

(Dunst 2006; Dunst & Swanson 2006)

Developmentally Appropriate Practice (DAP)

Promotes early care and education within an environment that offers content, materials, activities, and methodologies that are coordinated with a child’s level of development and for which the individual child is ready. DAP considers three dimensions of appropriateness:

y Age appropriateness

y Individual appropriateness

y Appropriateness for the cultural and social context of the child

(NAEYC 2009)

Family guided Routines Based Intervention (FGRBI)

Focuses on the development of intervention that accommodates family preferences, priorities, activities, and schedules. Includes steps to ensure natural environment practices are considered in all aspects of early intervention including:

y Introduction of concept of natural environments to the family, collecting information about activities and routines through a routines based assessment,

y Connecting the assessment information to the program plan,

y Involving the caregiver(s) in teaching and the child in learning process and monitoring progress

(Woods, 2012)

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Model Description References

Interest- Based Child Learning

This model builds on a child’s interests and assets as the focus of intervention and is based on the idea that a child’s interest in an activity will increased engagements which in turn will promote adult responsiveness and encouragement supporting the development of socially-adaptive functional capabilities and additional practice. Practice builds competence which in turn will promote use of the skill to explore the environment which will lead to mastery. Success is based on child’s increased opportunities to participate in socially and culturally meaningful activity. Interests of the child can be determined across contexts and tools have been designed to systemically identify interests and learning opportunities within the context of the family and caregivers.

(Raab, 2005; Wilson & Mott, 2006)

Participation- Based Services

The goals of participation-based services are to 1) promote a child’s participation in family and community activities and routines, and 2) facilitate developmental competence and learning. In a participation-based approach, early intervention professionals provide intervention for a child by teaching caregivers how to use two primary types of child interventions to promote their participation and learning:

y Adapting the environment, materials, or the activity/routine, including the use of assistive technology

y Embedding individualized learning strategies within family routines (Colyvas, Sawyer, & Campbell, 2010)

(Campbell & Sawyer, 2007; Campbell & Sawyer, 2009)

Parents Interacting with Infants (PIWI)

PIWI or Triadic Practices focuses on the parent-child relationship as the critical foundation for learning. Using a structured group-based methodology facilitators expand knowledge and ability of caregivers within the context of activities and routines.

TaCTICS, 2000; McCollum et al, 2001; Bsau et al, 2010)

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Model Description References

Resources Based Intervention Practices

Strategies focus on mobilizing and providing resources and supports to families to help them reach outcomes. Early intervention providers:

y Assist families to identify formal and informal supports/resources

y Identify sources and locations of formal and information supports/resources

y Build the capacity of the community to be responsive to individual family interest and priorities.

y This model has been shown to:

y Increase knowledge of the families and providers of the availability of community resources

y Increase the capacity of the family to problem-solve

y Promote the development of resource-exchange networks

y Increase parental satisfactions with resources

y Increase parental perceived control over resources procurement

y Promote child developmental progress

(Mott, 2006)

Routines- Based Intervention (RBI)

Routines- Based Intervention stresses the importance of engagement, independence, and social relationships within a naturally occurring child activity. Also, because EI is a collaborative process often including multiple caregivers, the importance of caregiver satisfaction is stressed.

(McWilliam, 2004)

((Footnotes)1 Children with many of these conditions are automatically eligible for early intervention in the District of Columbia. For a complete list of diagnosed conditions that make a child automatically eligible for early intervention in the District of Columbia, see the DC Early Intervention Diagnosed Condition List (http://learningei.org/documents/Eligibility_April_2014.pdf) and Segment 3: Eligibility Evaluation and Determination.

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District of Columbia Office of State Superintentent of Education

810 1st Street NE, Ninth Floor Washington, DC 20002