1. EARLY INTERVENTION & OCCUPATIONAL THERAPY SERVICES
AOTA ANNUAL CONFERENCE
April 11, 2008

2. Today’s Presenters: Tim Nanof, MSW (AOTA)
Leslie Jackson, M.Ed, OT (Easter Seals)
Anne Lucas, MS, OT-R (NECTAC)
Gloria Frolek Clark, MS, OTR/L, BCP, FAOTA (Early intervention & Schools)

3. Federal and State Policy Framework for Early Intervention Practice

4. What is IDEA?
Education, civil rights legislation that, since 1975, has
Ensured access to education and other support services for eligible children with disabilities
Since 1986, has provided incentives for States to serve infants and toddlers with disabilities and their families
Provided funds to support a statewide system of early intervention.

5. IDEA Part C Infants and toddlers with disabilities
Federal requirements for early intervention services, birth through 2

6. Other Parts of IDEA
Part B- Assistance to states for the education of all children with disabilities
Special education and related services for preschool and school aged children, 3-21.
Part D- National activities to improve education of children with disabilities.

7. Purposes (§601(d))
Ensure that children with disabilities have a free appropriate public education that emphasizes special education and related services to meet their unique needs and prepare them for further education, employment, and independent living.
Ensure that the rights of children with disabilities and parents of such children are protected.

8. Purposes
Assist States in the implementation of a statewide, comprehensive, coordinated, multidisciplinary, interagency system of early intervention services for infants and toddlers with disabilities and their families
Ensure that educators and parents have the necessary tools to improve educational results for children with disabilities by supporting system improvement activities; coordinated research and personnel preparation; coordinated technical assistance, dissemination, and support; and technology development and media services.
Assess, and ensure the effectiveness of efforts to educate children with disabilities.

9. What is Early Intervention?
Federal policy enacted in 1986 to motivate States to develop statewide systems of services and supports for infants and toddlers with disabilities (birth through age 2) and their families in recognition of "an urgent and substantial need" to
enhance the development of infants and toddlers with disabilities;
reduce educational costs by minimizing the need for special education through early intervention;
minimize the likelihood of institutionalization, and maximize independent living; and,
enhance the capacity of families to meet their child's needs (§631).

10. Part C Requirements (§632)
Early intervention services - developmental services that
Are provided under public supervision;
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;
Are designed to meet the developmental needs of an infant or toddler with a disability, as identified by the IFSP team, in 1 or more of the following areas: physical development; cognitive development; communication development; social-emotional development; or adaptive development;
Meet State standards.

11. Early Intervention Services (§632(4))
Services include:
family training, counseling, and home visits
special instruction
occupational therapy
service coordination services
early identification, screening, and assessment services
assistive technology devices and assistive technology services;
Are provided by qualified personnel;
Are provided in natural environments – to the maximum extent possible - including the home and community settings in which children without disabilities participate;
Are provided in conformity with an IFSP.

12. Infant or Toddler with a Disability (§632(5))
Individual under 3 years of age who needs EI services because they
Are experiencing developmental delays, as measured by appropriate diagnostic instruments and procedures in 1 or more of five developmental areas;
or has a diagnosed physical or mental condition that has a high probability of resulting in developmental delay;
May also include, at a State's discretion
At-risk infants and toddlers
Certain preschool-age children under the new flexibility provision.

13. Individualized Family Service Plan (IFSP; §636)
A written document developed by a multidisciplinary team, including the parents, and includes a description of the appropriate transition services for the infant or toddler
Based on a multidisciplinary assessment of the unique strengths and needs of the child and the identification of services appropriate to meet such needs, and
A family-directed assessment of the resources, priorities, and concerns of the family and the identification of the supports and services necessary to enhance the family's capacity to meet the developmental needs of the infant or toddler.
Is evaluated once a year and reviewed every 6 months (or more often where appropriate based on infant or toddler and family needs)
Is developed within a reasonable time after the assessment is completed.
Parents may consent to start of EI services before the assessment is completed.

14. Content of the IFSP
Child’s present levels of physical development, cognitive development, communication development, social or emotional development, and adaptive development, based on objective criteria;
Family's resources, priorities, and concerns relating to enhancing the development of the family's infant or toddler with a disability;
Measurable results or outcomes expected to be achieved for the child and family, including pre-literacy and language skills, as developmentally appropriate for the child,
Criteria, procedures, and timelines used to determine the degree to which progress toward achieving the results/outcomes is being made and whether modifications or revisions of the results or outcomes or services are necessary;
Specific EI services based on peer-reviewed research, to the extent practicable (new language), necessary to meet the unique needs of the child and family, including the frequency, intensity, and method of delivering services;

15. Content of the IFSP
Natural environments in which services will appropriately be provided, including a justification of the extent, if any, to which the services will not be provided in a natural environment;
Projected dates for initiation of services and the anticipated length, duration, and frequency of the services;
Identification of the service coordinator from the profession most immediately relevant to the child or family's needs (or who is otherwise qualified to carry out all applicable responsibilities) who will be responsible for the implementation of the plan and coordination with other agencies and persons, including transition services; and
Steps to be taken to support the child’s transition to preschool or other appropriate services.

16. Content of the IFSP
Parental Consent - the IFSP is to be fully explained to the parents and informed written consent is required prior to the provision of EI services described in the plan
Only those services for which the parents have given consent can be provided.
Confidentiality requirements – FERPA vs. HIPPA.

17. Minimum Components of a Statewide System (§635)
Rigorous definition of the term ‘developmental delay’ to be used by the State in order to appropriately identify children in need of EI services (new);
Appropriate EI services based on scientifically based research, to the extent practicable, are available to all infants and toddlers with disabilities and their families, including Native American children and children who are homeless;
Timely and comprehensive multidisciplinary evaluation of children’s needs and a family-directed identification of family needs;
An IFSP, including service coordination services;
A comprehensive child find system and referral system;
A central directory of EI services, resources, and research and demonstration projects;
A public awareness program;

18. Minimum Components of a Statewide System
A comprehensive system of personnel development (CSPD), including the training of paraprofessionals and primary referral sources;
Policies and procedures to ensure personnel are appropriately and adequately prepared and trained (including the use of paraprofessionals and assistants who are appropriately trained and supervised in accordance with State law, regulation, or written policy);
Single line of authority in a lead agency designated by the Governor;
Policy pertaining to contracting otherwise providing EI services;
Procedure for securing timely reimbursements of funds;
Procedural safeguards;

19. Minimum Components of a Statewide System
System for compiling data on the EI system;
State interagency coordinating council;
Policies and procedures to ensure that
to the maximum extent appropriate, EI services are provided in natural environments; and
the provision of EI intervention services for any infant or toddler with a disability occurs in a setting other than a natural environment that is most appropriate, as determined by the parent and the IFSP team, only when early intervention cannot be achieved satisfactorily in a natural environment.

20. Regulations
Federal Part C Rules specify additional requirements regarding:
Definitions (IFSP team; OT; service coordination; early intervention provider)
Timelines for assessments, completion of IFSP
Assessment/evaluation procedures
Parental consent requirements
Financing the EI system.

21. Proposed Part C Rules
Issued May 9, Public comment period closed July 23rd.
Proposed changes to Part C regulations based on IDEA 2004.
Department of Education will review comments and issue final rules at some point in the future.
Areas of interest for OT include:
Personnel qualifications (and who can to provide OT services)
Goal of Part C to support families’ capacity to care for their child with a disability
New definition of “multidisciplinary”
Timelines for evaluation/assessment and referral procedures
Funding/financing issues.

22. State Regulations State OT Practice Acts
State Part C Rules, Policies and Procedures

23. Key Principles
of Family
Centered Services

24. Family Centered Services (FCS)

25. Key Principles: FCS* Respecting family beliefs and culture
Enhancing family strengths and their capacity to enhance their child’s development
Supporting family as active participants in EI
*From Iowa’s Early Access/IDEA Part C: Guiding Principles and
Practices for Delivery of Family-Centered Services

26. Key Principles: FCS
Providing information and resources to assist family in decision-making

27. Addressing family needs and priorities as they change
Mobilizing informal family and community supports (e.g., important people, informal community supports)

28. Enhancing family capacity: IDEA
“. . .Urgent and substantial need to enhance the capacity of families to meet the special needs of their infants and toddlers with disabilities”
(20 USC 1431(a)(4))
“. . .a family-directed assessment of the resources, priorities, and concerns of the family and the identification of the supports and services necessary to enhance the family’s capacity to meet the developmental needs of the infant or toddler”
(20 USC 1436(a)(2))

29. Definition EI Services 34 CFR 303.12(a)(1)
“ . . .means services that are designed to meet the developmental needs of each child eligible under this part and the needs of the family related to enhancing the child’s development.”

30. Enhancing Family Capacity=
Confidence and Competence

31. Practices - Enhancing Family Capacity
Support good things that naturally happen with caregiver and child
Build on child and family strengths
Celebrate family successes
Support and encourage family decisions

32. Practices - Enhancing Family Capacity
Adapt communication/interventions to meet learning style (e.g., modeling, discussions, coaching)
Listen and reflect with families:
What’s working in everyday routines
What’s challenging (concerns)
What’s enjoyable, interesting, motivating
People (supports) in life
Places where spend time
What’s important

33. Practices - Enhancing Capacity: Use Open Ended Questions
Can you tell me about your day?
What types of things happen on most mornings? Afternoons? Nights? Weekends?
Where do you and your child spend time?
What types of things or activities do you and your child like to do (e.g., hiking, going on picnics, paying games at home)?
What things or activities do you and your child have to do on a regular basis (e.g., go to the store, give kids a bath, feed the horses, prepare meals, walk the dog)?
What are activities that you and your child have to do?
What are your child’s interests? What things does your child enjoy and what holds your child’s attention? (e.g., people, places, things such as toys, dog, being outside)
What makes your child happy, laugh and/or smile?
What routines and/or activities do your child not like? What makes this routine and/or activity difficult and uncomfortable for your child? What does your child usually do during the routine/activity?
Who are key family members, other caregivers, or important people who spend time with your child and in what settings does this occur?
Are there activities that you used to do before your child was born that you would like to do again?
Are there new activities that you and your child would like to try?
Are there any activities or places that you go (e.g., doctor’s appointments, visiting grandparents) that occur on a less regular basis (e.g., once a week)?
[See “Questions. . .” Handout]

34. Practices: Identify Learning Opportunities
Children learn best:
Engaging in everyday activities
Interacting with familiar people and places (relationship-based)
When interested and enjoyed
Learning based on previously mastered skills
When new skills are practiced over time

35. Practices - Enhancing Family Capacity
Explore “incidental teaching” that is occurring naturally
Help caregivers problem solve solutions to address challenges (using what’s working as a foundation)
Match interventions with family priorities and child/family interests and needs
Collaboratively decide and adjust frequency and intensity of services

36. Frequency and Intensity - Impact on Families

37. Service Coordination

38. Service Coordination Four models Dedicated Service Coordinator
Early Interventionist/Service Coordinator
Interagency Service Coordinator
Interim or Intake Service Coordinator

39. Knowledge Federal and state laws, regulations and rules
Agency procedures
State and local resources
Financial resources (“birth mandate”)

40. Knowledge (cont) Informal networks and advocacy groups
Transition procedures
Cultural and diversity needs
Family-centered practices

41. Duties OTs and OTAs Some states require specific training
Two Primary roles
Coordinate all services
Serve as a single point of contact for families

42. Responsibilities Assist family to access EI services
Coordinate provision of EI and other services
Facilitate timely delivery of services
Seek appropriate services

43. Summary Coordinate evaluations and assessments
Facilitate and participate in IFSP
Coordinate and monitor delivery of services
Inform family of advocacy services

44. Summary (cont) Coordinate services with medical and health providers
Facilitate development of the transition plan
HO: IFSP Process

45. Evaluation & Assessment

46. Evaluation and Assessment
Occupational Therapy Practice Framework
“focused on finding out what the client wants and needs to do and on identifying those factors that act as supports or barriers to performance”
(AOTA 2002, p. 616)

47. Occupational Profile
Use questions (see previous handout) to understand the family-child and caregiver-child.

48. Assessment OT Role in assessment:
Member of multidisciplinary team (generic)
Specific evaluations of OT domains

49. Purpose and Tools Match purpose (intent) with tool Screening
Diagnostic
Curriculum-based

50. Legal Requirements
Evaluation: procedures used…to determine initial and continuing eligibility
Assessment: ongoing procedures…to identify unique strengths/needs; resources, priorities and concerns of family.

51. Legal Requirements (cont)
Personnel must be trained to utilize appropriate methods and procedures
Include review of current health status and medical history
Evaluation in 5 primary developmental areas
Completed within 45 calendar days

52. Legal Requirements (cont)
Administered in parent’s native language or mode of communication, unless not feasible
Not racially or culturally discriminatory
“Multidisciplinary” (2+ disciplines or professions)

53. Eligibility State’s set criteria
Federal & State Governments also include Informed Clinical Opinion
Standardized measures may not be appropriate
Uses qualitative and quantitative info

54. Eligibility (cont) Shackelford (2002)
ICO: especially when standardized measures are inappropriate or unavailable
Use qualitative and quantitative information

55. Eligibility (cont) Bagnato (2006)
Evidence to support use of clinical-judgment tools
“potentially effective strategy for use in EI …with proper use of identified practice characteristics” (p. 6)

56. 5 Characteristics Operational definition of characteristic
Structured format for measuring
Info from multiple sources
Training in methods
Decision-making based on consensus of information
(Bagnato, 2006)

57. Developing Measurable
Outcomes

58. Measurable IFSP Outcomes: IDEA
“The IFSP shall be in writing and contain . . .a statement of the measurable results or outcomes expected to be achieved for the infant or toddler and the family, including pre-literacy and language skills, as developmentally appropriate for the child, and the criteria, procedures, and timelines used to determine the degree to which progress toward achieving the results or outcomes is being made and whether modifications or revisions of the results or outcomes or services are necessary;”
(20 USC 1436(d)(2))

59. Measurable Outcomes: Types
Child outcomes
Family outcomes

60. What Measurable Outcomes Equate to:
“What we want to see for
our child/family as a result of
early intervention”

61. High Quality Outcomes
Focus on functional participation in everyday routines and activities
Be important and meaningful to family
Expand activity settings to ensure competence
Result in functional intervention aimed at advancing child’s engagement, independence, and social relationships

62. What Measurable Outcomes Are Not
Decontextualized
With unclear purpose
Nonsensical
Unnecessary
Endless
Vague
Unmeasurable

63. What Measurable Outcomes Are Based On
Family hopes and dreams for their child
Family concerns and priorities
Child needs
Child strengths
Child and family interests/motivators
Everyday routines/learning opportunities
Activities that families want to do

64. Developing Measurable Outcomes: Steps
Step 1: Determine the functional area
Eating and chewing
Step 2: What routine(s) does this affect?
Lunch, dinner, restaurant
Step 3: “Child will participate in (routines in question)”
“___ will participate in lunch, dinner, and restaurant . . .”
Step 4: “ by ---ing” (address specific behaviors)
“ chewing her food and moving food from side to side with her tongue”

65. Developing Measurable Outcomes: Steps
Step 5: Add a criterion to determine when the child has met this skill
We will know she has these skills when she eats a cup of food using chewing and side to side tongue movements
Step 6: Add another criterion for generalization, maintenance or fluency, if appropriate
We will know she has generalized this skills when we see her do this once time at lunch, one time at dinner and one time at a restaurant within a period of a week
Step 7: Add timeline
In 6 months (to meet entire outcome)

66. Measurable Child Outcomes: Examples
This
"Romeo will be able to sit without much support for play and feeding activities.“ OR
"Romeo will be able to sit without support in order to play and eat for 15 minutes in up to three different settings.”
Not This
"To improve overall muscle tone."

67. Measurable Family Outcomes
What Parent States:
“We want to be able to take
Romeo with us in the car; we need a
travel car seat ”

68. Measurable Family Outcomes: Examples
This
“Caren and Mark travel safely with Romeo in the family car wherever they go“ OR
“Caren and Mark travel safely with Romeo in the family car to a variety of locations 100% of the time”
Not This
"To improve overall muscle tone."

69. Developing Outcomes Is wording jargon free, clear and simple?
Does wording emphasize the positive?
Are statements specific enough to measure change?
Are statements necessary and functional for child and family’s life and something desired by the family?
Does the statement reflect inclusive, community-based settings?

70. Services in Natural Environment
Handout
1. Everyday experiences and interactions
Use toys and materials found in the home
Build on families strengths and interests
Help caregivers engage child
Focus intervention on caregiver’s ability to promote child’s participation

71. Services in Natural Environment
3. Work with and support family and caregivers in child’s life
Build trust and establish “partnership”
Collaborative coach
Point out natural learning activities and “incidental teaching” opportunities
Involve families in discussions

72. Services in Natural Environment
7. Interventions based on explicit principles, validated practices, best available research and relevant laws and regulations
Keep abreast of research
Continually clarify principles and values
Use continuous assessment data and validate program practice
Keep abreast of regulations and laws and use evidence-based practice

73. AOTA Guide to OT Practice
“Supporting Heath and Participation in Life Through Engagement in Occupation.”

74. Questions???
AOTA website for more information: