Sunday, December 7, 2008

Paraprofessionals in Early Intervention

E-mail received from an early intervention leader in a progressive state, when it comes to quality services:

We are grappling with an issue of using PTAs/COTAs in the PSP model. Do you have some thought on the role these folks can or should play in a true PSP model? Specifically, we need to resolve for our system:

1. Can PTAs/COTAs serve as the Primary Service Provider and make the weekly home visits as long as their supervising PT/OT is participating in joint visits regularly?
2. Would they not have the ability to “work across disciplines” as the PSP due to the limited scope and focus of their discipline?

It's not an easy question to answer. For once, putting aside the bureaucratic concerns about ways to save money, I come down on the expertise needed to make good decisions about what to do on home visits. I have created time allocation charts of how home visit times might be allocated, which can be ordered through These charts show that time might be spent in hands-on consultation, verbal consultation, greetings, and relationship building. What percentage of time in the visit is spent on each activity varies from family to family and visit to visit.

It takes good judgment with individual families to decide how a given home visit is going to shape up. Then add to that the options, shown in anothe graphic, also available from me, when a home visitor asks how progress is being made with a specific outcome. Here we see that the simple question "How's it going with [Outcome No. 1]?" can lead to an enormous number of follow-up questions and activities, resulting in offering to demonstrate, considering the outcome met, upping the ante (i.e., changing the criteria for completion, trying an outcomes-by-routine matrix, changing the intervention or routine, tweaking implementation of the intervention by the parents, or refining the parents' intervention skill.

Can a COTA or PTA handle these decisions, especially if they're outside the person's field. I'm not saying a regular OT or PT (or other fully licensed professional) would necessarily be that much better, but if we follow the guidelines that providers should have the highest credentials within their disciplines.... It's true that classroom teachers aren't held to as high a criterion (i.e., there are classroom paraprofessionals), but that's because more flexibility and decision making, not to mention consultative, skill is needed as a home visitor than as a classroom teacher.

Assistants fit the old model better than the primary-service-provider model. We need the most sophisticated professionals we can get. It's time to raise the bar and stop thinking that "something's better than nothing." Lisbeth Vincent, one of the pioneers in our field, said exactly this in 1986, when 99-457 was passed.

Having said that, I will point out that in certain parts of the country, paraprofessionals appear to be really valuable. They are often members of the same community as the families they serve, they often get close to the families, and they are good at informal support. It's hard to knock that grassroots kind of resource. Unfortunately, however, it goes only so far.

I come down on the side of increasing the quality of the workforce more than the breadth (quantity) or it.

Tuesday, November 18, 2008

Doctors' orders

Hi Robin!

One of the barriers we continue to face with implementing evidenced-based practices is physician "orders" and information to families that their child needs a specific frequency of a specific therapy - with more being "required" the more significant the delay, disability or diagnosis. As we have worked in XXXXXXXX to teach practitioners about effective intervention, we are finding that while some or most understand, they are having trouble articulating the rationale and sticking with recommendations in the face of expectations and sometimes "demands" from families to provide what the physician has recommended or ordered. Can you point me to some articles, reports, research, etc. that we could used in our public awareness efforts with physicians and that providers could use with families to explain why we are recommending something different. It would be nice if we could come from strength - provide information that is compelling in and of itself - so providers don't feel that they have to "sell" their recommendations. Also, it is challenging to recommend something different in a way that doesn't put down the physician.

I don’t know of any materials that would directly help. As you might imagine, I deal with this all the time and here are the main messages I give:

  1. It is “illegal” for physicians to dictate services, let alone intensity of services, upon diagnosing a child; according to IDEA, this is the responsibility of the team. Doctors respond to “illegal”!

  2. We explain to parents that doctors base their recommendations on the diagnosis, as though all children with the same diagnosis had the same needs. “And of course your child is doing well, has awesome parents, and now has a team of early interventionists helping, so we’re not in a worst case scenario.”

  3. What the doctor means is that your child needs at least this much INTERVENTION, but doctors don’t understand the difference between intervention and service. And actually your child deserves even more intervention than the doctor prescribed. Let’s do the math and add up all the intervention your child will get from you and his other primary caregivers. The job of the SERVICES is to help you make those interventions work.

Tuesday, September 9, 2008

Child care reflected on IFSP

I have been grappling with the issue that the IFSP should reflect the child care hours a child in early intervention receives, in addition to the number of hours of official early intervention services (e.g., special instruction, family training, SLP, OT, PT, etc.). I thought the federal law specifically allowed for the listing of “services” paid for and unpaid for by the system, but it doesn’t. The IFSP must contain “a statement of specific early intervention services based on peer-reviewed research… necessary to meet the unique needs..., including the frequency, intensity, and method of delivering services.” Resources are mentioned in the law, of course, in the CPR section: “a statement of the family’s resources, priorities, and concerns….” So below I list places on the IFSP where child care and number of hours can be documented.

Ideally, every IFSP would document, in the natural environments section, how many hours a week the child was planned to (a) attend a child care center, (b) attend a family child care home, (c) receive child care from one primary nonparental child care provider (e.g., nanny/babysitter, family member). In the meantime, we might want to record it in one of the four places identified below. This would show everyone how much intervention the child care center is providing and probably not getting paid for, from early intervention funds.

Places on the IFSP Where Child Care Intensity Can Be Recorded

  • Concerns, priorities, and resources section

  • Section for documenting natural environments

  • Section for extra notes from the IFSP meeting

  • Strategies or action steps for outcomes/goals

(Thanks to Jacque Davis, Ph.D., for getting some background information on this for me.)