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.