Saturday, September 10, 2011

New Part C Regulations: Much Ado About Nothing

The finally arrived new Part C regulations have some interesting features. I haven’t compared the old with the new; CEC is going to do that within the month. Some of the new regulations are noteworthy for practitioners of the model described in Routines-Based Early Intervention, published by Brookes. Direct quotations from the new-regs document are italicized.
The two disciplines. The definition of multidisciplinary in §303.24 has been revised with respect to the individualized family service plan (IFSP) Team composition to require the parent and two or more individuals from separate disciplines or professions with one of these individuals being the service coordinator.
An interesting interpretation of a discipline is the inclusion of service coordinator, which is actually a role or function. But this will alleviate the pressure on IFSP teams who have previously thought they had to find two people other than the service coordinator. The intent, originally, was to have different perspectives from the field. Now, when we’re lucky enough to have a service coordinator with content knowledge about child development, family functioning, and disability, we’ll be fine. In states where service coordinators are limited in their content knowledge, there will theoretically be a loss. I can’t say, however, that I’ve noticed much of a gain by having two additional professionals from different disciplines. Evaluations have to be rushed anyway, and they’re just for determining eligibility—not for diagnosis, so we might as well make the process as efficient as possible. A good change.
Scientifically based research. Scientifically based research has the meaning given the term in section 9101(37) of the Elementary and Secondary Education Act of 1965, as amended (ESEA). 
Well, thanks. That’s pretty useless. You can, however, read the definition at (thanks to Oklahoma higher ed). Could have been clearer.
Transition. New §303.209(b)(1)(iii) provides that if a child is referred to the lead agency fewer than 45 days before that toddler’s third birthday, the lead agency is not required to conduct the initial evaluation, assessment, or IFSP meeting, and if that child may be eligible for preschool services or other services under Part B of the Act, the lead agency, with the parental consent required under §303.414, must refer the toddler to the SEA and appropriate LEA.
If this was already the regulation, I didn’t know about it. I assume it’s new. This definitely provides relief to the Part C program and makes sense. We still can’t be sure, though, that a child with a third birthday on June 1, for example, referred at the end of May won’t be made to wait until August or September before anyone will provide help. A good change, nevertheless.
The 45 days. New §303.310 (proposed §303.320(e)(1)) requires that, within 45 days after the lead agency or early intervention service (EIS) provider receives a referral of a child, the screening (if applicable), initial evaluation, initial assessments (of the child and family), and the initial IFSP meeting for that child must be completed (45-day timeline).
When the clock stops has long been a contentious issue, with states receiving conflicting messages from OSEP. Note that the regulation says the clock ends when the initial IFSP meeting is completed. Although this could be interpreted as the IFSP meeting for the first (i.e., initial) IFSP, it could also be interpreted as the first meeting about the IFSP. In our model, I have argued that this could be the Routines-Based Interview, even if the signing of the IFSP happens later—that is, after the 45 days are over. The two problems with my argument are, first, that, unless the RBI date is documented somewhere, no accountability is possible about meeting the 45 days. Second, it could delay service delivery, which is the point of the 45-day requirement. I don’t buy this second argument, however, because many parents have told us that the RBI itself is very beneficial. A good regulation, as long as it doesn’t get misinterpreted by states or the feds.
Abbreviation. “EIS” is the long-standing, commonly accepted abbreviation used in the field of early intervention and we do not anticipate any confusion by the abbreviation’s continued use in programs administered under Part C of the Act.
It is?
Purposes of early intervention. Two commenters recommended that, when describing the purpose of early intervention services in general, we retain the language that these services must be designed to serve “the needs of the family related to enhancing the child’s development” that is in current §303.12(a)(1).  The commenter stated that meeting family needs is a key component of an early intervention system and should be addressed routinely in IFSP development, rather than only upon family request.
The originally proposed regs had included “as requested by the family, the needs of the family.” In the final version “as requested by the family” was omitted to ensure that family needs should always be addressed, unless the family doesn’t want this. We shouldn’t wait for them to ask for their needs to be met. A good change.
Definition of early intervention services. One commenter requested that we clarify in the definition of early intervention services that EIS providers who work with infants and toddlers with disabilities and their families should focus their services on ensuring that family members and children have the tools needed to continue developing the skills identified in the IFSP whenever a learning opportunity presents itself even when a teacher or therapist is not present. 
A great comment. It might even have been mine. If not, I’m claiming it anyway. The feds weren’t swayed for the following reason:
However, in addition to the reasons stated, adding language to §303.13 as requested is not necessary because the definition of EIS provider in §303.12(b)(3) specifies that such providers are responsible for consulting with and training parents and others concerning the provision of early intervention services described in the IFSP of the infant or toddler with a disability.  Additionally, this consultation and training will provide family members with the tools to facilitate a child’s development even when a teacher or therapist is not present.
They missed a golden opportunity to discuss preparation for what happens between visits.
Types of early intervention services—family training, counseling, and home visits. One commenter recommended deleting the reference to “home visits” in the title of this paragraph because the commenter considered home visits to be a method of providing a service rather than a service in and of itself… Section 632(4)(E)(i) of the Act expressly states that early intervention services include family training, counseling, and home visits.  Thus, removing the reference to home visits from §303.13(b)(3) would be inconsistent with the Act.  .
No change was made. The discussion, however, shows that OSEP still is unclear about how children learn and how services work. The paragraph following the above discussion is as follows:
The language in §303.13(b)(3) does not mean that family training must occur in the home or include counseling.  Section 303.13(b)(3) merely defines three separate early intervention services –- family training, counseling, and home visits -- that may be provided to assist the family of an infant or toddler with a disability in understanding the special needs of the child and enhancing the child’s development.
This suggests the other services, such as special instruction, OT, PT, and speech-language are not also services that may be provided to assist the family of an infant or toddler with a disability in understanding the special needs of the child and enhancing the child’s development. It implies that the some services are for direct application to the child and others are for helping the family. Not how I see it!
Furthermore, I always thought home-based was a setting but not a service. You can’t like home visits in the service section of an IFSP, can you? I hope someone can straighten me out in a comment following this post. Unclear.
Sign language and cued sign services. The phrase “as used with respect to infants and toddlers with disabilities who are hearing impaired” has not been included in the definition of sign language and cued language services in new §303.13(b)(12).
The discussion includes the point that it isn’t only children who are hearing impaired who might benefit from signing. Well done.
Speech-language pathology services. Several commenters recommended adding such services as auditory habilitation and rehabilitation, dysphagia, auditory-verbal therapy, oropharyngeal, or feeding and swallowing services to the definition of speech-language pathology services in new §303.13(b)(15) (proposed §303.13(b)(12)).
No change was made because the definition in this section is not intended to be exhaustive. Good! We already have too much overspecialization in early intervention, leading to fragmentation of services and professionals whose focus is too narrow. We also have certain subspecialty groups trying to capture the market for certain types of children. Good nonchange.
Other services. Another commenter requested that the Department revise the language in this paragraph to indicate that any other services identified in the IFSP of an infant or toddler with a disability be based on proven methods or evidence-based practices…. Discussion: Mirroring this standard, §303.344(d)(1) requires that each IFSP include a statement of the specific early intervention services based on peer-reviewed research (to the extent practicable) that are necessary to meet the unique needs for the child and the family to achieve the measurable results or outcomes identified in the IFSP.
This whole idea of services, either those identified as the regular ones in Part C or “other services,” being based on peer-reviewed research is laughable. As much as I’d like to advocate for this regulation, the services used in Part C and the way they are implemented do not have a sufficient research base anyway. But we’re not going to do away with them. So, to apply a higher standard to other services would be ridiculous. Furthermore, in the past 7 years or so, when the field started acting serious about evidence-based practices, we have become bogged down in debates about which studies are good enough to be included in analyses of EBPs and how many studies from how many research groups need to be conducted to determine a practice is evidence based. And then we have the issue of gradations of evidence-based, because we’re loath to say a practice is or isn’t evidence based. And this discussion in the regs is about services, not even practices, and everything is hugely more complicated when we have such a broad scope as a “specific early intervention service.” Correct nonchange but the regs still don’t help us get rid of bogus treatments.
Services neither required nor funded under Part C. Section 303.344(e) provides for the IFSP Team to identify in the IFSP medical and other services that the child or family needs or is receiving through other sources, but that are neither required nor funded under Part C of the Act. 
This discussion about a rather pointless comment serves as a good reminder that these other services can be listed in the IFSP and they don’t commit the Part C program to pay for them. Many states, especially where education is the lead agency, shy away from (i.e., tell service coordinators not to) list these services, in case the family thinks the program is going to pay for them, as would happen on an IEP. Good reminder.
Infant or toddler with a disability. :   We have revised §303.21(a)(2)(ii) to add  “severe attachment disorders” to the list of diagnosed conditions that have a high probability of resulting in developmental delay. 
OK, but I think states still have the right to determine for themselves who’s on their special list for diagnosed conditions. Severe attachment disorders was the only addition, among a number suggested. The list is of examples only, however, so I don’t think it really matters.
Multidisciplinary. Multidisciplinary was defined in proposed §303.24, with respect to evaluation and assessment of a child, an IFSP Team, and IFSP development under subpart D of this part, as the involvement of two or more individuals from separate disciplines or professions or one individual who is qualified in more than one discipline or profession.
Back to this issue, but now focusing on how many people should be there. Apparently, the transdisciplinary-approach haters rallied to comment on the regs, because a number of comments wanted to ensure the regs didn’t allow just one person who might be qualified in two areas (service coordination and special instruction, for example?) to replace a group, which the commenter says is explicitly defined in Part B. Commenters requested that the definition be modified to ensure that multiple perspectives are included on each IFSP Team and adequate representation is not hampered or constrained on any given IFSP Team by an individual who is qualified in more than one discipline or profession. It’s a toss-up whether representation is more hampered in this situation or in one where two people have blinkers on, with respect to attending only to areas of their narrow training.
The discussion about evaluation and assessment includes the following: With respect to IFSP Team meetings, we believe it is important for the parent to be able to meet not only with the service coordinator (who may have conducted the evaluation and assessments), but also with another individual (whether that person is the service provider or another evaluator) to obtain input from two or more individuals representing at least two disciplines and have revised §303.24 accordingly.
They want two people there. For those states using medical as one of the professions, this is not the intent of this regulation, unless the child has a chronic illness or something similar. This regulation doesn’t address how a provider could meet with the family on an initial IFSP, before services have been determined. I suppose the feds would say that then an evaluator would serve as the second person. In our model, I want states and teams to consider a most likely primary service provider (MLPSP).
Some commenters, including possibly me, wanted a reference to transdisciplinary or interdisciplinary, but OSEP said, referencing specific team models in the regulatory definition of multidisciplinary is not necessary.
Natural environments. Two other commenters recommended the definition indicate that a clinical setting could be the natural environment, particularly when the service requires the use of specialized equipment that cannot be transported to the child’s home.  One commenter expressed concern that mandating services to be provided in settings where non-disabled children are present may suggest that the alternative is less than acceptable.  Another commenter recommended that the definition of natural environments require that services be provided within family routines and activities and opposed identifying specific settings.
We expected clinic-based professionals to challenge the natural-environments provision. Fortunately, the OSEP response was We do not believe that a clinic, hospital or service provider’s office is a natural environment for an infant or toddler without a disability; therefore, such a setting would not be natural for an infant or toddler with a disability. Good nonchange.
Section 632(4)(G) of the Act provides that natural environments may include home and community settings.  However, the reference to community settings was not included in the proposed regulations.  “Community settings” was added back in. Good change.
Qualified personnel. Additionally, §303.344(g), which provides that an IFSP contain information about the service coordinator, requires that the service coordinator be selected from the profession most immediately relevant to the child’s or family’s needs or be a person who is otherwise qualified to carry out all applicable responsibilities under Part C of the Act.  
I don’t know that this is a change, but most service coordinators in dedicated-service-coordination states are not from the profession most immediately relevant to the child’s or family’s needs, so let’s hope they’re otherwise qualified to carry out all applicable responsibilities…. The feds might have been thinking about service coordinators who are also providers to the family (the blended model). But the second half of the definition of the qualification is a complete cop-out, just when we probably needed to raise the qualifications. That responsibility is probably correctly with the states, but that means we’ll have to be vigilant about which states actually make it possible for families to have properly qualified (not as defined in the regs) service coordinators. Confusion and cop-out.
Paraprofessionals. The feds continue to allow paraprofessionals to “assist in the provision of early intervention services to infants and toddlers with disabilities.” They mention certification and supervision. It’s unclear to me whether a state could allow paraprofessionals to be the primary service providers or weekly home visitors to a family. I have serious reservations about the suitability of paraprofessionals serving in that role. Missed opportunity.
I have been through all 932 pages of the regs, and the items above were the only ones worthy of mention. I might have missed other notables, so I hope readers will post comments below if they have other changes to point out. Until someone points out something different to me, the most notable change I notice is counting the service coordinator as one of the two professionals.