Preschool Services Need Attention

It has become fashionable at early intervention/early childhood special education conferences to decry the supposed sorry state of affairs in Part C. In some places, criticism is warranted; in others, it's not. Many communities--the State of Missouri being one--are making significant strides towards excellent service delivery models.

 

 

Preschool services (Section 619 of Part B of IDE[I]A) have always been in a strange position. On the one hand, they receive much attention; on the other, they receive scant attention. They receive much attention in training in university programs for young children with disabilities, where much of the training is directed at preschool-aged children. In part, this emphasis is because of location: Students can be placed in classrooms for internships and student teaching, whereas placing students in home-based programs is much more problematic. Attention to preschool services is supposedly also revealed in conference presentations, where organizers and attendees alike are concerned about whether enough of the program is devoted to infants and toddlers and their families.

 

 

The scant attention I have noticed is in service delivery models.

 

• Just how are preschool services organized?
• What is the rationale?
• How much are administrators paying to dosage issues?
• Who are the targets of services?
• What philosophies underpin services?
• How much focus is on the influences of children's learning--children's learning opportunities?

 

These questions are related, and I will attempt to answer some of them. Others are for decision makers, practitioners, and families to consider, because my experience is that they often fail to consider them.

First, we can assume that, owing to what we now know about young brains and have long known about successful parenting, young children learn throughout the day better than they do in "lessons." This is related to the power of natural discriminative stimuli and to the difficulty young children, particularly those with developmental delays, have with generalization or "transfer."

Second, we can assume that what they are learning is far more than preschool behaviors (sitting, playing with play dough, negotiating with peers, etc.): They are still learning language, what their growing bodies can and cannot do, and how the world works, which is why learning opportunities exist throughout the day. This concept of alocated learning time is critical for understanding the difference between early childhood education and later education. The older children get, the more their learning can be concentrated into "school" (or Sunday school or piano lesson) time. In the preschool years, caregivers have the opportunity to teach throughout the day. This should make early childhood special educators think about their roles and opportunities.

Third, family systems theory, helpgiving theory, social support theory, and behavioral-ecological theory do not come to a grinding halt when the child turns three years of age. In Part C, there is some understanding that the whole of a child's waking hours is potential intervention time and that the environments in which the child finds him- or herself influence learning. Unfortunately, even though this understanding exist in theory, even in Part C it does not always translate into action. The situation is even worse in preschool, however, where service coordination is no longer a mandated service and where the (special) education mentality is pervasive.

• If family systems theory were acknowledged, preschool services would be organized to provide emotional, material, and informational support to families, including the systematic assessment of their needs and accountability on the IEP (if that document must continue to be the driving document) for developing family-level goals and providing supports to meet those goals.
• If helpgiving theory were acknowledged, preschool services would have an expanded view of family-centered practice, so they would attempt to meet families' needs for emotional, material, and informational support, rather than thinking that "parent participation" in school activities was most important.
• If social support theory were acknowledged, preschool services would see the link between child learning and family well-being and family well-being (quality of life) and their social support, especially informal support. Early childhood special education would therefore spend at least a little time getting to know families' ecologies and helping families preserve and, if they desire, expand their informal-support networks.
• If behavioral-ecological theory were acknowledged, preschool services would assess children's functioning throughout their typical day, through a family interview, and develop intervention plans that followed our knowledge of how young children learn. These plans would use children's interests and natural learning opportunities to teach them skills so they can participate successfully (i.e., be engaged) in their home, community, and school routines (activities).

Now let's discuss the number of hours that preschool services are provided to a child. If the child can go to school five mornings a week (e.g., 20 hours, allowing for a full 4 hours a morning instead of the measly 2.5 hours some preschool programs offer) or three full days a week (e.g., 15 hours, allowing for a full 8 hours), the school environment becomes a true learning environment. The child spends enough time there for learning opportunities to be distributed across time, and the child's "caregivers" during that time (i.e., teaching staff) spend enough time with the child that they become direct instructional or intervention agents themselves. This can be labeled the classroom model.

If these classrooms are self-contained (i.e., having only children with disabilities), they represent a dated approach that potentially violates moral and legal positions. If they are inclusive (i.e., at least half the children in each classroom have no disabilities), these classrooms are defensible and potentially excellent. This article is not about inclusion; it is about attention to children's learning opportunities and to their families.

Many preschool services are offered on a much leaner schedule, such as one to four 2.5-hour mornings a week, with the number of mornings being related to either the severity of the child's disability or the number of services the child has on the IEP. When a child is "at school" for such a small percentage of his or her waking time, we have to ask what the point of this service time should be. The child is transported in, sometimes by school bus, which is another whole discussion, sometimes by parents. Usually, the child is left "at school" for these short bursts of early childhood special education and related services. Family communication is limited to (a) notebooks, (b) intermittent home visits, or (c) discussions at arrival and departure, sometimes, with those families who do drop off and pick up their children. Often, that communication is about what the school people are working on, what the child did, and what the family can do to support the school's efforts. Sometimes, these short sessions at school are thought of as the times the child comes in for his or her therapies and special ed. Short times at school (i.e., fewer than 15 hours a week) can be thought of as the playgroup/clinic model.

Some preschool services are offered through itinerant services, which have the potential to acknowledge the theoretical bases I earlier described. Itinerant teachers can consult with a child's regular caregivers/teachers in  child care or other classroom-based settings, such as Head Start. If the consultation is done well, using an individualized-within-routines approach and not a pull-out approach, this model of service delivery has the potential to expand intervention throughout the child's classroom day every day. Unfortunately, sometimes itinerant services are restricted to special education, with the therapies still happening in clinical types of settings at a school. If therapists can also travel to children's regular-early-childhood classroom settings and adopt a "consultative approach to direct services" (which is not as contradictory as it sounds), we really have the potential to provide meaningful intervention. There's still the family piece though.... This approach is labeled the itinerant model.

School districts fear that the itinerant model is too expensive, compared to keeping all the personnel in centralized locations and shipping the children in, in groups. For the reasons given above, this solution has to be considered pragmatic but atheoretical, if the playgroup/clinic model is adopted. Beginning steps for preschool administrators can include the following.

1. Become familiar with the literature on the theory and research related to the concepts described in this article, so decisions are made on intellectually and empirically defensible grounds.
2. Work towards converting the playgroup/clinic sessions into family support sessions. After all, because they consist of such short bursts, many families are presumably available to transport the children or to care for them when they're not "at school." Do not call this "school" time, because that has the connotation of teachers working directly with children, and these family support sessions will be much more than that.
3. Take all the FTEs currently devoted to preschool special ed and related services, acknowledging that some therapists might work also with older children, and divide that number into the number of children with IEPs. Consider this then to be potential caseloads, with one professional serving as the primary interventionist with that child and family in whatever location seems appropriate. This is a radical but highly commonsensical approach to resource distribution--and defensible on child-learning and service delivery grounds.
4. Expand itinerant services, once caseloads are reallocated to a primary service provider. Ensure this is done with both therapies and special education, not just the latter.

What to Study

A colleague of mine was pondering what research question to ask next, which got me thinking about what I believe really needs to to be tackled.

If I were my colleague, I’d be curious about the actual amount of intervention children get—what we sometimes call the dosage question. Usually, this is measured in terms of the amount of time a child attends a program, but I’m interested in (a) how much intervention, typical or compensatory, does a child get from his natural caregivers and (b) how much program time is actually what Fisher, Berliner, et al. called “academic learning time” or true instruction. Part of my question is a political one: I simply don’t believe that only professional time counts. And I believe that a lot of professional time is incomplete teaching.

So what? First, if we could measure what children get from natural caregivers, we could count this as a buffer or asset that the child has. Second, if we could show that complete incidental teaching (setting up an engaging environment, following the child’s lead, eliciting elaboration, and ensuring there’s a consequence) is better than incomplete incidental teaching, which is better than nonelaborative responses, which is better than nonresponsive directives, we’d know more about the whole package of interventions children get and need.

Service Coordinators as Evaluators

I need some insight and thought you can help. We are facing some challenges at the Early Intervention System in XXXX because of service provider shortages. We never seem to have enough service providers … We’ve been brainstorming alternatives because the way our system was conceptualized is that our service providers use some of their time to do initial child assessments before the IFSP meeting and I would prefer that they use their time to provide services!!!!

We have a group of Service Coordinators that have different educational backgrounds (ex., Social Workers, Pschology, Counseling, etc.) All of them have a Bachelor Degree and most have been working for the EI System for an average of 3 yrs. and it is my perception that they have the skills to carry out child assessments. Would it be appropriate to train Service Coordinators so that they can do the initial Curriculum Based Assessment? We use the HELP (Hawaii Early Learning Profile). I checked the Regulations and they basically talk about state licenses and certifications regarding providing services but I’m not sure if it also applies to the assessment process?????

Are your service coordinators just service coordinators, not providers? If so, by and large, they are not necessarily trained early interventionists; most importantly, sometimes they are not trained in child development or disabilities (see McWilliam, 2006). On the other hand, neither was I when I was doing child assessments as a home visitor. And the HELP does not require any kind of licensure. So my conclusion is that, if the service coordinator knows child development and disabilities, he or she can do the evaluation. You are talking about evaluation for eligibility, aren’t you? If so, remember they are just trying to answer the question in or out? If your state allows the HELP, then they’re not that particular about the exactitude of the evaluation, since the HELP isn’t norm referenced. So that’s another argument for allowing the SCs to do the evals, if they’re knowledgeable. The Part C regs do not prevent service coordinators or anyone else from doing the evals.

McWilliam, R. A. (2006). What happened to service coordination? Journal of Early Intervention, 28, 166-168.

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?
OR
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 researchcenter@siskin.org. 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.

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.

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.)

Toy Bags

The following request for information came to me recently:

Hello I am emailing for advice and resources. I attended the seminar on routines based early intervention in XXXX.

I am a Director of an agency and we are discussing our roles as therapists and working towards shifting our thought process.

As we begin the shift of our staff "away" from bringing toys in - I was wondering if you had any resources or lists to help me with explaining the importance, and the role the therapy bag plays in the home? and the consequences? etc

any handouts? suggetions ? feedback?

example- parents WANT the providers who bring in the toy bags, not the ones who dont. "or" the therapists who "NEEDS" the items so they can have children learn skill or have they toys available

thank you for your help

Problems With the Toy Bag

There are two major problems with the toy bag. The first is that it sends a message to families that “your junk ain’t good enough.” Why else would we be bringing in other toys and materials. I recently conducted an RBI in which the mother told me that the home visitor brought toys that she already had in the home!

The second major problem, the really serious one, is that it implies that intervention occurs during the visit. If a home visitor gets down on the floor with the child and the toy bag an starts “working with” the child, it is not surprising that the parent would believe that the child is being taught. We have made the point in many places, including on this blog, that the purpose of weekly early intervention is not to teach children—that that is futile—but rather to provide caregivers with emotional, material, and informational support.

The persistent use of the toy bag thus leads to the attribution problem of parents’ attributing their children’s progress to weekly interactions with people outside the family instead of to ongoing interactions with regular caregivers. The consequences of parents’ making this erroneous attribution are obvious.

An indicator that the toy bag user him- or herself thinks that the intervention actually occurs during the visit is that they usually take the toys away at the end of the visit. If they believed that intervention is what happens between visits, they would leave the toys.

Another concern about the implication that intervention occurs during the visit is that so much of the visit is spent on triadic play among the home visitor, the child, and toys. Does anyone know of research that documents how much time families actually spend in such triadic play? I suspect it is a very small percentage of time.

So the staff in this program need to understand first how children learn (throughout days, not in lessons or sessions) and how services work (by supporting natural caregivers, not by working with the child weekly). Until they grasp those notions, they probably won’t understand what’s wrong with the toy bag.

Why do some parents want toy-bag-wielding home visitors? It’s because of the attribution problem. Once they are conditioned to believe that their child really needs direct, hands-on lessons with a teacher or sessions with a therapist, the empty-handed home visitor will look like a fisherman who forgot his pole, a carpenter without a saw, a plumber without a wrench—you get the idea. You probably also by now understand that early intervention is about teaching people to fish with their own poles, to make cabinets with their own saws, and to fix leaks with their own wrenches.

Some therapists say they need items. Hmmmm. What items are critical? Especially, what items are critical for supporting families to teach their children functional skills that the children need to participate in their routines? Surely nothing that comes out of a toy bag. After all, if the outcomes we’re working on are functional, that means we found out what the needs were in everyday contexts. We need to be working with the materials that are in those everyday contexts.

In addition to therapists or teachers saying they need items to do their home visiting job, other excuses for taking toy bags abound. One is that the toy bag items are for instruction; home stuff is for generalization. Another is that some homes have nothing (people in the U.S. actually say that with a straight face). Yet another is that parents want to see what their children might like. This is actually a reasonable reason to take toys—for children and families to try them out, but then leave them there for at least a week. Some fake interaction on a home visit doesn’t tell you whether the child will continue to be interested in the toy. These are mostly excuses that toy bag addicts make.

Yes, a number of experts in early intervention have identified the obsession with toy bags as an addiction! Some behaviors common to addicts will surface when toy bag addicts are told to stop taking them.

But program managers need to be prepared to ban toy bags, if they understand the points I’m making here. You can’t expect people to do something (or stop doing something) if you don’t tell them to do it (or stop doing it). The occasional bright home visitor will get it and abandon the toy bag as a result of training or reading or some other self-directed learning. But most addicts need to be told to stop.

The methadone treatment I suggest is a combination of the Routines-Based Interview and the Vanderbilt Home Visit Script. A future blog posting can address the VHVS, if there is interest. It was included in the training of the person who wrote me with this excellent question (at the beginning of this posting).

In conclusion then, (a) the staff need learn how children learn and how services work, (b) the program needs to ban toy bags (they are both symbolic and necessary for the propagation of atheoretical and nonempirical early intervention), and (d) the staff need to be trained to be support providers or consultants to the families. Only then will children get the amount and quality of early intervention they deserve, given the best available evidence.