Saturday, April 25, 2020

Eligibility Determination During Stay-at-Home Orders



child reading book
Photos from Unsplash

How can children with suspected delays be deemed eligible for Part C services if they cannot be tested? This post discusses our opportunities to focus our concept of early intervention on needs and prevention rather than on deficits and intervention. In normal times, states imposed a bottleneck to prevent too many children to enter early intervention and overwhelm the system. In the past few years, states have increased their eligibility bars and decreased the frequency of services. The first option has denied early intervention to children who might really benefit from it, such as children with mild autism, children with challenging behaviors, and children with environmental conditions putting them at risk for delays and eventual school failure—or prison. The second option has eroded the concepts of (a) a close relationship between the family and a primary service provider, sustained through weekly visits; (b) building the family’s capacity through the partnership for solution finding during the visit, followed by the family’s implementing their strategy and reflecting with their home visitor the next week; and (c) the primary service provider approach, with the family receiving weekly visits all right—but from people of different disciplines every week, leading to either conflicting messages or duplication of service.
Now, we cannot rely on those standardized tests to determine how delayed the child is, because we cannot test the child remotely. I do believe states and agencies can make do, and obtain family report about the child’s abilities. The problem is good test items are not necessarily functional. They are good test items because, when administered in a standardized way, they lead to an aggregate score, differentiating children along a continuum. The aggregate score is an important concept: How a child performs on an individual item is not important: The scores of all the items in a scale or a subscale are put together (i.e., aggregated) to see where the child scores. On norm-referenced tests, these can be compared to age norms, to determine how delayed a child is.

Families are not likely to be able to report a child’s performance on a nonfunctional test item. If it’s nonfunctional, it does not occur in everyday life, and therefore parents would have no idea how many blocks a child can stack in 45 seconds.

Perhaps we can take this opportunity to look at children’s functional profiles to determine whether early intervention is for them. I’d like to suggest a parent-completed tool, an interview, and a milestone checklist—the first to see how far behind on functioning, not test taking, the child is; the second to determine what the child’s and family’s needs are, to become the outcomes on an IFSP; and the third to see the extent to which the child has achieved milestones in routines.

Parent-Completed Tool for Functioning

Here, I describe the Measure of Engagement, Independence, and Social Relationships (McWilliam & Younggren, 2020), how to handle the difference between Internet and hand-written notes, helping families complete the MEISR, and how to interpret the profile to determine potential eligibility.

MEISR

The MEISR lists functional skills in 14 common home routines for children birth to three years of age. Figure 1 shows an example. Families rate their child’s abilities from not yet (1) to sometimes (2) to often or beyond this (3).


 
Figure 1. Sample MEISR, from Brookes webinar presentation

Handling Paper

Unfortunately, the MEISR is available only in paper version, so programs need to figure out ways to get the tool to families. They can obtain the MEISR at https://products.brookespublishing.com/Measure-of-Engagement-Independence-and-Social-Relationships-MEISR-Research-Edition-P1152.aspx. They can use snail mail or scanning to instruct families on how to complete the tool. Specifically, if they use snail mail, they will need to provide families with self-addressed stamped envelopes. This dated method is probably better used with a scanned copy of the form. Families can be instructed to (a) use Adobe to edit the scanned tool, to identify their score for each item; (b) use a pen or pencil and scan the response back or take pictures of the pages; or (c) tell their service coordinator what their responses are, via telephone.

Helping Families to Complete the MEISR

Some families might appreciate support in the scoring of the MEISR, so professionals will go through the tool with the family, with the professional recording the family’s score for each item. Again, this can be done with a shared screen or the family’s having a scanned copy of the MEISR in front of them.

 toddler playing wooden xylophone toy

Because the MEISR is comprised of functional items, it is not hard for families to record or report what their child does. Professionals can follow the guidelines in the MEISR Manual for establishing the basal and ceiling, so families do not have to answer all the questions. The guidelines are on the MEISR, so some families can follow them without any help.

Interpreting the Profile for Potential Eligibility

Now you have a completed MEISR, what do you do with this information. I recommend you calculate the percentage of items mastered for the child’s age. The directions for this calculation are on the tool and in the manual and are as described above. States can determine the cut-off for the percentage of total skills for the child’s age that they will use to make a child eligible. For example, one state might state that, if a child has mastered only 75% of the functional items up to his or her age, the child should be deemed eligible to receive Part C services. Another state, might set the criterion at 50%, meaning the child must have more significant functional delays. Because the RBM promotes prevention as well as intervention, we recommend as high a percentage as the state can manage.

The starting ages on the MEISR are not norm-referenced: They come from an examination of various tools and curricula, so they are not scientifically valid. The MEISR provides a profile of a child’s functioning, and we have included starting ages, to help professionals determine if the child is close to age-expected performance. But the MEISR cannot replace norm-referenced tests to determine delay. We propose the MEISR as a more functional but less precise method of determining eligibility when you cannot test children directly.

Interview to Determine Needs

A routines-based interview has been identified in many places as a viable needs assessment method, but THE Routines-Based Interview (RBI), as defined in the RBM, is particularly compelling. When people are trained to do the RBI to fidelity, the child outcomes are more functional (Boavida, Aguiar, & McWilliam, 2014; Boavida, Aguiar, McWilliam, & Correia, 2016). I recommend you conduct a Routines-Based Interview, if you’re trained to do so, or a routines-based conversation, if you’re not trained. You should be able to determine the child’s functioning in different routines, the family’s needs, and the outcomes/goals they want for their child and family.

Via technology, you can interview the family about their daily routines. This information will give you and the family ample information for them to decide on their outcomes/goals. These outcomes/goals can become the focus of tele-visits. To begin with, we need to know the child’s functioning in routines through the day.

Functioning

A child’s functioning in his or her routines is defined by the child’s engagement, independence, and social relationships. The extent to which the child can participate meaningfully (i.e., be engaged), be independent, and communicate and get along with others defines the child’s functioning.

Engagement
How meaningfully does the child participate at a given time of the day? For example, what’s the child ‘s participation like during hanging-out time? If the child reaches toys or other objects and keeps him or herself occupied during most of hanging-out time, the child is in good shape. If, on the other hand, the child doesn’t participate much, doesn’t stay involved very much, or participates at a lower level than we would expect, we would annotate these deficits with our method of “starring” iems. Virtually, starring items can happen by highlighting sections of notes or inserting asterisks.

Independence
How independently does the child function in this routine? What level of prompt or other assistance does the child need? Sometimes, children can function more independently than their caregivers let them, so we need to be sensitive to cultural and family concepts of how much a caregiver should help a child.

Social Relationships

Social relationships consist of communication and getting along with others, which are interrelated. How well does the child communicate during this routine and how well does he or she understand communication. How well does the child cooperate, play with, and otherwise interact with others in the routine? 
Together, engagement, independence, and social relationships (EISR) form the foundations of learning (McWilliam, 2008). In the RBM, they are assessed in context—in routines.

Family Needs

Asking families about their day-to-day activities evokes a number of family needs, especially when we ask them about whether they have enough time for themselves, their worries, and what they would like to change in their life. Some family needs are related to the child, such as having information about the child’s disability, learning sign language to help the child’s communication, or having information about resources to help the child. Other family needs are indirectly related to the child but meet the adults’ needs, such as furthering their education, working out, or having time with the partner. These family-level needs are important because of what, in the RBM, we call the two-bucket principle: A mother can fill her child’s bucket only to the exten that her bucket is full.

Goal Decision Making

The interview ends with the family’s making decisions, after reviewing what was discussed in the interview, about what they want to work on. The decide on 10-12 outcomes/goals and then put them into order of priority (i.e., importance). These functional child skills and family goals are then written to be measurable. Child goals have acquisition, generalization, and maintenance criteria.

Milestone Achievement

Families celebrate their children’s milestones. In our routines-based view of children’s and families’ functioning, we recognize that different routines produce different milestones. In the next few weeks, I will unveil a new milestone achievement chart to help families and early interventionists score children’s functioning.

Conclusion and Call to Action

We have heard that, during the stay-home order, states are

  • ·       Using the MEISR, the Carolina, or the AEPS to determine delays through clinical opinion;
  • ·       Developing an interim IFSP, expecting the formal evaluation to be late;
  • ·       Screening with the ASQ and ASQ-SE;
  • ·       Restricting eligibility to established conditions; and
  • ·       Using methods such as the MEISR or AEPS, to be confirmed with state-approved tools later.

 selective focus photography of girl holding her hair
We have heard that professionals have questions about how to conduct evaluations and assessments, how to determine COS ratings, and how therapists are to conduct evaluations. This blog post has addressed a number of these issues. Importantly, therapist-administered evaluations are not necessary to determine whether a child has a functional problem. By definition, if the problem is functional, a caregiver of the child in the relevant routine would know whether the child’s meaningful participation was compromised. Therapist would be needed to understand why the child was not engaged and what strategies might be employed to help the child.
States and agencies should not put the brakes on entry to Part C during the pandemic. Even more than normally, families need support. We can use functional assessment as suggested here to enroll children and their families. If necessary, we can confirm their delays later. Even better, we might learn that a functional assessment is actually a more authentic way of determining whether we can help them.

Boavida, T., Aguiar, C., & McWilliam, R. A. (2014). A training program to improve IFSP/IEP goals and objectives through the Routines-Based Interview. Topics in Early Childhood Special Education, 20(4), 200-211. doi:10.1177/0271121413494416
Boavida, T., Aguiar, C., McWilliam, R. A., & Correia, N. (2016). Effects of an in-service training program using the routines-based interview. Topics in Early Childhood Special Education, 36(2), 67-77.
McWilliam, R. A. (2008). The engagement construct. In R. A. McWilliam & A. M. Casey (Eds.), Engagement of every child in the preschool classroom (pp. 125-134). Baltimore, MD: Brookes.
McWilliam, R. A., & Younggren, N. (2020). Measure of Engagement, Independence, and Social Relationships. Baltimore, MD: Paul H. Brookes.

17 comments:

  1. The webinar on the Brooks Publishing Website provides an overview of the use of the MEISER and practical guidance for providers to use as a stand alone evaluation, or as a companion to the RBI. The webinar provided me with great insight and a thorough understanding of the tool.

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  2. Thanks for sharing this information as a solution for states figuring out new ways to "carry on" through a public health crisis. You make a compelling argument that "States and agencies should not put the brakes on entry to Part C during the pandemic. Even more than normally, families need support," and I completely agree. Figuring out the how tos and moving a statewide network of providers in an entirely new direction (on the fly) has not been easy - even just continuing to serve children with IFSPs has been a challenge.

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  3. I really love the emphasis on functional assessment. We are encouraging practitioners to use their tools while leaning on their informed clinical opinion, observation skills, parent report, and the great opportunities they are finding to observe and assess the child's *real* interactions with others and the environment. When you think about it, we are probably seeing more of what real life is like because we aren't present to alter those interactions (during the assessment and during visits). Even when we try not to, our presence as strangers changes what happens. Maybe one of the bright spots of the stay-at-home orders will be the growth we experience as practitioners in our own functional assessment, observation, and coaching skills and we'll all be better for it.

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  4. I appreciate the flexibility of using a "routines-based conversation" especially for those states who have not (yet) had staff fully trained in RBI. Thank you!

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