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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.
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.
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.