Introduction
Greetings from Seattle, Washington. I wanted to give you all a little bit more background about me. I started my private practice, Stepping Stones Therapy Network, from the trunk of my car 13 years ago. It has evolved into a bustling clinic where we help about 200 kids a week. I am also the author and blogger of Play It Forward Therapy. This is an online resource for OTs and OT assistants, teachers, and parents. I am especially passionate about occupational therapy as a profession. I think it is vital that we, not only advocate for OT, but also just to continue to show the value of the services that we provide and advocate for our patients.
Figure 1 shows a picture of me.
Figure 1. Advocating for OT.
I am at the Washington State Legislature advocating to get bills passed to help prevent barriers to insurance and so kids and families can get access. For all the therapists listening to this, I want to commend you first of all for the work that you are doing to help improve the lives of people. Thank you in advance already for all that you do.
No matter if you are already working in early intervention or hoping to do so in the future, I hope that all of you can gain some insight from this presentation.
The Early Intervention Model
- To provide services to families that support infant and toddler overall well-being and development.
- Multidisciplinary programs that rely upon close coordination and collaboration between educators, therapists, parents/caregivers.
- Parent education, coaching, and therapy services (OT, PT, SLP) in “natural environments”.
- Free community screenings and follow up assessment to identify at-risk children.
This model was developed to provide services for families to support infant and toddler's overall wellbeing and development. They are multidisciplinary programs that rely upon close coordination and the collaboration between educators, therapists, parents, and caregivers. This includes parent education, coaching, and therapy services, most commonly OT, PT, SLP, occurring in natural environments. Additionally, there are free community screenings and followup assessment to identify at-risk children as a key part of the Early Intervention Model.
Guiding Principles for Early Intervention (EI)
- AOTA endorses the following principals from the National Early Childhood Technical Assistance Center (2007)
- The following principles are what make early intervention a unique and special setting!
The American Occupational Therapy Association endorses the following principles from the National Early Childhood Technical Assistance Center. These are what make early intervention a unique and special setting.
Guiding Principle 1
- Infants and toddlers learn best through everyday experiences and interactions with familiar people in familiar contexts.
The first principle is that infants and toddlers learn best through everyday experiences and interactions with familiar people in familiar contexts. The most familiar people to children are their parents and caregivers. Most young children spend the most time at home, in childcare, or at school.
Guiding Principle 2
- All families with the necessary supports and resources can enhance their children’s learning and development.
The second principle is that all families with the necessary supports and resources can enhance their children's learning and development. As therapists, we help set our families up for success. Part of our job is to support the parents and to equip them with tools and resources that they need to help their child's development. We do not want to go in and problem-solve for the families. We want to be able to have a collaborative relationship to come up with solutions together. Keep in mind that you know OT best, but the parents know their child best. It is our job to educate and to equip families to be successful in helping their own kids. There is a saying that I like. Give a man a fish, he eats for a day. Teach a man to fish, he eats for a lifetime. We want to teach and empower parents with life skills, and this includes coaching parents in a variety of areas to help their kids.
Guiding Principle 3
- The early intervention process, from initial contacts through transition, must be dynamic and individualized to reflect the child’s family member’s preferences, learning styles, and cultural beliefs.
Guiding principle three is that the early intervention process from the initial contact through transition must be dynamic and individualized to reflect the child's family members, their preferences, their learning styles, and their cultural beliefs. There is never a cookie-cutter family situation. We must treat all families individually. It is important to be aware of all factors when working with families like demographics, education level, socioeconomic situations, and cultural differences. For example, when I worked at a birth to three center, 90% of my caseload was Spanish speaking as most of the parents had recently immigrated to the US. Several of the families on my caseload really benefited from additional community resources.
Guiding Principle 4
- Individualized Family Service Plan Outcomes must be functional and based on children’s and families’ needs and priorities.
The next principle is IFSP outcomes, or individualized family service plan outcomes. These must be functional and based on the children's and the families' needs and priorities. Again, we need to provide family-centered care. As a therapist, you might have all kinds of ideas for your treatment. However, you must make the outcomes family-driven and family-centered. This is a key aspect of the early intervention setting.
Guiding Principle 5
- Interventions with young children and family members must be based on…
- Explicit principles
- Validated practices
- Best available research
- Relevant laws & regulations
For principle number five, interventions with young children and family members must be based on explicit principles. Our treatments should include evidence-based practices based on OT research and other child developmental and scientific research. This is where you are going to apply your educational training to real-life practice. I know that when I was in school, some of the theoretical frameworks seemed rather abstract. However, once I actually started practicing as an OT, they became real to me. It is also important to stay within the federal and the state guidelines and the requirements for how early intervention services should be provided because they can be a little bit different from state to state.
Individuals with Disabilities Education Improvement Act (IDEA)
The Individuals with Disabilities Education Improvement Act, IDEA, is a federal law that mandates all states to provide all children, including those with disabilities, access to free, appropriate, public education. It is part C of IDEA that provides the funding for early intervention services for at-risk infants and toddlers from birth up until age three. Services must occur in natural environments. What is the natural environment? The is would be in a home or in community settings like school or childcare. Each state has its own regulations and requirements for the delivery of early intervention services. No matter where you are located, we are all united to help infants and toddlers.
Steps in the EI Process
- Identification and referral of children who are at-risk
- Assessment by a multidisciplinary team
- Parental consent
- Individualized Family Service Plan (IFSP), reviewed every 6 months
- Transition out of EI services or transitioning to an Individualized Education Program (IEP) upon turning 3 years old.
Step 1: Identification and Referral
Referral Sources
- Physicians
- Hospitals
- Parents
- Teachers
- Child Find Program through the local school district
This step is identifying children and referral sources. Most of the kids come to early intervention services after being referred by their pediatricians or after hospitalization in a NICU. Those coming from the NICU are almost automatically eligible for early intervention services given their health history. Parents, teachers, and the Child Find Programs, through the local district, can also be referral sources.
Step 2: Multidisciplinary Assessment
- Typical assessments are holistic and best for measuring the child’s behavior and performance in typical activities.
- Educator, OT, PT, and SLP may all be present with the family and child during the evaluation.
- The purpose is to generate family-centered goals or “Outcomes” based upon each team member’s assessment and parent input.
Step two is a multidisciplinary assessment. Typical assessments that we use in EI are holistic and measure the child's behavior and performance in typical activities or everyday routines. The educator, the OT, the PT, and the speech-language pathologist might all be present with the family and the child during the evaluation. The purposes of a multidisciplinary assessment are to have a well-rounded service plan and to generate family-centered goals. These are what we call outcomes based on each team member's assessment and parental input. For example, when I worked in early intervention, the educator, the OT, and the PT, and the SLP were all present with the family and the child during the evaluation. We each had our own areas of assessments to administer, and we had evaluation teams. I really got to know my colleagues' style as well as kind of the flow of how the evaluation should go. One therapist might be working with the child while the other is speaking with the parent. It really comes down to most importantly just making sure that the child and the family are feeling comfortable and welcomed by the team. Sometimes it can feel intimidating when you are worried about your child and coming in to have them assessed. We need to make them feel that we are there to help and to give families hope.
Common EI Assessments
The assessments below are examples that address adaptive, cognitive, social-emotional, communication and motor domains.
- Developmental Assessment of Young Children (DAYC-2): Ages birth to 5 yrs.
- Bayley Scales of Infant and Toddler Development: Ages 1 to 42 months
These two assessments are very well-rounded. These are what we use in Washington state.
Other Assessments
- PDMS-2: Peabody Developmental Motor Scales
- Includes subtests for reflexes, gross and fine motor skills for children ages birth- 5 years
- Infant Sensory Profile 2
- Caregiver questionnaire for babies from Birth–6 months
- Toddler Sensory Profile 2
- Caregiver questionnaire for toddlers ages 7–35 months
- DECA: Devereaux Early Childhood Assessment
- Social-emotional skills for infants and toddlers ages 1-36 months
Some of the other common assessments are the Peabody, and the Infant Sensory Profile, and the Toddler Sensory Profile. In Washington, we are required to use the DECA, which is the Devereaux Early Childhood Assessment. It assesses social-emotional skills in infants and toddlers. I think it is especially important for addressing infant mental health.
Step 3: Parental Consent
Step three is parental consent. We definitely need parental consent during this whole process. It is also the start of parent collaboration. This requires clear communication at the IFSP meeting and beyond. This is not only just getting consent, but it is also getting the parents to buy into how we can help and the services that we are offering.
Step 4: Individualized Family Service Plan (IFSP)
- Determine eligibility
- An IFSP is like a Plan of Care, however, instead of Goals, you have “Outcomes”
- Outcomes may be broken up into smaller intervention goals.
- The report should be written in parent-friendly language.
Step number four is the IFSP. We want to determine eligibility first. I work in a pediatric outpatient, and we call it a plan of care and establish goals. But in early intervention, they are called outcomes. The outcomes can be broken up into smaller intervention goals, but the report should be written in parent-friendly language. I love that it should be written in parent-friendly language. Right now in my current setting, I am writing for the insurance company with lots of medical language and jargon. As practitioners, it is a balance of writing the medical piece, but also making it understandable. So definitely in early intervention, we want to use parent-friendly language that is jargon-free and easily readable.
The core standard in Washington state is that a child needs to be more than 1.5 standard deviations in at least one area to qualify for services. However, the team can recommend more services even if the child's scores are below average, but they are not minus 1.5. For example, they can score minus 1.0 or minus .5 standard deviations. They are clearly below average, but they have not quite met the cutoff. They just need one assessment that has met the cutoff, but the team can decide if this child could also really benefit from other services. I really like that it includes our clinical judgment and recommendations as part of the IFSP plan.
8 Tips for Writing High-Quality Outcomes
- Base the outcome on information from the initial evaluation and ongoing assessment.
- Be sure to include the family’s priorities and their most urgent concerns.
- Make it functional and meaningful to the family’s life, activities, and routines.
- Use real-life contexts that include developmental domains (not discipline-specific).
- Use jargon-free, everyday language.
- Emphasizes the positive or the “wanted behavior”, not the negative.
- Use active words (e.g. sit, walk, talk, hold) with the child or family member’s name.
- Avoid using vague, passive words (e.g. increase, decrease)
Our documentation is another way that we show the value of what we do, and how we shine as therapists. The first tip is to base the outcome on information from the initial evaluation and ongoing assessment. Number two is to be sure to include the family's priorities and their most urgent concerns. Again, we might have our ideas of what we want to work on, but it is important to listen to the family. Sometimes, it takes some sifting out of what is the most important, or just asking them point-blank, "What are your top five goals?" Have them write down their top five priorities to make sure they feel heard and to also make sure that we are really sticking to family-centered care. Three is to make it functional and meaningful to the family's life, their activities, and their routines. We want to use real-life concepts that include developmental domains that are not just discipline-specific. You would not write an outcome saying, "In occupational therapy, the child will do {blank}." All disciplines should be able to read that outcome, and if that is an issue that comes up in their session, they should also be able to understand what you are talking about. Again, number five is using jargon-free everyday language, emphasizing the positive or the wanted behaviors and not the negative, or "more can-do language." Number seven is using really active words that are concrete like sit, walk, talk, and hold. It is also important to use the child's or the family member's name to individualize our outcomes. You want to avoid using vague or passive words, so like increase or decrease. Finally, you want to focus on specific skills.
Outcome Examples for OT
- Gracie will hold her sippy cup with both hands so she can drink by herself when thirsty.
- Erik will remain seated in his stroller or shopping cart when at the grocery store.
- Max will play in the backyard while getting around with his walker.
- Maddy will sleep through the night.
