Components of a Successful Early Intervention Program

Arlene Stredler Brown, CCC-SLP, CED

Colorado School for the Deaf and the BlindUniversity of Colorado – Dept. of Speech, Language, Hearing Sciences Marion Downs Hearing Center @ University of Colorado Hospital

The fundamental question is:The fundamental question is:

Do our universal newborn hearing Do our universal newborn hearing systems improve long-term outcomes systems improve long-term outcomes for children? for children?

And the answer must address: And the answer must address: Collecting dataCollecting data Single point of entrySingle point of entry Using family-centered Using family-centered

practicespractices Parent participationParent participation Using D/HH role modelsUsing D/HH role models Measuring child Measuring child

outcomesoutcomes Selecting a Selecting a

communication communication approachapproach

Accommodating Accommodating cochlear implantscochlear implants

Assessing functional Assessing functional auditory skillsauditory skills

Children with minimal Children with minimal hearing losshearing loss

Sign language Sign language instructioninstruction

Using program Using program consultantsconsultants

Programs for children Programs for children from minority cultures from minority cultures

Collecting Data to Support a Program

Individual child data: Baserate of child’s developmental skills: communication, language, functional auditory skills, phonologic skills, speech intelligibility, cognitive skills, other developmental domains

Individual parent data: Parents’ needs, characteristics of parent-child interaction

Aggregate program data: To measure program outcomes To support program initiatives

How can we collect data?

Checklists & surveys Videotape analyses Parent-administered protocols Standardized tests

F.A.M.I.L.Y. AssessmentF.A.M.I.L.Y. Assessment

Communication Intention Inventory

MacArthur Communicative Development Inventory

Phonological Evaluation

Speech Intelligibility Checklist

Auditory Skills Checklist

Play Assessment Questionnaire

Minnesota Child Development Inventory

Caregiver - Child Interactive Behaviors

Systematic Analysis of Language

Parenting Events

Family Needs Survey

Functional Vision Skills

Parent Therapist&/or Facilitator

Coder

X

X

X

X

X

X

X

X

X

X

X

X

X

Single Point of Entry into Early Intervention Issue:

74% of the children have their hearing loss diagnosed by 3 months of age; the average start of early intervention is 5 months of age. How can we maintain, and lower, the age at which children start early intervention?

Parents request service coordination from a person who can answer questions related to hearing loss and provide emotional support specific to issues related to hearing loss

Collecting Information: CHIP Facilitator Survey, CHIP Parent Survey

Evaluating the Data..

Information Shared with Families CHIP Parent Survey, 2003

Information requested by parents: Education: Hearing LossEducation: Hearing Loss 97%97% Education: Comm. ApproachesEducation: Comm. Approaches 97%97% Websites, books, videosWebsites, books, videos 95%95% Preparing for the IFSPPreparing for the IFSP 87%87% Education: Amplification/techEducation: Amplification/tech 82%82% Connecting w/ agencies 69% Attending audio. Evals 51% Education: Law 46% Connecting w/ D/HH role model 41% Family Advocate 18%

Single Point of Entry into Early Intervention Evaluating the Data: Many states that

depend solely on the Part C service coordinator have children starting early intervention > 6 months of age

Program Modifications: CIHAC develops guidelines for entry into early intervention

Transition from Diagnosis to Early Intervention

Audiologist Confirms Hearing Loss

Hearing Resource Coordinator is ContactedHearing Resource Coordinator is Contacted

Contacts family

Initiates data management

Contacts local agencies

Using Family-Centered Practices

Issue: More early interventionists need training to utilize family-centered strategies

Collecting Information: CHIP Facilitator Survey

Evaluating the Data: 5 true-false questions addressing implementation of

family-centered (versus child-centered) practices: 78% received a score of 70% or higher on these questions.

5 open-ended questions querying the use of family-centered practices: 58% of the facilitators supplied answers indicating they were implementing family-centered practices

Using Family-Centered Strategies

Program ModificationsConsultant hired to provide technical

assistance on use of family-centered strategies

CHIP Clinical Training ManualEarly Intervention Illustrated Series

PRIMARY PROCESSES

START….

Family IssuesFamily Issues

GOAL….

SECONDARY PROCESSES

Child OutcomesChild Outcomes

feelings

information

expectations

opinions

R a p p o r t

T r u s t R e s p e c t

communication approach

specific skills

Family-Centered Strategies The Home Team

The early interventionist helps parents to gain confidence: identify parents’ strengths, acknowledge acquired skills

Parents have the responsibility for their decisions

Continually monitor the pace & content of the intervention: at the time of diagnosis, at 3 month intervals, during transition to preschool

Produced by: CHIP, CSDB, Boys Town

The Art & Science of Home Visits.. Knowledge and skills of

the early interventionist Communication &

language development Child development Potential impact of hearing

loss Communication

approaches Amplification & listening

devices Assistive technology Values & culture

Tools of the TradeProduced by: CHIP, CSDB, Produced by: CHIP, CSDB, Boys Town, NMSD, SKI*HI, NCLIDBoys Town, NMSD, SKI*HI, NCLID

Rubric for a Home Visit

Colorado Home Intervention Program (CHIP) Colorado School for the Deaf and the Blind (CSDB) Copyright 2003

Parent Participation Issue: The most successful children are those with

high levels of family involvement; maternal communication skill predicts early reading skills, higher language skills, fewer behavior problems

Collecting Information: Moeller (2000), Calderone (2000)

Evaluating the Data: Moeller, 2000

112 children with mild to profound hearing loss No evidence of major secondary disabilities Variety of communication modes

Calderone, 2000 28 children with prelingual hearing loss moderately-severe - profound tested at 45-88 months of age

Parent Participation Program Modifications

Support family-centered intervention strategies Hire and train sign language instructors Assure access to parent-to-parent connections

(Families for Hands & Voices) Information Support Leadership

Train D/HH role models..

Deaf/Hard of Hearing Connections

Training on how to work with families Providing families emotional support Managing communication Deaf Culture Hard of Hearing issues Coordinating with the early interventionist Providing resources

Child Outcomes Issue: “ Children have many skills WNL for their

chronological age. However, when specific skills are evaluated, there is evidence that some elements of language development are more advanced than others.

Collecting Information: FAMILY Assessment; Minnesota Child Development Inventory (MCDI); Language Sample Analyses

Evaluating the Data 352 deaf and hard of hearing children Children assessed on 1 to 9 occasions Total number of assessments = 725

Child Outcomes

Evaluating the Data Chronological Age: 6 months - 6 years;3 months Mean = 34 months Cognitive Ability: Estimated to be within the normal

range (MCDI data) Hearing Loss: Bilateral, mild to profound Parents: Normal hearing, English is primary language Communication Approach: Full range of approaches MCDI: Selected items examined from 2 subscales:

Expressive Language, Comprehension/Conceptual (Receptive Language)

Results: Proportion of DelayNon-Verbal 1.14Pre-Literacy 1.05Colors/Numbers .97Rote Language .96Early Communication .87Concept Vocabulary .79Early World Knowledge .76Cognitive-Linguistic .71Grammar .66

Child Outcomes

Evaluating the Data: SALT: 219 children selected in the following

age groups (plus or minus 3 months) 3 years old (n = 90) 4 years old (n = 55) 5 years old (n = 49) 6 years old (n = 24)

Results: Total Number of Utterances

0

50

100

150

200

3 4 5 6

Hearing

Deaf/hoh

Chronological Age (years)

# of

Utte

ranc

es

Results: Mean Length of Utterance (words)

0

2

4

6

3 4 5 6

Hearing

Deaf/hoh

Chronological Age (years)

MLU

in W

ords

Family-Centered Intervention: Proven Strategies to Assure Positive Outcomes

Child Outcomes

Program Modifications: Raise Expectations: Review expectations of

facilitators and parents Intensity of Services: Consider increasing

frequency of services when children are 24-36 months of age

Extending Parent-Centered Services: Consider continuing parent-centered intervention while children are in preschool

Proficiency of Staff: Increase CO-Hear Coordinators’ time to provide mentoring to facilitators

Selecting a Communication Approach

Issue: National debate on the “optimal” or “correct” communication approach

Collecting Information: Multiple measures on the FAMILY Assessment

Evaluating the Data: Yoshinaga-Itano, et al, 1998; Mayne, et al, 2000)

Selecting a Communication Approach

No significant effect of communication mode on total language quotient

In an analysis of expressive vocabulary development, mode of communication did not have a significant correlation with vocabulary development

In a study of receptive vocabulary development, after controlling for cognition, mode of communication was not significantly associated with the number of words children understood

Selection of Communication Approaches Program Modifications

50% of families change the approach they use at least once during the 3 years in early intervention

CHIP philosophically supports and offers all communication approaches – Is this a trend?

Collaboration (versus competition) with other programs

Cochlear Implants and Communication Approach

Issue: Perceived concern (parents, physicians, audiologists) that use of sign language after implantation will limit development of oral communication

Collecting Information: FAMILY Assessment; MacArthur Communicative Development Inventory, Spontaneous Language Sample

Evaluating the Data 54 deaf children who received cochlear implants

English is the primary spoken language in the home Hearing parents Implanted by 5 years of age

Evaluating the Data..

Age at implantation Range = 13 months to 5 years;1 month Mean age = 31 months

Simultaneous Communication Participants: n=29 Selected children who signed in > 50% of utterances in pre-

implant tape No additional disabilities that could interfere with language

development

Results: Use of sign & spoken vocabulary (MacArthur)

0

20

40

60

80

100

Pre 0-5 6-11 12-23 18-23

Sign only

Sign+speech

Say only

Months Post Implant

% o

f Wor

ds

Results: Use of sign & spoken vocabulary (Language Sample)

020406080

100

Pre 0-5

6-11

12-1

7

18-2

3

24-2

9

30-3

536

+

Sign only

Sign+speech

Say only

Months Post Implant

% o

f Wor

ds

Cochlear Implants and Communication Approach Program Modifications:

Encourage maintaining communication approach used before implantation while new skills are acquired

Support families’ choice of communication approach

Development of Functional Auditory Skills Issue: Initial checklist had few items (14) which

did not reliably document progress nor did it provide a teaching guide for intervention

Collecting Information: FAMILY Assessment; Checklist of Auditory Skills

Evaluating the Data Assessment tool does not provide measurable

outcome data Program Modifications

Functional Auditory Performance Profile - FAPI (Stredler-Brown & DeConde Johnson, 2003)

Children with UHL Issue: Children with UHL are now being identified on a

regular basis through newborn hearing screening programs and efficacy data is needed to development a treatment protocol

Collecting Information: FAMILY Assessment Evaluating the Data..

n = 30 children 2 (7%) progressed to bilateral within first year of life 2 (7%) later diagnosed with bilateral losses that

apparently were present from birth One mild (30dB) in poorer ear One moderate, low frequency loss with normal

high frequency hearing

Children with UHL Evaluating the Data

n=15 children examined across measures and time Considered assessments after 12 months of age No additional disabilities Number of children with language delays

Delayed = 4 (27%) Borderline = 1 (7%)

Program Modifications Implement statewide program to provide information to parents

and professionals Provide developmental screening to monitor development Enhance service delivery through funding from the Marion

Downs Hearing Center NCBDDD @ CDC giving this topic consideration

Oral Communication Consultant Issue: Early interventionists request technical

assistance for children whose parents have chosen oral/aural communication (including simultaneous communication)

Collecting Information: CHIP Facilitator Survey Evaluating the Data

Facilitators send evaluation of site visit Program Modifications

OCC position co-funded by private AVT program and CHIP

Future: Evaluate auditory skills, phonologic repertoire, speech intelligibility of children receiving this technical assistance

Sign Language Instruction Program

Issue: Children who sign are developing expressive sign skills at a slower rate than their chronological age

Collecting Information: SALT transcripts Evaluating the Data: Parents’ sign skills are at

or slightly above the sign level of their child Program Modifications

Enhance delivery of sign language by assigning a sign language instructor

Provide up to 6 hours/month of home-based sign instruction from a native signer (e.g., D/HH adults, CODAs)

Develop curriculums, including the Integrated Reading Project (IRP)

Consultation Services Issue: Early interventionists (ToD/HH, SLPs,

Audiologists) do not always have sufficient information to diagnose and accommodate needs related to additional disabilities.

Collecting Information: CHIP demographic data Evaluating the Data

40% of children, B-3, have additional disabilities 30% of children, school-age, have additional disabilities 12% of children, B-5, have dual sensory impairments Parents’ level of emotional stress may require intervention

Program Modifications Specialty consultants are contracted to provide training,

technical assistance, home visits (PT, mental health, functional vision)

Participants & colleagues supporting this work are: The parents of children enrolled in early intervention

programs in Colorado 10 Regional Colorado Hearing Resource (CO-Hear)

Coordinators 115 CHIP Facilitators – the interventionists who do the

work on the front-lines Christie Yoshinaga-Itano, Allison Sedey, Karen Carpenter

and members of the research team at CU-Boulder Colorado School for the Deaf and the Blind (CSDB) Colorado Department of Education MCHB, NIH, CDC Colleagues in other states and countries who ask the

questions that direct us to find the evidence

For more information:

Check the CHIP webpage at:Check the CHIP webpage at:

www.csdb.org