Part C of the federal Individual with Disabilities Education Act (IDEA) establishes requirements for providing early intervention services to infants and toddlers with disabilities. States are authorized to develop their own eligibility criteria for Part C early intervention services, but they must comply with the definition contained in federal IDEA regulations.
Infants and toddlers with delays in one or more of five areas can qualify for Part C services. A delay in social or emotional development is one of the five domains. Children with a diagnosed mental condition that has a high probability of resulting in a developmental delay are also eligible. States may also include at-risk infants and toddlers in their definition of children eligible for Part C early intervention services. These infants and toddlers are those “who would be at risk of experiencing a substantial developmental delay if early intervention services were not provided to the individual… because of biological or environmental factors that can be identified (including low birth weight, …a history of abuse or neglect, and being directly affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure).”1 While every state must provide services to children with a delay--or at risk of delay if its definition includes them--in the domain of social-emotional development, the definition and criteria for establishing social-emotional delay vary across states (e.g., states differ in the severity of delay that must be documented).2
Federal regulations provide examples of early intervention services, including a number that a child with social-emotional delay might typically receive: “family training, counseling, and home visits… provided, as appropriate, by social workers, psychologists, and other qualified personnel,” “psychological services, including psychological counseling for children and parents, family counseling, consultation on child development, parent training, and education programs,” social work, and special instruction to acquire social interaction skills.3 Additionally, the Child Abuse Prevention and Treatment Act (CAPTA) requires states to develop plans that include “provisions and procedures for referral of a child under the age of 3 who is involved in a substantiated case of child abuse or neglect to early intervention services funded under Part C.”4 Children who have been exposed to maltreatment are at high risk of social-emotional delays and mental health problems.5
In fall 2017, Part C served 388,000 children from birth to age three.6 Currently, national data on the particular developmental delays and diagnosed conditions of children served by Part C are not routinely collected, nor are data on the types of services delivered or expenditures on different services.7
However, available evidence suggests that infants and toddlers with social-emotional delays and mental health conditions are underserved in Part C. The 2007 report of the National Early Intervention Longitudinal Study (NEILS) documents conditions in a nationally representative sample. This study found that a social or behavioral problem was the reason for a child’s Part C eligibility four percent of the time, although 32 percent of families reported they “often had a difficult time in figuring out what to do about their child’s behavior.”8 Studies of rates of social-emotional and behavioral problems among 1- to 3-year-olds have found prevalence ranging from 7 to 24 percent, though social-emotional and behavioral problems may be more prevalent among children with other developmental delays, for example among toddlers with language delays.9
NEILS also found that the most common services provided were speech/language therapy, special instruction, occupational therapy, developmental monitoring, and physical therapy, with each service provided to at least 37 percent of families. No other service was provided to more than 19 percent of families, and 80 percent of families received at least two services during their first six months in Part C.10
The federal government requires states to report on the progress of families in Part C, and one of the three child outcomes they must report on is “social relationships, which includes getting along with other children and relating well with adults.”11 In fiscal year 2017, 66 percent of Part C children showed greater than expected growth in social relationships, and 57 percent exited Part C at or above expectations in their social relationships.12 However, there have been a number of concerns raised about how these outcome data are collected and how they can be used to understand the Part C program and the children it serves.13
Overall, data on Part C services related to social-emotional delays and conditions are very limited, despite the fact social-emotional development is an important goal of Part C, and evidence suggests that many infants and toddlers experience social-emotional delays and mental health problems.
A 2005 position statement from the IDEA Infant and Toddler Coordinators Association (ITCA), a professional organization supporting state Part C programs and coordinators, called for integrating infant mental health approaches into Part C and made a number of policy recommendations to states.14 A 2009 policy survey of state Part C coordinators from the National Center for Children in Poverty (NCCP) found that policies supporting infant-early childhood mental health in Part C, many of which were recommended in the ITCA position statement, were not widespread among states.15 NCCP recently completed an updated version of this survey and will release a report on findings in 2020.
In order to receive federal IDEA funds, states are required to develop a State Systemic Improvement Plan (SSIP), a multiyear plan to increase the capacity of local early intervention programs to improve child and family outcomes. Each state is required to select a child or family outcome to improve as part of its SSIP. Thirty states included child social relationships as an outcome in their current SSIPs (AL, AK, AZ, CA, DE, FL, GA, HI, ID, IN, KS, MD, MA, MI, MT, NV, NJ, NM, NC, ND, OR, PA, RI, TX, UT, VT, WA, WV, WI, WY).
A challenge to identifying research on approaches to supporting the social-emotional development of children from birth to three with disabilities is that evidence-based interventions typically either have been used among children from birth to three without disabilities, or among children with disabilities but spanning a wider age range than Part C covers. For instance, Child-Parent Psychotherapy, an evidence-based dyadic treatment for children affected by trauma or who are at risk of insecure attachment or social-emotional problems, has shown positive impacts on the social-emotional outcomes of infants and toddlers (see PRiSM research summary on dyadic treatment); however its use among children with disabilities has not been extensively studied.16 Incredible Years, a parent training program, has shown positive impacts on reducing negative parent-child interactions and child behavior problems among children with developmental delays or disabilities; however the ages of the children studied were two to five years, with a mean age of almost four.17
However, two interventions—Trauma-Informed Behavioral Parenting and Triple P—have shown promising results in supporting the social-emotional development of infants and toddlers served by Part C.
Trauma-Informed Behavioral Parenting (TIBP; subsequently renamed Smart Start), is a parent coaching intervention designed to meet the social-emotional needs of toddlers enrolled in both Part C services and involved in child welfare. 18 It is based on the Parent-Child Interaction Therapy (PCIT) dyadic treatment model (see PRiSM research summary on dyadic treatment for more information on PCIT). In a study of TIBP, five early intervention (EI) providers participated in an initial nine-hour online and in-person training. Throughout the study, the EI providers also participated in in-person, hour-long monthly supervision trainings that included coaching and discussion of cases. TIBP was delivered in the homes of eight parent-child dyads over eight sessions before other EI services were begun by the same providers. Posttest findings included “gains in positive parenting skills, decreases in parenting stress, and decreases in child post-traumatic stress symptoms.”
Stepping Stones Triple P, an adaptation of Triple P, is an evidence-based parenting program for parents of children with disabilities. Two randomized controlled trials of SSTP were conducted with parents of children enrolled in Part C.19 In the first study, eight accredited Triple P providers delivered the 10-session program to 25 families in addition to their usual Part C services, while 24 families received Part C services as usual. While there were no significant differences between the two groups at 12 months on child and parent outcome measures (possibly attributable to a high attrition rate in the intervention group), children of parents who received Stepping Stones Triple P showed a significant decline in behavior problems. In the second study, 40 families of infants and toddlers participating in Part C were randomly assigned to receive SSTP; all families worked with Part C service coordinators who had undergone 18 hours of training with a curriculum to promote effective relationships between parents and young children. For families that received Stepping Stones Triple P, a stronger impact on the quality of the parent-child relationship was found at 12 months post-intervention.
The following intervention, while not studied while being used in Part C programs, has shown promising results for children’s social-emotional development when used with a population of children typically served by Part C. Responsive Teaching is a manualized, relationship-focused intervention that encourages parents to adopt strategies to help them interact more responsively with their children. A study of fifty mothers participated with their children (85 percent of the children were younger than 36 months), who were categorized as having pervasive developmental disorders (PDD) or developmental disabilities (DD).20 Mother-child dyads received weekly one-hour sessions with one of six early intervention specialists for a year. After participating in the intervention, mothers engaged in more responsive interactions with their children. Children with PDD made marked improvement in social-emotional development compared with children with DD, likely attributable to the fact that they had severe social-emotional problems at the beginning of the intervention, in contrast to children with DD, who did not.
Another study of Responsive Teaching examined its use with children with autism or pervasive developmental disorder (PDD); 80 percent of the children were younger than 36 months.21 Twenty mother-child dyads received weekly one-hour sessions with one of four early intervention specialists for eight to 14 months. After participating in the intervention, mothers engaged in more responsive interactions with their children and children showed significant improvements in social-emotional functioning.
While studies of infants and toddlers who receive evidence-based early childhood mental health services in Part C are lacking, results of a recent survey of state Part C Early Intervention Program directors suggest that many state Early Intervention programs offer participants evidence-based dyadic treatment and parenting interventions focused on child social-emotional outcomes. These interventions include Triple P and Circle of Security-Parenting programs, and Attachment Behavior Catch-Up, Parent-Child Interaction Therapy, and Child-Parent Psychotherapy dyadic treatment models.22 In view of the role at least some states’ Part C programs play in delivering or connecting families to these types of interventions, the Part C Early Intervention program can be viewed as helping infants, toddlers, and their parents achieve the positive outcomes reported by EB dyadic treatment and parenting programs (e.g., a more positive parent-child relationship, improved child social-emotional competencies, and a reduction in behavior problems). (See research summaries on parenting programs and dyadic treatment for more information.)
Other approaches to supporting the social-emotional needs of children in Part C have focused on supports for the existing early intervention workforce, through forms of professional development such as consultation, reflective supervision, and training.
In the Lafayette area of Louisiana, IECMH consultation services are offered to early intervention service providers, including speech and language therapists, occupational therapists, physical therapists, special instructors, family service coordinators, and program administrators (See Louisiana profile on PRiSM). Providers were reported to have increased their use of informed clinical opinion about social-emotional concerns in eligibility determinations; increased social-emotional screening of children in foster care, and increased focus among early interventions providers on family relationships as observed in focus groups.23
Illinois developed a pilot initiative in which a social-emotional consultant was embedded within Child and Family Connections offices, the agencies that provide local intake and service coordination for early intervention.24 The pilot also included training on supporting parent-child and early intervention provider-family relationships, reflective supervision and case consultation for service coordinators, and social-emotional screening for children. From pre- to post-pilot, data from participant questionnaires revealed perceived benefits and reported changes in practice from reflective consultation, reflective supervision, case consultation, and social-emotional screening. Participants also increased their knowledge of infant-toddler social-emotional development in eight assessed areas and reported increases in skills and use of relationship-based practices.
A qualitative study explored training early intervention (EI) providers in FAN (Facilitating Attuned Interactions), a method designed to increase EI providers’ awareness of parent concerns and capacity to collaborate with parents.25 Five EI providers received training, which consisted of a one-day training on infant mental health and attachment and two days of FAN training focused on theory of change, core processes, and active practice with the FAN. In addition, EI providers received reflective supervision (called facilitation sessions in FAN training), peer support, and mentoring. EI providers met with families for an hour on a weekly or biweekly basis. A focus group with the participating EI providers indicated that providers felt greater empathy with parents, engaged in greater collaboration with them, and felt more effective and satisfied with their work.