December 2015
Texas Department of Assistive and Rehabilitative Services
Division of Early Childhood Intervention Services
Specialized Skills
Training Workbook
1
December 2015
Table of Contents
What is the SST Workbook? ...................................................................................................... 4
Section 1 – Brain Development, Cognitive Processes and Executive Functioning .................... 6
Child Development - Review .................................................................................................. 6
Basics of Infant and Toddler Brain Development .................................................................... 6
Nutrition matters ................................................................................................................. 7
Positive relationships with primary caregivers are essential ............................................... 7
Experiences influence the brain – both positively and negatively........................................ 7
Myelination and Response Time ........................................................................................ 8
Cognitive Processes and Executive Function ......................................................................... 8
Executive Function – A Lifelong Skill .....................................................................................10
The Impact of Cognitive Skills on Overall Development ........................................................11
Executive Function – Extension ............................................................................................12
Section 2 – Scaffolding .............................................................................................................13
Scaffolding – Extension .........................................................................................................14
The ASD Toddler Initiative has developed two modules about effectively using and then
fading prompts. Although the focus of these modules is on infants and toddler with ASD, the
strategies outlined in the modules can be used with all children in ECI. ................................14
Module 1 – Least to Most Prompting: http://asdtoddler.fpg.unc.edu/prompting/stepsimplementing/least-most-steps-implementing ........................................................................14
Module 2 – Graduated Guidance Prompting: http://asdtoddler.fpg.unc.edu/tablecontents/steps-implementing/graduated-guidance-steps-implementing .................................14
Section 3 – What Does an SST Visit Look Like? .......................................................................15
Extension – Coaching Practices ............................................................................................17
Section 4 – Behavior and Social Emotional Skills......................................................................18
Challenging Behavior ............................................................................................................18
Why do toddlers tantrum as frequently as they do? ...............................................................23
Now You Try .....................................................................................................................24
Toileting ................................................................................................................................26
Challenging Behavior and Social Emotional Skills – Extension .............................................27
Section 5 – Developmental Strategies and Activities .................................................................29
Responsive Caregiving .........................................................................................................29
Routines, Natural Environments and Familiar Adults .............................................................33
2
December 2015
Now You Try: ....................................................................................................................35
Development and Learning ...................................................................................................37
Activity Analysis ................................................................................................................37
Cognitive and Social-Emotional Development and Activities .................................................39
Cognitive/Social-Emotional Activity Table ..........................................................................40
Activity Suggestions ..........................................................................................................43
Activity Suggestions ..........................................................................................................44
Activity Suggestions ..........................................................................................................45
Activity Suggestions ..........................................................................................................46
What are your activity ideas? ............................................................................................46
Now You Try: ....................................................................................................................47
Activity Suggestions ..........................................................................................................51
Activity Suggestions ..........................................................................................................52
Activity Suggestions ..........................................................................................................53
What are your activity ideas? ............................................................................................53
Now You Try: ....................................................................................................................54
Activity Suggestions ..........................................................................................................58
What are your activity ideas? ............................................................................................60
Now You Try: ....................................................................................................................61
Activity Suggestions ..........................................................................................................65
What are your activity ideas? ............................................................................................65
Now You Try: ....................................................................................................................66
Activity Suggestions ..........................................................................................................70
What are your activity ideas? ............................................................................................71
Now You Try: ....................................................................................................................72
Activity Suggestions ..........................................................................................................76
What are your activity ideas? ............................................................................................76
Now You Try: ....................................................................................................................77
Developmental Activities – Extension ....................................................................................81
Section 6 – Global Child Outcomes and Family Outcomes .......................................................84
Global Child Outcomes .........................................................................................................84
Family Outcomes ..................................................................................................................86
3
December 2015
Child Outcomes – Extension .................................................................................................86
Section 7 – Transition and School Readiness ...........................................................................87
Section 8 – Documentation of SST ...........................................................................................88
Why is documentation important? .........................................................................................88
Exercise #1 - Getting to know the readers .........................................................................90
Minimum Requirements.....................................................................................................92
Exercise #2 - Getting to know the rules .............................................................................93
Exercise #3 - Getting to know the required elements .........................................................94
What should progress notes look like? ..............................................................................97
Exercise #4 – Getting to know the contents of a progress note .......................................100
Exercise #5 – Getting to know when there’s room for improvement ................................110
What are some routine checks? ......................................................................................119
Check Your Answers for the Documentation Exercises .......................................................121
Getting to Know the Readers (page 83) ..........................................................................121
Getting to Know the Rules (page 85) ...............................................................................121
Getting to Know the Required Elements (page 86-88).....................................................121
Getting to Know the Contents of a Progress Note (page 92-93) ......................................122
Getting to know when there’s room for improvement (page 102-110) ..............................122
What is the SST Workbook?
This workbook, developed in conjunction with the Specialized Skills Training (SST)
document, is intended to be used by Early Intervention Specialists to enhance their
knowledge of Specialized Skills Training. Specialized Skills Training is a service that is
exclusively provided by Early Intervention Specialists employed by ECI programs
(programs who contract with the Texas Department of Assistive and Rehabilitative
Services to provide Part C services). It provides information essential to delivering
effective Specialized Skills Training, and extends the EIS’s knowledge of
developmentally appropriate activities for infants and toddlers. Additionally, the
workbook provides several opportunities for the EIS to practice implementing the skills
he/she has learned.
Early intervention Specialists can earn continuing professional education (CPE) credits
for completing portions of, or the entire workbook. The amount of CPE is determined by
the amount of time spent reviewing the information and completing the activities, up to
4
December 2015
10 hours per year. Use the CPE Documentation Log to determine how many hours of
CPE should be awarded. The EIS’s supervisor will need to fill in the number of hours
and sign the certificate. (https://admin.abcsignup.com/files/{07D0901F-86B6-4CD0B7A2-908BF5F49EB0}_59/36992/SSTcertificate.pdf)
5
December 2015
Section 1 – Brain Development, Cognitive Processes
and Executive Functioning
Child Development - Review
This section provides information about brain development and the building blocks of
cognitive processes in infants and toddlers. If you need a review of general infant and
toddler development, complete the Children’s Medical Services Infant and Toddler
Development Module - http://www.cmskids.com/providers/early_steps/training/itds/module1/module1.html
Basics of Infant and Toddler Brain Development
Providers of any early intervention service must understand the basics of infant and
toddler brain development. Brain development research answers the basic question of
why early intervention is so important and why a child should not wait until he/she goes
to school to receive services. Research demonstrates the brain is the most malleable or
“plastic” during the infant and toddler years.
The brain is much more sensitive to experience in the first few years of life than
in later years.(Tierney & NELSON III, 2009)
Providing early intervention services is both an exciting opportunity, because of the
potential for rapid change and improvement, and a great responsibility, because the
intervention, or lack of appropriate intervention, can have a life-long effect on the child.
During the infant and toddler period, the brain undergoes tremendous growth and
development. A newborn’s brain is only 25% of the size of an adult’s brain. In contrast,
a three year old’s brain is 80% of the size of an adult’s. During the first three years of
life, the brain develops millions of connections, or synapses, between the existing
neurons. At its peak, the cerebral cortex creates an astonishing two million new
synapses every second (Zero to Three). These connections are strengthened or
“pruned” depending on use.
The Zero to Three website has a “brain map” that provides information about brain
development at different ages. Link to the Zero to Three brain map:
http://www.zerotothree.org/child-development/brain-development/baby-brain-map.html
The key points about brain development addressed below are the basis for many of the
early intervention evidence based practices. EISs should incorporate these principles
into their SST visits and can use brain development research to explain why the
strategies based on these principles are effective.
6
December 2015
Nutrition matters
Have you ever wondered why IDEA requires that we assess the nutritional needs of
eligible children? A baby must have adequate nutrition in order to produce new brain
cells. Children who are malnourished have brains that are smaller than normal, because
of reduced dendritic growth, reduced myelination, and the production of fewer glia
(supporting cells in the brain which continue to form after birth and are responsible for
producing myelin). Inadequate brain growth explains why children who were
malnourished as fetuses and infants often suffer lasting behavioral and cognitive
deficits, including slower language and fine motor development, lower IQ, and poorer
school performance (Zero to Three). Early intervention services will not be very effective
if the child is not receiving adequate nutrition.
Positive relationships with primary caregivers are essential
Infants prefer human stimuli over everything else. They innately orient to people's faces
and would rather listen to speech or singing than any other kind of sound. Scientists
have not discovered any special tricks for enhancing the natural wiring phase in
children's brain development. Normal, loving, responsive caregiving seems to provide
babies with the ideal environment for encouraging their own exploration, which is
always the best route to learning (Zero to Three).
Experiences influence the brain – both positively and negatively
Researchers use the
term plasticity to describe the
brain's ability to change in response
to repeated stimulation. Our brains
prepare us to expect certain
experiences by forming the
pathways needed to respond to
those experiences. For example,
our brains are "wired" to respond to
This graphic demonstrates how brain synapses
the sound of speech; when babies
increase as the child grows. It also
hear people speaking, the neural
demonstrates how certain synapses are
systems in their brains responsible for
strengthened (darker/bolder lines) through
consistent use. Source: Corel, JL. The
speech and language receive the
postnatal development of the human cerebral
necessary stimulation to organize and
cortex. Cambridge, MA: Harvard University
function (Perry, 2006). The more babies
Press; 1975.
are exposed to people speaking, the
stronger their related synapses become. If the appropriate exposure does not happen,
the pathways developed in anticipation may be discarded or “pruned”. It is through
7
December 2015
these processes of creating, strengthening, and discarding synapses that our brains
adapt to our unique environment. Because the brain adapts to its environment, it will
adapt to a negative environment just as readily as it will adapt to a positive one (Child
Welfare Information Gateway).
Myelination and Response Time
Although all of the neurons in the cortex are produced before birth, they are poorly
connected. Newborns' brains contain very little myelin, the dense impermeable
substance that covers the length of mature brain cells and is necessary for clear,
efficient electrical transmission. This lack of myelin is the main reason why babies and
young children process information so much more slowly than adults. It explains why it
might take a toddler a minute or more to begin responding to a request such as "Joey,
bring Mommy the teddy bear." Myelination of the cerebral cortex begins in the primary
motor and sensory areas, regions receiving the first input from the eyes, ears, nose,
skin, and mouth. It then progresses to "higher-order," or association regions controlling
the more complex integration of perception, thoughts, memories, and feelings.
Myelination is an extended process: although most areas of the brain begin adding this
critical insulation within the first two years of life, some of the more complex areas in the
frontal and temporal lobes continue the process throughout childhood and perhaps well
into a person's 20s (Zero to Three).
In review, watch the one minute video clip from the Discovery Channel about brain
development: http://health.howstuffworks.com/human-body/398-understanding-thebrain-development-video.htm
Cognitive Processes and Executive Function
Cognitive processes are a major focus of Specialized Skills Training. As stated in the
SST document, EISs are credentialed specialists in:
 Infant and toddler development, both typical and atypical patterns
 Early childhood cognition, motivation and how infants and toddlers learn
 Typical infant and toddler behavior and challenging behaviors (biting, tantrums,
picky eating, sleep issues)
 Infant and toddler social interactions
 Understanding how developmental areas are interconnected
8
December 2015
Additionally, IDEA includes the following information in the definition of Special
Instruction (SST):
the design of learning environments and activities that promote the child’s
acquisition of skills in a variety of developmental areas, including cognitive
processes and social interaction.
The cognitive development domain includes four components describing how young
children develop and demonstrate abilities: exploring the world around them, solving
problems, remembering and retaining information, and pretending and using their
imagination. Cognitive development is growth in children’s thinking, reasoning, and
understanding. Positive early experiences supporting cognitive development contribute
to lifelong traits, such as curiosity and persistence.
The four components of the cognitive domain are part of a cognitive process called
Executive Function. Executive function “refers to a group of skills that helps us to
focus on multiple streams of information at the same time, monitor errors, make
decisions in light of available information, revise plans as necessary, and resist the urge
to let frustration lead to hasty actions” (The Center on the Developing Child at Harvard
University, Working Paper 11).
The building blocks to executive function are skills developed over time, starting as
early as the first year of life. SST is an appropriate service to help parents learn how to
support their child’s development of executive function skills. Three building blocks for
executive function are:
i.
ii.
iii.
Working memory - which includes the ability to following multiple-step
instructions and taking turns in group activities;
Inhibitory control - which makes the following possible: selective, focused,
and sustained attention. It also includes joint attention, and the ability to take
turns; and
Cognitive flexibility - which includes the ability to switch gears and adjust to
changed demands.
Watch the 5 minute video for an explanation of the building blocks of executive function
and how they work together: Executive Function: Skills for Life and Learning (2012)
Let’s look at how the skills of executive function relate to the cognitive process of
problem solving.
9
December 2015
Problem solving requires 4 steps:
1.
2.
3.
4.
Assessing the problem
Developing a plan to address the problem
Executing the plan
Evaluating the effectiveness of the plan
Skills needed to assess the problem include working memory of the issues related to
the problem and the ability to focus (inhibitory control) on the problem. Skills to
develop a plan include working memory of the available options and inhibitory
control to arrive at the best plan. Execution of the plan requires inhibitory control and
cognitive flexibility, as seen in the ability to change priorities or fix mistakes.
Evaluation of the plan requires the use of all 3 skills: working memory, inhibitory
control, and cognitive flexibility.
Executive function includes both cognitive processes and social interaction. As noted
above, the building block, inhibitory control, includes joint attention and turn taking.
Joint attention and turn taking are also foundational social skills. Behavior issues may
impact a child’s ability to benefit from intervention for delays in other domains.
So much of a toddler’s learning involves social interaction. As a result, an early
intervention program that promotes attention to people and social cues may pay
dividends in promoting the normal development of brain and behavior.
-Dr. Geraldine Dawson, a professor at the University of North Carolina,
Chapel Hill.
Executive Function – A Lifelong Skill
A new evidence base has identified executive function skills as being essential for
school achievement, success in work, and healthy lives. The Center on the Developing
Child at Harvard University has published a new two-page summary, InBrief: Executive
Function: Essential Skills for Life and Learning (2012), outlining how these skills
develop, what can disrupt their development, and how supporting them pays off in
school and life.
10
December 2015
The Impact of Cognitive Skills on Overall Development
EISs are the child development experts on the IFSP team. As such, it is important to
identify how the intervention provided to address cognitive and/or social-emotional
delays will impact the development of a child in the other developmental domains. The
BDI Summary Sheet example below demonstrates this connection for a child with a
motor delay. In this example, we can see that Angelita’s motor delay might be impacting
her performance in other domains that require motor skills. This same concept will hold
true for children with cognitive or social-emotional delays. Young children’ development
is interconnected. A delay in one area will more than likely affect the other
developmental areas. In the next section, you will have opportunities to practice making
those connections yourself by doing an activity analysis.
11
December 2015
Executive Function – Extension
1) After you have had an opportunity to practice some of the exercises in your
workbook, you will benefit from additional training on Executive Function. The Harvard
Center on the Developing Child has a new online training module to help early care and
education providers better understand and support the development of executive
function skills. The modules were produced by the Washington State Department of
Early Learning, in collaboration with the Center's Frontiers of Innovation initiative.
2) You will need to be able to talk about SST as a service to families, and as part of
your program’s public awareness activities. Neuroscientific research on the early brain
is a critical part of the evidence base for early childhood. Yet it can be difficult to
understand and convey this information. ReadyNation, in collaboration with the Center
on the Developing Child at Harvard University, has developed and compiled an array of
tools enabling individuals without a science background to understand and present this
evidence to diverse audiences. The following are a few tools available on the
ReadyNation website. http://www.readynation.org/advocacy-toolkit/).




Heavily annotated PowerPoint presentation that can be delivered in 12-15
minutes.
Four short (3 to 9 minute) videos from the Center on the Developing Child or
Invest in US, a project of the First Five Years Fund.
Talking points to accompany any of these videos. They can be used on their
own, or embedded in a larger presentation.
Briefs from the Center on the Developing Child which detail the foundations of
lifelong health, the science of early childhood development, the impact of early
adversity on children’s development, and early childhood program effectiveness.
3) The Harvard Center for the Developing Child has developed a guide which describes
a variety of activities and games that represent age-appropriate ways to support and
strengthen various components of Executive Function and Self-Regulation in children.
http://developingchild.harvard.edu/resources/tools_and_guides/enhancing_and_practici
ng_executive_function_skills_with_children/
12
December 2015
Section 2 – Scaffolding
In addition to their strong knowledge base in infant and toddler development, EISs must
also have a thorough grasp on how infants and toddlers learn. The phases of the
learning process are:
• acquisition - learning how to do the skill
• fluency- learning to do the skill smoothly and at natural rates
• maintenance - learning to do the skill after instruction has stopped
• generalization- learning to apply the skill whenever and wherever it is needed.
One of the most frequently used models in early intervention to support children’s
learning throughout the different phases is
“scaffolding”. The term scaffolding was coined by
researchers David Wood, Jerome Bruner and Gail
Ross based on Len Vygotsky’s theory of the Zone of
Proximal Development.
The zone of proximal development (ZPD) has
been defined as "the distance between the
actual developmental level as determined by
independent problem solving and the level of
potential development as determined through problem solving under adult
guidance, or in collaboration with more capable peers" (Vygotsky, 1978, p86)
Wood, Bruner and Ross proposed once the child, with the benefit of scaffolding,
masters the task, the scaffolding can then be removed and the student (child) will then
be able to complete the task again on his own. In early intervention, much of the
scaffolding or support you will provide is through prompts. The ASD Toddler Initiative
describes and provides video examples of commonly used prompts in early
intervention: http://asdtoddler.fpg.unc.edu/prompting-module/overview-prompting/whatprompting/types-prompts (Types of Prompts page only)
The Center for Medical Services provides more information about scaffolding in early
intervention. http://www.cmskids.com/providers/early_steps/training/itds/module4/lesson2_6.html
(Note that this link will take you to the middle of the larger training module. Information about
scaffolding can be found in the middle of the page and continues until the next page – the end of
the module.)
13
December 2015
Scaffolding – Extension
The ASD Toddler Initiative has developed two modules about effectively using and then
fading prompts. Although the focus of these modules is on infants and toddler with ASD,
the strategies outlined in the modules can be used with all children in ECI.
Module 1 – Least to Most Prompting: http://asdtoddler.fpg.unc.edu/prompting/stepsimplementing/least-most-steps-implementing
Module 2 – Graduated Guidance Prompting: http://asdtoddler.fpg.unc.edu/tablecontents/steps-implementing/graduated-guidance-steps-implementing
14
December 2015
Section 3 – What Does an SST Visit Look Like?
Do you have a thorough understanding of what an early intervention visit should look
like? Click on the link to access a short video from Virginia’s Part C Integrated Training
Collaborative, about Coaching in Early Intervention:
http://www.youtube.com/watch?v=sL_WOCu3Ptg
The Making It Work Service Delivery module introduces the basic structure of early
childhood intervention visits using the early intervention coaching model as developed
by M’Lisa Shelden and Dathan Rush. As a review, a service delivery visit should consist
of the following five steps:





Joint Planning
Observation
Action/Practice
Feedback
Reflection
The specialization and individualization of the service occurs during these five steps.
Every child and family will have different discussions during joint planning, different
activities will be observed, and different strategies will be used during the action and
practice phase. Additionally, feedback will be individualized to the family and will be
based on the strategy being taught and practiced. Likewise, the reflection phase will be
individualized to the needs of the child and family.
The activities used during the action and practice phase for Specialized Skills Training
visit should:


Assist the parent in supporting their child’s development across domains with an
emphasis on strengthening cognitive skills, positive behaviors and social
interactions, and
Promote the parent’s confidence and competence in addressing their child’s
development.
Furthermore, according to Texas Rule, SST visits should “…include skills training and
anticipatory guidance for family members, or other significant caregivers to ensure
effective treatment and to enhance the child's development.” By definition anticipatory
guidance is “guidance provided by an expert or knowledgeable group to those with a
particular interest (e.g., parents), anticipating likely upcoming concerns.” (Medical
Dictionary) When provided with practical developmental information prior to significant
physical, emotional and psychological milestones, parents are better able to anticipate
15
December 2015
impending changes, maximize their child's developmental potential and identify their
child's special needs.
There are numerous examples of the types of activities that can be used during SST
visits in this workbook. Remember, each SST visit will be individualized to the needs of
the child and family. Even SST visits for the same child should not look exactly the
same from week to week. Each of the five phases of the SST visit should evolve and
change based on the child’s progress.
No matter which strategies are being used, parent or caregiver engagement during SST
is crucial for the coaching process to be effective. You can ensure parent engagement
by including “return demonstration” as part of the action/practice portion of the visit.
Return demonstration allows the EIS to ensure that the parent understands how to use
the strategy or activity the EIS has taught. Return demonstration occurs in an SST visit
when:



The parent immediately practices an activity the EIS taught.
The parent shows the EIS a videotaped example of using a previously taught
activity with the child.
The parent demonstrates how she has used the strategy during a routine and
discusses the success or challenges.
Different parents will have varying degrees of ease demonstrating their understanding
of a concept. It is important to help all parents feel comfortable with this process. If
parent learning is emphasized throughout the pre-enrollment and IFSP process, parents
will be prepared for the approach, and you will be able to move toward complete
implementation of this valuable technique.
Documenting your service is an important and necessary part of your work. You can
use your documentation as a tool to support the coaching process. You reflect with the
parent about what was planned for the family to do since your last visit, and how well
the plan was implemented; what worked and what didn’t work. You discuss and
document your observations of the parent’s demonstration of the planned activities.
This gives you an opportunity to give positive feedback to the parent, tweak the activity
in some way if needed, and demonstrate your suggestions for changes or next steps.
You then document your feedback to the parent, and together, you plan what the family
will do until the next visit. Documenting all of this information will provide the family
reminders of everything that was discussed and things to do until your next visit.
Documenting all of these things takes time, so be sure to include this time when you
plan for the visits on the IFSP. Depending on the needs of the family, you can
16
December 2015
document as you go, or at the end of the visit. More information about documentation
of SST visits can be found in Chapter 8.
Extension – Coaching Practices
Coaching Quick Reference Guide by Dathan Rush and M’Lisa Shelden:
http://fipp.org/static/media/uploads/briefcase/briefcase_vol1_no1.pdf
Tips and Techniques for Effective Coaching Interactions by Dathan Rush and M’Lisa
Shelden: http://fipp.org/static/media/uploads/casecollections/briefcase_vol1_no2.pdf
Common Misconceptions about Coaching in Early Intervention by Dathan Rush and
M’Lisa Shelden:
http://fipp.org/static/media/uploads/casecollections/caseinpoint_vol4_no1.pdf
17
December 2015
Section 4 – Behavior and Social Emotional Skills
Challenging Behavior
During your work as an SST provider, you’re likely to encounter defiance, aggression
and other challenging behavior from the children you see. Toddlerhood in particular is a
time for children to learn the bounds of acceptable behavior. This is demanding for early
intervention providers, because the criteria for what is acceptable vary across cultures
and families. Even within a single family, it’s common for caregivers to disagree about
which behaviors are appropriate, and to have different ideas about the best way to
manage challenging behavior. As an EIS, you may be asked to help families deal with
typical toddler behavior problems. In other situations, you may recognize behavior
challenges, such as frequent or prolonged tantrums, are getting in the way of working
on and meeting IFSP outcomes.
All children benefit from having their social-emotional development supported through
positive and responsive relationships
with their parents and primary
caregivers. Therefore, the foundation for
all ECI services, including SST, is
responsive and supportive caregiving
practices. However, as demonstrated in
this graphic, some children need
intervention that is beyond positive
relationships and supportive
environments to address their delayed or
atypical social-emotional skills. This
chapter offers some strategies for
working with parents and caregivers to
address these challenging behaviors.
18
December 2015
Causes of Challenging Behavior and Strategies for Managing Them
Issue Related to
Challenging Behavior
Typical Development
Why It May Lead to Behavior
Problems
 Emotional and neurological response
to learning new skills (“Touchpoints”)
 Testing increased autonomy
 Anxiety about new experiences
Behaviors You Might See
Strategies To Try
 Refusing to comply with
instructions
 Tantrums or crying for no
apparent reason
 Waking during the night
(after sleep patterns have
been established)
 Saying “No” to every offer,
even those he or she wants
 Mild aggression toward other
children and familiar adults
 Consolable fear of situations
or people that did not bother
the child before
 Provide anticipatory guidance to
parents (See the Touchpoints
series by Brazelton for more
information)
 Help parents reframe
challenging behavior as a
typical response to new skill
development
 Help parents recognize positive
behaviors to reward
 Model and encourage parents to
ignore tantrums
 Help parents identify ageappropriate consequences for
aggression
19
December 2015
Issue Related to
Challenging Behavior
Environmental Triggers
Why It May Lead to Behavior
Problems
 Too many choices leading to
overstimulation or distraction
 Lack of opportunities for ageappropriate exploration
 Sensitivity to:
o Noise levels
o Particular noises (e.g. vacuum
cleaner)
o Temperature
o Crowds
o Itchy clothing
o Visually “busy” environments
Developmental Delays
Trauma
Behaviors You Might See
Strategies To Try
 Tantrums for no discernible
reason
 Screaming or crying for no
other reason
 Inattention to other people
 Acting without regard to
personal safety
 Withdrawing to another
environment
 Hyperactivity
 Help parents identify
environmental factors that might
cause discomfort
 Introduce potential triggers
gradually and pair with
something the child enjoys
 If problems are severe or
persistent, consult with OT to
see if sensory strategies might
be appropriate
 Frustration due to the child’s inability to
use skills (such as words to indicate
wants, or to move across the room to
get a toy)
 Parent’s inability to read the child’s
nonverbal cues, which may differ from
those of typical children
 Parental expectations for the child to
have the skills of a typically-developing
child
 Tantrums
 Aggression
 Overly sensitive neurological response
to even minor stressors sets off “fight
or flight” behavior
 Heightened wariness of danger
 Tantrums
 Aggression
 Sleeplessness
 Changes in appetite
 Help parents understand the
roots of the child’s frustration
 Help the parents teach the child
compensatory skills (e.g. signs if
the child’s words are
unintelligible)
 Identify and alert the parents to
cues the child is becoming
frustrated, is hungry, etc. to
prevent the undesirable
behavior
 If you suspect a child’s
challenging behavior is a result
of trauma, refer to a
professional with socialemotional expertise (e.g.
20
December 2015
Issue Related to
Challenging Behavior
Executive Functioning
Problems
Why It May Lead to Behavior
Problems
 Sense of uncertainty, helplessness and
lack of control
 Attachment problems, if abuse or
neglect occurred
 Reduced ability to connect
consequences with behaviors
 Difficulty focusing
 Difficulty transitioning from one activity
to another
 Reduced ability to interpret social cues
 Difficulty adapting to new environments
or changes in familiar ones
 Difficulty with delayed gratification
 Difficulty with listening attention and
processing auditory information
Behaviors You Might See
 Physical and emotional
withdrawal
 Nightmares
 Overly friendly and
affectionate to strangers
 Ritualized self-calming
behaviors
 Anxiety or fearfulness
 Hypervigilance
 Inattention
 Doesn’t follow rules
 Doesn’t seem to learn from
consequences
 Lack of awareness of safety
issues
 Aggression
 Hyperactivity
 Impulsivity
 Difficulty socializing with
other children
Strategies To Try
LMSW, LPC, Psychologist) with
expertise in very young children
 Teach caregivers to make sure
they have the child’s attention
before they speak to him
 Help the family find outlets for
the child’s high activity level
 For older children, play games
that reinforce paying attention
and not acting on impulse (e.g.
Mother May I, Simon Says, Red
Light/Green Light, Ring Around
the Rosey)
 Pair spoken information or
instructions with visual cues
 Make sure consequences are
immediate and of a short
duration
 Consult OT, SLP and/or
licensed professional with
expertise in social-emotional
development (e.g. LPC, LMSW)
if strategies are unsuccessful
21
December 2015
Issue Related to
Challenging Behavior
Medical/Physical Issues
Why It May Lead to Behavior
Problems
 Physical pain or discomfort decrease
ability to focus and learn
 Invasive or painful procedures may
result in trauma
 Side effects of medication can include:
o Increased activity level
o Gastric problems
o Increased aggression
o Drowsiness
o Sleeplessness
Parenting Issues
 Lack of consistency
 Expectations for the child to progress
and learn like typically-developing
children
 Ineffective or overly-harsh
consequences
 Lack of child development knowledge
Behaviors You Might See
Strategies To Try
 Inattention/lack of focus
 Frequent, inconsolable
crying or screaming
 Withdrawal
 Hyperactivity
 Aggression
 Help parents find the best times
of day for different activities
 Teach parents to use activities
the child finds calming or
stimulating depending on what
the child needs
 Accompany parents to medical
appointments to help them
explain any problematic side
effects
 Help parents establish calming
bed time routines if sleep is a
problem
 Consult RN, dietitian, OT or
licensed professional with
expertise in social-emotional
development (e.g. LCSW, LPC)
if strategies are unsuccessful
 Tantrums
 Aggression
 Withdrawal
 Doesn’t follow rules
 Anxiety
 Help parents develop ageappropriate consequences for
problem behaviors
 Provide anticipatory guidance
and other information on both
typical and delayed child
development
 Help parents identify when they
are not being consistent
 If concerns persist, consult a
licensed professional with
expertise in family relationships
(e.g. LPC, LCSW)
22
December 2015
Why do toddlers tantrum as frequently as they do?
Toddlers are known for their ability to go-go-go! Their high energy level, along with
increasing physical motor development, allows them to explore their curiosity and test
limits as their world expands. Because they are still developing executive function, this
can often lead to tantrums and behavior issues.
23
December 2015
The following table provides a list of comments parents might make during
a visit. There are several blanks at the end of the table to add in comments
that you have heard. This activity will help you develop a repertoire of
developmentally appropriate suggestions that can address parents’
concerns about their child’s behavior.
Consider what a more developmentally appropriate expectation would be, how you
would respond, and what strategies you would recommend when discussing behavior
concerns with a parent or caregiver. Fill in the blanks with your answers. Check with
your supervisor or an experienced EIS to see if he/she agrees with your responses and
suggested strategies.
What a parent
might say…
Clara does not like
books—she will flip
through pages
quickly while I try to
read to her.
Developmentally
appropriate
expectation…
Being able to focus
for a shorter period
of time, like pointing
and naming 1-2
pictures a page.
How you would
respond…
Strategies…
Toddlers have
shorter attention
spans and
sometimes have to
build up their
attention span
Start by sitting and
naming 1-2 pictures
a page, instead of
reading. Look at
books just after
snack time (if child
is sitting in a high
chair)
Now You Try
Gracie is hyper—
she will not sit still
to watch a movie
with us.
Ryan makes a
mess when he
feeds himself, but
he insists on doing
it alone and spills
half of his food on
the floor.
Ethan is
impatient—he
throws a tantrum at
the grocery store
while I’m doing the
weekly shopping.
24
December 2015
What a parent
might say…
Developmentally
appropriate
expectation…
How you would
respond…
Strategies…
Joaquin gets angry
when I don’t
understand what
he wants. He will
cry and scream
when I ask him to
tell me what he
wants.
Omar cries when
it’s time to leave
the park even when
I’ve told him we
can only stay for 30
minutes.
Elena does not like
to share her toys.
She will snatch
them away and say
“mine!”
25
December 2015
Toileting
Even parents of typically-developing toddlers may view toilet-training as a particularly
stressful task. The problems with toilet-training can be compounded with children with
disabilities or delayed development. Here are some tips to help parents and other
caregivers with toilet-training.
1. Make sure the child has the necessary skills to successfully learn to use the toilet
independently. These include:
 Feels discomfort when diaper is wet or dirty.
 Can effectively communicate needs.
 Can get to the bathroom independently.
 Can pull pants down independently.
If the child doesn’t have these skills, he/she may not be ready for toilet-training.
2. Help the parent identify effective reinforcers for the child that can be given quickly
after the desired behavior (sitting on the toilet for 3 minutes, urinating in the toilet,
etc.).
3. Start slow. See how long the child can sit on the toilet without getting up and
build from there.
4. Remind families to reinforce even small improvements. For example, if the child
was able to sit on the toilet for only 30 seconds before getting up, but is now able
to stay there for two minutes, he/she should be rewarded with praise or some
other reinforcer.
5. Make sure the child is getting plenty of fluid during the morning and early
afternoon.
6. Help families identify the best time to toilet-train in relation to meals and snacks
(for example, 30 minutes after eating).
7. Start toilet-training during a time when the family will be spending most of their
time at home, not when lots of appointments outside the home are scheduled.
8. Remind parents toilet-training is a time-consuming process. It should not be
started if caregivers don’t have much time to devote to the task.
9. Help the parent find ways to entertain the child while he/she sits on the toilet.
10. Remind parents toileting accidents are common in young children, and a child
should never be punished for these.
For additional tips on toilet training, visit: http://www.aota.org//media/Corporate/Files/AboutOT/consumers/Youth/Establishing-Toileting-Routines-forChildren-Tip-Sheet.pdf
Notes:
26
December 2015
Challenging Behavior and Social Emotional Skills – Extension
The Backpack Connection Series was created by Technical Assistance Center on
Social Emotional Intervention (TACSEI) to provide a way for teachers, early
interventionists and parents/caregivers to work together to help young children develop
social emotional skills and reduce challenging behavior
http://www.challengingbehavior.org//do/resources/backpack.html
TACSEI's "Making Life Easier" series is designed specifically for parents and
caregivers. This series of tip sheets contains valuable information on how to make often
challenging events easier to navigate, and even enjoyable, for both caregivers and
children.
http://www.challengingbehavior.org/do/resources/making_life_easier.html
The Center on the Social Emotional Foundations for Early Learning has designed
learning modules that provides guidance on infant and toddler social-emotional
development and responsive routines, environments and strategies to support an infant
or toddler’s social emotional development. The modules can be accessed at this link:
http://csefel.vanderbilt.edu/resources/training_infant.html. Participants should view the
PowerPoint, read the PowerPoint notes, review the video clips and complete the
activities.
The Center on the Social Emotional Foundations for Early Learning has also developed
a video about promoting social emotional competence. The video is 30 minutes long.
http://csefel.vanderbilt.edu/resources/social_emotional_competence.html
This guide from the Center on the Social Emotional Foundations for Early Learning
addresses biting: http://csefel.vanderbilt.edu/documents/biting-parenting_tool.pdf
The Center on the Social Emotional Foundations for Early Learning has also developed
a “What Works” series. These tip sheets are available in English and Spanish.
http://csefel.vanderbilt.edu/resources/what_works.html
Beyond Use Your Words: How Babies Begin to Develop Self –Control in the First Three
Years (Podcast – 24 minutes):
https://s3.amazonaws.com/zttpodcastseries/podcast/Brenda%20Jones%20FINAL.mp3?
s_src=podcast&s_subsrc=self_control
27
December 2015
Early Experiences Count: How Emotional Development Unfolds Starting at Birth
(Podcast – 23 minutes):
https://s3.amazonaws.com/zttpodcastseries/podcast/Ross%20Thompson%20FINALvs.
mp3
Shh, Shh, It’s Okay: Coping With Crying in Babies and Toddlers (Podcast – 23
minutes):
https://s3.amazonaws.com/zttpodcastseries/podcast/Pam%20High.mp3?s_src=podcast
&s_subsrc=crying
Establishing Bath Time Routines for Children (Two page tip sheet)
http://www.aota.org//media/Corporate/Files/AboutOT/consumers/Youth/BathTimeTipSheet.PDF
28
December 2015
Section 5 – Developmental Strategies and Activities
Normal, loving, responsive caregiving seems to provide babies with the ideal environment
for encouraging their own exploration, which is always the best
route to learning (Zero to Three).
This section will review the following:
 Ideas to support the family to help their child’s
development
 Strategies that fit into infant/toddler and family routines
 Developmentally appropriate activities
Watch the Serve and Return video from the Harvard University
Center on the Developing Child for more information about how
interactions from caregivers influence the architecture of a
child’s brain:
http://developingchild.harvard.edu/resources/multimedia/videos/three_core_concepts/serve
_and_return/
Responsive Caregiving
What is it?
Responsive caregiving is
a style of interaction in
which caregivers take the
time to pay attention to
what a child is signaling,
and then provide a
response meeting the
child’s needs in a loving
way.
How can parents be
responsive?
There are many kinds of
behaviors caregivers can
use to be responsive;
such as, voice tone, facial
expression, affection, and
talking about the child's
interest and ideas.
Why is it important
to Early Intervention
Specialists?
An EIS's knowledge of
Responsive Caregiving
can support the parents
in promoting their child's
development in all
domains.
29
December 2015
Responsive Caregiving
During this
period, brain
development
occurs at a very
rapid rate in
response to each
child’s early
experiences
The first three
years of life
are the most
important
years.
Research is clear
that Responsive
Caregiving is critical
to a child’s early
development.
The quality of these early learning experiences is
shaped by three factors: the caregiver with whom
the child spends his or her time, the child’s
nutrition, and the child’s environment.
30
December 2015
Responsive Caregiving
Observe
needs
Build safe
environments
for
exploration
Respond to
childs needs
Modulate
voice tone,
eye gaze and
facial
expression
Give
affection
Set limits
31
December 2015
There are many
kinds of
behaviors
caregivers can
use to be
responsive.
32
December 2015
Routines, Natural Environments and Familiar Adults
Responsive Feeding Practices
When therapeutic activities are embedded into the child’s and family’s
daily routine – the environment becomes therapeutic.
Feed infants directly and
assist older children when
they feed themselves
Feed slowly and patiently,
and encourage children to
eat, but do not force them
If children refuse many
foods, experiment with
different food combinations,
tastes, textures, and
methods of encouragement
Feeding times are periods of
learning and love – talk to
children during feeding, with
eye to eye contact.
Minimize distractions during
meals
Embed every activity into the child and family’s daily routines.
33
December 2015
Daily routines are meaningful contexts for young children to learn new skills because
they are predictable, functional, and occur numerous times throughout the day.
Interventions can be integrated into play, caregiving, and other activity based routines.
The following table gives examples of how activities can be built into the daily life of the
child. These examples are only a few ideas in which routines and activities can be used.
IFSP Outcomes
Daily Home
Routines
Ashley will say juice or
water to ask for
something to drink at
meal time or snack time
at least twice a day for
three weeks.
Ashley will walk
without having her
hand held to the
car from the house
in the morning and
from the car to the
house in the
evening daily for
two weeks.
Ashley will point to at
least three pictures
when named during
her bedtime story
every night for a
week.
Waking Routine
Greet her when she
wakes and cue her to
either put her hands up
or vocalize/verbalize a
request for assistance
out of her bed.
N/A
N/A
Breakfast
Give her options
between two food items
and/or drink items (e.g.
Do you want the
Cheerio’s or the
yogurt?). Have Ashley
verbalize a choice.
Model the words for her
to imitate.
Point to the eating
area, and ask her
to walk pushing her
walker to the
breakfast area.
Show a picture book.
Talk or sing about
the pictures in the
book. Point to each
picture when you talk
about it.
Offer hand to walk
her to changing
area.
Read picture books
which discuss
toileting.
Bathing/Toileting Ask her if she needs
or Dressing
her diaper changed,
encouraging her to
imitate “yes” or “no”.
34
December 2015
Snack Time
Give a small amount of
food or drink and ask if
she wants more, asking
her to sign or verbalize
“more”.
Point to high chair
and ask her to walk
to it. Provide
support if needed.
N/A
Play Time
Give her options
between two toys or
play objects. Model the
words she needs to use
to express her choice.
Assist her to play
ball (throw and
catch) while she is
standing.
Make a book with
photographs of
family members and
pets. Encourage her
to point to each
family member when
named. Assist her in
turning the pages.
Now You Try:
This exercise will help you develop a collection of activity strategies that can
be used to work on a variety of IFSP outcomes. Pick three outcomes from a
recent IFSP you developed. Fill in the outcomes at the top of the table and
add in activity ideas for each of the applicable routines. You may also add in
different routines at the end of the “daily home routines” column.
IFSP Outcomes
Daily Home
Routines
Waking Routine
35
December 2015
Breakfast
Bathing/Toileting
or Dressing
Snack Time
Play Time
.
Notes:
36
December 2015
Development and Learning
The development of a child into a highly complex being occurs synchronously across all
domains of development. Skills in the Gross/Fine Motor, Cognitive, Social/Emotional,
Speech, Language, Communication and Self Help/Adaptive domains develop together
in a continuous spiral with lower level skills laying the foundation for the emergence of
the next higher level skill.
Since the child is a holistic being and cannot be compartmentalized into any one
domain, it is the engagement of the whole being in various activities that leads to the
development of skills and learning. Learning occurs when the child actively engages in
and frequently practices skills, receives timely and appropriate motivation and feedback,
and when the activity occurs in an enjoyable setting involving personal interactions and
a considerable level of personal support with familiar adults.
Activity Analysis
Many of the enjoyable activities children engage in everyday cross developmental
domains. Activity analysis serves as a frame of reference when activities are identified
to address outcomes and developmental needs, and can show the connection of why
you using a particular activity.
Sample questions to ask (age ranges and activity are specific to this example):



Activity
Ball
throw
and catch
with
familiar
adult
How many developmental domains does this everyday play activity for children in
the age group of 30-36 months impact?
What skills are needed for a 30 month old child to engage in ball play for 5
minutes?
How can this activity be modified/graded/individualized for this child?
Gross
Motor
Fine Motor
Yes –sitting,
transitions,
standing,
crawling,
walking
Yes-midline
orientation,
bilateral
coordination,
eye-hand
coordination
Cognitive
Social/
Self Help
Speech/
Language/
Communication
Yes Balance,
following
directions,
bilateral
coordination
Yes –
turn-taking,
following
directions,
verbalizations
during
interaction,
requesting
Emotional
Yes attention,
working
memory,
inhibitory
control,
problem
solving
Yesmeaningful
interaction
with
significant
adult
37
December 2015
More examples:
Activity
Gross Motor
Fine Motor
Cognitive
Social/
Emotional
Self Help Speech/
Language/
Communication
Points to
and labels
pictures;
answers
simple
questions;
listens to
stories
read aloud
Yespositioning
(prone/sitting/
tall kneel/
standing)
Yes –
follow with
finger/finger
isolation/
visual
tracking/
localization
Yesattention,
memory,
processing
Yes –
bonding/
meaningful
interaction
N/A
Yes – receptive
and expressive
naming (nouns,
verbs,
adjectives, etc.),
wh-questions,
auditory attention
Activity
Gross Motor
Fine Motor
Cognitive
Social/
Emotional
Self Help
Speech/
Language/
Communication
Kicking
ball
Yes –
standing,
balance,
maintenance
of balance on
one foot while
kicking
No
Yes attention,
working
memory,
inhibitory
control,
problem
solving
Yesmeaningful
interaction
with
significant
adult
Yes balance,
following
directions,
bilateral
coordination
Yes – turntaking, following
directions,
verbalizations
during
interaction,
requesting
38
December 2015
Cognitive and Social-Emotional Development and Activities
The root skills needed to develop higher level cognitive processes, such as executive
function, develop during the infant and toddler period. These skills include working
memory, which is the ability to retain and work with information in the brain (WM);
inhibitory control, which is the ability to focus attention and filter distractions (IC); and
cognitive flexibility, which is the ability to switch mental or cognitive gears (CF).
Executive function includes both cognitive processes and social interaction.
Cognitive
Inhibitory Control
(IC)
Working Memory
(WM)
Cognitive
Flexibility (CF)
Social and emotional development is a broad domain which encompasses many skills
forming the foundation all children need to become healthy, happy, and successful
adults. Social/emotional skills include attachment/separation/autonomy (ASA),
development of self (recognizing others are there) (DS), and learning rules and
expectations- social interaction and play (RSI).
Social Emotional
Attachment/
Seperation/
Autonomy (ASA)
Development of Self
(DS)
Learning Rules and
expectations- social
interaction and play
(RSI)
39
Cognitive/Social-Emotional Activity Table
The following table explains how activities address the various components of cognitive and social-emotional domains.
June 2015
40
Age in
months
0-6
6-12
12-18
18-24
June 2015
Activity
Sing lullabies
and tell the
baby nursery
rhymes. Use a
soft and gentle
voice when
talking to
baby.
Hide toy under
cloth within
child’s reach,
remove cloth,
instruct child
not to touch,
hide toy
slightly out of
reach, remove
cloth
Take turns
rolling a ball
back and forth.
Story time-let
the child
choose books
WM
IC
CF
ASA
DS
RSI
Baby
remembers
familiar
voices
Soothing
voices help
baby resist
crying
Understands
different voices
may sing same
song
Becomes
attached to
soothing
voices
Identifies
preferred
voices or
songs
Response to
songs or
rhymes
promotes
social
development
Object
permanence
Not to touch
Seek other
methods of
retrieval
Autonomy
Not to
touch
Learns rules
Child has to
remember
what he/she
is supposed
to be doing
when it’s
his/her turn
again
Child
remembers
familiar
Joint
attention;
child has to
be able to
release the
ball and give
the adult a
turn
Wait to turn
the page
Understand
adjustments may
be made in the
way the partner
rolls the ball (e.g.
different
direction/to a
different partner)
Understanding
books come in
different sizes
Autonomy
Identifies
the turntaking
partner(s)
Learn
expectation of
returning the
ball once it is
received—
promotes turntaking skills
Becomes
attached to
Feels like
he/she is
in control
Learns rules of
turn taking and
reading (right
41
24-30
30-36
June 2015
to read and
help turn
pages, and
help him/her
name what
he/she sees.
Teach the
child simple
finger play
songs, like
“Eensy
Weensy
Spider” where
he/she can use
his/her fingers.
objects,
actions
Child has to
remember
the words to
the songs
and
remember
the finger
plays that go
with each
song
Make a “Me
Child has to
Book” with the remember
child. (Create a names of
book with
special
construction
people and
paper and
things, and
place pictures events
of familiar
occurring
adults in the
within each
book).
picture
and shapes, and
may have
several different
reading partners
reading
partner
of the
side up, turn
reading
page by page)
(by turning
pages)
Child has to
use the
appropriate
hand
movements
at certain
times
Ability to recall
which finger play
goes with which
song
Autonomy
Has to
attend to
and model
the
caregiver
who is
teaching
the finger
play
Response and
interaction to
songs and
finger plays
promotes
social
interaction and
play
Conversation
al turn-taking
Basic
Autonomy
understanding of
different
relationships with
the different
people in the
book.
Identifies
and
discusses
family
members
and
others in
life
Learns social
interaction and
conversational
rules
42
Activity Suggestions
0-2 Months
Call name when
approaching to
encourage head
turning from side to
side in supine.
Play Peek –a- Boo,
sing nursery
rhymes, tell stories
while holding child
in prone over
mothers tummy.
Hold child firmly, talk
to the child and rock
gently.
Anticipate child’s
needs. Keep
diapers and bottle
ready.
Use bright
mobiles,
rattles, or
squeaky toys
within 8-12
inches of
child's eyes.
Play in front of mirror,
label body parts,
repeat child's name ,
wait for eye contact
and response, and
reward child with
smile.
Encourage head
lifting in
prone/supine,
support at
shoulders while
handling during
daily routines.
June 2015
43
Activity Suggestions
0-2 Months
Move toys across
midline,
encourage
turning, talk and
sing to child while
looking into eyes.
Encourage rolling
supine to prone,
propping on arms
and hold in
supported sitting
while talking and
singing to child.
Lay child on side
with toys in front
to encourage
turning to side.
June 2015
Alternate
position of toys,
light source and
mobiles so child
will turn to look
at different
sides.
Lay child on
stomach with
pillow under chest
to encourage head
lifting.
Touch child’s
hand with object
then move it away
to encourage eye
tracking and
reaching with
hands.
44
Activity Suggestions
2–6 Months
At bedtime use
soothing voice to
calm; a music
box to lull baby
to sleep; sing
lullabies .
Repeat and
emphasize
child's name and
names of other
family member
when you talk to
child.
Tie soft colorful
ribbons around
ankles and wrists
when the baby
will have
constant
supervision.
Respond
quickly when
infants are
hungry by
feeding,
holding, and
cuddling them.
Caring for young
children with
disabilities or special
needs is the same as
caring for all young
children. All children
need love, good
nutrition, safety,
guidance, and positive
stimulation.
Bring child’s
attention to
hands and feet,
toes and fingers.
June 2015
Talk with infants
about what is
happening when
bathing, diapering,
and dressing.
(“Now I am
washing your
arms.”)
Show enthusiasm
for sounds made
through facial and
vocal expression
e.g. "Did you hear
that? A bell
ringing!"
45
Activity Suggestions
2-6 Months
 Listen to and sing with infants often, especially during daily routines, such
as feeding and diaper changes.
 Give infants safe toys that produce interesting results or movements in
response to their actions (cause and effect toys).
 Hold, cuddle, hug, smile, and laugh with infants.
 Hold during bottle feeding times, and talk with them in a calm and soothing
tone. Use the child’s name often during your conversations throughout the
day.
 Notice, understand, and follow the signals of infants, such as cries for
hunger or pain, turning away when full, or when ready to stop interacting.

Notice infants’ reaction when new people enter the room and introduce new
people by name to the infant.

Create surroundings without a lot of loud noises and distractions.

Place objects with different shapes, sizes, textures, and sounds within infants'
reach (make sure the objects are safe to mouth).

Name and describe objects infants are exploring and encourage them to
continue to play with the objects by telling them you like their “music” or banging.

Play “sound localization” games. Select a few sound makers – jingle bells,
rattles, crumpling paper, squeaky toys – make sounds 2 to 3 times, 5 to 7 inches
from babies face and wait for response. Repeat the activity from a different
direction and each time wait for baby to make eye contact with the sound maker.
What are your activity ideas?
June 2015
46
Now You Try:
Activity analysis will allow you to determine which developmental areas
are addressed when using a specific activity. Knowing this information is
critical when documenting how your SST service helps the child meet
his/her developmental outcomes and when explaining to parents and
caregivers why you are suggesting certain strategies. Pick some of the
activities from pages 40 – 44 and analyze them as demonstrated on pages 36-37. You
can review your analysis with your supervisor or another experienced EIS.
Activity
Gross Motor
June 2015
Fine Motor
Cognitive
Social/
Emotional
Self Help
Speech/
Language/
Communication
47
Analyze these activities even further by identifying some of the activities from the
previous table addressing cognitive and social/emotional development and determine if
they address the individual components of social/emotional and cognitive development.
Examples of this analysis can be found on pages 38-40. You can review your analysis
with your supervisor or another experienced EIS.
June 2015
48
Cognitive/Social-Emotional Activity Table
Activity
June 2015
WM
IC
CF
ASA
DS
RSI
49
Notes:
June 2015
50
Activity Suggestions
6-12 months
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Share books with older infants. Show them books with
interesting colors, patterns, pictures, and textures.
• Notice when older infants drop items and pick them up, and
allow them to repeat the dropping action.
• Allow older infants to touch your face, skin, or hair and name
body parts (“That’s my nose. Here’s your nose.”).
• Provide toys and objects that make noise, and create
opportunities to make and listen to different sounds together
(crunch leaves or bang on pots and pans).
• Notice and respond positively to older infants’ desire to play
games over and over again.
Create an environment that encourages discovery, and give uninterrupted playtime.
Give older infants safe toys to repeat motions, such as rocking, sliding, or balancing.
Engage and play alongside older infants.
Celebrate when older infants learn how to use a toy or object.
Recognize toddlers' interest in the natural world and help describe what they see,
hear, and experience.
Explore surroundings and talk about how things are similar and different.
Keep toys around that respond to older infants’ actions, such as pop-up boxes,
squeaky toys, and musical instrument toys.
Create a variety of safe spaces and objects for older infants to crawl over, around,
and through.
Give older infants similar toys of different sizes they can nest (bowls, measuring cups,
nesting cups).
Show excitement when older infants discover
new uses for things (putting blocks in a box or
pot).
Keep containers filled with objects around and
encourage filling and emptying the containers.
Watch for and encourage older infants’ use of
words, signs, and gestures, such as pointing
and reaching to signal what they want.
Play hide-and-find games by placing a toy under a cloth or other cover for older
infants to find.
June 2015
51
Activity Suggestions
6-12 months
•
•
•
•
•
•
•
•
•
•
•
•
•
Talk about familiar caregivers when they are not present.
Recognize older infants' favorite books and read with them
over and over again.
• Comment when older infants remember something belongs
to you or someone else (“Yes, those are Luna’s shoes.”).
• Notice and be responsive to older infants’ words, gestures,
laughs, gazes, and cries.
• Stay close by as older infants explore.
• Reassure older infants you will return when you need to
leave, explaining where you are going and when you will be back.
Introduce older infants to new people and allow them time to become comfortable.
Respond quickly and sensitively to toddlers’ emotional and physical needs.
Encourage sitting. Seat child between parents’ legs with hands bearing weight and
engage child with talking, singing, toys. Encourage and support transitions from prone
to all fours to sitting. Encourage crawling.
Encourage child to lift hips during diaper change. Facilitate by holding thighs and
bounce up and down.
Hold child in standing and bounce to music.
Encourage activities like going to a playground where the child can swing, slide, play
in a sand box and water play.
Place child in side sitting with picture book/toys in front to encourage weight bearing
on one side while engaging other hand in activity.
Stand the child between parents’ legs while parent is seated on a chair to encourage
supported standing. Parent can sing songs, rhymes,
and talk with the child.
Arrange furniture to encourage pull to stand and
cruising along furniture.
Draw happy face on feet/ hands to encourage
playing with hands, feet, fingers, and toes.
Pause during rhythmic bouncing or rocking game,
wait for child to indicate for more, or ask “do you
want more?” - then say “OK’ and resume game.
June 2015
52
Activity Suggestions
6-12 months
• Demonstrate action of toys, e.g.: banging blocks, spinning a top, winding a toy, and
•
•
•
•
•
turning on a radio. Wait to see if child follows. Give plenty of time for the child to
explore own methods. Express delight when child can imitate action. During playtime,
offer second toy. Wait for child to reach with other hand.
Play lots of social interaction games (peekaboo, pat-acake, I’m-going-to-get-you, etc.).
Use a variety of facial expressions during interaction and
to communicate feelings.
Encourage visual tracking by using brightly colored and
shiny toys, bringing them close to child’s face (8 inches
away), and moving them side to side and up and down.
Present in sitting, prone or on all fours objects like large
knobbed puzzles, small cones, rice/bean bins, musical
instruments, blocks, books, and differently textured toys.
Play with noisy materials.
Play with small edible objects, like cheerios, rice crispies, food-bananas, and soft
macaroni.
What are your activity ideas?
June 2015
53
Now You Try:
Activity analysis will allow you to determine which developmental areas are
addressed when using a specific activity. Knowing this information is
critical when explaining to parents and caregivers why you are suggesting
certain strategies. Pick some of the activities from pages 49-51 and
analyze them as demonstrated on pages 36-37. You can review your
analysis with your supervisor or another experienced EIS.
Activity
Gross
Motor
June 2015
Fine
Motor
Cognitive
Social/Emotional
Self Help
Speech/
Language/
Communication
54
Analyze these activities even further by identifying some of the activities from the
previous table addressing cognitive and social/emotional development and determine if
they address the individual components of social/emotional and cognitive development.
Examples of this analysis can be found on pages 38-40. You can review your analysis
with your supervisor or another experienced EIS.
June 2015
55
Cognitive/Social-Emotional Activity Table
Activity
June 2015
WM
IC
CF
ASA
DS
RSI
56
Notes:
June 2015
57
Activity Suggestions
12-18 months
• Describe in simple language (to the toddler) how toddlers can use their bodies to
•
•
•
•
•
•
•
•
•
make things move or change.
Model how toddlers can do different activities with toys (throw a ball into a basket).
Provide toys that require pushing, pulling, pouring, sorting, and matching.
Accept knowing toddlers will need comfort items (blanket, favorite toy, pacifier, etc.)
to bring with them on trips or visits to new places.
Connect with toddlers at naptime or
bath time.
Respond with affection and care
when approached by upset or hurt
toddlers.
Games: Creep through a maze of
boxes; a cloth tunnel, on uneven
surfaces (soft mattress on bed).
Stand child with back support by a
corner, let child hold large toy which
requires 2 hands, like ball play.
Practice independent standing –hold from behind and briefly let go; place child in
standing with a low stool/coffee table in front and encourage activities with both
hands (crumpling paper).
Place child in kneeling with a low coffee table/stool in front of him/her and encourage
bilateral activities such as making bubbles with an eggbeater in a bowl of soap
solution.
June 2015
58
•
Place child in half kneel in
front of a coffee table and engage
in two handed activities like
putting coins through a small
opening in a milk carton or piggy
bank.
• Stoop and recover activities- Have child sit on a stool. Encourage him/her to lean
•
•
•
•
•
•
•
•
•
down and pick up toys; repeat in kneel, half kneel and supported standing in front of
furniture.
Walk with bilateral support.
Walk with unilateral support/independent walking.
Utilize toys within a home; stacking toys, cups for pouring/ drinking, seriate baskets,
spinning toys, push/pull toys, musical instruments, nesting baskets, in-set puzzles,
piggy bank games.
Find a toy when it’s being moved/hidden. Hide toy under napkin and say “look under
your napkin!”
Finger paints.
Wind-up toys.
Picture books with shapes, colors, objects, sizes and animals.
Pointing games – pointing to communicate – picture books ask “where is the ____”,
wait for child to point to the correct named picture.
•
Play pointing games with friends, extended family and
pets.
•
Teach child to interpret pointing (“you are pointing to
the juice – do you want to drink?”).
•
Squeaking books.
•
Give simple directions to encourage listening and
following – include two objects (“Give me cup and spoon” and “Thank you for the
napkin and cup”). Repeat request if child doesn’t follow immediately.
Identify simple body parts (heads, knees, toes, tummy, etc.).
June 2015
59
What are your activity ideas?
June 2015
60
Now You Try:
Activity analysis will allow you to determine which developmental areas
are addressed when using a specific activity. Knowing this information is
critical when explaining to parents and caregivers why you are suggesting
certain strategies. Pick some of the activities from pages 56-57 and
analyze them as demonstrated on pages 36-37. You can review your
analysis with your supervisor or another experienced EIS.
Activity
Gross
Motor
June 2015
Fine Motor
Cognitive
Social/Emotional
Self Help
Speech/
Language/
Communication
61
Analyze these activities even further by identifying some of the activities from the
previous table addressing cognitive and social/emotional development and determine if
they address the different components of social/emotional and cognitive development.
Examples of this analysis can be found on pages 38-40. You can review your analysis
with your supervisor or another experienced EIS.
June 2015
62
Cognitive/Social-Emotional Activity Table
Activity
June 2015
WM
IC
CF
ASA
DS
RSI
63
Notes:
June 2015
64
Activity Suggestions
18-24 months
• Use the terms girl, boy, man, woman as opportunities arise during daily activities.
•
•
•
•
•
•
•
•
•
•
•
Gender discrimination at this age is based on clothing, hair, and name.
Identify gender of characters in picture books. Ask
“which child is the girl? Where is the boy?”
Match identical pictures by using family members
to match pictures.
During story time, choose story books with large,
colorful, uncomplicated pictures, few words on
each page, simple plot and sequence of events,
topics relevant to young children, and essential
phrases repeated throughout the story (e.g. Brown
Bear, Brown Bear).
Describe the function of body parts when they are
named during daily activity (Nose to smell flowers,
eyes to see colors, ears to hear music).
Identify objects by their functions. “The dog wants to play. What can he play with?”
“What do we ______ with?” Questions to ask include “what do we write with? What
do we make our hair with? What do we open a lock with?”
Play sorting games by sorting fruits from clothes, or books from toys.
Identify body parts in pictures.
Play house.
Label objects in the environment in writing.
At appropriate points during daily activities, teach the child what is safe and what is
unsafe.
Provide child with a dirt or sand and water area with tools, such as cups, scoops,
buckets, shovels, or sifters.
What are your activity ideas?
June 2015
65
Now You Try:
Activity analysis will allow you to determine which developmental areas
are addressed when using a specific activity. Knowing this information is
critical when explaining to parents and caregivers why you are suggesting
certain strategies. Pick some of the activities from page 62 and analyze
them as demonstrated on pages 36-37. You can review your analysis with
your supervisor or another experienced EIS.
Activity
Gross
Motor
June 2015
Fine Motor
Cognitive
Social/Emotional
Self Help
Speech/
Language/
Communication
66
Analyze these activities even further by identifying some of the activities from the
previous table addressing cognitive and social/emotional development and determine if
they address the different components of social/emotional and cognitive development.
Examples of this analysis can be found on pages 38-40. You can review your analysis
with your supervisor or another experienced EIS.
June 2015
67
Cognitive/Social-Emotional Activity Table
Activity
June 2015
WM
IC
CF
ASA
DS
RSI
68
Notes:
June 2015
69
Activity Suggestions
24-30 months
Stay close by while toddlers begin to explore their surroundings and people, and
as they begin to play or pretend play
• Ball games - roll back and forth, throw and catch, throw at a
target, kick ball.
• Activities with bubbles providing the child with opportunities
to blow bubbles.
• Create sculptures through play dough activities. Have child
name creation.
• Read picture books with child pointing out specific letters
and sounds.
• Interlock puzzles.
• Ride a tricycle.
• Walk up and down stairs providing support as needed.
• Use different media to provide opportunities for scribbling activities.
• Stack blocks.
• Build a tower and then let child knock down the tower.
• Make a train of animals or other objects within the house.
• Build a bridge/tunnel with couch cushions.
• Peg Board activities.
• Activities to encourage finger pointing like asking the child where objects are located
from a distance.
• Encourage self-feeding.
• Allow child to help with easy household chores.
• Work on following more complex directions by
giving the child 2-3 unrelated tasks.
• Provide opportunities for child to work on
undressing.
• Toilet training (see pg. 20 for ideas).
• Open and close zippers and large buttons.
• Teach child how to cope with fears.
• Encourage child to feel proud of self and the work
the child does.
• Begin to label feelings.
• Engage in pretend play.
June 2015
70
• Encourage using 4-5 word sentences.
• Include the pronouns me, mine, you etc. during communication with child.
• Provide consistent choices for child to make decisions.
• Add song and sorting to clean-up activities.
• Categorization – shape, color, size, animals.
• Create a sensory bin for sand and water play.
• Label names of rooms of the house.
• Match shapes and identify shapes.
• Increase attention while playing.
• Encourage asking simple questions.
• Answer all “what” and “why” questions asked by child.
• Encourage problem solving with tools with
switches, buttons, knobs, and keys.
• Encourage sticking and pasting activities
• Provide opportunities to sort more complex (34) items
• String beads.
• Fold paper.
• Help create self-concept and identity through
mirror play.
What are your activity ideas?
June 2015
71
Now You Try:
Activity analysis will allow you to determine which developmental areas
are addressed when using a specific activity. Knowing this information is
critical when explaining to parents and caregivers why you are suggesting
certain strategies. Pick some of the activities from pages 67-68 and
analyze them as demonstrated on pages 36-37. You can review your
analysis with your supervisor or another experienced EIS.
Activity
Gross
Motor
June 2015
Fine Motor
Cognitive
Social/Emotional
Self Help
Speech/
Language/
Communication
72
Analyze these activities even further by identifying some of the activities from the
previous table addressing cognitive and social/emotional development and determine if
they address the different components of social/emotional and cognitive development.
Examples of this analysis can be found on pages 38-40. You can review your analysis
with your supervisor or another experienced EIS.
June 2015
73
Cognitive/Social-Emotional Activity Table
Activity
June 2015
WM
IC
CF
ASA
DS
RSI
74
Notes:
June 2015
75
Activity Suggestions
30-36 months
• Encourage increased use of verbs, adjectives and adverbs “bring me the blue and
•
•
•
•
•
•
•
•
•
•
•
•
green balls,” “put the wet towel on the chair,” “roll the play dough to make it flat and
round.”
Sort by color.
Sort by size “Big, bigger, biggest,” “long, longer, longest.”
Ask what/where/why/who questions and wait for child’s answer.
Help child learn the meaning of “No.”
•
Set limits.
•
Provide opportunities for child to make simple
choices.
•
Understand the difference of one and many.
•
Use describing words for size and attributes of
objects (Is your shirt longer than mine or is it shorter?).
•
Encourage labeling of and words for more
complex emotions and feelings.
Prompt various expressions.
Interact with the child by reciting nursery rhymes and participating in storytelling
together.
Practice having child imitate five word sentences and learning opposites (the stove is
hot, the ice is ____?).
Involve child in activities which require hopping, jumping, climbing, running, riding a
tricycle, using a playground, jungle gym and obstacle course regularly.
Continue to encourage scribbling, copying simple shapes, puzzles, blocks, picture
books, sand and water play.
Provide household items for toddlers to sort into groups of similar colors, types, or
shapes (socks, cups, plastic lids).
Help toddlers mix colored water or finger paints and talk about the experience.
Provide encouragement for trying activities and playing with or meeting new people.
What are your activity ideas?
June 2015
76
Now You Try:
Activity analysis will allow you to determine which developmental areas
are addressed when using a specific activity. Knowing this information is
critical when explaining to parents and caregivers why you are suggesting
certain strategies. Pick some of the activities from page 73 and analyze
them as demonstrated on pages 36-37. You can review your analysis with
your supervisor or another experienced EIS.
Activity
Gross
Motor
June 2015
Fine Motor
Cognitive
Social/Emotional
Self Help
Speech/
Language/
Communication
77
Analyze these activities even further by identifying some of the activities from the
previous table addressing cognitive and social/emotional development and determine if
they address the different components of social/emotional and cognitive development.
Examples of this analysis can be found on pages 38-40. You can review your analysis
with your supervisor or another experienced EIS.
June 2015
78
Cognitive/Social-Emotional Activity Table
Activity
June 2015
WM
IC
CF
ASA
DS
RSI
79
Notes:
June 2015
80
Developmental Activities – Extension
Do you need more resources about incorporating learning activities into daily routines?
These extension activities provide more ideas for activities and strategies, offer
information about providing routines based intervention and suggest tips for involving
caregivers in the early intervention visit.
Resource
Name
Link
Early Learning
Guidelines
Children’s
Medical
Services
Training –
Module 4,
Lessons 2
(social
emotional
support)
http://earlylearningtexas.or
g/itelg.aspx
http://www.cmskids.com/providers/early_st
eps/training/itds/module4/le
sson2_1.html
Children’s
Medical
Services
Training –
Module 4,
Lesson 3 (motor
focused
activities)
http://www.cmskids.com/providers/early_st
eps/training/itds/module4/le
sson3_1.html
Children’s
Medical
Services
Training –
Module 4,
Lesson 4
(language
focused
activities)
http://www.cmskids.com/providers/early_st
eps/training/itds/module4/le
sson4_1.html
June 2015
Activity
Ideas/Strategies
Routines
Based
Intervention
X
Involving
Caregiver
X
X
X
X
X
X
X
X
X
X
(Note that this is training for
Florida’s Part C program.
However, this information can
be applied to the ECI program
in Texas. You do not need to
complete any of the activities
that require you to fill out the
Florida Part C forms.)
(Note that this is training for
Florida’s Part C program.
However, this information can
be applied to the ECI program
in Texas. You do not need to
complete any of the activities
that require you to fill out the
Florida Part C forms.)
(Note that this is training for
Florida’s Part C program.
However, this information can
be applied to the ECI program
in Texas. You do not need to
complete any of the activities
that require you to fill out the
Florida Part C forms.)
81
Children’s
Medical
Services
Training Module 4,
Lesson 5
(cognitive
focused
activities)
http://www.cmskids.com/providers/early_st
eps/training/itds/module4/le
sson5_1.html
Delaware Early
Learning
Foundations
Thinking
Differently about
Therapy
Materials
TaCTICS –
Using Routines
as Context for
Intervention
TaCTICS –
Involving
Careprovider in
Teaching and
Learning
FACETS –
Identifying
Family Activities
and Routines –
Conversation
Starters
FACETS –
Identifying Child
Care/Classroom
Activities and
Routines –
Conversation
Starters
More than Baby
Talk: 10 Ways
to Promote the
Language and
Communication
Skills of Infants
and Toddlers
http://www.dhss.delaware.g
ov/dms/epqc/birth3/files/dei
nfant_0211.pdf
http://tactics.fsu.edu/MIH/ha
ndouts/steps/training10s/set
1/TherapyMaterials.pdf
X
X
X
http://tactics.fsu.edu/mod
ules/modThree.html
X
X
X
X
X
June 2015
X
X
X
(Note that this is training for
Florida’s Part C program.
However, this information can
be applied to the ECI program
in Texas. You do not need to
complete any of the activities
that require you to fill out the
Florida Part C forms.)
http://tactics.fsu.edu/mod
ules/modFour.html
X
http://facets.lsi.ku.edu/sit
es/facets.drupal.ku.edu/fil
es/docs/Module2/Identifyi
ngfmilyroutines.pdf
X
X
X
http://facets.lsi.ku.edu/sit
es/facets.drupal.ku.edu/fil
es/docs/Module2/Identifyi
ngchildcarerout.pdf
X
X
X
http://fpg.unc.edu/sites/fp
g.unc.edu/files/resources/
reports-and-policybriefs/BabyTalk_WEB_20
15.pdf
X
82
HELP Activity
Guide
HELP at Home
Activity Sheets
for Parents
Teaching Your
Child to
Become
Independent
with Daily
Routines
Tips for Early
Care and
Education
Providers Tips and
concepts to
help you work
with young
children with
Autism
Spectrum
Disorder
Young Children
Develop in an
Environment of
Relationships
(Responsive
Caregiving)
Making the
MOST of
Creativity in
Activities for
Young Children
with Disabilities
June 2015
This is available from the
DSHS Audiovisual
Library if you don’t have a
copy at your program.
http://www.dars.state.tx.u
s/ecis/resources/library.s
html
This is available from the
DSHS Audiovisual
Library if you don’t have a
copy at your program.
http://www.dars.state.tx.u
s/ecis/resources/library.s
html
http://csefel.vanderbilt.ed
u/documents/teaching_ro
utines.pdf
X
X
X
X
X
X
X
X
https://www.acf.hhs.gov/s
ites/default/files/ecd/508_
tips_for_early_care_and_
education_providers_april
_2013.pdf
X
X
http://developingchild.har
vard.edu/index.php/resou
rces/reports_and_workin
g_papers/working_paper
s/wp1/
http://www.naeyc.org/files
/tyc/file/MitchellVol2No2N
EXT.pdf
X
X
X
83
Section 6 – Global Child Outcomes and Family Outcomes
Global Child Outcomes
In Texas ECI, we use the term “outcomes” in two different ways. The most common use
is in referring to individual IFSP outcomes. Those are the individualized goals an IFSP
team creates for each child based on the developmental needs of the child and the
priorities of the family. Developing individual IFSP outcomes is a team activity that is not
discipline-specific. You can find more information on developing individual child
outcomes in Making It Work, in the “IFSP Outcomes in a Box” training and the third
webinar from the Quality Services Series, Comprehensive Needs Assessment and
Developing Outcomes.
“Outcomes” is also used to refer to the three Global Child Outcomes. As an IFSP team
member, you may have been involved in determining ratings for a child related to
his/her developmental skills in three general skill areas or outcomes. Since 2009, each
state receiving federal funding for early intervention services has been required to
collect and report outcomes data to the Office of Special Education Programs (OSEP)
at the US Department of Education.
But the Global Child Outcomes are not just about collecting data. They articulate
meaningful, functional goals all parents have for their children, regardless of age or
ability. An overarching purpose for all ECI services is helping children achieve the
Global Child Outcomes.
The Three Global Child Outcomes are:
1) Children will have positive social-emotional skills (including positive social
relationships).
2) Children acquire and use knowledge and skills (including language and
communication skills).
3) Children take appropriate action to meet their needs.
Examples of Outcome 1 (positive social-emotional skills)
 Kassidy (22 months) and Landon (24 months) sit next to each other and stack
blocks to build towers.
 Jonathan (2 months) calms down when his mother picks him up when he is
fussy.
 Lara (31 months) plays group games, like London Bridge, at child care.
Examples of Outcome 2 (acquiring and using knowledge and skills)
 Carter (7 months) babbles when his dad talks to him.
 Marisa (11 months) likes to drop snacks from her high chair and watch them fall.
June 2015
84

Jesse (30 months) can identify most body parts when you point to them.
Examples of Outcome 3 (acting appropriately to meet needs)
 Sophia (9 months) picks up and eats Cheerios independently.
 Connor (22 months) runs without falling.
 Aiden (27 months) tells his mom “poopy” when he needs a diaper change.
You probably noticed many of these skills cross domains. For instance, for Sophia to
finger-feed independently, she is using skills in both the self-help and motor domains.
When Carter babbles in response to his dad talking to him, he’s using both social and
communication skills.
Regardless of the individual IFSP outcomes you’re working on with a child, they usually
fall under one or more of the Three Global Child Outcomes. As a provider of SST, you
are uniquely situated to help parents enhance a child’s abilities in all three of the Global
Child Outcomes. As an EIS, you can use your knowledge of child development across
domains to help the IFSP team assign accurate outcomes ratings, and to help other
team members build activities that cross domains into the strategies they teach families.
This workbook has provided numerous examples of working across domains to help
children develop the functional skills they need.
June 2015
85
Family Outcomes
Although most Early Intervention Specialists are aware of the Global Child Outcomes,
they may not be as familiar with the Family Indicator, also known as Family Outcomes.
Like the Global Child Outcomes, ratings on the Family Indicator for the State of Texas
are reported annually to OSEP. The Indicator refers to the percentage of families who
report ECI has helped them:
1) Know their rights.
2) Effectively communicate their children’s needs.
3) Help their children develop and grow.
In Texas, a sample of families who’ve been enrolled in ECI for at least six months
receive a survey with 47 questions related to the three family outcomes. All members of
a family’s ECI team, not just the assigned Service Coordinator, are responsible for
helping the family achieve the three outcomes included in the Indicator. SST is a critical
service for addressing the outcome, “Families help their child develop and learn.” As an
EIS, one of your primary roles is showing families how they can incorporate activities
that will enhance their child’s development into their daily lives. SST is more than
teaching the child new skills; its true purpose is helping parents learn how to improve
their child’s developmental trajectory.
Child Outcomes – Extension
There is specific training about the global child outcomes located on the DARS ECI
website: http://www.dars.state.tx.us/ecis/childoutcomes.shtml
June 2015
86
Section 7 – Transition and School Readiness
Transition planning not only includes an assessment of services a child might need
when he/she turns 3, but also includes an assessment of the skills the child needs to be
successful in the next service settings. The IFSP meeting which includes transition
planning could also include developing new outcomes to address these skills.
Review this infographic about skills all children need to be “school ready”:
http://www.zerotothree.org/public-policy/school-readiness-infographic.html . As you can
see, many of the skills and strategies experts recommend for school readiness are
embedded in all ECI services (relationships, everyday experiences, play).
Although all developmental areas need to be considered during transition planning,
more and more experts are emphasizing the importance of social-emotional skills as a
component of school readiness.
Social and behavioral competence in young children predicts their academic performance in the first
grade over and above their cognitive skills and family backgrounds (Raver & Knitzer, 2002)
(Read the full article at this link:
http://csefel.vanderbilt.edu/resources/inftodd/mod4/4.3.pdf)
As a specialist in cognitive skills, social skills and challenging behavior, EISs are
uniquely qualified to help prepare a child to be successful in school and other group
settings. Many of the developmental activities addressed in previous chapters will
support a child’s “school readiness”. In addition, the resources listed below provide
guidance on addressing specific skills a child will need to thrive in his/her future
settings.
Transitioning Between Activities: http://csefel.vanderbilt.edu/briefs/wwb4.pdf
Handout: http://csefel.vanderbilt.edu/briefs/handout4.pdf
Helping Children Understand Classroom Routines and Schedules:
http://csefel.vanderbilt.edu/briefs/wwb3.pdf
Handout: http://csefel.vanderbilt.edu/briefs/wwb4.pdf
Helping Children Manage Their Own Behavior:
http://csefel.vanderbilt.edu/briefs/wwb7.pdf
Handout: http://csefel.vanderbilt.edu/briefs/handout7.pdf
Key Math Skills for School: http://www.zerotothree.org/child-development/earlydevelopment/supporting-early-math-skills.html#key
Building Literacy Skills (24 – 36 months):
http://main.zerotothree.org/site/PageServer?pagename=ter_par_2436_language_what
June 2015
87
Section 8 – Documentation of SST
Most helping professionals, including Early Intervention Specialists, value their time
spent providing services above all other work related activities. On the list of work
related activities we don’t enjoy, documentation is frequently at the top of the list. It is
not unusual to view documentation as a necessary evil and overlook the importance of
having an accurate record of intervention. But, consider how important documentation is
to you outside of ECI. If you are visiting a medical specialist, wouldn’t you want the
medical record from your primary care physician to be complete, accurate and
thorough? When purchasing a home, wouldn’t you want the inspection report, any
disclosures about the home and the mortgage information to be thoroughly
documented?
In this chapter, we will consider the importance of documentation, review documentation
requirements, look at some routine quality checks, and complete practice exercises to
help strengthen the documentation of the services you provide.
Why is documentation important?
Let’s consider the varied reasons for record keeping. It can help to remember all of the
potential readers of our documentation. Potential readers include the child’s primary
care provider, other service providers, other team members, our supervisor, regulatory
agencies, third party payers, and the child’s parents. Each of these readers expects a
complete record adequately conveying the child’s functioning and what we did to
address the child’s needs.
The various readers have different reasons for reading our documentation. Here’s a
non-exhaustive list of some of the reasons we need to competently document what
happened in the service event:
1. Continuity of care within ECI – After the child is enrolled in ECI, we have
an obligation to provide services in a timely and efficient manner. This
includes providing services as planned in the IFSP. To meet this
responsibility it is critical for each of us to record what we did and what still
needs to be done so a peer can step in should we be unable to perform
services as planned.
2. Inform other service providers – Most of the children enrolled in ECI
receive services from other providers. This includes the primary care
physician or service agency making the referral as well as service
providers who will be helping the child and family after they leave ECI. We
have an ethical responsibility to provide a competent and professional
description of the child’s functioning and the interventions we provide.
June 2015
88
3. Inform program and agency management and supervision – Review
of service documentation is one of the ways our work is supervised. Every
progress note contains a wealth of information about the service provider.
The documentation can reflect strengths as well as weaknesses in the
professional’s ability to perform his/her job duties and to address the
child’s and family’s needs.
4. Parents’ right to know and informed consent – Parents have the right
to review records at any time. They have the right to know what we are
doing and why. They have a right to know if progress is being made or if
they are wasting their time and money.
5. Formal record of child’s functioning and response to services –
Parents’ rights extend to having a complete record of service delivery and
their child’s response to those services. In some cases our documentation
may be used to verify the need for additional services and aid in service
planning.
6. Formal record of performance of duty - In rare situations our
documentation can be subpoenaed into a court of law. In these situations
our documentation will stand as evidence we performed our duty
competently and ethically.
7. Data collection and contract compliance – The agency that employs
you receives federal and state money for the work you do. The ECI
program must be able to present evidence the money was spent for its
designed purpose. Usually this obligation includes being able to prove the
services had the desired positive effect for the child and family.
8. Reimbursement – Third party payers (i.e. private and public insurance)
pay for only those services which were provided. In addition, payment is
made for only needed services when the documentation indicates the
service is likely to obtain the desired positive effect for the child.
9. Professional pride and reputation – As stated in #3, every progress
note contains information about the service provider as well as the child.
The description of the service event and the completeness of the note
convey your knowledge and skill as a provider, and your regard for the
child and family. The professionalism of the note also conveys the value
you place on your role in the child’s life.
June 2015
89
Exercise #1 - Getting to know the readers
Each of these readers may review documentation for different purposes.
Select the best and primary reason from the column on the right that
describes what a reader is looking for in a review:
Reader
1. Co-workers
2. Other current service
providers
3. Supervisor
4. Parent
5. Future service
providers
6. Lawyer/Judge/Jury
7. State and federal
governments
8. Third party payers
9. Yourself
June 2015
Answer
Reviews documentation to
a. provide guidance and
feedback to improve the
provider’s ability to perform
his/her job duties.
b. verify the ECI program and
their employees and
contractors have been good
stewards of the public tax
dollar by delivering
effective, needed services.
c. make sure you have done
an adequate job in
providing the service and
accurately documented the
service event.
d. understand the child’s
progress to date and
develop appropriate
services after the child
leaves ECI.
e. ensure their provision of
service is consistent with
what has been done to
date.
f. verify the service provided
was necessary.
g. prove your role in an
alleged illegal or unethical
activity.
h. ensure their involvement
with the child and family
neither duplicates nor
contradicts the services
provided by ECI.
i. understand what is
happening to his/her child
90
and make sure there is a
benefit to the child.
June 2015
91
Our responsibilities as ethical and competent professionals include providing adequate
documentation that can be used for all the purposes listed above, and the importance of
documentation can’t be overemphasized. It is impossible to predict which reader and to
what purpose the reader will request access to our documentation. Fortunately, a well
written progress note will satisfy most readers and most purposes.
Minimum Requirements
Valid documentation of the provision of SST must contain some minimum elements.
The minimum elements for every ECI progress note are identified in state rule: Texas
Administrative Code, Title 40 (40 TAC), Part 2, Chapter 108, Subchapter K, Rule
§108.1111 (See 40 TAC §108.1111). Additionally, the minimum elements for every SST
progress note are identified in state rule: 40 TAC, Part 2, Chapter 108, Subchapter E,
Rule §108.501(f) (See 40 TAC §108.501).
Incomplete documentation can result in your agency having to return payment for a
service; this is known as recoupment. It can also create the impression the provider is
not qualified to provide the service or not adequately trained. Incomplete documentation
can also result in the judgment the service was not provided according to state
regulations or SST was not provided at all.
June 2015
92
Exercise #2 - Getting to know the rules
It’s critical to know the requirements for documentation. This exercise
helps you learn the ECI rule. Go to the state rule (40 TAC §108.501) to
complete this exercise.
1. Which three names must be documented?
2. Date of service and start time are required. Is the end or stop time required?
3. What does “method” refer to?
4. What are three techniques of engaging the parent or caregiver are spelled out in
the rule?
5. What piece of information from the IFSP must be carried over into the progress
note?
6. What about the child must be documented?
7. What about the service provider must be documented?
June 2015
93
Exercise #3 - Getting to know the required elements
It may seem silly to worry about each of the individual required elements.
The next exercise will help explain why each element is required. Use the
following phrases (a through m) to fill in the blanks in the numbered
paragraphs below.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
Child’s name
ECI program name
EIS’s name
Date and time of service
Length of time
Place of service
Method of service delivery
How we engaged the parent or caregiver
IFSP outcome
Child’s progress
Other relevant information
EIS’s signature
Credential as an EIS
1. The documented
can be used to verify a service was actually
provided. On a day to day basis this information enables the reader to
organize the content of the record into a chronological history of the child’s
development and services provided.
2. From a therapeutic perspective, there is a significant difference between
services being provided individually or in a group format. Therefore the
provision of group services requires additional justification and
permissions to be documented in the child’s record. Reimbursement for
group services is usually less per child than individual one-on-one
services. Including the
tells the reader whether individual or group
services were provided.
3. The primary purpose of intervention is to assist the family as they help
their child meet his or her developmental outcomes. Our sessions are
planned, modified and delivered in response to child change (or lack of
change), therefore the
must be documented. Information about how
the child is responding to intervention is necessary for services to continue
to be effective. Additionally, funding sources expect to see documentation
of the effect of services on the child’s development.
June 2015
94
4. Including the
in the progress notes tells the reader the purpose of
the service event. Without this information it can be impossible for the
reader to determine the need for the service event. If there is no need for
the service event then a third party payers has no reason to pay for the
service. Similarly, if there is no need for the service, parents have no
reason to incorporate the intervention into their daily routines or keep their
child enrolled in services.
5. The reader of the child’s record may not have access to the entire record
but may instead see single pieces of the record such as an isolated
progress note. Because the progress note is separated from the rest of
the chart the
must be on each progress note.
6. The state rules restrict the provision of SST to individuals who have
completed required training which establishes them as an expert in early
childhood development. Proof that an adequately trained professional
provided the service is shown when we include the
in the progress
note. Without this information it can be argued the person providing the
service was incompetent.
7. Including the
lets the reader know who is ultimately responsible for
the service. This information lets parents know who to contact if they have
any concerns. After the child leaves ECI, this information will help the
family and future service providers know who to contact to obtain
information about the child’s functioning, progress, and interventions used
while in ECI.
8. The
on the progress note serves the same function as a signature
does on any document: The person signing is verifying the content of the
document is true and accurate. When reimbursement for services is
involved, the person signing is confirming they provided the service as
described at the date and time indicated.
9. A distinguishing characteristic of ECI services is the majority of services
are provided in the child’s natural environment. Identifying the
lets
the reader know the services were provided in accordance with the ECI
model. This information is also entered into TKIDS as the DARS ECI
contract requires 98% of delivered services to occur in the natural
environment. The payment of some services may vary by service location
as well. For example the reimbursement for services in the home may be
higher than services provided in a clinic.
June 2015
95
10. The ECI approach to service delivery is holistic. This means the
assessment of the child’s and family’s needs and the interventions
provided address all aspects of the child’s functioning and life. The ECI
approach also uses an interdisciplinary team. This means individual
service providers work together to address all aspects of the child’s
functioning and life. Documentation of
proves we are addressing
the whole child and are making effort to share this information with the rest
of the team.
11. ECI programs must be able to justify the time billed to third party payers
and be able to demonstrate efficient use of contract funds. For these
reasons we include the
in the progress note. Information about the
time spent providing SST is also used by the state to determine the rate of
reimbursement for SST. Duration of service provision may also be used to
determine caseloads and inform supervision.
12. The component that differentiates ECI from other services is the
instruction to the parent and caregivers. Describing
tells the reader
we did provide the services according to the ECI model and rules. Failure
to include this information may result in the recoupment of payment as it
may be judged an ECI service was not provided. In addition, the omission
of this information conveys to the parent their involvement is unimportant.
13. Documenting the
tells the reader who provided the service. This
information is necessary to verify the service was actually provided. This
information also tells the reader who is responsible for all of the required
elements and content of the progress note.
June 2015
96
What should progress notes look like?
After reviewing all of the preceding material, you might be thinking there’s not enough
time to document completely or to include all these requirements in every note you
write. None of the requirements can be ignored, so we have to find a way to include
everything.
Straightforward requirements - Many of the requirements can be pre-printed on the
form, or filled in prior to your visit, including the date and place of service, the method,
child’s name, and the ECI program name. The IFSP outcome you will be working on is
included, but does not have to be exact – an accurate abbreviation will work.
Engagement of the Caregiver - Your engagement of the parent or caregiver is the
most important component of a SST session, and should be documented as such.
Parent training and instruction is what sets ECI apart from other providers, and it is the
reason funding sources pay for ECI services as separate and distinct from other
therapeutic services to children. The definition of SST specifically includes training and
guidance of caregivers, so without good documentation of this component, SST is
incomplete. There are several things to consider as we document our work with parents:




June 2015
Caregiver as learner - The primary learner during an ECI visit is the
caregiver, and this should be reflected in your progress note. What did you
teach? What feedback did you provide? What questions did you answer?
How did you coach?
Service delivery triad – The focus of each SST session is on ways the
caregiver can interact with the child to support the child’s development
and achievement of outcomes. The EIS works, not with the child, but with
the child and caregiver together.
Materials in home – Critical to the success of ECI services is the
caregiver’s ability to implement interventions when you are not there.
Therefore the interventions you demonstrate need to use materials that
exist in the natural environment. How did you assist the family to use the
objects, materials and toys to which they have ready access, either in their
home or in the community?
Familiar routines for every day learning – Because the caregiver will
implement the strategies you are teaching in the child’s daily life,
document how you discussed applicable routines with the parent.
97
Child responses and progress - The engagement of the caregiver is how we ensure
maximum learning and development for children enrolled in ECI. Infants and toddlers
learn best through everyday experiences and interactions with familiar people in familiar
contexts. The enrolled child is the target of intervention, and so we must also document
the child’s responses and progress. This means documenting:




the child’s response to the strategies and techniques being used (not the
child’s response to you as a provider.);
your expert observations of any progress, or lack of progress toward the
stated outcome;
parent reports about how the child has been responding to the intervention
in daily routines and activities (when you are not there); and
how you adjust strategies and techniques based on the child’s response
and progress or lack of progress.
Delivery of a skilled, professional service - Early intervention providers understand
play is the work of children, and play can be a therapeutic activity for a child. Your
documentation needs to reflect this understanding by describing:



June 2015
the purpose, as related to the stated outcome, of play activities;
how you applied your professional knowledge, expertise and skill; and
what you did during the session.
98
Since every reader of the child’s record is not an early intervention provider, the
responsibility falls on you to provide evidence of your application of skilled professional
knowledge and expertise in early childhood development. Words like, “observed,” and
“encouraged,” have little meaning unless you provide a description of how your
observations and encouragement relate to the child’s outcomes. The following table is a
collection of examples to help illustrate the difference between unskilled and skilled
activities.
Unskilled activities
Observing child and
parent/caregiver’s actions without
feedback
Skilled activities
Continuously assessing the child’s
and parent/caregiver’s performance
Making vague or relative comments
about performance
Providing objective data to show
progress such as accuracy, speed,
frequency, and independence
Practicing actions that do not vary in
complexity or level of cueing
Adjusting interventions to help the
child and family achieve outcomes
Playing without explaining the
therapeutic value of the play
Providing rationale for how the
activity relates to the outcome
Encouraging without including a
description of the technique used
Using expertise in child
development and behavior to
increase the child’s motivation and
success
Reminding without assessing or
addressing the possible barriers to
implementation
Sharing expertise in child
development and behavior with
parent/caregiver to increase the
parent/caregiver’s motivation and
success
June 2015
99
Exercise #4 – Getting to know the contents of a progress note
It’s important to both know the required elements, and to know how to
functionally document them in a progress note. This activity will provide
examples of how to document the required elements. The following are
examples of the above mentioned elements of a good progress note.
Which activity (1-11) matches which element (a-k)
Activity
1. I showed Mattie how to use
a rolled up bath towel to
support Trevor’s back.
Your Answer
Element
a. Caregiver as learner
2. Worked with Binh on better
positioning for Nguyen in his
highchair. Helped her choose
a large book that she wrapped
in a towel to put in the seat to
elevate him for better hand
use. With the towel roll
placed around his hips, he
was able to grasp objects with
both hands.
b. Service delivery triad
3. Kayla agreed diaper
changing time would be the
best opportunity to work on
the leg stretches the OT
showed her.
c. Materials in home
4. Aston played with his
blocks, placing them as
directed by Ashley, followed
by applause and praise from
Ashley when he did as
requested.
d. Familiar routines for
everyday learning
5. I noticed Lela was placing
Carlos’s toys too far out for
him to be interested in
crawling toward the toy. I
demonstrated how to gauge
e. Return demonstration
June 2015
100
Activity
how close to place the toy by
watching Carlos’s expression.
Your Answer
Element
6. Texemma stated the older
children are answering her
questions to Dylan so she’s
having a difficult time figuring
out if he’s hearing her let
alone understanding and
responding to her questions.
f. Child’s response to
intervention
7. I demonstrated how to drop
objects into a container to
make a “bang.” Nina tried it
several times with Pia and
agreed that approach
increased Pia’s interest in
releasing objects on
command.
g. Parent’s report of how
child is responding to
interventions
8. Kelly responded more
rapidly to tapping the picture
in the book than to verbal
prompts.
h. Observations of any
progress or lack of progress
9. While Charlie is
demonstrating more effective
grasping and releasing, he is
now throwing things rather
than placing them.
i. Adjustment of
interventions in response to
progress or lack of progress
10. I demonstrated blocking
Deon’s upward arm
movement at the same time I
asked him to give me his toy
car to reduce his ability to
throw instead of give.
j. Purpose of play
11. Kim loves it when Loc
sings to her. Coached Loc to
k. Delivery of a skilled
service
June 2015
101
Activity
pause for a few seconds
when singing “Old
MacDonald” to see if Kim
would make the animal
sound. Loc tried it, but his
pause was a little too short.
He tried again with a longer
pause, and Kim said, “mmm”
for the cow.
June 2015
Your Answer
Element
102
SST documentation should contain the following five components:
1.
2.
3.
4.
5.
Coaching and instructions to the family or caregiver,
Attention to how activities apply to child and family routines,
Modeling intervention techniques within everyday learning opportunities,
Evidence of a skilled professional service, and
The child’s response and progress.
The following sample of an SST progress note demonstrates how these five pieces of
information can come together in a single progress note. The sample note is separated
line by line, but would be written as a continuous narrative. You can see this note
contains the discussed components but is still fairly short. The documentation clearly
shows the EIS is always thinking about, and helping the parent understand, the
therapeutic purposes of the activities.
Codes for note:
coaching and instructions to the family or caregiver
attention to how activities apply to child and family routines
modeling intervention techniques within everyday learning opportunities
skilled, professional service
child’s response and progress
June 2015
103
SST Session
Date
5/30/13
Name
Rocky
Current Status;
Changes since
last visit
Pointing and gesturing more to try to tell them what he wants, but hasn’t
used any sign or words. Pointed toward toy area and vocalized when I
arrived to indicate his desire to play. Rpt - tantrums when they didn’t
understand him, 5-6 last weeks.
IFSP Outcomes
worked on
use 5 single words to tell us what he wants instead of tantrums
Activities with
caregiver to
address
outcomes
Arrived during afternoon playtime.
Dad and Mom present
I reviewed benefits of signing to encourage communication and words.
Dad and Rocky selected nesting cups from their toys.
Taught Dad sign for “cup”.
Demonstrated for Dad then he assisted Rocky hand-over-hand to sign
“cup” while Mom held the cups.
After three turns, Rocky signed and said “up” to ask for a cup.
Switched to Rocky’s favorite puzzle. Dad held puzzle pieces, Mom
physically assisted Rocky to sign “more”. Explained reducing
assistance to prompts/modeling, and taught signs for puzzle pieces
fish, dog, cat and bird which they then practiced while playing.
Suggested use signs often to refer to family dog and cat.
Emphasized importance of always saying the word clearly with sign.
Rocky completed puzzles, signed “more” with decreased physical
prompts.
Tantrums this week were usually at meal or snack time.
Reminded Dad - provide choices for snacks
You can encourage him to indicate choice by using sign or gesture; but
don’t withhold choices to point of frustration.
Reviewed and demonstrated the signs for eat, drink, cracker, and
apple. Agreed I will come during snack time next week and we will
work on that routine.
Reminders;
things to practice
till our next visit
June 2015
1) Use signs while playing with cups and puzzles.
2) Offer choices at snack time, and model the signs eat, drink, cracker
and apple.
3) Frequent use of signs “dog” and “cat”. Always say the word, and
encourage imitation.
104
Another example of an SST progress note
SST Session
Date
5/30/13
Name
Ryan
Current Status;
Changes since
last visit
Phyllis worked on attention span with books, but he’s uninterested. Sister tried
rolling car – he picks up, spins wheels won’t give it back. Hasn’t said “mama”
but “aa-aa-aa” noises to get attention, instead of grabbing or screaming.
Screaming still main way of getting attention.
IFSP Outcomes
worked on
Turn-taking; increase attention span and joint attention; say “Mama” to get
Mom’s (Phyllis) attention.
Activities with
caregiver to
address
outcomes
Phyllis borrowed library books with the word “mama” that SLP recommended.
She read to Ryan. I showed how to draw attention back to a picture with
exaggerated/ excited speech and using gestures and movements. Suggested
books with interactivity, like flaps or tabs, to help hold attention. She practiced
with Lift the Flap book and he attended for about a minute.
Tried ball instead of a car for turn-taking. Demonstrated hand-over-hand
assistance to roll the ball back for turn-taking. We switched places and she
used the hand-over-hand technique. Also demonstrated taking turns dropping
the ball into a laundry basket. Will practice reciprocal ball play in the afternoon
with sister.
I reminded Mom saying “aa-aa-aa” can be interpreted as purposeful
communication. When he makes the sound, she can say, “You want mama?
Here I am” and give him some attention. Reminded Mom ignoring screaming
and rewarding purposeful sounds will reinforce appropriate sound development.
Suggested 1) move most toys into closet to decrease distraction 2) move other
toys to shelf out of reach to stimulate request with sounds or gestures.
Discussed not using cars as a reward, but instead can use physical play he
enjoys, like bouncing on knee facing her.
Reminders;
things to
practice till our
next visit
Continue with book techniques practiced today. Rearrange toys as discussed.
Ball play with sister in afternoons.
There is no required format for service documentation and the ECI contractor may use
any format that works best for their staff. The world’s best format will not work, however,
if we don’t use the prompts provided on the form.
June 2015
105
Question:
I was told Medicaid prohibits two different services (e.g., Case Management and Skills
Training) being documented in the same progress note even though there is a separate billing
line for each service, clear demarcation in the narrative separating the services, and each
service met documentation guidelines.
DARS Response:
There is no prohibition to having two services documented on one sheet of paper. The
documentation of each service event must include all of the required elements per applicable
state and federal laws and regulations, including signature with the credentials required for
each service (e.g., “Service Coordinator” for the case management and “EIS” for the SST).
The content of each progress note should clearly identify the service provided and therefore
make it easy to determine which line on the billing strip applies to that section of the document.
Two services combined in one narrative make it difficult for the auditor to verify all of the
required elements per service are present and the correct amount of time per service was
billed. This inherent difficulty is amplified when the two services are poorly documented (e.g., it
is impossible to discern the case management activity from the SST activity).
What sort of things should l avoid in my documentation?
A. Play with no purpose – Professionals in the field of early intervention know the
value of play. Bubble blowing, reading books, playing in sand – you could probably
list a hundred fun, toddler activities that support development. Remember play is a
means to an end, and has a developmental or therapeutic purpose in SST. The
purpose needs to be clearly indicated in your notes.
Poorly documented
Well documented
Jack enjoyed looking at Spot lift-the-flapbook.
Explained and demonstrated to Inez
(mom) how to use single words when
looking at a book with Jack. She
practiced with their Spot lift-the-flap book.
B. Use of the term “encouraged” - The word “encourage” means to inspire or cheer.
It can indicate a child is developmentally able to do something, but just needs to be
coaxed to do it. You may be teaching a parent to provide positive reinforcement, or
teaching how to provide learning opportunities. Use of the term “encouraged” alone
does not convey a needed service was provided. An acceptable use of the term is
related to a technique to encourage a behavior in the child.
Poorly documented
Well documented
Encouraged Jack to pull up on the sofa.
Prompted Terrell (dad) to remove sofa
cushions for a lower surface, and to place
favorite toy on sofa to encourage Jack to
pull to stand.
June 2015
106
C. Use of the generic “we” – It’s important your progress notes describe what you did,
as a professional, during the session. It is equally important you reflect what the
parent practiced or demonstrated.
Poorly documented
Well documented
We named farm animals while Emma put
them in a puzzle.
I explained and modeled naming pieces
as Emma placed them in puzzle. Tanis
(mom) then practiced in play with another
favorite puzzle.
D. SST as “mini-therapy” – EISs are not therapy assistants. SST is a separate and
distinct service from any therapy that may be provided, and it is important SST
progress notes reflect this distinction.
Outcome
Therapy note
SST
Walking all over the house
PT teaches the parent
exercises to strengthen
legs and core muscles
(details of teaching and
demonstrating listed).
Suggested to Laswayn
(mom) ways to modify
living room to allow child to
move around freely, and to
encourage cruising.
(appropriate use of term
“encourage”)
Self-Feeding of finger
foods
OT teaches the parent
techniques for playing with
play dough to strengthen
hands and fingers, and
improve eye-hand
coordination.
Brainstorms with parent to
identify favorite foods
appropriate for finger
feeding. Assists parent
with positioning and
presentation of foods in
high chair.
Use of words to
communicate
SLP teaches parent how to
isolate and emphasize
specific early developing
speech sounds when
looking at books with the
child.
Coaches parent on naming
objects in the child’s
immediate environment
using single words, clear
speech, and drawing
child’s attention to the
object.
June 2015
107
E. Only strengths – It is important to build on a child’s strengths, and to help parents
identify and value the strengths of their child. Your progress notes must also
describe increments of child progress, and the steps you are taking to build on
strengths to correct deficits and address needs.
Poorly documented
Well documented
Trig can sit up on his own. Will continue
working on trunk strength.
Trig can sit up on his own but has
difficulty staying upright for more than a
few seconds. Showed mom how to use
cushions from the sofa for added support
as we work toward strengthening his back
muscles.
F. Narrative reflects only what the child did – Child progress and the child’s
responses to intervention are an important component of documenting services. Too
often, however, progress notes consist only of a description of what the child did
during a session, leaving out the coaching and instructions to the family or caregiver,
attention to family routines and the skilled, professional service.
Poorly documented
Well documented
Bella did a good job pasting flowers.
Robin (mom) practiced holding the pieces
of flower (petal, stem, leaf) next to her
mouth as she said the word three times
before handing the piece to Bella for
pasting.
Bella joined in singing The Farmer in the
Dell. She really enjoyed making the
animal sounds.
I suggested Robin wait to see if Bella
would offer an animal or initiate the sound
when singing the Farmer in the Dell. I
demonstrated starting the animal sound
but letting Bella finish it before joining
back in. Bella really seemed to enjoy
trying to make the animal noise before
Robin did.
G. Instructions to caregiver appear only in “Things to do till our next visit”
section - Instructions, coaching, discussion and problem solving with caregivers are
the most important components of SST (and all ECI services). Your progress notes
should reflect this emphasis throughout the session.
H. Wrong credential - remember; only an EIS is a qualified, authorized provider of
SST. If you sign your progress note as Service Coordinator, or Teacher, or Social
Worker or any other title, the service has been provided by someone who is not
qualified to provide the service.
June 2015
108
I. Illegible – An illegible entry is the same as no entry at all. Illegible notes are very
frustrating for all readers, be they a co-worker, supervisor, or parent. An auditor
reads service documentation to verify services were provided as billed and/or in
compliance with rule. If the note is illegible the auditor will not be able to affirm the
appropriateness of the services. This can result in a variety of different
consequences including recoupment of funds. If your handwriting is illegible to most
readers and beyond your control to correct, please ask your supervisor about the
possibility of using an accommodation such as transcription services or access to a
computer. Some options include:

Dragon Dictation (Android, Blackberry, iPhone)
http://www.nuancemobilelife.com/apps/dragon-dictation

Vlingo (Android)
http://www.vlingo.com/apps/android

Quick Voice to Text (iPhone)
https://itunes.apple.com/us/app/quickvoice2text-email-pro/id285877935
Please remember text and email are not secured transmissions. Never text or email a
child or family’s name or other identifying information.
June 2015
109
Exercise #5 – Getting to know when there’s room for improvement
This activity will help you become a documentation expert by providing
practice with both reviewing and correcting progress notes. The following
are real-life progress notes (names have been changed). Identify problems
with each note by answering these questions:
1. Does the note address an identified need and outcome?
2. Does the note follow the adult learner and service delivery triad?
3. Does the note provide documentation that the service provider is using
daily routines and materials in the home?
4. Does the note provide documentation of the child’s response to
intervention?
5. Is the application of professional knowledge clear?
Then try your hand at improving the progress note.
Note #1
Toby was seen today at home with mom and brother for scheduled SST session.
Toby is doing very well. Mom reports Toby is trying harder to say what he wants.
In the session I heard him say: baby, hi, puppy. Mom encourages him to repeat
sounds and single words. While playing we worked on:
-
Imitation of sounds, movements, single words, and simple phrases.
Encourage her to repeat what we would do.
Looked at books and pointing and naming pictures.
Finger plays and Toby would try to do movements.
Toby did great! Toby had a good session.
Now You Try
June 2015
110
Note #2
1. IFSP Outcomes (specify) Addressed:
Reduce tantrums, use signs, verbalize
2. What has happened since last visit?
Nadir has continued to respond to sounds over the last week and is recognizing
signs as well
3. What did we observe/try today? (specify actions/engagement of all participants in visit)
Nadir and class are on their way to the gym to play. Nadir holds Alberta’s hand and
she reports he has been giving her a lot of hugs this week after seeming mad at
her last week. She looks at him while she talks to EIS and he smiles at her and
wants to be picked up. Once In the gym he is ready to run and has to be told and
signed to sit back down while the teachers get the toys out. He goes on his own to
sit back down 3 times when he is told and shown the sign to sit. Once able to play
EIS and teacher work on the sign for ball, good, thank you, please, and sorry. He is
paying more attention when shown signs and when his back was towards me, EIS
called his name loudly and he turned. Teacher continues to struggle to keep his
cochlear on at times since it is so easy for him to grab it and pull it off, but she
consistently puts it back on correctly so he can benefit from it. In the classroom
she continues to work on signs with him and the other children as they look at
books.
4. What might we do different/continue? What will occur between visits?
Continue to sign to him and speak to him where he can dearly see your face and lips.
Make sure his cochlear is on throughout the day and tell him "no" when he grabs it.
If he has a tantrum, redirect him to an appropriate activity or ignore it.
Now You Try
June 2015
111
Note #3
Outcomes addressed:
Following directions (goal #9)
What’s happened since last visit (progress reported by family, concerns):
Salme is very inconsistent with following directions.
Summary of activities worked on today (include how those present participated and specific
progress noted by provider):
Met at daycare for scheduled SST visit with staff. Salme and other children
present. Staff watched provider as I played with Salme, giving her simple
directions paired with verbal and visual cues. Discussed with staff how this helps
cue Salme to what you are asking her to do. Modeled for staff how to use hand
over hand assistance to guide Salme through direction. Staff then practiced above
techniques with Salme while this worker observed and coached.
Activities to work on before the next visit:
*Give Salme verbal and visual cues when giving her directions.
*Use hand over hand assistance to guide Salme through the direction.
Now You Try
June 2015
112
Note #4
Others present:
Teachers, kids
Since our last visit:
Su-bin’s attention to task is improving
Goal(s) worked on today:
Gross motor, speech
Activities:
Met with Su-bin at Head Start, class was outside playing in the leaves! Teacher
was grabbing bunches and throwing them up in the air and kids were imitating. Subin threw his just above his shoulders so I helped him reach higher to extend
range. Encouraged him to stay involved in class activity. We ran through leaves and
all kids participated (class of 3 today!). Encouraged Su-bin to run and try to keep
up – he was last but was enjoying activity. Then he walked to nearby fence and
stooped and picked up leaves and poked them through the chain links. He repeated
“whee” and “whoa” when throwing leaves.
How can this be a part of your family’s daily weekly activities?
Encourage Su-bin to repeat words to describe activity.
Now You Try
June 2015
113
Note #5
Changes since last visit:
Grandmother reports he is starting to take 1-2 steps on his own now.
Worked toward IFSP outcome(s) of:
To eat table foods.
Today’s activities/observations and parent/caregiver participation:
Today Trevor participated in meal time. Observed Trevor kept calling out “mama”
and attempted to imitate some words “papa.” Discussed using signs to meal time to
help Trevor communicate “papa, more, drink, and finished.” Trevor began to wave
when he heard EIS say “bye bye” as she took turns having a conversation in hi
language. Trevor practiced bringing spoon to his mouth on his own. Discussed always
giving him a spoon at meal times to continue practice bringing spoon to his mouth.
Child’s progress and recommended activities:
1. Use signs to help Trevor communicate what he wants (more, food, drink, and
finished)
2. Give him an extra spoon while feeding him to practice bringing his spoon to his
mouth.
3. Name food items as you offer choices for Trevor to pick and recognize by
name.
Now You Try
June 2015
114
Note #6
IFSP Outcomes (specify) Addressed:
For Mica to become comfortable with EIS being in Mica’s home so EIS can instruct
Mom on strategies to use to increase Mica’s attention span. Mom wants Mica’s
attention span and joint attention to increase so he will be able to stay focused on
one activity for at least 10 to 15 minutes during playtime. Mica will request his
want/needs with words/word approximations during snack time and play time 5
times a day or 7 consecutive days.
What has happened since last visit?
Mom reports Mica is interested in playing with her when others (strangers) are not
around. However, he continued to cling to her when ST came for therapy. Mom
reported Mica did a first this week. He and Mom went to a playground at the mall.
Mom said Mica played with the other children some but mostly ran around doing his
own thing. However, Mom did report she saw Mica play “Duck Duck” at daycare this
week. This was interacting with other children.
What did we observe/try today? (specify actions/engagement of all participants in visit)
Today EIS instructed Mom we would sit on the floor with Mica. Mom presented
Mica with puzzles. At first Mica would identify some of the puzzle pieces and try
to put them in the correct opening. Mica even brought a puzzle over to EIS. This
was the first time he approached EIS. Some of the time Mica wanted to throw the
puzzle pieces. However, after using some distraction, Mica started playing with the
puzzle pieces in a different way. He turned them face down and moved them
around the room. He had his own plan. We made progress today because the second
half of the visit Mica seemed to be OK that EIS was there.
What might we do different/continue? What will occur between visits?
When playing with Mica, help him recognize when a picture is upside down. Help
Mica understand the concept of “upside down” with objects before trying pictures.
Left a handout for family: Right Side Up.”
Now You Try
June 2015
115
Note #7
Outcome:
Sign needs/wants
Arrived at childcare center for snack time. I sat beside Hector at the table with
Sally (tchr) and 4 other kids. Sally has started giving the children small portions of
snack foods instead of the whole thing at once as we discussed last week.
Demonstrated pausing to allow Hector time to request. I assisted Hector (hand
over hand) to sign “cookie” for another piece, and to sign “drink” for more juice. He
enjoyed the signs, and by the end of snack, he required only minimal prompt for
“drink”. Use of signs may help decrease Hector’s frustration about communication
and help decrease tantrums. Class had “free play” time during diaper changes. I
modeled using single words and two signs (truck and baby) to describe Hector’s
play. Modeled pausing to allow Hector time to imitate. Explained to Sally these
techniques allow Hector to learn more vocabulary, and is a start for reciprocal
communication that will decrease tantrums.
Now You Try
June 2015
116
Note #8
Current Status and changes since last visit:
Pointing and gesturing more to try to tell them what he wants. Had a few tantrums
when they didn’t understand him.
IFSP Outcome worked on:
To say words and have fewer tantrums
Activities with caregiver to address outcomes
Arrived during afternoon playtime. Dad and Mom present, reviewed benefits of
signing to encourage communication and words. Dad and Alex selected nesting cups
from their toys. Showed Dad how to sign “cup.” He assisted Alex hand-over-hand
to sign “cup” while Mom held the cups. After three turns, Alex signed and said “up”
to ask for a cup! Switched to Alex’s favorite puzzle. Dad held puzzle pieces; Mom
physically assisted Alex to sign “more.” Explained reducing assistance to
prompts/modeling, and taught them signs for puzzle pieces fish, dog, cat and bird.
Suggested use signs often to refer to pet dog and cat. Emphasized importance of
always saying the word clearly with sign.
Tantrums this week usually at meal or snack time. Suggested providing choices for
snacks, encourage him to indicate choice by using sign or gesture. Discussed some
specifics, reviewed the signs for eat, drink, cracker, and apple. Agreed I will come
during snack time next week and we will work on that routine.
Reminders about what to practice:
1. Use signs while playing with cups and puzzles.
2. Offer choices at snack time, and model the signs eat, drink, cracker and apple.
3. Frequent use of signs “dog” and “cat.” Always say the word, and encourage
imitation.
Now You Try
June 2015
117
Note #9
Outcome:
To crawl
Kim was in her high chair when EIS arrived. She was happy and smiling. We played
peek-a-boo for a short time to get her comfortable with EIS. Suong put a blanket
down and EIS pulled over the cube toy to play with. Suong set her on her bottom
and EIS placed the toys around her. She reached out for the blocks and pivoted on
her tummy. When she reached out for the cube which was placed quite aways away
she tried to go to her tummy but her leg got caught up under her so EIS showed
Suong how to gently pull her leg just a little bit under her and then Kim did the
rest of the work and she went to all fours. She immediately went down on her
tummy but the work on her arms was there. She reached for the blocks and mom
helped her place them where they go and turned on some music. She got very
excited and started to dance. When EIS attempted to fold her legs under her to
show mom how to help her stay that way, Kim got upset. Suong calmed her down
and we tried floor time again after a little bit.
Now You Try
June 2015
118
As seen in some of these examples, it is not possible to adequately document a service
with a few sentences hurriedly written. Your job duties include taking the time necessary
to adequately document what you have done.
A parent can refer to a well written progress note to guide their intervention with the
child in routines. In the days following a session, the note can remind the parent of how
to implement strategies and activities. It can help the parent remember what to look for
in the child’s responses, and the reasons for the activities.
Auditors use the content of a progress note to make a judgment about how much
should have been billed for a service. It seems clear that for an hour of service provision
you will need to write more than five or six lines. Descriptions not related to service
provision such as, “Kim was in her high chair when EIS arrived. She was happy and
smiling,” or are vague such as, “Toby did great! Toby had a good session,” do not
describe the service provided nor the effectiveness of the service provided.
Another truth that becomes self-evident in these examples is how important it is to have
quality SMART outcomes. If the outcome is not measurable it is not possible to
document what interventions are or are not effective over time. It is difficult to determine
how SST can be of assistance with vague outcomes such as “eat table foods.” The first
step you can take to ensuring the quality of your service documentation is to assist the
IFSP team in writing quality outcomes.
What are some routine checks?
As indicated earlier in this chapter, there are a number of oversight entities who may
review your documentation. To avoid negative findings in a review or audit you should
routinely double check your documentation to make sure your documentation is
adequate. The following is a non-exhaustive list of things you should be checking.
1.
2.
3.
4.
5.
Service is on the IFSP.
The note is legible to the average person.
All required documentation elements are present.
Signature includes the credential of EIS.
IFSP outcome is referenced and content of note addresses the identified
outcome.
6. Content of note addresses coaching, training, modeling, and instructing of
caregiver.
7. Content of note indicates application of provider’s professional expertise in
early childhood intervention.
8. Language used is understandable to the layperson (if technical language
is used, a non-jargon explanation is included).
June 2015
119
Using the information in this section of the workbook, create a checklist to use on your
progress notes. Reviewing documentation you’ve already completed will help you
identify areas needing improvement. You may want to get together with your supervisor
and see if your supervisor has identified areas you may want to strengthen in your
documentation. Tailoring your checklist to address areas for your professional
development will create a more valuable tool to you.
For example, if you’re good at describing the instruction provided to the caregiver but
sometimes you forget to ask the caregiver how they did with the interventions when you
weren’t there, you’ll probably want to be sure to include something like, “Content
includes caregiver report on using intervention” on your checklist. Another example
would be, “Content includes needs” to help remind you to address the child’s strengths
and needs.
June 2015
120
Check Your Answers for the Documentation Exercises
Getting to Know the Readers (page 83)
1.
2.
3.
4.
5.
6.
7.
8.
9.
e
h
a
i
d
g
b
f
c
Getting to Know the Rules (page 85)
1. Child, ECI contractor, EIS
2. No. Length of time is required. The ECI program can choose to use start and stop
time together to convey length of time.
3. Individual or group.
4. Coaching, discussing, and modeling.
5. The outcome goal that is being addressed
6. The child’s progress toward the IFSP outcome and any relevant new information.
7. Name, title as EIS, signature.
Getting to Know the Required Elements (page 86-88)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
d
g
j
i
a
m
b
l
f
k
e
h
c
June 2015
121
Getting to Know the Contents of a Progress Note (page 92-93)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
c
b
d
j
a
g
e
f
h
k
i
Getting to know when there’s room for improvement (page 102-110)
Note #1
Addresses an identified need and outcome? There is no indication of the intent of this
session. There is no identified need for this service event.
Adult learner and service delivery triad? There is no evidence of the EIS coaching or
modeling. “Mom encourages him” does not convey whether or not the mother is
using the techniques demonstrated to her. We do not know if the techniques used
by the mother were effective or if they need to be modified.
Daily routines and materials in home? While the note mentions things that probably
existed in the home (books, finger puppets) there is no indication interventions are
being incorporated into daily routines. While the brother is mentioned as being in
attendance, there is no indication the brother was incorporated into the session.
Child response to intervention? Comments the child did well or had a good session do
not convey any information. The note indicates words Toby said but there is no
indication if they spontaneously occurred or were the direct responses to the
interventions being used.
Application of professional knowledge? We do not know what techniques the EIS
demonstrated to facilitate Toby’s imitation of sounds, movements, single words, and
simple phrases. The EIS did not provide techniques that will encourage Toby to
describe what his mom or brother are doing. We did not know who did the looking,
pointing, and naming. We do not know the intent of looking at books and pointing
June 2015
122
and naming pictures. Similarly we do not know what was done with “finger plays”
nor why this will help Toby’s development.
June 2015
123
POSSIBLE IMPROVEMENT:
Today’s session included Toby, Milee (mom), and Toby’s older brother. Goal – saying
words in response to cue. Milee reported they use drive time to practice words. Brother
holds up object, brother and mom state the word, 3 times, then complete it if Toby
doesn’t. Milee says Toby always gives it a real good try – at the very least saying the
starting sound. Milee, brother, and Toby demonstrated. I recommended adding
movement to facilitate learning. Since Milee will be driving, this task falls to big brother
(he was thrilled). We practiced - brother selected the item and the movement – rocking
left right, bouncing in seat, etc. Lots of laughter. Toby tried every time. He completed
the words, “puppy” and “baby.” Much applause and hug from brother. I asked how
running narrative technique was going. Milee indicated she felt odd telling a two year old
how to make meatloaf. Reminded Milee speech depended upon hearing and seeing
others speak. Much discussion. Milee agreed to try bath time, telling Toby how to bathe,
to see if that felt more natural.
Note #2
Addresses an identified need and outcome? Neither “reduce tantrums” or “verbalize”
are addressed in what was done today (#3) section.
Adult learner and service delivery triad? In the description of what was done today (#3),
there is no indication of the EIS coaching or providing instruction to Alberta. We do
not know what “work on sign for…” means. The reader is left to assume the EIS is
teaching Alberta the signs for these words. If this is the case, professional
knowledge in child development is not needed here.
Daily routines and materials in home? This narrative indicates a failure to use the
naturally occurring routine of playing in the gym. Instead the child is required to
attend to the EIS and Alberta while his classmates are off playing without him.
Child response to intervention? The response to the “since last visit” prompt creates the
impression Nadir’s functioning has improved spontaneously and is not related to
the implementation of interventions. Comments about Nadir’s relationship with
Alberta are irrelevant, unless it has been negatively impacting Nadir’s
development. If the relationship has been negatively impacting development, the
observations should include mention as to why this information is important.
Similarly we do not know why stating he is paying more attention is important.
Given there is no outcome related to attention, no indication the EIS or Alberta are
doing something to increase attention or have discovered a technique that helps
Nadir to be more attentive, this information is also irrelevant. Similarly we do not
June 2015
124
know the significance of him responding to his name. We do not know what the
EIS is trying to prove or document with this comment.
Application of professional knowledge? The instruction provided by the EIS (#4) does
not require expertise in child development. Given the last two sentences in #3,
Alberta is doing what is expected of her, the EIS is not offering any refinements, so
no additional services are needed from the EIS.
POSSIBLE IMPROVEMENT:
1. IFSP Outcomes (specify) Addressed:
Respond to sign 5 times in a row, produce signs w/prompt 3 times in a row, and reduce
tantrums to once a week.
2. What has happened since last visit?
Alberta (teacher) stated Nadir is picking up some of the signs but not met criteria.
Already been one tantrum this week. Redirecting works better than ignoring. Nadir
responding to sounds - cochlear is going to work!
3. What did we observe/try today? (specify actions/engagement of all participants in visit)
Gym time with his class. Nadir high tailed it to the balls. Demonstrated how to step into
kids’ play to introduce signs (ball, please, thank you, sorry) with minimal disruption to
play. Alberta tried. Noticed she wasn’t making sure she had his attention before signing.
Recommended moving the signing of the word up to her lips so Nadir doesn’t have to
look two places to get the message. Alberta tried, Nadir did respond to “please” 3 times
in a row. Still not producing w/o prompt. Interruption irritated Nadir but no tantruming!
Agreed with Alberta that play may be too distracting for production of sign. Alberta
stated problems with Nadir taking off cochlear – saying no isn’t enough. Discussed
possible options. No skin irritation. Alberta will try blocking the grab and putting
something else in his hand.
4. What might we do different/continue? What will occur between visits?
1) Get Nadir’s attention and sign near mouth.
2) Request Nadir to sign during story time (less active)
3) Continue with redirection on tantrums
4) Block and redirect for cochlear
June 2015
125
Note #3
Addresses an identified need and outcome? Yes
Adult learner and service delivery triad? Yes
Daily routines and materials in home? There is no mention of routine or materials used.
Child response to intervention? There is no indication of the effectiveness of the
techniques being demonstrated to the daycare worker.
Application of professional knowledge? Yes
POSSIBLE IMPROVEMENT:
Outcomes addressed:
Following directions (goal #9)
What’s happened since last visit (progress reported by family, concerns):
Daycare staff reported they tried using the verbal cues as recommended but it does not
seem to be helping.
Summary of activities worked on today (include how those present participated and
specific progress noted by provider):
Staff watched as Salme and I played with some blocks - giving her simple directions
paired with verbal and visual cues. Discussed with staff how this helps cue Salme to
what you are asking her to do. Modeled for staff how to use hand over hand assistance
to guide Salme through direction. Staff then practiced above techniques with Salme
while EIS observed and coached. When Salme tired of blocks we moved to play dough.
Adding visual cues appears to be very helpful as Salme complied with most requests,
until she tired of blocks. Salme accepted hand over hand unless EIS moved too quickly.
Discussed how technique could be used throughout the day. Toughest time is when
Salme first gets there. Scheduled next week’s visit to Salme’s arrival time on
Wednesday.
Activities to work on before the next visit:
*Give Salme verbal and visual cues when giving her directions.
*Use hand over hand assistance to guide Salme through the direction, slowly.
June 2015
126
Note #4
Addresses an identified need and outcome? Gross motor yes, but not speech.
Adult learner and service delivery triad? No. There is no indication the EIS interacted
with the teacher.
Daily routines and materials in home? EIS is taking advantage of a spontaneously
occurring event. In spite of the form’s prompt to talk specifically about the family’s
routines, there is no indication the EIS has helped the teacher identify the best time
to incorporate the interventions. The prompt on the form itself conveys the
“Activities” of today’s service event are not expected to be a part of the family’s
routines.
Child response to intervention? There is no description of SST intervention. We do not
know what “helped him reach” and “encouraged” mean. We do not know if those
actions were effective.
Application of professional knowledge? No. There is no indication SST was provided.
POSSIBLE IMPROVEMENT:
Others present:
Teacher (Carla), kids
Since our last visit:
Carla stated the techniques we practiced last week are helping Su-bin’s attention to
task. No modification needed at this time.
Goal(s) worked on today:
Gross motor, speech
Activities:
At Head Start, class was outside playing in the leaves. Grabbing bunches and throwing
in the air. Pointed out to Carla this would be a good time to incorporate what PT showed
her last week to improve arm extension. Reminded Carla she doesn’t have to help
every time (and ignore other children). With Carla’s assistance Su-bin did better (got
above shoulders), quickly faded till Carla assisted again. Noticed he was repeating
Carla’s “whee”s and “whoa”s without prompting. Then running through leaves. I started
saying, “Run, run” and asking him what he was doing to prompt Carla. She picked up
the hint and incorporated into rest of outdoor activity. Questions to Su-bin got more
whees and whoas. Su-bin then turned to picking up leaves and poking them through the
fence. I pointed this out to Carla as another opportunity for extensions. Discussed if
June 2015
127
brief focused time at set time in day would work better for her. She said no, just needs
to remember to look for opportunities.
What might we do different/continue? What will occur between visits?
Look for arm extension opportunities - “outside time” may be most likely. Need to
identify the best opportunities for repeating words – outside with other children may be
too distracting.
Note #5
Addresses an identified need and outcome? No. It is not clear how saying or signing
words, waving goodbye, or using a spoon addresses the goal of eating table foods.
Adult learner and service delivery triad? There are two documented recommendations
(use sign and give Trevor a spoon). There is no indication of modeling, coaching,
or instruction.
Daily routines and materials in home? Yes, routine of eating.
Child response to intervention? We have observations of Trevor’s behaviors but they
are not connected to an intervention.
Application of professional knowledge? No. The outcome itself, as stated, is a poor
match for SST. Review of the IFSP and needs assessment indicates Lela (mother)
would like Trevor to “eat finger food solid food.” There is no indication of a
behavioral issue related to eating. Other outcomes include “identifying common
things.”
POSSIBLE IMPROVEMENT:
Changes since last visit:
Grandmother (Dulcea) reports interventions are working – he is starting to take 1-2
steps on his own now.
Worked toward IFSP outcome(s) of:
Self-feeding finger foods. Identify common items.
Today’s activities/observations and parent/caregiver participation:
Arrived at meal time. Dulcea offered pieces of toast, carrots, and fish sticks. Trevor
ignored/refused and stared at jar of baby food (carrots) on table. Recommended hiding
jar behind napkins and use as reward for finger feeding. Demonstrated. Dulcea picked
up quickly – one prompt to not come in too quickly with reward (too much in mouth).
Also good time to identify food items. Demoed: Ask Trevor which finger food he wants,
name food when offered, name food accepted. Trevor did not name food but repeatedly
June 2015
128
said “mama” and perhaps “papa.” After meal, demoed use of pictures to connect
spontaneous speech to correct items. Dulcea implemented w/o assistance. No evidence
of effectiveness – will tell over time.
Child’s progress and recommended activities:
1. Hiding baby food jar makes finger food more desirable.
2. Using jarred food as reward encourages him to eat finger food.
3. Naming items when offered and accepted helps Trevor to identify items.
4. Asking Trevor what he wants to eat encourages him to say what he wants.
Note #6
Addresses an identified need and outcome? No. There is no indication the EIS
addressed either the attention span or expressing needs outcomes. Referring back
to the IFSP and needs assessment, there is no documented need in the personalsocial domain. There is no outcome for Mica to be comfortable with the EIS.
Adult learner and service delivery triad? No. There is no indication of the EIS modeling,
coaching, or providing instruction.
Daily routines and materials in home? Yes.
Child response to intervention? One reference to an intervention “after using some
distraction” does appear to be successful. “Using distraction” was neither explained
nor taught to the parent.
Application of professional knowledge? No. There is no indication of SST being
provided in the “what did we try” section. The recommendations in the “What will
Occur between visits” section is unrelated to the stated outcomes and does not tell
the parent how they are to do what is being requested of them.
POSSIBLE IMPROVEMENT:
IFSP Outcomes (specify) Addressed:
Mom (Michele) wants Mica’s attention span and joint attention to increase so he will be
able to stay focused on one activity for at least 10 to 15 minutes during playtime. Mica
will request his wants/needs with words/word approximations during snack time and
play time 5 times a day or 7 consecutive days.
What has happened since last visit?
Michele reported the effectiveness of first ST session was limited – Mica clung to her.
Seems to be handling other social situations well, even their first trip to the playground
at the mall.
June 2015
129
What did we observe/try today? (specify actions/engagement of all participants in visit)
Given it was my first visit with Mica, spent a few minutes playing with a puzzle – I slowly
increased proximity and involvement. At same time I talked with Michele about things
that keep Mica’s interest, how to incorporate that into activities. We agreed to try car
sounds when driving puzzle pieces over to him. (No demo from me – Mica still cautious)
At first car sounds distracted from next step - identifying the piece. Michele was very
good at patiently prompting until Mica identified the piece with approximation.
Sometimes Mica would lose focus. Recommended different car sounds to get his
attention back. Beep beep seems to work very well, makes him laugh. After about
fifteen minutes suggested to mom to ask Mica what he wanted to play with next. Mica
gestured for his cars. Had to stop Michele from responding before Mica said “ca.”
Suggested she use each car as a separate learning opportunity – “Do you want the blue
car? Say blue.” Michele used beep beep to refocus w/o my prompting. Worked well
here as well.
What might we do different/continue? What will occur between visits?
Continue to use car sounds to help Mica focus during play time. Resist urge to respond
to Mica’s gestures during play and snack time.
Note #7
Addresses an identified need and outcome? Yes
Adult learner and service delivery triad? Yes
Daily routines and materials in home? Yes
Child response to intervention? Yes
Application of professional knowledge? Yes
POSSIBLE IMPROVEMENT:
Outcome:
Sign needs/wants
Arrived at childcare center for snack time. I sat beside Hector at the table with Sally
(tchr) and 4 other kids. Sally has started giving the children small portions of snack
foods instead of the whole thing at once as we discussed last week. Demonstrated
pausing to allow Hector time to request. Sally adjusted easily. I assisted Hector (hand
over hand) to sign “cookie” for another piece, and to sign “drink” for more juice. Sally
practiced assisting hand over hand. He enjoyed the signs, and by the end of snack, he
required only minimal prompt for “drink.” Use of signs may help decrease Hector’s
June 2015
130
frustration about communication and help decrease tantrums. Class had “free play” time
during diaper changes. I modeled using single words and two signs (truck and baby) to
describe Hector’s play. Modeled pausing to allow Hector time to imitate. Explained to
Sally these techniques allow Hector to learn more vocabulary, and it’s a start for
reciprocal communication that will decrease tantrums. Taught Sally signs for ball, block,
and paint. Sally practiced with me, will use with Hector at first opportunity.
Note #8
Addresses an identified need and outcome? Yes
Adult learner and service delivery triad? Yes
Daily routines and materials in home? Yes
Child response to intervention? Yes
Application of professional knowledge? Yes
POSSIBLE IMPROVEMENT:
Absolutely nothing.
Note #9
Addresses an identified need and outcome? Yes
Adult learner and service delivery triad? Yes
Daily routines and materials in home? Yes
Child response to intervention? Yes
Application of professional knowledge? Yes
POSSIBLE IMPROVEMENT:
Outcome:
To crawl
Suong (Mom) set Kim on her bottom on floor, EIS placed the toys around her. She
reached out for the blocks and pivoted on her tummy. When she reached out for the
cube which was placed quite aways, she tried to go to her tummy but her leg got caught
up under her so EIS showed Suong how to gently pull her leg just a little bit under her
and then Kim did the rest of the work and she went to all fours. She immediately went
down on her tummy but the work on her arms was there. She reached for the blocks
June 2015
131
and mom helped her place them where they go and turned on some music. She got
very excited and started to dance. When EIS attempted to fold her legs under her to
show mom how to help her stay that way, Kim got upset. Suong calmed her down and
we tried floor time again after a little bit, dancing while reaching for toys and Suong
assisting Kim in going to all fours.
June 2015
132