Early Intervention in Rural NaturalEnvironments: Maldng the Most of Your Time

Lee Ann Jung, Ph. D.

Kathcrine M. McCormick, Ph. D.

Kristine Jolivette, Ph. D.University of Kentucky

AbstractEarly intcrvcnrionists m rural settings face many barriers as they seek to provide elective services in natural environments for infants andtoddlers with disabilities and their families. This paper describes a model for addressing these barriers. Three components are described: theuse of natural learning opportunities, consultative service delivery, and transdisciplinary teaming.

Early Intervention in Rural NaturalEnvironments: Making the Most ofYour Time

Though early intervention for children birth to3 years was not added to legislation until 1986,programs For infants and toddlers with disabilitieshave existed since the mid-1970s. Many programsprovided early intervention to qualifying infantsand toddlers in centers or clinics exclusively forchildren with developmental delays anddisabilities. This center based model held clearadvantages for the provision of early interventionin rural settings. Programs using this model simplyinvited families to bring their children to a centeror clinic to receive needed developmental services.The center based model allowed early interventionprofessionals to serve a large number of childreneach day.

In response to lessons learned through researchand practice in early intervention, the words "naturalenvironments'" were added to early interventionlegislation in the 1991 amendments to theIndividuals with Disabilities Education Act (IDEA),P. L. 102 119. The Code of Federal Regulationsdefined natural environments in 1997 as "settingsthat are natural or normal for the child's age peerswho have no disabilit)'" {Sec. 303.18). Much like theleast restrictive environment provision for school-aged children, states that receive federal funding forearly intervention are mandated to include policiesand procedures to ensure "to the maximum extentappropriate, early intervention services are providedin natural environments" and "the provision of earlyintervention services for any infant or toddler occursin a setting other than a natural environment only if

early intervention cannot be achieved satisfactorily forthe infant or toddler in a natural environment" [Sec.303.12{c)].

For many programs that provided earlyintervention services prior to 1997, this newemphasis meant a major shift in service delivery.Administrators of such programs faced the challengeof completely transforming their programs after thepassage of IDEA 1997. Because of the semantics usedin the legislation, many people have focuseci primarilyon location, where the professional works with thechild (lung, in press). This shift in location posed aunique set of challenges to those serving ruralpopulations, both in terms of logistics as well asfinances.More than a Place

Changing the location of services to homes andcommunities where children live is a challenge withwhich early intervention service providers continue tostruggle. Some rural commimities are more than 3hours from the nearest early intervention program.Unlike previous years when educators and therapistscould serve 15 or 20 children per day at a center,service providers now oftentimes use an entireworkday to provide services during one home visit.At first glance this seems like a drastic reduction inservices, especially to children and families in ruralareas. However, if the other dimensions of the intentof natural environment legislation are considered,children can in fact receive more intervention thanthey would have received through a traditional,center-based program.

Merely moving the location of services fromsegregated to inclusive settings does not guaranteesupport to families (McWilliam & Strain, 1993). In

3D Rural Sp

fact, services that arc provided in a natural locationcan still be delivered in an unnatural manner. Forexample, a speech and language pathologist maytravel to an infant's home and work directly with thatinfant as if in a clinic while the caregiver is in anotherroom. A physical therapist may travel to a childcarecenter and pull a toddler to another room to providerange of motion exercises. Although these locationsare natural, clearly this type of service delivery ignoresthe purpose of the change in legislation (TurnbuU,Blue-Banning, Turhiville, & Park, 1999). Thefollowing parent quote provided by Turnbull ct al.(1999) illustrates explicitly how certain models ofservice delivery can transform the most naturalenvironment of a child's home into a completelyunnatural environment:

The message to me as a mother that nmspervasive in early intervention's emphasis ondevelopmental milestones was that we needed to 'fix'James. The harder I worked, the more he wouldachieve. And achievement was the name of thejjame. 'Developmental milestones'how I learnedto hate those words. They were the ^ old medals ofthe '^fix it' set.

I readily became James' teaeher. His playtimeat home beeame 'learninjj time'aetually all histime was learning time. Any free time we had athome was to be spent on his therapy or to be spentfeeling guilty that we weren't doin^ his therapy. Iremember one developmental milestone he neverachievedstacking three blocks. He had finallyachieved stacking two blocks; the next milestone wasstackinjj three. I modeled for him, prompted him,and finally held his hand while we did it together.Inevitably, when left to attempt it on his own, Jameswould pick up the blocks and throw them. He foundthis hysterically funny. His early interventionteacher thoujjht he was noncompliant. Jamesobviously didn't ^et the fact that his tieket toacceptance rested heavily on stacking those blocks.(p. 165)According to the literature, natural environment

means much more than location (Harbin et al., 1998,NECTAS, 2000). The broader intent was to movebeyond teaching the child to supporting families(McWilliam, 1995; McWilliam & Strain, 1993;NASDSE, 1999). "How [services] arc provided inthese natural environments is just as important aswhere it is provided" (Hanft & Pilkington, 2000, p.1). In this paper, we will describe a model for servingfamilies and their young children by emphasizing

natural learning opportunities, consultative servicedelivery, and transdisciplinary teaming.Natural Learning Opportunities

Oftentimes, the most efficient route to moreintervention is not through interventionists' visits butthrough intervention embedded in typical dailyroutines and delivered by natural caregivers utilizingnatural learning opportunities. The use of naturallearning opportunities mediates many of thechallenges typically reported by administrators,service providers, and families in rural settings. Forexample., many administrators report a scarcity oftherapists willing or available to work in rural areas.Also, many service providers complain that much oftheir time in serving rural populations is spent intravel. Because of this increase in travel time manychildren are visited only once a week or every otherweek. Many interventionists have concerns when achild's entire team cannot visit and provideintervention even weekly. How could this possibly beas good as trained teachers and therapists workingwith them every day.' However, intervention shouldnot be limited to several times per week. The logicalassumption is more visits by the early interventionteam members results in better outcomes forchildren. Is this necessarily true? Or could moreopportunities for learning which are embedded innatural routines by typical caregivers and familymembers result in equal or better outcomes forchildren.'

Natural learning opportunities occur throughouta child's day, whether learning is planned orunplanned {Dunst, Bruder, Trivette, Raab, &McLean, 2001). Picking vegetables in a garden, awalk in the woods, and washing dishes all providenatural learning opportunities. These activitiesprovide many teachable moments throughout the day(Cripe & Venn, 1997; Rule, Losardo, Dinnebeil,Kaiser, & Rowland, 1998). Parents intervene in theirchildren's development every day. They haveinfinitely more opportunities to enhance their child'sdevelopment than a professional who visits weekly ormonthly. Families do many wondertlil things withtheir children every day to teach them without everbeing told to do so by an inter\ entionist. These dailyinteractions between families and children have amuch greater impact on child progress than do earlyintervention sessions (Dunst, Bruder, Trivette, Raab,& McLean, 2001; Hanft & Pilkington, 2000;McWilliam, 2000). The use of natural learningopportunities embedded in daily routines can be

Rural Special education Ouarterlv 2004 25(3) 31

easily promoted through consultative service delivery.Consultative Service Delivery

Consultation is a triadic helping process in whicha child receives intervention from the caregiver, whowas advised by the service provider (File & Kontos,1992). Through consultation, caregivers are givenstrategies that allow them to maximize naturallearning opportunities or embed instruction intotheir daily routines and activities. Consequently, thechild has opportunities for intervention all day, everyday and in contexts that are meaningful to the childand family. For example, a child who is awake 12hours per day may receive a direct intervention onceper week for one hour. If no efforts are made to sharestrategies with the family during that hour, the childhas only one hour of opportuniU' for this particularintervention each week. Furthermore, the one-hourof opportunity is more than likely not embedded intoa natural routine. If instead that professional uses thehour to provide strategies to the caregivers, the childnow has 84 hours of opportunity for interventioneach week (Refer to figure 1). Certainly no caregivershould be consumed with thinking about providingtheir child with intervention 84 hours each week.That would be completely unnatural. However,opportunity for learning can be increased using thismodel. Even if the family only used suggestedstrategies during 2 hours each week, intervention hasincreased by 100 percent.

D I R E C T S K R V I r E S M O D K L

C O N S U L T A T I V E M O D E L

Figure 1. Weekly Intervention Opportunities

The implications of this model for families inrural environments are particularly exciting. Usingthis model children who previously received monthlydirect therapy from a therapist may now receive dailyintervention from natural caregivers. By expandingthe definition of intervention to include whathappens when professionals are not around, familiescan be empowered to take back their rightful role astheir child's first teacher.

Some professionals argue that teaching a familystrategies is not effective because parents were nottrained to learn how to provide intervention(Bernheimer & Keogh, 1995). However, in the early90s, the medical profession began to recognize theabilities of families to care for their children andbegan training parents on specific medical proceduresnecessary for the survival of children with complexhealth care needs. Parents mastered the ability tosuction tracheotomy tubes, feed their children viagastrostomy tubes, and monitor for and respond tobradychardias and apnea (Seitz & Provence, 1990).These procedures are for the most part much morecomplicated than the average intervention suggestedby a therapist or educator. The child's life depends onthe parent's ability to do these things correctly.Families in rural areas are empowered to care for theirchildren's medical needs and may go for months at atime without direction from medical personnel.Certainly if parents can learn to care for tracheotomyand gastrostomy tubes without ongoing supervisionthey can learn developmental intervention strategies.

Transdiciplinary TeamingDeciding frequency of visits and which

professionals on the team will visit the family can be acomplicated issue. Traditionally, questions like "Howsevere is the disability," "Will this parent followthrough," and "In which areas is the child delayed"have guided how often the child is visited and bywhom. At first glance, the logical course may seem tobe providing more services more frequently tochildren with delays in more areas or more severedisabilities. However, since professionals should besupporting the families' ability to functionindependently, visiting too often can send the wrongmessage. Professionals are giving themselves toomuch credit (and not enough to caregivers) to saythey must see a child with their own eyes every week.Furthermore, research has demonstrated that themore frequently families are visited and the greaternumber of professionals on the team, the less families

32 Murol Sp

Table 1Questions to decide who visits and how often

Old Questions New Questions1. How severe is the child's delay or disability?

2. Will this family follow through?

3. In what areas does this child have a delay?

1. How often will the child's intervention likely needto be changed?

2. How often do I need to go to support the family'scomfort in using intervention strategies?

3. Do the outcomes related to family concerns requiresupport from a specialist?

4. Can multiple outcomes be supported by a singleperson such as a special educator?

feel supported, and child outcomes are diminished(Dunst, 1999). Transdisciplinary intervention is aflexible, holistic and dynamic approach in which teammembers teach and learn from one another toprovide integrated intervention suggestions forparents and carcgivers (Linder, 1993).

Finding a balance between enough but not toomuch may be difficult for professionals, especiallywhen the financial constraint of traveling to serverural families is added. Three questions found inTable 1 can help guide professionals in determiningfrequency and team configuration for home visits: 1)How often will strategics likely need to be changed,2) How much support do the caregivers want or needto feel comfortable with the suggested strategies, and3) What type of support is needed?How often will strategies need to bechanged?

B\' asking how often the strategies will wtcd to bechanged, professionals will most likely arrive at adifferent fi-equency than if they had simply prescribedmore visits for those with more severe disabilit}'. Achild with more severe disabilities may requireintervention that will not need to be changed formonths at a time. For example, a child with multiple,severe disabilities may need positioning andmovement strategies designed by a physical therapist.These strategies will need modifications infrequently,certainly not weekly and quite possibly not evenmonthly. Visiting the child each week to assess thecarcgivers' ability to continue with a positioningstrategy' is not only unnecessary, but could also beintrusive in their lives and insulting of their ability. Aphysical therapist at tending a recent trainingremarked, "I go every week because the family wantsme to come, but each time I pretty much say, 'goodjob; keep it up.'" Instead, a single member of the

team could visit the family every week to ensure thefamily receives all supports they need. The other teammembers, including the physical therapist, could visitthe family with the primary support person lessfrequently. Not only is this configuration moreconsistent with recommended practice, but can alsoalleviate a great deal of financial burden on a programattempting to provide multiple, frequent services inrural settings.

What level of support does the family need?Instead of assuming that some caregivers will not

follow thrt)ugh with strategics, professionals shouldconsider what supports a caregiver will need in orderto follow through. A family who has a child withcerebral palsy, for example, may be afraid of hurtingthe child as they position and stretch her. This familymay need more frequent visits for a couple of weeksuntil they are comfortable with what they are doing.

In fact, research suggests that frequent visitingcan be counterproductive (Dunst, 1999). Frequentvisits may lead to exactly what professionals are tryingto guard againstlack of follow through. Visitingtoo frequently can actually be damaging tocaregivers' feeling of support, and damaging to childoutcomes (Dunst, 1999). Very frequent visiting mayalso imply that the caregivers are not perceived byprofessionals as competent in enhancing their child'sdevelopment. If interventionists focus on directteaching activities or therapy during the visit,caregivers may infer that instruction time, divorcedfrom their normal daily routine, is necessary for thechild to learn. Too frequent visiting may lead familiesor childcarc providers to believe that only earlyintervention professionals can make change in thedevelopment of children with delays or disabilities,which may lead to what many professionals describeas lack of follow through on the caregiver's part. If

Rural Spcdol education Quartarfy 2004 33

caregivers believe they have no power to increasedevelopment in their child, why would they followthrough? IF they feel interventionists have the powerto change their child's development,, of course theyare gong to want them to provide direct services asfrequently as possible.

What type of support is needed?In a center-based model, programs had the

luxury of providing a service for every delay for eachchild. For example, if a child had a delay in grossmotor development, the child received service from aphysical therapist. If a child had a communicationdelay, the child received service from a speech andlanguage pathologist . Natural environmentslegislation makes this type of service delivery difficult.,especially for families in rural areas. Furthermore,although this process of decision making may seemlogical, there are implications for this type ofdecision-making. If each team member claimsexclusive ownership of his or her developmentaldomain, a resulting team and service deliveryconfiguration may be three professionals visiting afamily weekly. If our goal is to help children withdelays and disabilities fluiction more normally, thishardly seems to be the answer. One family of a childwith multiple severe disabilities recently remarked, "Ifelt like a secretary. My life was consumed with [mychild's] appointments. . . . I finally had to put an endto it. It was scary, but I just had to decide which ofthese specialists I needed to keep and the rest had togo. If I hadn't., I would have had a disabled child anda nervous breakdown."

Deciding who are the appropriate team membersto visit is oftentimes a difficult process for teams. Indeciding who will visit the family, one starting pointcan be to discuss whether the type of support neededfor any given family defined outcome would best beprovided by a specialist (e.g., speech therapist) or ageneralist (e.g., special educator). A person who is anearly childhood special educator is qualified to designintervention addressing developmental delay in allfive areas of development. However, intervention ortherapy designed by a specialist is necessary whendelays in areas such as communication, motor

development, or feeding appear to be caused by adisorder, or if development in these areas is notfollowing the t>'pical trajectory of child development.

For example, an early childhood special educatorand a speech and language pathologist may evaluate achild with a communication delay and agree that thechild's delay does not appear to involve a disorder andwould best be addressed by providing the caregiverswith additional strategies to enhance communication.The team has several options: both service providersmay visit the child, the speech language pathologistmay visit the child, or the early childhood specialeducator may visit the child. Either service providercan address this t\'pe of delay, so there is no need forboth to visit. One person can then provide supportand build a relationship with the family.

Had the child's communication delay beensuspected by team members to be due to a disorder,the speech and language pathologist would need tohave designed intervention for outcomes related tothat area. If the child had no other delays, only thespeech and language pathologist would need toprovide services. A similar approach may be used for achild with multiple and severe disabilities to avoidmultiple visits each week and to maximize infrequentvisits. One example of a team configuration mightinclude monthly or bi-monthly visits by therapistsand weekly visits by a special educator. Though thespecial educator would not be qualified to developtherapy for a child, the special educator can addresswith the family the child's progress and family'scomfort with strategies to determine if the familyneeds a visit from any of the therapists sooner thanplanned.

ConclusionMany challenges are presented to early

intervention programs serving rural populations. Atfirst glance, a need to reduce numbers of visits tt) ruralfamilies may appear to be a serious disadvantageimposed by natural environments legislation.However, by asking a few simple questions to guidedecision making, teams can not only maximize theirtime but also improve outcomes for families andchildren.

34 RurQl Spadol CducotloA puorlcrlv 2004 23(5)

ReferencesBernheimer, L. P., & Keogh, B. K. {199S), Weaving interventions

into the fabric of everyday life: An approach to tamily assessment. Topics inEarly Childhood Special Education, 15, 415 433.

("ripe, I. W. and Venn, M. L. (1997), Family-guided routines torearly intervention services. Yourif) Exceptional Children, 7{I), 18-26.

IXinst, C;. I., Bruder, M. B., Trivctte, C. M., Rjab, M., & McU-an,M. (2001), Natural learning opportunities for infants, toddlers, andpreschoolers. Toun^ Exceptional Children, 4(3) 18 25.

Diinst, C. J. (1999). Placing parent education in conceptual andempirical context. Topics in Early Childhood Special Education, 19, 141-147.

Filc,N., & Kontos, S. (1992). Indirect service delivery through con-sultation: Review and implication for early intervention. Journal of EarlyIntervention, 16(3), 221-2^S.

Hanft, B. H., & Pilkington, K. O. (2000). Therapy in natural envi-ronments: The means or end goal for early intervention? Infants andToun/f Children, 12(A), 1-13.

Harbin, G., McWilliam, R., Shaw, D., Buka, S., Sideris, J., Kockack,T., Cialiaghcr, J., Tocci, L., West, T , & C;Urk, K. (1998), Implementing^federal policy for yottnji children with disabilities: How are we doinjj? Early('hildhood Research Institute on Service Utilization, Frank Porter Gra-ham c:hild Development Onter , Universit)' of Norrli Carolina at (ChapelHill.

Individuals with Disabilities Education Act, Amendments of 1991,PL 102-119, United States Code, 20, sectionsUOO et seq.

Individuals with Disabilities Education Act, Amendments of 1997,PL 105-17, United States Code, 20, sectionsMOO et seq.

Individuals with Disabilities Education Act, Amendments of 1997,PL 105-17, lUnitcd States 34 Code of Federal Regulations Part 303,Early Intervention Program for Infants and Toddlers with Disabilities]

hing, L. A. (in press). Effects of service coordinator variables onindicators of recommended practice in intiividualized family service plans.Journal of Early Intervention.

Lindcr, T. W. (1993). Transdisciplinary play-based intervention:Guidelines for developing meaningful curriculum for youn^ children. Bal-timore, MD: BrookeS-

McVVilliam, R. & Strain, P S. (1993). Service delivery models. In S.L, Odem & M. McLean (co-chairpcrsons), DEC recommended practices:Indicators of quality in programs for infants and yoitnjt children with spe-ctal needs and their families, {pp. 40-46). DF.C Task Force on Recom-mended Practices: The Council for Exceptional Children.

McWilliam, R. (1995). Integration of therapy and consultative spe-cial education: A continuum in early intervention. Infants and YoungChildren, 7(4), 29-38.

McWilliam, R. (2000). It's only natural to have early interventionservices in the environments where it's needed. Toun^ Exceptional Chil-dren Monograph on Natural Environments.

National Association of State Directors of Special Education(NASDSE) (1999). The U.S. Department of Education Broadcast onC^onnectLivc.com: Guidance on implementation of IDHA 1997, Re-trieved May 1, 2002 from h t t p : / / w w w , idcapolicy.org/lDEA%20S3tdlitL-%20Conf/march 3.htm

National Harly Childhood Technical Assistance System (NECTAS)(2000). OSEP-iimdcd early childhood projects. Retrieved May I, 2002from http://www.nectas.unc.edu/

Rule, S., Losardo, A., Dinncbcil, L., Kaiser, A., & Rowland, C.(1998). Translating research on naturalistic instruction into practice.Journal of Early Intervention, 2, 283-293.

Seitz, V, & Provence, S, (1990). Caregiver-focused models of earlyintervention. In S. J. Meisels, & |. P. Shonkoff (Eds.), Handbook of earlychildhood interi'ention (pp. 53-77). New York: C^ambridge UniversityPress.

Turnbull, A. P,, Blue-Banning, M., Turbivillc, V., & Park, J.(1999). From parent education to partnership education: A call fortransformed focus. Topics in Early Childhood Special Education, 19, 164-172.

Rural Special Cducatran Qwartcriy 2004 25(5) 55