Early Intervention 101: A Virtual Reality
Authors: Karen Borg, Director of the Parent Infant Program for the Blind and Visually Impaired, Utah Schools for the Deaf and Blind
Keywords: early intervention, IDEA, Part C providers, Part B, teleintervention, early childhood, Parent Infant Program, virtual instruction, distance learning, coaching
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Perspectives from Utah on Early Intervention Using Distance Tools
The Parent Infant Program for the Blind and Visually Impaired (PIPBVI), a division of Utah Schools for the Deaf and the Blind, serves the entire state of Utah, delivering services to every location that has a child aged birth to 3 who has a vision impairment. Utah has an urban corridor that extends through half its length, right in the middle of the state. The rest of the state consists of rural country that branches out away from that metropolitan area. Because of inclement weather, distance, and cold and flu seasons, we are not strangers to using distance learning technology to make virtual visits. Covid-19 has brought a whole new level of virtual to our practice, which has now been almost exclusively distance since March of 2020. This shift in our practice is having effects we haven’t yet been able to quantify or qualify, so we are leaning on what others have said about teleintervention as we navigate the continuing pandemic and craft a pathway past the pandemic into the future for our field. The one study that has been conducted on teleintervention in young children with visual impairment states:
“Conclusions drawn from the study suggest that teleintervention has the potential to be a successful and viable way to supplement, not replace, in-person O&M support home visits with families of children with BVI, particularly to increase the availability and frequency of services” (Phangia Dewald, 2019).
Our experience seems to echo Dr. Dewald’s conclusion. Virtual visits have greatly increased our reflective coaching abilities, thus empowering parents to participate more actively in routine-based strategies.
Some of the challenges of virtual visits include the difficulty of doing functional assessments; the ease families find in cancelling a virtual visit, making services less consistent; and the loss of families who refuse teleintervention, even during a pandemic. The unknown effects include the impact on child progress. It will be several months before that data is available, and the ramifications of COVID-19 will still be only estimated. Will families be less or more likely to seek services? Will they seek or shun virtual services? Face-to-face services? Will the pandemic produce a cohort of children who will be impacted for years to come as they turn three and enter Part B services (for students 3-22)? When all is said and done, the results are still likely to just be a guess of the impact of COVID-19.
What Does This Mean for Service Providers?
A little background for new providers:
If you are new to early intervention, or an outsider all together, it’s easy to ask, “How do you even give vision services to a baby? And why would you?” A moment of reflection and common sense will remind you that vision is foundational to every developmental domain. Vision loss changes the way a child learns because they are not able to learn incidentally through observation. Vision loss affects bonding, and good attachment leads to the security and confidence necessary to explore and interact with the world around us. Vision is the primary motivating sense for approximately the first year and a half of life.
COVID-19 has impacted staffing and service patterns in many areas. If you are a teacher of students with visual impairment (TVI) serving primarily students in Part B (age 3-22) and find yourself with Part C (birth-3) referrals, this article might provide some survival skills to help that transition be a bit smoother. The referral process in Part C of IDEA is a bit different from Part B. A referral for early intervention services could come from a doctor, parent, public agency, homeless shelter, etc. In Part C, determination of eligibility must be made within 45 days of the referral. In Part B, eligibility must be made within 60 days of consent to evaluate being given. Evaluation is free of charge to families in both cases. IDEA allows states to charge for other Part C services if they choose, but a free, appropriate public education is required in all states for Part B students.
Part C requires that services take place in the natural environment, which is defined as “…settings that are natural or typical for a same-aged infant or toddler without a disability, may include the home or community settings….” If the parent and the IFSP (Individual Family Service Plan) team determine that a setting outside of the natural environment is appropriate, it must be because skills cannot be achieved within the natural environment. In our program, an IFSP outcome such as safely navigating an unfamiliar environment might serve as the foundation for such a decision.
Finally, in Part C, the emphasis for service provision is the family. The service document is an Individual Family Service Plan. It is perfectly appropriate to write a goal (often called outcome) for the parents, caregivers, or guardians, such as, “Mom will master the Grade 1 Braille alphabet.” The IFSP is reviewed and amended as appropriate every 6 months, instead of annually. The family really does drive the Part C bus. The family chooses the outcomes (goals) and has a large say in the service pattern. Building relationships is paramount.
Building a Rapport
Before you call the family of a new referral, do your best to get as much information as possible from your referral source. Some important questions might include:
- Was the child in the NICU? How long?
- Is there a medical diagnosis?
- Is there a vision diagnosis?
- What are the family’s circumstances?
Many providers find it smooths the way to first introduce themselves by text, and upon getting a response, to set up an appointment for the first virtual visit. If possible, meet with both parents. Remind them of how you got the referral. Ask simple, direct questions and discuss their observations and concerns about vision. Find out about the family and their support systems and preferences.
In our program in Utah, more than half of the children aged birth to 3 with vision impairment have multiple differences. Many of these children are medically fragile, which contributes financial and emotional stress to their families’ situations. Families are worried, exhausted and overwhelmed. Listen carefully and empathetically to their concerns and their goals. Recognize that medical situations may frequently derail the visit schedule and that does not mean that the family isn’t committed to their child’s progress. As your relationship with the family deepens, point out how the strategies they’ve implemented have helped their baby progress. Help them network with other families who have children with visual impairment.
Assessment and Developing an Instructional Plan
In order to determine eligibility for services and develop an instructional plan, you’ll need to do some assessment. Many assessment tasks can be accomplished virtually. Send parents a list of the kinds of visual behaviors you’re interested in before you meet with them to begin evaluation. To have a good history of visual behavior, ask questions such as:
- What are the parents’ vision concerns?
- How is the child using their vision?
- Are there any unusual visual behaviors?
- Is the child meeting visual milestones?
- Have they seen an eye doctor? Is there an eye report? (in many states, eligibility for vision services in Part C is not based on an eye report, but on visual functioning).
When you have a chance to meet for the virtual visit, observe the child at play. Point out specific behaviors, “I see…. Did you see…?” After your first visit, you should have an idea of what still needs to happen for eligibility. Can you finish up virtually? Can you use materials in the family’s home? If not, consider dropping off materials for your next virtual visit. Could the family make some videos that would help you assess further? If it’s necessary to meet, make sure that you can do that in a place where COVID-19 protocols can be met, such as social distancing. Some homes are small enough that it is difficult to stay at least 6 feet away. Ensure that parents are willing to wear a mask.
After eligibility is determined, instructional planning can begin! Best practice requires that outcomes are measurable, observable, routine-based, and functional. They will be based on parent concerns and priorities, informed by your assessment. Remember, the purpose of our visits in Part C are not to do therapy; it is to coach parents to utilize strategies throughout the day, in typical routines, to enhance their child’s growth and development.
Conducting a Virtual Home Visit
Begin a home visit by asking the family how things are going generally (work, health, family in general, etc). Next, review the last visit, what you worked on, and how follow-up went for the family. Report on follow-up you may have committed to (getting an eye report, finding out about a community resource, etc.). Ask what they’d like to work on today. If an answer isn’t forthcoming, remind them what they prioritized at the close of the last visit and ask if that is still appropriate. You might also ask some reflective questions, such as, “Are there routines that aren’t going well? What is the hardest part of the day?” Such reflection can help keep the focus routines-based and may help the family member step out of the rut of “just another visit” to really measuring how the strategies and modifications you suggest can be beneficial on a day-to-day basis. When you determine the plan for your visit, ask the family to collect some things to use for the visit. This doesn’t need to be hurried or stressful. For example:
- Do you have the shape sorter we used last week? I can wait while you get it.
- Do you have a pan in the kitchen that we can use for banging
Make adjustments to the camera angle, positioning, etc. throughout the visit as needed. This, too, should be relaxed and natural.
Remember that the focus of any Part C visit, virtual or face-to-face, is the interaction between the parent and the child. The Part C provider shouldn’t spend more time interacting with the child than the parent! Being virtual really helps us practice our coaching skills and stay out of the way. Try not to be distracting when the parent has the child’s attention. Do feel free to give feedback when there’s a break. Be positive and specific in your instructions, for example:
- It looks like she could use a little support under her arms. Do you have a pillow we could use?
- What is he looking at? (If you see that the child’s visual attention is elsewhere). Could we bring that down to his eye level?
You should also feel free to drop things by, while keeping safety protocols in mind. Some things that aren’t available readily in many homes might include mylar (to look at, to grab, or to stuff into a pillow), a switch and switch activated toys, a brailler, a slinky, etc. Check with the parent to see what they might use in their routines.
As you prepare to close the visit, review what happened and how it went. Reflect with the parent about progress:
- What do they feel is going well?
- What seems to be a continuing challenge?
- What do they think might make progress more forthcoming?
Make a plan for dropping things off before the next visit, if necessary, and what you will follow up on for the next visit. Confirm the date and time of your next visit and what the family will do to be prepared for the next visit.
It is a unique privilege to serve families at the beginning of their special education journey. These families, many of whom are so new in the grief process and so frightened about the future, invite us into their homes, virtually and in person, to navigate their daily lives with them. We reflect with them on the realities of today and the potential of tomorrow. Part C providers teach strategies and make accommodations to allow all of the members of a family to enjoy each other and join together in the routines of their household and culture. The family’s life is enriched with possibility and participation. Our life is enriched by collaboration and the sharing in others’ dreams. Part C services may be new to you, but rest assured, they can inform your practice and enhance your life if you let them.
Phangia Dewald, N. B., Providing orientation and mobility support via in-person and teleintervention home visits for children with visual impairment in early intervention. (2019). Dissertations. 594. https://digscholarship.unco.edu/dissertations/594
TSBVI Coffee Hour Webinar: Distance Considerations for Birth to 3.