Recent CAPTA legislation mandated that all substantiated cases of maltreatment of infants and toddlers be referred to early intervention services to determine eligibility. Given the elevated levels of risk and delays reported, getting eligible maltreated children, ages birth through two years of age into Part C services seems an important task, perhaps more so because of the importance of this time period in child development. Part C service providers, however, may need new strategies to engage and work with maltreated children and their families. In addition to the negative consequences of maltreatment on childrens behavior and development, childrens families may be disorganized, suspicious of providers motives, overwhelmed by multiple services and providers, coping with substance abuse or early sobriety, or coping with other difficult problems. As a result, these children and their caretakers may not respond to routine early intervention practices.
Children coming to services from maltreatment backgrounds bring a new set of challenges to many early intervention practitioners. In addition to their developmental problems, maltreated infants and children may bring severe behavior problems (e.g., attachment disordered behaviors), problems in the family of origin, substitute caregivers who may not be knowledgeable about the child (e.g., a new foster family), multiple service providers and payment sources, and other challenges for interventionists to resolve (Vig, Chinitz & Shulman, 2005).
In particular, intervention with maltreated children, whether the child is in foster care or remaining with their family of origin, requires the active participation of family members. Part C services are by definition supposed to be directed to both children and families, in that the goal is to help caregivers incorporate intervention activities into the childs daily routines. Because behavioral and mental health disorders are related to maltreatment, Child Welfare Services interventions are often recommended to include parent training and other family-centered components because of the enormous influence parents have on their childrens outcomes, developmental or otherwise (Vig et al., 2005). Recent developments in parenting of maltreated children have focused on helping the caregivers to be more responsive to the variations in the childs response and to stay positively involved with their care, even if the children are initially unresponsive (Fisher, Burraston, & Pears, 2005).
Many Part C early intervention providers may not be well prepared to address the special considerations required when working with maltreated children. Many Part C providers are speech language therapists, occupational therapists and physical therapists. As Vig et al. (2005) point out; increasing interventionists knowledge will improve services and outcomes. In addition to developing new skills, early interventionists may use, or collaborate with others who are using specific treatment regimens designed to improve maltreated childrens behavior, address mental health problems including attachment problems, and promote development.
Discussions with Part C early intervention experts supported the concern that early intervention providers do not have extensive experience or training to work with children and particularly adults with mental health issues. Even for service providers experienced with such families, service provision can be difficult. Providing Part C providers with knowledge and professional support can greatly increase the likelihood of effective service provision with the end result of better child outcomes.
A major concern expressed by experts was that Part C early intervention primarily provides therapeutic services that are child-focused. Family-focused services in Part C are centered on family involvement in supporting child development. Part C does not typically provide services that include services for other family members, though Part C services may be adult focused; it is generally in the form of training for the parent to work with the child. In most cases, Child Welfare Services emphasize providing family-centered services because research, past experience, and theory suggest this will be the most effective intervention model for resolving behavior and mental health problems in the child and promoting a strong sense of connectedness among family members.
Part C services are based on the childs eligibility for services, predicated on developmental delay not maltreatment. The vast majority of services provided are speech-language therapy, physical therapy, occupational therapy, or home-based services from a developmental specialist or early interventionist. It is unusual for infants or toddlers to be eligible for Part C services because of behavior, though behavior is a concern for many parents of children with disabilities (Scarborough et al., 2007).
Families involved in child welfare may also present with problems that inhibit service provision. They may be suspicious of, or hostile towards, service providers. In the MECLI Study in Massachusetts, it is estimated that in addition to the 18% who refused referral that another 19% of families who accepted the referral did not engage with Part C (Lippitt, 2007). Court-ordered involvement may cause parents or caregivers to view a service provider as an intrusion rather than as a source of assistance. Home environments may be chaotic or, in the case of homelessness or residence in a shelter, non-existent.
Receipt of Part C services is voluntary, so court-ordered services are not part of the service culture, and for most, an unwelcome notion. Delivering court-ordered Part C services would require the development of procedural guidelines. A national survey of state Part C providers indicated that in regards to this matter there needs to be a determination of when to challenge caregivers decision to decline services. Specifically the differences in Part C and child welfare agency culture regarding mandating services should be resolved at the state and local level (Stahmer, et al, 2008).
In sum, three major challenges often need to be addressed by Part C early intervention providers. First, the focus of service should address the childs needs within the context of the family. Second, special strategies and techniques are often needed to engage, retain, and successfully serve child welfare families in Part C early intervention services. Finally, when possible, the intensity of services should be matched to the needs of children and families in order to facilitate a positive outcome.
Individualized Part C early intervention services as typically delivered to infants and toddlers with disabilities are unlikely to be of sufficient intensity, nor are they designed to be effective in addressing the root causes of maltreatment and severe family dysfunction. The effectiveness of Part C is generally predicated on the intervention that occurs as part of the childs daily routine between therapeutic sessions, rather than during sessions. Budget constraints or practitioner schedules may limit visits to as few as once a month. When missed and canceled appointments are factored in, visits may be even less frequent. Yet, maltreated children are often behind their peers developmentally, have behavior problems, and continue to experience poorly functioning home environments. These multiple needs call for intensive services to make a meaningful impact. Both families and providers may quickly become frustrated when low-intensity (infrequent or brief) services fail to provide a noticeable developmental benefit to cases in which higher intensity services are probably necessary.
Some immediate assistance for Part C providers, and their child welfare and mental health collaborators, in being able to refer children and families to specific treatment regimens designed for maltreated children or with direct applicability to them could be useful. Early Intervention Foster Care (Fisher et al., 2005) and The Incredible Years Parenting Program (Bauer & Webster-Stratton, 2006) are two examples of evidence-based interventions that have shown success with pre-school aged maltreated children. Specific issues have been laid out for interventionists, but it is not known to what degree Part C providers have begun to address these concerns.