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ECI: Making It Work - IFSP section
4. IFSP
Introduction
4.1 Moving on to IFSP
Notes:
MIW SC:
The Individualized Family Services Plan, or IFSP, documents the child’s strengths, needs, functional abilities, the family’s priorities for services, and the type and amount of services the child will receive. The IFSP form is completed by the team during the IFSP meeting, but the form reflects all of the information gathered during pre-enrollment, the evaluation, needs assessment, and the IFSP meeting.
Keep in mind that the IFSP form is much more than an actual document. The completed IFSP form is the result of the IFSP process. In this section of the module, you’ll have the opportunity to talk through the IFSP process and practice the related documentation.
4.2 Objectives (TBD)
4.3 IFSP and the 7 key principles
Notes:
MIW SC:
Which of the 7 Key Principles relate to the IFSP? All of the 7 key principles are relevant, but the fifth principle is the one that speaks directly to the IFSP: IFSP outcomes must be functional and based on children’s and families’ needs and priorities.
By listening to a family's concerns and priorities, you learn about many aspects of the family, their activities, and interests. This information is essential to developing meaningful IFSP outcomes.
The fourth principle is also important here: “The early intervention process, from initial contacts through transition, must be dynamic and individualized to reflect the child’s and family members’ preferences, learning styles and cultural beliefs.”
Scores on standardized tests can provide important information about a child, but they should not drive intervention. You will need more than test scores to understand a child’s functional abilities. As we saw in the previous section of the module, you collect a lot of information about the child and family throughout the evaluation & assessment process. Now, we bring all that information to the IFSP process, to ensure it is dynamic and individualized.
4.4 Activity: Does principle 4 look like this?
Principle 4:
The early intervention process, from initial contacts through transition, must be dynamic and individualized to reflect the child’s and family members’ preferences, learning styles and cultural beliefs.
Answer the following 2 questions: Does principle 4 look like this?
Question 1: Directing the IFSP process in a rote, professional-driven manner and presenting the family with prescribed outcomes and a list of available services.
A. Yes
B. No
The answer is B, No. It's important to listen to what the family wants for their child, share what you know as a professional, and then synthesize the discussion to develop an outcome meaningful to the family.
Question 2: Listening to families’ priorities & needs, preparing the family to participate in the IFSP meeting, and supporting them to develop the outcomes, strategies, activities, services and supports.
A. Yes
B. No
The correct answer is A, Yes. These behaviors demonstrate respect for the family, and support them as equal team members. This will also help strengthen your rapport and relationship with the family. Families engaged in the ECI process from the very beginning are more likely to be actively involved during service delivery.
4.5 IFSP in TAC & CFR
Notes:
MIW SC:
The rules and regulations related to the IFSP process are found in TAC, Title 40, Part 2, Chapter 108, Subchapter J: Individualized Family Service Plan and in the Code of Federal Regulations, Title 34, Part 303, Subchapter D, Sections 303.340 through 303.346.
Federal Regulations for IDEA Part C are listed here:
Check your understanding: Can you find this in TAC?
Question: What section of Rule addresses who must attend the initial IFSP meeting?
TAC is listed here: $ext.ViewTAC?tac_view=4&ti=40&pt=2&ch=108
Answer: TAC 108.1009.
In this section you'll also find who must attend the annual IFSP.
4.6 IFSP team
Notes:
MIW Coach:
The IFSP team consists of the parent and or caregiver, a service coordinator, and one additional professional with expertise in a different discipline than the service coordinator. In some instances, the service coordinator may have 2 roles: coordinating services for the family and providing services based on expertise in a specific discipline. One of the professionals on the IFSP team must be someone who was directly involved in the child's evaluation & assessment and in most cases there must be a Licensed Practitioner of the Healing Arts (LPHA) on the team.
If the family receives services from Early Head Start, Migrant Head Start, or other community agencies such as a Medicaid managed care program, staff from those agencies should be invited to participate to share additional information about the child and family. Parent consent is required before inviting providers from other agencies to the IFSP meeting.
Remember, the parents may want to invite other people to the IFSP meeting to provide additional information or to provide support.
The IFSP Form
4.7 Required elements
Notes:
MIW Coach:
Now let's take a look at the IFSP form. ECI requires specific elements be included in each IFSP. The instructions for the IFSP form (titled Required Elements of the IFSP) provide detailed directions for completing the form. The form contains prompts and some minimal instructions, but the Required Elements describes in detail the necessary components of an IFSP and how to document them. You should review the Required Elements and be familiar with the instructions.
4.8 Required elements on the web
Notes:
MIW Coach:
The Required Elements can be found on the ECI Website ()
On the left hand side of the page, click “For ECI Programs”
Now click on, ECI Provider Forms
The Required Elements for the IFSP, the Periodic Review of the IFSP and the Annual Evaluation of the IFSP can also be found on this page.
Here is a sample Initial IFSP Form: {07D0901F-86B6-4CD0-B7A2-908BF5F49EB0}_59/IFSP_form_initial.doc
Here is a sample IFSP annual review form: {07D0901F-86B6-4CD0-B7A2-908BF5F49EB0}_59/IFSP_form_annual.docx
Here is a sample IFSP Outcomes Form: {07D0901F-86B6-4CD0-B7A2-908BF5F49EB0}_59/IFSP_outcome_template.pdf
4.9 Get to know the IFSP form
Notes:
MIW Coach:
Take some time now to learn more about each section of the form. We will review what is documented in each section.
4.10 Physical development
Notes:
MIW Coach:
To develop outcomes and plan services, it is necessary for the IFSP team to describe a child’s functional abilities in his daily routines and identify his developmental needs. That description is completed by interviewing the family, and recording it in the first section of the IFSP referred to as the “Functional Abilities, Strengths and Needs Assessment”.
The IFSP form guides the team through the process of assessing and identifying the developmental strengths and needs of the child. The first section records physical development and covers health, nutrition, hearing and vision. Some of this information may have been gathered using the ECI Needs Assessment, ID and Referral Form, and can be summarized here. Concerns are noted, but functional information about each area is also required. Information that should be recorded here includes important medical history, diagnostic testing the child has undergone, and current health status.
Examples of what to document here include: a child’s medical diagnosis, history of frequent ear infections, surgeries, or use of medical equipment.
Also list all medications the child takes on a regular basis, including non-prescription medications. Some medications can cause side effects that can impact a child’s development such as a seizure or allergy medication that can cause the child to feel sleepy and lethargic and it is important for the team to be aware of this information.
The date of the last well child check or physical is included in this section. If the child was premature, enter his gestational age as calculated at the time of eligibility determination.
Vision and hearing should be described in functional terms to reflect how the child uses his hearing or vision within the context of everyday activities. Here are two examples: Jamie gets excited when she hears the school bus at the stop out front, because she knows her big sister is home”
Thomas can see his bottle on the table from across the room, and gets upset if someone does not get it for him quickly in the morning.
Even if there are no concerns about the child’s vision or hearing status, it is still important to describe the child’s status in functional terms. It is not sufficient to only write “family has no concerns” or “passed hearing screening”.
4.11 The routines section
Notes:
MIW Coach:
The next section of the IFSP describes the typical routines and activities of the child and family. Be sure to ask all the questions on the form, but don’t limit yourself to those questions. Use them as a springboard to start a discussion.
It is important to connect the child's evaluation results to the IFSP. If a child shows a significant delay on the BDI-2, that delay will be reflected in the description of the child. For instance, the evaluation may indicate a child has a delay in fine motor skills. That delay may impact his functional ability to self-feed and to play with toys. We need to describe strengths and abilities, but a clear description of developmental needs is also necessary to establish the child's need for services. We listen to and record the family’s concerns, but we also apply our professional expertise and experience to identify potential areas of need.
4.12 Discussing routines
Notes:
MIW Coach:
The Code of Federal Regulations requires that the description of the child cover all developmental domains to present a complete picture of the child’s abilities and needs. The IFSP form provides prompts for each routine to help you describe all the developmental areas relevant to the routine. Each routine has an associated prompt, which is related to several developmental domains.
Functional skills are skills a child is using in a meaningful way. For example, some children on the autism spectrum may use words, but not to ask for things they want. Don’t ask leading questions, such as, “Katelyn can feed herself with her fingers, right?” Instead ask, “What is lunch time like with Katelyn?” “What kinds of things does she eat and how does she eat them?” Ask open-ended questions to allow parents to give examples of how their child uses skills during daily routines.
The following 5 routines are listed in this order on the IFSP Form. Under each routine are sample questions on the form, along with the developmental domain(s) addressed with each question:
1. How Your Day Starts
a. How does your child let you know he/she is awake? (cognitive, communication and social-emotional)
b. How does your child get out of bed? (adaptive/ self-help and motor)
c. Is your child happy or sad when he/she wakes up? (social-emotional and communication)
2. Bathing, dressing, diapering and toileting
a. How does your child help with dressing? (communication, adaptive/ self-help and motor)
b. What does bath time look like for you and your child? Is bath time a fun or stressful time of day? (adaptive/ self-help, cognitive, communication, motor and social-emotional)
c. How does your child let you know that he/she needs a diaper change or to use the toilet? (adaptive/ self-help and communication)
3. Meal Times
a. What do meal times look like for your child? Is there anything difficult or special about meal times? (adaptive/ self-help, motor, social-emotional and communication)
b. How does your child let you know when he/she is hungry or thirsty, what he wants and when he is finished? (communication, adaptive/ self-help and cognitive)
c. What are your child’s likes and dislikes? How do you know? (communication and nutrition)
4. Play time and other daily activities
a. How does your child play? What does he/she like to play with? Are there times that are easier or more frustrating than others? (cognitive, communication, motor and social-emotional)
b. Does your child have the opportunity to be around other children and adults? If yes, how and where does your child interact with them? (cognitive, social- emotional)
c. How does your child act when you take them out in public? How does your child respond to separations and transitions? (motor, social-emotional and communication)
d. How does your child follow directions? Respond to limits? (cognitive, communication and social-emotional)
e. Are there certain days that look different? If yes, how does your child respond to the changes? (social-emotional)
5. Bed time and nap time:
a. How do you prepare your child for bed time and map time? How does your child let you now he/she is sleepy? (adaptive/ self-help, cognitive, communication and social-emotional)
b. How does your child fall asleep? How long does he/she sleep? (adaptive/self-help and social-emotional)
4.13 Child outcome codes
Notes:
MIW Coach:
The IFSP has a space in each routine for assigning global child outcome codes. Global child outcomes are not the same as IFSP outcomes. There is a dedicated module on the global child outcomes that is highly recommended for you to complete in the coming weeks. For now, we will discuss briefly here the relationship of global outcome measurement to the IFSP.
Global child outcomes apply to every child in ECI. They are rated by the team at a child’s entry to and exit from ECI. This information about individual children is then compiled and provides the state with data that is used to measure the effectiveness of ECI services.
The same three global child outcomes are measured for every child. Information about a child’s functional abilities across developmental domains is used to assign an outcome rating for the child’s:
· social-emotional skills (including social relationships)
· acquisition and use of knowledge and skills (including early language/communication); and
· use of appropriate behaviors to meet their needs
The description of the child in the IFSP provides supporting evidence for a child’s rating on the three global child outcomes. On the left side of the Routines section are columns that correspond to the three outcomes. An X in the box for a global early childhood outcome indicates information about the child's functional skills related to that routine can provide supporting evidence for that outcome. For example, in describing a child's functional abilities in his mealtime routines, you should record information about his social-emotional skills, his acquisition of skills, and his use of appropriate behaviors to meet his needs. The team will then make a determination about whether his functioning in that routine is
· age-appropriate (A),
· age-appropriate only occasionally or in some settings and situations (O),
· just below the child’s age level and might be considered as an emerging skill (I),
· well below the child’s age level, but are considered to be skills that could be built upon to help the child make progress in a particular area (N).
The ratings of A, O, I and N are then used to make decisions for the final Child Outcomes Ratings for that child, and are put in the “code” box
4.14 Strengths, needs, concerns, priorities
Notes:
MIW Coach:
The routines section also identifies strengths, needs, concerns, and family priorities. It is important that the team identify every routine affected by a developmental concern. For example, if a child is not walking, numerous routines will be affected. You can see this in the number of times “motor” is prompted as a developmental domain to be addressed when discussing a routine. The needs and concerns must be clearly identified in the IFSP. This provides documentation that services are needed, and will help the team develop appropriate outcomes later in the IFSP.
While interviewing the family, it is appropriate for the team to use their expertise to suggest to a family that a behavior seems like a concern or strength. There may be circumstances when a family considers a behavior to be both strength and a concern. In this case, both boxes may be checked, but the information written in the IFSP should make clear why this is so.
For each routine in which a need was identified, the team will help families decide if the routine is a priority. Remember, this is the family’s plan for their child, not the ECI professional’s plan. Sometimes, parents may identify a concern, but not wish to address it with an outcome. Place a priority number or a check next to every routine or behavior that is considered by the family to be a priority.
The team will then develop outcomes to address the needs and priorities, using the strengths of the child to build on when developing procedures and strategies.
4.15 Examples of routines
On your caseload, Elizabeth is one of your children. See example notes for Elizabeth for two routines: bathing and playtime. In each note, think about what might be strengths and what might be needs/ concerns.
4.16 Elizabeth’s routine: bathing
Example Note: Howard (Dad) baths Elizabeth in an infant tub. She does not have very steady head control, so she needs the extra support. Elizabeth does not really like being bathed and she usually cries. He has tried to distract her with brightly colored bath toys, but she still cries. She briefly looks at the toy when Howard shows it to her. Elizabeth moves her arms and kicks with her legs in the tub. She immediately quiets when Howard picks her up and wraps her in a towel. She seems to enjoy snuggling with Howard after her bath.
Question: Which of these are strengths and which are needs/ concerns?
Strengths: She briefly looks at the toy when Howard shows it to her. Elizabeth moves her arms and kicks with her legs in the tub. She immediately quiets when Howard picks her up and wraps her in a towel. She seems to enjoy snuggling with Howard after her bath.
Needs/concerns: She does not have very steady head control, so she needs the extra support. Elizabeth does not really like being bathed and she usually cries. He has tried to distract her with brightly colored bath toys, but she still cries.
4.17 Elizabeth’s routine: playtime
Example Note: Susie holds Elizabeth a lot and carries her in her sling. She enjoys sounds and looking at her mobile but needs help to turn her head completely to either side. Susie is concerned that Elizabeth might develop a flat spot on her head because she doesn’t seem to have the strength to pick her head up and turn it. Elizabeth spends most of her time at home.
Susie’s sister has visited several times. Elizabeth does not smile when being held or talked to by her aunt, but she isn’t fussy either. She has not had many opportunities to be around others.
She has only been to the doctor’s office once and Elizabeth remained asleep in her car for the entire car ride. Susie is not sure if Elizabeth’s car seat has enough support for her head. Elizabeth is a calm baby. She doesn’t cry a lot. When she does cry, she calms easily when Susie picks her up and carries her. She doesn’t seem to have any self-soothing techniques yet.
Question: Which of these are strengths and which are needs/ concerns?
Strengths: She enjoys sounds and looking at her mobile. She isn’t fussy either. Elizabeth is a calm baby. She doesn’t cry a lot. When she does cry, she calms easily when Susie picks her up and carries her.
Needs/ Concerns: She needs help to turn her head completely to either side. Susie is concerned that Elizabeth might develop a flat spot on her head because she doesn’t seem to have the strength to pick her head up and turn it. Elizabeth does not smile when being held or talked to by her aunt. Susie is not sure if Elizabeth’s car seat has enough support for her head.
4.18 Family resources
Notes:
MIW Coach:
The final item at the bottom of the Routines section is a description of the parent’s resources available to meet the developmental concerns and priorities that have been identified. This may include extended family, preschools, childcare, neighbors, resources within the home (toys, books, etc.), and neighborhood resources. Example: If the parent is concerned about the child’s social skills, a resource may be “The child has an opportunity to be around other children his or her age at home and at daycare.” Another example is: the child is delayed in walking. A resource for this family is the child’s older sibling. The ECI child loves to follow his older sister around the house, so the older sibling can be used to encourage the child to walk. Another example could be a child’s doctor or the child’s medical specialist, especially if the child is medically fragile, or if he is seeing specialist for his diagnosis.
After a discussion of the resources available to assist the family with the child’s developmental needs, the next step in the IFSP is to identify and document the child and family’s case management needs, and resources that might help meet those needs.
4.19 Child & family resources and case management needs
Notes:
MIW Coach:
The minimum requirements for case management are to monitor the implementation of the IFSP and to follow up with the family to ensure that the child's needs are being adequately addressed. The team should explain the statement at the top of the Child and Family Resources and Case Management Needs section on the IFSP to the family to inform them of these minimum requirements.
Service Coordinators must contact families on a regular basis to determine if services are being provided in accordance with their child's IFSP and determine whether the child's goals or outcomes are being met and if there have been changes in the child's needs.
Every child in ECI receives case management services, but some families may not understand the benefit of the service. Case management isn’t only for families with obvious social service needs. The team should talk to the family about how case management can help them access material, informational and support services and can help to ensure that their ECI services are meeting their family's needs.
The Child and Family Resources and Case Management Needs section is broken down into four areas, Medical, Educational, Social and Other. The team will review the information they have learned about the family and indicate if an item listed on the form is one of the following: a need for which an outcome will be developed; a need for which the family declines to develop an outcome; not identified as a need; or, a resource.
If the family has expressed a need that is not listed on the form, the team should check the “Other” box and document the need.
Completing this section of the IFSP is part of the initial needs assessment for case management.
There is also a space on the form that allows team members to document additional information about an identified need or resource. Service Coordinators - if you are documenting needs on this form after the initial IFSP, the notes section should be used to indicate the date when the new need was identified. The notes section can also be used to record any other important details about the resource or need.
At this point in the IFSP, the needs assessment has been completed. You have gathered relevant information from numerous sources, and compiled it in to a document that will now guide the team in developing outcomes and planning services to meet the needs of the child and family.
4.20 The outcomes section of the IFSP
Notes:
MIW Coach:
In the discussion of routines in the previous section of the IFSP, you learned about identifying developmental strengths and needs of the child, concerns of the team, and priorities of the family. The team will develop outcomes based on those needs and concerns.
4.21 What is an outcome
Notes:
MIW Coach:
An IFSP outcome describes an expected change -- a change that is a result or consequence of ECI services. It is a specific description of what a child will be able to do in a specified amount of time. IFSP outcomes are specific to each child and family. IFSP outcomes differ from the global child outcomes.
Outcomes should be designed to enhance a child’s ability to participate in family and community activities, and should directly address the family’s concerns and priorities for their child. Based on your professional knowledge, identify areas you think should be addressed and share your ideas with the team, always remembering the final decisions about outcomes rest with the family.
Caregivers have much more influence on a child's development than professionals. The professional's greatest impact comes from helping caregivers develop the skills and knowledge they need to help their child develop in the context of everyday activities. The brain of a young child is strengthened by positive early experiences, especially stable relationships with caring and responsive adults in safe and supportive learning environments. For this reason, we help parents look at their routines and then develop outcomes to support development within these routines.
4.22 Activity: IFSP outcomes and 7 key principles
Notes:
MIW Coach:
Principle 5 specifically addresses IFSP outcomes. It states: IFSP outcomes must be functional and based on children’s and families’ needs and priorities.
The following are 8 characteristics of what this principle looks like and doesn't look like in practice. Determine if you think each of these statements looks like or doesn’t look like Principle 5.
1. Writing IFSP outcomes based on test results.
a. Look like
b. Doesn’t look like
The correct answer is B. This does not look like Principle #5.
2. Changing outcomes to meet the evolving needs of the family.
a. Look like
b. Doesn’t look like
The correct answer is A; this does look like Principle #5.
3. Listing the services to be provided as an outcome.
a. Look like
b. Doesn’t look like
The correct answer is B. This does not look like Principle #5.
4. Writing targeted outcomes to fix problems.
a. Look like
b. Doesn’t look like
The correct answer is B; this does not look like Principle #5.
5. Reinterpreting what families say to better match the service provider’s ideas.
a. Look like
b. Doesn’t look like
The correct answer is B. This does not look like Principle #5.
6. Basing outcomes on the priorities of the family.
a. Look like
b. Doesn’t look like
The correct answer is A; this does look like Principle #5.
7. Writing outcomes that address the whole child.
a. Look like
b. Doesn’t look like
The correct answer is A; this does look like Principle #5.
8. Writing outcomes that are focused on family routines.
a. Look like
b. Doesn’t look like
The correct answer is A; this does look like Principle #5.
Routines
4.23 Take a closer look at the routines section
Notes:
MIW Coach:
Good job! You’ve taken a first look at each section of the form.
Now let’s go back to the routines section and take a closer look at how to describe routines and how to conduct the routines-based interview.
4.24: RBI video, part 1
Notes:
MIW Coach:
As you just saw, in the routines section of the IFSP form, you record information about the typical routines and activities of the child and family. An effective way of learning about those routines is to use a Routines-Based Interview or RBI. The RBI is a clinical, semi-structured interview used to assess the child’s engagement, independence, and social relationships within everyday routines. The interview also gauges the family’s satisfaction with home routines.
Note that the RBI does not result in a developmental score. It does result in a list of outcomes/goals chosen by the interviewee.
Now it’s time to learn about the typical routines and activities of the child and family. You will want to identify the family’s desired outcomes and goals.
The following video clips are from a routines-based interview. Take note of some strategies the interviewer uses to obtain additional information from the family. You'll notice that in this example, only one person is conducting the RBI, but keep in mind it is required to be conducted by an interdisciplinary team. After watching the video, you will answer a question.
4.25 RBI video part 1, self-check
This video takes place in the home with EIS, mother and father sitting at the kitchen table and toddler in the background.
Transcript of Video RBI-1:
EIS: Well I would like to thank you all very much for participating in this interview process with us today. The purpose of doing the interview like this is to access family’s needs so that we can help them develop a plan that’s going to be appropriate for you and it’s going to fit into your lifestyle so that we can set priorities about what to work on first.
Mom: Thank you
EIS: and what to work on second. Um I’m going to do this by asking a series of questions. I’m just going to ask you about what your daily life is like we’ll go through your daily schedule.
EIS: Um, let’s talk a little bit about what happens when you go in the car. You know when I called you the first time you were on your way to El Paso I think.
Mom and Dad both answered: we were on our way to actually on our way to San Diego.
EIS: oh you were in El Paso then.
Toddler begins making noises
Mom: shh…
EIS: So apparently they do fairly well in car trips?
Mom: Yes, well they’ve been traveling since they were just a couple weeks old each of them so on long road trips so there used to it.
EIS: Okay, so when you tell them we are going to I believe Walmart, Home Depot those are our favorite places to go to.
Mom: yea then it’s like okay shoes.. shoes.. where’s shoes?
EIS: So everybody’s good to go with that. Does he help you to put on his shoes when you’re going to go somewhere? He’ll go get them?
Mom: yea, he’ll go get them and I will put them on otherwise he’ll sit there and try to put them on.
EIS: But generally he is always ready to go. When you want to go somewhere he is good with that? But he wants his own car seat?
Mom: own car seat, and be the first one to be put in.
EIS: And if we rate going somewhere in the car how would we rate it?
Mom: It’s probably like a 5.huh sarge?
Mom and Dad both answered: It just depends generally it’s 9 times out of 10 it’s a five but there just these days. One day out of 30 you know he will be like he just wants to stay home, he will just throw a fit to get in the car and then throw a fit in the car and throw a fit where we are going, but it’s rare but still it happens.
Mom: He’ll just want rather stay home. Throw a fit wherever we are going.
EIS: Ok um, is that something that you see as typical child behavior or something that you see as unusual kind of thing for a child to do?
Mom: I think it’s unusual. Just because I’ve been around so many kids I never have seen it happen. But you know who am I to say it’s typical every child is different.
EIS: Alright, So sometimes when he does have those days where he doesn’t want to go and he has his behavior. What does he do?
Mom: Do you want to tell her?
Dad: He’ll let his body go limp when we’re trying to get him up. He won’t get up on his own like he normally does. We have to get him up then we have to get his shoes on him he’ll calm down for a few minutes and then he’ll start raising stink you know once we put him in the car then he’ll just scream the whole way until we get somewhere he wants to be.
EIS: Ok so when he just goes limp like that then do you just bodily pick him up and put him in the car and go ahead and do what you want to do?
Mom: mm hum.
EIS: OK then uh when we get to Walmart, Home Depot those places that we go what does he do? Does he ride in the cart? Does he walk?
Mom: It’s a mixture of both. He’ll walk you know if it’s both of us or he will ride in the cart if it’s just me he’ll sit in the back if I have to pick up you know one or two things. But when it’s with both of us unless he’s having one of his fit days he’ll walk. If he’s having a fit day then he’ll be in the cart.
EIS: Okay, so he can go either way when you go shopping?
Mom: kind of depends on how he is doing that day.
EIS: Okay if he’s walking does he go and take things off the shelves?
Mom: He’ll do what we ask him to we have a little back pack with a little tail on it looks like a monkey it has big ones and then little people on it.
EIS: Laughs and then says oh that’s cute.
Mom: yeah so we have that and we uh and so I’ll say you know go get the stuff off the shelf go put that in the cart you know and he’ll go and put the stuff it in the cart.
EIS: Okay so he helps then.
Mom: Yes if he is sitting in the cart he’ll help unload the cart at the end.
End of Transcript
Question: Which of the following statements is true about the video you just watched?
A. The interviewer only asked questions of the mother and did not attempt to include the father in the conversation.
B. The interviewer made the conversation feel as natural as possible by asking leading questions and then probing for more information to get a better description of the child’s functional abilities.
C. The interviewer does not use active listening techniques.
The correct answer is B. The interviewer made the conversation feel as natural as possible by asking leading questions and then probing for more information to get a better description of the child’s functional abilities. This was more of a conversation and not a person reading questions off of a list. The answer was not choice A, because the interviewer looked back and forth between the parents and would ask follow up questions from both parents. The answer was not choice C because the interviewer used active listening by making eye contact with the family, smiling, nodding her head and asking follow up questions.
4.26 RBI video part 2
Notes:
MIW Coach:
In this next clip, observe the father and how his demeanor and body language change from being disengaged in the previous clip to becoming more involved in the conversation.
Transcript, Part 2:
Dad: I just like, I would like to find out if we’re doing something wrong, honestly I’d like to find out if there’s any activities that we’re doing wrong I mean with the change in our lives.
Mom: I mean obviously we need to be sitting down and having meals with our kids and stuff like that and you know doing that kind of stuff.
Dad: But I mean I’d like to find out if there is something within ourselves you know that we are kind of caring over to the kids that our worries are being carried over to the kids.
Mom and Dad: without us even knowing it.
EIS: so something in your parenting maybe that you?
Dad: I’d like to find out if I am the driver of his behavior. Because I feel like that sometimes
Mom: trying to cut off the EIS: that maybe he is feeling our worries.
EIS: So you have a concern that maybe he if there is something that you do the kids are picking up. And they are responding to that in some way.
Dad: And just because I yell it just a challenge I was raised I was yelled at pretty bad so, unfortunately sometimes you learn by osmosis its’ just there.
EIS: Most people learn to parent by the way that they were parented.
Mom: Well I mean honestly in all fairness Kase has been through a lot. Surge, with my coping with my pregnancy being so bad and I was in the hospital almost all the time that kind of worry that you he went through.
Dad: Yea but I know that sometimes when he acts out I probably don’t respond to that the best way I generally tend to yell a little bit you know try to make him.
Mom: Try to grasp his attention by yelling
Dad: Unfortunately I was raised the way I got response from other stuff was to either yell at it or you know get it done myself. I’m at the point now where it’s like not working this yelling anymore maybe I’m just you know blowing higher at this point I just want to find out if I am at all a driver in this situation
Mom: It feels like a therapeutic session.
Mom and EIS laugh
EIS: Well actually the interview process I wouldn’t necessarily call it therapeutic
Mom: continues to laugh
EIS continues: but I think it is helpful for folks to step back for a minute and take a look at what their daily life is like you guys both have a very full very busy live and sometimes you don’t realize how much you’re doing until you look at it.
Mom: Laughs and says until you sit down and realize it.
EIS: That’s right.
End of transcript.
Now that you have watched the clip, the interviewer does a great job building rapport by calmly listening, not offering advice, supporting what the parents are expressing, and showing interest in the family’s strengths, needs, and priorities. By the end Dad feels very comfortable with the interviewer and Mom states “It feels like a therapeutic session.”
4.27 Modifying the questions
Notes:
MIW Coach:
Sometimes it is necessary to modify the questions in the routines section of the IFSP to conduct an appropriate and complete assessment.
Because Elizabeth is an infant, some of the questions are not applicable to her. You'd need to modify the questions to best suit her circumstances. For example, in the section about how the day starts, you could combine the questions and have a general discussion about the wake up routine in the morning.
You can ask these questions: “How many hours does the baby sleep? How do you know when she is awake? Can you leave her in her bed for a few minutes after she wakes?”
Instead of these questions: “How does your child let you know he/she is awake? How does your child get out of bed? Is your child happy or sad when he/she wakes up?”
Here's another example: In the bathing, dressing, diapering and toileting section, you might ask "How does Elizabeth respond to being dressed and undressed? Is there anything difficult about dressing and undressing?” instead of “How does your child help with dressing?”
4.28 Activity: Modifying questions for Elizabeth
Notes:
MIW Coach:
Now you try ... How would you modify the mealtime questions for Elizabeth? Think about these before looking at some possibilities.
Here are the mealtime questions on the IFSP form:
1. What do meal times look like for your child? Is there anything difficult or special about meal times?
2. How does your child let you know when he/she is hungry or thirsty, what he wants and when he is finished?
3. What are your child’s likes and dislikes? How do you know?
Now that you have prepared some answers, here are some possible modifications:
• How are you feeding Elizabeth?
• Who feeds her?
• Where do you feed her?
• Is there anything difficult or special about feeding?
• How many times a day do you feed her and how much does she take each time?
• How long does a feeding session usually take?
• If bottle fed, does she take the same amount of formula at each feeding?
• Does Elizabeth fall asleep while being fed? If yes, does this happen occasionally or on a regular basis?
4.29 Activity: Elizabeth's bathtime routine
Notes:
MIW Coach:
Here's some of the information Elizabeth’s team gathered about her bath time. Notice that even though Elizabeth is a young baby, it's possible to write up thorough descriptions of routines. You are going to use the bath time description to see how each of the domains was assessed: Motor, Vision, Social-Emotional, and Communication.
Description of bath time routine:
“Howard (Dad) bathes Elizabeth in an infant tub. She does not have very steady head control, so she needs the extra support. Howard feels more comfortable bathing her in a smaller space than in the regular tub. Elizabeth does not really like being bathed. She usually cries during her bath. Howard tries to bathe her as quickly as possible. He has tried to distract her with brightly colored bath toys, but she still cries. She does briefly look at the toy when Howard shows it to her. Elizabeth randomly moves her arms and kicks with her legs in the tub. She immediately quiets and stops crying when Howard picks her up and wraps her in a towel. She seems to enjoy snuggling with Howard after her bath.”
Take a moment to think about how you would assess each of the domains, then read the following to see how each domain was assessed...
Motor: “She does not have very steady head control,” and “Elizabeth randomly moves her arms and kicks with her legs in the tub.”
Vision: “She does briefly look at the toy when Howard shows it to her.”
Social-Emotional: “Elizabeth does not really like being bathed. She usually cries during her bath,” “…she still cries,” “She immediately quiets and stops crying when Howard picks her up,” and “she seems to enjoy snuggling with Howard after her bath.”
Communication: “She usually cries during her bath,” “…but she still cries,” and “She immediately quiets and stops crying when Howard picks her up and wraps her in a towel.”
4.30 Activity: Elizabeth's playtime routines
Notes:
MIW Coach:
Elizabeth’s team also gathered the information about her play skills. Notice again, we have a good thorough description of her routine. You are going to use the play time description to see how each of the domains was assessed: Motor, Vision, Hearing, Social-Emotional, and Communication.
Description of playtime routine:
“Susie holds Elizabeth a lot and carries her in her sling. Susie reports that Elizabeth enjoys sounds and looking at her mobile. Elizabeth needs help to turn her head completely in order to look at her mobile or to look at Susie when she sings or speaks to her. Susie is concerned that Elizabeth might develop a flat spot on her head because she doesn’t seem to have the strength to pick her head up and turn it.
Elizabeth has spent most of her time at home. Susie reports she has only taken Elizabeth to the doctor’s office one time and Elizabeth remained asleep in her car seat for the entire car ride. Susie is not sure if Elizabeth’s car seat has enough support for her head.
Elizabeth is a calm baby. She doesn’t cry a lot. When she does cry, she calms easily when Susie picks her up and carries her. She doesn’t seem to have any self-soothing techniques yet.
Susie’s sister has visited several times. Elizabeth does not smile when being held or talked to by her aunt, but she isn’t fussy either.”
Take a moment to think about how you would assess each of the domains, then read the following to see how each domain was assessed...
Motor: “Elizabeth needs help to turn her head completely,” “Susie is concerned that Elizabeth might develop a flat spot on her head because she doesn’t seem to have the strength to pick her head up and turn it,” “Susie is not sure if Elizabeth’s car seat has enough support for her head.”
Vision: “She enjoys…looking at her mobile.”
Hearing: “Elizabeth enjoys sounds.”
Social-Emotional: “Susie holds Elizabeth a lot and carries her in her sling,” “Elizabeth is a calm baby,” “She doesn’t seem to have any self-soothing techniques yet,” “Elizabeth does not smile when being held or talked to by her aunt, but she isn’t fussy either.”
Communication: “She doesn’t cry a lot. When she does cry, she calms easily when Susie picks her up and carries her.”
4.31 Activity: Connecting behaviors to routines
Notes:
MIW Coach:
Riley has delays in the areas of cognitive, communication, adaptive, and social emotional development, and it is important that the description of the child in the IFSP reflects concerns for his development as well as his strengths. Adelia, Riley’s mother, reported certain behaviors. Read the following description of his behaviors documented in the IFSP to learn more. Which routines are affected by the behavior? :
Beginning of Riley’s IFSP (from Handout):
How Your Day Starts:
Question: How does your child let you know he/she is awake?
Description: Riley usually walks downstairs by himself, but sometimes he will call out by saying “mama”. He will also say “up” to be picked up, but he does not put words together, and doesn’t use more than a few words. He likes for Mom to be the one to come in and get him if he is still in bed and is grumpy if Dad is the one to wake him up.
Question: How does your child get out of bed?
Description: He will crawl out of his toddler bed on his own by sliding down on his stomach with feet down first. His door is closed and he can turn the door handle to open it. If he hears us downstairs, he will come down by himself, holding on to the rail and alternating feet.
Question: Is your child happy or sad when he/she wakes up?
Description: He’s very sweet when he wakes up. He smiles when he finds us. We’ve taught him to blow a kiss when he sees us. He is surprisingly alert when he first wakes up, like he is ready for the day. If we have to wake him up, it takes him a little longer to wake up and he is a little grumpy.
Bathing, Dressing, Diapering and Toileting:
Question: How does your child help with dressing?
Description: Sometimes he doesn’t want to get dressed and fights me. I have tried offering him choices of clothing items by holding out one shirt at a time, but it just seems to make him angry. Other times he will help get dressed by pushing his arms through the sleeves and pulling his pants up once I get his feet through.
Question: What does bath time look like for you and your child? Is bath time a fun or stressful time of day?
Description: It is hard to get him in to the tub – he doesn’t want to leave the rest of the family, and will cry and sometimes try to bite. He is able to climb into and out of the tub on his own. He will take the washcloth from Mom and clean ledge. He babbles to himself in the tub, but we don’t understand any of what he says.
Question: How does your child let you know that he/she needs a diaper change or needs to use the toilet?
Description: He’s not toilet trained, but he doesn’t like to have a dirty diaper. He will come to us and tug on the front of his pants when he wants a fresh diaper. If I try to get a diaper, he sometimes gets a diaper and brings it back. He helps during diaper changes by lifting his legs while we change him.
Meal Time:
Question: What do meal times look like for your child? Is there anything difficult or special about meal times?
Description: Riley primarily finger feeds himself, but is able to use a spoon or fork. When he finishes what is on his plate, I show him different foods until he reaches out for the food he wants. If I don’t offer a choice he wants or if he is finished, he will scream and throw his plate. He does not name any food items or use any signs during meal time.
Question: How does your child let you know when he/she is hungry or thirsty, what he wants and when he is finished?
Description: He will come in to the kitchen and say “eat”, but this is the only word he uses. He gets frustrated when he can’t tell us what he wants to eat. If he is thirsty, he will point at his favorite sippy cup. Sometimes he will drink from our cup if it is within his reach. If he is finished eating, he will push his food away or climb out of his booster.
Question: What are your child’s likes or dislikes? How do you know?
Description: He likes to eat: chicken nuggets, cheeseburgers, hot dogs, peanut butter and jelly sandwiches, macaroni&cheese, French fries, grapes, strawberries, corn, baked beans, whole grain rice, and drinks milk and juice.
He does not like: steak, grilled chicken, broccoli, lettuce, tomatoes, mashed potatoes, peaches, or most soft textures. He will sometimes drink water but it is not his favorite.
Playtime and other daily activities:
Question: How does your child play? What does he/she like to play with? Are there times that are easier or more frustrating than others?
Description: He loves to run and play with the older boys at daycare – he follows them up and down the stairs on the playscape, and chases them around. While inside the daycare, he will put all of the toy cars in a row and is more interested in spinning the car wheels than driving the cars around the room. He lines up most toys at home as well instead of using the toy for the intended purpose.
Question: Does your child have the opportunity to be around other children and adults? If yes, how and where does your child interact with them?
Description: He loves being around the other children at daycare, and other kids in the neighborhood. He likes to try to imitate them, especially movements, and uses gestures and facial expressions to communicate, but no words. He is good at throwing balls toward his teacher and laughs when she pretends it hits her.
Question: How does your child act when you take them out in public? How does your child respond to separations and transitions?
Description: Taking him to the grocery store is difficult – he won’t stay with me and runs away, and when I try to put him in the cart, he screams and will have a tantrum. He wants to climb into and out of the car seat on his own. When dropped off at daycare, he walks in without a problem. Picking him up can be difficult if he is doing an activity he enjoys, but we can tell him there are animal crackers in the car, and he gets excited and runs to the car.
Question: How does your child follow directions? Respond to limits?
Description: When the kids are all playing out in the front yard it is hard for Riley. He can’t go in the street, but he tries to do that a lot. When we bring him back to the yard he will throw a tantrum. He doesn’t seem to understand directions at all.
Question: Are there certain days that look different? If yes, how does your child respond to the changes?
Description: Most days look the same for us. It may not be the exact same activity at home or daycare, but we try to keep him on a similar schedule as the daycare. We have already learned that he likes consistency, so we prepare with having his favorite snack or treat readily available for moving from one activity to another.
Bed Time and Nap Time:
Question: How do you prepare your child for bed time and nap time? How does your child let you know he/she is sleepy?
Description: He doesn’t like to go to bed. When he sees we are starting the bedtime routine he becomes upset and will try to bite. He has also done this at daycare naptime, and it is presenting a problem for them. We have tried separating him from the other children for nap so he does not wake them up and he wants to walk back to be near them.
Question: How does your child fall asleep? How long does he/she sleep?
Description: We try a few different approaches to get him to sleep like pat his back, rub his back, sing to him and tickle his arms. None of these approaches works consistently. When we finally get him down to sleep, he will sleep 10 hours through the night in his own bed.
End of Riley’s IFSP.
Quiz:
The following are some behaviors that Riley’s mother, Adelia, has reported, or that were identified during evaluation, written on the IFSP. Connect each general description of Riley's behavior to the routine(s) that demonstrate the behavior. Which routines are affected by this behavior?
Behavior #1: Riley runs, jumps and can go up and down stairs.
A. How the Day Starts
B. Bathing, Dressing, Diapering, Toileting
C. Meal Times
D. Play Time and other daily activities
E. Bed time and nap time
The correct answers are A and D. This behavior affects How the day starts since Riley walks downstairs to find his parents after he wakes up. It also affects Playtime and other daily activities because Riley loves to run and play with the older boys at daycare and goes up and down stairs on the playscape.
Behavior #2: When it’s time to make a transition to a different activity, he becomes frustrated and will scream, try to bite, etc.
A. How the Day Starts
B. Bathing, Dressing, Diapering, Toileting
C. Meal Times
D. Play Time and other daily activities
E. Bed time and nap time
The correct answers are B and E. This behavior affects Bathing, dressing, diapering, toileting because it is hard to get Riley in to the tub. He doesn’t want to leave the rest of the family, and will cry and sometimes try to bite. It also affects Bed time and nap time since Riley doesn’t like to go to bed. When he sees his parents are starting the bedtime routine, he gets upset and tries to bite, which he does at daycare nap time, too.
Behavior #3: We offer him choices, but he often becomes frustrated and cries.
A. How the Day Starts
B. Bathing, Dressing, Diapering, Toileting
C. Meal Times
D. Play Time and other daily activities
E. Bed time and nap time
The correct answers are B and C. This behavior affects Meal times because Mom shows Riley different foods until he reaches out for the food he wants. If she doesn’t offer a choice he wants or if he is finished, he will scream and throw his plate. It also affects Bathing, dressing, diapering, toileting since Mom offers Riley choices of clothing items by holding out one shirt at a time, but this only makes him angry.
Behavior #4: Riley uses a few words to communicate.
A. How the Day Starts
B. Bathing, Dressing, Diapering, Toileting
C. Meal Times
D. Play Time and other daily activities
E. Bed time and nap time
The correct answers are A and C. This behavior affects How the day starts because Riley lets Mom and Dad know he is awake by calling out “mama.” Then he will say “up” to be picked up, but he does not put words together or use more than a few words. This behavior is also affects Meal times, as Riley lets his parents know he is hungry or thirsty by saying “eat,” but he gets frustrated when he can’t tell them what he wants.
Outcomes
4.32 Outcomes and needs
Notes:
MIW SC:
You've done a great job with learning more about routines and how important they are to the IFSP process. Let's take a look now at outcomes.
Every outcome must relate to one or more identified needs. If an outcome is written, the need that corresponds should be clearly identified in the IFSP. But be aware that there is not a one-to-one correspondence between needs and outcomes; sometimes two or more related needs can be addressed by a single outcome. Similarly, every IFSP outcome does not need to have a corresponding service or be discipline-specific but all outcomes must be addressed through intervention.
4.33 Measurable outcomes
Notes:
MIW SC:
What makes an outcome measureable? The functional outcomes you develop must be measurable. That means the outcome:
• Describes a specific action or behavior that can be seen or heard. It does not require interpretation or guessing to figure out if it has been achieved.
• Describes the context or activity in which the action or behavior will be seen or heard.
• Describes how many times, or what distance or amount, or how often the action or behavior will occur. It has a reference point for the parent to easily see or hear when the outcome is achieved
• Indicates a realistic timeline identified for reviewing the action or behavior.
You'll have a chance to identify and write measurable outcomes in a little bit ...
4.34 Activity: Is the outcome measurable?
Recognizing measure outcomes activity: Measurable outcomes must meet all of these criteria: specific action by child; context (when/where); quantity and/or frequency; and timeline or target date. For each of the following six outcomes, which criteria does each outcome meet? Select all that apply.
Outcome #1: Mikal will be able to transition from his belly to sitting up and vice versa during the course of his daily routines.
A. Specific action by child
B. Context (when/where)
C. Quantity and/or frequency
D. Timeline or target date
E. None of these
The correct answer is A. As written, only the specific action is described by this outcome. Specific action by child is indicated: "be able to transition from his belly to sitting up and vice versa." Context (when/where) is not indicated. Although some context is given (daily routines) it should be more specific as to the type of routine. Also, no location is indicated (At home? In child care?). Quantity and/or frequency is not indicated. Timeline is not indicated (In 3 months? In six months?)
Now revise the outcome so it meets all the criteria. (Pause)
Rewritten measurable outcome: Mikal will be able to transition from his belly to sitting up and vice versa during floor time while mom cooks dinner. He will do this five times in one week (target date on outcome page).
Outcome #2: Sam will speak words clearly and label items in books and his environment and name family members daily for one month.
A. Specific action by child
B. Context (when/where)
C. Quantity and/or frequency
D. Timeline or target date
E. None of these
The correct answers are C and D. As written, the outcome gives a sense of the action to be performed but does not define it clearly. Context (when/where) is not indicated. Quantity and/or frequency: Daily, for one month. This outcome could be improved by specifying how many items or people the child will name. Timeline: Target date is written on outcome page.
Now revise the outcome so it meets all the criteria. (Pause)
Rewritten measurable outcome: Sam will use words his parents can understand to name pictures in books or photos of family members when his parents read to him at bedtime, daily for one month (target date on outcome page).
Outcome #3: Norah will be able to express her wants and needs in short three word phrases, like “Mom, I hungry.”
A. Specific action by child
B. Context (when/where)
C. Quantity and/or frequency
D. Timeline or target date
E. None of these
The correct answer is A. Specific action by child is indicated: “…express her wants and needs in short three word phrases.” Context (when/where) is not indicated. Quantity and/or frequency: The outcome does not specify how often Norah will be able to express her wants and needs (e.g., twice a day for two weeks). Timeline is not indicated.
Now revise the outcome so it meets all the criteria. (Pause)
Rewritten measurable outcome: Norah will be able to express her wants and needs during meals and snacks using three word phrases two times a day, for a week, before she starts preschool in the fall.
Outcome #4: William will follow simple directions that are part of his daily routine, such as “come here” and “stop” at least 5 times a day.
A. Specific action by child
B. Context (when/where)
C. Quantity and/or frequency
D. Timeline or target date
E. None of these
The correct answers are A and C. Specific action is indicated by child: Following simple directions such as “come here” and “stop”. Context (when/where): This outcome vaguely addresses the when (during daily routines) but not the where. Quantity and/or frequency is indicated: “ …at least five times a day” Timeline is not indicated. When will you know William has met this goal? It’s not indicated as written.
Now revise the outcome so it meets all the criteria. (Pause)
Rewritten measurable outcome: William will obey his parents when they say “stop” or “come here” at least five times a day while playing, four days in a week, before visiting grandma at Christmas.
Outcome #5: Janelle will call her mom and dad and make simple requests using words or signs.
A. Specific action by child
B. Context (when/where)
C. Quantity and/or frequency
D. Timeline or target date
E. None of these
The correct answer is E, none of the criteria are met with this outcome. More specificity is needed. No context is provided in the outcome as written. Quantity and/or frequency and timeline are not indicated.
Now revise the outcome so it meets all the criteria. (Pause)
Rewritten measurable outcome: Janelle will use a sign or a single word to ask for a toy when playing in the living room three days a week for a month (target date on form).
Outcome #6: Jack will eat two bites of his birthday cake using his hands.
A. Specific action by child
B. Context (when/where)
C. Quantity and/or frequency
D. Timeline or target date
E. None of these
The correct answers are A and C. Some specificity is provided in this outcome, but remember the more specific you are, the easier it will be for you and the parents/caregivers to report whether or not the outcome has been met. Context (when/where): Though you probably assume this would take place on Jack’s birthday, it is not actually written in the outcome. Quantity and/or frequency is indicated: “two bites.” Regarding timeline, the outcome does not specify when he must eat the two bites of birthday cake. What if it took Jack eight hours? Would that be a realistic outcome?
Now revise the outcome so it meets all the criteria. (Pause)
Rewritten measurable outcome: Jack will eat and swallow two pieces of his birthday cake on his birthday, within 15 to 20 minutes using his hands.
4.35: Activity, Developing a measurable outcome
Notes:
Families often describe very general goals or ideas of what they want their child to be able to do. A conversation is usually required to identify needs and develop a measurable outcome.
Read the following exchanges between a parent and a service provider, then write an outcome that is individualized and measurable for each scenario.
Beginning of Excerpt, Scenario 1:
Parent: “I just want my child to walk.”
SP: Where would you like for him to walk?
Parent: “I would like for him to walk when we go to the mall.”
SP: How far would he need to walk? How often would you like for him to walk? (A parent might respond that she wants the child to walk “everywhere." Closer questioning can reveal more specific information -- something like “Is there an activity that would be easier if he was walking?”)
Parent: “We go to the mall once a week to play in the indoor play area. There is an elevator not far from the door that opens near the play area on the second floor.”
SP: How much help would he need when he’s walking?
Parent: “I would like for him to walk by himself, at least a short distance.”
SP: How will things be easier for you when he can walk?
Parent: “I have a new baby who I must push in a stroller when we go to the mall. If Mark Anthony could walk, it would be much easier than pushing a stroller and having a two-year old on my hip.”
End of Excerpt, Scenario 1.
Now, write an outcome based on that scenario.
Beginning of Excerpt, Scenario 2:
Parent: “I just want my child to eat.”
SP: When we talked about his routines, you mentioned he only eats mashed potatoes or baby food. What else would you like him to eat?
Parent: “I would like him to eat little pieces of Chicken Nuggets and vegetables.”
SP: How would you like for him to eat?
Parent: “I don’t mind feeding him the food; I just want him to be able to chew it.”
SP: How much would you like him to eat?
Parent: “I would like him to chew and swallow at least half of the food I give him.”
SP: Where would you like him to eat?
Parent: “I want him to be able to eat his food with the family at home and at the restaurant.”
SP: When would you like him to eat?
Parent: “He eats breakfast just fine, because I give him cereal and there is no chewing involved. I would like for him to be able to chew meat and other foods at lunchtime, dinnertime, and when we go to restaurants.”
SP: How will things be easier for you when he can eat?
Parent: “I still have to buy jars of baby food, which has grown to be pretty expensive. If he chews his food, he can eat what the family is eating. I don’t mind cutting the food into small pieces, but I would like to give him what we eat.”
End of Excerpt, Scenario 2.
Now, write an outcome based on that scenario.
Beginning of Excerpt, Scenario 3:
Parent: “I just want my child to talk.”
SP: What kinds of things would you like for her to say? (e.g. specific words, phrases, etc.)
Parent: “Honestly, to start, I just want her to say ‘mama’.”
SP: At what times would you like her to talk?
Parent: “I would really like for her to say ‘mama’ to let me know she is awake and to let me know she wants a snack.”
SP: Who would you like her to talk to?
Parent: “She spends most of her time with me, so I would really like for her to call my name to get my attention.”
SP: How will things be easier when she can talk?
Parent: “I work from home and sometimes I am in my office downstairs. I don’t know when Giana wakes up because she isn’t able to say my name. If she could say ’mama‘, I could come get her without making her wait in her crib.”
End of Excerpt, Scenario 3.
Now, write an outcome for scenario 3.
4.36 Activity, Try writing an outcome
Notes:
MIW SC:
Let's try writing an outcome for one of the MIW children. Use the RBI info for Elizabeth's playtime to write an outcome for her. Remember that there is not necessarily a one-to-one correspondence between needs and outcomes; sometimes two or more needs can be addressed by a single outcome, but every outcome must relate to one or more identified need.
Beginning of Excerpt, Elizabeth’s playtime routines:
“Susie holds Elizabeth a lot and carries her in her sling. Susie reports that Elizabeth enjoys sounds and looking at her mobile. Elizabeth needs help to turn her head completely in order to look at her mobile or to look at Susie when she sings or speaks to her. Susie is concerned that Elizabeth might develop a flat spot on her head because she doesn’t seem to have the strength to pick her head up and turn it.
Elizabeth has spent most of her time at home. Susie reports she has only taken Elizabeth to the doctor’s office one time and Elizabeth remained asleep in her car seat for the entire car ride. Susie is not sure if Elizabeth’s car seat has enough support for her head.
Elizabeth is a calm baby. She doesn’t cry a lot. When she does cry, she calms easily when Susie picks her up and carries her. She doesn’t seem to have any self-soothing techniques yet.
Susie’s sister has visited several times. Elizabeth does not smile when being held or talked to by her aunt, but she isn’t fussy either.”
End of Excerpt, Elizabeth’s playtime routines.
Try writing a measureable outcome. (Pause)
(When finished), is your outcome like one of these?
1. Elizabeth will hold her head up and turn to look at her caregivers, and at her mobile or other toys without assistance, at least 3 times a day at home and 3 times a day when she is at daycare every day for 2 weeks.
2. Elizabeth will smile and make eye contact when being held and talked to, at least twice a day at home and twice a day when she is at day care every day for 2 weeks.
4.37 Activity, Outcomes for Riley
Notes:
MIW SC:
You will first be reading an excerpt from Riley’s RBI information. Based on the RBI info you will read for Riley, write two functional, measurable outcomes that can be worked on across routines: one to address speech and one to address behavior.
Beginning of Riley’s RBI Info (from handout):
How Your Day Starts:
Question: How does your child let you know he/she is awake?
Description: Riley usually walks downstairs by himself, but sometimes he will call out by saying “mama”. He will also say “up” to be picked up, but he does not put words together, and doesn’t use more than a few words. He likes for Mom to be the one to come in and get him if he is still in bed and is grumpy if Dad is the one to wake him up.
Question: How does your child get out of bed?
Description: He will crawl out of his toddler bed on his own by sliding down on his stomach with feet down first. His door is closed and he can turn the door handle to open it. If he hears us downstairs, he will come down by himself, holding on to the rail and alternating feet.
Question: Is your child happy or sad when he/she wakes up?
Description: He’s very sweet when he wakes up. He smiles when he finds us. We’ve taught him to blow a kiss when he sees us. He is surprisingly alert when he first wakes up, like he is ready for the day. If we have to wake him up, it takes him a little longer to wake up and he is a little grumpy.
Bathing, Dressing, Diapering and Toileting:
Question: How does your child help with dressing?
Description: Sometimes he doesn’t want to get dressed and fights me. I have tried offering him choices of clothing items by holding out one shirt at a time, but it just seems to make him angry. Other times he will help get dressed by pushing his arms through the sleeves and pulling his pants up once I get his feet through.
Question: What does bath time look like for you and your child? Is bath time a fun or stressful time of day?
Description: It is hard to get him in to the tub – he doesn’t want to leave the rest of the family, and will cry and sometimes try to bite. He is able to climb into and out of the tub on his own. He will take the washcloth from Mom and clean ledge. He babbles to himself in the tub, but we don’t understand any of what he says.
Question: How does your child let you know that he/she needs a diaper change or needs to use the toilet?
Description: He’s not toilet trained, but he doesn’t like to have a dirty diaper. He will come to us and tug on the front of his pants when he wants a fresh diaper. If I try to get a diaper, he sometimes gets a diaper and brings it back. He helps during diaper changes by lifting his legs while we change him.
Meal Time:
Question: What do meal times look like for your child? Is there anything difficult or special about meal times?
Description: Riley primarily finger feeds himself, but is able to use a spoon or fork. When he finishes what is on his plate, I show him different foods until he reaches out for the food he wants. If I don’t offer a choice he wants or if he is finished, he will scream and throw his plate. He does not name any food items or use any signs during meal time.
Question: How does your child let you know when he/she is hungry or thirsty, what he wants and when he is finished?
Description: He will come in to the kitchen and say “eat”, but this is the only word he uses. He gets frustrated when he can’t tell us what he wants to eat. If he is thirsty, he will point at his favorite sippy cup. Sometimes he will drink from our cup if it is within his reach. If he is finished eating, he will push his food away or climb out of his booster.
Question: What are your child’s likes or dislikes? How do you know?
Description: He likes to eat: chicken nuggets, cheeseburgers, hot dogs, peanut butter and jelly sandwiches, macaroni&cheese, French fries, grapes, strawberries, corn, baked beans, whole grain rice, and drinks milk and juice.
He does not like: steak, grilled chicken, broccoli, lettuce, tomatoes, mashed potatoes, peaches, or most soft textures. He will sometimes drink water but it is not his favorite.
Playtime and other daily activities:
Question: How does your child play? What does he/she like to play with? Are there times that are easier or more frustrating than others?
Description: He loves to run and play with the older boys at daycare – he follows them up and down the stairs on the playscape, and chases them around. While inside the daycare, he will put all of the toy cars in a row and is more interested in spinning the car wheels than driving the cars around the room. He lines up most toys at home as well instead of using the toy for the intended purpose.
Question: Does your child have the opportunity to be around other children and adults? If yes, how and where does your child interact with them?
Description: He loves being around the other children at daycare, and other kids in the neighborhood. He likes to try to imitate them, especially movements, and uses gestures and facial expressions to communicate, but no words. He is good at throwing balls toward his teacher and laughs when she pretends it hits her.
Question: How does your child act when you take them out in public? How does your child respond to separations and transitions?
Description: Taking him to the grocery store is difficult – he won’t stay with me and runs away, and when I try to put him in the cart, he screams and will have a tantrum. He wants to climb into and out of the car seat on his own. When dropped off at daycare, he walks in without a problem. Picking him up can be difficult if he is doing an activity he enjoys, but we can tell him there are animal crackers in the car, and he gets excited and runs to the car.
Question: How does your child follow directions? Respond to limits?
Description: When the kids are all playing out in the front yard it is hard for Riley. He can’t go in the street, but he tries to do that a lot. When we bring him back to the yard he will throw a tantrum. He doesn’t seem to understand directions at all.
Question: Are there certain days that look different? If yes, how does your child respond to the changes?
Description: Most days look the same for us. It may not be the exact same activity at home or daycare, but we try to keep him on a similar schedule as the daycare. We have already learned that he likes consistency, so we prepare with having his favorite snack or treat readily available for moving from one activity to another.
Bed Time and Nap Time:
Question: How do you prepare your child for bed time and nap time? How does your child let you know he/she is sleepy?
Description: He doesn’t like to go to bed. When he sees we are starting the bedtime routine he becomes upset and will try to bite. He has also done this at daycare naptime, and it is presenting a problem for them. We have tried separating him from the other children for nap so he does not wake them up and he wants to walk back to be near them.
Question: How does your child fall asleep? How long does he/she sleep?
Description: We try a few different approaches to get him to sleep like pat his back, rub his back, sing to him and tickle his arms. None of these approaches works consistently. When we finally get him down to sleep, he will sleep 10 hours through the night in his own bed.
End of Riley’s RBI info.
Now, pause now to write the two functional outcomes.
When you're done, take a look at the sample outcomes for Riley. Are yours similar to any of these?
Outcome #1: Riley will get into bed without biting his mother or screaming 5 nights a week for 4 weeks.
Outcome #2: Riley will pretend to drive a toy car on his racetrack at home and during center time at child care, instead of just spinning the car’s wheels at least once a day for three weeks.
Outcome #3: Riley will use words to request things (toy, activity, food, drink) instead of only pointing, reaching or grabbing for the item at least six times during the day for two weeks. (Notice this outcome crosses domains to include speech and behavior with full consideration of the whole child. Multiple disciplines could assist in meeting this goal and it is not discipline specific.)
4.38 Procedures and Quiz
Notes:
MIW SC:
Good job! You've learned a lot about writing measurable outcomes.
Once you have written an outcome, you will develop procedures to provide the family a general idea of what services will look like, in other words, how to achieve the outcome. How do you achieve outcomes with procedures? Let's see what you already know about procedures ...
Question: Which of the following statements are true about procedures? (select all that apply)
A. Address meaningful family activities and routines
B. Are detailed instructions about how to achieve the outcome
C. Address the uniqueness of each child and family
D. Describe how change and progress will continually be assessed
E. Describe how the family and staff will work together to achieve the outcome
F. Describe methods for coaching and teaching
The correct answer is A, C, D, E, F (all but B). Procedures address the uniqueness of each child and family; address meaningful family activities and routines that reinforce to the family; describe methods for coaching and teaching; describe how the family and staff will work together to achieve the outcome; and describe how change and progress will be continually assessed.
4.39 Example of procedures
Notes:
MIW SC:
Here is an example of an outcome taken from an IFSP:
I want Robert to be able to sit up by himself, in his highchair and in the cart at the grocery store, for up to 30 minutes, before the end of the school year (June, 2015)
Here are examples of the anticipated procedures to achieve the outcome:
• An ECI team member will meet you at the grocery store and will come to your home during lunch to try out different ideas.
• We will show you ways to place him in different seats, and will show you exercises you can do when you change his diaper that can help make him stronger.
• Your ECI team will ask you often how the ideas are working for you and about other activities you want to work on that involve Robert sitting up, and they will ask you how you feel about his progress.
Planning Services
4.40 Expert recommendations
Notes:
National experts provided guidance to Texas ECI on factors teams should consider in planning services. The following are what experts recommend.
1. The professional’s role is to provide support and strengthen families. In ECI, services are intended to teach, coach, and instruct the parent or caregiver as they help their child meet developmental outcomes. In planning, we consider how much help and support the caregiver will need, not how much “hands on” service the child will need.
2. A reasonable starting point for service planning discussions is one hour of service once a week. Meeting with a family once a week allows you to develop your relationship with the family and to help the parent adjust their routines as the child grows and changes. One hour a week should be a starting point in thinking about services; some families will need other frequencies of services depending on a variety of factors.
3. Consider creative variations in service patterns, such as providing more intense or frequent service early in a family’s early intervention experience, or co-visits when the family would benefit from having two providers present at the same time.
4.41 Planning services
Notes:
MIW Coach:
Planning Services is the final step in developing the IFSP. The team has completed the description of the child, assessment of developmental needs, identification of family priorities, and development of outcomes, which all lead to planning services to meet the identified needs. Every IFSP outcome does not need to have a corresponding service but all outcomes must be addressed through intervention.
IFSP outcomes are the basis for planning intervention. If an outcome is written, the need that corresponds should be clearly identified in the IFSP. For example, if the team identifies three outcomes for the child, this does not mean three different services must be provided, but all three outcomes must be addressed by the staff providing intervention visits.
The following will discuss where services will be provided, with whom, how frequently and what services are provided.
4.42 Services in the natural environment (Where are services planned)
Notes:
Where are services provided? Services must be provided in a child’s “natural environment”, that is, where children play, grow, and learn. Locations that are only for children with disabilities are not considered natural environments. The intent of providing services in the natural environment is to focus the intervention on supporting caregivers to enhance the development of children in their care. For most children, the natural environment will be their home or childcare, or other places in the community where typically developing children may be found. You can share with families the value of services in the natural environment by showing them how to maximize natural learning opportunities using everyday activities, and embedding intervention in daily routines.
4.43 Routine caregivers (With whom?)
Notes:
With whom are services provided?
MIW Coach:
ECI service providers may deliver services with a routine caregiver in place of the parent. This often means that the service will be delivered in a childcare setting, either in a center or a home. When services are planned to occur with a routine caregiver there are three planning requirements that must be met.
· A written justification in the IFSP of how the child will benefit from delivering the specified services with the routine caregiver.
· The parent provides a written authorization for ECI to provide services with the routine caregiver. The parent must also give written consent for the team to share information about the child's services with the routine caregiver.
· The name of the routine caregiver is documented in the child's record.
A member of the IFSP team must contact the child's parent at least once a month either face to face or by telephone to discuss the child's progress and services. Recommended practice is that any ECI professional who is delivering services with a caregiver maintain close communication with the family about the child’s progress.
4.44 Co-Visiting
Notes:
MIW Coach:
Co-visits occur when two or more service providers deliver different services to the child at the same time. Co-visiting is a creative variation in service planning, but can only occur when the family would benefit from having two providers present at the same time. Each service must be planned on the IFSP services page, and the team must write a justification in the designated space of how the child and family will receive greater clinical benefit from the services being provided at the same time. Some important things to remember about co-visits:
· They should NOT occur at every visit to a family
· Justification must be individualized to the child and family
· Justification must show benefit to parent and child
· Family convenience or the need for two providers to coordinate their services are not acceptable justifications.
An example of a justification for a co-visit:
The family will benefit from having SST and OT delivered at the same time once every two months. The providers will brainstorm with the parents ways to combine the positioning and sensory strategies with the SST learning activities into their daily routines. The team feels co-visits will help the family integrate all of the recommended strategies into a variety of routines, which will allow the child to make faster progress.
4.45 Factors determining frequency and intensity (how frequent?)
Notes:
MIW Coach:
As discussed previously, one hour per week of a service for a family should be considered as a starting point in planning. The frequency of supports and services provided by ECI will often change over time for an individual child and family, sometimes increasing, and sometimes decreasing, as needs change. Let’s look closer at the factors that the national experts described.
1. Child needs. Consider higher service levels for a family caring for a child with complex physical, developmental or medical needs.
2. Complexity of outcomes. When an outcome is complicated, crosses developmental domains, or will require skilled, technical coaching of a parent, the team should consider a service to be planned at more frequent intervals.
3. The confidence of the family in their ability to help their child learn. A parent who has limited or no experience interacting with young children may not feel confident implementing strategies to address outcomes.
4. Family needs, including their support network. In a family that has multiple needs and concerns beyond the development of their child, the parent might need more frequent service and support.
5. Anticipated intervention strategies. This is related to complexity of outcomes. If there are lots of details to remember about the strategies that will be implemented, or if it’s anticipated that the child will make rapid progress, a parent might need more support.
Other considerations beyond those pointed out by the national experts include family risk factors (such as parent’s cognitive limitations) or family stressors. The child’s age should be considered, and higher frequency of service is often indicated for very young children. Finally, the team should consider the number of different settings the child spends time in, and the provider’s skill level related to the needs of the child.
4.46 Self-check
Multiple choice question: Which of these are factors in determining frequency and intensity of services? (select all that apply)
A. Child's age
B. Family risk factors
C. Size of provider’s case load
D. Provider skill level
E. Provider’s availability to spend time with a particular family
F. Stressors
G. Complexity of outcomes
H. Number of settings child is in
I. Nature and complexity of child needs
The correct answer is A, B, D, F, G, H, and I. All are factors except for size of provider’s case load and provider’s availability to spend time with a particular family.
4.47 Frontloading
Notes:
MIW Coach:
A good starting point for services is one hour per week. But as you know, each child’s service needs are individual and may require an increase in frequency or intensity.
Sometimes providing more frequent services early on, or front-loading services, may be needed. Here are some examples:
• A parent needs to quickly acquire a specific skill that will be needed for a long time, such as how to lift, carry, bathe, and provide interaction opportunities for a child whose mobility is severely limited.
• The child is at a particular point in development, when emerging skills are about to take off.
• A very young child, when intervention can prevent or decrease later problems.
• For a child who may only be enrolled for a short time. For example a child who is eligible due to a qualitative delay, or a child who enrolls close to the third birthday.
• When a child has challenging behaviors and the family has to quickly learn how to manage challenging behaviors, so the child can benefit from daily learning opportunities.
• When there is an urgent need for a modification of the environment to help a family achieve an outcome, for example, help with positioning the child at meal time.
4.48 What services?
Notes:
MIW Coach:
Teams are sometimes confused about how to determine when to provide SST and when therapy should be provided. Here are five items that are suggestions for determining the type of service to plan:
1. All service planning should include a discussion of which professionals on the team have the knowledge and skills needed to support the family to help their child achieve the outcomes. The team should look at all of the outcomes, the child’s strengths and the family priorities, as well as the developmental needs of the child to determine which service (or services) to provide.
2. All early intervention providers should have knowledge, skills and abilities across all domains. The EIS should have expertise in child development, and may be the best intervention provider to address the child’s cognitive development. Cognitive development includes executive function, which develops most quickly after age 3. But the building blocks of executive function, which include memory, inhibitory control, and cognitive flexibility, develop before age 3. The EIS can help the team and family understand how the child’s cognitive development impacts other areas of development. For instance, turn taking, which is a cognitive skill, impacts a child’s communication skills and social/emotional skills.
3. Be flexible. The IFSP is a working document. It may be that initially the best provider for the family is a therapist. As the family’s confidence and competence in their abilities to generalize skills grow, the clinical expertise of the therapist may no longer be needed at the same intensity and frequency.
4. It’s important to remember that EISs are not therapy assistants, and SST is not a service provided when the therapist can’t come. Review the SST workbook and the services continuum(s) at your local agency, which provide guidance for planning services.
5. If you find yourself continually planning the same intensity and frequency of service in many IFSPs, you need to ask “Are the services I am planning truly individualized to the needs of the child and family?” Two children of the same age, with the same diagnosis, or the same BDI-2 scores, can have very different service plans, based on all of the individualized considerations that need to be made in planning.
4.49 Activity: Planning services
The Service Continuums explain what service the team should plan based on the brief descriptions below. (All service planning is individualized based on the functional abilities of the child, the needs of the family for collaboration, education, and training, and the experience and expertise of the team members.) What service should be provided for each of the following children. Only one service matches each child.
These are your choices:
A. SST, with consultation and support from SLP
B. Behavior Intervention
C. OT
D. SST, with consultation and support from PT
E. Speech Pathology Services
F. PT
G. SST, with consultation and support from OT
H. SST, with support from LPC
June has a moderate language delay. Her history indicates that she is progressing slowly, but according to developmental norms.
The correct answer is A: SST, with consultation and support from SLP
Abel, a 28 month old, has delays in the communication, personal social and cognitive domains.
The team noted that he did not make eye contact with them, and his mom reports that he has frequent tantrums during which he is inconsolable for up to 30-40 minutes.
The correct answer is B: behavioral intervention.
Tyrone has moderate delays in the cognitive and fine motor areas. The team noticed that he was interested in the toys during evaluation, but had difficulty manipulating the items, and in imitating movements.
The correct answer is C: OT
Susie is crawling and can easily move from crawl to sit, but is late walking.
The correct answer is D: SST, with consultation and support from PT.
Henry has a moderate language delay. His mom reports that he didn’t really babble or engage in vocal play, and when he talks, no one can understand him.
The correct answer is E: Speech Pathology
Caitlin is not sitting, has muscle tightness, and some tremors have been noted.
The correct answer is F: PT
Joaquin has moderate delays in the cognitive and fine motor domains. The team feels the delays are due to a lack of opportunity and exposure to toys and other play materials.
The correct answer is G: SST, with consultation and support from OT.
Cynthia, a 19 month old child, demonstrated some independent and oppositional behaviors during the BDI-2 that resulted in delays in the cognitive, personal social and fine motor domains. Her parents report that she has been throwing tantrums when told No.
The correct answer is H: SST, with consultation and support from LPC
4.50 Re-assessment as a service
Notes:
MIW Coach:
In ECI, every IFSP team includes a LPHA, a Licensed Professional of the Healing Arts. ECI Rule requires that when Specialized Skills Training (SST) is planned, the team must ensure interdisciplinary monitoring of child progress by also planning either a regularly occurring service by the LPHA or a re-assessment by the LPHA at least once every six months. In re-assessment, the LPHA will gather information about, and document the child’s progress, and provide input about whether the IFSP is meeting the needs of the child and the family.
A re-assessment by the LPHA is planned individually based on the needs of each child and family, but must occur at a minimum of once every six months. Remember, this is a minimum requirement. Re-assessment may be planned more often and should be planned to address the needs of the child and family. For example, the team may determine that a child with a mild to moderate language delay will receive SST with consult and support by the SLP once every six weeks. Or, for a child who seems to have a straightforward delay in walking (no apparent tone, neurological or other apparent causative factors), the team might plan SST 1 X a week to help the mother arrange the environment, learn facilitation skills, etc. with the re-assessment planned to occur every other month (1 X 2 months) by a physical therapist to closely monitor progress and make needed adjustments to strategies or services. Providing effective, needs-driven services requires that the re-assessment be meaningful to the child and family.
4.51 Individualizing services
Notes:
MIW Coach:
To individualize the IFSP services to the needs of the child and family, the team must use clinical judgment when making decisions about services. They need to ask a number of questions. Here are some questions that are often asked:
1. Which team member has the expertise needed to support the family? Which is the best professional (or professionals), to assist the family in accomplishing the outcomes?
2. What are the unique abilities and interests of the child and family ?
3. What developmental needs have been identified, and what outcomes were written to address the needs?
4. What other needs have been expressed by the family?
5. What community resources are available to the family?
4.52 Planning Services Wrap-Up
Notes:
MIW Coach:
You've learned a lot about planning services. Now let's look at how all this is documented on Services pages ...
Services Pages
4.53 IFSP services page
Notes:
MIW SC:
Let's take a look at the Services pages for the MIW children. Start with Andre, so you can first get familiar with parts of the form...
When you've looked at the services pages for all three children, you can move to the next section to learn about IFSP changes.
4.54 Walk-through of Andre services page
Notes:
MIW SC:
Here’s what Andre’s services pages look like…..
Location
The team must identify the location for every service on the IFSP Services Pages.
Method of service
Method of service must also be documented on the Services page. “Method” indicates whether the service is delivered individually to the child and caregiver, or in a group. Group services cannot be planned unless the family is also receiving an individual service. Group services are often beneficial because caregiver learning can often be maximized through structured interaction with other caregivers, and children might make fast progress on outcomes when exposed to planned interaction with other children. Ask your supervisor if group services are available in your program.
Funding of Services and Signatures
After planning IFSP services, the team must indicate how the services will be funded on the IFSP Services Page. Teams can check all funding sources that apply: ECI, Family Fees and Public or Private Insurance. The Family Cost Share agreement must also be completed after the family consents to the planned IFSP services. It is important to explain to the family that the IFSP services that are subject to the Family Cost Share cannot be provided until the parent signs the Family Cost Share agreement, acknowledging the monthly family cost share amount the parent is responsible for paying
Signatures
Signatures of the entire team are required on the IFSP. Before asking the parent to sign the IFSP, you will review the entire document with them emphasizing the needs that were identified, the outcomes developed, and the services to address those outcomes. The signature of the parent signifies their permission for the child to receive the services in the IFSP. The signature of other ECI team members indicates they participated in the development of the plan.
There is a separate signature block for the LPHA on the team. With this signature, the LPHA acknowledges that the plan is the recommendation of the team, and that the services are reasonable and medically necessary.
4.55 Elizabeth services page
Notes:
MIW SC:
Let’s talk about Elizabeth’s services and the reason for the expected frequency of services.
OT services are recommended 4 times per month.
Young infants experience rapid change. It is better to address the probable motor issues early to prevent more severe delays from occurring later. Susie is experiencing difficulty breastfeeding due to Elizabeth’s low muscle tone and as the OT, you will need to provide services more frequently to ensure Elizabeth is feeding appropriately.
SST is recommended 4 times per month.
Elizabeth’s mother (Susie) is a first time mom with a lack of experience in not only infants, but her child’s diagnosis. Elizabeth’s needs and outcomes will most likely increase in complexity and it is important to provide services regularly to address Susie’s concerns and questions. With the diagnosis of Down syndrome, there is a risk for vision and hearing impairments which will need to be monitored.
Nutrition services are expected 2 times a month.
The dietician might decide with Susie to provide services twice a month to address lack of weight gain due to a weak suck and possible heart defect, and to collaborate with Elizabeth’s OT and Lactation Consultant. It’s important for Elizabeth’s weight to be monitored frequently because of her Down syndrome diagnosis. Susie and the Dietician agree that Susie will be able to implement the strategies between visits to keep on target with the expected daily weight gain.
4.56 Riley services page
Notes:
MIW SC:
For Riley, let’s review his services and the reasons for the expected frequency of services.
Behavior Intervention (BI) was recommended 8 times per month,
Because Riley qualified with a qualitative determination of delay and may only be in services for six months, the team felt he would benefit from “front loading” his behavior intervention services. The frequent services will allow his service providers to coach both his family and his teachers so that everyone is using the same behavior intervention strategies and Riley has similar expectations for his behavior both at home and at childcare. Additionally, the team wants to assess Riley’s progress and whether he still needs 8 x a month services after two months. The team will meet after Verona’s evaluation to determine if the services are still appropriate or if they need to be changed.
Speech Therapy (ST) was recommended 4 times per month,
Speech therapy was recommended four times per month. Based on the results from the evaluation, issues with Riley being motivated to use speech and his articulation issues, the speech therapist will see Riley 4 times a month. The SLP will provide services with the parents twice a month and twice a month with the learning center to coach and support both on how to incorporate therapies into routines.
IFSP and the Family
4.57 Procedural safeguards
Notes:
MIW SC:
Let's review the procedural safeguards that apply to IFSP.
The contents of the IFSP must be explained to parents and parents must provide informed written consent before any early intervention service is delivered.
Parents have the right to:
1.) be present and participate in the development of the IFSP
2.) receive early childhood intervention services that are based on the individualized needs of the family
3.) consent to some, but not all ECI services
4.) receive all the services for which consent was given in the IFSP
5.) request an administrative hearing or file a complaint if they do not agree with the other IFSP team members
6.) indicate disagreement in writing with a part of the IFSP
7.) have the IFSP written in their primary language or mode of communication, and;
8.) receive a copy of the IFSP
Many of these rights are printed right on the form the parent signs at the time the IFSP is developed.
4.58 Quiz: Rights related to the IFSP
Which of the following are parents’ rights related to IFSP? (select all that apply)
A. The contents of the IFSP must be explained to parents and parents must provide informed written consent before any early intervention service is delivered.
B. The parent has the right to be present and participate in the development of the IFSP.
C. The parent must sign consent to develop the IFSP.
D. The parent has the right to either consent to all of the services on the services page, or none of the services.
E. The parent has the right to request an administrative hearing or file a complaint if they do not agree with the other IFSP team members.
F. The parent has the right to have the IFSP written in their primary language or mode of communication.
G. The parent has a right to receive a copy of the IFSP.
The correct answers are A, B, E, F and G. C, is not correct because the parent is given notification of the IFSP meeting. Consent is not needed to develop an IFSP. Consent is obtained for ECI to provide the IFSP services. D is not correct because the parent has the right to consent to some services and not others.
4.59 Disagreement with the IFSP
Notes:
MIW SC:
Sometimes a parent may not agree with the service recommendations of the IFSP team. It is important to remind the family that signing the IFSP does not mean the family agrees with the recommendations. Their signature indicates consent for ECI to provide the listed services.
If the family expresses any disagreements with the IFSP, it is important to inform your program director immediately. The family has the right to choose how to resolve their disagreement, including making a formal complaint, requesting mediation, or a due process hearing. Teams must provide services the family consents to while their disagreement is being resolved.
4.60 Quiz: Self-check: Family rights
Notes:
MIW SC:
There are also procedures related to the IFSP meeting that help ensure families’ rights are protected.
You want to schedule the IFSP meeting with Andre’s family. Which of the following are requirements for that initial IFSP meeting? (more than one answer may be correct)
A. It must be conducted by an interdisciplinary IFSP team which includes the family
B. It must be held at a convenient time and setting for the family
C. It must be scheduled with enough time for the family to invite other participants to attend
D. It can be conducted by phone
E. It must be conducted in the native language or mode of communication used by the family
The correct answer is A, B, C and E. D is incorrect because the initial IFSP must be conducted face-to-face; it cannot be conducted by phone. Regarding answer B, it must be held at a convenient time and setting for the family, this is usually the family’s home, but it could be another place the family identifies and feels comfortable in such as a relative’s home or a child care center.
4.61 Helping the family prepare
Notes:
MIW SC:
One of the ways to make the IFSP meeting successful is to prepare the family for the meeting, by discussing their importance on the IFSP team, talking how the meeting will be conducted, and letting them know they have the right to invite anyone to the meeting.
Here are some of the questions I asked Andre's family to think about BEFORE our IFSP meeting.
· What are your concerns and priorities regarding to the development of your child?
· Who else would you like to invite to participate?
· What would be a convenient time and place for us to meet?
· What are your child’s, strengths, likes and interests?
Many programs hold the IFSP meeting immediately after the evaluation, during the same home visit. If this is the practice at your program, these questions can be discussed with families in your initial conversations with them.
4.62 Activity: Encouraging parent participation
Notes:
MIW Coach:
Parents have the right to fully participate in the development of their child’s IFSP, but sometimes a parent may defer to the ECI professionals. What strategies can a team use to ensure that a parent is an equal partner in the IFSP development process?
Think of at least five strategies that you can discuss these strategies with your supervisor later.
Did you think about:
* Did you consider the role culture might play in developing the IFSP?
* How will you encourage the family to invite others who can support them to the IFSP meeting?
* What can you do to collect information about daily routines that is meaningful for the family and related to their developmental concerns for their child?
* How can you develop outcomes and procedures that are important to the family that will meet their unique needs?
* If you have observed IFSP meetings, what did your peers do to encourage the family to participate?
* What kinds of things might get in the way of full parent participation?
4.63 Multiple sources of information
Notes:
The family interview is key!
MIW Coach:
An open mind and active listening will allow you to collect the information needed to develop an intervention plan tailored to the family. During pre-enrollment, you gathered information that you should review at the IFSP meeting so parents do not have to repeat important information they’ve already shared with the team.
The family interview during the IFSP is a critical source of assessment information, but you may have other information to include. Consider discussing information provided by the person who referred the child or from the family during the initial phone call. If you have had contact with others who know the child and family, such as a grandparent, child care provider, or CPS worker, you may want to include what you learned from them as you discuss child and family strengths and needs.
The child’s medical records can also be an important source of information about the child’s needs, and must be reviewed, if available as part of the needs assessment.
Finally, the findings and recommendations from the ECI evaluation, or from other providers outside of ECI should be considered when discussing the strengths and needs of the child.
Also consider info from:
• referral source
• initial phone call from family
• others who know family
• medical records
• ECI evaluation
• providers outside ECI
Take some time now to review the various sources of information we have for Elizabeth and Riley ...
For Elizabeth, you have the following:
• Discharge paperwork, including Vision and hearing status, weight, feeding information, specialists, other associated dx
• Initial referral, Dx (diagnosis) of Down Syndrome, feeding concerns and…
• The initial phone call. Caretaker concern: "Elizabeth starts to cough while she is feeding and spills a lot of milk. It takes her such a long time to finish her bottle."
For Riley, you have:
• Initial referral: Referral source concerns: Riley does not use many words, gets frustrated.
• Initial Phone Call: Caretaker concerns “Riley always has bad reports from daycare, and at home it is difficult to understand Riley, so there are lots of tantrums.
• Phone call to daycare: (after consent obtained) Riley does not interact with other children, tantrums instead of using words, plays inappropriately with toys.
IFSP Reviews
4.64 Changing the IFSP
Notes:
MIW SC:
From new pets to new houses, families are always going through changes. By making changes to the IFSP outcomes, procedures and/or services, you can help the IFSP team and family address the family changes.
Once the initial IFSP is developed, changes are made by revising rather than by rewriting the entire IFSP. The IFSP should be viewed as a working document, changing and adapting as needed. Documentation in the child’s record must reflect continuing or changed services throughout the child’s enrollment.
Reviews of the IFSP must be conducted every six months at a minimum. However, if needed, there are times the parent or member of the IFSP team may request a review of the IFSP more frequently than every six months. Additionally, the services pages must be rewritten at least annually because services can be planned for no longer than one year. Reviewing the IFSP on a regular basis gives an opportunity to consider child progress, and the appropriateness of the outcomes, procedures, and services.
There are 3 types of IFSP reviews: a periodic review of the IFSP with revisions, a periodic review with no changes, and an annual review and evaluation of the IFSP. Let's first take a look at periodic reviews...
4.65 Periodic reviews
Notes:
MIW SC:
A periodic review is a review of the IFSP by the IFSP team, based on the assessment of the child, which results in the approval of or modifications to the IFSP. The periodic review consists of the following actions, which must be documented in the child's record and a copy of the review form must be provided to the parent:
(1) a review of the IFSP outcomes;
(2) a description of the child's current functional abilities and progress toward meeting each outcome;
(3) a review of the current needs of the child and family;
(4) the results of any new evaluations and assessments;
(5) the development of new outcomes or the modification of existing outcomes, as appropriate, which must be dated and attached to the IFSP.
4.66 If changes are needed
Notes:
If the parents and the rest of the team determines that changes to the type, intensity, or frequency of services are required:
1) The team completes an ECI required IFSP Services Page and provides a copy to the parent;
2) The team documents the rationale for:
a) a change in intensity or frequency of a service;
b) the addition of a new service; or
c) the discontinuation of a service; and
3) The contractor must continue to provide all planned early childhood intervention services not affected by the change while the IFSP team develops the IFSP revision and gathers all required signatures.
4) If the change is an increase in the intensity or frequency of a service, or the addition of a new service, and the family has private insurance, the parent must also sign a new consent to bill their insurance.
4.67 Activity: Periodic review for Riley
Notes:
MIW SC:
Take a look at Riley's Periodic Review (2 months). Riley's records must contain documentation of all IFSP team members' participation in the periodic review. Participation in the periodic review may be accomplished by a team member attending the meeting, face-to-face or by telephone, or by providing input and information in advance of the meeting. If a team member participates by means other than a face-to-face meeting, he or she must provide their most recent observations and conclusions about the child to the service coordinator. He or she must document in the child's record how this information was communicated to the service coordinator. For changes related to services provided by the AI or VI teacher, the teacher must be present.
With the exception of the annual meeting to evaluate the IFSP, reviews may be conducted with the Service Coordinator and the parent in a face-to-face meeting or by other means acceptable to the parents.
Beginning of Riley’s Periodic Review page:
Child’s Name: Riley
Client ID: 123456
Date of Birth: 7/1/2012
Current IFSP Date 9/1/2014; IFSP Review Date 10/31/2014
Start time: 2:30; End Time: 3:00
1. List IFSP team members/participants in attendance (include names and disciplines): Ronda
Burgundy, SC; Verona Corningstone, LPC
2. List IFSP members who were not in attendance but who were consulted (include names and disciplines) and document their input: Brianna Fantana, SLP
Notes: Riley is making some progress towards his outcomes. He is still demonstrating behavior challenges at home and at childcare. He seems to be frustrated with his inability to communicate. Recommend that the service level remain the same and add an outcome about using picture exchange cards.
3. Review IFSP outcomes and describe the child’s current functional abilities and progress toward meeting each outcome Riley is making some progress toward outcome #3. He is more verbal, but others outside of his immediate family have a hard time understanding what he is saying. He gets really frustrated when others cannot understand the words he is trying to use. Team feels using a picture exchange system may be helpful for reducing his frustration. Riley has had good days and challenging days with transitions. The team feels a visual reminder of the transition (visual schedule/calendar) will be helpful to him. Team will continue to work on outcome #1. Riley continues to prefer to spin the wheels on toy cars or trucks instead of pretending to “drive them”. He does not want other children around him when he is playing with cars of trucks.
4. Describe current needs of the child and family – include new and continuing developmental, case management, transition, etc. Adelia is concerned about Riley’s behavior and his lack of initiating interaction with other children. She would like more information about challenging behavior and a parent support group. Developed Riley’s transition plan. Reminded Adelia that Riley will need to be evaluated again for eligibility before 3/1/15.
The following items were checked:
• Developed new outcomes or modified existing outcomes – date and attach outcomes to the IFSP (Added procedures)
• Developed Transition Steps and Services – attach to the IFSP
5. Describe reasons for any modification to the plan and/or describe rationale for no changes
Services and outcomes were determined to still be appropriate and will remain at the same level as the previous IFSP. No new needs were identified during the review. A new services page needed to be developed because behavior intervention was planned for only two months with a re assessment. Services are still meeting the needs of Riley and his family.
End of Riley’s Periodic Review page.
Try creating a new Services page for Riley based on what you learn in the periodic review document.
4.68 Riley 2 month services page
Notes:
MIW SC:
After Verona’s evaluation, she and Ronda conducted an IFSP periodic review with Adelia. They discussed Riley’s progress and the results of Verona’s evaluation. The team decided that 8 x a month behavior intervention services and 4 x a month speech services were still appropriate for Riley. He continues to have behavior challenges at child care and at home, especially around transitions. He clearly shows that he is frustrated by not being able to communicate. The team discussed using picture schedules and picture exchange cards to help with his communication.
4.69 Periodic review - no change
Notes:
MIW SC:
If the team determines that no changes to services will occur, they must describe the rationale for making no changes and for recommending continued services. For example,
"Team and family are happy with Annabel’s progress toward her outcomes. Annabel’s outcomes and services are still appropriate. No new needs were identified during the review. Services are still meeting the needs of Annabel and her family."
4.70 Annual reviews
Notes:
MIW SC:
Here's what you need to know about annual reviews. Here are some questions to ask.
When does the annual IFSP occur?
An annual IFSP review occurs only after the child has been re-evaluated and determined eligible to continue receiving services.
Who attends?
If the child remains eligible, the annual review is conducted in a face-to-face meeting with the entire team and the family. The parent must be in attendance at the annual IFSP review. In addition, other family members or friends may be included at the parent’s request, including representatives from advocacy or parent support groups. The IFSP team must include staff from at least different disciplines who serve in the following roles: 1 or more members of the evaluation team, the LPHA, potential service providers, and the service coordinator. If the child is dually served by Early Head Start or Migrant Head Start, with parental consent, a representative from Head Start must be invited. The IFSP will serve as the Head Start Family Partnership Agreement. If the child is served by other agencies that provide case management or child care services, representatives of those agencies may also be invited, with parental consent.
What is addressed?
When evaluating the child’s IFSP, we are asking “How well did the plan work for the child and the family?” In order to fully answer this question, we need to look at the current status of the child and his progress on current outcomes.
This is the information that should be available:
1. The IFSP that is being reviewed and evaluated, including all of the current outcomes and periodic reviews.
2. The results of the BDI2, and any other assessments that have been done.
3. Input from team members who have been providing services to the child but are not at the meeting.
Based on current status and progress, the team will then determine whether new outcomes are indicated, and whether changes are needed to the services planned for the family.
4.71 Walkthrough of Annual review for Riley
Notes:
MIW SC:
Let's take a look at Riley's annual IFSP review and walk through each section.
The current health, hearing, vision and nutrition status of a child is covered in the first section of the annual form.
4.72 Walkthrough of Annual review for Riley (continued)
Notes:
MIW SC:
The next section of the annual IFSP review describes the child’s present level of development, organized around the three global child outcome ratings, as required by TAC. As in most components of the IFSP, we want to focus the conversation on the functional abilities of the child rather than isolated skills. In some cases, it might be appropriate to talk about skills that are typical for child at a given age. You may have already had this discussion when talking about the test scores from the eligibility determination.
A listing of items from the BDI-2, or from another developmental scale does not provide a description of a child’s functional abilities. If the description of the child consists only of items from a tool then the team has not described the child’s functional abilities, and the IFSP does not met the ECI rule requirement.
4.73 Activity: Annual review for Riley
Notes:
MIW SC:
Take a close look at Riley's annual IFSP review. Based on the information provided, write a new outcome for Riley and create a new services page.
Beginning of Excerpt: Annual Meeting to Evaluate the IFSP for Riley.
Child’s Name: Riley
Date of Birth 7/12/2012
Client ID 123456
Date of Current IFSP: 10/31/2014
Date of Meeting: 03/01/2015
Start Time: 4:30
Length of Time: 5:30
Determined continuing eligibility- Checked yes
Reviewed parent’s rights with parent- Checked yes
Reviewed Family Cost Share-checked yes
If child is between 27 and 33 months of age, complete Transition Steps and Services
(Already completed)
Describe the child’s current health and any updates to the medical history (include review of any applicable late onset risk factors) Riley has been fairly healthy over the last six months. He has had one ear infection. Riley’s shots are up to date and will have another well child check when he is 3. Riley has no ongoing health issue.
Describe child’s vision and hearing in functional terms. Adelia enjoys beading and Riley is great at finding her small beads that she drops on the floor. Riley loves sorting the beads. When Riley is outside, he turns and points when the neighbor’s dog barks and pulls Adelia over to see her. He also imitates the dog barking. Adelia reports that Riley runs to the door when he hears someone knock or ring the door bell. He is very curious to see who is visiting.
Describe child’s nutritional status Riley is a fairly picky eater. He will eagerly eat chicken nuggets, bread, cheese sticks and mac and cheese, but refuses to try much else. Riley drinks milk, juice and water. Adelia is not concerned at this point about his picky eating. He is well within normal development on the height and growth charts. Adelia also gives him vegetable juice and sometimes adds pureed vegetables to the mac and cheese.
1. Positive social-emotional development and relationships (communication, social emotional)
Riley sometimes uses tantrums, screaming and biting to communicate his frustration.
Riley shows some interest in the other children at the child care center. He follows them, especially during outside play. He doesn’t initiate play with others, but will play next to other children. He does not share in the transportation center (favorite toys).
Riley is affectionate with his mom and dad. He will seek affection sometimes and always gives hugs and kisses when others initiate it.
2. Acquiring and using knowledge and skills (cognition, communication, motor)
Riley says single words and occasionally puts two words together to request items. He frequently uses his picture cards to communicate what he wants during structured settings (circle time, choosing centers, dinner at home in the booster seat). He doesn’t use the picture cards as often during a new setting or when there is less structure.
When Riley is calm, he will play with toys appropriately. After a tantrum, he calms himself by spinning the wheels of a car or truck.
Riley loves puzzles, sorting and matching. He is able to put a five piece puzzle together independently.
3. Taking appropriate actions to meet needs (cognition, adaptive/self-help, motor)
Riley is able to feed himself with a spoon and fork and drinks from a small open cup.
Adelia had to put a lock on their back gate. Riley is very interested in the neighbor’s dog. He will drag a chair over to the back gate so he can unlatch the gate and try to get into the neighbor’s yard. Riley doesn’t seem to have an awareness of personal safety.
Riley is able to undress himself and helps getting dressed on most days.
IFSP Outcomes:
1. Riley still sometimes tantrums and bites at bedtime. This behavior has significantly reduced, but Riley has not met the full criteria to consider this outcome as “achieved”.
2. Riley plays with toys appropriately when he is calm. However, after a tantrum or when he is upset, he just spins the wheels of a car instead of using it appropriately.
3. Riley is using single words and will sometimes use his picture cards to request items. He does not have a lot of patience, so if he doesn’t get what he wants after a first request, he reverts to grabbing or has a tantrum.
4. Riley frequently uses his picture cards during structured settings. He occasionally uses the cards in new or non-structured settings. His behavior has improved at the store, but he still sometimes has tantrums or runs away.
All outcomes were partially achieved and recommended to be continued.
New Needs: Riley has started removing his clothing at inappropriate times. James (OT) noted that Riley may be doing this because the clothes make him feel uncomfortable (scratchy material and scratchy tags). Added outcome to address this need. New outcomes and transition steps and services were developed.
Current Case Management needs of the family: Revise outcomes and services as necessary
Adelia has contacted Texas Parent to Parent. She plans to attend their annual conference this summer. Will continue to explore transition options for Riley.
Services are going to change for Riley.
End of Excerpt: Annual Meeting to Evaluate the IFSP for Riley.
Based on the information provided, write a new outcome for Riley and create a new services page.
Now let’s look at a sample response.
4.74 New outcome for Riley
Notes:
MIW SSC:
Here's an example of Riley's new outcome. The outcome is geared for the family to implement.
“Riley will be able to tolerate wearing his clothing, without taking them off during a grocery store outing with Mom, 3 times a week for 4 weeks.”
Procedures/ Activities to Achieve this outcome:
• ECI staff will provide information about how to help Riley know what is expected of him at the grocery store.
• ECI staff will help you (the family) to determine what Riley is communicating with removing his clothes.
• ECI staff will help you (the family) learn how to replace removing his clothes with different communication methods.
• ECI staff will help you (the family) maintain the replacement behavior(s) and eliminate removing his clothes at inappropriate times.
• ECI staff will help you (the family) learn how to help Riley cope with unpleasant sensory stimulation.
Notice that this would not be the only new outcome. The team should develop an outcome about Riley trying to open the gate to get into the neighbor's yard to see their dog. The outcome should address increasing awareness of personal safety.
Also, the team should develop an outcome about initiating play with other children.
4.75 New services page for Riley
Notes:
MIW SC:
Notice that OT has been added to Riley's Services page. Let’s learn more about the OT service.
Occupational Therapy (OT)
The OT will provide services three times a month at home and three times a month at Riley’s learning center due to the sensory issues Riley appears to have and the short amount of time he will remain enrolled in ECI.
4.76 Activity: IFSP Review and the 7 Key Principles
Notes:
MIW Coach:
You've done a great job learning about how the IFSP can change during periodic and annual reviews. Let's take a look at key principles 4, 6 and 7 which all relate to the IFSP review and revision process.
Principle 4: The early intervention process, from initial contacts through transition, must be dynamic and individualized to reflect the child’s and family members’ preferences, learning styles, and cultural beliefs.
Principle 6: The family’s priorities needs and interests are addressed most appropriately by a primary provider who represents and receives team and community support.
Principle 7: Interventions with young children and family members must be based on explicit principles, validated practices, best available research and relevant laws and regulations.
The following statements are characteristics of what principles 4, 6 and 7 look like and don't look like for IFSP review and revision. Answer each of these 6 questions as to whether they look like or don’t look like Principles 4, 6, and 7.
1. Treating the family as having one learning style that does not change.
a. Looks like principles 4, 6, and 7.
b. Doesn’t look like principles 4, 6, and 7.
The correct answer is B.
2. Expecting the IFSP outcomes, strategies, and services not to change for a year.
a. Looks like principles 4, 6, and 7.
b. Doesn’t look like principles 4, 6, and 7.
The correct answer is B.
3. Changing the IFSP as often as needed to meet the child’s & family’s needs, priorities & lifestyle.
a. Looks like principles 4, 6, and 7.
b. Doesn’t look like principles 4, 6, and 7.
The correct answer is A.
4. Basing practice decisions for each child and family on continuous assessment data.
a. Looks like principles 4, 6, and 7.
b. Doesn’t look like principles 4, 6, and 7.
The correct answer is A.
5. Thinking that the skills and strategies you've used will always be effective or will be effective for every child.
a. Looks like principles 4, 6, and 7.
b. Doesn’t look like principles 4, 6, and 7.
The correct answer is B.
6. Keeping abreast of changing circumstances, priorities and needs.
a. Looks like principles 4, 6, and 7.
b. Doesn’t look like principles 4, 6, and 7.
The correct answer is A.
What the IFSP Means
4.77 What the IFSP means
Notes:
MIW Coach:
Throughout this section of the module, you've learned a lot of details about the IFSP process. But what is the IFSP at a fundamental level? The IFSP is a promise to children and families -- a promise that their strengths will be recognized and built on, their needs will be met in a way that is respectful of their beliefs and values, and their hopes and aspirations will be encouraged and enabled.
This promise is not a promise that families will get everything they want or that all children will reach the outcomes written in the IFSP. Rather, it is a promise that ECI staff will respect the strengths, values and dreams of every family. The promise of the IFSP is only as good as the attitudes surrounding it; remember that for each family you serve, the IFSP documents represent their hopes for their child.
This statement was developed by the Association for the Care of Children’s Health.
Citation: McGonigel, M. J., & Johnson, B. H. (1991). An overview. In M. J. McGonigel, R. K. Kaufmann, & B. H. Johnson (Eds.), Guidelines and Recommended Practices for the Individualized Family Service Plan (2nd ed.) (pp. 15-16). Bethesda, MD: Association for the Care of Children's Health.
4.78 Conclusion
Notes:
Congratulations! You have finished Section 4 of Making It work, the IFSP section.
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