The answer to this question is that we really don’t know. There isn’t any research in our field that firmly states that a certain level of EI service frequency is most effective. When you think about it, it’s not difficult to guess why this might be. We don’t believe in a one-stop shop mentality; in fact, our field is built on a foundation of individualized decision-making. So why is it, then, that most children in EI receive weekly services? Why weekly?
I think this is actually pretty frustrating because we really cannot say that weekly services are any more effective than twice a month, or any less effective than twice a week. We continue to choose “1x/week” because that’s the trend; it’s just the way we’ve always done it. With the push in our field to implement evidence-based practices, it’s a real challenge that we don’t actually have evidence for this important decision.
A Few More Reasons Why
Here are a few more reasons why answering this question is such a challenge:
It’s not easy to do good research in EI, with so many variables to control (or that can’t be controlled) in natural environments, so many differences among child and families, different IFSP outcomes, and different provider skills and knowledge. Of course, there’s also the important fact that we can’t withhold services for some infants or toddlers as a control group to test the effectiveness of a certain frequency for others. Because research in natural environments is so complex, it would be incredibly difficult to know if it really was the difference in service frequency that made the difference in the child’s outcomes – or was it due to differences in service provider skills, parent-child interactions, materials in the environment, etc. etc.
Because of these variables, it’s very unlikely that we’ll ever find a magic service frequency that works for all services, children, families, and outcomes.
We believe that the real intervention happens between visits. Figuring out how many visits will have the best impact on what happens between visits is the question.
These three reasons all weave together into a web that makes reaching the answer to our question a real challenge.
So How SHOULD We Decide Frequency??
When it comes to this decision, until we have evidence to guide the process, we do our best to consider all of these unique variables, mixed with our professional experience and the family’s preferences. Here are a few ideas about deciding on service frequency.
Rethink the Questions You Ask
Rather than focusing on the child’s delays or disabilities, Jung (2003) suggested that we ask these two questions::
1. How often will the child’s intervention likely need to be changed?
2. How often does the family need support to be comfortable in using intervention strategies? (p. 25)
These questions move the focus from the complexity of the child’s needs (from a deficit-based view) to what the family will need to support the child’s development. The first question challenges us to remember our role to support the family’s efforts and flips our old ideas that children with more complex needs must have lots of services. If strategies are unlikely to be changed frequently (e.g., because the child can benefit from more time to practice and learn between visits or the parent is able to use strategies effectively), then maybe service frequency and/or the amount of services on the IFSP can be less intense. Or, if we expect or need intervention outcomes to be achieved swiftly (e.g., when a newborn has feeding difficulties), maybe more frequent services will be most beneficial, at least initially. The second question is a great one to ask families to include their input in the decision-making process, rather than professional team members prescribing service frequency. The parents might not know the answer, or they might feel very clear about what they want to try. These questions push us to move past our assumptions about a child’s abilities or our own importance and focus on how we can support families.
The “I” in IFSP
Look at the IFSPs you and your team members write. Are all of the outcomes generally the same (e.g., “Sam will use 50 words to get his wants and needs met…”)? If they are, work with your team to write better, more individualized outcomes. Determining services MUST wait until after outcomes are developed. If outcomes aren’t individualized, services won’t be either.
Be mindful in thinking beyond “1x/week” and consider other options. Don’t take the easy way out and make the same recommendation for everyone. Some children and families will benefit from less frequent service, some from more frequent service, and some from service frequency that changes over time. Try something else and see if it works. If it doesn’t, well, that’s what an IFSP review is for.
How do you determine service frequency? Do you see “1/week” listed frequently on IFSPs? How do you help your team think of other options?
Jung, L. A. (2003). More better: Maximizing natural learning opportunities. Young Exceptional Children, 6(21), 21-26. doi: 10.1177/109625060300600303
Thank you, Dana for another great resource to share! I am in the middle of some challenging conversations with one team right now that is really struggling. I hope your article can support us in our shared understanding and decision making!
Good luck with your discussions, Amy. I’d love to hear if your team comes up with some creative solutions or has any advice for other teams experiencing similar circumstances.
So, we used your article as a jumping off point and had great discussion! Afterwards, we created a brief summary to share within our local service area in hopes of replicating a process we found helpful.
More vs. Different
I/We want more _____________ . Let’s ask some questions to see if it’s really more or different we need!
More vs. Different – Sometimes when we think we need “more”, we first need to look at how we are using the time we already have and ask ourselves if we should consider doing anything differently first. Could my current home visits encourage more active family participation with guided practice and feedback? Could my visits follow or focus more on routines with less time spent sitting and playing with toys? Maybe a different approach can have the impact we are hoping for!
More of the Same vs. More but Different – Sometimes we do need to think about providing more – but first we need to be clear on what the ”more” is – is it more of the same or more but different? Is it that we think the child needs more, the family needs more, or both? Does the family need more support in learning strategies or finding ways to incorporate strategies into their daily routines? If the child needs more opportunities to learn and practice skills, does the family then need more or different support in finding ways to identify or create those opportunities?
Big Picture is Less – We also want to keep our end goal in sight. In early intervention, when we are effective in our efforts to educate, support and empower families, over time they need us less, not more.
Thanks again, Dana for sparking such productive discussion in the field!
Thanks for sharing this, Amy! What a great resource. I really appreciate the thought process you all used here. You should turn this into a handout! I especially love your big picture statement!
I like how you framed this. It will help me today to deal with concern about is more therapy a good idea.
I’m glad this will help you, Sara! Considering whether or not more therapy is a good idea is often a tricky question. Do you find it harder when you think a therapy increase may be needed or when the parent has requested more?
Many factors play : what are the needs, concerns and priorities of the family? What types of activities will happen to help meet the families’ goals? Available resources,related supports( other services that are related to medical needs)
Yes, exactly Cecilia! I appreciate how you brought in the question of what other resources are available to the family – either needed resources or resources they already have in place. It might be easy to think that having many resources automatically means that fewer services will be needed. However, having many resources in place could mean that more services are needed so that the provider can support child care providers and other family members who care for the child OR it could mean that fewer services are needed because the family already has a strong foundation of support and just needs a little guidance. It really does depend on the individual child and family.
A big challenge that we face a lot in our area seems to be when Doctors and Clinics in the “medical world” (i.e. pediatricians, but especially local developmental pediatricians) tell a family, and write in their report that the child “needs ____ therapy at least three times per week” (and yes I recently saw that in a report!) A lot of times I find myself having conversations with families yet again about the differences between a “medical” model and a “developmental” model. In most cases the family understands and it doesn’t turn into a huge issue, but it can be frustrating for the family to get those recommendations and for the EI program to not provide those frequent services in most cases. I feel like sometimes the medical world is putting the family in the position to doubt that they are doing everything they can to help their child’s development, and to feel as though they are no competent in helping their child develop – but rather are being told they need “more therapy”
Yes, the challenge you describe seems to continue to happen in many places so you guys aren’t alone in your area. I think it’s an ongoing issue of collaboration with referral sources. Have you seen the American Academy of Pediatrics article supporting early intervention? It’s fantastic and it’s a great resource to share with folks in the medical world. Here’s a link to the article: Early Intervention, IDEA Part C Services, and the Medical Home: Collaboration for Best Practice and Best Outcomes.
Like Jennifer S. above, we too are challenged by the medical vs. developmental discussion which can be tough on families who are trying to understand recommendations from differing philosophies. Our local area just met with a developmental pediatrician who is interested in partnering with us to facilitate communication and collaboration – so I’m sharing both the blog article and the AAP resource with her and our group this morning – thanks, Dana!
Let me know how your meeting goes, Amy! If you or the pediatrician have any insights into how to address the medical vs. developmental issue, please do share!
Thanks for the article! This is really a frustrating topic for sure. Often times as a service coordinator it feels like a losing battle. Families and providers are almost always in favor of more services. Often they want more than weekly and with more than one provider. This is certainly not an educational model of services, but we have this idea in America that more is always better. The service coordinator often has to take the role of the bad guy asking questions like is this really appropriate, do you really need that many strategies, can you really commit to doing this and implementing these strategies when your provider isn’t there working with your child? Even with all these attempts the family and providers still can’t understand that more services doesn’t necessarily mean faster progress. To make things more challenging the at the state and federal level there are no limits on frequency of services! We could provide services all day every day, and im sure that would help, but thats not an educational model and it’s NOT something that is feasible considering the ever tightening budget constraints from the government. This NEEDS to be considered at a State and Federal level in order to maintain the program and more support needs to be shown at the local level. Thoughts anyone?!
You raise lots of interesting questions, Jenna! It’s such a challenge because frequency decisions, just like all other IFSP decisions, must be individualized. I really like the idea of focusing on how much support the parents/caregivers need, and you’re right, that this discussion is often mediated by the service coordinator. I think when a SC is feeling like she/he has to be the bad guy, it’s probably time for a team meeting with providers outside of the family’s home so that everyone can get on the same page. I doubt we’ll ever really see specific instructions or limits from the federal or state levels because of the requirement that our services be individualized, but I hear you on the need for guidance! There just isn’t really any research that says a particular frequency is the magic amount, and that makes this so much more challenging too! Hang in there. I’d love to hear from more service coordinators on this too!