Early social and emotional development includes the ability for young children to “form close and secure adult and peer relationships; experience, regulate, and express emotions in socially and culturally appropriate ways; and explore the environment and learn — all in the context of family, community, and culture” (Yates et al., 2008, p. 2). This describes the way infants and toddlers understand and communicate their emotions to build healthy relationships with those closest to them.

When you think about social and emotional development, all of the words above may come to mind. Each word is a critical component of social and emotional development. In early intervention, all practitioners play a key role in supporting the emotional well-being of every young child and their family.

Why and What You Can Do

“Social and emotional experiences with primary caregivers as well as interactions with other children and adults early in life set the stage for future academic and personal outcomes, and undergird other areas of development” (Darling-Churchill & Lippman, 2016, p. 2). You have a unique opportunity to nurture the connection between the caregiver and child and promote successful outcomes for each child you serve.

Here are eleven easy strategies you can implement to support social and emotional development:

1. Boost the parents’ confidence. This is a hard time for many parents. Parents may feel responsible for their child’s developmental delay. Building their confidence empowers them to feel competent. When someone feels good, it makes them happy. This helps promote positive parent-child interactions.

2. Support the child’s self-esteem. Children tend to avoid difficult tasks. After all, nobody likes failing. Boosting a child’s self-esteem gives him/her confidence to explore and try new things.

3. You can never give too much information. Explain what you are doing and why you are doing it. This helps parents understand the reasoning behind the intervention strategies you suggest or model.” Give parents plenty of opportunities to ask questions.

4. Focus on increasing positive parent-child interactions. Many children may resist demands placed on them. A positive parent-child interaction removes the feeling of a demand and makes the interaction playful and fun. It enhances the bond between the caregiver and child.

5. Read cues and intervene before a child is in his/her red zone. There are four stress responses a child may experience: Green zone, red zone, blue zone, or combo zone. Click here to read the checklist that identifies different behaviors associated with each zone. Positive emotions are associated with the green zone and negative emotions are associated with the other stress responses. Children are more likely to come back and stay in the green zone when parents are attuned to their moods and feelings. Becoming a detective for your child’s stress cues can be a great tool to improve attunement.

6. Model the behaviors you wish to see. We can help parents learn to model behaviors they want to see in their children as they grow into adults. Children learn how to manage big feelings in large part by watching their adults manage big feelings.

7. Explain the importance of comfort. Comfort is a big part of secure attachment. So often parents get mixed messages about comfort from society – sometimes it seems as if comfort is the same as creating a weak child. We can bust that myth by sharing the information we know about the role of comfort in early brain development.

8. Provide structure and routine. Routines are the safe walls around a child’s day. There is no RIGHT kind of routine but whatever it is, the more predictable for the child, the better. Routines that are repetitive for a child help them make sense of the world. They will always have another chance to practice the things they struggle with most.

9. Use positive behavior supports. A positive and proactive approach to supporting behaviors helps reduce parental stress and increase positive behaviors in children as they aim to please their parents. These strategies decrease reactivity and should be individualized for each child and situation.

10. Label emotions. Language is a major learning tool for children and during the young toddler and preschool years, we learn and use language as a way of making sense of the world. Putting words to feelings helps children learn that feelings are generally transient and aren’t a permanent state of being. This is something we should be regularly talking about with our parents.

11. Increase parent responsiveness. Parent responsiveness nurtures a safe, secure attachment allowing a child to explore and thrive in their environment as the child becomes more resilient and independent. Wonder with the parents about what their child may be feeling or thinking so they can respond in an intentional and positive way. 

What challenges or barriers do you face as an early interventionist supporting social and emotional development?

What other strategies would you add to support each child’s social and emotional development?

Additional Resources:

DEC Child Social-Emotional Competence Checklist

Supporting Social and Emotional Development: What ALL Early Interventionists Can Do Handout

References

Darling-Churchill, & Lippman, L. (2016). Early childhood social and emotional development: Advancing the field of measurement. Journal of Applied Developmental Psychology, 45, 1–7. https://doi.org/10.1016/j.appdev.2016.02.002 

Yates, T., Ostrosky, M., Cheatham, G., Fettig, A., Shaffer, L., & Santos, R. (2008). Research synthesis on screening and assessing social–emotional competence. Retrieved from Center on the Social Emotional Foundations for Early Learning http://csefel.vanderbilt.edu/documents/rs_screening_assessment.pdf

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Ever been in a home visit with a parent who is simultaneously using his/her phone while discussing the child with you? There are lots of ways that phones and screen time show up during visits. For instance, parents hand their child a phone to keep him quiet or distract other children in the home. Parents may pull out their phones to take down notes about interventions or the next appointment. They show us videos and pictures of exciting progress in milestones, or to ask a question about something going on with their child.

Cell phones and all other forms of screens are such a huge part of life today, including children’s lives starting as early as infancy and toddlerhood. As service coordinators and providers, we can choose to resist or ignore these changes, and feel frustrated with how they impact early intervention outcomes. OR, we can step up to the challenge of employing phones and technology as tools in our interventions and interactions with families.

AAP Screen Time Recommendations

The American Academy of Pediatrics has made a formal statement of recommendations for use of technology for children of all ages in their Media and Young Minds Policy (2016). Some specific advice for ages 0-3 includes:

• For children younger than 18 months, discourage the use of screen media other than video-chatting.
• For parents of children 18 to 24 months of age who want to introduce digital media, advise that they choose high-quality programming/apps and use them together with children, because this is how toddlers learn best. Letting children use media by themselves should be avoided.
• In children older than 2 years, limit media to 1 hour or less per day of high-quality programming. Recommend shared use between parent and child to promote enhanced learning, greater interaction, and limit setting.
• Recommend no screens during meals and for 1 hour before bedtime.

Parents often express guilt to providers over undesirable screen time issues with their child, and look to us for support. Advice from author, Lisa Guernsey, recommends that families and early childhood professionals consider the “Three C’s” when determining when and how to use various technologies: content, context and the individual child. Together with families, we can consider the following questions to begin supporting them in implementing the AAP’s recommendations, while keeping technology as a tool on our side.

• We can ask how does the content help children learn, engage, express, imagine, or explore?
• What kinds of social interactions are happening before, during, and after the use of the technology? Does it complement, and not interrupt, children’s learning experiences and natural play patterns?
• Does this technology match with this child’s needs, abilities, interests, and development stage? (Guiding Principles for Use of Technology with Early Learners, 2016)

7 Ways to Support Families and Outcomes Using Technology

Once we’ve evaluated the values of technology per each child’s situation, we can consider employing some of the following strategies for intervention and improvement.

1. Parents can use video chats as a new and exciting way for children to use their language and imitation skills with a variety of people.
2. Show parents how they can engage in an app or screen time activity together with their child to promote quality interactions.
3. At the end of a visit, encourage parents to set a reminder alert in their phone to practice certain strategies or focus on a specific interaction with their child.
4. Recommend apps that educate and support parents in understanding child development, such as: CDC’s Milestone Tracker, VROOM, and HelloJoey.
5. Educate parents about how to evaluate apps/programs for developmental appropriateness.
6. Coach parents in setting boundaries with screen time and managing challenging behaviors that may arise from this. Help them determine specific “screen free” routines throughout the day.
7. Remind parents that no “educational” technology or program is better for their child’s development than regularly engaging in interaction, exploration, and play everyday!

Share your thoughts and experiences below by leaving a comment:

How have you seen screens and technology impacting Early Intervention visits?

Have families ever asked for advice about apps or programs to help their child? How do you or would you respond?

Please share any great technology resources that you have found in the comments too!

References

Guiding Principles for Use of Technology with Early Learners. (2016). Retrieved from https://tech.ed.gov/earlylearning/principles/.

Radesky, J., and Christakis, D. (2016). Media and young minds. Journal of the Academy of Pediatrics, 138(5), doi:10.1542/peds.2016-2591.

Rachel Todd lives in Northern Utah and has worked as a Service Coordinator for the Up to 3 Early Intervention Program since 2017. She has a Bachelor’s degree in Family, Consumer, and Human Development emphasizing in child development and worked with families in Early Head Start programs before joining EI. She is also a graduate student in the Instructional Technology & Learning Sciences program at Utah State University and loves professional development of all forms. Rachel and her husband have a one-year-old son and a spoiled fur baby and love to get outside in the mountains together every chance they get! You can reach Rachel at
rachel.todd@usu.edu

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Wyatt is a happy 19-month old child who was recently released from the hospital, where he lived for the first 17 months of his life. Wyatt was born very prematurely and has been diagnosed with a visual impairment and cerebral palsy. You want to conduct an assessment to learn about Wyatt’s strengths and needs, especially related to communication, which is a priority for his family. When you look at the assessment tools, you worry that Wyatt is likely to score much lower than his chronological age. You wonder – Is this is good test to use? How do I get meaningful information that will help our team write good goals?

Thinking Beyond the Test Scores

From experience, we know that young children with multiple disabilities often perform much lower than their chronological or adjusted age on our developmental assessments. We walk into an assessment bracing ourselves for how to tell a family that their 19-month old son has the skills of a 4-7 month old infant. We struggle because we don’t want to hurt a parent’s heart with this difficult news. We also struggle because I think, on a deeper level, we realize that this information really isn’t all that meaningful. While we can quantify that Wyatt can or cannot do certain tasks on the test, we also know that qualitatively, Wyatt has had more experiences than a 4 or 7 month old infant. Wyatt may be just starting to roll over, hold a toy, and make babbling noises but he is not an infant.

Establishing a developmental age is something we have to do when children enter EI and annually to help us track progress. We can’t avoid it, and shouldn’t, because it is helpful when considering what will come next developmentally for Wyatt. Perhaps our more important task, then, is to think about how to gather meaningful information about Wyatt’s functional abilities, including how he communicates and engages others, acquires and uses knowledge, and takes actions to meet his needs.

Tips for Assessing Young Children Who Have Multiple Disabilities

I recently came across a great resource that prompted me to think more deeply about how we assess very young children with multiple disabilities: Assessing Communication and Learning in Young Children Who are Deafblind or Who Have Multiple Disabilities (Rowland, 2009) (PDF, New Window). This document includes some great tips that we could use if we really were conducting Wyatt’s assessment, such as:

Plan for extra time – It takes time to get to know the child and learn how to read his cues, how to position him, how to offer assessment materials, etc. Assessing Wyatt would involve more than observation and conversation with his caregivers; it would also be a process of experimentation to figure out what he can do and how to support him in doing it. Wyatt may also need extra time to complete activities and/or extra rest time between them.

Select appropriate assessment tools – Look for tools that include info about how to adapt assessment items for children with sensory or motor disabilities. The Carolina Curriculum for Infants and Toddlers and the Assessment, Evaluation, and Programming System for Infants and Children (AEPS) are two examples.

Gather information about Wyatt’s everyday life – Prepare a list of specific questions you want to ask, such as:

• How does Wyatt react when you talk to him?
• What cues do you notice that tell you what Wyatt wants/needs?
• What does Wyatt like to do/not like to do?
• How does he use his vision?
• What would you like for Wyatt to be able to do?
• What would make things easier for you/for Wyatt? 

Ask the caregiver to “show” you how she plays with Wyatt, positions him, and engages him. Find out about Wyatt’s interests, preferences, what motivates and alerts him, and what tires him out.

Do a “head to toe inventory” when assessing communication – Look for the child’s movements, reactions, and sounds and consider which appear to be voluntary and which have communicative intent. If you aren’t sure, keep observing throughout the assessment to see if you notice the behavior or sound again. Watch for patterns and take careful notes.

Always assess sensory and motor skills too – The presence of hearing, visual, and motor disabilities will affect how Wyatt communicates. He could have cognitive skills closer to his adjusted age, but his difficulties with movement and vision could make it really hard for him to show you what he knows.

Rather than approaching Wyatt’s assessment with the worry that he’ll score low, the author of the resource encourages us to approach it as a “process of discovery.” You will use all of your tools – the test results, specific observations, conversation with the family, insights from other team members – to try to discover what Wyatt can do now and what comes next for him. Helping Wyatt be an active participant in his daily life is our goal, regardless of whether his skills are at the 4-7 or 19-month levels.

What strategies do you keep in mind when assessing an infant or toddler with multiple disabilities?

How do you share assessment info with families?

Add your comments below!

Want more information? Visit our VEIPD topic pages on Motor Delays & Disabilities, Multiple Disabilities, and Visual Disabilities.

The post Assessing Children with Multiple Disabilities – Tips and a Great Resource! appeared first on Early Intervention Strategies for Success.

Marco was recently referred to early intervention (EI) due to suspected global delays. His family is living in a homeless shelter and only has one more week left before they must leave. His father is trying hard to find employment but is challenged by his lack of childcare. He is the sole caregiver for three children under the age of four.

Nellie was discharged from the hospital three days ago following a very lengthy stay of 16 months. She is a preemie with many medical complications. Weight gain has been a challenge for her and will need to be closely monitored now that she is home. Her family is eager to get EI in place to assist with Nellie’s feeding skills and encourage her overall development.

For both Marco and Nellie, time is of the essence. Both families are newly referred to EI, and both would benefit from immediate support. But wait…the assessment calendar is full and it might take the whole 45 days allowed for the timeline to assess these children and develop their IFSPs. Can they wait that long??

The Interim IFSP

Both situations are examples of when writing an interim IFSP would be very appropriate. Interim IFSPs aren’t written very often. They can be viewed as sort of an emergency measure for eligible children who need supports and services to begin immediately. In Marco’s case, his family could benefit from service coordination to help them find housing immediately. A service coordinator may also be able to link Marco’s father locate child care options so that he is able to find employment. Because of Nellie’s extensive medical history and current feeding needs, initiating services for her is of utmost importance. Both families are in need of support, Both children are eligible for EI – Marco, based on his developmental delays and Nellie, based on her extended NICU stay, prematurity, and delays. Fortunately for them, you don’t have to wait until the assessment calendar is open to get the ball rolling.

Requirements for the Interim IFSP

An interim IFSP is a relatively simple document. Only four pieces of information are required: the name of the child, the name of the service coordinator, the service the child will receive, and the parent’s signature. The corresponding pages of the IFSP form can be used for the interim IFSP, with the words “Interim IFSP” written at the top of the first page. With the interim IFSP in place, services can begin immediately. It’s extremely important to remember that having an interim IFSP in place does NOT extend the 45-day timeline. A full IFSP must still be in place within 45 calendar days after the date of referral.

Using an Interim IFSP

Let’s check in on both situations to see how developing an interim IFSP helped:

Marco – Once Marco was found eligible, an interim IFSP was developed with Marco’s father to initiate more intensive service coordination to assist the family. The service coordinator completed other required documentation with Marco (such as procedural safeguards and release of information forms so she could speak with the social worker at the homeless shelter), and began the process of arranging the assessment for service planning and IFSP meeting. Marco’s father and the service coordinator worked together closely, talking almost everyday. The service coordinator helped obtain a one month extension with the homeless shelter. Within two weeks, though, Marco’s father had accessed several programs through his local Department of Social Services for rent assistance and a subsidy for child care so that he could look for employment.

Nellie – Following the intake, Nellie was found eligible for EI based on a review of her medical records. An interim IFSP was written and physical therapy began three days later. The physical therapist was able to assist Nellie’s parents and her nurse in determining positioning options for safe feeding. A speech-language pathologist also began seeing Nellie and worked closely with her family and nurse to monitor her caloric intake and begin working on oral motor exercises to help Nellie learn oral feeding. Nellie’s assessment for service planning was held about a month later and a full IFSP was developed. The PT and SLP continued to support Nellie’s family, and were happy to report at the assessment that Nellie was gaining weight and holding her head in midline better during feeding times.

The interim IFSP allowed both families to receive immediate support that helped to stabilize their challenging situations. While this type of IFSP is not used very often, it can be an important tool that allows eligible children and their families to receive the support they need right away.

Have you written an interim IFSP before? How did you know that it was the right thing to do? 

Share you experiences using an interim IFSP in the chat below. Be sure to protect family confidentiality if you share a specific experience. 🙂

The post Writing an Interim IFSP appeared first on Early Intervention Strategies for Success.

Have you ever taken a yoga or dance class? If you haven’t, let me tell you about my experiences. In either class, I’ve always found myself in a big room in front of wall-sized mirrors facing an instructor. While soft music played, the teacher would call out the names of poses I was supposed to imitate. I’d try my hardest to get my body to cooperate, and found myself struggling with new poses that I’d never done before. I’d do my best to copy the instructor or even the person next to me (while praying I kept my balance). As far as I could tell, I was doing pretty well. It was only when the teacher came over and gently helped me hold my arm in the right position or reminded me to straighten my back that I really knew where I was in space and whether I was doing the pose correctly. With feedback on my performance, I was able to improve on what I was doing. Without feedback, I might have never figured out how to really do a grand plié because watching someone else only went so far. I needed to try the pose out myself, experience it, adapt it to what my muscles could do, and receive feedback from someone who knew about it. That feedback was an integral part of my learning. (Could I do a grand plié now without falling over…well, that’s another story… 🙂 )

Adult Learning Principle #5 – Feedback is How We Grow

Just like with ballet or yoga, adults who are learning something new need feedback on their learning and performance. Feedback is like a barometer we use to help us know whether or not we have understood something accurately or whether we are performing a new skill as intended. Without feedback, we only have our own perspective, which isn’t always accurate. While we may not always like the feedback we receive, we typically crave knowing if we are on the right track.

Feedback can come in different forms. It can be physical, as when a OT uses hand-over-hand guidance to help a father position a child for safe feeding. It is most often verbal, as when the SLP points out that the way the child care provider modeled the sign for “cow” beside the picture of the cow will really help the toddler understand what the sign means. Feedback might only come from the interventionist or from the caregiver, but is often more beneficial when it is a reciprocal, reflective process between both adults.

How Can We Use This Principle?

Ask for permission to provide feedback – As you talk with families about how EI works, encourage them to share their feedback and let them know that you will do the same. When you need to provide feedback, ask for permission first until you have developed a relationship where you can move into feedback easily.

Invite the parent’s feedback first – Ask the parent what she thinks about what she just did with her child – how it felt, what worked, what didn’t work, what she’d like to do next time – before you provide feedback. Inviting her to share first is probably more powerful because it facilitates her own reflection, which we know is so important for adult learning.

Be specific – Always use specific descriptors when sharing feedback. Rather than saying “you did a great job!,” specifically describe what went well and how you know it went well. If the parent’s use of an intervention strategy had a positive effect on the child, first ask the parent what she noticed about the child’s reaction. Then, you can share your observations as feedback; you might say something like “when you supported him at his hips, he was able to bear weight on his flat feet for longer this time.”

Be honest, positive and constructive – Feedback won’t always be an affirmation, but it can still be positive and helpful. Adult learners typically appreciate your honesty, and I think parents are really good at knowing when we aren’t being honest or when we’re uncomfortable. Be mindful of the verbal and body language you use and remember to convey your feedback in a way that supports the parent’s learning. Instead of “You didn’t support his head correctly” you could say “Did you notice how his head feel back? Let’s try again but this time, see if you can pick up him with your hand under his neck to keep his head up.”

Consider Two Examples

During Lacey’s visit, she coaches Michelle in how to help Tommy learn to roll over. She models how to hold a toy just out of Tommy’s reach while moving it around past his ear. She also shows Michelle how to place her hand on Tommy’s hip to guide him in rolling over. She suggests that Michelle watch what Tommy’s body does and how he shifts his weight during rolling. When it’s Michelle’s turn, Lacey notices that Michelle moves the toy very quickly and helps Tommy roll so much that he really doesn’t have to work at all.

Example #1: Lacey tells Michelle, “You really need to move the toy slower and let him help you with rolling. Let me show you again.” Lacey models again hoping Michelle will see how to do it this time. Michelle feels like Lacey thinks she isn’t listening or watching but she is.

Example #2: Before providing feedback, Lacey wants to see what Michelle thinks so she asks “How did you think that went?” Michelle responds that she thinks she did everything a little too fast because Tommy didn’t roll on his own at all. She wants to try again but isn’t sure how slow to go. Lacey said that she noticed the same thing. Michelle tries again and says that it’s too hard to move the toy and move Tommy’s hip at the same time. Lacey asks her which one she’s like to learn to do first. Since Michelle wants to learn to move Tommy’s hip, Lacey offers to move the toy. They work together, going slowly, until Michelle gets the hang of how to help Tommy move. Once she’s got it, she tries to move the toy too and gets excited when he rolls onto his belly for her.

When you use coaching, action/practice, reflection, and feedback are all often intertwined. When you share feedback, it’s often a means of sharing your expertise and facilitating reflection while wrapping it around the current practice activity. On your next visit, pay attention to how you share feedback and how the caregiver receives it. Also, reflect on how you receive the caregiver’s feedback – are you open to feedback about the strategies you suggest? Remember that feedback helps all of us grow so how you share it – and how you receive it – really matter!

As you can see in Example #2, Lacey welcomed Michelle’s feedback and made it safe for her to share her perspective. Lacey also responded to Michelle’s feedback by making it “okay” that she learn each step separately. Lacey didn’t have to share much direct feedback in this example because Michelle’s reflection did that for her.

Had Michelle not noticed that she was going too fast, what could Lacey do? How could she have shared feedback in a positive, constructive manner?

Don’t miss the rest of the posts in this series:

Adult Learning Principle #1: Making Intervention Immediately Relevant

Adult Learning Principle #2: Linking New Learning to Prior Knowledge

Adult Learning Principle #3: Active Practice and Participation are Key!

Adult Learning Principle #4: Practicing Intervention Strategies in Real-Time

The post Adult Learning Principle #5 – Feedback is How We Grow appeared first on Early Intervention Strategies for Success.

If you haven’t read it yet, be sure to check out the first blog post in this 2-part series, Milestone or Modern Convenience?  – Part I: Overuse of the Sippy Cup and Pacifier, to learn important information about an infant’s need for sucking and the risks involved with overuse of the pacifier and sippy, cup!

Now that you are familiar with the pluses and minuses of pacifier and sippy cup use,  what about when the parents are ready to help baby “give up” the sucking habit?   Again, as the resource for all things infant and toddler, we can suggest the following tried and true strategies.

Strategies for Breaking the Sucking Habit

Cut back – When ready to begin weaning, cut back on the time that the pacifier and/or sippy cup is available to the child. If the pacifier has been available to the child all day, every day suggest cutting back its availability to only nap and bedtime.  As for the sippy cup, cut back its use to only when the family is out and about.  When at home suggest offering the child a straw or open cup in its place.

Go cold turkey…if the child is ready – If going cold turkey is the method of choice pass along this wisdom: if the child is not ready, he may find something else to suck on, like a thumb or fingers.  However, if ready, this method may work just fine.  Suggest that, if going cold turkey, it is a good idea to rid the house (or at least baby’s line of sight) of all pacifiers and/or sippy cups.  If they remain in the cabinet or drawer, baby will know and will want them!

Provide additional comfort – In preparation of weaning a baby from the pacifier and/or sippy cup, provide him with an additional comfort item. If the child’s only “lovey” is the pacifier or sippy cup, having a back up “lovey” will still allow the child a comfort when his first choice is gone.

Understand that routines may change – Warn your families that routines may change when weaning baby from the pacifier and/or sippy cup, especially if it is used as the child’s primary comfort item. When the pacifier/sippy cup is gone, the child may need assistance with calming, temporarily;  swaddling, rocking, singing and some extra cuddles may be necessary until baby learns how to calm himself without the help of his pacifier or sippy cup.

Give the pacifier or sippy away to a new baby – Sometimes parents can convince the child to give up these items with some incentive.  However, it is suggested that the new baby receiving the child’s old pacifiers/sippy cups not live in the same house.  It will be more difficult for the child not to suck on a pacifier if there is one nearby.  Some parents are also able to negotiate a trade with their child:  “If you leave your pacifier under the Christmas tree, Santa will take it with him and leave you a present!”  If the child is ready, this trick is a gem!

Strategies for Parents to Avoid

Some tips to warn parents to not try are:

Never, ever cut the pacifier nipple and give it to the child – Yes, if there is no nipple for the child to latch onto they will be less interested in sucking the pacifier.  However, the risk of choking is too great to ever recommend this as a means of pacifier weaning.  Pacifiers have to pass what is called a “pull test” (PDF, New Window) during manufacturing. A cut nipple would not pass this pull test and would be deemed as unsafe for a child to have.

Do not shame the child for wanting to suck on his pacifier or sippy cup – Toddlers and preschoolers typically do not respond to being shamed into giving up the pacifier or sippy cup.  Telling the child that in order to be a “big kid” he must give up his most prized possession may just make him want it more.  And who can blame him, who really wants to “grow up” anyway?!

Do not recommend putting something that tastes bad on the nipple of the pacifier and/or sippy cup – I have known families to dip the nipple in chili powder to convince their toddler to stop sucking on his pacifier.  One sweet little guy I knew still wanted his pacifier so badly that he licked the chili powder off, little by little, chased it with water and eventually got his paci back.  Again, this is a case of the parent wanting the child to make the decision to give up the comfort item.  Not gonna happen!  Sometimes the parent has to be just that and take control.

So we wish you good luck as you head into the magical world of the paci and sippy cup.  It holds a strong spell on many little ones, but with the right guidance and when our families are ready, we can help them help their children kick the habit!

Do you have any suggested weaning methods to add to this list? 

What would you say to encourage your families to follow through with weaning their child?

Lacy Morise, M.S. CCC/SLP educates families on the risks involved with over-use of the pacifier and sippy as an early intervention speech-language pathologist in the West Virginia Birth to Three Program.  She guiltily confesses to allowing all of her children to abuse the use of the pacifier!  She owns Milestones & Miracles, LLC a company devoted to educating families about child development and the importance of PLAY!  Check out her website and blog and follow her on Facebook, Pinterest, Twitter and YouTube.

Website:  www.milestonesandmiracles.com

Blog:  www.milestonesandmiraces.com/blog/

Facebook: https://www.facebook.com/milestonesandmiracles

Pinterest: https://www.pinterest.com/milestonesm/

Twitter: https://twitter.com/MilestonesM

YouTube: https://www.youtube.com/watch?v=HmuWPFDcqZ4

The post Milestone or Modern Convenience? – Part II: What to Do When the Convenience Becomes a Hard to Break Habit appeared first on Early Intervention Strategies for Success.

Although shocking to many, the sippy cup is NOT a developmental milestone.  Nor is sucking on a pacifier, for that matter.  But why do we (therapists, parents and caregivers) celebrate these acquired “skills” as developmentally appropriate achievements?  Why do we allow these “skills” to happen for much longer than they should?  Is it just easier to always have a pacifier (aka mute button) in the baby/toddler’s mouth?  Sippy cups are so easy to take along with us everywhere, how can it be harmful if a preschooler continues to exclusively drink from one?

Benefits of the Pacifier and Sippy Cup

The pacifier is a great thing for infants. It meets a physiological need to suck and allows baby a way to comfort himself. It may reduce the risk of SIDS as it appears to allow baby’s airway to remain more open and prevent baby from falling into a deeper sleep. Not to mention the other fringe benefits like quieting rowdy babes, helping them sleep longer and making outings and car rides more enjoyable for all.  It certainly has a “place” in an infant’s world!  And the sippy cup is an awesome convenience must-have.  Drinks can be toted everywhere with baby/toddler and a sippy’s use means less spills to stain the carpet!  Beautiful!

Risks of Over-Use

But aside from these benefits, there are risks associated with the over-use of both.  Pediatricians and family physicians recommend weaning or stopping pacifier use in the second six months of life.  Shocking I know considering how many toddlers we see with pacifiers in their mouths!  The sippy cup can be skipped all together if natural development is occurring with no issue.  Created for convenience, the sippy cup now has an entire market (and aisle in most stores) devoted to it!  However a baby can transition to a straw (as early as 9 months) or open cup just as easily and drinking from both of these IS developmentally appropriate.

Key Points to Keep in Mind

As trusted resources on development, it is our job as early interventionists to inform families of both the positives and negatives of (prolonged) sucking.  Some points to keep in mind as you discuss these “milestones” with parents and caregivers:

Prolonged sucking on a pacifier puts children at (a higher) risk for misaligned teeth. As those tiny white pearls are erupting, the pressure of the nipple of the pacifier can cause teeth to move around and shift. Also, the pressure can cause their hard palate, the roof of their mouth directly behind the front teeth, to change. It can push the palate forward, again changing the position of the teeth. In his research, J. Poyak concludes, “The greater the longevity and duration of pacifier use, the greater the potential for harmful results.”

A sippy often allows access to drinks all day long for a toddler.  Not necessarily a bad thing, depending on what is in the sippy.  If it is a sugary drink, the sugar increases the risk of developing cavities.  The Medline Plus article titled, “Tooth decay – early childhood” states, “When children sleep or walk around with a bottle or sippy cup in their mouth, sugar coats their teeth for longer periods of time, causing teeth to decay more quickly.” Also, if a sippy is the only way a child gets liquids the developmentally appropriate skills of drinking through a straw and open cup are inhibited.

If children are allowed to have a drink (in a sippy or other cup) all the time, they may fill up on liquids and not eat meals as well, negatively impacting their nutrition.

Although inconsistent, research suggests a relationship between prolonged sucking and speech delays.  Barbosa et al. (2009) concluded in their research of 128 Patagonian preschoolers that, “The results suggest extended use of sucking outside of breastfeeding may have detrimental effects on speech development in young children.” When speech sound development is negatively impacted, so is the child’s intelligibility of speech making it difficult for others to understand them.

Sucking on a pacifier increases a child’s risk of developing otitis media (ear infection).  The AAP (American Academy of Pediatrics) and AAFP (American Academy of Family Physicians) advocate for limited to no use of the pacifier in the second six months of the child’s life to decrease this risk.

A pacifier or sippy cup that is always in the mouth of a child, even when the child is walking around, puts him/her at a higher risk for mouth injuries.  A 2012 study by Dr. Sarah Keim of Nationwide Children’s Hospital in Columbus, found that “a young child is rushed to a hospital every four hours in the U.S. due to an injury from a bottle, sippy cup or pacifier.”  When little ones are just learning to walk, doing two things at once requires a bit more coordination than they are capable of!

Besides the physical risks, beyond the age of 1 a stronger emotional attachment to the pacifier (or sippy cup) makes it increasingly difficult for the child to detach. The pacifier/sippy goes from meeting a physiological need during infancy to providing emotional comfort to the toddler when scared, upset or sleepy.

However, it is our job to know and respect the individuality of each child.  Therefore it is best practice to reassure parents that we recognize they know their child best.  We all want our children to be happy and if using a pacifier and/or sippy is what’s best for them and their family, that is okay.  Our job is to inform the families we serve the best we can.  Equipping them with knowledge on why prolonged sucking may be detrimental to their child allows the family to make the final call.  Education and Support, that’s what we are there for.

Have you ever had the “prolonged sucking” discussion with any of the families you serve? 

How might you begin this conversation with a family?

Today’s blog is Part I of a two-part series on prolonged sucking and what we can do to educate families about it.  Stay tuned for “Part II – What to do When the Convenience Becomes a Hard to Break Habit” next week featuring ideas you can share with families who are ready to wean their child off of the pacifier or sippy!

References

Barbosa, Clarita, Sandra Vasquez, Mary Parada, Juan Carlos Velez Gonzalez, Chanaye Jackson, N David Yanez, Bizu Gelaye, and Annette Fitzpatrick. “The Relationship of Bottle Feeding and Other Sucking Behaviors with Speech Disorder in Patagonian Preschoolers.” BMC Pediatrics. N.p., n.d. Web. 20 Mar. 2015. http://www.biomedcentral.com/1471-2431/9/66

EG, Gois, HC Rubeiro-Junior, MP Vale, SM Paiva, JM Serra-Negra, ML Ramos-Jorge, and IA Pordeus. “Influence of Nonnutritive Sucking Habits, Breathing Pattern and Adenoid Size on the Development of Malocclusion.” Angle Orthod.4 (2008): 647-54. Print. http://www.ncbi.nlm.nih.gov/pubmed/18302463

Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents (n.d.): n. pag. Web. 18 Mar. 2015. http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf (PDF, New Window)

Hauck, Fern R., MD, MS, Olanrewaju O. Omojokun, MD, and Mir S. Siadaty, MD, MS. “Do Pacifiers Reduce the Risk of Sudden Infant Death Syndrome? A Meta-analysis.” PEDIATRICS5 (2005): E716-723. Do Pacifiers Reduce the Risk of Sudden Infant Death Syndrome? A Meta-analysis. PEDIATRICS. Web. 17 Mar. 2015.  http://pediatrics.aappublications.org/content/116/5/e716

Keim, Sarah A., MA, MS, Erica N. Fletcher, MPH, Megan R.W. Tepoel, MS, and Lara B. McKenzie, PhD, MA. “Injuries Associated With Bottles, Pacifiers, and Sippy Cups in the United States, 1991-2010.” N.p., n.d. Web. 19 Mar. 2015. http://pediatrics.aappublications.org/content/129/6/1104.long

Natale, Ruby, PhD, PsyD. “Risks and Benefits of Pacifiers.” American Family Physician79 (2009): 681-85. – American Family Physician. Web. 18 Mar. 2015. http://www.aafp.org/afp/2009/0415/p681.html

Poyak, J. “Effects of Pacifiers on Early Oral Development.” Int J Orthod Milwaukee4 (2006): 13-6. Print. http://www.ncbi.nlm.nih.gov/pubmed/17256438

Regulatory Summary for Pacifier (n.d.): n. pag. U.S. Consumer Product Safety Commission. Web. 18 Mar. 2015. http://www.cpsc.gov//PageFiles/120645/regsumpacifier.pdf (PDF, New Window)

“Tooth Decay – Early Childhood: MedlinePlus Medical Encyclopedia.” S National Library of Medicine. U.S. National Library of Medicine, n.d. Web. 17 Mar. 2015. http://www.nlm.nih.gov/medlineplus/ency/article/002061.htm

Zardetto, CG, CR Rodrigues, and FM Stefani. “Effects of Different Pacifiers on the Primary Dentition and Oral Myofunction Structures of Preschool Children.” Pediatric Dentistry6 (2002): 552-60. Print. http://www.ncbi.nlm.nih.gov/pubmed/12528948

Lacy Morise, M.S. CCC/SLP educates families on the risks involved with over-use of the pacifier and sippy as an early intervention speech-language pathologist in the West Virginia Birth to Three Program.  She guiltily confesses to allowing all of her children to abuse the use of the pacifier!  She owns Milestones & Miracles, LLC a company devoted to educating families about child development and the importance of PLAY!  Check out her website and blog and follow her on Facebook, Pinterest, Twitter and YouTube.

Website:  www.milestonesandmiracles.com

Blog:  www.milestonesandmiraces.com/blog/

Facebook: https://www.facebook.com/milestonesandmiracles

Pinterest: https://www.pinterest.com/milestonesm/

Twitter: https://twitter.com/MilestonesM

YouTube: https://www.youtube.com/watch?v=HmuWPFDcqZ4

The post Milestone or Modern Convenience? – Part I: Overuse of the Sippy Cup & Pacifier appeared first on Early Intervention Strategies for Success.

It is hard to believe but it is almost May!  The final Talk of the two-part series, entitled “Ditch the Animal Sounds: Writing Appropriate Outcomes that Lead to Effective Implementation,” will be presented live on May 5^th!  In anticipation of the upcoming webinar, I am excited to share with you just a few of the key points that I will be presenting in the session

In my first two blog posts on articulation and addressing language development, I talked specifically about how important it is to remember that functional services should be based on the appropriate diagnoses of the young children with whom we work.  These kids DO need services—but when we are diagnosing appropriately and accurately, our services for infants and toddlers will typically be based on a diagnosis of a language disorder versus a speech sound disorder. With that in mind, we should, therefore, be providing services that focus on language development rather than on speech sound development…or better yet, we should be using best practices by coaching families to facilitate speech sound development within (rather than separate from) activities that target functional communication by and with the child!

Sounds easy enough to do, right?!

Outcomes – Focusing on What’s FUNCTIONAL

When we are working with a child who is really struggling to get his basic needs or wants met because he does not have the LANGUAGE, focusing specifically on and teaching a child to produce a bunch of animal sounds is really not a FUNCTIONAL choice.  So a child learns to ‘moo’ or ‘meow.’  Does that really help him get a drink of milk or call his mom when he needs her?!  Those sounds can be fun…and for most children, they really do grab their attention and make them smile…if not even eventually imitate.  But what about those children for whom language is a challenge?  When writing outcomes, animal sounds, environmental sounds, and silly sounds are just not functional.

…Think about this for just a minute…

Is the family’s goal for this child really to produce animal sounds or to imitate the sound of an airplane or a car engine?!

When we work with young children who are struggling with language development, we recognize that they need to be able to produce sounds in order to produce words.  Those sounds, however, need to be addressed within functional, natural contexts.  Addressing a child’s ability to obtain needs and wants by learning how to label desired objects or to make a verbal request…THESE are functional outcomes.  In order to request a drink, or to ask for more, or to label the boots that a little boy wants to wear to play in the snow, he needs to be able to produce an approximation of the words “milk”…and “more”…and “boots”.  While the outcome itself is not to produce the /m/ or the /b/ sounds specifically, the production of these sounds can and should certainly be EMBEDDED into the intervention itself.

What should these outcomes look like?  Need examples of functional outcomes for a toddler who presents with an expressive language delay or disorder?  How can or should we select target words to include within a child’s outcomes? Join me for the May 5^th Talk on Tuesday to answer these and other questions you may have about writing outcomes!

Intervention: What Does It Look Like?!

When I work with families, I always keep a few key considerations in mind…and these considerations—or TIPS—tend to form the foundation by which I coach the parents and the caregivers on ways that they can embed speech sound development into their everyday activities and routines.  Each of these tips is intended to help families embed speech sounds into play-based or routines-based, language rich activities while they are engaged with their children. By now, we are all aware of the fact that children need to be able to make sense of stimuli in order to learn from it.  In order for a child to process information, it needs to be presented within a normal, naturally occurring event or opportunity in his or her own environment.  Using flashcards to teach sounds or words, or creating superficial teaching opportunities like pushing a child to imitate sounds, is not going to work.  Infants and toddlers truly do NOT learn, and ultimately develop, speech or language through artificial methods.

Instead, their verbalizations—their LANGUAGE–should be based on models that we have provided within the natural routines and activities—these are the opportunities that will have meaning, and positively impact learning, for, a child. Young children will naturally imitate the speech sounds that are embedded within the language that they can, and want, and need to use within their everyday lives–even those who are struggling with their language.  They do NOT, however, tend to imitate sounds that do not have a place within naturally occurring, everyday activities and routines—and those are the opportunities in which we can encourage and coach families to embed sounds in language.

So…anyone want to know what these fancy tips are?  Again, be sure to tune in to the May 5^th Talk on Tuesday to learn more about how to work with families and coach caregivers to embed speech sound development into everyday routines and activities. 

Do you have some tried-and-true strategies that you use to embed speech sounds into natural learning opportunities with the families with whom you work? 

Share your ideas here!

If you missed either of Corey’s webinars, visit the Talks on Tuesdays 2015 recordings page on the VA Early Intervention Professional Development Center, or click below:

It’s Almost Never Apraxia: Understanding Appropriate Diagnoses of Speech in Early Intervention

Ditch the Animal Sounds: Writing Appropriate Outcomes that Lead to Effective Implementation

If you’d like to catch up on all of the posts in this series, visit:

What’s the Bottom Line Regarding Articulation in EI?!

Address the Language: The Speech Will Follow!

ICD-10 Codes and Insurance Reimbursement in EI: The Fun Stuff?!?

The post Ditch the Animal Sounds! – Who’s Ready for the Next Talks on Tuesday?! appeared first on Early Intervention Strategies for Success.

We definitely have challenges in getting specific-to-speech-related services paid for in early intervention (EI). And we should!  Targeting specific speech sounds in isolation before the age of three years does NOT make sense on a developmental level—and this is exactly why insurance companies tend to question the claims.  We know, however, that we need to address the needs of children who present with significant delays or disorders in language development, especially since we now understand that it is typically language that is the culprit when an infant or toddler is having difficulty communicating. We need to know, therefore, how to accurately bill for the child’s services as they relate to language.

The first order of business is to recognize that, in order to bill for services in the Commonwealth of Virginia, a service provider must submit a Current Procedural Terminology (CPT) code AND an International Classification of Diseases (ICD-9) code.  The CPT is an indication of “what you are doing with the child”. The ICD-9 is the condition or diagnosis of the child for whom you are providing services.

The Basics of the CPT Code!

When considering CPT codes that relate to speech and language in EI, the system is fairly straight forward!

• The code that can and should be used in conjunction with a comprehensive communication assessment is SLP 92523. This code specifically covers “evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language)”.
• The code that can and should be used in conjunction with intervention (i.e. treatment) that addresses the communication and language skills of our infants and toddlers is SLP 92507. This code specifically covers “language/communication (SLP)” treatment.

Not too complicated, right?!

What About the ICD-9 Code?!?!?!

Unfortunately, when considering ICD-9 codes (also known as “diagnosis codes”), things get a BIT trickier. There are a few considerations, however, that should help you navigate the murky waters.

Private insurance reimbursement under 18 months of age:

• Private insurance companies will pay for speech-language pathology services for children who have been diagnosed with hearing loss/impairment, cleft lip/palate, or feeding as it relates to a medical condition such as laryngeal malacia or neurological insult (i.e. bleed, encephalitis) that has affected the child’s suck/swallow/breathe coordination. These are all fairly straight forward as the private insurance companies recognize that these are conditions that can be medically justified.
• Private insurance companies will NOT typically pay for language or communication services for infants or toddlers because they do not consider a developmental delay to be medically necessary. The Apollo Managed Care – Criteria Review Committee, who has set these guidelines, considers services that address communication and language of infants and toddlers as “addressing typical development” and will instead refer families for developmental services provided by infant educators to offer language/communication “stimulation.”  Unfortunately, developmental services are not reimbursed by private insurance.

Medicaid reimbursement under 18 months of age:

Medicaid WILL pay for language-based and communication services for children under 18 months of age who have a diagnosed condition or who demonstrate a > 25% delay. If the infant or toddler is eligible for EI services, Medicaid will pay providers for the services!

And for those toddlers who are over 18 months of age?

While some private insurance companies will pay for SLPs to provide services to children with language/communication delays, they will still require medical justification to provide reimbursement.  According to Kelly Hill, the Chair of the Virginia Interagency Coordinating Council and a Pediatric Physical Therapist in Warrenton, VA, service providers should avoid using generic statements like “delayed milestones”. She suggests using a code associated with a child’s medical condition in combination with a 315 (expressive language-related) code whenever applicable.  Some examples include:

• 765.0 (prematurity) & 315.31 (expressive language disorder)
• 728.87 (muscle weakness) & 315.32 (mixed receptive-expressive language disorder)
• 758.0 (Down syndrome) & 315.31 (expressive language disorder)

The Glitches

There are always exceptions to the rule, and in the game of insurance and reimbursement, there are even exceptions to the exceptions!  For example, Medicaid, Carefirst, Blue Cross/Blue Shield (BC/BS), and UnitedHealthCare will reimburse for services submitted under the following diagnosis codes: 781.3, any 315 codes (developmental & expressive language disorders), 783.4 (lack of normal physiological development), 783.42 (delayed milestones), 317-319 codes (intellectual disability), or 784.61 (apraxia). Aetna and Anthem (the statewide subsidiary of BC/BS) will no longer cover services when these very same codes are submitted. These two companies WILL occasionally pay for SLP services, however, when presented with the 784.5 code (speech disorder –not otherwise specified).

Now What?!

According to Ms. Hill, adhering to the following suggestions will support your claims for services that facilitate communication and language with our EI families:

1. Document all diagnoses that the child has that are relevant to the services that you are providing! Include the Physician Authorization that also lists the diagnoses when submitting for reimbursement of services.
2. Be sure that any progress notes support and substantiate the treatment code that is being used. SLP notes are often scrutinized by medical reviewers and tend to be flagged for not providing clear outcomes that are being addressed with services.
3. Be consistent in your documentation in regard to the progress that a child is making toward his/her outcomes! Insurance companies want to see that your services are making a difference for the child with whom you are working.

As professionals, we recognize that we need to address the needs of children who present with significant delays or disorders in language and communication.  We know that when we address the language development and difficulties that infants or toddlers present, the speech will follow. Now, we also have a little more knowledge about how to honestly and accurately bill for the child’s services as they relate to their language and communication skills.

What are some of the successes and challenges you’ve faced while managing reimbursement for speech therapy services?

Share your experiences and questions in the comments below!

If you missed either of Corey’s webinars, visit the Talks on Tuesdays 2015 recordings page on the VA Early Intervention Professional Development Center, or click below:

It’s Almost Never Apraxia: Understanding Appropriate Diagnoses of Speech in Early Intervention

Ditch the Animal Sounds: Writing Appropriate Outcomes that Lead to Effective Implementation

If you’d like to catch up on all of the posts in this series, visit:

What’s the Bottom Line Regarding Articulation in EI?!

Address the Language: The Speech Will Follow!

Ditch the Animal Sounds! – Who’s Ready for the Next Talks on Tuesday?!

The post ICD-10 Codes and Insurance Reimbursement in EI: The Fun Stuff?!? appeared first on Early Intervention Strategies for Success.

Abby has significant motor delays. Her mother asks you some version of this question during every visit: “Is it my fault that Abby isn’t walking yet?” or “What did I do to cause this?” The question itself makes you uncomfortable, because you can’t really answer it well and because you feel like you’ve tried to answer it for the past several weeks. Each time Abby’s mother asks, you say that you don’t really know what is causing Abby’s delay but what’s important is that we keep supporting Abby’s development so that she can learn to move. You and Abby’s mother both recognize that this is the best one you’ve got…so why does she keep asking?

Emotional Questions Matter

It can be incredibly challenging to manage the emotions that pop up during EI visits – both with parents and within ourselves. When we see a parent struggling with guilt over her child’s developmental delay or disability, it can be difficult for us to know what to do or how to help. With a question like this about fault, it can be especially challenging because we really don’t have the answer. In most situations, the child will have a delay and we won’t know what caused it. It might be easy to think, well, it doesn’t really matter what caused it…what matters is what we do now. However, it probably matters ALOT to the parent.

When a parent asks a question like this, it’s important that we have an honest and appropriate answer. It’s also important to recognize (and say so) that sometimes we don’t have the answer but we can still acknowledge the emotions behind it. Abby’s mother is not hoping that her service provider will place the blame on her shoulders; instead, she may be hoping to share her anxiety and fear with someone she trusts. You may be the person she’s chosen to voice her fear to…what do you do then?

Answering this Tough Question

Here are a few things to consider when a parent asks you if it’s her fault:

Be honest and be kind

In most cases, the answer is that you really don’t know what caused the delay. Most likely, it wasn’t something the parent did, and you can say that too. If you DO think it was something that happened (or didn’t happen) in the child’s environment, like when a child has experienced neglect or there is a history of substance abuse, you can be gentle about this and redirect the focus of the conversation to what the parent is doing well now. I remember working with a parent who struggled to interact with her child during the day because she had so much else to do. Honestly, I felt that the lack of interaction had probably affected the child’s communication and interaction skills. Rather than answer “yes, not paying attention to him contributed to this delay” – which I would never say because how do I really know? – we talked about the changes she’d made since she found out that he needed more interaction and I praised her efforts. It was a tricky conversation because she did have a learning curve, but as she began to feel more like she was making a positive impact on her child’s development, the guilt she felt about the past seemed to lessen.

Acknowledge the parent’s feelings

I think it’s very appropriate to ask the parent to tell you more about how she’s feeling. You might invite it by saying something like “You’ve asked me that question several times on the last few visits. We can talk more about how you’re feeling about Abby’s development if you like.” You can open the door and see if she decides to share more. Inviting this discussion can also be tricky, though, because what comes through the door could be more than you can handle. Since most interventionists are not counselors, follow your instincts. If you suspect that the parent could benefit from more professional support, or maybe even another parent to talk to, offer to make that connection or see if the service coordinator can help. Sometimes, interventionists are afraid to have these conversations because they might distract from the “real” work of the visit. I would suggest to you that the real work might not be possible, or be unnecessarily challenging for the parent, if these feelings are left unacknowledged.

Acknowledge your own feelings & examine your own response

If a parent asks a question like this over and over, it could be because she is not getting an adequate answer. If you avoid answering, she may sense that and think you really do think it’s her fault. While we can’t be in control of how a parent interprets what we say, we can be mindful of the messages we send. Reflecting on your tone of voice, the words you choose, and your body language are important.

Follow your answer with encouragement

The question might really be a cry for hope and encouragement. A parent who asks this question may be very worried about the future. Follow your best answer by pointing out what the parent is doing well, how it’s a wonderful thing that she’s involved in early intervention, and that the child is making progress (if this is the case). Offer genuine reassurance and help the parent see that, regardless of why or what happened in the past, she has the opportunity now to make a big difference in her child’s life and you are there to help her do that.

There will be times when answering Abby’s mom’s question are easier than others. Just remember that this question is probably harder for the parent to ask than for you to answer. Answering it as best you can and following it with encouragement for what’s to come can be just what is needed.

How have you answered this question before?

What do you do when a parent expresses fear or anxiety over the child’s delay or disability?

Share your insights and suggestions below in chat.

The post Abby’s Mother Asks Again: “Is it my fault?” appeared first on Early Intervention Strategies for Success.