A large portion of infants and toddlers in foster care have been abused and/or neglected. According to Washington, DC-based Zero to Three, a nonprofit organization dedicated to bettering the lives of infants and toddlers, about 80 percent of babies in foster care have had prenatal drug exposure, and about 40 percent were born prematurely or underweight. Both these conditions are associated with developmental problems.

Furthermore, infants are the largest group entering foster care, and typically stay in foster care longer than foster children of other ages. The predominance of abuse and neglect, as well as complications related to frequent changes in caregivers, create serious challenges for infants and toddlers in foster care and the therapists who treat them in early intervention (EI).

EI is a program delineated in Part C of the Individuals with Disabilities Education Improvement Act (IDEA) to treat children under 3 years of age who have or are at risk for developmental delays. It is important to treat children early because the brain experiences vast growth during the early years. Without intervention, these infants and toddlers are vulnerable to long-term damage.

Essential components of EI include working in a child’s natural environments, embedding therapy into the child’s daily routines, using family-centered care, and treating the child with a team of professionals appropriate for the child’s needs−involving physical therapists (PTs), occupational therapists (OTs), speech-language pathologists (SLPs), and nutritionists, among others.

Natural Environment

EI providers are required to treat children in their natural environments, or where they perform their daily activities. This policy ensures that the infants and toddlers learn to use skills where they need them the most and where their caregivers can facilitate their learning. Stephanie Bruno, MS, CCC-SLP, who works in Delaware County, Pa., says, “You can use the child’s toys, books, etc. to demonstrate to the family how they can play appropriately with their own resources and how to stimulate speech and language using what they have.”
There are challenges, however, when working in the natural environment. “Some homes can be chaotic, dirty, and even dangerous,” explains Lesley Siemens, BS, RN, an early interventionist at St. Petersburg, Fla.-based Therapy Playhouse. A family’s economic situation can also pose problems for the therapist. “Some families have very few toys, books, etc. due to their financial situation and therefore resources are limited,” says Bruno.

Daily Routines

Regardless of the physical resources in the child’s house, the therapist treats the child by integrating therapeutic techniques into daily routines. Play is a daily routine that offers many opportunities for the child to mature developmentally. Robin McIntyre, PT, MS, CEIS, at the Hyannis, Mass.-based Cape Cod & Islands Early Childhood Intervention Program, explains this idea as “play with a purpose.”

When working with infants and toddlers in foster care, it is important to establish routines that can transfer to a new home in the case of a placement change. Juliann Woods, PhD, CCC-SLP, professor and chair of the Department of Communication Science and Disorders at Florida State University, explains, “Try to make [the routines] as simple but yet as effective as possible so that caregivers, as they change, can pick up that routine, and the child doesn’t have to start all over.” By working with the same routines from one home to another, the foster child has some continuity and is less at risk for regression.

Family-centered

Because EI is family-centered, the child’s family plays a central role in his or her treatment. William Frea, PhD, BCBA-D, co-founder and chief clinical officer of Culver City, Ca.-based Autism Spectrum Therapies, says, “EI is not something that someone comes into the home and does. EI is most effective when the therapist works with the caregivers to ensure that teaching strategies are embedded throughout all of their natural routines.” Caregivers provide essential information for the therapists, including the child’s motivations and specific struggles.

Beth Ennis, PT, EdD, PCS, ATP, co-owner of Louisville, Ky.-based All About Families, PLLC and assistant professor at Bellarmine University, explains this interaction as “a partnership: we have a good knowledge base of development and where the child should be, and [the parent is] the expert on the child.” Depending on the length of the relationship between the caregiver and foster child, however, the caregiver may not have a complete understanding of the child.

The therapist must remain sensitive to the individual needs and beliefs of the family. Sandra Schefkind, MS, OTR/L, pediatric coordinator of the American Occupational Therapy Association (AOTA), explains, “When a therapist provides service in the home, the therapist must respect the unique preferences and priorities of the family and recognize the cultural influences upon their habits and routines.”

Cultural differences between the treatment team and the family require cultural competence. “In our culture, there is a rich diversity of families in terms of values, beliefs, and languages,” says Diane Paul, PhD, CCC-SLP, director of Clinical Issues in Speech-Language Pathology for the American Speech-Language-Hearing Association (ASHA). “Sometimes responding to a particular family’s preferences and priorities requires a clinician to set aside his/her own value or belief system, and, of course, this may be quite challenging.”

While the therapist learns the child’s daily routines from the family, the family learns techniques to improve the child’s development from the therapist. “A primary goal of EI is to teach caregivers how to embed goals within typical activities and family routines,” says Paul. Caregiver education and support may be particularly important in a foster home.

“It is important to provide extra training, support, and guidance for foster parents who care for infants, toddlers, and very young children,” says Kimberly Diamond-Berry, PhD, assistant director of Zero to Three’s Court Teams for Maltreated Infants and Toddlers. “Foster parents often need assistance and training with caring for a child with special needs, a developmentally delayed child, or a child exposed to chronic trauma−for example, abuse, neglect, and substance abuse.”

Diamond-Berry’s court team communities support foster children’s biological parents in finding the resources−such as substance abuse treatment and mental health treatment−they need to become effective caregivers.

In addition to providing health services to biological parents, early interventionists may need to communicate the child’s progress to the biological parents. If the family wants to reunite, the biological parents need to learn the daily routines and methods of encouraging the child’s growth. Paul explains, “In many instances, social service agencies use early intervention service providers to develop training opportunities for the biological families who are unable to visit their children, such as incarcerated parents.”

Transitions 

Although transitions are challenging at any point in life, they can be dangerous for young children’s development. “There’s a small window in those early months and years, during the zero to three timeframe, where permanency is really important for the infants and toddlers,” says Diamond-Berry.  Otherwise, the child may struggle through transitions to different homes, caregivers, cultures, and early interventionists, precluding a strong relationship with an adult.


One way to ease transitions is to communicate often with both the previous and new caregivers so the new caregivers can learn about the child’s daily routines and successful therapeutic techniques. Planned foster care changes facilitate the transition process because there is time for a gradual shift to a new setting and family. Abrupt changes, on the other hand, can negatively affect the child. Experts report that unstable environments may make children distrust and fear others, and even regress in their expressive language skills.

Abuse and Neglect

Unstable environments include shifting caregivers as well as abuse and neglect, which many foster children have experienced. Treating infants and toddlers who have been abused and/or neglected poses challenges for the therapist and family. “Sometimes it is very difficult to address speech and language needs because their basic needs are not being met,” explains Bruno. “Therefore I spend time during the session addressing basic needs so that they are able to focus and function within their environment.”

Experts suggest that this population may require a slower-paced treatment plan than that for other children. “You work with [abused and neglected children] slowly and carefully, and build that trust relationship,” Ennis explains. “Then you can move on to other activities that may be a little more active and that might have initially scared the child.”     

Team Approach

Once a child is evaluated for EI, a team of therapists forms to meet the child’s needs. Traditionally, each therapist visits with the child separately to treat each specific need. Recently, however, some states have begun using a transdisciplinary model, in which a primary provider, with the support of the therapist team, treats the child’s main need.  Experts suggest that this model may enhance the team approach in EI. “The idea is to drop down the barriers between disciplines and incorporate services to the child in a holistic way,” says McIntyre.

The primary provider model encourages not only the therapists to work as a team, but also the family to work collaboratively with the primary provider. “Families have to be a part of [the primary provider] model, whereas there’s a tendency in our traditional model of therapy that the families almost become dependent on the therapists,” explains Ennis.

Resources

Despite the different needs of abused and/or neglected children, there is a lack of training for providing EI specifically for this population. “I think there’s a huge need for us to pay more attention to kids who have had abuse or neglect or are in foster care. I think we really need to learn more about them,” says Woods.

In fact, learning about patients is required of therapists. “It’s their obligation, their practice, and ethical obligation to continuously update their knowledge and skills and to meet the needs of their work situation,” says Schefkind. Resources that are offered to early interventionists include guidelines from organizations such as ASHA, AOTA, and the American Physical Therapy Association (APTA), and various conventions. 

When working with a team of therapists and families and focusing on daily routines in the natural environment, EI can be successful. However, it is important to recognize the specific challenges that children in foster care present, including a high prevalence of abuse and neglect and multiple changes in placement. As EI policies and practices develop, the needs of foster children with developmental delays may come to the forefront, which would provide more resources and more communication about how to best treat this population.

– Sabrina Rodak is the editorial intern at Therapy Times. Direct questions and comments to editorial@therapytimes.com.