Early Intervention in Rural Natural

Environments: Maldng the Most of Your Time

Lee Ann Jung, Ph. D.
Kathcrine M. McCormick, Ph. D.
Kristine Jolivette, Ph. D.
University of Kentucky
Abstract
Early intcrvcnrionists m rural settings face many barriers as they seek to provide elective services in natural environments for infants and
toddlers with disabilities and their families. This paper describes a model for addressing these barriers. Three components are described: the
use of natural learning opportunities, consultative service delivery, and transdisciplinary teaming.

early intervention cannot be achieved satisfactorily for

the infant or toddler in a natural environment" [Sec.
303.12{c)].
For many programs that provided early
Though early intervention for children birth to
3 years was not added to legislation until 1986, intervention services prior to 1997, this new
programs For infants and toddlers with disabilities emphasis meant a major shift in service delivery.
have existed since the mid-1970s. Many programs Administrators of such programs faced the challenge
provided early intervention to qualifying infants of completely transforming their programs after the
and toddlers in centers or clinics exclusively for passage of IDEA 1997. Because of the semantics used
children with developmental delays and in the legislation, many people have focuseci primarily
disabilities. This center based model held clear on location, where the professional works with the
advantages for the provision of early intervention child (lung, in press). This shift in location posed a
in rural settings. Programs using this model simply unique set of challenges to those serving rural
invited families to bring their children to a center populations, both in terms of logistics as well as
or clinic to receive needed developmental services. finances.
The center based model allowed early intervention More than a Place
professionals to serve a large number of children
Changing the location of services to homes and
each day.
communities where children live is a challenge with
In response to lessons learned through research which early intervention service providers continue to
and practice in early intervention, the words "natural struggle. Some rural commimities are more than 3
environments'" were added to early intervention hours from the nearest early intervention program.
legislation in the 1991 amendments to the Unlike previous years when educators and therapists
Individuals with Disabilities Education Act (IDEA), could serve 15 or 20 children per day at a center,
P. L. 102 119. The Code of Federal Regulations service providers now oftentimes use an entire
defined natural environments in 1997 as "settings workday to provide services during one home visit.
that are natural or normal for the child's age peers At first glance this seems like a drastic reduction in
who have no disabilit)'" {Sec. 303.18). Much like the services, especially to children and families in rural
least restrictive environment provision for school- areas. However, if the other dimensions of the intent
aged children, states that receive federal funding for of natural environment legislation are considered,
early intervention are mandated to include policies children can in fact receive more intervention than
and procedures to ensure "to the maximum extent they would have received through a traditional,
appropriate, early intervention services are provided center-based program.
in natural environments" and "the provision of early
Merely moving the location of services from
intervention services for any infant or toddler occurs segregated to inclusive settings does not guarantee
in a setting other than a natural environment only if support to families (McWilliam & Strain, 1993). In

Early Intervention in Rural Natural

Environments: Making the Most of
Your Time

3D

Rural Sp<iol Cdwcolten Quortcriy

2004

fact, services that arc provided in a natural location

can still be delivered in an unnatural manner. For
example, a speech and language pathologist may
travel to an infant's home and work directly with that
infant as if in a clinic while the caregiver is in another
room. A physical therapist may travel to a childcare
center and pull a toddler to another room to provide
range of motion exercises. Although these locations
are natural, clearly this type of service delivery ignores
the purpose of the change in legislation (TurnbuU,
Blue-Banning, Turhiville, & Park, 1999). The
following parent quote provided by Turnbull ct al.
(1999) illustrates explicitly how certain models of
service delivery can transform the most natural
environment of a child's home into a completely
unnatural environment:

natural learning opportunities, consultative service

delivery, and transdisciplinary teaming.

Natural Learning Opportunities

Oftentimes, the most efficient route to more

intervention is not through interventionists' visits but
through intervention embedded in typical daily
routines and delivered by natural caregivers utilizing
natural learning opportunities. The use of natural
learning opportunities mediates many of the
challenges typically reported by administrators,
service providers, and families in rural settings. For
example., many administrators report a scarcity of
therapists willing or available to work in rural areas.
Also, many service providers complain that much of
their time in serving rural populations is spent in
travel. Because of this increase in travel time many
The message to me as a mother that nms
children are visited only once a week or every other
pervasive in early intervention's emphasis on
week. Many interventionists have concerns when a
developmental milestones was that we needed to 'fix' child's entire team cannot visit and provide
James. The harder I worked, the more he would
intervention even weekly. How could this possibly be
achieve. And achievement was the name of the
as good as trained teachers and therapists working
jjame. 'Developmental milestones'how I learned
with them every day.' However, intervention should
to hate those words. They were the ^old medals of
not be limited to several times per week. The logical
the '^fix it' set.
assumption is more visits by the early intervention
I readily became James' teaeher. His playtime
team members results in better outcomes for
at home beeame 'learninjj time'aetually all his
children. Is this necessarily true? Or could more
time was learning time. Any free time we had at
opportunities for learning which are embedded in
home was to be spent on his therapy or to be spent
natural routines by typical caregivers and family
feeling guilty that we weren't doin^ his therapy. I
members result in equal or better outcomes for
remember one developmental milestone he never
children.'
achievedstacking three blocks. He had finally
Natural learning opportunities occur throughout
achieved stacking two blocks; the next milestone was a child's day, whether learning is planned or
stackinjj three. I modeled for him, prompted him,
unplanned {Dunst, Bruder, Trivette, Raab, &
and finally held his hand while we did it together.
McLean, 2001). Picking vegetables in a garden, a
Inevitably, when left to attempt it on his own, James
walk in the woods, and washing dishes all provide
would pick up the blocks and throw them. He found
natural learning opportunities. These activities
this hysterically funny. His early intervention
provide many teachable moments throughout the day
teacher thoujjht he was noncompliant. James
(Cripe & Venn, 1997; Rule, Losardo, Dinnebeil,
obviously didn't ^et the fact that his tieket to
Kaiser, & Rowland, 1998). Parents intervene in their
acceptance rested heavily on stacking those blocks. children's development every day. They have
(p. 165)
infinitely more opportunities to enhance their child's
According to the literature, natural environment development than a professional who visits weekly or
means much more than location (Harbin et al., 1998, monthly. Families do many wondertlil things with
NECTAS, 2000). The broader intent was to move their children every day to teach them without ever
beyond teaching the child to supporting families being told to do so by an inter\ entionist. These daily
(McWilliam, 1995; McWilliam & Strain, 1993; interactions between families and children have a
NASDSE, 1999). "How [services] arc provided in much greater impact on child progress than do early
these natural environments is just as important as intervention sessions (Dunst, Bruder, Trivette, Raab,
where it is provided" (Hanft & Pilkington, 2000, p. & McLean, 2001; Hanft & Pilkington, 2000;
1). In this paper, we will describe a model for serving McWilliam, 2000). The use of natural learning
families and their young children by emphasizing opportunities embedded in daily routines can be
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31

easily promoted through consultative service delivery.

Consultative Service Delivery

Consultation is a triadic helping process in which
a child receives intervention from the caregiver, who
was advised by the service provider (File & Kontos,
1992). Through consultation, caregivers are given
strategies that allow them to maximize natural
learning opportunities or embed instruction into
their daily routines and activities. Consequently, the
child has opportunities for intervention all day, every
day and in contexts that are meaningful to the child
and family. For example, a child who is awake 12
hours per day may receive a direct intervention once
per week for one hour. If no efforts are made to share
strategies with the family during that hour, the child
has only one hour of opportuniU' for this particular
intervention each week. Furthermore, the one-hour
of opportunity is more than likely not embedded into
a natural routine. If instead that professional uses the
hour to provide strategies to the caregivers, the child
now has 84 hours of opportunity for intervention
each week (Refer to figure 1). Certainly no caregiver
should be consumed with thinking about providing
their child with intervention 84 hours each week.
That would be completely unnatural. However,
opportunity for learning can be increased using this
model. Even if the family only used suggested
strategies during 2 hours each week, intervention has
increased by 100 percent.
D I R E C T

S K R V I r

E S

The implications of this model for families in

rural environments are particularly exciting. Using
this model children who previously received monthly
direct therapy from a therapist may now receive daily
intervention from natural caregivers. By expanding
the definition of intervention to include what
happens when professionals are not around, families
can be empowered to take back their rightful role as
their child's first teacher.
Some professionals argue that teaching a family
strategies is not effective because parents were not
trained to learn how to provide intervention
(Bernheimer & Keogh, 1995). However, in the early
90s, the medical profession began to recognize the
abilities of families to care for their children and
began training parents on specific medical procedures
necessary for the survival of children with complex
health care needs. Parents mastered the ability to
suction tracheotomy tubes, feed their children via
gastrostomy tubes, and monitor for and respond to
bradychardias and apnea (Seitz & Provence, 1990).
These procedures are for the most part much more
complicated than the average intervention suggested
by a therapist or educator. The child's life depends on
the parent's ability to do these things correctly.
Families in rural areas are empowered to care for their
children's medical needs and may go for months at a
time without direction from medical personnel.
Certainly if parents can learn to care for tracheotomy
and gastrostomy tubes without ongoing supervision
they can learn developmental intervention strategies.

M O D K L

Transdiciplinary Teaming

C O N S U L T A T I V E

Deciding frequency of visits and which

professionals on the team will visit the family can be a
complicated issue. Traditionally, questions like "How
severe is the disability," "Will this parent follow
through," and "In which areas is the child delayed"
have guided how often the child is visited and by
whom. At first glance, the logical course may seem to
be providing more services more frequently to
children with delays in more areas or more severe
disabilities. However, since professionals should be
supporting the families' ability to function
independently, visiting too often can send the wrong
message. Professionals are giving themselves too
much credit (and not enough to caregivers) to say
they must see a child with their own eyes every week.
Furthermore, research has demonstrated that the
more frequently families are visited and the greater
number of professionals on the team, the less families

M O D E L

Figure 1. Weekly Intervention Opportunities

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Table 1

Questions to decide who visits and how often

Old Questions
1. How severe is the child's delay or disability?
2. Will this family follow through?
3. In what areas does this child have a delay?

feel supported, and child outcomes are diminished

(Dunst, 1999). Transdisciplinary intervention is a
flexible, holistic and dynamic approach in which team
members teach and learn from one another to
provide integrated intervention suggestions for
parents and carcgivers (Linder, 1993).
Finding a balance between enough but not too
much may be difficult for professionals, especially
when the financial constraint of traveling to serve
rural families is added. Three questions found in
Table 1 can help guide professionals in determining
frequency and team configuration for home visits: 1)
How often will strategics likely need to be changed,
2) How much support do the caregivers want or need
to feel comfortable with the suggested strategies, and
3) What type of support is needed?

How often will strategies need to be

changed?
B\' asking how often the strategies will wtcd to be
changed, professionals will most likely arrive at a
different fi-equency than if they had simply prescribed
more visits for those with more severe disabilit}'. A
child with more severe disabilities may require
intervention that will not need to be changed for
months at a time. For example, a child with multiple,
severe disabilities may need positioning and
movement strategies designed by a physical therapist.
These strategies will need modifications infrequently,
certainly not weekly and quite possibly not even
monthly. Visiting the child each week to assess the
carcgivers' ability to continue with a positioning
strategy' is not only unnecessary, but could also be
intrusive in their lives and insulting of their ability. A
physical therapist attending a recent training
remarked, "I go every week because the family wants
me to come, but each time I pretty much say, 'good
job; keep it up.'" Instead, a single member of the

New Questions
1. How often will the child's intervention likely need
to be changed?
2. How often do I need to go to support the family's
comfort in using intervention strategies?
3. Do the outcomes related to family concerns require
support from a specialist?
4. Can multiple outcomes be supported by a single
person such as a special educator?
team could visit the family every week to ensure the
family receives all supports they need. The other team
members, including the physical therapist, could visit
the family with the primary support person less
frequently. Not only is this configuration more
consistent with recommended practice, but can also
alleviate a great deal of financial burden on a program
attempting to provide multiple, frequent services in
rural settings.

What level of support does the family need?

Instead of assuming that some caregivers will not
follow thrt)ugh with strategics, professionals should
consider what supports a caregiver will need in order
to follow through. A family who has a child with
cerebral palsy, for example, may be afraid of hurting
the child as they position and stretch her. This family
may need more frequent visits for a couple of weeks
until they are comfortable with what they are doing.
In fact, research suggests that frequent visiting
can be counterproductive (Dunst, 1999). Frequent
visits may lead to exactly what professionals are trying
to guard againstlack of follow through. Visiting
too frequently can actually be damaging to
caregivers' feeling of support, and damaging to child
outcomes (Dunst, 1999). Very frequent visiting may
also imply that the caregivers are not perceived by
professionals as competent in enhancing their child's
development. If interventionists focus on direct
teaching activities or therapy during the visit,
caregivers may infer that instruction time, divorced
from their normal daily routine, is necessary for the
child to learn. Too frequent visiting may lead families
or childcarc providers to believe that only early
intervention professionals can make change in the
development of children with delays or disabilities,
which may lead to what many professionals describe
as lack of follow through on the caregiver's part. If
Rural Spcdol education Quartarfy

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33

caregivers believe they have no power to increase

development in their child, why would they follow
through? IF they feel interventionists have the power
to change their child's development,, of course they
are gong to want them to provide direct services as
frequently as possible.

What type of support is needed?

In a center-based model, programs had the
luxury of providing a service for every delay for each
child. For example, if a child had a delay in gross
motor development, the child received service from a
physical therapist. If a child had a communication
delay, the child received service from a speech and
language pathologist. Natural environments
legislation makes this type of service delivery difficult.,
especially for families in rural areas. Furthermore,
although this process of decision making may seem
logical, there are implications for this type of
decision-making. If each team member claims
exclusive ownership of his or her developmental
domain, a resulting team and service delivery
configuration may be three professionals visiting a
family weekly. If our goal is to help children with
delays and disabilities fluiction more normally, this
hardly seems to be the answer. One family of a child
with multiple severe disabilities recently remarked, "I
felt like a secretary. My life was consumed with [my
child's] appointments. ... I finally had to put an end
to it. It was scary, but I just had to decide which of
these specialists I needed to keep and the rest had to
go. If I hadn't., I would have had a disabled child and
a nervous breakdown."
Deciding who are the appropriate team members
to visit is oftentimes a difficult process for teams. In
deciding who will visit the family, one starting point
can be to discuss whether the type of support needed
for any given family defined outcome would best be
provided by a specialist (e.g., speech therapist) or a
generalist (e.g., special educator). A person who is an
early childhood special educator is qualified to design
intervention addressing developmental delay in all
five areas of development. However, intervention or
therapy designed by a specialist is necessary when
delays in areas such as communication, motor

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development, or feeding appear to be caused by a

disorder, or if development in these areas is not
following the t>'pical trajectory of child development.
For example, an early childhood special educator
and a speech and language pathologist may evaluate a
child with a communication delay and agree that the
child's delay does not appear to involve a disorder and
would best be addressed by providing the caregivers
with additional strategies to enhance communication.
The team has several options: both service providers
may visit the child, the speech language pathologist
may visit the child, or the early childhood special
educator may visit the child. Either service provider
can address this t\'pe of delay, so there is no need for
both to visit. One person can then provide support
and build a relationship with the family.
Had the child's communication delay been
suspected by team members to be due to a disorder,
the speech and language pathologist would need to
have designed intervention for outcomes related to
that area. If the child had no other delays, only the
speech and language pathologist would need to
provide services. A similar approach may be used for a
child with multiple and severe disabilities to avoid
multiple visits each week and to maximize infrequent
visits. One example of a team configuration might
include monthly or bi-monthly visits by therapists
and weekly visits by a special educator. Though the
special educator would not be qualified to develop
therapy for a child, the special educator can address
with the family the child's progress and family's
comfort with strategies to determine if the family
needs a visit from any of the therapists sooner than
planned.

Conclusion
Many challenges are presented to early
intervention programs serving rural populations. At
first glance, a need to reduce numbers of visits tt) rural
families may appear to be a serious disadvantage
imposed by natural environments legislation.
However, by asking a few simple questions to guide
decision making, teams can not only maximize their
time but also improve outcomes for families and
children.

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