Individuals with Disabilities Education Act
Education Should Provide Additional Guidance to Help States Smoothly Transition Children to Preschool Gao ID: GAO-06-26 December 14, 2005Part C of the Individuals with Disabilities Education Act (IDEA) was established to ensure that infants and toddlers with disabilities, from birth to age 3, and their families receive appropriate early intervention services. Within the Department of Education (Education), the Office of Special Education Programs (OSEP) is responsible for awarding and monitoring grants to states for Part C according to IDEA requirements. To address questions about how states have implemented IDEA Part C, this report provides information on (1) how Part C programs differ in their eligibility criteria and whom they serve, (2) to what extent states differ in their provision of services and funding, and (3) how Education and state lead agencies help support and oversee efforts to implement Part C, such as identifying children for services and transitioning children to follow-on programs, such as IDEA Part B.
Eligibility criteria for Part C services for infants and toddlers with disabilities differ from state to state, but do not consistently explain the percentage of children served, which ranges between 1.3 and 7.1 percent. To determine eligibility, most states measure how much the child is delayed in one or more areas of early childhood development, while a few rely exclusively on a clinical team's judgment. Although IDEA Part C is intended to cover children from birth to age 3, most states provide the majority of their Part C services to children 2 to 3 years old. States have public awareness campaigns to identify more eligible infants and toddlers but cite a number of obstacles, including difficulty reaching children in rural areas or in families where English is a second language. The states we visited provide a similar set of services but vary in funding sources. States are required to make available certain early intervention services under IDEA, such as occupational, physical, and speech therapy. However, states report challenges recruiting and retaining professionals, such as speech language pathologists, to provide these services. States rely on various funding sources, but state general revenue funds were generally the largest source of early intervention funding. OSEP and state lead agencies have provided training and technical assistance and used data to monitor implementation of IDEA Part C, but OSEP has lacked some information from local officials needed to determine if children are smoothly transitioning from Part C to Part B. OSEP uses annual reports and performance indicators as part of its effort to monitor compliance with Part C and target technical assistance. For example, data on the percentage of children served help inform OSEP of states' efforts to identify all eligible children. States use similar approaches. Despite these activities, state officials cited challenges transitioning children to Part B services when they turn 3 years old. Education indicated that in preliminary and unpublished data from an ongoing study it had found that gaps occur throughout the year. Officials in the states we visited reported that some children who turn 3 during the summer experience gaps in service. If Part B eligibility is not determined prior to children turning 3 during the summer, then subsequent decisions about whether children should receive extended school year services cannot be made.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-06-26, Individuals with Disabilities Education Act: Education Should Provide Additional Guidance to Help States Smoothly Transition Children to Preschool
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Report to the Ranking Minority Member, Committee on Health, Education,
Labor, and Pensions, U.S. Senate:
United States Government Accountability Office:
GAO:
December 2005:
Individuals with Disabilities Education Act:
Education Should Provide Additional Guidance to Help States Smoothly
Transition Children to Preschool:
GAO-06-26:
GAO Highlights:
Highlights of GAO-06-26, a report to the Ranking Minority Member,
Committee on Health, Education, Labor, and Pensions, U.S. Senate.
Why GAO Did This Study:
Part C of the Individuals with Disabilities Education Act (IDEA) was
established to ensure that infants and toddlers with disabilities, from
birth to age 3, and their families receive appropriate early
intervention services. Within the Department of Education (Education),
the Office of Special Education Programs (OSEP) is responsible for
awarding and monitoring grants to states for Part C according to IDEA
requirements. To address questions about how states have implemented
IDEA Part C, this report provides information on (1) how Part C
programs differ in their eligibility criteria and whom they serve, (2)
to what extent states differ in their provision of services and
funding, and (3) how Education and state lead agencies help support and
oversee efforts to implement Part C, such as identifying children for
services and transitioning children to follow-on programs, such as IDEA
Part B.
What GAO Found:
Eligibility criteria for Part C services for infants and toddlers with
disabilities differ from state to state, but do not consistently
explain the percentage of children served, which ranges between 1.3 and
7.1 percent. To determine eligibility, most states measure how much the
child is delayed in one or more areas of early childhood development,
while a few rely exclusively on a clinical team‘s judgment. Although
IDEA Part C is intended to cover children from birth to age 3, most
states provide the majority of their Part C services to children 2 to 3
years old. States have public awareness campaigns to identify more
eligible infants and toddlers but cite a number of obstacles, including
difficulty reaching children in rural areas or in families where
English is a second language.
The states we visited provide a similar set of services but vary in
funding sources. States are required to make available certain early
intervention services under IDEA, such as occupational, physical, and
speech therapy. However, states report challenges recruiting and
retaining professionals, such as speech language pathologists, to
provide these services. States rely on various funding sources, but
state general revenue funds were generally the largest source of early
intervention funding.
Percentage of Early Intervention Services Most Frequently Provided:
[See PDF for image]
[End of figure]
OSEP and state lead agencies have provided training and technical
assistance and used data to monitor implementation of IDEA Part C, but
OSEP has lacked some information from local officials needed to
determine if children are smoothly transitioning from Part C to Part B.
OSEP uses annual reports and performance indicators as part of its
effort to monitor compliance with Part C and target technical
assistance. For example, data on the percentage of children served help
inform OSEP of states‘ efforts to identify all eligible children.
States use similar approaches. Despite these activities, state
officials cited challenges transitioning children to Part B services
when they turn 3 years old. Education indicated that in preliminary and
unpublished data from an ongoing study it had found that gaps occur
throughout the year. Officials in the states we visited reported that
some children who turn 3 during the summer experience gaps in service.
If Part B eligibility is not determined prior to children turning 3
during the summer, then subsequent decisions about whether children
should receive extended school year services cannot be made.
What GAO Recommends:
GAO recommends that Education provide states with additional guidance
on transition planning and services, especially for children who would
enter Part B during the summer. In comments on our draft, Education
cited an ongoing study of general transition issues. When Education
verifies the results of its study, it should use that information to
inform guidance to states on transition planning.
www.gao.gov/cgi-bin/getrpt?GAO-06-26.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Marnie Shaul at (202) 512-
7215, or shaulm@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Eligibility Criteria Differ among States but Are Not Consistently
Related to Percentage of Children Served:
Selected States Provide Similar Services but Vary in Funding Sources:
Both OSEP and States Use Data to Monitor Part C Compliance, but
Challenges Persist in Transitioning Children to Part B:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Select Federal and State Funding Sources for Early
Intervention Services:
Appendix II: Comments from the Department of Education:
Appendix III: GAO Contact and Staff Acknowledgments:
Table:
Table 1: Sources of Funding for Early Intervention Services in Site
Visit States:
Figures:
Figure 1: States Visited with Type of Agency Leading Part C and Number
and Percentage of 0-3 Population Participating in Part C:
Figure 2: Stages of a State Early Intervention System from Intake to
Service Delivery:
Figure 3: National Percentage of Children Receiving IDEA Services by
Age in 2004:
Figure 4: Examples of Services States Made Available to Infants and
Toddlers Covered by Part C:
Figure 5: Percentage of Early Intervention Services Most Frequently
Provided:
Figure 6: Examples of Federal and State Funding Sources:
Abbreviations:
CDC: Centers for Disease Control and Prevention:
IDEA: Individuals with Disabilities Education Act:
IEP: individualized education program:
LEA: local education agency:
NEILS: National Early Intervention Longitudinal Study:
OSEP: Office of Special Education Programs:
TANF: Temporary Assistance for Needy Families:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
December 14, 2005:
The Honorable Edward M. Kennedy:
Ranking Minority Member:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
Dear Senator Kennedy:
The first few years of a child's life are critical to development.
While most children attain developmental milestones as expected, some
children develop more slowly or develop differently because of
physical, mental, or environmental factors. Research suggests that for
an infant or toddler who exhibits developmental delay, has a diagnosed
condition that has a high probability of resulting in developmental
delay, or is substantially at risk of having a developmental delay
early intervention services, such as family counseling and physical
therapy, can have a significant impact on early childhood development.
To assist states in ensuring that such infants and toddlers receive
early intervention services and support, Congress appropriated $444
million in fiscal year 2004 for grants to states under Part C of the
Individuals with Disabilities Education Act (IDEA Part C). States used
Part C grants to arrange early intervention services for approximately
279,000 infants and toddlers with disabilities from birth to age 3.
Administered by the Department of Education's (Education) Office of
Special Education Programs (OSEP), Part C is intended to support
states' efforts to coordinate and leverage funding from other federal,
private, state, and local sources to ensure early intervention services
are available to eligible children. For services to children with
disabilities after their third birthday, IDEA Part B Section 619
provides grants to states to provide special education and related
services to children with disabilities aged 3 through 5 and, at a
state's discretion, to children before their third birthday.
Given your interest in the manner in which states have implemented the
provisions of Part C, we examined (1) how Part C programs differ in
their eligibility criteria and whom they serve, (2) to what extent
states differ in their provision of services and funding, and (3) how
Education and state lead agencies help support and oversee efforts to
implement Part C, such as identifying children for services and
transitioning children to IDEA Part B or other services.
We used multiple data collection methods to address these issues. We
conducted site visits to seven states--Colorado, Hawaii, Illinois,
Maryland, Massachusetts, New Jersey, and Oregon--and reviewed their
annual performance reports. We chose states to visit based on the type
of state agency responsible for coordinating the Part C program (lead
agency), number of children served, whether the state served at-risk
children, geographic location, and whether the state participated in an
OSEP-funded project aimed at early identification of infants and
toddlers. Figure 1 illustrates the states visited and selected
characteristics.
Figure 1: States Visited with Type of Agency Leading Part C and Number
and Percentage of 0-3 Population Participating in Part C:
[See PDF for image]
Note: Hawaii and Massachusetts serve at-risk children.
[End of figure]
In each of the selected sites, we met with state Part C coordinators,
states' Part B staff responsible for transitioning children to
preschool programs, and the manager of one or more local early
intervention programs. Because Medicaid--the federal-state health-
financing program for certain low-income individuals--can be an
important source of funds for early intervention services for Medicaid-
eligible children, we also met with Medicaid officials in three states.
Additionally, we met with OSEP officials and reviewed their guidance
and monitoring reports. We also analyzed 2002, 2003, and 2004 data
collected by Education. We used the most recent data available from
OSEP. These data, available at IDEAdata.org, include information about
infants and toddlers with disabilities, such as the services they
received, the location where they received them, and what follow-on
program they entered when they were no longer eligible for Part C. We
used information from IDEAdata.org for the 50 states and the District
of Columbia. Although we determined that some data provided by OSEP
were not reliable, we obtained documents demonstrating that the office
has controls in place to ensure a reasonable degree of accuracy and
reliability in many of its data, and determined that the data elements
we used were sufficiently reliable for our purposes. We also conducted
interviews with educational associations, officials from the Centers
for Disease Control and Prevention's National Center on Birth Defects
and Developmental Disabilities, and other experts. Our work involved
reviewing the availability and differences in types of services; we did
not examine the quality of services delivered or the appropriateness of
services provided to children. We conducted our work in accordance with
generally accepted government auditing standards between September 2004
and December 2005.
Results in Brief:
Nationwide, states' eligibility criteria for Part C services differ,
but are not consistently related to the percentage of children served.
State eligibility requirements vary for children who do not have an
established or diagnosed condition that has a high probability of
resulting in developmental delay. Most states require that such
children exhibit a specific level of developmental delay and be deemed
eligible according to an informed clinical opinion. A few states rely
exclusively on clinical judgment. For example, Arizona requires 50
percent delay in one or more aspects of development, such as physical
or emotional, while Hawaii relies on the judgment of a team of
clinicians. Moreover, eight states also include in their eligibility
criteria infants and toddlers who are at risk of having a substantial
developmental delay because of biological risks, such as low birth
weight, or environmental risks, such as parental substance abuse.
However, eligibility criteria do not sufficiently explain differences
in the percentage of all infants and toddlers in a state receiving
early intervention services. The Centers for Disease Control and
Prevention (CDC) reported a lack of data on the prevalence in the
general population of children under 3 who have developmental delays
and could benefit from early intervention services; many conditions
covered by the Part C eligibility definitions--such as learning
disabilities or emotional disorders--are not routinely tracked.
Although IDEA Part C is intended to cover children from birth to age 3,
most states (38) provide the majority of their Part C services to
children 2 to 3 years old. States have developed public awareness
campaigns to help identify more infants and toddlers in need of
services, but officials in the states we visited told us that a number
of obstacles prevented them from reaching all children as early as
possible, including difficulty in reaching children in families where
English is a second language or families living in rural areas.
The states we visited provided similar services and confronted similar
challenges recruiting and retaining staff to deliver them, but they
varied in funding sources. States are required to provide certain
services to children in early intervention programs, including
occupational, physical, and speech language therapy to help with skills
like feeding, walking, and talking. However, states reported challenges
recruiting and retaining individuals to provide these services,
especially speech language pathologists and occupational therapists.
State officials noted that providers often have to spend time traveling
to the homes of families to deliver services, which they said could be
burdensome, and they also noted salaries are often higher in the
private health care sector. States use various sources of funding to
support Part C services, with some relying on multiple funding sources
and others relying primarily on Part C and state general revenue funds.
State general revenue funds constituted the largest source of early
intervention funding in most of the states we visited, while local
funds were often a much smaller source. Officials in the states we
visited said there were challenges in accessing some funding sources,
such as Medicaid. We found inconsistencies in the funding data states
provided to OSEP as part of their annual performance reports, and OSEP
decided during our review that the data were incomplete and unreliable
and announced plans to stop collecting them.
OSEP and state lead agencies provide training and technical assistance
and use data to monitor implementation of IDEA Part C, but they have
lacked some information needed from local service providers to
determine if children are smoothly transitioning from Part C to Part B.
To monitor states' compliance with Part C requirements and to target
technical assistance, OSEP examines annual performance reports,
performance indicators, and other data provided by state lead agencies.
States, which are responsible for oversight of local programs, are free
to design their own oversight methods, but they generally described
approaches similar to OSEP's. Despite oversight and assistance
activities, state and local officials in the states we visited cited
challenges in transitioning children to Part B services when they turn
3 years old. In addition, in commenting on a draft of this report,
Education cited preliminary unpublished data that would suggest
transitions are a year-round problem. Officials in the states we
visited reported that some children who turn 3 during the summer
experience gaps in service during the transition process. The gaps
occur, in part, because school districts generally operate on a 9-month
academic calendar and some school districts may delay determination of
eligibility for any Part B services until the fall. If Part B
eligibility is not determined prior to children turning 3 during the
summer months, then subsequent decisions regarding extended school year
services cannot be made. Most officials said the frequency with which
extended school year services are provided to children transitioning to
Part B could not be determined because neither OSEP nor the state
collected extended school year data. Also, Part C officials and local
early intervention staff told us they face difficulties in finding out
if children are determined eligible for Part B. Not having eligibility
information hinders local early intervention staff's timely referral of
children found ineligible for Part B to other follow-on preschool
programs. Additionally, Part C officials are responsible for reporting
Part B eligibility to OSEP.
In its comments on a draft of this report, Education disagreed with our
recommendation that it incorporate into its research agenda a method
for determining how frequently children transitioning from Part C to
Part B do not receive services during the summer months. Education
noted that preliminary and unpublished data from a department study
indicate that gaps occur when children are transitioned from Part C to
Part B, not only during the summer, but whenever transitions occur.
Additionally, in response to our recommendation that if gaps in
services are found to be a problem, Education should provide states
with additional guidance on improving children's access to extended
school year services, Education stated that, based on its preliminary
data, there is no need to study extended school year services. We
modified our recommendation to acknowledge Education's ongoing study
and are now recommending that the Secretary of Education provide states
with additional guidance on transition planning and services for
children with birthdays during the summer and especially in cases where
children are likely to need extended school year services.
Additionally, when Education completes and verifies the results from
its ongoing studies relating to transitioning, it should use that
information to inform the department's guidance on transitioning.
Background:
According to research, comprehensive early intervention programs can
positively affect the progress of children with developmental delays
and children at risk of having a disability. Services provided by these
programs may include speech language therapy, family counseling, and
home visits. Research has linked early intervention services to
improvements in toddlers' behavior, interactions between parents and
children, infant development, and overall quality of life for children
and their families. Additionally, research has found increased mental
development and better vocabulary and reasoning skills for children who
received early intervention services when compared with those who did
not receive these services. Findings from the National Early
Intervention Longitudinal Study (NEILS), a research project sponsored
by the Department of Education, has found that parents report a high
degree of satisfaction after receiving 3 years of early intervention
services, reporting that their families are better off and that early
intervention services are having "a lot" of impact on their child's
development.[Footnote 1]
IDEA is the primary federal education law for infants, toddlers,
children, and youth with disabilities. Grants to states for early
intervention services and special education and related services for
children with disabilities and their families are provided mainly
through Parts C and B of the act. These parts have different histories
and are generally administered by different agencies at the state
level. IDEA Part C was established to ensure that infants and toddlers,
from birth to age 3, with disabilities or at risk of developing a
disability, and their families receive appropriate early intervention
services. Part C focuses on, among other things, enhancing the
development of infants and toddlers with disabilities by providing
services in a natural environment, such as the home or a child care
center. This part of the law seeks to improve the capacity of the
family to meet the child's needs and reduce educational costs by
minimizing the need for special education when the child is older. Part
B, in contrast, requires that services, to the extent possible, be
provided in educational settings, such as regular classrooms. Part B,
which includes state grants for children and young adults ages 3
through 21, and Part B Section 619 preschool grants for children 3
through 5, aims to ensure that children with disabilities have access
to a free appropriate public education. Funding for Part B is
significantly larger than for Part C programs. In fiscal year 2004,
Part C was funded at $444 million, and approximately 279,000 infants
and toddlers received services.[Footnote 2] In contrast, Part B state
grants and the Section 619 supplement for preschool services were
funded at $10 billion and $388 million, respectively, in 2004.
Approximately 6 million children were provided services under Part B
state grants, and over 693,000 children were provided preschool
services under Part B Section 619.
To meet Part C goals, states use funds to develop a statewide,
coordinated, multidisciplinary, interagency system of early
intervention services for infants and toddlers with disabilities and
their families. Developing such a system includes designating a lead
agency, preparation and dissemination of materials on the availability
of services, defining eligibility criteria, and delivering services. To
this end, each state has a designated lead agency responsible for the
administration, supervision, and monitoring of Part C. In contrast to
Part B, which is led by state education departments, Part C is led by
the health department in 16 states, education departments in 11 states,
and other departments, including combined health and human services
departments, in the remaining 23 states. States are expected to
leverage funding, services, and resources from other sources to provide
early intervention services. Each state must have a continuous process
of public awareness activities and evaluations designed to identify and
refer as early as possible all young children with disabilities and
their families who are in need of early intervention services. By law,
public awareness efforts should include disseminating information to
parents on available early intervention services and to all primary
referral sources, especially hospitals and physicians. Efforts may also
include television ads, pamphlets, and posters describing IDEA Part C
and how parents can access services for their child.
Once a child is referred and suspected of having a disability, states
are required to conduct an evaluation to determine if the child meets
the state's eligibility criteria. In order to be eligible for federal
funds under Part C, IDEA requires that states provide services to any
child under 3 years of age who is developmentally delayed. These delays
must be measured by appropriate diagnostic instruments and procedures
or validated by professional opinion, and may occur in one or more of
the areas of development--including cognitive, physical, communicative,
social or emotional development, and adaptive behavior, such as feeding
or toileting. States must also provide services to those children that
have a diagnosed mental or physical condition that has a high
probability of resulting in developmental delay. However, states are
free to define what constitutes a developmental delay and specify how
this will be measured. In addition, states may choose to serve children
who are at risk of having a substantial developmental delay. These may
include biological risks, such as low birth weight, and environmental
risks, such as parental substance abuse. Once an eligible delay has
been detected, service coordinators work with parents and others to
match children with services specific to their needs. Part C requires
that every state make certain services available, including special
therapies such as physical, occupational, or speech language therapy,
and family supports such as home visits. For example, an occupational
therapist may come to a child's home to teach a child to draw, which
involves hand and eye coordination. The law also requires that services
be provided in children's natural environments. Figure 2 illustrates
the typical process in early intervention programs.
Figure 2: Stages of a State Early Intervention System from Intake to
Service Delivery:
[See PDF for image]
[End of figure]
Children eligible for Part C can receive early intervention services
until they turn 3 years of age. Part C funds can be used to provide
services to children from their third birthday to the beginning of the
following school year, but as of 2004 only 14 states have adopted such
a policy. Thirty states allow for the use of Section 619 preschool
funds to provide services to children before their third birthday. As a
child approaches age 3, the local education agency (LEA) determines the
child's eligibility for Part B Section 619 preschool services. If
eligible for Part B Section 619, the child might also be eligible for
extended school year services. An extended school year ensures that a
child can continue receiving services even when schools are not in
session, for example, during the summer. According to Education, most
children under Part B do not receive extended school year services. By
contrast, Part C is a year-round program. Eligibility for an extended
school year is determined on an individual basis and is generally based
on how much a child will regress and the time it will take to regain
lost skills. During the most recent reauthorization of IDEA, in 2004,
Congress gave states the option of allowing children to continue to
receive services under Part C until they become eligible for
kindergarten.
Eligibility Criteria Differ among States but Are Not Consistently
Related to Percentage of Children Served:
States vary in both the criteria used to establish eligibility for
services and the means used to assess whether children fit these
criteria, but these differences are not consistently related to the
percentage of children receiving early intervention services. While
Part C is intended to serve infants and toddlers from birth to age 3,
the majority of children receiving services nationwide and in most
states are toddlers between ages 2 and 3. Officials in states we
visited told us that despite their various public awareness efforts,
there are a number of challenges in identifying all children eligible
for services, specifically reaching children whose families speak
limited English or live in rural areas. Comprehensive data on the
number of children who could benefit from early intervention are not
available; many conditions covered by Part C--such as emotional
disorders and learning disabilities--are not systematically tracked.
States Have Different Eligibility Criteria and Means of Assessing
Developmental Delay:
Nationwide, states' eligibility criteria for Part C services vary, with
most states specifying the amount of delay in development a child must
experience to be eligible for services, while a few rely exclusively on
the judgment of a multidisciplinary clinical team. IDEA generally gives
states the discretion to determine specific eligibility criteria and
diagnostic procedures. For example, Part C specifies that a child have
an established condition that has a high probability of resulting in a
developmental delay, or that a delay is present in one or more areas of
development--cognitive, physical, communicative, social or emotional,
or adaptive--and that all states allow for the use of informed clinical
opinion in their evaluation. However, states can determine the amount
of delay a child must experience in order to be eligible for services.
Part C also gives states discretion to identify the appropriate
diagnostic instruments to measure the extent of a child's delay or to
rely exclusively on the informed opinion of professionals. For example,
Arizona requires a 50 percent delay in one or more aspects of early
childhood development, such as physical or emotional development. New
Jersey's eligibility criteria vary depending on the number of areas in
which a child is developmentally delayed. The state requires that
children have a 33 percent delay in one area of development, but a 25
percent delay in two or more areas of development. The Centers for
Disease Control and Prevention noted that the significance and
implication of a given percentage delay vary across areas of
development. For instance, according to CDC, a 25 percent delay in
motor skills development has much different implications for services
for a child than a 25 percent delay in language development. Other
states' eligibility criteria are based on the number of months or
standard deviations from age norms. For example, in Massachusetts, a 24-
month-old child functioning at an 18-month-old level could be eligible
for services. In Georgia, a child whose cognitive abilities are at
least two standard deviations less than the abilities of most children
at the same age would be eligible for services. Hawaii does not specify
a percentage delay and instead relies on the judgment of a
multidisciplinary team, which generally includes either a speech
therapist or special educator and an occupational or physical
therapist. Despite wide variation in how states define eligibility,
variation among states in the percentage of children served is not
consistently explained by eligibility criteria. For example, Alabama,
which has broad eligibility criteria (25 percent delay in one or more
areas) served only 1.3 percent of infants and toddlers in 2004, while
North Dakota, which has stricter eligibility criteria (50 percent delay
in one area, 25 percent delay in two or more areas, informed clinical
opinion), served 2.8 percent of its infants and toddlers. In 2004 the
percentage of children served from state to state ranged between 1.3
and 7.1 percent.
Although not required by Part C, as of March 2005, 8 states--
California, Hawaii, Indiana, Massachusetts, New Hampshire, New Mexico,
North Carolina, and West Virginia--also served children at risk of
having a substantial developmental delay. For example, in Hawaii,
children from families where child abuse or neglect is present may
qualify for services. In Massachusetts, children born with low birth
weight or chronic lung disease may qualify for services. States that we
visited that do not serve at-risk children--Colorado, Illinois,
Maryland, New Jersey, and Oregon--expressed interest in serving them
but told us that the additional costs associated with increasing the
number of eligible children prevented them from doing so. Instead of
providing services to at-risk infants and toddlers under IDEA Part C,
some states track at-risk children or provide services to them through
other programs. For instance, in Ohio, children at risk are served
through a statewide program, funded in part by federal dollars, known
as Ohio Early Start. Through this program, they receive services
similar to those children receive under Part C.
Majority of Children Served under Part C Are between Ages 2 and 3:
While Part C funding is intended to serve infants and toddlers from
birth to age 3, the majority of children receiving services are
toddlers between ages 2 and 3. In 2004, infants, children under the age
of 1, constituted only 14 percent of the approximately 279,000 children
served nationwide, and 2 to 3-year-olds accounted for 54 percent.
Likewise, in 38 states, the majority of children served were 2 to 3-
year-olds. In Maryland and Illinois, 2 to 3-year-olds made up 54
percent and 55 percent of the children served, respectively. OSEP and
state officials told us that a majority of children enter the Part C
system after age 2 because this is the age at which speech language
delays become apparent and indicated that such deficiencies are not
easily detected in younger children. According to Education officials,
difficulty detecting deficiencies in younger children is due to
numerous factors, including difficulties in assessment, pediatrician or
parent "wait and see" attitudes, and lack of parental consent. Children
who enter the Part C program in infancy are generally those diagnosed
at birth with conditions such as chromosomal abnormalities and genetic
or congenital disorders.
It also appears that many children are eventually identified as needing
services when they become older. Part B Section 619, which serves
children ages 3 through 5 years, serves many more children than Part C,
as shown in figure 3. In 2004, Section 619 served over 693,000
children, compared with approximately 279,000 children under Part C,
and this pattern is mirrored in most states. This may be attributable
to a variety of factors. Some delays become more apparent as children
get older. Developmental delays are also more likely to be detected
once a child enters a group setting, such as a preschool or
kindergarten program, when comparison with peers may highlight some
delays. Additionally, some parents may turn to private insurance to pay
for services during the first few years of a child's life, and enter
the IDEA system when their child enrolls in a formal education program
at ages 3, 4, or 5. However, Massachusetts and Hawaii serve at least
the same number of children in their Part C programs as they do in
their Part B Section 619 programs. Both states include at-risk children
in their Part C eligibility criteria.
Figure 3: National Percentage of Children Receiving IDEA Services by
Age in 2004:
[See PDF for image]
[End of figure]
States Face Challenges in Identifying All Children Eligible for
Services:
Officials in the 7 states we visited told us that a number of obstacles
prevented them from reaching all children, even though all of these
states, as required by law, had developed public awareness campaigns to
help identify infants and toddlers in need of services. To inform the
public of the program, states used television, radio, and newspaper
ads; presentations at community fairs; and distribution of pamphlets
and brochures at doctors' offices, hospitals, and other appropriate
locations. For example, in one of the sites we visited, posters were
developed to hang in doctors' offices across the state to help inform
parents about Part C.
Despite their public awareness campaigns, the states we visited
reported having difficulty reaching all eligible children. Officials
noted that it can be especially difficult to reach families for which
English is a second language. While some states we visited produced
public awareness materials in Spanish, they had not expanded their
efforts to include materials in other languages. Officials also told us
that it can be hard to reach families who live in rural areas because
they may visit a pediatrician less frequently because of the long
distance they must travel to get to the doctor. While officials in 6 of
the 7 states we visited noted that physicians were the principal source
of referrals, they also told us that they believed physicians were
hesitant to make referrals to Part C programs because of a fear of
misdiagnosing a child with a disability. They believed that a
misdiagnosis could cause unnecessary anxiety in a parent whose child is
developing more slowly but would eventually begin to demonstrate age-
appropriate skills without needing early intervention services.
Additionally, the American Academy of Pediatrics found through its own
studies that a lack of understanding of the early intervention
program's processes and procedures is a barrier to physicians'
referring children.
Selected States Provide Similar Services but Vary in Funding Sources:
States provide a broad array of early intervention services to eligible
children and face similar challenges in recruiting and retaining staff
to provide these services, but they vary in the sources of funding they
draw from. States provide a wide range of medical and educational
services to children and their families and rely on professionals,
including occupational therapists, physical therapists, and speech
language pathologists, to deliver these services. Yet officials in the
states we visited reported that they are finding it increasingly
difficult to recruit and retain these individuals. To fund early
intervention services for children from birth to age 3, states relied
on funding from multiple sources, including federal, state, and private
funding. However, some states reported difficulties accessing certain
types of funding, such as Medicaid.
States Provided a Broad Array of Services to Infants and Toddlers, but
States We Visited Reported Challenges Recruiting and Retaining Staff:
As required under Part C, states provide a broad array of early
intervention services to infants and toddlers. Under Part C, infants
and toddlers with a disability are entitled to receive an evaluation of
their strengths and needs, service coordination, and support for a
smooth transition from early intervention to preschool programs. In
addition, children receive individualized services that may include
physical therapy, family counseling, and nutrition services. States, as
required by law, reported making all services shown in figure 4
available to infants and toddlers.
Figure 4: Examples of Services States Made Available to Infants and
Toddlers Covered by Part C:
[See PDF for image]
[End of figure]
Figure 5 shows that the most frequently received services nationwide
are speech language therapy, special instruction, physical therapy, and
occupational therapy. Psychological and nutrition services were among
the least frequently provided. The states we visited were similar in
their mix of services. For example, in states such as Maryland, Oregon,
and Colorado, speech language, physical, and occupational therapy, to
help with skills like feeding, walking, and talking, were the most
frequently provided services, and services such as psychological
services and nutrition services were rarely provided.
Figure 5: Percentage of Early Intervention Services Most Frequently
Provided:
[See PDF for image]
[End of figure]
These services were provided in a variety of settings, including the
home, hospital, and day care, and through public and private service
providers. For instance, according to Maryland officials, LEAs,
departments of health, and departments of human services in the state
provide services to infants and toddlers in addition to private
providers. In Massachusetts, a network of private programs provides
early intervention services under contract with the state.
Officials in each of the states we visited reported challenges in
recruiting and retaining staff to provide early intervention services.
Specifically, speech language pathologist and occupational therapist
were the most difficult positions to fill. Officials cited several
reasons for these challenges. Early intervention staff are required by
Part C to serve children in natural environments, such as homes or
child care centers. This requires staff to travel to these locations,
which can be time-consuming and costly. For instance, in Hawaii, state
officials told us that it is hard to schedule services for children in
neighboring islands because of the long travel times to reach them.
Additionally, state officials told us that salaries earned by early
intervention contractors were not always competitive with salaries and
benefits available in the private health care sector. These challenges
make it difficult for some early intervention programs to hire
professional staff. Understaffed programs can often result in heavier
caseloads in which children do not receive services or receive services
less often than intended.
States Use Various Funding Sources in Addition to Part C, but Selected
States Report Difficulties Accessing Funds:
To help pay for services for infants and toddlers, states draw on a
range of federal, state, and local funding sources. As shown in figure
6, states accessed funds from a variety of sources at the federal
level, including the Child Care and Development Block Grant, IDEA Part
B, and Medicaid, and from the state level. See appendix I for a
glossary of these federal and state funding sources.
Figure 6: Examples of Federal and State Funding Sources:
[See PDF for image]
[End of figure]
State general revenue funds represent the most frequently used funds by
states after federal Part C dollars. All 50 states reported using state
general funds.
For most states we visited, local support represented a small
proportion of reported early intervention funding, but in one--
Maryland--it accounted for 51 percent. However, states did report
receiving funds from local sources or through private insurance and
fees collected from a child's family. For example, New Jersey charges a
sliding monthly fee based on family size and income relative to federal
poverty guidelines. State officials said families that can afford to
contribute to the cost of service provision do so, but families that
cannot afford the fee still receive services. In fiscal year 2003, New
Jersey collected $43,862 in revenue from this fee, which made up less
than 1 percent of its reported early intervention service funding.
In 4 of the 7 states we visited, states provided most of the funding
for services for infants and toddlers, and Part C represented a smaller
percentage of total funding. For example, in Illinois, state general
revenue funds represented 57 percent of the total funding reported for
infants and toddlers with disabilities, and Part C funds represented 17
percent. However, Part C represented a larger percentage of reported
funding in certain states. For instance, in Colorado, Part C funds made
up 38 percent of funds reported for infants and toddlers with
disabilities. See table 1 for funding sources in the states we visited.
Table 1: Sources of Funding for Early Intervention Services in Site
Visit States:
(Dollars in millions).
Colorado;
Part C: $6.10;
Other federal: $0.00;
Medicaid: $3.10;
State general revenue: $6.80;
Other state: $0.00;
Private insurance/fees: $0.00;
Local support: $0.00.
Hawaii[A];
Part C: $2.00;
Other federal: $0.19;
Medicaid: $0.02;
State general revenue: $8.00;
Other state: $0.01;
Private insurance/fees: $0.00;
Local support: $0.41.
Illinois;
Part C: $15.20;
Other federal: $0.00;
Medicaid: $15.20;
State general revenue: $49.70;
Other state: $0.00;
Private insurance/fees: $6.20;
Local support: $0.00.
Maryland;
Part C: $7.60;
Other federal: $4.70;
Medicaid: $1.80;
State general revenue: $5.20;
Other state: $2.30;
Private insurance/fees: $0.01;
Local support: $23.20.
Massachusetts;
Part C: $8.40;
Other federal: $0.21;
Medicaid: $19.40;
State general revenue: $29.90;
Other state: $0.00;
Private insurance/fees: $32.20;
Local support: $0.00.
New Jersey;
Part C: $13.70;
Other federal: $0.50;
Medicaid: $4.40;
State general revenue: $40.60;
Other state: $1.00;
Private insurance/fees: $0.04;
Local support: $5.20.
Oregon[B];
Part C: $4.50;
Other federal: $0.00;
Medicaid: $2.10;
State general revenue: $8.00;
Other state: $1.80;
Private insurance/fees: $0.00;
Local support: $0.00.
Source: GAO analysis of fiscal year 2003 data provided by state
officials.
[A] Funding data for Hawaii are incomplete, as the state does not
include data from its Public Health Nursing Branch and Healthy Start
programs.
[B] Oregon's Medicaid data are for both Part B and Part C; the state
does not separate the two programs.
[End of table]
Beyond our collection of funding data in our seven site visits, we
looked at funding data for all 50 states by examining the information
states provided to OSEP as part of their annual performance reports.
Their data included federal, state, and local funding sources, as well
as the dollar amounts for each. However, during the course of our
review, we found that data were incomplete. For instance, Hawaii did
not report funding for two programs that provide early intervention
services. We found similar gaps in examining funding data reported to
OSEP by additional states.[Footnote 3] During the course of our review,
OSEP concluded the funding data from states were unreliable and
announced plans to stop collecting such data.
States we visited reported challenges in accessing certain funding
sources. For some smaller programs and funding sources, officials in
some states we visited said the paperwork was too cumbersome for the
small amount of funding they might receive in return. In other cases,
some officials reported difficulty obtaining Medicaid reimbursement for
Part C services. In Oregon, where the state department of education is
the lead agency, officials explained that the different terminology
educators use to describe certain needed services makes it hard to
access Medicaid for early intervention services. For instance, Medicaid
may pay for occupational therapy if the purpose is health-related in
nature--such as teaching a child to eat. But Medicaid may not provide
reimbursement if the stated purpose of the therapy appears educational,
such as teaching a child to grasp a crayon to draw.[Footnote 4] Despite
the challenges some states reported, Massachusetts officials cited a
strong and collaborative working relationship with Medicaid and private
insurance. For example, since 1985, the state has had operational
standards that include reimbursement of virtually all Part C services
through Medicaid.
Both OSEP and States Use Data to Monitor Part C Compliance, but
Challenges Persist in Transitioning Children to Part B:
OSEP monitors the states, which in turn oversee local Part C programs
by examining data on how well programs identify, serve, and transition
children to other programs when they are too old for Part C. In its
oversight, OSEP tracks data on program performance submitted by states
through annual performance reports and other mechanisms. As part of its
efforts, OSEP uses two key performance indicators--percentage of
infants and toddlers receiving early intervention services and the
percentage of these children receiving services in natural
environments--to target site visits and technical assistance to
programs most in need of guidance. States oversee Part C in similar
ways but are free, within certain parameters, to design their own
oversight strategies. Although federal and state data and oversight
efforts have helped identify some performance problems, challenges
remain in transitioning children from Part C to Part B Section 619 and
other follow-on preschool programs. In 5 of the 7 states we visited,
officials said that some children who turn 3 during the summer and are
eligible for Part B preschool experience service gaps when school is
not in session. OSEP does not have data on how frequently children are
provided extended year services during the summer months.
OSEP Monitors and Supports Implementation of Part C by Tracking Key
Data:
To ensure that programs are managed well and that eligible infants and
toddlers receive the services they need, OSEP monitors the states by
collecting and tracking key data. Specifically, each state submits an
annual performance report to OSEP, which includes a narrative on five
areas of program performance and plans for improvement. States report
on (1) what they are doing to identify children and the effectiveness
of these efforts; (2) how well they are helping families develop the
skills they need to help their children; (3) whether services are
provided to children in a natural environment, such as, home, day care,
or other programs for typically developing children; (4) whether
transition planning is available to children and their families; and
(5) what they are doing to supervise and manage local programs. States
report on progress or challenges in meeting performance goals and state-
developed indicators as well as projected timelines, activities, and
resources needed to achieve future targets. For example, with respect
to identifying all children eligible for services, Illinois set a goal
for the period covering July 2003 to June 2004 to increase the
percentage of children receiving early intervention services to 2.6
percent of all children and to screen 200,000 children for
developmental delays, approximately 37 percent of the state's
population age 0 to 3. In its annual performance report for that
period, Illinois described the strategies it used to exceed its
participation target--2.76 percent of children received services--and
explained why it fell 58,000 children short of its target for
screenings.
In addition to information submitted as part of the annual performance
reports, states also report data to OSEP in five areas: (1) number and
percentage of children receiving services, (2) the specific settings in
which children receive services, (3) number of children who stopped
receiving Part C services and the reason for stopping, (4) number and
types of services provided, and (5) the number of clinical personnel
employed or contracted to provide services. IDEA requires states to
submit data in the first three areas, and OSEP, under authority granted
to it in IDEA, requires states to submit data in the final two areas.
For future reporting periods OSEP plans to discontinue collection of
personnel data because they were found to be unreliable. Additionally,
OSEP will stop collecting information about the number and types of
services provided. The reporting data complement and inform topics
covered in the annual performance reports.
Failure to Reach a Key Child Identification Indicator Can Signal Part C
Compliance Problems:
OSEP uses the annual performance reports and other reporting data to
identify problem areas and target its oversight efforts. In particular,
OSEP compares states against the national average on two performance
indicators: (1) the percentage of all infants and toddlers in the state
receiving early intervention services, which was 2.2 percent as of
2003, and (2) the percentage of infants and toddlers with disabilities
receiving early intervention services in a natural environment, which
was 83 percent, as of 2002.[Footnote 5] These indicators were developed
by OSEP with input from interested parties, including states and the
Centers for Disease Control and Prevention.[Footnote 6] OSEP officials
said they chose these indicators because of their confidence in the
accuracy of the data and because they are closely linked to other Part
C requirements. OSEP considers whether states have fallen below the
national average when deciding whether to target states for technical
assistance and closer monitoring. In 2003, half of all states served
less than 2.2 percent of children. OSEP officials note that the
indicators do not directly measure compliance with Part C, but they
serve as an early warning signal that states may need assistance.
OSEP relies on the first performance indicator as a measure of the
level of access states are providing for early interventions and the
success of efforts to identify all eligible children. It has collected
this performance information since at least 1996, and the percentage of
the nation's children between birth and age 3 receiving services has
steadily increased since 1998--from 1.6 percent to 2.2 percent in 2003.
Twenty-five states met or exceeded this indicator in 2003. Of these 25
states, 7 served between 3.4 and 7.7 percent. The fact that half of all
states served 2.2 or more percent, and some served as high as 7.7
percent, combined with the known difficulties in reaching all eligible
children, suggests that the actual eligible population may be larger
than the number of children states are identifying. The Centers for
Disease Control and Prevention told us that comprehensive data on the
number of children who could benefit from early intervention are not
available.
OSEP pays particular attention to states that do not meet its
performance indicator. Failure to meet this indicator can be a signal
that the state is not doing enough to identify all eligible children
and raise public awareness of available early intervention services.
First, OSEP might encourage these states to seek help from technical
assistance centers or OSEP staff. States can get technical assistance
on an ongoing basis through several vehicles, such as conferences, six
regional centers, research and training centers, and a national center.
Second, OSEP might schedule a site visit, at which it would interview
state and local officials, providers, and parents and review program
data in more depth. After OSEP completes a site visit, it prepares a
monitoring report addressing strengths and areas of noncompliance with
Part C.
Using data from annual performance reports and site visits, OSEP has
found states out of compliance with Part C for a number of issues
related to the goal of identifying all eligible infants and toddlers
for services. OSEP finds states out of compliance for, among other
reasons, not making adequate public awareness efforts to inform
culturally diverse groups about available early intervention services,
not disseminating public awareness materials to pediatricians and other
referral sources in rural areas, not referring children from
underrepresented groups for services in a timely manner, and not
carrying out service coordination responsibilities. Between July 1,
2002, and June 30, 2003, 14 states were found out of compliance with
child identification requirements. These states served 0.9 to 7.7
percent of their population, with 9 of the 14 states serving less than
2.2 percent of their population. OSEP found Nevada (which was the state
that served the lowest percentage of infants and toddlers at 0.9
percent in 2003) out of compliance for not ensuring that all children
who may be eligible for early intervention services are identified,
located, referred, and evaluated in accordance with Part C. Hawaii,
which serves the largest percentage of children, including children at
risk of having a substantial developmental delay, was found out of
compliance because it lacked procedures to ensure evaluations and
assessments were conducted in all the areas required by Part C.
When states are not in compliance with Part C and do not show
improvement in their performance, even after receiving technical
assistance, OSEP has several options. Initially, OSEP might work with a
state on a plan of corrective action with a timeline, or issue a letter
to the state documenting the specific problems. As a last resort, OSEP
can impose formal sanctions against a state, including withholding
funds, referring the matter to the Department of Justice, entering into
a voluntary compliance agreement with a state and its respective lead
agency that sets a timeline for bringing the state into compliance, and
incorporating special conditions into a state's grant award. OSEP
reports that it rarely withholds funds or refers any noncompliance
issues for Part C programs to the Department of Justice. Two states,
South Carolina and Arizona, are currently on compliance agreements, and
several have special conditions in their grant awards.[Footnote 7]
OSEP is using its second performance indicator, on the percentage of
infants and toddlers with disabilities receiving early intervention
services in a natural environment, in the same way it uses data about
the percentage of all infants and toddlers in the state receiving early
intervention services. OSEP officials told us that on the basis of
provisions in the 2004 reauthorization of IDEA, they recently developed
a new set of performance indicators. States will submit to OSEP
baseline data on these measures in December 2005. The new indicators
generally build upon data currently being collected to look in new ways
at how states provide early intervention services in a natural
environment, identify children, transition children to follow-on
services, and address supervision and management issues. For example,
the new indicators for identifying children include a comparison of the
percentage of children served in each state with the average in other
states with similar eligibility criteria, and information about the
percentage of children who proceeded through the evaluation,
assessment, and service planning stages of the early intervention
system according to timelines required by Part C. Similarly, the new
transitioning indicators require information about the percentage of
children who receive timely transition planning.
States Have Responsibility for Oversight of Local Early Intervention
Providers:
State lead agencies play a critical role in monitoring and supporting
early intervention services through their responsibility for local Part
C programs. Instead of directly providing services to infants and
toddlers with developmental delays, in the states we visited, local and
regional early intervention programs generally deliver and coordinate
services. The states, then, are responsible for ensuring the local
programs are in compliance with Part C. States use many of the same
approaches as OSEP in monitoring and supporting local programs, such as
file reviews, reporting requirements, program certification or funding
awards, employing training and technical assistance staff, and
monitoring visits. States frequently interact with local early
intervention programs. For example, Massachusetts officials seek to
visit half of their 63 local programs each year.
OSEP encourages collection of outcome data from parents and is
sponsoring research on outcomes, which is scheduled to be completed in
2006. At least 4 of the states we visited monitor early intervention
services by conducting parent surveys. The surveys measure parental
satisfaction with the delivery of early intervention services, how well
parents feel services are coordinated, and parents' experiences working
with staff to transition their children to follow-on services. OSEP
provides funding for technical assistance to help states develop parent
surveys. These survey data and information from OSEP's National Early
Intervention Longitudinal Study are potential sources of outcome data
about early intervention services. Additionally, the Early Childhood
Outcomes Center, a 5-year project funded by OSEP, is providing
technical assistance to support states in developing and implementing
other outcome measurement systems for children with disabilities. The
Early Childhood Outcomes Center is attempting to develop outcome data
that can be aggregated at the national level, document program effects,
and improve programs at the local and state levels.
State Part C officials we spoke with explained that they have to hold
local early intervention programs accountable for the same performance
indicators for which OSEP holds them accountable. As with OSEP, state
Part C coordinators have taken actions to enforce compliance with IDEA.
Officials in Colorado said they had taken away funding from programs
that failed to comply with Part C requirements. Also, when states fail
to enforce IDEA requirements, they risk not only being found in
noncompliance, but also lawsuits brought by individuals under IDEA.
Such was the case in Hawaii and Illinois. In Hawaii, parents and mental
health advocates alleged that qualified handicapped children were not
receiving mental health services. In Illinois, plaintiffs alleged that
the state had a waiting list for children who were eligible for
services. Both states settled the lawsuits by agreeing to take specific
steps to come into compliance with the act.
Overseeing and Coordinating Transitions to Part B Remains a Challenge:
Although the information that OSEP and the states compile has helped
identify some performance problems, overseeing and coordinating
children's transitions to IDEA Part B remains a challenge. The
transition process involves several sequential steps, and when any of
these steps are delayed, a child could miss out on critical services
and providers can be left without important information on a child's
status. As a child nears age 3, local early intervention staff must
inform the child's family about follow-on programs that may be
available for the child, such as Part B Section 619. Local early
intervention staff, with the approval of the family, hold a conference
with the family and, if the child is potentially eligible under Part B,
LEA officials, to discuss any services the child may be eligible to
receive. This transition planning conference for children potentially
eligible under Part B, must occur at least 90 days before the child's
third birthday. Early intervention staff and the family must develop a
written transition plan. And if the child is believed eligible for Part
B services, early intervention staff must notify the LEA. The LEA must
determine the child's eligibility within a reasonable time frame, and
if the child is found eligible, a meeting to develop an individualized
education program (IEP) for the child must be conducted within 30 days.
Part B requires teachers, parents, school administrators, and related
services personnel to develop the IEP shortly after a child is found
eligible for Part B services, and the IEP guides the delivery of
special education supports and services for a student with
disabilities.
While IDEA requires states and local programs to provide transition
planning and follow these specific procedures, we found in our site
visits that delays still happen. Education cited preliminary
unpublished data that would suggest transitions are a year-round
problem. We found that delays generally occur for two reasons. First,
data in annual performance reports indicate that some states have
difficulty scheduling transition meetings 90 days in advance of a
child's third birthday. State and local officials we interviewed said
it was difficult to assemble all of the requisite individuals for the
conference before the deadline. Second, some state officials expressed
concern about the timing of the LEA's decision on a child's
eligibility. The decision may be delayed until the following school
year for children with summer birthdays because LEAs generally operate
on a 9-or 10-month academic calendar. In 5 of the 7 states we visited,
officials said that some children who turn 3 during the summer and are
eligible for Part B preschool experience service gaps when school is
not in session. As a result of these delays in the transition process,
some children who need extended school year services during the summer
may not receive them. Most of the states we visited do not keep track
of the number of eligible children who do or do not receive extended
school year services.
There are two potential ways to ensure children do not experience gaps
in services. First, extending Part C services until children are
eligible to enter kindergarten, which was permitted for the first time
with the reauthorization of IDEA in 2004, could mitigate some of the
challenges associated with transitioning children. However, none of the
states we visited plan to exercise this option. States indicated that
it would be too costly for them to extend Part C service and that Part
B officials are not willing to support doing so with Part B Section 619
funds. Second, Part C funds can be used to provide services to children
from their third birthday to the beginning of the following school
year, but an OSEP technical assistance center reports that as of 2004,
while 30 states permit such use of Part C funds, only 14 states have
adopted such a policy.
In addition to citing delays, state and local officials cited other
obstacles to a smooth transition for children. Local early intervention
programs sometimes have to work with multiple LEAs that each have their
own eligibility criteria for Part B, which complicates coordination.
For example, a local Massachusetts official said that her early
intervention program spans a geographical area that encompasses 13
different LEAs. Also, LEAs sometimes conduct their own evaluations,
contributing to the time needed for determining Part B eligibility.
State and local officials also reported that early intervention
programs often do not get final notification of a child's eligibility
for Part B services from the LEA. According to OSEP, this information
exchange may not occur for several reasons, including federal laws
relating to privacy and the need for parental consent to share results
of Part B evaluations. Without access to information on eligibility
decisions, early intervention staff do not know whether they need to
refer children who are denied Part B services to other follow-on
programs, like Head Start. State Part C officials are required to
report Part B eligibility information to OSEP when reporting why a
child stopped receiving services, but LEAs that administer Part B do
not always provide this information in a timely manner, if at all.
While two of the states we visited are in the process of developing
mechanisms for ensuring early intervention staff have access to
eligibility information, none are currently in use.[Footnote 8] OSEP
staff acknowledged that states need continued support to ensure Part B
officials share eligibility information with early intervention staff.
Conclusions:
Scientific research suggests that the earlier a child with disabilities
gets intervention services, the more effective these services may be in
enhancing a child's development. Before a child enters preschool,
states have substantially greater flexibility in determining which
infants and toddlers to serve. IDEA gives states the freedom to set
different eligibility criteria for early intervention services and
decide how they will evaluate children for eligibility. However, it is
partly these variations that make it difficult to determine if states
are actually meeting the early intervention needs of all their
developmentally delayed infants and toddlers.
One of the most pressing challenges is transitioning young children
with disabilities from services provided under IDEA Part C to Part B
preschool or other services at age 3. This transition requires that a
sequence of determinations and agreements among multiple stakeholders
take place in a timely way. Education reported in its comment that it
has preliminary data that suggest that service gaps may occur whenever
children transition. In our interviews with state and early
intervention officials, we found that transition is perhaps most
challenging for children who transition during the summer months. If
determination of eligibility for Part B is delayed, children can be
prevented from receiving necessary services, including those provided
through extended school year programs in the summer. Based on our
findings, and Education's preliminary findings from its ongoing study
of preschool services, it appears that without additional guidance,
some children exiting the Part C program and eligible for Part B
preschool may not receive all the services for which they are eligible.
Recommendations for Executive Action:
In order to assist states in providing a more seamless transition for
children with disabilities from IDEA Part C to Part B, or other
preschool programs, we are recommending that the Secretary of Education
provide states with additional guidance on transition planning and
services for children with birthdays during the summer, and especially
in cases where children are likely to need extended school year
services. Additionally, after Education completes and verifies the
results from its ongoing studies relating to transitioning, that
information should be used to inform the department's guidance to
states on transition planning.
Agency Comments and Our Evaluation:
We provided a draft of this report to Education for review and comment.
Education disagreed with the recommendation we made to incorporate into
its research agenda a method for determining how frequently children
transitioning from Part C to Part B do not receive services during the
summer months, and if gaps in services are found to be a problem,
provide states with additional guidance on improving children's access
to extended school year services. Education noted that preliminary and
unpublished data from a department study indicate that gaps occur when
children are transitioned from Part C to Part B, not only during the
summer, but whenever transitions occur. Additionally, Education stated
that based on its preliminary data, there is no need to study extended
school year service. We believe it is critical to provide children with
the services they need when they need them. If Part B eligibility is
not determined prior to children turning 3 during the summer months,
then related decisions, including those about extended school year
services, cannot be made. We believe that by providing additional
guidance, Education can help states improve transition planning and
services and help ensure that children do not experience gaps in
services during critical periods of their development.
Education also provided technical comments that we incorporated into
the report where appropriate. Education's written comments are
reproduced in appendix II.
We will send copies of this report to the Secretary of Education,
appropriate congressional committees, and others who are interested. We
will also make copies available to others upon request. In addition,
the report will be available at no charge on GAO's Web site at
http://www.gao.gov. If you have any questions about this report, please
call me at (202) 512-7215. Key contributors are listed in appendix III.
Sincerely yours,
Signed by:
Marnie S. Shaul, Director:
Education, Workforce, and Income Security Issues:
[End of section]
Appendix I: Select Federal and State Funding Sources for Early
Intervention Services:
The Child Care and Development Block Grant program is a discretionary
fund program that, among other things, supports state efforts to
provide child care to parents trying to achieve independence from
public assistance.
Children with Special Health Care Needs refers to a type of program
operated by particular states that provides financial assistance or
case management for needed medical treatment to children with serious
and chronic medical conditions to reduce complications and promote
maximum quality of life.
Developmental Disabilities Services refers to state programs that serve
and support individuals with mental retardation/developmental
disabilities and their families, including early intervention services.
For example, community developmental disability services are supported
by state funding in Kansas, which defines community developmental
disability services as those designed to meet needs associated with
work, living in the community, and individualized supports and
services.
Head Start and Early Head Start are comprehensive child development
programs that serve children from birth to age 5, pregnant women, and
their families. These programs are federally funded and locally
administered by community-based nonprofit organizations and school
systems. Grants are awarded by the Department of Health and Human
Services.
IDEA Part B, administered by the Department of Education, provides
grants to states to provide preschool services to children with
disabilities from age 3 to 5.
The Maternal and Child Health Services Block Grant program (Title V of
the Social Security Act) provides federal grants to states and
organizations with the aim of improving the health of mothers and
children. Among the many services supported by grants are support
programs for children with special health needs, care coordination,
transportation, home visiting, and nutrition counseling.
Medicaid is health insurance that helps people who cannot afford
medical care pay for some or all of their medical bills. Medicaid is
jointly funded by the federal and state governments to assist states in
furnishing medical assistance to eligible needy persons.
The Social Services Block Grant (SSBG) program allocates federal funds
to states to support a wide variety of social services programs for
adults and children.
Temporary Assistance for Needy Families (TANF) is a family assistance
block grant from the Department of Health and Human Services to states
that can be used to provide monthly cash assistance payments to
families as well as to finance services for TANF clients or other low-
income people to support their efforts to work.
Tobacco Funds were awarded to states as part of a settlement agreement
with major tobacco companies. Kentucky designated 25 percent of its
Phase I settlement to an early childhood initiative that includes First
Steps, its early intervention system. Kansas allocated all of its
settlement for children's services.
TRICARE is the Department of Defense's regional managed-care program
for delivering health care to members of the armed services and their
families, survivors, and retired members and their families. TRICARE
operates like health maintenance organization plans offered in the
private sector and other similar health insurance programs.
[End of section]
Appendix II: Comments from the Department of Education:
UNITED STATES DEPARTMENT OF EDUCATION:
THE ASSISTANT SECRETARY:
OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES:
NOV 14 2005
Ms. Marnie S. Shaul:
Director, Education, Workforce and Income Security Issues:
Government Accountability Office:
441 G. Street, NW:
Washington, DC 20548:
Dear Ms. Shaul:
Thank you for the opportunity to review the draft report entitled:
"INDIVIDUALS WITH DISABILITIES EDUCATION ACT, Study of Service Gaps
Could Help Education Guide States in Smoothly Transitioning Children to
Preschool" (GAO-06-26). I am pleased to respond on behalf of the
Department of Education (Department).
The draft report identifies transition of children with disabilities
from early intervention services under Part C of the Individuals with
Disabilities Education Act (IDEA) (for children birth to age three) to
preschool services under Part B of the IDEA (for children ages three
through five) as an area of concern. The Department recognizes that
transition is a long-standing challenge for Lead Agencies under Part C
and State Education Agencies under Part B with respect to ensuring that
children with disabilities who are eligible for preschool services
under Part B at age three are identified, evaluated and provided
services under Part B in a timely manner. However, preliminary data
from a Department-funded study (described below) indicate that the
service gap is specific to transition whenever that transition occurs
and not, as suggested by the draft report, specific to summer months.
The Office of Special Education Programs (OSEP) has funded a number of
projects in this area, most notably the "National Early Childhood
Transition Center" (NECTC), which is in its third year at the
University of Kentucky. The Center's URL is:
http://www.ihdi.uky.edu/nectc/. The Center is looking at all
transitions that children and families experience while receiving Part
C early intervention services and Part B preschool services. While the
project is still gathering data, results thus far indicate that
transition time is reduced for children when staff in both programs
formally recognize and plan for the actual time needed to accomplish
the logistics of transition. In addition, an important factor is the
nature of contacts, i.e., the working relationships between Part C
early intervention service providers and Part B preschool providers at
the local level.
The Pre-Elementary Education Longitudinal Study (PEELS), which was
initially funded by OSEP and is now housed at the Department's
Institute of Education Sciences, is examining the preschool and early
elementary school experiences of children with disabilities and the
outcomes they achieve. The study is following a nationally
representative sample of almost 3,000 children and includes transition
issues. The preliminary first wave of data from the PEELS indicates
that there are gaps between Part C and Part B preschool services for
approximately 30% of children, according to parent reports. For
children who are eligible for Part B preschool services the gap in
services averages five months. Further study will be conducted through
PEELS to verify these data.
The draft report recommends that the Department "incorporate into its
research agenda a method for determining how frequently children
transitioning from Part C to Part B preschool experience service gaps,
and if gaps in service are found to be a problem, provide states with
additional guidance on extended school year services" (emphasis added).
As noted above, the PEELS funded by the Department is already examining
the issue of gaps in service delivery between Part C and Part B
preschool. At this point, the study has found no correlation between
birthdates and particular months of service gaps. That is, spring or
summer birthdates are no more likely to lead to gaps in services than
fall or winter birthdates. Therefore, the draft report's recommendation
regarding the need for studying extended school year (ESY) services
seems inapposite, particularly when under Part B ESY services must be
provided only if a child's individualized education program (IEP) team
determines, on an individual basis, that the services are necessary for
the provision of a free appropriate public education (FAPE) to the
child.
In addition, the draft report may confuse readers in implying that
Parts C and B of the IDEA have similar eligibility and service
provision requirements. We recommend that the draft report include the
following language both in the transition section at page 26 and in the
Results in Brief section to clarify these requirements. Some children
exiting Part C may not be eligible for services under Part B. From
birth to age three, a child is eligible for early intervention services
under Part C because of established conditions or concerns about the
child's exhibiting developmental delay. By contrast, a child with a
disability at age three is eligible for preschool services under Part B
when the child meets particular disability criteria or, at the option
of State and local educational agencies, the child exhibits
developmental delay. In most cases, the developmental delay definition
for Part B is different from the Part C developmental delay definition.
As noted earlier, the OSEP-supported National Early Childhood
Transition Center is examining factors associated with and contributing
to timely and effective transitions. The work of this Center will
assist States in putting procedures and practices in place to reduce
gaps in services for children who are leaving Part C and eligible for
Part B preschool services.
As is customary, we are providing suggested technical and production
edits separately. Please note that many of the technical edits are
necessary to ensure the accuracy of the requirements under Parts B and
C of the IDEA. We are available to discuss any of our suggested changes
with your staff if this would be helpful.
Sincerely,
Signed by:
Assistant Secretary:
Enclosure:
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Marnie S. Shaul (202) 512-7215 or shaulm@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, the following individuals made
important contributions to this report: Betty Ward-Zukerman, Assistant
Director; Ramona Burton, Analyst-in-Charge; Daniele Schiffman, Analyst;
Rachael Chamberlin; Sherri Doughty; Avrum Ashery; Jonathan McMurray;
Beverly Ross; and Daniel Schwimer.
FOOTNOTES
[1] NEILS is tracking the outcomes of over 3,300 infants and toddlers
with disabilities and those at risk of a disability and their families.
The study tracks children starting from their experiences in early
intervention to early elementary school and will provide outcome data
on children and families receiving early intervention and how these
outcomes relate to child and family characteristics and the types of
services provided. The grant for the study ends in 2005 and the final
report is anticipated to be available in 2006.
[2] Part C was appropriated $441 million for fiscal year 2005.
[3] A 2004 expenditure study, conducted as part of the National Early
Intervention Longitudinal Study, concluded that early intervention
programs use a blend of federal, state, and local funding to provide
early intervention services, but that while programs could report
sources of funding, they had difficulty reporting precise amounts of
funding or breaking down the revenues by sources.
[4] We earlier reported challenges in coordinating Medicaid and IDEA
for school-aged children. See GAO, Medicaid and Special Education:
Coordination of Services for Children with Disabilities Is Evolving,
GAO/HEHS-00-20 (Washington, D.C.: Dec. 10, 1999).
[5] The national average for the percentage of all infants and toddlers
receiving early intervention services is calculated based on the birth
to age 3 population receiving early intervention services on December 1
divided by the total number of children ages 0 to 3 on that date. In
2004, 2.3 percent of the nation's infants and toddlers received early
intervention services. The national average for the percentage of
infants and toddlers with disabilities receiving early intervention
services in natural environments is calculated based on the number of
children receiving services in a natural environment (homes and
programs for typically developing children) divided by the total number
of children receiving services in all settings.
[6] An initial baseline performance goal of serving 2 percent of
states' population ages 0 to 3 was based on conditions under
observation by the Centers for Disease Control through the Metropolitan
Atlanta Developmental Disabilities Study. These observations did not
include certain conditions covered by Part C that are difficult to
detect in young children, such as learning disabilities and behavioral
and social/emotional problems.
[7] For additional information on OSEP's efforts to address issues of
noncompliance under Part B of IDEA see GAO, Special Education: Improved
Timelines and Better Use of Enforcement Actions Could Strengthen
Education's Monitoring System, GAO-04-879 (Washington, D.C.: Sept. 9,
2004).
[8] The most recent reauthorization of IDEA in 2004 includes a
provision for the local educational agency under Part B to invite, at
the request of the parent, the Part C coordinator or other Part C
representative to the child's initial individualized education plan
meeting.
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