Washington State
Institute for
Public Policy
110 Fifth Avenue Southeast, Suite 214  PO Box 40999  Olympia, WA 98504-0999  (360) 586-2677  FAX (360) 586-2793
EVIDENCE REVIEW OF PROGRAMS FOR INFANTS AND TODDLERS
WITH DEVELOPMENTAL DISABILITIES:
PRELIMINARY REPORT
The 2008 Washington State Legislature directed
the Washington State Institute for Public Policy
(Institute) to . . .
“. . . conduct a review of research on
service and support programs for children
and adults with developmental disabilities,
excluding special education, and an
economic analysis of net program costs
and benefits. The institute shall submit a
preliminary report of findings by January
1, 2009, and a final report by June 30,
2009.” 1
The “bottom line” goal of the study is to provide
the legislature with a summary of available
research on services and supports for
individuals with developmental disabilities, and
to estimate the costs and benefits of providing
these programs.
This document describes progress on the study
to date and discusses our review of the
research regarding specific early intervention
programs for infants and toddlers aged 0 to 3.
The final report will be released in June 2009.
Suggested citation for this report:
Stephanie Lee and Marna Miller. (2008). Evidence
review of programs for infants and toddlers with
developmental disabilities: Preliminary report.
Olympia: Washington State Institute for Public
Policy, Document No. 09-01-3901.
For additional information on this study, contact
Stephanie Lee at (360) 586-3951 or
slee@wsipp.wa.gov.
1 in Washington State.
ESHB 2687, Chapter 329, § 610 (17), Laws of 2008.
January 2009
Summary
The Washington State Institute for Public Policy was
directed by the 2008 Washington Legislature to estimate
the effectiveness, costs, and benefits of programs for
individuals with developmental disabilities (excluding
special education). To better focus our efforts, we
divided the review into two broad sections:
1) early intervention programs provided before a child
enters special education (i.e., infants and toddlers
aged 0 to 3), and
2) programs that are provided alongside special
education or after an individual is no longer eligible
for special education.
In this preliminary report, we study one basic question: Is
there evidence that specific early intervention programs
for children aged 0 to 3 with developmental disabilities
“work” to improve cognitive or developmental outcomes
for these children?
Methods
We conducted a systematic review of all research we
could locate to identify which early intervention
programs, if any, work to improve cognitive or
developmental outcomes for infants and toddlers with
developmental disabilities and their families. We found
that although there is a wide body of research about
early interventions with children under age 3, very few
programs have been rigorously evaluated.
Finding
There is very little evidence on the effectiveness of
specific early intervention programs for infants and
toddlers with developmental disabilities. We summarize
the findings on eight programs with at least one rigorous
evaluation on Page 6.
Next Steps
Our final June 2009 report will review evidence on the
effectiveness of supports and services to adults and
children with developmental disabilities across the
lifespan. In addition, the report will discuss the costs
and fiscal implications of implementing these programs
Focus of the Preliminary Report
In this preliminary report, we restrict our focus
to reviewing early intervention programs for
infants and toddlers with developmental
disabilities and delays. In our final report, we
will also include a review of programs for
adults with developmental disabilities, as well
as discuss the costs and fiscal implications of
implementing these programs in Washington
State.
Background
According to Washington State law, under
Revised Code of Washington 71A.10.020(3),
the definition of a developmental disability is:
A disability attributable to:
 Mental retardation;
 Cerebral palsy;
 Epilepsy;
 Autism; or
 Another neurological or other condition
closely related to mental retardation or
that requires treatment similar to that
required for individuals with mental
retardation.
Which:
 Originated before the individual turned
eighteen;
 Continued or can be expected to
continue indefinitely, and
 Results in substantial limitations to an
individual's intellectual and/or adaptive
functioning.2
Services for individuals with developmental
disabilities and their families available from the
state vary with the age of the disabled person.
In FY 2008, the average monthly number of
developmentally disabled clients enrolled
across Washington State was 36,916,3 and
the average number of children served by the
Infant Toddler Early Intervention Program
2
From DSHS Department of Developmental Disabilities
eligibility criteria, available at:
<http://www.dshs.wa.gov/ddd/eligible.shtml>
3
From DSHS RDA EMIS report, available at:
<http://rda3.dshs.wa.gov/emis_section/emis_folder/DD-
EMIS_Report.xls>
2
(described below) in an average month was
4,888.4
From birth to age three, children with
developmental disabilities and delays are
eligible for services through the Infant and
Toddler Early Intervention Program (ITEIP).
For qualifying children, ITEIP provides each
family with an Individualized Family Services
Plan (IFSP) that aims to educate parents about
their child’s developmental growth as well as
give the child developmental assistance such
that they might avoid the need for special
education and other services at a later age.
We provide more details about the eligibility
requirements for ITEIP later in this report. A
total of 8,723 children were enrolled in ITEIP at
some point in FY 2007.5
From age 3 to 21, developmentally disabled
individuals are entitled to a free public
education. Through the public school system,
eligible children and young adults receive an
Individualized Education Plan (IEP) and
services such as developmentally appropriate
preschool, special education services, speech
therapy, employment planning, and other
needed services.
After age 21, special education services are
no longer provided. In adulthood,
developmentally disabled individuals may be
eligible for services such as the Employment
and Day program, which provides training,
support, and paid jobs for those who are able,
and Community Access services with activities
and special assistance for those who may be
unable to work.
Throughout their lifetimes, individuals with
developmental disabilities are also eligible for
health services and supports through Medicaid,
if income requirements are met. For example,
families may qualify for Medicaid Personal
Care, which is regular personal assistance with
activities of daily living for a developmentally
4
From DSHS ITEIP monthly program data, July 2007 to
June 2008. Available at:
<http://www.dshs.wa.gov/iteip/DataSysAndTrain.html>
5
Washington State DSHS (November 2008). Infant Toddler
Early Intervention Program: 2008 Legislative Proviso Report.
Available at: <http://www.dshs.wa.gov/pdf/adsa/iteip/DDD-
ITEIP%20Finance%20Report%2011-01-08.pdf>
disabled person, provided in the individual’s A child is also eligible if he or she has a
residence. Additionally, individuals who meet diagnosed physical or mental condition that has
income and functional assessment a high probability of resulting in a developmental
requirements may also receive residential care delay, including but not limited to:
across a broad spectrum, from alternative living
 Chromosomal abnormalities associated
services that help a client live as independently
with mental retardation, such as Down
as possible in the community, to the full time
Syndrome;
residential care and medical services provided
 Congenital central nervous system birth
in a Residential Habilitation Center.
defects or syndromes, such as fetal
alcohol syndrome;
Other services provided to qualifying
 Deaf, blind, or deaf-blind;
individuals across their lifespan may include
 Established central nervous system
assistance from the Individual and Family
deficits resulting from hypoxia, trauma,
Service Program. This program covers
or infection;
supports such as respite care, therapy, excess
 Cerebral palsy;
medical costs, transportation, behavior
 Health impairments such as autism,
management, and recreational opportunities,
epilepsy, neurological impairment or
among others.
other chronic or acute or degenerative
health problems;
The legislative direction for this report
 Orthopedically impaired (i.e.,
specifically excluded special education from
impairments of the normal function of
the research review. Therefore, we organized
muscles, joints, or bones due to
the first part of our research review to focus
congenital anomaly, disease or
only on services and supports provided to
permanent injury); and/or
infants and toddlers, before they are eligible
 Microcenphaly (i.e., the circumference
for the special education entitlement.
of one’s head is 2 standard deviations
or more below the norm for one’s age
and sex).6
Infant Toddler Early Intervention Program
In Depth
These criteria are fairly broad, in that a child
does not have to have an “official” diagnosis in
As mentioned earlier, programs for infants and
order to be eligible for services. However, the
young children with developmental delays or
definition of eligibility does not include those
disabilities are supported by the Infant Toddler
“at risk” of developmental disability.
Early Intervention Program (ITEIP). The
federal Individuals with Disabilities Education
The categories of programs supported by
Act (IDEA), Part C, provides funds for early
ITEIP are:
intervention programs, with an aim to reduce
 Assistive technology devices and
children’s need for special education and
assistive technology services
other services as they grow up.
 Audiology (hearing)
 Early identification, screening, and
To qualify for ITEIP services, a child must
assessments services
have a 25 percent delay or show a 1.5
 Family resources coordination
standard deviation below his or her
 Family training, counseling, and home
chronological age in one or more of the
visits
following developmental areas:
 Health services
 Physical, including vision, hearing, fine  Medical services only for diagnostic or
or gross motor; evaluation purposes
 Cognitive;  Nursing services
 Communication;  Nutrition services
 Social or emotional;
 Adaptive. 6
From ITEIP services eligibility criteria, available at:
<http://www.dshs.wa.gov/iteip/Services_Elig.htm>.

3
  Occupational therapy
 Physical therapy
 Psychological services
 Social work services
 Special instruction
 Speech-language pathology
 Transportation and related costs
necessary to enable a child and family
to receive early intervention services
 Vision services
For the purposes of this study, we reviewed all
the research we could find about supports and
services to infants and toddlers under the age
of 3 and their families that fit within the above
categories.
We should note that not all of the categories
above had research evidence for us to review.
For example, the type of nutrition services and
transportation services provided through ITEIP
are rarely, if ever, subject to a rigorous
research evaluation. Moreover, several topics
encompassed programs that had been
researched, but with methods that did not
meet our standards for inclusion (see below).
In addition, not all of the programs we
included in our review are provided within the
state of Washington. Our goal, however, was
to review the available evidence on all early
intervention programs for infants and toddlers
with developmental disabilities.
Criteria for Inclusion in This Review
For our review, we assessed the evidence on
specific early intervention programs that fit
within the categories specified by ITEIP. Not
all of the categories include programs that
have been researched, but evidence we cover
in our review must meet three broad criteria.
1) Evaluation Design and Methodology
First, any program we include must have data
from an evaluation that examines outcomes
from a group that participates in a particular
program in comparison to an equivalent group
that does not participate in the program. The
groups do not necessarily have to result from
random assignment, but the evaluation must
4
show that any comparison group is indeed
comparable to the treatment group on pre-
existing variables (such as age, gender, race,
type and/or severity of disability) that may
influence outcome measures. At the very
least, if a study finds pre-existing differences
between groups, the study authors must
control for these differences in their analysis.
We do not consider studies that follow a single
treatment group’s changes over time to be
reliable enough to include in our analysis.
2) Population
For this particular review, we were interested in
evaluations of programs that served infants and
toddlers, aged 0 to 3, with developmental
disabilities or delays. Although many programs
ostensibly offered “early intervention,” often,
the average age of children studied in a
program evaluation was far higher than 3.
Because of our specific age focus in this
preliminary report, we excluded several
otherwise reliable evaluations. These
evaluations will be included in our final report
as part of our larger review of the evidence for
services and supports for those with
developmental disabilities.
Some early intervention programs are
designed to serve children with a particular
type of disability (such as Down syndrome or
cerebral palsy or autism), and others are
designed to apply to children with a variety of
developmental issues. We included all of
these types of programs, but we did not
include programs that work with “at-risk”
populations (such as low birthweight infants or
pregnant mothers with a series of risk factors
for developmentally delayed children). These
types of prevention programs fall outside the
legislative direction for this study.
3) Outcomes
Finally, the evaluations we included in our
review had to use quantifiable, standardized
measures that focus on outcomes like child
development, maturation, or progress. For
example, we included measures of mental and
physical development (e.g., Bayley Scales of
Infant Development, Griffiths Developmental
Quotient), child behavior (e.g., Developmental
Behavior Checklist, Vineland Adaptive
Behavior Scale), and IQ (e.g., Stanford-Binet
Intelligence Quotient). We also attempted to
include parental wellness measures, such as
for stress (e.g., Parental Stress Index) and for
depression (e.g., Beck Depression Inventory);
however, only one rigorous evaluation that
focused on infants and toddlers used these
kinds of measures.
Findings
For example, many evaluations of early
interventions use a single-case or single-
group design, in which a child’s or a group of
children’s outcomes are measured before and
after an intervention is provided. Sometimes,
change from pre-test to post-test is interpreted
as success of a program; without a
comparison group of untreated children, there
is no way to tell if observed differences
resulted from the intervention or were the
consequence of maturation/development or
some other, unmeasured factor.

In recent years, researchers have developed a

set of statistical tools to facilitate systematic “Missing” Programs
reviews of the evidence. Our goal for this
preliminary report was to use this set of In our review, we came across references to
procedures—called “meta-analysis” 7—to several popular interventions used with
combine the findings of a large number of autistic children for which we could not find
research studies and report on the any reliable research conducted with no-
effectiveness of various early intervention treatment comparison groups. These
programs. interventions include:
 Developmental, Individual Difference,
However, we found so few rigorous
Relationship-based therapy
evaluations of early intervention programs for
(DIR/Floortime™);
infants and toddlers, we were unable to
 Relationship Development Intervention;
conduct the meta-analysis as planned. The
 Responsive Teaching
eight programs with evaluations that met our
criteria are listed in Exhibit 1 (next page);
These interventions do have published
however, only one of these programs had
evaluations, but the research designs do not
more than one rigorous evaluation (intensive
incorporate a comparison group. These may
applied behavior analysis). Citations for the
indeed be effective interventions, but at this
research described in Exhibit 1 are detailed in
time, there is not enough research for us to
Exhibit 2 at the end of this document; a full
make a statement about these programs.
bibliography will be provided in our final report.

Gaps in the Research

When conducting our review, we did not find

an absence of research. On the contrary,
many well-known and innovative early
interventions for infants and toddlers with
developmental disabilities have been
evaluated. However, the methods used to
study these interventions are rarely sufficiently
rigorous to enable us to draw the conclusion
that the intervention causes a particular
outcome.

7
Specifically, we analyze the results of studies using meta-
analytic methods as described in M.W. Lipsey & D.B. Wilson.
(2001). Practical Meta-Analysis. Thousand Oaks: Sage
Publications.

5
 Exhibit 1
Rigorously Evaluated Early Intervention Programs for Infants and Toddlers
Type of
Program Disability Description of Intervention
Autism Preschool Autism Children received day care with a one-on-one
Program child care worker, plus 15 hours of educational received the Autism Preschool Program had
seminars for parents and daycare workers, 30
hours of on-site consultation to daycare
workers, and psycho-educational and
supportive work with families, including two
home visits.
Home-based Autism Three-hour home visits by a speech and
parent training language therapist every six weeks for 12
months. Goal was to train parents as
“therapists,” teaching attention skills, speech
and language skills, and behavior
management through structuring everyday
routines.
Intensive applied Autism 25-40 hours of one-on-one treatment per
behavior analysis week, for one to three years (length of
(Lovaas method) treatment varied by study). Treatment was
begun in the home, and gradually moved to
other environments as time went on. Focus is
on teaching children appropriate behaviors,
and speech and language skills, primarily
using positive reinforcement techniques.
Constraint-induced Cerebral Three weeks of physical or occupational
movement therapy palsy therapy for six hours per day to increase motor treatment, motor activity and new behaviors in
skills in child’s more impaired arm. Child’s less the more-impaired arms of children in the
impaired arm was casted to prohibit
movement and encourage development of the in children from the no-treatment comparison
less able extremity.
Vestibular Cerebral 16 sessions of vestibular stimulation (spinning
stimulation palsy in a rotating chair) over four weeks.
Developmental Down Biweekly, center-based therapy sessions with
therapy syndrome a primary therapist, focused on activities to
promote development (e.g., rolling, sitting,
reaching, speaking). Parents receive written
instructions to follow between sessions.
“Denver Model” of Various Bimonthly home visits from a trained
home visiting paraprofessional (mother of a child with
services special needs) for 12 months. Focused on
child development, safety, and especially
service coordination. Home visitors also called development (measured by the HOME scale),
the families, accompanied them to
appointments, and helped develop family
service plans.
Portage curriculum Various Weekly visits from an early intervention
advisor for two years. Parents were
considered to be primary therapists, and
worked with advisors to implement the
Portage Early Education Curriculum. The
goals are: increasing imitation, attentional
focus, awareness of space, self-help skills,
preacademic skills, and language acquisition.
6
Findings
One small study found that children who
average development scores (measured by the
Early Intervention or Preschool Developmental
Profile) and autistic behaviors (measured by the
Autistic Behavior Checklist) that were not
significantly different from those of a group who
received the one-on-one supported day care
services only.
One study in the UK found that, compared to a
group who received standard local services only,
children in the intervention group had average
development scores (measured by the Autism
Diagnostic Index, MacArthur Communicative
Development Inventory, and subscales of the
Griffiths Scale of Infant Development), and their
parents had stress scores (measured by the
Parenting Stress Index) that were not
significantly different.
Three studies found that, on average, children
who received the intervention were significantly
better behaved (measured by the Vineland
Adaptive Behavior Scale) compared with no- or
alternative-treatment comparison groups. In
addition, two studies found significantly higher
development for the intervention group. One
study found significantly higher IQ scores for
children in the intervention group, and one study
found that the use of special education services
did not differ significantly between intervention
and non-intervention groups.
One small study found that, after the brief
intervention group were significantly greater than
group.
One small study found that, three months after
treatment, mental and psychomotor
development (measured by the Bayley Scales of
Infant Development) was not significantly
different from a no-treatment comparison group.
One small study with infants found that six
months of the intervention produced no
significant difference in development (measured
by the Griffiths Developmental Quotient)
compared to a no-treatment comparison group.
One study found that, after one year of the
intervention, there were no significant
differences between the intervention group and
a no-treatment comparison group in child
emergency room visits, out-of-home placements
into foster care, or child maltreatment.
One small study in Greece found that, eight
months after completion of two years of
treatment, the intervention had significantly
higher development (measured by the Griffiths
Developmental Quotient) compared with a no-
treatment comparison group.
Next Steps 2) Estimate the costs of all programs,
including the funding sources.
1) Review the research evidence on
supports and services for older children We will also review the costs to Washington
and adults with developmental disabilities. State of implementing supports and services
for individuals with developmental disabilities.
In the final report, we will review the research The funding for various services comes from
evidence on supports and services for children federal as well as state sources; we will
over three, and for adults. We will locate all provide an overview of what services are
available evidence on programs such as: funded with what dollars. In addition, where
possible, we will review fiscal scenarios that
 Employment support
take into account alternative services and
 Community access services
supports provided to a particular segment of
 Assistive technology
the developmentally disabled population (e.g.,
 Behavior management
what it costs to care for an individual in a
 Respite care
Residential Habilitation Center compared with
 Personal assistance
an individual with similar characteristics
 Full-time residential habilitative care
residing with his or her family).
 Alternative living services
 Group and companion homes
Our final report, due in June 2009, will present
the results of these last two tasks, along with
If possible, we will conduct a meta-analysis of
detailed, technical information about our
the evidence to determine what services and
methodology.
supports, if any, work to improve outcomes for
developmentally disabled individuals and their
families.

7
 Exhibit 2
Citations to the Evaluations of Programs Listed in Exhibit 1

Applied Behavior Analysis for Autism

Howard, J.S., Sparkman, C.R., Cohen, H.G., Green, G., & Stanislaw, H. (2005). A comparison of intensive behavior analytic and eclectic
treatments for young children with autism. Research in Developmental Disabilities 26: 359-383.
McEachin, J.J., Smith, T., & Lovaas, O.I. (1993). Long-term outcome for children with autism who received early intensive behavioral
treatment. American Journal on Mental Retardation 97(4): 359-372.
Smith, T., Groen, A.D., & Wynn, J.W. (2000). Randomized trial of intensive early intervention for children with pervasive developmental
disorder. American Journal on Mental Retardation 105(4): 269-285.

Autism Preschool Program

Jocelyn, L.J., Casiro, O.G., Beattie, D., Bow, J., & Kneisz, J. (1998). Treatment of children with autism: A randomized controlled trial to
evaluate a caregiver-based intervention program in community day-care centers. Developmental and Behavioral Pediatrics 19(5): 326-334.

Constraint-Induced Movement Therapy for Cerebral Palsy

Taub, E., Ramey, S.L., DeLuca, S., & Echols, K. (2004). Efficacy of constraint-induced movement therapy for children with cerebral palsy with
asymmetric motor impairment. Pediatrics 113: 305-312.

“Denver Model” Home Visiting for Training Parents of DD Children

Rosenberg, S.A., Robinson, C., & Fryer, G.E. (2002). Evaluation of paraprofessional home visiting services for children with special needs and
their families. Topics in Early Childhood Special Education 22(3): 158-168.

Developmental Therapy for Down Syndrome

Piper, M.C. & Pless, I.B. (1980). Early intervention for infants with Down syndrome: A controlled trial. Pediatrics 65(3): 463-468.

Home-Based Parent Training for Parents of Autistic Children

Drew, A., Baird, G., Baron-Cohen, S., Cox, A., Slonims, V., Wheelwright, S., et al. (2002). A pilot randomised control trial of a parent training
intervention for pre-school children with autism: Preliminary findings and challenges. European Child & Adolescent Psychiatry 11: 266-272.

Portage Curriculum
Thomaidis, L., Kaderoglou, E., Stefou, M., Damianou, S., & Bakoula, C. (2000). Does early intervention work? A controlled trial. Infants and
Young Children 12(3): 17-22.

Vestibular Stimulation for Cerebral Palsy

Sellick, K.J. & Over, R. (1980). Effects of vestibular stimulation on motor development of cerebral-palsied children. Developmental Medicine
and Child Neurology 22: 476-483.

Document No. 09-01-3901

Washington State
Institute for
Public Policy
The Washington State Legislature created the Washington State Institute for Public Policy in 1983. A Board of Directors—representing the legislature,
the governor, and public universities—governs the Institute and guides the development of all activities. The Institute’s mission is to carry out practical
8
research, at legislative direction, on issues of importance to Washington State.