Thomas M. Longhurst, College of Health Professions, Idaho State University, Pocatello and Boise, 1997
Paraprofessionals make up about 20 percent of the early intervention and education workforce (Hebbeler, 1994). Striffler (1993) and Longhurst (1997) provide an overview of current trends in the utilization of paraprofessionals in early intervention and preschool services. The focus of this chapter will be on physical therapy, occupational therapy, and speech-language pathology and particularly those individuals that work in partnership with or alongside of professional level therapists as aides or assistants, which will be called
paratherapists (Longhurst & Witmer, 1994).
The Idaho Board of Vocational Education (1994 a, b, c, d, e, f; 1993) has developed Technical Committee Reports and Curriculum Guides that include appropriate performance standards, work setting task lists (competencies), duty areas, enabling objectives, practica suggestions, scope of practice statements, and supervision standards for physical therapy, occupational therapy, and speech-language pathology aides and assistants.
It is hoped that the information contained in these curriculum guides and in this chapter will be useful to educators in high school vocational-education programs, community colleges, vocational-technical schools, colleges and universities, as well as those involved with planning health occupation programs. The information is also provided as an aid to early intervention or special education administrators in program planning and implementation that involves aides and assistants in therapy services. This information should become even more relevant as the current shortages of therapists and paratherapists in early intervention, education and rehabilitation settings become even greater in the future (Hebbeler, 1994; Job Trends 2005, 1994).
There should be significant cause for concern for the future of therapy services in early intervention and the schools. With salaries in rehabilitation settings often twice those in schools and significantly better benefit packages, more and more therapists are focusing on rehabilitation in their training and signing on with rehabilitation hospitals or private practices after graduation.
The special focus of this chapter will be on an attempt to (1) clarify the differences between aides and assistants, (2) present the need and demand for paratherapists, (3) review appropriate pre-service training, subsequent on-the-job training, and structured career advancement training that provides career pathways for paratherapists in Idaho, and (4) present an efficient and effective model for the implementation of therapy services utilizing an intradisciplinary team approach, for example SLP Aide, R-SLPA, CCC-SLP. As the demand for more and better trained paratherapists increases, production of current high school and community college programs can be expanded and new programs created to graduate more and better-trained paratherapists for an expanding job market.
Striffler (1993) has provided an excellent overview of current trends in the utilization of paraprofessionals in early intervention and preschool services. Longhurst (1997) has provided an overview of team roles in therapy services.
Occupational therapists (OT) and physical therapists (PT) have for many decades utilized paraprofessionals, both at the aide and assistant levels, to make their therapy more productive and efficient. The profession of speech-language pathology (SLP) has studied the issue repeatedly over the last three decades (ASHA, 1970; ASHA, 1981; ASHA, 1995) with paraprofessional use increasing but without fully recognized educational standards or practice controls.
There has been minimal consistency in occupational titles. Bachelor level speech-language pathologists are called aides in Texas and persons with only a high school diploma called assistants in California.Ê No national guidelines have existed and there are essentially no training programs, accreditation of training programs, nor national credentialing available for paratherapists in speech-language pathology. All that is changing with the official endorsement of the use and credentialing of associate degree (or bachelorâs degree) speech-language pathology assistants by the American Speech-Language-Hearing Association (ASHA).
The question now is not if the speech-language pathology profession will accept the use of assistants, but how community college programs can best train these paratherapists. ASHA will register speech-language pathology assistants (R-SLPAs) and approve the educational programs in which they are trained. The Council for Exceptional Children (1997), along with a consortium of educational organizations, including ASHA, have a set of guidelines that differ somewhat from ASHA's and are specifically directed to service delivery in early intervention and education settings.
Generally speaking, ASHA-CCC speech-language pathologists will be required by ethical code to supervise only ASHA-credentialed R-SLPAs. That is, in the future (there will be a 1998-2001 grace period), speech-language pathologists with the CCC could not supervise any assistants who are not R-SLPAs. ASHA does limit the number of R-SLPAs supervised by one CCC-speech-language pathologist to three FTEâs while the Consortium Report is silent on this issue. To supervise more would likely be an ASHA code violation if the supervisor holds ASHA-CCC.
The Consortium Guidelines (CEC Consortium Report, 1997) leave credentialing at three levels (I, Aide; II, Assistant; III, Associate) to the state (licensing boards or state education agencies). The supervisor need not have the ASHA-CCC, but would generally be expected to have a masterâs degree in speech-language pathology. With regard to supervision, the Consortium Guidelines require, as a minimum, direct supervision of the first 10 hours of therapy after training and then 10 percent of all sessions, to include at least one in every ten consecutive sessions. ASHAâs supervision requirements are more stringent. The ASHA Guidelines specify that supervision of R-SLPAs consist of a minimum of 30 percent for the first 90 days of service (20 percent must be direct, on-site); and 20 percent after 90 days (10 percent direct). Both the ASHA and Consortium Guidelines specify the scope of responsibilities or scope of practice of assistants and they detail the exclusive responsibilities of the supervisor.
Aide vs Assistant Distinction
Appropriate assignment of paratherapist roles is addressed in state practice acts, licensure and certification regulations, as well as scope of practice statements of professional organizations such as the American Physical Therapy Association (APTA), the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association (ASHA).
Aide is a paratherapist title typically given to individuals with a low level of training and a very limited scope of practice. The aide is typically a non-licensed, non-certified employee who works under the direct supervision of the professional therapist. The aide carries out designated or specifically assigned routine tasks. These typically include transporting patients/students; maintaining, cleaning, and assembling materials, devices, and equipment; performing clerical duties, and working with patients/students in a very closely monitored and supervised therapy environment. On-site supervision by the therapist is typically recommended for best practice.Ê Typically, the aide is required to have a high school diploma or GED, be at least eighteen years old, and have completed some aide training in high school, a post-secondary educational facility, or on the job in a school, clinic, or hospital setting. Aides are often hourly employees with slightly above minimum wage pay and few fringe benefits. Some states recognize additional training or experience through pay grades or levels (I, II, III) within the aide category.
Assistant is a paratherapist title given to individuals with an associate degree from an accredited program in physical therapy or occupational therapy. The American Physical Therapy Association (APTA) (1988) or the American Occupational Therapy Association (AOTA) (1991) accredit such programs. There are only a few associate degree programs in speech-language pathology and currently there are no national program approval procedures for speech-language pathology assistants (SLPA), but one will be implemented soon (Longhurst, 1997). The Physical Therapist Assistant (PTA) and Certified Occupational Therapy Assistant (COTA) are typically certified and in most states a licensed employee. Some states certify or license SLPAs, however, ASHA is the nationally recognized credentialing organization. ASHA will provide registration for SLPAs (Paul-Brown, 1995). Assistants work under direct or indirect supervision of the therapist and continuous, on-site supervision is not required, although this may vary from state to state. Their scope of practice is significantly expanded from that of the aide. ÊTheir education, expertise, and clinical training allow them to focus their efforts on patient/student treatment. While they typically donât diagnose, develop or even change treatment programs, they work somewhat independently in carrying out treatment programs planned by the professional therapist. Salaries are typically about 50-75% that of an employed professional therapist and fringe benefits are typically much better than the aide and relatively comparable to that of the professional therapist.
Current and Future Needs
For all professions requiring at least a bachelors degree, therapists are well represented in the ten fastest growing professions. Physical therapists are listed third, with occupational therapists, sixth, and speech-language pathologists, eighth (Bureau of Labor Statistics Occupational Outlook Quarterly, 1994). It is expected that these professions will show an 88 percent, 60 percent, and 48 percent growth rate respectively by the year 2005 (Job Trends 2005, 1994). U.S. schools of allied health are gearing up to meet current and future needs (Blayney & Selker, 1992).
Actually, the demand for paratherapists exceeds, and will continue to outstrip the need for therapists. For occupations requiring some post-secondary education, physical therapy aides and assistants are ranked first with a projected 93 percent growth and occupational therapy aides and certified occupational therapy assistants (COTAs) are ranked third with a growth rate of 78 percent (Bureau of Labor Statistics Occupational Outlook Quarterly, 1994). The use of speech-language pathology aides and assistants is not as well developed as in physical therapy and occupational therapy and employment statistics are not readily available. It is expected that demand in the future for speech-language pathology aides and assistants may be as great as in occupational therapy and physical therapy.
Several factors are driving this tremendous demand for therapists and paratherapists. Federal policy has had a significant impact over the past three decades (Hanft, 1991), particularly with implementation of the Individuals with Disabilities Education Act (IDEA), which was reauthorized in 1997. Advanced medical science is saving more extremely low-birth-weight babies and those with significant birth defects. Early intervention programs are successfully involved in identifying infants, toddlers, and preschoolers with mild to severe disabilities who then move into school programs. Many of these children need the services of therapists and paratherapists (Yoder & Coleman, 1990).
The health care industry's use of therapy rehabilitation services, especially for adults, is growing at a very fast pace (McFarlane, 1992) and will continue to do so because of the demographics of the aging population (Spencer, 1989). This growth in rehabilitation services draws many therapists, especially in speech-language pathology, away from employment in early intervention and the schools. Although the nature of health care and educational reform is uncertain, essentially all proposed plans bode well for significantly increased utilization of paratherapists in both settings. It is likely that the early intervention and education will benefit most from increased production of paratherapists.
The need for paratherapists in rural communities is particularly great (Center for Disability Policy and Research, 1995). In general, these communities have low population density and are separated by distance and geographic barriers from metropolitan areas with their larger hospitals. Few professional-level therapists locate in rural communities. Expanded education in community colleges, which are much more likely to be in rural communities, could supply more paratherapists for employment there.
There is also an increasing recognition of a need to reduce the barriers that prevent students in rural areas, members of minority groups, displaced homemakers, the disabled, school drop-outs, alternative school students, and the impoverished from entering career pathways that may lead first to a paratherapist job and eventually professional therapist status. It is no secret that the therapy professions have been remarkably unsuccessful in attracting, recruiting, and educating members of underrepresented groups into their ranks and few therapists are multi-lingual (Campbell, 1994; Campbell & Taylor, 1992; ASHA Committee on the Status of Racial Minorities, 1991; Holmes, 1987).
The cost and rigor of university education, the lack of articulation agreements among institutions of higher education, high admission criteria, limited program seats, and the length and cost of university, professional school programs have been major barriers to persons from underrepresented groups entering the therapist workforce. Most OT and PT schools now charge very high program fees (often $5,000-$10,000 per year) over and above tuition. Post-secondary vocational/technical schools and community colleges have an exemplary record of reducing these barriers and providing program access. The use of paratherapists who are more likely to be from underrepresented groups would provide a cultural and linguistic link to the community served.
It is also apparent that professional therapist training programs have been minimally successful in providing the family-focused (Jeppson & Thomas, 1995 Bailey et. al., 1990), multidisciplinary, or transdisciplinary training (Rooney, Gallagher & Fullagar, 1993) that is typically acknowledged as best practice in early intervention, education, and rehabilitation. Opportunities for a strong family focus and especially for cross training (or, as it is sometimes called, multi-skilling) are much more feasible in post-secondary vocational/technical schools and community colleges at the aide or assistant levels than in universities at the professional therapist level. Many competencies at the aide and assistant level are comparable and cross-training or multiskilling should be the goal of any paratherapist training program (Pew Health Professions Commission, 1995).
Many of these barriers will remain or be exacerbated in the future, so a well-defined career pathway for paratherapists, with opportunities for cross-training and career advancement through well-articulated programs, takes on increasing social, economic, and best-practice importance.
We clearly need to train more professionals, decrease attrition, and distribute professionals more equitably (rural vs. urban, schools vs. hospitals). However, it is also clear, as Hebbeler (1994, p. 28) so appropriately, stated, that ã[o]f all of the possible responses to the problem of personnel shortages, restructuring how programs are staffed (utilizing paraprofessionals) may hold the most promise.ä
Many post-secondary, vocational/technical school, and community college certificate or degree programs are viewed as tickets to the job market. Vocational educators are fond of calling their programs ãhireä education.
Their focus is often on providing well-qualified technical or support staff to schools, business, and industry.
This is especially true for the rapidly expanding allied health occupations field. Only rarely are they viewed as entry ways to the healthcare professions.
There are clear distinctions between a health care job and a healthcare career and between health occupations and health professions. While preparation for a job is good, career education should be planned and executed to provide access to career advancement through paratherapist levels into the therapy professions, if the student has the financial resources, intellectual capacity, and motivation. Barriers for advancement should be removed and opportunities made readily available.
Career pathways for paratherapists in Idaho (see Appendix A) provide school guidance counselors, educators, parents, and students with an innovative way to look at preparing for the post-secondary transition to the workforce and the need for further education in a vocational/technical school or community college.
Within the paratherapist career pathway, students initially choose health occupations as a career major. The health occupations major includes high school coursework that prepares Idaho students to (1) enter directly into the workforce as a Developmental Disabilities Aide (DD), OT, PT, or SLP aide upon graduation; (2) continue education in a vocational/technical school or community college focused on technical preparation as an OT, PT, or SLP assistant; or (3) eventually pursue advanced baccalaureate or graduate study at a university to enter the professional therapist ranks. Every student in the health occupations major follows an educational plan for their major. Early in the high school years, students should receive competent counseling so that they can choose a career pathway and develop an appropriate educational plan. With this early career guidance, parents and students can make better-informed decisions about the studentsâ high school and post-secondary education and choose relevant courses and related volunteer and part-time work experiences to improve their practical skills.
Through an integration of academic and vocational programs, career pathways help Idaho educators design appropriate curricula. Vocational, academic, and clinical competencies are required in health occupations. For example, students need the academic competencies contained in psychology, human anatomy and physiology, biochemistry, and physics courses as well as applied vocational competencies contained in courses in keyboarding and computers, medical records, medical terminology, and emergency and safety procedures.
Career pathways help to integrate the academic curriculum with the vocational curriculum and, in turn, with clinical practicum by requiring high school educators not only to be proficient in their own discipline (psychology, biology, chemistry, physics), but possess collaborative competencies across disciplines to better meet studentsâ needs. A paratherapist career pathway provides high school educators in Idaho with a framework for developing and coordinating an integrated health occupations curriculum. The material being taught in one course, such as biology, is reinforced in vocational coursework (e.g., in instruction in universal precautions for infectious disease control) and this material in turn is then applied clinically in proper work-surface cleaning, hand washing, and latex glove use.
A health occupations major helps students, parents, educators, and guidance counselors clarify the relationship between education and the world of work. Whether the goal is pursuing a graduate degree, four-year degree, associate degree, short-term secondary training, on-the-job training or a high school diploma, students need to follow a career pathway to be most efficient and effective in acquisition of competencies.
Career pathways help both the university preparatory student and the vocational education student make relevant course selections in high school. Both students would choose the health occupations major. One may focus on courses in university preparatory mathematics, human anatomy and physiology, chemistry, and physics, while the second might focus on applied mathematics, applied biology, applied chemistry, and applied physics. Both would complete coursework in applied technology in health occupations (keyboarding and computers, medical records, medical terminology, and emergency and safety procedures) as well as appropriate workplace experiences.
Health occupations (and professions) require clinical practicum and work experience before one is considered fully prepared. Initial work-based learning activities should be exploratory such as clinical observations, job shadowing, short-term work experiences after school or in the summer, and community volunteer service. As the student progresses in the career pathway, experiences might include more concentrated clinical practicum, clerkships, and internships.
When these clinical activities are incorporated into the curriculum within the career pathway, they complement classroom training by providing related practical experience in the world of work. These experiences answer the question in the studentâs mind, ãWhy should I learn this?ä
Rush (1996) suggests that successful work-based learning experiences should include:
- careful planning of what students will learn and how they will learn it;
- competent clinical supervision, job coaching, and mentoring;
- evaluation and documentation of learning;
- opportunities at school and at work for thoughtful reflection on what has happened and what it means;
- multiple connections between school-based and work-based learning;
- work experiences related to the classes in the career pathway;
- school credit granted for work-based learning;
- parents knowledgeable about both school and work; and
- work-sites free of bias and stereotyping.
The students' academic transcript documents coursework that has been successfully completed. A portfolio of certificates of training documenting program completion and records documenting work-based experience (volunteer experiences, part-time work, clerkships, internships) are maintained by the student and guidance counselor. Just as official transcripts are transferable among higher education institutions, experience portfolios are transferable in Idaho. If competencies have already been met, there is no reason to meet them again (except re-certification as is required in CPR training).
Idaho High Schools
Through a career pathway, high school students graduate with one or more aide certificates in hand so that they can enter the job market immediately after graduation. The paratherapist career pathway should begin in the sophomore/junior years of high school or even earlier.
The intent is not for students at this point to decide on a specific occupation or profession, but to select an initial career pathway into which they can begin to direct their learning energies. Identifying a career pathway early can help students in selecting courses, school activities, volunteer and service activities, and even part-time employment.
There is some early preparation in life sciences and applied biology and then in general human anatomy and physiology. Keyboarding and computer skills are essential. Some background in applied chemistry, physics, and mathematics, as well as sociology/psychology is helpful. Typically a sophomore year class in Exploring Careers in Health Services is provided (McCutcheon, 1993). In the junior year, a full-year course in Health Occupations is completed (Simmers, 1993).
The senior year starts in the first half-year with a program in Developmental Disabilities Aide (DD Aide) training (Idaho Board of Vocational Education, 1993) with a certificate awarded upon completion.
In the second half of the senior year, students may elect to complete one or two aide programs with the most popular being PT Aide or, if time is available in the studentsâ schedule, the combined OT Aide and PT Aide program. A number of students have elected to complete classes required for high school graduation in the early morning, after school, or in the summer so that they can participate in aide training during the regular school schedule.
Two important national movements in vocational-technical education support high school career pathways for paratherapists. These are the School-to-Work movement (Perry, 1994; American Vocational Association, 1994) and the Tech Prep initiative (American Association of Community Colleges, 1994; Hull & Parnell, 1991). The School-to-Work program provides a practical system of integrating the high school classroom with real world experiences through schools and health care, community and work place partnerships. In this work-based learning program, the high school student participates in education at the work site that is closely connected to the high school curriculum. The immediate goal for students is aide training completion certificates that lead to a job in the chosen field upon high school graduation.
Idaho health care facilities, state agencies, and school district employers benefit from the School-to-Workprogram through lower training costs, an opportunity to shape the high school curriculum, and a larger and better skilled employee pool from which to hire. Because the students are working in the agencies, employers have an opportunity to see the quality of the studentsâ work before hiring full-time. The Tech Prep initiative, while similar to School-to-Work, has as its goal preparation in the high school curriculum for entry into a post-secondary vocational/technical school or community college associate degree program such as physical therapy assistant (PTA), certified occupational therapy assistant (COTA), or speech-language pathology assistant (SLPA). Completion certificates earned in high school as a DD Aide, PT Aide, OT Aide, or SLP Aide provide part-time employment opportunities while the student is pursuing an associate degree.
Idaho Post-secondary, Short-term Training
While the most efficient approach to training new employees at the aide level is through high school programs, access to training opportunities and entrance into a paratherapist career pathway also need to be provided at the post-secondary level. Post-secondary, short-term training is necessary for the 60 percent of high school students who pursued a general track in high school and neither obtained a marketable skill through high school vocational education nor successfully completed a college preparatory course of study.
The paratherapist career pathway can be entered through post-secondary, short-term training after high school graduation, sometimes many years later. For example, short-term training is made available in a highly accessible schedule through six regional, vocational-technical schools in Idaho. Students typically complete the DD Aide training of about 60 clock hours of instruction and then go on to one or more aide (PT Aide, OT Aide, SLP Aide) training programs, each about 60 contact hours in length. Each includes a supervised clinical component and mentored transition to the work place. Each training package is competency based and provides a completion certificate documenting that competencies have been demonstrated.
Idaho Vocational-Technical School/Community College Training
About 30 states have developed programs for training PTAs and COTAs, but there are currently only a few training SLPAs. Again, the APTA or AOTA accredit such programs to document at least minimal quality while ASHA is planning to approve SLPA programs.
Idaho State University, within its community college role, has completed initial curriculum planning and is proposing initiation of one of the first associate degrees in Speech-Language Pathology Assistanting. This curriculum development was planned to coincide with ASHA initiating program approval of training programs and registering of SLPAs (Paul-Brown, 1995), over the next few years.
The ISU course sequence for training SLPAs is shown in Appendix B. Most of the first year is used to fulfill general education requirements for an Associate of Science Degree. These courses are comparable to a typical freshman year and all courses can be utilized in the future for a Bachelor of Science in Speech Pathology and Audiology degree, if the student continues in the career pathway. The second year is focused on coursework in speech-language pathology assisting with a final spring-summer term consisting of closely supervised clinical practicum and associated applied seminars. ASHA requires two different, six-week placements totaling at least 70 clock hours supervised 50 percent of the time by a supervisor with the ASHA CCC in SLP.
University Baccalaureate/Graduate Education
A number of states have bachelorâs degree programs that lead to full certification/licensure in OT and pre-PT. There is a trend toward moving professional-level education in OT/PT to the graduate level. COTAs or PTAs should have the option of moving up the career pathway into upper division coursework after the associate degree to either complete a bachelorâs degree in OT or PT or to complete a preprofessional, or pre- OT or PT degree in majors such as biology, psychology, or special education. Usually admission requirements to most OT or PT programs are high and seats in programs are limited. Work experience as a COTA/PTA often provides some preference to applicants, but high GPA in specific prerequisite coursework, high Graduate Record Examination (GRE) scores, and excellent recommendations are required. Tuition is very expensive, frequently requiring additional and significantly higher professional school or program fees.
Baccalaureate degrees in speech-language pathology are readily available in most states but they have been viewed as pre-professional degrees for the last two decades that do not lead to work in SLP. A masterâs degree has been viewed as the minimum practice requirement by ASHA. Most states recognize the masterâs degree as the minimum for state licensure/certification and to meet the qualified provider provision of the Individuals with Disabilities Education Act (IDEA).
There are still a number of persons with bachelorâs degrees in the schools nationwide, but often they are working in some other position classification. With some minimal retraining, these persons could become R-SLPAs.
There are a number of baccalaureate in SLP graduates each year who for one reason or another do not go on to graduate school. Again, these persons, with some minimal retraining÷primarily the fieldwork experience÷would make excellent R-SLPAs, significantly expanding the SLP workforce available to the burgeoning service needs of infants, toddlers, school children, adults, and the elderly.
Utilization of paratherapists should be viewed positively. Certainly, those that choose not to supervise paratherapists should not be forced to do so. However, those that choose to qualify themselves and devote the time and energy to supervise paratherapists should be provided appropriate supervision time and resources (CEC, Consortium Report, 1997). When the Dallas (TX) Independent School District hired speech-language pathology assistants in 1994, the SLPs that agreed to supervise SLPAs received a pay raise.
Then they received a 25 percent reduction in their caseloads to allow for that supervision (
Moving forward on support personnel, 1995). That is a good example for other school districts nationwide.
With appropriate utilization of paratherapists, service deliverers can provide more services to more persons with disabilities at a more reasonable cost. Paratherapists can increase the current, typical frequency of one or two sessions per week to five-days-a-week intervention that automatically increases the possibility of improving outcomes and clearly may reduce the overall duration of therapy needed. If paratherapists can be used as extenders of services provided by therapists, the whole service delivery system can move forward a giant step with minimal, if any, erosion of quality of service, and at great cost savings. While some therapists fear paratherapists will cost them their jobs, their real fear should be that they will lose their jobs to healthcare and education reform if they donât provide intervention more relevant to the educational needs of students and become more cost effective. Clinical efficacy is an increasing concern in our cost-conscious and outcomes-based world. The appropriate training and use of paratherapists is the future of therapy services in early intervention and the schools.
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Career pathways for related service paratherapists in early intervention and education, Journal of Childrenâs Communication Development, 18:1, 28-30.
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Longhurst, T.M. & Witmer, D. (1994). Initiating paratherapist training in Idaho. New Directions, 15:3, 1-5.
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Rooney, R., Gallagher, J., & Fullagar, P. (1993). Distinctive Part H: Three case studies. Chapel Hill, NC: Carolina Policy Studies Program, frank Porter Graham Child Development Center, The University of North Carolina at Chapel Hill.
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I wish to acknowledge the work of Dorothy Witmer, Ed.D., former Health Occupations Supervisor, Idaho Division of Vocational Education for facilitating the development of the paratherapist Technical Committee Reports and Curriculum Guides (DD Aide, Vo. Ed. 269; PT Aide, Vo. Ed. 283; PT Assistant, Vo. Ed. 285; OT Aide Vo. Ed. 282; COTA Vo. Ed. 284; SLP Aide Vo. Ed. 293; SLP Assistant Vo. Ed. 292). These documents are available for $5.00 each from: Vocational Curriculum Dissemination Center, College of Education, University of Idaho, Moscow, ID 83844-3083, (208) 885-6556.
The thoughtful discussion and document editing of the many professional therapists and paratherapists in Idaho who made up the three (PT, OT and SLP) technical committees are also gratefully acknowledged.
Also acknowledged is the financial support from the Idaho Infant-Toddler Interagency Coordinating Council and the Idaho Infant-Toddler Program, Mary Jones, Manager, that was used to provide travel and operating expenses to the technical committee meetings as well as document preparation and printing expenses.
And finally to my long-time administrative assistant, Karen Lewis, thanks are extended for many hours of committee scheduling, preparing correspondence and drafts of the technical documents as well as preparing this chapter for publication.
Correspondence concerning this article should be addressed to the author at:
Idaho State University
Pocatello, Idaho 83209-8116
Phone (208) 236-2204
FAX (208) 236-4602