Early Intervention in Aotearoa New Zealand: Services and Challenges

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Full reference
Liberty, K. (2014). Early intervention in Aotearoa New Zealand: Services and challenges. NZ Research in Early Childhood Education Journal. Special Issue: Early Childhood Policy, 17, 115-146.

 

Original Policy Paper

Early Intervention in Aotearoa New Zealand: Services and Challenges

Kathleen Liberty
University of Canterbury, New Zealand

 

Abstract

This paper describes the bicultural model of early intervention in Aotearoa New Zealand, and the challenges facing the delivery of effective services.The early intervention system is inclusive of culturally different concepts of development, family, disability, wellbeing, risk, prevention and intervention, as well as Kaupapa Māori and Western science evidence-based practices. Service frameworks emphasise culturally appropriate interactions with children and families. However, challenges to improve services exist. Population growth and increasing prevalence of needs associated with early intervention challenge the existing coverage of services. New needs identification systems are highlighting significant gaps between the number of children likely to require early intervention and the number receiving services. Additional challenges in service delivery, retention of families, and difficulties with supporting children with early intervention needs in early childhood services also require attention. Finally, culturally appropriate services should be replaced by culturally responsive services to improve early intervention for Māori. It is urgent that a review of early intervention be undertaken to determine the best approaches to meet the needs of young children with early intervention needs.

Key words: Early intervention; service delivery; cultural responsiveness.

 

Introduction

Early intervention can be defined as a set of services and supports delivered as early as possible to ameliorate or prevent long-term problems (Feldman, 2004).  Supports can include the provision of information, referral to other services, such as counselling, assisting parents to access health care and disability support services, establishing parent groups, and other links and services to meet family needs (Guralnick, 2005)1.  In many countries around the world, early intervention services for young children with disabilities were initiated in the last century. During the past twenty years, Western cultural approaches to early intervention have moved from a model of one-to one “treatment” of the child in isolated or segregated settings to a model of supporting and empowering families (Cullen & Carroll-Lind, 2005).2

However, in Aotearoa New Zealand, a significant difference in the country’s history has produced a unique model of early intervention.  Aotearoa New Zealand’s founding document is the Treaty of Waitangi, which was an agreement of broad principles to found a bi-cultural nation and was signed between representatives of the Queen of England and Māori Rangatira (i.e., chiefs) in 1840.  The Treaty established equity and shared responsibilities in three principles of partnership, participation and protection and this implied cooperation and joint action in all aspects of national identity, development and governance. These principles have provided the impetus for a bi-cultural early intervention. Bi-cultural early intervention can be defined as a set of culturally responsive services and supports delivered as early as possible to promote and strengthen wellbeing.

Bi-cultural early intervention has evolved from the Western cultural model of early intervention and from the Māori-cultural understandings of wellbeing (Alliston, 2007; Ministry of Education, 2002, 2011; Ministry of Health, 2010a). Western philosophies and research about child development, child psychology, disability, special education and risk and resilience are evident in the framework of current services (refer Table 1). Some aspects of early intervention services, such as assessment of disability and a focus on the amelioration of the effects of the disability on the individual, have their foundations in Western approaches (Guralnick  2005; 2011; Ministry of Education, 2010a; Ministry of Health, 2012a).

Māori philosophy, (i.e., kaupapa Māori) of health and wellbeing, Te Whare Tapa Whā (Durie, 1996; 1998, 2001) is the partnership framework.  Te Whare Tapa Whā has been conceptualised as a metaphor for the construction of a strong whare/house for the whānau. The whare is supported by four cornerstones or posts; hinengaro (i.e., mental and emotional health), wairua (i.e., spiritual connectedness), whānau (i.e., family relationships) and tinana (i.e., physical health).  It is postulated that as all cornerstones are required for the whare to stand, any change or point of difference has interactive effects and could result in a detriment to wellbeing for the individual and whānau (e.g., disability status). Health and wellbeing arise within the whānau, rather than within an individual, as in the Western model.3  Aspects of New Zealand early intervention services, such as strengthening the family and family relationships, and focusing on wellbeing (rather than disability) have their foundations in Kaupapa Māori.

Table 1: Braiding a bi-cultural early intervention system

Aotearoa New Zealand’s Founding Document:  Treaty of Waitangi  [1840]
Principles Drawn from Western Science Bicultural Systems Perspective Principles Drawn from Kaupapa Māori

Developmental Framework informs all components of the system and centres on families.

Medical and DSM model of disability and developmental delay

Professional Development

Cultural Awareness

Whānau Ora / Health & Wellbeing

Framework from Kaupapa Māori (knowledge, traditions) informs all components of the family and centres on Health and well being

Ka Hikitia, Māori educational achievement as Māori

Taonga Tuku Iho, Cultural Aspiration

Interdisciplinary Teams

Developmental Domains

Developmental Progression

Developmental Assessment

Models of Family Interaction

Models of Family Risk

Cultural responsiveness

Ethical Codes [Family Consent]

Te Hikoitanga; Te Whāre Tapa Whā

The 4 Cornerstone Foundations of Health

Te Taha Hinengaro [Mental and Emotional Health]

Te Taha Wairua [Spiritual Awareness]

Te Taha Tinana [Physical Health and Change]

Te Taha Whānau [Family generations together]

Ata [growing respectful relationships]

Protocols based on Developmental Science and Evidence

Developmental Assessment

Functional Behaviour Assessment

Natural Environments

Activity-Based Intervention

Inclusion

Te Whāriki Early Childhood Curriculum

Learning Disposition Assessment

Cultural Safety

Early Intervention Specialist Service Standards

Protocols based on Tikanga Māori, Kaupapa Māori and He Mapuna te Tamaiti [the unique disposition of the child]

Te Kohanga Reo [Māori Language Preschool]

Te Oranga [Participation in Society]

Ako: Learning and teaching each other/Relationship based learning

Mana Ake [Unique Identity of Individual and Family]

 

Early intervention is also affected by other policies and initiatives.  New Zealand’s government has a strong policy commitment to families and young children, and aims to provide services to strengthen the wellbeing of all children, regardless of family income or family status or place of residence (Ministry of Social Development, 2012).  New Zealand was ranked first in the OECD countries in the provision of quality health care and patient-centred care (Department for Professional Employees, 2011; Schoen, Osborn, Doty, Squires, Peugh & Applebaum, 2009).  This ranking was based in part on the range of free services, including maternal and child health care during pregnancy and birth, and early intervention services. Doctor visits for children are free to age 6, including support for vision, hearing and other specialist health care.  In addition, struggling parents and families may also receive housing and income support.  This range of free services means that early intervention providers are able to refer children to additional specialist services without worrying about affordability for the family, unlike the situation in other countries. 

Early intervention is also affected by the policies of preschool education.  New Zealand is seventh in per-child funding of pre-primary education (OECD, 2011a). All children aged 3-5 years, including children with disabilities and early intervention needs are eligible for 20 hours per week of free early childhood education (Bushhouse, 2008). Many of the early childhood education services deliver the national bi-cultural early childhood curriculum Te Whāriki (Ministry of Education, 1996). Typically, early childhood services emphasise learning through play and do not include any structured instruction in pre-academic skills, pre-reading skills and so forth, and do not include structured teaching lessons that are implemented in primary school classrooms, unlike some overseas models of early childhood education.  Children with early intervention needs may also be included in Te Kōhanga Reo, Māori early-language centres. A system of free libraries, with free computers and high-speed internet access is available in many parts of the country, and parents are able to request materials from specialist libraries or other sources without additional fees.  The freely available access to educational settings for young children and to settings for parents to gather information about the needs of their children also strengthens early intervention services.

Finally, the national New Zealand Disability policy aims for full inclusion in every service sector and public arena (Minister of Disability Issues, 2010).  Thus, the inclusion and welcoming of parents and children with special needs is expected within all areas of public life, including access to primary and secondary schooling (Liberty, 2009). These historical and current contexts are the underpinnings of a coordinated national system of universal, free, targeted and intensive bi-cultural early intervention services and supports for families and whānau of young children with special learning needs.

 

Current bi-cultural service provision

Screening programmes and referral

Bi-cultural early intervention service is initiated through a process of referral to services, as shown in Figure 1. Referral can be initiated in a number of pathways.  For example, parents who have concerns can discuss these with their family physician, who can then refer to services. Alternatively, parents can themselves contact services.  Referrals can also be made by community health nurses or preschool educators.

Screening is another process than can result in referral.  Screening is a systematic process undertaken by qualified personnel to identify the potential presence of factors that may affect child development.  A series of screens is conducted throughout the developmental period, beginning prenatally. Prenatal screening for conditions associated with early intervention needs is provided free through the health care system and families/pregnant women may be screened by medical personnel to determine if there is high environmental risk to child development outcomes as a consequence of poverty, sole parenting, mental health problems, a history or substance abuse, or other problems. These screens may result in referral for prevention/early intervention services beginning during the prenatal period.

Standard screening protocols at the time of birth and at the time of discharge from hospital following birth identify issues requiring immediate treatment, including low birth weight, chromosomal differences, or hearing impairment (Ministry of Health, 2012b). The outcome of the screening may lead to referrals for further diagnostic investigations and treatment. Infants born low birth weight and/or premature and infants treated in the Neonatal Intensive Care Unit are referred directly for early intervention, which may even begin in hospital (National Health Board Disability Support Services, 2011a).


2014 NZRECE Journal Liberty paper figure 1 Figure 1: An overview of the early intervention system pathways in Aotearoa New Zealand

 

From the age of 4-6 weeks, the Ministry of Health makes available a schedule of free delivery of Well Child services for about 300,000 young children every year (Ministry of Health, 2110b; Tuhoy, 2010).  Services are built around health visits to parents and their child, in homes or, in community centres. Home visits begin at 4-6 weeks of age, and then occur at 8-10 weeks of age, 3-4 months, 5-7 months, 9-12 months, 15-18 months, 2-3 years, and between 4-4.5 years of age (i.e., The B4 School Check).  The health visits provide parent information (e.g., on preventing sudden infant death), parenting support (e.g., assistance with feeding problems) and screening.  For children with higher risks, such as an identified disability or very low birth weight, additional visits may be established. Systematic screens are provided at every visit.  These include screening for growth, developmental milestones, behaviour, oral health, vision, and hearing. Additional screens for family/whānau health (e.g., family violence, smoking cessation) are also incorporated. Families may be referred to appropriate services indicated by the screening results including to early intervention services (Wills, Matthews, Hedley, et. al, 2010).

Assessment and planning

Following referral to early intervention, processes of gaining informed caregiver consent are followed, as participation is voluntary.  Once families have consented, the next step is to assessment. The National Health and Disability Service provide a coordinated needs assessment service (National Health Board Disability Support Services, 2011b). A number of different service pathways are associated with the needs development and service specification processes, and an illustrative example/ overview is shown in Figure 1.

The aim of the assessment is to identify the child’s developmental status and needs, family/whānau resources, goals and needs, and to prioritise or sequence these (Child, Youth and Family & Ministry of Health, 2010). The Accident Compensation Corporation, a government funded agency providing personal injury cover, provides assessment services for infants and young children who have acquired a disability through traumatic injury (e.g., automobile accident, assault).  Families may also be assessed through the Work and Income Division of the Ministry of Social Development for financial support for the child and family. Following the assessment, the coordination services team identify, plan and review the services designed to address the identified goals and needs, including services provided through the government ministries as well as contracted service (Minister of Disability Issues, 2010). 

Assessment and planning for Māori whānau incorporates a cultural perspective including strengths, needs, information, connections, and supports relating to whakapapa (i.e., connections between the family, family histories), hapū (i.e., sub-tribes), iwi (i.e., tribes), whaka whānaugatanga (i.e., relating, relationships and supports), moemoeā (i.e., dreams and aspirations), mātauranga Māori (i.e., knowledge and experience of Māori, Māori world view), wairua (i.e., spiritual connectedness and beliefs) and mauiuitanga (i.e., physical, medical and mental health and wellbeing).  Planned assessment includes kaupapa Māori holistic approaches to health and wellbeing, including culturally safe and appropriate processes around engagement and validation of tikanga Māori (i.e., Māori cultural traditions and ways of knowing), including: rongoā (i.e., traditional healing), whānaugatanga (i.e., family relationships and connections), manaakitanga (i.e., kindness and hospitality), mātauranga Māori (i.e., traditional Maori education methodologies) and tautoko (i.e., support) for Māori self-determination of their own wellbeing. The assessment processes are localised to customary practices of different iwi and hapū and are undertaken by Māori with specialised knowledge and skills (Ministry of Education, 2010; Ministry of Health, 2004; Nga Oranga Mekameka Lifelinks, 2012).

Child development services (Ministry of Health)

Needs assessment may result in early intervention services through the Ministry of Health.  Services are provided by child development specialists, neurodevelopmental therapists, occupational therapists, and physiotherapists, working as teams. These teams work in conjunction with the services provided through the Ministry of Education (Ministry of Health & Ministry of Education, 2006) and the Ministry of Social Development (e.g., Family & Community Services, n.d a.).  Services focus on strategies to promote functional adaptation and support growth and development through daily living skills.  Information, support and education are provided to families and whānau to assist the child’s participation in daily living and active achievement of goals (National Health Board Disability Support Services, 2011b).

Early intervention services are also provided to support families with high environmental risk through programmes such as Early Start, Home Interaction Programme for Parents and Children (HIPPY) and Family Start which are coordinated in many parts of the country through Early Learning or Family Service Hubs (Eagen & Yarwood, 2010; Ferguson, Grant, Horwood & Ridder, 2005; Family & Community Services, n.d., a, b, c, d; Ministry of Social Development, 2010a).  These programmes are drawn from Western-science evidence-based interventions, with cultural adaptations for Māori families who are referred.  The introduction of the Whānau Ora Māori-centred health and social service delivery in 2010 provided an alternative approach, with Māori-led providers able to address referrals and provided services across the more traditional health, education and social service agencies (Boulton, Tamehana, & Brannelly, 2012).

Early intervention services (Ministry of Education)

Needs assessment and planning may result in referral to Ministry of Education early intervention services. These services may be provided concurrently with Child Development Services, or may follow those services as children are considered ready for early childhood education.  The hallmark descriptors of these early intervention services include: “family-centred practice; inclusive practice; natural environments for service delivery; team approach to service delivery, and culturally responsive services” (Ministry of Education, 2011, p. 5). Families work with a multi-disciplinary team led by an early intervention teacher to develop individual learning plans. Services including support for parenting and developmental supports within the home can begin at any time subsequent to the needs assessment.  This can include Incredible Years for Parents and Incredible Years for Early Childhood Teacher programmes (Ministry of Education, 2013a,b: Webster-Stratton, 2000) As the children approach the age of 3-years, individual plans may extend to including the child within a local early childhood centre, with the involvement of the early childhood educator.

Bicultural early intervention services are typically delivered through government supported local service providers4.  For Māori, the early intervention team includes a kaitakawaenga (i.e., Māori cultural advisor) and a manakitia te whānau (i.e.,  care for and protect the mana of the family) approach to assessment, which includes culturally respectful assessment practices based on cultural knowledge and traditions incorporated in identifying needs (Ministry of Education, 2009a). Children may be supported to attend Kōhanga Reo or a Māori led early childhood service.

 

Challenges

The bi-cultural early intervention system has evolved into a complex system.  However, the system is increasingly being challenged by factors both from without and within the service structure. These include pressures from increasing numbers of children with early intervention needs, problematic issues in the delivery of services and in meeting the needs of Māori.

Increasing population and prevalence

New Zealand’s population, particularly the proportion of young children, is growing, which means that the number of children needing early intervention services will increase.  However, this will be more than that associated with population growth, because there are also indications that the prevalence of disabilities and emotional and behavioural problems are increasing (Tuhoy, 2010). Recent statistics of emotional and behaviour problems in young children aged 2-4 years indicate that the midpoint of the estimated prevalence increased from 0.1% to 2% over the past five years, while diagnosed anxiety problems increased from about 0.01% to 1.7% (New Zealand Health Service, 2013). Intellectual disability ranges between 0.4 to 1.5% of young children, although young children are often diagnosed with developmental disability instead of intellectual disability (Ministry of Health, 2011a), and the trends show increasing numbers of young children admitted to hospital with a diagnosis of developmental disability (Craig, McDonald, Adams, Reddington, Oben & Wicken, 2011).  The prevalence of cerebral palsy may have increased due to the increasing survival of babies born low birth weight. The prevalence of autism and pervasive developmental disorders appears to be increasing (Craig, et. al, 2011). Although criteria for categorisation of a child with permanent hearing loss have recently changed, trends indicate gradual increases in prevalence (Craig, Adams, Oben, Reddington, Wicken, & Simpson, 2013), while the overall trends for children with Down syndrome fluctuated and neural tube defects declined (Craig, et. al, 2011). Accidental injuries, such as from automobile accidents, which may be associated with acquired disabilities, are increasing, as are intentional injuries and maltreatment (Craig, et. al, 2013; Craig, McDonald, Adams, Reddington, Oben, Simpson & Wicken, 2012).

The increasing prevalence of children with early intervention needs is associated with increasing income disparity, which affects all aspects of the health, education and disability systems (Morton et. al, 2012).  It is estimated that 20% of children are affected by income disparity (Children’s Social Health Monitor, 2009; Commissioner for Children, 2011; Ministry of Social Development, 2010). Despite New Zealand’s commitment to children, in 2009, it was ranked 29 out of 30 countries in child wellbeing, and was advised to concentrate on child health and child poverty (Craig, Adams, Oben et. al, 2013). Children living in poverty are at risk of increased behavioural, developmental, and disability needs (Halfon, Houtrow, Larson & Newacheck, 2012).  This is supported by statistics showing that the rate of depression, anxiety disorder and/or attention deficit hyperactivity disorder was 3.4% of children in the most economically deprived areas as compared to 2.8% in the least deprived areas (Ministry of Health, 2012a). Pre-term birth, low birth weight and child injuries, which are also associated with income disparity, are also risk factors for disability (Ministry of Health, 2012b).  While the overall rate of pre-term birth (7.4%) has increased since 2006-07, the increase is most marked in lower income areas (Craig, et al, 2013; Ministry of Health, 2012b).

Another factor contributing to the increase is increasing methamphetamine use among pregnant women.  New Zealand has one of the highest rates of usage in the world (United Nations Office on Drugs and Crime, 2011). Additionally, high rates of cannabis use (9.3-14.8%) and ecstasy (3.6-4.7%) are also concerning (LaGasse et. al, 2011).  About 48% of women continued to use alcohol while pregnant (Morton, et al., 2010).  Maternal use of these substances during pregnancy is associated with high risks of impairment in children’s development and behaviour (Brown & Graves, 2013; Singer et. al, 2012; Wouldes, LaGasse, Derauf et al, 2013).

Increasing prevalence is also associated with the exposure of children to violence. Although the exposure of children to violence occurs across the socio-economic spectrum, the number of these children is increasing (Caroll-Lind, Chapman, & Raskaukas, 2011). The Ministry of Social Development (2012) has identified that about 15% of young children may be at risk for mental health and learning issues, including children who suffer from maltreatment, with 21,000 cases reported in a single year.  In addition, more than 43,000 children witnessed family violence in that same year, which put them at risk for post-traumatic shock, anxiety or behavioural disorders (Caroll-Lind, Chapman, & Raskaukas, 2011; Litrownik, Newton, Hunter, English & Everson, 2003).

Screening

More than 90% of children in New Zealand receive at least one screen before school, as compared with about 20% of children in the USA (Bethell, Reuland, Schor, Abrahms & Halfon, 2011; Ministry of Health, 2010c).  A recent review of screening services resulted in changes, including the introduction of a more comprehensive check, the B4 School check (Ministry of Health, 2010b; 2010c, Tuhoy, 2010).  However, screening data from the B4 School Check indicated that the needs of many children were first identified at this screening, aged 4 years (Ministry of Health, 2012b).  During the period from July 2008 to February 2012, 143,431 children were screened.  Of these, 1.9% of children were identified as meeting criteria for referral for behavioural problems, 7.5% for vision and 6.4% for hearing. In addition, 3.3% of children had concerns for developmental delay in two or more domains (i.e., cognitive, social-emotional, motor, or language).  Wills and colleagues (2010) indicated that perhaps 74% met the criteria for services following assessment, and that only 14% of the conditions were identified previously (e.g., at the age 2-3 screen).  

It is concerning that so many children’s needs are first identified at age 4 years, or between the ages of 4 to 4yrs 6 months, because there will be little or no time following the screening and referral process for children to access early intervention services.  This indicates that there may be a problem with screening accuracy at the 2-3 year screen, or with screens at the younger ages.  Because of the later identification, children are not likely to access services with sufficient time to address their needs so that they can enter school ready to learn, as compared to those children whose needs are accurately identified at a younger age.  The Ministry of Health (2013) has identified as targets to improve the timing of screening. However, the screening protocols used at ages 2-3 years should also be reviewed in order to reduce the number of children whose early intervention needs are first identified just before they start school.

Another reason for the increased identification of potential problems in the B4 School Check is the possibility that such children had not previously been screened.  This can include children from two groups: children who did not attend preschool until age three or four, as screening is commonly initiated in preschool settings; and children whose parents refuse screening.  For instance, more than 20% of parents refuse hearing screening of their newborns (Craig, et. al, 2013). It is likely that many children who miss screening are from lower decile families who are among the groups less likely to participate in early childhood education or screening (Auckland Regional Public Health Service, 2012; D’Souza, Turner, Simmers, Craig & Dowell, 2012; Wills, et al, 2010). Thus, the newly identified children at age 4 may be previously unscreened.

Perhaps up to 20% of children missed the B4 School Screen in the most recent year (Health Improvement & Innovation Resource Centre, 2013). Unfortunately, there is a high probability that the unscreened group includes even more children who should be referred because of a probable disability, because many of the unscreened group are from low decile areas, or from population groups with higher rates of disabilities. For instance, in the calendar year report for 2011-2012, as the number of children screened increased toward 80%, the percentage of four year olds identified as meeting referral criteria for behavioural problems increased from 1.9% to 4.2% and developmental concerns from 3.3% to 5.4% (Ministry of Health, 2012 c, e).  The Ministry of Health has set increasing targets for the coverage of children in all of the Well Child checks (2013). However, it is anticipated that as the screening coverage improves, increasing numbers of children will be identified, and this will put additional pressure on early intervention services.

Referral rate

Most screening measures can be scored quickly, so that parents/carers can be referred to appropriate services immediately. However, a significant proportion of children meeting referral criteria appear to have missed out on referral.  For instance, of children with developmental delay in two or more domains, only 33.9% of children meeting this criterion were referred in the period September 2011 to July 2012 (Ministry of Health, 2012f).  Similarly, referral rates below 30% were recorded for severe behaviour problems. The Ministry of Health is investigating barriers and processes of referral that may differ across district health boards (Ministry of Health, 2012f). Referral is an essential step for early intervention.  If children are not referred, then early intervention support is not provided.  The Ministry of Health (2013) has identified this as a goal, setting a target of 86% referrals to improve processes. However, increasing the referral rate means that more children will be referred, creating additional pressure on early intervention services. Therefore, the recent screening and referral data indicate (1) an increase in the number of children with  early intervention needs over previous levels,  (2) that these are not identified until they are four years of age or older, and (3) that some children who meet criteria for referral are not being referred for services.

Family engagement

Pockets of data indicate there are challenges with other aspects of early intervention: only 15% of those eligible were offered an early intervention programme for families with a young child with autism, 30-40% of families failed to attend early intervention services following referral, and some intervention services report a 20% drop-out rate (Birkin, Ander, Seymour & Moore, 2008; Families Commission, 2011; Wills, et al 2010).  One family reported that they were threatened with the loss of publicly- funded physiotherapy if they augmented this by paying for private services, even though the public services were for one session of physiotherapy per month (Morton, 2013).  Families and children not accessing the services are likely to be those in the highest risk groups, Māori or Pacific Island families, or in families living in poverty, without stable homes, transportation or in rural areas with few services (Black, Butler, Dunbar & Wheeler, 2011; Families Commission, 2011). Investigations into the reasons for these concerning reports are needed in order to provide information to strengthen service delivery.

Staffing

Insufficient staff to provide services for children’s mental health and behavioural problems has been identified as a problem limiting service delivery (Commissioner for Children, 2011; Prime Minister’s Youth Mental Health Project, April 5, 2012; The Royal Australian and New Zealand College of Psychiatrists, 2010). In some regions, insufficient staff has resulted in large caseloads and waiting lists of 6-18 months, and some services, such as speech and language therapy, have stopped operating waiting lists, as services struggle to address such issues (Birkin, et. al, 2008; Gibson, Thorp & Moffit, 2011; Planning and Funding Directorate, 2011).

Transition to school

Although early intervention services can continue to age 8 years, support for learning delivered within the school system has different eligibility criteria and may be delivered by a different team, and the indicators are that children with early intervention needs are not receiving continuing services as they start school. This has been targeted for improvement by the Ministry of Education (2012). An additional concern is the need to increase the number of primary schools that are welcoming of children with high needs (Education Review Office, 2013).

Early intervention for Māori children

There are a number of issues in early intervention for Māori. Only 66% of Māori infants received Well Child services as compared to 90% of other children (Auckland Regional Public Health Service, 2012), and Māori infants have higher rates of cleft palate, neural tube abnormalities and other conditions associated with early intervention needs (Craig et al, 2012). Māori have lower rates of participation in Well Child checks (Ministry of Health, 2011b; Wills, et. al, 2010). Māori are over-represented in areas of poverty; the most deprived 10% of neighborhoods were home to 35 % of children aged 0-14 years of whom 72.4% were Māori (Ministry of Health, 2011b). And, as poverty is associated with disabilities, of Māori children aged 0-14 years, 14% had a disability, compared to 9% of non-Māori children (Māori Health, 2010; Office for Disability Issues and Statistics New Zealand, 2010). Experiences of racial discrimination, including verbal and physical attacks, and unfair treatment in health, housing and/or work further exacerbate health disparity for Māori (Harris, Tobias, Jeffreys, Waldergrave, Karlsen & Nazroo, 2006). Even with the higher rates of disabilities, providers are less likely to refer Māori to early intervention services (Ministry of Education, 2009b). Māori may also be less likely to engage in services (Dunn, 2012).  In addition, 25% of Māori children with an identified disability are not participating in any early childhood programme (Office for Disability Issues and Statistics New Zealand, 2010). One potential reason may be due to Māori cultural perceptions that Western-style services pathologise children with special needs rather than nurture them, or are perceived to ‘blame the parent’ for children’s needs (Birkin, et. al, 2008; Shields, Bishop, & Mazawi, 2005; Wells et. al, 2010). 

Addressing the challenge to provide effective early intervention support to Māori should involve moving beyond “culturally appropriate” bi-cultural services to “culturally-responsive” services drawn from kaupapa Māori (Dunn, 2012; Macfarlane, 2011).  Culturally responsive services may include assessments and intervention strategies that strengthen overall connectedness to the wider family and Māori culture, support family Tapa Wha, enhance Māori identity and provided within culturally appropriate services, such as Kōhanga Reo (Bevan-Brown, 2006; Rameka, 2011). 

The difference between culturally appropriate and culturally responsive services can be highlighted by a consideration of the language used in bi-cultural early intervention. In a presentation to Te Puna Wānanga and Ngā Pae o te Māramatanga, Eduardo Duran (2012) suggested that in Western languages, meaning is carried by nouns, but in many indigenous languages, meaning is carried by verbs. To aid in understanding a kaupapa Māori approach to early intervention, the Western term ‘intervention’ could be re conceptualised as ‘intervening.’  This term encompasses the action and changes by all participants in a partnership model in accord with the Treaty of Waitangi, whereas the term ‘intervention’ may have overtones of colonial strategies to change or ‘’modify’ indigenous peoples (Smith, 1999). 

The journey of intervening would have the aim of restoring or establishing Manaakitanga (i.e., collective well-being) by addressing all of the cornerstones simultaneously and in a coordinated fashion as early as possible through the family collective.  Intervening would involve growing respectful relationships (i.e., whānaungatanga), gradually integrating Māori protocols (i.e., tikanga Māori) and involving kaumātua (i.e., elders) and the entire whānau to establish mana (i.e., collective responsibility), including the process whereby the ‘early intervention team’, for example, becomes part of the whānau in an on-going commitment to change.  Linda Tuhiwai Smith (1999) identifies intervening strategies for healing and restoration, such as storytelling, celebrating, and remembering. These strategies could provide a sound basis for new forms of culturally responsive intervention strategies.5

Recruitment of Māori into training programmes is also a point of pressure. There is a shortage of Māori psychologists, speech language therapists, neurodevelopmental therapists, physical and occupational therapists and early intervention teachers (Curtis et al, 2012; Health Workforce Advisory Committee, 2006.).  One hypotheses for recruitment problems is that training is provided predominantly in the western model, which may be viewed as unsafe for kaupapa Māori;“Ako Pākehā atu, ka puta Pākehā mai” (Given Pākehā teaching, it will be Pākehā thinking that emerges) (Milne, 2005, p. 13). The challenge is to develop kaupapa Māori professional education and training by Māori for Māori, so that Māori can develop and deliver kaupapa Māori early intervention services within an overall government policy of service diversification (Ringold, 2005).  Training in cultural responsivity has been successful in engaging some Māori in early intervention services (Berryman & Woller, 2011) and increasing commitment to this training is evident in new initiatives from the Ministry of Education in training specialist early intervention teachers. Additionally, there has been recognition that the assumption that all Pacific cultures are similar is false.  Therefore, a ‘generic’ model of service provision for all is inappropriate (Bush, Chapman, Drummond & Fagaloa, 2009). The development of culturally appropriate services is underway for the growing number of families from Pacific Island nations, including Samoa, Fiji, and Tonga,

Disjunctions with early childhood services 

Differences in philosophies of service with early childhood education are affecting early intervention services.  From the perspective of early childhood education, some aspects of early intervention service are at odds with early childhood philosophy - for example, the use of ‘checklist-style’ screening (Williamson, Cullen, & Lepper, 2006). Parents and early childhood teachers are expected to tick boxes to indicate whether a child has behaviour problems. This form of assessment is very different to the strength-based narrative assessment used in early childhood centres (Liberty, 2009). Another point of disjunction is the use of diagnostic labels and protocols developed in the United States, which are based on ‘deficit’ models of disability (American Psychiatric Association, 2000)6.  A third potential disjunction is the assumption that strategies such as one-to-one instruction, exclusive play materials or an allocated teacher aide should be implemented within early childhood centres, although these strategies do not fit within the philosophy and curriculum of early childhood centres (Purdue, et. al, 2011). These issues may contribute to negative perceptions of early intervention held by early childhood educators (Bush, Chapman, Drummond & Fagoaloa, 2009; Purdue, et al, 2011). From the perspective of early interventionists, early childhood services are not inclusive or welcoming of children with early intervention needs, and staff do not understand such children and may exclude them, and may have difficulty establishing relationships with Māori (Education Review Office, 2012; Martin & Mills, 2012; Purdue, et. al, 2009; 2011). These disjunctions between early intervention and early childhood education are affecting the delivery of quality services to young children with special needs.

 

Conclusion

The development of an early intervention service sector that braided Western-cultural approaches to special needs in young children with kaupapa Māori models focusing on whanau and strength-based support has been a worthwhile journey. Innovative and effective practices have helped a large number of children.  However, several dynamic points of pressure on the system have implications for new directions.  These include pressure of increasing numbers associated with increasing population and increasing prevalence of emotional and behavioural problems and disabilities.  Screening coverage, referral rates, and service engagement are also issues indicating a system-wide concern.  In particular, concerns with Māori children and families must be addressed to meet overall government priorities in education, health and social welfare. The lack of effective services for young children with early intervention needs is likely to be associated with poor academic outcomes, conduct problems and violence, unemployment, and other social costs.

Given the indicators of increasing prevalence, which may be between 5-15%, it is important that early intervention services address this challenge by the expansion of coverage. Currently, the Ministry of Education has a target of 4% of children (Alliston, 2007), however, the number of children receiving early intervention services decreased by more than 500 children between 2011 and 2012 (Ministry of Education, 2012), although the total number receiving services through all of the service pathways is unknown due to complexities in the data management systems and cross-sectoral service provision.

Considering the increasing prevalence, and the constraints associated with the economy, some difficult decisions must be made about early intervention services.  New Zealand's per person funding for health is the 20th lowest in the OECD and it has reduced its spending on education since 2000 (OECD, 2011b). Although one approach is to increase funding for early intervention services (New Zealand Medical Association, 2012; Auckland Regional Public Health Services, 2012), early intervention services would not necessarily be improved by an increase in funds alone.  The Ministries of Health, Education and Social Development might find improvements and economies of scale by integrating services to reduce duplication.  These might include, for example, reducing resources presently directed at eligibility testing and assessment and increasing resources for family support through the use of a tiered Response to Intervention model (Coleman, Roth & West, 2009), or reducing in-home intervention services in favour of a community model (Reynolds, Ou, & Topitzes, 2004) delivered, for example, at early childhood hubs.

Bi-cultural early intervention has provided a sound foundation for the development of culturally appropriate services for Māori children and whānau.  However, the indicators of disparity affecting Maori children with early intervention needs directs attention to the goal of developing culturally responsive services, including Kaupapa Māori training for wellbeing professionals. The benefits of developing such services also include the potential that new models of early intervention to promote wellbeing will be powerful interventions for all children in Aotearoa New Zealand.

The recently announced government stocktake of child development services needs to be the first step in a systematic review that it is informed not only by parents, whanau, service providers and best practices drawn from the literature, but also by a meta-vision of cross sector and national coordination, as well as careful linkages into care and education for youth and adults.

 

Endnotes

1.  While early intervention can conceptually apply to any condition or problem, in New Zealand this term generally is associated with young children with disabilities or developmental disorders

2.  For a history of early intervention, the reader is referred to Cullen and Carroll-Lind, 2005, as a starting point.

3. Significant differences with Western concepts of child development also impact on early intervention. Briefly, these include, but are not limited to, the following.  1. Changes along life’s journey are not separated into discrete time periods, such as “infancy, early childhood, adolescence, but life’s journey is conceptualised, for example, as the flow of a river, with eddies, curls, currents, rocks, and river banks. Every child/person/whanau/hapu is to be respected as always a learner (i.e., Matapuna). 2. Similarly, child development is not conceptualised as occurring in “stages.” or as ‘steps’ which conceptually ‘progress’ or ‘lead upward’ to ‘adult thought’. 3. Conceptually separate ‘domains’ of development are not recognised (e.g., cognitive, physical, socio-emotional), nor are thoughts separated from emotions.  4. Developmental change is not conceptualised as occurring ‘within’ individuals, but as an “interconnecting eventing’ (i.e., Ako) that includes the child/ whanau/ hapu/ iwi.  5. Learning and change are not conceptualised as observable behaviours that can be objectively measured through observation and testing. 6. Kaupapa Māori does not accept the Western concept of normative comparisons (e.g., comparing an individual to a norm sample) as a way of establishing one’s place in the world.

4.  Please visit the Trust’s website to gain an overview of one Māori service provider’s approach to providing initial information to families and whānau over the internet on: http://ohomairangi.org.nz

5.  This section was informed by the following sources: Austin, 1992; Bishop 2003; Boulton, Tamehana, & Brannelly, 2012; Cherrington, 2009; “Cultural Perspectives”, 1987; Durie, 1994; 1995; 1998; 2005; 2007; Gerzon, 1992; Kara et al, 2011; Macfarlane, 2011; Macfarlane, Fickle, Savage, Macfarlane & Tarena, 2012; Mahuika, Berryman & Bishop, 2011; Mason, 1992; Milne, 2005; Moore & Wikaira, 1996; Mohi, McCudden & Glynn, 1993; Pere, 1982; Price, 1991; Rautaki Ltd & Māori and Indigenous Analysis, n.d., Ratima, Durie, Allan, Morrison, Gillies & Waldon, 1995; Ratima & Ratima, 2007; Ringold, 2005; Sachdev, 1989; Smith,1990; 1991.

6. A new edition was published in May, 2013, but is not yet in use in New Zealand.

 

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Acknowledgements

I would like to thank the following people for support and advice on the preparation of this paper: Jo Davies, Early Intervention Service Coodinator, Ministry of Education; Sonja Macfarlane, Senior Lecturer in Maori Health and Wellbeing, College of Education, University of Canterbury, and Pat Tuohy, Advisor on Child Health, Ministry of Health.

 

About the Author

Kathleen Liberty, Ph.D. is an Associate Professor in the School of Health Sciences, and convenor of the Early Intervention programme at the University of Canterbury.  She has been researching in early intervention and the learning of young children for more than twenty years.  She is currently involved in a longitudinal project studying the wellbeing of children who were in preschool at the time of the Canterbury earthquakes.  

 

 

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