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entitled 'Individuals with Disabilities Education Act: Education Should 
Provide Additional Guidance to Help States Smoothly Transition Children 
to Preschool' which was released on December 14, 2005. 

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Report to the Ranking Minority Member, Committee on Health, Education, 
Labor, and Pensions, U.S. Senate: 

United States Government Accountability Office: 

GAO: 

December 2005: 

Individuals with Disabilities Education Act: 

Education Should Provide Additional Guidance to Help States Smoothly 
Transition Children to Preschool: 

GAO-06-26: 

GAO Highlights: 

Highlights of GAO-06-26, a report to the Ranking Minority Member, 
Committee on Health, Education, Labor, and Pensions, U.S. Senate. 

Why GAO Did This Study: 

Part C of the Individuals with Disabilities Education Act (IDEA) was 
established to ensure that infants and toddlers with disabilities, from 
birth to age 3, and their families receive appropriate early 
intervention services. Within the Department of Education (Education), 
the Office of Special Education Programs (OSEP) is responsible for 
awarding and monitoring grants to states for Part C according to IDEA 
requirements. To address questions about how states have implemented 
IDEA Part C, this report provides information on (1) how Part C 
programs differ in their eligibility criteria and whom they serve, (2) 
to what extent states differ in their provision of services and 
funding, and (3) how Education and state lead agencies help support and 
oversee efforts to implement Part C, such as identifying children for 
services and transitioning children to follow-on programs, such as IDEA 
Part B. 

What GAO Found: 

Eligibility criteria for Part C services for infants and toddlers with 
disabilities differ from state to state, but do not consistently 
explain the percentage of children served, which ranges between 1.3 and 
7.1 percent. To determine eligibility, most states measure how much the 
child is delayed in one or more areas of early childhood development, 
while a few rely exclusively on a clinical teamís judgment. Although 
IDEA Part C is intended to cover children from birth to age 3, most 
states provide the majority of their Part C services to children 2 to 3 
years old. States have public awareness campaigns to identify more 
eligible infants and toddlers but cite a number of obstacles, including 
difficulty reaching children in rural areas or in families where 
English is a second language. 

The states we visited provide a similar set of services but vary in 
funding sources. States are required to make available certain early 
intervention services under IDEA, such as occupational, physical, and 
speech therapy. However, states report challenges recruiting and 
retaining professionals, such as speech language pathologists, to 
provide these services. States rely on various funding sources, but 
state general revenue funds were generally the largest source of early 
intervention funding.
Percentage of Early Intervention Services Most Frequently Provided: 

[See PDF for image] 

[End of figure] 

OSEP and state lead agencies have provided training and technical 
assistance and used data to monitor implementation of IDEA Part C, but 
OSEP has lacked some information from local officials needed to 
determine if children are smoothly transitioning from Part C to Part B. 
OSEP uses annual reports and performance indicators as part of its 
effort to monitor compliance with Part C and target technical 
assistance. For example, data on the percentage of children served help 
inform OSEP of statesí efforts to identify all eligible children. 
States use similar approaches. Despite these activities, state 
officials cited challenges transitioning children to Part B services 
when they turn 3 years old. Education indicated that in preliminary and 
unpublished data from an ongoing study it had found that gaps occur 
throughout the year. Officials in the states we visited reported that 
some children who turn 3 during the summer experience gaps in service. 
If Part B eligibility is not determined prior to children turning 3 
during the summer, then subsequent decisions about whether children 
should receive extended school year services cannot be made. 

What GAO Recommends: 

GAO recommends that Education provide states with additional guidance 
on transition planning and services, especially for children who would 
enter Part B during the summer. In comments on our draft, Education 
cited an ongoing study of general transition issues. When Education 
verifies the results of its study, it should use that information to 
inform guidance to states on transition planning. 

www.gao.gov/cgi-bin/getrpt?GAO-06-26. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Marnie Shaul at (202) 512-
7215, or shaulm@gao.gov. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

Eligibility Criteria Differ among States but Are Not Consistently 
Related to Percentage of Children Served: 

Selected States Provide Similar Services but Vary in Funding Sources: 

Both OSEP and States Use Data to Monitor Part C Compliance, but 
Challenges Persist in Transitioning Children to Part B: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Select Federal and State Funding Sources for Early 
Intervention Services: 

Appendix II: Comments from the Department of Education: 

Appendix III: GAO Contact and Staff Acknowledgments: 

Table: 

Table 1: Sources of Funding for Early Intervention Services in Site 
Visit States: 

Figures: 

Figure 1: States Visited with Type of Agency Leading Part C and Number 
and Percentage of 0-3 Population Participating in Part C: 

Figure 2: Stages of a State Early Intervention System from Intake to 
Service Delivery: 

Figure 3: National Percentage of Children Receiving IDEA Services by 
Age in 2004: 

Figure 4: Examples of Services States Made Available to Infants and 
Toddlers Covered by Part C: 

Figure 5: Percentage of Early Intervention Services Most Frequently 
Provided: 

Figure 6: Examples of Federal and State Funding Sources: 

Abbreviations: 

CDC: Centers for Disease Control and Prevention: 

IDEA: Individuals with Disabilities Education Act: 

IEP: individualized education program: 

LEA: local education agency: 

NEILS: National Early Intervention Longitudinal Study: 

OSEP: Office of Special Education Programs: 

TANF: Temporary Assistance for Needy Families: 

[End of section] 

United States Government Accountability Office: 

Washington, DC 20548: 

December 14, 2005: 

The Honorable Edward M. Kennedy: 
Ranking Minority Member: 
Committee on Health, Education, Labor, and Pensions: 
United States Senate: 

Dear Senator Kennedy: 

The first few years of a child's life are critical to development. 
While most children attain developmental milestones as expected, some 
children develop more slowly or develop differently because of 
physical, mental, or environmental factors. Research suggests that for 
an infant or toddler who exhibits developmental delay, has a diagnosed 
condition that has a high probability of resulting in developmental 
delay, or is substantially at risk of having a developmental delay 
early intervention services, such as family counseling and physical 
therapy, can have a significant impact on early childhood development. 
To assist states in ensuring that such infants and toddlers receive 
early intervention services and support, Congress appropriated $444 
million in fiscal year 2004 for grants to states under Part C of the 
Individuals with Disabilities Education Act (IDEA Part C). States used 
Part C grants to arrange early intervention services for approximately 
279,000 infants and toddlers with disabilities from birth to age 3. 
Administered by the Department of Education's (Education) Office of 
Special Education Programs (OSEP), Part C is intended to support 
states' efforts to coordinate and leverage funding from other federal, 
private, state, and local sources to ensure early intervention services 
are available to eligible children. For services to children with 
disabilities after their third birthday, IDEA Part B Section 619 
provides grants to states to provide special education and related 
services to children with disabilities aged 3 through 5 and, at a 
state's discretion, to children before their third birthday. 

Given your interest in the manner in which states have implemented the 
provisions of Part C, we examined (1) how Part C programs differ in 
their eligibility criteria and whom they serve, (2) to what extent 
states differ in their provision of services and funding, and (3) how 
Education and state lead agencies help support and oversee efforts to 
implement Part C, such as identifying children for services and 
transitioning children to IDEA Part B or other services. 

We used multiple data collection methods to address these issues. We 
conducted site visits to seven states--Colorado, Hawaii, Illinois, 
Maryland, Massachusetts, New Jersey, and Oregon--and reviewed their 
annual performance reports. We chose states to visit based on the type 
of state agency responsible for coordinating the Part C program (lead 
agency), number of children served, whether the state served at-risk 
children, geographic location, and whether the state participated in an 
OSEP-funded project aimed at early identification of infants and 
toddlers. Figure 1 illustrates the states visited and selected 
characteristics. 

Figure 1: States Visited with Type of Agency Leading Part C and Number 
and Percentage of 0-3 Population Participating in Part C: 

[See PDF for image] 

Note: Hawaii and Massachusetts serve at-risk children. 

[End of figure] 

In each of the selected sites, we met with state Part C coordinators, 
states' Part B staff responsible for transitioning children to 
preschool programs, and the manager of one or more local early 
intervention programs. Because Medicaid--the federal-state health- 
financing program for certain low-income individuals--can be an 
important source of funds for early intervention services for Medicaid- 
eligible children, we also met with Medicaid officials in three states. 
Additionally, we met with OSEP officials and reviewed their guidance 
and monitoring reports. We also analyzed 2002, 2003, and 2004 data 
collected by Education. We used the most recent data available from 
OSEP. These data, available at IDEAdata.org, include information about 
infants and toddlers with disabilities, such as the services they 
received, the location where they received them, and what follow-on 
program they entered when they were no longer eligible for Part C. We 
used information from IDEAdata.org for the 50 states and the District 
of Columbia. Although we determined that some data provided by OSEP 
were not reliable, we obtained documents demonstrating that the office 
has controls in place to ensure a reasonable degree of accuracy and 
reliability in many of its data, and determined that the data elements 
we used were sufficiently reliable for our purposes. We also conducted 
interviews with educational associations, officials from the Centers 
for Disease Control and Prevention's National Center on Birth Defects 
and Developmental Disabilities, and other experts. Our work involved 
reviewing the availability and differences in types of services; we did 
not examine the quality of services delivered or the appropriateness of 
services provided to children. We conducted our work in accordance with 
generally accepted government auditing standards between September 2004 
and December 2005. 

Results in Brief: 

Nationwide, states' eligibility criteria for Part C services differ, 
but are not consistently related to the percentage of children served. 
State eligibility requirements vary for children who do not have an 
established or diagnosed condition that has a high probability of 
resulting in developmental delay. Most states require that such 
children exhibit a specific level of developmental delay and be deemed 
eligible according to an informed clinical opinion. A few states rely 
exclusively on clinical judgment. For example, Arizona requires 50 
percent delay in one or more aspects of development, such as physical 
or emotional, while Hawaii relies on the judgment of a team of 
clinicians. Moreover, eight states also include in their eligibility 
criteria infants and toddlers who are at risk of having a substantial 
developmental delay because of biological risks, such as low birth 
weight, or environmental risks, such as parental substance abuse. 
However, eligibility criteria do not sufficiently explain differences 
in the percentage of all infants and toddlers in a state receiving 
early intervention services. The Centers for Disease Control and 
Prevention (CDC) reported a lack of data on the prevalence in the 
general population of children under 3 who have developmental delays 
and could benefit from early intervention services; many conditions 
covered by the Part C eligibility definitions--such as learning 
disabilities or emotional disorders--are not routinely tracked. 
Although IDEA Part C is intended to cover children from birth to age 3, 
most states (38) provide the majority of their Part C services to 
children 2 to 3 years old. States have developed public awareness 
campaigns to help identify more infants and toddlers in need of 
services, but officials in the states we visited told us that a number 
of obstacles prevented them from reaching all children as early as 
possible, including difficulty in reaching children in families where 
English is a second language or families living in rural areas. 

The states we visited provided similar services and confronted similar 
challenges recruiting and retaining staff to deliver them, but they 
varied in funding sources. States are required to provide certain 
services to children in early intervention programs, including 
occupational, physical, and speech language therapy to help with skills 
like feeding, walking, and talking. However, states reported challenges 
recruiting and retaining individuals to provide these services, 
especially speech language pathologists and occupational therapists. 
State officials noted that providers often have to spend time traveling 
to the homes of families to deliver services, which they said could be 
burdensome, and they also noted salaries are often higher in the 
private health care sector. States use various sources of funding to 
support Part C services, with some relying on multiple funding sources 
and others relying primarily on Part C and state general revenue funds. 
State general revenue funds constituted the largest source of early 
intervention funding in most of the states we visited, while local 
funds were often a much smaller source. Officials in the states we 
visited said there were challenges in accessing some funding sources, 
such as Medicaid. We found inconsistencies in the funding data states 
provided to OSEP as part of their annual performance reports, and OSEP 
decided during our review that the data were incomplete and unreliable 
and announced plans to stop collecting them. 

OSEP and state lead agencies provide training and technical assistance 
and use data to monitor implementation of IDEA Part C, but they have 
lacked some information needed from local service providers to 
determine if children are smoothly transitioning from Part C to Part B. 
To monitor states' compliance with Part C requirements and to target 
technical assistance, OSEP examines annual performance reports, 
performance indicators, and other data provided by state lead agencies. 
States, which are responsible for oversight of local programs, are free 
to design their own oversight methods, but they generally described 
approaches similar to OSEP's. Despite oversight and assistance 
activities, state and local officials in the states we visited cited 
challenges in transitioning children to Part B services when they turn 
3 years old. In addition, in commenting on a draft of this report, 
Education cited preliminary unpublished data that would suggest 
transitions are a year-round problem. Officials in the states we 
visited reported that some children who turn 3 during the summer 
experience gaps in service during the transition process. The gaps 
occur, in part, because school districts generally operate on a 9-month 
academic calendar and some school districts may delay determination of 
eligibility for any Part B services until the fall. If Part B 
eligibility is not determined prior to children turning 3 during the 
summer months, then subsequent decisions regarding extended school year 
services cannot be made. Most officials said the frequency with which 
extended school year services are provided to children transitioning to 
Part B could not be determined because neither OSEP nor the state 
collected extended school year data. Also, Part C officials and local 
early intervention staff told us they face difficulties in finding out 
if children are determined eligible for Part B. Not having eligibility 
information hinders local early intervention staff's timely referral of 
children found ineligible for Part B to other follow-on preschool 
programs. Additionally, Part C officials are responsible for reporting 
Part B eligibility to OSEP. 

In its comments on a draft of this report, Education disagreed with our 
recommendation that it incorporate into its research agenda a method 
for determining how frequently children transitioning from Part C to 
Part B do not receive services during the summer months. Education 
noted that preliminary and unpublished data from a department study 
indicate that gaps occur when children are transitioned from Part C to 
Part B, not only during the summer, but whenever transitions occur. 
Additionally, in response to our recommendation that if gaps in 
services are found to be a problem, Education should provide states 
with additional guidance on improving children's access to extended 
school year services, Education stated that, based on its preliminary 
data, there is no need to study extended school year services. We 
modified our recommendation to acknowledge Education's ongoing study 
and are now recommending that the Secretary of Education provide states 
with additional guidance on transition planning and services for 
children with birthdays during the summer and especially in cases where 
children are likely to need extended school year services. 
Additionally, when Education completes and verifies the results from 
its ongoing studies relating to transitioning, it should use that 
information to inform the department's guidance on transitioning. 

Background: 

According to research, comprehensive early intervention programs can 
positively affect the progress of children with developmental delays 
and children at risk of having a disability. Services provided by these 
programs may include speech language therapy, family counseling, and 
home visits. Research has linked early intervention services to 
improvements in toddlers' behavior, interactions between parents and 
children, infant development, and overall quality of life for children 
and their families. Additionally, research has found increased mental 
development and better vocabulary and reasoning skills for children who 
received early intervention services when compared with those who did 
not receive these services. Findings from the National Early 
Intervention Longitudinal Study (NEILS), a research project sponsored 
by the Department of Education, has found that parents report a high 
degree of satisfaction after receiving 3 years of early intervention 
services, reporting that their families are better off and that early 
intervention services are having "a lot" of impact on their child's 
development.[Footnote 1] 

IDEA is the primary federal education law for infants, toddlers, 
children, and youth with disabilities. Grants to states for early 
intervention services and special education and related services for 
children with disabilities and their families are provided mainly 
through Parts C and B of the act. These parts have different histories 
and are generally administered by different agencies at the state 
level. IDEA Part C was established to ensure that infants and toddlers, 
from birth to age 3, with disabilities or at risk of developing a 
disability, and their families receive appropriate early intervention 
services. Part C focuses on, among other things, enhancing the 
development of infants and toddlers with disabilities by providing 
services in a natural environment, such as the home or a child care 
center. This part of the law seeks to improve the capacity of the 
family to meet the child's needs and reduce educational costs by 
minimizing the need for special education when the child is older. Part 
B, in contrast, requires that services, to the extent possible, be 
provided in educational settings, such as regular classrooms. Part B, 
which includes state grants for children and young adults ages 3 
through 21, and Part B Section 619 preschool grants for children 3 
through 5, aims to ensure that children with disabilities have access 
to a free appropriate public education. Funding for Part B is 
significantly larger than for Part C programs. In fiscal year 2004, 
Part C was funded at $444 million, and approximately 279,000 infants 
and toddlers received services.[Footnote 2] In contrast, Part B state 
grants and the Section 619 supplement for preschool services were 
funded at $10 billion and $388 million, respectively, in 2004. 
Approximately 6 million children were provided services under Part B 
state grants, and over 693,000 children were provided preschool 
services under Part B Section 619. 

To meet Part C goals, states use funds to develop a statewide, 
coordinated, multidisciplinary, interagency system of early 
intervention services for infants and toddlers with disabilities and 
their families. Developing such a system includes designating a lead 
agency, preparation and dissemination of materials on the availability 
of services, defining eligibility criteria, and delivering services. To 
this end, each state has a designated lead agency responsible for the 
administration, supervision, and monitoring of Part C. In contrast to 
Part B, which is led by state education departments, Part C is led by 
the health department in 16 states, education departments in 11 states, 
and other departments, including combined health and human services 
departments, in the remaining 23 states. States are expected to 
leverage funding, services, and resources from other sources to provide 
early intervention services. Each state must have a continuous process 
of public awareness activities and evaluations designed to identify and 
refer as early as possible all young children with disabilities and 
their families who are in need of early intervention services. By law, 
public awareness efforts should include disseminating information to 
parents on available early intervention services and to all primary 
referral sources, especially hospitals and physicians. Efforts may also 
include television ads, pamphlets, and posters describing IDEA Part C 
and how parents can access services for their child. 

Once a child is referred and suspected of having a disability, states 
are required to conduct an evaluation to determine if the child meets 
the state's eligibility criteria. In order to be eligible for federal 
funds under Part C, IDEA requires that states provide services to any 
child under 3 years of age who is developmentally delayed. These delays 
must be measured by appropriate diagnostic instruments and procedures 
or validated by professional opinion, and may occur in one or more of 
the areas of development--including cognitive, physical, communicative, 
social or emotional development, and adaptive behavior, such as feeding 
or toileting. States must also provide services to those children that 
have a diagnosed mental or physical condition that has a high 
probability of resulting in developmental delay. However, states are 
free to define what constitutes a developmental delay and specify how 
this will be measured. In addition, states may choose to serve children 
who are at risk of having a substantial developmental delay. These may 
include biological risks, such as low birth weight, and environmental 
risks, such as parental substance abuse. Once an eligible delay has 
been detected, service coordinators work with parents and others to 
match children with services specific to their needs. Part C requires 
that every state make certain services available, including special 
therapies such as physical, occupational, or speech language therapy, 
and family supports such as home visits. For example, an occupational 
therapist may come to a child's home to teach a child to draw, which 
involves hand and eye coordination. The law also requires that services 
be provided in children's natural environments. Figure 2 illustrates 
the typical process in early intervention programs. 

Figure 2: Stages of a State Early Intervention System from Intake to 
Service Delivery: 

[See PDF for image] 

[End of figure] 

Children eligible for Part C can receive early intervention services 
until they turn 3 years of age. Part C funds can be used to provide 
services to children from their third birthday to the beginning of the 
following school year, but as of 2004 only 14 states have adopted such 
a policy. Thirty states allow for the use of Section 619 preschool 
funds to provide services to children before their third birthday. As a 
child approaches age 3, the local education agency (LEA) determines the 
child's eligibility for Part B Section 619 preschool services. If 
eligible for Part B Section 619, the child might also be eligible for 
extended school year services. An extended school year ensures that a 
child can continue receiving services even when schools are not in 
session, for example, during the summer. According to Education, most 
children under Part B do not receive extended school year services. By 
contrast, Part C is a year-round program. Eligibility for an extended 
school year is determined on an individual basis and is generally based 
on how much a child will regress and the time it will take to regain 
lost skills. During the most recent reauthorization of IDEA, in 2004, 
Congress gave states the option of allowing children to continue to 
receive services under Part C until they become eligible for 
kindergarten. 

Eligibility Criteria Differ among States but Are Not Consistently 
Related to Percentage of Children Served: 

States vary in both the criteria used to establish eligibility for 
services and the means used to assess whether children fit these 
criteria, but these differences are not consistently related to the 
percentage of children receiving early intervention services. While 
Part C is intended to serve infants and toddlers from birth to age 3, 
the majority of children receiving services nationwide and in most 
states are toddlers between ages 2 and 3. Officials in states we 
visited told us that despite their various public awareness efforts, 
there are a number of challenges in identifying all children eligible 
for services, specifically reaching children whose families speak 
limited English or live in rural areas. Comprehensive data on the 
number of children who could benefit from early intervention are not 
available; many conditions covered by Part C--such as emotional 
disorders and learning disabilities--are not systematically tracked. 

States Have Different Eligibility Criteria and Means of Assessing 
Developmental Delay: 

Nationwide, states' eligibility criteria for Part C services vary, with 
most states specifying the amount of delay in development a child must 
experience to be eligible for services, while a few rely exclusively on 
the judgment of a multidisciplinary clinical team. IDEA generally gives 
states the discretion to determine specific eligibility criteria and 
diagnostic procedures. For example, Part C specifies that a child have 
an established condition that has a high probability of resulting in a 
developmental delay, or that a delay is present in one or more areas of 
development--cognitive, physical, communicative, social or emotional, 
or adaptive--and that all states allow for the use of informed clinical 
opinion in their evaluation. However, states can determine the amount 
of delay a child must experience in order to be eligible for services. 
Part C also gives states discretion to identify the appropriate 
diagnostic instruments to measure the extent of a child's delay or to 
rely exclusively on the informed opinion of professionals. For example, 
Arizona requires a 50 percent delay in one or more aspects of early 
childhood development, such as physical or emotional development. New 
Jersey's eligibility criteria vary depending on the number of areas in 
which a child is developmentally delayed. The state requires that 
children have a 33 percent delay in one area of development, but a 25 
percent delay in two or more areas of development. The Centers for 
Disease Control and Prevention noted that the significance and 
implication of a given percentage delay vary across areas of 
development. For instance, according to CDC, a 25 percent delay in 
motor skills development has much different implications for services 
for a child than a 25 percent delay in language development. Other 
states' eligibility criteria are based on the number of months or 
standard deviations from age norms. For example, in Massachusetts, a 24-
month-old child functioning at an 18-month-old level could be eligible 
for services. In Georgia, a child whose cognitive abilities are at 
least two standard deviations less than the abilities of most children 
at the same age would be eligible for services. Hawaii does not specify 
a percentage delay and instead relies on the judgment of a 
multidisciplinary team, which generally includes either a speech 
therapist or special educator and an occupational or physical 
therapist. Despite wide variation in how states define eligibility, 
variation among states in the percentage of children served is not 
consistently explained by eligibility criteria. For example, Alabama, 
which has broad eligibility criteria (25 percent delay in one or more 
areas) served only 1.3 percent of infants and toddlers in 2004, while 
North Dakota, which has stricter eligibility criteria (50 percent delay 
in one area, 25 percent delay in two or more areas, informed clinical 
opinion), served 2.8 percent of its infants and toddlers. In 2004 the 
percentage of children served from state to state ranged between 1.3 
and 7.1 percent. 

Although not required by Part C, as of March 2005, 8 states-- 
California, Hawaii, Indiana, Massachusetts, New Hampshire, New Mexico, 
North Carolina, and West Virginia--also served children at risk of 
having a substantial developmental delay. For example, in Hawaii, 
children from families where child abuse or neglect is present may 
qualify for services. In Massachusetts, children born with low birth 
weight or chronic lung disease may qualify for services. States that we 
visited that do not serve at-risk children--Colorado, Illinois, 
Maryland, New Jersey, and Oregon--expressed interest in serving them 
but told us that the additional costs associated with increasing the 
number of eligible children prevented them from doing so. Instead of 
providing services to at-risk infants and toddlers under IDEA Part C, 
some states track at-risk children or provide services to them through 
other programs. For instance, in Ohio, children at risk are served 
through a statewide program, funded in part by federal dollars, known 
as Ohio Early Start. Through this program, they receive services 
similar to those children receive under Part C. 

Majority of Children Served under Part C Are between Ages 2 and 3: 

While Part C funding is intended to serve infants and toddlers from 
birth to age 3, the majority of children receiving services are 
toddlers between ages 2 and 3. In 2004, infants, children under the age 
of 1, constituted only 14 percent of the approximately 279,000 children 
served nationwide, and 2 to 3-year-olds accounted for 54 percent. 
Likewise, in 38 states, the majority of children served were 2 to 3- 
year-olds. In Maryland and Illinois, 2 to 3-year-olds made up 54 
percent and 55 percent of the children served, respectively. OSEP and 
state officials told us that a majority of children enter the Part C 
system after age 2 because this is the age at which speech language 
delays become apparent and indicated that such deficiencies are not 
easily detected in younger children. According to Education officials, 
difficulty detecting deficiencies in younger children is due to 
numerous factors, including difficulties in assessment, pediatrician or 
parent "wait and see" attitudes, and lack of parental consent. Children 
who enter the Part C program in infancy are generally those diagnosed 
at birth with conditions such as chromosomal abnormalities and genetic 
or congenital disorders. 

It also appears that many children are eventually identified as needing 
services when they become older. Part B Section 619, which serves 
children ages 3 through 5 years, serves many more children than Part C, 
as shown in figure 3. In 2004, Section 619 served over 693,000 
children, compared with approximately 279,000 children under Part C, 
and this pattern is mirrored in most states. This may be attributable 
to a variety of factors. Some delays become more apparent as children 
get older. Developmental delays are also more likely to be detected 
once a child enters a group setting, such as a preschool or 
kindergarten program, when comparison with peers may highlight some 
delays. Additionally, some parents may turn to private insurance to pay 
for services during the first few years of a child's life, and enter 
the IDEA system when their child enrolls in a formal education program 
at ages 3, 4, or 5. However, Massachusetts and Hawaii serve at least 
the same number of children in their Part C programs as they do in 
their Part B Section 619 programs. Both states include at-risk children 
in their Part C eligibility criteria. 

Figure 3: National Percentage of Children Receiving IDEA Services by 
Age in 2004: 

[See PDF for image] 

[End of figure] 

States Face Challenges in Identifying All Children Eligible for 
Services: 

Officials in the 7 states we visited told us that a number of obstacles 
prevented them from reaching all children, even though all of these 
states, as required by law, had developed public awareness campaigns to 
help identify infants and toddlers in need of services. To inform the 
public of the program, states used television, radio, and newspaper 
ads; presentations at community fairs; and distribution of pamphlets 
and brochures at doctors' offices, hospitals, and other appropriate 
locations. For example, in one of the sites we visited, posters were 
developed to hang in doctors' offices across the state to help inform 
parents about Part C. 

Despite their public awareness campaigns, the states we visited 
reported having difficulty reaching all eligible children. Officials 
noted that it can be especially difficult to reach families for which 
English is a second language. While some states we visited produced 
public awareness materials in Spanish, they had not expanded their 
efforts to include materials in other languages. Officials also told us 
that it can be hard to reach families who live in rural areas because 
they may visit a pediatrician less frequently because of the long 
distance they must travel to get to the doctor. While officials in 6 of 
the 7 states we visited noted that physicians were the principal source 
of referrals, they also told us that they believed physicians were 
hesitant to make referrals to Part C programs because of a fear of 
misdiagnosing a child with a disability. They believed that a 
misdiagnosis could cause unnecessary anxiety in a parent whose child is 
developing more slowly but would eventually begin to demonstrate age- 
appropriate skills without needing early intervention services. 
Additionally, the American Academy of Pediatrics found through its own 
studies that a lack of understanding of the early intervention 
program's processes and procedures is a barrier to physicians' 
referring children. 

Selected States Provide Similar Services but Vary in Funding Sources: 

States provide a broad array of early intervention services to eligible 
children and face similar challenges in recruiting and retaining staff 
to provide these services, but they vary in the sources of funding they 
draw from. States provide a wide range of medical and educational 
services to children and their families and rely on professionals, 
including occupational therapists, physical therapists, and speech 
language pathologists, to deliver these services. Yet officials in the 
states we visited reported that they are finding it increasingly 
difficult to recruit and retain these individuals. To fund early 
intervention services for children from birth to age 3, states relied 
on funding from multiple sources, including federal, state, and private 
funding. However, some states reported difficulties accessing certain 
types of funding, such as Medicaid. 

States Provided a Broad Array of Services to Infants and Toddlers, but 
States We Visited Reported Challenges Recruiting and Retaining Staff: 

As required under Part C, states provide a broad array of early 
intervention services to infants and toddlers. Under Part C, infants 
and toddlers with a disability are entitled to receive an evaluation of 
their strengths and needs, service coordination, and support for a 
smooth transition from early intervention to preschool programs. In 
addition, children receive individualized services that may include 
physical therapy, family counseling, and nutrition services. States, as 
required by law, reported making all services shown in figure 4 
available to infants and toddlers. 

Figure 4: Examples of Services States Made Available to Infants and 
Toddlers Covered by Part C: 

[See PDF for image] 

[End of figure] 

Figure 5 shows that the most frequently received services nationwide 
are speech language therapy, special instruction, physical therapy, and 
occupational therapy. Psychological and nutrition services were among 
the least frequently provided. The states we visited were similar in 
their mix of services. For example, in states such as Maryland, Oregon, 
and Colorado, speech language, physical, and occupational therapy, to 
help with skills like feeding, walking, and talking, were the most 
frequently provided services, and services such as psychological 
services and nutrition services were rarely provided. 

Figure 5: Percentage of Early Intervention Services Most Frequently 
Provided: 

[See PDF for image] 

[End of figure] 

These services were provided in a variety of settings, including the 
home, hospital, and day care, and through public and private service 
providers. For instance, according to Maryland officials, LEAs, 
departments of health, and departments of human services in the state 
provide services to infants and toddlers in addition to private 
providers. In Massachusetts, a network of private programs provides 
early intervention services under contract with the state. 

Officials in each of the states we visited reported challenges in 
recruiting and retaining staff to provide early intervention services. 
Specifically, speech language pathologist and occupational therapist 
were the most difficult positions to fill. Officials cited several 
reasons for these challenges. Early intervention staff are required by 
Part C to serve children in natural environments, such as homes or 
child care centers. This requires staff to travel to these locations, 
which can be time-consuming and costly. For instance, in Hawaii, state 
officials told us that it is hard to schedule services for children in 
neighboring islands because of the long travel times to reach them. 
Additionally, state officials told us that salaries earned by early 
intervention contractors were not always competitive with salaries and 
benefits available in the private health care sector. These challenges 
make it difficult for some early intervention programs to hire 
professional staff. Understaffed programs can often result in heavier 
caseloads in which children do not receive services or receive services 
less often than intended. 

States Use Various Funding Sources in Addition to Part C, but Selected 
States Report Difficulties Accessing Funds: 

To help pay for services for infants and toddlers, states draw on a 
range of federal, state, and local funding sources. As shown in figure 
6, states accessed funds from a variety of sources at the federal 
level, including the Child Care and Development Block Grant, IDEA Part 
B, and Medicaid, and from the state level. See appendix I for a 
glossary of these federal and state funding sources. 

Figure 6: Examples of Federal and State Funding Sources: 

[See PDF for image] 

[End of figure] 

State general revenue funds represent the most frequently used funds by 
states after federal Part C dollars. All 50 states reported using state 
general funds. 

For most states we visited, local support represented a small 
proportion of reported early intervention funding, but in one-- 
Maryland--it accounted for 51 percent. However, states did report 
receiving funds from local sources or through private insurance and 
fees collected from a child's family. For example, New Jersey charges a 
sliding monthly fee based on family size and income relative to federal 
poverty guidelines. State officials said families that can afford to 
contribute to the cost of service provision do so, but families that 
cannot afford the fee still receive services. In fiscal year 2003, New 
Jersey collected $43,862 in revenue from this fee, which made up less 
than 1 percent of its reported early intervention service funding. 

In 4 of the 7 states we visited, states provided most of the funding 
for services for infants and toddlers, and Part C represented a smaller 
percentage of total funding. For example, in Illinois, state general 
revenue funds represented 57 percent of the total funding reported for 
infants and toddlers with disabilities, and Part C funds represented 17 
percent. However, Part C represented a larger percentage of reported 
funding in certain states. For instance, in Colorado, Part C funds made 
up 38 percent of funds reported for infants and toddlers with 
disabilities. See table 1 for funding sources in the states we visited. 

Table 1: Sources of Funding for Early Intervention Services in Site 
Visit States: 

(Dollars in millions). 

Colorado; 
Part C: $6.10; 
Other federal: $0.00; 
Medicaid: $3.10; 
State general revenue: $6.80; 
Other state: $0.00; 
Private insurance/fees: $0.00; 
Local support: $0.00. 

Hawaii[A]; 
Part C: $2.00; 
Other federal: $0.19; 
Medicaid: $0.02; 
State general revenue: $8.00; 
Other state: $0.01; 
Private insurance/fees: $0.00; 
Local support: $0.41. 

Illinois; 
Part C: $15.20; 
Other federal: $0.00; 
Medicaid: $15.20; 
State general revenue: $49.70; 
Other state: $0.00; 
Private insurance/fees: $6.20; 
Local support: $0.00. 

Maryland; 
Part C: $7.60; 
Other federal: $4.70; 
Medicaid: $1.80; 
State general revenue: $5.20; 
Other state: $2.30; 
Private insurance/fees: $0.01; 
Local support: $23.20. 

Massachusetts; 
Part C: $8.40; 
Other federal: $0.21; 
Medicaid: $19.40; 
State general revenue: $29.90; 
Other state: $0.00; 
Private insurance/fees: $32.20; 
Local support: $0.00. 

New Jersey; 
Part C: $13.70; 
Other federal: $0.50; 
Medicaid: $4.40; 
State general revenue: $40.60; 
Other state: $1.00; 
Private insurance/fees: $0.04; 
Local support: $5.20. 

Oregon[B]; 
Part C: $4.50; 
Other federal: $0.00; 
Medicaid: $2.10; 
State general revenue: $8.00; 
Other state: $1.80; 
Private insurance/fees: $0.00; 
Local support: $0.00. 

Source: GAO analysis of fiscal year 2003 data provided by state 
officials. 

[A] Funding data for Hawaii are incomplete, as the state does not 
include data from its Public Health Nursing Branch and Healthy Start 
programs. 

[B] Oregon's Medicaid data are for both Part B and Part C; the state 
does not separate the two programs. 

[End of table] 

Beyond our collection of funding data in our seven site visits, we 
looked at funding data for all 50 states by examining the information 
states provided to OSEP as part of their annual performance reports. 
Their data included federal, state, and local funding sources, as well 
as the dollar amounts for each. However, during the course of our 
review, we found that data were incomplete. For instance, Hawaii did 
not report funding for two programs that provide early intervention 
services. We found similar gaps in examining funding data reported to 
OSEP by additional states.[Footnote 3] During the course of our review, 
OSEP concluded the funding data from states were unreliable and 
announced plans to stop collecting such data. 

States we visited reported challenges in accessing certain funding 
sources. For some smaller programs and funding sources, officials in 
some states we visited said the paperwork was too cumbersome for the 
small amount of funding they might receive in return. In other cases, 
some officials reported difficulty obtaining Medicaid reimbursement for 
Part C services. In Oregon, where the state department of education is 
the lead agency, officials explained that the different terminology 
educators use to describe certain needed services makes it hard to 
access Medicaid for early intervention services. For instance, Medicaid 
may pay for occupational therapy if the purpose is health-related in 
nature--such as teaching a child to eat. But Medicaid may not provide 
reimbursement if the stated purpose of the therapy appears educational, 
such as teaching a child to grasp a crayon to draw.[Footnote 4] Despite 
the challenges some states reported, Massachusetts officials cited a 
strong and collaborative working relationship with Medicaid and private 
insurance. For example, since 1985, the state has had operational 
standards that include reimbursement of virtually all Part C services 
through Medicaid. 

Both OSEP and States Use Data to Monitor Part C Compliance, but 
Challenges Persist in Transitioning Children to Part B: 

OSEP monitors the states, which in turn oversee local Part C programs 
by examining data on how well programs identify, serve, and transition 
children to other programs when they are too old for Part C. In its 
oversight, OSEP tracks data on program performance submitted by states 
through annual performance reports and other mechanisms. As part of its 
efforts, OSEP uses two key performance indicators--percentage of 
infants and toddlers receiving early intervention services and the 
percentage of these children receiving services in natural 
environments--to target site visits and technical assistance to 
programs most in need of guidance. States oversee Part C in similar 
ways but are free, within certain parameters, to design their own 
oversight strategies. Although federal and state data and oversight 
efforts have helped identify some performance problems, challenges 
remain in transitioning children from Part C to Part B Section 619 and 
other follow-on preschool programs. In 5 of the 7 states we visited, 
officials said that some children who turn 3 during the summer and are 
eligible for Part B preschool experience service gaps when school is 
not in session. OSEP does not have data on how frequently children are 
provided extended year services during the summer months. 

OSEP Monitors and Supports Implementation of Part C by Tracking Key 
Data: 

To ensure that programs are managed well and that eligible infants and 
toddlers receive the services they need, OSEP monitors the states by 
collecting and tracking key data. Specifically, each state submits an 
annual performance report to OSEP, which includes a narrative on five 
areas of program performance and plans for improvement. States report 
on (1) what they are doing to identify children and the effectiveness 
of these efforts; (2) how well they are helping families develop the 
skills they need to help their children; (3) whether services are 
provided to children in a natural environment, such as, home, day care, 
or other programs for typically developing children; (4) whether 
transition planning is available to children and their families; and 
(5) what they are doing to supervise and manage local programs. States 
report on progress or challenges in meeting performance goals and state-
developed indicators as well as projected timelines, activities, and 
resources needed to achieve future targets. For example, with respect 
to identifying all children eligible for services, Illinois set a goal 
for the period covering July 2003 to June 2004 to increase the 
percentage of children receiving early intervention services to 2.6 
percent of all children and to screen 200,000 children for 
developmental delays, approximately 37 percent of the state's 
population age 0 to 3. In its annual performance report for that 
period, Illinois described the strategies it used to exceed its 
participation target--2.76 percent of children received services--and 
explained why it fell 58,000 children short of its target for 
screenings. 

In addition to information submitted as part of the annual performance 
reports, states also report data to OSEP in five areas: (1) number and 
percentage of children receiving services, (2) the specific settings in 
which children receive services, (3) number of children who stopped 
receiving Part C services and the reason for stopping, (4) number and 
types of services provided, and (5) the number of clinical personnel 
employed or contracted to provide services. IDEA requires states to 
submit data in the first three areas, and OSEP, under authority granted 
to it in IDEA, requires states to submit data in the final two areas. 
For future reporting periods OSEP plans to discontinue collection of 
personnel data because they were found to be unreliable. Additionally, 
OSEP will stop collecting information about the number and types of 
services provided. The reporting data complement and inform topics 
covered in the annual performance reports. 

Failure to Reach a Key Child Identification Indicator Can Signal Part C 
Compliance Problems: 

OSEP uses the annual performance reports and other reporting data to 
identify problem areas and target its oversight efforts. In particular, 
OSEP compares states against the national average on two performance 
indicators: (1) the percentage of all infants and toddlers in the state 
receiving early intervention services, which was 2.2 percent as of 
2003, and (2) the percentage of infants and toddlers with disabilities 
receiving early intervention services in a natural environment, which 
was 83 percent, as of 2002.[Footnote 5] These indicators were developed 
by OSEP with input from interested parties, including states and the 
Centers for Disease Control and Prevention.[Footnote 6] OSEP officials 
said they chose these indicators because of their confidence in the 
accuracy of the data and because they are closely linked to other Part 
C requirements. OSEP considers whether states have fallen below the 
national average when deciding whether to target states for technical 
assistance and closer monitoring. In 2003, half of all states served 
less than 2.2 percent of children. OSEP officials note that the 
indicators do not directly measure compliance with Part C, but they 
serve as an early warning signal that states may need assistance. 

OSEP relies on the first performance indicator as a measure of the 
level of access states are providing for early interventions and the 
success of efforts to identify all eligible children. It has collected 
this performance information since at least 1996, and the percentage of 
the nation's children between birth and age 3 receiving services has 
steadily increased since 1998--from 1.6 percent to 2.2 percent in 2003. 
Twenty-five states met or exceeded this indicator in 2003. Of these 25 
states, 7 served between 3.4 and 7.7 percent. The fact that half of all 
states served 2.2 or more percent, and some served as high as 7.7 
percent, combined with the known difficulties in reaching all eligible 
children, suggests that the actual eligible population may be larger 
than the number of children states are identifying. The Centers for 
Disease Control and Prevention told us that comprehensive data on the 
number of children who could benefit from early intervention are not 
available. 

OSEP pays particular attention to states that do not meet its 
performance indicator. Failure to meet this indicator can be a signal 
that the state is not doing enough to identify all eligible children 
and raise public awareness of available early intervention services. 
First, OSEP might encourage these states to seek help from technical 
assistance centers or OSEP staff. States can get technical assistance 
on an ongoing basis through several vehicles, such as conferences, six 
regional centers, research and training centers, and a national center. 
Second, OSEP might schedule a site visit, at which it would interview 
state and local officials, providers, and parents and review program 
data in more depth. After OSEP completes a site visit, it prepares a 
monitoring report addressing strengths and areas of noncompliance with 
Part C. 

Using data from annual performance reports and site visits, OSEP has 
found states out of compliance with Part C for a number of issues 
related to the goal of identifying all eligible infants and toddlers 
for services. OSEP finds states out of compliance for, among other 
reasons, not making adequate public awareness efforts to inform 
culturally diverse groups about available early intervention services, 
not disseminating public awareness materials to pediatricians and other 
referral sources in rural areas, not referring children from 
underrepresented groups for services in a timely manner, and not 
carrying out service coordination responsibilities. Between July 1, 
2002, and June 30, 2003, 14 states were found out of compliance with 
child identification requirements. These states served 0.9 to 7.7 
percent of their population, with 9 of the 14 states serving less than 
2.2 percent of their population. OSEP found Nevada (which was the state 
that served the lowest percentage of infants and toddlers at 0.9 
percent in 2003) out of compliance for not ensuring that all children 
who may be eligible for early intervention services are identified, 
located, referred, and evaluated in accordance with Part C. Hawaii, 
which serves the largest percentage of children, including children at 
risk of having a substantial developmental delay, was found out of 
compliance because it lacked procedures to ensure evaluations and 
assessments were conducted in all the areas required by Part C. 

When states are not in compliance with Part C and do not show 
improvement in their performance, even after receiving technical 
assistance, OSEP has several options. Initially, OSEP might work with a 
state on a plan of corrective action with a timeline, or issue a letter 
to the state documenting the specific problems. As a last resort, OSEP 
can impose formal sanctions against a state, including withholding 
funds, referring the matter to the Department of Justice, entering into 
a voluntary compliance agreement with a state and its respective lead 
agency that sets a timeline for bringing the state into compliance, and 
incorporating special conditions into a state's grant award. OSEP 
reports that it rarely withholds funds or refers any noncompliance 
issues for Part C programs to the Department of Justice. Two states, 
South Carolina and Arizona, are currently on compliance agreements, and 
several have special conditions in their grant awards.[Footnote 7] 

OSEP is using its second performance indicator, on the percentage of 
infants and toddlers with disabilities receiving early intervention 
services in a natural environment, in the same way it uses data about 
the percentage of all infants and toddlers in the state receiving early 
intervention services. OSEP officials told us that on the basis of 
provisions in the 2004 reauthorization of IDEA, they recently developed 
a new set of performance indicators. States will submit to OSEP 
baseline data on these measures in December 2005. The new indicators 
generally build upon data currently being collected to look in new ways 
at how states provide early intervention services in a natural 
environment, identify children, transition children to follow-on 
services, and address supervision and management issues. For example, 
the new indicators for identifying children include a comparison of the 
percentage of children served in each state with the average in other 
states with similar eligibility criteria, and information about the 
percentage of children who proceeded through the evaluation, 
assessment, and service planning stages of the early intervention 
system according to timelines required by Part C. Similarly, the new 
transitioning indicators require information about the percentage of 
children who receive timely transition planning. 

States Have Responsibility for Oversight of Local Early Intervention 
Providers: 

State lead agencies play a critical role in monitoring and supporting 
early intervention services through their responsibility for local Part 
C programs. Instead of directly providing services to infants and 
toddlers with developmental delays, in the states we visited, local and 
regional early intervention programs generally deliver and coordinate 
services. The states, then, are responsible for ensuring the local 
programs are in compliance with Part C. States use many of the same 
approaches as OSEP in monitoring and supporting local programs, such as 
file reviews, reporting requirements, program certification or funding 
awards, employing training and technical assistance staff, and 
monitoring visits. States frequently interact with local early 
intervention programs. For example, Massachusetts officials seek to 
visit half of their 63 local programs each year. 

OSEP encourages collection of outcome data from parents and is 
sponsoring research on outcomes, which is scheduled to be completed in 
2006. At least 4 of the states we visited monitor early intervention 
services by conducting parent surveys. The surveys measure parental 
satisfaction with the delivery of early intervention services, how well 
parents feel services are coordinated, and parents' experiences working 
with staff to transition their children to follow-on services. OSEP 
provides funding for technical assistance to help states develop parent 
surveys. These survey data and information from OSEP's National Early 
Intervention Longitudinal Study are potential sources of outcome data 
about early intervention services. Additionally, the Early Childhood 
Outcomes Center, a 5-year project funded by OSEP, is providing 
technical assistance to support states in developing and implementing 
other outcome measurement systems for children with disabilities. The 
Early Childhood Outcomes Center is attempting to develop outcome data 
that can be aggregated at the national level, document program effects, 
and improve programs at the local and state levels. 

State Part C officials we spoke with explained that they have to hold 
local early intervention programs accountable for the same performance 
indicators for which OSEP holds them accountable. As with OSEP, state 
Part C coordinators have taken actions to enforce compliance with IDEA. 
Officials in Colorado said they had taken away funding from programs 
that failed to comply with Part C requirements. Also, when states fail 
to enforce IDEA requirements, they risk not only being found in 
noncompliance, but also lawsuits brought by individuals under IDEA. 
Such was the case in Hawaii and Illinois. In Hawaii, parents and mental 
health advocates alleged that qualified handicapped children were not 
receiving mental health services. In Illinois, plaintiffs alleged that 
the state had a waiting list for children who were eligible for 
services. Both states settled the lawsuits by agreeing to take specific 
steps to come into compliance with the act. 

Overseeing and Coordinating Transitions to Part B Remains a Challenge: 

Although the information that OSEP and the states compile has helped 
identify some performance problems, overseeing and coordinating 
children's transitions to IDEA Part B remains a challenge. The 
transition process involves several sequential steps, and when any of 
these steps are delayed, a child could miss out on critical services 
and providers can be left without important information on a child's 
status. As a child nears age 3, local early intervention staff must 
inform the child's family about follow-on programs that may be 
available for the child, such as Part B Section 619. Local early 
intervention staff, with the approval of the family, hold a conference 
with the family and, if the child is potentially eligible under Part B, 
LEA officials, to discuss any services the child may be eligible to 
receive. This transition planning conference for children potentially 
eligible under Part B, must occur at least 90 days before the child's 
third birthday. Early intervention staff and the family must develop a 
written transition plan. And if the child is believed eligible for Part 
B services, early intervention staff must notify the LEA. The LEA must 
determine the child's eligibility within a reasonable time frame, and 
if the child is found eligible, a meeting to develop an individualized 
education program (IEP) for the child must be conducted within 30 days. 
Part B requires teachers, parents, school administrators, and related 
services personnel to develop the IEP shortly after a child is found 
eligible for Part B services, and the IEP guides the delivery of 
special education supports and services for a student with 
disabilities. 

While IDEA requires states and local programs to provide transition 
planning and follow these specific procedures, we found in our site 
visits that delays still happen. Education cited preliminary 
unpublished data that would suggest transitions are a year-round 
problem. We found that delays generally occur for two reasons. First, 
data in annual performance reports indicate that some states have 
difficulty scheduling transition meetings 90 days in advance of a 
child's third birthday. State and local officials we interviewed said 
it was difficult to assemble all of the requisite individuals for the 
conference before the deadline. Second, some state officials expressed 
concern about the timing of the LEA's decision on a child's 
eligibility. The decision may be delayed until the following school 
year for children with summer birthdays because LEAs generally operate 
on a 9-or 10-month academic calendar. In 5 of the 7 states we visited, 
officials said that some children who turn 3 during the summer and are 
eligible for Part B preschool experience service gaps when school is 
not in session. As a result of these delays in the transition process, 
some children who need extended school year services during the summer 
may not receive them. Most of the states we visited do not keep track 
of the number of eligible children who do or do not receive extended 
school year services. 

There are two potential ways to ensure children do not experience gaps 
in services. First, extending Part C services until children are 
eligible to enter kindergarten, which was permitted for the first time 
with the reauthorization of IDEA in 2004, could mitigate some of the 
challenges associated with transitioning children. However, none of the 
states we visited plan to exercise this option. States indicated that 
it would be too costly for them to extend Part C service and that Part 
B officials are not willing to support doing so with Part B Section 619 
funds. Second, Part C funds can be used to provide services to children 
from their third birthday to the beginning of the following school 
year, but an OSEP technical assistance center reports that as of 2004, 
while 30 states permit such use of Part C funds, only 14 states have 
adopted such a policy. 

In addition to citing delays, state and local officials cited other 
obstacles to a smooth transition for children. Local early intervention 
programs sometimes have to work with multiple LEAs that each have their 
own eligibility criteria for Part B, which complicates coordination. 
For example, a local Massachusetts official said that her early 
intervention program spans a geographical area that encompasses 13 
different LEAs. Also, LEAs sometimes conduct their own evaluations, 
contributing to the time needed for determining Part B eligibility. 

State and local officials also reported that early intervention 
programs often do not get final notification of a child's eligibility 
for Part B services from the LEA. According to OSEP, this information 
exchange may not occur for several reasons, including federal laws 
relating to privacy and the need for parental consent to share results 
of Part B evaluations. Without access to information on eligibility 
decisions, early intervention staff do not know whether they need to 
refer children who are denied Part B services to other follow-on 
programs, like Head Start. State Part C officials are required to 
report Part B eligibility information to OSEP when reporting why a 
child stopped receiving services, but LEAs that administer Part B do 
not always provide this information in a timely manner, if at all. 
While two of the states we visited are in the process of developing 
mechanisms for ensuring early intervention staff have access to 
eligibility information, none are currently in use.[Footnote 8] OSEP 
staff acknowledged that states need continued support to ensure Part B 
officials share eligibility information with early intervention staff. 

Conclusions: 

Scientific research suggests that the earlier a child with disabilities 
gets intervention services, the more effective these services may be in 
enhancing a child's development. Before a child enters preschool, 
states have substantially greater flexibility in determining which 
infants and toddlers to serve. IDEA gives states the freedom to set 
different eligibility criteria for early intervention services and 
decide how they will evaluate children for eligibility. However, it is 
partly these variations that make it difficult to determine if states 
are actually meeting the early intervention needs of all their 
developmentally delayed infants and toddlers. 

One of the most pressing challenges is transitioning young children 
with disabilities from services provided under IDEA Part C to Part B 
preschool or other services at age 3. This transition requires that a 
sequence of determinations and agreements among multiple stakeholders 
take place in a timely way. Education reported in its comment that it 
has preliminary data that suggest that service gaps may occur whenever 
children transition. In our interviews with state and early 
intervention officials, we found that transition is perhaps most 
challenging for children who transition during the summer months. If 
determination of eligibility for Part B is delayed, children can be 
prevented from receiving necessary services, including those provided 
through extended school year programs in the summer. Based on our 
findings, and Education's preliminary findings from its ongoing study 
of preschool services, it appears that without additional guidance, 
some children exiting the Part C program and eligible for Part B 
preschool may not receive all the services for which they are eligible. 

Recommendations for Executive Action: 

In order to assist states in providing a more seamless transition for 
children with disabilities from IDEA Part C to Part B, or other 
preschool programs, we are recommending that the Secretary of Education 
provide states with additional guidance on transition planning and 
services for children with birthdays during the summer, and especially 
in cases where children are likely to need extended school year 
services. Additionally, after Education completes and verifies the 
results from its ongoing studies relating to transitioning, that 
information should be used to inform the department's guidance to 
states on transition planning. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to Education for review and comment. 
Education disagreed with the recommendation we made to incorporate into 
its research agenda a method for determining how frequently children 
transitioning from Part C to Part B do not receive services during the 
summer months, and if gaps in services are found to be a problem, 
provide states with additional guidance on improving children's access 
to extended school year services. Education noted that preliminary and 
unpublished data from a department study indicate that gaps occur when 
children are transitioned from Part C to Part B, not only during the 
summer, but whenever transitions occur. Additionally, Education stated 
that based on its preliminary data, there is no need to study extended 
school year service. We believe it is critical to provide children with 
the services they need when they need them. If Part B eligibility is 
not determined prior to children turning 3 during the summer months, 
then related decisions, including those about extended school year 
services, cannot be made. We believe that by providing additional 
guidance, Education can help states improve transition planning and 
services and help ensure that children do not experience gaps in 
services during critical periods of their development. 

Education also provided technical comments that we incorporated into 
the report where appropriate. Education's written comments are 
reproduced in appendix II. 

We will send copies of this report to the Secretary of Education, 
appropriate congressional committees, and others who are interested. We 
will also make copies available to others upon request. In addition, 
the report will be available at no charge on GAO's Web site at 
http://www.gao.gov. If you have any questions about this report, please 
call me at (202) 512-7215. Key contributors are listed in appendix III. 

Sincerely yours, 

Signed by: 

Marnie S. Shaul, Director: 
Education, Workforce, and Income Security Issues: 

[End of section] 

Appendix I: Select Federal and State Funding Sources for Early 
Intervention Services: 

The Child Care and Development Block Grant program is a discretionary 
fund program that, among other things, supports state efforts to 
provide child care to parents trying to achieve independence from 
public assistance. 

Children with Special Health Care Needs refers to a type of program 
operated by particular states that provides financial assistance or 
case management for needed medical treatment to children with serious 
and chronic medical conditions to reduce complications and promote 
maximum quality of life. 

Developmental Disabilities Services refers to state programs that serve 
and support individuals with mental retardation/developmental 
disabilities and their families, including early intervention services. 
For example, community developmental disability services are supported 
by state funding in Kansas, which defines community developmental 
disability services as those designed to meet needs associated with 
work, living in the community, and individualized supports and 
services. 

Head Start and Early Head Start are comprehensive child development 
programs that serve children from birth to age 5, pregnant women, and 
their families. These programs are federally funded and locally 
administered by community-based nonprofit organizations and school 
systems. Grants are awarded by the Department of Health and Human 
Services. 

IDEA Part B, administered by the Department of Education, provides 
grants to states to provide preschool services to children with 
disabilities from age 3 to 5. 

The Maternal and Child Health Services Block Grant program (Title V of 
the Social Security Act) provides federal grants to states and 
organizations with the aim of improving the health of mothers and 
children. Among the many services supported by grants are support 
programs for children with special health needs, care coordination, 
transportation, home visiting, and nutrition counseling. 

Medicaid is health insurance that helps people who cannot afford 
medical care pay for some or all of their medical bills. Medicaid is 
jointly funded by the federal and state governments to assist states in 
furnishing medical assistance to eligible needy persons. 

The Social Services Block Grant (SSBG) program allocates federal funds 
to states to support a wide variety of social services programs for 
adults and children. 

Temporary Assistance for Needy Families (TANF) is a family assistance 
block grant from the Department of Health and Human Services to states 
that can be used to provide monthly cash assistance payments to 
families as well as to finance services for TANF clients or other low- 
income people to support their efforts to work. 

Tobacco Funds were awarded to states as part of a settlement agreement 
with major tobacco companies. Kentucky designated 25 percent of its 
Phase I settlement to an early childhood initiative that includes First 
Steps, its early intervention system. Kansas allocated all of its 
settlement for children's services. 

TRICARE is the Department of Defense's regional managed-care program 
for delivering health care to members of the armed services and their 
families, survivors, and retired members and their families. TRICARE 
operates like health maintenance organization plans offered in the 
private sector and other similar health insurance programs. 

[End of section] 

Appendix II: Comments from the Department of Education: 

UNITED STATES DEPARTMENT OF EDUCATION: 
THE ASSISTANT SECRETARY: 
OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES: 

NOV 14 2005 

Ms. Marnie S. Shaul: 
Director, Education, Workforce and Income Security Issues: 
Government Accountability Office: 
441 G. Street, NW: 
Washington, DC 20548: 

Dear Ms. Shaul: 

Thank you for the opportunity to review the draft report entitled: 
"INDIVIDUALS WITH DISABILITIES EDUCATION ACT, Study of Service Gaps 
Could Help Education Guide States in Smoothly Transitioning Children to 
Preschool" (GAO-06-26). I am pleased to respond on behalf of the 
Department of Education (Department). 

The draft report identifies transition of children with disabilities 
from early intervention services under Part C of the Individuals with 
Disabilities Education Act (IDEA) (for children birth to age three) to 
preschool services under Part B of the IDEA (for children ages three 
through five) as an area of concern. The Department recognizes that 
transition is a long-standing challenge for Lead Agencies under Part C 
and State Education Agencies under Part B with respect to ensuring that 
children with disabilities who are eligible for preschool services 
under Part B at age three are identified, evaluated and provided 
services under Part B in a timely manner. However, preliminary data 
from a Department-funded study (described below) indicate that the 
service gap is specific to transition whenever that transition occurs 
and not, as suggested by the draft report, specific to summer months. 

The Office of Special Education Programs (OSEP) has funded a number of 
projects in this area, most notably the "National Early Childhood 
Transition Center" (NECTC), which is in its third year at the 
University of Kentucky. The Center's URL is: 
http://www.ihdi.uky.edu/nectc/. The Center is looking at all 
transitions that children and families experience while receiving Part 
C early intervention services and Part B preschool services. While the 
project is still gathering data, results thus far indicate that 
transition time is reduced for children when staff in both programs 
formally recognize and plan for the actual time needed to accomplish 
the logistics of transition. In addition, an important factor is the 
nature of contacts, i.e., the working relationships between Part C 
early intervention service providers and Part B preschool providers at 
the local level. 

The Pre-Elementary Education Longitudinal Study (PEELS), which was 
initially funded by OSEP and is now housed at the Department's 
Institute of Education Sciences, is examining the preschool and early 
elementary school experiences of children with disabilities and the 
outcomes they achieve. The study is following a nationally 
representative sample of almost 3,000 children and includes transition 
issues. The preliminary first wave of data from the PEELS indicates 
that there are gaps between Part C and Part B preschool services for 
approximately 30% of children, according to parent reports. For 
children who are eligible for Part B preschool services the gap in 
services averages five months. Further study will be conducted through 
PEELS to verify these data. 

The draft report recommends that the Department "incorporate into its 
research agenda a method for determining how frequently children 
transitioning from Part C to Part B preschool experience service gaps, 
and if gaps in service are found to be a problem, provide states with 
additional guidance on extended school year services" (emphasis added). 
As noted above, the PEELS funded by the Department is already examining 
the issue of gaps in service delivery between Part C and Part B 
preschool. At this point, the study has found no correlation between 
birthdates and particular months of service gaps. That is, spring or 
summer birthdates are no more likely to lead to gaps in services than 
fall or winter birthdates. Therefore, the draft report's recommendation 
regarding the need for studying extended school year (ESY) services 
seems inapposite, particularly when under Part B ESY services must be 
provided only if a child's individualized education program (IEP) team 
determines, on an individual basis, that the services are necessary for 
the provision of a free appropriate public education (FAPE) to the 
child. 

In addition, the draft report may confuse readers in implying that 
Parts C and B of the IDEA have similar eligibility and service 
provision requirements. We recommend that the draft report include the 
following language both in the transition section at page 26 and in the 
Results in Brief section to clarify these requirements. Some children 
exiting Part C may not be eligible for services under Part B. From 
birth to age three, a child is eligible for early intervention services 
under Part C because of established conditions or concerns about the 
child's exhibiting developmental delay. By contrast, a child with a 
disability at age three is eligible for preschool services under Part B 
when the child meets particular disability criteria or, at the option 
of State and local educational agencies, the child exhibits 
developmental delay. In most cases, the developmental delay definition 
for Part B is different from the Part C developmental delay definition. 

As noted earlier, the OSEP-supported National Early Childhood 
Transition Center is examining factors associated with and contributing 
to timely and effective transitions. The work of this Center will 
assist States in putting procedures and practices in place to reduce 
gaps in services for children who are leaving Part C and eligible for 
Part B preschool services. 

As is customary, we are providing suggested technical and production 
edits separately. Please note that many of the technical edits are 
necessary to ensure the accuracy of the requirements under Parts B and 
C of the IDEA. We are available to discuss any of our suggested changes 
with your staff if this would be helpful. 

Sincerely, 

Signed by: 

Assistant Secretary: 

Enclosure: 

[End of section] 

Appendix III: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Marnie S. Shaul (202) 512-7215 or shaulm@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, the following individuals made 
important contributions to this report: Betty Ward-Zukerman, Assistant 
Director; Ramona Burton, Analyst-in-Charge; Daniele Schiffman, Analyst; 
Rachael Chamberlin; Sherri Doughty; Avrum Ashery; Jonathan McMurray; 
Beverly Ross; and Daniel Schwimer. 

FOOTNOTES 

[1] NEILS is tracking the outcomes of over 3,300 infants and toddlers 
with disabilities and those at risk of a disability and their families. 
The study tracks children starting from their experiences in early 
intervention to early elementary school and will provide outcome data 
on children and families receiving early intervention and how these 
outcomes relate to child and family characteristics and the types of 
services provided. The grant for the study ends in 2005 and the final 
report is anticipated to be available in 2006. 

[2] Part C was appropriated $441 million for fiscal year 2005. 

[3] A 2004 expenditure study, conducted as part of the National Early 
Intervention Longitudinal Study, concluded that early intervention 
programs use a blend of federal, state, and local funding to provide 
early intervention services, but that while programs could report 
sources of funding, they had difficulty reporting precise amounts of 
funding or breaking down the revenues by sources. 

[4] We earlier reported challenges in coordinating Medicaid and IDEA 
for school-aged children. See GAO, Medicaid and Special Education: 
Coordination of Services for Children with Disabilities Is Evolving, 
GAO/HEHS-00-20 (Washington, D.C.: Dec. 10, 1999). 

[5] The national average for the percentage of all infants and toddlers 
receiving early intervention services is calculated based on the birth 
to age 3 population receiving early intervention services on December 1 
divided by the total number of children ages 0 to 3 on that date. In 
2004, 2.3 percent of the nation's infants and toddlers received early 
intervention services. The national average for the percentage of 
infants and toddlers with disabilities receiving early intervention 
services in natural environments is calculated based on the number of 
children receiving services in a natural environment (homes and 
programs for typically developing children) divided by the total number 
of children receiving services in all settings. 

[6] An initial baseline performance goal of serving 2 percent of 
states' population ages 0 to 3 was based on conditions under 
observation by the Centers for Disease Control through the Metropolitan 
Atlanta Developmental Disabilities Study. These observations did not 
include certain conditions covered by Part C that are difficult to 
detect in young children, such as learning disabilities and behavioral 
and social/emotional problems. 

[7] For additional information on OSEP's efforts to address issues of 
noncompliance under Part B of IDEA see GAO, Special Education: Improved 
Timelines and Better Use of Enforcement Actions Could Strengthen 
Education's Monitoring System, GAO-04-879 (Washington, D.C.: Sept. 9, 
2004). 

[8] The most recent reauthorization of IDEA in 2004 includes a 
provision for the local educational agency under Part B to invite, at 
the request of the parent, the Part C coordinator or other Part C 
representative to the child's initial individualized education plan 
meeting. 

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