1304.20

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Subpart B -- Early Childhood Development and Health Services

1304.20

Child Health and Developmental Services

(a) Determining Child Health Status

(b) Screening for Developmental, Sensory, and Behavioral Concerns

(d) Ongoing Care

(e) Involving Parents

(f) Individualization of the Program

Introduction to 1304.20

Head Start’s commitment to wellness embraces a comprehensive vision of health for children, families, and staff. The objective of 45 CFR 1304.20 is to ensure that, through collaboration among families, staff, and health professionals, all child health and developmental concerns are identified, and children and families are linked to an ongoing source of continuous, accessible care to meet their basic health needs.

The standards in this section address the initial determination of a child’s health status and developmental needs, and discuss ongoing services provided in collaboration with parents and professional service providers.

Performance Standard

1304.20(a)(1)(i)

(a) Determining child health status.

(1) In collaboration with the parents and as quickly as possible, but no later than 90 calendar days (with the exception noted in paragraph (a)(2) of this section) from the child’s entry into the program (for the purposes of 45 CFR 1304.20(a)(1), 45 CFR 1304.20(a)(2), and 45 CFR 1304.20(b)(1), "entry" means the first day that Early Head Start or Head Start services are provided to the child), grantee and delegate agencies must:

(i) Make a determination as to whether or not each child has an ongoing source of continuous, accessible health care. If a child does not have a source of ongoing health care, grantee and delegate agencies must assist the parents in accessing a source of care;

Rationale: To promote healthy development, every child needs a source of continuous, accessible health care that is available even after the child leaves Head Start. Each child visits this health care provider, on a schedule of preventive and primary health care, to ensure that problems are quickly identified and addressed, as early identification and treatment for health problems reduce complications and improve health outcomes. Because parents have the primary, long-term responsibility for their children’s health, it is critical for them to be as involved as possible in this health care process. This rationale serves 45 CFR 1304.20(a)(1)-(2).

Related Information: See 45 CFR 1304.20(e)(4) and 45 CFR 1304.40(f)(2)(i) for further information on assisting families to enroll and participate in a system of ongoing health care.

Guidance: Parents, as the primary caregivers of their children, play a central role in child health and developmental services. They provide important information, and their concerns about their child’s health and development are carefully addressed. Parents are encouraged to participate in health promotion activities, well child care, treatment for health problems, and follow-up health care, and to receive training and information on child health and development.

Staff also serve an important role in coordinating health services with families. Through interviews and through reviewing medical documents with parents, they help make a determination as to whether or not each child has a source of continuous, accessible, coordinated care that serves as a "medical home," one that can continue beyond the time of Head Start enrollment. Staff also help determine whether or not each child has a source of funding for health services, which is necessary to assure a prompt and complete assessment of a child’s health status.

If a child does not have a continuous source of care, staff and parents work together to plan strategies to ensure that the family acquires a medical home. Strategies include:

	Seeking assistance from the Health Services Advisory Committee to identify long-term providers, sources of funding for health services, and ways to inform community health providers about the health needs of Head Start children and families;
	Working with local Medicaid agencies to determine a child’s eligibility for medical assistance; and
	Carefully and periodically reviewing health records to ensure that recommended treatment and preventive services are being provided, and that plans are developed for treatment and follow-up.

It may be advantageous for staff to conduct enrollment activities and assist families in accessing health care prior to the time of the child’s entry into the program. Although the time frame for determining a child’s health status is 90 days after entry into the program, agencies strive to make this determination for each child as early as possible. Due to the rapid development of infants and toddlers, it is particularly important to begin services as early as possible.

Performance Standard

1304.20(a)(1)(ii)

(ii) Obtain from a health care professional a determination as to whether the child is up-to-date on a schedule of age appropriate preventive and primary health care which includes medical, dental and mental health. Such a schedule must incorporate the requirements for a schedule of well child care utilized by the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program of the Medicaid agency of the State in which they operate, and the latest immunization recommendations issued by the Centers for Disease Control and Prevention, as well as any additional recommendations from the local Health Services Advisory Committee that are based on prevalent community health problems:

Related Information: Refer to the schedule of well child care employed by the EPSDT program of the State Medicaid agency.

Schedules and recommendations for well child care will evolve over time, and it is the responsibility of each grantee to obtain current information. Sources for this information include the State Health Department and, for American Indian grantees, the Indian Health Service. Screenings to identify children who may have disabilities requiring further assessment are carried out within 45 days after a child enters the program. See 45 CFR 1304.20(b) and 1308.6(b) for additional screening information; and see 45 CFR 1304.20(a)(2) for time frames for programs operating 90 days or less.

Guidance: Each child’s health provider has primary responsibility for making decisions about the child’s health status and appropriate health services. One role of Head Start staff in determining that children’s well child care is up-to-date is to work with parents to ensure that health care professionals have conducted the required review of the child’s health, and have provided diagnostic testing and treatment, as needed.

The Health Services Advisory Committee (HSAC) strengthens recommended child health care guidelines by drawing upon its knowledge of the community. For example, the HSAC provides guidelines regarding:

	standards for prenatal care,
	the frequency of tuberculin and lead testing,
	the frequency of dental visits,
	preventive recommendations regarding the use of community water fluoridation, the topical use of fluoride, and various other dental services,
	testing and preventive measures for community health problems such as sickle cell anemia, intestinal parasites, Fetal Alcohol Syndrome/Effect, baby bottle tooth decay (infant dental caries), head lice, and Hepatitis A,
	recommendations for additional immunizations (e.g., children at high risk could be immunized against Hepatitis A), and
	whether the schedule of EPSDT services, as implemented in the community, adequately addresses all aspects of health.

Performance Standard

1304.20(a)(1)(ii)(A)

(A) For children who are not up-to-date on an age-appropriate schedule of well child care, grantee and delegate agencies must assist parents in making the necessary arrangements to bring the child up-to-date;

Related Information: See 45 CFR 1304.20(a)(2) for further strategies parents can use in bringing children up-to-date on a schedule of well child care.

In addition, see 45 CFR 1304.51(c)(1)-(2) for suggestions on communicating with families.

Guidance: Agencies work collaboratively with parents and providers to make arrangements for children to receive needed examinations and immunizations. Families, therefore, may be referred to local clinics and health professionals who provide such services at reduced fees or who accept Medicaid. Agencies may arrange for staff from the local health department or health providers to come to the agency to provide services, in recognition that some parents may have difficulty taking children to medical or dental appointments. Such arrangements are not a substitute for working toward the long-term strategy of linking children and families to an ongoing source of health care. Agencies also work collaboratively with the Health Services Advisory Committee and State and local health agencies to ensure that health providers, including managed care organizations, are informed about the full range of services covered under the Medicaid program.

Performance Standard

1304.20(a)(1)(ii)(B)

(B) For children who are up-to-date on an age-appropriate schedule of well child care, grantee and delegate agencies must ensure that they continue to follow the recommended schedule of well child care; and

Guidance: Program staff:

	Discuss with parents the importance of prevention, early intervention, and well child care;
	Speak with parents to ensure that they have arranged necessary well child care appointments with health care professionals;
	Assist families in arranging for transportation to and from appointments, as well as in locating child care, if needed;
	Provide other support, as necessary, to ensure appointments are kept; and

Ensure that parents understand their child’s eligibility for services under Medicaid programs and how to advocate for their child in a variety of health delivery systems, such as fee-for-service, managed care, sliding-fee or private insurance systems.

Performance Standard

1304.20(a)(1)(ii)(C)

Guidance: Tracking health care services involves maintaining child health records (see 45 CFR 1304.51(g)), which are used to:

	Provide a child development program suited to the individual child (see 45 CFR 1304.20(f) for additional information on individualization of the program);
	Identify needed preventive and corrective care; and
	Assure that such care is arranged.

Head Start staff and parents work with health care providers to ensure that after medical and dental examinations take place, results of the examination and the treatment plan, if necessary, become part of the child’s health record. In addition, records indicate progress in completing treatment for all conditions in need of follow-up.

Health records contain information of a confidential nature, and, therefore, are kept in a place not accessible to unauthorized persons. Those portions of the health information providing helpful guidance to staff are shared through reports and through conferences that translate the confidential health information into useful educational and administrative recommendations. The need for, and the nature of, such sharing is explained to the parents, and their written authorization obtained. Staff review health records with parents (see 45 CFR 1304.51(g) and 1304.52(h)(1)(ii) for additional guidance).

Performance Standard

1304.20(a)(1)(iii) & (iv)

(iii) Obtain or arrange further diagnostic testing, examination, and treatment by an appropriate licensed or certified professional for each child with an observable, known or suspected health or developmental problem; and

(iv) Develop and implement a follow-up plan for any condition identified in 45 CFR 1304.20(a)(1)(ii) and (iii) so that any needed treatment has begun.

Guidance: The evaluations and screenings required by 45 CFR 1304.20 are helpful in identifying a child in need of further examination or treatment. For such a child, staff responsible for tracking the delivery of health services, together with parents, assume responsibility for ensuring that health or developmental problems receive competent and continuing care until the issues are remedied, or until a pattern of ongoing care is established. To accomplish this, staff responsible for tracking the delivery of health services:

	Check regularly with parents and other staff members to determine if examinations or treatments have taken place;
	Collaborate with center-based and family child care staff and home visitors, for the careful and repeated review of health records;
	Encourage health professionals to explain all procedures to families; and
	Ensure that parents understand how to navigate the referral procedures in various health care delivery systems.

Whenever possible, health services treatment and follow-up are completed by the end of the program year. However, if completion is not possible, a system is established for continuing the treatment after the child leaves the program. Staff in migrant programs are urged to assist families in identifying follow-up care at their new location.

Performance Standard

1304.20(a)(2)

(2) Grantee and delegate agencies operating programs of shorter durations (90 days or less) must complete the above processes and those in 45 CFR 1304.20(b)(1) within 30 calendar days from the child’s entry into the program.

Related Information: See 45 CFR 1304.20(a)(1)(i)-(ii) for further guidance on determining a child’s health status.

Guidance: To make a health status determination, and to secure preventive care or immunizations as quickly as possible, a good working relationship with State and local health agencies is essential. To facilitate timely services, Head Start staff in programs operating for 90 days or less can arrange for and schedule health services to take place before or during the first weeks of the program. For example, appointments for health services can be scheduled before migrant families arrive. In addition, night and weekend appointments can be made to accommodate the migrant family work schedules.

Other strategies that facilitate the provision of health services include:

	Coordinating with community agencies to provide screenings on site;
	Certifying Head Start health staff to perform screenings and measurements, when possible; and
	Facilitating transitions for families by learning where families will be going next, so that child health records may be transferred, with parental consent, to a Head Start agency, elementary school, or other child development program near the family’s new home (see 45 CFR 1304.41(c)(1)(i) on the transfer of records).

Performance Standard

1304.20(b)(1)

(b) Screening for developmental, sensory, and behavioral concerns.

(1) In collaboration with each child’s parent, and within 45 calendar days of the child’s entry into the program, grantee and delegate agencies must perform or obtain linguistically and age appropriate screening procedures to identify concerns regarding a child’s developmental, sensory (visual and auditory), behavioral, motor, language, social, cognitive, perceptual, and emotional skills (see 45 CFR 1308.6(b)(3) for additional information). To the greatest extent possible, these screening procedures must be sensitive to the child’s cultural background.

Rationale: A timely and systematic approach toward screening indicates which children require a formal assessment of their developmental needs. An approach which uses multiple sources of information and is sensitive to a child’s cultural background provides a more valid "picture" of the child. This rationale serves 45 CFR 1304.20(b)(1)-(3).

Related Information: See 45 CFR 1308.6 for a description of the process of assessing children suspected of having disabilities.

Guidance: The screening process identifies children who need to be referred for more formal assessments in order to receive the benefit of interventions such as vision or hearing aids, mental health services, special education, or other related services. A coordinated review of pre-existing information, such as results from a recent vision screening performed through the EPSDT program, is combined with or supplemented by information gathered within the first 45 days of entry into the program.

The Head Start Program Performance Standards do not require that any particular strategy, instrument or technique be used. Appropriate procedures, however, should conform to sound early childhood practice and be valid, measuring what they are supposed to measure, and reliable, yielding consistent results over time and across users. Agencies consult with the program’s content area experts in health, child development and mental health, with parents, and with the Health Services Advisory Committee as they design and implement a developmental screening approach.

Milestones in the development of motor, language, social, cognitive, perceptual, and emotional domains should be viewed flexibly – particularly since a child’s development is affected by many factors, including heredity, health status, temperament and childrearing practices. The following are suggestions for performing and interpreting screenings:

	Consider the cultural, linguistic, and developmental background of the child when selecting tools or when conducting screenings and interpreting screening outcomes;
	Recognize that there is not widespread support for the use of any single screening instrument for identifying young children needing further assessment for behavioral or social-emotional concerns. A systematic and effective approach taps multiple sources, including

	staff and parent observations of actions and behaviors,
	health history,
	developmental history and current status, and
	family functioning, including relationships between the child and his or her parents and caregivers; and

Review the results to determine if the findings "match" what staff and the family know about the child.

Performance Standard

1304.20(b)(2)

(2) Grantee and delegate agencies must obtain direct guidance from a mental health or child development professional on how to use the findings to address identified needs.

Related Information: See 45 CFR 1304.24(a)(3)(i) on consulting with a mental health professional to design and implement program practices responsive to identified mental health needs.

Guidance: Agencies have a health, mental health or child development professional available to:

	Advise program staff on how to make timely referrals for comprehensive assessments by qualified professionals;
	Provide guidance for staff on the next steps to take should screening results indicate a need for further assessment;
	Assist home visitors in planning and delivering findings and other relevant information to parents;
	Solicit ideas on how to address children’s needs in the program and in the home; and
	Assist staff in determining appropriate procedures for developmental screening.

All professionals respect family cultural backgrounds and lifestyles.

Performance Standard

1304.20(b)(3)

(3) Grantee and delegate agencies must utilize multiple sources of information on all aspects of each child’s development and behavior, including input from family members, teachers, and other relevant staff who are familiar with the child’s typical behavior.

Guidance: The formal screening process is only one of several methods that can be used to establish developmental profiles of Head Start children. A system ensures that staff and parent observations are part of all screening processes, which include:

	screening instruments as described in 45 CFR Part 1308,
	the systematically recorded observations of teachers, home visitors, and parents (see 45 CFR 1304.20(d) for guidance on observational techniques),
	collections of representative work by children, such as artwork, dictated stories, or tape recordings of language samples,
	interviews with preschool children,
	videotapes and audiotapes,
	staff summaries of children’s progress as individuals and as members of groups, and
	parent feedback.

Performance Standard

1304.20(c)(1) & (2)

(1) Grantee and delegate agencies must establish a system of ongoing communication with the parents of children with identified health needs to facilitate the implementation of the follow-up plan.

(2) Grantee and delegate agencies must provide assistance to the parents, as needed, to enable them to learn how to obtain any prescribed medications, aids or equipment for medical and dental conditions.

Rationale: Collaboration and communication between parents and staff is essential for optimal child health outcomes. This rationale serves 1304.20(c)(1) & (2).

Related Information: See 45 CFR 1304.40(f)(2)(ii) and 45 CFR 1304.20(e)(4) for further information on encouraging parents to become active partners in their child’s health care process, and to advocate for their family’s health needs.

Guidance: To support an ongoing system of communication, program staff and parents regularly compare observations of the child, refine goals, discuss progress, ask questions, talk about the quality of care, and address difficulties and concerns as they arise.

Agencies help parents to locate transportation; find assistance to pay for medications, aids, or equipment; determine where to go to obtain prescription medications, aids, or equipment; and discuss any issues or questions parents raise. Staff assist parents in learning how to communicate and work with health professionals.

Performance Standard

1304.20(c)(3)(i) & (ii)

(3) Dental follow-up and treatment must include:

(i) Fluoride supplements and topical fluoride treatments as recommended by dental professionals in communities where a lack of adequate fluoride levels has been determined or for every child with moderate to severe tooth decay; and

(ii) Other necessary preventive measures and further dental treatment as recommended by the dental professional.

Rationale: Preventive dental services and treatment are designed to ensure that a child’s teeth and gums are healthy, and that dental health problems do not affect a child’s overall health. Fluoridation is one of the most effective means of preventing tooth decay.

Related Information: See 45 CFR 1304.23(b)(3) for information on promoting effective dental hygiene among children.

Guidance: Effective dental hygiene is promoted through the use of fluoride. Two types of fluoride treatment are:

	Fluoride supplements, which may be recommended by dental professionals when communities do not fluoridate their water. These supplements are particularly useful for teeth that have not yet erupted through the gums.
	Daily brushing with fluoride toothpaste, the best way to get topical fluoride, which acts on teeth that have already erupted through the gums.

Agencies address barriers to treatment to ensure that families secure recommended dental procedures. Barriers may include a lack of information, transportation, or funds; or the unwillingness of dental providers to serve Head Start children. When access to dental care is a problem for Head Start families, special efforts, such as those described in 45 CFR 1304.20(c)(5), may be appropriate.

Performance Standard

1304.20(c)(4)

(4) Grantee and delegate agencies must assist with the provision of related services addressing health concerns in accordance with the Individualized Education Program (IEP) and the Individualized Family Service Plan (IFSP).

Rationale: Addressing the health concerns of children with disabilities will enhance their opportunity to participate in, or fully benefit from, the Early Head Start and Head Start experience.

Guidance: The Individualized Education Program (IEP) for preschoolers or Individualized Family Service Plan (IFSP) for infants and toddlers represents an agreed-upon plan of action to support the achievement of important developmental outcomes for children including, in the case of infants and toddlers, supports for families. In these individualized agreements, agencies are expected to clearly identify the related services to be provided, in order to permit the participation of children with health concerns in Head Start or Early Head Start programs.

When the IEP or IFSP calls for the provision of a related service, staff are trained and supported for the roles they assume in securing or providing such services. Clear communication with parents regarding the type and schedule of related services to be provided is important.

Performance Standard

1304.20(c)(5)

(5) Early Head Start and Head Start funds may be used for professional medical and dental services when no other source of funding is available. When Early Head Start or Head Start funds are used for such services, grantee and delegate agencies must have written documentation of their efforts to access other available sources of funding.

Rationale: Head Start programs help families to access and to use existing services and resources. Head Start agencies supplement these resources when there is no other alternative for providing families with the services needed.

Related Information: See 45 CFR 1304.41(a)(2) for information on establishing ongoing and collaborative relationships with community organizations.

Guidance: A number of Federal, State, Tribal, and local programs provide treatment, referrals, or payments for medical and dental health care or for related services, including:

	Medicaid Early and Periodic Screening, Diagnosis and Treatment (EPSDT),
	Public Health Service programs, such as the Indian Health Service, the Migrant Health Program, Maternal and Child Health Bureau services, State Maternal and Child Health services, and State Children with Special Health Care Needs services,
	Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics, and
	Health departments (State, Tribal, or local).

Developing partnerships with local providers may take time and perseverance. When contacting community providers, agencies record information such as the date, name of contact, organization contacted, and the results of this contact. This record serves as documentation of their efforts to access funding sources.

The Health Services Advisory Committee also may be helpful in identifying other resources.

Resources need not be utilized solely because they are free. If existing service programs do not meet the needs of Head Start families, Head Start funds may be used as a supplement, but only after community resources and third-party payments have been used.

Performance Standard

1304.20(d)

(d) Ongoing care.

In addition to assuring children’s participation in a schedule of well child care, as described in section 1304.20(a) of this part, grantee and delegate agencies must implement ongoing procedures by which Early Head Start and Head Start staff can identify any new or recurring medical, dental, or developmental concerns so that they may quickly make appropriate referrals. These procedures must include: periodic observations and recordings, as appropriate, of individual children’s developmental progress, changes in physical appearance (e.g., signs of injury or illness) and emotional and behavioral patterns. In addition, these procedures must include observations from parents and staff.

Rationale: Because of the rapid development of young children, annual observations are not sufficient to record changes that have an impact upon a child’s health and development. It is important, therefore, to implement ongoing evaluation procedures that identify health or developmental concerns in a timely fashion.

Related Information: For additional information on child observations, see 45 CFR 1304.21(c)(2) and 45 CFR 1304.20(b)(3).

Guidance: Strategies for gathering observations and recordings on individual children include:

	When parents or staff observe changes, those observations are shared with a health professional. All sources of information are used in evaluating each child;
	For infants and toddlers, ongoing observations include patterns of eating, sleeping, elimination, and general activity, and this information is shared with parents daily;
	Children are observed throughout the day, as they participate in indoor and outdoor activities, routines, transitions, arrivals, and departures; and
	Parents are regularly provided with information on developmental milestones, and are asked for their observations concerning their child’s development.

Even when a child does not exhibit health or developmental problems, staff continue to assess his or her physical, social, emotional, and cognitive development to ensure the quick identification of health or developmental problems, as well as to be aware of the child’s developmental progress.

Performance Standard

1304.20(e)(1)

(e) Involving parents.

In conducting the process, as described in sections 1304.20(a), (b), and (c), and in making all possible efforts to ensure that each child is enrolled in and receiving appropriate health care services, grantee and delegate agencies must:

(1) Consult with parents immediately when child health or developmental problems are suspected or identified;

Rationale: As the primary caregivers and advocates for their children, it is important that parents be involved in all decisions regarding their children’s health care. Parents should be consulted when a health problem is suspected, informed of the reasons and benefits of all procedures recommended, and told about the results of all procedures. In addition, parents should be encouraged to prepare their children for health and developmental procedures, in order to increase their children’s comfort levels, reduce their fears and anxieties, and optimize children’s performance and the validity of the procedure. This rationale serves 1304.20(e)(1)-(5).

Related Information: See 45 CFR 1304.40(f)(2)(i)-(iii) for information on involving parents in a system of ongoing health care and in medical and dental health education programs.

Guidance: Staff develop skills to communicate with parents in a supportive manner, especially in discussing concerns about a child’s development.

Parents know their children and their family, and thus interpret a child’s behavior within the context of their own family and culture. In order to accurately assess a child’s health and development, parents share their observations and concerns with all appropriate individuals; and, in turn, parents are informed about observations made by others regarding their child. Parents are involved in all decisions and follow-ups for further evaluation and intervention. It is useful for parents and staff to meet frequently to share observations and concerns, and to jointly make plans for further evaluation and intervention. Such consultations and observations should be documented (see 45 CFR 1304.51(g) for information on record-keeping).

Performance Standard

1304.20(e)(2)

(2) Familiarize parents with the use of and rationale for all health and developmental procedures administered through the program or by contract or agreement, and obtain advance parent or guardian authorization for such procedures. Grantee and delegate agencies also must ensure that the results of diagnostic and treatment procedures and ongoing care are shared with and understood by the parents;

Guidance: Agencies use fact sheets or other educational materials to familiarize parents with the use and rationale of all health-related procedures, as well as to familiarize them with the types of questions to ask health care providers. The results of diagnostic and treatment procedures are shared and discussed with parents. Group meetings or one-on-one sessions are used to convey information, as parents need understandable information about what the results of procedures mean for their child’s health and development.

Performance Standard

1304.20(e)(3)

(3) Talk with parents about how to familiarize their children in a developmentally appropriate way and in advance about all of the procedures they will receive while enrolled in the program;

Guidance: Staff speak with parents about how to provide information on medical procedures to their children. Staff model, explain, and give examples in the program setting, during home visits, or during parent meetings on how to prepare children for health procedures — emphasizing that the demonstration or "acting out" of procedures ahead of time helps children to prepare for what takes place.

Performance Standard

1304.20(e)(4)

(4) Assist parents in accordance with 45 CFR 1304.40(f)(2)(i) and (ii) to enroll and participate in a system of ongoing family health care and encourage parents to be active partners in their children’s health care process; and

Guidance: Involving parents in their children’s health care includes:

	Promoting preventive health care for all family members;
	Introducing parents to existing resources, and helping them to become effective consumers of health care and to develop good relationships with health providers, so that they will feel comfortable utilizing managed care and fee-for-service systems, making appointments, calling for information, and communicating with the provider during visits;
	Encouraging parents to take their children to health and developmental appointments, and offering them access to safe transportation and other needed resources;
	Stressing the importance of keeping up-to-date health records in a safe place; and
	Encouraging parents to participate on the Health Services Advisory Committee.

In encouraging parents to accompany their children on health appointments, staff need to be aware of parents’ work schedules and work conditions, especially with regard to the parents of children in migrant programs. Staff make every effort to ensure that services take place when parents are able to attend; services are not delayed or denied due to parents’ working conditions.

Within a complex and changing health care system, Head Start staff, community partners, and other parents play an important role in helping families advocate for health needs. Effective health advocacy skills contribute to improved health care for Head Start children and family members. Head Start helps promote families’ health advocacy skills, such as identifying and documenting health concerns, networking with other families who may have similar needs, identifying available resources for information and services, and communicating effectively with health professionals and administrators — and, thereby, assist parents in accessing the health information and services they need.

Performance Standard

1304.20(e)(5)

(5) If a parent or other legally responsible adult refuses to give authorization for health services, grantee and delegate agencies must maintain written documentation of the refusal.

Guidance: Staff obtain timely, informed, and written parental consent for authorization of all health services provided or arranged. When parents raise concerns about recommended procedures, it is useful to speak with them about why they refuse treatment, and to describe the benefits and reasons for the recommended procedures. When parents express discomfort working with a provider or have concerns regarding services or procedures, staff assume the role of "liaison" between the parents and the provider, consulting with the Health Services Advisory Committee, as needed. When families refuse their authorization, those refusals need to be documented. See 45 CFR 1304.22(a)(5) for guidance in determining when a refusal for treatment may be considered child abuse or neglect.

Performance Standard

1304.20(f)(1)

(f) Individualization of the program.

(1) Grantee and delegate agencies must use the information from the screenings for developmental, sensory, and behavioral concerns, the ongoing observations, medical and dental evaluations and treatments, and insights from the child’s parents to help staff and parents determine how the program can best respond to each child’s individual characteristics, strengths and needs.

Rationale: Each child has an individual pattern of growth and an individual learning style. Most children will not require special education services to address their needs. However, children with disabilities often require a particular set of special services. This rationale serves 45 CFR 1304.20(f)(1)-(2).

Related Information: See 45 CFR Part 1308 for a description of required services for children with disabilities.

Guidance: Building upon the results of screenings, observations, and evaluations, activities are tailored, the curriculum adapted, and the physical environment modified to support each child’s learning style, and to be responsive to differences in style (see 45 CFR 1304.21(c)(2)).

Should a screening identify a child in need of further evaluation or diagnostic testing, and the subsequent results indicate that the child meets the eligibility criteria for a disability requiring special education services, an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) is developed, and services begin as soon as possible.

Performance Standard

1304.20(f)(2)(i)

(2) To support individualization for children with disabilities in their programs, grantee and delegate agencies must assure that:

(i) Services for infants and toddlers with disabilities and their families support the attainment of the expected outcomes contained in the Individualized Family Service Plan (IFSP) for children identified under the infants and toddlers with disabilities program (Part C) of the Individuals with Disabilities Education Act, as implemented by their State or Tribal government;

Related Information: Part C (formerly Part H) of the Individuals with Disabilities Education Act (IDEA) requires that States develop and implement a program of early intervention services for all infants and toddlers with disabilities and their families. Such a program must include written IFSPs specifying the major outcomes expected for each child and family, and the early intervention services necessary to help reach such outcomes. Each IFSP is a written plan developed by a multidisciplinary team, including parents or guardians, and contains:

	a statement of the infant’s or toddler’s present levels of physical, cognitive, language, speech, and psycho-social development and self-help skills,
	a statement of the family’s strengths and needs with regard to supporting the development of their infant or toddler,
	a statement of the major outcomes to be achieved, along with the criteria, procedures, and timelines used to determine whether progress has been made, and whether a revision of the outcomes or services is necessary,
	a statement of the specific early intervention services needed to meet each child’s and family’s needs, including frequency, intensity, and method of delivery,
	the projected dates for beginning services, and the anticipated duration of those services,
	the name of the case manager responsible for implementing the plan and coordinating with other persons and agencies, and
	the steps to be taken to support the child’s transition to preschool services, such as those specified under the IFSP and the IEP.

The IFSP reflects the kinds of intervention strategies and services the family believes will ensure that major outcomes for the child and family are achieved. Head Start services for infants and toddlers with disabilities are carefully tailored to each IFSP. Families are given continuing opportunities to express their preferences and concerns, in order to help identify the resources they bring, as well as the resources and service options they need to address their concerns.

Guidance: Development of the IFSP is a major step in a family-centered process of early intervention that emphasizes respect for family autonomy, independence, and decision-making and the development of partnerships between families and professionals to meet the individual needs of each child with disabilities. Ongoing communication with the local Part C agency will ensure that a coordinated approach supportive of families, but not duplicative or burdensome, is developed.

Performance Standard

1304.20(f)(2)(ii)

(ii) Enrolled families with infants and toddlers suspected of having a disability are promptly referred to the local early intervention agency designated by the State Part C plan to coordinate any needed evaluations, determine eligibility for Part C services, and coordinate the development of an IFSP for children determined to be eligible under the guidelines of that State’s program. Grantee and delegate agencies must support parent participation in the evaluation and IFSP development process for infants and toddlers enrolled in their program;

Guidance: Head Start staff share information with families about services for infants and toddlers with suspected disabilities, and refer families to the appropriate local early intervention agency. Staff recognize that the process for developing the IFSP is as important as the plan itself, and literally depends upon the development of strong partnerships between families and the professionals who help them. Even though assessment and IFSP development may be performed by another local agency, Head Start staff support families in the IFSP evaluation and development process by helping them to:

	Understand their rights, including the right to participate in the development of the IFSP and the right to approve or disapprove it;
	Gather preliminary information, such as pregnancy and birth histories, health records, and developmental observations that will assist in assessing the child’s needs;
	Understand the process of assessment and diagnosis, and the findings;
	Come to terms with fears, concerns, and needs;
	Articulate the family’s immediate and long-range intervention strategies and service priorities; and
	Learn how services from more than one agency can be coordinated.

Performance Standard

1304.20(f)(2)(iii)

(iii) They participate in and support efforts for a smooth and effective transition for children who, at age three, will need to be considered for services for preschool age children with disabilities; and

Related Information: See 45 CFR 1304.40(h) on involving parents in transition activities, and 45 CFR 1304.41(c) on transition services, especially (c)(2) concerning transitions for toddlers approaching their third birthday.

Guidance: Regulations for Part C of IDEA require the transition of infants and toddlers from Part C services to preschool services to be addressed, including:

	Discussions with and training of parents regarding transition issues, including future placements and long-range goals, strategies, and service priorities for the child and family;
	Preparation of each infant or toddler with disabilities for changes in service delivery or placement, including specific steps to help the child adjust to and function in a new setting;
	Discussions with parents about the IEP development process (see 45 CFR 1308.19); and
	Development of a transition plan at least six months before the child’s third birthday, as required by 45 CFR 1304.41(c)(2).

Head Start agencies are aware that, in some States, at the discretion of families, Part C services governing IFSP development and implementation may be substituted for the IEP services that are specified in Part B of IDEA. Agencies, therefore, should be aware of all applicable State laws and regulations in this area.

Performance Standard

1304.20(f)(2)(iv)

(iv) They participate in the development and implementation of the Individualized Education Program (IEP) for preschool age children with disabilities, consistent with the requirements of 45 CFR 1308.19.

Guidance: See 45 CFR 1308.19 for information concerning the development and implementation of the IEP, including: the contents of an IEP; the formation of multidisciplinary evaluation teams; and methods for involving parents in the IEP process.

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