Jin Y. Shin, PhD, Associate Professor of Psychology, Hofstra University
Intellectual developmental disabilities often create severe emotional and financial impacts on individuals and families, who may have to provide lifelong support. In addition, affected individuals and their families suffer from social isolation and stigma attached to disability due to traditional, religious, or social attributions for disability that exist in their indigenous cultures. In many Western and/or industrialized countries, it has been recognized that interventions delivered early in the lives of such children bring developmental gains and improve daily and social functioning (Ramey et al., 2007). Many of these countries mandate or make intervention services available to the affected infants and young children as soon as they are identified as disabled or at risk of developmental delay (Odom, 2003). Moreover, early intervention services typically address the needs of the family as well as those of the child, with much of the evidence suggesting that such intervention is beneficial to these children and their families (Ramey et al., 2007). In addition, high-quality, intensive educational efforts that begin early in life tend to lead to the greatest developmental gains (Ramey et al., 2007).
There is little research that documents the effects of early intervention in low- and middle-income countries (LMICs, Emerson et al., 2012). There are many children from LMICs whose medical conditions or developmental delays/disabilities would qualify them for early intervention services in the United States and other developed countries but who do not obtain such services because they are not identified early enough or because no such services are available in the community. In developed countries, such children typically receive intervention services that are multidisciplinary or interdisciplinary, with professionals from different disciplines coordinating their work. However, the institutions and teams of highly specialized professionals are not usually available in LMICs, which are short of professionals in every area of human service (Einfeld et al., 2012).
Early Intervention in Vietnam
Vietnam has a population of 97 million (CIA, 2019). One of the fastest-emerging economies in Asia, Vietnam is still a relatively poor country with a GDP of US $6,900 per capita (CIA, 2019). It is estimated that approximately 2.79% of children aged 2-17 have a disability (General Statistics Office, 2018). In Vietnam, the Law on Education legally entitles people with disabilities to equal educational rights (Rosenthal, 2009). Integrated education has been the focus of Vietnamese policy on special education. Since the inclusive education model has been implemented, the number of children with disabilities attending schools appears to have been rising steadily (Le, 2013).
However, the main barrier to special education in Vietnam is teacher training (Rosenthal, 2009; General Statitstics Office, 2018); there are few special education teacher training programs established in Vietnam. Although training for teaching children with disabilities is included in the national teacher training curriculum and there has been an increase in the number and skill level of special education teachers, educational programs and classroom conditions do not meet the demand for special education. Traditionally, Vietnamese children with disabilities have been cared for by their families, who often have viewed the children as burdens to society or objects of shame and pity (Hunt, 2005). Parents of children with disabilities in Vietnam report higher levels of stress and poorer health compared to those with normally developing children due to lack of social support, which is also related to lack of professional support and stigma-related lack of social interaction (Shin & Nhan, 2009).
Purpose of the Study
The purpose of the project was to assess the efficacy of a home-based intervention program for children between the ages of 3 and 6 years with developmental delays in Vietnam. The intervention was designed to provide treatment by trained student teachers to meet the needs of individual children and families in the natural setting of the home. These children and their families received weekly services at their homes for six months by trained college student teachers. The intervention services consisted of implementing weekly teaching goals with children and their parents by working directly with children and modeling teaching techniques for their parents. The children included in the study had never received intervention services before but needed remedial services due to their significant lack of developmental progress in kindergarten programs, which serve children ranging from 2 to 6 years of age before they move on to elementary schools.
We used the Portage curriculum (CESA 5, 2003), based on the successful implementation of the intervention program with the same aged children conducted in Vietnam from 2005 to 2007 (Shin et al., 2009). The assessment of the program efficacy was carried out by comparing children who received services for six months and those who did not. We used the 2005 Vineland Adaptive Behavior Scales-II (Vineland Scale; Sparrow et al., 2005) as an indicator of adaptive behavior and developmental competence. It was hypothesized that the children in the intervention group would show greater progress in adaptive behavior than the children in the control group.
Hanoi is the capital city of Vietnam and is made up of 10 districts. We contacted 30 kindergarten programs in seven of these districts. The kindergarten programs in Vietnam run from 9 a.m. to 5 p.m. every day and serve children from 2 to 6 years of age. Sixteen kindergarten programs participated in the project. Teachers of the kindergarten programs were asked to identify children as having intellectual delays, and their delays were confirmed by trained evaluators who administered the Vineland Scale.
Eighty children who met the study criteria participated in the intervention program. After matching by gender and age, these children were randomly assigned to the intervention and control groups. The children in the control group received the intervention services after six months. Regardless of their participation status in the intervention, all children were enrolled in kindergarten programs.
Procedures and Measures
Twenty student teachers were recruited from the Department of Psychology and Pedagogy of Hanoi National University of Education. We asked the students in upper class levels to participate in the project if they were interested in working with young children with developmental delays. Although they were interested in working with these children, none of the students had prior knowledge of or experience working with this population. Before they began the program, they received three months of weekly training conducted by Dr. Son Duc Nguyen, who was the lead investigator in Vietnam and a psychologist. An experienced clinical supervisor provided necessary training and clinical supervision of the teachers throughout the project period by attending the supervision meetings or by being available to speak with them by phone or to meet with them individually.
Each teacher was assigned to work in the homes of two children and provided the weekly home-visit services for six months. Each home-visit session lasted about an hour. The teachers used the Portage curriculum manual to develop teaching objectives and activities based on the needs and issues the parents raised about their children. Twenty student evaluators were recruited separately from the department, trained to administer the Vineland Scale, and evaluated the children at 0, 3, and 6 months.
The Vineland Scale (Sparrow et al., 2005) was used to assess the children’s development over the six-month intervention period. The scale provides a measure of adaptive behavior obtained through interviews with the parents. The scale generates the adaptive behavior composite, which is an overall adaptive behavior score. It consists of subdomains in the areas of communication, socialization, motor skills, and daily living.
We compared the adaptive behavior composite scores as well as the subdomain scores for the intervention and control groups at three time points. A repeated measures ANOVA was performed to examine the difference between the groups in terms of their improvement on the adaptive behavior composite (the overall adaptive behavior score) at three and six months. There was a significant group x time effect over the course of six months, indicating that the intervention group improved significantly more than the control group in overall adaptive functioning (see Figure 1).
Repeated measures ANOVAs were computed to examine group differences on four domains of the scale (communication, social skills, daily living skills, and motor skills). There were significant group x time effects over the course of six months for all domains except in the area of daily living skills. The intervention group made significant gains over six months in the areas of communication, social skills, and motor skills.
Another set of repeated measures ANOVAs was computed to examine differences between the two groups of children in 11 subdomains of the scale at three different time points during the intervention. Although the overall score of the communication domain showed a significant interaction effect, there were no interaction effects between group and time detected for the subdomains of communication, such as expressive, receptive, and writing skills domains. Among the subdomains of social skills, the areas of play and leisure time showed a significant group and time interaction, revealing that the intervention group did better than the control group over the course of six months. Among the subdomains of motor skills, the interaction between time and group was significant for both gross and fine motor skills, with the intervention group gaining significantly more than the control group over time in these areas.
The results of the project reveal that the strategies we have adopted to implement the intervention program for children with developmental delays in Vietnam are promising. The intervention group from the current project made significantly greater gains than the control group in overall adaptive behavior and in the areas of communication, socialization, and motor skills. The children in the intervention group improved in all areas except daily living skills compared to the control group.
Many of the children who participated in the study were repeating their grades at the kindergarten level and had not been able to move on to elementary school. For this reason, the parents were most anxious to see an improvement in their children’s study skills, which might be reflected in the improvement in the area of communication skills. Although the overall improvement in communication skills was significant, the gains in the specific areas of writing, reading, and comprehension skills were not significant, revealing the challenges that the children and their families still face in improving their academically related skills.
The children in the intervention group made significant improvements in socialization skills. While these children were excluded from social play by their peers, the fact that the teachers came to their home to work and play with them regularly appeared to play a major role in improving their social skills in the area of play. The teachers designed their session to be interactive and brought many materials to engage the children in a playful format. Many children could not wait for their “big brother” or “big sister” to show up at their house gate and to start their play session together.
There was no improvement in daily living skills; probably, the parents did not expect children in this age group to clean their rooms and to dress themselves. Regarding the motor skills, the teachers actively engaged the children in physical activities, such as playing with balls and physical exercises, along with exercises in fine motor skills, such as drawing. This might have helped to improve the motor skills of the children.
In the LMIC context, having a curriculum manual written in clear and simple language can be effective when teachers do not have a background in special education or much access to ongoing education, training, and supervision. A curriculum that offers strategies of behavior modification and ample examples of educational activities helped the teachers generate ideas and plans for their education program. Although the teachers were not experienced, with motivation, commitment, and close supervision, they could educate children with moderately and mildly delayed levels of intellectual capacity.
Another effective strategy in LMIC contexts could be the identification of educational institutions in settings where students could be recruited and trained as potential interventionists/ special education specialists. Those who are motivated and interested in working with such children can be effectively trained with ongoing supervision and feedback. The project was also a success in that the student teachers enjoyed working with the children and families, obtaining substantial experience and skills training throughout the program, with some inspired to pursue a career in special education. The parents also recognized the benefit of the intervention, with some hiring the student teachers to continue to work with their children after the intervention was over.
Our observations, experiences, and data from our time in Vietnam all indicate that an early intervention program for children with developmental delays and their families may be implementable in low-income nations where resources are sparse. The improvements that we report here were all achieved through a limited level of teacher skills and manualized treatments that are easy to use. While the program may not have met the needs of all individuals due to different levels and types of delays, it appears to be broadly applicable for the majority of children with developmental delays in improving their adaptive skills toward a level of independence. This program may be a short-term, feasible, resource-light intervention that can greatly improve the functioning of children with developmental delays in LIMCs and can have a lasting impact on the quality of life for these children and their families.
This project was supported by the Fogarty International Center/National Institutes of Health [5R21TW008436-02], USA.
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