Child: care, health and development. 1992.18,377-394

Portage guide to early intervention: cross-cultural aspects and intra-cultural variability p. STURMEY*,M. J.THORBURNt, J. M. BROWNt. J. REEDS, J. KAUR||and G. KING|| " Department of Psychology, Abilene State School, Abilene, Texas 79604, USA, i3D Projects, Spanish Town, Jamaica. tEarly Stimulation Project, Kingston, Jamaica, '^Learning Difficulties Research Group, School of Psychology, University of Birmingham, Birmingham, U K. and\\Department of Clinical Psychology, Dudley Road Hospital, West Birmingham District Health Authority, Birmingham, UK

Accepted for publication 28 May 1992

Summary The issues arising from implementing an early intervention service, developed in the rural United States in the late 1960s in a range of different cultural contexts over a period of a quarter of a century, are explained. Services from India, Bangladesh, Jamaica and the United Kingdom are compared. As well as considering cross-cultural aspects of Portage, variability within one country, the United Kingdom, is considered by comparing one service in an inner-city area and one in a rural area. INTRODUCTION Efforts to prevent and ameliorate developmental delays in childhood are to be found worldwide. Historically, more research has been reported from the developed nations of Western Europe and North America. However, many examples of early interventions may be found throughout the developing world (Mittler & Serpell 1985 Thorburn & Marfo 1990). Early intervention, when viewed from a global perspective, takes place in an extremely diverse range of contexts which materially affect the appropriateness and relevance of different forms of early intervention in different cultural contexts. This may be reflected in the range Correspondence: Dr P. Sturmey, Department of Psychology, Abilene State School Abilene Texas 79604, USA.

377

378 P. Sturmey et al.

and patterns of aetiology of developmental delay with consequent implications for prevention and intervention (Shah 1990a). Thus, in developing countries malnutrition, infectious diseases, maternal health and age, and birth asphyxia are major causes of developmental delay (Hasan & Aziz 1981). In contrast, in developed countries genetic causes are more common (Dupont 1981). Cultures will also vary according to their demography, infrastructure, material resources, family structure and roles, relevant religious beliefs and current health, educational and social practices related to the care and support of individuals with developmental delay. For example, in rural Pakistan marasmus is readily identified by mothers. Mothers typically believe that marasmus is caused by contact with another woman who also has a child with marasmus or who is ritually impure, or is caused by fright or spirit possession (Mull 1990). Paradoxically, treatments based on Western medical models, such as replacing dried cow dung with talcum powder as part of a newborn's wrappings, and replacing rock salt with powdered iodized salt, are accepted alongside these beliefs and alongside traditional treatments such as headbands to protect against the evil eye (Mull, Anderson & Mull 1990). The Portage Guide to Early Intervention (Shearer & Shearer 1972, Sturmey & Crisp 1986) is one form of early intervention which has had a spectacular international impact more so than any other early intervention service. National associations exist in the United States, the United Kingdom and Japan (Kushlick 1982, Yamaguchi 1990) and it has been implemented, sometimes in modified forms, in developing countries such as India, Pakistan, Bangladesh and parts of South America, as well as nations which occupy an intermediate position between developed and developing countries such as Jamaica (Thorburn 1981). Indeed, Mittler & Serpell (1985) in a review of international aspects of services to people with learning disabilities and their families, single it out as an example of home-based education for pre-school children who are at risk for developmental delays. Portage was developed in rural Wisconsin, USA, in the late 1960s. It is a home-based, educational approach in which the child is taught by a parent, typically the mother, on a daily basis. The family receive weekly visits from a home visitor who carries out an assessment on a criterion-related developmental checklist (Bluma, Shearer, Frohman & Hilliard 1976). Weekly teaching goals are selected through liaison with the parents, and the principles of learning are employed to help the child achieve the goal. Previous teaching goals are evaluated using

Portage guide to early intervention 379

daily records kept by the parents. The home visitor teaches the parent through modelling the current program with the child. In a typical British example the Portage service would be managed by a hierarchical management pyramid. For example, an educational or clinical psychologist might supervise a number of full-time home visitors each with a case load of eight to 10 families. The entire service might be monitored by a management committee which might receive data on the current case load, number of goals set and achieved, organize referrals from other agencies and liaise with other agencies as children pass on to pre-school nurseries or schools. In this article we explore the issues which arise from implementing an early intervention service developed in the rural United States in the late 1960s in a range of different cultural contexts over a period of a quarter of a century. To do this we compare services from India, Bangladesh, Jamaica and the United Kingdom. As well as considering cross-cultural aspects of Portage we will also consider variability within one country, the United Kingdom, by comparing one service in an inner-city area and one in a rural area. This is done by considering the following questions: (a) can the original service model be replicated, unmodified, in other contexts?; (b) what pattern of services are found in different countries and how does Portage relate to them?; (c) how are children referred?; (d) how do the differences in family structure and roles found in different countries affect the implementation of Portage?; (e) is the original curriculum readily applicable in new settings? and (f) how are staff recruited and trained? COUNTRIES SELECTED Demographic, social and economic indicators for the four countries are'presented in Tables 1, 2 and 3 (Commonwealth Secretariat 1987). The four countries selected represent a wide range of development, with Bangladesh and India being least developed and Jamaica being demographically more similar to, yet distinct from, the United Kingdom. Thus, Bangladesh and India can be characterized as having rapid population growth, a high proportion of the population aged under 15, relatively low life expectancy, and high infant mortality. There is relatively low access to services and large differences in male and female literacy rates. They have relatively low GNP per capita in an economy in which agriculture is important whereas annual GNP per

380 P. Sturmey et al.

TABLE 1. Demographic variables for Bangladesh. India, Jamaica and the United Kingdom in the mid-1980s Variable

Bangladesh

India

Jamaica

United Kingdom

Population (1000s) Area (1000s) Population density (km ') Annual population change (%) Aged under 15 years (%) Life expectancy (years) Infant mortality (per 1000 live births)

98 087 143 686 2-5 44-4 51

765 147 3287 232 2-2 39-7 56

2325 11 211 1-3 38-2 73

56 739 244 232 0-0 19-2 75

123

89

20

T A B L E 2. Social and service data for Bangladesh, India, Jamaica and the United Kingdom in the mid-1980s Variable

Bangladesh

India

Jamaica

United Kingdom

People per hospital bed Adult literacy —males (%) Adult literacy —females (%) Calorie consumption (% of requirement) Access to safe water—rural (%) Access to safe water — urban (%) Radios (per 1000 population) Daily newspaper (per 1000 population) Telephone (per 1000 population) Television (per 1000 population) Cars (per 1000 population)

3761 29 13

1400 55 29

374 90 93

114 98 98

81 55 15 . 6

96 33 77 44

111 85 100 331

132 99 99 940

6

19

48

526

1

4

62

514

2 1

3 1

77 65

332 307

T A B L E 3. Economic indicators for Bangladesh, India, Jamaica and the United Kingdom in the mid-1980s Variable

Bangladesh

India

Jamaica

Gross GNP ($M) GNP per capita Annual change in GNP per capita (%) GNP as agriculture (%) GNP as industry (%) GNP as manufacture (%) GNP as services (%)

$14 770 $150

$194 820 $2090 $250 $2227

$474 190 $8390

2-0 50 14 8 36

2-0 31 27 17 41

M 2 36 22 62

3-5 6 36 20 58

United Kingdom

Portage guide to early intervention 381

capita is increasing relatively rapidly. On several indicators, India is relatively more developed than Bangladesh. On all indicators, Jamaica and the United Kingdom are distinct from India and Bangladesh as having high life expectancy, lower infant mortality rates, high literacy rates and access to safe water. GNP per capita is of the order of 15-55 times greater and their economies are approximately 60% servicebased. A number of differences betwee.n Jamaica and the United Kingdom were noted. These Include a rather younger Jamaican population, rather higher infant mortality and rather lower access to services, information and transport and lower GNP per capita compared to the United Kingdom.

CASE EXAMPLES India and Bangladesh So far there are no detailed papers published on Portage in India and Pakistan, therefore, information has been collated from a number of separate sources. It should be noted that India is an extremely diverse country, spanning 31 degrees of latitude and 30 degrees of longitude, and is somewhat larger than the European community. The observations made here may well have to be qualified by many differences within these countries. There have been several accounts of Portage services based in India and Bangladesh (Parikh 1990, Zaman & Islam 1990): not one has implemented the model unmodified. The demography and infrastructure are so different that many of the assumptions implicit in Portage cannot be met. Resources are so limited and the population so large that many of the organizational features assumed in Western services are not available. Many of the effective methods of early intervention based on health and public services, which would doubtless prevent developmental delay, have yet to be fully implemented. For example, immunization against common childhood infections is often incomplete (Bhattacharya, Joshi, Raj & Dwivedi 1989). Shah has highlighted the importance of management of birth asphyxia by traditional birth attendants through training in resuscitation and the development of robust equipment (Shah 1990a). Shah also highlights the importance of malnutrition, both broad-based Protein Energy Malnutrition (PEM), as well as specific deficiencies such as iron, as well as simple.

382 P. Sturmey et al.

robust methods of recording and identifying at-risk mothers and babies (Shah 1990b). These concerns have been reflected in the modifications made to Portage services in India and Bangladesh. Both Zaman & Islam (1990) and Parikh (1990) included nutrition supplement programs for infants with PEM. Zaman & Islam's (1990) programme offered a glass of milk or an egg with a banana each day as a cheap, nutritious diet. In both of their services Portage, or a modification of it, was but one component of an overall service package. The service package included elements such as case detection and screening, genetic counselling for high-risk couples, which might be a major risk factor in some parts of India (Madhavan & Naruyan 1991), publicity for the programme through television, radio, newspapers and talks, and a toy library. In Parikh's (1990) account the service contact is rather different than that found in the UK. First, the main agency was a charity, the Association for the Welfare of Persons with a Mental Handicap in Maharashtra, rather than a governmental education, health or welfare department. She states that '. . .we have been privileged to utilize large existing infrastructures (especially governmental) . . . the premises offered to us by various institutions were given free of rent. . . this has made it possible for us to have no overheads at all — no . water bills, no electricity bills, etc."

Such an informal organizational arrangement would be unlikely in Western countries. Case finding and referral methods face a number of difficulties in developing countries. These include the size of the population in a catchment area and the high population mobility. For example, massive migration from rural to urban areas has occurred with the subsequent development of cramped, poor quality housing with a mobile population which is difficult to track (Hasan & Aziz 1981, Narayanan 1990). Added to this are the difficulties of lack of a service structure to routinely detect at-risk or delayed children. Recently, simple methods which are suitable for mass screening for developmental delays have been piloted in developing countries (Belmont 1984). The Ten Questions screen has been shown to be usable in many developing countries and to be psychometrically adequate to identify children with severe and profound developmental delays. This questionnaire has been used by Zaman & Islam (1990) for case finding

Portage guide to early intervention 383

in Bangladesh for the Portage service used there. Interestingly, Mull et al. (1990) report observations of families hiding severely malnourished or disabled infants, which might make case finding, in some situations, extremely difficult. Most forms of early intervention developed in the West either implicitly or explicitly depend upon the mother as the key agent of change. In India and Bangladesh family structure and roles may be different, where extended families, rather than nuclear families may be more common. In some situations the social position of the mother may be relatively weak in determining child care and dealing with agencies outside the family. However, this traditional model of family life may be altered by the processes of migration, urbanization and education. For example, in many families in urban slum areas mothers frequently engage in paid work outside the home. Thus, older brothers and sisters may become key caretakers (Shah 1990a), as well as other family members other than the child's mother. The applicability of Western curricula to developing countries has attracted considerable criticism (Baine 1987,1990). Several comments related to Portage services in India and Bangladesh reflect this. Several workers comment that simply translating the curriculum is inadequate as some items are irrelevant (OToole 1988) and other important items of infant and child behaviour are omitted. Parikh (1990) notes that'. . . the target group aimed at was the lowest socioeconomic groups for whom even the cheapest toy was not affordable'. Elsewhere she notes that 'A successful intervention program in India . . . should use minimum equipment and preferably household items like 'Katoris' and spoons'. Baine (1987, 1990) has been more forthrightly critical. Not only are almost all developmental assessments technically inadequate for developing countries (Baine 1990) but their content may be substantially irrelevant. Baine (1987) argues that the valuable time spent on teaching should be spent on functional, age-appropriate tasks which are immediately useful in everyday life rather than tasks supposedly preparatory for educational achievement. He advocates the use of ecological inventories to identify environments in which delayed and non-delayed children live or will live and to assess these tasks and behaviours required of them in these settings. These tasks and behaviours are then specified, listed in a curriculum and written as an instructional objective and task-analysed. Baine suggests that tasks, such as collecting eggs, fetching water or collecting wood, may be more important than putting pegs in boards.

384 P. Sturmey et al.

Staff recruitment and training have not been discussed in great detail in any of the papers identified. Both Parikh (1990) and Zaman & Islam (1990) discuss staff training in screening and case detection, using methods such as the Ten Questions. In accounts of Portage in India and Bangladesh little mention is made of the issues of training staff, parent-training, adequacy of record keeping and literacy of home visitors and parents. In sum, it appears that Portage has successfully and repeatedly been implemented in India and Bangladesh. However, it has required numerous modifications. Indeed, it appears that Portage forms only one of several components of early intervention services reflecting the radically different pattern of aetiology found in India and Bangladesh compared to Western countries. Jamaica Portage in Jamaica has been established since 1975 and there have been a number of publications on the service and on epidemiology (Thorburn 1990a, 1990b, Thorburn et al. 1991). In Jamaica the Portage model has been replicated with only relatively minor modifications. Differences include the use of Portage for all disabled children. Thus, the majority of children have not only learning disabilities, but it also includes children with hearing, speech, physical and, very rarely, visual disabilities. In Jamaica Portage is also used for older children who are disabled, in areas where there are few or no services for children with developmental delays. The total enrolment in 1990 was over 500 families of which 400 receive regular weekly home visits. The services are organized into geographical catchmentareas corresponding to parishes with populations of about 350 000. These include both urban areas, such as Kingston, and rural areas. Referrals are received mostly from health staff and medical doctors, although some referrals are also received from other agencies or are self-referrals. No population screening is routinely done. However, recently, as part of the international piloting of the Ten Questions screen (Belmont 1984) a survey of sections of the parish of Clarendon has been completed (Thorburn et al. 1991). This showed that key informants, e.g. community health aides, nurses and midwives identified very few children with disabilities compared to the survey method. Thorburn et al. (1991) suggest that there is relatively little awareness of disability amongst key informants. There are a wide range of family structures found in Jamaica. These

Portage guide to early intervention 385

include extended families, more commonly found in rural areas, and nuclear families, often with only one parent, more commonly found in Kingston. Many children grow up in homes where the father is absent or where the father just visits. Thus, much responsibility for child-care falls to women. In a recent survey of parents, 95% said they had time to teach their child and, on the whole, education is regarded highly by the majority of the population. However, severe economic hardship appears to make the task of teaching difficult. If the mother works, elements of child-care may be passed on to other family members. In rural areas transportation may be a problem, and even when fares and meals are provided, more than 50% of parents do not attend meetings, for example, for parent-training courses (Thorburn 1992). There have been few comments made concerning the use of the Portage curriculum in Jamaica. For most families there would be a lack of the manufactured toys and play-materials which feature in the Portage curriculum. There may also be important functional, everyday tasks which are not identified on the Portage curriculum. Staff recruitment and training have received considerable attention in Portage services in Jamaica, both in relation to professional and non-professional staff. In the pilot project 16 Child Development Aides (CDAs) were recruited in 1975, and a further 11 in the next year. School leavers were recruited from the National Youth Corps, a government programme to provide employment opportunities for school leavers. Staff have also been recruited from parents through parent-training workshops. The typical level of education of most community workers is sixth to eighth grade. Staff get a flexible training programme that consists of a 30-day course which includes basic training and orientation (3 weeks), physical disabilities and exercise (1 week), communication training and disabilities (1 week) and behaviour management (1 week). Content includes use of screening and assessment questionnaires, assessment of the activities of daily living, and writing individual programme plans. A more comprehensive matrix of staff-training has been developed for all staff in the service and is illustrated in Table 4. There is also regular training in health, nutrition, and social aspects of early intervention. Much of this training, especially the initial 30-day course includes a great deal of practical hands on training (Thorburn & Roeher 1980, Thorburn 1981). More recently, some workers recruited, have had greater educational qualifications and some are taking extra-mural university courses. Three have left to be trained as

386 P. Sturmey et al.

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Portage guide to early intervention 387

teachers. To date, CD As in the government service are still temporary employees and do not have job security or pensions. However, staff in 3D Projects do have pensions and health insurance. Professional staff are involved in training and supervision of CD As. However, these are few and far between, difficult to recruit, and may leave relatively quickly. For an 18 month period no rehabilitation coordinator could be found for one of the projects. This leads to poor morale, poor record keeping, inadequate follow-up of clients etc. (Thorburn 1988). Clearly, professional staff occupy a key role in services, which may be highly dependent upon their input. Portage services in Jamaica required fewer gross modifications than those in India and Bangladesh. Many of the differences relate to the setting up of new services for low priority groups in a setting where there is no strongly developed, government-based service framework for disabled children. Thus, whilst widespread illiteracy is not the major problem found in India and Bangladesh (see Table 2), many aides take on roles which would be taken on by professional staff such as physiotherapists or occupational therapists, etc. in more developed countries. United Kingdom The two services compared here, one from an inner-city area and one from a county-town and rural hinterland area, will be discussed together as they share many of the features discussed above. In the United Kingdom, over 300 Portage services exist. Typically these have geographical catchment areas which correspond to District Health Authorities or Local Authorities with populations of 250 000 to 400 000. Thus, one Portage service may cover one sector of a major city, or perhaps a large rural area as large as the county of Cornwall. All of these services have been set up since 1979 and thus rapid growth of these services has occurred over a 10-year period (Cameron 1990). Portage services are just one element in a complex of services for preschool children which are operated by the National Health Service, Social Services and charities (Sturmey 1991). Many Portage services are members of the National Portage Association, receive a national newsletter and may well have informal contacts with neighbouring Portage services. The fact that so many Portage services have been set up in the United Kingdom might, at first sight, seem to indicate that the Portage model has been replicated successfully and repeatedly in the UK.

388 P. Sturmey et al.

Certainly many accounts of Portage do demonstrate that the service model and curriculum can be implemented (Dessent 1984a). However, a noticeable trend can be discerned for accounts of services to also emphasize functions of Portage other than teaching skills to the children. These include general parental support, specific parental counselling methods, providing information for parents, co-ordination of services for the entire family, such that at times the skills teaching element is de-emphasized (Dessent 1984b). Portage services typically receive referrals for children with established developmental delays which are readily evident during the preschool years. Children with other disabilities, e.g. cerebral palsy, etc. will be seen by other specialized services if they do not have a learning disability. The exact pattern of referrals varies from one service to another depending upon the make-up of the local service. However, children may be referred from paediatricians, child development centres or a range of other local agencies. Many Portage services may refer older pre-school children to services such as pre-school nurseries. The two services considered here did not differ in any gross manner. The inner-city service had a very high proportion of recent immigrant families whereas the rural service did not (see Table 5). A number of studies of immigration in Birmingham have revealed a number of important factors which may be relevant (Stopes-Roe & Cochrane 1987, 1988, 1989, 1990). It is important to recognize the heterogeneity of immigrants and the importance of differences between groups of immigrants and individuals. The two major groups TABLE 5. The ethnic composition of children in the two British services Service Ethnic group

Inner city

Rural

Asian

53% (12) 34% (7) 5% (1) 5% (1) 21

0% (0) 0% (0) 93% (14) 7% (1) 15

Afro-Carribean Caucasian Mixed race Number of children

Portage guide to early intervention 389

of Immigrants in Birmingham are people from the Carribean and people from Asia. Afro-Caribbean people mostly immigrated to the UK in the 1950s at a time of labour shortage in the UK. Asian Immigrants have come from extremely diverse backgrounds such as India, Pakistan and Bangladesh, as well as Asians from parts of Africa such as Uganda and South Africa. Members of ethnic minorities include both first, second and third generation migrants. Asian immigrants include Hindus, Muslims and Sikhs. Stopes-Roe & Cochrane (1987) distinguish between three aspects of cultural assimilation. Cultural assimilation relates to food, drink and dress; structural assimilation relates to the pattern of contacts at work, in education and socially; finally, identificational assimilation relates to how a person feels and where they perceive home to be. In their study of Hindu, Sikh and Muslim families living in inner-city parts of Birmingham, Stopes-Roe and Cochrane (1987) found gender, generation and ethnic differences on measures of assimilation. For example, young adult children did not differ between themselves on measures of assimilation: all groups reported more assimilation than their parents. However, among parents, women tended .to be less assimilated than men and Hindus tended to be somewhat more assimilated than other groups. Similar findings were found in a study of child-rearing values (Stopes-Roe & Cochrane 1990). In a study of British and first and second generation Asian immigrants, it was found that first generation Asians were more likely to value conformist child characteristics, such as obedience, whereas white parents were more likely to place value on self-directing characteristics such as responsibility and self-control. No differences were found between second generation young Asian and young white people. No differences were found between Hindus, Muslims and Sikhs. Various changes in Portage have been noted when working with ethnic minority families. Some of these are fairly obvious such as the use of translators, and written and video materials in several languages. For example, the inner-city service employs a part-time Asian language interpreter for families who speak Punjabi, Urdu, Hindi or Mirpuri. The interpreter is available for home-visits and translating materials. Stopes-Roe & Cochrane (1990) found that Asian families were more likely to be extended rather than nuclear families. This is reflected in home-visits to extended families where family members other than the mother, such as grandmother, aunts or older siblings, may be present and may well be involved in teaching.

390 P. Sturmey et al.

Interestingly, although Stopes-Roe & Cochrane (1990) found that first generation Asian immigrants were less likely to have secondary or further education than white parents, no problems have been reported in relation to parental education. Thus, the inner-city area Portage service can make specific provision, allocate resources and develop materials and expertise in working with ethnic minority families. Little comment has been made about the use of the Portage curriculum in Britain. It is likely that many services use it as a rough basis for selecting goals. Even in American services only 50% of goals are taken directly from the curriculum (Shearer & Shearer 1976). It would be interesting to use environmental inventories to British families to establish common developmental tasks. It is possible that many important tasks (turning the video on, passing Mom her plate) are not to be found on the Portage curriculum. This probably reflects the fact that the Portage curriculum was developed in an ad hoc fashion and used other developmental tests as a source of items. Bardsley & Perkins (1985) found that Asian families using Portage were less likely than white families to have manufactured toys in the home. Cochrane (personal communication) has also found this but has also observed greater use of everyday household materials in play in first generation Asian families. This suggests that relevant target behaviours may well be different for both social behaviours and play in children in first generation Asian families. The majority of staff, home visitors, supervisors and management committee, have relevant professional qualifications although some services do use volunteers or parents as home visitors. Thus, most staff-training relates to the specific aspects of Portage services rather than more general aspects of child health and development. The National Portage Association organizes both induction courses for new staff and advanced courses for staff already experienced in Portage. Many services will organize this locally. A problem commonly encountered relates to recruitment and retention of staff and the lack of a formal career structure within Portage services for home visitors. DISCUSSION The implementation of Portage services or variants of them across the world is a remarkable phenomenon which raises a number of important questions related to a pre-school education-oriented form of

Portage guide to early intervention 391

early intervention. Portage services in developing countries have required substantial modification reflecting the available resources, the service infrastructure and local demography. This issue of cost is of great importance (O'Toole 1988). Other forms of early intervention are viable. Some of these may be cheaper and result in primary prevention of developmental delay (e.g. iodization of salt, prevention of birth asphyxia) and perhaps could be implemented on a comprehensive, nationwide basis. Portage services may, by themselves, be relatively less important in this context as direct agents of change. Rather, they may be one element of broader social changes seen as countries develop. Important demographic and cultural changes continue to take place in developed countries which may be relevant to some of the issues discussed here. For example, in North America, large-scale immigration from Hispanic cultures of mid and central America, the Caribbean and the Pacific rim continue at a high rate. The 1991 census in the United States revealed that 25% of Americans are from ethnic minorities and in some inner-city areas and some southern states a distinct Hispanic-American culture is developing. Thus, the importance of intra-cultural variability, immigration and cultural assimilation may become common issues for pre-school education throughout the developed world. Work on family structure and roles and early intervention has been relatively undeveloped. We need to know more about family members other than the mother and how they can play a fuller role in pre-school early intervention. Perhaps the area most frequently identified for further development is that of the curriculum for pre-school early intervention. The Portage curriculum is now a quarter of a century old, developed in the rural United States, and which selected items from Western developmental checklists in which items are chosen for their psychometric properties (e.g. reliability, ease of assessment) rather than their importance as teaching targets. As an alternative, a flexible procedure manual, rather than a checklist of target behaviours based on Baine's (1987) work on ecological inventories, mjght be more fruitful in identifying relevant targets, both in developing and developed countries in pre-school early intervention. ACKNOWLEDGEMENT This work arose out of the conference held by the Commonwealth

392 P. Sturmey et al.

Association for Mental Handicap and Developmental Disabilities, New Delhi, February 1990.

REFERENCES Baine D. (1987) Testing and teaching functional versus generic skills in early childhood education in developing countries. International Review of Education 33, 147-158 Baine D. (1990) Guide to the development, evaluation, and/or adoption and modification of tests for early childhood education in developing countries. In Practical Approaches To Childhood Disability ln Developing Countries: Insights From Experience And Research, eds M. J. Thorburn & K. Marfo, pp. 200-224. Department of Education, Memorial University. Newfoundland, Canada Bardsley J. & Perkins E. (1985) Portage with Asian families in central Birmingham. In Portage: The Importance Of Parents, eds B. Daly, J. Addington & A. Sigston. pp. 109-118, NFERNeison, Beckenham, Kent Belmont L. (1984) The International Pilot Study of Severe Childhood Disability. Final Report: Screening for Severe Mental Retardation In Developing Countries. Bishop Beckers Foundation, Utrecht, Netheriands Bhattacharya J., Joshi P.L., Raj G. & Dwivedi S. (1989) Strategies to step up recall induction in the Universal Immunization Program. The Journal of Family Welfare 3S, 21-25 Bluma S., Shearer J., Frohman A. & Hilliard J. (1976) Portage Guide to Early Education Manual, revd edn. Portage, Wisconsin, CESA-12 Cameron S. (1990) Portage in the UK. In A Challenge To Potentiality: The Vision of Early Intervention for Developmentally Disabled Children, ed. K. Yamaguchi. pp. 58-70. Portage Japan Association, Tokyo, Japan Commonwealth Secretariat (1987) The Commonwealth Factbook. Commonwealth Secretariat. London Dessent T. (1984a) What Is Important About Portage? NFER-Nelson. Windsor, Berks Dessent T. (1984b) What is important about Portage? In What Is Important About Portage? ed. T. Dessent, pp. 3-14. NFER-Nelson, Windsor, Berks Dupont A. (1981) Epidemiological studies in mental retardation. International]ournal of Mental Health 10, 56-63 Hasan Z. & Aziz H. (1981) Report on a population survey of mental retardation in Pakistan. International Journal of Mental Health 10. 23-27 Kushlick A. (1982) A national Portage association? In Working Together: Portage In The UK, ed. R. J. Cameron. NFHR-Nelson, Windsor, Berks Madhavan T. & Naruyan J. (1991) Consaguinity and mental retardation. Journal of Mental Deficiency Research 35, 133-139 Mittler P. & Serpell R. (1985) Services: an international perspective. In Mental Deficiency: The Changing Outlook, 4th edn. eds A. M. Clarke, A. D. B. Clarke & J. M. Berg. pp. 715-787. The Free Press, New York Mull D.S. (1990) Traditional perceptions of marasmus in Pakistan. Social Science and Medicine 10, 175-191 Mull D.S., Anderson J.W. & Mull J.D. (1990) Cow dung, rock salt, and medical innovation in the Hindu Kuhn of Pakistan: the cultural transformation of neonatal tetanus and iodine deficiency. Social Science and Medicine 30, 675-691 Narayanan H.S. (1990) A study of the prevalence of mental retardation in Southern India. International Journal of Mental Health 10, 28-36

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Portage guide to early intervention: cross-cultural aspects and intra-cultural variability.

The issues arising from implementing an early intervention service, developed in the rural United States in the late 1960s in a range of different cul...
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