Early Childhood Intervention in Portugal An Overview Based on the Developmental Systems Model

Research studies on early childhood intervention (ECI) in Portugal are diffuse regarding both program components and the geographical area under scrutiny. Since the 1990s, a growing body of knowledge and evidence in ECI is being gathered, based on postgraduate teaching, in-service training, and research. This article draws on the systems theory perspective outlined in the Developmental Systems Approach to Early Intervention (M. J. Guralnick, 2001, 2005a, 2011) to (a) depict paradigmatic shifts and scientific evidence, as well as social and political factors, setting the framework for the development of ECI policies and services in Portugal; (b) describe recent Portuguese legislation that established a national ECI system, and deductively analyze its content regarding the structural components of Guralnick’s Model; (c) examine the current status of ECI services according to the core principles and components of the Developmental Systems Model. Inspired by M. J. Guralnick’s suggestion (2000), the discussion addresses problems at different levels of the system, proposing an agenda for change in ECI in Portugal, underlining the need for the co-construction of a new culture, based on scientific evidence and on in-depth dialogues between researchers, practitioners, and communities. Key word: Portuguese early intervention system, historical and political framework, systems perspective

The evolution of ECI is unquestionably connected to the development of health, edu-cation, and social security policies (Bairrão, 2001). In the last 2 decades, the availability of child care for children younger than 6 years has increased dramatically: 30.2% of children aged between 4 months and 3 years (Gabinete de Estratégia e Planeamento, 2009) and 78.8% of children aged 3 to 6 years (Ministério da Educação, 2010) attended nonparental care in 2008. Preschool services for children aged 3 to 6 years are provided through the Ministry of Education; however, early childhood education and care services for infants and toddlers are still dependent on the Ministry of Solidarity and Social Security (Bairrão, Barbosa, Borges, Cruz, & Macedo-Pinto, 1989;Pessanha, Aguiar, & Bairrão, 2007).
Regarding special education, until the recognition of the Salamanca Statement (United Nations Educational, Scientific and Cultural Organization, 1994), children aged 0 to 6 years, with special needs, were mainly supported by health and social security services, focusing on diagnosis. Service provision was child centered, segregated, delivered by different specialists, aiming at reducing, avoiding, or removing deficits, with families receiving mainly financial and mental health supports (Bairrão, 2001(Bairrão, , 2003European Agency for Development in Special Needs Education, 2005). This unsatisfactory service provision created a very stressful situation for families of children with special needs, highlighting the need for a coherent and integrated system of special services and supports provided by well-trained professionals (Almeida, 2008;Bairrão & Almeida, 2003;Boavida & Borges, 1994;Felgueiras, 1997Felgueiras, , 2000. During the 1980s, concerns with the early detection of biological, psychological, and sociocultural determinants of developmental problems triggered international collaboration with specialists from the United Kingdom and the United States (Bairrão & Felgueiras, 1978), leading to the development of innovative projects. Two projects were particularly influential for Portuguese ECI. The first, the home-visiting project Portage Program for Parents, developed in the district of Lisbon in the early 1980s by the Direcção de Serviços de Orientação e Intervenção

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Psicológica, introduced innovative features: individualized planning of objectives and intervention strategies, a model of service coordination, and a system of in-service home visitors' training and supervision that created opportunities for interdisciplinary collaboration (Felgueiras & Breia, 2005). By introducing parental involvement in the intervention process as an essential feature for success, this project made a relevant contribution to a paradigmatic shift in ECI services (Almeida, 2000;Bairrão, 2003). Parents involved in this project valued their active participation and reported an increased sense of parental competence (Almeida, Felgueiras, & Pimentel, 1997;Almeida, Felgueiras, Pimentel, & Morgado, 1991). The second, the community-based Projecto Integrado de Intervenção Precoce de Coimbra, starting in 1989, provided individualized, comprehensive, family-centered supports involving health, education, social security, and community services. The high-quality in-service professional training, as well as the continuous and collaborative supervision provided to teams were important variables associated with the program's effectiveness (Boavida & Borges, 1994;Boavida, Carvalho, & Espe-Sherwindt, 2009). Parents participating in this project were satisfied with features of the parent-professional relationship (Boavida et al., 2009;Cruz, Fontes, & Carvalho, 2003). This coordinated, and transdisciplinary program constituted the starting point in the development of ECI in Portugal (Serrano & Boavida, 2011). Such a "bottomup" process led to the progressive awareness of Portuguese policy makers of the importance of ECI, thus influencing the outline of the legal provisions (European Agency for Development of Special Needs Education, 2005).
Over the 1990s, services were extremely variable from program to program, and sometimes even within the same program in aspects such as: the service delivery model, target population, goals, outcome measures, level of parental involvement, type, intensity, or duration of interventions (Boavida et al., 2009;European Agency for Development in Special Needs Education, 2005;Veiga, 1995). The state of the art in service delivery to children aged 0 to 6 years with special education needs, was depicted in a major national survey, indicating: (a) that the majority of children receiving ECI were over 3 years of age (83%) and only 25% of children began receiving services before the age of 3; (b) that assessment was predominantly monodisciplinary and informal and intervention was mainly child centered; (c) absence of a common theoretical framework in teachers' training in ECI; (d) scarcity of professional supervision; and (e) lack of program evaluation (Bairrão & Almeida, 2002. A study in the Lisbon district found significant differences between professionals' and families' perceptions regarding practices (Pimentel, 2005). However, 25% of the special education teachers working in communitybased projects reported innovative practices, namely, inter/transdisciplinary teamwork, interventions in natural settings, family involvement, and Individualized Family Service Plan (IFSP) implementation (Bairrão & Almeida, 2002. Within this historical and conceptual context, a diversity of characteristics from different models coexisted in intervention services. By the 1990s, the influences of the systemicdevelopmental perspectives (Bronfenbrenner & Morris, 1998;Sameroff & Fiese, 1990) and of the family-centered approach (Dunst, 2000) on service delivery were emergent. As a result, individualization of plans for families was scarce, with professionals evidencing difficulty in assuming a consultant role and in developing reciprocal actions with families (Pinto, Grande, Felgueiras, Almeida, Pimentel, & Novais, 2009).
Recognizing the need to create an organizational and integrated model of shared responsibilities for ECI, a task force involving representatives from the Ministries of Education, Solidarity and Social Security, and Health was established in 1994. This group developed the ECI model that framed the first legislation exclusively dedicated to ECI (Despacho Conjunto n. • 891/99 [DC 891/99]) " . . . for children from 0 to 6 years with disabilities or at risk for severe developmental delay, and their families" (p. 15,566). This legal provision, unique in Europe, was a landmark in the development of nationwide ECI services and included innovative features, some of which can be traced to the Developmental Systems Model proposed by Guralnick (2001), namely: (1) interagency network of resources, based on an intersectorial coordination of education, health, and social security services at the local, regional, and national levels; (2) transdisciplinary teamwork and service coordination; (3) family-centered approach, based on families' diverse needs and resources, as well as those existing in the community, thus reinforcing the authority of families in the decision-making process; (4) IFSPs implemented according to a family-centered philosophy; (5) preventive role of ECI, by serving children at risk; and (6) the importance of interventions, based on natural opportunities occurring in family and community settings. Results of a national study on the implementation of this law, documented relevant positive aspects (Felgueiras et al., 2006), namely, a substantial increase in the number of children aged 0 to 3 years covered by services-41%, as compared with the 25% reported earlier by Bairrão and Almeida (2002). Such an increase was especially noteworthy in regions where both local ECI teams and interdepartmental coordination teams were created at the district and regional levels. This was the case for the central region (Coimbra and Aveiro) as well as Alentejo, in southern Portugal, where Franco and Apolónio (2008) reported that from 2000 to 2007, there was an increase of 300% in the number of children aged 0 to 6 years covered by ECI services. Although this national report was never made public, it documented cross-country asymmetries in family involvement and in the level of participation of public agencies. The main barriers identified were associated with difficulties in implementing integrated activities among health, education, and social security sectors; financial constraints; and limitations in pro-fessional training and supervision (Felgueiras et al., 2006).
Other studies conducted at a national level reported a discrepancy between professionals' ideas valuing the family-centered approach and their actual practices. Specifically, professional practices failed to comply with the participative component of the familycentered approach, as described by Dunst (2000), confining their interventions to its relational component (Almeida, 2008;Pereira, 2009). The aspects found to be most problematic were related to: (a) implementating the IFSP; (b) engaging and strengthening family social networks, namely, informal supports; (c) building networks, based on existing community services and resources; (d) developing interventions with environmentally at risk families (Almeida, 2008); and (e) in-service training in ECI (Pereira, 2009).

CURRENT LEGISLATION THAT GOVERNS EARLY CHILDHOOD INTERVENTION AND EARLY CHILDHOOD SPECIAL EDUCATION
In October 2009, the Portuguese Parliament approved new legislation establishing the Portuguese NECIS-Decreto-Lei 281/99 (Decree-Law-DL 281/09). This legislation is a Public-Law, which may increase its effect in the provision of mandatory ECI for all eligible children from 0 to 6 years (Serrano & Boavida, 2011). However, the design of this new law did not account for evidence-based recommendations reported in previous studies. Consequently, advocacy committees of parents, ECI professionals, researchers, and politicians were created to assure the implementation of recommended practices. Also, of crucial importance, is the fact that this legislation establishing the NECIS was published one year after the legislation for special education (Decreto-Lei 3/2008 [Decree-Law-DL 3/2008]), also targeting preschool-aged children (3-6 years) in need of special support. This overlap between the two DL has not been addressed by specific guidelines, resulting in incoherencies that will need to be addressed in the future.
According to the DL 281/2009, ECI is defined as a set of preventive and rehabilitation measures of integrated support for children aged between 0 and 6 years (at risk for developmental delay or have established conditions) and their families. Using the biopsychosocial model (Engel, 1977) as a framework for approaching disability, this DL recommends the use of the International Classification of Functioning Disability, and Health-Children and Youth version (ICF-CY; World Health Organization [WHO], 2007) for eligibility and documentation purposes, stating that, in addition to developmental problems, the child's potential should be taken into account, and underlining the need to plan for changes in the child's environment. This legislation builds on national, regional, and local coordination structures involving, at each level, shared responsibility from the Ministries of Health, Education, and Solidarity and Social Security, with the collaboration of Private Institutions of Social Solidarity.
Specifically, the NECIS includes (a) a national coordination committee consisting of two delegates from each ministry and chaired by a delegate from the Ministry of Solidarity and Social Security, (b) five regional subcommittees, and (c) 149 local intervention teams. Each ministry is responsible for nominating professionals for regional subcommittees and for ensuring the assignment of professionals to local intervention teams. At the regional level, the subcommittees are responsible for managing human, material, and financial resources; for collecting and updating information between the national and the local levels; and for planning, organizing, and coordinating the actions of the local intervention teams. A Technical Supervision Nucleus should be put in place to support the regional subcommittees in (a) coordinating local agencies and services; (b) planning, organizing, and evaluating the functioning of local intervention teams; (c) analyzing and verifying the use of eligibility criteria; and (d) providing technical support to local intervention teams. Although efforts were made to rapidly constitute the local intervention teams, the NECIS was only partially in place in September of 2011.

PRINCIPLES UNDERLYING THE DEVELOPMENTAL SYSTEMS MODEL
In the last decades, there has been growing international consensus around a conceptual framework and recommended practices in ECI, indicating a paradigmatic shift from a traditional approach to disability, based on a child-centered medical model to a developmental contextualism framework (Bronfenbrenner & Morris 1998;Lerner, 2002Lerner, , 2005. However, the impact of these theoretical perspectives on the innovation of ECI professional practices is a long-term process. Prior to an analysis of how the structural components of Guralnick's Developmental Systems Model (Guralnick, 2001(Guralnick, , 2005a(Guralnick, , 2011 are represented in the current status of ECI in Portugal, we will consider how the three most prominent principles in the field (Guralnick, 2005a) are embedded in the Portuguese legislation.

Principle of developmental orientation
The Developmental Systems Model is explicitly centered on families and organized to address family and child characteristics and stressors in an attempt to strengthen the family's abilities (Guralnick, 2001). DL 281/2009 states that intervention should be implemented according to the needs of the family and should support families in accessing social, health, and educational services and resources. Similarly, the special education policy, DL 3/2008, states that the family should actively participate both in assessment and in Individualized Education Program (IEP) development. However, as specific guidelines and procedures were not established, this principle is not fully developed in the legislation.

Principle of inclusion
According to Guralnick's Developmental Systems Model (Guralnick, 2001(Guralnick, , 2005a(Guralnick, , 2011, inclusion involves support and service provision in natural environments, maximizing the participation of children and families in typical community activities. DL 281/2009 states that the NECIS should be developed according to family circumstances and within community contexts, and that, among other responsibilities, the local intervention teams should identify community needs and resources, streamlining formal and informal social support networks. Local intervention teams should also implement ECI in full coordination with preschool teachers, whenever children are attending infanttoddler, home-based, or center-based child care or preschool. The legislation clearly states the right of children to inclusion and full participation.

Principle of integration and coordination
DL 281/2009 clearly addresses the principle of integration at all levels of the NECIS, as described earlier. However, as is further discussed later, we do not find any specific guidelines concerning the processes of teamwork related to assessment, intervention, plan development, and implementation. Furthermore, coordination among the three ministries and even within each ministry has not yet been achieved. This process is highly challenging, involving the co-construction of meaning among agents from diverse backgrounds, with continuous and ongoing efforts for improvement. The coexistence of two different legislations to regulate ECI and special education in Portugal represents a serious challenge, as their mandates around the provision of services for children aged 3 to 6 years overlap, and their provisions are different. If not addressed, this challenge may compromise the effectiveness of ECI services in our country.

CURRENT STATUS OF SERVICES FOR CHILDREN WITH DISABILITIES OR AT RISK UNDER THE AGE OF 6
In this section, we analyze the Portuguese NECIS according to the components of the Developmental Systems Model for ECI for vul-nerable children and their families (Guralnick, 2001(Guralnick, , 2005a.

Screening program and referral
The Ministry of Health is responsible for ensuring the detection and referral of children to ECI. However, any individual (including parents) or agency may refer a potentially vulnerable child to ECI through the local intervention team. Presently under reform, the national health system includes local health centers and an increasing number of family health units (serving communities of between 4,000 and 18,000 citizens). Both centers and units comprise child and youth services, which offer overall screening to assess the attainment of growth and development milestones. Within the national health system, developmental assessment is provided, upon referral, in development centers situated in five main hospitals and in development clinics located in the district hospitals that include pediatric services. However, there are no specific guidelines for the procedures and measures to be used in developmental screening and assessment. Consequently, decisions about referral lack consistency, as they do not follow specific criteria and depend predominantly on the individual judgment of primary health providers. Decisions about services are made after families enter the ECI system.

Monitoring and surveillance
Local intervention teams must ensure the surveillance of children who are referred for assessment and do not meet eligibility criteria but require periodic reassessment, due to the nature of existing risk factors. Local intervention teams must also ensure referral of noneligible children who require social support, and professionals in these teams should cooperate with child protection services supporting those families. Specific protocols or guidelines regarding the frequency and format of such surveillance need to be provided to local intervention teams by either regional or national coordinating structures. Also, as will be further described, no protocols are available to support professionals in identifying risk

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factors and associated family stressors. The lack of such protocols may mean that the monitoring program is at risk, as it could be replaced by the periodic clinical assessment/survey of children from families at risk, conducted as part of the health services regular practice.

Point of access
There is no clear specification of a point of access. Local intervention teams, as community-based ECI services, can be considered the point of access to the NECIS as they are mandated to gather and manage referral, eligibility, and surveillance information. However, due to lack of dissemination initiatives, communities often ignore the existence of ECI services. Thus, the health professional area may continue to be the point of access for most children. In fact, the legislation states that the Ministry of Health, in addition to detection and referral responsibilities, should activate the early intervention process, as well as establish diagnosis and provide specialized orientation. The national ECI legislation and technical guidelines do not specify different service provisions for children with disabilities or developmental delays and for children at biological or environmental risk. Although this legal framework appears theoretically sound and conveys an inclusive philosophy, some factors may compromise the right of accessibility to the ECI system mainly for children at sociocultural risk. In fact, although children at risk may be referred for social support, no specific guidelines are available regarding their monitoring by local intervention teams. Also, the development of preventive intervention programs is not foreseen in the legal framework.

Comprehensive interdisciplinary assessment
The structure of the NECIS lacks this specific component, as the legislation and technical guidelines available to local intervention teams do not include any reference to a comprehensive interdisciplinary assessment. In fact, although the technical guidelines mandate that local intervention teams use a transdisciplinary model, professionals in these teams are merely required to analyze the referral form and to assess the eligibility criteria to decide on children's admission to the program. However, as previously mentioned, prior to referral, services under the Ministry of Health are required to refer children to hospital-based development centers or clinics to gather information for diagnostic and specialized guidance purposes. At present, no precise data are available on the comprehensive and interdisciplinary nature of this assessment. On the basis of previous studies conducted in Portugal (Bairrão & Almeida, 2002;Cardoso, 2006;Mendes, 2010;Pimentel, 2005) we may assume that both at the screening and at the referral level, the assessment is still predominantly mono-or multidisciplinary, with professionals implementing isolated assessment procedures and exchanging information informally or through reports or discussions during meetings.

Eligibility
In compliance with DL 281/2009, the NECIS Coordinating Committee released, in 2011, national eligibility criteria. By law, ECI services are provided to two groups of children aged between 0 and 6 years and their families: Group 1 is made up of children with limitations in body functions or body structures that limit their normal development and participation in typical activities, considering their age and social context. Group 2 includes children at severe risk for developmental delay, that is, with biological, psychoemotional, or environmental conditions that indicate a high probability of a relevant developmental delay. All children with established conditions, as well as children from Group 2 are eligible, when their situation is documented by specialized professionals. Children from Group 2 are eligible only when they accumulate four or more biological and/or environmental risk factors.

Assessment of stressors
Once families enter the ECI Program, the individualized early intervention plan (IEIP) is developed by the local intervention team. The IEIP involves a twofold process that should include children's assessment within their family setting as well as a description of the measures and actions that need to be implemented. Assessment should focus on the needs and resources of both the child and the family, and the IEIP should include information on the changes needed in the environment so that the child's potential may be realized. The ICF-CY (WHO, 2007) is mandated as a framework to document children's activities and participation (and respective limitations in functions), as well as the environmental factors that represent barriers or facilitators in their daily settings. The guidelines from the Technical Manual require local intervention teams to describe families' formal and informal support networks, needs, and priorities. Nevertheless, some conceptual contradiction is evident, as the IEIP requires teams to describe children solely on the basis of developmental domains. Although a focus on families is present in both the legislation and the IEIP requirements, we may assume, based on recent studies about Portuguese services, that a family-centered approach has not been broadly adopted. This reality is likely to compromise the effective assessment of family stressors, as well as the identification of family strengths. In fact, in addition to the conceptual contradictions mirrored in the IEIP structure, no protocols are available to guide professionals in capturing the complexity of intra and interpersonal factors and characteristics at the family level that may be causing distress and disruption of optimal patterns of interaction. Considering that assessment of stressors is conceptualized as the core component of the Developmental Systems Model in ECI (Guralnick, 2001(Guralnick, , 2005a(Guralnick, , 2011, it is crucial to address this issue as it compromises all subsequent components of the early intervention process.

Development and implementation of a comprehensive program
The IEIP must define the measures and actions needed to ensure the complementarity of services and agencies. Furthermore, local intervention teams must promote the cooperation between all parties involved in plan implementation. Local intervention teams are also required to promote the families' active participation in the assessment and intervention process, with case managers participating, together with families, in the identification of resources, concerns, and priorities and in decision making. On the basis of the ECI goals stated in the present legislation, services are to be tailored according to the needs of the family and interventions must prevent or reduce risks for developmental delay, support families in accessing social security, education, and health services and resources, and involve the community through social support mechanisms. However, and as previously stated, there is a lack of tools that may support early intervention practices by allowing professionals to acknowledge specific aspects of parent-child processes, as well as stressors that may influence child development. The need for such tools to support professional practice is underlined by data from a review of studies on ECI in Portugal that show evidence of the difficulties professionals have in assuming families as partners, although their ideas frequently express the desire to develop family-centered practices (Pinto et al., 2009). Decision rules for individualizing interventions are not available at this point, despite the fact that research on the individualization of services and on the quality of IEP and IFSP goals and objectives, prior to the implementation of the NECIS, suggests that these are areas of concern (e.g., Boavida, Aguiar, McWilliam, & Pimentel, 2010;Castro, Pinto, & Simeonsson, 2012;Ferreira, Coelho, & Pinto, 2012;Simões & Brandão, 2010).

Monitoring and outcome evaluations
At the individual level, the IEIP must include information regarding the timing of child and family evaluations. Although a time frame is not specified for this task, these evaluations must be completed, at least, annually. However, as assessment-intervention processes often seem to lack coherence (Boavida et al., 2010;Castro et al., 2012) and the assessment of family stressors is not clearly defined, the monitoring system is highly compromised. On the basis of this information, asymmetries between different teams are expected to occur, both at the monitoring and at the program evaluation levels, and there is high probability that both processes may occur on a monodisciplinary basis. At the national level, the National Committee is required to evaluate the NECIS every 2 years.

Transition planning
The new law requires that the IEIP includes a description of the procedures that ensure an appropriate transition process to preschool or to primary school. This intervention plan must be harmonized with the IEP when children enter public preschool or school. However, specific guidelines regarding the joint use of IEIP and IEP are not available. Although this component is of great relevance, as there are numerous transitions in children's lives that may affect family routines and thus be a cause of stress, research regarding transition planning is scarce in our country (Fonseca, 2006). Also, specific guidelines are needed to assist professionals in implementing a thorough assessment of the various transitions that may cause disruption for children and their families. Only then can they design processes for transition that specify the unique circumstances of each case within a specific community.

FUTURE RECOMMENDATIONS FOR THE EXPANSION AND IMPROVEMENT OF SERVICES IN PORTUGAL
Although noticeable progress was achieved in the Portuguese ECI system over the past 30 years, some constraints that hinder the implementation of a quality ECI system should be underlined. In this section, we propose an agenda for change in ECI in Portugal (Table 1), inspired in Guralnick's suggestions (2000), in scientific and historical evidence, and relying on the value of a long lasting in-depth dialogue between researchers and practitioners (Dunst & Trivette, 2009;Dunst, Trivette, & Hamby, 2010;Guralnick, 2001Guralnick, , 2005aGuralnick, , 2005bGuralnick, , 2011McWilliam, 2003McWilliam, , 2010.

CONCLUDING REMARKS
This article may help clarify directions of change toward a family-centered comprehensive ECI system and to state orientations for professional practice. Despite the fact that Portugal is currently one of the few European countries with a specific legislation on ECI (European Agency for Development in Special Needs Education, 2010), several legal specifications and practical changes are needed to improve the effectiveness of the systems included in the Portuguese NECIS. Guralnick's model (2001Guralnick's model ( , 2005a provides a structure to apply organizational changes, based on its principles, and describes specific components that highlight weaknesses in the system and support practical changes. Furthermore, as the NECIS is still in its first few months of implementation, efforts are being developed for the co-construction of coordinated and integrated processes, within and between services, at the national, regional, and local levels. We need a better understanding about how ECI professionals build their practices and potentially become agents of change. In fact, regarding Portuguese ECI, one problem that cuts across the system is the need for an effective cooperation between policies, regulations, and practices in diverse sectors and at different levels (national, regional, and local). Such cooperation between policymakers and professionals may stem from the development of shared responsibility and common aims to guarantee the families' and children's rights to ECI services, as stated by law.
Considering that services are acculturating systems that promote the development of attitudes, beliefs, and patterns of behavior in their participants, most families have been acculturated by former experiences, namely, throughout contacts with health and educational services in child-centered practices. Thus, practices that are not family centered may be reinforced by families, and it is the

ECI framework
To develop a set of guidelines providing local intervention teams with a common conceptual framework on family-driven, community-based, transdisciplinary practices. To define quality criteria and indicators for ECI practices. To establish a consulting committee at the national level comprising specialists of recognised scientific expertise. In-service training and supervision To define national in-service training and supervision guidelines targeting both local intervention teams and teachers from schools of reference in ECI. To develop in-service training within the national qualification system, according to principles of adult learning and based on effective methods. To differentiate technical supervision from the coordination and administrative functions stated in the ECI legislation; to ensure that technical supervision is provided by professionals with recognized expertise in ECI in order to facilitate communicational processes in the team, assuring actions of translation and mediation of ideas, research findings, and legislation contents.

Integrating legal dispositions
Promote national efforts to integrate the early childhood special education services and the ECI legal dispositions, currently overlapping, assuring that all children from birth to 6 years and their families receive support from transdisciplinary teams, within an integrated, community-based family-centered approach. Placement of teachers To develop specific rules and priority criteria, at a national level, for the placement of teachers within the ECI system. Priority criteria should include: graduate and postgraduate training in ECI, experience in the field, and in-service training. To assure that all professionals working with children with a disability or at risk, from birth to 6 years, integrate a unique system of service delivery, with local intervention teams serving as an aggregating structure.

Monitoring and surveillance
To develop comprehensive protocols to support decision making regarding the monitoring and surveillance of children at risk that do not meet referral criteria for ECI, assuring that children with vulnerable conditions are not left out of the system.

Interactions with families
To define specific guidelines for assessment-intervention processes and procedures to guide professionals in their interactions with families, enabling them to determine relevant family characteristics, such as needs and distress. Screening To develop a coherent and universal developmental screening protocol, using adapted and validated screening tools and related instruments, assuring equal opportunity of access to the NECIS. To ensure a more active role of health professionals, especially from pediatric services, in early detection and screening. To establish guidelines for decision making, by local entities at the community level, regarding different levels of screening (i.e., universal, selected, and targeted). Interdisciplinary assessment To define nationwide protocols for comprehensive interdisciplinary assessment, ensuring that essential information on children's health and development and families' needs is obtained and used in intervention plans and recommendations.
professionals' responsibility to contribute to changes in parental expectations and to involve them in the co-construction of a new culture (Lopes-dos-Santos & Carvalho, 2008). This is a challenging and long-term process that will require trust, perseverance, and goodwill in long-standing dialogues between scientific and practical discourse, embedded in the real-life situations of families and communities.