November 25, 2008 Features

Service Delivery in Natural Environments

Evaluating the Most Appropriate Treatment Setting for Infants and Toddlers With Hearing Loss

This article is part of a series contributed by Special Interest Division 9, Hearing and Hearing Disorders in Childhood. Division 9 works to provide a unified voice and advocacy for childhood hearing issues within ASHA.

In the following scenario, a service coordinator is initiating services during an Individualized Family Service Plan (IFSP) meeting with a mother of an infant with hearing loss.

"Mrs. Jones, together we have discussed your child's assessments, reviewed your child's strengths and your concerns, and developed both long-term and short-term goals to address these concerns. Now we need to discuss who should help you to address these goals, how often these services are needed, and where they should be conducted."

Most audiologists and speech-language pathologists working in early intervention may also think, "If this sounds like you have options, you are mistaken!" Too frequently, the child or family must bend to fit an existing service delivery model rather than being offered a truly individualized service plan that meets the specific developmental, communicative, educational, and social needs of the child and the family.

Professionals working in early intervention often have the best intentions when communicating information about service delivery to families. Parents are encouraged to participate fully in the development of their child's service plan, but federal law, state mandates, and program administrators' interpretation of specific statutes dictate how services will be delivered. To continue the dialogue, the clinician may say,"We have a person who can come to your home once a week to help you address these goals." And the parent may think, "This will save me time and gas money."

However, the question that should be asked is, "Where's the evidence to support that service delivery should be provided in the home for infants and toddlers with hearing loss and their families?" Not only do positive outcomes with this model need to be documented, but the cost benefits to this model should also be evaluated, especially when many states are reducing or tightly restricting funds for service delivery.

Natural environments are defined in the Individuals with Disabilities Education Act (IDEA, 2004) as services provided in the home and in community settings in which children without disabilities participate. In other words, intervention should take place in settings that are natural or normal for the child's peers who have no disabilities. IDEA 2004 states that "to the maximum extent appropriate, early intervention services are provided in natural environments" and "the provision of early intervention services for any infant or toddler with a disability occurs in a setting other than a natural environment that is most appropriate, as determined by the parent and the IFSP team, only when early intervention cannot be achieved satisfactorily for the infant or toddler in a natural environment" [IDEA, 2004 Title I, Part C, §635, (a), (16)]. Providing early intervention services in the natural environment is a legal requirement, not a guiding principle or suggestion.

Although research is limited on the provision of services in the natural environment, the premise behind this concept is to ensure family involvement, help with generalization of goals achieved, and follow the model of "least restrictive environment" that is applied to the school-aged population. At this point there is no evidence to support or deny that natural environment placement is in the best interest of the child with hearing loss and the family. One recommendation of the ASHA-CED (Council for the Education of the Deaf) Joint Committee (Fact Sheet, 2006) indicates the IFSP team "should not feel compelled to provide an undue burden of justification, as this would violate the spirit of the requirement that the IFSP be based on the individual needs of the child (Sec. 303.340)." Families should be prepared, however, for the state's early intervention system to require proof that their child will not succeed in meeting the goals detailed in the IFSP through services provided in a natural environment. Thus, the child must "fail" before other placement or service providers will be considered.

The Joint Committee on Infant Hearing (JCIH, 2007) recommends that decisions about service delivery be determined by parents with consideration of their desired outcomes for their child. Too often the concept of "natural environments" is defined as services being delivered only in the child's home. With this strict interpretation, families may not be provided adequate information about the range of community services available. If the early interventionist—and by extension the IFSP team—begin the conversation with the parents about the family's desired outcomes, then authentic family-centered services can be provided in the home, through a center-based program, or in both settings. Rather than allowing the setting to drive service delivery, the family's long-term developmental, communicative, educational, and social desires for their children will inform the IFSP team and shape the continuum of services provided.

Unfortunately, one of the major barriers to providing early intervention services to children with hearing loss in natural environments is the lack of well-trained service providers. Bruder and Dunst (2005) surveyed personnel preparation programs in special education, physical therapy, occupational therapy, speech-language pathology, and multidisciplinary training to determine to what extent training emphasized practitioner learning and mastery of established early intervention practices (family-centered intervention, teaming, service coordination, use of IFSP, and natural environments). The results indicated that "areas of content specific to early intervention service delivery are not fully embedded across personnel-preparation programs."

Thus, programs are not providing enough training to produce graduates who have even a basic foundation in family-centered practices and early intervention. Instruction, practica, and field-based experiences working with children with hearing loss and their families are often least available. Likewise, graduate programs in audiology are providing students only limited exposure to such areas as fitting young children with amplification—especially infants and toddlers—and best practices in early intervention (Rigsby, Bradham, Dickinson, & Mueller, 2007).

Because of universal newborn hearing screening, more children with hearing loss will be identified as infants, fitted with amplification, and referred for appropriate early intervention services. JCIH (2007) recommends that both home-based and center-based intervention options be offered and a plan be developed to meet parents' goals and desires for their child. Unfortunately, many families face obstacles in finding qualified service providers who can meet the audiological and communication needs of their infant with hearing loss.

By improving pre-service training and ensuring that those professionals already in the field have access to and knowledge about recommended practices in family-centered early intervention, more children with hearing loss will receive the critical services to which they are entitled, regardless of the setting in which the family chooses to have services provided.

K. Todd Houston, PhD, CCC-SLP, is an assistant professor of speech-language pathology in the Department of Communicative Disorders and Deaf Education, Utah State University (Logan), and a deputy director of its National Center for Hearing Assessment and Management. Contact him at

Tamala S. Bradham, PhD, CCC-A, is associate director of services, Vanderbilt Bill Wilkerson Center, National Center for Childhood Deafness and Family Communication (Nashville, Tenn.). Contact her at

cite as: Houston, K. T.  & Bradham, T. S. (2008, November 25). Service Delivery in Natural Environments : Evaluating the Most Appropriate Treatment Setting for Infants and Toddlers With Hearing Loss . The ASHA Leader.

Providing Services in the Natural Environment

Team members of an Individualized Family Service Plan have many issues to consider in their discussions of services in natural environments for an infant with hearing loss.

General Information

  • The scarcity of published research regarding the effectiveness of service delivery in the natural environment, especially to children with hearing loss and their families
  • The shortage of qualified personnel to deliver services
  • Room acoustics in the home or day care center and other distractions (i.e., television, telephone, people coming and going, pets, other children, etc.)
  • Limited opportunities to meet other children with hearing loss and their parents when services are provided outside a center
  • Lack of immediate access to audiological services if there are equipment problems

Service Delivery in the Home

  • Ground rules should be established (i.e., television off, telephone ringer muted, and visitors limited unless they are part of the treatment lesson plan).
  • The child and family should be ready for the session at the scheduled time.
  • Intervention should begin only when the parent/guardian is present and ready.
  • If possible, the length of the session and time of day should be varied to allow for more opportunities to expand language and generalization.
  • A decision should be made on whether a blended approach to intervention can be implemented, with parts of the sessions delivered in the natural environment and part delivered in a center-based program.

Service Delivery Away From Home

  • Does the center enroll typical peers in its program?
  • How often does the child visit the center? Does the family consider the center "a home away from home"?
  • Does the child have the opportunities in his or her "natural environment" to interact with similar children?
  • Is there a need to be close to audiological support?
  • Where does the family prefer to have services delivered—in the home, the center, or a combination of the two? 


Bruder, M. B. & Dunst, C. J. (2005). Personnel preparation in recommended early intervention practices: Degree of emphasis across disciplines. Topics in Early Childhood Special Education, 25(1), 25–33.

Joint Committee ASHA-CED (2006). Fact sheet: Natural environments for infants and toddlers who are deaf or hard of hearing and their families. Retrieved on July 3, 2008, from

Joint Committee on Infant Hearing (2007).Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics, 120(4), 898–921.

Rigsby, K., Bradham, T., Dickinson, W., & Mueller, H. G. (2007). Current practices in pediatric amplification and early intervention. Perspectives on Hearing and Hearing Disorders in Childhood, 17(1), 3–7. 


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