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This guidelines document is an official statement of the American Speech-Language-Hearing Association (ASHA). It was developed by ASHA's Ad Hoc Committee on the Role of the Speech-Language Pathologist in Early Intervention. Members of the Committee were M. Jeanne Wilcox (chair), Melissa A. Cheslock, Elizabeth R. Crais, Trudi Norman-Murch, Rhea Paul, Froma P. Roth, Juliann J. Woods, and Diane R. Paul (ex officio). ASHA Vice Presidents for Professional Practices in Speech-Language Pathology Celia Hooper (2003–2005) and Brian B. Shulman (2006–2008) served as the monitoring officers. The ASHA Scope of Practice in Speech-Language Pathology (ASHA, 2007) states that the practice of speech-language pathology includes providing services for infants and toddlers with communication needs. The ASHA Preferred Practice Patterns (ASHA, 2004e) are statements that define universally applicable characteristics of practice. The guidelines within this document fulfill the need for more specific procedures and protocols for serving infants and toddlers. It is required that individuals who practice independently in this area hold the Certificate of Clinical Competence in Speech-Language Pathology and abide by the ASHA Code of Ethics (ASHA, 2003b), including Principle of Ethics II, Rule B, which states that “individuals shall engage in only those aspects of the profession that are within their competence, considering their level of education, training, and experience.” This document was disseminated for select and widespread peer review to speech-language pathologists, speech, language, and hearing scientists; and audiologists with expertise in early intervention, family members of young children, graduate students in communication sciences and disorders, and related professionals. This document was approved by the ASHA Board of Directors (BOD 4-2008) in February 2008. The guidelines will be reviewed and considered for revision on a regular basis (within no more than 5 years from the date of publication). Decisions about the need for revision will be based on new research, trends, and clinical practices related to early intervention in speech-language pathology.
The development of communication skills is a dynamic process that is shaped by interdependent factors intrinsic to the child and in interaction with the environment. The reciprocal and dynamic interplay between biology, experience, and human development converge to influence developmental experiences. Most importantly, the course of development is alterable through provision of early intervention services.
The early intervention practices described in the Roles and Responsibilities of Speech-Language Pathologists in Early Intervention: Guidelines include those based on both internal (e.g., policy, informed clinical opinion, integrative scholarly reviews) and external evidence (e.g., empirical data) from the literature. As the Committee evaluated available external evidence, variation was apparent both in strength of the research designs and implementation (e.g., randomized control vs. observation without controls). Many of the practices detailed in the guidelines have not yet been studied adequately; however, when considered in terms of internal and external evidence, the practices demonstrate promise and were therefore included in the guidelines document.
Speech-language pathologists (SLPs) will need to consider both the strengths and the limitations of current empirical studies when evaluating the preponderance and quality of evidence for practices presented here. The Committee recognized that there are few areas of early intervention practice in which clear, unequivocal answers emerge from empirical research that can be applied confidently to broad classes of infants and toddlers with disabilities. In recognition of this, no attempt was made in this document to prioritize specific assessments, interventions, or treatment programs. The goal was to present a range of assessment and intervention practices with some basis in either internal or external evidence, in an effort to provide a backdrop against which clinicians can evaluate newly emerging external and internal evidence in making service decisions for particular children and families.
This document includes conclusions and recommendations derived from available empirical evidence that were formed by consensus of the ASHA Ad Hoc Committee on the Role of the Speech-Language Pathologist in Early Intervention through five face-to-face meetings and nine phone conferences between November 2004 and December 2007. However, SLPs recognize that in areas for which empirical evidence is lacking, extrapolations from evidence with other populations and applications of principles stemming from theoretical models, societal norms, and government mandates and regulations also are relevant for decision making. Recommended practices are expected to change as new evidence emerges. Within a collaborative context, SLPs should be able to articulate both the principles and the levels of evidence that undergird their service delivery practices. SLPs serve as an integral part of a team, including families, that is responsible for formulating and implementing service delivery plans that meet the unique communication needs of infants and toddlers. The recommended knowledge and skills needed by SLPs serving infants and toddlers are presented in a companion document (ASHA, 2008a). Further, a technical report providing background and a basis for understanding the communication characteristics and challenges of infants and toddlers with or at risk for communication disabilities also was developed by the committee to provide further information and guidance on the implementation of the roles and responsibilities outlined in the position statement (ASHA, 2008b).
Four guiding principles that reflect the current consensus on best practices for providing early and effective communication interventions for infants and toddlers (birth to age 3 years) serve as a foundation for the design and provision of services. Specifically, services are (a) family-centered and culturally responsive; (b) developmentally supportive and promote children's participation in their natural environments; (c) comprehensive, coordinated, and team-based; and (d) based on the highest quality internal and external evidence that is available.
An aim of all early intervention services and supports is responsivity to family concerns for each child's strengths, needs, and learning styles. An important component of individualizing services includes the ability to align services with each family's culture and unique situation, preferences, resources, and priorities. The term family-centered refers to a set of beliefs, values, principles, and practices that support and strengthen the family's capacity to enhance the child's development and learning. These practices are predicated on the belief that families provide a lifelong context for a child's development and growth. The family, rather than the individual child, is the primary recipient of services to the extent desired by the family. Some families may choose for services to be focused on the family, whereas others may prefer a more child-centered approach. Family-centered services support the family's right to choose who is the recipient of the services. Components of family-centered practices include offering more active roles for families in the planning, implementing, interpreting, and decision making in service delivery. Family-centered practices can maximize time and other resources, create closer alignment between family and professional decisions and plans, and increase decision making by families.
Effective early intervention services and supports are based on theoretical, empirical, and clinical models of child development which assume that the acquisition of communication occurs within a social and cultural framework, and which make use of commonly accepted theories about how individual children learn communication, speech, language, and emergent literacy skills. Early identification and intervention practices that are developmentally supportive are thought to include active exploration and manipulation of objects, authentic experiences, and interactive participation appropriate to a child's age, cognitive level and style, strengths, interests, and family concerns and priorities.
Early speech and language skills are acquired and used primarily for communicating during social interactions. Therefore, optimal early communication intervention services are provided in natural environments, which offer realistic and authentic learning experiences (i.e., are ecologically valid) and promote successful communication with caregivers. Authentic learning can maximize children's acquisition of functional communication skills and promote generalization of newly mastered behaviors to natural, everyday contexts.
In comprehensively meeting the needs of infants, toddlers, and their families, SLPs may be one of several professionals working with the child and family. In other instances, SLPs may be the initial contact for the child and family and may need to make referrals or enlist the assistance of other qualified professionals (e.g., when a child initially referred for speech-language assessment needs team-based assessment). As part of comprehensive early intervention services, SLPs can play a key role with their specialized knowledge about typical and atypical early development of communication, language, speech, feeding/swallowing, cognition, hearing, emergent literacy, social/emotional behavior, and the use of assistive technology.
In the current provision of the Individuals with Disabilities Education Improvement Act (IDEA 2004), children who receive Part C early intervention services may be seen by multiple professionals who are employed by different agencies representing differing team models. The term multidisciplinary is used in IDEA 2004 to convey the need for multiple professionals to be included on a team and to be involved in the Individualized Family Service Plan (IFSP) process. Other types of team models, such as interdisciplinary or transdisciplinary, may be the best approach to meet the specific needs of a child. Service providers have the responsibility for selecting the most appropriate team model for each infant and toddler and the family. Team models differ in the nature of the communication, contribution, and collaboration involved in the interaction among team members.
A transdisciplinary model typically includes some type of “role release” of one professional to another and is sometimes implemented as a primary provider model. In this model, one professional provides primary services to the child across disciplinary lines with other disciplines providing consultation to the primary provider. The use of transdisciplinary models with a primary service provider may be appropriate for SLPs. Early intervention is a field with many disciplines represented as practitioners and in which the roles vary according to the needs of the child. Teams benefit from joint professional development and also can enhance each other's knowledge and skills through role extension and role release for specific children and families. SLPs may serve as either primary providers or consultants in transdisciplinary models, and should be considered for the primary provider role when the child's main needs are communication or feeding and swallowing.
Comprehensive, coordinated, and collaborative team-based services help avoid fragmentation of services and supports to children and families. While the extent of collaboration in early intervention will vary depending on the team model that is used, as well as the lead agency's program guidelines and the knowledge and skills of the team members, the need for communication among team members and with the family is mandated by Part C of IDEA and must be supported by the administering agency.
Early intervention practices are based on an integration of the highest quality and most recent research, informed professional judgment and expertise, and family preferences and values. Evidence can be classified as external or internal: Internal evidence is drawn from a variety of sources including policy, informed clinical opinion, values and perspectives of both professionals and consumers, and professional consensus; external evidence is based on empirical research published in peer-reviewed journals.
The SLP is uniquely qualified to provide services to families and their children who are at risk for developing, or who already demonstrate, delays or disabilities in language-related play and symbolic behaviors, communication, language, speech, emergent literacy, and/or feeding and swallowing behavior. In providing these services, the SLP may participate in the following primary functions: (a) prevention; (b) screening, evaluation, and assessment; (c) planning, implementing, and monitoring intervention; (d) consultation with and education of team members, including families and other professionals; (e) service coordination; (f) transition planning; (g) advocacy; and (h) awareness and advancement of the knowledge base in early intervention.
The goal of prevention activities is to reduce the risk or mitigate the effects of risk factors on a child's development so as to prevent future problems and promote the necessary conditions for healthy development. SLPs have the opportunity to play an important role in the prevention of communication disorders, especially in the field of early intervention. SLPs can help young children avoid the onset of communication problems (“primary prevention”) by, for example, promoting positive communication interactions between children and caregivers. They can assist in the early detection of delays or deficits by participating in child-find and screening programs, thereby mitigating or eliminating the effects of a disorder (“secondary prevention”). Finally, they can help remediate an existing problem by providing early intervention services, thereby preventing future difficulties (“tertiary prevention”).
Screening for communication needs in infants and toddlers is a process of identifying young children at risk so that evaluation can be used to establish eligibility, and more in-depth assessment can be provided to guide the development of an intervention program. The aim of screening is to make a determination as to whether a particular child is likely to show deficits in communication development.
IDEA 2004 distinguishes between the terms evaluation and assessment. Evaluation refers to procedures that determine a child's initial and continuing eligibility for early intervention services and includes identification of the child's current level of functioning across cognitive, physical (including vision and hearing), communication, social/emotional, and adaptive development. In contrast, assessment refers to the ongoing process of describing the child's needs; the family's concerns, priorities, and resources related to the development of the child; and the nature and extent of the early intervention services required to meet the needs of the child and family. IDEA 2004 also specifies that both evaluation and assessment should be based on a variety of measures that include informed clinical opinion. The roles of SLPs in evaluation and assessment typically are to measure and describe communication and related behaviors, including feeding and swallowing, to share observations on other developmental domains, and to help in the decision-making process related to diagnosis, eligibility determination, and planning next steps for the child and family.
Screening, evaluation, and assessment will be accomplished through a range of measures and activities, including standardized tests and questionnaire formats, interviews, criterion-referenced probes, dynamic procedures such as diagnostic teaching, and observational methods. Information will be drawn from direct interactions with the child, from indirect means such as parent interviews and report forms, and from observation of the child in natural activities with familiar caregivers. Federal guidelines emphasize that no single tool will be adequate for either evaluation or assessment, and both must be accomplished using a range of tools in varied contexts. Further, eligibility decisions may not rely on the use of standardized measures alone. Rather, such decisions also are based on informed clinical opinion that is derived from multiple sources of information gathered in multiple contexts.
Once it is determined that a child is at risk for or has a communication deficit, the members of the early intervention team (e.g., family, SLP, pediatrician, early childhood special educator, audiologist, physical therapist, occupational therapist, home trainer, child care provider) develop a plan for services and supports (i.e., the IFSP or an equivalent) that includes intervention outcomes, approaches, methods, and settings. This plan will be based on information from the multidisciplinary assessment regarding overall concerns, priorities, and resources of the family combined with the SLP's analysis (and the team's observations) of the child's communication, language, speech, hearing, and feeding/swallowing behavior.
Service delivery models. The purpose of early intervention provided by SLPs is to maximize the child's ability to communicate effectively, and to enhance the family's ability to support their child's development. The selection of a service delivery model will vary and will be based on the particular needs of individual children and their families or caregivers. Service delivery models in early intervention vary along the dimensions of location and types, both of which influence the roles of the SLP and other team members in the provision of services. Historically, the location for early intervention service delivery has been in the home, center (e.g., special classroom, preschool, or child care center), or clinic. Recent federal legislation requires that early intervention services and supports be provided to the maximum extent appropriate in natural environments, including the home and community settings in which children without disabilities participate (IDEA 2004).
Types of service delivery models in early intervention range from the traditional, one-to-one, direct clinical model (i.e., pull-out) to more indirect collaborative approaches. Consultative and collaborative models are closely aligned with inclusive practices, involve services delivered in natural environments, and focus on functional communication during the child and family's natural daily activities and routines. The emphasis of these models moves from a unitary focus on direct or “hands-on” service delivery to the child to an integrated model that includes the child, family, caregivers, and the SLP in a collaborative role.
Research about service delivery models in early intervention is in an emerging phase, and as a result, some practices may be based more on policy and professional and family preferences than on theories or research. Furthermore, service delivery utilization studies and state-reported data indicate general adherence to standardized models such as weekly home visits or half-day classroom programs without individualization for child and family characteristics. These realities suggest the need for more flexibility in program implementation as well as more research on the effectiveness of various service delivery systems.
Intervention approaches and strategies. In the past 15 years, there has been increasing support of intervention occurring within the child's and family's functional and meaningful routines and experiences dispersed throughout the day rather than in tightly planned and executed activities. This shift away from traditional, clinical models for services for young children and their families is aligned with the federal mandate to provide services in natural environments and is responsive to the success of parent-implemented interventions. The use of routines and everyday activities as a context for embedded instruction involves (a) identifying the sources of learning opportunities occurring regularly in family and community life; (b) selecting, with the parents and caregivers, desired participation and desired communication by the child in the routines; (c) mapping motivating aspects and the child's interests within the routines; and (d) identifying facilitative techniques that will be used to maximize the learning opportunity.
Organization of the ever-expanding research base on effective intervention approaches and strategies in early intervention is challenging for a variety of reasons. The focus of intervention may be the parent or caregiver, the child, the dyadic interaction, the environment, or combinations of these factors. The agent of the intervention may be the SLP, another team member, a family member or peer, or varying combinations. The intervention may be in small or large groups, individual or massed, or distributed opportunities throughout the day. Much of the empirical data collected to date have been on preschoolers rather than infants and toddlers, and the quality and preponderance of the evidence are lacking for some intervention practices. However, there are intervention approaches and strategies for the SLP and team to consider that have some evidence to support their use by professionals and parents in both home and community settings for young children with a variety of disabilities.
Strategies with promising evidence fall into one of three groups: responsive interaction, directive interaction, and blended. Responsive approaches include following the child's lead, responding to the child's verbal and nonverbal initiations with natural consequences, providing meaningful feedback, and expanding the child's utterances with models slightly in advance of the child's current ability within typical and developmentally appropriate routines and activities. Responsive interaction approaches derive from observational learning theory and typically include models of the target communication behavior without an obligation for the child to respond. Among others, specific techniques include expansions, extensions, recasts, self-talk, parallel talk, and build-ups and breakdowns. Directive interaction strategies include a compendium of teaching strategies that include behavioral principles and the systematic use of logically occurring antecedents and consequences within the teaching paradigm. Blended approaches, subsumed under the rubric of naturalistic, contemporary behavioral, blended, combination, or hybrid intervention approaches, have evolved from the observation that didactic strategies, while effective in developing new behaviors in structured settings, frequently fail to generalize to more functional and interactive environments. The emphasis on teaching in natural environments using strategies derived from basic behavioral teaching procedures has been broadened to include strategies for modeling language and responding to children's communication that derive from a social interactionist perspective rooted in studies of mother–child interaction. The core instructional strategies are often identical to those used in direct teaching (e.g., prompting, reinforcement, time delay, shaping, fading) but also may include strategies that come from a social interactionist perspective (e.g., modeling without prompting imitation, expansions, recasts, responsive communication). Naturalistic language interventions may be used as the primary intervention, as an adjunct to direct teaching, or as a generalization promotion strategy.
Monitoring intervention. Because young children often change very rapidly, and families respond differently to their children at various periods in development, systematic plans for periodic assessment of progress are needed. The three broad purposes of monitoring are to (a) validate the conclusions from the initial evaluation/assessment, (b) develop a record of progress over time, and (c) determine whether and how to modify or revise intervention plans. Thus, the evaluation/assessment and intervention processes can be viewed as a continuous cycle of service delivery. Monitoring includes attention to both the child's IFSP as well as broader aspects of the child's development and behaviors, such as participation in routines, play, social interactions, and problem behaviors, to determine appropriate goals in these areas. For children in early care and education programs, attending to their levels of engagement in activities can help determine whether changes are needed in their classroom environment.
In delivering early intervention services and supports, SLPs assume important collaboration and consultant functions with team members, including the family and other caregivers, and other agencies and professionals. As part of the early intervention team, the SLP is uniquely qualified to help a family enhance their child's communication development through consultation and education. Because young children learn through familiar, natural activities, it is important for the SLP to provide information that promotes the parents' and/or other caregivers' abilities to implement communication-enhancing strategies during those everyday routines, creating increased learning opportunities and participation for the child.
In some cases, an indirect or consultant role is warranted. In this role, the SLP works with parents and other professionals to include language stimulation within other activities being addressed in the child's program. The consulting SLP can provide information and support to the parent and/or professional regarding the rationale and methods for providing indirect language stimulation, during a range of activities and routines. The SLP will continue to consult directly with the family and professional to monitor progress, and participate in development or revision of intervention plans. The indirect consultant role, while flexible to meet the child and family needs, is ongoing to ensure progress and appropriate implementation of the chosen strategies.
Service coordination is mandated under IDEA 2004 Part C and is defined as an active, ongoing process that assists and enables families to access services and ensures their rights and procedural safeguards. It is provided at no cost to families. The service coordinator is responsible for ensuring that every child and family receives a multidisciplinary evaluation and assessment, an IFSP, delivery of services in natural environments, and coordination of services. The SLP, as a member of the IFSP team, may in some instances assume these functions and therefore needs an understanding of the roles and responsibilities of the service coordinator.
A major goal of IDEA 2004 is to ensure a seamless transition process for families moving from one program to another as well as timely access to appropriate services. To this end, it is stipulated that there be a transition plan, that representatives of the sending and receiving programs take part, and that families play an active role. Although there are several types of transitions, including hospital to community-based programs, home-based to center-based programs, provider to provider, and early intervention to community-based preschool, the most dramatic transition occurs when the child moves from Part C early intervention to Part B school-based services, typically at age 3.
In this latter transition, a range of options exists, and the SLP will offer the level of assistance to families and team members appropriate for their particular role with that family.
Advocacy activities and products that raise awareness about the importance of early intervention are essential, and SLPs have a responsibility to play a part in this process. Mechanisms include working with other professionals; writing and editing textbooks, articles for consumer use and reference, and other resource materials to provide up-to-date and accurate developmental information; involvement in local, state, and national efforts to influence public policy; and development and dissemination of information to families, health care professionals, and others involved in the care of young children.
Continued experimental and clinical research is needed to obtain information and insight into several areas, including identification of risk factors, clarification of the interactions between risk and resilience factors that affect the likelihood or severity of early communication difficulties, development and refinement of identification methods to increase the accuracy of detecting children in need of services, development and refinement of interventions to prevent and treat developmental communication difficulties, and scientifically sound studies to demonstrate the efficacy and effectiveness of current intervention approaches and collaborative models of service delivery. Further, all those invested in enhancing the early intervention services delivered to young children and their families have a responsibility to be aware of and advance the knowledge base in early intervention. These stakeholders include preservice programs and higher education faculty, students, in-service providers, practicing clinicians, researchers, policy makers, and consumers.
The purpose of these guidelines is to address the role of the SLP in the provision of early intervention services to families and their infants and toddlers (birth to 3 years of age) who have or are at risk for developmental disabilities. [1] The roles and responsibilities of SLPs serving infants and toddlers include, but are not limited to, (a) prevention; (b) screening, evaluation, and assessment; (c) planning, implementing, and monitoring intervention; (d) consultation with and education of team members, including families, and other professionals; (e) service coordination; (f) transition planning; (g) advocacy; and (h) awareness and advancement of the knowledge base in early intervention. The guidelines discuss each of these roles along with the available evidence to support specific practices. The implementation of SLP roles and responsibilities in collaboration with families, caregivers, and other professionals is informed by a set of early intervention principles and values (see ASHA, 2008a).
The development of communication skills is a dynamic process that is shaped by interdependent factors intrinsic to the child and in interaction with the environment. The reciprocal and dynamic interplay between biology, experience, and human development converge to influence developmental experiences (National Research Council & Institute of Medicine, 2000). Most importantly, the course of development is alterable. The following four guiding principles reflect the current consensus on best practices for providing early and effective communication interventions (ASHA, 2008a).
An aim of all early intervention services and supports is responsivity to family concerns for each child's strengths, needs, and learning styles (Paul, 2007; Roth & Worthington, 2005). An important component of individualizing services includes the ability to align services with each family's culture and unique situation, preferences, resources, and priorities. The term family-centered refers to a set of beliefs, values, principles, and practices that support and strengthen the family's capacity to enhance the child's development and learning (Boone & Crais, 2001; Dunst, 2001, 2004; Individuals with Disabilities Education Improvement Act of 2004 [IDEA, 2004]; Polmanteer & Turbiville, 2000). These practices are predicated on the belief that families provide a lifelong context for a child's development and growth (Beatson, 2006; Bronfenbrenner, 1992). The family, rather than the individual child, is the primary recipient of service delivery to the extent desired by the family. Some families may choose for services to be focused on the family, whereas others may prefer a more child-centered approach. Family-centered services support the family's right to choose who is the recipient of the services. Early identification and intervention efforts are designed and carried out in collaboration with the family, fostering their independence and competence, and acknowledging their right and responsibility to decide what is in the best interest of their child (Dunst, Trivette, Starnes, Hamby, & Gordon, 1993). Family-centered services emphasize shared decision making about referral, need for assessment and intervention, types of assessment and intervention approaches, methods for monitoring and sharing information with others important to the child and family, development of functional outcomes, and implementation of intervention.
There is no single set of practices that is appropriate to meet the needs of all families. Family-centered early intervention practices respect family choices and decisions (Summers, Hoffman, Marquis, Turnbull, & Poston, 2005). Components of family-centered practices include offering more active roles for families in the planning, implementing, interpreting, and decision making in service delivery. Family-centered practices can maximize time and other resources, create closer alignment between family and professional decisions and plans, and increase decision making by families (Dunst, 2002; Summers et al., 2005).
All early intervention services and supports are directly influenced by the cultural and linguistic backgrounds of the family, child, and professionals. Every clinician has a culture, just as every child and family has a culture (ASHA, 2004c). SLPs need to recognize their own as well as the family's cultural beliefs, values, behaviors, and influences, and how these factors might affect their perceptions of and interactions with others. Like all clinical activities, early intervention services are inherently culture-bound because they reflect the beliefs, values, and interaction styles of a social group (Battle, 2002; P. H. Johnston & Rogers, 2001). Factors such as beliefs about child rearing, discipline, authority roles, and styles of communication, as well as views on disability and past experiences with health care or other professionals, can influence the family's interactions and decision-making process. In some cultures, for example, emphasis is placed on what a child can learn independently, whereas other cultures focus on what a learner can accomplish in collaboration with others. Therefore, different learning styles, and values regarding means of teaching and learning, necessitate different assessment and instructional approaches and strategies (Terrell & Hale, 1992; van Kleeck, 1994).
With the changing demographics in the United States and the differences that may occur between service providers and families in sociocultural characteristics (e.g., age, language, culture, race, gender, ethnicity, background, lifestyle, geography), it is important to gather information from families about the ways in which these factors may influence family/provider relationships and communication. For these reasons, some programs use cultural guides or cultural-linguistic mediators to facilitate communication and understanding between professionals and families (Barrera, 2000; E. W. Lynch & Hanson, 2004; Moore & Mendez, 2006). Moreover, from the perspective of “recommended practices” as well as policy (ASHA, 2004c; IDEA, 2004; National Association for the Education of Young Children [NAEYC], 2005), all materials and procedures used in the provision of early identification and intervention services and supports should be culturally and linguistically appropriate for the individual child and family.
Effective early intervention services and supports are based on theoretical, empirical, and clinical models of child development that assume the acquisition of communication occurs within a familial, social, and cultural framework, and make use of commonly accepted theories about how individual children learn communication, speech, language, and emergent literacy skills (Apel, 1999; Leonard, 1998; Paul, 2007). Early identification and intervention practices that are developmentally supportive include active exploration and manipulation of objects, authentic experiences, and interactive participation appropriate to a child's age, cognitive level and style, strengths, interests, and family concerns and priorities (Bredekamp & Copple, 1997; Roth & Baden, 2001; Sandall, Hemmeter, Smith, & McLean, 2005). Early intervention promotes social communication for children to enhance their competent, adaptive, and independent participation in their natural environments irrespective of their cognitive abilities. All young children have the need to communicate; therefore, factors such as their general ability level should not be used to exclude them from receiving services to promote their communication and interaction with caregivers and other persons in their environments (National Joint Committee for the Communication Needs of Persons With Severe Disabilities, 2003a, 2003b).
Early speech and language skills are acquired and used primarily for communicating during social interactions. Therefore, optimal early communication intervention services are provided in natural environments, which offer realistic and authentic learning experiences (i.e., are ecologically valid) and promote successful communication with caregivers. Authentic learning can maximize children's acquisition of functional communication skills and promote generalization of newly mastered behaviors to natural, everyday contexts (Bruder, 1998; Girolametto, Pearce, & Weitzman, 1997; Hart & Risley, 1995, 1999; McLean & Snyder-McLean, 1999; Roper & Dunst, 2003).
Natural environments for the team to consider in service decisions extend beyond a child's home and include the many and varied community settings in which children without disabilities participate. Community settings are places a child and family would typically be present, such as family- or center-based child care centers and community recreation programs, as well as more informal settings such as family or neighborhood gatherings, a local park, religious activity, or a grocery store. Family-identified community settings and activities are important sources of learning (Dunst, Bruder, et al., 2001; Dunst, Hamby, Trivette, Raab, & Bruder, 2000). When services are provided in natural environments, they offer the opportunity to highlight learning opportunities that are available within typical activities and routines that the family selects. Common activities or routines may include interactive play, book sharing, feeding, dressing, toileting, or other activities that occur repeatedly with family members, family friends, and other regular caregivers. However, it is important to remember that these activities will vary greatly depending on sociocultural factors and preferences of the family. Therefore, SLPs need to be careful not to impose their own ideas of what routines/activities a family should engage in with the child, letting the family identify those that are preferred. These types of naturally occurring activities offer opportunities for promoting children's participation and learning throughout the day using activities, materials, and people familiar to the family and child (Bernheimer & Weismer, 2007; Cripe & Venn, 1997; Dunst et al., 2000; Girolametto et al., 1997). Other benefits attributed to provision of early intervention services and supports in community settings include support and encouragement from others outside the family; improvement in child self-esteem; facilitation of social skills, adaptive skills, and positive behavior through peer modeling (Stowe & Turnbull, 2001); and enhanced sense of belonging on the part of the family (Bruder, 2001).
The SLP's participation in the child's and family's natural environments enhances the assessment and intervention processes through the identification of the child's and family's preferred routines and interests, facilitates access to everyday materials and toys, and encourages effective arrangement of the environment to promote communication in familiar and functional activities. The SLP promotes positive, responsive interactions between children and caregivers. The SLP should assess the child in the context of daily activities and demonstrate how to embed intervention into such activities, thereby increasing the frequency of communication opportunities for the child and caregivers (Cripe & Venn, 1997).
Infants and toddlers who have or are at risk for developmental delays and disabilities demonstrate a wide range of skills and deficits. Some may have severe involvement, with difficulties in multiple developmental domains (e.g., communication, adaptive behavior, social-emotional, cognitive, motor). Because all these developmental areas are highly interdependent during early childhood, and intervention efforts in one area may influence another, a comprehensive approach toward meeting family and child needs is recommended in these cases. Other children, in contrast, may have milder disabilities or may manifest a circumscribed disability in one primary area. Regardless of whether a child has severe or mild, single- or multiple-domain disabilities, comprehensive service provision will include any and all types of supports or resources the child needs and is eligible to receive (e.g., service coordination, assistive technologies, amplification).
In comprehensively meeting the needs of infants, toddlers, and their families, SLPs may be one of several professionals working with the child and family. In other instances, SLPs may be the initial contact for the child and family and may need to make referrals or enlist the assistance of other qualified professionals (e.g., when a child initially referred for speech-language assessment needs team-based assessment). As part of comprehensive early intervention services, SLPs can play a key role with their specialized knowledge about typical and atypical early development of communication, language, speech, feeding/swallowing, hearing, cognition, emergent literacy, social/emotional behavior, and the use of assistive technology. Further, a comprehensive approach takes into account the perspectives provided by the family and others whom they identify as significant to the child, including siblings, extended family, early care and education providers, and family friends.
Coordination and integration of services, including service coordination and teaming, are key components of effective implementation of comprehensive services. Many of the difficulties reported by families in caring for their infants and toddlers with disabilities result from poor coordination between services and among professionals (Harbin et al., 2004; McBride & Peterson, 1997; McWilliam et al., 1995). Further, research has suggested that belief in and ability to practice family-centered care are central to effective collaborative relationships between parents and service coordinators (Dinnebeil, Hale, & Rule, 1996). Still, the degree to which family-centered care is provided has been quite variable (Dinnebeil et al., 1996; Trivette, Dunst, & Hamby, 1996). Service coordination can be a primary service, or coordination can be achieved through the formulation of professional teams who jointly and in conjunction with the family plan comprehensive and coordinated services. In team settings, the SLP may serve (along with other professionals) as a service coordinator on a rotating basis, particularly when a child's primary needs are for speech-language intervention. In addition, some families may choose to take on the role of service coordinator, and the SLP and other professionals may serve as consultants to the family in the decision-making process. For SLPs providing services in settings where professionals from other disciplines are not readily available (e.g., private practice, some medical settings, university clinics), it is equally important that coordination of services is clearly articulated and used by all who interact regularly with the child. In these situations, it will be helpful for the SLP as well as the family to communicate actively with other professionals serving the child and with others in the child's daily environments (e.g., home, child care, preschool). In addition, when children are seen in settings that do not provide service coordination, the SLP is entitled to make a referral to the local early intervention system for formal service coordination.
Early intervention is a dynamic process that requires continuous assessment and monitoring to inform ongoing changes in service delivery in accord with children's developmental progress. Members of the IFSP team, required by Part C of IDEA 2004, are mandated to coordinate their approaches, consult with one another, and recognize that child and family outcomes are a shared responsibility. In settings where SLPs work independent of other professionals on the team (e.g., private practice, hospital settings, home-based services, university clinics), referral and consultation with other professionals (e.g., physical therapist, family physician, child care provider) and additional caregivers (e.g., grandparents, aunts, family friends) are important for understanding the scope of a child's strengths and needs. This pooling of information from a variety of sources also is recommended practice of ASHA (ASHA, 1991a) as well as related professions (Sandall et al., 2005), and is required in IDEA 2004.
In the current provision of Part C services, children who receive early intervention may be seen by multiple professionals who are employed by different agencies representing differing team models. Comprehensive, coordinated, and collaborative team-based services help avoid fragmentation of services and supports to children and families (ASHA, 1991a; Hebbler, Zercher, Mallik, Spiker, & Levin, 2003; IDEA 2004; National Research Council & Institute of Medicine, 2000). While the extent of collaboration in early intervention will vary depending on the team model that is used, the lead agency's program guidelines, and the knowledge and skills of the team members, the need for communication among team members and with the family is mandated and must be supported by the administering agency.
Common team models that are used include multidisciplinary, interdisciplinary, and transdisciplinary. Multidisciplinary teams typically make use of a process whereby children are seen by professionals from different disciplines who each separately complete an evaluation and/or assessment, make recommendations, and deliver their services independently. In these instances, integration of findings and recommendations typically is left to the family or service coordinator. This model may diminish the cohesiveness of services and the number of opportunities for professionals to interact with one another and the family. Many of the difficulties that families report in service delivery result from poor coordination between services and across professionals, emphasizing the need for integration of services (Harbin et al., 2004; McBride & Peterson, 1997; McWilliam et al., 1995). This is an especially important challenge to SLPs working as private contractors to the early intervention team.
Interdisciplinary teams characteristically work together, communicate consistently, coordinate information and resources, and collaborate with the families and each other to achieve priority outcomes. Effective interdisciplinary teams share responsibility for providing services based on identified child and family priorities, including communication skills. Although individual professionals may assess the child separately or in small groups, there is some attempt to communicate findings and recommendations to each other. In addition, some teams use an arena method whereby all or designated team members are present during the evaluation and/or assessment and professionals interact individually, collaboratively, or through observation of the child. Teams may use an integrated tool, discipline-specific tools, or some combination. Further, some teams meet before and after testing to consolidate their plans, findings, and recommendations. Family participation is also integrated, with their role ranging from being the child's play partner in the assessment process to being an observer and validator of information collected by professional team members. Family members inform the team's ongoing discussion of the child's strengths, preferences, and current skills. The professional team members can infuse dynamic assessment opportunities as the child interacts with family members and other familiar adults in typical routines and activities. Some teams choose to compile one report that includes each individual report; other teams write an integrated report. On interdisciplinary teams, the SLP is seen as the team member most qualified to guide the identification and development of the intervention approaches and strategies related to communication and to consult with the family and other team members; however, the SLP may not be the only team member involved in the intervention or may participate in the intervention as a consultant.
In a transdisciplinary model, all team members work closely to plan the assessment and the subsequent intervention, although typically one team member and the family will be responsible for the day-to-day implementation of intervention. Transdisciplinary models include some type of role release wherein one or more professionals take on, with the supervision and collaboration of the discipline-trained professional, some aspects of the roles and responsibilities of one or more of the other professionals. Ideally, in this model team, members provide training to one another about key behaviors to observe/document and then consult with other team members regarding interpretations and recommendations. Arena assessment, in which professionals of different disciplines simultaneously observe a child, may be included in transdisciplinary models.
The use of a transdisciplinary model, sometimes referred to as a primary service provider (PSP) model, is logically appealing and considered recommended practice by the Division for Early Childhood of the Council for Exceptional Children (DEC) for early intervention (Sandall et al., 2005). Infants and toddlers learn new skills across domains simultaneously and synchronously rather than in isolation. Coordination of services is enhanced when the team's message is unified in delivery by a lead member working closely with the family. The team, in concert with the family's preferences, selects the appropriate team member to serve as the primary provider. In some cases, this will be the SLP, while in others the PSP will be a member of a different discipline such as special education, nursing, or occupational therapy, and the SLP will play a support role. The team member is selected based on the needs of the child, relationships already developed with the family, and special expertise, but should not be established a priori by program policy or based on logistics such as travel or caseload.
The use of transdisciplinary or PSP models may be appropriate for SLPs. Early intervention is a field with many disciplines represented as practitioners and in which the roles vary according to the needs of the child. Teams benefit from joint professional development and can enhance each other's knowledge and skills as well as through role extension and role release for specific children and families. It is not appropriate or suitable for SLPs to be asked to train others to perform professional level services unique to SLPs or for SLPs to perform services outside of their scope of practice (ASHA, 1997a, 1997b).
Early intervention practices are based on an integration of the highest quality and most recent research, informed professional judgment and expertise, and family preferences and values (ASHA, 2005a; Glass, 2000; Meline & Paradiso, 2003; Schlosser & Raghavendra, 2003). Evidence can be classified as external or internal: Internal evidence is drawn from a variety of sources including policy, informed clinical opinion, values and perspectives of both professionals and consumers, and professional consensus; external evidence is based on empirical research published in peer-reviewed journals (Gillam & Laing, 2006; Porzsolt et al., 2003; Sackett, Strauss, Richardson, Rosenberg, & Haynes, 2000).
The interpretation of internal evidence may be based on a single factor or may reflect a synthesis of multiple perspectives and experiences. Policy, as a source of internal evidence, is based on federal, state, and agency legislation and guidelines, as well as the recommended practices of ASHA and related professional organizations. Informed clinical opinion is a type of internal evidence reflecting the values and beliefs of professionals, their prior and continuing education, personal and professional experiences, and application of the theory and scientific evidence for early intervention practices. Informed clinical opinion is displayed through a professional's ability to observe, document, apply, and evaluate the efficacy and effectiveness of early intervention practices and procedures for specific children and families. Internal evidence also takes into account the values and perspectives of the professionals and families involved. These values and perspectives are influenced by sociocultural, linguistic, educational, and economic factors, and they in turn influence and are influenced by the relationships among professionals, children, families, and the services delivered. A final component of internal evidence includes professional consensus whereby experts in the field have reached general agreement about certain principles and practices through consideration of theory, a review of existing evidence and policies, and their collective clinical experience. Statements of consensus often are published as recommended practices.
When evaluating external evidence, there are several factors that require consideration, and numerous classification systems have been developed for this purpose (e.g., Dollaghan, 2004; Fey & Justice, 2007; Finn, Bothe, & Bramlett, 2005; Porzsolt et al., 2003; Robey, 2004; Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996). Classification systems typically rate or judge the degree of confidence that the practices implemented are responsible for the observed findings. In evidence-based classification systems, the degree of confidence is evaluated according to several characteristics of the research design (e.g., random assignment to conditions, use of blind raters, prospective designs) and the degree of experimental control present in the design. Other factors that are considered in evaluating research quality include practice fidelity, validity of outcome measures, factors related to the participants and settings, and data analysis procedures.
Evaluation of practice fidelity focuses on description and implementation. The description of a practice or protocol should include a level of detail sufficient for replication by other providers. Fidelity of implementation should demonstrate that the intervention was in fact delivered in the manner in which it is defined. The validity of outcome measures should be established through reliability reports, evidence that the outcome measures are aligned with and reflect the intended purpose of the intervention, and evidence that the outcome was measured at a time that was appropriate and reasonable for documenting the effect of a practice.
Factors related to the participants, providers, and settings are central to evaluation of the likely effectiveness as well as generalizability of a practice. Evaluation of these components should consider the description of the participants, including any identification of subgroups (e.g., diagnostic, language status, ethnicity), descriptions of the person(s) who actually delivered the intervention (e.g., parent, SLP, teacher), and the settings in which the practice was tested (e.g., clinic, home, child care program, other community setting). Questions guiding evaluation of these factors should be centered on the extent to which the report includes important subgroups, settings, and providers. When variations in subgroups, settings, and providers are apparent, it is important to determine the extent to which effects can be estimated for these variations.
Evaluation of data analysis procedures focuses on the extent to which assumptions are met for selected statistical tests. Of importance is evidence for independence among participants in the research, both between one participant and another as well as for measures of performance for a given participant. Other considerations are sample sizes, power, and estimates of effect size. Documentation of the sample size and power are interrelated and allow for the evaluation of the sufficiency of the sample size to detect meaningful effects. In addition, estimates of effect size should be calculated to evaluate whether they are sufficient to support any claims of effectiveness that may be made.
Most classification systems view the strongest external evidence as that derived from meta-analysis and systematic reviews of a number of well-designed, controlled studies that include random allocation to treatment and contrast conditions. Weaker external evidence is accorded to literature reports that vary from these standards, including quasi-experimental designs, case studies, and groups without random assignment to conditions. “Best practice” recommendations, consensus panels, and expert opinion are not regarded as providing external evidence, but rather as components of internal evidence.
The literature review for these guidelines was drawn from sources provided by individual committee members in their respective areas of expertise as well as sources such as the (a) DEC Recommended Practices Research Review (B. J. Smith et al., 2002), (b) ASHA National Center for Evidence-Based Practice in Communication Disorders (N-CEP), and (c) Research and Training Center on Early Childhood Development (RTCECD; www.researchtopractice.info/index.php). The DEC Recommended Practices Research Review includes a thorough review of the literature on children from birth to 8 years of age that appeared in peer-reviewed journals through 1999 (B. J. Smith et al., 2002). N-CEP conducted a literature search for this Committee to identify empirical treatment studies or systematic literature reviews on speech, language, and/or communication in early intervention. Empirical studies were defined as those that included original data that addressed treatment outcomes through single-case, quasi-experimental, or experimental research. Systematic literature reviews were those that included an analysis of the evidence base for a particular instructional method or a group of methods. The N-CEP search was limited to peer-reviewed publications from 1980 to the present. Articles were classified by instructional method and disorder, and those where parents were taught to implement the intervention procedures. Studies were included in this review if they (a) included children under 3 years, (b) were reported in English, and (c) had original data relevant to one or more of the search terms (e.g., parent training, indirect language stimulation, script therapy, milieu teaching, language delay). A list of electronic databases used, search criteria, and search terms is available in the Appendix. Finally, the RTCECD and the What Works Clearinghouse were used to ensure that a comprehensive literature search was conducted (Dunst et al., 2002).
The early intervention practices described in this document include those based on both internal and external evidence from the literature. Some of the practices detailed here are based predominantly on internal evidence, while others rely on some external evidence. However, readers must recognize that the external evidence varies in strength of the research design and implementation (e.g., randomized control vs. observation without controls). Many of the practices discussed have not yet been studied to the degree and in the manner that would allow the evidence for them to be considered “strong” by certain evidence standards; however, when considered in terms of internal and external evidence, the practices that appear promising were included in this document. SLPs will need to consider both the strengths and the limitations of current empirical studies when evaluating the preponderance and quality of evidence for practices presented here. The Committee recognized that there are few areas of early intervention practice in which clear, unequivocal answers emerge from empirical research that can be confidently applied to broad classes of infants and toddlers with disabilities. In recognition of this, no attempt was made in this document to prioritize specific assessments, interventions, or treatment programs. The goal was to present a range of assessment and intervention practices with some basis in either internal or external evidence, in an effort to provide a backdrop against which the clinician can evaluate newly emerging external and internal evidence in making service decisions for particular children and families.
The SLP is qualified to provide services to families and their children who are at risk for developing, or who already demonstrate, delays or disabilities in language-related play and symbolic behaviors, communication, language, speech, emergent literacy, and/or feeding and swallowing behavior. In providing these services, the SLP may participate in the following primary functions: (a) prevention; (b) screening, evaluation, and assessment; (c) planning, implementing, and monitoring intervention; (d) consultation with and education of team members, including families and other professionals; (e) service coordination; (f) transition planning; (g) advocacy; and (h) awareness and advancement of the knowledge base in early intervention.
The goal of prevention activities is to reduce the risk or mitigate the effects of risk factors on a child's development so as to prevent future problems and promote the necessary conditions for healthy development (ASHA, 1991b; National Joint Committee on Learning Disabilities [NJCLD], 2006). SLPs have the opportunity to play an important role in the prevention of communication disorders, especially in the field of early intervention. Prevention can be conceptualized at three levels: primary, secondary, and tertiary. SLPs can help young children avoid the onset of communication problems (“primary prevention”) by, for example, promoting positive communication interactions between children and caregivers. They can assist in the early detection of delays or deficits by participating in child-find and screening programs, thereby mitigating or eliminating the effects of a disorder (“secondary prevention”). Finally, they can help remediate an existing problem by providing early intervention services, thereby preventing future difficulties (“tertiary prevention”). An example of the latter would be language intervention in the toddler/preschool years, which helps to prevent the need for subsequent school-based services (ASHA, 1991b). SLPs who assume an effective role in prevention will be knowledgeable about the various factors that place a child at risk for communication disorders, as detailed below in the Screening, Evaluation, and Assessment section.
Prevention activities often extend beyond the traditional intervention settings (e.g., clinic, Part C early intervention programs) into various community settings. In their implementation of prevention activities, SLPs have the responsibility to collaborate with local partners such as pediatric medical providers, early childhood education programs (e.g., Early Head Start or child care centers), libraries, and parent support groups to offer educational support as well as screening services. Information regarding known risk factors, “red flags” for possible communication deficits, and activities that promote positive early language and literacy development can be provided by offering in-service training and written resource materials. Establishing personal relationships with other providers in the community (e.g., early childhood educators, physicians, social service providers) and being responsive to inquiries or requests made by them for information or referral should increase their use of available screening and diagnostic resources.
Federal legislation (IDEA 2004) designates the following three risk categories for young children: established risk (i.e., a diagnosed medical condition or disorder that has a known effect on developmental outcomes), biological risk (i.e., a history of prenatal, perinatal, neonatal, and developmental events that may individually or collectively affect development), and environmental risk (i.e., early experiences that include health care, parental care, exposure to physical and social stimulation that if absent or limited may affect development). Children in the established risk category are universally eligible for services under IDEA 2004 Part C; that is, neither screening nor evaluation is necessary to establish eligibility for early intervention services. However, all states do not automatically provide services to children in the other two categories. Local programs also vary in terms of which risk categories are covered by their services. With the increased awareness of environmental and biological risk factors and their effect on later communication skills (and overall development), SLPs can integrate information on risk factors with screening, evaluation, and assessment information to help make decisions about early intervention services for individual children and their families (NJCLD, 2006). Screening for communication needs in infants and toddlers is a process of identifying young children at risk so that evaluation can be used to establish eligibility, and more in-depth assessment can be provided to guide the development of an intervention program. Its aim is to make a determination as to whether a particular child is likely to show deficits in communication development. Screening is also an important component of prevention, family education, and support that is particularly relevant for young children and their families.
As noted above, children who are identified at an early age with a diagnosed medical condition that is known to result in a communication and/or feeding/swallowing disorder (e.g., Down syndrome, hearing loss, cleft palate, low birth weight) are considered to have established risk and are automatically eligible for services. The medical conditions of these children, rather than their performance on a behavioral examination, serve as the eligibility criteria for early intervention services. Teams serving children likely to be identified at birth (or shortly after) should include an SLP to manage early communication and feeding needs. In some settings, the SLP's involvement begins in the neonatal intensive care unit (NICU) where specialized feeding/swallowing techniques can be promoted and used. In other settings, the SLP's participation begins when the infant visits the follow-up clinic. SLPs involved in follow-up of these infants with established risk have the responsibility to develop a detailed understanding of the children's medical records and conditions and to interview the children's families so that a comprehensive developmental history can be derived and documented. Use of standardized and criterion-referenced measures, checklists, and interview procedures should be supplemented by direct monitoring of development and by observation of the interaction between caregiver(s) and infant in multiple natural contexts.
Although certain medical conditions make it possible to identify at-risk children as neonates, similar indices are not readily available for identifying which children without known medical conditions may be at risk for difficulty in acquiring communication, language, speech, and feeding/swallowing skills. Some of these children will be identified by comprehensive child-find systems that include the input and guidance of an SLP. Therefore, SLPs also have a primary responsibility for selection and development of age-appropriate screening and assessment procedures. Moreover, there may be children without known medical conditions who show signs of risk, such as delayed development or loss of babbling during the latter half of the first year of life, failure to begin to use words, absence of a “vocabulary spurt,” failure to begin combining words in the second year of life, or feeding/swallowing difficulties as they transition from liquids to solids. In addition, there are children who exhibit some forms of communication (e.g., gestures, vocalizations, words) but do not use these skills to successfully interact with others. In the second and third years of life, however, the most common presenting complaint is the failure to begin talking and to engage in communication exchanges (U.S. Department of Education, 2003). For these children, as well as those who appear to have broad or generalized developmental delays, careful screening by an SLP is warranted to determine whether more intensive evaluation and assessment are needed. SLPs charged with the responsibility for early screening require knowledge of (a) the great variability that characterizes typical development, and (b) the wide variation in interactive styles surrounding successful communication and language development, particularly in populations from culturally and linguistically different backgrounds.
IDEA 2004 identifies communication as one of the developmental domains required in a comprehensive evaluation. IDEA 2004 distinguishes between the terms evaluation and assessment. The term evaluation refers to procedures that determine a child's initial and continuing eligibility for services and includes identification of the child's current level of functioning across cognitive, physical (including vision and hearing), communication, social/emotional, and adaptive development. In contrast, assessment refers to the ongoing process of describing the child's needs; the family's concerns, priorities, and resources related to the development of the child; and the nature and extent of the early intervention services required to meet the needs of the child and family. The legislation also specifies that both evaluation and assessment should be based on a variety of measures that include informed clinical opinion. The roles of SLPs in evaluation and assessment typically are to measure and describe communication and related behaviors, including feeding and swallowing, to share observations on other developmental domains, and to help in the decision-making process related to diagnosis, eligibility determination, and planning next steps for the child and family. In some communities, evaluation and assessment may be a two-part process in which one team of professionals evaluates the child to determine eligibility and then refers the child to another team for service coordination and/or other intervention services. In other areas, a single team may provide a combined evaluation/assessment and then provide service coordination and intervention planning services.
It is important, as specified in IDEA Part C regulations, for the evaluation and assessment to be conducted in the language(s) used by the child and family (both orally and in written form). Recommended practice for assessing children learning more than one language is to assess the child's skills in all the languages available to the child (Genesee, Paradis, & Crago, 2004; Langdon & Cheng, 2002). Thus, SLPs who do not speak the languages of the family may collaborate with interpreters or cultural mediators to ensure the accuracy of the assessment (ASHA, 1998a, 1998b, 1998c, 1998d, 2003a, 2004c; Langdon, 2002; Langdon & Cheng, 2002). Evaluation/assessment when there are language differences between the family and the SLP can be hindered by a lack of tools that have been developed in, or translated into, languages other than English. Given the limited availability of translated tools, SLPs screening children with multiple languages will need to pay particular attention to the psychometric properties of commonly used tools to determine their applicability to a particular child. Language alone should not present an insurmountable obstacle to the SLP, however. Frequently, children involved in early intervention services have not acquired verbal language. For these children, much of the SLP's assessment will focus on preverbal behaviors, including play, gesture, and other forms of nonverbal communication and interaction, as well as feeding skills. Many of these behaviors can be observed independently of verbal language and, when augmented with parent report obtained through the help of interpreters and cultural mediators, can serve as a foundation for informed clinical opinion regarding communication development status. As noted elsewhere, parental perspectives on the child's skills relative to the beliefs and values of the family and their culture are also important to gain.
The processes of screening, evaluation, and assessment present important opportunities integral to the guiding principles for early intervention. The eligibility determination process may be the first contact a family has with an SLP or a team of early intervention professionals. First contacts provide opportunities to develop a family-centered relationship and for the team to answer questions from families about their child's development. Although parents may know their child's communication status, they often have less information about typical communication milestones and early literacy development, the range of variability among children, and appropriate red flags for concern. Parents may be surprised to learn developmental expectations for the length of toddlers' sentences or the intelligibility of their speech. SLPs who are presented with a toddler who is talking but making numerous articulation errors can reassure parents about the developmental progression children follow to become fully intelligible. SLPs also can use this opportunity to discuss the ways in which language grows out of earlier communicative functions. For example, a 2-year-old may be referred because he or she is not yet talking, but the SLP may note a lack of preverbal communication acts such as requesting and commenting with gestures. This situation provides the opportunity for the SLP to help parents become more informed observers of their child's behavior, and to introduce the idea that the language delay may be only the most obvious symptom of a more pervasive disorder. Further, screening, assessing, and evaluating children from varied cultural and linguistic backgrounds provide opportunities to observe different parent–child communication styles so that assessment and intervention methods can be matched to the child's customary communication exchanges and promote a success-oriented perspective for future interactions. Finally, these processes aid in the prevention of communication, language, and early literacy disabilities through family education about the course of typical development, the ways in which the child demonstrates typical behaviors as well as the degree to which the child diverges from this pathway, and strategies for using natural learning opportunities to foster growth and development.
Screening, evaluation, and assessment will be accomplished through a range of measures and activities, including standardized tests and questionnaire formats, interviews, criterion-referenced probes, dynamic procedures such as diagnostic teaching, and observational methods. Information will be drawn from direct interactions with the child, from indirect means such as parent interviews and report forms, and from observation of the child in natural activities with familiar caregivers. Federal guidelines emphasize that no single tool will be adequate for either evaluation or assessment, and both must be accomplished using a range of tools in varied contexts. Further, eligibility decisions may not rely on the use of standardized measures alone. Rather, such decisions also are based on informed clinical opinion that is derived from multiple sources of information gathered in multiple contexts.
Screening and evaluation serve as gateways to services, and it is important that the measures used are valid, reliable, sensitive, specific, and representative. A valid instrument, whether standardized or criterion-referenced, should measure what it claims to measure, such as communication skill, and not something else, such as the motor ability to point or imitate. A reliable measure is stable and does not change based on who administers the test or when the test is administered. Measurement sensitivity means that children who actually have difficulties in the target area are accurately identified. Specificity means that children who do not have a problem in the area also are accurately identified (as not having a problem). To achieve these standards, tests need to have large, representative norming samples, and standardized measures should only be used for children who are represented within their respective norming samples. Collectively, validity, reliability, sensitivity, specificity, and representativeness are important psychometric properties that make a test fair. SLPs have the obligation to ascertain that standardized measures they use in screening, evaluation, and assessment show robust psychometric properties that provide strong evidence of their quality (Dollaghan, 2004). This obligation may be challenging for SLPs in early intervention due to the limited number of well-constructed and validated measures available for infants and toddlers, particularly those with applicability for a broad multicultural sample.
SLPs, through collaborative practice with other professionals and the family, interpret screening, evaluation, and assessment findings within the context of a child's overall development. Contextualized interpretation is of particular importance because communication is just one aspect of the dynamic, multifaceted interactions between children and their worlds that constitute their environment. Therefore, professionals need to recognize the importance of using screening, evaluation, and assessment tools that provide the most representative sample of a child's behaviors across a range of people and activities within the child's natural environments. If screening, evaluation, and assessment cannot take place in the child's natural environments, such as the home or child care setting, professionals can attempt to use tools and methods such as play with familiar objects and interactions with caregivers to obtain a representative sample of the child's communication behaviors. In addition, clinicians gather information about the child through parent and caregiver report, and use these data in the decision-making process.
A variety of areas of development contribute to facilitating later language acquisition in both typically developing children and those with atypical development (Calandrella & Wilcox, 2000; McCathren, Yoder, & Warren, 1999; Mundy, Kasari, Sigman, & Ruskin, 1995; Wetherby, Allen, Cleary, Kublin, & Goldstein, 2002). Many of these skills are predictive of later language outcomes and therefore can enhance professionals' abilities to make decisions about whether and when to intervene with a particular child. For these reasons, evaluation and assessment of infants and toddlers need to focus both on immediate needs (e.g., eligibility, intervention planning) and on behaviors known to be indicators of prognosis. The following section provides a brief overview of key components and reasons for their inclusion in evaluation and assessment of infants and toddlers who may have or be at risk for communication deficits.
A thorough evaluation/assessment includes a detailed review of the child's birth and medical history, developmental history, other potential risk factors (e.g., familial history of disabilities, low socioeconomic status, maternal depression, teenage or single parent, adoption), and protective factors (e.g., good medical care, familial support; NJCLD, 2006). For excellent guides to gathering information in family-friendly and culturally sensitive ways, see Bailey (2004), E. W. Lynch and Hanson (2004), Westby, Burda, and Mehta (2003), and Winton and Winton (2005). History of speech, language, and learning disabilities in parents and other family members also may be particularly useful in evaluating risk. Children with a family history of language and/or learning disabilities have a higher risk for communication deficits than do children with no such history (Gopnik & Crago, 1991; Hadley & Holt, 2006; Lewis, Ekelman, & Aram, 1989; Stromswold, 1998; Tomblin et al., 1997).
Throughout this document, the term dual language learners is used to include all young children who are learning more than one language, both those who are exposed to two languages from birth and those who have sequential exposure to two languages. As suggested by the NAEYC (2005), evaluation and assessment of young dual language learners should include information about the child's and family's history with language(s), the language the family typically speaks at home and in the community, other languages spoken in the home, the family's country of origin, the length of time in the United States, the child's age when first exposed to English, the amount of English exposure, and who in the family speaks English (and how well). In addition, it is often helpful to know about family members' formal education and their perceptions of their child and disabilities in general, along with their experiences with previous professionals (e.g., health care providers, child care providers). This type of knowledge can help professionals adap