Frequently Asked Questions: Qualified Providers in Early Intervention
It seems that many early intervention agencies are moving away from direct therapy and towards consultative models that have either one "lead" therapist providing all services or involve training the parents to implement therapy goals. What is driving this change?
There are several factors involved in how early intervention services are provided:
- IDEA Part C regulations stipulate that services should be provided in the natural environment within the context of the child's family and routines.
- Children who receive IDEA Part C early intervention services may be seen by teams, which include parents and multiple professionals. Service providers have the responsibility for selecting the most appropriate team model for each child and family.
- Early intervention is a field with many professionals; the roles vary according to the needs of the child and family. One professional known as the "primary service provider" or PSP, may provide direct services to the child and family with other professionals provide consultation to the PSP. SLPs may serve as either primary providers or consultants and should be considered for the primary provider role when the child's main needs are communication or feeding and swallowing. Team-based services help avoid fragmentation of services and supports to children and families.
Speech-language pathologist roles should be implemented in accordance with the following ASHA guiding principles for early intervention (ASHA, 2008):
- Services are family centered and culturally and linguistically responsive.
- Services are developmentally supportive and promote children's participation in their natural environments.
- Services are comprehensive, coordinated, and team based.
- Services are based on the highest quality evidence that is available.
Extensive information and references about these guiding principles and roles and responsibilities of speech-language pathologists in early intervention can be found in the ASHA technical report, position statement, guidelines, and knowledge and skills documents. Also see the 2008 ASHA Leader article by Julian Woods, Providing Early Intervention Services in Natural Environments.
Education and advocacy are needed so parents and caregivers recognize and request the skills of a qualified SLP and changes are made in legislation and reimbursement to allow young children to receive the high quality services they deserve.
What is ASHA doing to address issues in early intervention? Who can I turn to for assistance in my state?
ASHA is aware of the issues and challenges that our members are facing in early intervention. ASHA assists members on an individual basis by providing technical assistance and access to resources and information to help advocate for change. At the state level, ASHA works with state associations on initiatives to affect changes and, at the federal level, ASHA works on issues related to IDEA, Medicaid, and reimbursement for SLP services.
If you feel that early intervention services are not being provided in an appropriate manner, you may contact your state speech-language-hearing association. There is power in numbers. Ask them to file a complaint with the state's designated agency for early intervention services under Part C of IDEA. Often this is either the State Education Department or the State Health Department. Access a listing of Part C agencies by state.
The federal law that provides financial assistance to States to develop and implement early intervention services for infants and toddlers with disabilities and their families was modified in 2004 as part of the "Individuals with Disabilities Education Act of 2004" (P.L. 108-446).
Requirements in the revised law that may assist you in arguing for improved service delivery include:
"A State policy...that ensures that appropriate early intervention services based on scientifically based research, to the extent practicable, are available to all infants and toddlers with disabilities and their families..." [Section 635 (a) (2)]
"[a] comprehensive system of personnel development...that...shall include...promoting the preparation of early intervention providers who are fully and appropriately qualified..." [Section 635 (a)(8)(A)(ii)].
Use the discussion of best practice policy contained in this document to argue for the desired change. Ask that this change be included in the State's next application for Part C funds.
A copy of the complaint also should be sent to the unit of the U.S. Department of Education that monitors Part C implementation:
US Department of Education, OSERS
Office of Special Education Programs
400 Maryland Avenue SW
Washington, DC 20202
Within 60 days, the designated agency must issue a written decision that addresses each allegation in the complaint.
If the decision is not to your satisfaction, find out when the designated agency will be holding public hearings concerning its Part C application for the next year. These hearings are required by current regulation 34 CFR 303.110 (a)(2), which is still in effect until the U.S. Department of Education issues new regulations to implement the revised law. Through your state association, organize testimony at these hearings by both professionals and parents. The designated agency must review and consider all public comments before submitting its application. Public commentors also may wish to share their testimony with the U.S. Department of Education at the above address.
I contract with an early intervention agency and am being asked to implement not only the speech-language goals but also the physical and occupational therapy goals for children on my caseload. Is this within my scope of practice?
The Scope of Practice in Speech-Language Pathology outlines the areas in which an SLP can provide services, as well as the types of activities in which an SLP may engage. The Preferred Practice Patterns for the Profession of Speech-Language Pathology describe what is considered best practice for intervention and management of communication disorders and which professionals should be providing such services.
While it is appropriate to have knowledge of the goals of other professionals who are working with a child, and it is appropriate to reinforce acquisition and generalization of fine or gross motor skills, it is not appropriate for SLPs to provide services outside of their scope of practice. It is important to recognize the distinction between reinforcing the goals of another professional (e.g., using positioning devices designed by the PT during speech-language sessions) and establishing and measuring progress towards goals outside the SLP's scope of practice (e.g., determining the child's progress in sitting balance and making the decision to move forward to the next related goal). Ethically, you should not provide services in which you have not established competency. Legally, licensure laws delineate what an SLP can and cannot do.
Will my malpractice insurance cover me if I am overseeing and implementing PT and OT goals?
It is advisable to consult with your professional liability insurance carrier to determine coverage limitations. In most cases, the insurance will only cover an SLP who is practicing within the scope of practice for speech-language pathology.
Many children seen by the early intervention agency I contract with are not primarily English speaking. What resources does ASHA have available to assist me?
Every client has a culture, just as every clinician has a culture. SLPs must provide culturally competent services. There are several resources that ASHA has developed to assist SLPs in providing appropriate services:
I contract with an early intervention agency and, after a recent evaluation in which I found a 2 year-old child eligible for speech and language services, I was told by the case manager that the goals I helped develop during the IFSP would be implemented by an "early interventionist" that I would supervise. I am not sure of the qualifications of this person and don't feel comfortable with this arrangement. What should I do?
The first step you should take is to educate your administration about the role of the SLP in early intervention, including the qualifications and training of a certified SLP. ASHA-certified SLPs are uniquely qualified to provide early intervention services for children with, or at risk for, speech, language, literacy, and swallowing disorders. ASHA's Code of Ethics ensures that SLPs provide the highest quality of services. Specific language from the Code of Ethics that applies to this scenario includes:
Principle of Ethics I -Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally...
Rules of Ethics B. Individuals shall use every resource...to ensure that high-quality service is provided.
Rules of Ethics E. Individuals who hold the certificate of clinical Competence shall not delegate tasks that require the unique skills, knowledge, and judgment that are within the scope of their profession...
Principle of Ethics II, Rules of Ethics B—Individuals shall engage in only those aspects of the professions that are within the scope of their competence.
Other principles and rules may apply in specific situations.
You also may want to provide administrators with documents that support the role of the SLP in the early detection and treatment of communication and swallowing disorders. Such resources include:
Educating parents, caregivers, and other professionals about the qualifications of the SLP and the role of the SLP in early intervention is also an important step. When others know what an SLP does, they will know when to ask for an SLP to work with their child.
Different EI agencies use different titles for the individuals who provide direct services but are not SLPs. Regardless of what they are called, however, if you are asked to supervise them as they implement the goals you have developed with the family; they are acting as support personnel. ASHA has developed guidelines about supervising support personnel, specifically speech-language pathology assistants (SLPAs). However, just because someone is assigned to implement speech goals, they cannot automatically be classified as an SLPA. The SLP is the certified and licensed professional and these credentials are at stake when supervising anyone, particularly unlicensed personnel. In addition, the ASHA Code of Ethics states that an SLP must not delegate responsibilities that exceed the other person's scope of competency. If the "early interventionist" does not have sufficient competency to provide speech and language services, then the SLP should not delegate responsibility for implementing intervention goals to this person. Entering into a supervisory role under these circumstances is something the SLP must consider quite carefully. The Issues in Ethics Statement on Support Personnel further addresses issues related to the use and supervision of support personnel.
Question 2 above outlines what you can do if you feel that early intervention services are not being provided in an appropriate manner in your state. The bottom line is this: SLPs play an important role in early intervention and this role should not be diminished by agency regulations designed to reduce costs or streamline services, usually at the expense of quality. It is up to you to advocate for your profession within your local area and educate others about the importance of receiving services from an SLP.
What tools are available to help me educate parents and caregivers in my state about who SLPs are and what they do?
ASHA has developed a number of resources that can assist you in educating the public and advocating for the profession of speech-language pathology. These resources include: