Recipients of EI services may include infants and toddlers with a disability or a diagnosed physical or mental condition that has a high probability of resulting in developmental delay, including those who
- have congenital and/or developmental conditions (e.g., autism spectrum disorder, cerebral palsy, Down syndrome, fetal alcohol syndrome, hearing loss) and
- have acquired conditions (e.g., traumatic or other acquired brain injuries, illnesses or postoperative complications, abuse or neglect, hearing loss).
Young children who are English language learners with typical development do not qualify for EI services under Part C (IDEA, 2004). However, dual language learners with difficulties in acquisition of their native language and a second language (e.g., English) may be eligible for services.
The 39th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act reported that Asian, Black or African American infants and toddlers—and infants and toddlers with multiple racial/ethnic groups—were less likely to receive services under IDEA, Part C than were Native Hawaiian or Other Pacific Islander and White infants and toddlers. It was reported that American Indian or Alaska Native and Hispanic/Latino infants and toddlers were as likely to be served as all other racial/ethnic groups combined (U.S. Department of Education, 2017).
Under IDEA (2004), EI begins when a child is referred to the Part C system and ends when a child transitions out of EI—typically at 36 months of age. Having knowledge of federal/state laws and regulations, key terms, acronyms, and definitions used in EI will assist in navigating the Part C process.
The Early Intervention/IFSP Process chart from the Early Childhood Technical Assistance Center (ECTA).
Federal/State Laws and Regulations
Under Part C of IDEA (2004), states receive federal grants to provide comprehensive, coordinated EI services to all eligible infants and toddlers with disabilities, birth to 3, and their families.
The IDEA Part C Final Regulations (IDEA, 2011) give states the discretion to extend eligibility for Part C services through age 5 to children with disabilities who are eligible for services under Part B, Section 619 (Preschool Grants) and who previously received services under Part C.
States may differ in terms of which agency they designate to lead the Part C program (e.g., Department of Health, Department of Education, or Department of Rehabilitation Services) and what they choose to name their EI system (e.g., Infants and Toddlers, Early Steps, Strong Start).
Requirements for audiologists and speech-language pathologists (SLPs) who work in Part C EI programs also vary by state (see
ASHA State-by-State for State Early Intervention Requirements for Practice).
Point of Entry and Referral
Each EI system has a point of entry or local/regional contact point designated to accept referrals from sources who suspect a developmental delay or disability in an infant or toddler. Referral sources can include parents, caregivers, health care providers, teachers, child care workers, and social service personnel, among others. The IDEA (2011) requires providers to make referrals within 7 days after the infant or toddler is identified as having a possible delay or disability.
After receiving a referral, the lead agency or local EI service provider has 45 days to complete the screening (if applicable), initial evaluation, initial assessments, and initial team meeting to develop an initial Individualized Family Service Plan (IFSP) for the child and family (IDEA, 2004). Informed written consent must be obtained prior to initiation of services. Informed written consent and all interactions should be in the preferred language(s) of the family and/or caregivers. All attempts to obtain consent should be documented, along with contact method and/or language(s) used.
The 45-day timeline may be extended under limited circumstances, such as when a parent has not provided written informed consent. See ASHA's resource titled,
IDEA Part C Issue Brief: Referral Timelines and Requirements.
Once the lead agency receives a referral, a service coordinator is assigned to children and families to explain the EI process and help navigate next steps. The service coordinator typically serves as a family's case manager and single point of contact with the EI system. In some programs, professionals have dual roles, serving as both service coordinator and intervention provider. In other programs, there is a dedicated service coordinator. The service coordinator informs families of their rights and responsibilities, and when they need to provide informed consent (e.g., for evaluation).
Screening, Evaluation, and Assessment
The IDEA Part C defines screening, evaluation, and assessment as distinct processes with different purposes. These services must be provided to families in their native language (i.e., language normally used by an individual; IDEA, 2011). In the case of a child, native language means the language normally used by the child's parents. However, when conducting an evaluation and assessment, it may be developmentally appropriate to use the language(s) typically used by the child (which may be different from that of the parents). Screening, evaluation, and assessment are conducted in the language(s) most likely to yield an accurate picture of the child's skills (Division for Early Childhood [DEC], 2014; IDEA, 2011).
Screening refers to the process of identifying children who may need further evaluation to determine the presence of a developmental delay or disability. Under Part C, screening is not mandatory but is done at a state's discretion. If included in the state's post-referral procedures, screening is conducted using selected instruments administered by trained personnel in the lead agency or in an EI program.
At any time during the screening, a parent can request that the EI program conduct an initial evaluation, even if the results of the screening do not indicate the need for further evaluation.
Evaluation refers to the procedures used to determine a child's initial and continuing eligibility for EI services. No single procedure may be used as the sole criterion for determining a child's eligibility under Part C.
Evaluation considers data gathered from the following procedures:
- Administering an evaluation instrument
- Taking the child's developmental and medical history (including interviewing the parent/family)
- Identifying the child's level of functioning in each of the five developmental areas (cognitive, communication, physical, social or emotional, and adaptive)
- Gathering information from other sources—such as caregivers, health care providers, and educators—to get a holistic view of the child's strengths and needs
- Reviewing medical, educational, or other records (IDEA, 2011)
Assessment refers to the formal and informal in-depth procedures used to (a) identify a child's strengths and needs and (b) determine the appropriate EI services to meet those needs throughout the period of eligibility. Assessment in EI is an ongoing process. Culturally sensitive and linguistically appropriate assessments of both child and family occur to identify resources, priorities and concerns, and the supports and services necessary to enhance the family's capacity to meet the child's developmental needs (IDEA, 2011).
For more information, see the
Components of Screening, Evaluation, and Assessment section below.
IDEA (2004) designates that children with established risk (i.e., a diagnosed medical condition or disorder that has a known effect on developmental outcomes) are universally eligible for services under Part C. Otherwise, states have some discretion in setting eligibility criteria for Part C services, including how to define “developmental delay.” As a result, definitions of eligibility for Part C services can differ significantly from state to state.
States also have the option of serving children who show no delay but who are considered “at risk” for developmental challenges because of biological or environmental factors (e.g., repeated infections, prenatal drug exposure, history of abuse or neglect). IDEA Part C defines an at-risk infant or toddler as “an individual under 3 years of age who would be at risk of experiencing a substantial developmental delay if early intervention services were not provided to the individual” (IDEA, 2004).
When diagnostic assessment tools alone do not establish eligibility, the state lead agency must ensure that informed clinical opinion also be independently considered in the dynamic process of determining eligibility. However, once evaluation instruments have established eligibility, informed clinical opinion cannot negate these results (IDEA, 2011).
For children not found eligible for Part C services, families may choose to pursue EI through private or community resources and other federal or state-funded early childhood programs, such as home visiting or Early Head Start. If concerns about the need for EI services persist, families can request a re-evaluation through their Part C program at a later time.
States' and Territories' Definitions of/Criteria for IDEA Part C Eligibility from ECTA.
Individualized Family Service Plan (IFSP)
Once a child is found eligible, an Individualized Family Service Plan (IFSP) is developed by an interdisciplinary team, including the family and service coordinator. The IFSP is a document detailing the EI services and supports provided to the child and family and the outcomes to be achieved.
IDEA requires that the IFSP include
- the child's strengths, needs, and current levels of functioning;
- the family's concerns and priorities;
- services that the child and family will receive;
- the frequency, intensity, and method of delivering the services, including who will provide them, where they will occur, and in which language(s);
- outcomes that the family desires, timelines for achieving results, and methods of outcome measurement;
- a notation of the transition plan date; and
- a statement that EI services are based on peer-reviewed research (IDEA, 2004; 2011).
The required timeline for IFSP development and review is as follows:
- The IFSP must be developed 45 days from the date of referral.
- EI services must begin within 30 days of the IFSP being written and agreed upon.
- The IFSP must be reviewed at least every 6 months—or whenever the child has achieved a documented outcome or a new area of need is identified (IDEA, 2004).
Families can invite providers and others (e.g., family members, friends, and advocates) to attend IFSP meetings to provide support and advocacy. Families and other team members may also request review of the IFSP at any time for any reason.
Section 619 of IDEA gives states the discretion to extend an IFSP beyond the child's third birthday through age 5 years, when the child remains eligible for preschool special education and related services as a child with a disability. An extended IFSP must contain an educational component that promotes school readiness and incorporates pre-literacy, language, and numeracy skills (IDEA, 2011).
Funding and Reimbursement
Each state's Part C system is distinct in its funding structure. Part C programs coordinate EI funding from federal, state, local, and private sources.
Annual federal funding to each state Part C EI program varies, based on the census figures for the number of children in the general population aged birth through 2 years in each state. The majority of Part C funding tends to come from the state (Hebbeler, Greer, & Hutton, 2011). Typically, Part C federal funds cover EI administrative costs, whereas services are funded through the state, third-party payers, and families who pay fees for services (Searcy, 2018; Vail, Lieberman-Betz, & McCorkle, 2018).
Evaluations, assessments, IFSP development, and service coordination must be provided at no cost to families (IDEA, 2004). Some programs also offer additional EI services free of charge or on a sliding scale; however, specific policies vary from state to state. In some states, EI programs fund the cost of speech-generating devices when they are necessary for children to benefit from EI services, are listed on the IFSP, and are related to an IFSP outcome (Banajee, 2017). Some private insurance and Medicaid plans cover EI services.
When a child is not eligible for EI services, or transitions out of a Part C program, families may choose to self-pay or use their medical insurance to seek private services beyond what a school district offers.
Transitioning to Part B (Special Education) or Other Services
There are various transitions in EI. A family may experience one or more of these, including
- from provider to provider (e.g., developmental specialist to SLP) and
- from hospital or home-based programs to community-based programs (e.g., preschool special education, community-based preschool, Head Start, outpatient clinic, or private agency).
The most significant transition generally occurs when a child moves at age 3 years from Part C to Part B school-based services (IDEA, 2004). As a child approaches his or her third birthday, the IFSP team begins a formal transition process and develops a plan to ease the shift from EI to preschool special education (if eligible) or to another community-based service option (if not eligible).
Federal law mandates that there be a systematic plan for transition from a Part C EI program to the child's next program or other appropriate services, including programs for children who are no longer eligible for EI or special education but who still have ongoing needs. Representatives of the programs involved in the transition are required to take part in the planning, and families play an active role in the process.
The IDEA (2004) requires that the transition plan be established within 90 days of the child's third birthday but not before 9 months of his or her third birthday. Often, IFSP teams choose to begin the transition planning process when the child turns 2½ years. A notation of the transition plan date must be included on the original IFSP document.
EI professionals work to ensure a smooth transition for families from one program to another, as well as timely access to appropriate services (IDEA, 2004). Teams must consider the language(s) most linguistically relevant to the child at the time of transition in order to develop an effective plan for Part B services and educational access.
Team members, including audiologists and SLPs, need to be aware of all notification, documentation, and timeline requirements. They also must adhere to any policies regarding the extension of Part C services, if their state allows children beyond the age of 3 years to remain in Part C programs as eligible or until they enter kindergarten.
When audiologists and SLPs are acting as service coordinators, they
- have direct responsibility for oversight of transition activities;
- are knowledgeable about a wide range of resources in the community;
- ensure that families have available information on transition; and
- ensure that families know their state's opt-out rights, which allow parents a specified time period to object to disclosure of their child's information to state or local education agencies when the child is potentially eligible for preschool special education services.
Alternatively, as members of the IFSP team, audiologists and SLPs assist the child, family, and other professionals during the transition planning process (Searcy, 2018). In some cases, they may visit the new classroom or service provider with the family and/or take part in the initial individualized education program (IEP) meeting.
See ASHA's resource on
IDEA Part C Issue Brief: Transitions (Including Part C to Part B/Exiting Part C) for more information.
Speech-language pathologists (SLPs) in EI are qualified to provide services to families and their young children who demonstrate, or are at risk for developing, delays or disabilities in communication, speech, language, cognition, emergent literacy, and/or feeding and swallowing. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles for the SLP include:
- Demonstrating knowledge of typical developmental norms from birth to age 5 years across domains
- Engaging in prevention and early identification activities to promote healthy development and reduce risk factors that can impact a child's development
- Understanding federal, state, agency, and professional policies and procedures related to screening, evaluating, and assessing infants and toddlers with, or at risk for, disabilities
- Conducting screening, evaluation, and assessment to identify young children with, or at risk for, a delay or disorder
- Establishing eligibility for services and guiding the development of an intervention program,
- Making referrals to other professionals and informing the referral source of the outcome of the eligibility process, with the family's consent
- Developing a plan for implementing services and supports (i.e., the IFSP or an equivalent) that includes speech-language pathology intervention approaches, methods, and settings
- Gathering and reporting treatment outcomes and documenting progress
- Revising intervention plans and determining appropriate discharge criteria
- Collaborating with families, caregivers, agencies, and other professionals involved in the IFSP team to help them implement intervention strategies in everyday routines (See ASHA's resources on
Collaboration and Teaming and
Interprofessional Education/Interprofessional Practice [IPE/IPP].)
- Supporting family interactions that reflect cultural beliefs, values, and priorities
- Coordinating services (including evaluation and assessment, development of an IFSP, and access to resources) and ensuring they are implemented as agreed upon by the team. See ASHA's resource on
IDEA Part C Issue Brief: Service Coordination
- Participating in transition planning to ensure seamless transition and timely access to services for families moving from one program to another (e.g., from hospital to community-based intervention; from IDEA Part C EI services to Part B school-based services)
- Advocating at the local, state, and national levels regarding public policy, funding, and infrastructure (e.g., workload parameters) for EI services
- Raising awareness about the importance of EI by working with families and other professionals and developing and disseminating resources
- Remaining informed of current evidence-based practice in EI
- Helping advance the knowledge base related to the nature and treatment of speech, language, cognitive-communication, and swallowing development and disorders in infants and young children
As indicated in the
ASHA Code of Ethics (ASHA, 2016a), SLPs shall engage in only those aspects of the profession that are within the scope of their professional practice and competence, considering their levels of education, discipline-specific training, and experience.
The roles of the SLP will also be guided by state licensure regulations and the service delivery models implemented by EI agencies. The SLP should be considered a primary provider when the child's main needs are communication, emergent literacy, and/or feeding and swallowing.
Infants and young children are a unique population that requires the special knowledge, skills, and experience of audiologists specifically educated to provide services to pediatric populations ages birth to 3 years.
Provision of audiologic service in EI requires (a) the establishment of an accurate diagnosis of auditory and vestibular function, (b) effective family counseling conducted in parallel with the diagnostic process, and (c) timely service coordination.
Appropriate roles for audiologists include the following:
- Overseeing early identification (newborn and early childhood screening) programs (Joint Committee on Infant Hearing [JCIH], 2007) and ensuring that appropriate procedures are followed.
- Reporting results of newborn hearing screenings to state newborn hearing screening and follow-up programs (some states also have regulations requiring audiologists to report results of hearing evaluations).
- Establishing an accurate diagnosis of hearing status.
- Providing information about the child's hearing status and eligibility for Part C services to the referral source, with the family's consent.
- Coordinating timely audiologic services (ASHA, 2006).
- Evaluating infants and young children with hearing and vestibular deficits for amplification and other sensory devices, assistive technology, and vestibular rehabilitation.
- Fitting and maintaining amplification, other sensory devices, and assistive technology, and frequently validating that the devices are providing the intended benefit.
- Providing effective family support and counseling regarding the nature of auditory and vestibular conditions and implications for language development, modes/methods of communication, communication access strategies/accommodations, and acoustic modifications.
- Advocating for a continuous process of family-focused service delivery (see ASHA's resource on
Person-Centered Care in Audiology).
- Referring families to parent-to-parent support and other consumer-based organizations.
- Educating other professionals about the needs of infants and young children with hearing and vestibular/balance deficits and the role of audiologists in diagnosing and managing them.
- Coordinating services (including evaluation and assessment, development of an IFSP, and access to resources) as agreed upon by the team. See ASHA's resource on
IDEA Part C Issue Brief: Service Coordination.
- Advocating for the rights to and funding of services for infants and young children with reduced hearing, auditory disorders, and/or vestibular disorders.
- Remaining informed of research in the area of EI and helping advance the knowledge base related to the nature, identification, and treatment of hearing and vestibular deficits in infants and young children.
For additional information about the roles and responsibilities of audiologists in early hearing detection and intervention, see the Joint Committee on Infant Hearing Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs (JCIH, 2007) and Supplement to the JCIH 2007 Position Statement (ASHA, 2013).
See also ASHA's Practice Portal pages on
Newborn Hearing Screening,
Childhood Hearing Screenings, and
Permanent Childhood Hearing Loss.
As indicated in the
ASHA Code of Ethics (ASHA, 2016a),audiologists shall engage in only those aspects of the profession that are within the scope of their professional practice and competence, considering their levels of education, discipline-specific training, and experience. The roles of the audiologist will also be guided by state licensure regulations.
Five principles guide the implementation of speech-language pathology and audiology services in EI.
Services are Family-Centered
The term family-centered refers to a set of beliefs, values, principles, and practices that strengthen a family's capacity to enhance their child's development and learning (IDEA, 2004). Family-centered practices are responsive to each family's unique circumstances and provide families with complete and unbiased information to make informed decisions (DEC, 2014).
IDEA Part C requires that EI providers involve families in all aspects of a child's services to the extent that the family chooses. The family as a whole, not just the individual child, receives EI services that build upon their strengths (Crawford & Weber, 2014; DEC, 2014; Dunst, 2002, 2017; McWilliam, 2010b; Ross, 2018; Trivette & Dunst, 2007).
Families collaborate with professionals to design and implement individualized services that align with family preferences, resources, concerns, and priorities to foster engagement, independence, and competence (IDEA, 2011). This partnership creates a learning environment to support both the child's and family's needs, achieve mutually agreed upon outcomes, and promote family capacities (DEC, 2014; Roberts, Hensle, & Brooks, 2016).
Preferred practice indicates that families need to be involved and responsive to their child in order for intervention to be effective. Family members' individual needs, learning styles, values, beliefs, and expectations should be considered (Raver & Childress, 2015; Tomasello, Manning, & Dulmus, 2010). Services that include opportunities for families and caregivers to directly participate in intervention are essential to strengthen existing knowledge and skills and to promote the development of new abilities that enhance child and family outcomes (DEC, 2014).
See also ASHA's resources on
Family-Centered Practice and
Person- and Family-Centered Care.
Services are Culturally and Linguistically Responsive
IDEA Part C Final Regulations state that families of infants and toddlers with a disability must have access to culturally competent services (IDEA, 2011). Different cultural dimensions can influence a family's decisions about EI services and supports (see ASHA's resource on
examples of cultural dimensions). For example, perceptions/views of disability may inhibit decisions to seek services or may affect how a family approaches intervention. In family-centered EI, providers assist families to engage in services that support beliefs, customs, or rituals (Peredo, 2016; Segal & Beyer, 2006).
Prior written notice regarding EI services must be provided to families in their native language, unless it is clearly not feasible to do so. The regulations define native language as the language typically used by an individual. In the case of a child, native language is the language typically used by the child's parents.
EI services and supports are provided in the language(s) most likely to yield an accurate picture of the child's skills (IDEA, 2011; DEC, 2014). For children who are acquiring more than one language, EI providers often work with families and interpreters to support the home language(s) as well as acquisition of the language needed for academic success. It is essential that EI providers teach families and caregivers how to implement strategies in their home language to maximize understanding and carryover (Peredo, 2016).
See ASHA's resource on
IDEA Part C Issue Brief: Cultural and Linguistic Diversity and the Practice Portal pages on
Bilingual Service Delivery,
Collaborating With Interpreters, and
Services are Developmentally Supportive and Promote Children's Participation in Their Natural Environments
Developmentally supportive EI practices address family routines, concerns, and priorities through active exploration, authentic experiences, and interactions consistent with the child's age, cognitive-communication skills, strengths, and interests (DEC, 2014).
IDEA Part C requires that EI services be provided, to the maximum extent appropriate, in natural environments.These are settings that are considered typical for same-aged infants or toddlers without disabilities and may include home, child care, classroom, community, or other settings in which young children without disabilities participate (IDEA, 2004).
Familiar everyday experiences, events, and places should be used as opportunities to promote natural learning and incidental teaching throughout each day (Early Childhood Technical Assistance Center, 2008; Florida State University, n.d.; McWilliam, 2010b; Raver & Childress, 2015; Ross, 2018; Rush & Shelden, 2011; Swanson, Raab, & Dunst, 2011; Woods, 2008; Woods, Wilcox, Friedman, & Murch, 2011).
In the event that the IFSP team decides the natural environment is not the optimal setting for a child, justification must be included in the documentation of services.
See ASHA's resource on
IDEA Part C Issue Brief: Natural Environments.
Services are Comprehensive, Coordinated, and Team-Based
A comprehensive, coordinated, and team-based approach to EI is preferred practice to prevent fragmented service delivery and to maximize child and family outcomes.
IDEA Part C (IDEA, 2004) requires that members of the IFSP team coordinate their approaches, consult with one another, and recognize that child and family outcomes are a shared responsibility. Communication among team members and with the family is also mandated and must be supported by the administering agency.
Service coordinators—who can include audiologists and SLPs—monitor family needs, child progress, team dynamics, and implementation of the IFSP. Between IFSP meetings, team members can communicate by sharing notes, discussing strategies, and collaborating to solve challenges that arise. The service coordinator maintains regular communication with all team members and documents exchanges in the child's intervention record (Raver & Childress, 2015; Searcy, 2011).
Children who receive comprehensive EI services under Part C are often seen by multiple professionals (e.g., physicians, SLPs, audiologists, physical and occupational therapists, behavioral specialists, special educators), some of whom may be from different agencies with different team models. Collaboration will vary depending on the model used, the lead agency's policies and program guidelines, and the knowledge and skills of team members. When multiple professionals are working with the child and family, the service coordinator and other team members need to promote collaboration to facilitate communication and avoid redundancy.
Collaborative, coordinated teams work to develop interventions that complement one another rather than contradict or duplicate services. They also benefit from joint professional development and consultation to enhance each other's knowledge and skills for role extension (i.e., taking on responsibilities typically within the domain of other disciplines) and role release (i.e., sharing expertise, scope of practice, and intervention strategies with others; Boyer & Thompson, 2014; Coufal & Woods, 2018). Audiologists and SLPs in EI are encouraged to recognize shared competencies across disciplines in coordination and collaboration, family-centered practice, interventions informed by evidence, and professionalism to better support young children and their families (Early Childhood Personnel Center, 2017).
See ASHA's resources on
Collaboration and Teaming and
Interprofessional Education/Interprofessional Practice (IPE/IPP).
Services are Based on the Highest Quality Internal and External Evidence Available
EI practices are based on an integration of the highest quality and most recent research, informed professional judgment and expertise, and family preferences and values. 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. Evidence-based practice in EI evaluates all of these considerations to deliver services shown to achieve positive outcomes for young children and their families.
Evidence Maps for guidance on evidence-based decision making.
ECTA's Evidence-Based Practice Resources and
DEC Recommended Practices (DEC, 2014) for information specific to evidence-based service provision in EI.
See the Assessment sections of relevant
Evidence Maps for pertinent scientific evidence, expert opinion, and client/caregiver perspectives on specific clinical disorders and topics.
See the Screening, Evaluation, and Assessment section for detailed definitions of each procedure.
Screening, evaluation, and assessment protocols typically consider the following:
Factors related to the child and family
- Background—developmental and medical history
- Language(s) used
- Family concerns, priorities, and available resources/supports
- Family/caregiver–child interaction
- Environmental stressors
Factors related to the child's abilities
- Hearing status
- Functional listening skills
- Sensory, motor, and cognitive skills (including play and problem solving)
- Speech, language, and emergent literacy skills
- Emotional and social functioning
Screening is an important component of prevention, family education, and support that is particularly relevant for young children and their families. Screening may result in recommendations for rescreening, comprehensive assessments, or referral for other examinations or services.
Audiologists screen hearing and vestibular function. Hearing screening is within an SLP's scope of practice, as well.
Newborn hearing screening has been the standard of care in U.S. hospitals since 1999. Babies who do not pass their newborn hearing screening (NBHS) are referred for medical and audiologic follow-up. Screening and hearing evaluation data are reported to the state
Early Hearing Detection and Intervention (EHDI) program. The overarching goals of state EHDI programs are to ensure that
- all infants have access to hearing screening using a physiologic measure at no later than 1 month of age;
- all infants who do not pass the initial hearing screening and any subsequent rescreening have appropriate audiologic and medical evaluations to identify hearing status at no later than 3 months of age; and
- all infants with confirmed permanent hearing conditions receive EI services as soon as possible after diagnosis but no later than 6 months of age (ASHA, 2013; Centers for Disease Control and Prevention [CDC], 2017; JCIH, 2007; Yoshinaga-Itano, Sedey, Wiggin, & Chung, 2017).
Hearing screenings after the newborn period (0–6 months) are important for early identification and management of the hearing status that may have been either missed during NBHS or acquired after the newborn period. Children who are evaluated for EI services should receive a hearing screen as part of their comprehensive speech-language evaluation. Children under age 3 years who have been diagnosed with reduced hearing should be referred to both the state EHDI system and the
Early Intervention Program for Infants and Toddlers With Disabilities (Part C).
See ASHA's Practice Portal pages on
Newborn Hearing Screening,
Childhood Hearing Screenings, and
Permanent Childhood Hearing Loss.
See also the Joint Committee on Infant Hearing Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs (JCIH, 2007) and Supplement to the JCIH 2007 Position Statement (ASHA, 2013).
Screening for Vestibular Impairment
Young children often are unable to verbally describe vestibular symptoms (McCaslin, Jacobson, & Gruenwald, 2011; Wiener-Vacher, 2008). Instead, they may use actions, gestures, or emotions (e.g., covering ears with hands, crying).
Vestibular system impairments in young children may present as developmental delays in activities such as walking. Children who have autism, brain injuries, reduced hearing, otitis media, and certain syndromes (e.g., Usher's, Waadenburg, Pendred, Alport's) may be at increased risk of vestibular disorders.
Audiologists and SLPs should consider case history, gross motor milestones, balance, coordination, and parental concerns and refer for further evaluation and assessment when suspicions arise (Doettl & McCaslin, 2017).
See ASHA's Practice Portal page on
Balance System Disorders.
Speech, Language, Cognitive-Communication, and Swallowing Screening
SLPs screen for risk or presence of speech, language, cognitive-communication, and feeding/swallowing difficulties using a variety of tools. They select age-appropriate, culturally sensitive screening procedures that are conducted in the language(s) used by the child and family.
Screening typically includes
- direct interaction with the child;
- observation of interactions between child and caregiver(s) in natural contexts;
- interviews with family members or early childhood teachers regarding concerns about the child's skills; and/or
- professional-administered and parent-completed measures.
When evaluating screening results, clinicians should consider whether responses may be indicative of a difference or a disorder. This is critical when screening any child whose cultural or linguistic background, including dialects of English, is different from that of the normative sample used in the screening tool. See ASHA's Practice Portal pages on
Bilingual Service Delivery,
Cultural Competence , and
Collaborating With Interpreters.
Recommendations and referrals for further evaluation and assessment of infants and toddlers are often based on developmental expectations. To evaluate whether or not a child is meeting these expectations, the SLP needs to determine if results of the screening are a valid reflection of the child's typical behavior.
Clinical Topics Portal Pages for further information relevant to speech, language, cognitive-communication, and swallowing screening for specific clinical diagnoses and disorders in young children.
Pre-Assessment and Evaluation Planning Processes
Prior to evaluation and assessment, IDEA Part C requires that EI team members meet with the child and family to
- identify what the family wants and/or needs from the assessment process;
- identify language(s) to be used in the evaluation;
- identify areas and activities of strength and need for the child;
- determine roles/responsibilities that family members and caregivers will take in assessment; and
- determine times, locations, and activities that will facilitate the assessment process.
Evaluation and Comprehensive Assessment
IDEA (2004) identifies communication as one of the developmental domains required in a comprehensive evaluation. The legislation also specifies that both evaluation and comprehensive assessment be based on a variety of measures that include informed clinical opinion.
In some states, evaluation and assessment are separate processes in which one team of professionals evaluates the child to determine eligibility and then refers the child to another team for service coordination, assessment, and/or other intervention services. In other states, a single team may provide a combined evaluation/assessment and then provide service coordination and intervention planning services.
Although there may be overlap in the methods and teams that make up evaluation and assessment practices in EI, assessment usually encompasses more in-depth observations and information gathering than eligibility evaluations. The evaluation process is used to determine a child's eligibility for Part C services, whereas assessment results are typically an integral part of intervention planning. In addition, a larger group of professionals may participate in the assessment process. Ongoing assessment by various team members also helps determine response to treatment (Searcy, 2011).
Evaluation and Assessment Methods
Evaluation and assessment of infants and toddlers include more than testing. These processes involve a comprehensive set of activities to identify a child's strengths and challenges, address the family's concerns and priorities, and develop a plan for the next steps for the child and family (Crais, 2011; Raver & Childress, 2015).
IDEA (2004) requires that evaluation or assessment be completed using a range of tools in a variety of contexts. The law also states that eligibility decisions cannot be based on standardized measures alone. Such decisions must be supported by informed clinical opinion that is derived from various methods. See ASHA's resources on
assessment tools, techniques, and data sources and on
Ethnographic or routines-based interview and assessment protocols are particularly useful for gathering information about the family's environment and the child's participation in family-identified routines and activities (e.g., grooming, mealtimes, child care). Families have the opportunity to talk about their concerns, priorities, and current supports, including the child's level of engagement, independence, and participation in familiar contexts.
Information gathered through the interview and assessment serves as the context for development of the IFSP, collaborative intervention, and attainment of desired outcomes (Dunst, 2017; McCormick, Stricklin, Nowak, & Rous, 2008; McWilliam, 2010a, 2010b, 2016; McWilliam, Casey, & Sims, 2009; Searcy, 2018; Westby, 2009; Woods & Lindeman, 2008).
See also the assessment sections of relevant
Clinical Topics Portal Pages for information related to specific clinical diagnoses and disorders in young children.
Considerations in Assessing Young Children
- There are a limited number of standardized cognitive-communication assessments specifically for infants and toddlers; even fewer standardized tests exist for young children with acquired communication disorders from causes such as brain injury.
- There are few non-English standardized assessments.
- Cognitive and communication skills are still developing during this period; many children will be pre-verbal, impacting selection of assessment methods.
- Overall development is rapid, uneven, episodic, and highly influenced by the environment, with great variability within and among children; therefore, ongoing assessment is necessary to identify changes and/or emerging deficits, particularly as cognitive-communication demands increase (Ross, 2018).
- Young children often have limited attention and feel stressed or anxious in unfamiliar settings with unfamiliar people; using families/caregivers and the information they provide during assessment within typical daily routines in familiar environments (e.g., home, child care, community) is essential.
Sharing Information With Families
- Consider how cultural values affect information sharing with families. For example, parents who are deaf and have a child who is deaf may have different desires and expectations for their child than do parents who are hearing.
- Before discussing assessment results, audiologists and SLPs ask families to share their impressions of assessment activities, their concerns, and what they see as their child's strengths and needs (Woods & Lindeman, 2008).
- Families have varying knowledge about EI. They may feel uneasy giving input about the assessment or stressed if they are given more information than they are ready to hear. Providers need to meet families where they are, follow their lead, and provide information more than once, as needed (Caicedo, 2014; Raver & Childress, 2015; Searcy, 2011).
- The type and amount of information shared and the way it is shared may have an impact on how families and professionals feel about the assessment process and on follow-up decisions (Crais, 2011).
- Families need complete and unbiased information in terms that they can understand so they can make informed decisions and actively participate in conversations about next steps.
- Evaluation or assessment findings may sometimes be unexpected or difficult for families to hear. They may be overwhelmed, grieving, or in denial. It is important to address family emotions within the assessment and intervention process, as emotions can be a barrier to action (Bhat, 2017; Caicedo, 2014; Raver & Childress, 2015; Searcy, 2011; Searcy & Hughes, 2015).
See the Treatment sections of relevant
Evidence Maps for pertinent scientific evidence, expert opinion, and client/caregiver perspectives on specific clinical disorders and topics.
Various approaches and treatment strategies are available for audiologists and SLPs in EI. Selection depends on a number of factors, including the child's hearing, communication, and swallowing or feeding needs; the presence and severity of co-occurring conditions; and the family's cultural-linguistic background, values, and preferences.
Families and caregivers have a direct impact on their child's development and play a pivotal role in treatment outcomes. They need clear descriptions of what intervention involves and their roles. Audiologists and SLPs must recognize the preferred learning styles of families to effectively teach the skills that they will need to promote the child's participation in everyday natural settings (Florida State University, n.d., 2012; Friedman, Woods, & Salisbury, 2012; Ross, 2018; Swanson et al., 2011; Trivette, Dunst, Hamby, & O'Herin, 2009; Woods & Brown, 2011; Woods & Lindeman, 2008).
General Treatment Approaches
Treatment approaches to family-centered EI that promote functional outcomes include routines-based intervention and coaching (Crawford & Weber, 2014; Florida State University, 2011; McWilliam, 2010a; Rush & Shelden, 2011; Salisbury et al., 2017).
Routines-Based Intervention (RBI)
Routines-based intervention (RBI) is an approach that builds caregiver capacity using everyday activities as a context for embedded instruction (Florida State University, 2011; McWilliam, 2010a). The primary objective is to increase child and caregiver participation within their natural environment (McWilliam, 2010a, 2010b, 2016; Raver & Childress, 2015).
EI providers, families, caregivers, and/or teachers collaborate to develop child-specific strategies that are practiced during daily routines. Audiologists and SLPs who participate in RBI
- identify regular learning opportunities in family, preschool, and/or community life;
- work with parents, caregivers, and teachers to create communication and participation goals during learning opportunities;
- determine the child's interests, strengths, and motivators within daily routines; and
- establish techniques (e.g., naturalistic language facilitation and/or swallowing strategies) that will be used to maximize development and learning within these routines (Dunst, Raab, & Trivette, 2012).
RBI emphasizes caregiver-implemented intervention using toys and objects from the home to encourage practice and facilitate generalization of strategies used during treatment sessions (Crawford & Weber, 2014; Friedman et al., 2012; Woods et al., 2011). The Family Guided Routines Based Intervention Model (FGRBI) is one RBI program that incorporates IDEA Part C mandates, caregiver coaching, embedded interventions, and evidence-based practices based on adult learning principles (Florida State University, n.d.; Woods, et al., 2011).
Coaching is an approach that guides families, caregivers, and other professionals on how to build the capacity of all care providers to implement communication and swallowing strategies in natural environments. It is a complex process that involves consideration of adult learning methods (Dunst & Trivette, 2009; Roberts et al., 2016). Coaching uses clearly defined, observable, and measurable procedures to support others in their efforts to promote child learning and development. It is an interactive process that includes the following components, not always in this order:
- Joint planning
- Feedback (Akamoglu & Dinnebeil, 2017; Brown, 2016; Friedman et al., 2012; Hanft, Rush, & Shelden, 2004; McWilliam, 2010a; Rush & Shelden, 2011)
Coaching also involves more specific strategies such as
- direct teaching,
- guided practice,
- problem-solving, and
- prompting (Woods, et al., 2011).
The coaching process supports continuous engagement and ongoing self-assessment of learning in order to improve existing abilities, develop new skills or plans, and gain an understanding of EI practices (Brown, 2016; Rush & Shelden, 2011; Trivette et al., 2009; Woods & Brown, 2011; Woods et al., 2011). Coaching families is a common practice in caregiver-implemented interventions such as RBI and FGRBI.
Coaching colleagues is also an integral part of EI practice in general (Brown, 2016; Brown & Woods, 2015, 2016; Salisbury et al., 2017; Woods et al., 2011). Audiologists and SLPs work with colleagues in the context of everyday routines and activities to identify the most beneficial strategies for the child (Roberts et al., 2016).
Speech-Language Pathology Interventions
SLPs provide treatment to maximize a child's ability to communicate and/or swallow effectively and to enhance the family's capacity to support their child's development in everyday routines. SLPs treat children who use a variety of communication methods, including spoken language, sign language, cued speech, simultaneous communication (a combination of sign and spoken language), and/or augmentative and alternative communication (AAC). They may provide audiologic (re)habilitation services to children with hearing loss.
For prelinguistic infants and toddlers, treatment often focuses on engagement, meaningful play, and gestures (Roberts et al., 2016). For young children with complex communication needs, implementation of some form of AAC may be indicated (Smith, Barton-Hulsey, & Nwosu, 2016; Wright & Quinn, 2016).
Under Part C of IDEA, there has been a shift toward family-implemented interventions and collaborative consultation, instead of direct one-on-one intervention with the child only.
SLPs often coach families, caregivers, and other team members in how to implement functional, language-enhancing strategies during daily activities (Brown, 2016; Brown & Woods, 2015, 2016; Roberts & Kaiser, 2011; Roberts, Kaiser, Wolfe, Bryant, & Spidalieri, 2014; Searcy, 2011; Shelden & Rush, 2010).
Language-enhancing strategies taught within the context of family-centered EI include the following:
- Quantity-based strategies—focus on varying the amount and complexity of language directed toward child, regardless of the child's communication skills
- Responsive strategies—focus on self-talk (adult narrates what they are doing); parallel talk (adult narrates what child is doing); and imitation, expansion, or recasting of what the child says
- Directive strategies—focus on directing language production using open-ended questions, choice questions, or prompts (e.g., “Tell me about . . .”)
- Multimodal strategies—focus on providing tactile support (e.g., touch to initiate interaction) or visual support (e.g., combining gestures with words)
- Engagement-based strategies—focus on providing encouragement to engage in communication (e.g., shared reading and child-directed play) [Roberts et al., 2016]
Clinical Topics Portal Pages and
Evidence Maps for in-depth descriptions of these strategies and other evidence-based speech-language pathology interventions relevant to specific clinical diagnoses and disorders in young children.
Most audiologists working in EI provide audiologic (re)habilitation services for children who are deaf or hard of hearing. In addition, audiologists treat some young children for vestibular disorders. Family-centered EI services for children who are deaf or hard of hearing begin as soon as possible following identification but no later than 6 months of age, per EHDI's 1-3-6 guidelines and the JCIH (ASHA, 2013; CDC, 2017; JCIH, 2007).
Audiologists are responsible for providing families with unbiased information, recommendations, and the range of available educational and communication options to facilitate informed decision making. When choosing treatment approaches, the audiologist incorporates the family's goals, priorities, values, beliefs, culture, and linguistic background. Treatment decisions are fluid, ongoing, and responsive to the changing needs, preferences, and learning styles of the family.
Audiologists work collaboratively with teachers of the deaf and other members of the IFSP team (including SLPs) to provide services that foster communication and language development (ASHA, 2004, 2006, 2008). They work with children who use a variety of communication methods, including spoken language, sign language, cued speech, simultaneous communication, and/or AAC.
Audiologic intervention may include the following:
- Selecting, fitting, and evaluating personal hearing instruments (e.g., hearing aids, cochlear implants, bone-anchored hearing aids), hearing assistance technologies (e.g., frequency-modulated/digitally modulated systems), and visual technologies (e.g., home alerting devices) in the child's natural environment
- Training families and other team members in the use and management of technologies to troubleshoot barriers and support consistent, effective use
- Helping to determine and make appropriate acoustic modifications for the home, learning environments, and other natural settings
- Helping families learn and use the most effective modes and methods of communication, communication access strategies, and accommodations
- Conducting auditory skills training, including activities to improve sound awareness, discrimination, recognition, and comprehension
(ASHA 2004, 2006, 2008, 2013; English et al., 2017; Moeller, Carr, Seaver, Stredler-Brown, & Holzinger, 2013).
See ASHA's Practice Portal pages on
Newborn Hearing Screening,
Childhood Hearing Screenings,
Permanent Childhood Hearing Loss, and
Balance System Disorders. See also ASHA's resource on
Person-and Family-Centered Care.
Monitoring Interventions and Outcomes
Young children can change rapidly, and families respond differently to them at various stages of development. Therefore, systematic plans for periodic assessment of progress are needed.
Beyond the federally required IFSP review every 6 months, audiologists and SLPs need to regularly monitor changes in language, communication, and/or feeding and swallowing, as well as the effects of interventions and progress toward outcomes.
They also monitor priorities and needs, strategies and approaches, and models and locations of service delivery, so that plans can be modified if needed to meet the desired outcomes and changing needs of the child and family (Kuhn & Marvin, 2016).
Qualitative and quantitative data collection, including use of participation-based outcome measures to describe the child's involvement in activities with others, can assist in monitoring interventions by
- validating the conclusions from the initial evaluation/assessment;
- developing a record of progress over time;
- identifying facilitators or barriers;
- attending to levels of engagement (e.g., at home, at school, or with peers);
- determining whether and how to revise intervention plans; and
- ensuring fidelity of the intervention plan (i.e., degree to which an intervention is delivered as intended; Searcy, 2011, 2018; Wolery, 2004).
Monitoring interventions by measuring participation-based outcomes is meaningful to families because it facilitates conversations related to real-world expectations and functioning (Cunningham et al., 2017; World Health Organization [WHO], 2007; Wolery, 2004).
WHO's International Classification of Functioning, Disability and Health–Children and Youth Version (ICF-CY) provides a framework to assist audiologists and SLPs in evaluating interventions and outcomes in infants, toddlers, and preschoolers, including their ability to communicate, perform activities, and participate in everyday routines, play, and social interactions (WHO, 2007).
Factors Affecting Service Provision in EI
There are many factors affecting service provision in EI, including point of entry, access to EI services, and the service delivery approach used. Some examples follow.
- Infants, toddlers, and preschoolers do not have a single point of entry into a system for treatment. Eligible families can receive treatment through their state Part C agencies in the family's natural environments (i.e., locations where the child would be found if they did not have a diagnosed disability or delay). Children who are found to be ineligible for Part C may still receive supports in their natural environments, in clinics, or in inpatient or outpatient programs. However, families would need to access private funding or insurance to cover treatment when their child is determined to be ineligible for Part C EI services.
- Access to EI may be affected by logistical factors such as geographic location, transportation, or family responsibilities (e.g., work, child care). However, if a child is eligible for Part C services, access to EI must be provided regardless of these factors.
- Family beliefs, perspectives on disability, and understanding of the child's needs, levels of acceptance, grieving, and/or stress can also impact access.
- Some families and providers may need to develop a new understanding about their roles when EI service delivery approaches are more consultative and collaborative rather than traditional, child-centered treatment methods (Brown, 2016; Ross, 2018; Searcy, 2011; Searcy & Hughes, 2015).
Other factors that EI service providers report as challenges include the following:
- Change in eligibility criteria that exclude children who may be perceived (e.g., by families and providers) as needing services
- Insufficient reimbursement or funding for services
- Lack of communication among service agencies
- Difficulty accessing necessary resources (e.g., personnel shortages, lack of transportation)
- Limited number of qualified providers to deliver services
- Limited knowledge, training, and professional development for audiologists and SLPs in EI
- Varying levels of buy-in, support, engagement, and follow-through (e.g., from families, child care, or educational teams)
- Inconsistent implementation of strategies across child care, preschool, and home settings
- Family uneasiness with home visitors
- Loss to follow-up or poor attendance
- Limited collaboration among professionals working with the child and family
See ASHA's 2018 Schools Survey and SLP Health Care Survey 2017 for detailed summaries.
In addition to determining the optimal EI approach and treatment for the child and family, audiologists and SLPs consider other service delivery variables—including format, provider, dosage, and setting—that might affect treatment outcomes.
Format refers to the structure of the treatment session.
The shift from direct intervention toward consultative and collaborative approaches aligns with the federal mandate to provide family-centered services in natural environments (Coufal & Woods, 2018; McWIlliam, 2010a, 2010b; Raver & Childress, 2015; Roberts et al., 2016; Woods et al., 2011). Consultative and collaborative formats support inclusive practices and focus on the child's participation and functional communication during daily activities and routines.
Because Part C EI services are structured within the context of the child's home, community, and group care settings, the format regularly includes key people in those settings (e.g., parents, teachers, care providers, siblings, and peers).
For EI services outside of Part C programs, format selection depends on factors such as treatment setting (e.g., acute care, rehabilitation hospitals, home, preschool, and community), stage of intervention, severity of disorder, and the primary goals of the team at different points in the EI process. It is important to implement formats that are flexible and dynamic to allow for developmental growth and changing family priorities and concerns.
Telepractice can also be used to deliver face-to-face EI services remotely. This format fosters interdisciplinary collaboration, consultation, and coordinated care within naturalistic contexts (see, e.g., Cason, 2011; Cason, Behl, & Ringwalt, 2012; Hamren & Quigley, 2012; Houston, 2011, 2013; Olsen, Fiechtl, & Rule, 2012; Stredler-Brown, 2017). See ASHA's Practice Portal page on
Telepractice and resource on
Reimbursement of Telepractice Services.
Provider refers to the person providing the treatment (e.g., SLP, audiologist, or other professional, trained volunteer).
Although many children and families receiving EI services have multiple service providers from different disciplines, state Part C programs are increasingly using a primary service provider approach to service delivery (Marturana, McComish, Woods, & Crais, 2011).
Primary service provision emphasizes a transdisciplinary approach to EI service delivery that involves a team of professionals and a primary service provider (PSP), who serves as the primary point of contact for the family. Although there may be more than one service listed on the IFSP, the PSP is the professional—other than the service coordinator—who sees the family most often (Raver & Childress, 2015; Shelden & Rush, 2013). Audiologists and SLPs may serve as PSPs, which sometimes requires role release and role extension (see, e.g., Boyer & Thompson, 2014; Crais & Woods, 2016; Marturana et al., 2011).
Members of the transdisciplinary team support the PSP, child, and family through joint visits, consultations, team meetings, and coaching or formal training (Shelden & Rush, 2013). The PSP stays in regular contact with all team members to keep everyone updated on progress and family questions. Primary service provision often strengthens the knowledge and skills of audiologists and SLPs through teamwork with other professionals (Marturana et al., 2011).
The primary service provision model is not meant to limit a family's access to EI professionals and services. The intent is to address the child's development from a holistic perspective in the context of the family, rather than viewing the child from a discipline- or domain-specific perspective. The PSP helps the family and other team members consider how all aspects of development (e.g., communication, motor skills, play) overlap in the child's everyday life (Raver & Childress, 2015; Shelden & Rush, 2013).
This approach may be less intrusive because there are fewer professionals in the home or classroom, and it may help to reduce fragmented services, conflicting information, and caregiver stress (Boyer & Thompson, 2014; Crawford & Weber, 2014; King et al., 2009). The decision to use a PSP approach may be based on team input, on the child's and family's priorities and concerns, and on state and local policies for service delivery (Marturana et al., 2011).
Dosage refers to the frequency, intensity, and duration of service.
Some families and caregivers require more frequent contact and more concrete support, whereas others prefer more freedom to foster their own learning (Bagnato, Suen, & Fevola, 2011). Some individuals may prefer or benefit from extra support implementing interventions, or they may need new approaches to try. Others prefer longer intervals between visits, as this provides more time to use strategies, practice new skills in daily routines, and gain confidence in their own abilities (Dunst, Bruder, & Espe-Scherwindt, 2014; Keilty, 2010; Roberts et al., 2016).
Intervention characteristics (e.g., unfamiliarity, complexity) often guide decisions about dosage needs more than the severity of a disorder. Matching the strengths of providers to the needs of individual families and children is also essential to determine effective dosage (Kuhn & Marvin, 2016).
Setting refers to the location of treatment (e.g., home, community-based).
Federal legislation supports IFSP teams in determining the most appropriate location(s) for EI services and supports. Factors such as the family's geographical location, child and family needs and resources, and family preferences will help determine where services and supports occur (Dunst et al., 2014; Searcy, 2018).
IDEA Part C (IDEA, 2004) requires that intervention services and supports be provided to the maximum extent appropriate in natural environments, including home and community settings in which children without disabilities participate. For infants, toddlers, and families receiving services through Part C programs, the delivery of services in traditional clinical or medical locations may not be eligible for reimbursement by Part C because these are not the child's and family's natural environment. In some cases, IDEA allows for justification of service delivery in settings other than the natural environment. The IFSP team must document the necessary justification in order for Part C to consider payment for these services.
The natural environments for EI services and supports may change over time as family and child needs change. In addition, some children may receive EI services in more than one setting and/or outside of a Part C program altogether. Audiologists and SLPs deliver EI services outside of Part C programs in settings such as NICUs, pediatric acute care and rehabilitation hospitals, community clinics, child care programs, and private schools (Kellar-Guenther, Rosenberg, Block, & Robinson, 2014).
See section titled Services Are Developmentally Supportive and Promote Children's Participation in Their Natural Environments.