Populations

Early intervention (EI) services may include infants and toddlers with a disability or a diagnosed condition that has a high probability of resulting in developmental delay, including those with

• acquired conditions (e.g., traumatic or other acquired brain injuries, illnesses or postoperative complications, abuse or neglect, hearing loss) and
• neurodevelopmental conditions (e.g., autism spectrum disorder, genetic syndromes, cerebral palsy, Down syndrome, fetal alcohol syndrome, hearing loss).

Early exposure to multiple languages does not cause language delay or disability. Young children who are exposed to languages other than or in addition to English (i.e., multilingual learners) without a disability or diagnosed medical condition do not qualify for EI services under Part C based solely on limited English proficiency (Individuals with Disabilities Education Act [IDEA], 2004). However, multilingual learners with a language delay or disability may be eligible for services. See ASHA’s Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology.

Receipt of Services

Nationally, 6.8% of children from birth to 3 years receive IDEA Part C services (State of Babies Yearbook, 2023). A national survey of parents of children participating in EI determined that the vast majority had concerns about their children’s communication. Findings showed 41% of children were eligible for EI based on a speech or communication delay (Hebbeler et al., 2007).

Demographics

Research has found differences in access to EI services by child and family characteristics, including race, ethnicity, home language, age, sex, diagnosis, condition, and other household factors.

Race, Ethnicity, and Home Language

Nationally, 34.2% of children aged 9–35 months received a developmental screening. The percentage of Asian children (27.4%), Black children (28.6%), and Hispanic children (31.1%) who received a developmental screening was below the national average. The percentage of White children (36.7%) who received a developmental screening was above the national average (State of Babies Yearbook, 2023).

Studies from Colorado, Massachusetts, and Oregon showed differing EI referral rates for Black children, Asian children, Latino/a children, and children from varied language backgrounds (Clements et al., 2008; Cycyk et al., 2022; McManus et al., 2020). Similarly, studies from Massachusetts, Connecticut, and Oregon suggest differing evaluation rates in EI for Black or African American children, Latino/a Spanish-speaking children, and children from varied language backgrounds (Chan et al., 2022; Clements et al., 2008; Cycyk et al., 2022).

The 44th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act reported that, nationally, Asian, Black or African American, or American Indian or Alaska Native 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, Hispanic/Latino, or White infants and toddlers (Office of Special Education and Rehabilitative Services, 2022).

In one national study, Black and White children who were eligible for EI services received them at the same (albeit low) rate of 9% at 9 months of age, but at 24 months of age, Black children were 5 times less likely to receive EI services than White children (Feinberg et al., 2011). In another nationally representative study, children from homes where the primary language is not English were less likely to be enrolled in EI (Morgan et al., 2012).

“Children of color who are eligible for services are less likely to receive them and more likely to face challenges while receiving them. This is due to a variety of factors, including insufficient outreach and a lack of culturally competent services” (The Education Trust, 2021, p. 11).

Age and Sex

The National Early Intervention Longitudinal Study showed that 61% of children entering EI were male (Hebbeler et al., 2007).

Nationally, in 2019, the percentage of infants and toddlers under 1 year of age served under IDEA Part C increased to 1.4% and then, in 2020, decreased to 1.1%. The percentage of 1-year-olds served increased to 3.4% in 2019 and decreased to 3% in 2020. In 2019, the percentage of 2-year-olds served under IDEA Part C increased to 6.2%. The percentage then decreased to 5.3% in 2020 (Office of Special Education and Rehabilitative Services, 2022).

According to the U.S. Department of Education, in 2021, approximately 45,000 children ages birth to 1 year received services under IDEA Part C. Approximately 120,000 children ages 1–2 years and around 241,000 children ages 2–3 years receive services under IDEA Part C (U.S. Department of Education, 2023).

Diagnoses and Conditions

A national survey showed that most children are eligible for EI based on developmental delay (64%), followed by a medical condition (20%) and then a risk condition (16%; Hebbeler et al., 2007). Only six states serve children considered “at risk” for disabilities under IDEA (State of Babies Yearbook, 2023). Children with diagnosed and risk conditions typically began EI before 1 year of age, whereas those with a developmental delay typically entered EI around the age of 2 years (Hebbeler et al., 2007).

One national study found that significantly more Black children than White children qualified for EI services based on established medical conditions at 9 months of age. At age 24 months, Black children who qualified for services based on developmental delay alone were more than 8 times less likely than White children to receive services (Feinberg et al., 2011). “This racial disparity was particularly pronounced among children qualifying for services based on developmental delays that were difficult to detect and required observational assessment, indicating that there are racial inequities in timely access to screening, attention to potential developmental concerns, and resources within health and education systems” (The Education Trust, 2021, p. 8).

A nationally representative data set revealed that birth conditions such as very low birth weight predicted a sevenfold increase in the odds of receiving speech-language services at 24 months of age, whereas moderately low birth weight doubled the chances (Morgan et al., 2016).

Household Characteristics

More than half of children in EI had two or more risk factors for negative developmental outcomes (e.g., living in a household with one adult, being in foster care, having a primary caregiver with less than a high school education, living below the poverty level, living in a single-parent household; Hebbeler et al., 2007).

The percentage of children from low-income families who received a developmental screening was below the national average, at 29.5% as compared to 34.2% (State of Babies Yearbook, 2023).

Nationally, 28% of families participating in EI were at or below the federal poverty level (Hebbeler et al., 2007). Compared to White children, Black children eligible for EI services at age 24 months were significantly more likely to live in households with income below the federal poverty level (Feinberg et al., 2011).

Of children eligible for EI services, 69% were privately insured and 31% either were publicly insured or had no insurance. Compared to White children, eligible Black children were significantly more likely to have public insurance (Feinberg et al., 2011).

Children entering EI were more likely to have mothers who had no college education (Hebbeler et al., 2007). Compared to White children, Black children eligible for EI services at 24 months of age were significantly more likely to have mothers with lower educational attainment (Feinberg et al., 2011).

Children raised by a mother who was socially isolated were 44% less likely to receive services at 24 months of age. Children with a family member with mental illness or a learning disability were twice as likely to receive speech-language services at 24 months of age; it is unknown whether this is due to heritability or due to household connection to the health care system (Morgan et al., 2016).

See ASHA’s resource on social determinants of health.

Navigating the Part C EI Process

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. EI providers must follow both the IDEA (2004) statute and subsequent regulations, such as the IDEA Part C Final Regulations (IDEA, 2011). See also the ASHA Analysis of the 2011 IDEA Part C Final Regulations [PDF].

See The Early Intervention/IFSP Process [PDF] chart from the Early Childhood Technical Assistance Center (ECTA Center).

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, from birth to 3 years, and their families.

The IDEA Part C Final Regulations (IDEA, 2011) give states the discretion to extend eligibility for Part C services through the age of 5 years 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 EI 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 (2004) requires providers, not including caregivers who self-refer, to make referrals “as soon as possible but in no case more than seven 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 calendar 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. Families do have a right to refuse EI services.

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 on IDEA Part C: 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. As stated in IDEA Part C (2004), these services must be provided to families in their native language. In the case of a child, native language means the language and mode of communication that the caregiver normally uses with the child. 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, 2004).

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 (IDEA, 2004):

1. administering an evaluation instrument
2. taking the child’s developmental and medical history (including a caregiver/family interview)
3. identifying the child’s level of functioning in each of the five developmental areas (cognitive, communication, physical, social or emotional, and adaptive)
4. gathering information, such as questionnaires, from other caregivers, health care providers, and educators to get a holistic view of the child’s strengths and needs
5. reviewing medical, educational, or other records

Assessment refers to the formal and informal comprehensive 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. The developmental assessment tool used in services varies by state. Assessment in EI is an ongoing process. Culturally sensitive and linguistically appropriate assessments of both the 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 Clinical Components of Screening, Evaluation, and Assessment section below and ASHA’s resource on IDEA Part C: Cultural and linguistic diversity.

Eligibility

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. The list of categorically eligible medical diagnoses will be available at the state-level EI agency or at the local EI service provider or program. States with more restrictive eligibility criteria have lower rates of EI use (McManus et al., 2014).

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 EI 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, 2004).

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 reevaluation through their Part C program at a later time.

See States’ and Territories’ Definitions of/Criteria for IDEA Part C Eligibility [PDF] from the ECTA Center.

IFSP

Once a child is found eligible, an IFSP is developed by an interprofessional 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. EI services and supports are family-centered, culturally and linguistically responsive, and provided in the most natural environment. Language(s) used in all assessment and intervention services, which may involve interpreters, should also be reflected in the documentation.

IDEA requires that the IFSP include the following (IDEA, 2004):

• 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 and where they will occur
• outcomes that the family desires, timelines for achieving results, and methods of outcome measurement
• a notation of the transition plan date
• a statement that EI services are based on peer-reviewed research

The required timeline for IFSP development and review is as follows (IDEA, 2004):

• The IFSP must be developed 45 calendar days from the date of referral.
• EI services must begin within 30 calendar 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.

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 preliteracy, language, and numeracy skills (IDEA, 2004).

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. Based on each state’s census numbers of children birth through 2 years of age, the Secretary of Education allocates financial grants to the lead agency to help each state provide EI services through a statewide comprehensive interagency system (ECTA Center, 2023). 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 et al., 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),
• 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), and
• from one state to another state.

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 their 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 their 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 in 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 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.

The roles and responsibilities of audiologists and SLPs acting as service coordinators are as follows:

• direct responsibility for oversight of transition activities
• be knowledgeable about a wide range of resources in the community
• ensure that families have available information on transition
• 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 meeting. The members of the IFSP team also consider the language needs of multidialectal and multilingual populations.

See ASHA’s resource on IDEA Part C: Transitions (including Part C to Part B/exiting Part C) for more information. See also ASHA’s Practice Portal pages on Cultural Responsiveness and Multilingual Service Delivery in Audiology and Speech-Language Pathology.

Roles and Responsibilities of SLPs

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, 2016).

The following roles fall into the scope of practice for SLPs:

• Demonstrate knowledge of typical developmental norms from birth to age 5 years across domains.
• Engage in prevention and early identification activities to promote healthy development and reduce risk factors that can impact a child’s development.
• Understand federal, state, agency, and professional policies and procedures related to screening, evaluating, and assessing infants and toddlers with, or at risk for, disabilities.
• Conduct culturally responsive screening, evaluation, and assessment to identify young children with, or at risk for, a delay or disorder.
• Determine eligibility for services, ensuring that eligibility is based on true delay or disorder rather than linguistic or cultural differences.
• Guide the development of a family-centered intervention program.
• Make referrals to other professionals and inform the referral source of the outcome of the eligibility process, with the family’s consent.
• Develop a plan for implementing culturally and linguistically responsive services and supports (i.e., the IFSP or an equivalent) that includes speech-language pathology interventions, methods, and settings.
• Gather and report treatment outcomes and document progress.
• Revise intervention plans and determine discharge criteria.
• Collaborate with families, caregivers, agencies, and other IFSP team members to implement intervention strategies in everyday routines. (See ASHA’s resources on collaboration and teaming and interprofessional education/interprofessional practice [IPE/IPP].)
• Support family interactions that reflect the family’s cultural beliefs, values, practices, and priorities.
• Coordinate services depending on the state’s model of service coordination (including evaluation and assessment, development of an IFSP, and access to resources) and ensure they are implemented as agreed upon by the team. See ASHA’s resource on IDEA Part C: Service coordination.
• Participate in seamless transition planning to ensure 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).
• Advocate at the local, state, and national levels regarding public policy, funding, and infrastructure (e.g., workload parameters) for EI services.
• Raise awareness about the importance of EI by working with families and other professionals and develop and disseminate resources.
• Remain informed of current evidence-based practice in EI.
• Help 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, 2023), 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 needs are communication, emergent literacy, and/or feeding and swallowing. SLPs may also consult other team members to support communication and emergent literacy development.

Roles and Responsibilities of Audiologists

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:

• Oversee early identification (newborn and early childhood screening) programs (Joint Committee on Infant Hearing [JCIH], 2019) and ensure that appropriate procedures are followed.
• Report 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).
• Establish an accurate diagnosis of hearing status.
• Provide information about the child’s hearing status and eligibility for Part C services to the referral source, with the family’s consent.
• Coordinate timely audiologic services.
• Coordinate and conduct a comprehensive, culturally and linguistically appropriate assessment for the determination of candidacy for hearing aids, acoustic implants, cochlear implants, and/or other hearing assistive technology.
• Fit and maintain any hearing technology used by the child and ensure optimal performance and frequently validate that the technology is providing the intended benefit.
• Validate hearing technology use in a variety of communicative settings.
• Provide 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.
• Advocate for a continuous process of family-focused service delivery (see ASHA’s resource on Focusing Care on Individuals and Their Care Partners).
• Refer families to parent-to-parent support and other consumer-based organizations.
• Educate 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.
• Coordinate services depending on the state’s model of service coordination (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: Service coordination.
• Advocate for the rights to and funding of services for infants and young children with reduced hearing, auditory disorders, and/or vestibular disorders.
• Remain informed of research in the area of EI and help 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 following two resources from JCIH and ASHA:

• Joint Committee on Infant Hearing Year 2019 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs [PDF] (JCIH, 2019)
• Supplement to the JCIH 2007 Position Statement: Principles and Guidelines for Early Intervention Following Confirmation That a Child Is Deaf or Hard of Hearing (ASHA, 2013)

See also ASHA’s Practice Portal pages on newborn hearing screening, childhood hearing screening, and hearing loss in children.

As indicated in the ASHA Code of Ethics (ASHA, 2023), 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.

Guiding Principles of EI

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, not just the individual child, receives EI services that build upon their strengths (DEC, 2014; McCarthy & Guerin, 2022).

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 et al., 2016).

Preferred practice indicates that families need to be involved and responsive to their child to effectively implement intervention strategies. Clinicians consider family members’ individual needs, learning styles, values, beliefs, and expectations when providing services (McCarthy & Guerin, 2022; Raver & Childress, 2015). Services that include opportunities for families and caregivers to directly participate in intervention strengthen existing knowledge and skills and promote the development of new abilities that enhance child and family outcomes (DEC, 2014). A variety of factors, such as social determinants and cultural presumptions, impact a family’s engagement in EI, but EI providers can facilitate collaboration when providers trust parents as experts; provide information to navigate EI and to access other community resources; and were supportive, encouraging, flexible, genuine, respectful, compassionate, collaborative, and knowledgeable (Batz & Yadav, 2023).

See also ASHA’s resource on Focusing Care on Individuals and Their Care Partners.

Services Are Culturally and Linguistically Responsive

The IDEA Part C Final Regulations state that families of infants and toddlers with a disability must have access to culturally competent services (IDEA, 2004). 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 or 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 (Cycyk et al., 2021; Peredo, 2016). The clinician considers the following processes to make any cultural and linguistic adaptations to interventions (Cycyk et al., 2021):

• assess community needs and existing evidence-based interventions
• select the intervention that meets community needs
• consult with stakeholders (e.g., family, caregiver)
• develop adaptations systematically and collaboratively
• train staff on the adapted intervention
• pilot-test adapted intervention to prompt additional modifications
• evaluate the fully adapted intervention

The spoken native language may not be the same as the caregivers’ preferred written language. Therefore, prior written notice regarding EI services must be provided to families in their preferred 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 and mode of communication that the caregiver normally uses with the child.

EI services and supports are provided in the language(s) that the family is most comfortable using (DEC, 2014; IDEA, 2004). For children who are acquiring more than one language, multilingual EI providers or monolingual service providers collaborate with interpreters to support the home language(s). 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: Cultural and linguistic diversity and the Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology; Collaborating With Interpreters, Transliterators, and Translators; Cultural Responsiveness; and Language and Communication of Deaf and Hard of Hearing Children.

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). Most often, children received EI services in their homes (Office of Special Education and Rehabilitative Services, 2022).

Familiar everyday experiences, routines, events, and places are used as opportunities to promote natural learning and incidental teaching throughout each day (Center for Parent Information & Resources, 2021; Swanson et al., 2011; Woods et al., 2011).

If 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: 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 (ECTA Center, 2023; 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, avoid redundancy, and promote successful achievement of outcomes.

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 clinical data and observations. External evidence is based on empirical research published in peer-reviewed journals. Clinical expertise comes from a variety of sources, including policy, informed clinical opinion, and professional consensus. Client perspectives can come directly from family values and perspectives or may be found in qualitative research studies. Evidence-based practice in EI evaluates all of these considerations to deliver services shown to achieve positive outcomes for young children and their families.

See ASHA’s Evidence Maps and ASHA’s resource on evidence-based practice for guidance on evidence-based decision making.

See also ECTA’s Evidence-Based Practice resources and DEC Recommended Practices for information specific to evidence-based service provision in EI.

Clinical Components of Screening, Evaluation, and Assessment

See the Assessment sections of relevant Evidence Maps for pertinent scientific evidence, expert opinion, and client/caregiver perspective 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 and age(s) of exposure
• 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
• feeding/swallowing
• emotional and social functioning

Screening

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.

Audiologic Screening

Audiologists screen hearing and vestibular function. Hearing screening is within an SLP’s scope of practice, as well.

Hearing Screening

Newborn hearing screening has been the standard of care in U.S. hospitals since 1999. Babies who do not pass their newborn hearing screening 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, 2017; JCIH, 2019; Yoshinaga-Itano et al., 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 newborn hearing screening 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 screening, and hearing loss in children.

See also the following two resources from JCIH and ASHA:

• Joint Committee on Infant Hearing Year 2019 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs [PDF] (JCIH, 2019)
• Supplement to the JCIH 2007 Position Statement: Principles and Guidelines for Early Intervention Following Confirmation That a Child Is Deaf or Hard of Hearing (ASHA, 2013)

Screening for Vestibular Dysfunction

Young children often are unable to verbally describe vestibular symptoms (Janky, 2021; McCaslin et al., 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., enlarged vestibular aqueduct syndrome, Usher syndrome, Waardenburg syndrome, Pendred syndrome, Alport syndrome) 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 the presence of speech, language, cognitive communication, and feeding/swallowing difficulties using a variety of tools. They select age-appropriate, culturally and linguistically 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 distinguish a disorder within the dialect(s) and language(s) (Oetting et al., 2016). This is critical when screening any child whose cultural or linguistic background, including dialects or language varieties of English, is different from that of the normative sample used in the screening tool. If a screening measure does not have a normative sample that is representative of the child’s background or lacks appropriate psychometric properties (e.g., reliability, validity), then the clinician cannot report the measure’s standard scores. However, the clinician can adapt the screening measure with dynamic assessment procedures. All screenings and assessments heavily consider the family’s routines-based interview. See ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology; Cultural Responsiveness; and Collaborating With Interpreters, Transliterators, and Translators.

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.

See ASHA’s Clinical Topics Practice 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 the 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. If a child has a categorically eligible diagnosis, the EI entity may complete the evaluation as a baseline of present levels and not for eligibility purposes. 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 (ECTA Center, 2023).

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 using data triangulation methods or the converging evidence framework. See Castilla-Earls et al. (2020) for an example. See ASHA’s resources on assessment tools, techniques, and data sources and on dynamic assessment.

Information gathered through the interview and assessment serves as the context for development of the culturally and linguistically responsive IFSP, collaborative intervention, plans for caregiver education, and attainment of desired outcomes (Center for Parent Information & Resources, 2021; Hwang et al., 2013; Westby, 2009; Woods & Lindeman, 2008).

Interviews and Questionnaires

Ethnographic or routines-based interviews are useful for gathering information about the family’s environment; the child’s participation in family-identified routines and activities (e.g., grooming, mealtimes, child care); the family’s culturally informed beliefs, values, and practices; and prior experience with health care and educational settings. 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, as well as their preferences for service provision. Such interviews can also enhance the relationship between the clinician and the family and support collaborative partnerships (Hampton et al., 2023). Caregivers’ report of concerns about communication development, including in diverse populations with lower educational attainment, is also a valid indicator of delay or disorder (Restrepo, 1998). See ASHA’s Practice Portal page on Cultural Responsiveness for more information about ethnographic interviewing.

Language background surveys or questionnaires are important to collect information on the child’s home language(s) and language dialects/varieties. Such tools capture relative amount of input provided to the child in each language by their caregivers. Clinicians can use this information to guide decisions about the language(s) of evaluation/assessment and to interpret evaluation/assessment findings to discern difference from difference within delay or disorder.

Direct Observation

Direct observation of the child’s interaction with caregivers within typical routines provides information on the child’s functional communication abilities and how caregivers support child communication. Assessment of child functional communication can involve examining frequency and diversity of child gesture use, rate of intentional communication acts (gestures, vocalizations, verbalizations), range of communication functions, average length of utterances, sentence diversity, lexical diversity, and phonological inventory, among others. In addition, direct observation of caregiver–child interactions can support the assessment of the quality and quantity of caregiver input. Input quantity and quality influence many aspects of early child communication development (Zauche et al., 2016).

Dynamic Assessment

Dynamic assessment approaches may also be useful to evaluate a child’s learning potential, particularly when appropriate standardized measures are not available. Dynamic assessment offers an opportunity to determine how quickly or easily a child learns a particular skill with varied levels of support. Evidence of the utility of dynamic assessment in evaluating infants and toddlers is emerging (Spicer-Cain et al., 2023).

See also the Assessment sections of relevant Clinical Topics Practice Portal pages for information related to specific clinical diagnoses and disorders in young children.

Considerations for 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 or bilingual standardized assessments. Interpreting an English measure for administration in another language is not appropriate, and reporting standardized scores when the child’s background does not match the normative sample is not recommended.
• Test bias may occur. Test items may not be culturally or linguistically relevant or may not be relevant to the child’s context and experiences. In addition, there is situational bias to the question-and-answer assessment process. This process may be unfamiliar for children who are learning by observation.
• Cognitive and communication skills are still developing during this period; many children will be preverbal, impacting the 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 beliefs, values, and practices affect information sharing with families. Each family will perceive their child’s disability or condition differently. The family’s goals and expectations may vary for each child. Families may have differing levels of comfort asking questions and expressing disagreement.
• 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 (Center for Parent Information & Resources, 2021; Woods & Lindeman, 2008).
• Families may feel uneasy giving input about the assessment or stressed if they are given more information than they are ready to receive. Providers need to meet families where they are, follow their lead, and provide information more than once, as needed (Caicedo, 2014; ECTA Center, 2023; Raver & Childress, 2015).
• 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; ECTA Center, 2023).
• Families need complete and unbiased information in plain language terms in the language that they prefer so they can make informed decisions and actively participate in conversations about next steps. Consider the literacy levels of caregivers and whether written documents are the most appropriate method of sharing information.
• When collaborating with an interpreter, consider the interpreter’s background knowledge. Sharing EI-specific terminology and diagnostic/eligibility labels with interpreters ahead of meeting with the family can help to ensure accurate interpretation.
• 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; ECTA Center, 2023; Raver & Childress, 2015; Searcy, 2011; Searcy & Hughes, 2015). See ASHA’s Practice Portal page on Counseling in Audiology and Speech-Language Pathology.

Treatment

Various approaches and treatment strategies are available for audiologists and SLPs in EI. Selection depends on several 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 adapt to the learning styles of families to effectively teach the skills they need to promote the child’s participation in everyday natural settings (Center for Parent Information & Resources, 2021; Friedman et al., 2012; Swanson et al., 2011; Trivette et al., 2009).

General Treatment Approaches

Treatment approaches to family-centered EI that promote functional outcomes include routines-based intervention (RBI) and coaching (McWilliam et al., 2020; Salisbury et al., 2018).

RBI

RBI is an approach that builds caregiver capacity using everyday activities as a context for embedded instruction (McWilliam, 2010b; McWilliam & Younggren, 2019). 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 (McWilliam et al., 2020).

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; McWilliam et al., 2020). The Family Guided Routines-Based Intervention model is one RBI program that incorporates IDEA Part C mandates, caregiver coaching, embedded interventions, and evidence-based practices based on adult learning principles (ECTA Center, 2023; McWilliam et al., 2020; Woods et al., 2011).

Coaching

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, 2012; Pellecchia et al., 2020; Roberts et al., 2016; Salisbury et al., 2018). 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 (Akamoglu & Dinnebeil, 2017; Brown, 2016; Friedman et al., 2012):

• joint planning
• observation
• action/practice
• reflection
• feedback

Coaching also involves more specific strategies such as the following (Woods et al., 2011):

• direct teaching
• modeling
• listening
• questioning
• guided practice
• problem solving
• prompting

The coaching process supports continuous engagement and ongoing self-assessment of learning to improve existing abilities, develop new skills or plans, and gain an understanding of EI practices (Brown, 2016; ECTA Center, 2023; McWilliam et al., 2020; 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 Family Guided Routines-Based Intervention.

Coaching colleagues is also an integral part of EI practice in general (Brown, 2016; 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; Salisbury et al., 2018).

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; Tait et al., 2021). For young children with complex communication needs, implementation of some form of AAC may be indicated (Light et al., 2021; Smith et al., 2016; Wright & Quinn, 2016). Family-centered AAC interventions empower families to promote their child’s communication growth (Wright & Quinn, 2016). A child does not need to meet certain prerequisites, such as cognitive skills, language skills, or age, to use AAC (Romski & Sevcik, 2005). AAC does not limit spoken language abilities (Kasari et al., 2014; Leonet et al., 2022; Walters et al., 2021). See ASHA’s Practice Portal page on Augmentative and Alternative Communication for more information, including the different types of AAC, assessment and treatment approaches, and vocabulary selection.

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 et al., 2014; Salisbury et al., 2018). Such interventions support child communication development and caregiver use of language facilitation strategies (Heidlage et al., 2020).

Language-enhancing strategies taught within the context of family-centered EI include the following (Madigan et al., 2019; Paavola-Ruotsalainen et al., 2018; Rantalainen et al., 2022; Roberts et al., 2016):

• quantity-based strategies—focus on varying the amount and complexity of language directed toward the 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 the 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)

See ASHA’s Clinical Topics Practice 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.

Audiology Interventions

Most audiologists working in EI provide aural (re)habilitation services for children who are deaf and hard of hearing (DHH). In addition, audiologists treat some young children for vestibular disorders. Family-centered EI services for children who are DHH 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; Centers for Disease Control and Prevention, 2017; JCIH, 2019).

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.

EI audiologists work collaboratively with clinical audiologists, teachers of the deaf, and other members of the IFSP team (including SLPs) to provide services that foster communication and language development (ASHA, 2004, 2008). They work with children who use a variety of communication methods, including spoken language, sign language, cued speech, simultaneous communication, and/or AAC.

EI audiologists may be involved in the following interventions for DHH children between the ages of birth and 5 years (ASHA, 2004, 2008, 2013; Casoojee et al., 2021; English et al., 2017; Moeller et al., 2013):

• Collaborating with a child’s clinical audiologist to select, fit, and evaluate 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

See ASHA’s Practice Portal pages on Newborn Hearing Screening, Childhood Hearing Screening, Hearing Loss in Children, Balance System Disorders, and Language and Communication of Deaf and Hard of Hearing Children. See also ASHA’s resource on Focusing Care on Individuals and Their Care Partners.

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, assist in monitoring interventions by doing the following (Searcy, 2011, 2018; Shelden & Rush, 2014; Wolery, 2004):

• validate the conclusions from the initial evaluation/assessment
• develop a record of progress over time
• identify facilitators or barriers
• attend to levels of engagement (e.g., at home, at school, or with peers)
• determine whether and how to revise intervention plans
• ensure fidelity of the intervention plan (i.e., degree to which an intervention is delivered as intended)

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; Shelden & Rush, 2014; Wolery, 2004; World Health Organization [WHO], 2007).

The WHO’s International Classification of Functioning, Disability and Health–Children and Youth Version 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, family responsibilities (e.g., work, child care), or financial resources. However, if a child is eligible for Part C services, access to EI must be provided regardless of these factors.
• Family values; beliefs; perspectives on disability; and understanding of the child’s needs, levels of acceptance, grieving, and/or stress can also impact access. See, for example, Núñez and Hughes (2018) and Peredo (2016).
• A mismatch between the cultural and/or linguistic background of the provider and the family can impact trust, understanding, and rapport-building (Ng et al., 2022). Providers are encouraged to examine their implicit biases and continually develop skills in culturally and linguistically responsive care (Hyter & Salas-Provance, 2019).
• 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
• restrictive eligibility criteria or state/agency policies
• insufficient reimbursement or funding for services
• lack of communication among service agencies
• limited time and large caseloads
• difficulty accessing necessary resources (e.g., personnel shortages, lack of transportation, appropriate measures, interpreters)
• limited number of qualified providers to deliver services
• limited knowledge, training, and professional development for audiologists and SLPs in EI, especially for serving culturally and linguistically diverse populations
• 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
• lack of research

See ASHA’s Schools Survey and SLP Health Care Survey for detailed summaries.

Service Delivery

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

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). 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, impact of the 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 remotely deliver synchronous EI services. This format fosters interdisciplinary collaboration, consultation, coaching, and coordinated care within naturalistic contexts (see, e.g., Hamren & Quigley, 2012; Houston, 2013; Larson et al., 2022; Olsen et al., 2012; Stredler-Brown, 2017). See ASHA’s Practice Portal page on Telepractice and resource on reimbursement of telepractice services.

Provider

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 (PSP) approach to service delivery (Lineberger, 2022; Marturana et al., 2011).

Interprofessional practice (IPP) through transdisciplinary teaming supports primary service delivery. Primary service provision emphasizes an IPP approach to EI service delivery that involves a team of professionals and a 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; Lineberger, 2022; Marturana et al., 2011). See ASHA’s resource on interprofessional education/interprofessional practice (IPE/IPP).

Members of the IPP 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 (Lineberger, 2022; 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; Lineberger, 2022). 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 (Lineberger, 2022; Marturana et al., 2011).

Dosage

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 et al., 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 et al., 2014; James, 2022; 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 (James, 2022; Kuhn & Marvin, 2016).

Setting

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, 2011) 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 neonatal intensive care units, pediatric acute care and rehabilitation hospitals, community clinics, child care programs, and private schools (Kellar-Guenther et al., 2014; Weglarz-Ward et al., 2020).

See the section above titled Services Are Developmentally Supportive and Promote Children’s Participation in Their Natural Environments.

ASHA Resources

• ASHA State-by-State
• Assessment Tools, Techniques, and Data Sources
• Birth-to-Six Program: What IDEA Says
• Collaboration and Teaming
• Consumer Information: Early Intervention
• COVID-19: ASHA Web Event Series on Service Delivery Considerations in Early Intervention
• COVID-19: ASHA Web Event Series on Service Delivery Considerations for Private Practice in Speech-Language Pathology
• Current IDEA Part C Final Regulations (2011): Analysis and Issue Briefs
• Dynamic Assessment
• Early Hearing Detection and Intervention (EHDI)
• Focusing Care on Individuals and Their Care Partners
• Frequently Asked Questions: Qualified Providers in Early Intervention
• Identify the Signs
• Interprofessional Education/Interprofessional Practice (IPE/IPP)
• Payment and Coverage of Audiology and Speech-Language Pathology Telepractice Services
• Practice Policy
• Guidelines for Audiologists Providing Informational and Adjustment Counseling to Families of Infants and Young Children With Hearing Loss Birth to 5 Years of Age
• Knowledge and Skills Needed by Speech-Language Pathologists Providing Services to Infants and Families in the NICU Environment
• Learning Disabilities and Young Children: Identification and Intervention
• Loss to Follow-Up in Early Hearing Detection and Intervention
• Supplement to the JCIH 2007 Position Statement: Principles and Guidelines for Early Intervention Following Confirmation That a Child Is Deaf or Hard of Hearing
• The Use of FM Amplification Instruments for Infants and Preschool Children With Hearing Impairment
• Social Determinants of Health

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• Autism Navigator
• Birth to 5: Watch Me Thrive!
• Center for Parent Information & Resources
• Centers for Disease Control and Prevention: Learn the Signs. Act Early.
• Division for Early Childhood
• Early Hearing Detection & Intervention – Pediatric Audiology Links to Services (EHDI-PALS) Directory
• Early Childhood Hearing Outreach (ECHO) Initiative
• Early Childhood Personnel Center (ECPC)
• Early Childhood Technical Assistance Center (ECTA Center)
• Early Intervention Services
• Part C of IDEA
• Part C State Systems and Coordinators
• Practice Improvement Tools: Using the DEC Recommended Practices
• Research and Reference Portal
• EI Excellence
• Family Guided Routines-Based Intervention (FGRBI)
• Yes you can! Routines-Based Intervention and Telepractice [Video]
• Routines-Based Telepractice Visit Checklist [PDF] (Evidence-based International Early Intervention Office)
• FIRST WORDS Project: The Florida State University College of Medicine: Autism Institute
• Head Start: Early Childhood Learning & Knowledge Center
• Hear to Learn
• IDEA Infant & Toddler Coordinators Association
• Illinois Early Intervention Clearinghouse
• Key Principles of Early Intervention and Effective Practices: A Crosswalk With Statements From Discipline Specific Literature [PDF]
• National Association for the Education of Young Children
• National Association of Neonatal Therapists
• States’ and Territories’ Definitions of / Criteria for IDEA Part C Eligibility [PDF]
• Virginia Early Intervention Professional Development Center: Tools of the Trade
• Zero to Three
• 200 by Two: An Early Intervention Guide on Communication and Language Development [Video]

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Acknowledgments

Content for ASHA’s Practice Portal is developed and updated through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Early Intervention page:

• Winnie Chung, AuD, CCC-SLP
• Lauren M. Cycyk, PhD, CCC-SLP
• Cheryl Deconde Johnson, EdD
• Elaine McCarty, AuD, CCC-A
• Karen F. Muñoz, EdD, MS, CCC-A
• Patricia A. Prelock, PhD, CCC-SLP
• Christina Royster, EdD, CCC-SLP, BCS-CL
• Sharon S. Ringwalt, PhD
• Kathleen D. Ross, MS, CCC-SLP
• Dathan D. Rush, EdD, MA, CCC-SLP
• Karyn Lewis Searcy, MA, CCC-SLP
• Arlene Stredler-Brown, PhD, CCC-SLP
• Juliann J. Woods, PhD, CCC-SLP

In addition, ASHA thanks the members of the Ad Hoc Committee on the Role of the Speech-Language Pathologist in Early Intervention, whose work was foundational to the development of this content. 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.

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for the Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Early intervention [Practice portal]. https://www.asha.org/Practice-Portal/Professional-Issues/Early-Intervention/