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Q&A So, You Want To Try Early Intervention? - August 2009

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So, You Want To Try Early Intervention?

By: Jennifer Fusco M.A. CCC-SLP

Although many Speech and language pathologists work in the school or hospital settings there are other rewarding areas of practice to consider. If you are interested in early intervention as a specialty, you may consider moving away from the school or hospital and into the home environment!

I currently work primarily with the early intervention population in the home based setting. Here are some frequently asked questions and practical strategies.

Where And How Are Early Intervention Services Provided?

15 years ago, speech and language services for the early intervention population were often provided in schools and clinics, generally with a team and parents present. Today much of this care has evolved with a move toward “natural environments.” Thus, services are encouraged to be provided in a child’s natural environment; this is often the child’s home, but can also be a day care facility, school or clinic.

In the county in which I work, the home environment is considered the most desirable location of service. We can work with parents and families directly in the home, focusing on the child’s natural opportunities to communicate throughout the day. Thus it is the most common place of service, and the primary focus of this article.

Having the opportunity to work in a day care or school can be beneficial if teachers are willing to discuss and carry out strategies. If a teacher is open to it, I may even ask to “co-teach” while following the teachers lead, in order to model strategies for the teacher to use with a child during the day (such as signs, AAC, or verbal modeling). I often find it difficult to get a chunk of 1:1 time with a teacher to discuss and work on therapy strategies. To offset this, provide written literature and use email to discuss strategies, review, or provide suggestions for the following session.

A unique benefit to daycare or school is the opportunity for social interaction with peers. I use “recess” or “free play” to encourage social interaction and provide strategies for the child, in addition to modeling and discussing with the teachers.

In daycare and school environments, parent involvement may be more difficult to achieve. I have worked with children on the autism spectrum in a group at a school, and found that group social skills work in the early intervention period can be very beneficial. The difficulty for me was consistent communication with parents, and the quality of and consistency in carry over of skills to the home. I tried parent training classes, but was still unable to measure parent’s comprehension and use of strategies to the home. Motivating parents and training them to continue the practice at home is nevertheless an important component here.

Another alternative is clinic based intervention. This may also provide an opportunity for group intervention and/or peer social interaction. Parents are more readily available than in a school or day care, but the environment may not be the most “natural.” It is generally the least desired location. The rest of this article will focus on home based intervention since it is the most common and natural place of service.

So You’Ve Decided On Home Based Care. How Are Parents And Caregivers Encouraged To Get Involved?

First and foremost, it is important to take the time to build a positive rapport with all parents! After all, I am a guest in their home every week and there to help them. It is important to remember that all parents and family dynamics are different and to be respectful when entering another person’s home and family. I have found more success with children when I get families involved. This allows them to share in the responsibility of their child’s progress. To get parents involved, I like to use several strategies:
  • Homework: I give homework weekly. I use a work sheet that I made that lists the child’s name, date, current goals addressed today and homework suggestion. I complete it during the session and give to the parent. It serves not only as a recap of the session, but it also gives written information on what can be done at home. I usually provide 1- 3 strategies on this homework sheet.
  • Checklists: I also use self check lists for parents after several sessions of discussing strategies. It allows a parent to self assess what they are doing at home, as well as provide written ideas and strategies for them as a reminder. It is just for the parent, and I often do not review it just so parents won’t feel like they are being critiqued.
  • Video feedback: Sometimes I use immediate video feedback during sessions after teaching a parent certain strategies so that they can see what they are doing themselves. During the feedback time, point out the intervention strategies that the parents used successfully.
  • Observation and coaching: Include parent-child observation time in order to assess strategies, and then ask if the parent would like direct “coaching” time when the parent interacts with their child.

I turn now to emphasizing a positive approach to parental-therapist relations. I may make a “suggestion” for what could be done, rather than a criticism, and point out the positive strategies that are working. I don’t ever want a parent to feel judged or criticized!

Some parents need more support than others (emotional, coaching, education). The strategies that I use to get parents involved vary from child to child. It really depends on the parent and their level of needed support, an assessment only you can make.

What Are Some Pros And Cons Of Working In Home Based Care?

There are many “pros” to the early intervention field. It is a great way to work directly with families and parents of young children. Because we are often at the client’s house weekly, we can develop close relationships with the family. It is not uncommon for parents to confide in me concerns and difficulties, thus, I feel like I can add “counselor” to the list of job descriptions.

A benefit of working in the home is working directly with parents and siblings, as well as observing the family dynamics. Seeing the family dynamics can give a lot of invaluable information for therapy. It is important to be sensitive to cultural diversity of families, and understand family priorities and values. It is often easier to “coach” parents on skills, and to modify the environment if needed (i.e. providing visual cues around the home) when you are actually there. It is also a natural environment for the child to learn language and communication skills.

From a business perspective, other pros include the reduced amount of “no shows,” reduced caseload size, and ability to work from home at times (i.e. for documentation).

There are some “cons” of providing home based care. First, it is difficult to provide social skills work; however siblings may be used to address these skills. It is difficult to work as a “team,” and you may feel isolated from other professionals. It takes more effort to gain information the team could provide. Also, completing paperwork on the go may be more difficult.

From a business perspective, the cons include: the time traveling to each client’s house, including wear and tear on your car and the rising price of gas. I am not reimbursed for travel because I am self-employed, but this may be something to negotiate if working as an employee. Currently, there are off-setting tax benefits, for example, I am eligible for a tax write off for mileage, and a home based office. Due to the travel time, I can only fit a few clients into a working day, thus my salary may be affected by my lower caseload. I have to charge a higher rate for home based intervention to offset the costs.

An additional consideration for EI specialists is personal safety. It is important to ensure your own safety first. Locking doors, parking close to the house, working in daylight hours and being aware of what is going on in the neighborhood are important. Thankfully, I have never been in an unsafe situation. I know the area that I work well, and may decline to provide services if I feel my safety would be compromised.

How Do You Get Referrals And Payment For Services?

I have a contract with a county board of MR/DD. They provide referrals to me, and I receive new ones almost daily. I have also contacted local school districts to let them know that I will work privately with students over the summer. Additionally, word of mouth spreads fast for therapists that are willing to go to a client’s home! As a parent of two young ones myself, I can see the value in not having to leave my house for therapy!

Another easy way to go into EI is to work for an agency or clinic that already has an EI contract in your area. PediaStaff works with a lot of these companies. They have therapists that are working in EI settings as both permanent employees and contract employees of these agencies. Working with a contract agency can have its advantages. It allows the therapist to do less worrying about where their caseload will come from, provides guidance on paperwork, and also allows the therapist to work with a team. Personal health insurance may also be provided through an agency.

Regarding payment of services, every county in our state, Ohio, operates differently. There are state and federal funds that may be used to provide early intervention services (part C of the IDEA). In our county, the Board of MR/DD contracts with individual providers and pays for services at their rate of reimbursement. The county in which I live operates differently and does not contract with individual providers but with agencies. Private pay, insurance, and alternative county or state funds may also be used to pay for services, but the therapist generally must be on the provider list. Check with the county in which you would like to practice for more information.

What Are The Basic Skills Needed To Effectively Work In Ei?

It is important to have knowledge of typical development in children from birth to age three. To be effective in this field, you must also feel comfortable and work well with families (including training/teaching, coaching). Skill with oral motor and feeding development is also vital, as is the sound knowledge of alternative and augmentative Communication (AAC) such as sign language, PECS, devices- low and/or high tech. Therapy itself often involves knowledge of natural interventions aimed at promoting communication, interaction, speech and language development, modifying the environment, and related cognitive and play skills. Additionally, it is important to know about social skill development due to the recent rise in diagnosis of children on the autism spectrum now well before age 3. A positive attitude and willingness to have fun, be silly, creative, resourceful and flexible (things do not always go as planned when working with toddlers!!) are certainly helpful in this business!

How Do I Manage The Paperwork?

The paperwork varies depending on what is required from the third party reimbursement source. If you receive payments privately or directly, the process may be simplified to the standard progress notes, progress reports, evaluations and business related paperwork.

Accurate, consistent data keeping is very important in measuring outcomes and providing effective treatment, particularly in this era of providing evidence- based practices. Some therapists use mini recording devices. In order to keep data when working, I use clip boards, but they are often cumbersome with a child on the go. Another technique that works for me was putting a piece of masking tape for each goal on my arm/leg with the goal on it and a pen to make tally marks if I am with an active client; I pull off the tape and put on the pre-copied goal sheet and use it to write my online notes later.

I used to write my notes at the end of the day, but it would add another hour to my day. I tried to write them during the session, but it always takes away time from direct care. I am now required to submit my notes online, thus I am back to writing notes at the end of my day, usually at home. I shorten the time by having some of the pre-written note with goals stored in my computer files, filling in the blanks and cutting and pasting where appropriate. This gives me a computer copy that I can print out for my own files as well.

What Non-Therapy Materials To Bring:

Since an EI speech-language pathologist goes from place to place, here are some good things to keep in your car to make your time more efficient. One very important non therapy item to have in your car includes a hands free phone with charger.

Additionally, in the summer months, I take one or two frozen water bottles and let them thaw in my car. By the end of the day I have a nice cold bottle of water! Particularly in the winter, a thermos for hot tea or coffee keeps my drink warm throughout the morning. I also love my thermal lunch bag. It can be expensive (not to mention unhealthy) to eat out daily, so I like to pack my own lunch. I add a frozen cold pack into the thermal lunch bag and have a nice lunch ready to go. I have found that I always need tissues and paper towels. I’ve spilled too many cups of coffee over the years! Keeping an umbrella in the car is handy for those pop up showers. I also keep hand sanitizer and extra plastic bags for dirty toys. It is a good idea to have jumper cables and a first aid kit in the car as well. I also include an extra set of goal and homework sheets.

In my trunk area, I keep a big box to store toys and activities, as well as a big, strong, and sturdy canvas bag to carry toys and activities into houses for each session. I keep a portable mini file cabinet for working folders, file folder games, home made materials, and activities that might need extra protection in the trunk.

What’s In The Big Bag??

Although there is a movement toward “bagless” therapy in which therapists use only toys that the child would have in his/her own environment, I still bring in my big bag. Parents have told me that they like to see what I have and how I use it, giving them ideas about what their child might like or what they can purchase for themselves. Novel toys are also a little more entertaining and can capture and hold a child’s attention more than everyday toys. I always bring a few key therapy materials: bubbles, balloons and a pump, wind-up toys, oral motor items (tongue depressors, whistles, gloves, vibration toys, lotion, washcloth, lollipops, licorice, and smarties if parent allows it). I have interactive books, puzzles, play dough, Mr. Potato Head, balls/trains/trucks, and hand sanitizer as well. I have a few songs with home made or found manipulatives to go along (i.e. old MacDonald, itsy spider, if you’re happy, row your boat...).

I always carry a Picture Exchange Communication System (PECS) book that contains core vocabulary with pictures and photos of toys that I have in the bag. I also bring homework sheets and literature regarding specific skills that I would like the client to work on (i.e. imitation, sign language, identifying nonverbal language, extension and expansion, etc.) I have created communication pictures to go along with stories, activities and songs. I put manipulatives in zip lock baggies with titles taped on and keep them with the corresponding activity or book. I buy books that relate to “activities of daily living” (ADLs) such as bath, dinner, and school that assist in learning functional vocabulary. The children can use the communication pictures in various ways (such as matching, identifying, and using within a PECS). There are no boundaries to your creativity, and you may want to develop your own materials. I also have books that I have created to teach play skills.

What Do I Do On The First Visit?

First impressions are critical to setting the pace for an effective EI relationship.
Building strong rapport, observing, and interviewing the family is vital. I observe the family dynamics and gather pertinent and updated information. I like to find out what prompted the parents to seek a speech and language evaluation and find out their primary concerns. I always get information by watching the family interact, and even by observing how their environment is set up. For example, are toys organized? Is there a designated play area? Is the television on? Do the parents and/or siblings play with toddler on the floor?

Often, the first visit involves standardized testing. I usually begin with a standardized test after getting to know the child, his family, and his environment. I rarely finish the testing in one session. It is important to spread the evaluation across several sessions to get a true picture of how they are performing.

As soon as I have parental consent, I may try to get to know the therapy team. I may contact the EI specialist and other therapists working with the family to gain more information. If possible, it may be helpful to go with other therapists that work with the family and observe what they are doing to advance the care of the child.

When Do I Transition The Child To A New Program?

The transition into school aged programs begins prior to age three. In our county, the school district is usually responsible to evaluate the child prior to entering a school aged program. Non school-based therapists can provide reports and information or help assess children.

When the child is ready for this transition, I write a discharge summary describing the current goals, status, and recommendations. I generally discontinue services, and transition into another speech therapist if therapy is recommended to continue because of the expense involved, reimbursement changes and time commitment.

I have followed kids beyond the three year old transition and ended up seeing some until pre-adolescence! It can be expensive for the therapist to purchase new materials, including assessments, to match the appropriate age of the client.

Reimbursement entities may also change with transition. This increases the administrative time for the therapist.

For all of these reasons, I transition children to a new therapist at age three, and focus on early intervention services. This helps me to keep my costs low, and to focus on building therapy materials specific to this age. I can only pack so much into my car! If I begin an age diverse caseload, before long, there would be no early left in the intervention! However, for some therapists this may be ideal. The therapist would have a “ready made” caseload possibly for years, with few referrals needed. That would be a decision made based on your own goals and area of practice.

Early intervention can be a rewarding and enjoyable area of practice. Like most, it has its share of difficulties, but great advantages as well. If you are independent and enjoy working with families and young children, it may be the place for you! For more information, or to join a parent and therapist discussion forum on this subject please check out my website at!

This Month's Featured Author: Jennifer Fusco M.A. CCC-SLP

Jennifer Fusco is an ASHA certified and Ohio State Board of Speech/language pathology licensed speech-language pathologist. She has been working in the field of speech-language pathology for 15 years, and specializes in the treatment of young children with language, feeding, and autism spectrum disorders. She is the developer and administrator of

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