IDEA Part C: Implications for Audiologists and Speech-Language Pathologists Who Provide Services for Infants and Toddlers with Hearing Loss and Their Families

What IDEA Says (Selected Sections)

• At-Risk Infant or Toddler
• Early Intervention Services
• Health Services
• Native Language
• Natural Environments
• Early Intervention Services in Natural Environments
• Qualified Personnel
• Public Awareness Program
• Central Directory
• Comprehensive Child Find System
• Referral Procedures

§303.5 At-Risk Infant or Toddler

"Means a child under 3 years of age who would be at risk of experiencing a substantial developmental delay if he or she did not receive early intervention services. At the state's discretion, at-risk infant or toddler may include a child under 3 who is at risk of experiencing developmental delays because of biological or environmental factors, including low birth weight, respiratory distress as a newborn, oxygen deprivation, brain hemorrhage, infection, nutritional deprivation, a history of abuse or neglect, and effects of direct exposure to illegal substances or withdrawal symptoms resulting from prenatal drug exposure."

Implications For ASHA Members

Audiologists and speech-language pathologists (SLPs) need to be aware that:

• Infants and toddlers with hearing loss are eligible for Part C services because they have a diagnosed condition that, without treatment, has a high probability of resulting in developmental delay.
• Even mild and unilateral hearing loss can lead to delays in development of speech and language skills.
• Eligibility requirements vary from state to state.
• All families of infants with bilateral or unilateral permanent hearing loss that is 30 dB HL or greater should be considered eligible for early intervention services (Joint Committee on Infant Hearing, 2007).

What ASHA Members Can Do

Audiologists and SLPs should:

• Be aware of their state's eligibility guidelines and facilitate the inclusion of infants and toddlers with hearing loss.
• Ensure that children under age 3 are referred to both the state Early Hearing Detection and Intervention (EHDI) and Part C programs as soon as they have been diagnosed with hearing loss.

§303.13 Early Intervention Services

"(1) Assistive technology device and assistive technology service are defined as follows:

(i) Assistive technology device means any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of an infant or toddler with a disability. The term does not include a medical device that is surgically implanted, including a cochlear implant, or the optimization (e.g., mapping), maintenance, or replacement of that device.

(ii) Assistive technology service means any service that directly assists an infant or toddler with a disability in the selection, acquisition, or use of an assistive technology device. The term includes-

(A) The evaluation of the needs of an infant or toddler with a disability, including a functional evaluation of the infant or toddler with a disability in the child's customary environment;

(B) Purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices by infants or toddlers with disabilities;

(C) Selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices;

(D) Coordinating and using other therapies, interventions, or services with assistive technology devices, such as those associated with existing education and rehabilitation plans and programs;

(E) Training or technical assistance for an infant or toddler with a disability or, if appropriate, that child's family; and

(F) Training or technical assistance for professionals (including individuals providing education or rehabilitation services) or other individuals who provide services to, or are otherwise substantially involved in the major life functions of, infants and toddlers with disabilities."

Implications For ASHA Members

Audiologists and SLPs need to understand that:

• The definition of assistive technology device does not list specific devices (e.g., cochlear implants [CIs], hearing aids, and hearing assistive technology).
• Funding for assistive technology devices varies from state to state.
• CIs and mapping (optimization) and maintenance of CIs cannot be paid for with federal Part C funds.
• Other services surrounding the selection, acquisition, or use of technology are listed as covered services.

What ASHA Members Can Do

• Audiologists and SLPs with specialized training in aural habilitation should take responsibility for training Early Intervention (EI) providers and parents to perform daily listening checks and troubleshoot the child's device(s).
• Parents and providers should be encouraged to provide the child's audiologist and SLP with regular feedback regarding auditory, speech, and language outcomes. Working together, the entire team can help ensure that technology—including CIs, hearing aids, or other recommended hearing assistive technology (e.g., FM listening systems)—are providing proper benefit.
• Audiologists and SLPs should be prepared to support the family in establishing consistent hearing aid use by helping the family identify challenging situations and suggesting specific coping strategies.
• Audiologists and SLPs should evaluate the child's typical acoustic environments to ensure that the deleterious effects of background noise are not compromising auditory language learning.
• Members on the individualized family service plan (IFSP) team, including the family, should consider equipment needs based on the desired developmental goals selected for the child and be aware of state Part C policies regarding acquisition of equipment.
• Members of the IFSP team should support the child and family in accessing high-quality technology, including hearing aids, CIs, and other assistive devices when appropriate.
• Members of the IFSP team should be aware of and maintain current information on alternate funding sources (e.g., Medicaid, private insurance) for assistive devices (e.g., hearing aids and CIs) not covered by Part C funds.

§303.13 Early Intervention Services

303.13(b)(2)
"(2) Audiology services include—
(i) Identification of children with auditory impairments, using at-risk criteria and appropriate audiologic screening techniques;
(ii) Determination of the range, nature, and degree of hearing loss and communication functions, by use of audiological evaluation procedures;
(iii) Referral for medical and other services necessary for the habilitation or rehabilitation of an infant or toddler with a disability who has an auditory impairment;
(iv) Provision of auditory training, aural rehabilitation, speech reading and listening devices, orientation and training, and other services;
(v) Provision of services for prevention of hearing loss; and
(vi) Determination of the child's individual amplification, including selecting, fitting, and dispensing appropriate listening and vibrotactile devices, and evaluating the effectiveness of those devices."

Implications For ASHA Members

Audiologists and SLPs need to understand that:

• Part C regulations continue to underscore the full range of audiology services, including identification, assessment, and treatment of hearing loss.
• The provision of audiology services for infants and toddlers with hearing loss requires specialized knowledge, skills, and equipment.
• Newborn hearing screening programs now allow earlier access to diagnostic, amplification, and intervention services for infants and toddlers with hearing loss.
• Hospital newborn hearing screening programs should use the expertise of audiologists in selection of screening equipment, training of personnel, and monitoring of outcomes.

What ASHA Members Can Do

Audiologists should fully understand and implement preferred evidence-based practice when serving infants and toddlers with hearing loss and refer families to appropriate facilities if their practice does not provide comprehensive pediatric services.

Audiologists and SLPs providing services for infants and toddlers should:

• Continue to seek professional development and mentoring opportunities.
• Ensure that families and professionals are informed that audiologists, as well as SLPs, who have the knowledge and skills to provide assessment and/or habilitation services should be included on the assessment and intervention teams for infants and toddlers with hearing loss.

§303.16(c) Health Services

"The term does not include —

(1)(iii) Services that are...related to the implementation, optimization (e.g., mapping), maintenance, or replacement of a medical device that is surgically implanted, including a cochlear implant.

(A) Nothing in this part limits the right of an infant or toddler with a disability with a surgically implanted device (e.g., cochlear implant) to receive the early intervention services that are identified on the child's IFSP as being needed to meet the child's developmental outcomes.
(B) Nothing in this part prevents the EIS provider from routinely checking that either the hearing aid or the external components of a surgically implanted device (e.g., cochlear implant) of an infant or toddler with a disability are functioning properly."

Implications For ASHA Members

Audiologists and SLPs need to understand that the consistent use of properly fitted and functioning equipment is an important first step in the development of normal auditory, speech, and language skills for infants and toddlers with hearing loss for whom spoken language is a goal.

Additionally, parents and caregivers will need to learn to manage technology and the acoustics of the child's listening environment and to incorporate specialized communication techniques and strategies into the child's daily routines.

The provision of early intervention services for families and children who have hearing loss requires specialized knowledge and skills.

What ASHA Members Can Do

• Audiologists and SLPs with specialized training in aural habilitation should take responsibility for training EI providers and parents to perform daily listening checks and troubleshoot the child's device(s).
• Providers and parents should be encouraged to provide the child's audiologist and SLP with regular feedback regarding auditory, speech, and language outcomes. Working together, the entire team can help ensure that technology—including CIs, hearing aids, or other recommended hearing assistive technology (e.g., FM listening systems)—is providing proper benefit.
• Audiologists and SLPs should be prepared to support the family in establishing consistent hearing aid use by helping the family identify challenging situations and suggesting specific coping strategies. Additionally, audiologists and SLPs should evaluate the child's acoustic environments to ensure that the deleterious effects of background noise are not compromising auditory language learning.
• Audiologists and SLPs should continue to seek professional development and mentoring opportunities to maintain or develop the specialized knowledge and skills required to support optimal developmental outcomes.

§303.25 Native Language

"(a) Native language, when used with respect to an individual who is limited English proficient or LEP (as that term is defined in section 602(18) of the Act), means —
(1) The language normally used by that individual, or, in the case of a child, the language normally used by the parents of the child, except as provided in paragraph (a)(2) of this section; and
(2) For evaluations and assessments conducted pursuant to §303.321(a)(5) and (a)(6), the language normally used by the child, if determined developmentally appropriate for the child by qualified personnel conducting the evaluation or assessment.
(b) Native language, when used with respect to an individual who is deaf or hard of hearing, blind or visually impaired, or for an individual with no written language, means the mode of communication that is normally used by the individual (such as sign language, Braille, or oral communication)."

Implications For ASHA Members

Audiologists and SLPs should understand that:

• Communication throughout the EHDI process will be most effective when the family's primary/preferred language is used through direct communication, whenever possible. Interpreters may be needed to assist and must meet state standards and guidelines.
• The children of families who lack the necessary economic resources, who have poor health care services, or who face barriers accessing comprehensive information because of language, literacy, or cultural differences are especially at risk for late identification of hearing loss.
• Parents face challenges soon after the confirmation of their child's hearing loss, including decisions regarding medical procedures, selection of hearing technology, communication methodologies, language choices, and early intervention services and approaches.
• Families have the right to receive comprehensive information about all available options for their child. This understanding is enhanced when professionals are well informed and when the family's cultural and linguistic background is respected.
• Formal and informal support from a variety of sources, including other families with children who are deaf and hard-of-hearing, promotes parental well-being, positively affects parent–child interaction, and helps guide decision making.

What ASHA Members Can Do

Audiologists and SLPs should ensure that:

• Intervention programs are designed based on the family's informed choices, traditions, and cultural beliefs and values.
• Both spoken and written communication and educational materials are provided in the family's primary/preferred language.
• The IFSP team considers the following when planning services for infants and toddlers with hearing loss:
  • Opportunities to meet with other infants and toddlers with hearing loss and their families.
  • Opportunities to interact with and be instructed by individuals who are proficient in the family's communication method of choice (e.g., ASL, total communication, auditory verbal therapy).

§303.26 Natural Environments

"Natural environments means settings that are natural or typical for a same-aged infant or toddler without a disability, may include the home or community settings, and must be consistent with the provisions of §303.126."

§303.126 Early Intervention Services in Natural Environments

"Each system must include policies and procedures to ensure, consistent with §§303.13(a)(8) (early intervention services), 303.26 (natural environments), and 303.3 4 4(d)(1)(ii) (content of an IFSP), that early intervention services for infants and toddlers with disabilities are provided —
(a) To the maximum extent appropriate, in natural environments; and
(b) In settings other than the natural environment that are most appropriate, as determined by the parent and the IFSP team, only when early intervention services cannot be achieved satisfactorily in a natural environment."

Implications For ASHA Members

Audiologists and SLPs should understand that:

• The family's long-term developmental, communicative, educational, and social desires for their children should inform the IFSP team and shape the continuum of services.
• Family-centered services should be provided in the home or community settings unless it is determined by the IFSP team, which always includes the parent, that services would be better provided in settings other than the natural environment (e.g., a center-based intervention program).
• Families should be provided with accurate information about the range of community services available.
• It is the IFSP team's responsibility to ensure that parents have access to information about all intervention and treatment options and counseling regarding hearing loss.

What ASHA Members Can Do

Audiologists and SLPs should:

• Avail themselves of appropriate education, mentoring, and experience in order to support delivery of family-centered, early intervention services in natural environments.
• Ensure that the IFSP team considers the following when planning services for infants and toddlers with hearing loss:
  • Access to qualified providers who have expertise in serving young children with hearing loss
  • Room acoustics in the home or childcare center that are conducive for auditory skill development
  • Consistent use of hearing aids and other hearing assistive technology in all settings (e.g., home childcare settings)
  • Opportunities to meet with other children with hearing loss and their families
  • Opportunities to interact with others (both peers and adults) who are proficient in their communication method of choice (e.g., ASL, total communication, auditory verbal therapy)
  • Appropriately functioning equipment

§303.31 Qualified Personnel

"Qualified personnel means personnel who have met State approved or recognized certification, licensing, registration, or other comparable requirements that apply to the areas in which the individuals are conducting evaluations or assessments or providing early intervention services."

§303.13 Early Intervention Services

"(c) Qualified personnel. The following are the types of qualified personnel who provide early intervention services under this part:

(1) Audiologists

(2) Family therapists

(3) Nurses

(4) Occupational therapists

(5) Orientation and mobility specialists

(6) Pediatricians and other physicians for diagnostic and evaluation purposes

(7) Physical therapists

(8) Psychologists

(9) Registered dieticians

(10) Social workers

(11) Special educators, including teachers of children with hearing impairments (including deafness) and teachers of children with visual impairments (including blindness)

(12) Speech and language pathologists

(13) Vision specialists, including ophthalmologists and optometrists

Implications For ASHA Members

Audiologists and SLPs should:

• Be aware of their state's standards for licensure or certification for qualified early intervention personnel. Additionally, according to the regulations, paraprofessionals or assistants can assist in the provision of services if they are appropriately trained and supervised in accordance with state law, regulation, or written policy.
• Be aware of professional practice guidance related to service provision for this population.
• Know that the U.S. Department of Education continues to require that evaluations and assessments be conducted by qualified personnel.
• Understand that services for infants with hearing loss and their families should be provided by professionals who have the specialized knowledge and skills required to serve this population.

What ASHA Members Can Do

• Audiologists who provide these services should adhere to current professional guidance for working with this population.
• Audiologists and SLPs who provide habilitation services to children with hearing loss must possess the knowledge and skills to assist the family and child in developing competency in their desired communication methodology and to support the family's choice.
• Audiologists and SLPs working with infants and toddlers with hearing loss and their families should have expertise in the areas of parent-infant intervention, habilitation, hearing loss, and technology in order to provide the highest quality of services.
• Audiologists and SLPs should abide by their state's current laws and regulations, as well as ASHA guidance on the use and supervision of assistants in the provision of intervention services.

§303.116 Public Awareness Program

"Each system must include a public awareness program that
(a) Focuses on the early identification of infants and toddlers with disabilities; and
(b) Provides information to parents of infants and toddlers through primary referral sources in accordance with §303.301."

Implications For ASHA Members

Audiologists and SLPs should know that:

• A comprehensive state public awareness program is critical for educating families, physicians, and others about the importance of early identification and treatment of childhood hearing loss.
• Families of children who are born with hearing loss may not yet understand the importance of early hearing detection and intervention. A public awareness system that is designed to help educate consumers regarding the importance of early hearing detection and intervention may help reduce loss to follow-up from newborn hearing screening programs.

What ASHA Members Can Do

Audiology and SLPs should:

• Partner with their state EHDI and Part C programs to develop and disseminate educational materials regarding the implications of hearing loss and next steps when hearing loss is suspected.
• Be aware of the contact information for both their state EHDI and Part C coordinators to share with consumers.

§303.117 Central Directory

"Each system must include a central directory that is accessible to the general public (i.e., through the lead agency's Web site and other appropriate means) and includes accurate, up-to-date information about—
(a) Public and private early intervention services, resources, and experts available in the State;
(b) Professional and other groups (including parent support, and training and information centers, such as those funded under the Act) that provide assistance to infants and toddlers with disabilities eligible under Part C of the Act and their families; and
(c) Research and demonstration projects being conducted in the State relating to infants and toddlers with disabilities."

Implications For ASHA Members

A central directory will help families of children with hearing loss to readily identify state and local resources, including private providers, professional associations, parent groups, and advocacy associations.

What ASHA Members Can Do

Audiologists and SLPs who provide services to infants and toddlers with hearing loss:

• Should maintain in the state's central directory current and accurate information regarding their services and be sure that they are known to their state's EHDI program.
• Can use information contained in the central directory to help guide families to other resources that may be appropriate for them.

§303.302(c)(1)(ii)(J) Comprehensive Child Find System

State EHDI systems are now added to the list of programs with which the Part C lead agency must coordinate its Child Find efforts.

Implications For ASHA Members

Better coordination between the state EHDI and Part C programs will help ensure a smooth transition for children identified through newborn hearing screening.

Audiologists and SLPs need to understand the importance of:

• Helping families meet the EHDI goals of identification by 1-month, diagnosis by 3-months, and enrollment in intervention by 6 months of age.
• Linking families of children with hearing loss who are under the age of 3 years to the state Part C program. By linking these families to Part C, members can assist families in accessing state resources, including intervention services and funding.

What ASHA Members Can Do

Audiologists and SLPs should:

• Ensure referral of families of children under3-years old with hearing loss to the state Part C program as soon as possible, but no more than 7 calendar days after the child has been identified.
• Identify and help address barriers to successful transitions between EHDI and Part C programs (e.g., lack of coordination and transparency among state agencies, lack of understanding of referral processes and eligibility for services, language barriers) in their individual states.

§303.303 Referral Procedures

"(a) General.
(1) The lead agency's child find system described in §303.302 must include the State's procedures for use by primary referral sources for referring a child under the age of three to the Part C program.
(2) The procedures required in paragraph (a)(1) of this section must —
(i) Provide for referring a child as soon as possible, but in no case more than seven days, after the child has been identified; and...."
(c) Primary referral sources. As used in this subpart, primary referral sources include —
(1) Hospitals, including prenatal and postnatal care facilities;
(2) Physicians;
(3) Parents, including parents of infants and toddlers;
(4) Child care programs and early learning programs;
(5) LEAs and schools;
(6) Public health facilities;
(7) Other public health or social service agencies;
(8) Other clinics and health care providers;
(9) Public agencies and staff in the child welfare system, including child protective services and foster care;
(10) Homeless family shelters; and
(11) Domestic violence shelters and agencies."

Implications For ASHA Members

Audiologists and SLPs who identify hearing loss or language delays in children younger than 3-years old are considered to be primary referral sources by the state lead agency. As primary referral sources, audiologists and SLPs have a responsibility to initiate a referral to the Part C program "as soon as possible," but not more than 7-calendar days after identification.

What ASHA Members Can Do

Because of their role in the EHDI process, audiologists and SLPs should be aware of state reporting methods, forms, and requirements. By working closely with EHDI and Part C programs, audiologists and SLPs can help promote seamless transitions between diagnosis of hearing loss and intervention services.

Resources

• 2011 IDEA Part C Final Regulations [PDF]
• ASHA IDEA Part C Issue Briefs
• Centers for Disease Control and Prevention—EHDI Program
• Joint Committee on Infant Hearing (JCIH)
• National Early Childhood Technical Assistance Center (NECTAC)
• OSEP TA Community—Part C Settings—Services in Natural Environments
• Service Provision to Children Who Are Deaf and Hard of Hearing, Birth to 36 Months