Natural Setting: Early Intervention in the Home or Clinic

Early intervention for children under age three is mandated by the Individuals with Disabilities Education Act (IDEA), the federal law governing special education. Part C of IDEA requires that infants and toddlers eligible for early intervention receive services in natural environments as much as possible. However, in some cases, services may also be provided in a clinical setting, such as a therapy clinic or a center-based program.

Natural environments are settings that are natural or typical for a same-aged infant or toddler without a disability, and may include the home or community settings. Clinic-based therapy is therapy received in a medical setting outside of your home — this may be at a doctor’s office, a hospital, a dedicated therapy clinic, or even a therapist’s home clinic. The therapy is provided in a setting that has been designed for that purpose, which gives the therapist and child access to a wider range of specialized equipment and simulated settings constructed for therapeutic use.

Another type of clinical setting is a center-based program. These early intervention programs are usually available beginning around age 18 months, although there are some programs that serve infants as well. Center-based programs mimic classrooms and teach socialization, routines, and behavior expectations, and they often have on-site OTs, SLPs, PTs, behaviorists, and feeding specialists. A center-based program can be key to setting up toddlers for success in preschool and beyond as they help kids learn and practice skills in a kid-friendly, stimulating environment.

Note: if a center-based program provides integrated therapy services, the child’s therapeutic needs may be considered met by that program. However, a therapist might recommend that the child be seen both in the center-based program and for 1:1 therapy outside the program. In that case, for funding, you will need to provide documentation of medical necessity and be able to demonstrate that this is not a duplication of services due to the child’s additional needs.

In-home therapies

The biggest benefit to getting EI services in the natural environment (usually in-home) is that kids might feel safer being in a familiar setting with familiar smells, sights, objects, and people. They can learn skills in their home environment where they spend most of their time, with people with whom they are familiar, such as parents, siblings, and caregivers. In-home therapy also helps incorporate certain daily living skills like eating or bathing more easily into the program, and it can also target specific skills to help the child access their natural environment. Children may also require home-based therapies when it is difficult to transport them due to medical complexities or significant difficulties with car rides, when they are immunocompromised, or when there is no clinic-based program within a reasonable distance from their home.

Most private insurance companies, especially HMOs, will only offer early intervention services in-clinic. But there may be cases where you will want your child’s services to take place in-home or are otherwise unable to utilize your insurance’s therapy benefits. Some examples:

• Your personal circumstances and/or work schedule pose a barrier to traveling to the clinic.
• Your insurance has in-network providers, but there is a long waiting list (this will be discussed below).
• There’s no in-network provider within a reasonable distance from you, and/or your child has a hard time with car rides or mobility. “Try keeping a child with significant behavior or sensory issues strapped in a car seat for an hour each way,” Concoff Kronbeck says. “That's going to be a problem, and it's going to be potentially harmful to the child. It will be harder for them to benefit from the therapy if they're totally dysregulated by the time they get to the appointment because they've had to endure a long car ride.”

Clinic-based therapies

Sometimes, getting services in-clinic is a better fit for kids. Clinics and centers can offer more structure in the environment as well as access to larger or more varied equipment. For example, a child with sensory integration difficulties might benefit from access to swings, hammocks, ziplines, a trampoline, areas for messy play, a ball pit, etc. A child may also require a space with a selection of adaptive equipment (such as walkers or gait trainers in various sizes, or swings or chairs designed for kids who need trunk support) and safety features, such as a large area with a thick mat to protect from falls. While therapists usually bring therapeutic supplies with them to in-home therapies, some of this equipment may be difficult to transport.

A clinic might also be more appropriate if it would be difficult to do therapy due to factors in the home environment. Concoff Kronbeck says, “As a parent, if there are a bunch of other siblings running around and it's distracting the child, you might want to be outside the home for early intervention therapies…Or if the family’s home doesn’t have room to do physical therapy — for example, if there isn’t a lot of open space, or somebody is renting a room with their child, they might not have a space to do certain therapies. Not everyone has access to a yard, either. So it just really depends on the family's circumstance.”

You may have specific needs or preferences regarding therapeutic setting, but ease of access will depend on your funding route, and you may need to fight for your child’s needs. The settings that are most readily available will depend on how you’re accessing and funding early intervention services. In short, Concoff Kronbeck explains, the starting question is, “Who’s paying for it?”

“With early intervention,” Concoff Kronbeck explains, “you go through your private insurance first. And with private insurance, the in-network providers will usually be in a clinic-based setting. If it's a PPO that will accept a superbill from an out-of-network provider, you might be able to find a therapist who can come to your home and then issue superbills that you can submit to your insurance. But if it's an HMO, services are generally going to be in a clinic. So if [funding] is coming through private insurance, it's going to depend on what your insurance covers.”

For people who don’t have private primary insurance, Concoff Kronbeck explains, “Medicaid is generally not going to provide in-home services [either] because the plans contract with outside clinics.”

Concoff Kronbeck says that if a state disability agency, such as Regional Center in California, is paying, “then 1:1 therapy is usually going to be in-home as the default, unless clinic-based services are recommended.”

Early intervention services from the local education agency are generally provided only to children with certain low-incidence disabilities, like vision or hearing impairment. SELPA funding can also be used for low-incidence needs, and only if the child has a single disability.

As you can see, in-home and clinic-based services are available for all ages, and are funded in many ways. To learn more about how early intervention is funded, read our article What Is Early Intervention? - The 4 Ws of Early Intervention.

Benefits

• For in-home therapy, the therapist travels to you! This can be especially important if you have a medically complex child, for example, and need monitors, feeding tubes, and other medical equipment you can’t travel with. It’s also helpful by reducing the amount of germs your child is exposed to, compared to going to a clinic or center. Home-based therapies can also help you see how you can incorporate the therapies at home when you’re alone with your child. Kids can also receive services in a familiar environment with familiar smells, sights, objects, and people.

• For clinic-based programs, therapists have more access to specialized equipment such as therapy swings, walkers, standers, etc. If your child is in a center-based program, you can also have multiple therapists seeing your child in one visit, such as a OT, PT, and speech therapist, and they can collaborate on goals and have an integrated treatment plan. Clinics may also be more controlled settings, which can reduce sensory input from distractions that might be happening at home. They can also incorporate socialization goals that can’t be met while working in the home setting.

How long can a child receive early intervention services?

When going through private insurance, a child can get services as long as they are medically necessary and your child qualifies based on insurance. With state early intervention programs, services are provided until the age of 3. After this, your child would continue services through the school district.

Questions to ask yourself

• When trying to determine which setting is best for your child, here are some questions to consider:
• What works best for your family’s lifestyle and schedule?
• What are your child’s needs, and what kind of therapies does your child require?
• Does your child feel more comfortable with a therapist in the home, or are they okay traveling to a new setting?
• Where is the location of the clinic? How often will the therapies be provided? Can your child travel back and forth regularly?
• Do you have transportation?
• Does your child have equipment in the home they need access to?
• Will the therapy be more beneficial in a clinic/center?
• Can your child be around other children in a clinic?
• What is the home environment like? Is your child easily distracted at home? Are their other siblings who might interfere?
• Do you want to incorporate therapy exercises at home?
• What does your insurance cover, and what can your family afford?
• What does your care team think is the best option for your child? Can they recommend one or the other?
• Would you and your child benefit from a center- or classroom-based early intervention program? Which program offers services that your child needs? For example, creativity, motor skills, language, social/emotional, etc.

Where to start

The first step is to tell your child’s provider and ask for appropriate assessments and screenings. Your child’s provider may refer you to a specialist if further assessment is required. Read our article The 4 Ws of Early Intervention: WHO Do You Go to for Help? for more information on building a care team. With early intervention services, professionals such as developmental-behavioral pediatricians, occupational therapists, physical therapists, and speech therapists will evaluate your child to identify areas of concern, such as delays in socialization, behavior, development, or learning. They’ll then put together a plan to address those areas with different types of therapy.

You can contact your state or territory’s early intervention program to find out if your child can get services to help. In California, this would be Early Start. California parents can also request a screening for services directly through Regional Center, who will evaluate the child to determine their eligibility for early intervention services; a referral from a professional is not needed.