The 4 Ws of Early Intervention: WHEN Should You Start Evaluations and Therapies?
Parents often wonder, “When should we start? Is it too early? Too late?” We reached out to a speech-language pathologist, a physical therapist, an occupational therapist, and a behavioral therapist to discuss when parents should start thinking about starting therapies, as well as some early milestones to look for and other valuable advice.
Speech-language pathologist Amy Wilhelm (M.S., CCC-SLP), owner of Splash for Speech, Inc., shares some key facts about the importance of early intervention: “Too many times I have heard from families who are concerned that their child may be behind in their language skills and have been advised by their pediatrician to ‘wait and see.’ Sometimes it’s three months, sometimes six months, sometimes longer. However, when eighty percent of brain growth occurs during the first three years of life, time is of the essence.”
With this in mind, Wilhelm advises: “If a parent is concerned about their child’s development, the family should be referred to their state’s early intervention program. Every state has one that is authorized under Part C of IDEA (in California it’s called Early Start). These programs are staffed with certified professionals who specialize in early childhood development. The evaluation is free, and a licensed speech-language pathologist will assess the child to determine if there is the presence of a developmental delay or disorder that requires intervention and treatment. By fifteen months, a child should be producing six or more words. A child who hasn’t spoken any words between fifteen and eighteen months is considered a ‘late talker.’ At that time, if a child is behind, a referral for early intervention services is warranted.”
“Researchers have shown that twenty to thirty percent of ‘late talkers’ do not outgrow their language delay and have ongoing difficulties, needing intervention to help them with their language and literacy skills. Early language intervention can increase their odds for long-term success in language, literacy, and other important areas.”
When it comes to physical therapy, Dr. Alyssa P. VanOver, physical therapist and Cuevas Medek Exercises (CME) practitioner, reminds us that it’s wise to be proactive as early as possible. “If there is anything traumatic about a child’s birth, a parent should be looking for any signs of gross motor delay right from the start,” she says. “It’s challenging as a first-time parent to know what you may be looking for, because you don’t have the ability to compare your child’s development to a previous experience.”
Here are a few milestones to look for within a baby’s first year:
- “One of the earliest signs to look for is when a baby is on their back,” VanOver says. “Are they moving their arms and legs symmetrically? Does the right side move as much or the same as the left side?”
- By four months, a baby should have enough head control to lift their head when you pull them up to sit by their arms. “If this level of head control is not present by four months, PT should be considered,” VanOver says.
- “Another milestone to look for is self-supported sitting posture by seven months,” VanOver says. “This means a baby can support themselves in upright sitting with a straight or vertical spine and some arm propping. A forward-flexed spine in sitting is not part of typical development. If you see your child flexed forward during sitting at this stage, it is concerning. Also, propped sitting using arms is a very brief stage of development (about two weeks); after that, your child should not be relying on upper extremities for support in sitting.”
- “A final key milestone is that a child should be able to stand with their chest or upper extremity supported only at an elevated surface such as a sofa or table by ten months.”
VanOver continues, “If your child is not moving symmetrically within the first few months and has not met the head control gross motor milestone of being able to lift their head against gravity while being pulled up to sit, there is room for concern.”
Getting a second opinion
Remember that if you feel your doctor isn’t as concerned as you feel they should be, you can ask for a second opinion. “I find that without a significant birth history, most physicians are reluctant to provide a diagnosis early on, as the spectrum of gross development is not set in stone,” VanOver says. “If a parent has concerns about development, a child’s pediatrician tends to be the first person to notice delays or make a referral. If a pediatrician does not seem as concerned, seek a second opinion or ask for a referral for a gross developmental assessment. A more thorough gross developmental assessment will reveal any possible delays. The earlier any delays are addressed, the more opportunities a child has for development and change.”
As for frequency of therapy sessions, VanOver says it’s up to the therapist — and the child’s needs — to make this determination. But remember:
“The goal of all therapies is neuroplasticity — forming new brain connections,” she says. “And it all comes down to practice. Whether that practice happens 1:1 with a therapist, at home with a parent, or self-initiated by the child, a child needs lots of opportunities to practice new skills and maintain those they’ve already developed.”
Leah Hiller, MA, OTR/L, occupational therapist and owner of Hiller Therapy, also stresses the positive impact of early intervention. “If challenges arise early on, so should the right support,” Hiller says. “Little ones are like Play Doh; their brains are malleable sponges just waiting to absorb, change, and grow. With a nudge in the right direction, a child's entire trajectory changes.”
Kimberly Gardener, OTD, SWC, CAS, agrees: “Ideally, earlier is better when starting interventions. Research has shown that early intervention has the best outcomes for success later in life. Although children can continue to make wonderful progress past the age of three, their nervous systems and brains are much more malleable at younger ages, and can be expected to make the greatest improvements at that time. This is also why certain government programs such as Regional Center often only provide rehabilitative services outside of school for this population.”
"If you have any sort of feeling that your child may be falling behind or struggling with something, there's no reason to not seek a consultation from a therapist," says Melissa Epstein of Thrive Occupational Therapy. She adds that there is no harm in trying out services, even if the child ends up not needing them. "If you provided a typical child with occupational therapy, there will be benefits even if they don't need it. Especially with early intervention; if a child is behind in a certain thing, they're not going to qualify for services, but they could definitely benefit from therapy." She adds:
"It's never too early to start therapy. There are NICU occupational therapists working on feeding issues or sensory regulation issues for neonatal preemies. OT starts day one; it doesn’t have to wait until your child is behind for three or four months. Kids do develop at different times, but if they're a month or two outside that window and you're still thinking something isn't right, have it checked out. If your child catches up on their own or even faster, that's awesome, but no harm has been done."
Epstein also explains that the benefits of early intervention from an occupational therapy standpoint include improved sensory processing, fine visual motor skills, and gross motor skills.
Behavioral therapy is one aspect of early intervention that can be used to address various developmental concerns. Dr. Sarah Pelangka, BCBA-D and owner of KnowIEPs, explains: “In my professional opinion as a BCBA-D, children with developmental delays are recommended to initiate behavior therapy as a part of their early intervention program as early as twelve to eighteen months of age. At this age, behavior therapy really focuses on targeting the development of those fundamental skills that children need to successfully explore and access their immediate environment, as this is how young children learn — through play and social exploration.”
Behaviorists can support families in many different ways, depending on the situation. Dr. Pelangka explains,“A behaviorist can support a parent in developing a successful sleep schedule so the child can be more alert and ready to learn. Behaviorists can also support parents with eating routines — such as strategies for eating with utensils, successful feeding times, or drinking from a cup — development of play skills, and the use of functional communication.”
The role of the family and other service providers
Dr. Pelangka also emphasizes the role of the family in successful behavioral therapy. “The bulk of early intervention behavior services come in the form of parent education. It’s assumed that at this young age, the child is primarily with their parent; in order for these skills to develop, the strategies must be implemented consistently throughout the child’s day (as opposed to a few hours during a therapy session).”
Dr. Pelangka tells us that behavior therapy can target multiple areas of development to include adaptive/self-help skills, communication, social-emotional development, motor development, and more. However, she says, when working with young children for early intervention purposes, the behaviorist should work in conjunction with the additional specialists on the child’s team to ensure that a comprehensive wraparound service is provided.
“If a child requires supports in the areas of communication and motor development, for example, the behaviorist should consult with and follow the expertise of the occupational and/or physical therapists, as well as the speech and language therapist,” Dr. Pelangka explains. She adds:
“A behaviorist can assist in ensuring that the child is ready to access the support of these specialists by way of teaching the therapists how to read the child’s cues, increase motivation in the teaching environment, and recognize when the child may need a break. The behaviorist can also help teach the child to functionally communicate their wants and needs, as well as support the family in implementing recommended strategies throughout the day.”
Now that you’ve learned about when to start, read about why early intervention is important.