Section 2: Guidelines for Infants and Toddlers Under IDEA Part C

The guidelines for infants and toddlers emphasize the dynamics of the home with the family’s needs and priorities as central to the collaborative decision- making process and extent to which the child actually uses a particular device within family routines and activities. It includes 11 chapters, addresses myths and barriers, and delivers supportive documents and information in eight appendixes. 

Consideration of AT 

Consideration of AT for an infant or toddler is not used in the place of other needed services, rather the assistive technology: 

• should increase, maintain, or improve the functional capabilities of a child; 
• should enhance a child’s participation in a routine or activity; 
• should provide opportunities for learning; 
• should complement existing services; 
• should be developmentally and age appropriate; 
• should be appropriate for the environment where the child spends his or her day; and 
• may be needed by some children from all levels of the continuum, concurrently or consecutively.

The family’s needs and priorities are central to the collaborative decision- making process and will determine the extent to which a child actually uses a particular device within family routines and activities. 

Assessment of AT 

Because the needs of infants and toddlers changes rapidly (due to rapid growth and development, family expectations, family circumstances, where the child spends his or her day, and a change of caregivers), assessment of the infant and toddler is an ongoing process both in a formal and informal way. Although the type and extent of AT required may not be apparent when a child begins receiving Birth to Three services, the need for AT devices and services in other instances and developmental stages may be (or are often) unmistakable and immediate. Professionals of many disciplines (e.g., early intervention teachers, occupational therapists, physical therapists, speech and language pathologists, and audiologists) are the Birth to Three providers who typically consider the need and recommend AT for infants and toddlers. 

Birth to Three providers should base assessments on the child’s developmental performance in his or her customary environment, focusing on what the child needs to do or is not currently able to do within the routines of the family and those that are a priority for the family. AT devices ranging from no-tech to high-tech may be introduced at any point during the child’s enrollment. Selection of low- and moderate-level devices may not require formal assessment, taking into account what AT the child has tried or currently uses with reflection on what is working and what is not. 

The assessment process should provide the Individual Family and Support Plan (IFSP) team with clear recommendations about the purpose, selection, acquisition, and use of assistive technology (section 2, figure 2). Collaboration and communication with the child’s primary medical provider regarding the selected AT is appropriate and necessary. The medical provider is an essential IFSP team member who participates in the procurement process when seeking funding from the child’s health insurance carrier, including Medicaid. The child’s health carrier often requires a detailed medical prescription of the devices to submit a claim for approval. 

Documentation of AT 

Documentation of the need for AT devices and services is critical. In the IFSP development, the service coordinator can help set the stage for discussing family priorities and needs by talking to or interviewing the family about the child’s typical participation in everyday activities/routines. Section 4 of the IFSP (Daily Activities) enables the discussion to reveal what is working well during daily activities and what is not (examples of additional tools that may facilitate this process are the Routines-Based Interview (RBI) (Siskin Children’s Institute, 2006) (section 2, appendix 1 and appendix 2) and the Assessment of Family Activities and Routines (Thomas Jefferson University, n.d.) (section 2, appendix 3 and appendix 4). 

Once the IFSP team has determined that assistive technology is needed to support the child’s outcome(s), the IFSP should reflect the assistive technology devices and services in as clear a fashion as possible. When assistive technology is required, the IFSP should include it, regardless of price, in several places and at a minimum in sections 6, 7 and 8. 

Funding 

Once the child’s Birth to Three program has determined the appropriate assistive technology device, it is responsible for putting funding options in place for obtaining AT. Currently the New England Assistive Technology Resource & Education Center (NEAT) is the gateway to vendors that assists Birth to Three programs with training, maintaining a database of devices, and obtaining AT devices. 

The Birth to Three system funds assistive technology devices and services as the payer of last resort (being the responsibility of the family, program, and vendor to pursue all other funding options with a list for potential resources noted in the guidelines). If the device costs less than $250, the program can pay for the device or can attempt to access third-party reimbursement. If the device costs $250 or more, the program should pursue funding as well as submit the Assistive Technology Device Request Form Form 3-11 (section 2, appendix 5) to the Birth to Three system. The service provider should submit this request form concurrent with the pursuit of third-party reimbursement. 

Although there are specific protocols and procedures related to funding for the Birth to Three system (see Funding Assistive Technology), once AT has been identified the NEAT Center will help the provider find an appropriate vendor who will assist with insurance paperwork for both used and new equipment and through the family’s health insurance (including Medicaid). The local Birth to Three program is responsible for initiating and participating in the process to bill commercial insurance or Medicaid for AT for those children whose parents have given permission. Insurance and Medicaid customarily fund equipment that fits under the category of durable medical equipment (DME). If commercial insurance pays for all or some of the cost of a device, that amount may be applied against the annual and lifetime caps for DME benefits in the child’s health insurance plan. 

If the program is working with a DME vendor, the vendor will likely take responsibility for the insurance billing. To access insurance (for a device costing any amount) or Medicaid funding (for devices over $250), the program and vendor must provide with the insurance claim a physician’s detailed prescription for the devices (the vendor will often assist by providing the specific device and accessories to the primary medical provider). 

The Birth to Three provider prepares a Letter of Medical Necessity (LMN) (section 2, appendix 6). The customary items within the LMN should include: 

• personal benefit (how does this device increase participation in daily activities related to independence, choice, self-determination, reduced costs for caregivers, and living a full, abundant, and dignified life); 
• investment (besides the health and functional benefits of the device, what are the costs of not providing the requested AT); and 
• equipment choice (why is this particular equipment the most appropriate choice, what features make this equipment the right choice, and can it adapt to the child’s needs over time even though it may cost more initially) (Goebel, 2009).

The Birth to Three system is responsible for funding only equipment intended to achieve functional outcomes identified on the IFSP; however, no new devices or equipment should be requested for children who are 2 years, 9 months of age or older, as equipment requested during this period would not be available long enough to make progress on identified outcomes (except for initial hearing aids if the child is newly enrolled in Birth to Three after age 2 years, 9 months). 

The Birth to Three program is advised to submit the Assistive Technology Device Request Form (section 2, appendix 5) to the Birth to Three system while pursuing third-party funding. A copy of the current IFSP must accompany this form. Requests should reflect all costs for the acquisition of equipment, including shipping and handling, fitting and customization, and extended warranties. The Birth to Three system has an approved dispensing fee for services needed to acquire hearing technology for young children, and Medicaid has its own rate for dispensing fees. 

The Birth to Three central office staff will review the AT-funding request and return a decision to the provider program on Form 3-11 (section 2, appendix 5). If approved, Form 3-11 will include the date of approval and the maximum amount of reimbursement allowed. Despite specifics related to insurance, unique circumstances, and schedules (see Accessing Birth to Three Funding), the requesting program should notify the Birth to Three fiscal office so that it does not set aside funds unnecessarily if funding has been requested and approved by the Birth to Three system and a third-party covers the full cost of the device. 

The party that paid for a majority of a device owns assistive technology devices purchased for children enrolled in the Birth to Three system. If third- party funding ends up paying more than 50 percent of the purchase price of the device, then the device belongs to the family. If Birth to Three funds pay for 50 percent or more of the device, the Birth to Three system owns that device. Programs are responsible for tagging all equipment purchased with Birth to Three funds with inventory tags (supplied by the Birth to Three fiscal office) to record information in the database that NEAT maintains. 

Whenever possible, the local Birth to Three programs should consider obtaining insurance and/or maintenance contracts when purchasing AT. Parents are also requested to insure the AT devices under their homeowner’s or renter’s insurance policy if possible. 

The child’s Birth to Three program is responsible for maintaining and repairing the AT device. If any devices or services are part of a child’s IFSP, then the technology must be available to the child for fulfilling the IFSP’s outcomes and objectives. If a device needs repair or maintenance, the Birth to Three program is responsible for providing alternative access or temporary use of another device or equivalent during the time the regularly used device is out of service. The NEAT Center provides minor repair service for AT that the Birth to Three system owns. Note: If the child continues to use assistive technology after age 3, the Birth to Three system will not assume responsibility for any repair or maintenance. 

Implementation of AT 

The implementation of assistive technology involves the child’s entire team working together and sharing responsibility to support the child’s use of the assistive technology according to a collaboratively developed written plan. Parent or caregiver input regarding preferences and feelings about devices is often a determining factor for successful implementation and use of AT (Illinois: Early Intervention Assistive Technology Guidelines, 2007). 

The implementation plan should be easy to understand and delineate the steps of a routine/activity (identified by the family) when AT will be used, the devices that will be used, what the adult will do, and what the child is expected to do as a result of using the AT (examples of an implementation plan can be found in section 2, appendix 7 and appendix 8). All members of the IFSP team must understand what is expected of them concerning the implementation of the AT, such as: 

• why the AT was selected; 
• the purpose the AT serves; 
• how it enhances the child’s functional skills; 
• when and how often it will be used; 
• how AT will be used in combination with other AT; 
• which adults are responsible to ensure that the AT is used as planned; and 
• how the AT will be coordinated with other therapies.

As the implementation plan is carried out, the service provider should monitor the child’s performance and adjustments made to support the child’s progress. Following acquisition of the devices, the Birth to Three provider is responsible for: 

• setup; 
• organization of equipment and materials; 
• temporary use of a comparable device if the original is unavailable for an extended time; and 
• timely replacement of a nonrepairable device.

The Birth to Three professional responsible for the AT services coordinates collection of this information and interpretation of changes. The adults who will assume responsibility to record information about the child responses to the AT should be clearly determined so that assessment of AT effectiveness occurs informally during routine early intervention visits as well as formally at IFSP reviews. There may be a recommendation to the IFSP team, at a review, to engage the consultation of a specialist or to schedule a formal assistive technology assessment, if the team has not completed one previously. 

Some assistive technology categories require the inclusion of designated licensed professionals for the assessment, implementation, and evaluation process. The Birth to Three program is responsible for locating and engaging providers who possess the needed expertise when the program lacks the competency to select a needed AT device. 

Evaluation of AT effectiveness is a dynamic, responsive, ongoing process and occurs over time. Throughout the child’s enrollment in Birth to Three, examination of what is/is not working and why, along with which elements need to be changed should occurr, including measuring changes in the child’s performance related to functional outcomes. 

Transition and AT 

All children enrolled in the Birth to Three system are required to have a plan in place to ensure a smooth transition to preschool or other appropriate services and supports. The IFSP team must develop a transition plan as part of an IFSP meeting (initial, periodic review, or evaluation of the IFSP held at least annually), which it can update several times to reflect the different stages of the transition planning process. Section 5 of the IFSP should record transition steps and services. Transition plans that include assistive technology should clearly address the use of assistive technology and the anticipated need for continued use once the child is no longer enrolled in the Birth to Three system. 

Transition plans for children who use assistive technology should address the child’s use of AT devices and services as the children transfer from one setting to another. The transition plan should list any AT obtained through the Birth to Three system and how the child will use it once he or she transitions out of the Birth to Three system. 

When a child exits the Birth to Three system, assistive technology equipment Birth to Three owns and that the child uses may transition with him or her so that the child can continue to use the device at home, in school, or in the community as needed and as appropriate. However, the Birth to Three system will no longer assume responsibility for repair or maintenance. 

Training and AT 

Training for the child, family, and team are integral to implementation and may be ongoing as needs change, participating adults change, and the child’s abilities change. Early intervention professionals are responsible for providing appropriate instruction and follow-up for all adults involved in using the AT. 

The Birth to Three system has a contract with the NEAT Center in Connecticut to provide training to Birth to Three programs and has purchased seating at each workshop, which it offers without cost to Birth to Three providers. The center schedules training events each year specific to early interventionists as well as assistance in selecting appropriate and cost-effective devices.