Healthcare delivery models are constantly changing and evolving in order to meet the needs of patients. The pediatric early intervention population of 0 to 3 years old is no exception. When designing treatment plans for this population, the recommendation is to provide services in the child's "natural environment." According to the American Physical Therapy Association (APTA), Section on Pediatrics, Natural Environments in Early Intervention Services Fact Sheet, natural environments are "home (family life) and community-life settings that are natural and typical for children without a disability and their families" (APTA, Section on Pediatrics, 2008). However, this is not always the case.

Early intervention has typically used a multidisciplinary approach involving physical therapists, occupational therapists, and speech/language pathologists. The team also includes school psychologists, school social workers, and teacher consultants. These professionals work together to evaluate the needs of the child and design a multidisciplinary treatment plan providing needed therapy services in a one-on-one or group format located at early childhood centers. The teacher consultant, and occasionally the social worker or psychologist, visit the home and work with the child on a regular basis. However, Part C of the Individuals with Disabilities Act (IDEA) outlines that "eligible infants and toddlers are entitled to early intervention services in natural environments where children live, learn, and play" (APTA, Section on Pediatrics, 2010). This directive encourages the shift of therapy to focus on multidisciplinary care delivered in the home rather than in early childhood centers.

Providing services in a child's home environment allows opportunities to evaluate the child's challenges in a more realistic setting. The therapist can more accurately assess the barriers to daily functioning encountered in the home. The child is more likely to demonstrate their natural abilities as well as their difficulties in an environment where they are most comfortable. In a study in the Netherlands, 82% of the professionals who provided home consultations to 133 families felt that providing services in the home was more beneficial than in a rehabilitation center (van Maren-Suir et al., 2018). They reported that being in the home afforded them a unique opportunity to evaluate and gain a greater understanding of the child's environment, allowing them to customize their treatment and advice to fit the context in which the child functioned on a daily basis.

Providing treatment in the home environment allows the therapist to create a partnership with family and caregivers. Therapists can utilize what is normally available to the child and family, affording parents and caregivers greater opportunity to practice and follow through on skills addressed during therapy sessions. Construction of therapy sessions should focus on the child's and family's needs, making it relevant to each individual. Therapists need to incorporate toys and equipment that are readily available to the child instead of bringing in their own collection. Treatment sessions should include one-on-one intervention with the child as well as consistent instruction and education for the parent/caregiver on how to incorporate new skills. When therapists simply transfer the clinic model of treatment into the home, keeping parents and/or caregivers in the observer role, the child's ability to generalize their new skills to daily situations is limited and the parent is not assisted in understanding how to facilitate their child's development in everyday situations.

In response to therapists concerned that moving the location of therapy out of rehabilitation centers would limit their ability to provide "real therapy," Hanft and Pilkington (2000) explored both the benefits and acknowledged the challenges of providing therapy within the context of daily life. The authors argue that the location of therapy is just as important as how the therapy is provided, and follow up with suggested guidelines for provision of therapy services in natural environments.

In order to practice effectively in natural settings, it is important that therapists working in early intervention are competent in their skills as pediatric rehabilitation professionals, and also have the knowledge required to meet the guidelines of part C of IDEA. In 1990, the APTA Section on Pediatrics published recommended competencies for physical therapists practicing in early intervention programs and conducted a review and update in 2005. Chiarello and Effgen (2006) identified only one major change from the original document: the provision of services in natural environment.

In 2005, Bruder and Dunst investigated the degree to which multiple healthcare disciplines educated students on early intervention practices. The study found that physical therapy students had the least amount of training in natural setting practice areas when compared with students in early childhood special education, occupational therapy, speech-language pathology, and multidisciplinary programs (Bruder & Dunst, 2005). In response to inconsistencies in teaching pediatric physical therapy content in entry-level physical therapy educational programs, the Section on Pediatrics established five essential pediatric competencies (Rapport et al., 2014). Although these competencies do address family-centered care, they do not specifically address treatment in natural settings. These findings suggest that physical therapy students may not be prepared to meet the service delivery requirements or needs for the early intervention population upon entry-level graduation.

As the shift from clinic-based to home-based service delivery continues to grow in the early intervention population, it is imperative that therapists are competent in using their skills in the home and other natural settings. It is important for graduate physical therapy programs to examine curricular content to ensure that new graduates have opportunities to practice in natural settings and therapists currently practicing in this area seek out continuing education to increase their competency. For more information about continuing education on this topic visit: https://pediatricapta.org/special-interest-groups/sigs.cfm?SIG=EI.

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