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Early Intervention Options for
Infants and Toddlers with Hearing
Loss
A. Brancia Maxon, Ph.D.
T. Foust, Au.D.
R. Winston, M.A.
K. Ditty, M.S.
P. Martin, Ph.D.
National Center for
Hearing Assessment
and Management
UNHS and Early Intervention
• Universal newborn
hearing screening has
resulted in
– decreased age of
identification
– decreased age of
diagnosis
– decreased age of
amplification fitting
Ultimate Goal of UNHS
• Primary purpose of UNHS is to ensure that
– these very young children and their families
are enrolled in EI services within first few
months of life
– EI services are appropriate for the varied and
extensive needs of infants with hearing loss
and their families.
Early Intervention Benchmarks
• Infants enrolled in family-centered EI by 6
months old
• Infants enrolled in family-centered EI program
with professionals knowledgeable about
communication needs of infants with hearing
loss
• Amplification use begins within one month of
diagnosis when appropriate and agreed on by
family
JCIH, 2000
Early Intervention Benchmarks
• Infants with hearing loss have ongoing
audiological management - not to exceed 3
month intervals
• Language development in family’s chosen
communication modality and commensurate
with developmental level and similar to that
for hearing peers of a comparable
developmental age.
• Families participate in and express
satisfaction with self-advocacy.
JCIH, 2000
Principles of Intervention for Infants
and Toddlers with Hearing Loss
• Ongoing audiological assessment and
management must be conducted by staff
trained to work with infants and young
children.
• The intervention team should assist the
family in learning about the nature of their
child’s hearing loss.
Principles of Intervention for Infants
and Toddlers with Hearing Loss
• Intervention requires a team approach.
• family is the most important member of
this team
• team supports, assists and advises families on
how to best meet child’s unique needs
• team provides family with access to a wide
variety of information that is shared in an
unbiased manner.
Principles of Intervention for Infants
and Toddlers with Hearing Loss
• Parents and children are partners in
communication.
• Parents and children develop a
communication system so a language system
can develop.
• Language acquisition begins at birth and
develops through interactions with the family
in daily routines.
Principles of Intervention for Infants
and Toddlers with Hearing Loss
• EI program helps parents understand,
manage and maintain amplification or
other sensory devices.
• EI program helps parents understand their
legal rights so they may advocate for their
child.
• EI should take place in natural
environment (Part C IDEA - U.S.)
Principles of Intervention for Infants
and Toddlers with Hearing Loss
• These are achievable
goals
• Practical
implementation
affected by cultural,
geographic, linguistic
and socioeconomic
factors
Information for IFSP
• Moderate to Profound Hearing Loss
– Medical Intervention
• Medical clearance for hearing aids
• Monitoring for middle ear problems
• Genetic assessment and counseling .
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
• Moderate to Profound Hearing Loss
– Audiological Intervention
• Amplification selection, fitting, validation
• Audiological evaluation at least every 3 months
– Monitoring hearing levels for any change
– focus on residual hearing
– amplification use
– speech and language development
• consider communication modality
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
• Moderate to Profound Hearing Loss
– Communication Intervention
• Speech and language development
• Listening development
• Direct service
– Bombard with vocabulary, correct structures and
speech sounds
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
• Mild Hearing Loss
– Medical Intervention
• Medical clearance for hearing aids
• Monitoring for middle ear problems
• Genetic assessment and counseling
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
• Mild Hearing Loss
– Audiological Intervention
• Amplification selection, fitting, validation
• Audiological evaluation at least every 3 months
– Monitoring hearing levels for any change
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
• Mild Hearing Loss
– Communication Intervention
• Speech and language development
– Stimulate consonant production – especially unvoiced
sounds
– Reinforce all vocal attempts
• Listening development
– Expect and wait for searching response to speech
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
• Mild Hearing Loss
– Communication Intervention
• Speech and language development
– Stimulate consonant production – especially
unvoiced sounds
– Reinforce all vocal attempts
• Listening development
– Expect and wait for searching response to
speech
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
• Mild Hearing Loss
– Parent Education
• Modeling stimulation techniques
• Facilitating carry over of mastered skills
• Use of daily routines for communication
development
• Need for full-time amplification
• Difficult listening conditions
(Brackett, Maxon and Blackwell, 1993)
Issues in EI resulting from UNHS
• Mild losses
– Parent expectations
• Speaking – length of time between enrollment
and first words
• hearing – must be convinced of importance of
keeping on hearing aids
– Professional expectations
• Knowledge of very early communication
development
Information for IFSP
• Unilateral Hearing Loss
– Medical Intervention
• Monitoring for middle ear problems
• Genetic assessment and counseling
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
•
Unilateral Hearing Loss
–
Audiological Intervention
•
Audiological evaluation at least every 3 months
–
•
•
Monitoring hearing levels for any change in normal
ear
Determine if amplification and/or sound field FM is
beneficial
Determine listening environment effects in all daily
living situations
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
•
Unilateral Hearing Loss
– Communication Intervention
•
•
Monitoring speech and language
development
Monitoring listening development
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
•
Unilateral Hearing Loss
– Parent Education
•
•
•
•
Use of daily routines for communication
development
Establishing good listening conditions
Situating the child’s good ear appropriately
Use of amplification when appropriate
(Brackett, Maxon and Blackwell, 1993)
Issues in EI resulting from UNHS
• Unilateral Hearing Losses
– 35 to 48% of sensorineural hearing losses
are unilateral
– Unilateral hearing loss has significant
effects
• average percentage: 25% language
30% math
32% social
Issues in EI resulting from UNHS
• Unilateral Hearing Losses
– Parent expectations
• Hearing: the child reacts to most sounds including
speech and environmental
– difficult to understand potential negative outcomes
• Communication: minimal differences when compared to
infants with normal hearing
– difficult to understand potential negative outcomes
– Professional expectations
• Effects of difficult listening on hearing
Information for IFSP
•
Conductive Hearing Loss
– Medical Intervention
•
•
Medical treatment of middle ear disease is
critical
Fluid may continue and need pressure
equalizing tubes
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
•
Conductive Hearing Loss
– Audiological Intervention
•
Ongoing audiological evaluation
– Monitoring hearing levels with and without fluid
•
Determine listening environment effects in all
daily living situations
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
•
Conductive Hearing Loss
– Communication Intervention
•
•
•
•
Monitoring speech and language
development
Monitoring listening development
Increasing caregiver input
Employing vocal play
– Stimulating consonant production
– Expect and wait for responses to speech
– Reinforce all vocal attempts
(Brackett, Maxon and Blackwell, 1993)
Information for IFSP
•
Conductive Hearing Loss
– Parent Education
•
•
Model techniques for enhancing vocal play
Establishing ways to increase input during
daily routines
(Brackett, Maxon and Blackwell, 1993)
Issues in EI resulting from UNHS
• Conductive Hearing Losses
– Parent expectations
• hearing – separating medical and auditory
issues
• communication – changes in hearing result in
potential effect on speech and language
development
– Professional expectations
• Working closely with physicians
Parent Perceptions of EI
• At diagnosis
– parents wanted to know cause of the hearing loss
regardless of degree of loss their child had.
– Parents of children with milder degrees of hearing
loss preferred to have more educational
information
• e.g., understanding the audiogram
– Parents of children with severe to profound losses
wanted emotional support.
(Harrison and Roush, 2004)
Parent Perceptions of EI
• Later in early intervention
– parents wanted to know about how their child was
going to learn to speak and use hearing.
– Parents of children with milder losses wanted to
know about timelines and early intervention
– Parents of children with severe to profound losses
were interested in cochlear implants
(Harrison and Roush, 2004)
Parent Perceptions of EI
• The benefits of amplification are
important to parents.
– almost 70% of parents interviewed
questioned the benefit of the hearing aids
their child was using.
– less than 15% felt their child’s performance
with the hearing aids met their
expectations.
(Sjobad, et al, 2004)
Parent Perceptions of EI
• This may have occurred because parents
were not well informed about hearing aids
and their benefit.
– Need to be sure the child’s hearing aids were
appropriately fit.
– Concerns about damaging the child’s residual
hearing may result in under amplification and poor
auditory responses.
– Therefore, the parents will not see what they
expect.
(Sjobad, et al, 2004)
Early Intervention and continuous
early childhood hearing
screening
The Hearing Head Start Project
From 2001 – 2004, NCHAM conducted a pilot project
helping early intervention programs. . .
 Migrant Head Start
 American Indian Head Start
 Early Head Start
. . . update hearing screening practices for children 0 - 3
years of age using OAE technology.
Why is Continuous Hearing
Screening so Important?
 As many as 50% of infants who refer from newborn hearing
screening are lost to follow-up.
 Hearing loss can occur at any time in a child’s life.
 Approximately 35% of preschool children will have repeated
ear infections before 3 years of age, sometimes resulting in
fluctuating conductive hearing loss.
 Without regular, physiologic screening, hearing loss is often
impossible to detect.
OAE Screening/Referral
Outcomes
3487 children screened (using a 3 - step screening protocol)
181 (5%) were referred for medical/audiological follow-up
17 identified with hearing loss
 53 identified with outer or middle ear disorder requiring
medical or surgical intervention
18 normal
 82 exited program or parent refused follow-up
Native American Populations:
Considerations In Providing Quality EI
• The foundation for successful EI is
respect for the native way of life and
their traditions
• Treat the child as a “whole” person
• Incorporate culturally receptive
materials
Native American Populations:
Considerations In Providing Quality EI
• Appreciate importance of the family
structure and their strong connection to
their community
• Collaborate and partner with other
programs and services
• Guide families through the system
Rural Area + Low SES: EI Realities
• Difficult to achieve “buy-in” regarding
family-centered care
– Cultural mismatch
– Invasiveness
– Religious influence
– Day-to-day existence
Rural Area + Low SES: EI Realities
• Other contributing factors
•
•
•
•
low literacy levels of families
lack of transportation to services
lack of trained providers
non - English speaking families,
finding materials in family language
working through a translator
• funding sources
Cultural Diversity
• Gender, race,
religion, ethnicity,
language, income,
and age are all
factors to be
considered in
developing Early
Intervention
strategies
Cultural Diversity
• A growing number of children
with hearing loss in the United
States are from families that are
made up of non-native English
speaking.
• The 2000 U.S. Census shows
that nearly one out of five
Americans speak a language
other than English at home.
Cultural Diversity
• Informational materials should be
provided in native languages for parents
and at understandable reading levels.
• Communication options chosen by families
for their child should be respected and
supported.
Cultural Diversity
• Alberg and Kerr (2004) developed a list of
considerations for service providers working
with multicultural populations.
– Families are more comfortable with service
providers who speak their language and
understand their culture.
– Printed material should be available in the
language of the client base.
• There may be different dialects among people from the
same country.
Cultural Diversity
• Racial, cultural and socioeconomic
differences may exist among individuals from
the same country.
• Interpreters may have difficulty explaining
medical and technical information
– May be difficult for the family to understand.
• Families sometimes enter the U.S. illegally.
– will not qualify for public assistance medical and
technical services (e.g., hearing aids)
– finding financial assistance for these families is
challenging, at best
Home visits - Issues
• Respect the home environment (shoes)
• Accept offers of hospitality (coffee, food)
• Feel comfortable working in the home
(cleanliness, animals)
• Dress appropriately for the environment
(sitting on the floor)
• Be on time (arrival and departure)
• Integrate family into the sessions
Summary
• EI services can be
conducted in a
variety of settings
• EI services can
meet the needs of
all infants/toddlers
with hearing loss
and their families