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The Ethics of EHDI:
What Audiologists Need to Know
Les R. Schmeltz, Au.D.
Karen Munoz, Ed.D.
Karen Clark, M.A.
The Ethical Framework
The Ethical Framework
• Codes of ethics are agreed upon minimum
standards of practice for the conduct of a
profession
• Audiologists are free to exceed these
standards
• Specific codes apply only to members of
that organization
• Codes for all 3 audiology organizations are
very similar
AAA Code of Ethics
Principle I: Members shall provide
professional services and conduct research
with honesty and compassion, and shall
respect the dignity, worth and rights of those
served
AAA Code of Ethics
• Rule 1a: Individuals shall not limit the delivery of
professional services on any basis that is
unjustifiable or irrelevant to the need for the
potential benefit of such services.
• Rule 2a: Individuals shall not provide services
except in a professional relationship, and shall not
discriminate in the provision of services to
individuals on the basis of sex, race, religion,
national origin, sexual orientation or general
health (or age??)
AAA Code of Ethics
• Principle 2: Members shall maintain high
standards of professional competence in
rendering services
AAA Code of Ethics
• Rule 2a: Members shall provide only those
professional services for which they are
qualified by education and experience
• Rule 2b: Individuals shall use available
resources, including referrals to other
specialists………..
AAA Code of Ethics
• Rule 2c: Individuals shall exercise all reasonable
precautions to avoid injury to persons in the
delivery of professional services or execution of
research.
• Individuals shall provide appropriate supervision
and assume full responsibility for services
delegated to supportive personnel. Individuals
shall not delegate any service requiring
professional competence to unqualified persons
AAA Code of Ethics
• Rule 2e: Individuals shall not permit
personnel to engage in any practice that is a
violation of the Code of Ethics
• Rule 2f: Individuals shall maintain
professional competence, including
participation in continuing education
AAA Code of Ethics
• Principle 3: Members shall maintain the
confidentiality of the information and
records of those individuals receiving
services or involved in research
AAA Code of Ethics
• Principle 4: Members shall provide only
services and products that are in the best
interest of those served
AAA Code of Ethics
• Principle 5: Members shall provide
accurate information about the nature and
management of communicative disorders
and about the services and products offered
AAA Code of Ethics
• Rule 5a: Individuals shall provide persons
served with the information a reasonable
person would want to know about the nature
and possible effects of services rendered, or
products provided or research being
conducted
AAA Code of Ethics
• Rule 5b: Individuals may make a statement
of prognosis, but shall not guarantee results,
mislead, or misinform persons served or
studied
• Rule 5e: Individuals shall maintain
documentation of professional services
rendered
AAA Code of Ethics
• Principle 6: Members shall comply with the
ethical standards of the Academy with
regard to public statements or publication
AAA Code of Ethics
• Rule 6b: Individuals public statements
about professional services, products or
research results shall not contain
representations or claims that are false,
misleading or deceptive
Ethics and Practice Decisions
Infant Diagnostic Testing
Infant Diagnostic Testing
Practice Decisions:
• Test battery components
– Position statements, state guidelines
• Equipment needed
– Based on test requirements
• Referrals following identification of hearing loss
• Examiner expertise
– Examination of evidence, identification of learning
gaps, continuing education
Infant Test Battery
Joint Committee on Infant Hearing Year 2000 Position Statement
• Child and family history
• Physiologic measures
– ABR
• Click
• Frequency-specific
• Bone conduction
– OAE
– Middle ear measures
• High frequency probe tone
• Observation of behavioral response to sound
Equipment Required
Practice Questions:
• Do I have OAE equipment?
• Do I have a high frequency probe tone on
my immittance bridge?
• Do I have an ABR unit with click, tone
burst, AND bone conduction?
If the answer is no to ANY of the above, you
are not equipped to do infant diagnostic
testing
Referrals
Practice Questions:
• Do I know the necessary referrals to make
following the identification of a hearing
loss?
• Do I know the reporting requirements?
• Do I know the recommended time frame?
• Do I know what the resources are in my
region/state?
Examiner Expertise
Practice Questions:
• Do I have training and experience in all
components of the infant test battery?
– What are my learning gaps
• Do I need knowledge?
– Find an online course and/or conference
– Read articles
• Do I need skills?
– Identify a hands-on workshop
– Find a mentor (experienced co-worker or colleague)
Infant Diagnostic Testing
Ethical Considerations:
• Do I have the requisite knowledge and skills to
serve this population?
– If not, have I identified my learning gaps AND
identified resources to update my knowledge and skills
to competently serve this population?
• Do I have the necessary equipment to test this
population?
If the answer is NO to either question – refer out
Amplification
Amplification
Practice Decisions:
• Process:
– Selection
– Verification
– Validation
• Equipment needed
• Examiner expertise
Amplification Process
American Academy of Audiology (2003) Pediatric Amplification Protocol
• Selection
– Technology/Earmold characteristics
– Individual Real-ear-to-coupler-difference (RECD)
• Verification
– Real-ear or simulated measures (soft/med/loud)
• Caregiver hearing instrument orientation
• Validation
– Benefits/limitations, measures/tests
• Follow-up and Referral
Equipment Needed
Practice Questions:
• Do I have a real ear analyzer?
– Does it have RECD capability
– Is there an option for a speech signal
(preferable)?
• Do I have hearing instrument software and
supplies designed for pediatrics?
• Do I have a loaner hearing aid program?
Examiner Expertise
Practice Questions:
• Do I have training and experience in all
aspects of the amplification process for the
infant population?
– What are my learning gaps?
• Do I need knowledge?
– Find an online course and/or conference
– Read articles
• Do I need skills?
– Identify a hands-on workshop
– Find a mentor (experienced co-worker or colleague)
Infant Amplification
Ethical Considerations:
• Do I have the requisite knowledge and skills to
serve this population?
– If not, have I identified my learning gaps AND
identified resources to update my knowledge and skills
to competently serve this population?
• Do I have the necessary equipment to fit this
population?
If the answer is NO to either question – refer out
Guidelines and Position
Statements (partial list):
• Joint Committee on Infant Hearing Year 2000 Position Statement
• State EHDI Guidelines
• American Speech-Language-Hearing Association (ASHA): Guidelines
for the audiologic assessment of children birth to 5 years of age
• ASHA: Sedation and topical anesthetics in audiology and speechlanguage pathology
• American College of Medical Genetics: Genetics evaluation guidelines
for the etiologic diagnosis of congenital hearing loss
• American Academy of Audiology Pediatric Amplification Protocol
(2003)
Availability of State EHDI Guidelines
(Random Review)
State
Diagnostics
Reporting
Hearing
Aid
Referral
A
X
X
X
X
B
X
C
X
X
X
X
X
D
X
X
E
X
X
X
X
X
F
G
X
EI
Early Intervention
Charting a
course
through the
ethical issues
of early
intervention
isn’t always
clear.
One View of the Ethics Issue
Hands and Voices, a national parent
organization serving families of
children who are deaf are hard of
hearing, addresses the concept of
Bias vs. Personal Belief System
Hands and Voices 2006
Included with permission
Bias
vs.
• Intentionally
influencing the
audience
• Manipulating people,
information, and
events to achieve a
predisposed outcome
Personal Belief
System
• Sharing the benefit of
our experience &
education with each
other
• Connecting on
common ground
• Credibility
Copyright © 2006 Hands & Voices
Included with permission
Bias
• Intentionally
influencing the
audience
• Manipulating
people,
information, and
events to achieve a
predisposed
outcome
vs.
Professional
Practices
• Sharing knowledge gained
through our education and
experience in pediatric
audiology.
• Providing families with the
information and resources
to assist them in making
the intervention choices
that work for their child
and family.
Ethical Issues and Practices in:
• Early Intervention
Recommendations
• Monitoring and
Follow-Up
• Direct Early
Intervention Service
Provision
Recommendations
Ethical Considerations
• Early intervention programs.
– Knowledge of programs within the region
– Knowledge is current and based on fact rather than
heresay.
• Communication options.
– Information available on wide range of options.
– Printed information, resources for additional
information including EI programs who can provide
support in this area.
• Knowledge of local and national parent support
groups.
Recommendations
Questions to Consider
• Have I visited, met with, or had a telephone discussion
with any of the early intervention programs within my
region? Is my information current?
• Do I feel that I can present information on
communication choices in an unbiased way?
• If I do have a professional bias toward one communication
approach, how do I inform the family? How do I insure
they can learn about the other options?
Signed English
Discussion Scenario
Program recommendation scenario
The audiologist shares information on several
early intervention programs. The parent
asks which program is best. The audiologist
replies that while she has not had a lot of
direct experience with any of the programs,
that most parents in her practice tend to be
very pleased with the services in Program
X.
Discussion Scenario
Communication Recommendation Scenario
A family tells their audiologist the following:
• They are very confused with all the information about
communication methodolgies.
• They ask the audiologist to tell them the right thing to do.
The audiologist listens to the parents and says:
• A lot of other parents have felt the same way and that it can
be confusing
• What’s right for one family may not be right for another;
he asks what they have learned thus far.
• In his professional opinion that Method X is the best thing
given the type and amount of hearing loss their child has.
Discussion Scenario
Cochlear Implant Recommendation Scenario
An audiologist is overheard to say that most parents
have expectations for cochlear implant success
that are way too high. For this reason the
audiologist always tells the parents the reasons
that an implant probably won’t work as well as
they think it will. She says that she does this
because no one else does and it’s important for
parents to know the truth.
Monitoring and Follow-Up
Ethical Considerations
• Ongoing diagnostic assessment
– Position statements, state guidelines
• Potential problems that may impact early
intervention
– Medical, amplification, communication,
parental support
• Partnership with other members of the early
intervention team
Monitoring and Follow-Up
Questions to Consider
• Do I actively work to minimize the time between
confirmation of hearing loss and amplification?
– Do I monitor infants with amplification at
recommended intervals?
• Do I follow pediatric protocols for ongoing
assessment of infants and toddlers?
• Do I know and communicate with other members
of the IFSP team? Do I obtain releases and share
updated audiological information with the team?
Monitoring and Follow-Up
Questions to Consider
• Do I understand the complexities of early
intervention and audiological management for
infants and toddlers with medical syndromes and
auditory neuropathy/auditory dys-synchrony?
• Do I understand the increased impact of OME for
children with sensorineural hearing loss?
Monitoring and Follow-Up
Questions to Consider
• Am I aware of the potential problems that can
impact early intervention?
– consistency of amplification, ear mold problems,
effectiveness of communication methodology
• Do I work in partnerships with other members of
the team so that I can know if problems are
occurring?
– responsive to concerns, respect for opinions
• Am I aware of and responsive to a family’s needs
for support?
Discussion Scenario
Monitoring and Follow-Up Scenario
The EI specialist tells the audiologist that the family
is not keeping the aids on the baby. The mother
reports that the hearing aid is too loud and that it’s
“hurting” the baby. The EI specialist asks for
suggestions or more information. The audiologist
says the next available appointment is in a month
and that if the family isn’t comfortable putting on
the aids, to leave them off until the next
appointment.
Direct EI Service Provision
Ethical Considerations
• Competence in direct service provision
– training, experience with infants/toddlers,
family-centered practices, research based,
current
• Ongoing assessment
• Partnership with other members of the
intervention team
Direct EI Service Provision
Questions to Consider
• Do I have the training and
experience required to work with
infants and toddlers?
• Do I utilize family-centered
practices?
• Am I familiar with all areas of
child development?
• Are my intervention strategies
appropriate for infants and
toddlers rather than preschool
strategies downsized?
Direct EI Service Provision
Questions to Consider
•Do I utilize appropriate assessment strategies?
– Monitor progress over time?
– Assess in all areas of child
development and/or collaborate
with others to know this
information?
– Use assessment to guide
intervention?
– Use assessment to determine if a
change in intervention is
warranted?
Direct EI Service Provision
Questions to Consider
• Do I work in partnership with other
members of the early intervention team?
• Do I value the expertise of others members
of the team?
• Do I resolve professional differences in a
way that does not put the parents in the
middle of a professional disagreement?
Early Intervention
Best Practice and Guidelines
• Alexander Graham Bell Early Intervention Best
Practice Model
• The National Agenda: Moving Forward on
Achieving Educational Equality for Deaf and Hard
of Hearing Students (April 2005) Goal One: Early
Identification and Intervention
• Report and Recommendations of the 2004
National Consensus Conference on Effective
Educational and Health Care Intervention for
Infants and Young Children with Hearing Loss