Christine Yoshinaga-Itano

Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs

THE POSITION STATEMENT The Joint Committee on Infant Hearing (JCIH) endorses early detection of and intervention for infants with hearing loss. The goal of early hearing detection and intervention (EHDI) is to maximize linguistic competence and literacy development for children who are deaf or hard of hearing. Without appropriate opportunities to learn language, these children will fall behind their hearing peers in communication, cognition, reading, and social-emotional development. Such delays may result in lower educational and employment levels in adulthood.1 To maximize the outcome for infants who are deaf or hard of hearing, the hearing of all infants should be screened at no later than 1 month of age. Those who do not pass screening should have a comprehensive audiological evaluation at no later than 3 months of age. Infants with confirmed hearing loss should receive appropriate intervention at no later than 6 months of age from health care and education professionals with expertise in hearing loss and deafness in infants and young children. Regardless of previous hearing-screening outcomes, all infants with or without risk factors should receive ongoing surveillance of communicative development beginning at 2 months of age during well-child visits in the medical home.2 EHDI systems should guarantee seamless transitions for infants and their families through this process.

Current state of knowledge: Language and literacy of children with hearing impairment

The purpose of this paper is to provide a review of past and current research regarding language and literacy development in children with mild to severe hearing impairment. A related goal is to identify gaps in the empirical literature and suggest future research directions. Included in the language development review are studies of semantics (vocabulary, novel word learning, and conceptual categories), morphology, and syntax. The literacy section begins by considering dimensions of literacy and the ways in which hearing impairment may influence them. It is followed by a discussion of existing evidence on reading and writing, and highlights key constructs that need to be addressed for a comprehensive understanding of literacy in these children.

THE EFFICACY OF EARLY IDENTIFICATION AND INTERVENTION FOR CHILDREN WITH HEARING IMPAIRMENT

From these findings, the inevitable conclusion is that identification of hearing loss by 6 months of age, followed by appropriate intervention, is the most effective strategy for the normal development of language in infants and toddlers with hearing loss. Identification of hearing loss by 6 months can only be accomplished through universal newborn hearing screening. Some questions that arise as a result of these studies include: What can one conclude from the finding that the language skills of children with mild hearing losses are no better than those with greater losses? If the finding holds up, it indicates a great need for investigations into biobehavior theories of language acquisition and into the part played by the prenatal 4 months of hearing. And it also shows a need for answering the question, When does a hearing loss begin?, because it certainly seems that all hearing losses are similar in their outcomes. Can the findings from these studies be used to benefit normally hearing children who are at risk for language delays as a result of limited language environments? Such children suffer from auditory deprivation just as surely as those with hearing losses. If the language skills of the latter children can be brought to normal range by early intervention, the same strategy may help high-risk populations. The efficacy of early intervention is just as valid for these children as it is for the children with hearing impairment. Now that the benefits of early identification of children with congenital hearing loss have been demonstrated, these benefits should be extended to all children who are at risk for language delays, with appropriate interventions applied immediately.

The development of deaf and hard of hearing children identified early through the high-risk registry

The high-risk registry was used as a screening device for identifying hearing loss for many decades in Colorado. It reportedly missed approximately 50% of all infants with congenital sensorineural hearing loss (Mehl & Thomson, 1998; Parving, 1993; Watkins, Baldwin, & McEnery, 1991). Little is known about the developmental characteristics of this population. This article describes children identified through the high-risk registry. These children have been divided into two groups according to their age of identification: (a) deaf and hard of hearing children identified before age 6 months, and (b) deaf and hard of hearing children identified between ages 7 and 18 months. The children identified before age 6 months and receiving intervention at an average of 2 to 3 months after identification of hearing loss had significantly higher levels of receptive and expressive language, personal-social development, expressive and receptive vocabulary, general development, situation comprehension, and vowel production. The high-risk registry used for newborn hearing screening has been replaced by universal newborn physiological hearing screening in the state of Colorado.

Supplement to the JCIH 2007 position statement: Principles and guidelines for early intervention after confirmation that a child is deaf or hard of hearing

EI services represent the purpose and goal of the entire EHDI process. Screening and confirmation that a child is D/HH are largely meaningless without appropriate, individualized, targeted and high-quality intervention. For the infant or young child who is D/HH to reach his or her full potential, carefully designed individualized intervention must be implemented promptly, utilizing service providers with optimal knowledge and skill levels and providing services on the basis of research, best practices, and proven models. The delivery of EI services is complex and requires individualization to meet the identified needs of the child and family. Because of the diverse needs of the population of children who are D/HH and their families, well-controlled intervention studies are challenging. At this time, few comparative effectiveness studies have been conducted. Randomized controlled trials are particularly difficult for ethical reasons, making it challenging to establish causal links between interventions and outcomes. EI systems must partner with colleagues in research to document what works for children and families and to strengthen the evidence base supporting practices.

Principles and Guidelines for Early Intervention After Confirmation That a Child Is Deaf or Hard of Hearing

This document is a supplement to the year 2007 position statement of the Joint Committee on Infant Hearing and provides comprehensive guidelines for establishing strong early intervention (EI) systems with appropriate expertise to meet the needs of children who are deaf or hard of hearing (D/HH). Optimal outcomes can only be achieved when there is high quality to the universal newborn hearing screening programs, the audiologic diagnostic process of confirmation that a child is D/HH and fitting of amplification, and the provision of appropriate, individualized, targeted, and high-quality EI services. There are 12 best practice guidelines for EI programs that include the provision of timely referral to EI services with providers who have knowledge and skills in early childhood deafness and hearing loss, infusion within the system of partnerships with parents as well as professionals who are D/HH, longitudinal developmental assessments for monitoring the childs development, data management systems that include developmental outcomes, a process to monitor the fidelity of the intervention, and appropriate services for children with additional disabilities, those from non-English speaking families, and those from special populations, including unilateral hearing loss and auditory neuropathy/dyssynchrony.

Current state of knowledge: implications for developmental research--key issues.

This is the final article in a series of five review articles and one editorial that summarizes the proceedings of the National Institute on Deafness and Other Communication Disorders workshop on Outcomes Research in Children with Hearing Loss held December 12 and 13, 2006. The purpose of this article is to highlight the recommendations that emerged during the workshop, addressing the developmental needs of children with hearing impairment. The information in this summary is based on the National Institute on Deafness and Other Communication Disorders workshop minutes available at http://www.nidcd.nih.gov/funding/programs/hb/outcomes/recommendations.htm. General research issues focus on funding mechanisms, access to a sufficient population, experimental cohorts and control groups, research methods and outcomes, standardization of testing across agencies and intervention programs, and facilitating access to data. Discussion of those issues is followed by an outline that presents future needs in outcomes research, including research design, sources of variance, research needs and gaps, and development of measurement tools.

Using Language ENvironment Analysis to Improve Outcomes for Children Who Are Deaf or Hard of Hearing

Very little is known about the language environments of children in the United States in non-English-speaking homes. There is currently no published research that analyzes deaf or hard of hearing children in Spanish-speaking households, although the Colorado Home Intervention Program demographics indicate that these households account for 10 to 15% of the population of children who are deaf or hard of hearing. In other geographic regions in the United States, it is likely that the population of deaf and hard of hearing children from Spanish-speaking homes is considerably larger. The Spanish-speaking population in the United States has grown considerably within the last 5 to 10 years and will continue to expand. For these children to receive adequate treatment, research must be conducted to understand their language environment. The Language ENvironment Analysis (LENA) System uses a small recording device to collect, analyze, and sort a childs language environment into multiple categories and analyzes variables such as child vocalizations, adult words, and conversational turn taking. The normative data for the LENA System are from families who are English-speaking. The article demonstrates the feasibility of using the LENA System to gain understanding of the language environment of a child who is deaf or hard of hearing in a Spanish-speaking household.

The Role of Educators of the Deaf in the Early Identification of Hearing Loss

About 16,000 babies each year will be identified with hearing loss by age 3 months once universal newborn hearing screening becomes a reality. Identification of hearing loss in infancy, followed by appropriate intervention by age 6 months, can result in normal language development, regardless of degree of hearing loss. As the average age of identification of hearing loss moves downward toward 2 months, children with hearing loss will enter the educational system earlier and with language skills commensurate with those of their hearing peers. In order to provide appropriate services to children with hearing loss and their families, early interventionists will need to forge links to health care providers involved in universal newborn hearing screening programs, to have specialized training in deafness and hearing loss, and to have expertise in providing services to very young children and to children with hearing loss in the broad range from mild to profound.

The Missing Link in Language Development of Deaf and Hard of Hearing Children: Pragmatic Language Development

This article will provide information about the Pragmatics Checklist, which consists of 45 items and is scored as: (1) not present, (2) present but preverbal, (3) present with one to three words, and (4) present with complex language. Information for both children who are deaf or hard of hearing and those with normal hearing are presented. Children who are deaf or hard of hearing are significantly older when demonstrating skill with complex language than their normal hearing peers. In general, even at the age of 7 years, there are several items that are not mastered by 75% of the deaf or hard of hearing children. Additionally, the article will provide some suggestions of strategies that can be considered as a means to facilitate the development of these pragmatic language skills for children who are deaf or hard of hearing.