the status of early hearing detection and intervention in the united states karl r. white, phd...

The Status of Early Hearing Detection and Intervention in the United States

Karl R. White, PhDNational Center for Hearing Assessment and Management

Utah State University

www.infanthearing.org

Number of Hospitals Doing Universal Newborn Hearing Screening

3 3 11 26 60 120243

462712

934

2050

-100100300500700900

110013001500170019002100

Nu

mb

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f P

rog

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s

Improved ScreeningTechniques/Equipment

Why is Implementation of Newborn Hearing Screening Accelerating?

Improved ScreeningTechniques/Equipment

Acceptance byPolicy Makers

Why is Implementation of Newborn Hearing Screening Accelerating?

Endorsements for Universal Newborn Hearing Screening

• National Institutes of Health

• American Academy of Pediatrics

• Maternal and Child Health Bureau

• Centers for Disease Control & Prevention

• Joint Committee on Infant Hearing

• American Academy of Audiology

• American Speech-Language-Hearing Association

• National Association of the Deaf

Improved ScreeningTechniques/Equipment

Acceptance byPolicy Makers

Why is Implementation of Newborn Hearing Screening Accelerating?

Increased Number ofSuccessful Programs

Improved ScreeningTechniques/Equipment

Acceptance byPolicy Makers

Why is Implementation of Newborn Hearing Screening Accelerating?

Increased Number ofSuccessful Programs

PublicAwareness/Demand

Blindness separates people from things.Deafness separates people from people.

--- Helen Keller

Why is Early Identification of Hearing Loss so Important?

• Hearing loss is the most frequent birth defect.

Rate Per 1000 of Permanent Childhood Hearing Loss in UNHS Programs

Sample Prevalence

Site Size Per 1000

Rhode Island (3/93 - 6/94) 16,395 1.71

Colorado (1/92 - 12/96) 41,976 2.56

New York (1/95 - 12/97) 69,761 1.95

Texas (1/94 - 6/97) 52,508 2.15

Hawaii (1/96 - 12/96) 9,605 4.15

New Jersey (1/93 - 12/95) 15,749 3.30

Incidence per 10,000 of Congenital Defects/Diseases

30

12 11

6 52 1

0

10

20

30

40

Hearing Loss

Cleft lip or palate

Down Syndrome

Limb defects

Spina bifida

Sickle Cell Anemia

PKU

Why is Early Identification of Hearing Loss so Important?

• Hearing loss is the most frequent birth defect.

• Undetected hearing loss has serious negative consequences.

Reading Comprehension Scores of Hearing and Deaf Students

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

8 9 10 11 12 13 14 15 16 17 18

Deaf

Hearing

Age in Years

Schildroth, A. N., & Karchmer, M. A. (1986). Deaf children in America, San Diego: College Hill Press.

Gra

de

Eq

uiv

alen

ts

Effects of Unilateral Hearing Loss

MathLanguage

MathLanguage

Social

MathLanguage

MathLanguage

Social

0th 10th 20th 30th 40th 50th 60th

Percentile Rank

Normal Hearing Unilateral Hearing Loss

Keller & Bundy (1980)(n = 26; age = 12 yrs)

Peterson (1981)(n = 48; age = 7.5 yrs)

Bess & Thorpe (1984)(n = 50; age = 10 yrs)

Blair, Peterson & Viehweg (1985) (n = 16; age = 7.5 yrs)

Culbertson & Gilbert (1986)(n = 50; age = 10 yrs)

Average ResultsMath = 30th percentile

Language = 25th percentileSocial = 32nd percentile

Effects of Mild Fluctuating Conductive Hearing Loss Teele, et al., 1990

194 children followed prospectively from 0-7 years.

Days child had otitis media between 0-3 years assessed during normal visits to physician.

Data on intellectual ability, school achievement, and language competency individually measured at 7 years by "blind" diagnosticians.

Results for children with less than 30 days OME were compared to children with more than 130 days adjusted for confounding variables.

Effect Size for Outcome Measure Less vs. More OME

WISC-R Full Scale .62Metropolitan Achievement Test

Math .48Reading .37

Goldman Fristoe Articulation .43

Teele, D.W., Klein, J.O., Chase, C., Menyuk, P., Rosner, B.A., and the Greater Boston Otitis media Study Group (1990). Otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years. The Journal of Infectious Diseases, 162, 685-694.

Why is Early Identification of Hearing Loss so Important?

• Hearing loss is the most frequent birth defect.

• Undetected hearing loss has serious negative consequences.

• There are dramatic benefits associated with early identification of hearing loss.

Yoshinaga-Itano, et al., 1996

Compared language abilities of hearing-impaired children identified before 6 months of age (n = 46) with similar children identified after 6 months of age (n = 63).

All children had bilateral hearing loss ranging from mild to profound, and normally-hearing parents.

Language abilities measured by parent report using the Minnesota Child Development Inventory (expressive and comprehension scales) and the MacArthur Communicative Developmental Inventories (vocabulary).

Cross-sectional assessment with children categorized in 4 different age groups.

Yoshinaga-Itano, C., Sedey, A., Apuzzo, M., Carey, A., Day, D., & Coulter, D. (July 1996). The effect of early identification on the development of deaf and hard-of-hearing infants and toddlers . Paper presented at the

Joint Committee on Infant Hearing Meeting, Austin, TX.

13-18 mos(n = 15/8)

19-24 mos(n = 12/16)

25-30 mos(n = 11/20)

31-36 mos(n = 8/19)

0

5

10

15

20

25

30

35

Identified BEFORE 6 Months

Identified AFTER 6 Months

Expressive Language Scores for Hearing Impaired Children Identified Before and After 6 Months of Age

Chronological Age in Months

Lan

gu

age

Ag

e in

Mo

nth

s

13-18 mos(n = 15/8)

19-24 mos(n = 12/16)

25-30 mos(n = 11/20)

31-36 mos(n = 8/19)

0

50

100

150

200

250

300

Identified BEFORE 6 Months

Identified AFTER 6 Months

Vocabulary Size for Hearing Impaired Children Identified Before and After 6 Months of Age

Chronological Age in Months

Vo

cab

ula

ry S

ize

0.8 1.2 1.8 2.2 2.8 3.2 3.8 4.2 4.80

1

2

3

4

5

6

Identified <6 mos (n = 25)

Identified >6 mos (n = 104)

Age (yrs)

Lan

gu

age

Ag

e (y

rs)

Boys Town National Research Hospital Study of Earlier vs. Later

Moeller, M.P. (1997). Personal communication, moeller@boystown.org

129 deaf and hard-of-hearing children assessed 2x each year.

Assessments done by trained diagnostician as normal part of early intervention program.

Tremendous ProgressDuring the Last Decade

• Less than 30 hospitals with UNHS in 1993; compared with more than 2000 today

• More than 2 million babies are screened every year prior to discharge

• 34 states have passed legislation related to newborn hearing screening

The Other Side of the Coin . . . .

• 2,200 hospitals are not yet screening for hearing loss

• Almost 2 million babies are NOT screened every year prior to discharge

• Existing legislation is of variable quality

• Only 9 states (accounting for 7% of the births) have implemented reasonable statewide programs

• Follow-up rates are often alarmingly low

• Some hospitals have unacceptably high referral rates

Status of EHDI Programs in the United States

• Universal Newborn Hearing Screening

Universal Newborn Hearing Screening

• With over half of all babies are screened prior to discharge, has newborn hearing screening become the standard of care?

• There are hundreds of excellent programs - - - regardless of the type of equipment or protocol used

• Many programs are still struggling with high refer rates and poor follow-up

Status of EHDI Programs in the United States

• Universal Newborn Hearing Screening

• Effective Tracking and Follow-up as a part of the Public Health System

Rate Per 1000 of Permanent Childhood Hearing Loss in UNHS Programs

Sample Prevalence % of Refers

Site Size Per 1000 with Diagnosis

Rhode Island (3/93 - 6/94) 16,395 1.71 42%

Colorado (1/92 - 12/96) 41,976 2.56 48%

New York (1/96 - 12/96) 27,938 1.65 67%

Utah (7/93 - 12/94) 4,012 2.99 73%

Hawaii (1/96 - 12/96) 9,605 4.15 98%

Tracking "Refers" is a Major Challenge(continued)

Initial Rescreen Births Screened Refer Rescreen Refer

Rhode Island 53,121 52,659 5,397 4,575 677 (1/93 - 12/96) (99%) (10%) (85%) (1.3%)

Hawaii 10,584 9,605 1,204 991 121(1/96 - 12/96) (91%) (12%) (82%) (1.3%)

New York 28,951 27,938 1,953 1,040 245 (1/96-12/96) (96.5%) (7%) (53%) (0.8%)

Status of EHDI Programs in the United States

• Universal Newborn Hearing Screening

• Effective Tracking and Follow-up as a part of the Public Health System

• Appropriate and Timely Diagnosis of the Hearing Loss

Audiological Diagnosis

• Equipment and techniques for diagnosis of hearing loss in infants continues to improve

• Severe shortages in experienced pediatric audiologists are delaying confirmation of hearing loss

• Most states are having serious problems linking babies with diagnostic follow-up

Status of EHDI Programs in the United States

• Universal Newborn Hearing Screening

• Effective Tracking and Follow-up as a part of the Public Health System

• Appropriate and Timely Diagnosis of the Hearing Loss

• Prompt Enrollment in Appropriate Early Intervention

Early Intervention

• Part C of IDEA is an under used resource

• Services are generally quite good for babies with severe profound bilateral loss, but less adequate for babies with more moderate loss

Key Concepts for Early Intervention

Transactional Developmental Family Focused Holistic Transdisciplinary

Communication Choices

• American Sign Language

• Total Communication

• Auditory Verbal

• Auditory-Oral

• Cued Speech

Technology Decisions

• Audiological Evaluation

• Hearing Aids

• Cochlear Implant

• Assistive Devices

Status of EHDI Programs in the United States

• Universal Newborn Hearing Screening

• Effective Tracking and Follow-up as a part of the Public Health System

• Appropriate and Timely Diagnosis of the Hearing Loss

• Prompt Enrollment in Appropriate Early Intervention

• A Medical Home for all Newborns

What Is a Medical Home?

• A primary care physician provides care which is:

• Accessible

• Family-centered

• Comprehensive

• Continuous

• Coordinated

• Compassionate

• Culturally effective

EHDI and the Medical Home

Parent Groups

Mental Health

Birthing Hospital

Audiology

Primary Provider

Child/Family

ENT

GeneticsEarly

Intervention Programs

3rd Party Payers

Deaf Community

Services for Hearing Loss

Status of EHDI Programs in the United States

• Universal Newborn Hearing Screening

• Effective Tracking and Follow-up as a part of the Public Health System

• Appropriate and Timely Diagnosis of the Hearing Loss

• Prompt Enrollment in Appropriate Early Intervention

• A Medical Home for all Newborns

• Culturally Competent Family Support

What do families want to know when a child is diagnosed with hearing loss….

• What do we do next?• When must we take action?

• Where do we get more information?• How do we decide?

• Who will help us?• Why do we need early intervention?

Emotions of Families with a Deaf orHard of Hearing Baby

• (grief) Reactions to Unexpected Diagnosis

• (pressure) Urgency of Communication Decisions Search

• (confusion) Search for Experienced Professionals

• (isolation) Availability of Services and Support

Status of EHDI Programs in the United States

• Universal Newborn Hearing Screening

• Effective Tracking and Follow-up as a part of the Public Health System

• Appropriate and Timely Diagnosis of the Hearing Loss

• Prompt Enrollment in Appropriate Early Intervention

• A Medical Home for all Newborns

• Culturally Competent Family Support

• Elimination of geographic and financial barriers to service access