an update an update judith gravel, phd chair, jcih the children’s hospital of philadelphia

An UpdateAn Update

Judith Gravel, PhDJudith Gravel, PhDChair, JCIHChair, JCIH

The Children’s Hospital of PhiladelphiaThe Children’s Hospital of Philadelphia

Member Organizations; Current Representatives

• American Academy of Audiology– Alison Grimes; Christie Yoshinaga-Itano

• American Academy of Otolaryngology Head & Neck Surgery– Patrick Brookhouser; Stephen Epstein

• American Academy of Pediatrics– Betty Vohr; Albert Mehl

Member Organizations; Current Representatives

• American Speech-Language-Hearing American Speech-Language-Hearing AssociationAssociation– Judy Gravel; Jack RoushJudy Gravel; Jack Roush

• Council for the Education of the DeafCouncil for the Education of the Deaf– Beth Benedict; Cynthia AshbyBeth Benedict; Cynthia Ashby

• Directors of Speech & Hearing Programs Directors of Speech & Hearing Programs in State Health and Welfare Agenciesin State Health and Welfare Agencies– Linda Pippins; David SavageLinda Pippins; David Savage

JCIH DocumentsJCIH Documents

• 19701970 – National Joint Committee on – National Joint Committee on Newborn Hearing Screening formedNewborn Hearing Screening formed

• 19721972 – Joint Committee on Newborn – Joint Committee on Newborn Hearing Screening Supplement – HRRHearing Screening Supplement – HRR

• 1982 1982 – Joint Committee on Infant – Joint Committee on Infant Hearing (JCIH) StatementHearing (JCIH) Statement

• 19901990–JCIH Position StatementJCIH Position Statement

• 19941994–JCIH 1994 Position Statement: JCIH 1994 Position Statement:

detection of HL by 3 months of age, detection of HL by 3 months of age, intervention by 6 monthsintervention by 6 months

Year 2000 Year 2000

Position StatementPosition StatementPrinciples and Guidelines Principles and Guidelines

for EHDI Programsfor EHDI Programs

JCIH 2000JCIH 2000 Components of an EHDI ProgramComponents of an EHDI Program

Hearing screening: Hearing screening: 1 month1 month Confirmation Confirmation of hearing loss: 3 of hearing loss: 3

monthsmonths Intervention: Intervention: 6 months 6 months (enrollment (enrollment

in early intervention program)in early intervention program)

JCIH 2000JCIH 2000 Components of an EHDI ProgramComponents of an EHDI Program

Multi-disciplinary Multi-disciplinary team approachteam approach

Family-centeredFamily-centered, seamless, , seamless, quality services quality services

Information systemsInformation systems for tracking for tracking & follow-up& follow-up

The Joint Committee on Infant Hearing (JCIH) is recognized both nationally and internationally for its role in shaping public health policy with regard to early hearing detection and intervention (EHDI) programs.

As such, position statements and guidelines have addressed new and emerging issues in EHDI

Since publication of JCIH 2000:

• Data and experiences have become available that impact practice

• Several issues have need to be readdressed

• New data have become available• All have resulted in deliberation and work

by the JCIH over the last five years, ultimately leading to the decision to develop JCIH 2005

White 2003; 2004White 2003; 2004

“Shortage of experienced pediatric audiologists for assessment and hearing aid fitting” obstacle to quality EHDI programs

– 2001: greater concern than 1998

– 2004: 2nd most serious obstacle

Survey of State EHDI OfficialsSurvey of State EHDI Officials

Rankings: 13 Obstacles to Quality EHDI Programs White 2004

Documents Currently Available Documents Currently Available on Pediatric Audiology Serviceson Pediatric Audiology Services

• Pediatric Working Group 1996

• AAA Pediatric Amplification Protocol 2003

• ASHA 0-5 year Guidelines 2004

• AAA – in progress 2005

• JCIH 2000

JCIH 2000JCIH 2000 Personnel ConsiderationsPersonnel Considerations

Provided broad suggestions regarding Provided broad suggestions regarding the assessment & management the assessment & management

procedures and knowledge and skills procedures and knowledge and skills needed by professionals providing needed by professionals providing

services to infants and young childrenservices to infants and young children

• Child & family history

• Electrophysiologic threshold measure

• EOAE

• Measurement of middle ear function

JCIH 2000JCIH 2000 Audiologic Evaluation: birth – 5 monthsAudiologic Evaluation: birth – 5 months

• Child & family historyChild & family history• Behavioral audiometry Behavioral audiometry • EOAEEOAE• Acoustic ImmittanceAcoustic Immittance• Speech perception measuresSpeech perception measures• Parental reportParental report• Screen communication milestonesScreen communication milestones• ‘‘Cross-check’ with ABRCross-check’ with ABR

JCIH 2000JCIH 2000 Audiologic Evaluation: 6 – 36 monthsAudiologic Evaluation: 6 – 36 months

• Prescriptive procedure & real ear measurement

• Verification & Validation

• Complementary or alternative sensory technology (FM; CI)

• Long-term monitoring

JCIH 2000JCIH 2000 Audiologic Habilitation: AmplificationAudiologic Habilitation: Amplification

Delineating a Center for Infant Audiology Service excellence and expertise; Disseminating thos recommendation to State EHDI Coordinators, Early Intervention officials, professionals, and families (Role for JCIH)

versus

Credentialing of Audiologists who provide infant audiology services (Role of professional organizations)

• Contract from Maternal and Child Health Bureau to Boys Town National Research Hospital– Develop and disseminate recommendations

on infant audiology services

• Initially: survey, review & collection of documents relating to existing pediatric audiology practice in U.S. and other countries (Canada, UK, Australia)

– Brandt Culpepper, Townsend University

Data Collection - 2003

• Survey of State EHDI systems

• Web searches for additional resources

• Compiled & Reviewed national & international policies, guidelines, and recommendations

Culpepper

American SamoaCommonwealth N. Mariana Is.GuamPuerto RicoVirgin Islands

States with List of Infant Audiology Service Providers

Yes

Pending

No

Culpepper 2003


States with Infant Hearing Assessment Guidelines

Recommended

Pending

Nonedeveloped

Mandatory

Culpepper 2003


States with Infant Amplification GuidelinesStates with Infant Amplification Guidelines

Existing

Pending/Draft

No knowndocument

Mandatory

Culpepper 2003


States with ‘Credentials’ Recognizing Pediatric Audiologists

Yes

Pending

No

N=56

Culpepper 2003

MCHB Working Group on Infant MCHB Working Group on Infant Audiology ServicesAudiology Services

• Patrick Brookhouser • Barbara Cone-

Wesson• Brandt Culpepper• Judy Gravel• Michael Gorga• Mary Pat Moeller• Linda Pippins

•Jack Roush

•Richard Seewald

•Yvonne Sininger

•Patricia Stelmachowicz

•Anne Marie Tharpe

•Judy Widen

•Christie Yoshinaga-Itano

MCHB Working Group on Infant Audiology Services

• Conducted face-to-face meeting• Reviewed materials• Drafted document on

assessment, management and follow-up of infants with hearing loss & their families

• Shared goal of seamless service provision within family centered context

• Knowledge of entire pediatric hearing health care service delivery system

• Audiologic services delivered within context of the EHDI system

MCHB Working Group: MCHB Working Group: Key Principles of Key Principles of

Infant Audiology ServicesInfant Audiology Services

National EHDI Goals

• Goal 1: screening by 1 month

• Goal 2: screen positive infants receive diagnostic audiologic assessment before 3 months

• Goal 3: infants with hearing loss begin appropriate early intervention before 6 months

National EHDI GoalsNational EHDI Goals• Goal 4: infants & children with late onset,

progressive, or acquired hearing loss receive early ID

• Goal 5: infants with hearing loss will have a medical home

• Goal 6: States will have complete EHDI Tracking & Surveillance System to minimize loss to follow-up.

• Goal 7: States will have comprehensive system that monitors and evaluates progress towards the EHDI Goals & Objectives.

• Personnel with experience in assessment & management of infants and children with hearing loss

• Commensurate knowledge & test equipment necessary for use with current pediatric hearing assessment methods & hearing aid selection and evaluation procedures



• Audiologic diagnostic process is ongoing: frequent follow-up visits necessary

• Timely provision of services, without long delays between tests



• Hearing aid fitting, early intervention & referral for medical evaluation proceed as soon as hearing loss is confirmed

• Complete medical evaluation & child and family history are part of diagnostic process



• Changing ear canal acoustics: impact on assessment & management

• Otitis Media with Effusion (OME)

• Sedation



Components of Hearing Assessment to Confirm Hearing Loss by 3 months of age

• Case/family history• Otoscopic inspection• FS air- & bone-conduction ABR thresholds• High-level click-ABR • EOAE• Tympanometry (1 kHz probe freq) & AMEMR• Observations of auditory behaviors• Counseling family

MCHB Working Group:

Facilities & Equipment Specific to Facilities & Equipment Specific to Electrophysiologic Testing of InfantsElectrophysiologic Testing of Infants

• Electrophysiologic instrument – Capable of frequency-specific air- and

bone-conducted assessment

– Option for using contralateral masking and ipsilateral notched-noise masking

MCHB Working Group:

Facilities & Equipment Specific to Facilities & Equipment Specific to Electrophysiologic Testing of InfantsElectrophysiologic Testing of Infants

• Diagnostic OAE instrument– providing more that pass-refer outcome– variable stimulus type, frequency, level– flexible response-analysis techniques

• Acoustic immittance equipment – 1 kHz and 226 Hz probe frequency options– Contralateral & ipsilateral AMEMR options

MCHB Working Group:

Facilities for Behavioral Audiologic Diagnostic Assessment

• Conditioned response procedures (VRA, TROCA, CPA)

• Sound treated test booth

• Audiometer with insert earphones

• Bone vibrator with pediatric headband

• Sound field capability

• Multiple toy reinforcers/cabinets and/or video reinforcement system

• EOAE• Real-ear

measurement system• Acoustic immittance

system• Sound level meter

MCHB Working Group:

Facilities for Amplification Selection & Fitting

• Audiometric assessment/acoustic immittance

• Instrumentation to perform electroacoustic analysis & real ear measures with test signals appropriate for use with current technology

• Computer system allowing use of fitting software for current technology

MCHB Working Group:

Facilities for Amplification Facilities for Amplification Selection & FittingSelection & Fitting

• Consignment hearing aids appropriate for infants & toddlers

• Equipment & supplies: high-quality ear mold impressions in infant ears

• Appropriate test environment

• Loaner hearing aid program

• Hearing Aid Orientation kits

MCHB Working Group:

Based on MCHB Working Group document:

JCIH Stratification System for Quality Infant Audiology Services

Levels of Service – MA Model (infants & children required to be referred to DPH-approved facilities)

• Level 1 – serve children birth to 3 years– Sedated & non-sedated ABR– Other traditional pediatric audiologic testing

• Level 2 – serve children birth to 3 years– non-sedated ABR– Other traditional pediatric audiologic testing

• Level 3 – serve children 6 months (CA) to 3 years– Other traditional pediatric audiologic testing including, but

not limited to sound field testing, play audiometry, tympanometry, and OAE,

Development and Dissemination of Development and Dissemination of Materials on JCIH QIAS Stratification Materials on JCIH QIAS Stratification SystemSystem

• Families

• State EHDI Coordinators

• Primary Care Providers

Terry Davis, LSU Medical Center – healthcare literacy; MCHB contract

JCIH 2005 JCIH 2005 Position Statement and GuidelinesPosition Statement and Guidelines

In Development:In Development:

Maintain general framework of JCIH 2000Maintain general framework of JCIH 2000

• Provide interval history 2000-2005Provide interval history 2000-2005– Recognize federal agencies in the development of Recognize federal agencies in the development of

EHDI systemsEHDI systems

• Review relevant literature published in the Review relevant literature published in the interval & updateinterval & update


Update, Expand & Revise Principles:Update, Expand & Revise Principles:

• PreventionPrevention

• Family centered EHDI processFamily centered EHDI process

• 1-3-6 maintained 1-3-6 maintained

• Timely access to high-quality technology; reimbursedTimely access to high-quality technology; reimbursed



• Simplified, integrated point of entry to early Simplified, integrated point of entry to early intervention systemintervention system

• Professionals: pediatric-specific & discipline-Professionals: pediatric-specific & discipline-appropriate knowledge and skillsappropriate knowledge and skills

• Monitoring for hearing loss & surveillance effortsMonitoring for hearing loss & surveillance efforts



• Information for families; professional Information for families; professional continuing and pre-professional continuing and pre-professional educationeducation



• Information systems – electronic health Information systems – electronic health records records

• Reimbursement for professional servicesReimbursement for professional services


2005 overarching theme: Follow-up 2005 overarching theme: Follow-up

• Highlight challenges impacting follow-up Highlight challenges impacting follow-up and tracking of infants after screeningand tracking of infants after screening

• Offer recommendationsOffer recommendations


Issues Related to Follow-up:Issues Related to Follow-up:

• States sharing information on individual States sharing information on individual childrenchildren

• Assignment of follow-up responsibilities at Assignment of follow-up responsibilities at each step of the EHDI processeach step of the EHDI process



• Organized surveillance efforts after the Organized surveillance efforts after the newborn periodnewborn period

• Screening of communication milestonesScreening of communication milestones



• Targeting special populations for intense follow-up:Targeting special populations for intense follow-up:– Multiple disabilitiesMultiple disabilities– Unilateral hearing lossUnilateral hearing loss– Mixed hearing loss: breaking cycle of delayed confirmatory Mixed hearing loss: breaking cycle of delayed confirmatory

teststests– Possible candidates for CIPossible candidates for CI


Revisions in Existing Sections:Revisions in Existing Sections:

• ScreeningScreening

• Auditory neuropathy sectionAuditory neuropathy section

• Audiologic Habilitation section Audiologic Habilitation section

• Early Intervention sectionEarly Intervention section

• Surveillance section Surveillance section


• Revision of surveillance section:Revision of surveillance section:“Risk Indicators for Progressive or Delayed-Onset

Sensorineural Hearing Loss and/or Conductive Hearing Loss”– Audiologic monitoring of infants with risk indicators

who pass NHS– Every 6 months to age 3 years


• Concept Paper 2003: White (NCHAM) Concept Paper 2003: White (NCHAM) • Questioned the desirability of the JCIH 2000 Questioned the desirability of the JCIH 2000

surveillance recommendationsurveillance recommendation• Concluded that:Concluded that:

– little evidence regarding late-onset hearing loss in little evidence regarding late-onset hearing loss in infants with risk indicatorsinfants with risk indicators

– practice of gathering risk factors in neonatal period practice of gathering risk factors in neonatal period was costly & time consuming and likely to be missedwas costly & time consuming and likely to be missed

– Feasibility of audiologic evaluation of infants 2 x yearFeasibility of audiologic evaluation of infants 2 x year– ? Wise use of limited resources? Wise use of limited resources

In 2003, JCIH worked on revision of surveillance section and considered:

• Medical Home role: – ID risk indicators regardless of screening pass– Query parent at each visit regarding communication:

refer on parent concern– Refer any child with diagnosed disability– Routine screening of communication development; refer

any child with delays

• Testing hearing of every child enrolled in the Early Intervention System

Revisions in Existing Sections:Revisions in Existing Sections:

• Roles & Responsibilities: will now address transitioning Roles & Responsibilities: will now address transitioning from birth to 3 programs to 3 to 5 programsfrom birth to 3 programs to 3 to 5 programs

• Institution and agencies: to include Federal Institution and agencies: to include Federal commitment to pre-professional and professional commitment to pre-professional and professional trainingtraining


Other Issues/Topics:Other Issues/Topics:

• Genetics & genetic Genetics & genetic counseling/evaluation in the EHDI counseling/evaluation in the EHDI contextcontext


www.jcih.org

an update an update judith gravel, phd chair, jcih the children’s hospital of philadelphia

Documents

intervention ehdi programs

ehdi programsjcih

publication of jcih

early hearing detection

ehdi programhearing

quality ehdi programs2001

quality ehdi programs

young children jcih