Trends in Early Identification and Early Intervention in Infants Identified with Hearing Loss

Introduction

As the first decade of the 21st century comes to a close, opportunities for communication and educational success for young children with hearing loss have never been better. This newfound success has been built upon changes in the early identification of hearing loss, the timely provision of appropriate early intervention services, and the effective use of advanced hearing technology, such as digital hearing aids and cochlear implants. Speech-language pathologists, as key members of an interdisciplinary team, often render a vital service in developing the communication abilities of young children with hearing loss. To be effective in this role, speech-language pathologists must be aware of the historical trends in universal newborn hearing screening and how these programs are being implemented around the country. Furthermore, speech-language pathologists must be knowledgeable about the communication outcomes that are occurring for children with hearing loss who are identified early and receive appropriate audiological follow-up and early intervention services.

Universal Newborn Hearing Screening: Historical Timeline

Permanent hearing loss is the most common birth defect in the United States - affecting approximately three newborns per 1000 births (White, 2004). Unfortunately, the practice of screening the newborn's hearing took decades to implement, even though medical professionals advocated such steps more than sixty years ago (Ewing & Ewing, 1958).

In the mid 1960's, the Babbidge Report (Babbidge, 1965) to the U.S. Secretary of Health, Education, and Welfare recommended a universal approach for the "early identification and evaluation of hearing impairment." While some states had effective programs to identify children who were a high risk for hearing loss, children who did not present with any risk indicators - some 50% of the population - usually left the hospital or birthing center without a diagnosis. Thus, a more reliable and universal (i.e., screening all newborns not just those who are high risk) approach to newborn hearing screening was needed (U.S. Preventive Services Task Force, 2008).

Screening a newborn's hearing was hampered due to a lack of sensitive testing equipment and reliable procedures, which resulted in limited progress in implementing universal newborn hearing screening programs. Then, in the mid 1980s, the emergence of inexpensive and accurate hearing screening equipment (Herrmann, Thorton, & Joseph, 1995; Kemp & Ryan, 1993) allowed infants and young children to have their hearing screened effectively and efficiently.

In 1988, at least three significant events occurred to further focus attention on the need to identify infants with hearing loss. First, the Commission on Education of the Deaf published "Toward Equality: Education of the Deaf," (Commission on Education of the Deaf, 1988) that documented the average age of identification for profoundly deaf children in the United States was 2.5.

Second, a group of national experts was convened by the U.S. Department of Education and the Bureau of Maternal and Child Health to advise federal agencies about the viability of establishing early hearing screening and identification guidelines. The advisory group recommended that demonstration projects be established to study the cost efficiency of screening techniques that were in use but not widely available (Advisory Group on the Early Identification of Children with Hearing Impairments, 1988).

Later that year, Surgeon General C. Everett Koop issued a challenge to the nation: "By the year 2000, 90% of children with significant hearing loss be identified by 12 months of age" (Mauk & Behrens, 1993). Dr. Koop's challenge raised the public awareness of childhood hearing loss and placed needed pressure on the medical and educational communities to implement new procedures that would speed the early identification of hearing loss in newborns.

The Joint Committee on Infant Hearing (JCIH), a group of representatives from professional organizations that have an interest in the early identification of childhood hearing loss and early intervention, issued a position statement in 1990 that recommended high-risk infants be screened for hearing loss prior to their discharge from the hospital or birthing center and no later than three months after their birth (JCIH, 1990). Within the same year, the U.S. Department of Health & Human Services released the "Healthy People 2000" report (U.S. Department of Health & Human Services, 1990), which established broad national goals and objectives on a range of public health issues. The report established the goal of reducing "the average age at which children with significant hearing impairment are identified to no more than 12 months by year 2000."

By the early 1990s, considerable momentum was in place nationally and in many states to implement standards for universal newborn hearing screening. In 1993, the National Institutes of Health (NIH) issued a consensus statement - "Early Identification of Hearing Impairment in Infants and Young Children" (NIH, 1993) − recommending that all newborns be screened for hearing loss prior to leaving the hospital or birthing center. A year later, the JCIH released another position statement that recommended "all infants with hearing loss should be identified before three months of age and receive intervention by six months of age" (JCIH, 1994). By 1999, the American Academy of Pediatrics (AAP) fully endorsed the recommended practices set forth by the JCIH (Pediatrics, 1999).

The turn of the century brought a new JCIH position statement (JCIH, 2000) that further defined the principles and operating guidelines for state-level Early Hearing Detection and Intervention (EHDI) Programs. These standards were adopted widely, resulting in approximately 45 states requiring or mandating some form of universal newborn hearing screening and tracking program. Because of these efforts, more than 96% of all newborns today receive a hearing screen before they leave the hospital or birthing center (National Center for Hearing Assessment & Management, 2009).

While universal newborn hearing screening has proven to be effective, an estimated 50% of infants who experience a failure result during the screening protocol do not receive a confirmed diagnosis from a pediatric audiologist or do not enroll in early intervention services (Center for Disease Control, 2008). These infants have been labeled "lost to follow-up" and considerable efforts are now being employed at the state and national levels to ensure that children receive a timely diagnosis of hearing loss and are immediately enrolled in early intervention services. In 2007, the JCIH released another position statement (JCIH, 2007) that addressed various issues related to lost to follow-up. Namely, the JCIH illuminated specific areas of concern and made recommendations that support a more effective and seamless EHDI system, decrease the loss to follow-up, and improve outcomes for all children with hearing loss (JCIH, 2007).