TVR_106-3

Volume 106, Number 3
ISSN 0042-8639
Winter 2006
The Volta Review
Alexander Graham Bell Association
for the Deaf and Hard of Hearing
Early Hearing Detection and Intervention:
Trends, Progress and Challenges
Edited by
Melody Harrison, Ph.D.

Volume 106, Number 3
ISSN 0042-8639
Winter 2006
The Volta Review
Alexander Graham Bell Association
for the Deaf and Hard of Hearing
Early Hearing Detection and Intervention:
Trends, Progress and Challenges
Edited by
Melody Harrison, Ph.D.

The Volta
Review
Early Hearing Detection and
Intervention: Trends, Progress
and Challenges
233 Foreword
Melody Harrison, Ph.D.
237 Early Intervention for Children with Permanent Hearing Loss:
Finishing the EHDI Revolution
Karl R. White, Ph.D.
259 Statewide Collaboration in the Delivery of EHDI Services
Joni Alberg, Ph.D., Kathryn Wilson, M.A., CCC-SLP, Cert. AVT, and
Jackson Roush, Ph.D., CCC-A
275 Family Empowerment: Supporting Language Development in
Young Children Who Are Deaf or Hard of Hearing
Jean L. DesJardin, Ph.D.
299 Management of Young Children with Unilateral Hearing Loss
Sarah McKay, Au.D.
Volume 106, Number 3
ISSN 0042-8639
Winter 2006
Organized in 1890 to encourage the teaching of speech, speechreading and the use of residual hearing to
people who are deaf or hard of hearing, the Alexander Graham Bell Association for the Deaf and Hard of
Hearing (AG Bell) welcomes to its membership all who are interested in improving educational, professional
and vocational opportunities for people who are deaf or hard of hearing. Affiliated with AG Bell are the
Parent Section, the Deaf and Hard of Hearing Section and the International Professional Section.
321 Early Spanish Speech Acquisition Following Cochlear Implantation
Jan Allison Moore, Ph.D., Scott Prath, M.A., and Adrianne Arrieta, M.A.
343 Bilateral Cochlear Implantation in Children: Experiences
and Considerations
Andrea Bohnert, M.T.A.-F., Vera Spitzlei, Dipl.-Ing., Karl L. Lippert, Ph.D.,
Dipl.-Ing., and Annerose Keilmann, M.D.

365 Early Cochlear Implant Experience and Emotional Functioning
During Childhood: Loneliness in Middle and Late Childhood
Efrat A. Schorr, Ph.D.
381 Early Hearing Detection and Intervention in Developing
Countries: Current Status and Prospects
Bolajoko O. Olusanya, M.D., M.Phil.
419 Beyond Early Intervention: Providing Support to Public
School Personnel
Kathryn Wilson, M.A., CCC-SLP, Cert. AVT
433 Author Index for Volume 106
Permission to Copy: The Alexander Graham Bell Association for the Deaf and Hard of
Hearing, as copyright owner of this journal, allows single copies of an article to be made for
personal use. This consent does not extend to posting on Web sites or other kinds of
copying, such as copying for general distribution, for advertising or promotional purposes,
for creating new collective works of any type, or for resale without the express written
permission of the publisher. For more information, contact AG Bell at 3417 Volta Place,
NW, Washington, DC 20007, e-mail editor@agbell.org, or call 202/337-5220 (voice) or
202/337-5221 (TTY).
232 Table of Contents

The Volta Review, Volume 106(3) (monograph), 233-235
Foreword
Melody Harrison, Ph.D.
When I began working at the University of North Carolina over 25 years
ago, the first child I served in our university clinic was an 11-month-old infant
who had a severe-to-profound hearing loss. At that time, she was the youngest
child with whom I had ever worked. I was thrilled to have the opportunity
to provide speech and language services to a young mother and a baby who
wasn’t even old enough to qualify as a toddler!
Today in many parts of the world, including the United States, identification
of hearing loss at age 10 months and fitting with hearing aids at 11
months would be considered woefully late. Between 1993 and 2005, the percentage
of newborns in the United States whose hearing was screened at birth
rose from 3 to 93 percent and the age at which hearing loss was confirmed
dropped dramatically. Digital hearing aids became available and cochlear
implant technology improved. Equally significant was the development of a
procedure for fitting hearing aids to the unique properties of a child’s small
but growing ears.
The combination of early identification and technological innovation has
provided us with the tools to revolutionize long-term outcomes for children
who are deaf or hard of hearing. Yet, we are faced with challenges few
professionals could have imagined 15 years ago. Although the benefits of
early intervention are gaining increasing acceptance around the world, in
areas where resources are meager, the age of identification is measured in
years rather than months and intervention is not at all early. For some children,
it is nonexistent. In those places, we must think collectively and creatively
about how to use current technology in a manner that meshes with the
cultural and economic realities of a specific region.
Even prosperous countries such as the United States experience the significant
strains early identification has placed on early intervention services.
Access to qualified providers for families and children with hearing loss
continues to be a major challenge. Few professionals have been adequately
prepared to work with children ages birth to 3, and the majority have not
been educated in methodologies that promote access to spoken language. In
fact, many professionals who work under the direction of a state’s Part C
early intervention program have no educational background in childhood
hearing loss at all. Further, there is little research to guide professionals to
Foreword 233

serve children with a mild, moderate or unilateral hearing loss—all which can
now be identified shortly after birth. As increasing numbers of children are
identified with hearing loss at earlier ages, the number of children referred for
services continues to steadily rise, creating further demands for qualified
service providers. Although the challenges related to service coordination can
appear insurmountable, the potential for making an extraordinary difference
in the lives of young children with hearing loss has never been greater.
This monograph on early intervention unites contributors from around the
world, from Nigeria to Israel, Germany and the United States, and offers a
range of perspectives and approaches to the conundrums that, to some degree
or another, we all face. We begin our journey in the United States with Karl
White, Ph.D., director of the National Center for Hearing Assessment and
Management, who discusses potential solutions for the challenges faced by
early intervention service providers across the country following wider
implementation of newborn hearing screening.
Next, Joni Alberg, Ph.D., executive director of BEGINNINGS for Parents of
Children Who Are Deaf and Hard of Hearing, Inc., and her colleagues outline
a model of collaboration among state agencies to benefit children and families
in North Carolina.
Jean Desjardin, Ph.D., advanced research associate in the Children’s Research
and Evaluation (CARE) Center at the House Ear Institute, explores the
relationship between parents’ sense of their own competence to guide their
child’s early development and how it influences their child’s acquisition of
spoken language.
In the past, many children with unilateral hearing loss were identified only
after they had begun to struggle academically during their school years.
Newborn hearing screening now makes it possible to identify this population
at birth. Sarah McKay, Au.D., senior audiologist at the Center for Childhood
Communication at The Children’s Hospital of Philadelphia, focuses on the
issues and challenges associated with managing unilateral hearing loss in
very young children.
For many years, bilingual learners in the United States were located almost
solely along the southwestern border of the country. Today, none of the 48
contiguous states is completely unilingual. Jan Moore, Ph.D., and colleagues
present a case study of the spoken Spanish-language development of a child
who received a cochlear implant at age 20 months. The case study is designed
to expand on existing knowledge regarding Spanish language development
among at-risk children to improve services for this population.
Next, Andrea Bohnert, M.T.A.-F., and colleagues at the University Clinic
Mainz, Germany, share their experiences with bilateral implantation and auditory
development among 41 young children. The article also discusses several
factors that must be considered when evaluating children for bilateral
implants.
Efrat Schorr, Ph.D., a postdoctoral fellow at the Gonda Brain Research
234 Foreword

Center at Bar Ilan University, Ramat Gan, Israel, investigates the relationship
between early cochlear implantation and its effects on loneliness in middle
and late childhood.
London-based Bolajoko Olusanya, M.D., M.Phil., explores different approaches
to culturally appropriate early identification and intervention in
developing countries as well as key challenges and possible approaches to
building service capacity.
Our journey ends in the Unites States, where Kathryn Wilson, M.A., CCC-
CLP, Cert. AVT, director of the Resource Support Program at the Office of
Education Services for the North Carolina Department of Health and Human
Services, transitions the reader out of early intervention into the realm of
public school. Wilson’s article describes a service model used in North Carolina
to support public school teachers serving children who have transitioned
from early intervention services.
In the spirit of the unique cultural, governmental and professional frameworks
within which we all work, the articles in this monograph issue are
intended to prompt us to think critically about each topic and ask, “What can
I implement in my setting?” “What theories and practices do I question?”
“What excites me?” My hope is that each of you will read with a critical mind
and open heart as we move forward in our shared quest to provide the very
best to each child and family we serve.
Melody Harrison, Ph.D.
Foreword 235

The Volta Review, Volume 106(3) (monograph), 237-258
Early Intervention for
Children with Permanent
Hearing Loss: Finishing the
EHDI Revolution
Karl R. White, Ph.D.
The value of identifying permanent hearing loss during the first few months of life
and providing effective treatment to ameliorate or even eliminate the negative consequences
has been recognized for many decades. Unfortunately, improvements in
achieving this goal were very gradual until the early 1990s. At that time, the combination
of technological advances in screening and diagnostic equipment and hearing
technologies created a revolution in our ability to identify and provide
intervention to children with permanent hearing loss during the first few months of
life.
Evidence continues to accumulate that for those children who are identified early
and provided with appropriate hearing technologies and early intervention, dramatic
progress is often possible. However, there are many infants and young children who
are not yet benefiting from this revolution because timely and appropriate early
intervention services are not available in many parts of the country. Part of the reason
why so many children are missing out on these benefits is there has not been sufficient
coordination between the state Early Hearing Detection and Intervention (EHDI)
programs and the federally sponsored Infant and Toddler programs for which states
receive partial funding under Part C of the Individuals with Disabilities Improvement
Act of 2004. This article discusses how the early intervention aspects of EHDI
programs could be improved by closer attention to the components required under
Part C of eligibility criteria, child-find and referral systems, preservice and inservice
personnel development, coverage of hearing aids and public awareness programs.
Introduction
At the beginning of this decade, the U.S. Department of Health and Human
Services issued national health objectives (Healthy People 2010, 2000) that
Karl White, Ph.D., is a professor of psychology at Utah State University and the founding
director of the National Center for Hearing Assessment and Management (NCHAM).
Finishing the EHDI Revolution 237

identified the most significant preventable threats to the health of people in
the United States and established national goals to improve people’s health
and well-being. Developed by a broad array of stakeholders and using the
best scientific evidence available, the objectives in Healthy People 2010 were
predicated on the simple but powerful idea that broad awareness of understandable
health objectives will enable various stakeholders to work together
to achieve important outcomes.
The fact that early identification of permanent hearing loss in children 1 was
included as one of the goals in this high-visibility national plan is an important
indication of how thinking about early identification and intervention
with children who are deaf or hard of hearing (referred to hereafter as DHH
children) has changed over the last 20 years. Goal 28-11 from Healthy People
2010 states, “Increase the proportion of newborns who are screened for hearing
loss by age 1 month, have audiologic evaluation by age 3 months, and are
enrolled in appropriate intervention services by age 6 months.” The idea
behind this goal is not new, but the belief that it could be achieved is a
significant change in what people have believed for the past hundred years.
Some of the first to advocate for systematic and sustained efforts to identify
DHH children during the first few months of life were Ewing and Ewing
(1944), when they called for the:
need to study further and more critically methods of testing hearing in
young children . . . during this first year the existence of deafness needs to
be ascertained . . . training needs to be begun at the earliest age that the
diagnosis of deafness can be established. (page 309)
For more than 50 years following the Ewings’ call to action, many people
agreed that it was important to identify DHH children early and provide
early intervention services, but most were skeptical that it could be done
effectively. For example, as recently as 1996, the prestigious United States
Preventive Services Task Force, while noting that “congenital hearing loss is
a serious health problem associated with developmental delay in speech and
language function,” concluded that “there is little evidence to support the use
of routine, universal screening for all neonates.”
Skepticism about the practicality of early identification and intervention
with DHH children began to change in the late 1980s when Dr. C. Everett
Koop, then the Surgeon General of the United States, recognized the potential
of technological advances in procedures and equipment for revolutionizing
1 Many different terms are used to refer to children with permanent hearing loss (e.g., deafness,
hearing impairment, auditory disorders). Recognizing that there are limitations to any single
term, this article will use the term “deaf and hard of hearing (DHH) children” to refer to children
who are deaf or hard of hearing, except in those cases where another source is being quoted.
238 White

the way in which newborn hearing screening, diagnosis, and early intervention
was being done.
Deafness in infants is a serious concern because it interferes with the development
of language–that which sets humans apart from all other living
things . . . early intervention with hearing impaired children results in improved
language development, increased academic success, and increased
lifetime earnings . . . [and] actually saves money since hearing impaired
children who receive early help require less costly special education services
later . . . . I am optimistic. I foresee a time in this country . . . when no
child reaches his or her first birthday with an undetected hearing impairment.
(as reported in Northern & Downs, 1991, pp. 2-3)
Dr. Koop’s commitment to early identification of DHH children and his
optimism that it could be successfully implemented surprised many people,
especially because fewer than 3% of all newborns in the United States were
screened for hearing loss at that time (White, 2004). The average age of identification
of DHH children was 2 1 ⁄2 to 3 years and had changed little during
the previous fifty years (Toward Equality, 1988).
As a result of Dr. Koop’s efforts, the Department of Health and Human
Services established a goal to “reduce the average age at which children with
significant hearing impairment are identified to no more than 12 months”
(U.S. Department of Health and Human Services, 1990). The rationale that
accompanied this objective stated:
. . . it is difficult, if not impossible, for many [children with congenital
hearing loss] to acquire the fundamental language, social, and cognitive
skills that provide the foundation for later schooling and success in society.
When early identification and intervention occur, hearing impaired children
make dramatic progress, are more successful in school, and become
more productive members of society. The earlier intervention and habilitation
begin, the more dramatic the benefits. (p. 460)
During the next 15 years, positive changes in early identification of DHH
children began happening faster and faster. Instead of the gradual evolutionary
changes that had characterized the previous 100 years, revolutionary
changes that began to occur improved both the process and the outcomes in
many areas for DHH children. For example, as shown in Figure 1, the percentage
of newborns screened for hearing loss increased from 3% in 1993 to
93% in 2005 (NCHAM, 2006a). The widespread implementation of universal
newborn hearing screening programs reduced the average age of identification
for DHH children from 30 months to six months as noted by Harrison,
Roush and Wallace (2003).
Forty states have now passed legislation requiring newborn hearing
Finishing the EHDI Revolution 239

Figure 1. Percentage of newborns screened for hearing loss.
screening (NCHAM, 2006b), and the number of children under age 5 receiving
cochlear implants has more than quadrupled in the last five years to over
2,000 children per year (NCHAM, 2006c). These changes mean that for those
DHH children who are identified early, fit with appropriate hearing aids or
cochlear implants and receive early intervention services from appropriately
trained staff, many are able to progress at age-appropriate rates (Kennedy et
al., 2006; Moeller, 2000; Yoshinaga-Itano, Sedey, Coulter, & Mehl, 1998), require
few, if any, special education services and result in educational cost
savings of at least $400,000 per child (Honeycutt et al., 2003; Mohr et al., 2000).
Although many more DHH children are receiving the benefits of early
intervention and modern assistive listening devices now compared to 20
years ago, there are still many DHH children and their families who are not
(CDC, 2006a). In fact, a recent letter sent to all state early intervention programs
from officials at the Department of Education and the Department of
Health and Human Services (NCHAM, 2006d) noted that there was a “growing
national crises in the provision of essential early intervention and health
care services for infants and toddlers with hearing loss.” That letter stated:
Studies have demonstrated that when hearing loss of any degree, including
mild bilateral or unilateral hearing, is not adequately diagnosed and addressed,
the hearing loss can adversely affect the speech, language, academic,
emotional, and psychosocial development of young children . . .
Although efforts to identify and evaluate hearing loss in young children
have improved, there is still anecdotal evidence to suggest that many
240 White

young children with hearing loss may not be receiving the early intervention
or other services they need in a timely manner that will enable them to
enter preschool and school ready to succeed.
As emphasized by this letter, the importance of providing effective early
intervention services to DHH children is the focus of increased emphasis, and
there is widespread agreement that the families of DHH infants and young
children should have access to appropriate educational services in whatever
mode of communication the family chooses (OSERS, 2006). However, this is
impossible in many parts of the country because of serious shortages and
inadequate geographical distribution of:
• educational programs that use the most up-to-date methods for teaching
language in the mode of communication selected by the family,
• health care and education professionals who are trained and knowledgeable
about current methods for effectively educating children with hearing
loss,
• adequate in-service training programs for individuals already in the field
of deaf education and preservice programs for individuals entering the
field and
• information, public awareness and family support programs for helping
families make informed decisions about the educational options for
DHH children.
The shortages noted above have occurred in part because of the success of
universal newborn hearing screening. The fact that the average age of identification
had gone from 30 months to three months during the past ten years
means that there are many more DHH infants and toddlers to be served.
Twenty years ago, most of these children were not identified until they were
too old to qualify for birth-to-three programs. As shown in Figure 2, federally
funded Part C programs that serve children ages birth to three have historically
served between 1.2 and 2.3 percent of this population. Newborn hearing
screening programs are adding another three children per thousand, which
equates to a 17% increase in the average number of infants and toddlers
served during the last 15 years. Such an increase is difficult for a program to
accommodate when it is already seriously underfunded (Limb, McManus, &
Fox, 2006).
Another factor contributing to these shortages is that in most parts of the
country, early intervention systems for DHH children were developed at a
time when the majority of DHH children were not identified until two to five
years of age, and digital hearing aids and cochlear implants were not available;
thus, the nature of services provided was very different. Very few Part
C early intervention providers have the specialized training necessary to
provide state-of-the-art services to DHH infants and toddlers (Marge &
Finishing the EHDI Revolution 241

Figure 2. Percentage of infants and toddlers served in Part C programs.
Marge, 2005). For example, prior to universal newborn hearing screening
programs, the vast majority of DHH children identified before age 3 were
those with severe or profound bilateral hearing losses. Today, many infants
and toddlers with mild and moderate or even unilateral hearing losses are
being identified before age 3 months. These children require very different
types of services than those needed by DHH children with bilateral severe/
profound losses.
The initiation of universal newborn hearing screening in the early 1990s
started a revolution in our ability to identify DHH children at very young
ages. These revolutionary changes provide great opportunities, but many
DHH children and their families are not yet benefiting to the degree that they
should. How can this situation be improved? Although the solutions will
require many different strategies and resources from many stakeholders, part
of the solution is already in place–but underutilized. In 1997, Congress passed
Public Law (PL) 99-457–the Individuals with Disabilities Education Act (IDEA),
which provided resources and guidelines for all states to offer early intervention
services to infants and toddlers with disabilities. Better coordination
between this federal program and the activities of state EHDI programs
would do much to strengthen the early intervention components of EHDI
programs. The remainder of this article will show how the Infant and Toddler
portion of IDEA (often referred to as Part C after the section of the law that
outlines how states must provide services to infants and toddlers with disabilities)
can be used to finish the EHDI revolution. By using the framework
and infrastructure defined by Part C of IDEA, professionals serving DHH
children and their families will be more effective in creating successful early
intervention services for thousands of DHH infants and toddlers being identified
by universal newborn hearing screening and diagnostic programs.
242 White

Part C of IDEA
In 1975, Congress recognized that children with disabilities often did not
receive the education and related services needed to make the developmental
progress of which they were capable. As a result, Congress passed landmark
legislation in 1975 (PL 94-142, The Education for All Handicapped Children Act),
requiring states to provide all 5- to 21-year-old children with disabilities with
a free and appropriate education in the least restrictive environment. In 1986,
Congress amended that Act with PL 99-457, which was reauthorized and
amended in 1997 as PL 105-17, and again in 2004 as PL 108-446. In the 1986
amendments, Congress called for the creation of statewide, coordinated, multidisciplinary,
interagency programs for the provision of appropriate early
intervention services for all infants and toddlers with disabilities. This section
of the law, known as Part C (formerly known as Part H), did not actually
require states to provide early intervention services but instead made partial
reimbursement of the costs of services readily available to states that wished
to participate. All states have chosen to participate and have established Part
C programs for children ages birth to three years. Section 631 of the current
law (the Individuals with Disabilities Education Improvement Act: Part C–Infants
and Toddlers with Disabilities) is designed to:
• enhance the development of infants and toddlers with disabilities to
minimize the potential for developmental delay,
• reduce the education costs to society by minimizing the need for special
education and related services after infants and toddlers with disabilities
reach school age,
• minimize the likelihood of institutionalization and maximize the potential
for independent living in society,
• enhance the capacity of families to meet the needs of their children and
• enhance the capacity of states and local programs to meet the needs of
underrepresented populations, particularly minority, low income, inner
city and rural populations.
States choosing to participate in the Part C program (which all states have
done) are required to meet a set of minimum requirements as outlined in
Section 635 of the statute (NECTAC, 2006). Some of these requirements govern
the system’s infrastructure and apply in about the same way for all
children with disabilities (e.g., designating a lead agency for providing general
administration and supervision, developing policies for contracting for
services, providing procedures for timely reimbursement of funds, establishing
procedural safeguards, compiling and reporting data about the early
intervention system and creating a state interagency coordinating council).
The remaining requirements call for the creation of components to be applied
differently depending on the child’s disability. Better understanding of these
Finishing the EHDI Revolution 243

components will contribute to improving the quality of early intervention
services for DHH children. The following components are particularly relevant
for creating a strong EHDI system and will each be discussed in the
following sections: (1) eligibility criteria, (2) comprehensive child-find and
referral systems (3) comprehensive systems of personnel development, (4)
appropriate early intervention services and (5) public awareness programs.
Section 634 of the law notes that:
Eligibility Criteria
in order to be eligible for a grant . . . a state shall provide assurances to the
secretary that the state has adopted a policy that appropriate early intervention
services are available to all infants and toddlers with disabilities in
the state and their families.
The federal regulations accompanying the law (34 CFR Part 303.16) require
states to provide appropriate early intervention services to any infant or
toddler:
who is experiencing developmental delays as measured by appropriate
diagnostic instruments and procedures in one or more of the areas of
cognitive development, physical development, communication development,
and adaptive development; or [who has] a diagnosed physical or
mental condition that has a high probability of resulting in developmental
delay.
Infants and toddlers with permanent hearing loss will almost always exhibit
developmental delays in one or more of the specified developmental
areas if appropriate early intervention services are not provided. However,
existing measures of development are not sensitive enough to measure these
delays until children are at least a year old, which is far too late for early
intervention programs to begin. (Kral & Tillein, 2006; Yoshinaga-Itano, Sedey,
Coulter, & Mehl, 1998). Thus, if they are to be eligible, most DHH children
will have to qualify for Part C services under the condition that they have “a
diagnosed physical or mental condition that has a high probability of resulting
in developmental delay.” In fact, the federal regulations for this section of
the law use “severe sensory impairments, including hearing and vision” as
one of the examples that would make a child with no measured delays eligible
for Part C services.
How the eligibility criteria are operationalized is left to the discretion of
each state, but the criteria must be described in detail in a plan the state
submits to the federal government. To better understand how states are providing
services to DHH children, the written state plans submitted to the
244 White

federal government were obtained and analyzed (NCHAM, 2006e). As expected,
all of the 55 states and territories indicated that services would be
provided to a child who had a diagnosed physical or mental condition that
has a high probability of resulting in development delay. In describing the
conditions for which their state would provide such services, only 37 of the55
(67%) listed hearing loss, auditory impairment, deafness, or something similar
as one of the specific conditions that would make a child eligible for Part
C services. This suggests that some Part C program officials may not recognize
the negative consequences that occur when DHH children do not begin
receiving early intervention during the first few months of life.
Furthermore, only 7 of the 55 states and territories (13%) provided any kind
of operational definition that could be used to determine if a specific DHH
child would be eligible for services (e.g., any child with bilateral sensorineural
hearing impairment greater than 40 dB qualifies for services). Twelve other
states (22%) provided some type of operational definition for hearing loss in
other documents but did not include it in the official state plan. Detailed
information about the eligibility criteria in each state plan and associated state
documents is available at www.infanthearing.org (NCHAM, 2006e).
The fact that the official state plan for so many Part C programs does not
specifically address the eligibility criteria for DHH children is concerning
because it suggests that these children may not be consistently served in Part
C programs. Even in those plans that include references to DHH children, it
is often unclear whether children with unilateral hearing loss will be served,
what degree of hearing loss is required to make a child eligible for services
and what type of diagnostic testing must be done to qualify a child for
services (the operational definitions in the existing state plans range from
very specific criteria, which indicate degree, type and laterality of hearing
loss, such as is the case in the state of Washington, to vague statements about
parental concern or failure on hearing screening tests).
The current situation would be significantly improved if those responsible
for the state’s EHDI program and other stakeholders (e.g., parents, audiologists,
primary healthcare physicians, etc.) would work with Part C program
officials to define specific well-defined eligibility criteria for DHH children to
be enrolled in the Part C programs. Examples of states that have done a
relatively good job of this include Connecticut, Louisiana, New Hampshire
and Washington (although some of these eligibility criteria are included in
other documents from the state and not in the state plan submitted to the U.S.
Department of Education). Being clear about which DHH children are eligible
for Part C services would be relatively easy and would yield valuable benefits.
Comprehensive Child-Find and Referral System
Section 635(a)(5) notes that each state’s Part C program must include “a
comprehensive child-find system . . . for making referrals to service providers
Finishing the EHDI Revolution 245

that includes timelines and provides for participation by primary referral
sources.” The federal regulations for this part of the law found at 34 CFR Part
303.321 note the following:
(b) Procedures. The child find system must include the policies and procedures
that the State will follow to ensure that
(1) All infants and toddlers in the State who are eligible for services
under this part are identified, located, and evaluated; and
(2) An effective method is developed and implemented to determine
which children are receiving needed early intervention services.
(c) Coordination.
(1) The lead agency . . . shall ensure that the child find system under
this part is coordinated with all other major efforts to locate and
identify children conducted by other State agencies responsible for
administering the various education, health, and social service programs
relevant to this part . . . .
(2) The lead agency . . . shall take steps to ensure that—
(i) There will not be unnecessary duplication of effort by the various
agencies involved in the State’s child find system under this
part; and
(ii) The State will make use of the resources available through each
public agency in the State to implement the child find system in
an effective manner.
(d) Referral procedures.
(1) The child find system must include procedures for use by primary
referral sources for referring a child to the appropriate public
agency . . .
(2) The procedures required in paragraph (b)(1) of this section must—
(i) Provide for an effective method of making referrals by primary
referral sources;
(ii) Ensure that referrals are made no more than two working days
after a child has been identified; and
(e) Timelines for public agencies to act on referrals.
(1) Once the public agency receives a referral, it shall appoint a service
coordinator as soon as possible.
(2) Within 45 days after it receives a referral, the public agency shall—
(i) Complete the evaluation and assessment activities in Sec.
303.322; and
(ii) Hold an IFSP meeting, in accordance with Sec. 303.342.
IDEA clearly specifies that state agencies responsible for administering
various education, health and social service programs must work together to
identify children who would benefit from and need services under IDEA.
246 White

Figure 3. Per child funding from Part C of IDEA.
This point is also emphasized by the Year 2000 Position Statement from the
Joint Committee on Infant Hearing (JCIH), which notes that:
In accordance with the Individuals with Disabilities Education Act (IDEA),
referral to a public agency must take place within 2 working days after the
infant has been identified as needing evaluation. Care can be facilitated by
involving a public agency, as the role of this agency is to appoint a service
coordinator, identify an audiologist to complete the audiologic evaluation,
and identify other qualified personnel to determine the child’s level of
functioning.
Unfortunately, many state EHDI programs are not well coordinated with Part
C programs. In a survey of state EHDI coordinators conducted by NCHAM
(2006a), only 57% of state EHDI coordinators indicated that they had “good
or excellent coordination and cooperation” with their state Part C program.
Of state EHDI coordinators, 34% did not know or said there was not someone
on the Part C Interagency Coordinating Council with expertise and experience
in serving infants and toddlers with hearing loss and 16% of the state
EHDI programs indicated they did not report children identified with hearing
loss to the state’s Part C programs. Only 40% of the state EHDI programs
reported that children enrolled in the state Part C programs for reasons other
than permanent hearing loss were regularly checked for hearing status.
Infants who do not pass the newborn hearing screening are clearly at risk
for permanent hearing loss and should be included in the Part C child-find
system. Unfortunately, given the current funding limitations, it is unlikely
that Part C programs will assume responsibility for another substantial population.
As shown in Figure 3, per child funding for Part C of IDEA has been
declining since 1999. In terms of real dollars from initial program funding in
Finishing the EHDI Revolution 247

1991, there is only about $1,000 available per child to cover all of the Part C
services, including child-find activities.
Given the number of children currently served, the expectation that Part C
will be responsible for conducting diagnostic evaluations of all of infants
referred from newborn hearing screening programs is unrealistic. This means
that Part C would be responsible for approximately 33% more children in
their child-find activities, which would be very difficult given the resources
Part C has available. Nonetheless, it is imperative that state EHDI programs
and Part C programs find ways to collaborate more effectively on child-find
activities. At the very least, better information sharing between programs and
more systematic evaluation of hearing loss of children already enrolled in
Part C programs should be established. Given the requirements in the IDEA
regulations for completing evaluations and developing an individualized
family service program for children identified with disabilities within 45 days
of referral, Part C and EHDI programs must work together to eliminate
waiting periods for diagnostic evaluations so that services can be provided in
a timely manner.
Comprehensive System of Personnel Development
IDEA requires state early intervention systems to operate “a comprehensive
system of personnel development [that promotes] the preparation of
early intervention providers who are fully and appropriately qualified to
provide early intervention services (34 CFR 303.168).” As the age of identification
for DHH children has decreased and cochlear implants and digital
hearing aids have become more widely available, the nature of early intervention
services for DHH children has changed. Approximately 95% of DHH
children are born to hearing parents (Mitchell & Karchmer, 2004). Given
recent evidence about the ability of DHH children who received early cochlear
implants and high-quality early intervention to achieve similar levels
as their hearing peers (Cheng et al., 2006; Geers, 2004), it is not surprising that
increasing numbers of parents are choosing auditory/oral programs, which
focus on teaching DHH children to listen and speak, rather than sign language-based
programs, which, historically is how most DHH children were
educated. For example, Brown (2006) compared the choices made by parents
of DHH children in North Carolina in 1995 and again in 2005. North Carolina
is one of the few states in the country that has a well-developed early intervention
program for DHH children that includes a full range of auditory/oral
and sign language-based options. In 1995, 40% of families chose auditory/
oral options compared to 60% who chose sign language-based options. In
2005, 85% of families chose auditory/oral options compared to 15% who
chose sign language-based options. Such a dramatic change over a ten-year
period has important implications for how early intervention program providers
are trained.
248 White

Figure 4. Primary emphasis of personnel preparation programs for teachers of the
deaf or hard of hearing. Although many programs describe themselves as
providing “comprehensive” services, most have a primary emphasis on a specific
approach, as indicated by the curriculum offerings, the placement of graduates, the
type of practicum available, etc. Classification of programs on this map considered
those factors in conjunction with annual self-report survey data from the 2004 and
2005 issues of the American Annals of the Deaf.
Currently there are about 70 university-based programs for preparing
teachers of the deaf or other professionals to work with DHH children. Based
on information contained in the 2004 and 2005 issues of the American Annals
of the Deaf, combined with information about faculty publications, curriculum,
the placement of graduates and program Web sites, these programs
were classified as to whether the primary emphasis was on sign languagebased
or auditory/oral-based options. As shown in Figure 4, the vast majority
of these programs focus primarily on sign language-based options. In fact, of
all graduates from DHH teacher-education programs in 2004, only 8% were
from programs that focused primarily on auditory/oral options. This is similar
to the distribution of programs funded by the Office of Special Education
and Rehabilitative Services (OSERS) for teacher preparation of professionals
working with DHH children. Of the 19 OSERS-funded programs for teachers
of DHH children, only three have an auditory/oral emphasis.
Thus, Part C programs are in a difficult position. The vast majority of
Finishing the EHDI Revolution 249

parents, when they are given an option, choose auditory/oral-based programs.
In contrast, the vast majority of teachers graduating from universitybased
deaf education programs are trained primarily in sign language-based
options. Adjusting the mix of options in a way that provides families with the
choices they would like to have will be challenging and, yet, is essential to
meet the requirements of IDEA.
Appropriate Early Intervention Services
Section 635 of PL 108-446 requires that DHH children be provided with
“appropriate early intervention services based on scientifically based research.”
According to the JCIH (2000), almost all infants and children with
permanent hearing loss need some form of assistive listening device (either
hearing aids or a cochlear implant) for early intervention services to be effective.
If the family decides to have an assistive listening device for the child,
selection and fitting should be provided as soon as possible. Because DHH
children are more likely than adults to have asymmetric losses and configurations
of hearing loss that are more varied than adults, DHH infants and
children often require different features and capabilities in their hearing aids
than those typically used by adults. Children’s hearing aids must provide a
signal that makes all speech sounds audible and comfortable and ensure
intensities are limited to safe levels (Pittman & Stelmachowicz, 2003; Stelmachowicz
et al., 2000; Pittman, Stelmachowicz, Lewis, & Hoover, 2003; American
Academy of Audiology, 2003). Recently developed digital hearing aids
with features such as wide dynamic range compression, automatic feedback
cancellation and multiple channels can achieve these goals in contrast to
analog hearing aids, which are often unable to accommodate these demands.
If DHH children are not provided with assistive listening devices during
the first few months of life, there are serious negative consequences. Without
auditory input and consistent early intervention programs that focus on
teaching language, DHH children almost always lag behind their peers in
language, cognitive and social-emotional development (JCIH, 2000). Several
studies have shown that by the time they are eight years old, deaf children are
already 1 1 ⁄2 years behind their hearing peers in reading comprehension scores
(Schildroth & Karchmer, 1986; Gallaudet Research Institute, 1996) and half of
all deaf children graduate from high school with a fourth grade reading level
or less (Gallaudet Research Institute, 1996). Such deficits are not limited to
children with bilateral hearing loss. Children with unilateral hearing loss are
ten times as likely to be held back at least one grade, compared with children
who have normal hearing (Oyler, Oyler, & Matkin, 1998). Furthermore, studies
comparing children with unilateral hearing loss to matched groups of
children with normal hearing find that children with unilateral hearing loss
lag behind their hearing peers by one-half to two-thirds of a standard deviation
by the time they reach the third or fourth grade (Blair, Peterson, &
250 White

Viehweg, 1985; Brookhouser, Worthington, & Kelly, 1991; Culbertson & Gilbert,
1986).
When DHH children are not identified early and provided with appropriate
access to auditory input and early intervention programs, there are also
significant costs to society in terms of direct medical costs, special education
expenditures and lost productivity. According to Chambers, Shkolnik, &
Perez (2003), DHH children required more than twice the annual per student
educational expenditure as children without disabilities ($15,992 versus
$6,556) in the year 2000. Another study (Schroeder et al., 2006) found that the
average economic costs per year for children with bilateral moderate, severe
or profound hearing loss were nearly four times those for hearing children
($26,207 versus $7,823). Many of the negative outcomes DHH children have
historically experienced can be minimized or avoided completely if they are
provided with appropriate amplification and early intervention that focuses
on teaching language (Yoshinaga-Itano, 1998; Moeller, 2000; Kennedy et al.,
2006).
In spite of the consensus among professionals about the importance of
fitting hearing aids as early as possible, data from various sources suggests
that it is quite difficult for many DHH children to obtain hearing aids. For
example, most private health insurance plans explicitly exclude coverage for
hearing aids (Nemes, 2004). A recent survey of hearing aid users found that
only 16% of children had any coverage of hearing aids through their private
health insurance plan (Rhoades & Powell, 2002, No. 35). Fox, McManus, &
Reichman (2002) reported that only 7% of the most commonly sold private
health insurance plans offered hearing aid coverage.
More than half of all children in the United States are covered by Medicaid,
which generally does provide coverage for hearing aids. Unfortunately, reimbursement
rates are so low that most children do not obtain the type of
hearing aids they need. McManus et al. (2004) found in a 15-state region that
average Medicaid fees for hearing aids and other auditory audiology services
were only 38% of those paid by private health insurers. Furthermore, in many
states, “medical necessity” guidelines require that Medicaid provide the
“least costly alternative.” Consequently, analog aids, rather than digital aids,
are often provided to children despite clear evidence that digital aids would
be more beneficial (AAA, 2003).
At the present time, Part C programs seldom pay for hearing aids, It would
seem however, that Part C should be a source of funding to provide appropriate
hearing aid technology to DHH children when other sources are unavailable.
According to IDEA, funds from Part C cannot be used to pay for
services that would otherwise have been paid for from another public or
private source (34 CFR 303.520). However, because both Medicaid and private
insurance plans are unlikely to cover the type of hearing aids needed for
DHH children to make optimal developmental progress, Part C should be
available to fill the gap.
Finishing the EHDI Revolution 251

Historically, the federal Department of Education ruled that education
agencies are not required to provide a personal device that a student would
require, whether in school or not (and this would apply to hearing aids).
However, in 1990, Congress added the definitions of assistive technology
devices and services to the Education of the Handicapped Act by incorporating
the definitions of assistive technology devices included in the Technology
Related Assistance for Individuals with Disabilities Act of 1988 (PL 101-476). Those
amendments make it clear that assistive technology must be provided as a
part of a free and appropriate public education whenever it is necessary for
the child to benefit from educational services. The same requirements apply
to early intervention services under Part C. Assistive technology device is
defined in that legislation as follows:
The term “assistive technology device” means any item, piece of equipment,
or product system, whether acquired commercially off the shelf,
modified, or customized, that is used to increase, maintain, or improve
functional capabilities of individuals with disabilities.
In its passage of the Individuals with Disabilities Education Improvement Act
on December 3, 2004, Congress continued to emphasize the important role
played by assistive technology devices and services in the education of students
with disabilities. In the preamble to that statute, it was noted that:
almost 30 years of research and experience has demonstrated that the education
of children with disabilities can be made more effective by . . . supporting
the development and use of technology, including assistive
technology devices and services, to maximize accessibility for children with
disabilities.
Thus, it seems clear that Congress intended for hearing aids to be covered by
Part C programs to the extent that they are not covered by other sources and
to the degree that they are necessary to assist in meeting the developmental
needs of DHH children. The fact that Part C programs have been hesitant to
pay for hearing aids could be a function of the limited amount of funding
available to these programs. Nonetheless, it seems clear that early provision
of appropriate hearing aids will lead to better outcomes for students and in
the long term will actually save money. Thus, state EHDI programs should
continue to work with Part C programs to ensure that hearing aids are available
through Part C when they are not available from other sources.
Public Awareness
A major obstacle in providing effective early intervention services to DHH
children has been making various stakeholders aware of the progress that has
252 White

Table 1. Estimates From Primary Health Care Providers Regarding When Children
Can Be Fit with Hearing Aids
Type of Physician
Age at Which Hearing Aids Can Be Fit
Less than
1 month
2-3
mos
4-6
mos
7-11
mos
15+
mos
Pediatrician (n = 1145) 36.3% 16.9% 29.0% 2.1% 15.6%
Family Physician (n = 531) 38.2% 15.6% 23.2% 0.9% 22.0%
Neonatologist (n = 52) 28.8% 21.2% 32.7% 0.0% 17.3%
Ear, Nose & Throat Specialist (n = 58) 27.6% 15.5% 20.7% 1.7% 34.5%
been made in the last 15 years. Many of these changes affect the way early
intervention services should be provided. Unless people are aware of these
changes, they will continue to make decisions based on old data, thus preventing
DHH children and families from accessing the most effective services.
One particularly important group who need to be educated about the
progress that has been made are primary healthcare providers. The American
Academy of Pediatrics has worked hard to include pediatricians in the early
intervention process for all children with disabilities (AAP, 1999a, 2001). One
area in particular in which the AAP has worked to educate healthcare providers
is the recent advances in early identification of hearing loss and how
that should impact the advice they give to parents about early intervention
services for their DHH child (AAP 1999b, 2006).
There is still much work to be done in this area. In a recent study reported
by Moeller, White, & Shisler (2006) in which responses to a survey were
collected from almost 2,000 primary care physicians from across the United
States, it was found that even though pediatricians and other primary care
providers recognized the benefits of early detection and intervention for
DHH children, many of them were not current in their understanding of how
early intervention services can best be provided to this population. For example,
in response to an open-ended question in which they were asked,
“What is your best estimate of the earliest age at which a child can begin
wearing hearing aids,” 41.6% said this could not occur until children were six
months of age or older. As shown in Table 1, the results were not much
different for pediatricians, family physicians, neonatologists and ENTs. Respondents
were also asked to list any specialists to whom they would “routinely
refer the family of a child with a confirmed permanent hearing loss.”
According to the JCIH (2000), all such children should be referred for an
ophthalmological and genetic evaluation. Yet, less than 1% of the respondents
indicated they would refer the child to an ophthalmologist, and only 9%
indicated they would refer the child to a geneticist. Almost half of the respondents
gave incorrect responses to the question asking which children
would be candidates for cochlear implant surgery (indicating that children
Finishing the EHDI Revolution 253

with unilateral profound losses, bilateral mild to moderate losses, and unilateral
mild to moderate losses would be candidates for a cochlear implant).
These gaps in knowledge are all the more concerning given that 89% of the
respondents said that they were very confident or somewhat confident in
explaining the newborn hearing screening process to parents who had questions
about their infant’s results.
The fact that primary healthcare providers are unaware of many of the
recent improvements in early intervention services for this population is not
surprising given how rapidly changes have happened and the relatively
small percentage of DHH children in the population. Nonetheless, effective
early intervention services depend, in large part, on families obtaining upto-date,
accurate information, and primary healthcare providers are a primary
and trusted source of information for many families (Arnold et al.,
2006). Therefore, an important part of strengthening the early intervention
system will be to ensure that healthcare providers (including nurses, nurse
practitioners and physician assistants) are educated about the changes that
have occurred during the last 15 years.
Conclusions
The importance of identifying DHH children as soon as possible and providing
them with appropriate early intervention services (including medical,
audiological and educational services) has been recognized for many years. In
the last 15 years, technological advances and the widespread implementation
of universal newborn hearing screening programs have stimulated progress
at an accelerated rate. Unfortunately, for many DHH infants and young children,
improvements in the early intervention process have lagged behind
other components of EHDI.
Completing the EHDI revolution will require systematic and sustained
attention to providing comprehensive, up-to-date early intervention services
to children identified through newborn hearing screening programs. Part Cof
IDEA provides a framework for these changes to occur. However, in the past
EHDI programs and Part C programs have not worked together as comprehensively
as they should. The framework for such cooperative work is present,
but more attention needs to be given to ensuring that all DHH children
are eligible for Part C services and that EHDI screening and diagnostic programs
are better coordinated with Part C child-find procedures. Additionally,
both preservice and inservice personnel preparation activities must become
responsive to changes in parent preferences for the type of intervention they
want for their child. Hearing aids and other assistive listening devices must
be more accessible to all DHH children and, finally, various stakeholders
must become educated about the progress and changes that have occurred in
the last 15 years.
254 White

Acknowledgments
Preparation of this manuscript was supported in part by the Maternal and
Child Health Bureau under Grant Number 6 H61 MC 00006.
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258 White

The Volta Review, Volume 106(3) (monograph), 259-274
Statewide Collaboration in
the Delivery of EHDI Services
Joni Alberg, Ph.D, Kathryn Wilson, M.A., CCC-SLP, Cert. AVT ® , and
Jackson Roush, Ph.D., CCC-A
Introduction
In 1999, North Carolina enacted legislation requiring the screening of all
newborn infants for hearing loss as part of a comprehensive statewide effort
to achieve early hearing detection and intervention (EHDI). This law (NCAC
43F.1201) requires physiologic screening prior to hospital discharge unless
declined by the parents or precluded by medical complications. Results are
then reported to the North Carolina State Laboratory for Public Health. Since
full implementation in August 2000, more than 700,000 babies have been born
in the state’s 90 birthing hospitals, and most have been screened successfully.
In the first few years following this legislation, much of the time, energy and
financial resources of the EHDI system were devoted to the screening itself:
establishing programs, equipping nurseries and training staff. But with each
passing year, there has been growing awareness of the need to focus on the
services that must be provided after the screening: comprehensive audiologic
assessment, otologic examination, and for infants found to have permanent
hearing loss, family support and referral for early intervention services.
This has resulted in opportunities as well as challenges and, not surprisingly,
there has been mixed success. Most importantly, those involved with
the statewide EHDI system have come to recognize that early identification
and intervention require the coordination and collaboration of many programs,
agencies, and institutions (JCIH 2000). The following program description
examines three components of North Carolina’s statewide EHDI
program that have undergone substantial growth and development as a result
of newborn screening: (1) the clinical and educational programs of the
Joni Alberg, Ph.D., is the executive director of BEGINNINGS for Parents of Children Who Are
Deaf or Hard of Hearing, Inc. Kathryn Wilson, M.A., CCC-SLP, Cert. AVT ® , is the director
of the Resource Support Program in the Office of Education Services for the North Carolina
Department of Health and Human Services and an adjunct professor at the University of
North Carolina-Chapel Hill. Jackson Roush, Ph.D., CCC-A, is professor and director of the
Division of Speech and Hearing Sciences, University of North Carolina School of Medicine at
Chapel Hill, and the section head for audiology at the University of North Carolina Center for
the Study of Development and Learning.
Statewide EHDI Collaboration 259

University of North Carolina at Chapel Hill (UNC), which are based in the
UNC School of Medicine and UNC Hospitals (UNCH); (2) services to families
provided by BEGINNINGS for Parents of Children Who are Deaf or Hard of
Hearing; and (3) services provided through our statewide network of early
intervention programs, administered by the Office of Education Services
(OES) in the North Carolina Department of Health and Human Services
(DHHS), as well as strategies for building a comprehensive program. In addition
to describing successful outcomes, this report examines aspects of each
component that have been frustrating or problematic and the ongoing efforts
to improve quality of care and access to services for all families in North
Carolina.
The University of North Carolina at Chapel Hill
The hospitals at UNC provide inpatient and outpatient clinical programs
for the UNC School of Medicine, serving patients from each of North Carolina’s
100 counties. Every year thousands of infants and their families are
served in UNC’s Women’s and Children’s Hospitals. UNC otolaryngologists
deliver specialized ear, nose and throat services to more than 30,000 patients
annually. The pediatric audiology program at UNCH has grown substantially
since the onset of newborn hearing screening, from two to three comprehensive
infant diagnostic assessments per month in 1999 to an average of 30 per
month in 2007 (P. Roush, personal communication, January 2007). The Carolina
Children’s Communicative Disorders Program (CCCDP), affiliated with
the Department of Otolaryngology, includes a pediatric cochlear implant
program; the Center for Acquisition of Spoken Language Through Listening
Enrichment (CASTLE), which offers an auditory/oral preschool for children
with hearing loss; and assessment-intervention services provided by speechlanguage
pathologists and teachers, some of whom are Certified Auditory-
Verbal Therapists. Through CASTLE, the CCCDP offers internships, a
summer institute in Auditory-Verbal therapy, an annual conference, and
mentoring for professionals in the development of spoken language through
audition. The close working relationship between the UNCH pediatric audiology
program and the CCCDP, which together follow more than 1,300 children
who are deaf or hard of hearing, makes it possible for the audiologists,
otolaryngologists, speech-language pathologists and intervention specialists
to participate in weekly team meetings to monitor children’s progress and
make recommendations regarding implant candidacy (C. Brown & P. Roush,
personal communication, January 2007).
In addition to providing clinical services, both UNCH and CCCDP make
important contributions to graduate education. Students in the UNC Doctor
of Audiology (Au.D.) program, which is based in the Division of Speech and
Hearing Sciences, participate in a full range of pediatric services. Audiology
trainees participate in newborn and neonatal intensive care unit hearing
260 Alberg, Wilson, & Roush

screening, physiologic assessment of infants referred from screening using
frequency-specific auditory brainstem response (ABR) and other physiologic
measures, pediatric hearing aid selection and fitting and cochlear implant
evaluation and mapping. In their first year, students observe and provide
assistance to the pediatric audiologists. Second- and third-year students are
enrolled in clinical externships involving assessment and management of
hearing loss in infants and young children. Both the UNCH Pediatric Audiology
program and the CCCDP provide externship placements for fourthyear
students.
Accomplishments and Challenges
Growth in the number of families served has necessitated an increase in the
number of pediatric audiologists available to provide clinical services. The
large and growing caseloads have made it possible for audiologists at UNCH
to acquire expertise evaluating and managing newly identified infants. Physiologic
assessment including ABR, auditory steady-state responses (ASSR),
otoacoustic emissions and acoustic immittance measures are performed routinely
with infants in natural sleep, in conscious sedation and, when necessary,
under general anesthesia.
For infants referred to UNCH without health complications, the average
age of diagnosis is approximately 3 months. When families concur with the
recommendation for hearing aid use, the initial fitting is typically completed
within two weeks. Infants are followed every four to six weeks for monitoring
of earmolds, hearing aid use, and middle ear status.
Once infants reach a developmental level of 6-7 months, physiologic tests
are supplemented with behavioral measures using visual reinforcement audiometry
(VRA). VRA can be used successfully with most infants to obtain
threshold measures for each ear from 250 to 4000 Hz by 9 months of age.
Initial hearing aid selection and fitting is accomplished with real-ear-tocoupler
difference (RECD) measurements, a “real-ear” method appropriate
for young children who are deaf or hard of hearing. Hearing aids are fitted
using the Desired Sensation Level prescriptive formula that targets gain and
output to ensure that sound is both audible and comfortable (Bagatto et al.,
2005). If families concur, fitting can move forward with minimal delay because
of an efficient approval process that allows earmold impressions to be
taken and hearing aids ordered at the time of diagnosis. Once hearing threshold
levels are established for both physiologic and behavioral measures, children
are followed every three months until approximately 3 years of age and
then every four to six months thereafter.
Aided speech perception measures are completed as soon as children have
the requisite language skills. Initially, these measures are accomplished
through the identification of closed sets of objects and pictures. As children’s
speech and language abilities increase, appropriate open set tests are used.
Statewide EHDI Collaboration 261

When children begin to walk and the distance between speaker and listener
increases, personal FM systems are introduced to families for home use. The
North Carolina Assistive Technologies program funds one pair of digital
hearing aids, a personal FM system, and hearing aid repairs and earmolds
until children reach age 3. Unfortunately, when a child turns 3 they are no
longer eligible to receive funds from this program. Families must find other
resources with which to purchase technology for their children. In addition to
self-pay, options include the state Medicaid program and a state-funded program
for families who do not qualify for Medicaid but have limited financial
resources.
In addition to providing early, accurate audiologic management, the UNC
program provides services that support families and are sensitive to cultural
differences. Although providing collaborative, family friendly services can be
challenging in a large medical center, the audiologists are committed to providing
family-centered care that transcends the practice setting. Children’s
hearing care needs are different from those of adults and, as a result, accommodations
have been made to allow for the time and staffing necessary to
provide appropriate pediatric management.
When hearing loss is identified in an infant, a comprehensive otologic
work-up is required. At UNC and other centers where comprehensive care of
infants with hearing loss is provided, the components of the otologic work-up
include examination of the ears, a thorough case history and relevant laboratory
studies. At UNCH, imaging studies, such as MRI are completed on all
children with permanent hearing loss. Information obtained from radiologic
studies permits identification of congenital ear abnormalities, such as enlarged
vestibular aqueducts and cochlear nerve deficiency (small or absent
eighth nerves), allowing audiologists and otolaryngologists to make informed
decisions regarding appropriate habilitative options. Ophthalmology and genetics
consultations also are offered to families. Children who receive a diagnosis
of neural conduction disorder (auditory neuropathy/dyssynchrony)
are referred for comprehensive neurological evaluation.
For some children acoustic amplification is insufficient even with early
identification and intervention (Davidson, 2006). The team approach at UNC
allows for regular monitoring and review of children’s progress to determine
those who are candidates for cochlear implantation and when implantation
should occur. At weekly team meetings otolaryngologists, audiologists, and
speech-language pathologists discuss children referred for cochlear implantation.
Before scheduling a surgery date, speech-language pathologists communicate
with the child’s parents, local therapists, and teachers to ensure that
adequate services will be in place after implantation.
Despite a well-integrated and collaborative team approach, many challenges
remain. Appropriate management of young infants is time consuming
and expensive. In addition to specialized instrumentation and clinical expertise,
institutional support is needed to manage the financial burden associated
262 Alberg, Wilson, & Roush

with providing comprehensive care when reimbursement from third-party
payers or the family is insufficient to cover all costs associated with the
program. In North Carolina, as in many states, only a few centers have the
expertise and institutional support needed to provide specialized care to
infants. Consequently, some families must travel a considerable distance to
obtain services, and inevitably, some are unable to access services because of
logistical challenges or expenses associated with transportation and followup.
The difficulties have been especially acute for low-income rural families
and those whose first language is not English. At this time, tracking and
surveillance remain difficult for these and other disadvantaged families.
Many families also experience financial pressures. Although state funding
for hearing aids, FM systems, repairs and earmolds adequately covers children
under the age of 3, when they turn three, financial assistance for hearing
aids is limited to families who meet eligibility criteria. Given the high cost of
hearing instruments, even families with relatively good incomes may be burdened
by the cost of replacement hearing aids.
In addition to challenges that exist at a systems level certain areas of audiology
management remain difficult. For example, when infants show no
response to both ABR and ASSR, a period of uncertainty exists until residual
hearing status can be supplemented by behavioral assessment. A more mundane
but crucial issue—acoustic feedback—remains a challenge when the
degree of hearing loss requires high output levels from the hearing aid.
The decision of when to offer cochlear implantation also can be difficult.
When little or no progress with acoustic amplification is seen, the decision
generally is uncomplicated, but when progress is measurable but less than
anticipated, the reasons why may be difficult to determine. Further, as the
age of implantation has declined, speech perception measures appropriate for
use with older children cannot be used, making it necessary to rely on threshold
measures and progress reports from early intervention specialists. It is
hoped that promising new applications of cortical-evoked potentials and
evaluation of infant speech perception using behavioral measures will eventually
lead to evidenced-based clinical procedures helpful in addressing this
important issue.
Other populations for whom clinical management is controversial or uncertain
are infants, toddlers, and young children with unilateral hearing loss
and those with neural conduction disorders (auditory neuropathy/dyssynchrony).
Clinical research in these areas is under way (Rance, 2005), but
evidenced-based protocols for clinical management are lacking at this time.
Important challenges remain, but it has been gratifying to see growth,
development and coordination of pediatric assessment procedures, intervention
services, and educational experiences for graduate students. But even the
most comprehensive audiology, otolaryngology and other hospital- or clinicbased
services are not sufficient to provide the support families need when
hearing loss is first identified. Much of the success in North Carolina in recent
Statewide EHDI Collaboration 263

years is attributable to partnerships among EHDI-related agencies within the
state. BEGINNINGS has been a vital link between the hospital and early
intervention services.
BEGINNINGS for Parents of Children Who Are Deaf or
Hard of Hearing
For more than 20 years, BEGINNINGS has provided emotional support,
unbiased information about all communication and education options and
technical assistance to parents of children who are deaf or hard of hearing
ages birth to 22. It also supports parents who are themselves deaf or hard of
hearing and whose children may or may not have hearing loss. Further,
information and assistance is available to professionals who work with these
families.
The belief that parents should be the primary decision makers for their
child is a guiding principle for BEGINNINGS. When a child in North Carolina
is diagnosed with a hearing loss, the parents are informed about BEGIN-
NINGS and invited to talk with a parent educator. Audiologists are the
primary source of family referral, though anyone can make a referral. In
addition, parents of any child with hearing loss can obtain services until the
child reaches age of 22. 1
A parent educator is assigned to each family referred to BEGINNINGS.
Identifying information about the family and child (e.g., address, phone numbers,
age of identification, type of hearing loss) is entered into a database. This
information is confidential, and specific procedures have been established for
maintaining each family’s privacy. Parent educators obtain written permission
from parents to share information with other professionals. Before contacting
the family, the parent educator first contacts the referral source to gain
additional information regarding the family and their needs. The parent educator
then meets with the family at a convenient time and place, usually in the
family’s home. Initially, home visits are to ensure that parents understand
their child’s hearing loss and provide information regarding financial assistance,
language development, communication options and early intervention
services. Parent educators emphasize the importance of keeping all appointments
with the audiologist and encourage parents to enroll their child as soon
as possible in North Carolina’s early intervention program, which is described
later.
Although parent educators encourage parents to arrange their own appointments
with various service agencies, BEGINNINGS provides assistance
if needed. Parent educators work closely with the North Carolina Early
1
Services to adults in North Carolina are available through the NC Division of Services to the
Deaf and Hard of Hearing.
264 Alberg, Wilson, & Roush

Intervention Program for Children Who Are Deaf or Hard of Hearing (EIP).
BEGINNINGS routinely provides information about families being served
whose children are under 3 and services provided by BEGINNINGS. This
“service progress log” is exchanged biweekly with the EIP and the regional
Child Health Audiology Consultants from the North Carolina Early Hearing
Detection and Intervention program. This communication tool has been invaluable
in ensuring families are served in a timely manner as they move
from diagnosis to intervention. Additionally, face-to-face meetings with representatives
from the EIP, BEGINNINGS and the Division of Public Health
occur quarterly to discuss strategies for improving communication, follow-up
with families who have been challenging to find or serve and other issues that
arise. Once services are in place, frequent contact with BEGINNINGS is not
needed. Parent educators check in with families periodically and at specific
educational milestones, such as transition from early intervention to preschool
(see the article by Wilson, this issue, page 419).
Important changes occur once children turn age 3 in North Carolina and in
most states. Under Part C of the Individuals with Disabilities Education Act
(IDEA), services from birth to 3 are set forth in an Individualized Family
Service Plan (IFSP) and, in North Carolina, are administered by the Division
of Public Health. After age 3, responsibility for educational services is transferred
to the state Department of Public Instruction, necessitating the creation
of an Individualized Education Program (IEP). Parent educators play an important
role in assisting families in developing goals for their child’s IEP.
They explain educational rights and accommodations, assist parents in articulating
their goals for their child, and, if requested, accompany the parents
to an IEP meeting to ensure that the plan is written in a way that will facilitate
success in the educational setting. One of BEGINNINGS’ most important
goals is to help parents develop the knowledge and skills they need to become
advocates for their child and family, and parent educators focus on
helping parents gain the confidence they need to accomplish this goal, even
if it means encouraging them to function more independently.
Parent educators also provide school-based support, such as classroom
observations and teacher in-service education, to ensure children have the
supports and modifications necessary for full access to classroom instruction.
They advise the school about the need for assistive technology and explain
the school’s responsibility to provide it. They accompany parents to audiologic
appointments to support them as they learn about their child’s hearing
loss and to help them understand the information provided. This service has
been especially valuable to parents whose first language is not English. BE-
GINNINGS has two Hispanic outreach/parent educators who are native
Spanish speakers. They do not provide interpreter/translation services;
rather, they support parents in their native language. Support is specific to
each family but may involve helping parents understand their child’s audiogram
and becoming aware of what is involved in managing their child’s
Statewide EHDI Collaboration 265

hearing loss, including audiologic management and early education services,
the types of services that are available to their child and family and assistance
in accessing those services. In 2006, families whose primary language in the
home is Spanish comprised approximately 14 percent of 287 families served.
Presentations and workshops for teachers, school nurses, related professionals
and students enrolled in North Carolina’s colleges and universities are
part of the BEGINNINGS mission as well. Outreach programs recently were
expanded to provide practicum opportunities for students in the UNC speech
and hearing programs. These experiences allow students to interact with
families in their natural environment.
All of the services BEGINNINGS provides to parents and professionals in
North Carolina are at no charge to families. The majority of funding comes
through a state appropriation from the North Carolina General Assembly.
This appropriation is directed to the OES and administered through a contract
with BEGINNINGS. The contract specifies services to be provided and
includes accountability requirements. Additional funding comes from other
contracts, grants and private donations. Most of the support BEGINNINGS
provides is to parents of young, newly identified children. Referrals to serve
these families have more than doubled since the implementation of statewide
newborn hearing screening.
Because the service delivery system for early intervention (IDEA Part C)
and the public schools (IDEA Part B) is administered by two separate state
agencies and the nature of early intervention and public school education is
different, parent educators have found it important to stay in close contact
with parents during and after the transition. When children turn 2 1 ⁄2 years
old, the parent educator contacts the family to discuss the transition and
changes they will encounter when their child enters the local education
agency (LEA). To facilitate this process, parent educators contact the early
intervention program and work closely with the service provider as they
prepare families for this important transition. For example, the parent educator
frequently will accompany the early intervention teacher to the family’s
home to discuss the upcoming transition. Together, the EI teacher and parent
educator will help the parents set goals for their child’s IEP. Close communication
among BEGINNINGS, the early intervention staff and LEA representatives
is key to ensuring successful transitions.
Accomplishments and Challenges
The services BEGINNINGS provides to parents of children with hearing
loss are tailored to each family’s specific needs. Parents have reported gratitude
for the support provided by their parent educator, and surveys administered
anonymously to parents in 2006 overwhelmingly confirmed their
satisfaction with BEGINNINGS services. Of the 49 surveys returned, 94% of
parents agreed or strongly agreed with all nine satisfaction statements.
266 Alberg, Wilson, & Roush

Having served families for more than 20 years, BEGINNINGS has become
an integral part of the EHDI programs in North Carolina. Based on growth in
the number of families requesting services each year, awareness of and need
for the services clearly is recognized. In fiscal year 2005, 294 families new to
BEGINNINGS and 203 families returning for additional services were served.
In fiscal year 2006, the number of families new to BEGINNINGS remained
about the same (281) while the number of returning families increased to 250.
Based on the first 7 months of fiscal year 2007, new families to BEGINNIGNS
are expected again to remain about the same (296 projected) while the number
of returning families is expected to increase significantly (354 projected).
Support for 60 IEP meetings was provided, and staff delivered numerous
in-services, workshops and presentations to a variety of professionals. A new
challenge BEGINNINGS is facing is the influx of families who speak Spanish/
Mexican dialects indigenous to a specific village or location in their country
of origin. These families do not speak or read English or Spanish, and typically
the only option for our Hispanic outreach/parent educators is to relyon
a family member who knows the dialect. This is seen as an ongoing challenge
as BEGINNINGS serves a growing number of families from diverse backgrounds.
The BEGINNINGS model not only has grown in North Carolina, but also
is being used in other states. In 2004, BEGINNINGS formed a partnership
with the National Center for Hearing Assessment and Management
(NCHAM) in Utah as part of a federally funded outreach project to provide
technical assistance to state EHDI programs as they develop family support
services. Four states are working to develop programs similar to BEGIN-
NINGS, and 10 others have requested support as they explore options for
family support. Within the NCHAM collaboration, BEGINNINGS staff provide
training, demonstrating parent educator techniques for providing services
and unbiased information to families in a supportive and culturally
sensitive manner.
North Carolina Early Intervention Services
In North Carolina, Part C services under IDEA are administered by the
Division of Public Health in the Department of Health and Human Services.
A statewide system of 18 regional Children’s Developmental Services Agencies
(CDSAs) provides a portal of entry into the state’s Infant-Toddler Program.
At the CDSA, children receive evaluation services, eligibility
determination and a service coordinator for those deemed eligible. The child’s
service coordinator is responsible for developing the IFSP, which defines
family and child goals and the necessary services to achieve these goals, and
ensuring it is reviewed and modified as needed every six months.
Once enrolled through the CDSA and assigned a service coordinator,
Statewide EHDI Collaboration 267

infants and toddlers who are deaf or hard of hearing are eligible to receive
services through the OES early intervention component. This component, the
Early Intervention Program for Children Who are Deaf or Hard of Hearing,
provides direct, specialized services to children and their families. At the state
level the program is administered by the OES superintendent. Three regional
directors are in place to manage the program at the local level. Each director
supervises a team of licensed teachers of the deaf who, in turn, provide direct
services to children and families. Each region also employs a licensed speechlanguage
pathologist with expertise in auditory/oral and Auditory-Verbal
approaches, Cued Speech, Total Communication, American Sign Language
and the diagnosis and treatment of a variety of coexisting speech and language
disorders.
In the first few weeks after a child’s enrollment in the early intervention
program, service providers administer a variety of assessments to collect
baseline performance measures. Teachers and therapists obtain information
regarding communication and language, social-emotional, cognitive, vocabulary
and motor development. These assessments are conducted in an effort to
supplement rather than supplant or duplicate the information gathered by
the CDSA. In addition to the baseline evaluation, all early intervention service
providers follow a protocol requiring administration of a variety of assessments
every six months. Test results are interpreted, and written reports are
provided to parents.
In accordance with Part C of IDEA, services are implemented in natural
environments, and for most children this is the home environment. Services
may be delivered in day care settings. Most children receive at least one home
visit per week from either the teacher of the deaf or the program’s speechlanguage
pathologist, and efforts are made to schedule visits at times that are
most convenient for the family.
A primary goal of the program is to involve parents and other family
members to the greatest extent possible. Administrators, teachers and related
personnel recognize the importance of a family-centered approach, one that
focuses on working primarily with regular caregivers rather than with children.
Although the federal law mandates that early intervention services
must occur in natural environments, this provision is not exclusively about
where services are provided. Walsh, Rous and Lutzer (2000) emphasized that
the natural environment mandate is not being met when providers work with
children without including parents and caregivers in the session. In the North
Carolina program an effort is being made to actively engage family members.
During parent participation sessions, teachers and therapists address questions
and concerns from the family, review the child’s progress since the
previous session, identify goals, model strategies and techniques and guide
parents as they practice effective strategies. Teachers and therapists also assist
caregivers in identifying appropriate ways to carry over goals during the
course of daily routines. Through this process parents understand their role
268 Alberg, Wilson, & Roush

as primary teacher and the importance of daily interactions in achieving
desired outcomes.
Accomplishments and Challenges
Every effort is made to enroll children and begin intervention immediately
after referral. It is noteworthy that at no time in the referral process is a child
placed on a waiting list. An additional strength of the program is the requirement
that all professionals be licensed in deaf education and/or speechlanguage
pathology. Thus, services are implemented by specialists rather
than by generalists. Furthermore, providers must complete requirements to
obtain the state’s Infant-Toddler Credential. To earn this credential, professionals
must demonstrate knowledge, skills and expertise with the birth-tothree
population, including parent-centered practices. The Infant-Toddler
Credential, in combination with licensure in deaf education and/or speechlanguage
pathology, is important to ensuring that children and families receiving
early intervention services have access to appropriately trained
personnel.
Implementation of baseline and ongoing assessment practices provides
practitioners with essential information to guide intervention, monitor progress
and make changes as necessary to meet the family’s goals. Although this
aspect of the program can be time consuming, routine assessment every six
months for the birth-to-three population can be regarded as a program
strength and a practice necessary for appropriate intervention. Because parental
involvement is deemed an essential component for children with special
needs to make appropriate progress, the program endeavors to empower
parents as key decision makers and teachers and to actively involve them in
each intervention session.
With input from teachers, therapists and parents, administrators continually
review program practices to determine components that are working
well and to identify concerns and challenges. It is well documented that a
substantial number of children who are deaf or hard of hearing also present
with one or more disabilities (Picard, 2004). The Gallaudet Research Institute
(2003) reported that as many as 40 percent of children who are deaf or hard
of hearing have additional challenges ranging from severe cognitive impairments
to mild learning differences that are not apparent until school age.
Children enrolled in the early intervention program present with a variety of
syndromes, developmental disabilities and medical conditions. Given the
range of additional challenges, it is not always possible to identify and assign
early intervention personnel who already have knowledge and expertise in
the particular areas needed. In those situations early intervention personnel
often find themselves in the position of working with children and families
with special needs outside the scope of their existing training and expertise,
at least initially. When faced with serving children with additional challenges,
Statewide EHDI Collaboration 269

early intervention program personnel collaborate with other professionals
both within the early intervention program and externally to identify resources
to assist them in meeting the needs of these children with multiple
disabilities.
North Carolina, like many other states, has experienced rapidly growing
Hispanic and Latino populations (Grieco, 2003), but as reported by Johnson
(2004) only 5 to 10 percent of teachers of the deaf in the United States are
members of an ethnic minority. Like many states, the current workforce of
early intervention providers in North Carolina is primarily white, female,
hearing and English speaking. Clearly, teachers from diverse backgrounds,
those who speak more than one language and those trained in practices to
meet the needs of children and families of various backgrounds are needed to
enhance the effectiveness of family-centered intervention. During fiscal year
2005-2006, 189 children were enrolled in the early intervention program, 37
percent by age 6 months (J. Dunn, M. Hice, & L. Kendall, personal communication,
September 2006). Although far short of our goal to enroll all children
by age 6 months, the complexities associated with multiple disabilities, non-
English-speaking families, loss to follow-up and other challenges often result
in later identification and diagnosis, which in turn result in later enrollment
in early intervention. North Carolina is well on its way to implementing
Hearing Link, a statewide electronic tracking and data system. The pilot
phase of Hearing Link began in February 2005 with full implementation
expected by the end of calendar year 2008. This system has the potential to
move the state forward in achieving the goal of enrollment in early intervention
by age 6 months.
In addition to ongoing efforts aimed at earlier enrollment for intervention
services, future plans include review of assessment practices, instruments,
frequency of administration and how results are reported and used to make
decisions about service delivery. Additionally, the population of children and
families served reflects students from varied racial and ethnic backgrounds,
especially Latino/Hispanic cultures. Training and supporting early intervention
providers working with children who have multiple disabilities, increasing
parent participation and enhancing collaboration with professionals from
other disciplines are key to meeting the needs of all children.
How Are We Doing? Developing a Statewide
Evaluation Plan
Although significant challenges remain, North Carolina’s EHDI programs
continue to expand and improve. Even so, it is difficult to determine the level
of success without a comprehensive evaluation plan that includes measurement
of child and family outcomes. In 2005, OES and BEGINNINGS, in
cooperation with UNC, embarked on an effort to address this need. Recently
a one-year pilot project addressed several important questions related to
270 Alberg, Wilson, & Roush

statewide EHDI goals. What is the age of screening, diagnosis and intervention?
If goals are not being achieved, what are the barriers to timely identification
and intervention? Are children leaving early intervention with
expressive and receptive language skills that are similar to those of their
hearing peers? What are the children’s language outcomes as they move
through preschool and at ages 4, 5 and 6? These questions are being addressed
through data collection efforts involving staff from several EHDI
components. Answering them will take time, but progress is under way.
The OES–BEGINNINGS database now includes age of identification, age of
hearing instrument fitting, age of early intervention, type and intensity of
intervention and level of parent involvement. Also included is a description
of the type and degree of hearing loss and, when known, the etiology. The
database includes other conditions or disabilities that co-occur with hearing
loss as well as specific language outcomes at age 3 based on the Preschool
Language Scale-Fourth Edition (PLS-4; Zimmerman, Steiner, & Pond, 2002).
The outcomes from the OES and BEGINNINGS longitudinal study should
eventually provide the information needed to better evaluate the success of
the state EHDI programs and provide guidance for program review and
improvement. Preliminary findings indicate that nearly half the children are
scoring within the average range for total language as measured by the PLS-4.
Efforts are now underway to combine language measures with developmental
assessments in order to better understand and interpret each child’s progress.
Other Statewide Collaboration
Child Health Audiology and Speech-Language Consultants
North Carolina is fortunate to have the services of regional audiology and
speech-language consultants employed by the Division of Public Health. Six
child-health audiology consultants cover the entire state to provide a variety
of services, including tracking infants referred from newborn screening,
monitoring hospital compliance with screening protocols, conducting inservice
training for screening personnel and providing technical assistance
regarding newborn screening. Seven child-health speech-language consultants
work with the audiology team to assist with tracking, surveillance and
follow-up. They also assist families with applications for assistive technology
and enrollment in children’s special health services.
Continuing Education for Parents and Professionals
Each year EHDI programs in North Carolina collaborate to plan and deliver
a statewide conference on topics relevant to early identification, assessment
and intervention. On even years UNC hosts a two-day pediatric
Statewide EHDI Collaboration 271

audiology symposium that brings together approximately 100 pediatric audiologists
and professionals from related disciplines. Topics include physiologic
and behavioral assessment of infants, pediatric hearing aid fitting and
audiologic management of special populations, such as infants with neural
conduction disorders or unilateral hearing loss. During the meeting, EHDI
program coordinators provide updates and information regarding statewide
programs. In alternate years, a three-day statewide EHDI conference provides
content to a broader audience, including parents, early intervention professionals,
administrators, physicians, audiologists and speech-language pathologists.
Funding from the Centers for Disease Control and Prevention and
corporate support have made it possible to deliver these conferences at an
affordable cost to attendees.
Parent-to-Parent Support
Hearing Impaired Toddlers and Children Have Unlimited Potential
(HITCH-UP), a volunteer organization founded by parents and now active in
two metropolitan areas, provides monthly support groups for families. Operated
entirely by parents without public support, HITCH-UP plays an important
role in providing peer support, exchange of information and adviceto
professional organizations for improving and expanding services to families
with children who are deaf or hard of hearing.
Conclusion
Statewide collaboration in the delivery of EHDI services is not easily
achieved. Early identification, comprehensive audiologic and otologic evaluation,
appropriate selection and fitting of hearing instruments and enrollment
in family-centered early intervention services require a dedicated team of
professionals working within a service delivery model that is accessible, well
coordinated and appropriately funded. Table 1 describes some of the essential
goals of a comprehensive EHDI system. Achieving them is an ongoing challenge
that is never finished, but working toward full inclusion of families
within a collaborative statewide model is our long-term objective.
North Carolina has a longstanding commitment to families whose children
are deaf or hard of hearing, but important challenges remain: a growing
number of children with health conditions or disabilities that exist in addition
to hearing loss, a growing number of non-English-speaking families and a
shortage of early intervention providers with expertise and communication
skills needed to serve these special populations. For children with neural
conduction disorders or unilateral hearing loss, audiologists must make clinical
decisions based on limited evidenced-based research. Decisions regarding
whether and when to provide cochlear implantation also can be challenging,
especially when the child is making some progress with amplification. For all
272 Alberg, Wilson, & Roush

Table 1. Goals for a Comprehensive Statewide EHDI System
• A comprehensive statewide hearing screening program using protocols and
procedures appropriate for the well baby or neonatal intensive care unit
nurseries.
• Audiologic and otologic expertise necessary to provide timely and accurate
diagnostic evaluations for infants referred from newborn screening.
• Application of hearing technologies (hearing aids, cochlear implants)
appropriate for the child and consistent with family preferences.
• Capacity to provide advocacy, emotional support and information to parents
and children regardless of communication option or place of residence.
• Accurate and culturally sensitive information to families regarding all
communication and education options given as soon as possible after diagnosis.
• Well-qualified professionals with the knowledge, skill and specialization needed
to serve young children with hearing loss, including those with coexisting
disabilities and special needs.
• A statewide plan for in-service and continuing education.
• A tracking system that follows children and families through each component
of the EHDI system.
• A surveillance system for children at risk for late-onset or progressive hearing
loss.
• Regular meetings of key agencies to review and evaluate the EHDI system.
• Developmental assessments every six months for children ages birth to 3.
• Written reports to parents providing the results of formal and informal
assessments.
• Knowledge and cultural competence needed to serve non-English-speaking or
bilingual families.
• Administration of early intervention services by a central agency or, when a
single agency is not possible, careful coordination of each early intervention
component to enable uniformity and consistency in the application of policies,
procedures and clinical practices.
• Clearly articulated procedures to ensure successful transition from early
intervention (Part C) services to school-based (Part B) services.
• Comprehensive statewide evaluation of child and family outcomes to determine
the strengths and needs of the EHDI system.
• Participation and inclusion of families to the full extent desired in each
component and at each level of the EHDI system.
children, the transition from early intervention at age 3 to the local school
system is an important one, and for many families it is a time of stress and
uncertainty. Despite these challenges, progress will continue. We are confident
that advances in technology combined with parent-professional collaboration
will allow each child to achieve the best possible developmental
outcomes.
Acknowledgments
We thank the following individuals for their contributions to the North
Carolina EHDI programs and to the content of this program description:
Statewide EHDI Collaboration 273

Cyndie Bennett, superintendent of the Office of Education Services; Carolyn
Brown, director of the Carolina Children’s Communicative Disorders Clinic
and CASTLE Preschool; and Patricia Roush, director of pediatric audiology,
UNC Hospitals.
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274 Alberg, Wilson, & Roush

The Volta Review, Volume 106(3) (monograph), 275-298
Family Empowerment:
Supporting Language
Development in Young
Children Who Are Deaf or
Hard of Hearing
Jean L. DesJardin, Ph.D.
The current model of early intervention with children who are deaf or hard of
hearing emphasizes parental self-efficacy and involvement. The purpose of this study
was to investigate the relationships between mothers’ self-efficacy beliefs and involvement
and children’s language skills in a group of mothers of children who are deaf or
hard of hearing and wear hearing aids (N = 32). Mothers completed a questionnaire
(Scale of Parental Involvement and Self-Efficacy), and mother-child interactions were
videotaped. Mothers’ self-efficacy beliefs related to developing their children’s speech
and language were positively associated with higher level facilitative language techniques
(recast and open-ended question), and one lower level technique (closed-ended
question). Perceived involvement was also positively related to lower level techniques.
Regression analyses indicated that the same higher level techniques were associated
with children’s language skills. Findings present early intervention implications for
professionals who work with families and children who are deaf or hard of hearing.
Introduction
Families of young children who are deaf or hard of hearing have many
more opportunities today than in years past to develop a child’s spoken
language skills. In the past, parents may have felt isolated in their search for
resources related to hearing loss, with parent-professional partnerships traditionally
marked by “power over” relationships that are defined by professionals
presuming a higher sense of competence and greater knowledge than
parents (Turnbull, Turbiville, & Turnbull, 2000). The present model of early
intervention, referred to as the empowerment model (Turnbull & Turnbull,
Jean DesJardin, Ph.D., is an advanced research associate in the Children’s Research and
Evaluation (CARE) Center at House Ear Institute in Los Angeles, Calif.
Empowering Families of Young Children Who Are Deaf 275

2001), places an emphasis on parental involvement in an equal partnership
with the professional. In this professional-parent partnership, both work collaboratively
to learn from each other about better ways to support the child’s
language development.
Current recommended practices for children who are deaf or hard of hearing
emphasize the importance of not only parental involvement, but also
parental competence. Both the Individuals with Disabilities Education Improvement
Act (IDEIA, 2004) and the Division of Early Childhood (DEC) Recommended
Practices in Early Intervention/Early Childhood Special Education (Sandall,
McLean, & Smith, 2000) specify that one desired outcome of early intervention
is for parents to perceive themselves as capable of supporting their
children’s growth and development—parental self-efficacy. Parental beliefs
will, in turn, make an impact on the child’s learning. The role of early intervention
professionals is to support parents as they seek to gain access to the
information they require to become competent and confident in the skills
necessary to support their children’s development (McWilliam & Scott, 2001;
Turnbull et al., 2000). Parents’ beliefs about their skills and involvement in
their children’s early intervention program are critical components for children’s
language learning.
Parental Self-Efficacy
Parental self-efficacy beliefs are defined as one’s sense of knowledge and
abilities to perform or accomplish daily parenting tasks and roles. According
to self-efficacy theory (Bandura, 1997), parental self-efficacy beliefs should
incorporate (1) the level of specific knowledge pertaining to the behaviors
involved in child-rearing and (2) the degree of confidence in one’s own ability
to carry out the specific parental role. For example, Conrad, Gross, Fogg, and
Ruchala (1992) noted that mothers’ increased knowledge alone did not result
in better interactions with their young children. Increased knowledge and
confidence together, however, resulted in more effective interactions with
their hearing toddlers.
A key component of self-efficacy theory states that parents’ efficacy beliefs
are linked to the goals they have for their children (Bandura, 1989). These
goals may translate into parental practices that support their children’s ability
and persist until the goals are attained (Brody, Flor, & Gibson, 1999; DesJardin,
2004). In other words, a person who is self-efficacious both knows about
and persists in attempting a given task until success is achieved, whereas
self-inefficacious individuals may have the knowledge needed, but may be
unable to persist because of self-doubt. Thus, parents of children who are deaf
or hard of hearing need the knowledge and skills necessary to build their
children’s spoken language abilities, but, to achieve confidence in those skills,
they also need to use those skills daily as they interact with their children.
Indeed, maternal self-efficacy beliefs may influence mother-child interactions.
In a sample of mothers and their hearing infants, Teti and Gelfand
276 DesJardin

(1991) found that maternal self-efficacy mediated the negative relationship
between mothers’ depressive symptoms and mothers’ behaviors reflecting
responsiveness (e.g., warmth and sensitivity) to their infants. Maternal selfefficacy
also remained positively associated with maternal responsiveness,
after controlling for all other factors (e.g., income level, perceptions of infant
difficulty and social-marital support). These findings suggest a link between
mothers’ belief in their own abilities and maternal behavior.
The link between mothers’ self-efficacy and maternal behaviors may need
to be tailored to the specific needs of children who are deaf or hard of hearing.
As suggested by Bandura (1989), parental perceived knowledge and confidence
of specific skills must be measured for a particular population. Although
there are parenting scales that tap into parents’ self-efficacy for other
populations of children with disabilities (Akey, Marquis, & Ross, 2000; Trivette
& Dunst, 2003), only one has been specifically designed for parents of
young children who are deaf or hard of hearing (Scale of Parental Involvement
and Self-Efficacy [SPISE]; DesJardin, 2003). Using this particular measure,
DesJardin (2004) examined a sample of 24 mothers with preschool
children with cochlear implants (mean age = 3.7 years). Mothers’ perceived
self-efficacy in terms of developing their children’s language at the first timepoint
in data collection (Time 1) related positively to children’s receptive and
expressive language skills one year later (even after controlling for their
child’s language skills at Time 1).
In that same study at Time 2 (DesJardin, 2004; Time 2), with the inclusion
of eight more mother-child dyads (N = 32), mothers’ sense of efficacy also was
related to specific facilitative language techniques employed during motherchild
interactions. Mothers who perceived themselves as more knowledgeable
and competent in developing their children’s language skills provided
their children with higher level language techniques (recast and open-ended
questions). These same techniques were associated with better child language
outcomes. Conversely, mothers who perceived themselves as less knowledgeable
and competent in terms of developing their children’s language
used lower level language techniques (linguistic mapping, directives and
imitations). Although there is evidence to suggest that lower level techniques
support language learning in hearing children with severe expressive language
delays (Girolametto, Weitzam, Wiigs, & Pearce, 1999), these techniques
did not seem to support preschool children with cochlear implants whose
language ages were approximately 2 1/2 years. Consistent with Bandura’s
model, mothers’ self-efficacy beliefs appear related to the developmental language
goals endorsed for their children that may link to the ways in which
parents interact with their children.
Parental Involvement
Parental involvement is another pivotal feature in present-day early intervention
programs. Over the past several years, researchers have found that
Empowering Families of Young Children Who Are Deaf 277

family involvement strongly influences parent and child outcomes for children
who are deaf or hard of hearing (Calderon, Bargones, & Sidman, 1998;
Calderon, 2000; Moeller, 2000). Parent involvement has been shown to relate
positively to better parental communication exchanges with their children
(Calderon et al., 1998), more advanced language outcomes in kindergartenaged
children (Moeller, 2000) and later educational development (Calderon,
2000; Calderon & Naidu, 2000; Yoshinaga-Itano, 2000). Moreover, Calderon
and Naidu (2000) found mothers’ communication skills, rather than direct
parental involvement in their children’s education programs, related significantly
to their children’s language and early reading skills.
The way in which parents are involved is also important for children’s
language learning. Young children learn new words in the contexts of their
daily experiences and, particularly, through interactions with their caregivers.
According to the social-interactionist theory, the main emphasis is on
caregiver linguistic input (Hoff-Ginsberg, 1997). Variation observed in children’s
language skills may strongly be linked to the quantity (e.g., number of
words) and quality (e.g., facilitative language techniques) of the caregiver’s
linguistic input (Girolameto et al., 1999; Hart & Risley, 1999). For example,
language techniques, parallel talk and recasting have been reported to relate
positively to children’s rapid language development (Fey, Krulik, Loeb, &
Proctor-Williams, 1999; Kaiser & Hancock, 2003).
The Guidelines in Division of Early Childhood (DEC) Recommended Practices in
Early Intervention emphasize parental responsiveness to children’s linguistic
attempts for facilitating optimal language development (Cook, Tessier, Klein,
& Armbruster, 2000; Sandall et al., 2000). Facilitative language techniques,
such as imitation and expansion, may enhance language learning in young
children at the single-word stage of language development (Girolametto et
al., 1999). In contrast, language techniques such as parallel talk, recast and
open-ended questions may elicit better responses from children who are at
the two-to-three-word language level (Fey et al., 1999; Hulit & Howard, 1997;
McNeil & Fowler, 1999). Indeed, language techniques that are “fine-tuned” to
children’s language levels accelerate children’s expressive language development
(Yoder & Warren, 1998).
Hearing mothers of children who are deaf may intuitively adapt their
language techniques to their children’s language level. Koester, Papousek, &
Smith-Gray (2000) noted that “intuitive parenting is a proficient yet often
overlooked communication technique used by parents when interacting with
their deaf toddlers” (p. 56). For example, a mother may use a higher level
technique, such as an open-ended question and, if the child does not respond,
adapt her linguistic input to a lower level technique, such as a closed-ended
question. In fact, hearing mothers of children who are deaf may intuitively
make adaptations to their children’s linguistic abilities and demonstrate response-control
behaviors (e.g., questioning) to compensate for their child’s
deafness (Lederberg & Prezbindowski, 2000).
278 DesJardin

Mothers’ sense of involvement may also influence language techniques
while interacting with their children who are deaf. Findings from a longitudinal
study of 24 mothers of children with cochlear implants (DesJardin, 2004)
suggest that mothers’ perceived involvement in their children’s language
development at Time 1 was related to higher level facilitative language techniques
(parallel talk, recast and open-ended questions) one year later. Even
after controlling for their children’s language ages at Time 1, these same
techniques were also associated with their children’s language outcomes.
Conversely, mothers who felt less involved in their children’s language program
exhibited lower level language techniques (linguistic mapping, imitation
and directive). Such lower level techniques, in turn, related negatively to
their children’s language skills for this population of mothers and preschool
children who are deaf and use cochlear implants. Furthermore, at Time 2, and
with the inclusion of eight more mother-child dyads (N = 32), higher level
language techniques, recast and open-ended questions remained predictor
variables for children’s receptive and expressive language skills, respectively,
even after controlling for children’s length of cochlear implant use for this
group of mothers and their young children who use cochlear implants (Des-
Jardin, 2006).
Although there is theoretical and empirical support for self-efficacy and
involvement in parents of young children and, specifically, children with
cochlear implants, we do not know if the same holds true for mothers of
young children who use hearing aids. The goal of the present study was to
examine the relationships between mothers’ perceived self-efficacy and involvement,
and children’s language outcomes, in a group of mothers and
children who use hearing aids. This study addresses two research questions:
(1) Are perceived maternal self-efficacy and involvement associated with
facilitative language techniques during mother-child interactions? and (2)
What are the maternal predictor variables for children’s language outcomes?
Method
Participants
The author recruited mothers and children from the Children’s Auditory
Research and Evaluation (CARE) Center, located at House Ear Institute in Los
Angeles. The CARE Center serves children ages birth to 18 years and their
families, providing a range of clinical services that include initial diagnosis of
hearing loss and audiological follow-up services.
Mothers
Thirty-two mothers and children who are deaf or hard of hearing participated
in this study. As shown in Table 1, mothers averaged 36 years of age
Empowering Families of Young Children Who Are Deaf 279

Table 1. Demographic Characteristics for Mothers (N = 32)
(range = 23-53), most had some level of college experience (78.2%) and the
majority was in the upper middle-income level (62.5%) or above, with an
average yearly income level of $50,000. Most of the mothers were Caucasian
(53.1%) and spoke English (96.9%).
Children
Mothers’ Characteristics
Mean; (SD)
Range: 23-53 years
Age 36.3; (6.25)
Education level Elementary: 0; (0.0%)
High School: 7; (21.9%)
Some College: 3; (9.4%)
Bachelor’s Degree: 7; (21.9%)
Postgraduate: 15; (46.9%)
Household income $100,000 = 10 (31.3%)
Ethnicity Caucasian: 17; (53.1%)
Latino: 11; (34.4%)
Asian-American: 2; (6.3%)
Other: 2; (6.3%)
Primary home language English 31 (96.9%)
Spanish 1 (3.1%)
Marital status Married 29 (87.5%)
Single 2 (9.4%)
Divorced 1 (3.1%)
All of the children presented with bilateral sensorineural hearing loss, were
hearing aid users and had been enrolled in a family-centered intervention or
school-age program for at least three months. As noted in their medical
charts, none of the children had an additional disability or developmental
delay. As displayed in Table 2, this is a heterogeneous group of children who
ranged in age from 1.1-6.0 years (M = 3.0 years). As a group, the children were
identified with hearing loss and enrolled in a family-centered early intervention
program at approximately 12 months and received hearing aids at approximately
18 months. At the time of testing, 25 children used an auditory/
oral modality of communication and seven children used auditory/oral with
some sign support. As per the Reynell Developmental Language Scales, children’s
mean receptive and expressive language skills were 29 months and 25
months, respectively.
280 DesJardin

Table 2. Demographic Characteristics of Children (N = 32)
Measures
Children’s Characteristics
Mean; (SD)
(Range in months)
Gender Boys: 17; (53.1%)
Girls: 15; (46.9%)
Age at testing 36 months (20.2)
(25-72)
Age at identification 11.7 months (15.9)
(

In the self-efficacy section, mothers rate 10 questions on a Likert-type scale
ranging from “not at all” (1) to “very much” (7). Questions in this section relate
to mothers’ perceptions about their level of influence on their child’s auditory
development. The questions selected were derived from using exploratory
factor analysis. Two subscales emerged and Cronbach’s alpha coefficients
suggested high internal consistency for each subscale: (1) Maternal Self-
Efficacy of Sensory Device Use, the extent to which a mother believes that she
has the knowledge and skills to following through with prescribed sensory
aid maintenance; and (2) Maternal Self-Efficacy of Child’s Speech-Language
Development, the extent to which a mother believes that she has the knowledge
and skills to affect her child’s speech and language development (see
Appendix for subscale items and Crochbach’s [1951] alpha coefficients, ranging
from 0.80-0.87).
The involvement section consists of 11 questions on a Likert-type scale
ranging from “not at all” (1) to “very much” (7). The queries in this section
include items related to a mother’s perception of her involvement in her
child’s sensory device use and family-centered intervention or school-age
program. Using exploratory factor analysis, two subscales emerged: (1) Maternal
Involvement of Sensory Device Use, the extent to which a mother
believes that she is involved in her child’s use of sensory device and listening
development; and (2) Maternal Involvement of Child’s Speech-Language Development,
the extent to which a mother believes that she is involved in her
child’s speech-language development and family-centered intervention program
or school-age program (e.g., therapy, home visits and IFSP/IEP meetings)
(see Appendix for subscale items and Cronbach’s [1951] alpha
coefficients ranging from 0.76-0.83).
The SPISE was developed and pilot tested with a focus group that consisted
of three audiologists, a teacher of the deaf, a speech-language pathologist and
two parents of children with hearing loss (one child with hearing aids and
one child with a cochlear implant). Thus, the SPISE offers secure content
validity. Although the predictive validity of the SPISE is unknown at this
time, future avenues of research will investigate the relationships between
items on the SPISE and performance on a variety of observed tasks during
parent-child interactions.
(2) The Reynell Developmental Language Scales, Third Edition (RDLS III)
(Reynell & Gruber, 1990). The RDLS-III are individually administered tests of
verbal comprehension and expressive language skills for young children. The
RDLS III uses toys (e.g., ball, doll), pictures of objects (e.g., window, flower)
and real objects (e.g., spoon, cup) to elicit responses from the child. The two
scales of the RDLS have been widely used both with hearing children and
children who are deaf (Stallings, Gao, & Svirsky, 2002; Svirsky, Robbins, Kirk,
Pisoni, & Miyamoto, 2000). The RDLS calculates raw scores and standard
scores and their age equivalents based on normative data from children with
normal hearing. The present investigation used auditory-oral raw scores in
282 DesJardin

the data analyses because almost all of the children had standard scores that
were below the floor of 63 or 64. There was, however, sufficient variability in
the raw scores for meaningful statistical analysis.
(3) Mother-Child Interactions. Mothers and children engaged in free play
and storybooks together. During free play, mothers were asked to engage
their children with two Mr. Potato Head (Lerner, 1952) fun activity kits (one
kit designed to construct a female potato and one kit designed to construct a
male potato) for seven minutes. The Mr. Potato Head activity kits came with
various parts to engage the children in fantasy play (e.g., scuba goggles,
dress-up shoes, various hats). Mothers were instructed to “play with your
child as you would normally do at home when you have free time” and to
interact with their children using whatever mode or modes of communication
they use normally at home (auditory/oral or auditory/oral with sign support).
Following free play, mothers were provided two storybooks, What Next,
Baby Bear! by Jill Murphy (1983) and Frog, Where Are You? by Mercer Mayer
(1969). What Next, Baby Bear! is a relatively short, colorfully illustrated book
appropriate for preschoolers with a fantasy narrative about a little bear’s
travel preparations for a trip to the moon. This book has been used in several
other mother-child interaction studies with young hearing children (Weizman
& Snow, 2001). Frog Where Are You? is a relatively short, wordless picture
book and has been used in more than 150 studies studying children acquiring
50 different languages and investigating children’s narrative language development
(Berman & Slobin, 1994; Hoff-Ginsberg, 1997). Mothers were instructed
to “read with your child as you would normally do at home when
you have time,” choosing either book to begin and then continuing with the
other book when they were finished with the first book.
Procedures
Prospective participants received an invitation letter and stamped, selfaddressed
postcard. Those interested in the study completed the postcard
and returned it to the CARE Center to schedule appointments. Mothers who
indicated interest in participating in the study received the SPISE questionnaire
in the mail two weeks before their scheduled appointments and either
brought the completed questionnaire to the appointment or mailed it to the
House Ear Institute in a stamped, self-addressed envelope.
The mother-child interaction sessions were conducted in a comfortable
playroom at the CARE Center. The first seven minutes consisted of free play.
Following free play, the mothers and children interacted with the two books
described above for approximately 5 minutes each. Interactions were videotaped
using a digital camera (Canon Optura 30) hidden behind a one-way
mirror. Following the videotaping session, the children were administered
Empowering Families of Young Children Who Are Deaf 283

the Reynell Developmental Language Scales. All language assessments were
given in a child’s primary mode of communication (auditory/oral or auditory/oral
with sign support). For this study, the analyses used auditory-oral
raw scores.
Transcription and Reliability
Data Preparation
All speech, vocalizations and signs produced by the mother and child were
transcribed in full by the author, using the Codes for the Human Analysis of
Transcripts (CHAT) transcription system. To establish inter-rater reliability of
transcription, a speech-language pathologist from the CARE Center transcribed,
in full, 10% of the randomly selected videotaped data. The calculation
of word-by-word correspondence yielded a high reliability between transcribers,
ranging from 95-98% agreement for mothers and children’s intelligible
verbal utterances and 88-93% reliability for mothers’ and children’s
utterances that also contained some signs. The analyses used mother and
child vocal and signed utterances.
Each mother’s transcribed utterance — linguistic phrase or sentence — was
coded for one higher level and lower level facilitative language technique
(during both free play and storybook conditions, as defined in Tables 3 and
4, respectively). Proportional scores of each facilitative language technique
were calculated and used in the analyses to avoid penalizing less talkative,
yet very responsive, mothers. Accordingly, proportional data were calculated
by dividing the total number of each language technique by the overall number
of mothers’ linguistic attempts. The CARE Center speech-language pathologist
coded 25% of the transcripts, randomly selected to establish testretest
reliability. A line-by-line analysis revealed high agreement between
coders, ranging from 94-98% reliability.
Results
Relationships Between Maternal Perceived Self-Efficacy and Facilitative
Language Techniques
Pearson product correlations were conducted to examine the relationships
between the two self-efficacy subscale items (sensory device use and speechlanguage
development) and the 10 facilitative language techniques. As displayed
in Table 5, statistically significant positive relationships emerged
between self-efficacy in terms of developing their children’s speech-language
and two higher level facilitative language techniques, recast (r = 0.48; p < 0.05)
and open-ended question (r = 0.38; p < 0.05). A significant positive relationship
also emerged between this same self-efficacy subscale item and one
284 DesJardin

Table 3. Definitions and Examples of Higher Level Facilitative Language Techniques
Higher Level Facilitative
Language Techniques Definition Examples
Child is playing with a toy car and mother
says, “You are making the car go fast!”
Child says, “Doggie go,” and mother says,
“The doggie is going.”
Child says, “Doggie go,” and mother says,
“Did the doggie go?”
Mother says, “Tell me more about where
the bear is going. How do you think the
bear is going to get there?”
Parallel talk Providing linguistic input directly about what the
mother or child is doing, as long as child is
directly looking at the activity.
Expansion Repeating the immediate preceding child
utterance approximation or verbalization by
adding one or more morphemes or words
without adding new information.
Recast Repeating the immediate preceding child
utterance approximation or verbalization in a
question format.
Open-ended question Stating a phrase or question that the child can
answer in a two- to three-word phrase or more.
Empowering Families of Young Children Who Are Deaf 285

Table 4. Definitions and Examples of Lower Level Facilitative Language Techniques
286 DesJardin
Lower Level Facilitative
Language Techniques Definition Examples
Mother says, “That is a mustache,” “There is
the moon” or “I see the bear.”
Child hands mother a toy dog and vocalizes;
mother says, “Doggie.” Child pushes a book
away and vocalizes; mother says, “All
done.”
“Is that the bear?” or “Do you like that book?”
Child says, “Hat,” and mother says, “Yeah,
hat.” Child says, “Potato has a hat,” and
mother says, “Yes, a hat.”
“Uh huh, you got it!” “That’s right!” “Yeah!”
“Very good.” “Let’s see.” “Uh oh!” ”Wow!”
“Come here.” “Read the word.” “Turn the
page.” “Listen to me.” “Sit down.” “Look
right here.”
Label Labeling a toy or picture (child may or may
not be looking directly at the object).
Linguistic mapping Putting into words or interpreting the child’s
intended message using the context as a clue
(child uses a preceding vocalization that is
not recognizable as an approximation of a
word).
Close-ended question Stating a question that the child can answer
with only one word.
Imitation Direct repeat or imitation of child’s preceding
vocalization or verbalization without adding
any new words. Mother may reduce the
sentence by imitating fewer words.
Comment Stating a comment to keep the conversation
going or to positively reinforce the child.
Directive Telling the child to do something or
commanding a behavior.

Table 5. Relationships Between Maternal Self-Efficacy Subscale Items and Mothers’
Facilitative Language Techniques
Facilitative Language
Techniques
Maternal Self-Efficacy:
Sensory Device
Maternal Self-Efficacy:
Speech and Language
Parallel talk 0.20 0.07
Expansion 0.07 0.33
Recast 0.04 0.48*
Open-ended question 0.33 0.38*
Linguistic mapping 0.08 0.09
Closed-ended question 0.24 0.46*
Imitation 0.12 0.24
Label –0.11 –0.11
Directive –0.34 –0.57**
Comment –0.32 –0.16
*p < 0.05; **p < 0.01
lower level technique, closed-ended question (r = 0.46; p < 0.05), and a negative
relationship emerged with the lower level technique, directive (r = –0.57;
p < 0.01).
Relationships Between Maternal Perceived Involvement and Facilitative
Language Techniques
Two self-efficacy subscale items (sensory device use and speech-language
development) were correlated with the 10 facilitative language techniques. As
Table 6 illustrates, perceived involvement in terms of the child’s sensory
device related positively with one higher level technique, open-ended question
(r = 0.41; p < 0.05), and had a negative association with one lower level
technique, directive (r = –0.65; p < 0.01). There were no statistically significant
associations between mothers’ perceived involvement of their child’s speechlanguage
development and any higher level techniques; however, perceived
involvement related positively to two lower level techniques, closed-ended
question (r = 0.48; p < 0.05) and imitation (r = 0.38; p < 0.05).
Further correlation item analyses with the questions pertaining to this particular
parental involvement subscale revealed statistically significant positive
and negative relationships between the subscale items and lower level
techniques. Mothers’ perceived notion of difficulty to check and listen to the
children’s hearing aids on a daily basis related positively to the use of the
imitation technique, (r = 0.37; p < 0.05). There were also positive relationships
between mothers’ perception of how much speech-language therapists or
early interventionists demonstrate listening-language activities and mothers’
comfort level in performing listening-language techniques in their homes
without a professional present, and the use of the lower level technique,
closed-ended question (r = 0.40; p < 0.05 and r = 0.51; p < 0.01, respectively).
Empowering Families of Young Children Who Are Deaf 287

Table 6. Relationships Between Maternal Involvement Subscale Items and
Mothers’ Facilitative Language Techniques.
Facilitative Language
Techniques
Maternal Involvement:
Sensory Device
Maternal Involvement:
Speech and Language
Parallel talk 0.25 –0.16
Expansion 0.19 0.7
Recast 0.25 0.19
Open-ended question 0.41* 0.26
Linguistic mapping 0.14 –0.12
Close-ended question 0.28 0.48*
Imitation 0.15 0.38*
Label –0.15 –0.14
Directive –0.65** –0.44*
Comment –0.25 0.24
*p < 0.05; **p < 0.01
Relationships Between Facilitative Language Techniques and Children’s Receptive and
Expressive Language Skills
Pearson product correlations were conducted between the 10 facilitative
language techniques and children’s receptive and expressive language raw
scores. Statistically significant positive relations emerged between two higher
level techniques, recast (r = 0.64; p < 0.01; r = 0.63; p < 0.01) and open-ended
question (r = 0.58; p < 0.01; r = 0.60; p < 0.01) for children’s receptive and
expressive language respectively. Negative associations emerged between
two lower level techniques, label (r = –0.60; p < 0.01; r = –0.53; p < 0.01) and
directive (r = –0.54; p < 0.01; r = –0.50; p < 0.05) and children’s receptive and
expressive language outcomes, respectively. Generally speaking, this pattern
of correlation is consistent with the view that mothers’ use of higher level
facilitative language techniques tends to be associated with more advanced
development in children’s language skills.
Stepwise regression analysis was performed, controlling for children’s
pure-tone average and length of hearing aid use, to further explore the relationships
between mothers’ facilitative language techniques and children’s
receptive and expressive language skills. The higher- and lower level facilitative
techniques that related positively to mothers’ self-efficacy and involvement
in the previous analyses were included in the regression analyses
(recast, open-ended question and closed-ended question). Children’s puretone
average and length of hearing aid use was entered in block 1, and
facilitative techniques were entered sequentially in block 2 and block 3. As
shown in Table 7, pure-tone average and length of hearing aid use accounted
for a significant amount of the variance in children’s receptive language skills
(45%). Mothers’ use of recast and open-ended question were also significant
predictor variables of children’s receptive language, for a total of 23.3% of the
288 DesJardin

Table 7. Summary of Regression Models for Mothers’ Linguistic Input and
Children’s Receptive Language Skills
Regression Models R R 2
variance. Similarly, children’s pure-tone average and length of hearing aid
use also accounted for 44% of the variance in children’s expressive language
skills, with the use of recast and open-ended question accounting for an
additional 24.3% (see Table 8).
Discussion
Change in R 2
Significance in
F Change
Model 1 0.674 0.454 0.000
Model 2 0.771 0.594 0.140 0.005
Model 3 0.829 0.687 0.093 0.010
Predictors
Pure tone average in better ear –0.295 0.016
Length of hearing aid use 0.230 0.094
Open-ended question 0.348 0.007
Recast 0.370 0.010
Early intervention practices for young children focus on empowering families
and building their sense of self-efficacy and involvement as they support
their children’s early development (DesJardin, 2005; McWilliam & Scott, 2002;
Sandall et al., 2000; Turnbull & Turnbull, 2001). Despite these recommended
practices, few studies have investigated parents’ sense of self-efficacy and
involvement in their children’s early intervention program for families of
children who are deaf or hard of hearing. Of particular interest were the
relationships between maternal facilitative techniques and children’s receptive
and expressive language skills. Results from this study generally confirm
previous findings among young children who are deaf (DesJardin, 2004) in
terms of the positive associations between maternal perceived self-efficacy
and involvement, and facilitative language techniques. In essence, early intervention
implications may be further generalized to a larger population of
young children who are deaf or hard of hearing.
Similar to the DesJardin (2004) study on preschool children with cochlear
implants, findings from this study provide evidence that maternal perceived
self-efficacy and involvement in terms of developing children’s speechlanguage
development (rather than sensory device use) relates to specific
higher level facilitative techniques during mother-child interactions for children
with hearing aids. These same techniques are also associated with children’s
language skills. Furthermore, these higher level techniques have been
noted in prior research to facilitate later language skills in preschool hearing
children (Baumwell, Tamis-LeMonda, & Bornstein, 1997; Kaiser & Hancock,
2003).
Empowering Families of Young Children Who Are Deaf 289

Table 8. Summary of Regression Models for Mothers’ Linguistic Input and
Children’s Expressive Language Skills
Regression Models R R 2
Change in R 2
Significance in
F Change
Model 1 0.666 0.444 0.000
Model 2 0.771 0.595 0.151 0.004
Model 3 0.829 0.688 0.092 0.010
Predictors
Pure tone average in better ear –0.315 0.010
Length of hearing aid use 0.197 0.149
Open-ended question 0.364 0.005
Recast 0.369 0.010
Maternal beliefs about their children’s language learning, however, also
were positively associated with one lower level technique (closed-question).
It could be that mothers in this study were intuitively adapting their language
techniques to their children’s linguistic attempts. As prior research has suggested
(Lederberg & Prezbindowski, 2000), hearing mothers of children who
are deaf may intuitively make adaptations to their children’s linguistic abilities
and demonstrate response-control behaviors (e.g., questioning) to compensate
for their children’s deafness. Mothers in this study who felt more
knowledgeable and confident in developing their children’s language also
may have been tailoring the language techniques to their children’s linguistic
attempts.
Contrary to the findings in the DesJardin (2004) study, no significant relationships
emerged between mothers’ perceived involvement and any of the
higher level facilitative language techniques for the mothers in this study. On
the other hand, perceived involvement in developing their children’s speech
and language skills related positively to two out of the six lower level techniques
(imitation and closed-ended questions). These same techniques were
not related to their children’s language abilities. These findings suggest that
mothers of children with hearing aids may be receiving varied information
regarding how to support their children’s language learning. Furthermore, it
is plausible that early intervention professionals working with these mothers
and children may be providing inaccurate information regarding language
techniques to support the children’s language skills. In fact, further subscale
item analyses revealed that there was a positive relationship between two
items on the SPISE questionnaire; (1) mothers’ sense of comfort when conducting
listening-language activities at home without the presence of the
professional and (2) the frequency with which early intervention professionals
demonstrated listening-language techniques to mothers and mothers’ use
of a lower level technique (closed-ended question).
Facilitative language techniques must be tailored to children’s language
290 DesJardin

level. As children approach the two-to-three-word stage of language development,
particular techniques are essential for them to develop more complex
language. Facilitative language techniques such as parallel talk (Yoder, Mc-
Cathren, Warren, & Watson, 2001), recast (Fey et al., 1999) and open-ended
questions (Lilly & Green, 2004) encourage conversation, eliciting more complex
grammar and syntactic skills. These techniques are used more frequently
after children achieve a more advanced level of lexical and grammatical understanding
(Hulit & Howard, 1997). Conversely, techniques such as linguistic
mapping, imitation and closed-ended questions are more didactic in
nature and necessary for children who are at the prelinguistic and one-word
level of language development (Yoder et al., 2001).
Implications for Family-Centered Early Intervention
Early intervention programs emphasize the importance of supporting family
strengths and collaborating with caregivers to facilitate better interactions
with their children (Chidress, 2004; Roper & Dunst, 2003). By tailoring their
behaviors to the strengths of individual families, interventionists hope to
provide caregivers with a sense of confidence and competence — selfefficacy
— about their children’s current and future learning and development
(Dunst, 2000; Sonnenstrahl-Benedict & Raimondo, 2003). In turn, parental
self-efficacy of certain skills (e.g., facilitative language techniques) may
enhance children’s language learning (DesJardin, 2006). Thus, encouraging a
mother’s sense of efficacy in developing her child’s language skills is an
important goal in early intervention and should be taken into consideration
when formulating an Individual Family Service Plan (IFSP) or Individual
Education Plan (IEP).
One way to enhance parents’ self-efficacy is to employ a mentorship approach.
In a mentorship model, parents receive hands-on training and practice
with constructive and encouraging feedback based on the parent’s
strengths and needs. Providing caregivers continual feedback enhances their
generalization of newly learned techniques across various activities and settings
(Woods, Kashinath, & Goldstein, 2004). Ultimately, the goal of any
mentorship relationship is for parents to achieve independent, confident use
of techniques that will enhance their children’s language development.
Through a mentorship model, parents would also receive ongoing demonstrations
of skills. A finding of great concern from this study was the significant
positive relationship between mothers’ sense of involvement in their
children’s speech-language development and lower level language techniques.
Further analyses of the data suggested that mothers’ perception of
how much early intervention professionals or therapists demonstrate listening-language
activities was related to mothers’ use of lower level language
techniques. Early intervention programs highlight the importance of embedding
language techniques in naturally occurring interactions with children
within daily routines and activities (Dunst, 2000; Fewell & Deutscher, 2004;
Empowering Families of Young Children Who Are Deaf 291

Roper & Dunst, 2003). Everyday occurrences such as mealtime, hand washing,
playing with toys and bedtime routines are common in most families.
Parents may benefit from a visual reminder of learning opportunities and
activities they can use during the week (Dunst et al., 2001). Moreover, professionals
working with families of children with hearing aids must demonstrate
how to embed facilitative language techniques in everyday natural
language learning experiences (Woods et al., 2004).
Language techniques also should be further tailored to a child’s language
level. According to Vygotskian theory (1962), children develop linguistically
through caregiver interactions that reflect children’s zone of proximal development
(ZPD). A child’s ZPD is defined as the distance between a child’s
current level of development and the level in which the child can function
with adult assistance. For example, for a child who is deaf or hard of hearing
whose language age is at the prelinguistic stage of development, parents’ use
of lower level language techniques (e.g., imitations and expansions) that have
been shown to facilitate language learning in younger hearing children reflect
the child’s zone of proximal development. For preschool children who are at
the two- to three-word linguistic stage, however, higher level language techniques
(recast and open-ended questions) best facilitate children’s language
development. When parents use this form of support, they are helping their
children gain communicative competence and confidence (Vygotsky, 1978;
White, 1985).
Study Limitations
A few limitations of the present study should be mentioned. First, the
sample of mothers in this study may not be a true reflection of mothers and
children in the general population of families of children who are deaf or hard
of hearing. Although many families from lower socioeconomic status and
diverse cultures come to the CARE Center for services, mothers in this study
were all in the middle- to above-average income range with some college
experience. Consequently, the results of this study must be viewed cautiously
when applied to mothers of lower socioeconomic status and mothers in other
geographical locations. Furthermore, the facilitative language techniques examined
in this study may not be consistent with the child interactions that
typify parenting styles in other cultures (van Kleeck, 1994).
Second, the various kinds of family-centered early intervention programs
were not investigated in this study. The families who participated in this
study came from various states and public and/or private family-centered
intervention programs. Within the kinds of programs offered, early intervention
professionals may employ various teaching and communication methodologies
(Auditory-Verbal, Total Communication, etc.). It is most probable
292 DesJardin

that the mothers received different services and, possibly, different instructions,
regarding intervention language techniques. Future work controlling
for the different types of family-centered intervention programs will be fruitful.
Third, the SPISE is a self-report measure of self-efficacy and involvementin
parents. Previous research has suggested that, for many social constructs,
self-report measures may not necessarily reflect what the parents actually do
in their homes (Akey et al., 2000). Although self- reports of how people
perceive their knowledge and competence may be reasonably valid, selfreports
of participatory behavior may show less consistency (e.g., parents’
involvement in the development of their children’s IFSP). Nevertheless, the
SPISE offers researchers and practitioners valuable information in terms of
parents’ perception of specific skills related to their children’s sensory device
and speech-language development (see DesJardin, 2003, for further research
on and practical use of the SPISE).
Summary
Both the Individuals with Disabilities Education Improvement Act (IDEIA, 2004)
and the Division of Early Childhood (DEC) Recommended Practices in Early Intervention/Early
Childhood Special Education state the importance of not only
family involvement, but also early intervention practices implemented in a
manner that strengthens parents’ sense of competence in guiding their children’s
early development. Findings from this study highlight the influence of
parental self-efficacy and involvement on children’s spoken language development.
Families of children who are deaf or hard of hearing could benefit
from early intervention programs that capitalize on parents’ sense of efficacy
and facilitative language techniques that are tailored to their children’s language
level.
Acknowledgments
The author wishes to express a very special thank you to the mothers and
children who participated in this study. Support for this research was provided
by the National Institute on Deafness and Other Communication Disorders
(NIDCD) of the National Institutes of Health, grant #R01DC006238.
The author would like to thank Laurie Eisenberg, Ph.D. for her valuable
contributions throughout this project. Gratitude is also expressed to the
CARE Center’s research language consultant, Donna Thal, Ph.D., who provided
expertise and guidance in videotape analyses, and Kathleen Lehnert,
M.A., CCC-SLP, for transcription and videotape coding.
Empowering Families of Young Children Who Are Deaf 293

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Empowering Families of Young Children Who Are Deaf 297

Appendix
Scale of Parent Involvement and Maternal Self-Efficacy (SPISE) Subscale Items for Maternal
Self-Efficacy and Parent Involvement
Maternal Self-Efficacy Parent Involvement
298 DesJardin
Child’s Speech and Language
Internal Consistency Reliability;
Cronbach’s = 0.83
Child’s Sensory Aid Use
Internal Consistency Reliability;
Cronbach’s = 0.76
Child’s Speech and Language
Internal Consistency Reliability;
Cronbach’s = 0.87
Child’s Sensory Aid Use
Internal Consistency Reliability;
Cronbach’s = 0.80
How often are you invited to
participate in home visits/therapy
with your child?
How hard is it for you to
check your child’s hearing
aids/cochlear implant
every day?
How much do you feel you
know how to help your
child develop sounds?
How comfortable are you with
participating in home visits/therapy
with your child?
How hard is it for you to put
on your child’s hearing
aids/cochlear implant
every day?
How much do you feel you
know about and are able to
do speech-language
activities/strategies with
your child at home on a
How much do you feel that you
know about and are able to check
and put on your child’s hearing
aids/cochlear implant on a daily
basis?
How much do you feel you know
about and are able to adjust the
settings of your child’s hearing
aids (volume) or cochlear implant
(programs) on a daily basis?
How often does the teacher or
speech-language pathologist show
you listening/language activities?
How hard is it for you to
check your child’s listening
skills, using the Ling
Six-Sound Test every day?
How many days per week
will your child wear
his/her hearing aid or
cochlear implant?
How many hours per day
will your child wear
his/her hearing aid or
cochlear implant?
daily basis?
How much do you feel you
can positively affect your
child’s speech
development?
How much do you feel you
can positively affect your
child’s language
development?
How much do you feel you
can positively affect your
child’s early development?
How much do you feel you know
about and are able to check your
child’s listening skills daily, using
the Ling Six-Sound Test?
How much do you feel that you
know how to help your child
How much are you comfortable doing
the listening and language activities
with your child when the teacher or
therapist is not there?
How often do you feel that the teacher
of the deaf includes you in the
planning of your child’s IFSP or IEP?
How comfortable are you in helping to
develop your child’s IFSP or IEP?
develop words?
How much do you feel you can
positively affect your child’s
listening development?

The Volta Review, Volume 106(3) (monograph), 299-319
Management of Young
Children with Unilateral
Hearing Loss
Sarah McKay, Au.D.
Children with unilateral hearing loss (UHL) are at risk for academic, speech and
language and social-emotional difficulties. To date, most of the evidence documented
in the literature has been obtained from school-age children, most of whom were
diagnosed with UHL after enrollment in school. Following the widespread institution
of universal newborn hearing screening, most children are now screened prior to three
months of age. Consequently, infants with UHL are being identified years before
entering school, leaving hearing health and early intervention professionals asking
how to best serve this population of children. Until evidence is obtained that will
direct best practice initiatives, caregivers can take advantage of this previously nonexistent
“window of opportunity” to provide optimal auditory environments for their
children. It is the responsibility of audiology professionals and other professionals who
provide services to children with hearing loss to be proactive and educate parents and
caregivers so all children with UHL have the best chance for success.
Introduction
The risks associated with unilateral hearing loss (UHL) in children have
been well documented in the literature. Specifically, children with UHL are at
higher risk for educational, speech-language and social-emotional difficulties
than their peers with normal hearing (Bess & Tharpe, 1984, 1986; English &
Church, 1999; Oyler, Oyler, & Matkin, 1988). Before the advent of universal
newborn hearing screening (UNHS), many children with UHL were not identified
until school age (Brookhauser, Worthington, & Kelly, 1991). Most states
have now implemented UNHS, and children with congenital UHL are being
identified in the first weeks of life. Although this early identification of hearing
loss is clearly an advantage, it leaves caregivers with questions. Roush
(2000) stated that “for all families, it is imperative that they leave the diagnostic
evaluation with the knowledge that much can and will be done to
ameliorate the effects of hearing loss for their child” (p. 58).
Sarah McKay, Au.D., is a senior audiologist at The Center for Childhood Communication at
The Children’s Hospital of Philadelphia.
Management of Young Children with Unilateral Hearing Loss 299

Parents want to know why their child has UHL, what the impact will be
and what they can do to help their child. Early identification allows the
audiologist to connect with the parents, share relevant information about
UHL, listen to parents’ fears and build trust. Most of the evidence to date has
been on older children. Professionals who diagnose and treat this population
of newly identified babies are faced with new questions. How do we help
young children avoid or minimize some of the deleterious effects of hearing
loss? Does aggressive early intervention lower children’s risk of later educational
difficulties? How do we know which children are going to experience
difficulties? Can we justify changing early intervention policy based on evidence
seen in the school-age population? We know that language outcomes
of children with bilateral hearing loss are improved if intervention is initiated
within the first year of life (Moeller, 2000; Yoshinaga-Itano, 1998). Should we
expect this benefit in children with UHL? Although there is evidence of the
benefit of early intervention for infants with hearing loss as well as evidence
that supports the difficulties school-age children with UHL may encounter, is
it enough to support changes in the way we manage infants and toddlers with
UHL? Gravel et al. (2005) examined whether changes in policy and practice
were warranted based on the evidence presented from previous studies. With
regard to mild and unilateral hearing losses, they noted:
While a body of work suggests that about half of elementary and middle
school-age children with mild bilateral or unilateral hearing loss have some
degree of academic or social-emotional difficulties, as yet there is little
direct evidence in larger sample sizes using prospective research designs
that mild forms of bilateral or unilateral hearing loss are related to developmental
delays in the infant and preschool-age population. There are no
studies concerning which individual infants and toddlers with mild forms
of hearing loss are more likely to experience school-related problems at
older ages and what the influence of other intrinsic and extrinsic variables
is on these children’s developmental outcome.” (p. 219)
The topic of UHL is not new to the audiology profession. With regard to the
profession’s response to UHL, Oyler et al. (1988) stated:
Historically, the involvement of hearing health professionals in the management
of children with unilateral hearing loss has been limited. The
conventional approach was to identify the cause of the hearing loss and to
assure the parents that there would be no handicap.” (p. 18)
In 2005, the Centers for Disease Control and Prevention (CDC) and the
Marion Downs Hearing Center cosponsored “The National Workshop on
Mild and Unilateral Hearing Loss.” More than 50 professionals with expertise
300 McKay

in mild and/or unilateral hearing loss convened to review and discuss current
information related to the identification and appropriate intervention for
children with mild and unilateral hearing losses. Areas covered were prevalence
and screening; diagnosis, amplification and outcomes; and early intervention,
eligibility and clinical practice. The information generated in this
workshop was comprehensive and illuminated the need for future research
with this population of children. This need was particularly evident when
considering infants and preschool children with UHL. When children with
UHL remain unidentified until they are school age, or until problems arise,
intervention is often failure based. Although identifying children with UHL
at birth presents some unanswered questions, it also allows professionals
who care for them to be proactive in their care. Evidence gathered in the
school-age population may help to guide future research endeavors in the
birth-to-3 population and help to support decisions about best practices.
Status of Early Hearing Detection and Intervention Programs
Currently, 40 jurisdictions (38 states, the District of Columbia and Puerto
Rico) have legislation in effect for early hearing detection and intervention
(EHDI) programs (National Center for Hearing Assessment and Management,
2006). The specific guidelines vary from state to state. Some states
require that all babies be screened, whereas others require only babies born at
specified hospitals and still others, a specified percentage of babies born. For
a variety of reasons, it may not be feasible to screen all babies before discharge:
Not all babies are born in hospitals, some babies are discharged early,
prior to before screening, or parents deny newborn hearing screening. An
estimated 90% of infants born in the United States, however, are being
screened for hearing loss (Directors of Speech and Hearing Programs in State
Health and Welfare Agencies, 2003).
Eligibility criteria for early intervention services through the Individuals
with Disabilities Education Improvement Act of 2004 (IDEA 2004) Part C and Part
B also vary from state to state. Although Part C allows eligibility for early
intervention services if a child has a condition that places him or her at risk
for developmental delay, specifics regarding hearing loss vary. Some state
Part C and Part B programs define eligibility for services based on percentage
of delay. For instance, in Alaska, established risk conditions are those that
“have a high probability of resulting in a 50% developmental delay.” In
Connecticut, children with UHL are not automatically eligible for services.
Eligibility in Florida specifies sensorineural hearing loss in excess of 50 dB HL
in the worst ear. (A state-specific guide to services is available at www
.infanthearing.org.) Some babies are eligible to receive services immediately,
whereas others are entitled to an evaluation and periodic monitoring. Once a
child is three years old and eligibility is based on the criteria stated in IDEA
Part B, services most often are based on existing delay.
Management of Young Children with Unilateral Hearing Loss 301

Incidence of UHL
Impact of UHL
Definitions of UHL have varied over the years, but generally, a UHL is a
loss in one ear of any degree (mild to profound) (American Speech-Language-
Hearing Association, 2006). The incidence of UHL is approximately 0.83/
1,000 (Prieve et al., 2000). If the incidence is divided into categories of babies
who were in the neonatal intensive care unit and well-baby nursery, the
incidence is 3.2/1,000 and 0.41/1,000, respectively. It should be noted that
these numbers might not accurately reflect the number of children with mild
UHL because current UNHS technologies are not sensitive to mild degrees of
hearing loss. Johnson et al. (2005) found that 80% of infants with later confirmed
bilateral mild hearing loss or UHL were not referred (using a passrefer
criterion) when a two-step, two-technology hearing screening protocol
(Otoacoustic Emissions [OAE] and automated Auditory Brainstem Response
[ABR] testing) was used.
Prevalence of UHL
The prevalence of UHL in the school-age population is approximately 3%
to5% according to Bess, Dodd-Murphy and Parker (1998) and 5.6% according
to Niskar et al. (1998). These figures are alarming, particularly compared to
incidence rates of UHL in the neonatal population (0.83/1,000). Although
some children in the older age group have late-onset or acquired hearing loss,
it is speculated that others may have had existing mild hearing loss at birth
that was fluctuating or progressive in nature. This information is pertinent
because children with speech and language delays may be enrolled in early
intervention programs, and their early intervention providers may be the first
to detect signs of hearing difficulty.
Psychoacoustic Impact
The difficulties that children with UHL experience have explanations
rooted in psychoacoustics. Binaural advantages include localization, binaural
summation, reduction in the head shadow effect and binaural release from
masking. Localization difficulties on the horizontal plane have been documented
(Bess & Tharpe, 1986; Morrongiello, 1989). Localization is affected
because individuals with UHL do not have the benefit of interaural time and
intensity cues. Typically, when sound approaches from one direction, the
interaural time difference between ears allows one to determine from which
direction the sound is coming. With UHL, one may not be able to hear those
time differences (depending on the degree of UHL) and, thus, can have difficulty
localizing.
302 McKay

Children with UHL experience difficulties understanding in noise, in
large part, because they do not have the benefit of binaural release from
masking. Normal hearing in both ears allows one to filter out noise to better
hear the speech signal. Individuals with UHL do not have this advantage. As
Bess and Tharpe (1986) demonstrated, children with UHL exhibit greater
difficulty understanding nonsense syllables in noise than children with normal
hearing.
Binaural summation is the increased perception of loudness when sound is
heard by two normal hearing ears rather than by just one. For a speech signal
the advantage is approximately 3 to 8 dB (Lieu, 2004). Children with UHL do
not have the advantage of binaural summation. This disadvantage may contribute
to their difficulty with understanding speech from a distance.
The difficulties resulting from a lack of binaural advantage are magnified
in children. They do not yet have the language base to fill in the gaps when
speech enters from the impaired side, is present in noise or comes from a
distance. Therefore, children with UHL may benefit from accommodations to
counteract or preempt these psychoacoustic limitations. Such accommodations
can be made at home and in a child’s preschool. These may be in the
form of acoustic modifications, placement strategies and amplification or FM
systems.
Studies summarized by Emmer (1999) revealed that auditory deprivation
was documented in children with binaural hearing loss who were fit monaurally,
in adults with sensorineural UHL and in the unaided, poorer ear of
those adults with asymmetrical sensorineural hearing loss. Emmer noted that
auditory deprivation is more marked and has earlier onset in individuals
with UHL than in those with bilateral hearing loss who were fit monoaurally.
Additional evidence cited in this review indicated that auditory deprivation
“involves alteration in the central nervous system during a critical period of
development” (p. 26). Emmer provided an illustrative case of a 4-year-old
child with bilateral hearing loss. She had relatively equal speech perception
abilities in each ear but chose to wear only one hearing aid. By age 8, the
child’s speech recognition abilities had declined in the unaided ear. It should
be noted that the phenomenon of acclimatization (improvement following
auditory deprivation) also has been observed following later introduction of
amplification to the unaided ear. With regard to UHL, questions remain
about whether providing stimulation to the affected ear through amplification
would avoid auditory deprivation and overcome these psychoacoustic
challenges.
Educational Impact
The difficulties children with UHL experience were first described in detail
in the 1980s. As previously mentioned, this population of children typically
was not identified until they were school age (Brookhauser et al., 1991).
Management of Young Children with Unilateral Hearing Loss 303

Children with UHL are at risk for academic delays, and grade failure has been
noted (Bess & Tharpe, 1986; Oyler et al., 1988). In the Bess and Tharpe (1986)
study, 35% of children with UHL were found to have failed a grade. This
finding was 10 times higher than the greater Nashville county average of 3.5%
for grades K to 6. Oyler et al. (1988) found that 24% of children with UHL had
failed a grade in school, again approximately 10 times greater than the county
average (2% for grades K to 8). These findings were stunning. In addition,
Bess and Tharpe found that 13.3% of children with UHL were in need of
resource assistance. Oyler et al. reported 40.7% of these children were receiving
special services. More recently, English and Church (1999) noted that
grade failure was no longer a preferred practice; therefore, grade failure could
not be compared with the 1980s studies. English and Church did find that a
large percentage (54%) of children with UHL received individualized special
education services. The nature of the services varied, with most (27%) in the
area of fitting and monitoring of amplification; 16% in resource room support
for reading and math; 6% in speech-language and listening therapy; and 5%
in either physical therapy, occupational therapy, vision therapy or counseling.
At the CDC “National Workshop on Mild and Unilateral Hearing Loss,”
Neault (2005) provided an excellent summary of the results of five studies on
a total of 190 children with UHL. Comparing bilateral to unilateral listeners
across a variety of tasks, the average scores of “bilateral listeners” performed
at the 50th percentile, whereas “unilateral listeners” were poorer in all areas
(math, 30th percentile; language arts, 25th percentile; social skills, 32nd percentile).
Children with severe to profound UHL also have been found to have
a lower full-scale IQ score on the Wechsler Intelligence Scale for Children-
Revised (WISC-R) than children with lesser degrees of UHL (Culbertson &
Gilbert, 1986; Klee & Davis-Dansky, 1986).
Speech and Language Impact
Some studies have indicated that children with UHL are at risk for speech
and language delays. Kiese-Himmel (2002) evaluated the emergence of oneand
two-word phrases in children with UHL. She found that the average age
for first words was within normal limits (12.7 months). However, the average
age for first two-word utterances was found to be delayed (23.5 months). The
defined norm for the emergence of two-word phrases in this study was 18
months. Lieu (2004) reported on the findings of the Colorado Home Intervention
Program (CHIP) that followed the language abilities of 15 children
with UHL since infancy. Of the 15 children, four (27%) were found to have
significant language delays, and one (7%) was found to have borderline language
delays.
Social-Emotional Impact
Because of the psychoacoustic variables mentioned earlier, sound often is
audible but not always understandable to children with UHL. This disadvantage
304 McKay

can leave a child appearing inattentive, disinterested or aloof. These negative
perceptions can affect school and peer interactions. When a child is not able
to hear conversations in groups, he or she may feel insecure or “left out,”
which can lead to difficulties with behavior and peer relationships. Bess et al.
(1998) studied groups of third, sixth and ninth graders with minimal hearing
loss (including UHL) and found that these children had greater dysfunction
than their peers with normal hearing on domains of stress, self-esteem and
behavior.
Teacher Perceptions of Children With UHL
Minimal hearing loss (a term that includes UHL) has been described as an
“invisible acoustic filter” (Flexer, 1995). Children with UHL may not exhibit
obvious difficulties. If teachers are not informed that a child has UHL, they
may never know that the hearing loss exists. Hearing aids, which alert teachers
to children with bilateral hearing loss, are not always recommended or
chosen for children with UHL, and as mentioned previously children with
UHL are at risk for academic delays (Bess & Tharpe, 1984; Brookhauser et al.,
1991; English & Church, 1999; Oyler et al., 1988). Teacher perceptions about
children with UHL have been studied. Dancer, Burl and Waters (1995) obtained
Screening Instrument for Targeting Educational Risk (SIFTER) questionnaires
from teachers of children with UHL. They found that teachers gave
lower scores to children with UHL in all five areas of the SIFTER: academics,
attention, communication, participation and behavior. Culbertson and Gilbert
(1986) reported that teachers rated 39% of children with UHL as “below
average” compared to 5% for their peers with normal hearing. Children with
UHL were described as giving up easily on new and difficult tasks and
needing more direction for task completion. They also received more negative
ratings than their peers with normal hearing in the areas of dependence and
independence, attention to task, emotional ability, peer relations and social
confidence. Teachers and care providers of children with UHL should be
informed of the child’s hearing loss, or they may draw other (negative) conclusions
about the child based on his or her performance, attentiveness and
behavior. Bess & Tharpe (1986) illuminated the need for teachers to receive
training regarding children with UHL and the everyday problems they may
encounter. They also warned that teachers need to be informed about issues
regarding localization, listening in noise and safety issues. Although this
warning was intended for teachers of school-age children, it would be just as
applicable to daycare and preschool teachers. Any knowledge that helps a
teacher understand the unique challenges of his or her students should be
beneficial.
Recommendations
To the author’s knowledge, best practice guidelines have not yet been
identified for infants and toddlers with UHL, which leaves those who work
Management of Young Children with Unilateral Hearing Loss 305

with this population of children to make recommendations and choose options
based on evidence from an older population. This section delineates
some of these options and possible ways to apply them to a younger population.
Amplification Options
Some studies have reported on the efficacy of amplification with UHL, but
most have been with school-age children. Little is known about the benefit of
early amplification for infants and toddlers with UHL. The Special Consideration
section of the American Academy of Audiology (AAA, 2003) Pediatric
Amplification Protocol addresses the fitting of amplification on children with
UHL as follows:
Use of hearing aid amplification is indicated for some children with unilateral
hearing losses. The decision to fit a child with unilateral hearing loss
should be made on an individual basis, taking into consideration the child’s
or family’s preference as well as audiologic, developmental, communication,
and educational factors. (p. 3)
The choice of when to fit a child with amplification may depend on different
factors. Evidence on the efficacy of fitting babies with UHL with hearing
aids does not yet exist; thus, parents and audiologists find themselves
examining other factors. The timing of initial fitting with a hearing aid may
have social ramifications. If parents choose to wait to fit their child with a
hearing aid until the child experiences failure (i.e., later elementary grades),
the attitudes of the child’s peers toward the amplification at that time may be
poorer than they would have been at a younger age (Dengerink & Porter,
1984; Riensche, Peterson, & Linden, 1990). These studies show that older
children perceive their peers who wear hearing aids to be less smart and less
attractive. Younger (preschool) children have no negative attitudes toward
their peers who wear hearing aids. It is possible, therefore, that earlier versus
later amplification may allow a child to develop positive self-esteem and
friendship/peer groups in which a hearing aid goes unnoticed.
The use of conventional hearing aids with children who have moderately
severe or better hearing in the impaired ear has met with some success, as
subjective rating scales indicate (Kiese-Himmel, 2002; McKay, 2002). A questionnaire
administered to parents of children with UHL who wore hearing
aids and asked parents to rate how their child was doing at present versus
before amplification (McKay, 2002). The results were very positive, with 72%
of parents and patients reporting benefit (improved or greatly improved) on
questions involving different listening environments. Additionally, all of the
parents reported being happy with their decision to fit their child with a
hearing aid. Fifty percent wished they had fit their child with a hearing aid
306 McKay

sooner. Most of the children in this questionnaire group were school age. For
the children who were under three, ratings were more neutral. These younger
children had not yet encountered some of the listening difficulties that older
children experience, which may account for the neutral ratings. Kiese-
Himmel (2002) reported 81% acceptance from children with moderately severe
or better UHL who wore a hearing aid but “very poor use of hearing aid
or no use of hearing aid” (p. 59) when the hearing loss was severe or profound.
With a lesser degree of hearing loss, it may be possible to achieve a
more balanced sense of hearing between the ears. All available audiologic
information, including electrophysiological and behavioral test results, in
conjunction with verification measures, such as real ear probe measures with
desired sensation level (DSL) targets, always should be used to ensure appropriate
fitting.
As parents seek sources to inform themselves about options for their newly
diagnosed baby with UHL, it is important to give them information about all
possible devices, including those that would not be recommended or are not
an option at that time. Examples are contralateral routing of signal (CROS)
amplification, bone-anchored hearing apparatus (BAHA) and even a cochlear
implant. Although most hearing professionals know that a child is a candidate
for a cochlear implant only if he or she has bilateral severe-to-profound
hearing loss, parents and well-intending relatives and friends do not. It is a
simple strategy to inform parents about all available technologies to avoid
confusion or disappointment.
The AAA (2003) Pediatric Amplification Protocol also addresses the use of
CROS amplification. The CROS system has been purported to be useful in
quiet situations, especially in cases where the signal originates on the side of
the impaired ear. The protocol cautions audiologists that CROS amplification
may not be beneficial in the classroom because of the introduction of noise to
the normal hearing ear through the microphone on the impaired side (Kenworthy,
Klee, & Tharpe, 1990). The CROS system, therefore, should not be
considered for young children.
The BAHA was originally intended for individuals with conductive or
mixed hearing loss but has recently been marketed for individuals with UHL.
Because of issues related to anatomical maturation, the BAHA is only Federal
Drug Administration approved for use in children over 5. The premise of
fitting a BAHA on a person with severe or profound sensorineural hearing
loss is to allow transcranial delivery of a signal. Although there are reports of
BAHA fittings on adults with UHL (Wazen, Ghossani, Kacker, & Zschommler,
2001; Wazen, Ghossani, Spitzer, & Kuller, 2005; Wazen et al., 2003), to
the author’s knowledge, there are no reports to date on children with severe
or profound sensorineural hearing loss in one ear. It could be speculated that
the introduction of noise to the impaired side, which is sent transcranially to
the normal side, would have a similar impact on a child to that of a CROS aid.
A great deal more evidence regarding outcomes for adults and older children
Management of Young Children with Unilateral Hearing Loss 307

who have UHL and the BAHA implant should be obtained to determine if
surgical implantation of BAHA in children with UHL is beneficial.
The benefit of FM technology in this population has been well documented
(Flexer, 1995; Kenworthy et al., 1990; Updike, 1994). Increasing the signal-tonoise
ratio for a child who is developing language is clearly an advantage. As
with the aforementioned studies, most evidence has been conducted among
school-age children. In the infant and toddler population, one must think
creatively about which listening situations FM use could be beneficial. These
situations might include while a child is in a stroller or car seat or during
instructional time in a day care or preschool environment. Another factor to
consider is the best choice for routing the FM signal. If a child already has a
hearing aid, the audiologist may choose to couple an FM receiver to it. Another
option is to couple the FM receiver to the normal hearing ear through
an ear-level FM system. Personal and sound field FM systems also may be an
option. To the author’s knowledge, no evidence is available to indicate the
most appropriate choice of FM for a preschool-age child with UHL. In keeping
with the AAA (2003) Pediatric Amplification Protocol, decisions must be
made on an individual basis. As a child approaches school age, or if he or she
is already receiving early intervention services, it is recommended that the
decision be coordinated with the child’s educational audiologist or hearing
support teacher. They may have additional important information about the
class setting, and use of FM with other students will need to be considered.
This information is not typically available to the clinical audiologist.
Medical Considerations
Upon diagnosis of UHL, parents should be informed of additional recommended
evaluations. Understanding the rationale behind these recommendations
as well as the potential results and implications is important for all
care providers, even those not directly involved in the evaluations, because
parents may have immediate questions. Recommendations may need to be
made over a series of appointments to avoid crossing the fine line between
empowering and overwhelming parents. The child’s primary care physician
(PCP), who should act as “gate keeper” for all subsequent medical referrals,
should be informed immediately of the diagnosis and recommendations. The
Joint Committee on Infant Hearing (JCIH, 2000) Year 2000 Position Statement:
Principles and Guidelines for Early Hearing Detection and Intervention Programs
described the importance of the medical home model, which allows pediatricians
and PCPs to be the center of all care for the child:
Pediatricians and other primary care physicians, working in partnership
with parents and other health-care professionals, make up the infant’s
“medical home.” A medical home is defined as an approach to providing
308 McKay

health care services where care is accessible, family-centered, continuous,
comprehensive, coordinated, compassionate, and culturally competent.
Pediatricians act in partnership with parents in a medical home to identify
and access services needed in developing a global plan of appropriate and
necessary health and habilitative care for infants identified with hearing
loss. (p. 801)
The JCIH position statement also made the following statement about the role
of the PCP:
The infant’s pediatrician or other primary care physician is responsible for
monitoring the general health and well-being of the infant. In addition, the
primary care physician in partnership with the family and other health care
professionals, assures that audiologic assessment is conducted on infants
who do not pass screening and initiates referrals for medical specialty
evaluations. (p. 804)
The position statement made specific recommendations for medical referrals
following the diagnosis of sensorineural hearing loss that include evaluations
by otolaryngology; genetics; ophthalmology; developmental pediatrics; neurology;
and, as needed, nephrology and cardiology. These recommendations
are posted on many Web sites of otolaryngology departments in major medical
centers across the country. These evaluations are further described here.
Otologist/Otolaryngologist
Children with UHL should be referred to an otolaryngologist to rule out
outer or middle ear pathology, look at inner ear structures and screen for
other associated conditions. The otolaryngologist may recommend the following
tests:
CT scan of the temporal bone to check for evidence of middle ear and
inner ear anomalies. Findings from this scan may give information about
whether the hearing loss may progress in one ear or both.
Magnetic resonance imaging (MRI) to check for inner ear malformations
and status of the auditory nerve and pathways.
Urinalysis to screen for associated kidney abnormalities.
Echocardiogram (ECG) to rule out prolonged QT (the interval between
two points [Q and T] on the common electrocardiogram) associated with
Jervell and Lange Neilsen syndrome. An ECG sometimes is ordered for
children with UHL but often is conducted for bilateral sensorineural
hearing loss.
Blood work if thyroid dysfunction, autoimmune disease or a specific
infection is suspected.
Management of Young Children with Unilateral Hearing Loss 309

Progression of hearing loss is a concern in children with UHL and warrants
comprehensive baseline medical and audiologic testing and close audiologic
monitoring. Hearing loss not only can progress in the impaired ear, but also
can become bilateral. The CHIP currently collects information about the development
of children with UHL. This group reported that close to 10% of
participants had UHL that progressed to bilateral hearing loss (CHIP, 2005).
In a review of the existing literature on children with UHL, Lieu (2004) noted
a study reporting that that five out of 35 children with UHL were found to
have progressive losses, and 11 had inner ear anomalies (Bamiou, Savy,
O’Mahoney, Phelps, & Sirimanna, 1999). When examining characteristics of
sensorineural hearing loss in children with inner ear anomalies, Coticchia,
Gokhale, Waltonen and Sumer (2006) found that children with inner ear
anomalies were most likely to have UHL. Another population of children at
risk for progressive hearing loss are those with cytomegalovirus. Alerting
physicians about the possible causes and incidence of progressive hearing
loss will help them become aware of the importance of close audiologic
monitoring and convey the importance of listening to parents if they express
concern that their child’s hearing has changed. It is important for educational
and therapeutic care providers of a child with UHL, who may be the first to
detect subtle changes in a child’s auditory or speech abilities, to be informed
of this risk as well.
Alerting caregivers of children with UHL that outer and middle ear conditions
may cause additional temporary hearing loss also is important. The
JCIH (2000) made the following statement with regard to medical management
of middle ear pathology:
The impact of OME (otitis media with effusion) is greater for infants with
sensorineural hearing loss than those with normal cochlear function. Sensory
or permanent conductive hearing loss is compounded by additional
conductive hearing loss associated with OME. OME further reduces access
to auditory/oral language stimulation and spoken language development
for infants whose families choose an auditory-oral approach to communication
development. Prompt referral to otolaryngologists for treatment of
persistent or recurrent OME is indicated in infants with sensorineural hearing
loss. (p. 807)
Most young children experience OME during their early childhood. An
established relationship with an otolaryngologist will be helpful in vigilant
management of OME in children with UHL.
Genetics
Children with sensorineural hearing loss should be referred to a geneticist
to determine possible etiology or association with a syndrome. A comprehensive
genetics evaluation will likely include:
310 McKay

Dysmorphology examination
Complete family and medical history
Audiologic testing of parents and siblings
Gene testing if syndrome is suspected
Ophthalmology
Every child with permanent hearing loss is referred to ophthalmology to
ensure optimal visual acuity. Most known disorders that have both visual
and hearing problems, such as Usher’s syndrome, are usually present only in
children with bilateral hearing loss.
Neurology
A neurological examination is recommended only if hearing loss is considered
to originate past the point of the outer hair cells of the cochlea (i.e.,
auditory neuropathy, neural hearing loss or central disorder). Findings of
abnormal ABR results in conjunction with present OAE would lead to this
recommendation.
Nephrology
This referral is made only when kidney function is in question.
Speech-Language Pathology
Any child with UHL should be referred for an initial evaluation with a
speech-language pathologist. Subsequent evaluations to monitor development
also are recommended.
Parental Education and Advocacy
Upon receiving the news that their child has a UHL, parents will have
immediate questions and concerns. Roush and Harrison (2002) found that
after a child has been diagnosed with hearing loss, parents wanted to know
about (1) the cause of the hearing loss, (2) how to cope with the emotional
aspects of the hearing loss, (3) how to understand the audiogram, (4) how
their child will learn to listen and speak and (5) the ear and hearing. These
prioritized concerns were those of parents of children with newly identified
bilateral hearing loss. Although the answers may not be the same for a child
with newly diagnosed UHL, it is important to be aware of parents’ concerns.
Providing information to parents at this point may alleviate some of their
fears. Knowing that they will be able to advocate for their child by having the
information they need can be empowering. Even if a child is not eligible for
Management of Young Children with Unilateral Hearing Loss 311

ongoing services because of a specific state’s Part C eligibility restrictions, an
initial evaluation and scheduled monitoring allows an opportunity for these
parents to be informed. Ideally, parents should receive written information
after the evaluations for their reference. This information should include
ways to help their child at home and in his or her day care or preschool
environment. Calderon (2000) looked at the outcomes of children with hearing
loss and parent involvement and found that parental communication
skills had an impact on the outcomes. Parents should be given information on
normal development of speech and language milestones. Additionally, they
may benefit from information on how to be a good language model for their
child and stimulate language as well as the importance of monitoring language.
The following are examples of information to share with parents:
When you are holding or feeding your baby, try to make sure your
child’s normal hearing ear is facing you.
Always be aware of where your child’s normal hearing ear is facing. It
should always be facing you or those talking to your child. Think about
this when your child is at dinner, in the car or in her stroller, for example.
Try to avoid letting your child’s normal hearing ear face a noise source,
such as a dishwasher.
Try to make eye contact and use facial expressions.
Get your child’s attention before talking to him or her.
Talk about what you are doing within your daily routine.
Start conversations and take turns talking.
Help your child localize sound by using visual cues.
Use repetition.
Look for cues that your child understands what you are saying.
Expand your child’s vocabulary by using other adjectives and adverbs.
Play listening games (auditory version of “I Spy”).
Raise your voice slightly and face him or her when you are at a greater
distance (walking your baby in the stroller).
Parents should be aware of the listening situations in which their child may
experience the most difficulty. These situations include listening in environments
that are noisy or when there is distance between the parent and the
child. Parents should know that if they call their child and give him or her
instructions from another room, the child might hear them but not understand
what was said.
Parents should be guided on how to best advocate for their child with
regard to early intervention and education if their child experiences difficulties.
For example, in the state of Pennsylvania, information is compiled in a
booklet by the Parent Education Network (2003) that outlines much of the
information parents will need to know as they navigate the early intervention
312 McKay

and educational systems. Topics covered include an overview of special education
laws, explanation of the evaluation process, Individualized Family
Service Plans and Individualized Education Programs (what to ask for), what
to look for in an early intervention program, classroom strategies and appendices
with useful definitions and checklists for parents.
Education of Day Care and Preschool Providers
The phrase “preferential seating” is familiar to all who work with children
with hearing loss and is consistently recommended for children with UHL.
Although preferential seating may be helpful, the recommendation is not
always straightforward and may give caregivers the impression that it is the
solution. We must think beyond preferential seating and the typical classroom.
Parents should be informed about how to carefully choose day care
providers and preschools and how to advocate for their child’s needs once the
child is enrolled in a facility. Ideally, written information should be given to
a care provider (day care or preschool teacher), and a hearing care specialist
should meet with this person to explain how to best meet the needs of the
child in his or her environment. Information about the difficulties older children
with UHL may experience should be shared with teachers of younger
children to alert them to potential problems. Examples of difficulties seen in
some older children with UHL are fatigue, inattentiveness, frustration and
behavior and social problems. Teachers can be given strategies to help the
child in the day care or preschool environment, such as the following:
Teach the children (and staff) in the class good “listening etiquette.”
When one person is talking, everyone listens. Although this is not practical
during play or free time, it should be exercised during structured
lessons.
Try to get the child’s attention by calling his or her name before giving
instructions.
Use a visual cue, such as pointing to the child who is to speak next. This
will direct the child toward the direction in which to turn.
Try to face the child when speaking.
Be aware of the child’s placement in the class. Do not place him or her
near a noise source, such as an air conditioner. Proximity is important;
therefore, place the child near you and with his or her normal hearing ear
facing you.
Have a nonverbal cue that can be used to regain attention (i.e., tap on the
shoulder followed by eye contact) if the child seems inattentive.
Try to place noisy centers off on their own.
Take interest in the child’s hearing aid or FM system (if applicable). Let
the child share it at “show and tell.” Acquire and read children’s books
that explain hearing loss and hearing aids.
Management of Young Children with Unilateral Hearing Loss 313

Environmental and Acoustic Modifications
Educating parents regarding the importance of good acoustic environments
for their child will aid them in choosing appropriate day care or preschools.
Crandell and Smaldino (2001) addressed the importance of acoustic
friendly classrooms. Although most applications these authors noted were
made to a typical grade school class, they can be implemented in day care and
preschool classes as well. Some recommendations are as follows:
Avoid day care programs and preschools that practice “open class”
teaching with many classes within a large area. The child with UHL
needs the least amount of competing noise.
Request area rugs if there is not wall-to-wall carpeting.
Use window treatments (thick materials).
Avoid using hard surfaces whenever possible. Use an alternative such as
a corkboard.
Use tennis balls or rubber tips on the bottoms of chairs.
In play or leisure areas, place soft seating such as bean bag chairs.
Use creative artwork such as decorated egg crates, material or rug strips
and Styrofoam balls hung from the ceiling.
Place movable boards at an angle in the room.
Turn off noisy equipment (i.e., computers, tape recorders) when not in
use.
Try to keep doors and windows closed.
Audiologic Monitoring
The importance of close monitoring must be stressed to all involved in the
care of a child with UHL. Audiologic monitoring is needed to ensure that
hearing sensitivity remains stable in both ears. It is particularly important in
light of the high incidence of progressive hearing loss in this population.
Speech and language monitoring may help to pick up subtle difficulties that
a child may have and allow for remediation before a child is school age.
Parents and teachers may find functional auditory measures helpful in tracking
the ongoing auditory abilities of a child with UHL. Oticon, Inc., published
a brochure that recommends specific measures based on age and degree of
hearing loss (Tharpe & Flynn, 2005). Specific measures to be completed by
parents and teachers for the birth-to-3 age group and the 3-to-5 age group are
recommended. Close monitoring allows professionals to interact with parents,
answer questions and raise awareness. Such opportunities only can be
beneficial.
Conclusion
School-age children with UHL are known to be at risk for academic and
speech-language delays. With the widespread implementation of UNHS,
314 McKay

many children with congenital UHL are now being identified in their first
months of life. Recently this population of children has drawn interest and
focus from groups such as the CDC, the AAA, and ASHA. Information
should continue to evolve with regard to best practices for young children
with UHL. Future evidence will shape consistent policy in the best interest of
these children. At The National Workshop for Mild and Unilateral Hearing
Loss (2005), participants in working groups outlined future research needs, a
brief sampling of which is as follows:
Increase public and professional awareness of UHL.
Develop recommendations on how to best inform parents about the
potential outcomes of children with UHL.
Collect outcome data on amplification for UHL (early versus late, FM
versus hearing aid).
Compare the effects of early FM system use, hearing aid use and no
amplification on communication, educational and social-emotional outcomes
in children with UHL.
Develop more sensitive and age-appropriate outcome measures and
functional assessments for the birth-to-3 age group.
Conduct descriptive studies of successful early intervention systems;
successful state systems can serve as useful models.
Share research findings with state Part C coordinators for use in updating
their eligibility criteria.
Conduct randomized trials to compare outcomes for children who receive
early intervention with those who do not.
Investigate long-term outcomes to determine whether children from
birth-to-3 who experience delays are the same children experiencing
delays in school.
Identify factors that predict successful speech, language and behavior
outcomes.
A complete list of future needs as well as the proceedings of this workshop
can be found at www.cdc.gov/ncbddd/ehdi. Although questions remain
about the best practice for infants and toddlers with UHL, early identification
gives hearing health and early intervention professionals a unique “window
of opportunity” not previously available. As EDHI programs’ current and
future research begin to gather the evidence needed to establish consensus
and mandates, those who care for children with UHL will be able to use this
evidence to develop and implement practices and recommendations that will
optimally benefit these children. As questions are answered over the coming
years, it will be critical to reinforce the need to share the results with the Part
C coordinators in order to effect changes in eligibility criteria. Although it is
important to acknowledge there are little data regarding outcomes for very
young children with UHL, there are strategies that may mitigate potential
Management of Young Children with Unilateral Hearing Loss 315

negative effects of unilateral hearing. We do have recommendations for parents
on how to help their child now. We know that early intervention is
beneficial to children with hearing loss, and we know that parental involvement
positively influences outcomes. By continuing to educate parents and
those who work with or care for a child with UHL, we will enable these
individuals to better help the child, advocate for the child and teach the child
how to advocate for him- or herself. Considering the potential deleterious
effects of UHL, professionals must be responsible for proactively educating
parents and caregivers so that all children with UHL have the best chance for
success.
Acknowledgments
The author wishes to thank Judith Gravel, Ph.D., Carol Knightly, Au.D.,
and Anne Marie Tharpe, Ph.D., for their ongoing support and guidance in her
interest in unilateral hearing loss in children.
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Management of Young Children with Unilateral Hearing Loss 319

The Volta Review, Volume 106(3) (monograph), 321-341
Early Spanish Speech
Acquisition Following
Cochlear Implantation
Jan Allison Moore, Ph.D., Scott Prath, M.A., and
Adrianne Arrieta, M.A.
The purpose of this paper is to document the early Spanish speech development of
a toddler, K, whose cochlear implant was activated at age 20 months. The contribution
of K’s developmental pattern to research is unique in that Spanish is the sole
language of the home, as well as being the language of intervention up to 16 months
postimplant (3 years chronological age). Early organization of consonant-vowel
structures was consistent with other cochlear implant (CI) recipients who were learning
English and generally support the theoretical perspective that the oral motor
system has a fundamental role in the organization of early speech production. Overall
accuracy of speech of words at 12 months postimplant showed that K had substantially
greater word accuracy compared to English-speaking CI peers with the same age
of implantation and device. These results highlight the phonetic and phonologic
differences between English and Spanish which have direct clinical application in the
provision of speech intervention services to children whose first language is Spanish.
Introduction
Speech and hearing professionals in the United States often have limited
exposure in working with families and children from multilingual homes or
from monolingual homes in which English is not spoken. This exposure is
even more limited in low-incidence disabilities in childhood such as hearing
loss. In addition, most graduate training programs do not routinely offer
Jan Allison Moore, Ph.D., is an assistant professor in the Department of Communication
Sciences and Disorders at the University of Texas at Austin. Scott Prath, M.A., completed his
graduate degree in communication sciences and disorders at the University of Texas at Austin.
He currently works with Spanish-speaking early childhood intervention and school-age populations
in central Texas. Adrianne Arrieta, M.A., received a master’s degree in communication
sciences and disorders from the University of Texas at Austin. She currently works as
a public school-licensed bilingual speech-language pathologist in Pflugerville, Texas.
Early Speech Acquisition in Spanish 321

specific information regarding differences and benchmarks of communicative
development of languages other than English.
This paper has two primary purposes. First, it will serve as an introductory
tutorial of differences between Spanish and English in the area of early speech
development. Second, this paper will discuss emerging speech patterns and
accuracy in a child, K, whose implant was activated at age 20 months and for
whom Spanish is his first language. Our study focuses on Spanish, but it
should be noted that K also began to develop English within the educational
system. It is hoped that speech-language pathologists, audiologists and teachers
of children with hearing loss will have increased awareness of the process
of acculturation of new immigrant families in the United States. This knowledge
should positively impact the ways in which we work with families from
minority backgrounds.
First, an overview of typical speech development will be presented along
with the theoretical background of the Frame Content Theory (MacNeilage &
Davis, 2000). The Frame Content Theory (FC) is the theoretical perspective
that drives our analysis of early speech. This will be followed by some general
statistics regarding Spanish language use in the United States and specific
information on typical development of speech in Spanish, speech development
in children with hearing loss and speech development in children with
cochlear implants (CI). This will be followed by the details of our case study
and implications for service delivery for families from Spanish-speaking
homes.
Review of the Literature
Typical Development of Prelinguistic Vocalization Patterns
The development of the sound system leading up to the production of
words has been well documented (Oller, 1980; Stark, 1980; Vihman, Macken,
Miller, Simmons, & Miller, 1985; Vihman, Ferguson, & Elbert, 1986). The stage
that is of particular importance to this study is the development of true
consonant-vowel (CV) syllables around age 7 months. This stage, the canonical
babbling stage, is significant because the vocalizations sound much more
“speech-like” in that they are syllabic in nature. Canonical babbling lays the
foundation for the rapid timing of syllable production, which is present in all
languages, and the basis for word production. Canonical babbling is defined
as rhythmic production of consonant-vowel (CV) syllables. The syllable
strings in canonical babbling may be reduplicated or variegated. Reduplicated
babbling (e.g., “dudududu”) was once thought to precede variegated
babbling (e.g., “dadi”) but these two forms of syllable production arise during
the same time period (Stark, 1980) rather than sequential stages of development.
322 Moore, Prath, & Arrieta

Theories on Speech Development
Theories vary widely accounting for how and why the speech mechanism
develops to eventually produce meaningful speech. Although it is now generally
accepted that sound qualities in canonical babbling are continuous with
sound qualities in the early word period (Vihman et al. 1985), there are
varying theories as to why preverbal vocalizations and canonical babbling
take place.
The theoretical perspective of this research is one that accounts for the
dependable and universal nature of babbling and the maturation of the oralmotor
system. Davis and colleagues (Davis, MacNeilage, & Matyear, 2002)
addressed these issues biologically in terms of the Frame Content Theory. The
“frame” or structure of speech is provided by the rhythmic oscillation of the
mandible. The “content” (consonants and vowels) of an utterance is placed
within a frame. The FC Theory is based on knowledge of the evolution of
speech and language. The movement of the frame is believed to have
emerged from reflexive motions of ingestion such as eating and sucking.
Vowels (V) evolve from the open aspect of mandibular movements, whereas
the closing phase creates a consonant (C).
At the canonical babbling stage, the tongue and lips do not operate independently
of the rhythmic cycles of the mandible. “Changes in amplitude of
the mandibular cycle would result in height changes for vowels (e.g., [ae]
verses [i]) and manner changes for consonants (e.g., [d] versus [j])” (Davis &
MacNeilage, 1995, p. 3). Further, these researchers state that alternations between
oral and nasal sounds appear when control is gained over soft palate
closure. The basis of babbling exists within the timing and development of the
action and not in descriptions of phonological representations.
Biological assertions relating physical movements to speech cannot be language
specific or dependent. That is to say, speech development is universally
challengeable, and similar outcomes result across an array of ambient
(native) languages. MacNeilage and colleagues (MacNeilage, Davis, Kinney,
& Matyear, 2000) suggest that in early development an infant babbles in
similar patterns regardless of ambient language. In their study on serial organization
in infants across languages, consistencies in babbling productions
were explored across six populations (English, French, Swedish, Japanese,
Brazilian Portuguese and Quichua). Later, Lee (2003) investigated this phenomenon
in Korean. Results of these studies yielded patterns of syllable
organization in words and babbling that contain some universal consistencies
(MacNeilage et al., 2000). These consistencies refer to the distribution of preferred
syllable shapes seen in typically developing children with normal hearing.
These CV syllable shapes include the “pure frame” or labial consonant
(e.g., b, m) followed by a central vowel (e.g., a), the dorsal consonant (e.g., k,
g) followed by the back vowel (e.g., u, o) and the coronal consonant (e.g., t, d,
s) followed by a front vowel (e.g., e, ae). The “pure frame” that occurs when
Early Speech Acquisition in Spanish 323

labial consonants are paired with central vowels are considered “pure” in the
sense that the sound is solely the result of mandibular movement. The consonant
is formed as the lips come together, and the vowel is formed while the
tongue is in a resting position (MacNeilage & Davis, 2000).
Syllables first appear in an infant’s repertoire as monosyllables (Vihman et
al., 1985). Normally these syllables begin with a consonant and end with a
vowel (MacNeilage et al., 2000). MacNeilage and his colleagues also state that
the CV sequence is so important that it is “often given the status of the only
universal syllable type” (MacNeilage et al., 2000, p. 154). Following the appearance
of these syllables in isolation, an infant begins to reduplicate (Oller,
1980).
Reduplicated syllable production (babbling) is the result of repeated oscillations
of the mandible. Mandibular movements appear earlier than lingual
or labial movements in canonical babbling because oscillation is easiest when
the articulators stay in one place (Davis & MacNeilage, 1995; Davis et al.,
2002; MacNeilage & Davis, 2000; MacNeilage et al., 2000). Initially, 50% of the
total syllable is reduplicated and 67% of the consonants are reduplicated
(Davis & MacNeilage, 1995). As the child starts to produce his or her first
words, 30% of the total syllables are reduplicated and 73% of the consonants
are reduplicated (MacNeilage, Davis & Matyear, 1997). As variegated babble
leads into full words, there is very little reduplication in the child’s attempts
at speech (MacNeilage, et al., 2000).
In summary, prelinguistic babbling is the biological result of mandibular
oscillations that are accompanied by phonation (Davis & MacNeilage, 1995;
MacNeilage & Davis, 2000; MacNeilage et al., 2000). Many of these syllable
patterns that are created during babbling are universal, without influence of
ambient language (MacNeilage et al., 2000). This being said, an explanation of
speech development, even for a Spanish-speaking child, would be generic up
until babbling makes the transition into first words (Oller, 1980; Locke, 1983).
With the development of first words we would expect sound sequences intrinsic
to Spanish to emerge.
In regard to children with hearing loss, Oller and Eilers (1988) highlighted
the necessity of audibility in the development of true canonical babbling
defined both by the CV nature of production and also the rapid timing of the
syllables and rapid transitions between consonant and vowel. A few studies
have documented the development of syllables in children following cochlear
implantation (McCaffrey, Davis, MacNeilage, & von Hapsburg, 2000; Moore,
Davis, & Tobey, 2004; von Hapsburg, 2003). CIs provide audibility to the
infant, albeit in a compromised form, in terms of temporal, frequency and
loudness resolution. These preliminary studies have described in detail the
emergence of speech patterns in a small number of children who have received
implants. Overall, early syllable development of these children with
CIs have supported the notion of frame dominance in their syllable organization;
however, other preferred patterns of syllables were also observed,
324 Moore, Prath, & Arrieta

indicating an interaction of a normal oral-motor system, an impaired auditory
system and the effect of learning speech via direct intervention.
Although FC has been supported via studies of both typically developing
children with normal hearing and those with hearing loss, the theory, to our
knowledge, has yet to be tested on a child in which hearing loss and language
difference co-occur. The universal nature that the FC Theory proposes will be
further scrutinized in the discussion of our participant’s vocalization patterns
in Spanish. Therefore, our first question will be: How does K’s syllable development
relate to the results seen with other children with implants and
children from different language groups? With this in mind we will examine
highlights of typical development in Spanish.
Typical Development of Speech in Spanish
The population of Spanish speakers worldwide is approximately 322 million
(Encarta, 2004). In the United States alone, 10% (35 million) of the population
is Hispanic, and this number is projected to double by 2030 (U.S.
Census Bureau, 2000). In the states that border Mexico, the percentage of
speakers using Spanish as their primary language often exceeds 30% of the
population. These demographic changes have increased the possibility that
an interventionist or researcher will come into contact with Spanish and
Spanish-speaking cultures. This becomes problematic when “most speechlanguage
pathologists are not Spanish speakers, [and] may not be sufficiently
aware of the important phonological differences [of] Spanish” (Goldstein &
Iglesias, 1996, p. 82). The international and domestic research communities
have responded with a plethora of information concerning Spanish developmental
tendencies, including work by Acevado, Bedore, Fernandez, Goldstein,
Iglesias, Jimenez, Quilis and Washington.
Phonology
The phonologies of English and Spanish have many similarities (Quilis &
Fernandez, 1999). Although both languages utilize the same alphabet, the
Spanish phonetic system is more concise compared to English. Spanish has 18
consonant phonemes compared to 26 in English (Goldstein & Iglesias, 1996).
These totals do not include allophonic or dialectal variations within either
language. Spanish lacks the glottal stop, the voiced affricate (judge), the
voiced /ð/ and unvoiced // (thigh, thy), the voiced /ʒ/ (azure) and unvoiced
/ʃ/ (shy), the /z/, the /ŋ/ (sing), and the flap /ɾ/ (as in butter).
English, on the other hand, does not employ the trilled /rr/ or the (canyon)
of Spanish (Quilis & Fernandez, 1999).
Spanish Vowels
The Spanish vowel space is like most Latin languages, relying on five
vowels /a/, /e/, /i/, /o/ and /u/ (compared to 13 in English). Diphthongs
Early Speech Acquisition in Spanish 325

are as prevalent in Spanish as they are in English. A Spanish diphthong is the
combination of one hard vowel (/a/, /o/, /u/) and one weak vowel (/i/,
/e/) or the combination of two weak vowels (Quilis & Fernandez, 1999).
When vowels and consonants form syllables, speech patterns that are found
in Spanish can be identified through studying the order of phoneme acquisition,
syllable shape, word length and phonological processes.
Defining normal phonological acquisition for Spanish speakers is difficult
due to the diversity of the populations that are often studied (Goldstein &
Washington, 2001). In English, dialectal variations are generally defined by
vowel differences (Goldstein & Iglesias, 1996). Contrarily, Spanish dialectal
changes are marked by shifts in consonantal classes such as fricatives, liquids,
glides and nasals (Goldstein & Iglesias, 1996). Nevertheless, some similar
trends can be generalized throughout.
Spanish Consonants
There is consensus among many researchers that nearly all phonemes in
Spanish are acquired by four years of age (Acevedo, 1993; Jimenez, 1987;
Anderson & Smith, 1987; Goldstein & Washington, 2001). In one example,
Acevado (1993) found that Mexican-American children acquire all phonemes
by age four except /j/, /l/, // and /s/. Mann and Hodson (1994) cite
Terroro’s 1979 study of Venezuelan children in which he found that after age
four, only /j/, /l/, //, /s/, /r/ and // were not mastered. The differences
regarding outlying phonemes could be the result of differences between the
children studied (Anderson & Smith, 1987), dialectal differences between the
populations (Goldstein & Iglesias, 1996) or variations in the studies themselves
(Acevedo, 1993; Jimenez, 1987). Universally, stop consonants were
acquired first, followed by nasals, then fricatives and affricates, with liquids
being the last sounds to appear (Goldstein & Washington, 2001). This suggests
that K’s development in Spanish should resemble the progression of
sound acquisition of English once auditory input begins.
Syllable Structure in Spanish
The syllable structures in Spanish are highly dominated by CV sequences
(Goldstein & Cintron, 2001). This is a crosslinguistic phenomenon in babbling
(MacNeilage et al., 2000), but Spanish retains the CV-dominated syllable type
in the adult language (Quilis & Fernandez, 1999). Isolated vowels are second
most regular (18%), and syllables that end with consonants (CVC, VC, CCVC)
are the least common (Goldstein & Cintron, 2001). This syllable structure is
vastly different from English, which is dominated by CVC syllable structure.
Syllable Complexity in Spanish
The average length of words in any language is directly related to syllable
structure. Basically, when a language does not support final consonants, such
326 Moore, Prath, & Arrieta

as Spanish, automatically there are a limited number of one-syllable words.
The number of one-syllable words would be restricted to the finite combination
of C+V (Quilis & Fernandez, 1999). This is clearly evident in Spanish.
Goldstein and Cintron (2001) used syllable count to determine word length of
Spanish-speaking children and noted that 83% of the words created were two
syllables in length.
Development of Speech in Children with Hearing Loss
A great deal of research has focused on the role of audition as it relates to
the development of speech (Oller, Eilers, Bull, & Carney, 1985; Yoshinaga-
Itano, Stredler-Brown, & Jancosek, 1992; Steffens, Eilers, Fishman, Oller, &
Urbano, 1994; Yoshinaga-Itano, 1998a, 1998b; Oller & Eilers, 1988; Stoel-
Gammon & Otomo, 1986; Ertmer et al., 2002; Tye-Murray & Kirk, 1993; Kirk,
Sehgal, & Miyamoto, 1997; Tobey, Geers, & Brunner, 1994). Children receive
greater access to language due to discoveries concerning early diagnosis,
treatment and advances in hearing aid fitting techniques (Yoshinaga-Itano,
1998a). Identifying relationships between speech and audition has hastened
and improved therapy (Yoshinaga-Itano et al., 1992). Demonstrating the advantages
of early exposure to the sound system validated the initial “experimental”
attempts at cochlear implantation (Niparko & Wilson, 2000).
It is not enough to say that audition and speech are uniquely intertwined
(Wallace, 1998). Some components of speech and audition develop symbiotically
where one has to be present for the other to exist. Other aspects of
speech and audition develop independently and have been shown to be
present when the other is absent (Yoshinaga-Itano et al., 1992). The interaction
of speech and hearing systems may also differ across time (Oller, 1980),
depending on severity of the hearing loss and concomitant problems (Yoshinaga-Itano
et al., 1992; Wallace, 1998). Additionally, a loss of hearing affects
each parameter of speech (e.g. prosody, perception) in a unique way (Oller &
Eilers, 1988; Oller et al., 1985). A timeline of vocal development assists in
highlighting how speech develops in a child that is hearing impaired.
There has been considerable debate as to whether children who have a
hearing loss vocalize in the same manner as children with normal hearing. As
Oller and Eilers (1988) describe in their study on audition and babbling, this
confusion is the result of treating vocalizations as one developmental period.
When infant vocalizations are categorized into precanonical and canonical
utterances, the relation that speech has to hearing becomes more clearly defined
(Oller & Eilers, 1988). The focus of this particular study is on canonical
vocalizations; therefore, the literature that highlights differences between
typically developing children with normal hearing and those with hearing
loss at the canonical stage will be presented.
Infants with a severe-to-profound hearing loss do not develop the same
canonical vocal patterns that are innate in typically developing children
Early Speech Acquisition in Spanish 327

(Yoshinage-Itano et al., 1992; Steffens et al., 1994; Oller et al., 1985;
Stoel-Gammon & Otomo, 1986). The delay in onset of babble is the most
notable difference. Steffens and colleagues (1994) reported that in infants with
profound hearing loss, canonical vocalizations do not normally appear until
the twelfth month and have been reported to appear as late as the 31st month
(Steffens et al., 1994). In addition, the acoustic characteristics of the timing of
the consonant-vowel components of the syllable are longer than occur in
typically developing children (Oller & Eilers, 1988).
The onset of canonical babble marks a point at which true divisions can be
drawn between typically developing speech in children with normal hearing
and speech produced by a child with a hearing loss. Aberrations in vocal
development are present in the number of productions and the types of
productions, as well as suprasegmental properties such as prosody and duration.
Differences in organization of vocalizations related to lack of syllable
productions in infants with profound hearing impairment can be more clearly
related to a reduction or absence of hearing. This fundamental difference
alters a child’s transition to speech (Wallace, 1998).
Degree of Hearing Loss
The degree of hearing loss is the greatest contributing factor to the impairment
of speech development (Yoshinaga-Itano et al., 1992; Yoshinaga-Itano,
1998b; Wallace 1998). There is a magnitude of difference in speech abilities in
children who operate across the mild-moderate-severe hearing loss continuum
(Stoel-Gammon & Otomo, 1986). Even a minimal amount of residual
hearing greatly improves a child’s chances at producing accurate speech
when compared to a child with no access to the sound system. Degree of
hearing loss is the most reliable source for predicting speech deficits and
intelligibility later in childhood (Yoshinaga-Itano, 1998b; Wallace, 1998). Babbling
in the first year of life is often the focus of studies on speech and
intelligibility of children who are deaf. However, many children who babble
at levels similar to typically developing children with normal hearing do not
develop intelligible speech (Yoshinaga-Itano, 1998b). In her study of 20 children
with HI, Wallace (1998) found that degree of hearing loss was the greatest
predictor of intelligibility and speech ability later in life. At 5-10 years of
age, 82% of those children judged to have a mild-to-severe hearing loss were
intelligible. Contrarily, no child with a severe hearing loss was intelligible.
Wallace concluded that “an exclusive focus on canonical babble . . . will not
provide a full understanding of the development of speech in the deaf and
hard of hearing population because looking at canonical babble alone misses
the issue” (Wallace, 1998, p. 131). Unfortunately, the claims of this study were
confounded by poor methodology. Certainly one cannot predict overall intelligibility
or speech deficits later in childhood from babbling; however,
canonical babbling lays the foundation for speech timing and coarticulation
that is fundamental to speech production.
328 Moore, Prath, & Arrieta

In summary, young children with severe-to-profound deafness exhibit
speech, which is characterized by short, monosyllabic utterances that primarily
consist of bilabial and nasal sounds. The speech may be arrhythmic, varying
in amplitude and reliant on sounds that provide visual or tactile feedback.
The degree of hearing loss greatly influences speech, and in the absence of
hearing there is little to no chance of developing an intelligible speech system.
Understanding this, cochlear implantation has succeeded in giving a child
with profound deafness access to the speech spectrum. The advances in this
field are perpetual and increasingly more accurate. Children who have never
received benefit from amplification usually begin to hear, and their development
is as unique as it is extraordinary. Research has begun to chronicle
speech development along the path from deafness to hearing. Unfortunately,
most of the existing data has been restricted to English-speaking populations.
Development of Early Speech in Children with Cochlear Implants
Much available research describes children on a case-by-case basis, with a
few studies doing comparisons across individuals (Geers & Tobey, 1992). In
comparison studies, however, it is not easy to correlate data because each
child differs in age of implantation, severity of hearing loss, concomitant
issues (e.g., motor impairment), preexisting speech and pre- and postlingual
deafness (Kirk, 2000). However, data on children with cochlear implants can
be collectively summarized to provide projections of speech development.
Additionally, those individual differences that confound studies have been
found to serve as predictors of later intelligibility (Yoshinaga-Itano, 1998a).
Speech Acquisition
Cochlear implantation improves the rate at which a child with hearing loss
moves through early speech developmental stages (Ertmer et al., 2002a, Ertmer,
Leonard & Pachuilo, 2002b; Moore & Bass-Ringdahl, 2002). In a study on
vocal development in young children with cochlear implants, Ertmer et al.
(2002b) documented the speech development of two implanted children.
Eighty-five percent of one participant’s vocalizations were precanonical prior
to implantation and only 14% one year after. The second subject’s development
was less dramatic but still showed a proportional increase in canonical
sounds following implantation. On the average, children implanted at 18
months of age begin canonical babble at 6.5 months postimplant (Moore &
Bass-Ringdahl, 2002).
Upon moving into the canonical stage, children with cochlear implants
tend to acquire sounds in relatively the same manner and order as hearing
children (McCaffrey et al., 1999). This is contrary to infants with profound
deafness wearing hearing aids who typically exhibit delayed and reduced
Early Speech Acquisition in Spanish 329

vocal productions (Oller et al., 1985); however, it should be noted that advances
in hearing aid technology and early identification may also lead to
more normal sequences of development than the set of children reported by
Oller in the mid 1980s. Ertmer and Mellon (2001) followed the vocal development
of a child implanted at 20 months. Their study measured the vocal
development of a child with a cochlear implant to see how her gains compared
to the rate of typical development. Results showed utterance productions
resembling typical developmental patterns but which began later than
normal (postimplant). The fact that the child’s progression of vocal skills
occurred at a rate faster than reported in typical development supports the
notion that implantation during a linguistically rich period can aid in the
acquisition of language (Ertmer & Mellon, 2001).
One of the greatest predictors for determining later developing intelligibility
is identifying the degree of hearing loss (Yoshinaga Itano, 1998b; Geers,
2002; Geers & Tobey, 1992). Yoshinaga-Itano found that “children with profound
hearing loss had significantly poorer speech than children with mild
through severe hearing loss” (1998b, p. 220). Added to this, early onset of
hearing loss has devastating effects on speaking skills (Geers & Tobey, 1992).
Yoshinaga-Itano (1998b) suggests that even a minor amount of residual hearing
vastly improves speech output. She states that the difference is so great
that only two categories of hearing loss are needed: hearing impaired (mild
through severe) and profound.
Age of Onset, Age of Implantation
The age of onset and the age that a child is implanted dramatically alter the
time frame in which a child is learning to speak (Yoshinaga-Itano, 1998b;
Ertmer et al, 2002; Blamey et al., 2001). Ertmer et al. (2002b) present data on
two children who received cochlear implants. Participant D lost his hearing
at age 3 years and was implanted at 7 years, 6 months. Participant B was
identified with hearing loss at age 5 months and was implanted at age 3.
D showed higher preimplant speech variability, probably due to three years
of hearing exposure. After being implanted, he had rapid success in producing
intelligible sounds with errors involving stop consonants and omitting
fricatives. B’s preimplant speech was minimal. Postimplant he began producing
/m/, /b/ and many vowels, but most of his utterances were nonmeaningful.
His speech developed slowly through the precanonical and canonical
stage before making meaningful sound. The authors note that B had other
impairments that slowed his growth. However, the exposure to language that
D received before becoming deaf offered him a quicker, more accurate access
to the sound system.
Much is known about the development of speech following cochlear implantation
due to the multifaceted nature of existing literature. Case studies
and group designs offer insight into the effects of age of implantation, severity
of hearing loss, and situational influences, as well as intelligence. By
330 Moore, Prath, & Arrieta

documenting speech production patterns, tentative norms and developmental
expectancies have been established. However, nearly all of the research
currently available has been derived from English-speaking children. Information
is needed to test the universal nature of some of the existing research
on cochlear implantation. Additionally, clinicians working in the field need
developmental norms in order to serve a culturally diverse population.
This case study is an effort to provide such culturally and linguistically
sensitive information. The following questions are posed by using a longitudinal
case study method during the first 17 months postimplant of a
Spanish-speaking child: (1) Will babbling and first word consonant-vowel
co-occurrence patterns in Spanish differ from that of typically developing
children and English-speaking children with cochlear implants? (2) Will the
timeline of development of canonical babbling be consistent with other children
implanted at the same age? (3) What is the impact of language use
(Spanish or English) on accuracy of speech production at 1 year postimplant?
(4) Will our participant’s overall accuracy in Spanish differ from CI peers who
are in English-speaking families?
Methods
Participants
The focus of this study was to follow the serial organization of early speech
of a monolingual Spanish-speaking CI recipient. Our participant, K, lives with
his parents and one older brother. K’s brother speaks Spanish and has learned
English in school and would be considered a balanced sequential bilingual.
This means that his English and Spanish skills are equivalent and that language
development in his first language, Spanish, was mastered prior to the
introduction of English at age six. The parents’ only language is Spanish. K’s
parents have a large social network of relatives and friends who all speak
Spanish. The parents reported all electronic and print media in the home was
in Spanish, with the exception of K’s brother’s school texts. Spanish was also
the language of all speech and audiology intervention that K and his family
received up to three years of age. His early intervention utilized an oral-aural
approach in Spanish. At age three he was enrolled in an English oral preschool
program for children with hearing loss within the local school system.
There was no oral Spanish preschool programming available to the family in
the community. An oral education methodology was selected by his parents
as part of his early intervention and preschool programming. Spanish was
also exclusively used in the interactions of all three authors with the family
during the course of this study.
K was identified as having a profound sensorineural hearing loss at birth.
There is a positive history of hereditary hearing loss within his extended
family. He received a Nucleus 24 M device in the right ear that was activated
Early Speech Acquisition in Spanish 331

at 20 months of age. His surgery was unremarkable will a full insertion of the
electrode array. He utilizes the ACE (Advanced Combination Encoder) strategy.
His medical history is unremarkable except for the presence of rightsided
motor weakness that was noted in infancy. The parents did not provide
any specific information regarding the etiology of this condition. His motor
asymmetry has become less apparent as he has grown and has not impacted
his ability to engage in gross motor skills such as walking or throwing. He is
left handed. It is not certain whether this is due to natural occurrence or due
to restricted use of his right hand in infancy. Fine motor skills were not a
reported concern of the parents during the study period. His preverbal communication
was normal, with K engaging in turn-taking, gesturing, facial
expression and appropriate eye contact, which provided further evidence of
normal nonverbal communicative development.
To answer the third question on the accuracy of speech production across
languages, data from four other children who received Nucleus 24 implants
between 18-20 months were used as a control group. Like K, the children in
the control group had uneventful medical and surgical histories. Data collection
and analysis for this group was identical to that of K. These children were
also participants in research on longitudinal speech production following
cochlear implantation. The group was composed of two boys and two girls
from two-parent, middle-class, English-speaking homes. The children in the
control group were being educated orally.
Data Collection, Transcription, Reliability and Analysis
Data were obtained in the home at monthly intervals one month prior to
implantation and continued monthly postimplant for the duration of the
study. The participants were videotaped in natural play contexts with their
parents and all three of the authors. Sessions were 45-60 minutes in duration.
Data were collected using a Canon digital video recorder and aided by a Telex
wireless microphone that K wore.
The second and third authors transcribed each recording. Speech-like productions
including consonant- and vowel-like productions that occurred in
isolation or in syllables were transcribed and classified using the International
Phonetic Alphabet. The transcription included all productions that were produced
independently, via imitation, or prompting. Transcriptions included
all vocalizations that were babbling or speech-like in nature. The following
types of vocalizations were transcribed: singleton vowel productions, singleton
consonant productions (nasals, fricatives), and CV or VC syllables.
Laughing, crying and other nonspeech vocalizations were not transcribed.
Syllables including glottals (e.g., /h/) were excluded from the analysis because
these speech sounds are not produced in the oral cavity. The data were
entered into the Logical International Phonetics Programs or LIPP (Oller &
Delgato, 1993) for analyses of accuracy and syllable shape. Target productions
332 Moore, Prath, & Arrieta

were determined by the child’s productions, knowledge of their expressive
language vocabulary and the overall context of the child’s interactions with
toys or with his parents. At the times, parents would indicate the target form
of a word.
Ten percent of the data were analyzed for reliability. A graduate student in
speech-language pathology who was not directly involved with the project
provided the reliability for each of the sessions. Reliability consisted of calculating
point-to-point consistency of both vowels and consonants for each
utterance analyzed. Reliability for vowel transcription was 79%, and subsequent
analysis of the data suggested many of the transcription differences
regarded height of the vowel. For example, in a few instances the reliability
transcriber heard high-front (/i/), whereas the original transcriber recorded
front-central vowels. Differences in regard to position (e.g., central for back)
did occur but only in a few instances. Reliability for consonant transcription
was 75% for sessions between 0-6 months postimplant but improved to 90%
as K entered his second year of device use. With consonants, most of the
sounds transcribed were congruent. Class differences were the main sourceof
error (e.g., /b/ for /d/) usually confusing alveolar and bilabial sounds.
CV co-occurrence patterns were classified according to the FC Theory by
place of articulation, and observed-to-expected ratios calculated to determine
whether each pattern occurred significantly above chance. In addition, chisquare
tests of significance were performed for each age interval and group
to determine whether the observed co-occurrence patterns occurred more
frequently than by chance.
Results
Onset of Canonical Babbling
The growth of K’s speech relative to the activation of his CI is commensurate
with data recently reported by Moore and Bass-Ringdahl (2002). There
was an increase in vocal play after CI activation while a surge in vocalizations
and canonical babble occurred approximately six months postactivation.
See Figure 1 for the growth in syllables produced in the first six months
postimplant.
CV Co-Occurrence Patterns
K’s intrasyllabic CV co-occurrence patterns were examined to see whether
they were consistent with the predictions of the Frame Content Theory. The
chi-square tests of significance indicated that K did show a slight trend for
production of the preferred CV syllable patterns seen in typically developing
children during the first six months of implant use; however, the results were
Early Speech Acquisition in Spanish 333

Figure 1. Growth of syllable productions over the first six months postimplant.
nonsignificant. Insufficient data were obtained to test the hypothesis for dorsal
consonants at the 1-6 month interval. At the 8-10 month interval and the
13-16 month interval, K consistently produced coronal-front syllables that
would be expected under frame dominance; however, he also produced patterns
which would not be expected, such as dorsal consonants paired with
central vowels. The chi-square tests at the 8-10 month interval ( 2 (df=4)=
19.91, significant) and the 13-16 month interval ( 2 (df = 4) = 22.29, significant)
were statistically significant, indicating that the patterns observed are significantly
different from those that would occur by chance. Table 1 illustrates the
intrasyllabic CV co-occurrence patterns for each of the age intervals. Overall,
these results are consistent with syllable development of monolingual English
learning CI infants and toddlers (Moore, Davis, & Tobey, 2004).
Syllable Shape
The overall content of K’s speech can be described as having a high percentage
of CV syllables (51%), followed in frequency by singleton vowels
(21%). VC combinations made up 8% of the vocalizations, and singleton
consonants, primarily /m/, were present in 6% of K’s vocal attempts. There
was a consistent growth in all syllable types across the six sessions with the
exception of VCV (e.g. /b/). The VCV vocalizations were initially made in
isolation. As utterance length increased, this combination appeared less frequently.
334 Moore, Prath, & Arrieta

Table 1. Observed-to-Expected Ratios for CV Co-Occurrence Patterns From 0-6,
8-10 and 13-16 Months Postimplant
Group
Vowel
Accuracy
At the 12-month postimplant interval, overall accuracy for word productions
was calculated for K and four English-speaking controls who had received
their CIs at the same chronological age as K. At 12 months
postimplant, K’s overall accuracy level was 60% compared to an average of
23% accuracy for the four English-speaking children. These results are found
in Figure 2.
Discussion
Production
Consonant
Coronal Labial Dorsal
0-6 m Front 1.09 0.88 —
Central 0.98 1.02 —
Back — — —
8-10 m Front 1.22 0.99 0.36
Central 1.01 0.94 1.18
Back 0.60 1.31 1.17
13-16 m Front 1.16 0.51 1.06
Central 0.84 0.94 1.09
Back 1.11 0.80 0.69
Note. Values exceeding 1.0 indicate CV patterns exceeding chance; however, the data at the 0-6
month interval were not statistically significant. The distribution of syllable shapes at the older
age intervals was statistically significant, indicating that the distribution is different from that
occurring by chance. Patterns bolded in the shaded boxes are consistent with the FC Theory.
Those patterns bolded in unshaded boxes are occurring at greater-than-chance levels but are not
consistent with the frame dominance theory.
The purpose of this study was to document speech productions of a prelinguistically
deaf, Spanish-speaking child who received a cochlear implant at
20 months of age. In the process of gathering this information, other discoveries
were also made regarding the uniqueness of how Spanish develops
when auditory input is delayed. Many similarities do exist between Spanish
and English concerning gross developmental features such as timing, content
and order of sound acquisition. However, linguistic features of Spanish also
uniquely influence other aspects of speech production such as accuracy.
Onset of Canonical Babbling
The growth in speech production across the first six months postimplantation
is commensurate with data introduced by Moore and Bass-Ringdahl in
Early Speech Acquisition in Spanish 335

Figure 2. Mean accuracy data for English-speaking children (1-4) and K at one
year postimplant. All the children were implanted at 18-19 months of age. K’s
accuracy exceeded that of English speakers due to a more concise phonetic
structure of the language and a preponderance of CV word shapes in Spanish.
These forms would be easier to master at a younger age.
2002. Equal to the nine children that were followed in their study, canonical
vocalizations emerged for K at six months, three weeks. The process of activation
can be characterized by an immediate increase in vocalizations, a
period of development in which each individual child shows gains and regressions,
a hiatus or decrease in activity, followed by an explosion in speech.
Further research is needed to identify whether there are true milestones at
months two through five. For instance, if all children uniformly experience a
hiatus or a regression prior to incredible gains, then the increase at six months
will be predictable, and therapy can be planned to take advantage of this time
of growth. This data suggest that the immediate increase in speech development
at six months postimplant is not dependent on the ambient language of
the speaker, intervention or simply audibility.
The explosion in speech production at six months postactivation is matched
by an increase in syllable diversity. Large syllable strings (eight to eleven)
were present in single instances throughout the first five months postactivation.
By the end of the data collection period, large syllable sequences were
recorded in abundance. This data suggests that the “explosion” that has been
shown to occur six months postactivation is an increase in number as well as
complexity.
CV Co-Occurrence Patterns
K’s CV co-occurrence pattern of CV syllables produced in both babbling,
and word attempts were consistent with previous studies of children with CI.
336 Moore, Prath, & Arrieta

His Spanish language use did impact his organization of early CV syllables
compared to CI peers exposed to English. Although some aspects of K’s CV
pairs were consistent with that of typically developing children, other patterns
were inconsistent. This would indicate that children with CIs exhibit
more normal serial organization of speech, but not normal development.
Longitudinal studies on this topic will help determine whether this different
serial organization of early speech impacts speech intelligibility during the
preschool years or later.
Syllable Shape
When viewing consonant and vowel co-occurrence as a whole, K’s speech
was dominated by open syllables (ending in a vowel), which is congruent
with the speech of children with hearing loss (Oller et al., 1985; Oller & Eilers,
1988; Yoshinaga-Itano et al., 1992; Davis et al., 2002), as well as with the
Spanish language (Goldstein & Cintron, 2001).
Accuracy
The phonemic and syllable structure of Spanish heavily influenced overall
word accuracy measures at 12 months postimplant. K’s overall accuracy
clearly exceeded that of peers exposed to English. A more concise vowel and
consonant structure as well as a preponderance of CV syllables that would
lead to vowel final consonants in Spanish likely affected this accuracy score.
Therefore, clinicians working with Spanish-speaking children and families
should expect higher levels of accuracy in the earlier stages of speech development.
As vocabulary increases, more complex multisyllabic words will
need to be mastered by Spanish speakers, and it is likely that overall accuracy
may drop as children attempt these complex forms. Thus, there appears to be
a phonetic and phonologic trade-off between Spanish and English. In Spanish,
the concise vowel space and consonant repertoire coupled with open
syllables (CV) leads to increased accuracy on two-syllable word forms typical
in Spanish. In contrast, the more complex English phonology and CVC word
forms lead to less accuracy at the early word stage.
Conclusions
Our participant, K, has made significant progress in Spanish language
acquisition in his first 16 months postimplant. Clinicians working with Spanish-speaking
children should emphasize the phonetic and syllable structure
of the native language in early intervention programs. Like children with
normal hearing, it is hoped that as the sound system and lexicon of a first
language are established, children like K will develop competent English
skills as well over time.
Early Speech Acquisition in Spanish 337

Although the knowledge that currently exists today regarding Spanish
development and at-risk populations is extremely limited, it is hoped that
case studies like this one will contribute to improved services to children and
families from minority language backgrounds. This limited knowledge is a
major concern considering the high number of Spanish-speaking clients on
the caseloads of current speech-language pathologists and audiologists. Future
research is needed to expand our research knowledge of how Spanish
develops when hearing is absent or diminished and when audibility is restored
using a cochlear implant.
Future studies of one or more children similar to K are needed to compare
with the findings from this study. This study is limited by having only one
participant. As more Spanish-speaking children receive cochlear implants,
the pool on which studies can be based will be broadened. Knowledge concerning
verbal productions of Spanish-speaking CI children will greatly aid
the professional populations that serve Spanish-speaking children by providing
norms or guidelines for development.
Acknowledgments
This research is supported by the National Institutes of Health research
grant R-01 HD277733-03 (The University of Texas).
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Early Speech Acquisition in Spanish 341

The Volta Review, Volume 106(3) (monograph), 343-364
Bilateral Cochlear
Implantation in Children:
Experiences and
Considerations
Andrea Bohnert, M.T.A.-F., Vera Spitzlei, Dipl.-Ing.,
Karl L. Lippert, Ph.D., Dipl.-Ing., and Annerose Keilmann, M.D.
Between 2000 and 2006, the University Clinic for Ear Nose and Throat and
Communication Disorders in Mainz, Germany, performed 41 bilateral cochlear implantations
in children. This article addresses some of the factors to be considered in
a decision to bilaterally implant a child, including the age of the child at the first
implant, the length of time between the first and second implants, the age of the child
at the time of the second implant and the level of auditory learning experienced with
the first implant. At the time the article was written, 33 of the 41 children were able
to participate in speech discrimination testing in quiet and in noise. The children’s
localization abilities were also reported. All of the tests concerning hearing, localization
and speech understanding with the implants were conducted as part of the
child’s regularly scheduled appointments to verify the settings of each speech processor
and the performance with both implants. The information shared in this article
reflects findings from clinical practice and was not obtained in a controlled research
protocol. Nevertheless, the experiences and observations reported are clinically relevant
to those involved in or contemplating bilateral cochlear implantation of young
children.
Andrea Bohnert, MTA-F, holds teaching posts at the University Clinic Mainz and the Teaching-Unit
for Logopedics and is senior MTA-F in audiology and pedaudiology at the University
Clinic for ENT and Communication Disorders in Mainz, Germany. Vera Spitzlei, Dipl.-Ing.,
is a member of the audiology team at the University Clinic for ENT and Communication
Disorders in Mainz, Germany. Karl L. Lippert, Ph.D., Dipl.-Ing., holds teaching posts in
electroacoustics and audiology at the University Clinic Mainz and at the Teaching-Unit for
Logopedics. Annerose Keilmann, M.D., is a senior physician at the University Clinic for
Communication Disorders in Mainz, Germany, and head of the department of communication
disorders at the University Clinic for ENT, also in Mainz.
Bilateral Cochlear Implantation in Children 343

Introduction
Since the early 1980s, when multichannel cochlear implants (CIs) became
available, cochlear implantation has become a widely accepted treatment of
severe hearing disorders in patients of all ages in Europe and the United
States. During the following decade and a half, unilateral cochlear implantation
was routinely performed at the University Clinic for Ear, Nose, and
Throat (ENT) and Communication Disorders in Mainz, Germany (Biesalski,
Lippert, & Bohnert, 1985). In the early 1990s, workgroups in Australia began
investigating the potential of bilateral cochlear implantation (van Hoesel,
Tong, Hallow, & Clark, 1992). In 1996, an adult patient in Wuerzburg, Germany
was successfully implanted with two multichannel devices. Four weeks
after the initial fitting, this patient demonstrated significant improvement in
speech recognition in quiet and in noise. Two years later, the Wuerzburg team
performed the first bilateral implant in a child (Mueller, 1998, 1999). The
success of these first two cases led to further investigations (Kuehn-Inacker,
Shehata-Dieler, Mueller, & Helms, 2004) and influenced the acceptance of
bilateral cochlear implants in children (Mueller, 2005).
In 2000, following the success in Wuerzburg, the first pediatric bilateral
cochlear implant surgery was performed at the University Clinic for ENT and
Communication Disorders at Mainz, Germany. In the intervening six years,
41 children have been bilaterally implanted. This article presents some of the
clinical considerations and guidelines in pediatric bilateral implantation that
have evolved from experiences with those young patients and reports on the
children’s sound localization abilities and speech discrimination in quiet and
in noise conditions.
Guidelines in Bilateral Implantation
In 2005, a panel convened at the Second Meeting Consensus on Auditory
Implants in Valencia, Spain published a consensus statement on bilateral
cochlear implants (Offeciers et al., 2005). Included in the consensus statement
were recommendations for the fitting of two cochlear implants in the following
types of patients: (1) those in whom the benefits obtained with one cochlear
implant is poor, (2) patients with meningitis who develop cochlear
ossification (with recommendations to perform implantation as soon as possible
to achieve full implantation) (3) children with permanent bilateral profound
hearing loss (with recommendations to pay special attention to young
children who are in their speech and language acquisition years) and (4) in
adults who want to restore binaural hearing or need it in order to remain in
their chosen profession (Offeciers et al., 2005; Hoth, 2006).
In the discussion of the staging of bilateral implants, there was consensus
that one-stage bilateral implantation surgeries are more cost effective but
should only be conducted by experienced surgeons and centers. Regarding
344 Bohnert, Spitzlei, Lippert, & Keilmann

the time interval between the two surgeries in children, the recommendation
was that a short interval of less than 6-12 months “enables prelingually deaf
children to achieve good performance with the second implant within a few
weeks” (Offeciers et al., 2005, p. 918). A longer period between surgeries
would increase the probability of a longer and more intense period of habilitation
for the child to become accustomed to a second implant.
Advantages of Binaural Hearing
In the normal auditory system, binaural hearing provides advantages that
are unavailable to the listener with unilateral hearing. For example, spatial
hearing, localization, and signal source discrimination in quiet as well as
noise are possible only with binaural hearing. During localization, individuals
with binaural hearing use interaural time and level differences (headshadow
effect), as well as diffraction phenomena, sonic reflections at the
auricle and the so-called squelch effect (Laszig et al., 2004; Schleich, Nopp, &
D’Haese, 2004) to determine where the sound source originates. Thus, binaural
hearing provides significant advantages, especially in noisy environments
(Blauert, 1974). These studies led to the presumption that bilateral
implantation can provide advantages to children with hearing loss.
With the advantages of the normally functioning binaural system serving
as a model (Blauert, 1974), several goals that support bilateral implantation in
children can be determined. These include: (1) to provide hearing thresholds
in the non-implanted ear that could permit the development of speech discrimination
ability, (2) to decrease listening effort, (3) to provide the possibility
of localization for increased safety in daily life (traffic, etc.) and (4) to
increase speech discrimination in noise.
Parent Acceptance of Bilateral Cochlear Implantation
The decision to pursue a cochlear implant is a challenging process for many
parents. When the option of bilateral cochlear implantation has been presented
to parents at our center, almost all of them have ultimately elected a
two-stage implantation process rather than simultaneous surgeries. There are
several factors that guide families in the decision to pursue unilateral implantation
before proceeding to a second device. Some parents are concerned that
the implant will not provide sufficient auditory benefit to their child and
want evidence of success before proceeding. Or, a family may elect to “save”
one ear for the possibility of medical or technological advances that provide
a different treatment option. The situation in which parents seem to be most
comfortable pursuing bilateral implantation occurs when a child becomes
deaf following meningitis. The risk of rapid cochlear ossification following
meningitis reduces the likelihood of optimal implant success if the surgery is
Bilateral Cochlear Implantation in Children 345

delayed, thereby increasing parental acceptance of simultaneous bilateral implantation.
It is essential to discuss parents’ expectations regarding their child’s auditory
development when he or she receives the first implant and again upon
receiving the second implant. It has been our experience that fitting a child
with a cochlear implant often creates high expectations in parents. When a
second implant is being pursued, expectations can be even higher. Most
parents who seek bilateral implantation are pursuing “normalcy” for their
child. Their objectives are for their child to go to school with their hearing
peers and develop as a child with normal hearing. There are cases in which
this is possible, but surgery alone cannot assure this outcome. Interdisciplinary
collaboration and communication among the family, pediatric audiologists,
physicians, early interventionists and other therapists are necessary for
parents and professionals to understand the complexities of each case and to
attempt to establish reasonable expectations for all involved. Many factors
affect outcomes for each child, including the age of the child at the first and
second implants and the length of time between the two implants. Resources
for therapy in the family’s community and their commitment to following
through with therapy and reinforcing it at home significantly affect outcomes.
To the degree possible, all of the factors that can influence the child and
family in their daily routines should be identified and discussed in relation to
the cochlear implants.
Timing the Second Implant Surgery
A growing body of research (Govaerts et al., 2002; Manrique, Cervera-Paz,
Huarte, & Molina 2004; Zwolan et al., 2004; Keilmann, Gaida, & Limberger,
2005; Kral, Hartmann, Tillein, Heid, & Klinke, 2002a; Kral, Hartmann, Tillein,
Heid, & Klinke, 2002b; Yoshinaga-Itano, Sedey, Coulter, & Mehl, 1998; Yoshinaga-Itano,
2002) has provided evidence that children with profound hearing
loss who receive a cochlear implant by their second birthday achieve higher
scores on speech discrimination testing and do so at a faster rate than children
with similar hearing losses who are implanted later in life. The results of
studies demonstrating improved success of children unilaterally implanted at
younger ages (Sharma, Dorman, Spah, & Todd, 2002), combined with studies
regarding the benefits of binaural hearing in normally hearing children, have
provided support for bilateral cochlear implantation in children at younger
ages.
Challenges in Binaural Fitting of Speech Processors
The initial fitting of the second speech processor should be conducted as an
independent fitting, entirely distinct from the fitting of the first speech processor.
Because each cochlea has a unique anatomy, as well as physiologic
346 Bohnert, Spitzlei, Lippert, & Keilmann

conditions, it is seldom, if ever, possible for the electrode array to be placed
in exactly the same configuration in both ears. As a result, fitting should be
conducted as an individualized process for each ear, even in the same patient.
For these same reasons, the first processor’s map should never be used as the
basis for the initial fitting of the second processor. Among the children fitted
with binaural cochlear implants in this clinic, none have had identical maps
in both of their speech processors.
Perceiving, processing, storing and retrieving auditory information are
complex tasks. Children who are candidates for cochlear implants have a
wide range of abilities and strategies for performing these tasks. Although the
most important and fundamental principle in cochlear implant fitting is that
every fitting is unique, to achieve a “good cochlear implant fitting” for each
child a few universally valid fitting guidelines are recommended.
Most important is that the child should never be overstimulated during the
fitting procedure. Overstimulation creates an association between “hearing”
and pain, which immediately reduces the likelihood of a successful fitting of
the speech processor. A second principle is that within the first fitting session,
all channels that are available for stimulation should be activated. At our
clinic this occurs over the first week of fitting. Once all channels are activated,
subsequent increases in current levels will produce stimulation patterns without
changing the basic sound characteristics. This applies to cochlear implant
systems running the authentic CIS strategy (i.e., fast, continuous stimulation
on all electrode-channels). During each stimulation cycle, all channels will be
activated and are able to provide information. Stimulation patterns produced
by using feature extraction only contain parts of the original input signal.
Interpolation of channel settings should be avoided. Individual testing and
verification of all settings of each channel are necessary to achieve maximum
benefit, as even small changes in fitting data may cause significant changes in
the child’s hearing sensation (Lippert & Bohnert, 2005; Bohnert, 2005). And
finally, the effect of binaural loudness summation must be considered during
fitting of the second ear. Summation intensity may differ considerably from
child to child; thus, careful attention to this phenomenon is essential in each
fitting. In some cases the summation effect leads to an obvious change in the
child’s behavior. When this occurs, the stimulation level of the first fitted ear
is reduced step-by-step until “normal” is reestablished.
Influence of Age on Second Processor Fitting
Children younger than two years appear to experience the least difficulty
adjusting to a second implant and the resulting bilateral auditory signal.
Among children at this age, hearing with a cochlear implant is still in the
initial stages, and integration of the second signal into the child’s existing
auditory processing strategies is more easily accomplished. This factor, combined
with the shorter period between the first and second implants, makes
Bilateral Cochlear Implantation in Children 347

fitting the second processor easier in younger children. Regardless of the
child’s age, fitting the second processor must be done cautiously in a stepby-step
process. At the University Clinic in Mainz, speech processor fittings
are accomplished during two one-week inpatient hospital stays. During the
first fitting session, each electrode in the array is activated. As electrodes are
activated and added to the array, the child’s responses to a wide variety of
sounds, experienced in everyday situations, are observed by the family and
clinic staff. On the basis of observations and reports of behavioral changes,
the electrodes may be adjusted. This collaborative effort by the family and
staff is very beneficial, so that by the end of the week the child has been fitted
to an effective level of performance. During the second stay, the child’s behavior
is observed and fine tuning of the speech processor is completed.
After age 2, the process of fitting the second cochlear implant can become
more complex. As the children become older at the age of the second implant,
or as the length of time between implants increases (the two factors are often
related), a variety of responses to bilateral stimulation have been observed. In
either case, the child has had a longer period of time to become accustomed
to the speech signal provided by a single implant. Some children accept the
second implant without complications or resistance, even when there has
been a considerable delay between the first and second cochlear implant
surgeries. In other cases, introduction of additional sound from a second
implant can confuse or irritate the child. To reduce a negative response to
stimulation provided by the second implant, fitting should proceed in a careful
and systematic manner. In some rare cases, it will be helpful to set processor
levels in a way that stimulation is below the threshold of perception at
the initial fitting. Thus, the auditory nerve and auditory cortex are slightly
stimulated without disturbing the child. Increasing stimulation intensity in a
step-by-step manner while carefully observing the child’s behavior appears to
increase acceptance of the second processor.
When the child is able to tolerate an initial stimulation level of the second
implant beyond the threshold of perception, speech discrimination scores
with bilateral activation often decrease. Because each child has a unique
history of auditory experiences, cochlear implant benefit and neurological
maturation, it is not possible to predict accurately the length of time speech
discrimination might be adversely affected. It has been reported, as also observed
at our clinic that, after a period of acclimatization, the child’s speech
discrimination scores improve and scores with bilateral activation become
superior to previous unilateral speech discrimination scores (Kuehn-Inacker
et al., 2004).
Habilitation
In Germany, there are several possible scenarios for habilitation/rehabilitation
that vary according to location. In most cases the initial fitting of the
device takes place in the clinic where the patient received his or her cochlear
348 Bohnert, Spitzlei, Lippert, & Keilmann

implant. All of the subsequent adjustments as well as the habilitation/
rehabilitation will occur at that clinic. Some clinics provide the option of an
inpatient stay; others can only provide outpatient appointments. The University
Clinic for ENT and Communication Disorders, Mainz, is able to provide
an inpatient stay in the hospital. Younger children under age 5 or children
with multiple handicaps must be accompanied by parents or caregivers.
Many of the older children attend their inpatient stay without parents. Typically,
the child is initially seen for one week. Then, following a four-week
period of habituation, the child has one more week of inpatient stay, during
which programming is adjusted. During this time, the audiologists, speechlanguage
pathologists and other professionals have the opportunity to see the
child several times per day. This provides the opportunity to pay special
attention to the child’s individual needs.
All specialized therapies can be tailored to each child’s specific needs. Most
of the children are very familiar with the clinic because it is the same place
they go for hearing evaluations and hearing aid fittings and know the physicians,
audiologists and other therapists. In most cases the staff has known
the child and family since the child was first diagnosed. Therefore, a relationship
has been established over a period of months and often years that creates a
sense of confidence on the part of both the family and the professionals.
In our clinic, clinical testing occurs every three months during the first year
after cochlear implantation. Between 12 and 24 months after the first fitting,
appointments are made twice a year or more often if needed. In addition, an
annual speech and language evaluation occurs. The cochlear implant team
also meets with the child’s early interventionist once or twice a year to discuss
the child’s progress.
An important aspect in fitting the second processor is balancing pitch and
loudness in comparison to the contralateral side. This has to be checked both
in therapy sessions as well as at home. Families have the opportunity and
responsibility to observe the children at home where the acoustic conditions
are quite different from those in the fitting and therapy environments.
To reinforce the child’s awareness of sound in the newly implanted ear,
therapy should be conducted with the first implant turned off, and parents
are advised to have their child experience hearing with the new processor
alone for a certain portion of the day.
Several factors should be considered in devising an appropriate therapy
plan. The child’s age at implantation and the time between fittings are very
critical factors. Beginning at age 2 1 ⁄2, children become aware of themselves
and their environment. For example, children at that age who have used one
implant for a while are often reluctant to “give away their good ear.” If
children have adequate language development, they can be told that their
second ear has been “sleeping” for a while and now has to be awakened very
carefully. With a shorter time period between the two implantations, integration
of the new implant and auditory synchronization will develop more
Bilateral Cochlear Implantation in Children 349

quickly and naturally. Children who receive their second implant during the
preverbal or early language development usually accept bilateral stimulation
after a very short time.
When there has been a period of more than two years between implants, a
more intense and time-consuming habilitation phase should be anticipated
for the second implant. As a general rule, the longer the time between implants,
the more extended the habilitation process is likely to be. In children
who received their first implant at an older age, the training in sound localization
and discrimination of speech in noise will require more intensity and
a longer time period.
Loudness Scaling
As soon as possible, loudness scaling should be conducted to attain more
detailed information about hearing sensations following electrical stimulation
(Zorowka, Heinemann, & Bohnert, 1995). Up to a developmental age of approximately
four years, balancing binaural cochlear implants has to be based
upon the results of aided audiometry and behavioral observation. This will
also be the case for children with multiple disabilities or those who have not
attained a developmental age of four to five years. For all of these children,
testing each ear separately in free sound field, with different frequencies of
narrow-band noise as the test stimuli, can provide basic information for balancing.
Determining balancing information from behavioral observation is
very difficult because competency at localization of the sound source is required
for this task. Most children require a long period of bilateral cochlear
implant use to develop localization abilities.
An effective tool for balancing bilateral cochlear implant systems in slightly
older children is loudness scaling. The scaling method used during fitting
sessions will be very helpful in achieving reliable results. The better the child
is trained to perform the scaling tasks, the more reliable the information used
for balancing will be. Children who have a developmental age of four to five
years will most like be able to identify reliable loudness level with a scale
illustrated by drawings of children reacting to sounds. The drawings depict
children reacting to sound at different loudness levels ranging from “I can’t
hear it” to “too loud.” A picture of the touchscreen used in the University
Clinic in Mainz for scaling loudness levels is presented in Figure 1. Figure 2
shows an example of a scaling profile conducted by a cochlear implant user
for 500, 1000, 2000 and 4000 Hz. The lines through the black dots indicate the
individual loudness progression at a particular frequency, compared to loudness
as evaluated by normal hearing persons.
Description of the Children
The speech discrimination scores reported in this article are based upon
the performance of 41 children with bilateral cochlear implants. All of the
350 Bohnert, Spitzlei, Lippert, & Keilmann

Figure 1. Touchscreen for loudness scaling (Wuerzburger Hoerfeld, WESTRA).
children involved were implanted in two-stage procedures. The preimplant
variables within the group, such as age at first implant, age at second implant
and the time between implants, vary widely. The age of the children at first
implantation ranged from 6 months to 9 years, 1 month (see Table 1). The
second implant was received at ages ranging from 1 year, 2 months to 11
Bilateral Cochlear Implantation in Children 351

Figure 2. Graphic example of a loudness scaling profile for a cochlear implant user.
years, 6 months. Among this group of children, five were bilaterally implanted
before age 2. Twenty-two received the second implant before age 6,
and 14 were bilaterally implanted after age 6. The amount of time between the
first and second implants also varied widely (see Table 2). The shortest period
of time between implant one and implant two was 3 months, whereas the
longest interval was 7 years, 8 months. Among the group, 18 children received
the second implant within two years of the first, whereas 23 children
experienced a period of more than 2 years between the first and second
implant.
The data reported here were collected as part of routine clinical evaluations
and were analyzed retrospectively. It is important to note that the results
were attained in specific test environments and do not necessarily reflect the
children’s skills in “real life” situations.
Audiometric Information
All audiometric tests were conducted within the routine clinical examination
and evaluation of the implant systems, as is the practice at this clinic.
Monaural aided CI thresholds were measured in all children in free sound
field using narrow-band noise. In most cases, aided audiometry was carried
out at 250, 500, 1000, 2000, 4000 and 8000 Hz. Depending upon the child’s
age, tests were conducted via visual reinforcement or play audiometry.
352 Bohnert, Spitzlei, Lippert, & Keilmann

Table 1. Patients
Patient ID
Age at
First Implant
[y;m]
Age at
Second Implant
[y;m]
Time Lag
[y;m]
Current Age
[y;m]
TT 0;06 1;02 0;08 3;02
EF 0;06 1;09 1;03 4;08
WP 0;08 1;04 0;08 3;08
HL 0;09 3;06 2;09 4;11
BL 0;10 1;02 0;04 1;05
SJ 0;10 2;01 1;03 2;07
ED 1;01 3;08 2;07 4;04
JP 1;01 4;06 3;05 4;11
WC 1;01 3;04 2;03 7;08
RM 1;02 1;07 0;05 3;04
NKP 1;02 2;06 1;04 7;10
SN 1;03 3;08 2;05 5;01
KL 1;05 4;03 2;10 7;11
MAA 1;06 3;02 1;08 6;07
HJ 1;07 2;02 0;07 4;01
HM 1;07 2;05 0;10 5;05
KuK 1;08 3;02 1;06 3;09
RS 1;09 4;01 2;04 7;02
KeK 1;10 2;10 1;00 4;11
WA 1;10 7;06 5;08 8;01
RP 2;00 2;10 0;10 6;09
ZR 2;01 2;04 0;03 5;00
EM 2;03 8;04 6;01 8;07
LC 2;03 9;06 7;03 11;05
VHP 2;04 5;09 3;05 9;08
LT 2;04 7;02 4;10 11;06
PR 2;06 3;02 0;08 4;00
HP 2;06 4;11 2;05 7;09
MS 2;08 8;04 5;08 11;07
MJN 2;10 10;04 7;06 12;04
EJL 2;11 5;07 2;08 6;09
UF 2;11 6;04 3;05 12;05
JF 3;00 3;08 0;08 6;03
LDM 3;00 9;03 6;03 12;10
WJ 3;05 8;10 5;05 9;07
OM 3;06 7;03 3;09 8;06
GM 3;10 11;06 7;08 13;07
TJM 4;00 6;00 2;00 7;10
SM 4;01 7;04 3;03 9;09
SS 5;10 9;09 3;11 15;04
LL 9;01 9;09 0;08 14;00
Note. Children are listed in ascending order, based on age at first implantation.
Bilateral Cochlear Implantation in Children 353

Table 2. Patients
Patient ID
Time Lag
[y;m]
Age at
First Implant
[y;m]
Age at
Second Implant
[y;m]
Current Age
[y;m]
ZR 0;03 2;01 2;04 5;00
BL 0;04 0;10 1;02 1;05
RM 0;05 1;02 1;07 3;04
HJ 0;07 1;07 2;02 4;01
TT 0;08 0;06 1;02 3;02
WP 0;08 0;08 1;04 3;08
PR 0;08 2;06 3;02 4;00
JF 0;08 3;00 3;08 6;03
LL 0;08 9;01 9;09 14;00
HM 0;10 1;07 2;05 5;05
RP 0;10 2;00 2;10 6;09
KeK 1;00 1;10 2;10 4;11
EF 1;03 0;06 1;09 4;08
SJ 1;03 0;10 2;01 2;07
NKP 1;04 1;02 2;06 7;10
KuK 1;06 1;08 3;02 3;09
MAA 1;08 1;06 3;02 6;07
TJM 2;00 4;00 6;00 7;10
WC 2;03 1;01 3;04 7;08
RS 2;04 1;09 4;01 7;02
SN 2;05 1;03 3;08 5;01
HP 2;05 2;06 4;11 7;09
ED 2;07 1;01 3;08 4;04
EJL 2;08 2;11 5;07 6;09
HL 2;09 0;09 3;06 4;11
KL 2;10 1;05 4;03 7;11
SM 3;03 4;01 7;04 9;09
JP 3;05 1;01 4;06 4;11
VHP 3;05 2;04 5;09 9;08
UF 3;05 2;11 6;04 12;05
OM 3;09 3;06 7;03 8;06
SS 3;11 5;10 9;09 15;04
LT 4;10 2;04 7;02 11;06
WJ 5;05 3;05 8;10 9;07
WA 5;08 1;10 7;06 8;01
MS 5;08 2;08 8;04 11;07
EM 6;01 2;03 8;04 8;07
LDM 6;03 3;00 9;03 12;10
LC 7;03 2;03 9;06 11;05
MJN 7;06 2;10 10;04 12;04
GM 7;08 3;10 11;06 13;07
Note. Children sorted in ascending order according to time lag between first and second implant.
354 Bohnert, Spitzlei, Lippert, & Keilmann

Figure 3. Averaged aided audiogram of children with a cochlear implant.
The averaged aided audiogram for all ears of all bilaterally implanted
children is shown in Figure 3, with standard deviations. The figure indicates
that variability of detection is nearly equal at each of the different test frequencies.
The mean threshold for all children is in the range of 30 dB HL.
Mean values are also shown for the aided audiograms with the first implant,
(Figure 4, left) and with the second implant (Figure 4, right).
Both averaged audiograms show similar results and correspond with the
mean values for all ears in Figure 3. These results indicate that the children
have similar thresholds. This fact alone, however, does not guarantee similar
speech discrimination abilities, which vary considerably among the children.
Other factors, such as the child’s chronological and developmental ages, the
presence of co-occurring health, learning or cognitive challenges and the time
between first and second implant surgery, also influence performance in
general as well as performance on specific measures.
Figure 4. Averaged aided audiograms of children with first (left) and second
implants (right).
Bilateral Cochlear Implantation in Children 355

Speech Discrimination Tasks
In addition to aided audiograms, some children were able to participate in
speech discrimination testing with their cochlear implants. Speech discrimination
tests were selected according to the child’s age and speech development.
Listed in Table 3 are the speech discrimination tests, with appropriate
age ranges, used at the University Clinic in Mainz. The age ranges listed are
for normal hearing children who are typically developing. All speech discrimination
tests were conducted in open set both in quiet and in noise
conditions. In the quiet condition, the child was seated in front of the speaker
at a distance of 1 meter. Tests were conducted first with the child wearing a
monaural implant and again with input from both implants. It is important to
obtain information about each implant in a monaural listening situation, as
well as information regarding binaural listening performance. Comparison of
these different sets of information can be useful in determining the contribution
of each implant in binaural performance. This can be especially important
information in fitting the second implant to maintain optimal speech
discrimination and compatibility with the first implant.
Children’s Speech Discrimination Performance in Quiet
Speech discrimination in quiet was conducted with open-set materials for
all children. Of the 41 children implanted, 33 were able to participate in
speech discrimination testing. Due to differences in developmental ages
among the children, the number and complexity of the tests completed by
each child varied. Fifteen of the younger children were able to attend to only
one binaurally presented speech discrimination test. Eighteen of the children
were able to respond to speech discrimination testing in both binaural and
monaural modalities. Discrimination scores of speech presented at 65 dB HL
Table 3. Speech Discrimination Tests Used at the University Clinic in Mainz with
Children Who Have Normal Hearing
Test Material Age Ranges
Mainzer I mono- and bisyllabic words 2 years, 6 months to 3 years,
5 months
Mainzer II mono- and bisyllabic words 3 years, 6 months to 4 years,
5 months
Mainzer III mono- and bisyllabic words 4 years, 6 months and older
Göttinger I monosyllabic words 4 years, 6 months to 5 years,
11 months
Göttinger II monosyllabic words 5 years, 11 months and older
Freiburger Zahlen four-syllabic numerals 8 years and older
Freiburger Wörter monosyllabic words 8 years and older
356 Bohnert, Spitzlei, Lippert, & Keilmann

with the first implant (monaural), the second implant (monaural) and with
two implants (binaural) are shown in Figure 5.
Three of the 18 children (SM, WJ and OM) were not able to discriminate
speech with their second implant monaurally because it had just been fitted.
Despite this, two had binaural speech discrimination scores that exceeded
monaural scores with the first implant alone. The third child’s binaural scores
were slightly less than those attained with the first implant.
Seven of the children demonstrated better binaural speech discrimination
than either of their two monaural scores, indicating the presence of binaural
advantage. These children ranged in age from 4 years, 11 months to 12 years,
5 months. The length of time between implant one and implant two ranged
between 8 months and 7 years, 6 months. In nine children, binaural speech
discrimination scores and their better monaural scores were the same. Overall,
their performance ranged between 60% and 100%, and in five of the nine,
performance was at the 90 th percentile or higher. Of the five children who
scored at the 90 th percentile, all had received their first implant by age 2 years,
4 months. Among these children the time between first and second implant
ranged from 10 months to 7 years, 3 months. At the time of testing they had
worn both implants between 3 years, 11 months and 4 years, 4 months.
Two other children attained monaural and binaural scores at the 80 th percentile.
They received their first implant later, between age 2 years, 8 months
and 9 years, 1 month. At the time of testing they had worn bilateral implants
for 3 years, 3 months and 4 years, 3 months, respectively.
Figure 5. Monaural and binaural speech discrimination scores with a cochlear
implant at 65 dB.
Bilateral Cochlear Implantation in Children 357

The last two children with equal monaural (better ear) and binaural scores
had speech discrimination scores of 60% and 70%. Their ages at the first
implant were 1 year, 2 months and 2 years, 10 months. At the time of testing
they had been binaurally fitted for 2 years, 6 months, and 11 years, 4 months.
In two children, binaural speech discrimination scores were worse than in
the monaural condition. One child was initially implanted at age 2 years, 11
months and the other at age 3 years, 5 months. The second implant occurred
at the age of 6 years, 4 months for the first child and 8 years, 10 months for
the second. The monaural versus binaural scores for both children differedby
10%, which equals a difference of one word.
These results indicate that the time between implants does not necessarily
predict binaural performance. It should also be stressed once again that the
fitting of the second implant can initially have a deleterious effect upon
speech discrimination scores. This is more likely to be the case when the time
period between the first and second implant is substantial. The integration of
a new auditory signal is a process that requires adaptation over a period of
time that varies from one individual to another.
Speech Discrimination Performance in Noise
Speech discrimination tests in noise were also carried out in monaural and
binaural conditions. In the test setting, the child was seated in front of the
speaker at a distance of 1 m. The broad-band noise signal was presented by
a speaker placed directly behind the child at a distance of 1 m. Speech was
presented at a level of 65 dB HL, and the noise signal was presented at 60 dB
HL creating a signal-to-noise ratio (SNR) of +5 dB.
Speech discrimination in noise was tested in a total of 24 children. Of this
group, 12 children were tested in both binaural and monaural conditions. Six
other children were tested monaurally in both ears, but not in a bilateral
condition. Six additional children were tested monaurally in one ear only,
because they were unable to concentrate on the test any longer. Test results
for all children are shown in Figure 6.
Nine of the 24 children could discriminate speech better binaurally compared
to the monaural test situation. The age at time of first implant ranged
from 1 year, 1 month to 9 years, 1 month, with a time lag between first and
second implant of between 10 months to 7 years, 6 months. At the time of
testing, they had been implanted binaurally between 2 years and 6 years, 1
month. The improvement between binaural and monaural conditions ranged
from 10% to 40%.
For two children there was no difference between monaural and binaural
test performance. The children were first implanted at ages 2 years, 1 month
and 9 years, 1 month. The first child was bilaterally implanted eight months
later, and the other child received a second implant 2 years, 8 months later.
The binaural performance of one child (WJ) was worse than monaural
358 Bohnert, Spitzlei, Lippert, & Keilmann

Figure 6. Speech discrimination in noise in monaural and binaural conditions.
performance. This particular child was first implanted at the age of 3 years, 5
months and received the second implant 5 years, 5 months later. At the time
of testing, the child had been bilaterally implanted for a period of only nine
months.
Localization
The ability of the children with bilateral implants to localize sound was
tested in a five-speaker arrangement, usually at 60 dB with 1 kHz narrowband
noise. The speaker arrangement is shown in Figure 7. The child was
instructed to point in the direction of the presented sound signal. When the
child pointed correctly, he was reinforced by a light inside the speaker. Localization
was rated only after a child was able to reliably understand the
directions “left” and “right.” To assist the child in learning to localize sound
sources, early interventionists provided special training emphasizing directional
hearing during the fitting and rehabilitation phase. This training was
even more important when the child had not had sufficient hearing to localize
prior to implantation.
Localization Performance
Ten of the 41 children were able to localize sound in a test situation. They
ranged in age from 3 years, 2 months to 12 years, 5 months. All had been
Bilateral Cochlear Implantation in Children 359

Figure 7. Loudspeaker arrangement for testing localization.
bilaterally fitted for a minimum of two years. The children had been bilaterally
implanted for a period of time ranging from 2 years to 6 years, 1 month.
The children received their first implant at ages ranging from 6 months to 4
years, 1 month and the second between 1 year, 2 months and 10 years, 4
months. The length of time between the first and second surgeries varied
from 8 months to 7 years, 6 months. The results indicate that even children
who were implanted at older ages were able to develop sound localization
ability. The children who were able to demonstrate localization in the test
situation had worn two implants between 2 years and 6 years, 1 month. The
parents of those children who had less than one year of unilateral implant
experience reported that they were also able to localize the sources of sounds
in daily life. Among the children who did not demonstrate localization in the
clinical setting, the majority of their parents reported that they were able to
localize the direction of sound sources in daily life.
On the basis of parents’ reports and clinical experiences, localization
abilities typically become more precise over time (Mueller, 2005). Important
factors in localizing environmental sounds and voices, especially in an uncontrolled
acoustic environment are room acoustics and the characteristics of
the sound produced.
Discussion and Summary
It should be reiterated that the results reported here were all obtained as
part of routine clinical evaluations of performance with cochlear implants and
are not research data. The group of children was heterogeneous. Their
chronological and developmental ages varied widely, which affected their
attention spans and motivation to complete a task. Because of the variability
in child characteristics, not all children responded to the same tasks. Thus, the
360 Bohnert, Spitzlei, Lippert, & Keilmann

findings cannot be statistically analyzed but are presented as descriptive
information.
All of the children reported upon here wore bilateral cochlear implants,
and as is typically the case for children with implants, had average aided
thresholds of 30 dB HL across the speech spectrum. Thus, all the children had
aided thresholds allowing them to detect sound in both binaural and monaural
conditions.
Ten of 41 children were able to reliably localize narrow-band noise at least
in terms of “left” and “right.” All of the children who were able to localize
had been bilaterally implanted for a minimum of two years. In a similar
study, Mueller (2005) showed that children implanted bilaterally for 18
months demonstrated localization to a sound source. Because the information
reported here is drawn from clinical records, it is not possible to report the
results of fixed time interval testing.
As reported by Kuehn-Inacker et al. (2004), several children who were able
to respond to both monaural and binaural speech discrimination testing demonstrated
improvement in speech discrimination with two implants compared
to the monaural condition. Performance could not be attributed to the
age at which the child received the initial implant or the second implant, or
the amount of time that had elapsed between the first and second fittings. A
similar lack of correlation between age of implantations or time between the
fittings was reported by Kuehn-Inacker et al. (2004).
Testing of speech discrimination in noise was successfully conducted in 12
of the children. Most of these children showed better performance in binaural
compared to the monaural condition. As in discrimination of speech in quiet,
there was no correlation between scores and the age of the first or the second
implant, or the amount of time that had elapsed between the two implantations.
All of the children accepted the second implant from the time of initial
fitting and have worn both implants consistently. Generally, bilateral fitting
has brought about improved performance in complex listening situations in
all of the children discussed here. This improved performance was not obvious
in all of the test situation results, but parents and children have reported
the benefits of bilateral implantation. These include increased self-esteem and
self-assurance, faster orientation to acoustical changes in the environment,
decreased listening effort, longer attention span, and better concentration.
Parents reported feeling more confident about their children’s safety in situations
such as roads with busy traffic. They also reported that their children
are able to become comfortable more quickly in unfamiliar situations. Parents
and children reported feeling positive about their decision to have a second
implant.
An advantage of bilateral implantation in general is the fact that, in those
cases of technical or mechanical malfunction or defect of one device, the
Bilateral Cochlear Implantation in Children 361

children will retain monaural stimulation. For school-age children, this auditory
input can be critical. In addition, the children have access to auditory
information in their everyday lives (Brill, 2004).
In general, it has been the experience in this clinic that when there is a
shorter time period between the first and second implant fitting, the aural
habilitation therapy can be conducted simultaneously. In this situation there
is less effort for the child to integrate the new sound provided by the second
implant and use both implants comfortably within a shorter period of time.
Not all of the children demonstrated improved bilateral performance in the
test situations. It is important to know, however, that all of the children
accepted the second implant and have worn bilateral fittings constantly. Additionally,
the parents and the children both report decreased listening effort
and improvements in daily life activities with the second implant.
Among all of the children who were bilaterally implanted at an older age,
the timespan between the first and second surgeries was longer than the time
between the first and second implant surgeries of children implanted at a
younger age. They required a longer period of aural habilitation and a longer
time was required to achieve performance comparable to that of the younger
children with bilateral fittings.
The decision to proceed with a second cochlear implant must be made
carefully. It requires close cooperation among the child the family, and professionals
from a variety of disciplines, including pediatric audiologists, early
interventionists, otolaryngologists, speech-language pathologists, teachers
and other specialists. The decision to proceed with bilateral cochlear implantation
must always be made with within the context of each child’s unique
family situation as well as their social, emotional and educational status and
not simply upon improving hearing levels in both ears. Although having two
ears available for listening is beneficial, it will not necessarily solve all of a
child’s problems. In fact, occasionally the expectations placed upon a child
with bilateral implants by parents, teachers and professionals can be overwhelming
to the child. Thus, expectations must be reasonable and realistic.
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364 Bohnert, Spitzlei, Lippert, & Keilmann

The Volta Review, Volume 106(3) (monograph), 365-379
Early Cochlear Implant
Experience and Emotional
Functioning During
Childhood: Loneliness in
Middle and Late Childhood
Efrat A. Schorr, Ph.D.
The importance of early intervention for children with hearing loss has been demonstrated
persuasively in areas including speech perception and production and
spoken language. The present research shows that feelings of loneliness, a significant
emotional outcome, are affected by the age at which children receive intervention with
cochlear implants. Earliest cochlear implantation is associated with lowest levels of
loneliness during middle and late childhood. Compared to children with normal
hearing, children with cochlear implants are not more lonely than their peers with
normal hearing.
Introduction
Awareness of the importance of early intervention for all children with
disabilities has steadily grown in recent decades. Great strides are being made
in the early detection and intervention for infants and children with hearing
loss. In the United States and other countries, the introduction and increased
use of universal newborn hearing screening programs has made it possible to
detect hearing loss in the first days of life. The Joint Committee on Infant
Hearing (2000) has advocated hearing screening for all newborns, with the
goal of confirming hearing loss before 3 months of age and beginning intervention
services before 6 months of age.
The availability of improved technological means to assess hearing in infants
and young children and to habilitate hearing loss with advanced digital
hearing aids and cochlear implants has changed the prospects for many children
with severe and profound hearing loss. Research has shown that infants
Efrat A. Schorr, Ph.D., is a postdoctoral fellow at the Gonda Brain Research Center at Bar Ilan
University, Ramat Gan, Israel.
Loneliness in Children with Cochlear Implants 365

with hearing loss who receive early intervention services before 6 months of
age may display age-appropriate language skills at 5 years (Yoshinaga-Itano,
1995; Yoshinaga-Itano, Sedey, Coulter, & Mehl, 1998). A growing body of
research literature demonstrates that children with congenital hearing loss
who receive cochlear implants at young ages show improved cognitive
(Sharma, Dorman, & Spahr, 2003), language (Nicholas & Geers, 2006; Tomblin,
Barker, Spencer, Zhang, & Gantz, 2005) and hearing and speech perception
outcomes (Harrison, Gordon, & Mount, 2005; Nikolopoulos, Gibbin, &
Dyar, 2004; Schorr, Fox, vanWassenhove, & Knudsen, 2005; Svirsky, Teoh, &
Neuberger, 2004) compared with children who receive the implants later.
Less is known about the effects of early intervention for children with
hearing loss on social and emotional outcomes. Because more children are
receiving cochlear implants at younger ages, it is imperative that professionals
and researchers from across disciplines work together to learn more about
the effects of early cochlear implantation on the wide range of social and
emotional aspects of child development, such as the development of selfregulation
and self-control, social competence, and peer relationships. Understanding
the social and emotional implications of an early period of
deafness followed by the unique experience of hearing with a cochlear implant
is essential to supporting the development of this growing group of
children. The study presented here is an introductory chapter of the multifaceted
research goals that lie ahead.
Children as young as 5 years demonstrate an understanding of feelings of
loneliness (Cassidy & Asher, 1992). They are able to explain that loneliness
involves both being alone and feeling sad or depressed, a very close definition
to that given by adults (see Peplau & Perlman, 1982, for a general discussion
of loneliness). Research has demonstrated that loneliness in middle childhood
is not a fleeting mood; rather, it is a stable and often long-lasting problem for
children (Hymel & Franke, 1985; Renshaw & Brown, 1993).
Loneliness during childhood develops when children feel that they are not
socially competent and feel rejected by their peers over a relatively long
period of time (Asher & Wheeler, 1985; Renshaw & Brown, 1993). The children
who are most susceptible to feelings of loneliness are those who are
rejected by their peers and are characterized as being socially withdrawn or
inhibited (Cassidy & Asher, 1992; Crick & Ladd, 1993; Parkhurst & Asher,
1992). In addition, children who express feelings of loneliness and social
dissatisfaction in the school setting often have distinct behavioral characteristics.
Young children who reported feeling very lonely at school demonstrated
more aggressive and disruptive behaviors and were viewed as being
less prosocial and shyer than children who did not feel very lonely (Cassidy
& Asher, 1992). Having a close friend, however, has been identified as a
protective factor that buffers children from feeling very lonely even if they are
socially rejected from the peer group (Renshaw & Brown, 1993; Rubin, Coplan,
Nelson, Cheah, & Lagace-Seguin, 1999).
366 Schorr

Hearing loss places children at a specific risk for failure to establish and
maintain positive social relationships with peers (Marschark, 1993). Evidence
suggests that children with hearing loss (without cochlear implants) who are
placed in mainstream schools and classrooms with children with normal
hearing do not form close relationships with their peers (Antia, 1982; Calderon,
2000; Farrigua & Austin, 1980; Greenberg & Kusche, 1989, 1993; Marschark,
1993; Suarez, 2000). For example, Stinson and Lang (1994) described
social outcomes for children with hearing loss (without cochlear implants) in
mainstream school settings, reporting that “the likely consequence of mainstreaming
is social isolation, not integration, and this kind of social experience
is not conducive to the deaf child’s social development” (p. 157). Research on
the social experiences of children with hearing loss (without cochlear implants)
in mainstream educational settings has found that these children feel
isolated and lonely in their school environments (Gaustad & Kluwin, 1992;
Mertens, 1989; Newcomb & Bagwell, 1995; Saur, Popp-Stone, & Hurley-
Lawrence, 1987).
It is important to examine the feelings of loneliness in children with cochlear
implants, especially in light of the possibility that they are often the
only child with hearing loss in their mainstream educational setting (Stinson
& Lang, 1994). Furthermore, critics of cochlear implants have warned about
the potential identity problems facing children with prelingual hearing loss
who receive cochlear implants as young children. They argue that these children
are unable to truly take part in the hearing world and will inevitably be
excluded from full social lives with hearing people (Crouch, 1997; Lane, 1997).
In the present investigation, we sought to assess the feelings of loneliness
in children with cochlear implants. We asked several specific questions about
loneliness. (1) Are children with cochlear implants lonelier than children with
normal hearing? (2) Do early experience-related factors, such as the age at
which hearing loss is confirmed, age at which a child first receives hearing
aids or age at which child receives a cochlear implant, influence loneliness
later on in childhood? (3) Are present-day factors such as speech perception
or language proficiency related to loneliness?
Method
Participants
Thirty-seven children (19 girls and 18 boys) with cochlear implants, ages 5
to 14 (M = 9 years), participated in this study. All of the children were born
deaf, had no additional significant disabilities (e.g., blindness, autism), used
spoken English as their primary mode of communication and their native
language, had nonverbal IQ scores in the average range (a minimum score of
85 on the Matrices subtest of the Kaufman Brief Intelligence Test [K-BIT;
Kaufman & Kaufman, 1990]) and had a general language proficiency level of
Loneliness in Children with Cochlear Implants 367

5 years (i.e., met the age cut-off on both the Peabody Picture Vocabulary
Test-III [PPVT-III; Dunn & Dunn, 1997] and the age-appropriate Grammatic
Understanding subtest of the Test of Language Development-Primary
[TOLD-P; Newcomer & Hammill, 1997], Test of Language Development-
Intermediate [TOLD-I; Hammill & Newcomer, 1997] or Test of Adolescent
and Adult Language-Third Edition [TOAL-3; Hammill, Brown, Larsen, &
Wiederholt, 1994]).
The age at which the children received their cochlear implant ranged from
16 months to 8 years, 3 months, with a mean age at implant of 3 years, 2
months. All children had a minimum of one year of cochlear implant experience
at the time of participation in this study. The duration of cochlear
implant use ranged from 19 months to 10 years, 6 months, with a mean of 5
years, 9 months. The children were from the mid-Atlantic United States.
Parent report indicated that 32 children were educated exclusively in mainstream
or general education classrooms, three were educated in partial mainstream
classrooms and two were educated in self-contained special education
classrooms.
The comparison group consisted of 37 children with normal hearing whose
native language was English. They were matched individually to the children
with cochlear implants by gender and age, within three months of the birth
dates of the children with cochlear implants. All the children with normal
hearing had nonverbal IQ scores in the average range (a minimum score of 85
on the K-BIT Matrices subtest), and no additional disabilities.
Loneliness Assessment
Materials
The Loneliness Scale (Asher & Wheeler, 1985, revised from Asher, Hymel,
& Renshaw, 1984) was used to provide an account of feelings of loneliness.
Responses to this 24-item questionnaire are provided on a five-point Likert
scale. Sixteen items focus on feelings of loneliness and social dissatisfaction in
school, and 8 items are “filler” items. The 16 primary items include four
domains: (1) children’s feelings of loneliness (“I am lonely at school”), (2)
children’s appraisal of their current peer relationships (“I don’t have any
friends in class”), (3) children’s perceptions of the degree to which important
relationship needs are being met (“There are no other kids I can go to when
I need help at school”) and (4) children’s perceptions of their social competence
(“I’m good at working with other children in my class”). Split-half
reliability between forms is 0.83, and Cronbach’s alpha is 0.90 (Asher et al.,
1984; Crick & Ladd, 1993). The participants were asked to respond to each
item on a five-point scale (1 = that’s always true of me, 2 = that’s true about
me most of the time, 3 = that’s sometimes true about me, 4 = that’s hardly ever
true about me and 5 = that’s not true about me at all).
368 Schorr

Nonverbal IQ Assessment
Nonverbal intelligence was assessed with Matrices subtest of the K-
BIT (Kaufman & Kaufman, 1990). All test items contain pictures and abstract
designs and require a pointing response so that cognitive ability can be assessed
independently of oral language proficiency. Cognitive functioning information
was used to ensure that each participant’s nonverbal intelligence
was within normal limits.
Speech Perception Assessment
The participants’ ability to understand spoken language accurately was
assessed with the Lexical Neighborhood Test (LNT) and Multisyllabic Lexical
Neighborhood Test (MLNT) (Kirk, Pisoni, & Osberger, 1995). The LNT and
MLNT measure speech perception through assessment of open-set word recognition.
The LNT contains two 50-item lists of monosyllabic words, and the
MLNT consists of two 24-item lists of two- and three-syllable words. In each
test, half of the words are considered lexically “easy,” meaning that they are
common and have few phonologically similar words. Half are considered
lexically “hard,” meaning that they are words that occur infrequently and
have many phonologically similar words. This pair of tests was designed
specifically for use with children with cochlear implants. Good test-retest
reliability (0.83 for lists one and two, both easy and hard components) and
interlist equivalency have been demonstrated (Kirk, Eisenberg, Martinez, &
Hay-McCutcheon, 1999). Percentage of correct words for the easy and hard
word lists of both the LNT and MLNT were scored, and an average of the four
subtests was calculated.
Language Assessment
General language proficiency was assessed with measures of receptive semantics
and syntax. The PPVT-III (Dunn & Dunn, 1997) was administered to
all participants, and one of three different subtests of receptive syntax performance
was administered to each. For participants ages 5 years to 7 years,
11 months, the Grammatic Understanding subtest of the TOLD-P (Newcomer
& Hammill, 1997) was used. For children ages 8 years to 11 years, 11 months
the Grammatic Understanding subtest of the TOLD-I (Hammill & Newcomer,
1997) was administered. For children ages 12 years to 14 years, 11 months, the
Listening/Grammar subtest of the TOAL-3 (Hammill et al., 1994) was used.
Language proficiency scores were computed with the sum of standard score
obtained on the PPVT and the age-appropriate subtest of syntax.
Procedure
All of the participants took part in a one-day assessment at the Child
Development Lab at the University of Maryland, College Park, or at another
Loneliness in Children with Cochlear Implants 369

location. Informed consent was obtained from the accompanying parent before
beginning testing. The accompanying parent completed a questionnaire,
providing information on the child’s audiological, educational and family
background.
All tests were administered individually to each participant in a quiet
room. The loneliness, IQ, speech perception and language tests were administered
in variable order. The examiner explained to the participant that his or
her answers to all of the questions would remain confidential. All participants
were given a written copy of the Loneliness Scale (Asher & Wheeler, 1985),
and the examiner read each test item aloud, allowing participants time to
respond on paper and ask questions if clarification was necessary. The test
items were read orally to minimize the concern that reading ability might
affect the reliability of the assessments. Scores were summed, with a range of
16 (low loneliness) to 80 (high loneliness).
Results
Description of Feelings of Loneliness of Children with Cochlear Implants
The participants with cochlear implants reported an average score of 32.62
(SD = 10.78) on the Loneliness Scale out of the lowest possible score of 16 to
the highest possible score of 80. This mean loneliness score is comparable to
that of the sample reported in the Asher et al. (1984) original study describing
the Loneliness Scale, which was 32.51 (SD = 11.82). There was considerable
variability in the scores for the participants with cochlear implants, which
ranged from 16 to 60 in the present study.
Loneliness of Children with Cochlear Implants Compared to Children with
Normal Hearing
As a group, the participants with normal hearing reported an average score
of 28.19 on the Loneliness Scale (SD = 8.32). An analysis of variance (ANOVA)
was conducted to determine whether the cochlear implant and normal
hearing groups differed in their reports of loneliness (see Table 1). The
Table 1. Mean Differences in Loneliness by Group for Children with Cochlear
Implants and Children with Normal Hearing
Children With
Cochlear Implants
M (SD)
Children With
Normal Hearing
M (SD) df F
Loneliness average score 32.62 (10.78) 28.19 (8.32) 1,72 3.920
Note. N = 37 for both study groups.
370 Schorr

participants with cochlear implants did not significantly differ from the participants
with normal hearing in their report of feelings of loneliness at school
(p > 0.05).
Effects of Early Experience-Related Variables on Loneliness
Although the participants with cochlear implants did not report feeling
significantly more lonely than the participants with normal hearing, quite a
bit of variability was found in the scores obtained in the study group. Zeroorder
correlations were generated to examine the relationship between loneliness
and early experience-related variables (see Table 2).
A linear regression procedure was used to assess the relationship between
early experience-related variables and mean loneliness scores. Specifically,
we tested whether the age hearing loss was confirmed, age at first amplification
with hearing aids or age at activation of cochlear implant predicted the
loneliness score. We used present chronological age as a covariate in the
regression models to minimize the influence of maturation-related changes
because of the wide age range of participants. The analyses revealed a nonsignificant
relationship between the age hearing loss was confirmed [F(1,31)
= 0.868, p > 0.05, R 2 change = 0.026] and age at first amplification with hearing
aids [F(1,32) = 0.538, p > 0.05, R 2 change = 0.016]. A significant relationship
between age at implant and loneliness score was found [F(1,34) = 4.836, p <
0.05, R 2 change = 0.119), indicating that older age at implant was associated
with higher loneliness scores (ß = 0.450). This model as a whole accounted for
16.6% of the variance in loneliness scores. Figure 1 presents scatter plots of
these relationships.
In addition, we found that the type of amplification used before cochlear
implant surgery was related to loneliness score. Thirty-five of 37 participants
had used hearing aids before their cochlear implant activation (data were not
available for two of the participants). Of those 35, nine also used FM personal
sound systems (see Flexer, 1999, for details on FM technology) with their
hearing aids. An ANOVA indicated that the participants who had used FM
Table 2. Correlations Between Early Experience-Related Variables and Loneliness
1 2 3 4 5
1. Loneliness score — –0.113 –0.084 –0.121 0.403*
2. Age hearing loss confirmed — 0.984** 0.852** 0.379*
3. Age at first amplification — 0.841** 0.379*
4. Age intervention program began — 0.265
5. Age at implantation —
Note. Significant correlations appear in bold type.
*Significant at the 0.05 level.
**Significant at the 0.01 level.
Loneliness in Children with Cochlear Implants 371

Figure 1. Loneliness score and age at implantation, age that hearing loss was
confirmed and age at first use of amplification.
systems were significantly less lonely than participants who had only used
hearing aids [F(1,33) = 6.529, p > 0.05). The participants who had used FM
systems (n = 9) had a mean loneliness score of 26.33 (SD = 5.20), with a
minimum score of 20 and a maximum score of 34. The participants who used
only hearing aids (n = 26) had a mean loneliness score of 35.92 (SD = 10.76),
372 Schorr

with a minimum score of 16 and a maximum score of 60. The hearing aids
group versus hearing aids plus FM group also differed in chronological age
and age at implantation. The participants who had used FM systems were
younger (91 versus 116 months of age at testing) and received their cochlear
implant at a younger age (23 versus 45 months). We interpret these results
with caution because of the unequal size of the groups (n = 26 versus n=9),
but they can provide some guidance for best practices for intervention with
children with cochlear implants.
Relationship Between Present-Day Factors and Loneliness
Regression models showed a relationship between the age at which participants
received their cochlear implant and their loneliness score. We
wanted to examine whether speech perception or spoken language skills
served as the mediator for this association. In other words, we asked whether
early age of implantation leads to better speech perception and spoken language
skills, which, in turn, affect loneliness; i.e., the better one can communicate,
the less lonely one might feel. In this scenario, loneliness is affected
only indirectly by early experience variability in age of implantation because
speech perception or language skills are the factors that truly influence loneliness.
Zero-order correlations were computed to examine the relationships between
loneliness and speech perception and language skills (see Table 3).
Speech perception and language skills were closely related to each other, but
neither of these variables corresponded to the mean loneliness score in a
significant way. Regression models using chronological age and speech perception
and chronological age and language skills as covariates were computed.
In the two models, neither speech perception [F(1,33) = 1.548, p > 0.05,
R 2 change = 0.043] nor language skills [F(1,34) = 0.495, p > 0.05, R 2 change =
0.014] accounted for the variability in the loneliness scores.
Because of the null findings in these regression analyses, a post-hoc power
Table 3. Correlations Between Speech Perception and Language Skills
and Loneliness
1 2 3 4
1. Loneliness score — –0.106 –0.203 0.403*
2. Speech perception score — 0.703** 0.126
3. Composite language score — –0.056
4. Age at implantation —
Note. Significant correlations appear in bold type.
*Significant at the 0.05 level.
**Significant at the 0.01 level.
Loneliness in Children with Cochlear Implants 373

analysis was conducted to determine whether there was sufficient power in
the research design to permit detection of a true effect. For the regression
analysis involving speech perception as the dependent variable, the observed
power value of 0.35 was indicated (confidence intervals of 95% for B = –0.133
to 0.551). For the regression analysis involving language skill as the dependent
variable, the observed power was 0.24 (confidence intervals of 95% for
B=–0.256 to 0.124). Both of these effect sizes are relatively small, indicating
that the failure to find significant effects of the speech and language variables
on the loneliness measure could be the result of insufficient sample size rather
than the weak connection between these variables. Nonetheless, our findings
indicate that in this sample, speech perception and language skills are not the
factors that influence loneliness. Rather, there appears to be a direct link
between age of implantation and feelings of loneliness in middle and late
childhood that is present regardless of speech perception and language skills.
Discussion
The purpose of this study was to assess the feelings of loneliness of children
with cochlear implants and to try to place this investigation within the
broader context of loneliness among a normative sample of children with
normal hearing. As well, we wanted to investigate the influence of factors that
are unique to children with cochlear implants on loneliness. The participants
with cochlear implants reported feelings of loneliness at school that were
relatively low. These children appear to perceive a sense of support and feel
included in their school settings. These findings are in contrast with the
reports of social exclusion in school from children with hearing loss without
cochlear implants (i.e., Stinson & Lang, 1994). Several potentially significant
differences were found between the experiences of the present sample of
children with cochlear implants and those without cochlear implants reported
previously in the literature. First, children with cochlear implants in
the present study all used spoken language fluently, which allowed them to
participate in their classrooms without the need for a sign language interpreter.
This ability also allowed them to spend most, if not all, of their time
in the inclusive classroom as opposed to being a “visitor” who came and went
from the classroom frequently. These factors could permit the child to become
a true “member” of the classroom social group, despite his or her hearing loss
(see Antia, Stinson, & Gaustad, 2002, for a discussion of “membership” and
“visitorship” for students with hearing loss in inclusive education).
The participants with cochlear implants reported feelings of loneliness
that were very similar to the participants with normal hearing. This result
seems to run counter to the arguments of cochlear implant opponents who
felt that children with cochlear implants would inevitably feel excluded from
the hearing social world around them. It may be helpful for parents and
professionals to know that children with cochlear implants are not necessarily
374 Schorr

lonelier than their peers with normal hearing. Indeed, we found significant
variability in the feelings of loneliness of the participants with cochlear implants—some
reported feeling quite lonely at school—but the results overall
show that being a child with hearing loss with a cochlear implant in a mainstream
school does not necessarily mean they will be lonely.
There appears to be a strong connection between the age at which a child
receives a cochlear implant and feelings of loneliness at school years later.
Also, it seems that while the development of speech and language skills is
essential to social functioning, it alone does not determine whether a child
will feel lonely in school. Rather, one reasonable interpretation of the results
is that the opportunity for children with congenital hearing loss to truly
participate in their family and school environments begins when they receive
their cochlear implants. Thus, perhaps the participants who received their
implants at the youngest age developed feelings of belonging and inclusionin
their school settings in a similar manner as the participants with normal
hearing. Although they may catch up impressively in their speech and language
skills, children who received their cochlear implants at older ages may
take longer to attain a feeling of belonging or may have difficulty feeling that
they belong at all.
The curious results of the relationship of FM system use to loneliness,
despite the nonsignificant relationships between other early amplification
factors, may be understood in the following manner. It seems that, auditory
experience before cochlear implantation per se does not have the same effect
on feelings of loneliness as it does after the cochlear implant. Auditory experience
prior to implantation may not play a significant or obvious role in
later emotional outcomes because children with profound to severe hearing
loss may derive very little benefit from the hearing aids used prior to implantation.
However, FM system use may have an important influence on the
attitudes of parents, teachers and other significant adults. Perhaps using an
FM system encourages parents and teachers to talk to the child with hearing
loss, to include the child in the conversation, and to think of him or her as a
part of the goings on in a way that they quite naturally might not if the FM
system were not in use. Thus, the use of an FM system with hearing aids
before early cochlear implantation represents the “best practice” to prepare
children with hearing loss to tune in to the conversations taking place in their
environment and be primed to pay attention. If understood in this light, the
finding that early FM system use is associated with feelings of loneliness in
school later on in childhood is understandable.
The results of the present study imply that the advantages of early cochlear
implantation extend to the domain of emotional functioning. They seem to
indicate that although cochlear implants provide the potential to acquire
good speech and language skills; this is not all they do. Arguably, they provide
the potential for children to develop healthy emotional perspectives of
themselves and their place in the world around them. Once the children
Loneliness in Children with Cochlear Implants 375

eceive cochlear implants, significant others may feel that they are real communication
partners, and importantly, the children begin to view themselves
as capable communication partners.
“Best practice” is an important idea to consider for children with hearing
loss. Although early identification of hearing loss and early amplification
with hearing aids did not predict feelings of loneliness outcomes, early cochlear
implantation did. However, they are essentially related because early
cochlear implantation is only a possibility for children if hearing loss is detected
and the intervention process is begun early. In light of the reality of the
cochlear implant candidacy process and the often cumbersome journey leading
up to cochlear implant surgery, early cochlear implantation only is possible
when hearing loss is detected at birth or soon afterward. Based on the
results of the present study, the provision of cochlear implants to appropriate
candidates as early as suitable should be considered the best practice for
children with severe to profound hearing loss. As well, the results of this
study imply that we should not discount the importance of amplification with
appropriate hearing aids and FM systems before the implant surgery because
their use may be important for reasons that extend beyond the raw numbers
of decibel gain with the devices. Rather, hearing aids and FM systems may
influence the important adults (as well as the child him or herself) to consider
the child with hearing loss as a listener.
Finally, some of the participants with cochlear implants reported feeling
quite lonely in their classrooms. It is important to have this information
because strategies can be sought to help these children feel less lonely in
school. Although it would not be a simple proposition to intervene and ameliorate
feelings of loneliness, awareness of the problem is a necessary first step
in that direction (see Margalit, 1996, for a discussion of intervention strategies
for loneliness in children with disabilities).
This study contributes insights into the exploration of the emotional and
social impact of cochlear implant use on the lives of children. Further research
is needed to learn whether loneliness is related to other emotional or social
issues for children with cochlear implants. More information also is needed to
gain a better understanding of many other emotional aspects of development
that may be affected by hearing loss and the use of a cochlear implant.
Longitudinal research would provide a more comprehensive portrait of emotional
development in children with cochlear implants. We hope this study
will raise awareness of the importance of emotional issues in development
and that more research will follow.
In conclusion, the study reported here emphasizes the importance of early
detection and intervention for children with hearing loss as essential to
speech and language development. Early intervention also has important
effects on feelings of loneliness in these children. The trends in the United
States and other countries toward earlier detection and intervention for children
with hearing loss are encouraging, and it is crucial to raise awareness so
376 Schorr

that all children can benefit from the earliest detection and appropriate intervention
for hearing loss.
Acknowledgments
This research was supported by the American Hearing Research Foundation
and a National Research Service Award grant (F31 DC006204-01A1) to
E.A.S. from the National Institutes of Deafness and Other Communication
Disorders, National Institutes of Health. The author would like to thank the
children and parents who participated in the study. Sincere appreciation and
thanks go to Nathan A. Fox and Froma P. Roth at the University of Maryland
for their guidance and support for this project.
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Loneliness in Children with Cochlear Implants 379

The Volta Review, Volume 106(3) (monograph), 381-418
Early Hearing Detection and
Intervention in Developing
Countries: Current Status
and Prospects
Bolajoko O. Olusanya, M.D., M.Phil.
Infant hearing screening is emerging rapidly as a silent global revolution for the
early detection of children with congenital or early onset hearing loss to ensure timely
enrollment in family-oriented intervention programs for the development of spoken
language. This article examines the overriding and interrelated scientific, ethical and
economic considerations for early hearing detection and intervention (EHDI) in
developing countries against the backdrop of relevant resolutions of the World Health
Assembly (WHA) and current global programs on early childhood developmentofthe
World Bank, United Nations Children’s Funds (UNICEF) and the United Nations
Educational, Scientific and Cultural Organization (UNESCO). The need to determine
and develop culturally appropriate EHDI programs is indicated by the significant
proportions of births that occur outside regular hospitals in some countries based
on lessons from ongoing projects. The key challenges and possible approaches to
building local service capacities to advance this vital, social, educational and public
health initiative also are highlighted.
Introduction
Hearing screening for babies dates back to 1944 when Sir Alexander and
Lady Ethel Constance Ewing of Great Britain demonstrated the need to develop
methods of testing hearing in young children in the first year of life
(Ewing & Ewing, 1944). The Ewings were among the earliest to investigate
infant behavioral responses to auditory stimuli using sounds from toys,
Bolajoko Olusanya, M.D., M.Phil., is a research fellow at the Institute of Child Health and the
Great Ormond Street Hospital for Children NHS Trust, University College London; a fellow
of the Royal College of Pediatrics and Child Health, United Kingdom; and an international
fellow of the American Academy of Pediatrics. She has successfully pioneered hospital and
community-based infant hearing screening programs in Nigeria in collaboration with the
country’s federal health department.
EHDI in Developing Countries 381

noisemakers, crumpled paper and the human voice. Further interest in neonatal
and infant hearing screening by various researchers subsequently culminated
in the formation of the U.S. Joint Committee on Infant Hearing
(JCIH) in 1969 to improve and coordinate efforts for the early detection of
congenital hearing loss.
As a result of the limitations of available behavioral screening techniques,
the JCIH recommended in 1972 the screening of only high-risk babies based
on a set of five risk factors, which were expanded to 10 in 1994 (American
Academy of Pediatrics, 1995). However, selective screening based on risk
factors was found to miss a significant number of infants with hearing loss
(Mauk, White, Mortensen, & Behrens, 1991; Watkin, Baldwin, & McEnery,
1991). After much debate (Bess & Paradise, 1994), universal newborn hearing
screening (UNHS) emerged as the preferred method of early hearing detection
and subsequently as a standard of care in the United States and many
developed countries (Bamford, Uus, & Davis, 2005; JCIH, 2000; Lutman &
Grandori, 1999; Russ et al., 2002; Weichbold, Nekahm-Heis, & Welzl-Mueller,
2006; White, 2003). This practice has facilitated a growing enrollment of children
detected with significant hearing loss (averaging 30 to 40 dB or more
over frequencies 500 to 4000 Hz) into family-oriented intervention services in
the first year of life (Harrison & Roush, 2003; JCIH, 2000; Uus & Bamford,
2006; Weichbold et al., 2006). Much of the current success is attributable to
significant advancements in screening technologies and hearing devices as
well as to improved research to establish the efficacy of early intervention on
the communication skills and quality of life of infants with hearing loss.
In a recent report, Morton and Nance (2006) rightly acknowledged that
newborn hearing screening is a silent revolution and that “better hearing for
all nations is an achievable, important goal” (p. 2152). However, current
dispositions toward the globalization of EHDI are varied and seem to range
from cautious optimism to enthusiastic support (Mencher & Devoe, 2001;
White, 2006; Grandori & Hayes, 2006). Reticence towards EHDI initiatives is
commonly linked to the prevailing socioeconomic challenges and the burden
of fatal childhood diseases. This tends to distract attention from the vast
majority of survivors in this region who need to thrive and develop optimally
in their early crucial years. Children with disabilities are the most vulnerable
and those with hidden disabilities like permanent hearing loss are easily the
most neglected and the most disadvantaged (Olusanya, Ruben, & Parving,
2006b).
Another major obstacle to supporting EHDI efforts in developing countries
is the lack of representative data reflecting the peculiarities and the great
diversities within and across the more than 140 countries in this region
(United Nations Children’s Funds [UNICEF], 2005; World Bank, 2006). Although
pilot studies are ongoing in a growing number of countries, progress
towards early hearing detection and intervention (EHDI) is still quite limited
and underreported. Against this backdrop, this review presents the rationale
382 Olusanya

for promoting EHDI in developing countries, highlights the current global
impetus for EHDI, examines current options and progress towards early
hearing detection and concludes with a discussion of the scope, status and
prospects of intervention services.
Rationale for EHDI in Developing Countries
The decision to screen for hearing loss in early childhood in any community
must be based on rational and universally accepted criteria for screening
in order to justify its introduction as an essential public health service. The
major scientific, ethical and economic considerations relevant to screening for
infant hearing loss in developing countries are examined in this section.
Scientific Considerations
A population-based screening may be defined as “the systematic application
of a test or inquiry to identify individuals at sufficient risk of a disorder
that would benefit from further investigation or direct preventive action
among people who have not sought medical attention or intervention because
of symptoms of that disorder” (Wald, 2006 [p. 53]; Strong, Wald, Miller, &
Alwan, 2005 [p. 12]). It entails the early detection of a disorder that is known
to cause significant morbidity, suffering, disability or death if detected at a
later stage and for which early intervention is possible and efficacious.
At least five principles should be satisfied before any screening program is
implemented (American Academy of Pediatrics [AAP], 1999; Bess & Paradise,
1994; National Screening Committee (UK), 2003; Olusanya, Luxon, & Wirz,
2005a; Screening Brief, 2001; Strong et al., 2005):
1. The condition or disorder must be a significant health problem in the
target population.
2. Evidence must exist that the condition cannot be prevented effectively
from occurring (i.e. not fully amenable to primary prevention).
3. The screening procedure or test must be simple, safe and valid.
4. The treatment or intervention must be effective and available.
5. The benefits from the screening program must outweigh the associated
risks.
Significance of PECHL in Developing Countries
As noted aptly by Mencher (2000), a major challenge in many developing
countries is the dearth of epidemiological data on permanent congenital and
early onset hearing loss (PCEHL). Paradoxically, such data can only be obtained
reliably when infant hearing screening is implemented. Prevalence
estimates for PCEHL before the widespread implementation of UNHS ranged
EHDI in Developing Countries 383

from 1.5 to 6 per 1,000 live births (Bachmann & Arvedson, 1998; Barsky-
Firkser & Sun, 1997; Yoshinaga-Itano, Sedey, Coulter, & Mehl, 1998). Basedon
the outcomes of several large-scale UNHS programs in developed countries,
the incidence of bilateral PCEHL (>40 dB HL) is estimated as 2 to 4 per 1,000
live births (Smith, Bale, & White, 2005; White, 2004). If the poorer health and
socioeconomic conditions in developing countries and the significant proportion
of births occurring outside hospitals were considered, the incidence of
PCEHL (>40 dB HL) in many developing countries likely would rise to at
least 6 per 1,000 live births (Olusanya et al., 2006b). For instance, Ansari (2004)
reported a survey conducted in India in which 4 of every 1,000 children born
in that country were identified with severe-to-profound hearing loss. When
moderate-to-severe hearing loss was included, the report suggested an even
higher incidence of hearing loss. These data, therefore, would suggest that of
the 119.7 million annual live births in developing countries (UNICEF, 2005),
about 718,000 are likely to have PCEHL (Olusanya & Newton, in press).
In addition, the World Health Organization (WHO) latest estimates show a
more than two-fold increase within a decade in the population of persons
with significant hearing loss (>40 dB HL) worldwide from 120 million in 1995
to at least 278 million in 2005 (WHO, 2006a).
Two-thirds of the world’s population of children and adults with hearing
loss live in developing countries. Hearing loss in 68 million people is estimated
to have existed since childhood, but this estimate may be understated
because several risk factors for PCEHL, including those listed by the JCIH, are
associated with poor maternal and child health care in developing countries.
PCEHL is also the most common communication disorder that prompts consultation
with physicians (Somefun, Lesi, Danfulani, & Olusanya, 2006).
Based on these facts, PCEHL is unlikely to be a less significant psychosocial,
educational and health condition in developing countries than in developed
countries where UNHS currently is mandatory.
Limitations of Primary Prevention of PCEHL
It has been suggested that at least 50% of the burden of hearing loss across
all age groups can be prevented (Alberti, 1996; Smith, 2003; WHO, 2006a).
Prevention in a generic sense consists of three levels of disease control and
management: primary, secondary and tertiary (see Table 1).
Primary prevention for PCEHL is concerned with the prevention of its
occurrence or any condition that may lead to its occurrence and includes such
activities as immunization, avoidance or rational use of ototoxic drugs and
improved obstetric care, personal hygiene and living conditions. For primary
prevention to be effective, there must be accurate knowledge of the causes
and associated risk factors for PCEHL in a given setting (Morzaria, Westerberg,
& Kozak, 2004). Available studies suggest that the possible causes of
PCEHL in a significant proportion (about 20-57%) of children with hearing
384 Olusanya

Table 1. Levels of Prevention for Congenital and Early Onset Hearing Loss
Level of Prevention Description
Primary
Aim: To prevent
occurrence of PCEHL or
any condition that may
lead to its occurrence
Secondary
Aim: To detect and treat
early or modify the effects
of PCEHL where there is
no treatment.
Tertiary
Aim: To provide an entry
point for the care and
management of the child
with PCEHL.
● Vaccination against rubella, mumps and meningitis
(hemophilus influenzae type B and meningococcus)
● Avoidance and cautious use of ototoxic drugs
● Widespread public education to prevent neonatal
jaundice from
• Iso-immunization
• Exposure of infants who may be G6PD deficient to
hemolytic agents, such as camphor and
menthol-containing household substances
• Umbilical sepsis
● Prenatal diagnosis and termination of pregnancy for
significant congenital abnormalities
● Premarital counseling on the dangers of
consanguinity for genetic diseases in general and
specifically for hearing loss
● Improved maternal and child health services
including prompt decision-making process for
cesarean section when indicated
● Management of maternal HIV infection for the
prevention of vertical transmission through
• Use of antiretroviral drugs (HAART) during
pregnancy
• Delivery by cesarean section
• Avoidance of breast feeding
● Malaria control and prophylaxis
● Parental empowerment through education and
gainful employment
● Early detection through newborn hearing screening
and enrollment in early intervention programs
● Widespread awareness of language milestones and
risk factors for hearing loss during ante-natal classes
for pregnant women and postnatal classes and
immunization clinics for new mothers
● Preschool screening programs to identify children
missed by infant hearing screening
● Technology for auditory-based communication for
mainstreaming
• Provision of hearing aids and support services
• Provision of cochlear implants
● Teachers equipped through education and training
to provide effective classroom auditory-based
communication support for children with mild to
moderate hearing loss
● Classroom accommodations (e.g., preferential seating,
acoustic treatment of classrooms, sound field systems)
● Consideration of alternate visual communication
options (e.g., Cued Speech, Sign Language)
EHDI in Developing Countries 385

loss in the developing world are unknown, thus forestalling primary prevention
as a comprehensive solution (Derekoy, 2000; Elango, Chand, & Purohit,
1992; Gray, 1989; Holborow, Martinson, & Anger, 1982; Minja, 1998; Sellars &
Brighton, 1983). Moreover, vaccinations against notable causes of PCEHL,
such as meningitis, mumps and rubella, are rare in many developing countries
(WHO, 2002). The standard of maternal and child health care in many of
these countries is poor and unlikely to reach levels comparable to those of
developed countries in the foreseeable future (UNICEF, 2005).
Secondary prevention, therefore, is imperative in view of the possibilities
offered by newborn or infant screening for early detection and intervention.
Secondary prevention for prelingual hearing loss involves taking action to
prevent PCEHL from becoming a disability through early hearing detection
followed up with appropriate and timely intervention. Infant hearing screening,
therefore, is essentially a preventive and vital social, educational and
health care service. Regardless of the limitations with primary prevention,
however, screening is not an alternative “primary prevention” strategy but a
complement to ongoing efforts to prevent and curtail known risk factors for
PCEHL (Alberti, 1996; Kumar, 1997; WHO, 2006).
Tertiary prevention is concerned with the rehabilitation of persons with
disabilities. Tertiary prevention for PCEHL, therefore, seeks to prevent the
disability posed by restricted hearing sensitivity from becoming a “handicap”
or disability that hinders an individual’s daily functioning and participation
in society at large (Stephens, 1996; WHO, 2001). It embraces the provision of
hearing aids or cochlear implants and associated services, family-oriented
support services, special education and equitable social integration.
Efficiency of Screening Methods
Currently, parental suspicion or concern prompted by a child’s inappropriate
or lack of response to sound is the most common mode of detecting
PCEHL in many developing countries. Parental suspicion often provides
valuable impetus for detection and a prescreening method; however, health
professionals do not always act upon parents’ observations (Glascoe, Maclean,
& Stone, 1991; Roberts, 1996). Moreover, this passive form of detection
often occurs well after the child is 24 months old, which is late for optimal
intervention for speech and language development (Gopal, Hugo, & Louw,
2001; Mukari, Vandort, Ahmad, Saim, & Mohamed, 1999; Olusanya, Luxon, &
Wirz, 2005b). Parental suspicion may be earlier for children with severe-toprofound
hearing loss, but confirmation often is not obtained until the child
is 5 years of age. The delay sometimes is attributable to health professionals
not responding to parental concern (Prendergast, Lartz, & Fiedler, 2002). In
China, the use of a five-item questionnaire was explored as a screening technique
among parents of 6- to 8-month-old infants, and it had varying degrees
of success (Newton, Liu, Ke, Xu, & Bamford, 1999). Though simple and inexpensive
to administer, the questionnaire was unreliable in detecting slight
386 Olusanya

or unilateral hearing loss because it relied solely on parental observation. The
effects of these types of hearing losses may be subtle enough that parents are
not alerted easily to their presence. The use of risk factors to identify children
with hearing loss has been attempted in some countries (Ali, Khan, Baloch, &
Aziz, 2004; D’Mello, 1995; Maisoun & Zakzouk, 2003), but up to 50% of
children with hearing loss were undetected by this method, and the presence
of some risk factors was difficult to elicit reliably. Thus, sole reliance on
parental observation or high-risk screening is inefficient and not advisable.
An ideal screening test should be simple to apply, safe and valid. The test
is valid if it is highly sensitive (i.e., it detects the majority of babies with
hearing loss) and highly specific (i.e., it excludes most babies without hearing
loss). Otoacoustic Emissions (OAE) and Automated Auditory Brainstem Response
(AABR) are the only two objective tests currently that satisfy these
criteria with documented sensitivity and specificity in excess of 90%, especially
when combined into a two-stage screening protocol (Davis et al., 1997;
Hall, Smith, & Popelka, 2004; Kennedy, Kimm, Thornton, & Davis, 2000; Mehl
& Thomson, 2002; Vohr et al., 2001a). They are used presently, in various pilot
newborn hearing screening programs in developing countries (Attias et al.,
2006; Bener, ElHakeem, & Abdulhadi, 2005; Chapchap & Segre, 2001; Habib
& Abdelgaffar, 2005; Khandekar, Khabori, Mohammed, & Gupta, 2006; Lin,
Huang, Lin, Lin, & Wu, 2004; Low, Pang, & Ho, 2005; Mathur & Dhawan,
2006; Mukari, Tan, & Abdullah, 2006; Ng, Hui, Lam, Goh, & Yeung, 2004;
Olusanya & Okolo, 2006a; Quintos, Isleta, Chiong, & Abes, 2003; Swanepoel,
Hugo, & Louw, 2006; Yee-Arellano, Leal-Garza, & Pauli-Muller, 2006). There
is no reason to expect that these tests will be unacceptable among mothers in
any infant hearing program because they are noninvasive, painless and quick
to administer. In the absence of objective screening measures, the age of
detection of PCEHL will remain unacceptably high (Canale et al., 2006; Gopal
et al., 2001; Harrison, Roush, & Wallace, 2003; Parving, 1999; Yoshinaga-Itano,
2004).
Treatment for PCEHL
The value of early detection is optimized if effective intervention exists and
is accessible to children identified with PCEHL. The time from birth to about
5 years of age is a critical or sensitive phase for the acquisition of speech and
language skills (Carney & Moeller, 1998), but optimal outcomes are best
achieved in the first year of life (Kennedy et al., 2006; Moeller, 2000; Yoshinaga-Itano
et al., 1998). The provision of amplification also is essential for
children with PCEHL in the developing world; however, amplification devices
are seldom prescribed for children earlier than 2 years of age because of
late detection of PCEHL and because infants often are considered too young
to be fitted with these devices even when parents can afford to purchase
them. For these reasons, enrollment in schools for children with hearing loss
EHDI in Developing Countries 387

still constitutes the predominant intervention option for parents. Often, such
enrollment is delayed until age 10 because of late diagnosis and parental
preference for auditory-based intervention, which physicians rarely offer
(Olusanya et al., 2005b). Even when enrollment into schools for children with
hearing loss occurs at much earlier ages, reading and comprehension abilities
are about 50-60% of the children’s chronological age by the time they leave
school, which is typically at age 18. A survey among hearing parents in
Nigeria indicated that they, like parents in other countries, want their children
with hearing loss to be aided promptly so they can acquire spoken
language–feelings similar to parents in other countries (Luterman & Kurtzer-
White, 1999; Olusanya et al., 2005b; Russ et al., 2004; Young & Tattersall,
2007).
Recognizing the constraints of many developing countries to provide relevant
intervention services due to knowledge gap and scarcity, the WHO has
published guidelines for manufacturing affordable hearing aids, delivery of
audiological services and personnel training to encourage auditory-based
intervention services (Kumar, 2001; WHO, 2004). In addition, low-cost and
solar-powered hearing aids currently are being manufactured in developing
countries to encourage wider use (Parving & Christensen, 2004). It is not
unusual for appropriate early intervention services to be in short supply in
developed countries, a situation that relevant professional associations and
stakeholders in those countries seek to address (JCIH, 2000; Uus, Bamford,
Young, & McCracken, 2005). Anecdotal evidence suggests that as infant hearing
screening programs become established and the health care system increasingly
tasked by unmet patients’ demands, further public and/or private
sector initiatives will emerge towards the development of relevant services to
satisfy growing needs.
Benefits Versus Risks of Screening
Apart from the specific benefits already documented for developed countries,
infant hearing screening programs empower parents to make informed
and timely choices that offer their children the best start in life (Glover, 2003;
Russ et al., 2004; Young & Tattersall, 2007). Additional benefits as they relate
to developing countries have been discussed in greater detail elsewhere (Olusanya,
Luxon, & Wirz, 2004). From a societal standpoint, UNHS has been
associated with significant cost savings in health expenditures in developed
countries (Schroeder et al., 2006), and this also is likely to be applicable to
developing countries.
The emotional/psychological effects of false-positives are the principal adverse
consequences thought to be associated with UNHS (Hewlett & Waisbren,
2006; Vohr, Letourneau, & McDermott, 2001; Watkin, Baldwin, Dixon,
& Beckman, 1998). However, many surveys of parents have shown that only
a few have anxiety about infant hearing screening and that anxiety levels
388 Olusanya

were usually higher when babies were scheduled for rescreening (Vohr et al.,
2001b; Weichbold & Welzl-Mueller, 2001). In fact, maternal anxiety following
positive screening outcomes can be moderated markedly by effective communication
to parents that a referral for subsequent screening test(s) is not by
itself a confirmation of hearing loss (Crockett, Wright, Uus, Bamford, & Marteau,
2006; Hewlett & Waisbren, 2006; Stuart, Moretz, & Yang, 2000).
Maternal anxiety and stress are equally associated with true-positives, but
these effects may not necessarily be considered as adverse consequences of
screening because they are inevitable even without screening. False-negative
screening results give false assurance to parents and health professionals and
delay diagnosis. Similarly, infant hearing screening could miss some children
with PCEHL that is progressive or is delayed-onset, giving parents a false
sense of assurance.
The paucity of high-quality, randomized controlled studies on the benefits
and the potential psychological effects of UNHS remains a continuing global
challenge (Thompson et al., 2001), but as demonstrated in the many countries
where UNHS is offered routinely, the majority of parents feel the benefits of
early detection and intervention through infant hearing screening far outweigh
these potential adverse outcomes (Clemens, Davis, & Bailey, 2000;
Davis et al., 1997; Hergils & Hergils, 2000; Luterman & Kurtzer-White, 1999;
Stuart, Moretz & Yang, 2000; Weichbold & Welzl-Mueller, 2001).
Moreover, the value of knowing about a “hidden” disability that, inevitably,
will become apparent at a later stage when the prospects for optimal or
effective intervention have diminished significantly is unquantifiable, especially
for parents in some traditional communities who would otherwise seek
unorthodox and sometimes potentially harmful treatments for the symptoms
of hearing loss (Andrade & Ross, 2005; Odebiyi & Togonu-Bickersteth, 1987).
In fact, parents often are angry and distraught when health care workers
delay providing vital information on their child’s health status (Glover, 2003;
Magnuson & Hergils, 2000; Russ et al., 2004). Thus, available scientific evidence
clearly demonstrates that screening infants for PCEHL is most likely to
be a worthwhile public health care service for developing countries.
Ethical Considerations
Universal screening is usually offered to people who have not sought medical
attention on account of the symptoms of a disorder. When a condition is
“hidden” or “invisible” and has no major adverse and visible consequences,
it may be difficult to justify the need for screening, especially when intervention
services for those with the condition are limited. However, the adverse
effects of PCEHL are inevitable and likely to become apparent at a time when
intervention is, at the very best, suboptimal. Therefore, it can be argued that
it is unethical to withhold screening for a condition that will manifest itself
eventually with adverse consequences, regardless of the availability of services
to deal adequately with the problem. Nonetheless, screening for such a
EHDI in Developing Countries 389

condition must still satisfy the basic ethical principles of autonomy (the right
to choose), non-maleficence (obligation to avoid causing harm), beneficence
(obligation to provide benefits and to balance benefits against risks) and
justice (obligation of fairness in the distribution of benefits and risks) (Olusanya,
Luxon, & Wirz, 2006a).
Parental Autonomy
Parents must be educated sufficiently on the benefits and potential adverse
effects of the screening process, and their consent must be obtained before
conducting the screening. Every pregnant mother expects to give birth to a
healthy baby and leave the birthing center with the assurance that her apparently
well child has every chance to thrive and develop optimally. Parental
consent for screening, therefore, can be obtained readily if it is presented
as a routine neonatal examination that is painless, noninvasive and can be
quickly administered prior to hospital discharge.
The health professional must handle the screening process with sensitivity
because the arrival of a newborn is both a joyous and an emotion-laden event
for the parents and the entire family. Parental reaction to the disclosure of
PCEHL is likely to be one of shock, denial, grief, anger and depression (Hedderly,
Baird, & McConachie, 2003; Kurtzer-White & Luterman, 2003) and may
be compounded by unfavorable or superstitious beliefs toward congenital
disabilities in some traditional communities, which could undermine the effectiveness
of the intervention process (Byford & Veenstra, 2004; Kiyanga &
Moores, 2003; Stephens, Stephens, & Eisenhart-Rothe, 2000). The most opportune
time to begin discussing the importance of screening with parents, therefore,
is probably during maternal and child health clinics, particularly before
delivery (Arnold et al., 2006).
Benefits Versus Harms of Screening
Balancing the benefits of screening against its potential adverse effects is
also an ethical issue because of the inherent limitations of a screening test. The
risks of false assurance that a child has no hearing loss or of unnecessary
anxiety for a child falsely detected with hearing loss as previously mentioned
must not be ignored. The latter is of greater concern for service providers
because it places unnecessary burden on the limited resources. Practical ways
of minimizing these risks include delaying screening beyond 48 hours after
birth to eliminate the effect of vernix plugs, conducting a two-stage screening
with OAE and ABR and minimizing the effect of ambient noise during
screening, which could be a daunting challenge for hospitals located in noisy
environments (Hall, Smith, & Popelka, 2004; Headley, Campbell, & Gravel,
2000; Jacobson & Jacobson, 1994; Kennedy et al., 2000; Maxon, White, Culpepper,
& Vohr, 1997). From an ethical standpoint, these potential adverse
390 Olusanya

Table 2. World Bank Classification of Countries by Income Levels*
Income Group (GNI
Per Capita)
effects or challenges are insignificant when compared with the many benefits
of infant hearing screening in developing countries (Olusanya et al., 2006a).
Distributive Justice
Number of
Countries Partial Listing of Countries
Low income (US$10,725)
Ghana
54 Brazil, Cuba, Indonesia,
Philippines, Syria,
Jordan, Thailand, China
33 Argentina, Botswana,
South Africa, Mexico,
Malaysia
15 Brunei, Pueto Rico, Saudi
Arabia, Kuwait, Qatar,
United Kingdom,
United States
Note. GNI, gross national income. *The World Bank (2006).
Degree of Need for
External Support
Substantial
Some
Minimal
None
The requirement for distributive justice in the use of scarce resources is a
significant consideration for many low- and middle-income countries but is
less so for high-income countries in the developing world (see Table 2). A
simple generalization of the individual capacities of developing countries to
afford EHDI services is fundamentally inappropriate. Some developing countries
in the middle- or high-income group are in a position to implement a
publicly funded EHDI comparable to or approximating the standards of programs
in developed countries. Distributive justice requires the identification
and recognition of best practices in public health care to guide health professionals,
regardless of the economic status of each country. Distributive justice
also requires equity of access to essential health care, especially among the
potential beneficiaries (Landman & Henley, 1999). On a global level, distributive
justice would suggest that EHDI be implemented in developing countries,
which account for 90% of children with PCEHL, especially because
EHDI programs have been considered vital in the developed world, which
accounts for only 10% of children with PCEHL.
Against this backdrop, the implementation of EHDI in developing countries
is ethically justified to warrant the systematic and widespread introduction
and development of relevant services.
EHDI in Developing Countries 391

Figure 1. How health expenditures are financed globally.
Economic Considerations
A major reservation regarding the introduction of EHDI relates to whether
governments in developing countries can afford these services as part of basic
public health care. This concern often emanates from the perspective in developed
countries in which EHDI services are publicly funded and offered at
minimal or no charge to consumers. There are striking disparities in global
spending patterns for health care services between low/middle-income and
high-income countries that should not be overlooked, as shown in Table 2
and Figure 1 (Gottret & Schieber, 2006). For instance, the public share of total
health expenditures ranges from 65% in high-income countries to 29% in
low-income countries, with private expenditure accounting for the balance. A
common and significant feature in developing countries is that user fees are
charged for most services (including medications) at all levels of health care
delivery. Although such fees are associated more with private providers of
health services, they are not uncommon among public health institutions in
many countries. As a result, out-of-pocket spending in low-income countries
accounts for 66% of total health expenditure (or about 93% of private expenditure)
compared with 20% of total health expenditure (or about 56% of
private expenditure) in high-income countries (see Figure 1). Foreign loans
and grants from multilateral institutions like the World Bank and charitable
contributions from various donor agencies often augment government spending,
but altogether these external sources rarely account for more than 10% of
392 Olusanya

total public expenditure (Gottret & Schieber, 2006). The implication of this
spending pattern is that the introduction of any public health intervention
cannot be solely predicated on the capacity of the government to provide
needed services.
In any country, PCEHL exists among children in all socioeconomic classes.
Just as income varies widely among nations so, too, do individual capacities
within and across communities. Even in low-income countries, there will
always be some individuals who can afford the services for themselves and/
or to help others. In many communities, therefore, the disposable income
available to individuals is the sum of their own resources plus those that may
become available to them from other benevolent individuals who are moved
by the special health needs of others. Besides, the manner in which individuals
choose to prioritize their spending often is unpredictable and complex. For
instance, some communities may consider socially stigmatized diseases more
important and well-deserving of communal support than nonstigmatized
diseases, even if they are less prevalent (Kapiriri & Norheim, 2002), and are
likely to place higher premium on the needs of children than those of adults
(Landman & Henley, 1999).
Given the financial constraints faced by most governments, it is, perhaps,
more plausible for governments to facilitate public-private partnerships for
pilot studies, create public awareness, and set standards for best practices.
Public-private partnerships for EHDI are likely to be more successful if they
are preceded by the inclusion of goals for early childhood development in
general, and early hearing detection in particular, in the national health policy
(The Government of Brazil, 2006; Federal Republic of Nigeria, 2005; Nascimento
et al., 2006; Olusanya et al., 2005a). Governments also can play an
essential role in ensuring that training curricula for health professionals provide
updated skills for the broad spectrum of prevailing health care needs
and are not just limited to fatal childhood diseases. As countries contemplate
national or community-based health insurance schemes (Gottret & Schieber,
2006), it should be possible also to explore the inclusion of EHDI services in
a few countries such as Brazil and South Africa (Swanepoel, 2006).
Current Global Impetus for EHDI
It is very common for governments in developing countries to tailor their
national health programs to the policies and priorities of major multilateral
agencies of the United Nations such as WHO, UNICEF, the World Bank and
the United Nations Educational, Scientific and Cultural Organization
(UNESCO). In addition, many governments depend on expert advice and
technical inputs from these organizations in constructing their national health
and educational policies. This practice often assures the inflow of external
financing for national programs. For these reasons, it is essential to establish
a link for EHDI within the current global agendas of these institutions.
EHDI in Developing Countries 393

The World Health Assembly (WHA), which is comprised of the health
ministers of United Nations member states, is responsible for setting the
policies of the WHO to reflect the health care preferences of its members. In
1995, the WHA passed a resolution regarding the prevention and control of
major causes of avoidable hearing loss and the “early detection in babies,
toddlers, and children, as well as in the elderly, within the framework of
primary health care” (WHO, 1995 [p. 1]). This resolution was passed within
the context of the WHO’s definition of health, which seeks to promote physical,
mental and social well-being and not merely amelioration of disease. The
resolution addressed the growing problem of disabling (>40 dB HL) hearing
loss and its adverse consequences for language acquisition, optimal childhood
development and educational achievement. Among other issues, the
resolution recognized the need for early hearing detection but did not recommend
how to achieve this goal. This omission was not unexpected, considering
the keen debate in the United States that was occurring around this
period on the most appropriate and effective strategy for EHDI (Bess &
Paradise, 1994). The resolution also outlined specific roles for United Nations
member states and the WHO while encouraging public-private partnerships
to address this problem.
In 2005, a decade after another resolution relevant to the management of
hearing loss was passed by the WHA on disability management and rehabilitation
(WHO, 2005). Similarly, this resolution urged collaborative action
by the WHO and United Nations member states to reduce risk factors contributing
to disabilities during pregnancy and childhood. The resolution also
encouraged the early identification and intervention for disabilities, especially
during pregnancy and childhood, including family counseling, access
to appropriate assistive technology and community-based rehabilitation programs.
UNICEF is the United Nations’ agency responsible for the well-being of the
world’s children. One of its five cardinal priorities is the promotion of optimal
early childhood development because the organization believes that giving a
child the best start in life lays the foundation for learning and school achievement.
The organization has recently expressed interest for the needs of children
who have been “excluded and made invisible” by hearing loss and other
disabilities and should therefore be supportive of national efforts to help
these children in their early crucial years for optimal development such as
early hearing detection and intervention (UNICEF, 2005).
UNESCO provides for an Early Childhood Care and Education (ECCE)
initiative under its Education For All (EFA) program launched and adopted
by 164 countries in 2000 (UNESCO, 2006). The ECCE is aimed at supporting
children’s survival, growth, development and learning from birth to entry
into primary school, especially for the most vulnerable and disadvantaged
children. It recognizes that early childhood is a time of remarkable brain
development that lays the foundation for later learning. It also asserts that it
394 Olusanya

is more cost effective to institute preventive measures and support for children
early on than to compensate for the disadvantage as they grow older
(UNESCO, 2006). EHDI is therefore consistent with the ECCE priority.
In addition, the ongoing United Nations’ millennium development project,
based on a collective declaration by 189 member countries in 2000, constitutes
the global agenda for the mobilization and prioritization of resources to the
developing world till year 2015 (United Nations, 2005). The first two of eight
millennium development goals (MDGs) are focused on the eradication of
extreme poverty and the completion of full course of primary education by
children everywhere. It has been demonstrated that failure to detect and
manage PCEHL through UNHS in developing countries will significantly
undermine the realization of these two goals (Olusanya et al., 2006a).
These major global initiatives provide valuable platforms and impetus for
the promotion of EHDI in the developing world. Failure to extend UNHS to
developing countries in particular may undermine optimal early childhood
development and exacerbate the already vast health inequality between developed
and developing nations. In fact, it is now widely acknowledged
(inclusive of the World Bank) that an investment in early childhood, which
embraces EHDI, offers significant long-term returns for national development
(Young, 2007). These considerations have also prompted recent efforts to
redress the exclusion of childhood hearing loss and adult hearing loss of
childhood onset in the current global disease control priorities of the World
Bank for developing countries (Jamison et al., 2006; Olusanya & Newton, in
press).
Options for Early Hearing Detection in
Developing Countries
Current pilot infant hearing screening programs in developing countries
are either hospital- or community based. The rationale behind each model,
protocols for implementing screening, possible challenges and highlights
from current programs in developing countries are examined in this section.
Rationale
Hospital-Based Screening
Screening babies in hospitals before discharge is desirable for at least two
primary reasons. First, screening eliminates the need to ask mothers to return
specifically to have their babies tested. Parents are likely to be less enthusiastic
to seek detection of an invisible and non-life-threatening handicap in
their apparently normal babies. Taking an apparently well child to the hospital
for any “check-up” is viewed as socially and culturally inappropriate in
many communities because of the notion that hospitals are established only
to serve the sick. Second, screening helps health care professionals to satisfy
EHDI in Developing Countries 395

an important ethical obligation of ensuring that babies have been examined
and tested for hidden, detectable abnormalities before discharge.
Screening Protocols
A common protocol is a two-stage screening, first with Transient-Evoked
Otoacoustic Emissions (TEOAE) followed by AABR for children referred
from the first-stage (i.e., TEOAE) screen. This protocol often is associated with
minimal false-positive rates (specificity >90%) without significant reduction
in sensitivity (Hall et al., 2004; Kennedy et al., 2000). Most screening instruments
are simple to use, allowing a person without prior audiological expertise
to conduct the screening after a brief period of training.
Although nurses are skilled in securing informed parental consent before
screening and may be members of the screening team for this purpose, adding
this responsibility to the nurses’ workload could be counterproductive. In
many settings, nurses are likely to view this task as being less important than
other routine clinical duties. Where mothers are commonly to be discharged
within 48 hours, screening often is recommended as close to discharge as
possible to minimize false referral due to vernix plugs in the baby’s ears.
Possible Challenges
Given the low prevalence rates for congenital hearing loss, the majority of
babies are expected to pass the first-stage screen. Finding a suitable section
within the hospital ward is necessary to minimize false referral rates where
the ambient noise levels are excessive. This could a major challenge for hospitals
with severe space constraints. When the number of babies awaiting
screening is large, some mothers may be too impatient to wait and may never
return. In addition, babies who are unsettled because their mothers have not
established lactation would be difficult to test within the short time available
for screening in “baby-friendly hospitals,” where exclusive breast feeding is
promoted routinely.
Moreover, as shown in Figure 2 (UNICEF, 2005; WHO, 2006b) a significant
proportion of births occur outside regular hospitals in many developing
countries. For instance, in South Asia the proportion of births with skilled
attendants (a proxy for hospital deliveries) varies from as low as 13% in
Bangladesh to 43% in India (compared with about 99% in developed countries).
Consequently, many babies in these regions will be missed by hospitalbased
UNHS programs. The obvious challenge then is to locate where the
majority of babies are born within these communities and establish effective
ways of attracting parents for hearing screening services.
Progress Reports from Current Projects
Hospital-based UNHS pilot projects have been implemented in Nigeria,
South Africa, India, Pakistan, Saudi Arabia, Iran, Qatar, Jordan, Oman, China,
Hong Kong, Taiwan, Malaysia, Philippines, Singapore, Brazil and Mexico
396 Olusanya

Figure 2. Proportion of births in hospital facilities (1996-2004). Based on data from
UNICEF (2005) and WHO (2006b).
(see Table 3). One of the oldest projects was started in a private hospital in
Brazil in 1988 and has expanded to more than 230 sites nationwide (Chapchap
& Segre, 2001). It is possibly one of the most organized and successful UNHS
programs at present in the developing world.
Based on available reports, the number of babies screened has varied from
406 in the Philippines to 36,095 in four hospitals in Singapore. The duration
of the reported data ranges from five months in Nigeria, South Africa and
Hong Kong to 60 months in China. It is pertinent to mention that these pilot
programs still are ongoing in most (if not all) of these countries.
Reports from these countries confirm that hospital-based UNHS is feasible.
The attitudes of parents and health care professionals generally were favorable;
however, some challenges remain unresolved. For instance, high default
rates for follow-up services are common and require effective data management
and tracking systems. Most programs were initiated and entirely managed
by health professionals in hospitals with little or no government
funding. Some have been made possible through equipment donations or
loans from manufacturers, supplemented by financial support from local
non-governmental organizations. Most of these countries have no free national
health care service or publicly administered health insurance schemes;
thus, only parents who can afford to pay seek these services. In the Nigerian
project parents currently are not required to pay for services, including hearing
aids. In other countries, parents pay for hearing aids if required, sometimes
at highly subsidized rates. Data on screening costs per baby still are
EHDI in Developing Countries 397

Table 3. Pilot Programs on Infant Hearing Screening in Developing Countries
Country (Reference) Year Started (Location) Setting/ Coverage Protocol Total Screened (Duration)
398 Olusanya
Nigeria (Olusanya & Okolo, 2006) 2005 (Lagos) Hospital, MCC: UNHS OAE, AABR 1,132** (5 months)
South Africa (Swanepoel et al., 2006) 2003 (Pretoria) Hospital, MCC: UNHS OAE 510* (5 months)
India (http://healthlibrary.com) 2003 (Kochi) Hospital: TNHS OAE 2,500* (N/A)
Pakistan (Ali et al., 2000) 1999 (Lahore) Hospital: UNHS OAE 756* (N/A)
Saudi Arabia (Habib & Abdelgaffar, 1996 (Jeddah) Hospital: UNHS OAE 11,986*(96 months)
2005)
Iran (Grandori & Hayes, 2006; Masoud 2002 (Tehran, Mashad) Hospital: UNHS OAE 16,000+** (6 months)
et al., 2006)
Qatar (Bener et al., 2005) 2003 (Doha) Hospital: UNHS OAE 2,800* (11 months)
Jordan (Attias et al., 2006) 2001 (multiple cities) Hospital, MCC: UNHS OAE 8,251** (N/A)
Oman (Khandekar et al., 2006) 2003 (multiple cities) Hospital, MCC: UNHS OAE, AABR 21,387** (12 months)
China (Grandori & Hayes, 2006; Xu 2000 (Nanjing) Hospital: UNHS OAE, AABR 8,800* (60 months)
et al., 2006)
Hong Kong (Ng et al., 2004) 1998 (Hong Kong) Hospital: UNHS OAE, AABR 1,064* (5 months)
Taiwan (Lin et al., 2002) 1998 (Taipei) Hospital: UNHS OAE, AABR 6,765* (24 months)
Malaysia (Mukari et al., 2006) 2000 (Kuala Lumpur) Hospital: UNHS OAE 4,437* (11 months)
Philippines (Quintos et al., 2003) 2000 (Manila) Hospital: UNHS OAE 406* (12 months)
Singapore (Low et al., 2005) 2002 (Singapore) Hospital: UNHS OAE, AABR 36,095** (24 months)
Brazil (Chapchap & Segre, 2001) 1996 (Sao Paulo) Hospital: UNHS OAE 4,196* (36 months)
Mexico (Yee-Arellano et al., 2006) 2005 (Mexico City) Hospital: TNHS, UNHS OAE, AABR 3,066* (24 months)
Note. Abbreviations: MCC, maternal and child health clinic; UNHS, universal newborn hearing screening; OAE, Otoacoustic Emissions; AABR,
automated Auditory Brainstem Response; TNHS, targeted newborn hearing screening; N/A, not available.
*Screening results from one site only.
**Screening results from more than one site.

scant, although they are likely to vary from country to country, depending on
the screening protocol adopted. Generally, screening instruments and associated
consumables remain expensive, but the costs could be reduced significantly
through bulk purchasing among many screening sites. Future product
development by manufacturers may eliminate or minimize expensive consumables,
and donors may be able to provide screening instruments at a
reduced cost. Shortages of relevant manpower and facilities for diagnostic
evaluation as well as poor public awareness also have been cited in some
countries. These issues can be addressed through systematic and ongoing
human capacity building and parent and health professional education. Hospital-based
UNHS programs should be effective in detecting the majority of
babies with congenital hearing loss, as in Latin American countries where a
significant proportion of births occur in hospitals (UNICEF, 2005) (see Figure
2). However, a complementary program would be required in communities
with low rates of hospital-based deliveries.
Community-Based Screening
Rationale
In many developing countries, home births and deliveries at private maternity
homes run by birth attendants account for the majority of babies born
outside of hospitals (WHO, 2006b). The rest are delivered in health facilities
within church premises or before arrival at hospitals. Contemplating newborn
hearing screening programs at these various locations is a logistical
challenge; however, the experiences in most of these countries show that
mothers from all birthing locations take their babies to immunization clinics
at designated community health centers. Routine childhood immunization is
perhaps the most well-established public health program globally due to the
substantial technical and financial support received yearly from UNICEF, the
WHO and several donor agencies and partners. Its popularity is derived from
its preventive value for most fatal childhood diseases and because it is offered
free to parents. Consequently, immunization clinics have been used as platforms
for delivering new child health intervention packages, especially in the
developing world (WHO, 2002). They provide a ready framework for introducing
infant hearing screening (Olusanya et al., 2004). Community-based
screening, however, is not limited to immunization clinics and may be implemented
during infant welfare clinics (Bantock & Croxson, 1998; Kapil, 2002;
Lin et al., 2004; McPherson, Kei, Smyth, Latham, & Loscher, 1998). In addition,
community-based screening can be considered as a complement where
there is a high rate of babies missed due to early discharge or the inability of
the screening personnel to cope with the high birth rates in some public
hospitals in heavily populated areas (Mathur & Dhawan, 2006). Conducting
screening in infants’ homes, as has been reported in some developed
countries, is not a practicable option in developing countries because of the
EHDI in Developing Countries 399

Table 4. Typical National Immunization Schedule for Infants in Developing
Countries
enormous logistical challenges associated with this strategy (Oudesluys-
Murphy & Harlaar, 1997; Owen, Webb, & Evans, 2001).
Service Delivery
Reports from the developed world suggest that favorable outcomes still
may be achieved if hearing loss is detected within the first year of life
(Kennedy et al., 2006; Moeller, 2000). A typical national immunization schedule
for developing countries offers a number of options within the first year
of life for infant hearing screening (see Table 4). Bacille Calmette-Guérin
(BCG) immunization often records the highest uptake of all the vaccinations
administered in the first year in many developing countries (UNICEF, 2005).
However, the age at which babies are presented for various immunizations
varies widely within and across communities. For instance, the age at presentation
for BCG immunization in Nigeria typically ranges from 1 to 136
days (75 th percentile, 24 days; 95 th percentile, 61 days) (Olusanya & Okolo,
2006a). A similar variation has been reported in South Africa for the first
diphtheria-pertussis-tetanus (DPT) immunization at 6 weeks (Swanepoel et
al., 2006). This variation in age and timing has the advantage of facilitating
early detection for a significant number of infants with progressive or delayed-onset
congenital hearing loss and those from acquired causes that
would have been missed under hospital-based UNHS. These categories of
hearing loss commonly are associated with prevailing adverse perinatal conditions
in many developing countries (Olusanya & Okolo, 2006b). In addition,
this platform provides the chance to screen sick babies (now recovered) who
could not be tested or immunized during admission.
Possible Challenges
Recommended Age
Vaccine Birth 6 Weeks 10 Weeks 14 Weeks 9 Months
Bacille Calmette-Guérin (BCG) x
Oral polio* x x x x
Diphtheria-pertussis-tetanus (DPT) x x x
Hepatitis B* x x x
Haemophilus influenzae type b* x x x
Yellow fever* x
Measles x
Note. From World Health Organization (2002).
*Not provided in or applicable to all countries.
Difficulties may arise when routine immunization programs are interrupted
because of vaccine shortages or other extraneous reasons. For instance,
400 Olusanya

a widely reported controversy concerning polio vaccination in some Nigerian
states would have disrupted any adjunct programs, including infant hearing
screening (Fleck, 2004; Mitka, 2004; Renne, 2006). Despite the possibility of
program disruptions, the experiences in many countries strongly suggest that
routine immunization programs are still the most effective platform for integrated
child health intervention globally. Another major challenge arises
when screening cannot be completed and babies require follow-up visits in
addition to scheduled immunization clinics. It may be useful in this situation
to ascertain likely difficulties the affected parents may encounter in keeping
follow-up appointments and then to offer appropriate support, such as compensation
or reimbursement for transportation fares. Moreover, a registry of
babies with incomplete screening tests may be maintained at subsequent
immunization clinics for tracking purposes.
Progress Reports from Current Projects
Preliminary results from two pilot programs in South Africa and Nigeria
confirm that infant hearing screening at immunization clinics is feasible and
worthwhile in developing countries, although more reports are needed from
other regions because screening protocols may differ from country to country
(see Table 3). For instance, the screening program in South Africa used a
protocol consisting of a first-stage distortion product OAE and a highfrequency
probe tone (1 kHz) tympanometry for infants ages birth to 12
months. A planned second-stage screen with AABR was discontinued because
of practical difficulties with administering the test (Swanepoel et al.,
2006). Rather, the first-stage protocol was repeated for subsequent stages.
Only 40% of those scheduled for the second-stage screen returned, possibly
due to the timing of follow-up visits outside a routine immunization schedule.
In contrast, a two-stage protocol with an initial TEOAE screen at BCG
immunization clinics was used in the program in Nigeria. Those referred
from the first-stage screen were scheduled for a second-stage screen with
AABR within a week. The uptake for the second-stage screen improved from
50% at the initial stages of the program to 75% subsequently. Babies older
than 3 months often were difficult to test with this screening protocol; thus,
it was necessary to exclude them from the two-stage screening, which reduced
coverage to 83% of babies attending the BCG clinics. Although the
default rates from South Africa and some other developing countries are
high, they are comparable to reported rates in the early stages of most UNHS
programs in the developed world (Korres, Balatsouras, Nikolopoulos, Korres,
& Ferekidis, 2006; Mehl & Thomson, 2002). Effective data management and a
comprehensive tracking system are vital to minimizing avoidable loss to
follow-up.
Additional details on the progress towards early hearing detection in developing
countries based on a collaborative, transnational survey have been
described elsewhere (Olusanya et al., 2007).
EHDI in Developing Countries 401

Scope and Status of Intervention
Perhaps the foremost benefit of infant hearing screening is the timely
knowledge it provides for parents who otherwise may experience a wide
range of emotions and seek ineffective solutions as they begin to suspect their
children’s atypical response or lack of response to sound. This is quite typical
in many communities in developing countries where superstitious beliefs and
recourse to unorthodox practices are prevalent (Andrade & Ross, 2005; Byford
& Veenstra, 2004; Kiyanga & Moores, 2003; Odebiyi & Togonu-
Bickersteth, 1987; Stephens et al., 2000). Children with PCEHL are capable of
learning and acquiring spoken language like their peers with normal hearing.
Current technological advances not only facilitate prompt and accurate detection,
but also offer children with PCEHL the opportunity to develop spoken
language. Because the majority of parents use spoken language and lack
interest in any other form of communication, there are major incentives for
parents to seek appropriate help for their children as early as possible when
the most benefit can be provided. Evidence on the status of intervention
services following early hearing detection is scanty because such services are
offered predominantly by private providers who often are reluctant to provide
information on their services for research purposes (Madriz, 2000; Russo,
2000). The target of intervention services is not necessarily to provide the
entire range of options currently offered in developed countries (Gabbard &
Schryer, 2003; Gravel & O’Gara, 2003) but to focus on functionality, affordability
and what is culturally appropriate within an ethical framework (Flett
& Stoffell, 2003). For instance, in Brazil, improved interactions between children
with hearing loss and their families were reported following a specialized
speech and hearing intervention program comprising speech therapy,
sign language and oral language workshops for the children; sign language
workshops for hearing parents; and a parent support group (Grandori &
Hayes, 2006). In addition, the use and effectiveness of “experience books” in
monitoring progress of infants enrolled in early intervention programs from
babbling to first words and language comprehension have been reported also
in Brazil (Novaes, Mendes, & Figueiredo, 2006). In general, the communication
options currently available to parents can be considered under two broad
categories: auditory based and nonauditory based.
Auditory-Based Communication
The term “auditory based” includes the development of spoken language
through the use of hearing devices to facilitate full integration of the child into
mainstream society. It does not preclude the use of speechreading, facial
expressions and naturally occurring gestures.
The first hurdle in this approach is parental acceptance of hearing aids for
402 Olusanya

their babies at such an early age because hearing aids are associated more
commonly with elderly people. The issue of cosmetic acceptability is then
likely to follow (Furuta & Yoshino, 1998; Mutton & Peacock, 2005). Behindthe-ear
hearing aids publicly announce an invisible disability in a baby, which
could be culturally embarrassing to parents and cause them great stress in
responding to inquiries from neighbors and friends about these “strange”
devices in an apparently normal child. During the initial stages, some parents
may be vulnerable to the not uncommon misconception that hearing aids are
not necessary because the child will outgrow the disability. Some even may
be offered unorthodox therapies, such as medicinal plants and animal fat to
treat the “hearing ailment” (Andrade & Ross, 2005; Kale, 1995; Odebiyi &
Togonu-Bickersteth, 1987).
The cost of hearing aids, ear molds, batteries, drying capsules and repairs
is another important consideration. In some countries, such as Brazil, Mauritius
and South Africa, hearing aids are provided free or subsidized in public
hospitals. However, the quality of hearing aids provided is limited to the
most basic models and there are always long waiting lists of eligible patients
of all ages, although preferences may be given to infants and young children
(Swanepoel, 2006).
Many of these factors apply to an even greater extent to the use of cochlear
implants and influence the parents’ decision-making process (Lynas, 2005;
Munoz-Baell & Ruiz, 2000). It is not uncommon to find that even after making
an informed and appropriate choice, parents still seek more time to adjust to
the new reality and it is always prudent not to pressure them to immediately
follow up on their choices.
A great motivation for parents often comes from the assurance and evidence
that all the efforts involved in supporting the child are worthwhile.
Testimonials of other parents with successful experiences are valuable and
just as powerful as the displeasure of unsatisfied parents to prospective parents,
which is perhaps the greatest challenge for service providers in developing
countries. Parents would make any necessary financial sacrifice in
anticipation of visible progress in speech and language development; however,
the challenge for the interventionist is securing the ongoing parental
participation crucial to achieving satisfactory language outcome that is commensurate
with the quality of the services provided.
A further challenge is the multilingual settings in many developing countries
where most families have a second national language along with an
ethnic or tribal language. The language used in the home environment may
be different from that used by the interventionist or in the educational setting.
This may present difficulties for the interventionist and ultimately undermine
the efficacy on Auditory-Verbal intervention programs if not well managed
(Gupta, & Chandler, 1993; Penn, 1998).
Support from primary care physicians, nurses and ancillary health workers
EHDI in Developing Countries 403

is essential for the prompt enrollment and retention of children in familyoriented
intervention programs because they are usually the first to be contacted
by parents about health-related concerns. However, this group of
workers requires appropriate education on the range of current possibilities
with EHDI in order to provide well-informed counsel to parents. Such training
also should help them recognize and acknowledge the limits of their
competencies and professional experience and refer parents for appropriate
and timely intervention services within the context of the multidisciplinary
participation required for optimum outcomes. The use of nonspecialists during
an acute shortage of qualified professionals is necessary but should be
limited to providing basic support and referral services (Shrestha, Baral, &
Weir, 2001; Wirz & Lichtig, 1998).
In an attempt to address some of these issues, the WHO (2004) developed
guidelines on hearing aids and hearing services in developing countries. This
initiative includes efforts aimed at providing affordable hearing aids and
services and setting up services for delivery, fitting, follow-up, repair and
training. Recognizing that less than 10% of hearing aids manufactured worldwide
and that only 750,000 of the estimated 32 million hearing aids needed
annually reach developing countries, a global partnership called “WWHearing
— Worldwide Hearing Care for Developing Countries” —has been inaugurated
to address the complex task of providing sufficient quantities of
affordable hearing aids and services for developing countries (WHO, 2006).
This group comprises key stakeholders, such as policymakers, service providers,
trainers and users in developing countries; major donors; and expert
advisers across relevant professional disciplines. Already, low-cost, solarpowered
hearing aids increasingly are being made available (Parving &
Christensen, 2004), usually at less than US$100 each but still far from the
WHO’s target price of US$40. Many groups like Godisa (based in Botswana),
Project IMPACT, Comcare, Hearing International and Christoffel-
Blindenmission are engaged actively in the task of achieving this target price
(McPherson & Brouillette, 2004).
The obvious concern is the trade-off between cost and functionality (Olusanya,
2004). Presently, most of the instruments and services being developed
are primarily for adult users, and these may have very limited use for the
pediatric population. Further research is needed on this age group. In contrast
to the progress made toward affordability and availability of hearing aids,
cochlear implantation is still beyond the reach of many communities in the
developing world, although notable progress is evident in a growing number
of countries (Belal, 1986; Berruecos, 2000; Farhadi, Daneshi, Emamjomeh, &
Hasanzadeh, 2000; Grandori & Hayes, 2006; Swanepoel, 2006; Zeng, 1995). As
the benefits of amplification become more established, the additional benefits
available from cochlear implantation also will become apparent.
Effective auditory-based intervention require more than the fitting of hearing
devices (Meadow-Orlans, Spencer, Koester, & Steinberg, 2004). It requires
404 Olusanya

active, ongoing, culturally appropriate collaboration between the intervention
specialists and the child’s family. Parents must be engaged to be active
participants in the intervention program and discouraged from shifting more
attention to siblings without special needs at the expense of the child with
hearing loss. However, the interventionists must be sensitive to parental emotions,
stress and grief as they adjust to the special and often unfamiliar needs
of an apparently healthy child. To be effective, early intervention must facilitate
developmentally appropriate language skills and enhance the family’s
understanding of its infant’s strengths and needs, build family support and
confidence in parenting the child and promote the family’s ability to advocate
for the child especially for suitable educational placement (JCIH, 2000). Unfortunately,
there are many institutional and cultural barriers to mainstreaming
in developing countries, but these are not insurmountable (Eleweke &
Rodda, 2000). Parents collectively can become catalysts for policy changes
through effective advocacy.
Another major challenge is the acute manpower shortages in many countries;
only few tertiary academic institutions offer audiology-related training
except for special education or ear, nose and throat surgery (Alberti, 1999;
Madriz, 2000; Russo, 2000; Swanepoel, 2006). In this vital area, governments
can play an effective role at minimizing cost by equipping educational institutions
to provide relevant and up-to-date training and promoting exchange
programs with overseas institutions in developed countries. The training
curricula for health professionals, interventionists and teachers need to be
adapted and enhanced appropriately. In addition, because primary care physicians
wield considerable influence over parental health-seeking behaviors,
it also is important to identify and address reasons for their ineffectiveness at
facilitating a prompt referral process for timely/appropriate intervention as
well as their poor adherence to EHDI guidelines for best practices (Moeller,
White, Shisler, 2006; Kemper, Uren, Moseley, Clark, 2006; Cabana, Rand,
Powe, Wu, Wilson, Abboud, Rubib, 1999). For example, as part of efforts to
accelerate training to increase the availability of relevant manpower and enhance
professional involvement, various nongovernmental cross-country initiatives
to provide Internet-based training are being developed by groups in
Nigeria and South Africa with support from nonprofit organizations in the
United States, Australia, the United Kingdom and Canada.
Similarly, free Internet-based training support for parents increasingly is
becoming more widely available from various hearing health-related organizations.
However, such Internet-based educational resources may be of limited
use in areas of developing countries where the literacy rates are low,
computer access limited and social infrastructures poorly developed. Nevertheless,
progress toward self-development through further learning and community
support for persons with special needs is evident in a growing
number of countries. Overall, prospects are still good for high-quality service
delivery for persons with hearing loss (Silverman & Moulton, 1997), and
EHDI in Developing Countries 405

international agencies and relevant professional associations can play a crucial
role in fostering the attainment of this goal more rapidly.
Nonauditory-Based Communication
The most common and oldest form of intervention for children with
PCEHL in developing countries is enrollment in schools for children with
hearing loss in which sign language is the predominant mode of communication.
Such enrollment often occurs as late as age 10 because parents are
reluctant to accept this mode of communication. The delay also has been
attributed to past failure in accessing auditory-based intervention. Thus, the
nonauditory-based communication option is fast becoming an alternative
choice when all options for auditory-based intervention have been exhausted,
found unsatisfactory due to the lack of requisite expertise or simply do not
exist. Some parents may be compelled to choose this option for economic
reasons or if they themselves already have sign language skills. Parents, of
course, reserve the right to choose nonauditory-based interventions for other
reasons but in many cultures, the social stigma of having to learn sign language
can be a major disincentive for parents of children with PCEHL (Munoz-Baell
& Ruiz, 2000).
Many developing countries have no provision for persons with disabilities
in general. Public schools for children with hearing loss often are overpopulated,
poorly maintained and dependent on charitable donations, thereby
limiting their capacity to adapt to educational and technological advances.
Government mandates, similar to the Individuals with Disabilities Education Act
or the Americans with Disabilities Act, governing employment rights for people
with disabilities also do not exist in many developing countries. The prevailing
culture of noninclusion isolates persons with hearing loss from wider
society for life. Therefore, it is not uncommon to find that children with
PCEHL grow up without any independent means of livelihood and end up
among the “poorest” of the poor (Elwan, 1999; Olusanya et al., 2006b). This
concern is a major one for indigent parents who desire a better life for their
children so that their children may provide them economic support in their
old age. Parents are unlikely to ignore these considerations when choosing a
communication option for their children with hearing loss. Regardless of the
preferred communication mode, early intervention through early hearing
detection is more efficacious and desirable.
Conclusions
EHDI services in most of the developed world have begun to address
effectively the burden of permanent congenital and early onset hearing loss to
children, their families and society. Hospital-based universal hearing screening
of newborns and infants substantially supported by public funding makes
406 Olusanya

this goal achievable. Reservations toward promoting similar programs in
developing countries are no longer warranted as demonstrated by the voluntary
progress that has been and continues to be made by primarily
nongovernmental organizations in providing sustainable and culturally appropriate
EHDI programs. The prospects of government-backed free EHDI
services may be dim; however, the majority of patients in developing countries
who currently bear the cost of other health services would likely be
willing to take advantage of effective, time-bound hearing health interventions
if they were available. Several opportunities exist for international organizations
and relevant professional associations to be engaged actively in
support of EHDI in developing countries. Positive evidence emerging from
the growing number of pilot programs affirms the value of using alternative,
cost-effective, community-based platforms in which conventional hospitalbased
newborn screening programs miss the majority of babies who are born
outside regular hospitals and who are at greater risk of prelingual hearing
loss. The current resolutions of the WHA on the global prevention of hearing
impairment and the management of disability; as well as the early childhood
initiatives by UNICEF, UNESCO and the World Bank provide additional
moral impetus for extending this “silent, achievable and important revolution”
throughout the developing world to forestall the communicative, educational,
social and economic disabilities associated with early childhood
hearing loss.
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418 Olusanya

The Volta Review, Volume 106(3) (monograph), 419-431
Beyond Early Intervention:
Providing Support to Public
School Personnel
Kathryn Wilson, M.A., CCC-SLP, Cert. AVT ®
At age 3, children with hearing loss transition from Part C early intervention to
Part B public school services. These children represent a heterogeneous population
when considering factors such as communication approaches; speech, language, auditory
and cognitive skills; social-emotional and motor development; parental involvement;
hearing technology; ethnicity and additional challenges such as learning
disabilities. School personnel must have the necessary knowledge, skills and abilities
to serve this diverse population. This article describes the North Carolina Resource
Support Program (RSP), an outreach program designed to address the needs of public
school personnel serving students who are deaf or hard of hearing ages 3-21. Program
components including staff, services and future directions are discussed.
Introduction
Amazing strides have been made to screen newborns for the presence of
hearing loss and to provide early intervention to infants and toddlers who are
deaf or hard of hearing in the 21st century. The benefits of early identification
and early intervention are well documented. For children identified in the
first months of life, fit with appropriate amplification and enrolled in early
intervention in a timely manner, research suggests that speech, language and
vocabulary outcomes as well as social-emotional development are significantly
better than for children who are identified later (Yoshinaga-Itano, 1995,
2004; Yoshinaga-Itano & Sedey, 2000; Yoshinaga-Itano, Sedey, Coulter, &
Mehl, 1998). The 1-3-6 model for screening, diagnosis, amplification and enrollment
in intervention ensures that more children transition from early
intervention to public school services with age-appropriate speech, language,
vocabulary and social-emotional skills. In this new era of early identification
and intervention, children can be fit with hearing aids in the first months of
Kathryn Wilson, M.A., CCC-SLP, Cert. AVT ® , is director of the Resource Support Program
in the Office of Education Services for the North Carolina Department of Health and Human
Services and an adjunct professor at the University of North Carolina—Chapel Hill.
Beyond Early Intervention 419

life. A growing number of children also are receiving cochlear implants during
the birth-to-three years. With increased access to information, parents
may explore a variety of communication approaches and choose from an
array of options.
In the United States, a transition from early intervention services to preschool
services occurs at age 3. School personnel are faced with the challenge
of meeting the needs of a heterogeneous group of children who are deaf or
hard of hearing as well as those who have additional learning difficulties and
are from ethnically diverse backgrounds. What are successful methods for
training and supporting school personnel in their endeavors to implement
effective programming and practices in public schools? This article describes
the North Carolina Resource Support Program (RSP), an outreach program
that addresses the needs of public school professionals who serve children
who are deaf or hard of hearing at transition time and beyond.
Background
Although it is increasingly possible for children who are identified early to
develop communication and language skills in close parallel to their hearing
peers as a result of improved screening procedures and appropriate amplification
technology and intervention programs, most of these children and
their families require ongoing intervention, support and guidance during the
preschool years. For example, North Carolina has been screening newborns
for hearing loss for almost seven years and has a comprehensive early intervention
program for children ages birth to 3. During fiscal year 2005-2006,
77% of three year olds transitioning from early intervention to public school
preschool services qualified for ongoing special education services and had
an Individualized Education Program (IEP) in place at the time of transition
(J. Dunn, personal communication, August 21, 2006; R.A. Everett & L. Kendall,
personal communication, August 14, 2006).
Given the robust relationship between oral language and success in reading
(Katz, Shankweiler, & Liberman, 1981; Mann, Shankweiler, & Smith, 1984;
National Institute of Child Health and Human Development, 2005; Shankweiler,
Liberman, Mark, Fowler, & Fischer, 1979; Snow, Tabors, Nicholson, &
Kurland, 1994; Storch & Whitehurst, 2002) and the formal reading process
that now typically begins near the end of the kindergarten year rather than in
first grade, it is vital that children acquire the requisite language, phonological
awareness and vocabulary skills before entering kindergarten in order to
prepare adequately for the learning-to-read process. Variables such as the age
of identification, appropriate amplification and early intervention determine
linguistic outcomes and school success for children who are deaf or hard of
hearing. In addition, the skills and training of the child and family’s service
providers are regarded as key factors that affect the child’s progress. Kozleski,
Mainzer and Deschler (as cited in Luckner, 2003) stated, “Whether in special
420 Wilson

education or general education, there is growing evidence that the single
most important influence in a student’s education is a well-prepared, caring
and qualified teacher” (p. 5). A knowledgeable and well-trained teacher is
essential to providing the necessary support and guidance to children and
their families during early intervention and following transition from early
intervention to public preschool services. This is true for children who transition
from early intervention with age-appropriate or near age-appropriate
language and vocabulary skills to ensure that they receive the ongoing support
necessary to maintain language and vocabulary levels similar to those of
their peers who are typically developing and to those children who demonstrate
significant delays in language and vocabulary. Children in this second
category are particularly at risk for problems related to success in reading and
subsequent academic failure (Ling, 1989; Robertson, 2000). Because of the
potentially significant education delays the children in this group demonstrate,
the need for highly qualified professionals is even more substantial.
That all children are deserving of qualified educators and related service
personnel is a widely accepted view. The challenge is the shortage of appropriately
trained personnel to meet the needs of the new generation of children
with hearing loss identified at or near birth who transition from Part C early
intervention services to public school Part B services at age 3. At the preservice
level, only eight out of 70 colleges and universities with deaf education
programs in the United States offer specialized training in auditory/oral
education (Houston & Harrison, 2006). Because most college and university
deaf education programs don’t focus on developing the specialized skills
professionals need to work with children learning spoken language, teachers
of the deaf, speech-language pathologists and audiologists already working
in the field often pursue continuing education opportunities to develop these
skills. Professionals can take advantage of online training programs such as
FIRST YEARS, workshops and seminars provided by hearing aid and cochlear
implant manufacturers, certificate programs, CEU opportunities offered
through professional organizations and mentoring programs. The
remainder of this article discusses detailed information about the North Carolina
RSP, a state-funded and -operated program that provides training and
support to public school personnel who serve students who are deaf or hard
of hearing ages 3 to 21.
History
The Office of Education Services RSP
In October 1999, North Carolina mandated newborn hearing screening in
the state’s birthing hospitals. Historically, most children were not identified
and enrolled in early intervention until age 2. Before 2000, children who were
Beyond Early Intervention 421

identified as deaf or hard of hearing received early intervention and preschool
services until age 5 and, in some cases, until age 6 through the Department
of Health and Human Services (DHHS). The DHHS served children
until kindergarten entry, although federal and state policy stated that public
school programs—Part B—were responsible for children age 3 and older.
Beginning with the 2001-2002 school year, North Carolina public schools
began assuming responsibility for serving children upon their third birthday.
With this transfer, new service delivery challenges for children who are deaf
or hard of hearing were presented to administrators of public school services
at the state and local levels.
Perhaps the greatest challenge for public school systems is the lack of
appropriately trained educators and speech-language pathologists to meet
the needs of the new generation of infants and toddlers who are deaf and
hard of hearing. Beginning in 1999-2000, at the same time that North Carolina
implemented universal newborn hearing screening, the state began to experience
a paradigm shift in the communication options parents were choosing.
Presently, the combination of universal newborn hearing screening and the
provision of information about all communication options through organizations
such as BEGINNINGS for Parents of Children Who Are Deaf or Hard of
Hearing, Inc., has resulted in the majority of parents choosing a spoken language
approach (BEGINNINGS, 2005) (see the article by Alberg, Roush and
Wilson, this issue, page 259). Data gathered by the Office of Education Services
indicate that for fiscal year 1996-1997, 60% of families chose a sign
language option, and the remaining 40% chose either the Cued Speech, Auditory-Verbal
or auditory/oral options. A review of statistics from the last
quarter of fiscal year 2005-2006 showed that 65% of families in the statewide
birth-to-three program chose either the Auditory-Verbal or auditory/oral
approach, 15% chose Total Communication, 6% identified the “other” category
and 14% were “undecided.” Although the majority of the 115 North
Carolina public school systems employed one or more teachers of children
who are deaf or hard of hearing and all employed speech-language pathologists,
only a limited number of systems had professionals with specialized
training in working with children with cochlear implants and whose primary
mode of communication was spoken language.
An additional challenge to school systems was serving preschool-age children.
Historically, schools did not begin to provide services to children who
are deaf or hard of hearing until entry into kindergarten. Although the RSP
was established to provide support to public schools serving preschool children,
it also began receiving, and has continued to receive, requests to provide
support for older students. Typical cases include students who were
identified late, implanted late or transitioned from one communication approach
to another; students for whom English is not the primary language
spoken in the home; and students for whom there are concerns regarding
reading comprehension and achievement. To provide the essential support
422 Wilson

for both developmental and remedial learners, the need for a well-trained,
experienced and highly qualified team was identified as a fundamental component
of adequate service delivery.
Staff
The RSP began with two full-time positions and has expanded to include
three full-time and two part-time staff. Program staff are licensed as teachers
of the deaf, speech-language pathologists and audiologists and have specific
expertise and experience in a variety of communication approaches. The team
comprises Certified Auditory-Verbal Therapists ® , individuals fluent in the
Cued Speech approach and skilled signers. Members of the team are either
licensed, certified or demonstrate expertise in more than one communication
approach or area of licensure. Two members of the team are National Board
Certified teachers in special education. These same two staff members have
obtained the Highly Qualified status in keeping with requirements of the No
Child Left Behind Act. Additionally, team members have work experience in a
variety of settings, including public schools, residential schools, early intervention
home-based services, private practice and a hospital-based cochlear
implant program. The average number of years of experience for team members
is 27, with a range of 20 to 35 years. In an effort to maximize resources
already in place, the RSP was established and staffed with existing funding
and vacant positions allocated for one of North Carolina’s schools for the
deaf. No new funding or allocations were required to implement this muchneeded
outreach component.
As described, members of the RSP team have many years of experience in
all communication approaches and with a variety of age groups. The depth
and breadth of staff expertise and specific knowledge allow the program
director to triage each request and assign the most appropriate person or
persons to a case. In addition to staff expertise and experience, other factors
that seem to promote success and changes in teaching practices among professionals
served by the RSP include the following.
All team members have worked in public schools, which increases the
RSP staff’s credibility. As one staff member stated, “They know we have
walked in their shoes.”
Team members understand the high cost of educating children with
special needs and the financial constraints most schools face. Staff members
are skilled in helping public school personnel to identify and maximize
existing resources.
Staff members are able to provide ongoing and continuous support.
Responses to referrals and requests for support are made in a timely
manner (i.e., one to two business days).
RSP staff can develop a clear picture of what is needed by helping
Beyond Early Intervention 423

Services
professionals to develop a plan of action and then to “work their plan.”
The results increase staff members’ motivation.
RSP staff members are willing to work side by side with professionals
not just by telling them what to do, but also by showing them how to
do it.
Emphasis is placed on self-evaluation. School professionals are encouraged
to self-evaluate the effectiveness of their practices and programs
before staff make suggestions and recommendations.
A variety of services are offered to professionals in public schools, including
consultation, observations, evaluations, IEP development, staff development
and mentoring. Although the RSP was established primarily to provide
support to professionals, parents also may request support. In either case (i.e.,
parent or professional request for support), services only are provided at the
invitation of the school system’s exceptional children’s director. RSP staff
strive to work in concert with both school system personnel and families
rather than in the role of advocate for either entity.
Consultation. Consultative services are provided in person or through phone,
fax or e-mail. An onsite consultation usually is provided in conjunction with
an observation of a student in the school setting.
Observations. For students in both special and regular education settings, observations
can be requested for several different purposes, including assessment
of the acoustic environment; level of student participation and ability to
process information in a group setting; appraisal of the placement; use of
appropriate modifications, accommodations, strategies and techniques; and
delivery of services in accordance with the IEP. In some situations, checklists,
such as those available from Children’s Hospital Boston, are used to assist the
observer in assessing a student’s potential to transition from sign language to
a spoken language approach or to a mainstream setting. Typically, a meeting
is held immediately after an observation in order to provide an overview of
findings, respond to questions from school personnel and develop an action
plan if needed. The RSP staff member sends a written report detailing the
observation and suggestions to the school system and parents after the onsite
observation and consultation. Table 1 depicts the type and number of consultative
services the RSP team delivered during the period of July 1, 2005, to
June 31, 2006. For the same period, 21 onsite observations were conducted for
students age 3 to 5, and 23 onsite observations were conducted for students
age 5 to 21.
Evaluations. These are conducted in the areas of speech, receptive and expressive
language, vocabulary, listening, speech perception and written language.
424 Wilson

Table 1. Type and Number of RSP Consultative Services Delivered from July 1,
2005, to June 31, 2006
Consultative Service Phone Fax E-Mail In Person
Parents 126 0 69 114
Professionals 306 13 939 439
Although most school systems in North Carolina have the capacity to evaluate
children with both formal and informal measures, the RSP receives requests
for assistance in this area. A request for evaluation services usually
occurs when a school system does not have a professional with the appropriate
skills to assess the student in one or more areas or, in some situations,
a second opinion is desired. In either case, the RSP team involves the professional(s)
working with the student during the entire evaluation process in an
effort to build capacity at the local level through onsite training in the administration,
scoring and interpretation of a variety of assessments. School
professionals are asked to exhaust all of their available resources for evaluations
before seeking support from the outreach program. During fiscal year
2005-2006, 130 evaluations were completed.
IEP development. The Individuals with Disabilities Education Act requires that an
IEP include the student’s present level of performance, proper goals and
benchmarks and criterion for mastery, how and when progress will be reported
to parents, related services, frequency and intensity of services and
accommodations and modifications needed for a student to access the curriculum.
For families going through the IEP process for the first time as the
child transitions from early intervention, the process can be confusing and
overwhelming. Early intervention programs emphasize family-centered practices.
During the birth-to-three period, an Individualized Family Service Plan
(IFSP) provides the framework for the services the child receives. The goals
set forth in the IFSP primarily are family driven and reflect the parents’
priorities. When a three-year-old child with hearing loss transitions, there is
a shift from the family-centered practices endorsed by early intervention
programs to a more formal and rule-driven process. Parents require information
and guidance about the IEP process well in advance of the child’s
third birthday in order to prepare adequately for transition from early intervention
to public preschool services.
North Carolina has developed procedures to enhance the transition process
for children who are deaf or hard of hearing and their families. Once the child
reaches age 2, the regional early intervention program director notifies, in
writing, the appropriate Local Education Agency (LEA) regarding the child’s
birth date, expected date of transition, communication approach and other
relevant information to benefit the LEA in preparing for transition. Giving the
Beyond Early Intervention 425

school system notification a full year in advance of the actual transition is
recommended to grant the LEA time to identify appropriate personnel to
meet the child’s unique communication needs. North Carolina guidelines also
recommend a meeting with service providers, the infant-toddler service coordinator
and the parents six months before transition. At this meeting parents
are informed of all service options for the child, which may include visits
to various sites and settings. A transition planning meeting is convened 90
days before the child’s third birthday. Evaluations are reviewed, and the need
for additional evaluations is determined. IEP development and possible
placement options may be discussed. One month before the child’s third
birthday the preschool IEP team convenes. The IEP document may be completed
and signed at this time to become effective on the child’s third birthday.
What roles, then, do RSP staff play during the development of the initial
IEP? RSP staff attend very few IEP meetings; however, they often play a key
role in assisting parents and professionals with the development of an appropriate
IEP outside of the formal IEP meeting. This service is provided
through the consultation model. Keeping in mind that the overarching goal
for the RSP is to work effectively and collaboratively with parents and professionals,
the team’s role is to provide information and support rather than
to advocate for either the professionals or the parents. Parents who need an
advocate present for IEP meetings are encouraged to access the services of the
parent educators employed by BEGINNINGS.
In addition to requests for support at transition, RSP staff also receive
requests for IEP development for older students who demonstrate educationally
significant language delays. In general, these students are more than two
years delayed in their understanding and use of language. They often
struggle in mainstream environments, and increased special education services,
alternative testing procedures and non-diploma pathways are being
considered. For a variety of reasons, these students have not met their IEP
goals and objectives for one or more years and continue to fall farther behind
academically. Using a model first introduced by Walker (2004) RSP staff assist
school professionals and parents with developing a long-term, multiyear plan
to close the existing language gap. Closing the language gap is one of the
factors regarded as necessary for success in the mainstream. Once a student
has attained language skills that are approximately age appropriate, he or she
has greater potential to learn a variety of academic subjects and ultimately
complete the requirements required for high school graduation. The longterm
plan consists of specific information regarding projected rate of progress
for each year of the plan in language and vocabulary. A long-term plan
describes both the kinds of special education services and the amount of time
needed daily or weekly to achieve the desired outcomes. Like an IEP, a
long-term plan is developed with both parent and professional input. Unlike
the IEP, a long-term plan defines parental roles and responsibilities in the
426 Wilson

process of closing the language gap in terms of participation in weekly parent
sessions and amount of recommended carryover time outside of the school
environment. All components needed to achieve the target of age-appropriate
language skills are identified and discussed. Assisting local school professionals
and parents of remedial students in the development and implementation
of long-term plans is regarded as an extremely valuable component
offered by the RSP. The expectation is that developing and implementing this
concept will increase the number of students who are deaf and hard of hearing
in the state who will be able to read and write on a par with their hearing
peers upon graduation from high school.
Staff development. Regularly providing a variety of workshop training opportunities
to public school personnel is a primary objective of the RSP. To meet
this objective, the RSP contracts with the Auditory Learning Center, a private,
nonprofit agency in Raleigh funded by the General Assembly of North Carolina.
The RSP director and the executive director of the Auditory Learning
Center meet at least two times a year to discuss training needs identified by
public school personnel and to plan the training calendar. Modules from the
Auditory-Verbal International, Inc., Standardized Curriculum (2000-2003) are
presented regularly, with topics such as hearing and audiology, cochlear
implants, spoken language, parent guidance, development of auditory function,
Auditory-Verbal strategies and techniques and mainstreaming. In addition
to the modules, the Auditory Learning Center presents seven days of
training throughout the course of a school year on the Bloom & Lahey (1978)
model of normal language development. Although the modules are presented
“live,” some can be accessed through satellite set-ups at remote locations,
making training more affordable and accessible for professionals who
might otherwise have to travel long distances. In addition to the annual
calendar for training, the RSP team responds to requests from individual
school systems. The team provides workshops at the invitation of the exceptional
children’s director to address professionals’ training needs at the local
level. There is no charge to public schools for workshops presented by the
RSP, and school systems are encouraged to invite and include personnel from
neighboring districts so that as many professionals as possible can benefit
from the workshops. During fiscal year 2005-2006, 141 training sessions or
workshops were conducted for 883 education professionals and 68 parents.
Mentoring. Workshops are one way of meeting staff development needs; however,
this format cannot meet the needs of all professionals. The RSP staff
recognized the need to develop multiple strategies for personnel development
of adult learners who exhibit a variety of learning styles. Some professionals
find it challenging to apply information presented in workshops or
in-service trainings to their everyday “real-world” school setting. According
to the Westchester Institute for Human Services Research (1998), effective
Beyond Early Intervention 427

training programs emphasize feedback and follow-up. Therefore, in addition
to the series of workshops for public school personnel, a mentoring component
has evolved to provide regular, ongoing, onsite support to assist professionals
in applying workshop content to practice.
Gallacher (1997) described the stages of mentoring relationships, characteristics
of effective mentors, the components of a mentoring program and the
challenges associated with the mentoring process. When a request for mentoring
is received, it is essential that RSP staff first have a clear understanding
of the mentee’s reasons for the request. Is the request based on the needs and
interests of the professional, or is the professional being encouraged to have
a mentor by administrators or perhaps a student’s family? Once the purpose
and goals are established, a plan is developed to define how often and how
long mentoring activities will occur and the specific types of mentoring activities.
The mentor and mentee discuss how feedback will be given both
during and following a session. Because the majority of mentoring activities
that RSP staff provide occur on site rather than by video review, travel time
in addition to the time necessary for the actual visit; review of the lesson plan
before the visit; report writing; and communication through phone, fax and
e-mail all must be taken into consideration when developing a plan. Mentoring
is indeed a time-intensive process for both mentors and mentees, and both
parties must take steps to ensure that all necessary resources are available and
in place. The effectiveness of the mentoring relationship also is examined
regularly. Clearly, this type of personnel development requires planning,
strong organizational skills, openness to feedback, positive attitudes, selfevaluation
skills and sustained commitment to achieve long-term goals.
Future Directions
The RSP has experienced an increase in the number of services requested
and delivered each year since its inception. It is expected that this trend will
continue at least in the foreseeable future as more parents and professionals
become aware of the outreach services available to them; as more children
enter public schools with varying needs; and as the current workforce pursues
the knowledge, skills and abilities to address the needs of a new generation
of students who are deaf or hard of hearing. The RSP will continue to
provide observations, consultations, evaluations and support for IEP and
long-term plan development. The team also will support school systems that
decide to establish classroom programs for students who are deaf and hard of
hearing when needs cannot be met in regular or resource settings. In addition
to the workshops currently offered, the team is working in partnership with
the Auditory Learning Center and BEGINNINGS to develop more workshops,
including a newly developed workshop that will address variables
that influence successful outcomes in reading and literacy; developmental
sequences and intervention strategies for reading aloud, oral narration and
428 Wilson

phonologic and phonemic awareness; and a variety of application activities.
Other topics school system personnel have requested include information
and intervention strategies for working with students who have additional
learning difficulties and providing services to children from bilingual and
non-English-speaking homes. It is expected that the mentoring component
will continue to develop given the growing body of evidence to support the
effectiveness of this type of personnel development. Finally, the RSP staff
envision establishing a Web site that will allow North Carolina professionals
to communicate and network with one another regarding ideas, concerns and
information related to improving the education of students who are deaf and
hard of hearing.
Conclusion
Many positive developments have taken place in recent years for children
who are deaf or hard of hearing, their parents and the professionals who
serve them. Unquestionably, the movement toward early identification increases
potential for communicative competence, success in school and independence.
Many variables contribute to successful outcomes. Chief among these are
the skills and expertise of the professionals who guide the child and family
through early intervention, the preschool years and beyond. Evidence suggests
that preservice programs specializing in auditory/oral and Auditory-
Verbal practices are limited. A variety of in-service programs are available,
although many require professionals to travel and training-related expenses
can be prohibitive.
In response to changes in early identification and the role of public schools
in providing services to preschool children who are deaf or hard of hearing,
the Office of Education Services established the RSP to assist in meeting the
needs of public school personnel. A variety of services and activities designed
to build capacity at the local level are provided by a well-trained and highly
qualified staff at no cost to the public schools. Now in its fourth year of
operation, the RSP continues to expand in terms of number of requests and
services provided. Being able to provide onsite support is one of the major
advantages identified by both RSP staff and recipients of the program’s services.
The challenges encountered in North Carolina are likely to be experienced
in other states, and the RSP can be an effective and replicable model for
providing outreach to school personnel.
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Beyond Early Intervention 431

The Volta Review, Volume 106(3) (monograph), 433-434
Author Index for Volume 106
106(1)
Charlesworth, Ann; Charlesworth, Robert; Raban, Bridie; and Rickards, Field.
(2006). Reading Recovery for Children with Hearing Loss. The Volta Review
106(1), pp. 29-51.
Eriks-Brophy, Alice; Durieux-Smith, Andrée; Olds, Janet; Fitzpatrick, Elizabeth;
Duquette, Cheryll; and Whittingham, JoAnne. (2006). Facilitators and
Barriers to the Inclusion of Orally Educated Children and Youth with Hearing
Loss in Schools: Promoting Partnerships to Support Inclusion. The Volta
Review 106(1), pp. 53-88.
Most, Tova; Aram, Dorit; and Andorn, Tamar. (2006). Early Literacy in Children
with Hearing Loss: A Comparison Between Two Educational Systems.
The Volta Review 106(1), pp. 5-28.
Verté, Sylvie; Hebbrecht, Lies; and Roeyers, Herbert. (2006). Psychological
Adjustment of Siblings of Children Who Are Deaf or Hard of Hearing. The
Volta Review 106(1), pp. 89-110.
106(2)
Dillon, Caitlin M.; and Pisoni, David B. (2006). Nonword Repetition and
Reading Skills in Children Who Are Deaf and Have Cochlear Implants. The
Volta Review 106(2), pp. 121-145.
Neuss, Deirdre. (2006). The Ecological Transition to Auditory-Verbal
Therapy: Experiences of Parents Whose Children Use Cochlear Implants.
The Volta Review 106(2), pp. 195-222.
Reed, Charlotte M.; and Delhorne, Lorraine A. (2006). A Study of the Combined
Use of a Hearing Aid and Tactual Aid in an Adult with Profound
Hearing Loss. The Volta Review 106(2), pp. 171-193.
Robertson, Lyn; Dow, Gina Annunziato; and Hainzinger, Sarah Lynn. (2006).
Story Retelling Patterns Among Children with and Without Hearing Loss:
Effects of Repeated Practice and Parent-Child Attunement. The Volta Review
106(2), pp. 147-170.
106(3)
Alberg, Joni; Wilson, Kathryn; and Roush, Jackson. (2007). Statewide Collaboration
in the Delivery of EHDI Services. The Volta Review 106(3), pp. 259-
274.
Author Index 433

Bohnert, Andrea; Spitzlei, Vera; Lippert, Karl L.; and Keilmann, Annerose.
(2007). Bilateral Cochlear Implantation in Children: Experiences and Considerations.
The Volta Review 106(3), pp. 343-364.
DesJardin, Jean L. (2007). Family Empowerment: Supporting Language Development
in Young Children who are Deaf or Hard of Hearing. The Volta
Review 106(3), pp. 275-298.
McKay, Sarah. (2007). Management of Young Children with Unilateral Hearing
Loss. The Volta Review 106(3), pp. 299-319.
Moore, Jan Allison; Prath, Scott; and Arrieta, Adrianne. (2007). Early Spanish
Speech Acquisition Following Cochlear Implantation. The Volta Review
106(3), pp. 321-341.
Olusanya, Bolajoko O. (2007). Early Hearing Detection and Intervention in
Developing Countries: Current Status and Prospects. The Volta Review
106(3), pp. 381-418.
Schorr, Efrat A. (2007). Early Cochlear Implant Experience and Emotional
Functioning During Childhood: Loneliness in Middle and Late Childhood.
The Volta Review 106(3), pp. 365-379.
White, Karl R. (2007). Early Intervention for Children with Permanent Hearing
Loss: Finishing the EHDI Revolution. The Volta Review 106(3), pp. 237-
258.
Wilson, Kathryn. (2007). Beyond Early Intervention: Providing Support to
Public School Personnel. The Volta Review 106(3), pp. 419-431.
434 Author Index