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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