Transcript “Out of the Ears of Babes”

An Update
Judith Gravel, PhD
Chair, JCIH
The Children’s Hospital of Philadelphia
Member Organizations; Current
Representatives
• American Academy of Audiology
– Alison Grimes; Christie Yoshinaga-Itano
• American Academy of Otolaryngology
Head & Neck Surgery
– Patrick Brookhouser; Stephen Epstein
• American Academy of Pediatrics
– Betty Vohr; Albert Mehl
Member Organizations; Current
Representatives
• American Speech-Language-Hearing
Association
– Judy Gravel; Jack Roush
• Council for the Education of the Deaf
– Beth Benedict; Cynthia Ashby
• Directors of Speech & Hearing
Programs in State Health and
Welfare Agencies
– Linda Pippins; David Savage
JCIH Documents
• 1970 – National Joint Committee on
Newborn Hearing Screening formed
• 1972 – Joint Committee on Newborn
Hearing Screening Supplement – HRR
• 1982 – Joint Committee on Infant
Hearing (JCIH) Statement
• 1990
–JCIH Position Statement
• 1994
–JCIH 1994 Position Statement:
detection of HL by 3 months of age,
intervention by 6 months
Year 2000
Position Statement
Principles and Guidelines
for EHDI Programs
JCIH 2000
Components of an EHDI Program
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Hearing screening: 1 month
Confirmation of hearing loss: 3
months
Intervention: 6 months (enrollment
in early intervention program)
JCIH 2000
Components of an EHDI Program
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Multi-disciplinary team approach
Family-centered, seamless,
quality services
Information systems for tracking
& follow-up
The Joint Committee on Infant Hearing
(JCIH) is recognized both nationally and
internationally for its role in shaping public
health policy with regard to early hearing
detection and intervention (EHDI)
programs.
As such, position statements and
guidelines have addressed new and
emerging issues in EHDI
Since publication of JCIH 2000:
• Data and experiences have become
available that impact practice
• Several issues have need to be
readdressed
• New data have become available
• All have resulted in deliberation and
work by the JCIH over the last five
years, ultimately leading to the
decision to develop JCIH 2005
Survey of State EHDI Officials
White 2003; 2004
“Shortage of experienced pediatric
audiologists for assessment and
hearing aid fitting” obstacle to quality
EHDI programs
– 2001: greater concern than 1998
– 2004: 2nd most serious obstacle
Rankings: 13 Obstacles to
Quality EHDI Programs White 2004
Documents Currently Available
on Pediatric Audiology Services
• Pediatric Working Group 1996
• AAA Pediatric Amplification Protocol
2003
• ASHA 0-5 year Guidelines 2004
• AAA – in progress 2005
• JCIH 2000
JCIH 2000
Personnel Considerations
Provided broad suggestions regarding
the assessment & management
procedures and knowledge and skills
needed by professionals providing
services to infants and young children
JCIH 2000
Audiologic Evaluation: birth – 5 months
• Child & family history
• Electrophysiologic threshold
measure
• EOAE
• Measurement of middle ear
function
JCIH 2000
Audiologic Evaluation: 6 – 36 months
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Child & family history
Behavioral audiometry
EOAE
Acoustic Immittance
Speech perception measures
Parental report
Screen communication milestones
‘Cross-check’ with ABR
JCIH 2000
Audiologic Habilitation: Amplification
• Prescriptive procedure & real ear
measurement
• Verification & Validation
• Complementary or alternative sensory
technology (FM; CI)
• Long-term monitoring
Delineating a Center for Infant Audiology
Service excellence and expertise;
Disseminating thos recommendation to
State EHDI Coordinators, Early
Intervention officials, professionals, and
families (Role for JCIH)
versus
Credentialing of Audiologists who provide
infant audiology services (Role of
professional organizations)
• Contract from Maternal and Child Health
Bureau to Boys Town National Research
Hospital
– Develop and disseminate recommendations
on infant audiology services
• Initially: survey, review & collection of
documents relating to existing pediatric
audiology practice in U.S. and other
countries (Canada, UK, Australia)
– Brandt Culpepper, Townsend University
Data Collection - 2003
Culpepper
• Survey of State EHDI systems
• Web searches for additional
resources
• Compiled & Reviewed national &
international policies, guidelines,
and recommendations
States with List of
Infant Audiology Service Providers
Culpepper 2003
Yes
Pending
No
American Samoa
Commonwealth N. Mariana Is.
Guam
Puerto Rico
Virgin Islands
States with Infant Hearing
Assessment Guidelines
Culpepper 2003
Mandatory
Recommended
Pending
None
developed
American Samoa
Commonwealth N. Mariana Is.
Guam
Puerto Rico
Virgin Islands
States with Infant Amplification Guidelines
Culpepper 2003
Mandatory
Existing
Pending/Draft
No known
document
American Samoa
Commonwealth N. Mariana Is.
Guam
Puerto Rico
Virgin Islands
States with ‘Credentials’
Recognizing Pediatric Audiologists
Culpepper 2003
N=56
Yes
Pending
No
American Samoa
Commonwealth N. Mariana Is.
Guam
Puerto Rico
Virgin Islands
MCHB Working Group on Infant
Audiology Services
• Patrick Brookhouser
• Barbara ConeWesson
• Brandt Culpepper
• Judy Gravel
• Michael Gorga
• Mary Pat Moeller
• Linda Pippins
•Jack Roush
•Richard Seewald
•Yvonne Sininger
•Patricia Stelmachowicz
•Anne Marie Tharpe
•Judy Widen
•Christie Yoshinaga-Itano
MCHB Working Group
on Infant Audiology Services
• Conducted face-to-face meeting
• Reviewed materials
• Drafted document on
assessment, management and
follow-up of infants with hearing
loss & their families
MCHB Working Group:
Key Principles of
Infant Audiology Services
• Shared goal of seamless service
provision within family centered
context
• Knowledge of entire pediatric hearing
health care service delivery system
• Audiologic services delivered within
context of the EHDI system
National EHDI Goals
• Goal 1: screening by 1 month
• Goal 2: screen positive infants receive
diagnostic audiologic assessment before 3
months
• Goal 3: infants with hearing loss begin
appropriate early intervention before 6
months
National EHDI Goals
• Goal 4: infants & children with late onset,
progressive, or acquired hearing loss receive
early ID
• Goal 5: infants with hearing loss will have a
medical home
• Goal 6: States will have complete EHDI
Tracking & Surveillance System to minimize loss
to follow-up.
• Goal 7: States will have comprehensive system
that monitors and evaluates progress towards
the EHDI Goals & Objectives.
MCHB Working Group:
Key Principles of
Infant Audiology Services
• Personnel with experience in assessment
& management of infants and children
with hearing loss
• Commensurate knowledge & test
equipment necessary for use with current
pediatric hearing assessment methods &
hearing aid selection and evaluation
procedures
MCHB Working Group:
Key Principles of
Infant Audiology Services
• Audiologic diagnostic process is ongoing:
frequent follow-up visits necessary
• Timely provision of services, without long
delays between tests
MCHB Working Group:
Key Principles of
Infant Audiology Services
• Hearing aid fitting, early intervention
& referral for medical evaluation
proceed as soon as hearing loss is
confirmed
• Complete medical evaluation & child
and family history are part of
diagnostic process
MCHB Working Group:
Key Principles of
Infant Audiology Services
• Changing ear canal acoustics:
impact on assessment &
management
• Otitis Media with Effusion (OME)
• Sedation
MCHB Working Group:
Components of Hearing Assessment to
Confirm Hearing Loss by 3 months of age
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Case/family history
Otoscopic inspection
FS air- & bone-conduction ABR thresholds
High-level click-ABR
EOAE
Tympanometry (1 kHz probe freq) & AMEMR
Observations of auditory behaviors
Counseling family
MCHB Working Group:
Facilities & Equipment Specific to
Electrophysiologic Testing of Infants
• Electrophysiologic instrument
– Capable of frequency-specific air- and
bone-conducted assessment
– Option for using contralateral masking
and ipsilateral notched-noise masking
MCHB Working Group:
Facilities & Equipment Specific to
Electrophysiologic Testing of Infants
• Diagnostic OAE instrument
– providing more that pass-refer outcome
– variable stimulus type, frequency, level
– flexible response-analysis techniques
• Acoustic immittance equipment
– 1 kHz and 226 Hz probe frequency options
– Contralateral & ipsilateral AMEMR options
MCHB Working Group:
Facilities for Behavioral
Audiologic Diagnostic Assessment
• Conditioned response
procedures (VRA,
TROCA, CPA)
• Sound treated test
booth
• Audiometer with
insert earphones
• Bone vibrator with
pediatric headband
• Sound field capability
• Multiple toy
reinforcers/cabinets
and/or video
reinforcement system
• EOAE
• Real-ear
measurement system
• Acoustic immittance
system
• Sound level meter
MCHB Working Group:
Facilities for Amplification
Selection & Fitting
• Audiometric assessment/acoustic
immittance
• Instrumentation to perform electroacoustic
analysis & real ear measures with test
signals appropriate for use with current
technology
• Computer system allowing use of fitting
software for current technology
MCHB Working Group:
Facilities for Amplification
Selection & Fitting
• Consignment hearing aids appropriate for
infants & toddlers
• Equipment & supplies: high-quality ear
mold impressions in infant ears
• Appropriate test environment
• Loaner hearing aid program
• Hearing Aid Orientation kits
Based on MCHB Working Group
document:
JCIH Stratification System for
Quality Infant Audiology
Services
Levels of Service – MA Model
(infants & children required to be referred to
DPH-approved facilities)
• Level 1 – serve children birth to 3 years
– Sedated & non-sedated ABR
– Other traditional pediatric audiologic testing
• Level 2 – serve children birth to 3 years
– non-sedated ABR
– Other traditional pediatric audiologic testing
• Level 3 – serve children 6 months (CA) to
3 years
– Other traditional pediatric audiologic testing including,
but not limited to sound field testing, play audiometry,
tympanometry, and OAE,
Development and Dissemination of
Materials on JCIH QIAS Stratification
System
• Families
• State EHDI Coordinators
• Primary Care Providers
Terry Davis, LSU Medical Center –
healthcare literacy; MCHB contract
In Development:
JCIH 2005
Position Statement and Guidelines
JCIH 2005
Position Statement and Guidelines
Maintain general framework of
JCIH 2000
• Provide interval history 2000-2005
– Recognize federal agencies in the
development of EHDI systems
• Review relevant literature published
in the interval & update
JCIH 2005
Position Statement and Guidelines
Update, Expand & Revise Principles:
• Prevention
• Family centered EHDI process
• 1-3-6 maintained
• Timely access to high-quality
technology; reimbursed
JCIH 2005
Position Statement and Guidelines
Update, Expand & Revise Principles:
• Simplified, integrated point of entry to
early intervention system
• Professionals: pediatric-specific &
discipline-appropriate knowledge and
skills
• Monitoring for hearing loss &
surveillance efforts
JCIH 2005
Position Statement and Guidelines
Update, Expand & Revise Principles:
• Information for families; professional
continuing and pre-professional
education
JCIH 2005
Position Statement and Guidelines
Update, Expand & Revise Principles:
• Information systems – electronic
health records
• Reimbursement for professional
services
JCIH 2005
Position Statement and Guidelines
2005 overarching theme: Follow-up
• Highlight challenges impacting followup and tracking of infants after
screening
• Offer recommendations
JCIH 2005
Position Statement and Guidelines
Issues Related to Follow-up:
• States sharing information on
individual children
• Assignment of follow-up
responsibilities at each step of the
EHDI process
JCIH 2005
Position Statement and Guidelines
Issues Related to Follow-up:
• Organized surveillance efforts after
the newborn period
• Screening of communication
milestones
JCIH 2005
Position Statement and Guidelines
Issues Related to Follow-up:
• Targeting special populations for
intense follow-up:
– Multiple disabilities
– Unilateral hearing loss
– Mixed hearing loss: breaking cycle of
delayed confirmatory tests
– Possible candidates for CI
JCIH 2005
Position Statement and Guidelines
Revisions in Existing Sections:
• Screening
• Auditory neuropathy section
• Audiologic Habilitation section
• Early Intervention section
• Surveillance section
JCIH 2005
Position Statement and Guidelines
• Revision of surveillance section:
“Risk Indicators for Progressive or DelayedOnset Sensorineural Hearing Loss and/or
Conductive Hearing Loss”
– Audiologic monitoring of infants with risk
indicators who pass NHS
– Every 6 months to age 3 years
• Concept Paper 2003: White (NCHAM)
• Questioned the desirability of the JCIH
2000 surveillance recommendation
• Concluded that:
– little evidence regarding late-onset
hearing loss in infants with risk indicators
– practice of gathering risk factors in
neonatal period was costly & time
consuming and likely to be missed
– Feasibility of audiologic evaluation of
infants 2 x year
– ? Wise use of limited resources
In 2003, JCIH worked on revision of
surveillance section and considered:
• Medical Home role:
– ID risk indicators regardless of screening
pass
– Query parent at each visit regarding
communication: refer on parent concern
– Refer any child with diagnosed disability
– Routine screening of communication
development; refer any child with delays
• Testing hearing of every child enrolled in
the Early Intervention System
JCIH 2005
Position Statement and Guidelines
Revisions in Existing Sections:
• Roles & Responsibilities: will now address
transitioning from birth to 3 programs to 3
to 5 programs
• Institution and agencies: to include
Federal commitment to pre-professional
and professional training
JCIH 2005
Position Statement and Guidelines
Other Issues/Topics:
• Genetics & genetic
counseling/evaluation in the EHDI
context
www.jcih.org