1. Connecting with Appropriate Early Intervention Programs Antonia Brancia Maxon, Ph.D New England Center for Hearing Rehabilitation

2. Birth to Three Mission To strengthen the capacity of families to meet the developmental and health- related needs of their infants and toddlers who have delays or disabilities. Connecticut Birth to Three

3. CT Birth to Three Guidelines Service Provision Families will have equal access to a coordinated program of comprehensive services that: –foster collaborative partnerships –are family centered –occur in natural settings –recognize best practice in early intervention –are built on mutual respect and choice

4. Service Guideline 5, CT Birth to Three (October, 1999) Pediatric Audiologist Criteria can evaluate a childs hearing within a short time after being contacted for an appointment specializes in working with infants and young children- worked with large numbers of them provides hearing aids child in a timely manner

5. Service Guideline 5, CT Birth to Three (October, 1999) Pediatric Audiologist Criteria makes earmold impressions dispenses hearing aids has loaner hearing aids available provides hearing aids on a trial basis

6. Service Guideline 5, CT Birth to Three (October, 1999) Pediatric Audiologist Criteria has resources to repair hearing aids quickly has worked with the Birth to Three System is familiar with the procedures of the Birth to Three System including IFSP development and procedures for acquiring hearing aids or assistive technology

7. Service Guideline 5, CT Birth to Three (October, 1999) Pediatric Audiologist Criteria will review the results of the audiogram with the family at the time of the evaluation will provide a comprehensive written report, with a copy of the audiogram in a timely manner

8. CT Birth to Three Guidelines Enrollment Establish guidelines Eligible child –automatic enrollment criteria - diagnosed condition –significant developmental delay Selecting a program

9. CT Birth to Three Guidelines Enrollment Develop Individualized Family Service Plan (IFSP) –All services speech and language development auditory development assistive technology –Goals and objectives –Timelines

10. CT Birth to Three Guidelines Principles of Intervention for Infants and Toddlers with Hearing Loss 1. Early identification and diagnosis is essential. 2. Ongoing audiological assessment and management must be conducted by staff trained to work with infants and young children.

11. CT Birth to Three Guidelines Principles of Intervention for Infants and Toddlers with Hearing Loss 3. The intervention team should assist the family in learning about the nature of their childs hearing loss.

12. CT Birth to Three Guidelines Principles of Intervention for Infants and Toddlers with Hearing Loss 4.Intervention requires a team approach. The family is the most important member of this team. The mission of the Birth to Three System is to support, assist and advise families on how to best meet their childs unique needs. This should include access to a wide variety of information that is shared in an unbiased manner.

13. CT Birth to Three Guidelines Principles of Intervention for Infants and Toddlers with Hearing Loss 5.Parents and children are partners in communication. Parents and children must develop a communication system in order for a language system to develop. 6.Language development begins as soon as a child is born and develops through interactions with the family in daily routines.

14. CT Birth to Three Guidelines Principles of Intervention for Infants and Toddlers with Hearing Loss 7.Parents need to understand and mange the hearing aids and/or auditory equipment for their child. A program must help the family learn how to maintain any hearing aids or equipment. 8.Parents are advocates for their children who are deaf or hard of hearing. EI should help parents understand their legal rights.

15. Pediatric amplification fitting Initiate amplification process immediately after diagnosis Select, fit and validate amplification within first few months Does not require exhaustive audiological data Conduct real-ear measures Use functional measures of benefit Scheduling flexibility

16. Basic Audiological Information Used to Fit Amplification Hearing Sensitivity –ABR click + low frequency pulse tones –Target audiogram: 500, 1000, 4000 Hz –Individual ear measures: insert phones, localization Middle Ear Status –Tympanometry Tolerance –Stapedial reflexes

17. Prescriptive Approach to Hearing Aid Fitting Desired Sensation Level - DSL (Seewald, et al, 1996) –Uses minimal audiometric data –Real ear measures –Adjustments for pediatric ears –Used to determine target gain and output settings

18. DSL Goal Provide optimal gain across maximum frequency range –Infant acquiring language has access to speech of others –Infant acquiring language has access to own speech

19. Accessing the Speech Signal Primary purpose of amplification Maximal exposure to speech spectrum Develop auditory feedback loop Speech must be well above detection within an appropriate dynamic range

20. Hearing Aid Fitting/Validation Ongoing process with flexible instrument Clinical measures –More audiological data - setting adjustment Observe behaviors, communication, environment –Audiologist –Family –Service providers

21. Pediatric Audiologists Responsibility Must be able to schedule evaluations, earmolds, etc immediately Must be able to make a decisions rapidly Must be able to provide amplification rapidly Must be aggressive about amplification Immediate response to parents needs Immediate response to infants needs

22. Benefits of Early Amplification When diagnosis and hearing aid fitting occur in first six months of life and early habilitation is initiated, infants with hearing loss will perform at levels superior to those who do not have early appropriate diagnosis and habilitation (Yoshinago-Itano, 1997). Infants with severe-profound hearing loss who use hearing aids by six months of age acquire language and vocal communication at ages equivalent to infants with normal hearing (Robinshaw, 1995).

23. Aural Habilitation Programming Use of residual hearing –detection to discrimination Integrated approach –speech perception/production –language/communication Parent education –amplification –listening environment –facilitating language acquisition

24. Communication Modality Spoken language options –oral/aural –cued speech –total communication Signing Exact English Seeing Essential English American Sign Language (ASL)

25. Professional Issues: Pediatric Audiologists Present number of pediatric audiologists Guidelines for pediatric audiology Credentialing pediatric audiologist –development of standards –overseeing agency Establishing link from diagnostics to fitting

26. Professional Issues: Pediatric Aural Habilitation Pediatric aural rehabilitationist –expertise in infant development infant auditory development infant speech and language acquisition –experience working with infants and their families –flexibility in scheduling

27. Professional Issues: Pediatric Aural Habilitation Present number of pediatric aural rehabilitation providers Guidelines for pediatric aural rehabilitation providers Credentialing pediatric aural rehabilitation providers –development of standards –overseeing agency Establishing link from fitting to aural rehabilitation

28. Professional Issues: Audiological Guidelines Must establish –Maximum time until diagnosis made –Minimal audiological information for amplification fitting –Maximum time until amplification fitting –Maximum time until enrollment in management program –Age-appropriate diagnosis and management

29. Medical Intervention Hearing aid fitting is dependent on medical status of auditory system Middle ear effusion has a significant impact on infants with sensorineural hearing loss –immediate access to medical intervention –ongoing medical management Cochlear implant candidacy

30. Professional Issues: Medical Intervention Pediatricians and ENTs with expertise in –infant hearing loss and otologic conditions –amplification for infants –pediatric cochlear implant candidacy Physician experience working with early intervention agencies and personnel –facilitating referral and implementation of programming Accommodation of families –flexible scheduling –time for counseling

31. JCIH, 2000 Early Intervention Benchmarks Infants enrolled in family-centered EI by 6 months old Infants enrolled in family-centered EI program with professionals knowledgeable about communication needs of infants with hearing loss Amplification use begins within one month of diagnosis when appropriate and agreed on by family

32. JCIH, 2000 Early Intervention Benchmarks Infants with hearing loss have ongoing audiological management - not to exceed 3 month intervals Language development in familys chosen communication modality and commensurate with developmental level and similar to that for hearing peers of a comparable developmental age. Families participate in and express satisfaction with self-advocacy.