The Ethics of EHDI: What Audiologists Need to Know Les R. Schmeltz, Au.D. Karen Munoz, Ed.D. Karen Clark, M.A.

The Ethical Framework

The Ethical Framework Codes of ethics are agreed upon minimum standards of practice for the conduct of a profession Audiologists are free to exceed these standards Specific codes apply only to members of that organization Codes for all 3 audiology organizations are very similar

AAA Code of Ethics Principle I: Members shall provide professional services and conduct research with honesty and compassion, and shall respect the dignity, worth and rights of those served

AAA Code of Ethics Rule 1a: Individuals shall not limit the delivery of professional services on any basis that is unjustifiable or irrelevant to the need for the potential benefit of such services. Rule 2a: Individuals shall not provide services except in a professional relationship, and shall not discriminate in the provision of services to individuals on the basis of sex, race, religion, national origin, sexual orientation or general health (or age??)

AAA Code of Ethics Principle 2: Members shall maintain high standards of professional competence in rendering services

AAA Code of Ethics Rule 2a: Members shall provide only those professional services for which they are qualified by education and experience Rule 2b: Individuals shall use available resources, including referrals to other specialists………..

AAA Code of Ethics Rule 2c: Individuals shall exercise all reasonable precautions to avoid injury to persons in the delivery of professional services or execution of research. Individuals shall provide appropriate supervision and assume full responsibility for services delegated to supportive personnel. Individuals shall not delegate any service requiring professional competence to unqualified persons

AAA Code of Ethics Rule 2e: Individuals shall not permit personnel to engage in any practice that is a violation of the Code of Ethics Rule 2f: Individuals shall maintain professional competence, including participation in continuing education

AAA Code of Ethics Principle 3: Members shall maintain the confidentiality of the information and records of those individuals receiving services or involved in research

AAA Code of Ethics Principle 4: Members shall provide only services and products that are in the best interest of those served

AAA Code of Ethics Principle 5: Members shall provide accurate information about the nature and management of communicative disorders and about the services and products offered

AAA Code of Ethics Rule 5a: Individuals shall provide persons served with the information a reasonable person would want to know about the nature and possible effects of services rendered, or products provided or research being conducted

AAA Code of Ethics Rule 5b: Individuals may make a statement of prognosis, but shall not guarantee results, mislead, or misinform persons served or studied Rule 5e: Individuals shall maintain documentation of professional services rendered

AAA Code of Ethics Principle 6: Members shall comply with the ethical standards of the Academy with regard to public statements or publication

AAA Code of Ethics Rule 6b: Individuals public statements about professional services, products or research results shall not contain representations or claims that are false, misleading or deceptive

Ethics and Practice Decisions

Infant Diagnostic Testing

Infant Diagnostic Testing Practice Decisions: Test battery components Position statements, state guidelines Equipment needed Based on test requirements Referrals following identification of hearing loss Examiner expertise Examination of evidence, identification of learning gaps, continuing education

Infant Test Battery Joint Committee on Infant Hearing Year 2000 Position Statement Child and family history Physiologic measures ABR Click Frequency-specific Bone conduction OAE Middle ear measures High frequency probe tone Observation of behavioral response to sound

Equipment Required Practice Questions: Do I have OAE equipment? Do I have a high frequency probe tone on my immittance bridge? Do I have an ABR unit with click, tone burst, AND bone conduction? If the answer is no to ANY of the above, you are not equipped to do infant diagnostic testing

Referrals Practice Questions: Do I know the necessary referrals to make following the identification of a hearing loss? Do I know the reporting requirements? Do I know the recommended time frame? Do I know what the resources are in my region/state?

Examiner Expertise Practice Questions: Do I have training and experience in all components of the infant test battery? What are my learning gaps Do I need knowledge? Find an online course and/or conference Read articles Do I need skills? Identify a hands-on workshop Find a mentor (experienced co-worker or colleague)

Infant Diagnostic Testing Ethical Considerations: Do I have the requisite knowledge and skills to serve this population? If not, have I identified my learning gaps AND identified resources to update my knowledge and skills to competently serve this population? Do I have the necessary equipment to test this population? If the answer is NO to either question – refer out

Amplification

Amplification Practice Decisions: Process: Selection Verification Validation Equipment needed Examiner expertise

Amplification Process American Academy of Audiology (2003) Pediatric Amplification Protocol Selection Technology/Earmold characteristics Individual Real-ear-to-coupler-difference (RECD) Verification Real-ear or simulated measures (soft/med/loud) Caregiver hearing instrument orientation Validation Benefits/limitations, measures/tests Follow-up and Referral

Equipment Needed Practice Questions: Do I have a real ear analyzer? Does it have RECD capability Is there an option for a speech signal (preferable)? Do I have hearing instrument software and supplies designed for pediatrics? Do I have a loaner hearing aid program?

Examiner Expertise Practice Questions: Do I have training and experience in all aspects of the amplification process for the infant population? What are my learning gaps? Do I need knowledge? Find an online course and/or conference Read articles Do I need skills? Identify a hands-on workshop Find a mentor (experienced co-worker or colleague)

Infant Amplification Ethical Considerations: Do I have the requisite knowledge and skills to serve this population? If not, have I identified my learning gaps AND identified resources to update my knowledge and skills to competently serve this population? Do I have the necessary equipment to fit this population? If the answer is NO to either question – refer out

Guidelines and Position Statements (partial list): Joint Committee on Infant Hearing Year 2000 Position Statement State EHDI Guidelines American Speech-Language-Hearing Association (ASHA): Guidelines for the audiologic assessment of children birth to 5 years of age ASHA: Sedation and topical anesthetics in audiology and speech-language pathology American College of Medical Genetics: Genetics evaluation guidelines for the etiologic diagnosis of congenital hearing loss American Academy of Audiology Pediatric Amplification Protocol (2003)

Availability of State EHDI Guidelines (Random Review) Diagnostics Reporting Hearing Aid Referral EI A X   B C D E F G

Early Intervention

Charting a course through the ethical issues of early intervention isn’t always clear.

One View of the Ethics Issue Hands and Voices, a national parent organization serving families of children who are deaf are hard of hearing, addresses the concept of Bias vs. Personal Belief System Hands and Voices 2006 Included with permission

Bias vs. Personal Belief System Intentionally influencing the audience Manipulating people, information, and events to achieve a predisposed outcome Sharing the benefit of our experience & education with each other Connecting on common ground Credibility Copyright © 2006 Hands & Voices Included with permission So what’s the difference in function between PBS and BIAS?

Bias vs. Professional Practices Sharing knowledge gained through our education and experience in pediatric audiology. Providing families with the information and resources to assist them in making the intervention choices that work for their child and family. Intentionally influencing the audience Manipulating people, information, and events to achieve a predisposed outcome

Ethical Issues and Practices in: Early Intervention Recommendations Monitoring and Follow-Up Direct Early Intervention Service Provision

Recommendations Ethical Considerations Early intervention programs. Knowledge of programs within the region Knowledge is current and based on fact rather than heresay. Communication options. Information available on wide range of options. Printed information, resources for additional information including EI programs who can provide support in this area. Knowledge of local and national parent support groups.

Recommendations Questions to Consider Have I visited, met with, or had a telephone discussion with any of the early intervention programs within my region? Is my information current? Do I feel that I can present information on communication choices in an unbiased way? If I do have a professional bias toward one communication approach, how do I inform the family? How do I insure they can learn about the other options? Bilingual Auditory Verbal Signed English

Discussion Scenario Program recommendation scenario The audiologist shares information on several early intervention programs. The parent asks which program is best. The audiologist replies that while she has not had a lot of direct experience with any of the programs, that most parents in her practice tend to be very pleased with the services in Program X. On all of these scenarios, my thought would be to read them. Then ask participants if they agree with the statement and/or what the audiologist might reply to the questions instead.

Discussion Scenario Communication Recommendation Scenario A family tells their audiologist the following: They are very confused with all the information about communication methodolgies. They ask the audiologist to tell them the right thing to do. The audiologist listens to the parents and says: A lot of other parents have felt the same way and that it can be confusing What’s right for one family may not be right for another; he asks what they have learned thus far. In his professional opinion that Method X is the best thing given the type and amount of hearing loss their child has. Same here – what, if anything, is OK with the answer, what might be changed, what instead

Discussion Scenario Cochlear Implant Recommendation Scenario An audiologist is overheard to say that most parents have expectations for cochlear implant success that are way too high. For this reason the audiologist always tells the parents the reasons that an implant probably won’t work as well as they think it will. She says that she does this because no one else does and it’s important for parents to know the truth. I actually heard an audiologist say this last month during a workshop. We really don’t need three scenarios under recommendations so maybe I should cut it but it seems like a good example of where’s the place to draw the line on realistic information sharing.

Monitoring and Follow-Up Ethical Considerations Ongoing diagnostic assessment Position statements, state guidelines Potential problems that may impact early intervention Medical, amplification, communication, parental support Partnership with other members of the early intervention team

Monitoring and Follow-Up Questions to Consider Do I actively work to minimize the time between confirmation of hearing loss and amplification? Do I monitor infants with amplification at recommended intervals? Do I follow pediatric protocols for ongoing assessment of infants and toddlers? Do I know and communicate with other members of the IFSP team? Do I obtain releases and share updated audiological information with the team?

Monitoring and Follow-Up Questions to Consider Do I understand the complexities of early intervention and audiological management for infants and toddlers with medical syndromes and auditory neuropathy/auditory dys-synchrony? Do I understand the increased impact of OME for children with sensorineural hearing loss? Communicate to families and other memes of the intervention team?

Monitoring and Follow-Up Questions to Consider Am I aware of the potential problems that can impact early intervention? consistency of amplification, ear mold problems, effectiveness of communication methodology Do I work in partnerships with other members of the team so that I can know if problems are occurring? responsive to concerns, respect for opinions Am I aware of and responsive to a family’s needs for support?

Discussion Scenario Monitoring and Follow-Up Scenario The EI specialist tells the audiologist that the family is not keeping the aids on the baby. The mother reports that the hearing aid is too loud and that it’s “hurting” the baby. The EI specialist asks for suggestions or more information. The audiologist says the next available appointment is in a month and that if the family isn’t comfortable putting on the aids, to leave them off until the next appointment. I like this one because there are so many areas to address within this one event.

Direct EI Service Provision Ethical Considerations Competence in direct service provision training, experience with infants/toddlers, family-centered practices, research based, current Ongoing assessment Partnership with other members of the intervention team

Direct EI Service Provision Questions to Consider Do I have the training and experience required to work with infants and toddlers? Do I utilize family-centered practices? Am I familiar with all areas of child development? Are my intervention strategies appropriate for infants and toddlers rather than preschool strategies downsized? Support the outcomes desired by the family? Support families in their role as primary language facilitators?

Direct EI Service Provision Questions to Consider Do I utilize appropriate assessment strategies? Monitor progress over time? Assess in all areas of child development and/or collaborate with others to know this information? Use assessment to guide intervention? Use assessment to determine if a change in intervention is warranted?

Direct EI Service Provision Questions to Consider Do I work in partnership with other members of the early intervention team? Do I value the expertise of others members of the team? Do I resolve professional differences in a way that does not put the parents in the middle of a professional disagreement?

Early Intervention Best Practice and Guidelines Alexander Graham Bell Early Intervention Best Practice Model The National Agenda: Moving Forward on Achieving Educational Equality for Deaf and Hard of Hearing Students (April 2005) Goal One: Early Identification and Intervention Report and Recommendations of the 2004 National Consensus Conference on Effective Educational and Health Care Intervention for Infants and Young Children with Hearing Loss