As a result of effective universal newborn hearing screenings, identification of hearing loss occurs earlier and more frequently than ever before. Previously, hearing loss was typically not diagnosed or effectively managed until the second or third year of life. However, with current protocols, hearing loss can be identified and appropriate amplification can be fit within the first few months of life.
Otoacoustic emissions, steady state and frequency specific auditory brainstem evoked response and multiple frequency tympanometry assist in determining the type and degree of hearing loss, as well as the mechanical functioning and neural integrity of the auditory mechanism (Goldstein and Aldrich, 1999; Hall, 2000; Hood, 1998; Sininger, and Abdala, 1998). Importantly, hearing aid fitting protocols for selecting electroacoustic parameters for amplification have been developed with specific norms for infants and children (Sandlin, 2000; Seewald, 1995).
Early intervention typically consists of diagnosis, management and treatment of hearing loss, particularly regarding the pediatric population. However, the true scope of ''early intervention'' also includes counseling the patient and family members, planning and implementing an Individual Family Service Plan (IFSP), addressing communication, educational, social and emotional needs of the child and family, educating the family regarding legal rights, identifying potential funding sources and programs appropriate for the family (if needed) and helping the family develop skills necessary for advocacy and success in raising a child with hearing impairment (American-Speech-Language-Hearing Association,1994). Early intervention involves the entire family and their interactions with multiple professionals.
Raver (1999) defines collaboration as ''an interactive process that enables teams of people with diverse expertise to generate creative solutions to mutually defined problems'' (p.345). Raver goes on to suggest the collaboration process is one in which the participants ''do things with, not to'' (p. 345) one another.
Collaboration among professionals and families in the effective delivery of service to infants and children with hearing loss is not only imperative, it is mandated. The Education of the Handicapped Act Amendments of 1986 (P.L. 99-457) and Part B and Part C (formerly referred to as Part H) of the Individuals With Disabilities Act, 1991 (IDEA; P.L.102-119) support early intervention and collaboration among professionals and families. Part B pertains to pre-school through school-age children, while Part C refers to infants and toddlers. Part C further mandates that agencies work together to provide early intervention in a collaborative manner through family centered services (IDEA Part-C). This legislation sets the parameters for various disciplines engaged in service delivery (McLean and Odom, 1996).
The Joint Committee of the American-Speech-Language-Hearing Association and the Council of Education of the Deaf (1994) described the necessary roles, knowledge and experience of team members providing early intervention to children who are deaf and hard of hearing from birth to 36 months, as presented in IDEA-Part C.
A multidisciplinary team approach is specified in which two or more disciplines provide services in a collaborative manner, along with the parents. All stages of intervention (including identification, assessment, planning and management) should be conducted by professionals with appropriate qualifications. Professionals and parent(s) should be equal partners on the team. Compliance with these guidelines suggests several team members are required to meet the needs of the infant or child.
Audiologists are typically the first professional to identify hearing loss in infants and children. While the audiologist's expertise typically includes diagnosis, management and treatment of hearing loss, their expertise may not include related topics, and therefore the support and guidance of other professionals may be paramount in effectively and maximally managing the hearing impaired child. For instance, collaboration between audiologists, educators of the deaf, state agencies and other professionals provides the basis for an effective multidisciplinary team. Unfortunately, especially in rural communities, assembling a true multidisciplinary team may be difficult.
In an effort to provide public schools with guidelines for delivering educational service to students with deafness or hearing loss, the National Association of State Directors of Special Education (NDASE) published a guidelines document (NDASE, 1997). Within the guidelines is a charge to administrators to ensure multiple disciplines are represented on the multidisciplinary team. The document states ''no assessment measures should be given, no results interpreted, and no programming decisions should be made by one individual alone'' (p. 43). It is also clearly stated that individuals with knowledge of hearing loss must participate on the team. While teachers, school psychologists, counselors, and others may participate as team members, the team must have more than one member with knowledge of hearing loss. The guidelines state that if only one individual with knowledge of hearing loss is available within the educational system, it is the system's responsibility to find and contract with another individual so the spirit of the multidisciplinary team is met.
Matsumoto, Rushmer and Talbott (1993) described several benefits of a collaborative team relationship between the audiologist, parents and infant-family specialist. The assertion was that as parents and infant-family specialists participate as an integral part of the audiological team, they ''become empowered to make decisions and requests and develop knowledge of what constitutes quality audiological services for their child'' (p. 26). The five main areas of benefit presented were:
- Parents (and to a lesser degree specialists) have the greatest knowledge of the child. They are most aware of the child's likes and dislikes, what will ''turn him on'' or ''turn him off'' to the testing.
- Specialist and parents will gain first hand experience regarding how the audiologist carries out testing.
- Audiologist and specialist will have greater understanding of each other's responsibilities in working with the family, thereby making it easier to integrate services into a whole rather than merely two separate parts put together.
- Participation on the audiologic team enhances parent's understanding of the audiological evaluation process, results, and terminology.
- Audiologist can gain first-hand information regarding amplification use and needs (pp. 26-27).
Drawing from support in the literature, current best-practice protocols and legislative mandates, a collaborative approach to evaluation, assessment, planning and management of hearing loss in infants and young children has been organized through Minot State University in Minot, North Dakota. The following is a description of the collaborative program that is currently evolving in our area. The program is constantly being adapted as new families participate and present unique needs.
Team Members:
The core members of the multidisciplinary team consist of an audiologist from Minot State University, an audiologist from Trinity Health/Trinity Hospital, an educator of the deaf from the Parent-Infant Outreach Program from the North Dakota School for the Deaf and the parents. Other members of the team vary depending on the needs and situation of the child/family. Teams may also involve a speech/language pathologist, preschool teacher, physician, infant development specialist, or other specialists as appropriate. Given the rural nature of North Dakota, some team interactions occur via telephone, fax, email, letters, or other forms of communication.
Each core team member is certified by their respective national certifying agencies. Additionally, the educator of the deaf (on the core team) has specific training in early intervention with emphasis in speech, auditory skill development, language, communication and academics for children with hearing loss. Since early interventionalists generally do not have specific training in techniques related to hearing loss, it is crucial that the educator of the deaf fill this role on the team.
Assessment and Diagnostics:
Infants and children are referred to the team in a variety of ways. Most referred children have failed universal infant hearing screenings. Other children are referred from rural hospital newborn hearing screening programs, physicians, educators or other specialists.
The referred child is initially seen by the team audiologist for review of their case history and diagnostic audiometric testing. Transient and distortion product otoacoustic emissions and/or behavioral testing are completed. If results suggest hearing loss, frequency specific auditory evoked responses are obtained. An audiologist and the educator of the deaf are present for this testing. If the results are positive for hearing loss the presence of both team members assists the family in receiving immediate information, counseling and the multidisciplinary support network can be initiated at the time of diagnosis.
Following the diagnosis of hearing loss, the child is seen for evaluation by all core team members at Minot State University. Behavioral hearing testing is attempted, distortion product and transient otoacoustic emissions are repeated and acoustic immittance studies are performed to confirm the diagnosis. Parents are counseled regarding the results of diagnostic tests and early clinical observation and the child's physician is contacted by the core team. Genetic, metabolic and other medical consults or examinations may be arranged as the physician deems appropriate.
Throughout the identification and evaluation phase, the educator of the deaf participates in the audiologic evaluations and early intervention process. The educator of the deaf conducts home visits and provides information regarding auditory, speech and language development as well as communication modality options. Additionally, the educator of the deaf assists the parents in accessing appropriate agencies.
Amplification Process:
The amplification process begins as soon as the parents and other team members choose to proceed. While the goal is to fit amplification as soon as possible following the diagnosis of hearing loss, it is important that the family be involved with, and agree with, this decision. By the time these issues are addressed, the educator of the deaf and the audiologist have already established a ''team relationship'' with the parents. Importantly, because the parents have been included in all phases of the identification, evaluation and early management process, the decision to amplify is often an expected next step.
When choosing amplification, it has been helpful for all team members to express observations and concerns. For example, the audiologist present the recommended amplification options appropriate for the child, to the team members. The educator of the deaf discusses the educational, developmental and environmental issues. The parents relate their questions and concerns regarding amplification to the team. Approaching amplification in this manner assists in meeting the needs of the child and the family.
All core team members are present at the initial fitting of amplification. Standard pediatric protocols for assessment, verification, and validation of hearing aid fitting are followed to ensure appropriate fitting.
Information from parents, educator of the deaf, teachers, daycare providers, and others is continuously obtained and frequent follow-up appointments are made.
Continued Intervention:
While the amplification fitting is in process, the Individual Family Service Plan (IFSP) is developed with input from all team members. This meeting may take place in the child's home, in the clinic, or in a meeting area as best meets the needs of the team. Family strengths, as well as their needs and concerns are outlined and a current analysis of the child's functioning is compiled based on formal and informal assessments. Subsequent goals and objectives are developed to address areas identified by the team.
The educator of the deaf provides home visits on a regular basis and is present at subsequent clinic visits. One benefit of home visits is that information and observations are frequently obtained, specific to the child in their environment, which may be overlooked, or not addressed, in the traditional clinical environment.
The collaborative relationship between the audiologist, educator of the deaf and parents continues during the ongoing service provision. Building on the foundation of trust among the professionals and parents, the goal remains to ''integrate services into a whole rather than merely two separate parts put together'' (Matsumoto et. al., 1993).
Throughout service provision, the interactions of the team serve to model the process of collaboration for the family. Parents become familiar with related terminology and concepts, which subsequently assists them in gaining the knowledge and skills necessary to foster the child's development. This empowers parents to actively participate in seeking information, making informed decisions and advocating for their child. Early collaboration also allows the parents a framework on which to build future interactions with professionals.
The intervention process evolves through the preschool years. In preparation for transition into school services (typically age three years) the core team coordinates transition planning meetings with other agencies. This assists in supporting the collaboration between professionals and the family. Since local school districts may have difficulty locating an educator of the deaf within their system, consultative services from the North Dakota School for the Deaf outreach program are available. The core team members usually continue to participate depending on the educational placement of the child.
The observation of the team has been that the transition to the school years has been smoother for children who have been part of a multidisciplinary team since identification of hearing loss.
Summary:
An example of a collaborative approach to amplification in infants and children has been presented. Using the collaborative team approach, audiologists, educators of the deaf and parents, create an effective team for providing amplification and early intervention to infants and children. Although the method of implementation of the program will need to be adapted to each setting, the underlying principles remain the same. It is essential that all team members, especially core team members, practice the elements of true collaboration: interaction, support, trust and respect. When this approach is taken, the outcomes of effective early intervention are realized.
To illustrate the collaborative approach, a case study is presented below. Many details of the case have been left out to maintain confidentiality. Additionally, the intent of this case presentation is to provide an overview of procedures rather than a specific formula for intervention. While this is not to be considered a ''textbook perfect'' case, this case demonstrates how the team navigated specific challenges to reach the goal of effective early intervention.
Case Study: (A brief overview)
A full term, healthy male infant was referred to the core team upon failure of the universal newborn hearing screening. There was no family history of hearing loss, no complications in the pre, peri or post-natal phase, APGAR scores were excellent and in general, there were no identifiable concerns for possible hearing loss. At one month of age distortion product otoacoustic emissions were completed and were depressed or absent at all frequencies. High frequency tympanometry suggested normally functioning middle ear systems. Physician evaluation supported the findings from tympanometry. Three days later, auditory evoked potentials were obtained with click stimuli yielding thresholds in the 50 to 60dBnHL range bilaterally. Frequency specific auditory evoked studies were subsequently completed one month later and supported previous data. A discussion with the parents, physician, audiologist and educator of the deaf occurred.
Bilateral ear impressions were taken two weeks after the team discussion. A recommendation was made to repeat the auditory evoked response studies in two and four months to monitor possible progression of hearing loss.
During the two weeks following the ear impressions, various friends and family members told the parents that a second opinion was warranted since the infant seemed to respond to some sounds. Since the educator of the deaf had already begun home visits with the family, these concerns were immediately part of a team interaction. The infant was referred to another facility. The parents reported that the audiologist completed sound field testing and determined the infant responded to frequency modulated tones within expected levels for chronological age at approximately 75dBHL.
The parents perceived that the child did not have a hearing loss as a result of this second evaluation. The infant was seen by a third audiologist, whose findings supported the original diagnosis, suggesting significant hearing loss. However, the parents were reluctant to proceed with amplification due to the previous sound field testing and the continued pressure from friends and family that the infant appeared to hear certain sounds.
After several team discussions, the family was referred to a facility outside of the state for a fourth opinion. Unfortunately, the child had bilateral otitis media with effusion and the facility stated that although the click evoked potential studies demonstrated some type of hearing loss at approximately 50 to 60dBnHL, the hearing loss was probably confounded by the middle ear involvement. Again, the parents felt that perhaps the hearing loss was not serious. At this point, the infant was four months old.
Throughout the evaluation process, the educator of the deaf continued to make home visits and the core team audiologists met with the parents. Through repeated testing, multiple team interactions and comparison of the infant's auditory and communication development to normally hearing infants, the parents requested trial amplification.
The infant was amplified at seven months with binaural, behind the ear, digital hearing aids using the Desired Sensation Level prescriptive method. Routine follow-up visits to assess, verify and validate the fitting were completed. The educator of the deaf continued to provide auditory training, parent education and other services in the home. By the time the infant was 13 months of age, consistent electrophysiological and electroacoustic data, along with aided and unaided sound field measurements were obtained.
At the time of this writing, the child is just over two years of age. Otoacoustic emissions and electroacoustic measurements continue to be monitored. Behavioral testing using conditioned play audiometry has been initiated. No measurable change has occurred in the hearing loss. Language skills are commensurate with normally hearing peers. Speech and auditory skills are continuing to develop. The core team members continue to collaboratively provide services and the parents are comfortable with being active participants in this process.
REFERENCES
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Goldstein, R. and Aldrich, W.M. (1999). Evoked potential audiometry. Allyn & Bacon: Boston.
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