1. National Center for Hearing Assessment and Management
The Status of Early Hearing Detection and Intervention in the United States
Karl R. White, PhD
National Center for Hearing Assessment and Management
Utah State University

2. Number of Hospitals Doing Universal Newborn Hearing Screening
Number of Programs

3. Why is Implementation of Newborn Hearing Screening Accelerating?
Improved Screening
Techniques/Equipment

4. Why is Implementation of Newborn Hearing Screening Accelerating?
Improved Screening
Techniques/Equipment
Acceptance by
Policy Makers

5. Endorsements for Universal Newborn Hearing Screening
National Institutes of Health
American Academy of Pediatrics
Maternal and Child Health Bureau
Centers for Disease Control & Prevention
Joint Committee on Infant Hearing
American Academy of Audiology
American Speech-Language-Hearing Association
National Association of the Deaf

6. Why is Implementation of Newborn Hearing Screening Accelerating?
Improved Screening
Techniques/Equipment
Increased Number of
Acceptance by
Successful Programs
Policy Makers

7. Why is Implementation of Newborn Hearing Screening Accelerating?
Improved Screening
Techniques/Equipment
Acceptance by
Increased Number of
Policy Makers
Successful Programs
Public
Awareness/Demand

8. Blindness separates people from things.
Deafness separates people from people.
--- Helen Keller

9. Why is Early Identification of Hearing Loss so Important?
Hearing loss is the most frequent birth defect.

10. Rate Per 1000 of Permanent Childhood Hearing Loss in UNHS Programs
Sample Prevalence
Site Size Per 1000
Rhode Island (3/93 - 6/94) 16,
Colorado (1/ /96) 41,
New York (1/ /97) 69,
Texas (1/94 - 6/97) ,
Hawaii (1/ /96) 9,
New Jersey (1/ /95) 15,

11. Incidence per 10,000 of Congenital Defects/Diseases

12. Why is Early Identification of Hearing Loss so Important?
Hearing loss is the most frequent birth defect.
Undetected hearing loss has serious negative consequences.

13. Reading Comprehension Scores of Hearing and Deaf Students
Grade Equivalents
Age in Years
Schildroth, A. N., & Karchmer, M. A. (1986). Deaf children in America, San Diego: College Hill Press.

14. Effects of Unilateral Hearing Loss
Normal Hearing
Unilateral Hearing Loss
Keller & Bundy (1980)
Math
(n = 26; age = 12 yrs)
Language
Peterson (1981)
Math
(n = 48; age = 7.5 yrs)
Language
Bess & Thorpe (1984)
Social
(n = 50; age = 10 yrs)
Math
Blair, Peterson & Viehweg (1985)
(n = 16; age = 7.5 yrs)
Language
Math
Culbertson & Gilbert (1986)
(n = 50; age = 10 yrs)
Language
Social
Average Results
0th
10th
20th
30th
40th
50th
60th
Math = 30th percentile
Percentile Rank
Language = 25th percentile
Social = 32nd percentile

15. Effects of Mild Fluctuating Conductive Hearing Loss
Teele, et al., 1990 )
194 children followed prospectively from 0-7 years. )
Days child had otitis media between 0-3 years assessed during normal visits to physician. )
Data on intellectual ability, school achievement, and language competency individually
measured at 7 years by "blind" diagnosticians. )
Results for children with less than 30 days OME were compared to children with more than
130 days adjusted for confounding variables.
Effect Size for
Outcome Measure Less vs. More OME
WISC-R Full Scale
.62
Metropolitan Achievement Test
Math
.48
Reading
.37
Goldman Fristoe Articulation
.43
Teele, D.W., Klein, J.O., Chase, C., Menyuk, P., Rosner, B.A., and the Greater Boston Otitis media Study Group (1990).
Otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years.
The Journal
of Infectious Diseases ,
162 ,

16. Why is Early Identification of Hearing Loss so Important?
Hearing loss is the most frequent birth defect.
Undetected hearing loss has serious negative consequences.
There are dramatic benefits associated with early identification of hearing loss.

17. Yoshinaga-Itano, et al., 1996 6
Compared language abilities of hearing-impaired children identified
before 6 months of age (n = 46) with similar children identified after 6
months of age (n = 63). 6
All children had bilateral hearing loss ranging from mild to profound,
and normally-hearing parents. 6
Language abilities measured by parent report using the Minnesota
Child Development Inventory (expressive and comprehension scales)
and the MacArthur Communicative Developmental Inventories
(vocabulary). 6
Cross-sectional assessment with children categorized in 4 different
age groups.
Yoshinaga-Itano, C., Sedey, A., Apuzzo, M., Carey, A., Day, D., & Coulter, D. (July 1996).
The effect of early
identification on the development of deaf and hard-of-hearing infants and toddlers
. Paper presented at the
Joint Committee on Infant Hearing Meeting, Austin, TX.

18. Expressive Language Scores for Hearing Impaired
Children Identified Before and After 6 Months of Age 35 30 25
Language Age in Months 20 15 10
Identified BEFORE 6 Months 5
Identified AFTER 6 Months
13-18 mos
19-24 mos
25-30 mos
31-36 mos
(n = 15/8)
(n = 12/16)
(n = 11/20)
(n = 8/19)
Chronological Age in Months

19. Vocabulary Size for Hearing Impaired Children
Identified Before and After 6 Months of Age
300
250
200
Vocabulary Size
150
100
Identified BEFORE 6 Months 50
Identified AFTER 6 Months
13-18 mos
19-24 mos
25-30 mos
31-36 mos
(n = 15/8)
(n = 12/16)
(n = 11/20)
(n = 8/19)
Chronological Age in Months

20. Boys Town National Research Hospital Study of Earlier vs. Later)
129 deaf and hard-of-hearing children assessed 2x each year. )
Assessments done by trained diagnostician as normal part of early intervention program. 6
Identified <6 mos (n = 25) 5
Identified >6 mos (n = 104) 4
Language Age (yrs) 3 2 1
0.8
1.2
1.8
2.2
2.8
3.2
3.8
4.2
4.8
Age (yrs)
Moeller, M.P. (1997).
Personal communication ,

21. Tremendous Progress During the Last Decade
Less than 30 hospitals with UNHS in 1993; compared with more than 2000 today
More than 2 million babies are screened every year prior to discharge
34 states have passed legislation related to newborn hearing screening

22. The Other Side of the Coin . . . .
2,200 hospitals are not yet screening for hearing loss
Almost 2 million babies are NOT screened every year prior to discharge
Existing legislation is of variable quality
Only 9 states (accounting for 7% of the births) have implemented reasonable statewide programs
Follow-up rates are often alarmingly low
Some hospitals have unacceptably high referral rates

23. Status of EHDI Programs in the United States
Universal Newborn Hearing Screening

24. Universal Newborn Hearing Screening
With over half of all babies are screened prior to discharge, has newborn hearing screening become the standard of care?
There are hundreds of excellent programs regardless of the type of equipment or protocol used
Many programs are still struggling with high refer rates and poor follow-up

25. Status of EHDI Programs in the United States
Universal Newborn Hearing Screening
Effective Tracking and Follow-up as a part of the Public Health System

26. Rate Per 1000 of Permanent Childhood Hearing Loss in UNHS Programs
Sample Prevalence % of Refers
Site Size Per with Diagnosis
Rhode Island (3/93 - 6/94) 16, %
Colorado (1/ /96) 41, %
New York (1/ /96) 27, %
Utah (7/ /94) , %
Hawaii (1/ /96) 9, %

27. Tracking "Refers" is a Major Challenge
(continued)
Initial Rescreen
Births Screened Refer Rescreen Refer
Rhode Island
53,121
52,659
5,397
4,575
677
(1/ /96)
(99%)
(10%)
(85%)
(1.3%)
Hawaii
10,584
9,605
1,204
991
121
(1/ /96)
(91%)
(12%)
(82%)
(1.3%)
New York
28,951
27,938
1,953
1,040
245
(1/96-12/96)
(96.5%)
(7%)
(53%)
(0.8%)

28. Status of EHDI Programs in the United States
Universal Newborn Hearing Screening
Effective Tracking and Follow-up as a part of the Public Health System
Appropriate and Timely Diagnosis of the Hearing Loss

29. Audiological Diagnosis
Equipment and techniques for diagnosis of hearing loss in infants continues to improve
Severe shortages in experienced pediatric audiologists are delaying confirmation of hearing loss
Most states are having serious problems linking babies with diagnostic follow-up

30. Status of EHDI Programs in the United States
Universal Newborn Hearing Screening
Effective Tracking and Follow-up as a part of the Public Health System
Appropriate and Timely Diagnosis of the Hearing Loss
Prompt Enrollment in Appropriate Early Intervention

31. Early Intervention Part C of IDEA is an under used resource
Services are generally quite good for babies with severe profound bilateral loss, but less adequate for babies with more moderate loss

32. Key Concepts for Early Intervention
Transactional
Developmental
Family Focused
Holistic
Transdisciplinary

33. Communication Choices
American Sign Language
Total Communication
Auditory Verbal
Auditory-Oral
Cued Speech

34. Technology Decisions Audiological Evaluation Hearing Aids
Cochlear Implant
Assistive Devices

35. Status of EHDI Programs in the United States
Universal Newborn Hearing Screening
Effective Tracking and Follow-up as a part of the Public Health System
Appropriate and Timely Diagnosis of the Hearing Loss
Prompt Enrollment in Appropriate Early Intervention
A Medical Home for all Newborns

36. What Is a Medical Home?
A primary care physician provides care which is:
Accessible
Family-centered
Comprehensive
Continuous
Coordinated
Compassionate
Culturally effective

37. EHDI and the Medical Home
Birthing Hospital
Audiology
Parent Groups
Mental Health
Primary Provider
Child/Family
ENT
3rd Party Payers
Deaf Community
Early Intervention Programs
Genetics
Services for Hearing Loss

38. Status of EHDI Programs in the United States
Universal Newborn Hearing Screening
Effective Tracking and Follow-up as a part of the Public Health System
Appropriate and Timely Diagnosis of the Hearing Loss
Prompt Enrollment in Appropriate Early Intervention
A Medical Home for all Newborns
Culturally Competent Family Support

39. What do families want to know when a child is diagnosed with hearing loss….
What do we do next?
When must we take action?
Where do we get more information?
How do we decide?
Who will help us?
Why do we need early intervention?

40. Emotions of Families with a Deaf or Hard of Hearing Baby
(grief) Reactions to Unexpected Diagnosis
(pressure) Urgency of Communication Decisions Search
(confusion) Search for Experienced Professionals
(isolation) Availability of Services and Support

41. Status of EHDI Programs in the United States
Universal Newborn Hearing Screening
Effective Tracking and Follow-up as a part of the Public Health System
Appropriate and Timely Diagnosis of the Hearing Loss
Prompt Enrollment in Appropriate Early Intervention
A Medical Home for all Newborns
Culturally Competent Family Support
Elimination of geographic and financial barriers to service access