An Update Judith Gravel, PhD Chair, JCIH The Children’s Hospital of Philadelphia

1. An Update Judith Gravel, PhD Chair, JCIH The Children’s Hospital of Philadelphia

2. 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

3. 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

4. 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

5. 1990 • JCIH Position Statement • 1994 • JCIH 1994 Position Statement: detection of HL by 3 months of age, intervention by 6 months

6. Year 2000 Position Statement Principles and Guidelines for EHDI Programs

7. JCIH 2000Components of an EHDI Program • Hearing screening: 1 month • Confirmation of hearing loss: 3 months • Intervention: 6 months (enrollment in early intervention program)

8. JCIH 2000Components of an EHDI Program • Multi-disciplinary team approach • Family-centered, seamless, quality services • Information systems for tracking & follow-up

9. 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

10. 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

11. White 2003; 2004 Survey of State EHDI Officials “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

12. Rankings: 13 Obstacles to Quality EHDI ProgramsWhite 2004

13. 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

14. JCIH 2000Personnel Considerations Provided broad suggestions regarding the assessment & management procedures and knowledge and skills needed by professionals providing services to infants and young children

15. JCIH 2000Audiologic Evaluation: birth – 5 months • Child & family history • Electrophysiologic threshold measure • EOAE • Measurement of middle ear function

16. JCIH 2000Audiologic Evaluation: 6 – 36 months • Child & family history • Behavioral audiometry • EOAE • Acoustic Immittance • Speech perception measures • Parental report • Screen communication milestones • ‘Cross-check’ with ABR

17. JCIH 2000Audiologic Habilitation: Amplification • Prescriptive procedure & real ear measurement • Verification & Validation • Complementary or alternative sensory technology (FM; CI) • Long-term monitoring

18. 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)

19. 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

20. Data Collection - 2003 Culpepper • Survey of State EHDI systems • Web searches for additional resources • Compiled & Reviewed national & international policies, guidelines, and recommendations

21. States with List of Infant Audiology Service Providers Culpepper 2003 Yes Pending No American Samoa Commonwealth N. Mariana Is. Guam Puerto Rico Virgin Islands

22. States with Infant Hearing Assessment Guidelines Culpepper 2003 Mandatory Recommended Pending None developed American Samoa Commonwealth N. Mariana Is. Guam Puerto Rico Virgin Islands

23. 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

24. States with ‘Credentials’ Recognizing Pediatric Audiologists Culpepper 2003 N=56 Yes Pending No American Samoa Commonwealth N. Mariana Is. Guam Puerto Rico Virgin Islands

25. Patrick Brookhouser Barbara Cone-Wesson Brandt Culpepper Judy Gravel Michael Gorga Mary Pat Moeller Linda Pippins MCHB Working Group on Infant Audiology Services • Jack Roush • Richard Seewald • Yvonne Sininger • Patricia Stelmachowicz • Anne Marie Tharpe • Judy Widen • Christie Yoshinaga-Itano

26. 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

27. 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

28. 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

29. 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.

30. 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

31. 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

32. 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

33. MCHB Working Group: Key Principles of Infant Audiology Services • Changing ear canal acoustics: impact on assessment & management • Otitis Media with Effusion (OME) • Sedation

34. MCHB Working Group: Components of Hearing Assessment to Confirm Hearing Loss by 3 months of age • 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

35. 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

36. 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

37. MCHB Working Group: 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 Facilities for Behavioral Audiologic Diagnostic Assessment

38. 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

39. 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

40. Based on MCHB Working Group document: JCIH Stratification System for Quality Infant Audiology Services

41. 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,

42. 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

43. In Development: JCIH 2005 Position Statement and Guidelines

44. 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

45. 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

46. 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

47. JCIH 2005 Position Statement and Guidelines Update, Expand & Revise Principles: • Information for families; professional continuing and pre-professional education

48. JCIH 2005 Position Statement and Guidelines Update, Expand & Revise Principles: • Information systems – electronic health records • Reimbursement for professional services

49. JCIH 2005 Position Statement and Guidelines 2005 overarching theme: Follow-up • Highlight challenges impacting follow-up and tracking of infants after screening • Offer recommendations

50. 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