Early Hearing and Communication Development

Chapter X: Conclusion

Based on formal reviews of published scientific evidence, as well as on expert opinion and consultations with a broad range of stakeholders throughout Canada, the Canadian Working Group on Childhood Hearing (CWGCH) has determined that early hearing and communication development (EHCD) programs incorporating universal newborn hearing screening (UNHS) are feasible and are likely to yield significant overall benefit, relative to traditional methods of identifying permanent hearing impairment in very young children in Canada.

It is necessary, however, to place these inferences in a broad context and perspective. There are geographic variations in demographics, epidemiology and health systems infrastructure. These will affect system performance, many aspects of design and implementation of new programs, and the incremental costs and benefits from such programs.

The evidence reviewed indicates that, while it is possible to develop successful EHCD programs, meticulous attention to all aspects of program design and quality management is necessary in order to achieve substantial net benefits with high cost efficiency. Such programs constitute a chain of events, and the integrity and performance of the overall chain are dominated by its weakest links. The ultimate goal is not merely to screen all babies, but to actually deliver effective services to all children and families in need.

The lack of full consensus on the merits of EHCD based on UNHS can be attributed to several factors. First, there has been an emphasis on long-term language outcomes as the primary index of benefit. While such outcomes are important, they are complex and are mediated by a host of variables that are poorly understood. Yet, the target disorder is hearing impairment and, therefore, amelioration of such impairment and reduction of its duration are the most direct, primary health outcomes. Also, there has been relatively little exploration of concomitant, potential benefits from early identification, such as its impact on family communication, decision making and quality of life. Such possible benefits, as yet poorly understood, may underlie evidence that most families endorse early identification.

Second, the pace of developments in this field is rapid, with the result that lengthy clinical trials, and inferences based upon them, may not reflect current performance accurately. This is most likely in the areas of false-positive screening referrals, diagnostic errors and quality of intervention processes. New evidence has come to light, even throughout the period of the deliberations of the CWGCH.

Finally, the rationale for new programs must reflect societal values and ethics, but these have received little attention, despite their importance.

These issues are crucial and must be weighed, along with the available evidence, when considering whether to implement a new EHCD program.

In summary, then, newborn hearing screening leads to early identification of hearing impairment. Such early identification leads to improved hearing and facilitates communication development.

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