Early Hearing and Communication Development

Chapter II: Background

The Canadian Historical Perspective on Early Hearing and Communication Development

Author: Dr. Andrée Durieux-Smith

In the past 35 years, the importance of the early identification and management of hearing impairment in children has been the subject of many conferences and task forces in Canada. During this time, recommendations have been formulated addressing the need to identify permanent childhood hearing impairment (PCHI) early in children, with three main themes recurring consistently. These include: the methods to identify hearing impairment accurately in newborns and infants; the population to be screened; and the need to educate physicians, other health care professionals and parents on the signs of hearing impairment in children.

In the 1960s, a conference on "The Young Deaf Child" took place in Toronto, bringing together more than 30 experts from North America, Great Britain, Scandinavia and the Netherlands.¹ The objective of the meeting was to find ways to alleviate the handicap to auditory communication imposed by early hearing impairment. The participants were already aware of the importance of early hearing and communication development (EHCD). Considerable discussion took place on "definitive tests of hearing." Systematic reviews of available tests were presented including new electrical techniques to detect cortical evoked responses to sound in young infants. The hope of identifying hearing impairment soon after birth was expressed, but the technology was not yet available. Neonatal hearing testing was seen as a goal; even then, the possibility of universal neonatal testing was discussed but seen as not achievable because of a lack of accurate methods.

Participants at this conference decided that a focus on infants at risk was a good starting point. However, consensus was not reached on the age at which the use of amplified sound should be initiated. The majority agreed that two years was the maximum delay that could be acceptable, even though some advocated for the use of amplification by 2 months of age. Participants felt that, although research on the most valid and reliable methods was necessary, programs needed to be developed to identify children by 6 months of age. Two steps were recommended - the use of a high-risk register, and the screening of healthy babies in well-baby clinics using simple, well-planned tests and questionnaires.

Ten years later in the 1970s, the Nova Scotia Conference on the Early Identification of Hearing² took place in Halifax. The focal point of discussion at this conference was the approval of methods for screening the hearing of newborns and for identifying children most likely to have a hearing impairment. The recommended procedures included the use of the high-risk register, together with behavioural screening. It is now well known that screening newborns and infants with behavioural tests is not sensitive, specific or reliable.³ Discussions took place on the most accurate methods to assess hearing impairment in infants and whether this was possible. The resulting queries became the subject of a second conference entitled the Early Diagnosis of Hearing Loss in Children,⁴ which took place in Saskatoon. This conference dealt with methods for confirming the presence and degree of hearing impairment within the first six months of life as accurately, rapidly and economically as possible.

Four papers were presented on electrophysiological methods at the Saskatoon conference, and the auditory brainstem response (ABR) was seen as a viable method to accurately identify hearing impairment in graduates of a neonatal intensive care unit (NICU).^5,6 Although it was agreed that more research on ABR was necessary, the clarion call of the Saskatoon conference was that it is possible to identify hearing impairment in the newborn. This was a major breakthrough. At the time, ABR equipment was expensive and its use was seen as being restricted to the screening of high-risk infants. One of the major recommendations of this conference was that infants should be diagnosed by 6 months of age and management initiated immediately.

In the 1980s, several centres in Canada began to carry out research using ABR, most often with babies from NICUs. The results of this research were presented at a symposium - the Canadian Experience in Neonatal Hearing Assessment by ABR,⁷ which took place in 1983 during the biennial meeting of the Electric Response Audiometry Study Group in Ottawa. The research presented at the symposium by Canadian researchers clearly showed that ABR was a powerful tool for the identification of hearing impairment in newborns and infants.

Also in the 1980s, the Health Services Directorate of Health and Welfare Canada (now Health Canada) established a multidisciplinary Task Force on Childhood Hearing Impairment. One of the objectives of the Task Force was to document the activities taking place in each province and territory in the areas of prevention, early detection, diagnosis and management of children with a hearing impairment. Another objective was to develop consensus guidelines that would facilitate the development of strategies leading to the EHCD of children with a permanent hearing impairment. In addition, an awareness campaign on hearing impairment in children, funded by the Health Promotion Directorate, was launched to alert primary care physicians to the importance of early hearing detection and intervention in children with hearing impairment.⁸

To meet one of the objectives of the Task Force, questionnaires were sent to all provincial and territorial health and education ministers to gain information on the identification and management of children with hearing impairment in Canada. The results indicated that no province-wide policies existed at the time, that regions were developing their own individual programs, and that some programs existed in local hospitals as a result of local initiatives. The Task Force developed recommendations to address these issues which were published in a report in 1985.

In the 10 to 15 years that followed, significant progress took place in the development of rapid, valid, reliable and cost-effective technology based on the use of objective physiological measures. In addition, universal screening became the recommendation as targeted screening of high-risk newborns was seen as missing a large number of children with PCHI who had no identifiable risk factors.^9,10

At a time when, in the United States, large universal newborn hearing screening (UNHS) programs were successfully developed,^11-14 a survey was carried out to determine the state of hearing screening programs in Canada. The survey results showed that only 10% (35 out of 384 respondents) of birthing hospitals in Canada had some kind of newborn hearing screening program, and that a wide variety of hearing screening approaches were used. The results of the survey, which was carried out 15 years after the report of the Task Force on Childhood Hearing Impairment was released, also showed that very few of the task force recommendations were in fact carried out.

In 2000, the Canadian Association of Speech-Language Pathologists and Audiologists and the Canadian Academy of Audiology published a Position Statement on Universal Newborn and Infant Hearing Screening in Canada.¹⁵ It shows that large systematic programs are at different stages of development in many parts of Canada. In 2000, for example, the Ontario government announced that an Infant Hearing Program would be developed for the province - newborns have been screened since 2002. And in Alberta, a grant from the Alberta Health Innovation Fund has led to the development of a demonstration project on newborn hearing screening.

In addition, at the time of writing this report, the provinces of New Brunswick and Prince Edward Island had announced the development of provincial EHCD programs.

Conclusions

• The importance of the early identification and management of hearing impairment in children has been recognized in Canada for almost four decades.
• There was no systematic approach to the development of region-wide early hearing and communication development (EHCD) programs before 2000.
• Since 2000, programs have been developed in parts of Alberta, New Brunswick, Ontario and Prince Edward Island, and they are at different stages of development in many other provinces and territories.

Key References

1. Davis H, editor. The young deaf child: Identification and management. Acta Oto-Laryngol. 1965;206(Suppl):1-258.
2. Mencher G. Early identification of hearing loss. New York: Karger; 1976.
3. Durieux-Smith A, Picton TW, Edwards C, et al. The Crib-O-Gram in the NICU: An evaluation based on Brainstem Electric Response Audiometry. Ear Hearing. 1985;6:20-4.
4. Gerber SE, Mencher GT, editors. Early diagnosis of hearing loss. New York: Grune and Stratton; 1978.
5. Galambos R. Use of the auditory brainstem response (ABR) in infant hearing testing. In: Gerber SE, Mencher GT, editors. Early diagnosis of hearing loss. New York: Grune and Stratton; 1978. p. 243-57.
6. Picton TW. The strategy of evoked potential audiometry. In: Gerber SE, Mencher GT, editors. Early diagnosis of hearing loss. New York: Grune and Stratton; 1978. p. 279-307.
7. Durieux-Smith A, Picton TW, editors. Neonatal hearing assessment by auditory brainstem response. The Canadian experience. J Otolaryngol. 1985;14(Suppl):1-55.
8. Durieux-Smith A, Gibson G, Shea R, et al. Information kit on childhood hearing impairment [brochure]. Ottawa: Health Canada.
9. National Institutes of Health. Consensus Statement: Early identification of hearing impairment in infants and young children. Bethesda, MD: 1993.
10. Joint Committee on Infant Hearing [homepage on the Internet]. Year 2000 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. 2000 Jun. Available from: <http://www.infanthearing.org/jcih/>. Also available in: Audiology Today (Special Issue) 2000 Aug.
11. Mehl AL, Thomson V. The Colorado Newborn Hearing Screening Project, 1992-1999: On the threshold of effective population-based Universal Newborn Hearing Screening. Pediatrics. 2002;109(1):1-8.
12. Dalzell L, Orlando M, MacDonald M, et al. The New York State Universal Newborn Hearing Screening Demonstration Project: Ages of hearing loss identification, hearing aid fitting and enrollment in early intervention. Ear Hearing. 2000;21(2):118-30.
13. Vohr B, Carty LM, Moore PE, Letourneau K. The Rhode Island Hearing Assessment Program: Experience with statewide hearing screening (1993-1996). J Pediatr. 1998;133(3):353-7.
14. Brown DK, Dort JC, Sauve R. Newborn Hearing Screening Programs: A truly Canadian perspective. J Speech Lang Pathol Audiol. 2000;24(2):48-58.
15. CASLPA-CAA Position Statement on Universal Newborn and Infant Hearing Screening in Canada. J Speech Lang Pathol Audiol. 2000;24(3):139-41.

Brief International Overview

Authors: Krista Riko and Dr. Martyn Hyde

Many countries are addressing questions and issues surrounding early detection of deaf and hard of hearing newborns and promotion of communication development.

In the United States, the National Campaign for Hearing Health (NCHH) reported that, as of May 2003, 86.5% of all babies born in the U.S. were being screened, and that 38 states as well as the District of Columbia had early hearing and communication development (EHCD) legislation or mandates. Interestingly, of the 13 states reported to have no legislation or policies in place, some reported screening rates as high as 97.6%. Screening rates by state ranged from 22% to 99.5%, but more than two thirds of all states reported that more than 90% of babies were being screened¹.

The quality of the U.S. screening programs was also evaluated. The quality criteria were: the percentage of babies screened, the presence of a state-wide system of coordination, training, quality assurance and establishment of follow-up. Of all the state programs, 40 were rated "excellent" (90%+ coverage and the presence of the other quality indicators); 5 were "good"; and 6 were rated "unsatisfactory" (less than 79% of babies had been screened and there was an absence of the other quality indicators). These evaluations highlight the importance of considering not only screening coverage, but also the other key factors that contribute to program quality.¹

In the United Kingdom, the Newborn Hearing Screening Programme (NHSP) aims to implement hearing screening for all newborns. It will be implemented gradually across the country in three phases, with all areas participating by 2006. As of early 2003, the 23 areas of the first phase had introduced the program and the second phase areas also started participating in early 2003. The NHSP website provides a wealth of information about this program (http://www.nhsp.info).

In Australia, New South Wales is the only state offering universal newborn hearing screening (UNHS) that is funded by the state government. In Western Australia, a state-funded newborn hearing screening program exists in several hospitals that cover about half of the state's births. In other states there is a combination of state-funded and individual hospital coordinated at-risk screening programs. All Australian states and territories have groups that are actively lobbying for UNHS.²

The great international interest in early identification and related issues has been evident in four international conferences that have been held in Como, Italy, since 1998: the European Consensus Conference on Neonatal Hearing Screening (1998), and the International Conference on Newborn Hearing Screening, Diagnosis and Intervention (2000, 2002 and 2004). These conferences have provided an international forum for delegates from over 50 countries to share ideas on a spectrum of topics relevant to the evolution of the world-wide phenomenon of ECHD. Information about these conferences can be found on the 2004 International Conference on Newborn Hearing Screening, Diagnosis and Intervention website (http://www.NHS2004.polimi.it).

As of early 2003, there is no central international inventory of programs but a number of useful electronic sources can be accessed for the most current information. The National Center for Hearing Assessment and Management (NCHAM), located at Utah State University in the United States, has a website (http://www.infanthearing.org) that provides a plethora of information including, for example, basic information for starting programs, available resources and related U.S. statistics. Also located on the website is a newsletter, Sound Ideas, published quarterly, which frequently provides international updates. For example, in November 2002, the newsletter published a report about Croatia, which stated that the country is "well on its way to having a nationwide newborn hearing screening, diagnosis and intervention program."

The European Commission in Brussels (Quality of Life Programme) also has an informative publication - the Newsletter of Project AHEAD II, which stands for Advancement of Hearing Assessment Methods and Devices - Immediate Intervention (http://www.biomed.polimi.it/aheadii/ahead_ii_frames.htm). This newsletter provides international updates and conference/meeting information several times a year for those interested in keeping abreast of the international situation.

Conclusions

• Many countries such as the United States and the United Kingdom have developed universal newborn hearing screening (UNHS) programs and programs related to communication development.
• Other countries are at different stages of program development.

Key References

1. National Campaign for Hearing Health [homepage on the Internet]. State Report Card, 2003 [cited 2003 Aug 13]. Available from: <http://www.hearinghealth.net/pages/home>.
2. King A. Australian Hearing. Personal communication. 2003.

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