HEARINGIMPAIRMENT

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The Ear and Its Work

The sense of hearing provides a background,which gives a feeling of security and

participation in life. It plays a critical role in thedevelopment of speech and language and inmonitoring one’s speech.

The ear is a complex, but delicate structuredesigned to perform a variety of functions: to ableto hear very soft sounds over a wide frequencyrange as well as withstand the very loud sounds, todiscriminate between sounds that vary in pitch andloudness; to be able to locate the direction of arrivalof a sound and in the presence of noise, to be ableto switch on and off a sound of interest.

The human ear perceives simple tones in therange of 20 to 20,000 Hz and also complex signalssuch as speech and music. Both types of signalsare used in the assessment of hearing loss.

Impact of Hearing ImpairmentConsequences of hearing impairment will

depend on the ear/s involved, the degree and thetype of hearing loss and the age of onset.

Hearing impairment leads to loss of normalverbal communication. Due to distortion ofsounds, differentiation of environmental sounds,including speech, is difficult; making soundslouder does not improve the clarity or quality ofsound. Similarly, recruitment, which is anabnormal growth in loudness, a characteristic of

Chapter 1

Introduction

damage to the inner ear, makes it difficult to tolerateloud sounds.

For children with hearing impairment,congenital or acquired before development ofspeech and language, normal speech developmentis interfered with.

With unilateral hearing impairment also,there is difficulty in localizing sound, reducedspeech discrimination. Lower speech and languagedevelopment in children has significant effect ontheir educational, linguistic and auditory perceptualdevelopment.

The hearing-impaired persons have incommon, their difficulty in hearing spoken andother sounds. They also depend on what they seewhich they supplement to what they hear.

AssessmentHearing sensi t iv i ty of each ear i s

measured separately and the severity/degree ofhearing impairment/ hearing loss is generallyclassified in seven categories as per Goodman’s(1965) classification and an additional category- slight hearing loss is added between thenormal hear ing and mild hear ing lossespecia l ly when assess ing the hear ingsensitivity of young children. Table 1 showsthe c lass i f icat ion of severi ty of hearingimpairment.

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Table 1: Classification of Severity ofHearing Impairment

Classification PTA range indBHL

Normal Hearing -10 to 15

Slight Hearing Loss 16 to 25

Mild Hearing Loss 26 to 45

Moderate Hearing Loss 46 to 55

Moderately-severe Hearing Loss 56 to 70

Severe Hearing Loss 71 to 90

Profound Hearing Loss 91 and more

The level of normal conversational speechis approximately 65dBSPL. Thus, for a person withhearing impairment of 60dBHL or more, verbalcommunication would be difficult. This level ofhearing impairment has been equated as 40%hearing impairment as in Persons with Disability(Full Participation, Equal Opportunity andProtection of Rights) Act, 1995. The definition ofhearing disabled as stipulated in the PWD Act, 1995is a person who has a minimum of 60dBHL ofhearing impairment in the better ear in speechconversation frequencies.

Percentage of Hearing Disability(Threshold + Speech DiscriminationScore Based)

The Ministry of Social Justice andEmpowerment, Government of India notifiedguidelines for evaluation of various disabilities andprocedure for certification vide Notification No.16-18/97-NI dated 1st June 2001. Procedure forcalculating hearing disability is based on pure tonethresholds as well as speech discrimination scorein order to arrive at the percentage of the disability.The minimum degree of disability should be 40%in order to be eligible for any concessions/ benefits.

Issue of Disability CertificateThe certificate of disability is to be issued by

a medical board consisting of at least threemembers, of which one shall be anotolaryngologist. Percentage of disability can bedetermined considering Pure Tone Average andSpeech Discrimination Score as shown in Table 2.

Table 2: Percentage of Disability

Category Type of PTA of Better Speech Discrimination PercentageImpairment Ear in dBHL Score of Better Ear of Disability

I Mild 26-40 80-100% < 40%

II(a) Moderate 41-60 50-80% 40-50%

II(b) Severe 61-70 40-50% 51-70%

III(a) Profound 71-90 <40% 71-100%

III(b) Total >91 Very Poor 100%

To obtain Speech Discrimination scores,specialized skills, instruments and standardizedtests are required. Neither the range of instruments

nor standardized tests for speech discrimination invarious languages are presently available in allcenters in the country.

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Chapter 2

Historical Perspective

Historical developments have been dealt withcomprehensively in the Disability Status

Reports published by the RCI, in 2001 and 2003.Since then, significant events such as establishmentand support of early identification and earlyintervention centers by the AYJNIHH, Mumbaiand the Disability Helpline initiated during 2004-05 are worthy of mention.

Establishment of Early InterventionCenters and Training of Personnel

A collaborative project by AYJNIHH,Mumbai and Balavidyalaya, Chennai on ‘EarlyIdentification and Early Intervention towardsInclusive Education of Children with HearingImpairment (0 to 5 years)’ was initiated in 2002.An urgent need was felt to lower the age ofidentification of hearing impairment andstrengthen intervention service delivery. If a largernumber of children with hearing impairmentacquire abilities ensuring their success inmainstream education, they pave the way for moreseverely affected children to avail the services ofspecial schools. The gains shown by children whohave gone through the process of early interventionin India were convincing enough to start a greaternumber of early intervention programs on a pilotproject basis. However, the diploma and degreecourses in special education do not focus enoughon aspects of habilitation with very young childrenwith the exception of the Diploma in TrainingYoung Hearing Impaired Children which isavailable only in three centers in India. This would

mean that any effort to initiate early interventionservices should be accompanied by short termtraining programs for qualified professionals.These programs should be aimed at equippingrehabilitation professionals to handle aspectsespecially pertinent to very young children.Keeping these issues in view, the project wasevolved. The project was conceptualized in twophases:

Phase I: Training of manpower to enablethem to handle very youngchildren.

Phase II: Running the early interventionprograms.

Under the project, it was decided that a one-month orientation program would be given toalready qualified professionals to work withchildren in the age range of 0 to 5 years. Sevencenters were chosen to run the project, namelyAYJNIHH, Mumbai; its four regional centers atSecunderabad, Delhi, Bhubaneshwar and Kolkata;Balavidyalaya, Chennai and NISH, Trivandrum.A training package with curriculum specified, videofilms and manual was evolved. The uniformity ofexecution across centers was ensured through aprogram for Training of Trainers (TOT). Tworepresentatives from each of the seven centersattended the TOT program. Each center wasdirected to periodically conduct one monthorientation programs with an aim to have at least 5per year with ten trainees per batch. Special schools

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already running programs for pre-school childrenand institutions conducting diploma and degreecourses in special education were approached andencouraged to depute professionals/suggestcandidates from among past students of degree anddiploma courses. Interested fresh and orunemployed special educators were also enrolled.

The seven centers under the project werealready providing diagnostic and or interventionservices for children in the 0 to 5 year age group.Thus it was decided that for the second phase, itwould be ideal to run the intervention programsunder close supervision of these centers. Each ofthe centers could appoint a teacher/speech-language pathologist and audiologist who hadundergone the one month orientation program. Ifa center had more than 25 children, two teacherscould be employed. The center could also appointtwo ayahs/helpers. Until now, the focus was on the0 to 2.5 year age group. This was reflected in theorientation programs as well which focused onlyon this age group. The next stage of orientationprograms to handle the 2.5 to 4.5 year age groupwill be launched in the near future. The project isbeing monitored by an advisory group consistingof senior professionals.

Since its commencement in the year 2002,nearly 100 rehabilitation professionals have beentrained through orientation programs to equipthem to handle the 0 to 2.5 year age group. Nearly150 children with hearing impairment under theage of 2.5 years have received intervention at theseven centers under the project. AYJNIHH plansto increase the number of intervention centers bytraining more professionals and also by providingtechnical as well as financial assistance to the extentpossible.

Disability HelplineFrequently due to lack of awareness among

the persons with disabilities and the community,the early identification and rehabilitation processesare delayed. Also the benefits of services offeredby Government and Non-Governmentorganizations for the rehabilitation of persons maynot be availed of by the target group on accountof lack of information. The Disability Linelaunched by AYJNIHH, Mumbai in 2005 wasenvisaged to bridge this gap to some extent byenabling the public to have easy access toinformation regarding disabilities, the servicesavailable in their neighborhood as well as theschemes and concessions offered by theGovernment.

Specifically, the Disability Line providesinformation about:

• Different types of disabilities.

• Diagnosis and intervention strategies.

• Diagnostic and therapy centres.

• Educational opportunities and Specialschools.

• Vocational training and jobopportunities.

• Special Employment Exchanges.

• Government Schemes and facilities.

• Organizations working for PWDs.

• Prevention and management ofdisabilities.

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• DRS/NHFDC forms by fax.

Disability Help Line has presently beenimplemented in Maharashtra, Goa and DelhiTelecom Circles and can be accessed by dialing thefollowing telephone numbers:-

Maharashtra/Goa : 022-26404019/24/43or 155206

Delhi : 011-29825094/95

The implementation of Disability Line forUP, MP, Bihar, Tamil Nadu, Assam & West Bengalare in the pipeline. It would be possible to coverthe whole country in a span of five years or so.

Thus the Disability Helpline would help overcomethe barrier of lack of information which hasblighted many lives in the past.

The most promising development in recentyears is the coming together of a diverse group ofprofessionals, parents/caregivers, policy makers, laypersons and the hearing-impaired themselves inthe prevention, diagnosis/identification andmanagement of hearing-impairment. Such ascenario portends well for persons with disabilitiesas well as for the professionals in the variousspheres of rehabilitation.

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Chapter 3

Manpower Development

Introduction

Manpower in the field of Speech and Hearingconsists of professionally qualified persons

who are involved in a spectrum of activities relatedto persons with impairment–hearing and/orcommunication employed in diverse settings–hospitals, rehabilitation centers, special schools,regular schools, speech and hearing centers,training and research institutions.

Training ProgrammesTraining programs available at various levels

are discussed below:

Under-graduate: B.Sc. (Speech andHearing), AST, BASLP.

Post-graduate: M.Sc.(Speech and Hearing),MASLP, M.Sc. Speech-Language Pathology, M.Sc.Audiology.

Admission RequirementsThose who have successfully completed pre-

university (10+2) in the science stream areadmitted to the B.Sc. course.

To the two-year program, MASLP, candidateswith B.Sc. (Speech and Hearing) or equivalentfrom a recognized institution are admitted.Admission requirements have moved fromperformance at the Bachelor’s level to the entrancetest conducted by the respective universities.

VariationsVariation in the eligibility for admission at

the under-graduate level among universities exists;Physics, Chemistry and Biology combination iscompulsory at the 12th standard level, but othercombinations are also acceptable.

Variations in post-graduate program earlieraffiliated to the Mumbai University, shifted in 2006to Maharashtra University of Health Sciences,Nashik provides for specialization either inAudiology or Speech-language Pathology, in partII (Final year).

Since 2003, M.Sc. (Speech and Hearing)affiliated to Mysore University has been replacedby Master’s degree in Audiology or Speech-language Pathology, a pattern also followed bothat Mangalore and Bangalore Universities.

Training institutions being required to followthe norms of the affiliating universities, variationsamong different programs are seen in depth ofinformation, method of teaching, differences in thepattern of examination and in following thesemester system as against the annual system.These are also true of the Master’s level programs.

The Bachelor’s program currently runs forfour years; during the first three years the focus ison preparing theoretical knowledge base andproviding insights into developing requisite clinicalskills followed by the internship year.

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Despite the uniformity maintained due toRCI regulations regarding minimal infrastructurefacilities, there still exists inter-program variabilitydue to the differences in budgetary allocation andavailability of funds in the various institutions. Thenational institutes have larger budgets therebyenabling state-of-the-art facilities for their trainees.The programs that have to depend on their ownresources are not able to provide similar facilities.

InternshipIntroduction of internship as per the RCI

guidelines, prior to the award of degree, is aprogressive step, which has the merits of creatingparity among the various degree courses andproviding services in the rural areas. Institutionalvariations in the settings, in the placement duration,payment of stipend, are in need of furtherregulations.

Recent years have witnessed a global shift inthe perception and treatment of Persons withDisabilities towards a human rights perspective.This has influenced the various training programsbringing about modifications, time and again, inthe type and content of courses in Speech andHearing, both at the B.Sc. and M.Sc. levels.

Doctoral ProgramThe Ph.D. program in speech and hearing

was available so far only at AIISH, Mysore affiliatedto the University of Mysore. Some candidates havealso got their doctorates in allied streams such asLinguistics and Psychology from otherUniversities/institutions. In spite of interest inpursuing doctoral degrees, the fact that full-timecandidates only were being accepted by Universityof Mysore, and availability of guides werelimitations.

The demand for professionals withdoctorates is on the increase with the advent ofmany new training programs and the recruitmentrules for teaching institutions. The next doctoralprogram in speech and hearing has commencedat AYJNIHH, Mumbai from the year 2007 withaffiliation to Maharashtra University of HealthSciences, Nashik.

Diploma in Hearing, Language andSpeech (DHLS)

Earlier known as Diploma in Managementof Communication Disorders (DMCD) and alsoDiploma in Communication Disorders (DCD), itis a one-year course post higher secondary schoolcertificate qualifying them to assist the speech andhearing professionals and to take up routine clinicalactivities. This program is being conducted in about15 institutions in different parts of the country.

Contrary to the course objectives, most ofthe products are found to be self-employed orworking in private ENT setups as speech andhearing professionals. This may possibly be becausethe government does not include the post of speechand hearing assistant in their grant-in-aid schemesfor schools for the deaf or the mental relardationor the spastics.

Wherever possible and feasible, the DHLSpersonnel may work as substitute teachers orteacher aides in schools. The syllabus and theexaminations currently conform to RCIregulations.

The AIISH, Mysore plans to launch theDHLS program through the distance mode,simultaneously in five different locations in thecountry.

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Diploma in Hearing Aid and Ear MouldTechnology

The RCI has standardized a training programin ear mould making and hearing aid technologyfor those successful at higher secondary level. Aone-year course, started at AIISH, Mysore since2002-03, generates skilled personnel. AYJNIHH,Mumbai also conducts a similar, short durationprogram for educators and personnel working inspecial schools.

Disparity Between Available andRequisite Manpower

About 25 institutions offer Bachelor’s degreeand about 10 institutions offer Master’s degree inSpeech and Hearing across the country.Approximately 750 candidates graduate at differentlevels each year which is woefully short comparedto the needs of manning training programs,furthering the growth of the profession, providingservices. The skewed distribution, geographically,of available professionals in the country and onaccount of emigration of the professionals overseas,the shortage felt is more acute. There is economicfactor also, the cost per trainee being approximatelyRs. 3 lakh/student (Savithri, 2003).

The magnitude of brain drain among speechand hearing post-graduates is reported to be 48%(Nambiar and Shah, 2006). The reasons cited beingbetter financial gains (62%), better career prospects(62%), and better academics. Whereas 50% wentabroad seeking employment, about 30% left forhigher education, and other 20% for personalreasons.

An increasing number of training programsare coming up in smaller towns of the country,sometimes in the same State where two or moretraining programs already exist. The courses mustalso be designed to meet the needs in the country

rather than duplicating without review thecurricula followed in other countries. Theseissues need to be addressed by the professionalassociations and the relevant policy makingforums.

A close evaluation of training programs mustbe undertaken periodically in the light of currentpotential employment opportunities.

Resources for TrainingShortage of human resources to man the

training programs is a major challenge. Freshgraduates with little or no experience are recruitedto provide training to the new entrants.

Published resource material used for thetraining programs are mainly from the West, whichcost substantially. Availability of Indian editions andan increasing number of Indian journals comingup in the field of speech and hearing and allieddisciplines has reduced the budgetary burden.

Programs attached to medical institutionssuch as TNMC, Mumbai; SRMC, Chennai; andMAHE, Manipal have access to extensive medicalliterature.

Access to the main university libraries by thespeech and hearing trainees being limited, therespective programs have to have their ownlibraries. Many institutions have also providedcomputer and internet facilities to the traineesthereby increasing the resource base.

Continuing EducationContinuing Education (CE) is the key for

ensuring that professionals adapt to newdevelopments, which will lead to the growth ofthe profession with consequential benefits to theindividual and to the society.

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CE may be obtained through workshops,seminars, symposiums and conferences conductedby institutions, by the professional associations atthe State and the National levels. These may beRCI approved CE programs of three or five day-duration since it is mandatory for the professionalsto attend such programs for the renewal of theirRCI registration.

Career ProspectsCurrently, a professional in the area of speech

and hearing is able to find employment in a varietyof settings, unlike in the past. However, there is adistinct difference in the number of opportunitiesand the type of work available to those with interestin Audiology and those affiliated to Speech-language pathology. The latter can practice at lowerinvestment since infrastructure requisite is less, butis more man-hour intensive, while the practice ofAudiology requires considerably more financialinvestment, but less manpower dependent.

In spite of the absorption of our graduates injobs in diverse settings, the jobs are isolated andthe one or two persons employed there have toattend to all aspects of the discipline. In someinstances, the rigorous training imparted to thetrainees is not being fully utilized for want of therequisite infrastructure including audiometricrooms and test instruments. A lack of awarenessabout the diverse role the speech and hearingprofessional plays in diagnosis and management,may lead to their being treated as technicians, oftenin a subordinate position withoutacknowledgement of their role as competentmembers of an interdisciplinary diagnosticmanagement team.

RemunerationProfessionals whose work includes a wide

range of duties such as teaching, clinical supervisionand/or clinical services do not get comparableremuneration. Also employment settings dictatethe salary structure and not the duties or theacademic qualifications.

Possessing higher than the requisite academicqualifications does not guarantee betterremuneration for the individual professional,irrespective of how earned while on the job or onstudy leave. This leads to dissatisfaction/ frustrationleaving little motivation among the professionalswho have aptitude and abilities to improve theirqualifications and skills.

Our training programs are well received bothin the country and outside; programs in otherdeveloping countries have looked for support fromour programs. Many professionals, products of ourprograms, have been admitted into doctoralprograms in specialized streams earning accolades.The American Speech-Language-HearingAssociation takes cognizance of the course workcompleted in India for purposes of ClinicalCertification, both in Speech-Language Pathologyand Audiology.

Manpower in Special Education of theHearing Impaired

Special education can be thought of as ameans of secondary and tertiary prevention ofimpairments that eluded primary prevention. Theaim of the special educators is to enable the childrenwith hearing impairment to realize their fullpotential, so that they can achieve a respectableplace in society and enjoy a better quality of life.

Special educators have traditionally beenprimarily placed in special schools for children withhearing impairment. In the prevailing conditions,there are various types of educational programs

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available in India for children with hearingimpairment as given below:

(1) Early Childhood Education or EarlyIntervention programs (Pre-schoolEducation) for infants and youngerchildren (0 to 5 years) with varyingdegrees of hearing impairment.

(2) Special school programs for childrenwith substantial degree of hearingimpairment.

(3) Integrated education programs forchildren with milder degrees ofimpairment in a regular school set up.

(4) Inclusive Education under the SarvaShiksha Abhiyan Scheme wherechildren with impairment of differenttypes and degrees are educated in regularschools with normal peers.

(5) Apart from this, persons with disabilitywithin age group of 14-35 are given theopportunity for education throughNational Open School (NOS).

Thus, it can be seen that there is change inthe focus of education from segregation toinclusion, and late intervention to earlyintervention. A numerical increase is seen in thespecial educators working as early interventionists,resource persons in regular schools and itinerantteachers in inclusive education.

Teacher Training Programs and othertechnical services for the deaf in the countryreceived a boost with the establishment of Ali YavarJung National Institute for the HearingHandicapped (AYJNIHH) in Mumbai in 1983. Atthat time, only eight centers were conductingteacher training programs as reported by Dr. RitaMary (1993). Besides conducting D.Ed. [nowD. S. E. (H.I.)] and B.Ed. (H.I.) at its headquarters

in Mumbai and regional centers in the north(NRC), south (SRC) and east (ERC), AYJNIHHalso has collaborative centers, involving the StateGovernments and the NGOs.

Recognition of the dearth of master trainersto be appointed as faculty at these centers and thepoor quality of the model teaching schools,prompted negotiations with the Universities ofOsmania (Hyderabad) and Calcutta, forcommencement of the B.Ed. (H.I.) trainingprogram at the SRC and the ERC of AYJNIHH,in addition to the programs conducted at Mumbaisince 1997. This enabled several schools to upgradetheir D.Ed. training levels. The M.Ed. (H.I.)program was started at AYJNIHH from 1995–96,and is affiliated to the University of Mumbai.

The training programs in Special Educationfor the Hearing Impaired are regulated by the RCI.Presently there are two centers offeringM.Ed.(H.I.), 15 offering B.Ed. (H.I.) while 38 offerD.S.E. (H.I.) and three centers offer D.T.Y. (H.I.).In spite of the many special educators trained atvarious levels, a wide gap exists between supplyand demand.

Keeping this in view, NCERT through itsRegional Institutes started Multi-category TeacherTraining Programs, which includes orienting theregular school teachers to categories ofimpairments and the modifications required forteaching such children. Such teachers were thenenrolled in Integrated Schools under I.E.D.C.(Integrated Education of Disabled ChildrenScheme) and P.I.E.D. (Project Integrated Educationfor the Disabled).

Distance EducationRCI has also recognized technical expertise

of the Madhya Pradesh Bhoj (Open) University(MPBOU) for conducting the B.Ed. Special

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Education program through the distance mode.Other Universities have also begun to showinterest in running similar programs.

Resources for TrainingAs most trainees in these courses, especially

the diploma courses, are from vernacular mediumwith poor knowledge of English, their limitedexperience in using reference material, utilizationof the resource material from Western countriesposes a major limitation. Short duration of theprograms is an added constraint.

RCI has invited experts in the respectivesubject to prepare requisite material in languageeasy to understand. Some experts have also takenan initiative in developing resource material inregional languages such as Marathi, Tamil, Telugu,etc.

ResearchSince the M.Ed. program has been

introduced, there has been an increased focus on

conducting applied research in the field ofeducation of the hearing impaired. However, manygraduate level teacher training programs do notinclude sufficient input to the teacher traineesabout research and documentations. Systematicorientation towards research would bring aboutfruitful outcome.

ConclusionThere is a need to gear the training programs

to meet the specific needs of the multi-lingual andmulti-cultural population of the country. In spiteof the big strides in the past several decades, muchneeds to be done especially to retain theprofessionals to provide quality services in the causeof which there has been a heavy investment. Ifemigration is a problem, so is professional mortalityand seeking other vocations within the country.

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Chapter 4

Incidence and Magnitude ofHearing Impairment in India

The National Sample Survey Organization(NSSO) and Census of India, defined

hearing disability in a manner not requiring servicesof professionals, standard test procedures and a testenvironment meeting stringent criteria.

Hearing Disability (NSSO Perspective)In the International Year for the Disabled

Persons, the NSSO undertook during the secondhalf of 1981, the most comprehensive survey in its36th round for collecting information related topersons with disability.

In 1991, the NSSO with an extendeddefinition of disability, conducted its 47th roundof survey in July-December 2002, on the specificrequest of the Ministry of Social Justice andEmpowerment, Government of India. Its 58thround of survey was conducted adopting a stratifiedmulti-stage sample design methodology. Itincluded information on physical and mentaldisability, socio-economic characteristics of thedisabled persons, such as age, literacy, vocationaltraining, and the cause, age of onset of disability,marital status, educational level, livingarrangements and activity status.

As this was one of the more comprehensivesurveys, defining disability was done in a verycareful and guarded way to minimize the bias onthe part of the investigators and the respondents.The definition of disability and each type ofdisability was carefully agreed upon by a group withexperts in their respective areas.

Hearing disability was defined as a person’sinability to hear properly. As non-medicalinvestigators/non-professionals conducted thesurvey, hearing disability was assessed based on thequantum of impairment in the better ear. If aperson reported normal hearing in one ear and totalloss of hearing in the opposite ear, normal hearingwas the verdict for the purpose of the survey.

Usage of hearing aids was not taken intoaccount in assessing hearing disability. A person wasstated to have profound hearing impairment if he/she could not hear at all or could only hear loudsounds (such as thunder) or used only gestures tocommunicate.

If a person could only hear when the speakershouted or could hear only if the speaker was sittingin front, hearing loss was considered severe.

Moderate hearing disability was the verdict,if a person having hearing loss did not fit either inprofound or severe category. Such a person wouldask for repetitions when spoken to or would liketo see the face of the speaker. In other words, if theperson reports difficulty in conductingconversation due to hearing problems, he wasconsidered to be in the moderate category ofhearing disability.

Hearing Disability (Census of India,2001 Perspective)

Interest in enumerating the number ofpersons with hearing impairment began in 1876

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in India. In the past counting of such people didnot indicate adopting a clear definition.

The recent head count conducted by Censusof India, 2001 defined persons with hearingdisability as those who cannot hear at all (deaf) orcan hear only loud sounds which clearly excludedpeople who had hearing impairment but who couldhear through use of amplification devices.However, the Census did include as disabled,people who could not hear with one ear but his/her other ear was functioning normally.

The Magnitude of the ProblemAs on 1st March 2001, India’s population

stood at 1,027,015,247 and projected populationin 2016 would be 1,263,543,000 (Census of India,2001). With the present set of concept of hearingdisability, the Census of India, 2001 counted1,261,722 people in whom hearing disability existed(Males 53.4% and Females 46.59%).

A majority of persons with hearing disabilitywere identified in rural India (81.06%) except in

the Union Territory of Chandigarh, Delhi, andDaman and Diu.

NSS 58th Round of Survey estimatedpersons with disability to be 18.49 million (1.8 percent of the total population). Ten per cent of thepersons with disability are likely to have hearingdisability of moderate to profound degree. Thisnumber is likely to go up if we add lower degreeof hearing disability.

Prevalence and Incidence of DisabilityA broad idea about the magnitude of

disability can be known if we compare theprevalence of disability as found in NationalSample Surveys conducted at different points oftime. Tables 1 and 2 show that there is a significantdecline in the prevalence and incidence of disabilityincluding hearing disability. This can be attributedto the general growth in health, education andinfrastructure sector.

Table 2: Incidence Rate of Hearing Disabled Persons Per 100,000 Persons

NSS 36th Round 1981 47th Round 1991 58th Round 2002

Rural 19 15 8

Urban 15 12 7

Table 1: Prevalence Rate of Disabled Persons Per 100,000 Persons (Hearing Disability)

NSS 36th Round 1981 47th Round 1991 58th Round 2002

Rural 1844 (573) 1995 (467) 1846 (310)

Urban 1420 (390) 1579 (339) 1499 (236)

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The incidence is almost the same in both therural and urban India. The incidence is alsoobserved to be higher among males than femalesas is the prevalence rate.

The rates among males are 9 and 8, as against7 and 6 among females, respectively, in rural andurban areas.

ConclusionPersons with hearing impairment constitute

a significant portion of our population who can becontributing citizens. Efforts made to providediagnostic and therapeutic services and the effortsput forth to mainstream them will create aninclusive, barrier-free and rights-based society forpersons with disabilities.

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Chapter 5

National Program of Prevention ofHearing Impairment in Operation

A national program on prevention of hearing impairment carried out will discharge our

responsibilities as well as comply with thestipulations in the Persons with Disability Act,1995.

Measures stipulated in the Act to be takenfor prevention and early detection of hearingimpairment include conducting surveys todetermine the underlying cause of disabilities;utilizing various methods to prevent disabilities;screening of children at least once a year; providingtraining to staff at the primary health centres; takingsteps for prenatal, perinatal and postnatal care ofchildren; educating the public and creatingawareness through mass media.

Some or all of the above activities arebeing carried out in different centres acrossthe country.

Surveys to Determine the Cause ofDisabilities

Data has accrued on the hearing status ofadults. But there is dearth of information on theincidence and prevalence of hearing impairment,among infants and children. Throughquestionnaires alone, valid and reliable informationon hearing loss cannot be garnered. Only surveyswhere competent persons have evaluated theinfants or toddlers would provide the numberswith hearing-impairment in this age group.

Methods to Prevent DisabilitiesThe most effective way to carry out

prevention is through pubic education. Educatingdifferent target groups on the causes of hearingimpairment creates greater awareness among them.The increased awareness should help in preventinghearing impairment.

As the manpower directly dealing with theneeds of the hearing impaired is comparatively less,availing services of allied professionals becomesnecessary in creating the country-wide awareness.Existing grass root level personnel working in theDepartments of Health, Education, and Womanand Child, is being used effectively in educatingthe general public on prevention of hearingimpairment.

While the nomenclature varies depending onthe State involved, the function or job descriptionof these personnel is by and large the same. Thisgroup of enthusiastic individuals could beempowered to function more effectively with theright kind of encouragement.

It is imperative that a prevention programshould provide immunization for expectant mothers,infants and adolescent girls to such conditions asmaternal rubella, measles and meningitis.

It is important to reduce the incidence ofhearing problems in children since its effects aremore devastating especially on their

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communication abilities which in turn would affecttheir school performance. Being the future citizensof the country, they should be given the necessaryhelp at the earliest.

While the above measures may reduce theoccurrence of hearing problems, this would nottotally eliminate the problem. Hence, it is essentialto carry out tests to identify the presence of ahearing problem. These tests should be carried outat the earliest to enable early rehabilitation both interms of fitting appropriate amplification devicesand providing speech and language therapy. Earlyrehabilitation is required since there is a criticalage for speech and language development. The laterthe hearing impairment is identified, the gap to bebridged between normal and hearing impairedindividuals would be more. Further, thepsychological stress in such individuals would beless since they would have better speech andlanguage skills, which in turn would enable themto succeed in inclusive set ups. Children with goodspeech and language would also find it easier tofind appropriate job placements later in life. Notonly it is important to identify hearing loss early inindividuals with a congenital hearing loss but alsoin those with an acquired hearing loss since hearingis required for monitoring of speech.

At the program on “National Consensus onPrevention, Identification and Management ofHearing Impairment” held at the All India Instituteof Speech and Hearing, Mysore, in 2005, variousexperts involved with hearing conservation,representing government and the non-governmentsectors, gave their viewpoints.

Personnel Involved in PreventionThe consensus among experts was that

prevention of hearing impairment should becarried out at the doorstep of each household by

grass root level workers, such as, Anganwadiworkers, Accredited Social Health Activists(ASHAs), traditional birth dais and Auxiliary NurseMidwives (ANMs) or Multipurpose HealthWorkers (MPHWs). In the absence of these in thelocality, the responsibility would be taken byEducation Guarantee Scheme (EGS) teachers orLower Primary School (LPS) teachers who wouldbe supervised by a medical officer at the PrimaryHealth Centre (PHC) (Figure 1).

PHC Medical Officer

ANMs andAnganwadi Workers

EGS and LPS teachers

Figure 1: Allied personnel involved in the prevention of hearing

impairment

Training of the Professionals

Figure 2 shows the personnel involved in thecascading of information to the grass root levelworkers.

Apex InstituteProfessionals

Master Trainers (Taluk Health Officer,Medical Officer, School Teachers)

Anganwadi Workers/ASHAs/ANMs/MPHWs

Figure 2: Personnel involved in cascading of information to the grass root level workers

115

Number of Professionals to be Trainedat a time

Figure 3 depicts the number of professionalsto be trained at a time.

Professional from Apex Institute(1 professional)

Master Trainers (20 trainers)

Grass root level workers(2 batches of 30 workers each,

in a PHC covering a populationof appox. 30,000)

Figure 3: Professionals and the number to be trained in a session

Duties of the ProfessionalsThe qualified speech and hearing

professionals, from the apex centres, would orientthe master trainers on prevention of hearingproblems as well as on basic evaluation to be carriedout by the grass root level workers. The evaluationswould include: administration of the high riskquestionnaires, carrying out behavioralobservations and orientation to audiological testsrequiring instrumental usage. The duties of thespeech and hearing professionals and the othersinvolved would be as follows:

Duties of the Medical Officer

(a) Get himself trained on the hows of earlyidentification of hearing impairment.

(b) Train and orient the grass root levelworkers.

(c) Monitor the activities of the ANMs/anganwadi workers.

(d) Determine whether in a given case is atrisk for a hearing loss using the high riskregister for medical professionals.

(e) Practice early medical remedy in casesof external and middle ear infections.

(f) Suggest appropriate referrals as andwhen required.

ASHAs / ANMs / Anganwadi workers / EGS and LPSteachers must

(a) Get trained on early identification ofhearing impairment.

(b) Orient the general public on how toprevent a hearing loss:

(i) Inform them about possible causesof hearing loss.

(ii) Educate them about immunizationand also administer vaccinations oninfants, adolescent girls andexpectant mothers.

(c) Determine whether a given case is at riskfor hearing loss using the high riskregister for medical professionals.

(d) Screen for hearing loss throughbehavioural observation audiometry.

(e) Suggest appropriate referrals as andwhen required.

The “High Risk” babies should be identifiedat birth and screened immediately. They shouldbe asked to follow-up regularly subsequently for 2to 3 years.

It is essential that there is co-ordinationamong all the professionals associated in theprevention and identification of hearing loss sincebest results are an outcome of team efforts. Figure4 provides an illustration of the linkage betweenthe professionals that are involved.

116

Protocol to be Used for Infant ScreeningDue to cost factor, the protocol that is

currently suggested for prevention andidentification is restricted to using simplebehavioural techniques. However, in due course,it is proposed to use the protocol developed by

Figure 4: Illustrating the linkages among the professionals

Yathiraj, Vanaja and Manjula based on theliterature. All children who might have a hearingloss should be identified by the age of 3 monthsirrespective of whether or not they are at highrisk (Figure 5).

117

Figure 5: Flow chart of the test protocol suggested to be used for infant hearing screening

118

Protocol Used for Screening SchoolChildren

It is also necessary to identify school-goingchildren with hearing impairment. Hearing lossin school-going children can be identified by theteacher by using a checklist regarding the signs andsymptoms of hearing loss. In addition, it isrecommended that Ling’s 6 sound test may be used.Teachers can carry out this test with minimaltraining. For children who can read, the test canbe carried out in small groups. They could be askedto select the correct sound (phoneme) from a groupgiven in a print form. For younger children, thescript could be associated with pictures such“aaaah” with sweets or “iiiiii” with brushing theteeth. Depending on the region where the test isbeing administered, the choice of phonemes wouldvary.

Frequency and Media to Train theProfessionals

Once in two years, refresher programsshould be conducted in the local language usingminimum technical terms for the master trainersand their support staff using audio-visual aids anddemonstration of the test procedures. Using thematerials available at the national institutes, thetraining sessions should follow a test module,which incorporates pre- and post-evaluation of thetrainees’ understanding of the disorder, itsassessment and management.

Currently, the All India Institute of Speechand Hearing, Mysore, has put in place the infantscreening program at a few districts in the southernstates. Team effort is a necessary ingredient for thesuccess of a program purporting to identify hearingloss where every member and all concerned workin co-ordination.

119

Chapter 6

Early Identification and Intervention

The issues in early identification to beaddressed are (i) population/location of

screening, (ii) technique/tools for screening, (iii)human resources for screening, (iv) cost, (v)challenges in screening, and (vi) intervention forthe identified.

Population/Location of ScreeningThe larger projects/services have dealt with

both universal hearing screening as well asscreening only those at high risk.

Under the Project of Prevention of Deafnessundertaken at All India Institute of Speech andHearing, Mysore, funded by the Ministry of Healthand Family Welfare, Government of India, Yathirajet al. (2002) reported screening of 28,750 infantsover a period of five years.

Under its Child Care Center, the IndianAssociation of Pediatrics (IAP), Cochin branchinitiated in 2002, a newborn hearing-screeningprogram of high-risk babies. Screening is carriedout using portable automated OAE equipment inall the NICU (Neonatal Intensive Care Units) of19 hospitals with a higher number of deliveries.Those failing the first screen have a repeat screenfour weeks later, followed by ABR if they failedagain.

Basavaraj and Nandurkar (2007) reported onscreening 353 at-risk, 276 high-risk and 77 at-no-risk neonates and infants aged 1 day to 9 months ata tertiary hospital in Mumbai. The HRR criteria

given by Joint Committee on Infant Hearing(2000) was used to develop and evaluate an infanthearing screening module to identify bilateralsevere to profound hearing loss. Behavioral,TEOAE and ABR techniques were compared withthe involvement of the mother/caregiver forbehavioral screening and the nurse for bothbehavioral and TEOAE screening.

They reported that 25% of the babies werenot available for screening due to various reasons.For screening no-risk babies, the parents as well ashospital staff were non-cooperative. Suitablelocation for screening (with ambient noise with<45 dBA) was available near the NICU, but notin the general ward/nursery.

Nagapoornima et al. (2007) reported a largescale incidence study among neonates in the Indiancontext. They examined the incidence of hearingimpairment in a cohort of 1,769 (at risk 279 andat-no-risk 1490) neonates who sought care at atertiary hospital in Bangalore over a period of 3.5years. They screened both neonates as a non-randomized cohort from a population of 8,192neonates seeking care at that hospital. The HRRcriteria were as per the American Joint Committeestatement on Infant Hearing Screening (2000).TEOAE Screening was used at the first level by 6weeks of age. The failed neonates underwent asecond screen within 3 weeks of first screen. ABRand BOA confirmed hearing loss on second failure.The authors reported a general incidence of 5.65per 1000 screened. Further, the incidence in high-

Section IHearing Screening for Early Identification

120

risk infants was 10.75 per 1000 whereas that forno-risk infants was 4.70. Their results show thatscreening only the ‘at risk infants’ may result inmissing out 70% of the newborns with hearingimpairment.

Mathur and Dhawan (2007) report aboutTEOAE screening of 1000 randomly selectedneonates in the first 48 hours of life in a tertiaryhospital. Those failing the first screening were re-screened using TEOAE at three weeks, threemonths and six months of age. Infants who didnot ‘pass’ at these stages were subjected to ABRand oto-endoscopy. They recommend the TEOAEscreening at three months of age as the pass rate ofTEOAE at 48 hours was only 79%, which increasedto 97% at 3 months.

Apart from these, neonatal infant hearingscreening programs are under way in several othertertiary hospitals such as Sri Ramachandra MedicalCollege, Chennai, Post-graduate Institute ofMedical Education and Research, Chandigarh, AllIndia Institute of Medical Sciences, New Delhi,etc. and as part of training programs in sometraining institutions.

Technique/Tools for ScreeningThe technique/tools used for hearing

screening have a lot to do with the population andfunds available for screening. The objective of thescreening also determines the technique and toolsused. From the abundant literature available onhearing screening programs undertaken in USA,UK, Australia and other developed countries, it isevident that the objective of screening is to identifyall degrees and types of hearing loss in each ear. InIndia, one may have to work out the requirementbearing in mind the infrastructure facilitiesavailable for follow up.

Behavioral Observation TechniqueBehavioral Observation Technique continues

to be used even though they do not provide earspecific results for screening as reported byAnupriya (2001), Yathiraj et al. (2002)), Basavarajand Nandurkar (2007), Nagapoornima et al.(2007).

ChecklistsHearing screening checklists have been used

to obtain the report of the caregivers regarding theauditory behavior of their children. One suchchecklist is incorporated in the Interactive VoiceReception System (IVRS) of the DisabilityHelpline launched by Ali Yavar Jung NationalInstitute for the Hearing Handicapped, Mumbai.

In the website www.checkhearing.nic.in,Basavaraj et al. (2006) have incorporated four suchcheck lists for four different age groups. Thechecklists have been validated and they report theoverall sensitivity and specificity of the checklistsas 82% and 75%, respectively.

HRRHigh Risk Register (HRR) continue to be

used as a screening technique. Several versions ofHRR specific to Indian population have beenreported in RCI Disability Status reports (2000 and2003). Several projects use the HRR of AmericanJoint Committee on Infant Screening (2000) as abenchmark HRR.

OAEA variety of makes and models of OAE such

as, fully automated, hand held screeninginstruments, diagnostic instruments are available(see Table 5 for details). Thus, OAE screening hasbeen used widely in the developed countries

121

reporting very high sensitivity and specificity forboth TEOAE and DPOAE measures. However,the same has not been documented in the Indianstudies.

ABRAutomated ABR has been used for screening

in the last decade. Portable instruments withautomated ABR and OAE are available. Thesensitivity and specificity of ABR has beendocumented to be very good. However, ABR hasbeen used more as a second step for theconfirmation of hearing loss in the screeningprocess.

Human resource for screeningHuman resource is directly related to the

tools used, but the validity of screening results inrelation to different categories of human resourcesis lacking apart from sporadic published/unpublished reports.

Basavaraj and Nandurkar (2007) studied thefeasibility of utilizing mothers/care-givers andnurses in hearing screening and report nosignificant differences between the mother/caregivers, nurses and audiologists in carrying outbehavioral screening in case of bilateral severe toprofound hearing loss; also there was no significantdifference between the nurse and the audiologistwhen automated TEOAE was the equipment inuse.

HRRs especially those developed for medicaland non-medical persons (Anitha, 2001) can beadministered by a whole range of personnelincluding trained volunteers.

Hearing checklists are being used under theproject ‘Prevention of Deafness’ at AIISH, Mysoresince 1995-96 to identify school children withhearing loss. Checklists are available on the websitewww.checkhearing.nic.in which can be used bycaregivers, pre-school/school teachers and also forself-assessment by the older group.

Behavioral screening is carried out by trainedtechnicians or audiologists especially if the tool isa kit of noise makers. Training is also required todevelop the skills to observe the auditorybehavioural response.

A checklist to screen school children underthe scheme of Sarva Shiksha Abhiyan of Ministryof Human Resource Development, Governmentof India is also available.

Attempts have been made to sensitize thecaregivers about the normal developmental stagesof auditory behaviour by means of handouts. TheDisability Helpline of AYJNIHH, Mumbaiprovides this information through its IVRS.

OAE screening is mainly done byaudiologists. Nurses have been trained to use theautomated OAE in projects (Basavaraj andNandurkar, 2007). The scenario is same as for ABRscreening.

Besides the techniques/instrumentsmentioned in Table 1, high risk registers and checklists to be used for various age groups have beendeveloped and are in use.

122

Tab

le 1

: Hea

rin

g Sc

reen

ing

Too

ls/M

eth

ods

Sl.

Sour

ce o

fFr

eque

ncies

Type

of

Teste

rA

ppro

xim

ate

No.

stim

uli

(in

Hz)

cove

red

Res

pons

eco

st (i

n R

s.)

1.A

set

of n

oise

mak

ers

with

aB

ehav

iora

l (ey

e bl

ink,

Trai

ned

Pers

onne

l10

00-1

500

com

bina

tion

of th

e ite

ms

star

tle, f

acia

l gri

mac

e,m

entio

ned

belo

w:

loca

lizat

ion,

etc

.)i)

Dru

mi)

800-

1700

Hz

(pea

k at

800

Hz)

ii)M

etal

Kha

njee

raii)

1140

-736

0 (p

eak

at 2

500

Hz)

iii)

Jing

les

iii)

800-

1700

(pe

ak a

t 608

0 H

L)iv

)Sq

ueal

er (

high

freq

uenc

y)iv

)M

axim

um b

etw

een

4 an

d 8

kHL

v)W

oode

n ra

ttle

v)90

0 to

160

0 H

zvi

)St

eel b

ell

vi)

>40

00 H

z

2.H

and

held

aud

io s

cree

ners

Beh

avio

ral (

invo

lunt

ary

i)Pr

ofes

sion

als—

i)12

50 to

250

0i)

Pure

tone

s (d

iscr

ete

and/

ori)

500

Hz,

1 k

Hz,

2 k

Hz,

4 k

Hz

resp

onse

, viz

., ey

e bl

ink,

audi

olog

ists

for

indi

geno

ussw

eep

freq

uenc

y)st

artle

, fac

ial g

rim

ace,

ii)Tr

aine

don

e (a

vaila

ble

ii)N

BN

(di

scre

te a

nd/o

rii)

Cen

ter

freq

uenc

y of

500

Hz,

loca

lizat

ion)

. Beh

avio

ral

Pers

onne

lat

AYJ

NIH

H,

swee

p no

ise)

1 kH

z, 2

kH

z, 4

kH

zre

spon

se a

s in

pla

y/M

umba

i)iii

)E

nvir

onm

enta

l sou

nds

iii)

Vari

able

freq

uenc

yst

anda

rd a

udio

met

ry if

ii)20

,000

-40,

000

the

subj

ect i

s ol

d/fo

r th

ein

telli

gent

eno

ugh

and

impo

rted

one

s.w

ithou

t ass

ocia

ted

prob

lem

s

3.Po

rtab

le s

cree

ning

aud

iom

eter

s50

0 H

z, 1

kH

z, 2

kH

z &

4 k

Hz

Beh

avio

ral (

cond

ition

ed-d

o-25

,000

onw

ards

resp

onse

s)

4.H

andh

eld

Tym

pano

-met

ers

NA

Phys

iolo

gica

l mea

sure

,i)

Aud

iolg

ists

and

viz.

, tym

pano

gram

Oto

lary

ngol

ogis

ts

ii)A

uom

ated

one

s1.

2 la

khs

onw

ards

may

be

used

by

tech

nici

ans

5.H

andh

eld

Imm

ittan

ce m

eter

sN

APh

ysio

logi

cal r

espo

nse

-do-

2.0

lakh

s on

war

dsTy

mpa

nogr

am &

pre

senc

e/ab

senc

e of

Aco

ustic

ref

lex

123

6.Im

mitt

ance

Aud

iom

eter

NA

Phys

iolo

gica

l res

pons

e,A

udio

logi

sts

2.3

lakh

s on

war

dsTy

mpa

nogr

am A

cous

tic&

Oto

lary

ngol

ogis

tsth

resh

old

7.O

AE

scr

eene

ri)

TE

OA

EC

licks

to e

licit

OA

E in

freq

uenc

yPh

ysio

logi

cal r

espo

nse

i)A

udio

logi

sts

&1.

3 la

kh o

nwar

ds

band

s of

1 k

Hz,

1.5

kH

z, 2

kH

z, 2

.8 k

Hz

TE

OA

EO

tola

ryng

olog

ists

& 4

kH

z, (

may

var

y fr

om m

ake/

mod

elii)

Nur

ses

to m

ake/

mod

el)

ii)D

POA

E1

kHz,

2 k

Hz,

2.5

kH

z, 3

kH

z, 4

kH

zD

POA

E A

utom

ated

-

do-

3.0

lakh

onw

ards

& 6

kH

zeq

uipm

ent g

ives

res

ult a

spa

ss /r

efer

8.D

iagn

ostic

OA

E w

ith T

EO

AE

/-d

o-Ph

ysio

logi

cal r

espo

nse

Aud

iolo

gist

s &

4.5

lakh

s on

war

dsD

POA

E o

ptio

nsT

EO

AE

/DPO

AE

Oto

lary

ngol

ogis

ts

9.A

utom

ated

AB

R•

Clic

ksR

esul

t as

pass

/ref

erA

udio

logi

sts

&2.

0 la

khs

onw

ards

•To

ne b

urst

s of

500

Hz,

1 k

Hz,

Oto

lary

ngol

ogis

ts2

kHz

& 4

kH

z

10.

Dia

gnos

tic A

BR

•C

licks

Phys

iolo

gica

l res

pons

e-d

o-4.

5 la

khs

onw

ards

•To

ne b

urst

s of

500

Hz,

indi

catin

g A

BR

wav

e1,

2 &

4 k

Hz

form

to a

sses

s th

resh

old

of h

eari

ng

11.

ASS

RA

M/F

M fr

eque

ncie

s of

500

Hz,

Phys

iolo

gica

l res

pons

esA

udio

logi

sts

7.0

lakh

s on

war

ds1,

2 &

4 k

Hz

indi

catio

nT

hres

hold

of h

eari

ng a

tth

e re

spec

tive

freq

uenc

ies

Inst

rum

ents

with

a c

ombi

natio

n of

the

abov

e ar

e al

so a

vaila

ble.

124

High Risk Register/Checklists for ScreeningDeveloped in India between 2000 and 2007

(1) HRR for Medical persons (Anitha, T.,2001)

(2) HRR for Non-medical persons (Anitha,T., 2001)

(3) Hearing Screening Checklist (Basavarajet al. 2006)

(i) 0-2 years

(ii) 2-6 years

(iii) 6-18 years

(iv) 18+ years

(4) The Screening Checklist for AuditoryProcessing (SCAP) (Yathiraj &Mascarenhas, 2002)

(5) Self Assessment Hearing Handicap :Short-form scale (Vanaja, 2000)

(6) Checklist for identification of hearingimpairment in school going children,Department of Audiology, AIISH,Mysore

Challenges in ScreeningChallenges in undertaking newborn/infant

hearing screening are: the lack of awareness in boththe public and the professionals regarding theimportance of early identification of hearingimpairment; high levels of ambient noise in thetest areas in hospitals; deliveries at homes especiallyin rural areas with the assistance of dais/otherattendants; poor follow-up bringing the initialefforts to nought; and scarcity of technicalmanpower.

Hearing Screening in SchoolsAs part requirement of the clinical work of

under-graduate programs (in Speech andHearing), the school screening has received a

fillip. Government of India Gazette notificationof June 2001 with respect to disability screeningand certification has recommended including 500Hz, 1, 2 and 4 k Hz for hearing screening at 25dBHL. The Non-Government Organizations(NGOs) such as Rotary, Lion, Jaycee Clubscontinue to participate in arranging schoolscreening programs. However, documentation/publication of reports on school screeningprogram continues to be minimal.

The introduction of Sarva Shiksha Abhiyan(Education For All) of Ministry of HumanResource Development in the year 2001 hassensitized the primary and secondary schoolauthorities under the State Governments to arrangehearing screening, the school teachers being trainedto identify hearing impairment in children besidesother disabilities. Budgetary provision has beenmade for such activities as well as for theintervention of the children identified withdisabilities.

Identification of Auditory ProcessingDisorders in school-going children needs urgentattention. The screening checklist developed byYathiraj and Mascrenous, 2002 is not used as widelyas desirable due to lack of awareness of thecondition by parents and teachers.

Identification of Noise-induced andAge-related Hearing Loss

No significant progress has been made inscreening industrial workers and others forsuspected noise induced hearing loss. The same isthe status with regard to age-related hearing loss.

People seeking training or employment in theaviation sector are referred to institutes/hospitalsfor audiometry. Self-assessment questionnaires(Vanaja, 2000) developed can be put to use to coverlarger population.

125

National Programme for Preventionand Control of Deafness (NPPCD)

The Ministry of Health and Family Welfare,Government of India in 2006, launched the pilotphase of the National Programme in Preventionand Control of Deafness. One of the objectives isearly identification, diagnosis and treatment ofhearing loss.

In the first phase, a pilot project is beingconducted in 25 districts in 10 States and 1 unionterritory for two years, from 2006 to 2008. It isproposed to expand this programme, in a phasedmanner, to include a total of 203 districts coveringall the States and Union Territories by 2012.Table 2 shows distribution of the same.

Table 2: States/Union Territories, Medical Colleges and Districts Covered under the Pilot Phase of NPPCD

Sl. No. State/UT Medical College Districts

1. Andhra Pradesh Osmania Medical College/ • Mehboob NagarGovt. ENT Hospital, Hyderabad • Nalgonda

• Hyderabad

2. Assam Guwahati Medical College, Guwahati • Kamrup• Sonitpur• Nalberi

3. Gujarat Govt. Medical College, Jamnagar • Jamnagar• Rajkot• Bhavnagar

4. Karnataka All India Institute of Speech and • MandyaHearing, Mysore • Hubli

• Hassan

5. Manipur RIMS, Imphal • Imphal

6. Sikkim Sikkim Manipal Institute of Medical • GangtokSciences, Gangtok

7. Tamil Nadu Christian Medical College, Vellore • Vellupuram• Vellore• Thanjavur

8. Uttarkhand Himalayan Institute of Medical • HaridwarSciences, Dehradun • Dehradun

• Narendernagar

9. Uttar Pradesh King George Medical University, • BarabankiLucknow • Gorakhpur

10. Delhi Lady Harding Medical College, Delhi • North west• West

11. Chandigarh Govt. Medical College, Chandigarh • Chandigarh

126

The fact that early identification not followedby intervention is of no consequence needs noelaboration.

The services/facilities available for earlyintervention in the country is covered under thefollowing: (i) Medical intervention, (ii) Aids,appliances and cochlear implant, and (iii) Auditoryand speech-language training.

(i) Medical InterventionAccumulated wax and otitis media are two

conditions that require medical intervention inschool children. Follow up data is not available tothe extent desirable. Otolaryngologists beingavailable only at the district hospitals, the PHCdoctor manages the ear/conductive hearingproblem at the primary center. Anganwadi workersand other grass root level health workers are trainedto handle acute ear pain, foreign body in the earcanal, etc.

There are about 600 district hospitals in thecountry but not all may have ENT specialists norinfrastructure for audiological assessment. Thescenario is expected to improve as NPPCD hasmade budgetary provisions to meet the deficienciesand a ‘medical kit’ for grass root workers to attendto the ear problems.

(ii) Aids, Appliances and CochlearImplant

Fitting appropriate hearing aids are a crucialstep in initiating successful intervention especiallyin children with pre-lingual hearing impairment.

The status of availability of ‘state-of-art’hearing aids of all styles, makes and models (digital

and analog) in the Indian market have improvedto a great extent with the liberalization of the importpolicies. It is estimated that about 1.85 lakh hearingaids are distributed/sold annually. Of these, about1.25 lakh body level aids are distributed under theADIP scheme. The rest are either assembled orimported for sale in the country.

The Scheme of Assistance to DisabledPersons (ADIP) of Ministry of Social Justice andEmpowerment, Government of India, providesRs. 8,000 per aid per ear for the beneficiary.Binaural aids are provided to school- going childrenwhich may be replaced with new hearing aids everytwo years. Income for eligibility for fully andpartially subsidized aids currently is Rs.6,500 p.m.and Rs.6,501 to Rs.10,000 p.m. respectively. Asolar battery charger with two AA rechargeablebatteries are also included for the beneficiaries.Other appliances such as the auditory trainers, taperecorders and assistive listening devices are notprovided under the ADIP scheme.

The cost of hearing aids is reimbursed foremployees under ESI and CGHS schemes. Someof the State Governments have also made provisionfor distribution of free/subsidized hearing aids. SSAhas budgetary provision to provide hearing aids tothe school going children. Of late, Ministry ofHealth and Family Welfare, Government of Indiaunder NPPCD has finalized the rate contract forBehind-the-ear (BTE) hearing aids.

The hearing aid manufacturers arecontinuing to bring out new models byincorporating advanced technology. TheGovernment sector has not made any significantcontribution in developing indigenous hearing aid.

Section II

Early Intervention for the Identified Population

127

Center for Design of Advance Computing(CDAC), Trivandrum under a project funded byMinistry of Information and Technology hasdeveloped proto types of digital body level hearingaids along with indigenous programming system.This project is in collaboration with AIISH,Mysore.

Hearing aid analyzers, which help inmonitoring the quality of hearing aids are availablein the institutes offering speech and hearing coursesas it has been made mandatory to have them as perthe RCI requirement. Apart from these trainingcenters (which are about 30 in number) theseequipments are available with the hearing aidmanufacturers and some special schools.

Assistive Listening Devices (ALD) such asTV listening aid, alarm devices, telephone listeningaid are not as widely used as would be desirable,though a few companies deal with these devices.

Cochlear implant is not an option by choice,but in terms of candidacy and cost (varying fromRs.5 lakhs to Rs.10 lakhs). Among the elite hearingimpaired, cochlear implant is picking up well,especially in the prelingually deaf. Marketingstrategies and the outcome of cochlear implant inthe implanted children seem to have contributedto the popularity. Three popular brands of cochlearimplant (Nucleus, Medel and Clarion) aremarketed in the country.

AFMC, Pune and INS Ashwini Hospital,Mumbai have made provision for free cochlearimplant for their beneficiaries. Certain corporatehouses also have donated funds to some privatehospitals to help the economically weaker section.The outcome of cochlear implant is good(especially with the pediatric population) wherevera team of professionals is involved.

The network of hearing aid dealers of the

major hearing aid manufacturers in the countryhave provision to supply the spares for the hearingaids (such as cords for body level aids, prebent tubesfor BTE aids) as well the repair of the hearing aid.Repair facilities are available at the major traininginstitutes, some NGOs and private practitioners.Directory of Services published by AYJNIHH,Mumbai provides more information on this issue.

Ear MouldsThe ear mould is the final link between the

hearing aid and the ear. Custom made ear mouldare prepared only at institutions in cities and bysome NGOs and private practitioners. DistrictDisability Rehabilitation Centers (DDRC) ofMinistry of Social Justice and Empowerment hasfacilities for custom ear mould (website:www.socialjustice.nic.in). Facilities to make soft earmolds are available at some centers and with thehearing aid manufacturers/distributors.

(iii) Auditory/Speech-LanguageTraining

Available services are comparatively more inthe urban than the rural sector; the caregivers fromthe latter sector can avail of demonstration therapy,with the objective of facilitating home training.Several early intervention centers run by parentgroups continue to offer quality services. Specialeducators are also involved in auditory/speech-language training though it remains the domain ofthe speech-language pathologists/audiologists.

Recognizing the importance of auditory/speech-language training for the cochlear implantrecipients, the team approach has had a positiveimpact on the caregivers. An increasing numberof special educators and caregivers have benefitedfrom the workshops/training programs in auditory/verbal therapy organized by the manufacturers/distributors of cochlear implants.

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Certificate courses for the caregivers (ofchildren with developmental disabilities) has beenlaunched by AIISH, Mysore and IGNOU incollaboration with the RCI.

To meet the special needs of the age group0 to 5 years, orientation programs of one-monthduration aimed at manpower development areconducted at seven centers across the country byAYJNIHH, Mumbai in collaboration withBalavidyalaya, Chennai.

Availability of affordable educational materialsuch as picture story books, puzzles, audio/videotapes, educational toys, attractive stationery itemshas improved due to the access, through internet,to pictures/material. Indigenously developedsoftware and websites are also available for auditorytraining and speech-language training.

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Chapter 7

Educational Services for Children withHearing Impairment

Introduction

Education of children with hearing impairment in India is just a little over a hundred years

old.

After Independence, improvements wereseen with the establishment of many new schoolsin the 1950s and many programs based on the newtechnology came up in the 1960s.

The sixties saw the establishment of theAll India Institute of Speech and Hearingin Mysore where facilities for diagnosis of hearingimpairment in infants and young children wereavailable. Initially, the Institute also providedchildren with body worn, pocket model hearingaids through an Indo-Danish Aid program. Youngchildren were diagnosed and fitted with suitablehearing aids. This paved the way for theestablishment of the new era schools that used thelatest technology available for educating infants andyoung children with hearing impairment.

For the first time in the country, schools werecreated for early intervention. Infants and youngchildren used individual hearing aids whichfacilitated development of early verbal language.They could be integrated into regular school.

Parents of hearing-impaired children werethe first ones to start these Early Interventionprograms. As contribution of the parents and familymembers gained importance, they were motivatedto take an active role in the education of the hearingimpaired infants and young children.

Educational Provisions Available Today

Schools

At present, over 500 schools for the hearing-impaired children are available in the country. TheGovernment established and administers someschools whereas the NGOs run many others.

Most of the schools, still residential, admitchildren aged 5 years and above who spend theentire school year in the hostels; they go home onlyduring summer vacation. Provision of vocationalcourses and sheltered workshops facilitatesspending almost the entire lifetime of somestudents in these schools.

Schools do not go beyond 8th standard insome States such as West Bengal. Beyond this, theNational Open School is the option.

Schools go up to Higher Secondary level insome States like Tamil Nadu and Maharashtra withvariation in the syllabus for the hearing–impairedstudents; same syllabus as in the regular educationsystem in Tamil Nadu; separate syllabus with awaiver for some subjects in Maharashtra.

Colleges

Two colleges for the Deaf, one in Chennai,Tamil Nadu affiliated to the University of Madrasand another in Valakam, Kerala conduct degreecourses in Commerce and Art subjects; a thirdprogram is under the Indira Gandhi National OpenUniversity, New Delhi.

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The Early Intervention Centres are able tomotivate the family members to take part in theeducation of hearing impaired children whichhelps them develop early verbal language skills. Insome cases, parents and family members haveassumed the responsibility of educating hearingimpaired infants and young children with helpfrom sources such as ENT clinics, speech andlanguage professionals and special educators. Theyhelp the children develop early verbal languageskills and join mainstream schools.

Percentage of Children Having Accessto Education

Assessing the percentage of children whohave access to education is difficult as the exactnumber of children with hearing impairment isnot available. The population of children withhearing impairment from birth to 14 years isestimated to be around 3,07,600. Their educationalstatus in India is as follows:

Graduation and above : 0.9%

Higher Secondary : 1.1%

Secondary : 2.5%

Middle School : 7.6%

Primary School : 19.5%

Without any schooling : 68.8%

The survey shows that only 31% of thehearing impaired children get enrolled in anyschool and only one-third of them continue afterprimary level. The 0.9% of the high achieversincludes children from special schools as well asthe children who get mainstreamed directly orfrom early intervention programs.

Possible reasons for low enrolment ofchildren in schools may be:

(1) There is not enough number of schoolsto enroll all the children.

(2) A majority of schools are situated in citiesand big towns.

(3) Not enough awareness about theavailability of educational services.

(4) Poor economic background of thoseliving in urban slums and rural areas.

The high dropout rate of children can be dueto: poverty, lack of awareness, illiteracy amongparents and family members, and lack of goodeducational system.

Qualitative Aspects of EducationImparted

There was no uniformity in the trainingoffered to teachers of the hearing impaired.Recently, the Rehabilitation Council of India hasrevamped the training courses. However, theeducators are faced with many problems which arediscussed below.

Hearing Aids

• In the ADIP schemes of the Ministry ofSocial Justice and Empowerment,Government of India, only thosehearing aids approved are distributedwhich limits the choice.

• Many parents in the economicallyweaker sections are not able to meet therecurring expenses: replacement of cellsmultiple times in a month, broken cordand damaged receivers, replacement ofear moulds as and when the childoutgrows them.

• Suitable hearing aids are not available toall the children enrolled in the schools.Hearing aids of high-end technology areexpensive. The cells required are verycostly and available only in metro cities.

• Lack of adequate repair services locally.

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• Downtime is more when the childrenin some schools are allowed to use thehearing aids only inside the classrooms.

• Poor knowledge in maintenance andtroubleshooting of hearing aids.

• Lack of periodical review andreplacement of hearing aids, which maynot be meeting the child’s needs forvarious reasons.

• Deprivation of effective hearing aidusage due to improper choice of hearingaids, use of rundown cells and damagedaccessories.

Family/Child Related Factors

• Even in case of day scholars, the schoolsdo not receive family support due topoverty/illiteracy/lack of motivation ofthe family members.

• When the medium of instruction in theschool is not the mother tongue, thechild is being taught in a language whichprecludes communication at homebetween the family members and thechild.

• Many special educators face tremendouspressure in the classroom. Enrolled late,children between 4 years and 10 yearsare admitted into the preparatory classes.

Teachers

• The teachers also have to deal withchildren who have already acquiredsecondary disabilities due to late start.Frustrated children end up with behaviorproblems. Some children suffer fromadditional disabilities and there are nospecific counselors to provide help inthese areas.

• Teachers in the pre-schools are not reallyequipped to help children with hearingimpairment. The duration of trainingprograms conducted is too short to beof real benefit.

• The children admitted areheterogeneous with respect to hearingloss, intelligence, age and familybackground. Hearing loss may rangefrom moderate to profound. Intelligencemay range from borderline to superior.Even with a small class of 8 to 10, thespecial educator finds it extremelydifficult to do justice to every child onaccount of the heterogeneity of thechildren.

• Low salary scales results in schools notbeing able to recruit better teachers.

Schools

• Many schools are not able to develop theinitial linguistic skills of the pupils as theyare forced to follow the textbooks, i.e.,teach academic skills primarily. As aresult children develop rote memorywithout actually internalizing the inputsgiven by the teachers. This ultimatelyreflects in poor social and psychologicalmaturity of pupils.

• The sign language used by some of thespecial schools is not well developed.

• In the residential set up, the students donot receive any input after school hours.

Hearing impairment is different from otherdisabilities. Given an early start, the atrophy ofresidual hearing can be averted and the childrencan be helped to develop early verbal language skillswhich in turn would enable them to bemainstreamed from first standard onwards.

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Meeting the Educational Needs ofChildren with Multiple Disabilities

Educating children with multiple disabilitiesis a difficult task. In India training programs to trainteachers to help children who are ‘deaf-blind’ hasonly recently begun.

As on date, there are no recognized programsto train teachers to help the hearing impaired childwith additional problems such as mentalretardation, autism spectrum disorder, learningdifficulties and spasticity.

ConclusionAs children with disabilities are likely to

suffer from more than one disability, new trainingprograms have to be developed to enable teachersto handle children with more than one disability.

Improved efforts at the planning as well as atthe implementation level is likely to bring aboutthe necessary improvement in the education ofchildren with hearing impairment and otherdisabilities.

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Chapter 8

Parental and Community AttitudeTowards the Disabled

Introduction

The earlier the parent/family accept the fact ofimpairment and follow a well-planned

rehabilitation program under professionalsupervision, the better are the chances for the childand the family to lead a more normal life.

Parental attitudes towards disability includeinter alia acceptance, rejection, indifference andoverprotection.

Acceptance

Some parents are able to accept the sensoryimpairment and show love and concern by lookingfor ways and means to help their child. With thispositive attitude, they soon learn how much theythemselves can do to help their child and howmuch their child is capable of achieving. The otherfamily members may follow suit. Thus, theparental attitude of acceptance helps the child toachieve his potential.

RejectionThere are parents who consider it a stigma

affecting social status and prospects of the otherfamily members if their child has a disability. Theyare averse to acknowledging the presence of sucha child in their family, providing the bare necessitiesof food, shelter and clothing. Some parents sendtheir disabled child to an institution and wash theirhands off him/her.

Indifference

In some cases, parents/family accept thedisabled child and try to find ways to help. Theyshow their love and concern for the child, but theyfind it difficult to treat the child on par with otherchildren in the family. This not only hampers theall round development of the disabled child, butmay also lead to additional problems.

Overprotection

Some parents work towards the developmentof the child, but feel the need to shelter and protectbecause of the disability. Overprotection denies thechild the opportunity to achieve his potential invarious areas of development.

Social Attitude Towards Disability

There has been a change in the societalattitude towards the disabled because of greaterawareness regarding the needs of the disabled andtheir capabilities, and due to increased literacy,especially among women.

The attitude of the parents goes to make thatof the community towards the disabled child. Ifthere is parental willingness to provide the childwith his requisites including emotional support,and providing opportunities for realizing hispotential, the community and society at largewould follow suit.

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The Changing ScenarioGender inequality perceived among the

hearing handicapped is changing in the present dayas women are being given priority in many areas.Much importance is being given to their educationespecially to the disabled girl child. DPEP has aseparate intervention cell to ensure equalopportunities to the girl child in the classroom andin society.

The latest draft of the National Policy onDisabilities has a separate section on women withdisability which is a major development forimproving the status of the disabled girls.

Under the scheme of assistance to disabledpersons for purchase/fitting of aids/appliances(ADIP scheme) the Government endeavors toprovide persons with hearing impairment with aidsand appliances at minimum cost. One of theconditions is that 25% of aids/appliances shouldbe provided to female children/women.

In the Scheme of National Scholarship forPersons With Disabilities, 500 awards giventhrough institutions are equally distributedbetween the male and female students withdisability for pursuing higher and technicaleducation.

Two important schemes, ‘Sarva ShikshaAbhiyan’ and ‘Mahila Samakhya’, are beingimplemented by the Department of ElementaryEducation and Literacy; these primarily aim toreach the girl child including the disabled ones.

The Women and Child DevelopmentDepartment operates programs for persons withdisability. Besides coordinating the implementationof the PWD Act, 1995, it also supports their

economic empowerment through provision ofloans through NHFDC for self–employment andmicro-finance for self-help groups.Implementation of schemes for special schools,scholarships/stipends to students with disability,and pension to severely disabled persons are otherresponsibilities of the Department.

Marital Status of Disabled WomenThe marital status of a girl often determines

her position in society and family. Motherhood alsoplays a crucial role to determine her social status.

For women with disabilities, finding asuitable life partner poses difficulties. Hencemarriage and motherhood seem beyond theirdreams. The disabled women are perceived aspotential burden on the family as they may not beexpected to earn their livelihood and beeconomically independent and/or contribute to thefamily income.

ConclusionA person’s success depends on the

opportunities available to him or her. This is verytrue for children with disability. If children withdisability are identified at a very young age andprovided early intervention, they will developoptimally and reach their potential for developmentenabling them to become contributing membersof society.

Parents of hearing impaired persons and thecommunity play a major role in empowering themthrough providing a strong and stable foundation.With the focus on their abilities andacknowledgement of their right to lead fulfilledlives, undoubtedly much can be achieved.

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Chapter 9

The Role of Government and NGOs in C.B.R. andOther Programmes Developed in the Country

IntroductionRehabilitation of persons with disabilities has

gained momentum in India during the last decadewith several states as well as the UnionGovernment launching programs for their benefit.Community Based Rehabilitation and IntegratedChild Development schemes are two major thrustareas in this endeavor.

Community Based RehabilitationCommunity based rehabilitation for persons

with disabilities (PWDs) was initiated in thedeveloped countries by the World HealthOrganization in 1983. The initial medical focusshifted to the social sphere later.

W.H.O. suggested that the program beintegrated into the already established PrimaryHealth Care System in rural areas. Accordingly,intervention activities were shifted frominstitutions to the community, the family membersand community volunteers, a move whichminimized many difficulties/obstacles such astravel and expenses, associated with institutionbased activities.

Since medical rehabilitation alone was notsufficient to complete the rehabilitation process,C.B.R. programs added interventions such aseducation, vocational training, social rehabilitationand prevention. Thus, C.B.R. today follows a socialrather than a medical model.

C.B.R. attempts to restore or maximize the

full potential and functions of PWDs in theirnatural environment within the family and thecommunity. Its objectives are: to empower PWDsand the communities, to encourage PWDs achievetheir potential, to remove physical barriers, socialand physiological building strategies forsustainability. It also aims at changing negativeattitudes, addressing human rights issues andsharing information, promoting social integrationand learning from communities (Hartley, 2002).

Role of the Government in PromotingC.B.R.

To facilitate smooth operation of the C.B.R.programs, the Government must set upmanagement structures which include policy-making and planning, decentralization, putting inplace appropriate administrative infrastructures.Onward referral systems, provision of resources,training personnel, monitoring and evaluation areother aspects to be covered.

The Government must formulate newpolicies, promote/review existing ones to rectifyany deficiencies in available health services andeducational facilities and in vocationalopportunities that affect the lives of the personswith disabilities.

By formulating a detailed policy statement,the Government puts down the goals to beachieved, changes to be implemented, identifypersonnel responsible, a time frame for changes tobe brought about and a commitment made to

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provide the resources. The Government must usean affirmative strategy to promote participation ofthe disabled.

The Government must mobilize resourcesthrough central and local government bodies,communities and non-government organizations.Some of these resources are – funds, personnel,equipment, transportation, physical structures,statistical services, research activities andinformation availability.

One of the key features of C.B.R. programis decentralization. It must be followed by changeof attitudes. Those responsible for decentralizationmust ensure that the plans and issues concerningthe disabled are streamlined at district and lowerlevels of the local government.

All stakeholders have to be involved insensitization of the technical personnel, politicaland district level authorities to increase awarenessand appreciation of the issues that the persons withdisabilities have to face.

The training of the persons with disabilitiesis essential in building their confidence, capacitiesand capabilities towards realizing their potentialand in actively participating and demanding thatattention be paid to the issues that affect them.

Training of families and communities hasraised awareness on causes, management andprevention of disabilities and has contributedtowards a change in attitude and increasedawareness concerning the provision of resources.

The Government must ensure thattreatment, education, employment and legalservices are operating efficiently. The central andthe state level governments have created severalreferral options – major hospitals, special schoolsand vocational rehabilitation centers. TheGovernment also monitors and evaluatescommunity-based programs.

Due to financial constraints, the governmenthas not been able to extend the C.B.R. programsthroughout the country. Secondly, census data forease of planning and resource allocation for thedisabled has not been adequate (Hartley, 2002).

Role of NGOs in C.B.R. and OtherSimilar Programmes

The efforts of the NGOs have undoubtedlyincreased community awareness about theimportant issues in CBR programmes.

The fundamental difference between theNGOs and the Government agencies is that theNGOs focus on the efforts made by the peoplethemselves to organize and set up sustainableinstitutions, whereas the Government focuses ondelivery of goods and services. The NGOs have apropensity to work in small locations, achievingimpact on the ground, as compared to theGovernment services that usually address the needsof the majority with lesser attention given to themembers of civil society, who may have no voice.

International donors and the Governmentshould incorporate the capacity of the local NGOsinto their plans and programs so that their activitiescan be complementary.

With the current privatization strategies inthe developing countries, NGOs should buildskills that enable them to compete with the privatesector in contracting Government jobs. While theprivate sector may have better skills in bidding forGovernment jobs, the NGOs have widerexperience in working with communities.

Local NGOs have made efforts to make goodthe gaps in promoting the participation of theidentified stake holders, e.g., persons withdisabilities, their parents, the local community, etc.,to redress issues of access to C.B.R. services forpeople with disabilities through various strategies

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that may include (a) Resource mobilization, (b)Community mobilization and sensitization, (c)Community education and training, (d) Attitudeand behavior change, (e) Capacity building, (f)Mechanisms for social and economicempowerment, (g) Research and informationdissemination, (h) Networking, lobbying andadvocacy. Through their participation, local NGOshave served as links between the grass root leveland the international organizations, which havefostered the development of C.B.R.

Local NGOs have the potential to serve asimportant instruments and catalysts for socialchange. For this to happen, there must be aquantum shift in how C.B.R. is perceived and theroles played by the professionals, disabled activistsand the community members involved. A holisticapproach is required to effectively address the feltneeds of the disabled and the problems andchallenges faced by them and their families.

Participation by local NGOs has been verycrucial in the implementation of C.B.R. programs,though the government may take on moreresponsibilities. The NGOs must share theirexpertise in working in a complementary andcoordinated way and not to compete in theimplementation or fund raising for C.B.R.programs in the developing countries (Thomas &Thomas, 2003; Hartley, 2002).

Schemes Undertaken by StateGovernments for Disabled People

Among the schemes initiated by the variousState Governments for the welfare of the disabledpersons, some are nationwide and some are state-specific.

Provision of scholarships and reservation of2-3% seats in I.T.I’s (e.g. Delhi) and 3% jobs is a

common feature across several Indian States/UTs:Kerala, Assam, Bihar, Chandigarh, Dadra & NagarHaveli, Daman & Diu, Orissa, Andaman &Nicobar Islands, Goa, Punjab, Haryana, AndhraPradesh and Delhi.

Aids and appliances are provided fully freeof cost by the States of Punjab, Orissa, Delhi,Mizoram and Goa.

C.B.R. programmes are successfully run inthe States of Andhra Pradesh and Karnataka, butno details are available about other states.

The Andhra Pradesh Government provides3% seats in Government B.Ed. Colleges, languageexemption and grace marks for the deaf. TheGovernment of Kerala provides grant-in-aid tovoluntary organizations, financial assistance to thehandicapped and distress relief fund to the disabledfor medical and surgical purposes. Vocationaltraining centers for the disabled are also provided.

Rehabilitation centers at regional, districtlevels, besides vocational training centers have beenstarted by the Government of Orissa.

The Government of Punjab provides loans(Rs. 2 lakhs) for self-employment, financialincentives for marriage and exemption in medicalexamination fee.

The Delhi Government allots D.D.A. shopsand unemployment allowance to the disabled.

The Government of Karnataka sanctionsmaintenance/conveyance allowance, and busconcessions to the disabled and grant-in-aid to theNGOs. Running schools for the hearing impaired,establishment of a Braille press and a “sound”library are a few more end-results of itsthoughtfulness.

The Mizoram Government has trainingcenters, which impart training to persons with

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disabilities in different trades like tailoring, knittingand shoe-making to enable them to earn theirlivelihood. It provides allowances and pensions tothe disabled.

The Government of Goa rewards a normalperson for accepting a person with disabilities as alife partner. Assisting voluntary organizations forsetting up special schools, providing financialassistance to institutions for taking up detection,intervention and prevention of disabilities are a fewmore of the endeavors of the Government of Goa.

The Gujarat Government has special schoolswhere vocational training is provided for childrenwith impairment, hearing and visual.

Persons with disabilities are eligible to receivefree vocational training and free Braille books, bookallowance and exemption in payment ofexamination fee from the Himachal Pradesh andthe Tamil Nadu Governments, respectively(Menon, 2001).

Central Government Schemes for theRehabilitation of Disabled Persons

The Ministry of Social Justice andEmpowerment, Government of India, under itsscheme to promote voluntary action for personswith disabilities provides grants to the NGOs. Thisis implemented under the heads of salaries,infrastructure development (Hostel + School),rental costs, maintenance grant, stipend to students,transport allowance, grant for vocational training,sports equipment as well as grant for P.T. / O.T. /Speech therapy equipment/special educationmaterial, and grants for seminars, workshops andrural camps.

C.B.R. is an important project initiated bythe Ministry of Social Justice and Empowerment,involving such diverse manpower as ruralrehabilitation volunteers, C.B.R. personnel,

workers for the mentally retarded, social workers,therapists, social educators and vocational trainers.

Also included are legal literacy andcounseling projects, environment-friendly andeco-promotive projects for persons withdisabilities.

The ADIP scheme for purchase/fittings ofAids and Appliances is implemented by theMinistry of Social Justice and Empowerment.Disabled individuals also get scholarships forpursuing education from 9th standard to suchcourses as M.A., L.L.M.

The National Handicapped Finance andDevelopment Corporation (NHFDC) promotesself-employment among individuals with mentalretardation, cerebral palsy and autism. Loanassistance for self-employment in small businessfor the disabled, and loan assistance for agriculturalactivities are available through the NHFDC.

In early 1985, the Government of Indialaunched the District Rehabilitation Center (DRC)Scheme to provide services to those with locomotordisabilities, speech and hearing and the visuallyimpaired, the mentally handicapped and those withmultiple handicaps, operative in 11 different localesin the country. The themes are: prevention, earlydetection, medical intervention, surgicalcorrection, fitment of artificial aids and appliances,therapeutic services inclusive of physiotherapy,speech therapy and occupational therapy, vocationaltraining, provision of educational services in specialand integrated schemes, community and familycounseling.

At the village level the Integrated ChildDevelopment Scheme (I.C.D.S.) functionaries liketeachers and local health workers, undertake thework of disability prevention. They refer cases toPrimary Health Center (PHC)/Community

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Health Centre (CHC)/District Centre ofVoluntary Organization which have specializedrehabilitation personnel. Both medical andparamedical personnel are being trained indisability intervention.

Direct services to the handicapped personsat the headquarters in conjunction with the localhospital authorities are sometimes arranged,courtesy District Rehabilitation Centers.

Composite Rehabilitation ServicesThe 107 Composite Rehabilitation Service

Centers located in 107 districts in the countrypromote early detection and prevention ofdisability, fitment of aids, follow-up and repair ofassistive devices. Vocational training and gainfulemployment is also intended. There are alsoTraining Centers for Adult Deaf, mostly at thetrade-man level.

Regional Rehabilitation Centers for theSpinal Injured

These have been taken up on 90:10 Centre-State sharing basis to establish four regional centers(RRC’s) for the spinal injured, who requiretreatment, long term specialized rehabilitationservices and management for life. Equipment forthese centers is being received from Italy.

National Program for Rehabilitation ofPersons with Disabilities

A State sector scheme, it has provision fortwo community based rehabilitation workers ateach Grampanchayat and two multipurpose

rehabilitation workers at the block level. Its focusis on prevention, early detection and informationdissemination, utilizing the services ofprofessionals such as the physiotherapist, theoccupational therapist, the orthotic and prostheticengineers. The states of West Bengal, Kerala, TamilNadu and Andhra Pradesh run this program.

Child Guidance CentersAll the child guidance centers provide centre

based bio-psychosocial intervention withmultidisciplinary teams in place. They reach outto children with developmental difficulties,academic problems, learning disability,hyperactivity, autism spectrum disorders andbehavior problems. Some child guidance centershave trained manpower such as grass-root levelworkers (Bal Sevikas) and school teachers tobecome force multipliers for supportiveinterventions for children (Singh, 2004).

ConclusionAlthough several states, union territories and

the Government of India have implementedseveral programs/schemes for the disabled, theconsequent benefits have not accrued to all thosein need and not in all states. Further, there is alsovariation in the types of benefits.

Community based rehabilitation is still in itsinfancy. It needs to be implemented in all the statesof India. A broad based strategy is needed to getbenefits of these schemes to reach persons in everystate.

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Chapter 10

Research and Development

Introduction

In a multilingual and multicultural countrywhere a new profession has arrived, R & D

activities are both a necessity and an opportunity.A large population, illiteracy and initially non-existing, but later progressing to inaccessibleservices, brought out the resourcefulness of theinvolved and the concerned.

Need for Research and DevelopmentalActivities

On account of the multidimensional facetsof hearing impairment, R & D activities call for in-depth studies, both inter and multi-disciplinary.This calls for synchronized development in thecore discipline as well as in allied disciplines.

Achievements in technology, bio-technology,information technology, and digital technologyhave ushered in developments in accessibility todigital programmable hearing aids, cochlearimplant surgery, related rehabilitation technologyand auditory genetic diagnosis.

Exploration of indigenous technology andtechniques is crucial to bring benefits oftechnological advances within the reach of theeconomically weakest among the disabled to meettheir needs, whether for identification/diagnosis orhabilitation/rehabilitation. Use of locally availableresearch tools and materials for the developmentof appropriate aids and appliances in the Indiancontext must be expedited so that for want of the

diagnostic tools, diagnostic protocols are notcompromised.

Manpower Development

In human resource development, content oftraining programs as well as different levels needto be evolved to meet unique needs in the country.For instance, are all the courses stacked presentlyfor earning the degrees, graduate/undergraduate,appropriate for our needs? Is uniformity in theadmission requirement for the courses in terms ofthe level completed, the subjects studied, age limitsjustified? Would it be appropriate to introduce anelement of aptitude in the selection of candidatesto reduce mortality before or after completion? Inview of the needs, can we sandwich courses whichutilize the services of the trainees appropriately sothat manpower at several levels is available insteadof or in addition to the diploma/certificate courses?

It must be inculcated early in the trainees sothat their efforts be it in the preparation of theirproject work, dissertation or doctoral thesis shouldbe relevant to our developing economy.

Client Requirement

Exploring alternate sources of funding forclients should be an area of concern. In Denmarkevery person is provided customized servicesthrough CBR. In the U.S. almost 70% of thepopulation is covered by insurance.

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Areas Investigated

The broad scope of research activities thatimpinge either directly or indirectly in the areaof hearing impairment could be delineated asbelow:

In the early days of the arrival of the speechand hearing profession in the country, ofnecessity, efforts were directed at increasingawareness of the problem among the alliedprofessionals and the lay public, adapting theprocedures, the techniques the professionalshad acquired during their training overseas,etc. Simultaneously, clinical services, whichserved as practical training ground for thetrainees, were provided.

Early Identification

Identifying school children with hearing andspeech problems (Nikam & Dharmaraj, 1971) andinfant screening in the maternity hospital projectswere taken up in the late 1960s at AIISH, Mysore.Subsequently, utilization of state-of-the-artinstrumentation/technology such as impedance,ABR and Otoacoustic emission were notable.Projects at the Master degree level and other studieswith the specific objectives to evaluate the differentscreening techniques have been taken up.

Attempts were made to develop a masshearing-screening test for use over the radio andT.V.

Presently, the manpower involved in earlyidentification includes also professionals, alliedprofessionals—medical, non-medical, grass rootlevel workers–anganawadi workers, ANMs, etc.

Tests/QuestionnairesPaper and pencil tests for self-assessment,

questionnaires for early identification of noise-

induced hearing loss have also been developed.

Preparation and maintenance of high riskregisters, and infant cry analysis (Gopal, 1992) wereother attempts at early identification of hearingimpairment.

LocationSite for screening activity is varied: Hospitals,

district hospitals, PHC Centers, schools, etc., arethe varied sites for screening activities.

Development/Adaptation of DiagnosticTest Materials

Studies especially devolving from Masters’dissertations were directed to the development oftest material and tests for speech audiometry(Mayadevi, 1976). Interest in this area led to thedevelopment of tests of SRT and speechdiscrimination in several Indian languages.Adaptations of English language test material forIndian population also drew attention.

Some investigators directed their efforts atdevelopment of tests for the detection of centralauditory processing disorders. Some exploredconstruction of their own tests or tried adaptationof existing ones meant for other purposes.

Development of NormsNorms established for different auditory

disorders were incorporated into routine testingprocedures and were also used by alliedprofessionals such as ENTs, neurologists.

Public Education/OrientationThis is an area which continues to be in the

forefront of the R & D. Pamphlets, slogans,lectures, printed articles are employed widely.Much scope is there for improvement. Firstly, theobjective is to be defined. It seems little thought

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goes into making the printed material suitable/attractive for specific target groups. Secondly, whatare the objectives? Is it to increase awareness, toachieve what purpose - is it to increase referralsfrom the target group, to bring down theprevalence/incidence, to increase the number ofsatisfied hearing aid users, to organize self-helpgroups and similar objectives? Thirdly, afterdetermining the target group, the appropriatenessof the presentation/material is to be examined. Isit to be the printed material (hand outs, articles,and posters), an audio-visual presentation, talk bya professional/affected individual/parent,prominent personality, theater, music or other? Thetime and place—a social-religious occasion,organized camps, mass gatherings such asexhibitions, fairs, are yet to be evaluated for theirsuitability and cost effectiveness. Lastly, how is thesuccess to be measured?

Amplification DevicesEarly attempts at manufacturing hearing aids

resulted in crude trouble prone instruments. Withthe passing of time, research activities led tosophisticated indigenous technology includingnoise suppression circuits. FM systems,programmable/digital hearing aids have appearedin the Indian market.

Ear mould technology too underwent ametamorphosis resulting in improved acousticsignal output and flexibility for tailoring hearingaid responses to individual needs (Babu & Chitre,1973). The advent of BTEs and ITEs in the 1980sprovided impetus for further developmentalactivities though research efforts in this directionwere only sporadic.

Utility of various hearing aids for differentclinical groups was explored. Follow up studiesrevolved around acceptability, care and

maintenance, the costs involved and electroacoustic characteristics of hearing aids over time(Pandalay & Murthy, 1972). Surveys of the statusof the instruments and their accessories were alsotopics of interest.

Methods of hearing aid evaluation andselection were debated as technology made rapidstrides. Computerized instrumentation formeasuring and determining hearing aid benefitsfor the user was an alternate. Studies conductedexamined the issues from various viewpoints,related to hearing aid fitting using differentinstrumentation.

Assistive Listening DevicesAssistive listening devices appeared on the

Indian scene in the late 1980s. Developmentalactivities using indigenous technology resulted incheaper and more suitable devices for localconsumers. Examples are the doorbell alarm,vibralarm, telephone amplifier, telephone ringindicator and tactile aids. In recent times, the adventof SMS facility for mobile phone users has enabledthe literate hearing impaired to experience the joyof instant communication.

The multilingual culture and ethos of Indiahas always posed special challenges to professionalsinvolved in assessment and remediation of speech-language disorders. The multiplicity of languageshas called for the development of tools in variouslanguages, adaptation of western tests,investigations on the acoustic aspects of individuallanguages, as well as attention to speech perception(Oyer, Richard, Rajaguru & Kapur, 1972).

Speech-language characteristics of theclinical population, especially the hearing impaired,has been an area of avid interest to researchers.Much effort has also gone into treating speech and

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language defects in such persons and indevelopment of tools to measure the outcome.

Research StrategiesDiverse strategies have been employed.

Surveys have been conducted for the study of noisepollution in cities. Incidence and prevalence ofhearing disorders amongst children and adults inrural and urban areas have also been surveyed.

Efficacy of tactile aids as compared to hearingaids, are studied using an experimental approachas also the effect of extended frequencyamplification on speech discrimination ability ofchildren with hearing impairment. Single casestudies are the choice in describing the outcomesof specific treatment approaches or to highlight thedifficulties encountered in differential diagnosis.

SettingsVaried settings are desirable as per the

objective. Investigations of language acquisitionamong typically developing children take place inthe natural, home environment. However, theefficiency of auditory site-of-lesion test is alwaysevaluated in an environment where acoustic/temperature/humidity conditions are undercontrol.

Effects of noise on hearing, hearing screeningtests may be studied in a lab or in the field such asa school, factory or a hospital. The purpose dictatesthe choice of environment for recording speechsamples.

Smaller towns may provide quiet rooms fora variety of purposes.

The Scenario TodayThe Persons with Disabilities Act, 1995 states

that the appropriate Government and local

authorities shall promote and sponsor research,inter alia, in the following areas:

(a) Prevention of disability.

(b) Rehabilitation including communitybased rehabilitation.

(c) Development of assistive devicesincluding their psycho-social aspects.

(d) Job identification.

(e) On site modification in offices andfactories.

Recent literature shows that effort has beenexpended on empowerment of mothers,prevention of hearing loss, and the training andemployment of persons with hearing impairment.At the Ali Yavar Jung National Institute for theHearing Impaired, R&D projects completed tilldate include:

(1) Know your hearing sensitivity online.

(2) Socio-economic impact and additionalcost incurred in the upbringing ofpersons with hearing impairment inIndia.

(3) Developing modified school text booksfor children with hearing impairment.

(4) Gender differences in providingrehabilitation services to persons withhearing impairment.

(5) Standardization of Indian Adaptation ofGrammatical Analysis of ElicitedLanguage - Pre-sentence Level(GAEL - P) Test in Marathi.

(6) Disability line for the Persons withDisabilities.

(7) Brain Drain... Is it affecting speech andhearing services in India?

(8) Development of software andconventional kit of ‘Language

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Improvement Indicator ’ - aneducationally relevant languageassessment tool to be used for teachersof the students with hearing impairment.

ConclusionThe current scenario of research in India

leaves much to be desired. Research has for longbeen relegated to the back burner due to the heavycaseload engaging the attention, time and energy

of the professionals. It seems the opportunityprovided thus for collating, analysis andinterpretation are not utilized fully. Poor efforts atdocumentation and publication leads to atremendous loss both for the professionals as wellas the advocates of the hearing impaired.

In keeping with the trend worldwide, thereis need to strengthen evidence based clinicalpractices besides other thrust areas.

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Chapter 11

Vision of the Future

The future beckons…………….. and a newage. Advances in many fields have contributed

in no small measure to development in the field ofrehabilitation. The spillover may be expected tobenefit the disabled sectors well into the nextdecade. The major thrust of developments wouldinclude the following.

Prevalence Rate of DisabilityAs a result of intense preventive initiatives,

medical intervention, better access to health careand nutrition and an increased general awareness,the prevalence rate has shown a marked downwardtrend. There is also a decline in the prevalence rateof hearing and speech disability from 467 to 342 inrural areas and from 339 to 254 in urban areas from1991 to 2002.

With the availability of more sensitive tools,an increase in the geriatric population inter alia thedemand for identification, diagnosis andmanagement of the hearing-impaired is more likelyto increase over the next two decades.

International Classification ofFunctioning, Disability and Health(WHO, 2002)

Assessment of the effect of disability in thecontext of personal and environmental factorsshould be addressed besides evaluating the natureand extent of the impairment suffered by anindividual. Defining disability along the ICFguidelines needs to be hammered out. Efforts arealready on to incorporate the ICF perspective inthe curriculum as has already been done in

countries such as USA, Australia, Indonesia andThailand. Similar strategies would need to be usedby other countries.

Self Help Group (SHG), andWomen with Disabilities (WWD)

The Biwako Millennium Framework (BMF,2002) has placed greater emphasis on empoweringthe PWDs and WWDs. Self Help Groups hastensuccessful empowerment. A very successful modelhas been created through a World Bank assistedproject called “Indira Kranthi Pathan” (previouslycalled ‘Velugu’) in Andhra Pradesh. The packagefor the trainers includes: to resolve conflicts, tosensitize and mobilize the society, to identifyincome generating avenues within the localcommunity, to enable convergence to services, etc.There is need to further consolidate the coursedesign, and research the issues from variousperspectives.

The Aging SocietyOver 6% of India’s population is above the

age of 60 years; a sizeable number of them mayactually have a long term disability or chronicconditions during some periods, before the endcomes.

The foreseeable solution to meeting thelong-term care needs of PWDs during the BabyBoom Aging Wave is to concentrate on thecomprehensive, community based providersystems, including home care, and congregateliving scheme. The need to develop infrastructuresand means to support the needs for expanded care

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will be challenges faced by societies. Meeting theseneeds in institutional settings is precluded byprohibitive costs and practical barriers besidescontradicting the wishes of the people to be served.The training programs and services provided mustbe sensitized to meet the needs of the seniorcitizens.

Capacity Building in Research Relatedto Services and Technology

A lot is done and but more is needed. Ourproduction capacity for aids and appliances is lessthan 10%. Little R & D has gone into theapplication of electronics: strategies must beevolved to sift material, technologies, usercomforts, need, demand, marketing, production,distribution, monitoring and evaluation. India hasa first and also a third world. The needs of boththese worlds along with the emerging sequencesof development have to be anticipated and faced.A welfare state needs to augment human resourceoriented technology to help persons withdisabilities to be employed. The technologicalapplications for employbility of the disabled,prevention of disabilities through industrialaccidents, and also Virtual Reality technology needto be augmented to achieve Social Justice.

Research and investigations should beundertaken to generate statistics about theemployment status of persons with disability(Abdul Kalam, 2004). This is especially requiredfor those who become disabled due to accidentsand other disasters.

Adaptive research with a view to develop cost

effective, user friendly and durable aids andequipments for disabled persons with the help ofvarious technological institutes should beundertaken in the areas of enhanced personalmobility and verbal/non-verbal communication.Design changes in articles of common usage shouldbe encouraged. The key to maximizingeffectiveness of research is the dissemination andsharing of information on the research outcome.

Phenomenal amount of work andexperimentation is happening within the teachingcommunity. Documenting the innovations andfindings, in addition to undertaking researchactivities, need to be encouraged amongst theteachers. Many training programs do not have theinput and wherewithal for research anddocumentation. Hence orientation for research andrefresher courses would bring out fruitfulresearches and documentation, which would helpfellow professionals to reduplicate the success ofothers and find solutions to their failures.

ConclusionIn the years to come institutional building

as well as team building may be key elements thatcould influence the rehabilitation scenario. Teamscomprising of experts from Basic and HearingSciences, and Technology may work together toevolve strategies that could pave the way foraddressing issues in hearing impairment fromdifferent perspectives. A radical change may emergefrom such an endeavor as the scenario would thenbe shaped by the collective efforts of manydisciplines of Science and Technology – aconsortium that rarely operates in India.

Experts who contributed to the section on Hearing ImpairmentMr. R. Rangasayee (Editor) Dr. Vijayalakshmi Basavaraj Ms. Joan D’melloDr. Geetha Mukundan Dr. Asha Yatiraj Mrs. Varsha GattooDr. Rita Mary Dr. Ashok Kumar Sinha Dr. Sudhir BhanMrs. S. Narayanaswamy Mrs. Valli Annamalia Mrs. Usha Dalvi

Mrs. Aparna Nandurkar

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