Our FutureChristine Yoshinaga-Itano, Ph.D.

University of Colorado, Boulder

Department of Speech, Language & Hearing Sciences

What’s changed• Almost every birthing hospital in the

US has instituted a newborn hearing screening program.

• There are 4 million babies born each year in the US

• 2 of every 1000 of these babies will be identified with a permanent and significant hearing loss

• Diagnosis of hearing loss should occur by 3 months of age

What’s changed• Referral to intervention should occur

within 48 hours of the diagnosis of hearing loss

• Where are the children going?

• Currently, the vast proportion of these children are referred to Part C, infant/toddler

THE PROBLEM• Optimal outcomes

• Require

• the highest level of expertise

• in deafness and hearing loss

• at the very beginning

How many children?

• 8,000 to 12,000 children

• could be identified each year

• within the first two months of life

Referral to intervention• Too many points of entry into the system

• Public• State Schools for the Deaf• Education/Health systems

• Private• Public

• Local Educational Agencies• Part C/ Infant-Toddler

• Families are getting lost in the system or appropriate service is delayed.

• INFANT/TODDLER – PART C• IS THE MOST COMMON REFERRAL

• NO OUTCOME DATA FOR NON-CATEGORICAL INTERVENTION

Deafness/Hearing Loss system• All of the successful outcomes data

comes from programs with specialized services for families with children who are deaf or hard of hearing:

OUTCOME DATA• Colorado Home Intervention

Program

• Boys Town Institute Program

• Washington State Early Intervention Program

• Ski-HI early intervention programs

• Auditory-verbal program in UK

SINGLE POINT OF ENTRY

• The Colorado System• Birthing Hospitals• Diagnostic Audiology• Co-Hear Coordinators• Categorical intervention services

• Quality Assurance• On-going training• Options:

• Sign Language Instruction – Deaf/HOH• Integrated/Shared Reading Program• Families for Hands and Voices

Colorado system• Referral from diagnostic audiology

goes to one of 9 regional Co-HEAR coordinators, who are specially trained early-intervention specialists.

• Originally, instituted by the Colorado Department of Public Health and Environment

• Now operated through the Colorado State School for the Deaf and Blind

Co-HEAR system

• Insures that information provided to parents is similar for all families and as unbiased as possible

• Initial counseling and information provided to parents is by an individual with a very high level of knowledge and experience.

Transition from Diagnosis to Early Intervention

Audiologist Confirms Hearing Loss

Hearing Resource Coordinator is ContactedHearing Resource Coordinator is Contacted

Contacts family

Initiates data management

Contacts local agencies

Qualifications of the CO-Hear Coordinator

• Experience working as an interventionist with D/HH infants and toddlers

• Ability to work in partnership with families with specific training for parents of children with hearing loss

• Ability to coordinate and organize activities, including training about hearing loss, with other agencies

• Has sufficient knowledge about infants and toddlers who are D/HH to provide technical assistance to interventionists and professionals from other agencies

• Ability to assume a leadership role

Credentials of the CO-Hear Coordinator

• CCC-A

• CCC-SLP

• Teacher of the D/HH

Responsibilities of the CO-Hear Coordinator – to Support the EHDI Program

• Inputs referral data into the state EHDI program database

• Assists with development and implementation of early intervention programs’ policies and procedures to reflect best practices

• Collects data relevant to early intervention program growth & program evaluation

• Monitors customer satisfaction

• Participates on local ICC for Part C

• Maintains a working relationship with community programs (e.g., Part C, Child Find, local school district programs, local public health offices) by offering information about hearing loss, communication approaches, unique assessment needs of D/HH children

Responsibilities of the CO-Hear Coordinator – to Support Direct Service Providers

• Hires and assists with training of new interventionists

• Supervises interventionists in the region• Disseminates information• Organizes regional workshops• Monitors and reviews interventionists’ quarterly

reports

• Provides 1:1 mentoring to early interventionists• Working with infants• Implementing a family-centered

approach • Supporting selection of a variety of

communication approaches • Expertise in implementing each

communication approach • Learning the “art and science of a home

visit”

Responsibilities of the CO-Hear Coordinator – to Support the Family

• Providing information• counseling strategies (e.g., grieving, coping)• communication approaches• program options

• Securing funding for amplification and early intervention

• Providing service coordination – as the identified service coordinator or in collaboration with the identified service coordinator

Recruiting and Training Hearing Resource Coordinators

• Identify geographic regions• Number of children with hearing loss• Realistic driving range• Familiarity with the community’s services

& supports

• Hold regular administrative meetings

• Provide reimbursement

Coordinating with Part C – State Level

• EHDI Advisory Committee • EHDI Task Forces• Document EHDI system for all stakeholders

(e.g., memos, phone conferences, etc)• clarify the roles of people and organizations that

have expertise specific to sensory disability • An infant or toddler whose primary disability is a

sensory loss must have an assessment team member with expertise specific to infants and toddlers with that disability

• When a referral for a child with a sensory disability is received, an appropriate resource for children with sensory disabilities will be contacted so they may participate in initial contacts with the family

• Recommendation that the multi-disciplinary assessment include assessment procedures and instruments that are appropriate for infants and toddlers with hearing loss (e.g., emphasis on communication, language, modality, functional auditory skills)

• Distribute names of the Hearing Resource Coordinators and their respective counties

• The Hearing Resource Coordinator might be the most appropriate person to act as the Service Coordinator

Coordinating with Part C – Community Level

• Hearing Resource Coordinators attend service coordinator training sponsored by the lead Part C agency

• Hearing Resource Coordinators, or their designee, attends the initial IFSP

• Hearing Resource Coordinator sponsors and attends meetings with local Part C staff

Coordinating with Child Find

• Regional workshops• EHDI statistics• What parents want to know• Unique elements of assessment (e.g.,

audiological report, modality preferences, functional auditory skills)

• Integrating federal and state initiatives (EHDI, Part C, Child Find, State school for the Deaf)

• Meetings in individual school districts• Articles in newsletters• Funding is assumed by the parent organization

(e.g., EHDI funds, State School for the Deaf)

Who are the children entering Kdg• Early-identified prior to 6 months• Early intervention in the first 6 months• Language levels similar to children with

normal hearing with similar cognitive levels – on average (Yoshinaga-Itano, Coulter & Thomson, 2000, 2001)

• 75% with intelligible speech (mild through severe) and profound with cochlear implants by 5 years of age (Yoshinaga-Itano & Sedey, 2000)

• Social-emotional skills at age level (Yoshinaga-Itano & Abdala-Uzcategui, 2000)

INFANT/TODDLERS

• Hard-of-hearing children are more similar to children with

• Moderate to profound hearing loss• Than to children with normal hearing

• In Speech Production (Yoshinaga-Itano & Sedey, 2000)

• And• Language Production (Yoshinaga-

Itano et al., 1998)

PRESCHOOL-AGED CHILDREN• Vocabulary levels are similar to

normally hearing peers (Garafalo & Yoshinaga-Itano, 2005)

• Spoken English syntax is still delayed, as speech production skills are developing (Sedey, 2004)

• Pragmatic language skills are delayed (Sedey, 2004)

• Speech production skills are delayed

• (Yoshinaga-Itano & Sedey, 2000)

• Preschool-aged children with significant hearing loss require highly specific and specialized instruction specific to hearing loss

• In order to enter kindergarten with total language skills and speech production on par with their normally hearing peers

Children who do not maintain age-appropriate communication skills

• Later-identified children (Yoshinaga-Itano et al., 1998; Yoshinaga-Itano, Coulter & Thomson, 2000, 2001)

• Multiply disabled – 40% of population but severity and impact on communication varies (Yoshinaga-Itano et al., 1998)

• Children from non-English speaking families (Nelson, Cardon & Yoshinaga-Itano, 2005)

Special populations

• Children with progressive hearing loss

• Children with acquired hearing loss

• Children with unilateral hearing loss transitioning to bilateral hearing loss

• Children with auditory neuropathy/dysynchrony

Early-identified/early implanted• Children with profound hearing loss

• Trends for cochlear implantation

• Early implantation • Below 2 years of age (Yoshinaga-Itano,

in press)• Regardless of method of

communication• Developing intelligible speech before 5

years of age• Maintaining age-appropriate language

development

Children with auditory neuropathy/dysynchrony

• Approximately 10% of children with bilateral hearing loss (Thomson, Portnuff & Yoshinaga-Itano, 2005)

• Some children who once had otoacoustic emissions but have lost them

• Frequently poor hearing aid users – visual learners

• Some are candidates for cochlear implants

Children with unilateral hearing loss• Children born with SN unilateral hearing

loss who have progressed to SN bilateral hearing loss- 25% of unilateral population

• Asymmetrical hearing loss – • Can have unusual configurations – rising

configurations

• 30% of remaining unilaterals have significant language delays

• Typically have intelligible speech

• Etiologies unknown in 80% of cases

Children from non-English speaking families

• High proportion of later-identified• High proportion of multiply disabled• High proportion of auditory

neuropathy/dysynchrony• High proportion of genetic hearing

loss• Some cultures have consanguinity

issues

• High proportion of ototoxicity• Some cultures dispense ototoxic drugs

over the counter (i.e. China, Mexico)

Children with multiple disabilities

• Increase in low birth weight premature infants

• Severe neurological/cognitive deficits

• Visual disabilities

• Emotional/behavioral disorders

• Learning Disabilities

• Autism/Spectrum Disorder

Deaf Education Reform• Most children identified within the

first few months of life• More than 15,000 children identified

each year and in intervention in the first 6 months

• Great intensity of service required in the first five years of life

• New populations: Children with minimal hearing loss to profound hearing loss, unilateral and bilateral, auditory neuropathy/dysynchrony

• Need for intensive language instruction• Need for intensive auditory/speech

stimulation• Need for Parent education – first five years

of child’s life• Need for single point of entry into

intervention• Need to provide similar service to all

families no matter where they live• Need for expert knowledge in hearing loss

Need for systems change• Parent-infant programs

• Preschool programs

• Day schools – center-based programs

• Residential programs

• THE GOAL FOR: ACADEMIC/COMMUNICATION EXPECTATIONS –

• COMPARABILITY

• WITH HEARING PEERS

Accountability

• Assessments• Consistency within state for

assessment protocols• Consistency nationally for assessment

protocols• Assessments that are necessary for

intervention planning

• Goals guided by assessment data

Statewide developmental databases

• What teaching strategies work?• Are there some developmental areas

that require additional in-service training of teachers and parent-infant interventionists.

• What sub-populations require different teaching strategies?

• State statistics- incidence/prevalence• Success of EHDI/UNHS programs

Single point of entry• State Schools for the Deaf

• State-wide programs• Infant programs• Colorado enrolls almost 300 children

birth through 36 months through the Colorado State School for the Deaf and Blind

• Preschool-aged services would enroll approximately 300 more children

• Elementary school-aged children in center-based programs and residential programs is diminishing• Programs for socialization

• Middle school/High school• At-risk prevention for social/emotional

issues

Residential placement

• Children requiring individualized and intensive educational instruction• Multiply disabled• Neurological/cognitive disabilities• Motor disabilities• Autism• Social-emotional behavioral disorders

Challenge for Deaf Education

• Flexibility

• Adaptability

• Communication success

• Options

• Meeting diverse needs

• Rapid change

A is for AccessCheryl DeConde Johnson, Ed.D.

Colorado Department of Educationjohnson_c@cde.state.co.us;

www.cde.state.co.us

Achieving Authentic

Accessibility for Students who are Deaf and

Hard of Hearing

Communication- driven

High Standards

Critical MassFull

Access

What does Communication Access Mean?

• Able to receive information• Having language to identify what is received• Interweave of cognition and language to

derive meaning• Able to actively participate in flow of

conversation e.g., communication ease

Communication access occurs when there is “shared meaning”.

The Faces of Deaf Education

Modes of Communication

listening/speaking…………………………………………. visual/signing

Languages

English/Spanish (spoken)………American Sign Language (visual)

THE SPI RALI NG EFFECTS OF DEAFNESS source unknown

CULTURAL

ECONOMIC

VOCATIONAL

PSYCHOLOGICAL

SOCI AL

EDUCATIONAL

EXPERI ENTI AL

COMMUNI CATION

LANGUAGE

AUDITORY

ECONOMIC

VOCATIONAL

PSYCHOLOGICAL

SOCIAL

EDUCATIONAL

EXPERIENTIAL

COMMUNICATI ON

LANGUAGE

AUDITORY

VOCATIONAL

PSYCHOLOGICAL

SOCIAL

EDUCATIONAL

EXPERIENTIAL

COMMUNICATI ON

LANGUAGE

AUDITORY

PSYCHOLOGICAL

SOCIAL

EDUCATIONAL

EXPERIENTIAL

COMMUNICATI ON

LANGUAGE

AUDITORY

SOCIAL

EDUCATIONAL

EXPERIENTIAL

COMMUNICATI ON

LANGUAGE

AUDITORY

EXPERIENTIAL

COMMUNICATI ON

LANGUAGE

AUDITORY

COMMUNICATI ON

LANGUAGE

AUDITORY

LANGUAGE

AUDITORY

AUDITORY

Change in Educational Placements-D/HH Students Ages 6-21

Source: US Dept of Ed., 24th Annual Report to Congress, Appendix A, Table AB2, 2002

Year

<21% of time out of

regular class

21-60% of time out of

regular class

>60% of time out of

regular classSeparate Facility

1988-89 26.9% 21% 33.6% 18.6%

1992-93 29.4% 19.7% 28.1% 22.7%

1999-2000

CO

40.3%

65.7%

19.3%

8.4%

24.5%

14.6%

15.8%

11.1%

• WE CAN MEET THE NEEDS OF THE NEW GENERATION OF CHILDREN WHO ARE DEAF OR HARD OF HEARING

• WILL WE ACCEPT THE CHALLENGE?