Early Hearing Detection and Intervention (EHDI) programs have created an unprecedented demand for speech and language services for infants and toddlers with permanent hearing loss. With their education and clinical experiences in communication development, speech-language pathologists contribute vital skills to teams serving babies with hearing loss and their families in early intervention (EI) settings. Yet many SLPs have limited experience working with children with hearing loss or providing family-centered EI with babies and parents. More SLPs who have knowledge and experience in this area are needed, as legislation and best-practice models recommend that EI services be provided by highly qualified professionals with expertise in working with young children and families.
The ASHA position statement, Roles and Responsibilities of Speech-Language Pathologists in Early Intervention, outlines four guiding principles for SLPs who provide EI services. It recommends that such services be family-centered and culturally and linguistically responsive; developmentally supportive and promote participation in natural environments; comprehensive, coordinated, and team-based; and based upon the highest-quality available evidence.
Four Clinical Needs
With these guiding principles, SLPs should be aware of four clinical needs unique to providing effective and motivating EI for children and families.
1. Help families establish full-time amplification use and manage the hearing devices.
This first skill is of high priority because it deals with the SLP's role in helping parents manage their baby's hearing aids (HA) or cochlear implants (CI). The HAs or CIs are the means by which the young child's developing brain gains access to sound; if parents have included auditory and spoken language development among the goals for their child (even if they are also using visual communication), full-time device use is an important first milestone to be achieved. Although an audiologist will fit the devices and monitor the hearing loss, the SLP still plays a crucial role in providing ongoing support to parents on issues such as how to insert the devices, how to work quickly toward full-time use, and how to respond when the child pulls the devices out. Recently published data of a small sample of children suggest that families of babies with hearing loss may be experiencing more difficulty achieving full-time hearing device use than previously known (Moeller, 2007). These data include even children who were identified early and received EI in a timely manner.
2. Select developmentally and linguistically appropriate materials incorporating both routine and novelty.
This second skill relates to the developmental appropriateness of EI materials used with babies with hearing loss. Materials designed for even slightly older children are typically inappropriate for infants and toddlers. For example, pictures—which are two-dimensional representations of reality—are more difficult to interpret than are real objects. The younger the child, the more realistic should be the objects (such as pretend food or dolls with clothing).
Children with hearing loss often have a gap between their cognitive and linguistic abilities, a factor that also influences the choice of treatment materials. A young child is best served when SLPs balance the child's competing interests in routine (infants enjoy playing with the same objects repeatedly) and novelty (extending the child's attention by regularly introducing new toys).
3. Be able and willing to discuss communication options, and encourage parents to see communication along a continuum.
Parents of babies with hearing loss balance the demands of everyday family life with the demands of developing their child's communication at home, as do parents of all babies enrolled in EI. But the parent of a baby with hearing loss has the additional—often stressful—task of making decisions about communication methodology, including American Sign Language, manually coded English signs, auditory-oral approaches, or some combination of these.
Parents usually will have made an initial decision about methodology when the first Individualized Family Service Plan is written, before beginning EI. Parents need reassurance that if a child's needs change over time, an initial decision is not a lifelong commitment to one approach. Communication methodologies fall along a continuum, and what may have been appropriate in the early months of EI may require alteration as the child ages.
This issue is of particular importance for families of babies with profound hearing loss who have chosen a CI for their child, but are waiting for surgery until the baby reaches the age recommended by the CI center. Most babies awaiting CI surgery wear traditional hearing aids; some derive benefit from the aids, others do not. Some families struggle with whether or not to use sign as a temporary communication method prior to CI surgery, often relying on the SLP for advice. SLPs may want to counsel families by discussing the pros and cons of using sign prior to CI, based on what is known from published parents reports (Robbins, 2006) that reflect families' experiences with the use of sign during this time. No published research studies address this specific topic; reports from those who have used sign pre-CI may be useful clinical tools (see Table 1 [PDF]).
4. Be flexible. Follow the child's lead and know appropriate ways to counsel parents.
SLPs conducting EI with parents and their babies with hearing loss should view sessions as dynamic opportunities for interaction, not as lesson plans to be completed. Very young children are not as motivated to please adults as much as they are to obtain a desired object. The SLP must take this motivation into account, for instance, when playing games involving object selection (e.g., "Can you find the horse?") because the infant's choice may reflect the infant's toy preference rather than auditory or linguistic ability. All babies become fatigued with vigorous play and have highly variable attention spans. For those with hearing loss, this variability may be more acute because of communication limitations that lead to frustration. Babies may be alert one session, then cranky and uncooperative the next.
The flexible clinician may still have a productive session, using the time to review materials, discuss the baby's adjustment to amplification, and, above all, to listen to parents' questions and expressions of concerns. Parental stress levels associated with having a child with hearing loss have been found to be very high, even relative to parenting a child with other chronic conditions (Quittner et al., 2004). In addition, parents often go through recurring cycles—rather than stages—of sadness, grieving, and acceptance of the hearing loss. SLPs who provide EI to this population should be prepared to deal with the emotional reactions of families, not simply to provide technical information.
Increasing Knowledge and Experience
These four clinical issues may be considered priorities by SLPs working in EI settings with babies with hearing loss and their parents. Becoming experienced in these areas is essential if an SLP is to be considered an appropriate provider of EI with this population (JCIH, 2007). Some suggestions for increasing clinical competence in this area include:
- Enroll in continuing education to learn about EI practices and children with hearing loss. Short-term commitments include day-long workshops, online courses, or multiple-hour "virtual conferences" offered by ASHA, hearing aid companies, cochlear implant manufacturers, and other providers. More extensive training is available through online programs (e.g., First Years; Professional Preparation in Cochlear Implants [PPCI]).
- Observe experienced clinicians. This method is a powerful learning tool. There are few substitutes for watching a "master clinician" in action. The SLP who seeks opportunities to observe EI sessions, with family permission, may gain substantial practical knowledge in a relatively short period of time.
- Participate in a mentoring relationship. This method helps transfer principles to reality. The mentor observes the SLP working with children with hearing loss, gives feedback and encouragement, and provides advice in challenging clinical situations.
- Engage in self-study of literature in both research and clinical domains. This method is important for the SLP who needs to stay current about research findings, evidence-based practices, and informed clinical opinions.
Natural Environments with Children with Hearing Loss
The concept that EI services should promote children's participation in their natural environments, as outlined in Part C of the Individuals with Disabilities Education Act, is a well-intentioned goal, given that the purpose of any intervention is to develop skills that carry over into real life. Nonetheless, misguided implementation of the natural environments policy has had negative consequences for many children with hearing loss and their families. Some states' increasingly rigid interpretation of "natural environments" has meant that in these jurisdictions, the EI location (i.e., intervention always must take place in the child's home) takes precedent over any other considerations—including a clinician's knowledge and experience, efficient use of the expertise of a limited number of specialists in hearing loss, the acoustic and learning conditions within the home, and family choice.
These interpretations exist in the absence of any published evidence showing an advantage of home- vs. center-based EI for babies with hearing loss. Beyond Newborn Hearing Screening, a document from the 2004 Consensus Conference, states, "The cost of sending highly trained professionals out to homes, where much of the day is spent in travel, is a tremendous waste of a valuable and powerful resource. Certainly some home-visit or community time is extremely valuable, but not as an exclusive setting for service provision" (Marge, D., & Marge, M., 2004). Furthermore, the Joint Committee on Infant Hearing Year 2007 Position Statement recommends that, "In response to a previous emphasis on natural environments … both home-based and center-based intervention options should be offered," and adds, "The key component of providing quality services is the expertise of the provider specific to hearing loss."
SLPs providing EI to families and babies with hearing loss should use materials that are user-friendly, with home suggestions that can be shared with others in the family. In addition, musical experiences for young children with hearing loss have been associated with higher outcomes in communication development (Gfeller et al., 1999). This finding is not surprising, given that music and speech share many of the same characteristics (rhythm, phrasing, and melodic contours). Including music in EI activities encourages parents to rely on what they already know (such as lullabies and finger plays), stimulates aspects of rhythm and melody that are also shared by spoken language, and reinforces turn-taking, a critical milestone in communication development.
Examples of related materials include: Rossi's Learn to Talk Around the Clock; the SKI-HI curriculum (2004); Sindrey's Listening Game for Littles; and the John Tracy Home Correspondence course, which offers free home lessons in a number of different languages, giving parents a sense of empowerment as they observe their baby's progress. A second program by Rossi, Learn to Talk Around the Clock at Childcare, addresses a long-standing need for a curriculum written specifically for child care providers of young children with hearing loss. TuneUps (2007) is an integrated speech and music therapy program that weaves music into traditional intervention activities.
Support from other families fills a gap that even experienced clinicians often cannot fill. The Listen-Up Web site has a vast array of information, resources, and links for parents, with particular emphasis on families helping families by sharing tips, products, and services they have found useful with their child with hearing loss. Local chapters of the Guide-by-Your-Side program of Hands and Voices helps families make connections with other families of children with hearing loss and encourages mentoring of families with newly identified babies by experienced parents.
A final issue relates to the high number of children with hearing loss who have one or more additional disabilities, recently estimated at about 40% (Parrish & Roush, 2004). SLPs, therefore, will not be the only professional providing services to almost half of their EI caseload. Unfortunately, the ability to work in a team setting, to be reimbursed for such teaming, and to centralize a child's care around service coordination remain elusive goals. Yet, with more SLPs becoming experienced in providing EI to families and babies with hearing loss, it is our profession's responsibility to ensure that the guiding principles of EI are upheld in the services we provide.