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An Update Judith Gravel, PhD Chair, JCIH The Children’s Hospital of Philadelphia

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An Update Judith Gravel, PhD Chair, JCIH The Children’s Hospital of Philadelphia. Member Organizations; Current Representatives. American Academy of Audiology Alison Grimes; Christie Yoshinaga-Itano American Academy of Otolaryngology Head & Neck Surgery

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slide1

An Update

Judith Gravel, PhD

Chair, JCIH

The Children’s Hospital of Philadelphia

member organizations current representatives
Member Organizations; Current Representatives
  • American Academy of Audiology
    • Alison Grimes; Christie Yoshinaga-Itano
  • American Academy of Otolaryngology Head & Neck Surgery
    • Patrick Brookhouser; Stephen Epstein
  • American Academy of Pediatrics
    • Betty Vohr; Albert Mehl
member organizations current representatives3
Member Organizations; Current Representatives
  • American Speech-Language-Hearing Association
    • Judy Gravel; Jack Roush
  • Council for the Education of the Deaf
    • Beth Benedict; Cynthia Ashby
  • Directors of Speech & Hearing Programs in State Health and Welfare Agencies
    • Linda Pippins; David Savage
jcih documents
JCIH Documents
  • 1970 – National Joint Committee on Newborn Hearing Screening formed
  • 1972 – Joint Committee on Newborn Hearing Screening Supplement – HRR
  • 1982 – Joint Committee on Infant Hearing (JCIH) Statement
slide5
1990
    • JCIH Position Statement
  • 1994
    • JCIH 1994 Position Statement: detection of HL by 3 months of age, intervention by 6 months
slide6
Year 2000

Position Statement

Principles and Guidelines

for EHDI Programs

jcih 2000 components of an ehdi program
JCIH 2000Components of an EHDI Program
  • Hearing screening: 1 month
  • Confirmation of hearing loss: 3 months
  • Intervention: 6 months (enrollment in early intervention program)
jcih 2000 components of an ehdi program8
JCIH 2000Components of an EHDI Program
  • Multi-disciplinary team approach
  • Family-centered, seamless, quality services
  • Information systems for tracking & follow-up
slide9

The Joint Committee on Infant Hearing (JCIH) is recognized both nationally and internationally for its role in shaping public health policy with regard to early hearing detection and intervention (EHDI) programs.

As such, position statements and guidelines have addressed new and emerging issues in EHDI

since publication of jcih 2000
Since publication of JCIH 2000:
  • Data and experiences have become available that impact practice
  • Several issues have need to be readdressed
  • New data have become available
  • All have resulted in deliberation and work by the JCIH over the last five years, ultimately leading to the decision to develop JCIH 2005
white 2003 2004
White 2003; 2004

Survey of State EHDI Officials

“Shortage of experienced pediatric audiologists for assessment and hearing aid fitting” obstacle to quality EHDI programs

  • 2001: greater concern than 1998
  • 2004: 2nd most serious obstacle
documents currently available on pediatric audiology services
Documents Currently Available on Pediatric Audiology Services
  • Pediatric Working Group 1996
  • AAA Pediatric Amplification Protocol 2003
  • ASHA 0-5 year Guidelines 2004
  • AAA – in progress 2005
  • JCIH 2000
jcih 2000 personnel considerations
JCIH 2000Personnel Considerations

Provided broad suggestions regarding the assessment & management procedures and knowledge and skills needed by professionals providing services to infants and young children

jcih 2000 audiologic evaluation birth 5 months
JCIH 2000Audiologic Evaluation: birth – 5 months
  • Child & family history
  • Electrophysiologic threshold measure
  • EOAE
  • Measurement of middle ear function
jcih 2000 audiologic evaluation 6 36 months
JCIH 2000Audiologic Evaluation: 6 – 36 months
  • Child & family history
  • Behavioral audiometry
  • EOAE
  • Acoustic Immittance
  • Speech perception measures
  • Parental report
  • Screen communication milestones
  • ‘Cross-check’ with ABR
jcih 2000 audiologic habilitation amplification
JCIH 2000Audiologic Habilitation: Amplification
  • Prescriptive procedure & real ear measurement
  • Verification & Validation
  • Complementary or alternative sensory technology (FM; CI)
  • Long-term monitoring
slide18
Delineating a Center for Infant Audiology Service excellence and expertise; Disseminating thos recommendation to State EHDI Coordinators, Early Intervention officials, professionals, and families (Role for JCIH)

versus

Credentialing of Audiologists who provide infant audiology services (Role of professional organizations)

slide19
Contract from Maternal and Child Health Bureau to Boys Town National Research Hospital
    • Develop and disseminate recommendations on infant audiology services
  • Initially: survey, review & collection of documents relating to existing pediatric audiology practice in U.S. and other countries (Canada, UK, Australia)
    • Brandt Culpepper, Townsend University
data collection 2003
Data Collection - 2003

Culpepper

  • Survey of State EHDI systems
  • Web searches for additional resources
  • Compiled & Reviewed national & international policies, guidelines, and recommendations
slide21

States with List of

Infant Audiology Service Providers

Culpepper 2003

Yes

Pending

No

American Samoa

Commonwealth N. Mariana Is.

Guam

Puerto Rico

Virgin Islands

slide22

States with Infant Hearing

Assessment Guidelines

Culpepper 2003

Mandatory

Recommended

Pending

None

developed

American Samoa

Commonwealth N. Mariana Is.

Guam

Puerto Rico

Virgin Islands

slide23

States with Infant Amplification Guidelines

Culpepper 2003

Mandatory

Existing

Pending/Draft

No known

document

American Samoa

Commonwealth N. Mariana Is.

Guam

Puerto Rico

Virgin Islands

slide24

States with ‘Credentials’ Recognizing Pediatric Audiologists

Culpepper 2003

N=56

Yes

Pending

No

American Samoa

Commonwealth N. Mariana Is.

Guam

Puerto Rico

Virgin Islands

mchb working group on infant audiology services
Patrick Brookhouser

Barbara Cone-Wesson

Brandt Culpepper

Judy Gravel

Michael Gorga

Mary Pat Moeller

Linda Pippins

MCHB Working Group on Infant Audiology Services
  • Jack Roush
  • Richard Seewald
  • Yvonne Sininger
  • Patricia Stelmachowicz
  • Anne Marie Tharpe
  • Judy Widen
  • Christie Yoshinaga-Itano
slide26
MCHB Working Group

on Infant Audiology Services

  • Conducted face-to-face meeting
  • Reviewed materials
  • Drafted document on assessment, management and follow-up of infants with hearing loss & their families
mchb working group key principles of infant audiology services
MCHB Working Group: Key Principles of Infant Audiology Services
  • Shared goal of seamless service provision within family centered context
  • Knowledge of entire pediatric hearing health care service delivery system
  • Audiologic services delivered within context of the EHDI system
national ehdi goals
National EHDI Goals
  • Goal 1: screening by 1 month
  • Goal 2: screen positive infants receive diagnostic audiologic assessment before 3 months
  • Goal 3: infants with hearing loss begin appropriate early intervention before 6 months
national ehdi goals29
National EHDI Goals
  • Goal 4: infants & children with late onset, progressive, or acquired hearing loss receive early ID
  • Goal 5: infants with hearing loss will have a medical home
  • Goal 6: States will have complete EHDI Tracking & Surveillance System to minimize loss to follow-up.
  • Goal 7: States will have comprehensive system that monitors and evaluates progress towards the EHDI Goals & Objectives.
mchb working group key principles of infant audiology services30
MCHB Working Group: Key Principles of Infant Audiology Services
  • Personnel with experience in assessment & management of infants and children with hearing loss
  • Commensurate knowledge & test equipment necessary for use with current pediatric hearing assessment methods & hearing aid selection and evaluation procedures
mchb working group key principles of infant audiology services31
MCHB Working Group: Key Principles of Infant Audiology Services
  • Audiologic diagnostic process is ongoing: frequent follow-up visits necessary
  • Timely provision of services, without long delays between tests
mchb working group key principles of infant audiology services32
MCHB Working Group: Key Principles of Infant Audiology Services
  • Hearing aid fitting, early intervention & referral for medical evaluation proceed as soon as hearing loss is confirmed
  • Complete medical evaluation & child and family history are part of diagnostic process
mchb working group key principles of infant audiology services33
MCHB Working Group: Key Principles of Infant Audiology Services
  • Changing ear canal acoustics: impact on assessment & management
  • Otitis Media with Effusion (OME)
  • Sedation
components of hearing assessment to confirm hearing loss by 3 months of age

MCHB Working Group:

Components of Hearing Assessment to Confirm Hearing Loss by 3 months of age
  • Case/family history
  • Otoscopic inspection
  • FS air- & bone-conduction ABR thresholds
  • High-level click-ABR
  • EOAE
  • Tympanometry (1 kHz probe freq) & AMEMR
  • Observations of auditory behaviors
  • Counseling family
facilities equipment specific to electrophysiologic testing of infants

MCHB Working Group:

Facilities & Equipment Specific to Electrophysiologic Testing of Infants
  • Electrophysiologic instrument
    • Capable of frequency-specific air- and bone-conducted assessment
    • Option for using contralateral masking and ipsilateral notched-noise masking
facilities equipment specific to electrophysiologic testing of infants36

MCHB Working Group:

Facilities & Equipment Specific to Electrophysiologic Testing of Infants
  • Diagnostic OAE instrument
    • providing more that pass-refer outcome
    • variable stimulus type, frequency, level
    • flexible response-analysis techniques
  • Acoustic immittance equipment
    • 1 kHz and 226 Hz probe frequency options
    • Contralateral & ipsilateral AMEMR options
facilities for behavioral audiologic diagnostic assessment

MCHB Working Group:

Conditioned response procedures (VRA, TROCA, CPA)

Sound treated test booth

Audiometer with insert earphones

Bone vibrator with pediatric headband

Sound field capability

Multiple toy reinforcers/cabinets and/or video reinforcement system

EOAE

Real-ear measurement system

Acoustic immittance system

Sound level meter

Facilities for Behavioral Audiologic Diagnostic Assessment
facilities for amplification selection fitting

MCHB Working Group:

Facilities for Amplification Selection & Fitting
  • Audiometric assessment/acoustic immittance
  • Instrumentation to perform electroacoustic analysis & real ear measures with test signals appropriate for use with current technology
  • Computer system allowing use of fitting software for current technology
facilities for amplification selection fitting39

MCHB Working Group:

Facilities for Amplification Selection & Fitting
  • Consignment hearing aids appropriate for infants & toddlers
  • Equipment & supplies: high-quality ear mold impressions in infant ears
  • Appropriate test environment
  • Loaner hearing aid program
  • Hearing Aid Orientation kits
slide40

Based on MCHB Working Group document:

JCIH Stratification System for

Quality Infant Audiology Services

levels of service ma model infants children required to be referred to dph approved facilities
Levels of Service – MA Model(infants & children required to be referred to DPH-approved facilities)
  • Level 1 – serve children birth to 3 years
    • Sedated & non-sedated ABR
    • Other traditional pediatric audiologic testing
  • Level 2 – serve children birth to 3 years
    • non-sedated ABR
    • Other traditional pediatric audiologic testing
  • Level 3 – serve children 6 months (CA) to 3 years
    • Other traditional pediatric audiologic testing including, but not limited to sound field testing, play audiometry, tympanometry, and OAE,
development and dissemination of materials on jcih qias stratification system
Development and Dissemination of Materials on JCIH QIAS Stratification System
  • Families
  • State EHDI Coordinators
  • Primary Care Providers

Terry Davis, LSU Medical Center – healthcare literacy; MCHB contract

slide43

In Development:

JCIH 2005

Position Statement and Guidelines

slide44

JCIH 2005

Position Statement and Guidelines

Maintain general framework of JCIH 2000

  • Provide interval history 2000-2005
    • Recognize federal agencies in the development of EHDI systems
  • Review relevant literature published in the interval & update
slide45

JCIH 2005

Position Statement and Guidelines

Update, Expand & Revise Principles:

  • Prevention
  • Family centered EHDI process
  • 1-3-6 maintained
  • Timely access to high-quality technology; reimbursed
slide46

JCIH 2005

Position Statement and Guidelines

Update, Expand & Revise Principles:

  • Simplified, integrated point of entry to early intervention system
  • Professionals: pediatric-specific & discipline-appropriate knowledge and skills
  • Monitoring for hearing loss & surveillance efforts
slide47

JCIH 2005

Position Statement and Guidelines

Update, Expand & Revise Principles:

  • Information for families; professional continuing and pre-professional education
slide48

JCIH 2005

Position Statement and Guidelines

Update, Expand & Revise Principles:

  • Information systems – electronic health records
  • Reimbursement for professional services
slide49

JCIH 2005

Position Statement and Guidelines

2005 overarching theme: Follow-up

  • Highlight challenges impacting follow-up and tracking of infants after screening
  • Offer recommendations
slide50

JCIH 2005

Position Statement and Guidelines

Issues Related to Follow-up:

  • States sharing information on individual children
  • Assignment of follow-up responsibilities at each step of the EHDI process
slide51

JCIH 2005

Position Statement and Guidelines

Issues Related to Follow-up:

  • Organized surveillance efforts after the newborn period
  • Screening of communication milestones
slide52

JCIH 2005

Position Statement and Guidelines

Issues Related to Follow-up:

  • Targeting special populations for intense follow-up:
    • Multiple disabilities
    • Unilateral hearing loss
    • Mixed hearing loss: breaking cycle of delayed confirmatory tests
    • Possible candidates for CI
slide53

JCIH 2005

Position Statement and Guidelines

Revisions in Existing Sections:

  • Screening
  • Auditory neuropathy section
  • Audiologic Habilitation section
  • Early Intervention section
  • Surveillance section
slide54

JCIH 2005

Position Statement and Guidelines

  • Revision of surveillance section:

“Risk Indicators for Progressive or Delayed-Onset Sensorineural Hearing Loss and/or Conductive Hearing Loss”

    • Audiologic monitoring of infants with risk indicators who pass NHS
    • Every 6 months to age 3 years
slide55
Concept Paper 2003: White (NCHAM)
  • Questioned the desirability of the JCIH 2000 surveillance recommendation
  • Concluded that:
    • little evidence regarding late-onset hearing loss in infants with risk indicators
    • practice of gathering risk factors in neonatal period was costly & time consuming and likely to be missed
    • Feasibility of audiologic evaluation of infants 2 x year
    • ? Wise use of limited resources
slide56
In 2003, JCIH worked on revision of surveillance section and considered:
  • Medical Home role:
    • ID risk indicators regardless of screening pass
    • Query parent at each visit regarding communication: refer on parent concern
    • Refer any child with diagnosed disability
    • Routine screening of communication development; refer any child with delays
  • Testing hearing of every child enrolled in the Early Intervention System
slide57

JCIH 2005

Position Statement and Guidelines

Revisions in Existing Sections:

  • Roles & Responsibilities: will now address transitioning from birth to 3 programs to 3 to 5 programs
  • Institution and agencies: to include Federal commitment to pre-professional and professional training
slide58

JCIH 2005

Position Statement and Guidelines

Other Issues/Topics:

  • Genetics & genetic counseling/evaluation in the EHDI context
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