Section II: Myths and Facts About Early Identification and Intervention
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By Marilyn Sass-Lehrer, PhD/February 2014
Myth 1: Early identification works even without early intervention.
Fact 1: Early identification without early intervention is ineffective.
Unfortunately, early intervention by qualified providers is not always readily available. Families may have difficulty finding providers who understand the issues involved and can answer their questions accurately and completely. Families may have to wait weeks or even months before they are able to find a program with specialists who have the expertise to work with them and their child.
The time between the confirmation of their child's hearing status and participation in an early intervention program, if delayed, can be very frustrating for families. Families may be confused about what it means to be deaf or hard of hearing. They may have difficulty finding information and services, or may be upset or sad that this has happened to their child. Lack of professional support and guidance may be detrimental not only to the family's sense of well-being but also to the child's development.
Researchers have shown that parent-child interactions are affected by the family's sense of social support and well-being (Koester & McCray, 2011; Meadow-Orlans & Steinberg, 2004). Positive parent-child interactions promote the child's social, communication, and language development and are the building blocks for literacy and academic achievement. Young children acquire language through intimate interactions with their family and other caregivers. Infants are particularly sensitive and responsive to language interactions and acquire cognitive and communicative structures that promote language learning early in life. Through routine and caring interactions, young children acquire both the language and social mores that link them to their family, culture, and community.
Implications for Families and Service Providers
Early hearing detection and identification programs need to ensure that families are immediately referred to programs and services that can support their emotional needs and provide them with information and resources to enhance their abilities to promote their child's early developmental needs. Early intervention programs should include specialists knowledgeable and experienced in working with families with young children who are deaf or hard of hearing. Researchers concur that child outcomes are better when professionals working with them have specialized training (Kennedy, C, McCann, D, Campbell, Kimm, & Thornton, 2006; Moeller, 2000, 2007; Yoshinaga-Itano, 2003).
Newborns should receive hearing screening shortly after birth (which happens in the vast majority of cases in the United States). Technicians and audiologists who have the responsibility of informing parents/caregivers that their baby is deaf or hard of hearing must be sensitive and responsive to families (Young & Tattersall, 2007). Few families with newborns suspect that their baby might have limited hearing, and the news that their child did not pass the newborn hearing screening may elicit a strong emotional response. A combination of emotional support, including support from both professionals and families, and information for families is critical.
State systems are expected to have information and resources available for professionals and families with deaf and hard of hearing children to ensure timely evaluations and referrals to early intervention services (Raimondo, 2011). Many states are still in the process of developing these resources and ensuring that they are comprehensive and accessible to all families. Families, deaf adults, and professionals should work with the Early Hearing Detection and Intervention (EHDI) systems in their states to ensure that information provided to families is comprehensive and provides them with accurate and helpful information.
Myth 2: Children who are deaf or hard of hearing will experience delays in communication and language.
Fact 2: Early, quality intervention minimizes communication and language delays for many children.
One of the primary goals of early intervention is to support parent-child communication. With limited access to hearing, infants are unable to understand spoken language well enough to acquire an understanding of their world or to learn how to talk. Researchers generally agree that early visual language models are critical for deaf and hard of hearing children to acquire a good foundation in language (Spencer & Marschark, 2011). Children who have full access to comprehensible language as well as quality early intervention services provided by qualified professionals have a high probability that they will begin school with a good foundation in language and effective communication skills (Yoshinaga-Itano, Sedey, Coulter, & Mehl, 1998; Moeller, 2000).
While young children who are hearing acquire language naturally from their hearing parents and other caring adults, hearing caregivers with children who are deaf or hard of hearing usually need guidance from professionals to adapt their sound-based, auditory communication to include visual strategies that will stimulate their children's language growth. Deaf mentors or advisors can provide this kind of support to families and promote language outcomes. Calderon (2000) found that mothers' communication skills were a good predictor of a child's language, early reading, and social-emotional development. Parents/caregivers and children communicating effectively with each other from the earliest months of life establish a foundation for language acquisition in spoken and/or signed language that may prevent or minimize language delays.
Implications for Families and Service Providers
During the first few months of life, the infant should receive a complete evaluation of his or her hearing and vision abilities from a skilled pediatric audiologist and vision specialist. Knowing each child's abilities will help families and specialists understand how to capitalize on the child's strengths. Families should receive support from professionals and other parents, including those professionals and parents who are deaf, to help them adjust to their child's communication needs and to ensure that their child's language development is on track.
During this time, parents/caregivers and professionals should observe and assess the child's use of residual hearing, visual attention, acuity, gestures, and vocalizations. Observations of behavioral responses and communication initiatives will also uncover how the child responds best to different language stimuli. Professionals should help parents/caregivers learn how to utilize visual and auditory avenues available to the child to establish early communicative interactions and acquire skills, such as gaining and directing attention and turn taking. For more information, visit:
While early identification and early intervention make a big difference in the lives of most children, continued support from families, skilled professionals, and specialized programming is necessary to ensure that these children do not fall behind. Professionals and family members are right to establish high expectations for their child's development (Young & Tattersall, 2005).
School age programs for young children who are deaf and hard of hearing need to adapt services to meet the needs of this promising new population of young children and involved families by providing programming that further propels these children's linguistic development (Nussbaum, Waddy-Smith, & Doyle, 2012).
Myth 3: Only some children who are deaf or hard of hearing benefit from early identification and early intervention services.
Fact 3: Children benefit from early identification and effective early intervention regardless of individual differences.
Researchers have found that infants who participated with their families in quality early intervention programs before the children's first birthday outperformed their peers who did not receive similar services until later (Moeller, 2000, 2007; Yoshinaga-Itano et al., 1998; Yoshinaga-Itano, 2003). Children enrolled in early intervention programs by 6 months of age did better on measures of language (signed or spoken) and social-emotional development than later-identified peers regardless of their gender, ethnicity, socioeconomic status, communication modality, hearing levels, and/or presence of multiple disabilities (Yoshinaga-Itano, 2003).
Young children who are enrolled early in an appropriate early intervention program are 2.6 times more likely to have language skills within the average range in the first five years of life than a child who does not have this advantage (Yoshinaga-Itano, Coulter, & Thomson, 2000). All children benefit, despite differences in gender, ethnicity, socioeconomic status, communication modality, hearing level, or presence of multiple disabilities. These children tend to have better language (both signed and spoken) as well as better emotional-behavioral adjustment and social development. Not only do children benefit, but families who receive support through early intervention appear to adjust more quickly to their child's hearing status than families whose children's limited hearing abilities were not identified until later (Pipp-Siegel et al., 2002).
Young children who were not identified early but who have families that are highly involved may be able to "catch up" according to research by Moeller (2000) and Calderon (2000). The first six months of life appear to be crucial for language acquisition; however, according to these researchers, young children who missed this early opportunity but who have families that are actively engaged in early intervention (e.g., actively participate in early intervention sessions and meetings, respond positively to their child and communicate effectively with them, are strong advocates for their children) have strong language and verbal reasoning skills. These studies indicate that early intervention and family involvement are powerful influences and strong predictors of success for children who are deaf or hard of hearing.
Implications for Families and Service Providers
Early identification and intervention programs should ensure that hearing screening and effective follow-up and referral programs are available to all children and their families regardless of socio-economic status, ethnicity, and/or individual child abilities. Every child and family benefits from an early start. Research studies suggest that many families have barriers that make access to early intervention difficult. For example, some families must travel long distances to access services. Others lack transportation, financial resources, and/or assistance or have difficulty understanding the recommendations from providers due to differences in languages or cultures (Shulman et al., 2010).
Early intervention programming must include a strong family support component that is responsive to the family's feelings, cultural perspectives, and concerns and is designed to encourage positive adaptation and acceptance of their child. Programs should view families as partners and design programs and services so that family involvement is paramount. Families should understand the powerful influence they have over their child's development and be provided support to participate in early intervention activities and develop the skills they need to foster effective early communication (Meadow-Orlans et al., 2003).
Myth 4: All infants who are deaf or hard of hearing and their families should receive the same early intervention services.
Fact 4: Early intervention services must be individualized to meet the unique backgrounds and abilities of young children who are deaf or hard of hearing and their families.
Children who are deaf or hard of hearing and their families are extremely heterogeneous (Gallaudet Research Institute, 2011), with special concerns, unique priorities, and various levels of resources (Meadow-Orlans et al., 2003). Families may have other deaf or only hearing family members, cultural and ethnic traditions, or educational experiences and values that influence their viewpoints and involvement in early intervention. Families differ in the experiences they have had with individuals who are deaf or hard of hearing as well as in their perspective about what it means to be deaf or to be deaf with disabilities. The types of services appropriate for children will depend on a variety of factors, including age, the child's hearing levels, if the child has a disability, the family's familiarity with being deaf, and other cultural and linguistic factors.
Implications for Families and Service Providers
Professionals must be sensitive to individual child and family differences to ensure there is a comfortable fit for the family and that the program and services are responsive to their unique situation and their child's special needs. A mismatch between the services offered and what the family believes should be provided for their child may result in a lack of participation or engagement in early intervention activities. Services for families must be flexible to meet individual situations and responsive in ways that families find most helpful.
Myth 5: There is one best communication approach for all children who are deaf or hard of hearing.
Fact: 5: No one communication approach works for all children.
People who are deaf use a variety of communication and language strategies to communicate depending upon the individuals with whom they are communicating and the situation. Communication opportunities for deaf people include using visual, aural, and oral modalities. The language they use may be American Sign Language (ASL), English, or another native language in spoken and written forms. Families with young children who are deaf or hard of hearing want to know which approach or combination of approaches will work best to facilitate language acquisition for their child and are surprised to find that there is no one right way for everyone.
The communication modalities and languages used with infants and their families in early intervention programs range from an emphasis on ASL as a first language to a focus on listening and spoken language using listening technologies and discouraging the use of visual information, such as sign language or speechreading. Some programs encourage families to use only one language at a time (ASL or English) and not to combine modalities (visual and auditory). Other programs promote the use of combined modalities, such as signing in English word order while speaking. Young children who have been provided with timely and effective early intervention, including full access to language, are able to acquire more than one language and demonstrate the ability to adapt modalities (sign and spoken) for different communication partners and purposes.
Research efforts to determine the best communication approach for all children have not demonstrated that one modality or language (or a combined use of modalities and languages) results in language levels that are equal to those of hearing children at similar ages or developmental stages (See Spencer & Marschark, 2011). In addition, there is no evidence to date that suggests that the use of one communication modality is better than another for all children who are deaf. On the other hand, there is also no evidence that indicates that the use of sign language interferes with the development of spoken language and, in fact, it may support spoken language development (Yoshinag-Itano, 2006).
One group of children who consistently demonstrate age equivalent language skills are children with deaf parents who sign to their infants from birth. In one study, children whose parents/caregivers provided their infants with full access to language from birth through ASL demonstrated language levels that were parallel to the spoken language levels of their hearing peers at 18 months of age (Meadow-Orlans, Spencer, & Koester, 2004). In this same study, the researchers found that children whose hearing mothers incorporated some signs into their communication interactions were likely to have better expressive vocabularies by 18 months of age than those children whose mothers relied only on spoken language. These children's vocabulary levels were, however, still below those of their hearing peers. Some researchers have suggested that children whose primary communication is oral and rely on spoken language with hearing aids or cochlear implants can demonstrate, under specific conditions, the ability to acquire age-appropriate language skills (Geers, 2002; Nicholas & Geers, 2007). More research is needed to examine if children such as those in the above studies maintain language growth equal to their hearing age peers (Spencer & Marschark, 2006).
Families often experience tremendous angst as they try to make the best choices for their child and often change their decisions over time. Professionals, unfortunately, may add stress by their lack of evidence-based information or strong biases (Meadow-Orlans et al., 2003). Determining whether communication will be most effective through the use of ASL, listening and spoken language, signs and spoken language, or Cued Speech is a process that requires collaboration between families and professionals (Marge & Marge, 2005). Gathering information about the child's strengths and developmental abilities and family priorities and resources can help professionals guide the decision-making process. The communication modality and language choices families make are not always based on the extent of their child's hearing abilities, data collected through a series of assessments, or even the recommendations of professionals. Families' decisions often reflect their views of the world, their experiences, their goals for their children, and their individual family situations (Wainscott, Croyle, & Sass-Lehrer, 2004; Steinberg, Bain, Montoya, Indenbaum, & Potsic, 2000). Researchers suggest that the communication modality is less important than the quality of parent-child communication (Calderon; 2000; Moeller, 2000; 2007).
Implications for Families and Service Providers
Service providers can support the child's acquisition of language by facilitating effective parent-child communication that results in functional and enjoyable communicative exchanges between parent and child (Meadow-Orlans et al., 2003). Family members with young children who have limited sign skills should be encouraged to use the sign skills they have, as well as spoken language, rather than limiting communication to fit the skills they possess. Early intervention specialists can connect families with signing deaf adults to provide their young children with full access to language and help families learn how to communicate effectively with their children.
Professionals and parents should be mindful that language, rather than the form of communication (sign or speech), is the best predictor of their child's literacy and academic performance. Professionals should avoid pressuring families to select one approach over another before the family has had an opportunity to learn about the opportunities available, meet deaf and hard of hearing adults, and discover their child's strengths and abilities. Professionals can help parents and caregivers set realistic expectations and develop the skills they need to be responsive to their child's communication attempts and develop skills that will ensure fully accessible language-learning environments. Professionals can be most helpful by working with families to support positive parent-child interactions that focus on effective skills for communicating with their children.
Families need comprehensive information from professionals about the various communication modalities and languages used by individuals who are deaf or hard of hearing. Many families will be motivated to investigate more about communication and language on their own. Professionals can be helpful by providing information, resources, and opportunities for families to discuss the issues with other parents, adults who are deaf and hard of hearing, and other professionals. The decision-making process is most effective when families keep an open mind and are responsive to their child's language progress and the effectiveness of the communication strategies they are using. See Supplement to the 2007 JCIH Position Statement (2013), appendices 2 and 3, for examples of monitoring listening and spoken language and ASL development for parents and providers, http://pediatrics.aappublications.org/content/131/4/e1324.long#ref-19.
Myth 6: Young children who are deaf or hard of hearing should receive services from specialists and in settings that are designed for children who are deaf.
Fact 6: Young children and families benefit from services provided by specialists and in settings that provide services for other young children who are deaf or hard of hearing and their families.
A provision in the Individuals with Disabilities Education Act (IDEA) indicates that "...to the maximum extent appropriate, [early intervention services] are provided in natural environments, including the home, and community settings in which children without disabilities participate (IDEA, 2004, section 632(4)(G)(H)). This provision has been misunderstood to mean that children with disabilities cannot receive services in separate center-based settings that are specially designed to meet their needs. Consideration of special language and communication needs, and opportunities for direct communication with peers and adults in the child's language and communication modality(ies), are appropriate rationale for center-based services (ASHA, 2008b). For more information on the federal legislation and how it protects the rights of deaf and hard of hearing children, see Info to Go: Legislation, Policy.
The Joint Committee of the American Speech-Language-Hearing Association and the Council on Education of the Deaf recognized that professionals and families needed guidance to determine appropriate settings for services for children below 3 years of age. As a result, they developed A Fact Sheet on Natural Environments for Infants and Toddlers Who are Deaf or Hard of Hearing and Their Families (ASHA, 2006).
There is a strong value in this country to include children with special needs in settings with children without special needs. While access to programs and services for all children is essential, most children need language and communication models that are fully accessible to them to acquire the skills they need. Children and families benefit from specialized early intervention services provided by competent professionals who have the knowledge and skills to ensure that young children will achieve age-appropriate language, cognitive, and social outcomes.
Young deaf and hard of hearing children are benefitting from early identification and programming. The challenge, however, is ensuring that all children and their families have the opportunity to participate in programs that are staffed with professionals who have the appropriate knowledge and skills. These programs should also include deaf and hard of hearing adults who are fluent users of the language(s) and communication modality(ies) of the children and families. An appropriate setting will also include language and social peer models for the children. The physical setting (i.e., whether in a school or clinic) is less critical than the expertise of the staff and the opportunities and resources available to families and children.
Implications for Families and Service Providers
The place where services are provided to families and their very young children should be determined by the family and professionals working with the child and based on the child's needs. For many families, this means that they may participate in early intervention activities in a variety of settings. The home may be the most appropriate location for services for one family, while for another family a better place might be a child care program or another location in the community. Programs should also offer a setting where specialists and other families with deaf or hard of hearing children can come together to share information as well as give and receive support.
A program that includes at least some center-based programming can be beneficial for children who are deaf or hard of hearing and their families. A center location often has the advantage of providing a multidisciplinary team of specialists skilled and experienced in working with children who are deaf or hard of hearing and who have the knowledge and skills to promote effective adult-child communication and child language acquisition. In one setting, families can access professionals such as audiologists, speech-language pathologists, sign language specialists, and occupational therapists with expertise in working with young children who are deaf or hard of hearing without traveling to several different locations. A center can provide a place where families can meet other families with similar experiences, and their children can interact with other children who are also deaf or hard of hearing. A center-based program also has the advantage of providing families with opportunities to interact in meaningful ways with adults who are deaf or hard of hearing and who are part of the professional team Center programs can provide an environment conducive to advancing the development of listening skills and/or visual communication, and provide services needed to support the child's use of assistive visual, listening, and other communication-related technologies.
Myth 7: Any early intervention specialist or speech-language pathologist can provide appropriate services for infants and toddlers who are deaf or hard of hearing and their families.
Fact 7: Qualified personnel with specialized preparation are essential for providing appropriate services and achieving successful outcomes for young children who are deaf or hard of hearing and their families.
The increase in the number of infants identified for early intervention services and the scarcity of programs preparing specialists has resulted in a shortage of qualified personnel to work with families with young deaf and hard of hearing children. Unfortunately, some families are in a situation in which they must accept services from individuals with limited knowledge or wait for services to become available. Many families find that they must seek out information and resources on their own and hope for the best. Others receive services from individuals who do not understand the complex issues related to being deaf and who may inadvertently misguide them. Although many families are receiving services from committed professionals, they may not always have the knowledge and skills that will provide the best start for their young children.
The quality of early education and developmental services depends on the quality of the specialists. Researchers suggest that outcomes for young children and their families are better when providers have specialized training in early intervention for children who are deaf or hard of hearing (Calderon, 2000; Kennedy et al., 2005; Nittrouer & Burton, 2001; Yoshinaga-Itano, 2003). Qualified professionals have knowledge and expertise in a wide range of areas that are not limited to one specific discipline. Professionals may have backgrounds in education of deaf children, early childhood education, speech and language pathology, counseling, or other areas. According to the research as well as recommendations from professional organizations and initiatives, professionals working with infants and toddlers who are deaf or hard of hearing should have knowledge and skills in the following nine areas: (1) family-centered practices; (2) socially, culturally, and linguistically responsive practices; (3) language acquisition and communication development; (4) infant and toddler development; (5) screening, evaluation, and assessment; (6) auditory, visual, and tactile technologies; (7) planning and implementation of services; (8) collaboration and interdisciplinary practices; and (9) professional and ethical behavior, legislation, policies, and research (Stredler-Brown, Moeller, & Sass-Lehrer, 2009). Also see Supplement to the 2007 JCIH Position Statement (2013), http://pediatrics.aappublications.org/content/131/4/e1324.
A qualified professional working in partnership with the family can ensure that the benefits accrued from early identification are not lost and are indeed maximized to facilitate the best early beginnings for young children.
Implications for Families and Service Providers
There is presently a shortage of professionals who have the specialized training to work with this unique population of young children and their families. A concerted and immediate effort should be made to increase the number of individuals who enter the field of early intervention for children who are deaf or hard of hearing. Program administrators should provide ongoing professional development and support for the early intervention providers in their programs. Early intervention specialists who are currently working with families should take advantage of professional learning opportunities to help them develop and maintain the skills they need to deliver appropriate and effective services for young children and their families.
Families seeking early intervention programs should look for professionals who are knowledgeable about early development, what it means to be deaf or hard of hearing, and how to work with families. In addition, they should look for professionals who are proficient in the language and communication modalities that will provide their young children with full access to language and help them develop the skills they need to promote their children's language acquisition. An early start without qualified personnel to ensure effective services and practices will not provide young children with the foundations they need to reach their potential.