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So Your Child Has a Hearing Loss
So Your Child has a Hearing Loss: Next Steps for Parents is a booklet published by the Alexander Graham Bell Association for the Deaf and Hard of Hearing (AGBell). The AAO-HNS is posting this online version of the booklet as a service to our members' patients.
Introduction
Your child with a hearing loss can succeed - in school, in work, and in life! It is important to keep this as your focus, whatever your child's age or degree of hearing loss. While you will have the support of many professionals, ultimately you as parents will make many decisions about what is in the best interest of your child. As with all children, there is no magic formula for raising a child with a hearing loss. It helps to maintain a positive attitude, educate yourself about hearing loss, seek out the best resources, and take an active role in your child's education. Most of all, keep in mind that your child is a child first, and a child with a hearing loss second.
This online booklet is written for parents of children of all ages and all degrees of hearing loss. With so much to cover, the information presented here is only a brief overview, supplemented with a variety of reference and resource materials so you can follow up on subjects more thoroughly. In addition, you are encouraged to join the Alexander Graham Bell Association for the Deaf and Hard of Hearing for access to a huge variety of resources, including educational programs for you and your child, a large inventory of books and other publications, video tapes, conferences, and a national support network.
Will your child have a "normal" life? While some mild-moderate losses can be surgically or medically corrected, most hearing loss is a permanent condition. Thus, your child's life will have its challenges. However, these challenges sometimes turn into advantages. For example, the ability to work hard and concentrate more, coupled withthe routines of audiologic and language therapy, frequently produces children who are self-disciplined and focused. Moreover, the outcomes for children with hearing loss have greatly improved in the last two decades due to major advances in technology and emphasis on programs of early detection and early intervention.
Emotional Impact of the Diagnosis: Parents can benefit from counseling and support after the diagnosis of hearing loss. Grief, anger, fear and denial are natural responses for hearing parents to feel when they find out their child has a hearing loss. Their expected "normal" child has a problem and this problem is going to present many challenges. We convey love through our words and tone of voice as well as through hugs and kisses. We soothe a child through the sound of our voice, or by singing a lullaby. We teach children that the objects in their room, their toys, their food, and the people around them all have names. We show children how to pronounce words by our example. We discipline and warn children of danger through words as well as actions. How are we going to do this now?
Deaf parents of deaf children are not necessarily prone to grief because they are already familiar with living in a world without sound. Deaf parents may feel more comfortable with a child who is deaf, because this seems natural. But this isn't the case for most hearing parents, who probably know little or nothing about hearing loss and who may never have known a child with a hearing loss. Many deaf parents will teach their child sign language as naturally as hearing parents unconsciously teach their child to speak. But hearing parents must commit themselves to the goal of helping their child listen and speak in order to participate fully in a hearing world, or the equally arduous task of becoming fluent in sign language and learning about Deaf culture.
Grief is a common emotion and an honest expression of disappointment and fear of the unknown. Grief that is not acknowledged or dealt with can lead to denial of a child's problem, which in turn can lead to procrastination in taking constructive action. Unacknowledged grief can lead to unfocused and displaced anger on the part of parents which can last a lifetime. Acknowledging grief, painful as it may be, will clear away anger and denial, allowing parents to most effectively nurture their child.
What is Early Detection, and Why Is it Important?
Early detection simply means discovering a hearing loss at a very early age - hopefully in the first few days of life. Advances in research and technology have created the means for this to happen. Previously, children's hearing could only be tested by observing a child's behavioral responses to sounds. Today's automated hearing-screening machines do all of the work, so even a sleeping baby's hearing can be measured. Many hospitals now screen a newborn's hearing before he/she is discharged from the hospital. (The sidebar describes the types of hearing tests used with infants and young children.)
These early exams are referred to as "screenings" rather than "tests", because their results are not definitive. They can only screen out those babies who are likely to have a hearing loss from those likely not to have a hearing loss. If an initial screening comes back "positive", then a second screening and follow-up testing are performed to confirm whether a hearing loss is present and, if so, the type and nature of the loss.
In the hospital, nurses, aides, or other hospital personnel may do the screening, but the test interpretation and follow-up evaluation should be performed by an audiologist (i.e., someone with an advanced degree and appropriate licensure/certification in evaluating hearing). If a hearing loss is suspected, your pediatrician should refer your child to an ear, nose and throat doctor (otolaryngologist), to rule out any cause of hearing loss which could be medically or surgically corrected. Some parents also decide to seek genetic counseling because, of the many causes of hearing loss, some are hereditary. You may want to know whether you or your spouse carry a gene for hearing loss, or whether the hearing loss is part of a "syndrome" (cluster of symptoms), which may cause related medical problems.
The next step after the diagnosis is to find an audiologist whom you feel comfortable with, and who you feel confident will help you manage your child's hearing loss. It is entirely within your rights to "shop" for an audiologist by scheduling initial meetings with several practitioners. You can locate audiologists in your area by asking for referrals from your pediatrician and/or otolaryngologist, as well as by asking other parents of children with hearing loss who they use. When seeking an audiologist for your child, inquire whether your practitioner has experience working with pediatric patients and be sure to observe during your initial visits his/her level of rapport with your child. The American-Speech-Language-Hearing Association (ASHA) can refer you to an audiologist in your area via their Consumer Helpline (800-638-8255).
How Young Children's Hearing is Screened and Evaluated
Newborns and infants can be tested without their cooperation. There are two commonly used measures-both can be performed on a sleeping infant-that require no response from your baby and are not painful or uncomfortable.
ABR (Automated Brain Stem Response): Sounds are presented through earphones while the baby rests quietly or sleeps. Brainstem responses to sound are measured through small electrodes, which are taped on the baby's head. These responses are processed by a computer.
OAE (Otoacoustic Emissions): A small probe tip is inserted into the baby's ear canal. It measures the function of the inner ear, or cochlea.
Behavioral Testing: These types of tests are used when children are old enough to turn their head in response to sound, or play a game. These tests measure the quietest sounds your child can hear, your child's ability to understand words, and whether fluid or some other obstruction is present in the middle ear.
Acoustical Impedance tests can be administered to children of all ages and can help identify middle ear problems (e.g., presence of fluid and status of eardrum) through a non-invasive and computerized technique.
What is Early Intervention?
"Early intervention" means starting a specialized program to help your child right away! We introduce the term since you will hear it used frequently by professionals. Time is of the essence because a child's brain is programmed to learn language during the first six years of life-the first three years being the most critical. After this period, it is very difficult to acquire language and speech skills. Therefore, the earlier the intervention starts, the less of the precious six-year "window of opportunity" is lost.
Early intervention can take many forms, such as getting children fitted for hearing aids, providing counseling and support for parents, and teaching parents how to stimulate speech and language in their child.
One of the first steps will be to get hearing aids for your child. Depending on the degree of your child's loss, hearing aids will ideally enable your baby to hear many sounds. This includes both environmental sounds (for example, the sound of a rattle or a dog barking) and the sounds of speech. Basically, hearing aids work by boosting the intensity ("loudness") level of sounds at different frequencies ("pitches"). Higher-frequency sounds, such as "t", "p" and "s", need a greater loudness boost to be heard than low frequency sounds, such as "a", "o" and "ah". Hearing aids can be programmed to fit the needs of individual hearing patterns, such as boosting intensity level for high frequency sounds that your child may not hear at all and less for low frequency sounds that your child may hear better.
Hearing aids have improved dramatically in recent years-some have built-in FM systems and directional microphones which can reduce (but not eliminate) background noise. Speak to your audiologist about the options available to your child and what technology may best suit his or her needs.
Regardless, hearing aids do not correct hearing as perfectly as glasses correct vision. Individual sounds may be somewhat distorted. Because hearing aids amplify all sounds, including background noise, it may still be difficult for your baby to hear and understand speech in noisy situations unless you are standing close by.
How Hearing Aids Work: A hearing aid is an electronic, battery-operated device that amplifies sound to improve listening comprehension. Hearing aids receive sound through a microphone, then convert it to electronic signals, which are then amplified and sent to the ear through a tiny speaker. Your audiologist will select a hearing aid that provides amplified sound across the pitch range in which your child has difficulty hearing but that is still comfortable across the pitch range in which he/she has usable hearing.
Your audiologist will fine-tune the amount of amplification the hearing aids provide based on your child's loss. Even a child with a mild hearing loss may need amplification. By analyzing the audiogram, your audiologist can learn what type of hearing loss your child has. The diagram below offers a simplified explanation of what your child's audiogram says about his/her hearing loss.
| If your child... |
Then... |
| Can hear low-pitched sounds but not high sounds |
The audiogram is classified as a "sloping" configuration |
| Can hear high-pitched sounds but not sounds that are low in pitch |
The audiogram is classified as a "rising" configuration |
| Requires the same amount of amplification to hear a sound, regardless of its pitch |
The audiogram is classified as a "flat" configuration |
Types of Hearing Aids
There are three main types of hearing aids. Behind-the-ear hearing aids are used most frequently in infants and children.
- Behind the ear (BTE) hearing aids, not surprisingly, fit behind your child's ear. They are frequently used with pediatric patients as they tend to be most compatible with the physical characteristics of infants and young children. Additionally, a mini-FM system can be used in combination with BTEs to improve a child's ability to hear speech. BTEs are connected to earmolds, which are pieces of soft plastic custom-made to fit your child's ear. Earmolds help keep the hearing aid in place and provide the channel through which sound is delivered into the ear canals. As with clothing and shoes, children do outgrow their earmolds and will need to have them replaced once or twice per year. Infants' earmolds, however, will need to be replaced about once every two months due to your child's rapid growth across his or her first year. One symptom of children outgrowing their earmolds is the presence of "acoustic feedback". When the earmold isn't fitting well, sound will be able to escape the ear canal and will be re-amplified by the hearing aid microphone, producing feedback in the form of a high-pitched squealing sound.
- In the ear (ITE) hearing aids fit completely in the outer ear. The case, which holds the components, is made of plastic and must be replaced as the ear grows. For this reason, ITE aids are not used frequently with young children. This style of hearing aid is used most frequently for those with mild to severe hearing losses.
- In the canal (ITC) hearing aids fit into the ear canal and are customized to fit the size and shape of the user's ear canal. Like ITE aids, ITC aids must be replaced as the ear grows and, as a result, are not often selected for pediatric use. Like ITE aids, ITC aids are employed most frequently for mild to moderately severe hearing loss. The small size of both ITE and ITC aids make them difficult to adjust and/or to remove for young children.
On the horizon: Implantable hearing aids (IHAs) comprise both bone-anchored hearing aids (BAHAs) and middle ear implants (MEIs). A BAHA is useful for those with either congenital atresia of the ear canal or chronic middle ear dysfunction (typically chronic otitis media) that prevents the optimal use of conventional hearing aids. Many of the candidates for a BAHA are those who have used bone conductors worn on the scalp with a spring-loaded device that exerts pressure on the skin. The BAHA offers a level of sensitive hearing not achievable with these conventional bone conductors. The FDA has approved the use of BAHAs for all age groups, including children as young as 2 years. The long-term experience with use of the BAHA in Sweden and England suggests that the device may be a preferred alternative to surgery to open the ear canal or repair the middle ear mechanism, particularly in children with the Treacher-Collins or Goldenhaar syndrome. MEIs are used for persons with purely sensorineural hearing losses.
Parents' Hearing Aid Survival Kit
- Hearing aid battery tester-to check the battery level each day
- Hearing aid stethoscope-to perform a daily listening check
- Forced-air stethoscope-to remove moisture and ear wax from the sound channel of the earmold
- Hearing aid dehumidifier-to store hearing aids overnight
- Earmold lubricant-to facilitate earmold insertion and reduce the likelihood of acoustic feedback
- Earmold disinfectant-to keep your child's ears healthy and happy!
-ASHA, Let's Talk, May/June 99, pp. 43-44.
Types of Hearing Aid Circuitry
- Analog/Conventional-Your audiologist determines the volume and other specifications your child requires in a hearing aid and a laboratory builds an aid to meet these needs. This is generally the least expensive type of circuitry.
- Analog/Programmable-Your audiologist uses a computer to program your child's hearing aid. This circuitry can accommodate more than one program so that your child can change the program to receive better sound across different listening conditions.
- Digital/Programmable-Your audiologist uses a computer to program your child's hearing aid and can adjust the sound quality and response time on an individual basis. Digital hearing aids use a computer chip and, as a result, offer the most flexibility to your audiologist in making adjustments. Digital hearing aids also offer a number of settings that allow the user to manipulate the amplification of incoming sound in specific frequencies where it's difficult to hear. Digital circuitry is the most expensive of the above options.
Most of the time, two hearing aids are recommended for your child. Research studies on adults have shown that those people who have a hearing loss in both ears, but habitually wear only one aid, lose the ability to recognize speech in the other ear. This phenomenon is known as "auditory deprivation." Once the ability to recognize speech has been lost, it cannot be restored. If your child has a hearing loss in both ears, using two hearing aids prevents auditory deprivation and helps your child to localize sound and to hear better even in noise.
Hearing aids are expensive, so you will want to understand exactly your audiologist's terms of purchase. You will also want to know whether your audiologist has a variety of hearing aids for your child to try. Some good questions to ask your audiologist are found in the sidebar. While a few insurance companies include coverage of hearing aids, most exclude them. Check your policy before purchase. Some families have been successful in urging their employers, or lobbying insurance companies directly, to offer such coverage.
What can you do if you cannot afford hearing aids? Under the federal law supporting special education (entitled the Individuals with Disabilities Education Act, or IDEA) if your child is already enrolled in a public school education program. You will find further information about IDEA and special education later in this document.
For more information on hearing aids, see the AG Bell What are Hearing Aids online brochure
If Hearing Aids Aren't the Answer, Learn About Cochlear Implants
If your child receives negligible benefit from hearing aids after wearing them for a reasonable time, has a severe-profound hearing loss, and is at least 18 months of age, he/she may be a candidate for a cochlear implant. At this writing, the desirability of earlier implantation is being considered and some research centers have begun implanting earlier.
A cochlear implant is an electronic device designed to provide sound detection as well as improved speech understanding and speech production. The cochlear implant is surgically implanted in the ear. It bypasses the damaged parts of the ear and sends electrical "sound" directly to the hearing nerve (the auditory nerve). Research suggests that implantation during the critical ages for speech and language development (between 2 and 5 years), is important for obtaining the best results. The earlier a child can be implanted within this "window of opportunity", the greater the likelihood that he/she will make optimal use of a cochlear implant and achieve good speech and hearing results. However, researchers are still not able to predict how well an individual child will do following a cochlear implant.
The surgery takes two to three hours and can be undertaken on an outpatient basis or, at most, an overnight stay. The procedure is covered by most insurance companies. For an eligible child with a severe-to-profound hearing loss, cochlear implantation can significantly improve a child's success with speech development and listening but only if parents are highly motivated, and there is a quality follow-up program available. The literature on cochlear implants is extensive. Additionally, there are a number of informative Web sites addressing all aspects of cochlear implantation.
For more information on cochlear implants, contact AG Bell to request a free copy of our brochure titled Kids and Cochlear
Implants: Getting Connected. In addition, many books and informational materials are available from the AG Bell Publications department.
Will My Child Need Early Intervention? All children with hearing loss require some degree of educational and habilitative intervention. Any level of loss can create challenges for a child, especially in an academic environment. Even a child with a mild to moderate loss-provided it goes undetected or untreated- has a higher likelihood of repeating a grade than does a child with normal hearing.
Mild Loss: A child with a mild loss may have subtle problems which are not obvious either to parents or teachers. In fact, in the past, mild hearing losses have generally been overlooked as a significant factor in a child's speech and language development or academic performance. Recent studies, however, debunk this myth. A child with a mild loss will benefit from favorable acoustics, hearing aids and/or a personal FM system. Soundfield amplification may be helpful if the classroom is noisy or reverberant (echoes). Favorable seating and lighting, as well as ongoing monitoring of language and speech development, is important as well. Depending on the level of loss, your child may benefit from speech-language therapy and speechreading skills.
Moderate Loss: A child with a moderate hearing loss will benefit from routine audiological evaluations and ongoing monitoring of speech and language development, reading, and written language. Amplification-hearing aids and assistive devices such as personal FM systems-are imperative. Classroom acoustics should also be addressed. A child with a moderate loss will benefit from speech-language therapy to work on any language delays or difficulty in pronouncing certain sounds. If your child is not yet school age and is showing speech and/or language delays, a parent-infant or preschool program with special emphasis on developing these skills is recommended.
Severe to Profound Loss: Children with severe or profound losses should be enrolled in a parent/infant program that addresses their specific needs as soon as possible. These types of programs are outlined in the next section. When school-age, children in this category need ongoing monitoring of speech and language progress and routine audiology checks. Hearing aids and assistive listening devices (like FM systems) are essential, as is a favorable acoustical environment. Your child may also benefit from the use of an interpreter and/or notetaker in the classroom.
Hearing loss is measured in decibels: the greater the decibel level, the louder the sound. Hearing is considered normal when a person chan hear sound at a loudness of between 0-15 decibels. The table below shows the four categories of hearing loss and the decibel level needed to detect sounds in each category.
|
| Level of Hearing Loss |
Decibel Level |
Sound Equivalent |
| Mild |
15-40 dB |
Cannot hear a whispered conversation in a quiet atmosphere at close range. |
| Moderate |
40-60 dB |
Cannot hear normal conversation in a quiet atmosphere at close range. |
| Severe |
60-90 dB |
Cannot hear speech; can only hear loud noises such as a vacuum cleaner or lawn mower at close range. |
| Profound |
over 90 dB |
Cannot hear speech; may only hear extremely loud noises such as a chain saw at close range or the vibrating component of loud sound. |
Where Can I Find an Early Intervention Program in My Community?
Most states offer early intervention parent/infant programs through the local school system for parents and children with disabilities up to age three. These programs are free of charge as required by federal law. The school system evaluates your child and then develops a plan with your family for your child based on the evaluation. This plan is named the Individual Family Service Plan, or IFSP.
A good parent/infant program provides consultation on acquiring hearing aids and assistive listening devices, parent counseling, explanation of the various communication options for children with hearing loss, and training in the communication option selected on the advice of professionals and the preference of the family. It is important to note that under these federally mandated parent/infant programs, parents are entitled to help select the communication option for their child. The emphasis in these programs is on working with the family unit, not just the child with the hearing loss.
In addition to the public school, there may be a private parent/infant program for children with hearing loss in your community. If you are interested in privately-run programs emphasizing oral communication, contact AG Bell for more information.
"Communication Options" - What Does That Mean?
School systems use a number of systems of communication for children who are deaf or hard of hearing. As a parent, you will find the information on communication options often conflicting and confusing, and one of your most difficult tasks will be to decide on the best option for your child. This may, in part, be dictated by what is available in your community. Large metropolitan area may offer several options.
Auditory/Oral - These programs teach children to make maximum use of their residual hearing through amplification (hearing aids or cochlear implants), to augment their residual hearing with speech (lip) reading, and to speak. This approach excludes the use of sign language. The philosophy behind the Auditory/Oral method is to prepare children to work and live in a predominately hearing society.
Auditory/Verbal - The auditory/verbal approach is similar to the auditory/oral approach, except it does not encourage lip-reading. This method emphasizes the exclusive use of auditory skills through one-on-one teaching. It excludes the use of sign language, while emphasizing the importance of placing children in the regular classroom ("mainstream education") as soon as possible.
Cued Speech - This is a visual communication system combining eight handshapes (cues) that represent different sounds of speech. These cues are used simultaneously with speaking. The hand shapes help the child distinguish sounds that look the same on the lips-such as "p" and "b". The use of cues significantly enhances lip-reading ability. It is a particularly good system for a child who may not be able to learn entirely though amplified hearing.
Total Communication - Total communication uses a combination of methods to teach a child, including a form of sign language, finger spelling, speech reading, speaking and amplification. The sign language used in total communication (SEE sign) is not a language in and of itself, like American Sign Language, but an artificially-constructed language following English grammatical structure.
American Sign Language (Bilingual/Bicultural) - In this method, American Sign Language is taught as the child's primary language, and English as a second language. American Sign Language is recognized as a true language in its own right and does not follow the grammatical structure of English. This method is used extensively within the Deaf community, a group that views itself as having a separate culture and identity from mainstream society.
If you feel confused at this point, you are having a normal parental reaction! Ninety percent of parents who have a child with a hearing loss possess normal hearing themselves. Your knowledge of hearing loss probably extends to having seen it profiled occasionally on television or in the movies. The variety of educational options may make little sense to you right now. Which education methodology should you choose for your child? Should you enroll your child in the public program or with a private therapist or in a private school?
These decisions will be clearer after you've done some homework. As you gain knowledge, the right decision for you and your family will be clearer. We suggest that you take the following steps to help in gathering information in order to make an informed decision.
- Read about the different educational options. A good book to start with is Choices in Deafness by Sue Schwartz, distributed by AG Bell. The book presents parental and professional views on all of the major educational options. You can also request publication catalogs and free brochures from AG Bell and other national organizations listed in the reference section of this booklet.
- Visit the available programs in your community. Start by calling your local school district and asking for the person in charge of parent/infant programs for children with hearing loss. Make an appointment to talk with the person in charge and visit the program. Call AG Bell for a list of private programs in your area. Even if you are unsure about a private option, visiting such a program gives you a frame of reference for evaluating your public school's program and for requesting specific accommodations.
- Communicate with other parents and professionals about local programs. What does your audiologist think of the local school program? Is there a better one in a nearby school system? Ask your audiologist to connect you with a parent of a slightly older child who could tell you about the local programs. Find out about the quality of the programs beyond the preschool level. Another good source of information is AG Bell chapter members.
- After you have called or visited programs in your area and done some reading, make a list of educational options available, along with your impression of the quality of each program. The list might look like the one on the one below.
| Communication Options Checklist |
| |
Available in my Community? |
My Impression |
| Auditory-Oral |
|
|
| Auditory-Verbal |
|
|
| Cued Speech |
|
|
| Total Communication |
|
|
| American Sign Language |
|
|
Perhaps you have decided on an educational option that is not available in your community, or does not seem to have quality staffing and programming. If so, are you willing to relocate? As your child gets older, would you consider a residential program?
What Happens When My Child Turns Three?
When children turn three, they are ready for transition to a pre-school program. Transitions from one school program to another can be bumpy. Remember your first day in kindergarten? Or your first day of high school? This experience will be even more intense for you child with a hearing loss. Preparation in the form of visiting the new program, working with your current IFSP team to prepare for the transition, and having a clear idea of what you are looking for in a quality educational program will help smooth this passage for you and your child.
To help parents evaluate educational programs, AG Bell's Public School Caucus published guidelines of what constitutes an ideal program for children pursing some form of an oral option. AG Bell has many publications on this subject and frequently includes related articles in its bi-monthly magazine for members, Volta Voices. For information about educational programming for children pursuing forms of manual communication, (i.e., Bilingual-Bicultural or Total Communication), contact the National Association of the Deaf or the American Society for Deaf Children.
AG Bell's guidelines outline eleven components of an ideal program for children who are learning to use, maintain, and improve all aspects of their verbal communication to the greatest extent possible. A summary of these guidelines follows. For a complete set of these guidelines, contact AG Bell.
| Guidelines for an Auditory Education that Works |
| (1) Obtain an Individualized Education for Your Child |
A commitment to individualizing educational programming to fit the child's strengths and needs, including initial and on-going assessment, goal-setting, and documentation of progress-all with parental involvement. |
| (2) Commit to Aggressive Audiological Management to Promote the Use of Residual Hearing |
The education program, school or district will have immediate access to audiological services which must include periodic audiological testing, assurance that the student is wearing appropriate hearing aids and/or other assistive devices, teacher/parent education regarding the use of amplification, daily monitoring of hearing aids in the classroom, easy and fast access to minor repair services, and availability of batteries, loaner aids, and FM systems. |
| (3) Maximize the Development of Spoken Language |
A commitment to helping children with hearing loss develop intelligible spoken language to the greatest extent possible. |
| (4) Provide Support and Guidance to Parents |
A commitment to providing support to parents through constant communication from the program's leaders and staff. This should include information on all aspects of hearing loss, opportunities for parents to share feelings and experiences with other parents, and informing parents of their rights. |
| (5) Employ Superior Educational Staff |
A commitment to hiring and retaining well-trained, well-supported, available staff. Teachers, audiologists and speech-language pathologists should have appropriate licensing and/or certification in their area of expertise. |
| (6) Offer Options in Educational Settings |
A commitment to providing a range of available educational settings including: full-time regular class; full-time regular class with supportive services; part-time regular class/part-time special class; full-time special class in a regular school; full-time special class in a special school; residential/day school; home or hospital services. |
| (7) Adhere to IDEA |
A commitment to placement in one of the above settings that is in full compliance with all of the rules and regulations set forth by state law under the Individuals with Disabilities Education Act. |
| (8) Provide Services to Parents and Families |
A commitment to providing a range of support services; examples include: (a) audiology, (b) speech/language pathology, (c) sensory integration, physical and occupational therapy, (d) counseling services for students and families; (e) behavioral management, (f) social work services, (g) academic tutoring, (h) oral interpreting, (i) note takers, (j) career counseling (k) respite child care, (l) coordinated services from other agencies, if needed. |
| (9) Offer a Curriculum Mirroring (as closely as possible) the Mainstream Classroom |
If the child is not enrolled in a regular classroom, a commitment to teaching a curriculum that is similar to that presented in the regular classroom. |
| (10) Ensure an Environment that Fosters Learning |
A commitment to ensuring a physical environment conducive to listening and speech reading. That environment should be quiet, acoustically favorable, well-lit and equipped with assistive listening devices. |
| (11) Select Informed and Sensitive Teachers in Mainstream Settings |
If a child is in the regular classroom, a commitment to providing teachers with a thorough orientation in working with children with hearing loss, and to offering teachers with assistance from, and access to, specialists in the field. |
How Can I Help my Child Succeed in School?
Master the Special Education Maze
Every child with a disability enrolled in the public school system is guaranteed a free, appropriate education under a federal law called the Individuals with Disabilities Education Act (IDEA). Federal law stipulates that the education be individually tailored to the child's needs. Unlike regular education where "one curriculum fits all", IDEA specifies that special education must be individually tailored to your child's needs. The law also stipulates that the student should be placed in the "least restrictive environment." The meaning of "least restrictive environment" has been a source of debate and controversy since IDEA was passed. To some it simply means an environment where a child is most likely to thrive, but to others it denotes an environment most similar to the regular classroom and regular curriculum. Either definition may be applicable. For example, students who are able to compete in a regular classroom (usually with support through tutors, speech/language therapy, etc.) may be best prepared to enroll in higher education or compete in mainstream society. On the other hand, a child who attends a small private school for hearing-impaired children (i.e., a restricted environment) may blossom with the individual attention and support.
In theory, children's special education services are supposed to be tailored to their needs. In practice, children are apt to receive a generic set of services based on their disability, rather than on their individual strengths and weaknesses. As a result, parents must be aggressive in requesting accommodation for their child(ren). Unfortunately, schools have been known to discourage the use of technology or other supports that would help a student with hearing loss due to their financial cost. However, unlike general education, special education allows parents to have some say in their child's educational programming and supplementary services. You can help your child receive appropriate educational services, if you know what to ask for. Before you can influence your child's educational program, however, you must master the special education maze, and learn to play under the special education rules. For example, you may request a particular service for your child, and the school may agree on it; however, if it does not appear in writing in your child's special education plan, your request may not be legally binding.
The foundation of your child's education is the Individualized Education Plan, known as the IEP. An IEP is a legal, written plan that specifies special education and related services necessary to meet the individualized needs of a student with a disability. You must become familiar with the IEP process, and the way an IEP plan is written. You can influence your child's education through your participation in this process.
Either the school or the student's parent(s)/guardian(s) may request an IEP meeting. The meeting occurs at a mutually convenient time and place. Those attending will share the results of your child's evaluation and discuss its findings. Parent(s)/guardian(s) will have an opportunity to ask questions.
The Report of the Commission on the Education of the Deaf provides that an IEP for a child who is deaf or hard of hearing should consider the following:
- the student's communication needs;
- the family's preferred mode of communication;
- the student's linguistic needs;
- the severity of the student's hearing loss and his or her potential for using residual hearing;
- the student's academic level; and
- the student's social, emotional, and cultural needs.
The IEP must include plans for behavioral intervention and discipline as well as a statement of the supplementary aids and services needed in regular education classes. The IEP becomes effective as soon as possible following the meeting. Reviews of the IEP must be conducted at least on an annual basis but you will likely want more frequent reviews if it appears that your child's needs are not being met. As a parent, you are not required to sign the IEP. You have the right to refuse services if you determine them to be inappropriate. The school district can then go to a hearing, or you as a parent can request a hearing.
For more information about the IDEA, Doenload a free copy of our brochure titled A Great IDEA: I.D.E.A., the I.E.P. Process and Your Child.
Some Things You Never Want to See in an IEP:
- Progress made on the current IEP is not documented.
- No information is given about the student's level of performance.
- Too many goals are listed (four or five are usually enough).
- Objectives are vague and unmeasurable.
- The same goals are repeated year after year.
- Amounts and types of services needed, such as speech-language therapy, are not specified.
- Goals are unrelated to curriculum or to activities.
- Placement is determined before needs are established.
- A regular classroom is not considered as an option.
- Goals are written for school staff rather than for the student.
A poorly written IEP can lead to vague programming and lack of accountability. (Source: COPE, 300 I St. N.E. Washington, DC 20002.)
Learn About Techniques and Technology that Assist Learning in the Classroom
Classroom support aids enhance the listening and learning environment for your child. Aids can refer to pieces of equipment or strategies for learning. Not all of the support aids listed below are necessary for every child, and some are needed only as your child reaches middle school age. You can work with the classroom teacher to set up a supportive classroom environment for your child. Whatever you and the IEP team decide is important to meet your child's needs, document in writing.
Possible Classroom Support Aids under IDEA for Children who use Auditory Approaches
| Classroom Support Aids |
Definition |
| Preferential, or favorable, Seating |
Sitting close to the teacher or other speakers, in order to optimize listening and visual clues. |
| Sound Field System |
An assistive device that improves listening in noisy or reverberant environments (like classrooms). Like a mini loud-speaker system, a sound field system amplifies the decibel level of a teacher's voice. Small speakers in the classroom bring the enhanced loudness to all students. Teachers enjoy using the sound field system because it saves wear and tear on their voice. |
| FM System |
An assistive device that improves listening in noisy environments (like classrooms). The teachers voice is transmitted by a microphone worn on his/her lapel via radio waves to the student, who receives the sound through a receiver that connects to the child's hearing aids or cochlear implant. For most children in the mainstream, an FM system is an important supplement to hearing aids and cochlear implants. Can be provided by the school for classroom use. |
| Notetaker |
A person with normal hearing takes classroom notes for the student; often the notetaker is another classmate with good note-taking skills. Note-taking becomes increasingly important at the middle school level. |
| Captioned Videos |
A caption line, similar to printed English subtitles. Captioned videos can be played on any T.V. manufactured after 1993, or with older sets using a separate device called a closed caption decoder. Teachers need to check that videos are captioned; unfortunately, most videos are not and it is very difficult for anyone with a significant hearing loss to follow an uncaptioned video. For help in finding these captioned videos, see the reference section. |
| Oral Interpreter |
A qualified professional who serves as a link between the speaker and the student. The oral interpreter silently mouths the words of the speaker, augmented with natural gestures. Supports understanding with the use of these strong visual cues. OI is usually introduced at the middle school level. The student has the right to the provision of an oral interpreter; however the lack of trained OIs limits availability. The school may need to train someone to provide this service. |
| C-Print Captioning |
C-Print is a speech-to-print system in which a hearing captionist (transcriber) types the words of the teacher and other students as they are being spoken into a lap-top computer. Students who are deaf or hard of hearing can read these real-time exchanges on a second lap-top computer or TV monitor. Additionally, the text file is stored and can be edited, printed and distributed to students after class. C-Print is designed to replace both interpreters and notetakers in the classroom. Contact AG Bell to learn more about C-Print. |
| Cued Speech Interpreter |
A qualified professional who serves as a link between the speaker and the student. The cued speech interpreter silently mouths the words of the speaker and simultaneously uses handshapes to cue the child as to what sounds are being spoken. Students have the right to a cued speech interpreter; however the lack of trained CSIs limits availability. The school may need to train someone to provide this service. |
| Acoustical Improvements |
This refers to minor changes/additions to classrooms designed to reduce ambient noise; acoustical improvements include: carpeting, acoustic ceiling tiles, double-paned windows, installation of a lower, sound-absorbing, suspended ceiling in older, higher-ceilinged classrooms, use of thick draperies at windows, elimination of background music, rubber tips on chair, table and desk legs, repair of heating/cooling/ventilation-associated noise, and avoidance of open-plan classrooms. |
| Real-time captioning |
"Real-time" (instant) transcription of speech by a real-time captioner (someone using courtroom stenographer equipment). The real-time captioner enters the lecture or classroom dialogue into a computer which shows up on a video screen or laptop computer which the student then reads. Currently the cost of classroom transcription is high and some schools oppose its use for this reason. However, a number of parents have been successful in obtaining its use in the classroom. |
Suggestions for Parents whose Child is Entering a Regular Classroom
In order for your child to have a successful mainstream experience, the whole school - from the principal to the physical education teacher to the students - needs to be involved. Most faculty in your neighborhood school will have had little experience with teaching children with hearing loss, and you will find that the level of enthusiasm for working with your child often depends on the tone set by the principal.
Children should not be placed in a regular neighborhood classroom unless it is fairly certain that they have the skills and background to succeed there. Your child's teacher will need extra support, training, and time to work with auxiliary staff (i.e., a hearing resource teacher, speech/language pathologist). All of the school faculty, including custodians and cafeteria workers, should be alerted well before the new term begins that your child will be entering school. This helps to ensure that your child's academic year goes smoothly.
Before the school year begins, you and your child should meet with the classroom teacher a few times. As children get older, they can meet with the teacher alone. This will provide an opportunity for you and your child to discuss previous academic achievements, strengths and weakness, as well as information about communication techniques, classroom supports, etc. You can also check to make sure that support staff have shown the classroom teacher how to check a hearing aid, use an FM system, order captioned videos and so forth. Throughout the year, it helps if you provide encouragement to the staff, and maintain some "oversight" as the school year progresses.
All of the staff should be aware of how to best communicate with your child, even though they may interact on a limited basis, such as at assemblies, break time or after-school activities. The students need an orientation, too. This can be handled tactfully, giving them a sense of participation rather than making it seem like a burden. Most people want to be helpful, if they know what to do. If your child and the teacher feel comfortable, it is often helpful for the teacher to give a unit on communication awareness, introducing the concept of hearing loss, its effect on communication, and information about exciting technology, such as captioned videos, relay systems and hearing technology. The overall goal for success is to achieve commitment and enthusiasm, emphasizing the fact that good communication techniques will benefit all students, not just the child with a hearing loss.
For more information on partnering with mainstream teachers, contact AG Bell to request a free copy of our brochure titled Have a Winning Year Teaching Your Child Who Is Deaf or Hard of Hearing .
How Can You Make Your Home Communication-Friendly?
There are lots of ways you can make your home communication-friendly for your family and your child's friends. In fact, technology is going to make a huge difference in your child's life, equalizing the playing field between those who have normal hearing and those who do not. One of the exciting aspects is that much of this is "mainstream" technology, used by everyone, not just people with hearing loss.
You probably already have some of this equipment at home. Do you have a computer and access to the Internet? This will become your child's lifeline! Email has become ubiquitous and it is one of the simplest ways for people with and without hearing loss to communicate. Every year millions of people open Internet and email accounts, as the price of computers and Internet services decrease. In fact, people with hearing loss are usually the first to use new services, such as instant messaging or "chat rooms". Additionally, the Internet is a "no hassle" way to conduct research for school projects. There are also computer programs that are excellent for stimulating language and speech skills.
If you have a fax machine, you have another device that is excellent for non-verbal communication. One of the good features of faxes is that you have a "hard copy" of your communication. This way, both parties can be certain they have understood one another, avoiding mix-ups and misunderstandings which can occur in conversations where communication is difficult.
If you have a television set manufactured after 1993 with a screen that is 13 inches or larger, your child has instant visual access to TV. You may have noticed the number of programs that are captioned, designated with a "CC" in every television program guide. Television captioning is similar to the written text line you see running across the bottom of foreign movies. You may have also seen the captioning line used on televisions in noisy places like airports and restaurants.
You will need to use the closed captioning button on your T.V. to access the caption line. Check your T.V. instruction booklet if you are unsure how to activate closed captioning. Older televisions do not have a closed captioned button, but you can buy a separate closed captioned decoder from specialty catalogs featuring assistive devices. However, it may be a better investment to purchase a new television, rather than a caption decoder.
Your child can use a telephone, too. Children with mild-moderate losses, or even severe-to-profound losses (if they are well-aided or have a cochlear implant, and have been taught to use residual hearing), may be able to use the regular telephone. As a first step, ensure that your phone has a volume control option so that your child may amplify the caller's voice as necessary. Also, your child needs a hearing aid with a telephone ("t") switch, and a hearing-aid compatible telephone. Newer phones are all manufactured to be compatible with t-switches. If you have an older phone, your child will have to try it out with the t-switch turned on. Some of the digital wireless phones will emit a loud, squealing sound if used with a "t" switch. If you are going to purchase a digital wireless phone that your child will use, you need to have him/her try it out before committing to the purchase.
A TTY machine can be attached to your regular phone to turn the auditory signal into a visual print-out. In order to use a TTY, your child needs to know how to type and to read. The phone set is not held up to one's ear, but placed on the TTY machine. The person types in the message, and the words are transmitted to the person on the other end who also has a TTY machine. The message is read, one line at a time, on a small screen. There are a variety of TTY machines - some are very small and portable, others are desk units with the capability of printing a "hard copy" of the conversation. TTY machines can be ordered through specialty catalogs.
So, what do you do if the person being called doesn't own a TTY? Thanks to another federal law, the Americans With Disabilities Act, a nation-wide relay system has been set up. The person with the TTY first calls a relay operator. The relay operator gets the second party on the line. Now the person with the TTY starts typing in the conversation. The relay operator reads the message over his/her TTY and relays that message verbally to the second party. The second party answers verbally, the operator types in that message and it is relayed to the person with the TTY. The parties can talk as long as they wish. The rates for long-distance are reduced for relay calls, because they take longer than regular calls. The relay number for your state is located in the front pages of your telephone book.
There are other pieces of equipment that make communication helpful-for example, vibrating pagers with digital readouts, watches with vibrating alarms, visual alarm clocks-and dozens of gadgets and accessories helpful for enhancing communication. Keep your eyes and ears open for new technology and new ways of using existing technology. Consult AG Bell and other organizations serving the deaf and hard of hearing, and send for some of the specialty catalogs on assistive devices. Attend the AG Bell convention to learn more about advances in technology through our technology forums and research symposia.
Having Fun and Broadening Horizons
Life cannot be all work! Friends, hobbies, travel, art, sports, family outings, part-time jobs, etc. all make life richer and more interesting.
When it comes to hobbies and extra-curricular activities, follow your children's interests, and don't impose any limits or restrictions. Heather Whitestone, a former Miss America who is deaf, is an accomplished ballet dancer. Her stunning dance performance during the Miss America pageant helped clinch the title for her. Curtis Pride, also hearing impaired, is a professional baseball player. Evelyn Glennie is considered the world's finest concert drummer, and happens to have a hearing loss. The fact that there is an association of private pilots who are deaf is further proof that a hearing loss is not a barrier to one's passions in life. The Americans With Disabilities Act has helped make most public facilities accessible to people with disabilities while advances in technology continue to open doors.
While children should not be limited by hearing loss, they may also enjoy joining groups or involving themselves in an activity primarily for children who are deaf or hard of hearing. Being with other children who have a hearing loss can provide a comfortable communication setting surrounded by people who may have a special camaraderie with one another. AG Bell's national mentoring program and leadership conferences for young adults are designed to facilitate exactly these sorts of interactions. Mentoring activities provide children with opportunities to socialize, as well as to meet successful young adults with hearing loss.
Activities with others who are deaf or hard of hearing
- Camps - There are a number of camps across the country which are either exclusively for children with hearing losses, or encourage their participation. Some of these camps are primarily "manual," some are "oral," and some are mixed. AG Bell maintains a list of these camps, as do other organizations.
- Peer groups and socializing - Parents may want to consider establishing a peer support group for their children with hearing loss. To locate other families with children who are hearing impaired, contact your state AG Bell chapter, OPTION-a consortium of private schools for children with hearing loss, or other schools in the area emphasizing the auditory approach. Groups can be structured, meeting regularly, or ad hoc, meeting occasionally. Sessions can be held at your home, or at a museum, park or nearby restaurant. The objective is simply to provide your child with the opportunity to meet new people and have fun in a welcoming environment. Parents also benefit from the support they receive from others who have experienced the same joys and challenges associated with raising a child with hearing loss.
- Youth activities at conferences and conventions run by organizations serving deaf persons. Most large national organizations hold conventions and welcome the attendance of children. AG Bell, for example, develops a customized convention program for children and teen attendees that is a mixture of free play, structured learning opportunities (learning about hearing loss or self-advocacy), organized activities (like face painting or art projects) and field trips-all under the watchful eye of our counselors (who are parents or professionals in the field). Since conventions are usually held at attractive destinations, many families choose to make this their summer vacation.
- School Activities: Public schools are required to provide reasonable accommodation during school activities. This may take the form of having assistive listening devices available during the activity, or even providing an interpreter, for example for a school assembly. Unfortunately the laws do not spell out what is "reasonable" and the services to be provided are negotiated between parents and school administrators. If the accommodation places an excessive financial burden on the school, it may not be deemed reasonable. For example, it might not be reasonable for the Honor Society to provide an interpreter for every meeting, but it would be reasonable to provide an interpreter for an induction banquet, or group attendance at a cultural event. Another criterion for "reasonable" is that the special request be made ahead of time, so that the person in charge of the activity has adequate time to make the appropriate arrangements.
- The Arts: The Americans with Disabilities Act requires reasonable accommodation at theatrical and other cultural events in your community. Again, "reasonable" often applies to cost and difficulty, although certain accommodations such as ALDs must be provided. While a non-profit group sponsoring a free play for children may argue that hiring an interpreter would be overly burdensome, such a request is likely to be a reasonable accommodation for institutions supported by government or for-profit entities. Many theaters have special, interpreted performances or, on request, make scripts available prior to performances.
- The Movies: The ADA does not require movies to be open captioned (i.e., captions running across the bottom of the screen and viewed by the entire audience) but it does encourage the scheduling of special captioned movie showings. These are being offered on an increasingly frequent basis. Many large cities now show captioned versions of first-run movies on a limited schedule. Contact local organizations serving deaf and hard of hearing persons for information about captioned movies in your locale, or log onto www.tripod.org; this site provides a listing of captioned showings nationwide. Additionally, closed captioning technology such as Rear Window, which allows viewers with hearing loss to access captioning that is not visible to the audience at large, has become increasingly important. The benefits of this technology is that it allows people who are deaf or hard of hearing to attend any showing of a film that has been captioned, without having to wait for a special viewing. The prevalence of closed caption technology is expected to grow, and you can expect to see more and more innovation in this area as time goes on.
Additionally, all movie theaters must provide assistive listening devices (ALDs) upon request. These ALDs should be available at all showings and, depending on your child's level of loss, can enhance your child's ability to hear the film's dialogue, songs, etc.
- Sports: Many children with hearing loss find a "level playing field" in sports. With the emphasis on physical, rather than linguistic skills, children who are deaf or hard of hearing can excel in sports activities. The reasonable accommodation rules apply to sports activities but you will likely need to educate the organizers about your child's needs.
- Friends: If your child has difficulty making friends, you can be a catalyst by making your home a warm and welcoming place for kids to hang out. Have computer games, captioned videos, sports equipment and, of course, snacks available, and don't interfere too much!
- Travel: If you travel to large, popular tourist destinations, like Disney World, you should expect reasonable accommodations, such as assistive listening devices and captioning. Even so, it is a good idea to check ahead of time to confirm what they have available. It's best to make your request for special accommodations ahead of time as well. If your child uses a TTY, a hotel should provide one; once again, it's wise to request this equipment when making your reservation, rather than upon arrival. All public accommodations-meaning all facilities that are open to the public-must provide reasonable accommodation, such as TTYs, pay-phone TTYs, amplified phones, interpreted programs, etc.
As Your Child Gets Older
Continue to look to A.G. Bell as a resource providing both you and your child with the best information available on topics ranging from schools offering the auditory approach to hearing technology to summer camps. Take advantage of the wonderful friendships that can be built through our mentoring program, get involved in an AG Bell state chapter and meet other families like yours, become adept at negotiating IFSPs and IEPs by turning to AG Bell for advocacy tips, and join us at our summertime biennial conventions to learn more about innovations in the field of hearing loss.
Most importantly, watch your children grow, explore, laugh and sing and speak-using their own beautiful voices.
References and Resources
A selected list of organizations follows; for a more complete listing, contact AG Bell directly.
Organizations Serving Parents of Children Using Auditory Approaches:
Alexander Graham Bell Association for the Deaf and Hard of Hearing 3417 Volta Place, NW Washington, DC 20007-2778 (202) 337-5220 (v) (202) 337-5221 (TTY) (202)-337-8314 (fax)
The Alexander Graham Bell Association for the Deaf and Hard of Hearing is an information center on hearing loss, emphasizing the use of technology, speech, speechreading, residual hearing and written and spoken language. AG Bell focuses specifically on children with hearing loss, providing ongoing support and advocacy for parents, professionals and other interested parties.
We publish books and brochures on the subject of hearing loss, auditory approaches in education, advocacy, employment and advances in hearing technology. AG Bell also publishes a magazine, Volta Voices, and a scholarly journal, The Volta Review. We offer resource/referral services to individuals with questions about hearing loss and auditory approaches.
AG Bell provides financial aid to qualifying applicants for mainstreamed, auditory-based education at pre-school, school-age and university levels. Regional conferences and bi-ennial conventions are held to educate both members and non-members on issues relating to hearing loss. Finally, AG Bell provides governmental and education advocacy services through its state chapters, children's rights coordinators and international affiliates.
Auditory-Verbal International, Inc. 2121 Eisenhower Avenue, Suite 402 Alexandria, VA 22314 (703)739-1049 (v) (703)739-0874(tty)
National Cued Speech Association 23970 Hermitage Road Shaker Heights, OH 44122 (800) 459-3529
Option Schools (private oral programs) (877) 672-5332 (v) (877) 672-5889 (tty) Interested parents can receive a free copy of "Dreams Spoken Here," a video profiling education using auditory approaches.
Organizations Providing General Information about Hearing Loss:
American Academy of Audiology 8300 Greensboro Drive, Suite 750 McLean, VA 22102 (800) 222-2336 (v/tty) (703) 610-9022 (v/tty) (703) 610-9005 (f) Email: molek@audiology.org
American Academy of Otolaryngology-Head and Neck Surgery 1 Prince Street Alexandria, VA 22314-3357 (703) 836-4444 (v) (703) 519-1585 (tty) (703) 683-5100 (f) Email: info@entnet.org
American Speech-Language-Hearing Association 10801 Rockville Pike Rockville, MD 20852 (800) 638-8255 (v/tty) (301) 897-7355 (f) Email: actioncenter@asha.org
Cochlear Implant Club International 5335 Wisconsin Avenue, NW Suite 440 Washington, DC 20015-2034 202-895-2781 (v/tty)
National Institute on Deafness and Other Communication Disorders Information Clearinghouse 1 Communications Ave Bethesda, MD 20892-3456 (800)241-1044 (v) (800)241-1055 (tty)
Self-Help for Hard of Hearing People 7910 Woodmont Avenue Suite 1200 Bethesda, MD 20814 301-657-2248 (v) 301-657-2249 (tty) 301-913-9413 (f) Email: national@shhh.org
Organizations Serving Families Using Manual Approaches:
National Association of the Deaf 814 Thayer Avenue Silver Spring, MD 20910-4500 (301) 587-1788 (v) (301) 587-1789 (tty) (301) 587-1791 (f) Email: nadinfo@nad.org
American Society for Deaf Children 1820 Tribute Road, Suite A Sacramento, CA 95815 (800) 942-ASDC (v/tty) (916) 641-6084 (v/tty) (916) 641-6085 (f) Email: ASDC1@aol.com
Regional Organizations:
Contact AG Bell to learn which of our more than 30 state chapters are closest to you! Additionally, in most areas of the country there exist specific centers devoted to providing a comprehensive set of services for children with hearing loss. Please contact AG Bell to identify one in your area.
Author Credits
AG Bell would like to thank Susan Coffman, Director of Professional Programs and Services from 1986 to 1998, for volunteering her time in writing the first draft of this booklet. Current Director of Member Services Rebecca Parlakian's work in building upon and expanding the original draft has been invaluable as well.
We would also like to thank:
- Vickie Thomson and Alison M. Grimes, both of whom are clinical audiologists, on behalf of the American Academy of Audiology;
- Neil O. Ward, M.D., interim Executive Vice President of the American Academy of Otolaryngology-Head and Neck Surgery;
- Evie Cherow, Director of Audiology, on behalf of the American Speech-Language-Hearing Association;
- Donna L. Sorkin, Executive Director of AG Bell;
- Stephen Epstein, M.D., Past President of AG Bell;
- John K. Niparko, M.D. of the Department of Otolaryngology-Head & Neck Surgery at The Johns Hopkins University; and
- Sue Griebler, a strong advocate for early identification in the state of Maryland for their time and generosity in reviewing the booklet for accuracy.
© 2002 by Alexander Graham Bell Association for the Deaf and Hard of Hearing
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