MICHIGAN’S EARLY HEARING DETECTION AND INTERVENTION SYSTEM

GUIDELINES FOR EARLY INTERVENTION

The goals of newborn hearing screening are to provide a hearing screen to all newborns before
one month of age, to ensure that all newborns who do not pass the birth admission hearing screen
obtain a diagnostic outcome before three months of age, and for all infants identified with
hearing loss to obtain intervention services before six months of age (See Attachment C for
eligibility). The Joint Committee on Infant Hearing defines the targeted hearing loss for
universal newborn hearing screening programs as permanent bilateral or unilateral, sensory or
conductive hearing loss, averaging 30-40 dB or more in the frequency region important for
speech recognition (approximately 500-4000 Hz). Identifying a baby with hearing loss as early
as possible, can allow early intervention strategies to optimize the critical language learning
years of a young child. The goal of early intervention is to provide every child with a hearing
loss the opportunity to develop an effective communication system. Thus, a primary focus of
early intervention is on providing parent(s)/caregiver(s) with the information and skills needed to
communicate naturally with their child, as they are engaged in everyday activities.

Research on brain development indicates that the critical time for learning language is from birth
to three years of age. Without early identification of hearing loss and subsequent intervention,
children are at risk of missing the opportunity for communication and socialization development
during early life experiences. The wealth of learning that takes place as the young child
develops language is the basis for later literacy and educational development. Likewise, the
communication skills, academic achievement, social skills and level of self-esteem acquired by
the child will be important factors in determining life options and success as an adult.

I. EARLY INTERVENTION PROCESS

A. Early On Michigan
Upon confirmation of hearing loss, a referral to Early On Michigan, at 1-800-
EARLY ON (1-800-327-5966), must take place within 2 working days. An
interim Service Coordinator will facilitate the assessment and individualized
program planning for the family (See Attachment A: Early On Michigan
Referral Process to Intervention). When the parent(s)/caregiver(s) sign the initial
consent for educational evaluation, they will receive a booklet describing their
legal rights (Procedural Safeguards). The state and federal governments have
established timelines from referral to assessment to service provision. It is
strongly recommended that Service Coordinators, working with families, have
knowledge of local early intervention programs/services for young children with
hearing loss, as well as available resources and service agencies. This information
can be found in the Services For Children Who Are Deaf or Hard of Hearing; A
Guide to Resources for Families and Providers (DCH-0376), which can be
obtained, free of charge, by calling the MDCH/EHDI Program at (517) 335-9560.
B. Individualized Family Service Plan (IFSP)
The Service Coordinator will assist the family in developing an Individualized
Family Service Plan (IFSP). This document will list the services to be provided
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to the child and the family, based on the child's and family's abilities and needs.
The IFSP needs to address the communication needs of the child and his/her
family so effective communication can begin immediately. To ensure full
participation in the IFSP, parent(s)/caregiver(s) should be informed of
communication choices and the importance of their role in making that choice.
This information sharing should continue as the interventionists and
parent(s)/caregiver(s) work as a team, while monitoring the child's
communication development.

II. PRINCIPLES OF EFFECTIVE EARLY INTERVENTION

Infants with confirmed hearing loss should receive intervention as soon as possible or
within 45 days of identification of the hearing loss. Professionals in both health care and
education, who possess expertise in hearing loss and its effects on early development,
should provide this service. Early intervention programs should be family-centered and
interdisciplinary. Family-centered care involves the following:
1. Recognizing that the family is the constant in a child's life while the
service systems and personnel within those systems fluctuate.
2. Facilitating parent/caregiver-professional collaboration at all levels of
health care and in educational intervention.
3. Honoring the racial, ethnic, cultural, and socioeconomic diversity of
families.
4. Recognizing family strengths and individuality and respecting different
methods of coping.
5. Sharing with parent(s)/caregiver(s), on a continuing basis and in a
supportive manner, complete and unbiased information on the various
modes of communication used with children who are hearing impaired and
the common beliefs about each.
6. Encouraging and facilitating family-to-family support and networking.
7. Understanding and incorporating the development needs of infants,
children and their families into early intervention services.
8. Implementing comprehensive policies and programs that provide
emotional and financial support to meet the needs of families.
9. Assurance that the design of early intervention services is flexible,
accessible, and responsive to family needs.
Professionals should provide parent(s)/caregiver(s) with spoken, written, and/or signed
information, as needed, to enable them to make informed choices related to
communication options, educational programs, and other services (e.g. Family Support
Network). At the diagnostic audiologic evaluation, the audiologist should provide the
family with a copy of the Services For Children Who Are Deaf or Hard of Hearing; A
Guide to Resources for Families and Providers (DCH-0376), which can be obtained, free
of charge, by calling the MDCH/EHDI Program at (517) 335-9560. The Medical Home
and the Service Coordinator should ensure that the family has received a copy of the
resource guide. The resource guide is a starting point for parent(s)/caregiver(s) to obtain
information about services. The Service Coordinator should ensure that the family has
Early Intervention 35

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access to other information on general child development as well as the unique needs
related to hearing loss and language development. This can be facilitated by the family
1) working with professionals, 2) interacting with other parent(s)/caregiver(s) of children
with hearing impairment, 3) interacting with adults who are deaf or hard of hearing, and
4) working with organizations or agencies serving as resources on hearing impairment
and deafness. In supplying information to families, professionals must recognize and
respect the family's natural transitions through the grieving process at the time of initial
identification of hearing loss and at different intervention decision-making stages
(Cherow, Dickman, & Epstein, 1999; Luterman, 1985; Luterman & Kurtzer-White,
1999).
A. Audiologic Intervention
For parent(s)/caregiver(s) who decide to provide their child with amplification,
early intervention services can provide a vital opportunity for stimulation of the
child's auditory system. This can be accomplished through the use of hearing
aids, FM systems, cochlear implants or other assistive technology. Information
regarding these options will be made available to parent(s)/caregiver(s) by the
diagnostic audiologist who will provide them with a copy of the Services For
Children Who Are Deaf or Hard of Hearing; A Guide to Resources for Families
and Providers (DCH-0376), which can be obtained, free of charge, by calling the
MDCH/EHDI Program at (517) 335-9560. Input from the interventionists and the
parent(s)/caregiver(s) will assist the audiologist in assessing the child's hearing
status, the child's benefit from the current amplification system and the need for
adjustments. The following best practices are recommended:
1. Amplification
a. Binaural hearing aids are recommended for children with bilateral
hearing loss. Use of amplification should be initiated within one
month of confirmation of hearing loss, or as soon as possible.
b. Audiologic management should include real-ear measures and
electroacoustic analysis and/or reprogramming of the child's
hearing aids.
c. Aided and unaided responses across the speech frequencies should
be obtained, as early as possible, but no later than twelve months
following confirmation of a hearing loss. Behavioral response for
ear-specific information (both aided and unaided) should be
obtained as early as possible, but no later than 2 years after
confirmation of hearing loss. This may mean frequent initial visits
to the audiologist.
d. New earmolds should be obtained as frequently as necessary,
dependent on the growth of the child.
e. For audiologic results indicating auditory neuropathy (ABR fail,
OAE pass), the appropriateness of hearing aid use may be hard to
determine (Hood, 2000).
f. Amplification Management and Maintenance

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Families should be counseled regarding the need for audiologic

follow-up to monitor the function, use, and appropriateness of
amplification. Families should be counseled regarding the need to
perform daily listening checks and the need for audiological re-
evaluation of a child’s amplification. Periodic audiological re-
evaluation should include a recheck within 1-2 weeks after the
initial fitting, and at 3 month intervals for children age 0-3 years;
every 6 months for age 4-6 years; and every 6-12 months for
school age children. The frequency of follow-up may need to be
increased if fluctuation/progression of the hearing loss is noted
and/or if progress is questioned. Ongoing communication between
the clinical audiologist and the members of the early intervention
team is critical.
2. Audiologic Monitoring
All children with identified hearing loss (i.e., hearing levels > or = to
25 dB HL, unilateral or bilateral, permanent or fluctuating) should receive
periodic audiologic monitoring as per the suggested schedule listed below.
An immediate audiologic evaluation should be scheduled when there is
concern related to change in hearing or hearing aid function.
a. Bilateral sensorineural hearing loss and permanent conductive
hearing loss:
1) Age 0-3: Every 3 months, after hearing loss is confirmed.
2) Age 4-6: Every 6 months, if intervention progress is
satisfactory.
3) Age 6 years or older: Every 6-12 months if progress is
satisfactory.
b. Transient conductive hearing loss (e.g., otitis media with effusion),
unilateral or bilateral:
Should be monitored after medical treatment (completion of
antibiotic treatment, PE tubes, etc.), and/or at least on a 3-4 month
basis until resolved and normal hearing is confirmed.
c. Unilateral hearing loss (sensorineural or permanent conductive):
Infants with unilateral hearing loss should be monitored every 3
months during the first year, then on a 6-months basis after the first
year, to rule out changes in the normal hearing ear.
B. Educational Intervention
The mounting evidence for the crucial nature of early experiences in brain
development provides the impetus to ensure learning opportunities for infants and
young children with hearing loss. Intensive early intervention can positively alter
the cognitive and developmental outcomes. Early intervention services should be
designed to meet the individualized needs of families and infants, including
addressing acquisition of communicative competence, social skills, emotional
well-being, and positive self-esteem (Karchmer & Allen, 1999). Effective
intervention should also provide ongoing assessment through frequent evaluation
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of a child's progress by the parent(s)/caregiver(s) and interventionists to ensure

that a child is progressing at an expected rate. The six frequently cited principles
of effective early intervention follow (Meadow-Orleans, Mertens, Sass-Lehrer, &
Scott-Olson, 1997; Moeller & Condon, 1994; Ramey & Ramey, 1992, 1998;
Stredler-Brown, 1998; Tomblin, Spencer, Flock, Tyler, & Gantz, 1999).
1. Developmental Timing
This refers to the age at which services begin and the duration of
enrollment. Programs that enroll infants at younger ages and continue
longer are found to produce the greatest benefits.
2. Program Intensity
The amount of intervention is measured by multiple factors, such as the
number of home visits/contacts per week for the infant and family's
participation in intervention. Greater developmental progress occurs when
the infant and family are actively and regularly involved in intervention.
3. Direct Learning
This principle encompasses the idea that center-based and home-based
learning experiences are more effective when there is direct (provided by
trained professionals) as well as indirect intervention.
4. Program Breadth and Flexibility
This notes that successful intervention programs offer a broad spectrum of
services and are flexible and multifaceted to meet the unique needs of the
infant and family, including infants with additional disabilities beyond
their hearing loss.
5. Infant and Family Individual Differences
The rate of progress and benefits from the program will differ. Not
everyone progresses at the same rate nor benefits from the programs to the
same extent.
6. Environmental Support and Family Involvement
The benefits of early intervention continue over time depending on the
effectiveness of existing supports such as family involvement and
environmental supports such as home, school, peers and Medical Home.
C. Communication Skills Intervention Components
The unique features of an early intervention program for children who are deaf or
hard of hearing should include the following components. The family, supported
by the IFSP team will determine which specific components would be part of
each child's intervention plan.
1. Language Skills Development
The development of communication skills, particularly language skills, is
fundamental to a child’s academic, social, cognitive, and linguistic
development, as well as mental and physical well-being and will
determine, to a great degree, whether that child can become a productive,
fulfilled, and capable adult. A child's communication begins developing
from birth through natural interactions and conversations between the
child and his/her caregivers. Effective interaction between the caregiver
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and the young deaf or hard of hearing child is extremely important if

language is to develop. Children express communicative intent through a
variety of gestures, facial expressions, and vocalizations. The growth in
both oral and/or sign language development should be consistent with the
developmental expectations for the child’s age and cognitive abilities.
Language development should include acquisition of phonologic (for
spoken language), visual/spatial/motor (for signed language),
morphologic, semantic, syntactic, and pragmatic skills. Communication
can be facilitated through:
a. Teaching parent(s)/caregiver(s) to respond to these expressed
messages appropriately. This will help the child develop an
effective communication system. Topics covered should include
prelinguistic (selective attention and turn taking) development.
b. Providing parent(s)/caregiver(s) with information specific to
language development and with family-involved activities that
facilitate language. As parent(s)/caregiver(s) learn about how
communication develops, how to foster and stimulate effective
caregiver-child interactions, and how to monitor and evaluate their
child's communication they will reach a decision regarding
communication methodology that is appropriate for their child and
the entire family.
2. Auditory Skills Development
Young children who are deaf or hard of hearing need the opportunity to
learn to use their amplified residual hearing or a cochlear implant to gain
meaning from the world of sound. The auditory program should educate
parent(s)/caregiver(s) and children on the development of the hierarchy of
listening skills:
a. Detection: The process of determining whether sound is present or
absent.
b. Discrimination: The process of perceiving the differences between
sounds, especially speech sounds.
c. Identification: The process of learning the labels or names for
what has been heard.
d. Comprehension: The process of understanding the meaning of
acoustic messages.
3. Hearing Aid Program
Parent(s)/Caregiver(s) need to learn how the hearing aids work, how to
care for them, and how to operate them. Parent(s)/Caregiver(s) also need
information on related topics, such as understanding the degree and nature
of their child's hearing loss, the importance of well functioning hearing
aids for spoken language development, and how speech is perceived.
They also need information on assistive technology, including but not
limited to: FM listening devices, tactile aids, t-coils, captioning, alerting
devices, and cochlear implants. In supplying information to families, it is
Early Intervention 39

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important for professionals to prioritize information presentation in light

of the vast array of new information families receive after the initial
identification of hearing loss in their child.
4. Parent(s)/Caregiver(s) Support
Parent(s)/Caregiver(s) are the best models for their children. A very
important role of the early interventionist is to offer parent(s)/caregiver(s)
guidance and resources to enable them to develop the skills needed to
provide their child with an effective communication system.
Interventionists are encouraged to be aware of the uniqueness of each
family's dynamics and the impact that a child with a hearing loss has on
the dynamics. As stated earlier, parent(s)/caregiver(s) should be given
unbiased information on each communication option (American Sign
Language, Auditory/Oral, Auditory/Verbal, Cued Speech, and Manually
Coded English). After parent(s)/caregiver(s) decide on a communication
approach, they should be encouraged to learn as much as they can about
that approach and use it regularly in communication at home. The
communication approach selected should be reevaluated if the child is not
developing communication at the expected rate.
a. Ongoing information
Parent(s)/Caregiver(s) should be provided with ongoing
information and experiences, as needed, in the following areas:
1) Communication choices, in an unbiased manner
2) Opportunities to meet older children or adults, with varying
degrees of hearing loss, who communicate using spoken
language
3) Opportunities to meet older children or adults who
communicate through the use of sign language
4) How to access educational services
5) How to access public or private services for audiological
management, hearing aids and other assistive devices,
speech therapy, and/or sign language tutoring/classes
6) Agencies that may provide financial assistance
7) Special education laws and parents’/caregivers’ rights
8) Community support systems and programs (e.g.,
counseling services, social services, and infant mental
health services)
These resources can be found in the Handbook, Services For
Children Who Are Deaf or Hard of Hearing; A Guide to Resources
for Families and Providers, which can be obtained, free of charge,
by calling the MDCH/EHDI Program at (517) 335-9560.
D. Medical Intervention Coordination
Ongoing medical intervention is an important part of the overall early intervention
plan for young children with hearing loss. It is important for the family to have a
Medical Home for the medical management of the child and monitoring of
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ongoing developmental milestones. The Medical Home should be involved in

collaborating efforts related to family service coordination. The Medical Home
can provide referrals related to specialty care (e.g., ophthalmology, speech
pathology, audiology, etc.), can monitor the child for the presence of middle ear
effusion so that hearing is not further compromised, and can counsel the family
regarding the benefits of genetic evaluation (i.e., which may provide information
on etiology of hearing and other related medical conditions). The Medical Home
also plays an important role in reinforcing the importance of early intervention
services and monitoring ongoing developmental progress.
E. Standards For Early Intervention Service Providers
1. Trained Personnel
It is critical to the success of early intervention programs to have trained
personnel providing the intervention. Since newborn hearing screening
can help to identify children with hearing impairment at a very young age,
it provides an opportunity to prevent the severe language delay that occurs
with later identification. In order to optimize the opportunity for
communication development during these early months, the intervention
services providers must have the knowledge and experience to: 1) respond
to parents’/caregivers’ questions, 2) provide them with information on
hearing impairment and its effects, and 3) model the ways in which they
can provide language stimulation during daily activities with their baby.
2. Knowledge and Skills of Service Providers
Standards for early intervention service providers for young children who
are deaf/hard of hearing and their families have been reported in the
"Early Intervention Protocol" document published by the State of
Colorado. This list provides a comprehensive guide for knowledge and
skills of staff, but can also be used as an inclusive guide to the breadth of
information which should be shared, over time, with the family of the
newly identified child with hearing loss, as needed (See Attachment B:
"Standards for Early Intervention Service Providers…..").

III. QUALITY INDICATORS FOR EARLY INTERVENTION PROGRAMS

Quality Indicators are quantifiable goals or targets by which an early intervention
program can be monitored and evaluated. Indicators are used to evaluate progress and to
point to needed next steps in achieving and maintaining a quality early intervention
program (O'Donnell & Galinsky, 1998). All infants should be served as described below.
1. Infants with hearing loss should be enrolled in a family-centered early
intervention program within 45 days of confirmation of hearing loss.
2. Families should receive intervention from professional personnel who are
knowledgeable about the communication needs of infants with hearing
loss.
3. Infants with hearing loss and no medical contraindication should begin use
of amplification when appropriate and agreed on by family within 1 month
of confirmation of hearing loss.
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4. Infants with amplification should receive ongoing audiologic monitoring

at intervals not to exceed 3 months.
5. The goal for all infants enrolled in early intervention programs is to
achieve language milestones in the family's chosen communication mode
similar to that for hearing peers of a comparable developmental age.
Language growth should be monitored at periodic intervals (i.e. 6-month
intervals) to assess progress.
6. Families should participate and express satisfaction with the intervention
program.

IV. MONITORING SYSTEM FOR MICHIGAN

The monitoring system for reporting a child’s entry into, and progress in, early
intervention is an important part of the Michigan Early Hearing Detection and
Intervention System. The Early On Michigan reporting system, already in place,
should assist in notifying the MDCH/EHDI Program (FAX: (517) 335-8036) of a child’s
enrollment into early intervention services as needed, with consent of the
parent(s)/caregiver(s).

Early Intervention 42

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