Hearing impairment detection and intervention in children from centre-based early intervention programmes

Abstract

The study aimed to describe ages at identification and initiation of early intervention (EI) services for children enrolled in centre-based EI programmes in Gauteng, as well as to describe the nature of EI services that the children received. The researchers conducted retrospective record reviews of the EI programme files. In addition, caregivers of eight children identified with hearing impairments and enrolled in centre-based EI programmes in Gauteng completed a newly constructed questionnaire. The caregiver questionnaire produced data pertaining to the child's family demographics, background information and schooling history. Descriptive statistics were used to analyse the data, using frequency distribution and measures of central tendency. None of the children received newborn hearing screening services, thus they were identified late following maternal suspicion of hearing impairment. Late identification of the hearing impairment resulted in suboptimal initiation of EI services. All the children received aural habilitation and/or speech–language therapy services. These findings indicate that there is a great need for the establishment of widespread early hearing detection and intervention programmes that will lead to earlier identification of infant and childhood hearing impairment and timely initiation of EI services.

Keywords

Early hearing detection early intervention hearing impairment universal newborn hearing screening

Introduction

The negative effects of an undetected hearing impairment on a child’s speech and language development are widely reported (Sininger et al., 2010; Van Dyk et al., 2015). These negative effects can be further exacerbated by the poor socio-economic conditions and burdened healthcare systems characteristic of developing contexts such as South Africa (Meyer et al., 2012). However, children with hearing impairment can develop speech and language abilities on par with peers with normal hearing, if the hearing impairment is identified early enough and intervention is initiated timeously (Meyer et al., 2014). Hence, universal newborn hearing screening (UNHS) is either recommended or already practiced and legally regulated in many developed countries (Lasisi et al., 2014; Petersen and Ramma, 2015; White et al., 2010).

UNHS is the most preferred model for early detection of hearing impairment owing to the existing evidence that this model is a cost-effective approach for the timeous and effective detection of hearing impairment (Khoza-Shangase and Harbinson, 2015). Through UNHS, the age of a confirmed hearing impairment has decreased to between two and three months of age in developed countries (Swanepoel, 2009). Unfortunately, this advancement has not carried over to developing contexts, where two-thirds of the world’s children with hearing impairment reside (Olusanya et al., 2006). Only 7.5% of public sector hospitals and 53% of private sector hospitals offer NHS programmes in South Africa (Butler et al., 2015). UNHS is offered by less than 1% of public sector hospitals and 15% of private sector hospitals (De Kock et al., 2015). Owing to the lack of universal and systematic implementation of newborn hearing screening (NHS) in South Africa, children with hearing impairment are still identified late, after the age of 12 months (Storbeck and Young, 2016). Consequently, suboptimal ages at hearing aid fitting when children are older than 24 months have also been reported (Meyer et al., 2012).

Undoubtedly, one of the main benefits arising from the implementation of UNHS programmes is early detection of hearing impairment in children (Lasisi et al., 2014). Although hearing screening in newborns creates an opportunity, it is not a guarantee of optimal outcomes. Early access to quality early intervention (EI) services is a critical component of this successful system (Yoshinaga-Itano, 2013). As a result of the widely reported benefits of early hearing detection and intervention (EHDI) internationally, numerous EI programmes have been implemented in South Africa through hospital-based, home-based and centre-based programmes (Ackah and Appiah, 2011; Moodley and Storbeck, 2016). Various studies have been conducted to determine the outcomes of hospital-based and home-based EI programmes (Moodley and Storbeck, 2016; Storbeck and Young, 2016). However, there is a dearth of evidence originating from centre-based EI programmes that demonstrate the outcomes of these programmes. The current study was conducted to determine the ages at identification of hearing impairment and the initiation of EI services for children who are enrolled in centre-based EI programmes in Gauteng.

Methods

Prior to commencement of the study, ethical clearance was obtained from the university’s human research ethics committee (medical) (protocol number: M130240). Furthermore, the work adhered to the Helsinki Declaration of 1975, as revised in 2008 (General Assembly of the World Medical Association, 2014).

Objectives

To determine the ages at identification of hearing impairment for children enrolled in centre-based EI programmes in Gauteng.

To determine the ages at initiation of EI services for children enrolled in these centre-based EI programmes.

To describe the nature of EI services provided to children enrolled in these centre-based EI programmes.

Research design

This study employed a descriptive research design, employing a retrospective record review of participant’s centre-based EI programme files and self-administered caregiver questionnaires. In order to gain access to the participants, the researchers obtained written permission from the two EI preschool centres, allowing the researchers access to the preschool files in order to identify potential participants for the current study. Subsequently, the researchers compiled a list of all possible participants' contact details using purposive non-probability sampling. Primary caregivers of all potential children were contacted by telephone and invited to participate in the study. Consent forms were then emailed to potenial caregiver participants after they indicated that they were willing to allow the researchers to review their child’s preschool records and participate in the research study. The primary population included caregivers of children who were identified with a hearing impairment and had graduated from the EI preschool centre between 2008 and 2009.

Description of the participants

The caregivers of eight children identified with hearing impairment and enrolled in centre-based EI programmes participated in the current study. All caregiver participants were female. The children comprised of four males and four females. Six of the children were white and two were of a mixed race (coloured). Four of the children were enrolled at EI Centre A, and the other four were enrolled EI Centre B for their preschool education.

Materials

Data collection was conducted using a retrospective record review of files and caregiver questionnaire. The questionnaire was developed by the researchers. The caregiver questionnaire was worded in English, which is the medium of instruction and communication at the EI centres. The questionnaire comprised of three sections: Section A was related to family demographics, Section B was related to the child's background information and Section C was related to the child's schooling history.

Data analysis

Due to the descriptive nature of the current study, data were analysed using descriptive statistics. Univariate analysis was conducted in the study, according to two major characteristics, namely, measures of dispersion and measures of central tendency (Creswell, 2009).

Results

Eight caregivers of children identified with hearing impairment and enrolled in centre-based EI programmes participated in the current study. The children comprised of four males and four females, ranging in age from 9.7 years to 12.7 years, with a median age of 11.1 years. Six of the children were white and two were coloured. Four of the children were enrolled at EI centre A, and the other four were enrolled EI centre B for their preschool education.

The children's ages at graduation from the EI preschool centres ranged from 5.2 years to 7.7 years, with a median age of 6.4 years (Table 1). The children were enrolled in the EI preschool programmes for periods ranging between two years and five years, with a mean of three years.

Table 1.

Profile of children with a hearing impairment enrolled in EI preschool centres.

Child no.	Gender	Age (years)	Grade	No. of years at EI preschool	Age at graduation from EI preschool (years)
1	Female	9.9	4	3	5.2
2	Male	10.8	3	2	6.3
3	Male	11.7	3	3	7.0
4	Female	10.9	3	4	6.2
5	Male	9.7	4	2	5.0
6	Female	12.7	5	5	7.0
7	Female	10.3	4	1	6.8
8	Male	12.5	5	5	7.7

EI: early intervention.

Ages at identification of the hearing impairment

Ages at identification of the hearing loss ranged from 7 months to 49 months, with a mean age at identification of 27 months, and the median age was 24 months. None of the children received NHS, thus all of the children in the current study were identified late following maternal suspicion of the hearing impairment (Table 2).

Table 2.

Ages at identification and suspicion of the hearing impairment.

Child no.	Age at suspicion (months)	Age at identification (months)	Suspicion– identification interval (months)	Cause for suspicion	EI team member to suspect hearing impairment
1	31	31	0	Not talking	Mother
2	24	25	1	Not performing at the same level as peers	Teacher
3	48	49	1	Ill-disciplined, not listening during story time and constantly asking for repetitions	Teacher
4	16	16	0	After spending a month in hospital subsequent to contracting pneumococcal (Streptococcus) meningitis, the mother suspected a hearing impairment because the child was not reacting to sounds as the child had done prior to the hospitalization. But the mother was told by two paediatricians that she was overreacting	Mother
5	14	15	1	Not talking	Mother
6	7	7	0	Not reacting to loud noises	Mother
7	48	49	1	The child was taken to speech–language therapy due to delayed language development and a hearing evaluation was scheduled	Mother
8	18	24	6	Not talking	Mother

EI: early intervention.

For six of the eight children, the child's caregiver suspected that their child had a hearing impairment due to delayed speech and/or language development. Significantly, two of the children presented with risk factors for a late-onset hearing impairment; however, they were not referred for hearing screening services. One child was born prematurely at 30 weeks and diagnosed with an infection in her left shoulder, elbow and knee for which she had to be intubated and high doses of intravenous medications were administered. The second child was born prematurely at 34 weeks and intubated for 10 days due to hypoventilation. Furthermore, two of the children presented with a history of otitis media which may result in speech and language impairments, and neither were referred for hearing screening services.

Notably, all the children who were suspected of presenting with a hearing impairment were identified with the hearing impairment within a month following suspicion of the hearing impairment.

Ages at initiation of EI services

To determine the age at initiation of EI services, the researchers obtained results pertaining to both ages at provision of amplification devices and ages at provision of habitation services. Results of the study revealed a significant delay in initiation of EI services following identification of the hearing impairment. The ages at initiation of EI services ranged between 17 months and 50 months, with a mean age at initiation of services of 29.9 months and a median age of 24 months.

Ages at provision of amplification devices ranged between 18 months and 52 months, with the median age at provision of amplification devices being 32.25 months and the mode being 30 months (Table 3). Reasons for delays in provision of amplification devices were not investigated as part of the current study and are implications for future studies.

Table 3.

Ages at provision of amplification devices.

Child no.	Age at identification (months)	Age at amplification (months)	Identification–amplification interval (months)
1	31	36	5
2	25	35	10
3	49	49	0
4	16	20	4
5	15	18	3
6	7	18	11
7	49	52	3
8	24	30	6

None of the children received timely access to EI services owing to late identification of the hearing impairment. EI services were initiated at ages ranging between 17 months and 50 months, with a median age of 29.88 months and a mode of 24 months (Table 4).

Table 4.

Ages at initiation of EI services.

Child no.	Age at identification (months) of HI	Age at initiation of EI services (months) for HI	Identification–initiation interval (months)
1	31	38	7
2	25	26	1
3	49	49	0
4	16	17	1
5	15	17	2
6	7	18	11
7	49	50	1
8	24	24	0

EI: early intervention; HI: hearing impairment.

Nature of EI services

All eight children received aural habilitation and/or speech–language therapy (Table 5). In addition, one child received intervention from a psychologist because of behavioural problems. This child was diagnosed with defiant and oppositional behaviour, which is suspected to be due to intrauterine exposure to drugs. Two of the children received occupational therapy to improve their attention and fine motor skills. These services were accessed on a weekly basis with the exception of the psychologist who saw the child on an ad hoc basis.

Table 5.

EI services received by the children.

Child no.	EI services received at the EI preschool centres
Child no.	Speech–language therapy and audiology	Occupational therapy	Psychology
1	Yes	No	No
2	Yes	No	Yes
3	Yes	Yes	No
4	Yes	No	No
5	Yes	No	No
6	Yes	No	No
7	Yes	No	No
8	Yes	Yes	No

EI: early intervention.

The children received speech–language therapy services from private speech–language therapists or following enrolment at the centre-based EI programme. Speech–language therapy services for four of the children were initiated when they were enrolled in the centre-based EI programmes. However, speech–language therapy services for the other four participants were initiated with a speech–language therapist in the private sector and were subsequently referred to the centre-based EI programmes.

Discussion

The first major finding of the current study is that the children were identified late at ages ranging between 7 months and 49 months. These findings far exceed the target of the earliest possible identification of the hearing impairment at no later than four months, as recommended by the Health Professions Council of South Africa (HPCSA) (HPCSA, 2007). However, these results are not unique to the current study. Butler et al. (2015) investigated the age of identification of congenital hearing impairment in the private and public healthcare sectors in the Free State Province in South Africa. Results of the study revealed that the age of identification of congenital hearing impairment in the public sector was 3.71 years and 3.01 years in the private sector. It is widely reported that children identified with hearing impairment after the age of six months might fall considerably behind their early identified peers and could show delayed speech and language throughout childhood (Khoza-Shangase and Michal, 2014). Hence, this finding pertaining to age at identification highlights the need for establishing effective and viable UNHS across the geographically varied hospitals and clinic settings in South Africa (Khoza-Shangase and Harbinson, 2015; Petersen and Ramma, 2015).

It is widely reported that without UNHS, identification of hearing impairment may be as late as two years of age (Butler et al., 2015; Khoza-Shangase and Harbinson, 2015; Meyer et al., 2014; Storbeck and Young, 2016; Swanepoel et al., 2013), following suspicion of the hearing impairment typically after critical periods of language development milestones have passed (Joint Committee on Infant Hearing, 2007). Similarly, seven of the eight children in the current study were suspected as presenting with hearing impairment after the age of 12 months and as late as 4 years of age. Only one of the children was suspected as presenting with a hearing impairment at seven months old. Suspicion–identification intervals demonstrated prompt action by caregivers upon suspicion of the hearing impairment. Maternal awareness of infant and childhood hearing impairment may prompt earlier suspicion of the hearing impairment, thus potentially decreasing the ages at identification of the hearing impairment until effective implementation of UNHS is realized. This can be achieved by broadening the health education given to mothers during antenatal care, especially to include awareness of developmental milestones, infant hearing impairment and its impact on speech and language developmental (Swanepoel, 2009).

In addition to increasing maternal awareness of infant hearing impairment, awareness of healthcare professionals involved in paediatric management relating to infant hearing impairment is also essential. This is particularly so considering that three of the children presented with risk factors associated with permanent congenital, delayed-onset or progressive hearing impairment in childhood (Khoza-Shangase et al., 2010). Moreover, two of the children presented with case history factors may result in speech and language impairments (Owen, 2004). Failure of healthcare professionals to refer these participants for a hearing screening is of concern. This implies poor awareness of the risk factors for infant hearing impairment as well as the importance of early identification among paediatric healthcare practitioners. This can be remedied by establishing closer working relationships between paediatric healthcare practitioners and audiologists. Through collaborative work, children with high risk factors for hearing impairment can be identified early (Scheepers et al., 2014). Furthermore, if UNHS is mandated for every newborn in South Africa, it will facilitate support and education of these healthcare practitioners, thus ensuring best practice (Swanepoel et al., 2013).

The second major finding of the current study revealed suboptimal initiation of EI services. Because of delayed ages at identification of hearing impairment, a delayed age at provision of amplification devices was to be expected (Swanepoel et al., 2013). In a national survey of paediatric audiology services conducted by Meyer et al. (2014), similar suboptimal provision of amplification devices at ages older than 24 months was reported. An average delay of 5.25 months between identification of the hearing impairment and provision of amplification devices was found in the current study. The current findings of suboptimal provision of amplification devices demonstrate poor adherence to the HPCSA (HPCSA, 2007) guidelines for best practice, which recommend provision of amplification devices within one month of identification of the hearing impairment. Provision of amplification devices as soon as possible after a child has been identified with the hearing impairment is of crucial importance as lack of auditory stimulation has an effect on the development of the child’s speech and language skills (Meyer et al., 2014). In addition to mandated UNHS, necessary budget provisions are required to ensure that children identified with hearing impairment in South Africa are promptly provided with amplification devices. A limitation of the current study is that contributing factors for delays between identification of the hearing impairment and provision of amplification devices were not investigated.

In addition to suboptimal provision of amplification devices, late initiation of EI services was reported in the current study. The average age for initiation of EI services was 29.88 months. These results reveal that the children received EI services later than the recommended age of 6–24 month (Scheepers et al., 2014) and outside the widely postulated 6–18 months period of optimal development (Fulcher et al., 2015; Petersen and Ramma, 2015). Hence, the findings of the current study on EI services for children with hearing impairment are a cause of great concern, highlighting lack of established EI programmes in South Africa.

Once ages at initiation of EI services were established, the researchers sought to describe the nature of EI services that the children received. All eight children received speech–language therapy and audiology services. In addition, two of the children received occupational therapy services and only one child received psychological intervention. The current study’s finding of all children having received speech–language therapy and audiology services reinforces the significant role of the speech–language therapist and audiologist in the management of children with hearing impairment. It is also in agreement with the EHDI programme’s goal of ensuring that children with hearing impairment maintain age-appropriate development with regard to language abilities. In addition, other EI specialists must be included in meeting the communication needs of the hearing-impaired child, taking into account both the child’s and family’s needs.

Conclusion

Children with hearing impairment enrolled in centre-based EI programmes in Gauteng were identified late following maternal suspicion of the hearing impairment. Consequently, ages at initiation of EI services were also delayed at ages later than international benchmarks and HPCSA (2007) guidelines and at ages which preclude optimal development.

The findings of the current study indicate an urgent need for systematic planning at various levels of service delivery for the implementation of widespread EHDI services on par with international gold standards. This would lead to earlier identification of infant and childhood hearing impairment. Furthermore, through early identification of hearing impairment, EI may also be achieved, enabling children with hearing impairment to perform on par with counterparts who present with normal hearing.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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