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United States Government Accountability Office:
GAO:
Report to Congressional Requesters:
May 2011:
Deaf And Hard Of Hearing Children:
Federal Support for Developing Language and Literacy:
GAO-11-357:
GAO Highlights:
Highlights of GAO-11-357, a report to congressional requesters.
Why GAO Did This Study:
Deaf and hard of hearing children can face significant challenges
developing the language and literacy skills needed to succeed in
school and become self-sufficient adults. The federal government
supports these children through the Early Hearing Detection and
Intervention (EHDI) program, which awards grants to states to develop
systems to screen and diagnose newborns and infants for hearing loss
and refer them for appropriate interventions. Also, the Individuals
with Disabilities Education Act (IDEA) supports and funds early
intervention and special education services for children with
disabilities, including deafness and hearing loss.
To better understand how federal programs support deaf and hard of
hearing children, GAO was asked to examine the: (1) extent of hearing
loss among children, (2) settings in which these children are
educated, (3) factors that help deaf and hard of hearing children
acquire language and literacy skills, and (4) challenges to providing
appropriate interventions for these children. GAO analyzed data on
hearing loss; reviewed research literature; interviewed educators,
national organizations, parents, and state and federal officials; and
examined relevant federal laws and regulations. A draft of this report
was provided to the Departments of Education and Health and Human
Services for review and comment. Each provided technical comments,
which were incorporated into the report, as appropriate. GAO makes no
recommendations in this report.
What GAO Found:
Available data indicate hearing loss affects a small percentage of
children. In 2008, the prevalence of hearing loss among infants under
12 months was 0.1 percent, or about 1 diagnosed case per 1,000
screened. While the Centers for Disease Control and Prevention (CDC)
does not collect hearing test data for children under age 12, other
than EHDI data, federal surveys conducted from 2005 to 2009 estimated
3 percent or fewer of children nationwide under age 12 had hearing
problems. Based on nationwide hearing examination data for youth aged
12–17 from 2005 to 2008, an estimated 1 percent had at least moderate
hearing loss in one or both ears.
Deaf and hard of hearing children are educated in a variety of
settings, from regular classrooms to separate schools for the deaf.
Data from the U.S. Department of Education (Education) indicate that
in fall 2008 the majority of these children who received special
education did so in regular early childhood programs or regular
classrooms for at least part of their day.
Experts GAO interviewed agreed that several key factors are critical
for helping deaf and hard of hearing children acquire language and
literacy skills. Early exposure to language—either spoken or signed—is
critical because during the first few years of life it is easiest for
children to learn language. Also, parents need to have information on
the full range of communication options available so that they can
make informed choices to meet their children’s individual needs.
Similarly, experts told GAO that education for these children should
be individualized and that there should not be one standard approach
for educating them. Additionally, having skilled professionals, such
as qualified interpreters in regular classrooms, is important for
ensuring that children with hearing loss receive the same information
as their hearing classmates.
Limited information and resources are challenges to providing deaf and
hard of hearing children with appropriate interventions. Experts
indicated that parents may not always receive information on the full
range of communication options available, and may not understand the
importance of enrolling their children in early intervention services.
Additionally, a lack of data can limit efforts to evaluate early
intervention outcomes. The EHDI law calls for CDC and the Health
Resources and Services Administration in the Department of Health and
Human Services (HHS) to support states in the evaluation of early
intervention efforts—programs that are, in part, provided under IDEA.
These agencies suggested that privacy requirements may restrict the
information that EHDI and early intervention programs can share,
limiting efforts to evaluate outcomes for children. However, HHS and
Education are taking a number of steps to identify best practices for
sharing data and tracking the outcomes of deaf and hard of hearing
children who receive early intervention services. Experts also cited a
shortage of qualified teachers and interpreters as a major challenge.
Moreover, providing services for these students can be costly and it
is difficult for schools to provide a variety of options, especially
in rural areas.
View [hyperlink, http://www.gao.gov/products/GAO-11-357] or key
components. For more information, contact George A. Scott at (202) 512-
7215 or scottg@gao.gov.
[End of section]
Contents:
Letter:
Background:
Hearing Loss Affects a Small Percentage of Children:
Most Deaf and Hard of Hearing Children are Educated in Regular
Classrooms:
Early Exposure to Language and an Individually Tailored Education Are
Vital to Developing Language and Literacy Skills:
Limited Information and Resources are Challenges to Providing
Appropriate Interventions to Children:
Concluding Observations:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Summary of Key Provisions of IDEA Part C and Part B
Programs:
Appendix III: National Survey Estimates of Hearing Loss for Children
Aged 0-17:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Types of Hearing Loss:
Table 2: Educational Settings of Children with Hearing Loss in the 50
States Served Under IDEA Part B in Fall 2008:
Table 3: National Surveys of Children with Hearing Loss:
Table 4: Organizations Interviewed or Providing Written Input:
Figures:
Figure 1: Percentage of Deaf and Hard of Hearing Students by Primary
Communication Mode Used for Instruction:
Figure 2: Federal Support for Children with Hearing Loss:
Figure 3: Percentage of All Students Aged 3-21 in the 50 States Served
by IDEA in 2008 by Primary Disability:
Abbreviations:
CDC: Centers for Disease Control and Prevention:
Education: U.S. Department of Education:
EHDI: Early Hearing Detection and Intervention:
HHS: U.S. Department of Health and Human Services:
HRSA: Health Resources and Services Administration:
IDEA: Individuals with Disabilities Education Act:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
May 25, 2011:
The Honorable Tom Harkin:
Chairman:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
The Honorable George Miller:
Ranking Member:
Committee on Education and the Workforce:
House of Representatives:
Children who are deaf or hard of hearing[Footnote 1] can face
considerable challenges developing the language and literacy skills
they need to succeed in school and become self-sufficient, productive
adults. Although experts suggest that deaf and hard of hearing
children who receive appropriate educational and other services can
successfully transition to adulthood, research indicates that many do
not receive the necessary support early on or during their school
years to keep up with their hearing peers. For example, according to
one study, the median reading comprehension score of deaf or hard of
hearing students at age 18 was below the median of fourth-grade
hearing students.[Footnote 2]
In response to your interest in how federal programs support deaf and
hard of hearing children, this report provides information on: (1) the
extent of hearing loss among children in the United States, (2) the
settings in which these children are educated, (3) factors that have
been shown to help deaf and hard of hearing children acquire language
and literacy skills, and (4) challenges that exist to providing
appropriate interventions for these children.
To respond to the first objective, we analyzed available data from
hearing tests and several national surveys conducted from 2005 to
2009. We assessed the reliability of the survey data by (1) performing
electronic testing of required data elements, (2) reviewing existing
information about the data and the system that produced them, and (3)
interviewing agency officials knowledgeable about the data. We
determined that the data were sufficiently reliable for the purposes
of this report. To address the second objective, we analyzed 2008
special education data--the most recent data available--on the
Individuals with Disabilities Education Act reported to the U.S.
Department of Education (Education). For our third objective, we
interviewed experts from national organizations representing
educators, parents, and the deaf community to obtain their views on
the acquisition of language and literacy skills in deaf and hard of
hearing children. We also reviewed published literature from 2005 to
2010 to identify factors associated with deaf and hard of hearing
students' language and literacy development. To address our fourth
objective, we reviewed federal supports for children with hearing
loss--such as the Early Hearing Detection and Intervention program and
programs under the Individuals with Disabilities Education Act that
serve children with disabilities--and relevant federal laws,
regulations, and guidance. We interviewed officials from Education and
the U.S. Department of Health and Human Services (HHS) responsible for
administering these programs and experts from national organizations.
We also conducted site visits to Colorado, Massachusetts, and
Washington--states which varied in the percentage of children with
hearing loss educated in regular classrooms and in the characteristics
of their state schools for the deaf. During the visits we spoke with
state, school district, and school officials about state and local
efforts to provide educational services to deaf and hard of hearing
children, as well as any challenges and gaps in services for these
students. We also interviewed parents of deaf and hard of hearing
children about their views on their children's educational
experiences. See appendix I for additional information on our scope
and methodology.
We conducted this performance audit from March 2010 to May 2011 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
Background:
Hearing Loss among Children:
Hearing loss can vary by type, level of severity, age at onset, and
cause. Experts generally agree on the major types of hearing loss:
conductive, sensorineural, and mixed (see table 1).[Footnote 3]
Table 1: Types of Hearing Loss:
Type of hearing loss: Conductive;
Description: Conductive hearing loss results when sounds are prevented
from going through the outer or middle ear, such as by a malformation
of part of the ear or ear infections. This type of hearing loss can
often be corrected with medicine or surgery.
Type of hearing loss: Sensorineural;
Description: Sensorineural hearing loss occurs when there is a problem
in the way the inner ear or hearing nerve works, such as from illness
or noise exposure.
Type of hearing loss: Mixed;
Description: Mixed hearing loss includes both conductive and
sensorineural hearing loss.
Sources: Centers for Disease Control and Prevention and the American
Speech-Language-Hearing Association.
[End of table]
Hearing loss can also be classified by its level of severity and
whether one or both ears are affected. The level of loss can range
from slight to profound.[Footnote 4] Hearing loss may be present in
one ear (unilateral) or in both ears (bilateral). The level of loss in
the two ears may be the same or different.
Hearing loss may be present at birth or may develop later. It can also
be described as sudden or progressive (worsening over time), and
stable or fluctuating. The National Institute on Deafness and Other
Communication Disorders reports that about 50-60 percent of severe to
profound cases of childhood hearing loss are due to genetic causes.
[Footnote 5] However, about 90 percent of infants who are born deaf
are born to hearing parents. Experts also suggest nearly 25 percent of
children with hearing loss have one or more other developmental
disability, such as cerebral palsy or vision loss.
There are two primary types of personal assistive devices used to
improve children's hearing--hearing aids and cochlear implants.
[Footnote 6] Hearing aids amplify sound and can be worn by children as
young as infants.[Footnote 7] According to the Centers for Disease
Control and Prevention, children with severe to profound hearing loss
may benefit from a cochlear implant. Unlike hearing aids, cochlear
implants are surgically implanted devices that process sound from the
environment and ultimately signal the brain, which can learn to
recognize these signals in a meaningful way. According to available
data from the U.S. Food and Drug Administration, as of April 2009,
about 25,500 children in the United States had received cochlear
implants.
Communication Modes for Deaf and Hard of Hearing Children:
Deaf and hard of hearing children can communicate in a variety of
ways, including signing and speaking. Signing can take many forms,
including American Sign Language, which is a complete and complex
language with its own syntax and grammar that uses a combination of
signs made with the hands and other movements, such as facial
expressions and postures of the body. Other forms of visual
communication are based on spoken language, such as Cued Speech--which
uses hand shapes to represent different sounds in the English
language, for example--and can aid lip-reading. Signing Exact English
is a sign system that corresponds to literal English. A communication
mode may also combine the use of signing with speech. A survey of deaf
and hard of hearing students in 2007-2008 found that more than half,
nationwide, learned in speech-only environments (see figure 1).
Figure 1: Percentage of Deaf and Hard of Hearing Students by Primary
Communication Mode Used for Instruction:
[Refer to PDF for image: pie-chart]
Speech only: 52%;
Sign with speech: 35%;
Sign only: 11%;
Cued speech and other methods: 2%.
Source: Gallaudet Research Institute (November 2008). Regional and
National Summary Report of Data from the 2007-08Annual Survey of Deaf
and Hard of Hearing Children and Youth. Washington, DC: GRI, Gallaudet
University.
[End of figure]
Federal Support for Children with Hearing Loss:
From birth through age 21, the federal government supports the
educational needs of deaf and hard of hearing children, and other
children with disabilities, through a variety of means (see figure 2).
Figure 2: Federal Support for Children with Hearing Loss:
[Refer to PDF for image: illustrated horizontal bar chart]
Early Hearing Detection and Intervention:
Hearing screening:
Age: 1 month.
Follow-up evaluation[A]:
Age: 3 months.
Referral to early intervention:
Age: 6 months.
Individuals with Disabilities Education Act (IDEA) (for eligible
children):
Early intervention for eligible children (IDEA Part C Program):
Age: Birth to 3 years.
Special education services for eligible children (IDEA Part B Program):
Age: 3 to 21 years.
Source: GAO analysis of select federal laws and programs.
[A] For infants who screen positive for hearing loss.
[End of figure]
Early Hearing Detection and Intervention (EHDI). HHS, through its
Centers for Disease Control and Prevention (CDC) and Health Resources
and Services Administration (HRSA), provides grants and assistance to
states to develop, monitor, and collect data on early hearing
screening, evaluation, and intervention programs and systems.[Footnote
8] The Joint Committee on Infant Hearing[Footnote 9] developed
national program goals for early screening and intervention that aim
to ensure that all newborns are screened for hearing loss before 1
month of age, that infants who do not pass the screening receive a
full evaluation before 3 months, and that those identified with
hearing loss receive early intervention services before 6 months.
[Footnote 10] Congress reauthorized the EHDI program in December 2010,
with amendments specifying that the purpose of the grants is to help
states develop programs to ensure that children who are referred from
state screening programs receive prompt evaluation and diagnosis and
the appropriate educational, audiological, and medical interventions.
[Footnote 11]
Individuals with Disabilities Education Act (IDEA). To support the
educational needs of children with disabilities, including those who
are deaf or hard of hearing, Congress originally enacted IDEA in 1975,
[Footnote 12] most recently reauthorizing and amending it in 2004.
[Footnote 13] IDEA authorizes federal funding for early intervention
and special education and related services for children with
disabilities through two main programs: the Infants and Toddlers with
Disabilities (Part C) program,[Footnote 14] which supports early
intervention services for children younger than 3 years of age, and
the Assistance for Education of All Children with Disabilities (Part
B) program,[Footnote 15] which supports the special education needs of
children aged 3-21 (see appendix II).[Footnote 16] While IDEA Part C
and B programs have different eligibility criteria and children are
evaluated for each program separately, Education considers the
effective transition between the programs a priority and requires
states to support families through a timely transition process.
[Footnote 17] States are also required by IDEA to develop transition
plans for children exiting the Part C program.
As a condition of receiving IDEA funds, states must meet several
requirements, including:
* identifying and evaluating all children with disabilities to
determine whether they are eligible for early intervention or special
education and related services;
* providing early intervention in accordance with an individualized
family service plan[Footnote 18] (Part C) or special education and
services in accordance with an individualized education program
[Footnote 19] (Part B), as developed by a team that includes the
parent and qualified professionals; and,
* to the maximum extent appropriate, providing early intervention
services in a natural environment and educating children with
disabilities with children who are not disabled.[Footnote 20]
As of fall 2008, more than 78,000 deaf and hard of hearing children
aged 3-21 in the 50 states received services under IDEA Part
B,[Footnote 21] or about 1 percent of all students served by IDEA Part
B nationwide (see figure 3).
Figure 3: Percentage of All Students Aged 3-21 in the 50 States Served
by IDEA in 2008 by Primary Disability:
[Refer to PDF for image: pie-chart]
Specific learning disabilities: 38%;
Speech or language: 22%;
Intellectual, emotional, or developmental disabilities[B]: 19%;
Physical or other disabilities[A]: 12%;
Developmental delay: 6%;
Multiple disabilities: 2%;
Hearing loss: 1%.
Source: U.S. Department of Education data from www.ideadata.org.
Note: This figure likely represents an undercount of all children 3-21
with hearing loss served under IDEA, as data are collected by primary
disability. According to Education, data for children up to age 3 are
not available by disability category under the Part C program.
[A] Physical or other disabilities category includes orthopedic
impairments, visual impairments, deaf-blindness, traumatic brain
injury, and other health impairments.
[B] Intellectual, emotional, or developmental disabilities category
includes intellectual disabilities, emotional disturbance, and autism.
[End of figure]
Hearing Loss Affects a Small Percentage of Children:
According to the most recent hearing screening data available from
CDC's EHDI program, the prevalence of hearing loss among newborns and
infants younger than 12 months in 2008 was approximately 0.1 percent,
or about 1 diagnosed case for every 1,000 screened.[Footnote 22] That
year, more than 3 million infants, or 97 percent of births nationwide,
were screened for hearing loss. Of those screened, 2 percent failed.
[Footnote 23] Further audiological testing for those infants who
failed a screening revealed that about 7 percent were subsequently
diagnosed with hearing loss and about 41 percent were diagnosed with
normal hearing. However, further information on the hearing status for
the majority (53 percent) of these children was unavailable to CDC for
a variety of reasons; most often, states reported that families could
not be contacted or were unresponsive.[Footnote 24] As a result there
is no information available to CDC to confirm hearing loss in more
than half of infants who failed their hearing screening test that
year. It should be noted that the recent reauthorization of the EHDI
program included a provision that may help remedy this problem.
Specifically, the reauthorization amended the EHDI law to provide that
funding to states can be used to develop efficient models to ensure
that those who fail an initial screening receive follow-up care by a
qualified health care provider and that states will be encouraged to
adopt models to increase the rate of follow-up for these children.
[Footnote 25]
Data on children beyond infancy similarly suggest a low prevalence of
hearing loss. While the CDC does not currently collect hearing test
data for children younger than the age of 12, apart from the data
collected under the EHDI program,[Footnote 26] HHS surveys from 2005
to 2009 indicate an estimated 3 percent or fewer of children
nationwide in this age range had hearing problems.[Footnote 27] (See
appendix III for more information.) In addition to the EHDI program,
the CDC sponsors hearing examinations of youth from ages 12 through 19
through the National Health and Nutrition Examination Survey.[Footnote
28] Based on these examinations from 2005 to 2008, an estimated 1
percent of 12-17 year olds nationwide had at least moderate hearing
loss in one or both ears.[Footnote 29] When we compared the
demographic characteristics of those with moderate to moderately-
severe hearing loss to those with normal hearing to mild loss, we
found no statistically significant differences in the distributions of
sex, race, or poverty status[Footnote 30] between the two groups.
Most Deaf and Hard of Hearing Children are Educated in Regular
Classrooms:
Children who are deaf or hard of hearing are educated in a variety of
settings, ranging from regular classrooms alongside hearing peers to
separate schools and residential facilities for children with hearing
loss. According to data from Education, the majority of deaf and hard
of hearing children who received special education through IDEA Part B
in fall 2008 did so in regular early childhood programs or regular
classrooms, for at least part of their day (see table 2).
Table 2: Educational Settings of Children with Hearing Loss in the 50
States Served Under IDEA Part B in Fall 2008:
Educational setting for children ages 3-5: In regular early childhood
program more than 80% of time;
Percentage of children ages 3-5: 32.9%;
Educational setting for children ages 6-21: In regular classroom more
than 80% of time;
Percentage of children ages 6-21: 53.3%.
Educational setting for children ages 3-5: In regular early childhood
program 40-79% of time;
Percentage of children ages 3-5: 6.7%;
Educational setting for children ages 6-21: In regular classroom 40-
79% of time;
Percentage of children ages 6-21: 17.2%.
Educational setting for children ages 3-5: In regular early childhood
program less than 40% of time;
Percentage of children ages 3-5: 13%;
Educational setting for children ages 6-21: In regular classroom less
than 40% of time;
Percentage of children ages 6-21: 15.8%.
Educational setting for children ages 3-5: Separate classroom[A];
Percentage of children ages 3-5: 26.6%;
Educational setting for children ages 6-21: n/a;
Percentage of children ages 6-21: n/a.
Educational setting for children ages 3-5: Separate school;
Percentage of children ages 3-5: 13.5%;
Educational setting for children ages 6-21: Separate school;
Percentage of children ages 6-21: 8.2%.
Educational setting for children ages 3-5: Other[B];
Percentage of children ages 3-5: 4%;
Educational setting for children ages 6-21: Other[B];
Percentage of children ages 6-21: 4.7%.
Educational setting for children ages 3-5: Data unavailable[C];
Percentage of children ages 3-5: 3.4%;
Educational setting for children ages 6-21: Data unavailable[C];
Percentage of children ages 6-21: 0.9%.
Source: GAO analysis of Education data from www.ideadata.org.
Note: Data in each column do not sum to 100 due to rounding.
[A] Separate classroom is not an available category for students aged
6 to 21.
[B] Other may include placement in a private school by parents or
residential or correctional facilities, home or hospital environments,
or service provider locations.
[C] Data that are unavailable were either not reported to Education or
suppressed to limit disclosure due to the small number of children.
[End of table]
Under IDEA, the degree of a child's hearing loss alone should not
dictate a particular educational setting. According to the law,
decisions about the setting in which deaf or hard of hearing children
are educated should be based on consideration of a child's language
and communication needs, opportunities for direct communication with
peers, and access to instruction in the language and communication
mode the child uses, among other factors. During our site visits, we
observed deaf and hard of hearing students in regular classrooms with
hearing students, aided by interpreters; in self-contained classrooms
of deaf and hard of hearing children in local public schools; and in
schools for the deaf. Students may also divide their time among
multiple educational settings. We also observed students who spent
most of their time in a self-contained classroom but attended some
classes, such as art and music, with hearing peers, and met with
students who divided their time between a deaf school and a regular
classroom in a local public school. Students from deaf schools may
choose to participate in other public school programs in order to take
advantage of advanced placement courses or other course offerings not
available in the deaf school.
Early Exposure to Language and an Individually Tailored Education Are
Vital to Developing Language and Literacy Skills:
Early Access to Language Helps Deaf and Hard of Hearing Children Build
Language and Literacy Skills:
Experts we spoke with stated that it is important to expose deaf and
hard of hearing children to language as early as possible in life.
They told us that the first few years of a child's life are the most
critical for learning language because it is during this time when the
brain is rapidly developing that it is easiest to learn language.
Several educators we spoke with shared stories of deaf children who
did not receive services until later in childhood and subsequently
lagged behind. Officials at one school also said that the age at which
children are first exposed to language is a good predictor of their
future language skills. Research into language development bears this
out. One study examining children with moderate to profound hearing
loss compared those who were exposed to language through an early
intervention program before they were 3 months of age with those who
enrolled later. The study found that by the time these children were
12 to 16 months old, those who started earlier were already
demonstrating more advanced language skills.[Footnote 31]
The benefits of early language exposure are not tied to any one
language or communication mode. Experts we interviewed agreed that
early exposure aids deaf and hard of hearing children in the
acquisition of language skills, whether the language is signed or
spoken. A study focusing on children with cochlear implants found that
those who received an implant before 2 ˝ years of age developed speech
more rapidly and had better pronunciation and vocabulary than children
who received an implant at an older age.[Footnote 32] Similarly,
research indicates that children exposed to sign language early and
consistently develop larger vocabularies more quickly than those who
are not.[Footnote 33]
Experts and advocates we interviewed also indicated that it is
important for parents to have access to information on the full range
of communication options. They told us that informed parents are
better able to make decisions about communication modes and assistive
technologies that meet the needs of their children. In laying out
principles for EHDI programs, the Joint Committee on Infant Hearing
[Footnote 34] in 2007 stated that families should be made aware of all
communication modes and available assistive hearing technologies. The
committee added that a family's decision-making process should be
guided by informed choices and desired outcomes. Because children can
benefit from early intervention regardless of their communication
mode, knowing the range of options can help a family make a decision
that best suits its needs.
Education Should Be Individualized, Including Delivery by Qualified
Professionals with Knowledge of Hearing-Related Issues:
Educators and advocates we spoke with told us that deaf and hard of
hearing children should have an education tailored to their individual
abilities and needs. These experts told us that because the needs of
deaf and hard of hearing children can vary widely, there should not be
one standard approach for educating them. The provision of an
individualized education for all children with disabilities based on
their unique needs is a key requirement of IDEA. In addition,
Education has issued guidance[Footnote 35] to help ensure that the
unique communication and related services needs of deaf and hard of
children are addressed. We observed examples of schools providing
individualized and flexible approaches during our visits to states. In
one regional program in Massachusetts, students have the opportunity
to take classes in regular classrooms with other high school students,
but may spend part of their time in separate classrooms for subjects
where they need extra help. Also, we visited a school in Colorado
where children receive additional help in writing and vocabulary every
other day in a resource center.
Educators and advocates also highlighted the importance of having
staff with knowledge of hearing-related issues to provide services to
deaf and hard of hearing students. Guidance from the National
Association of State Directors of Special Education notes that it is
important that audiologists in schools have specific training to work
with these students and that teachers who work with this population
also be trained in deaf education.[Footnote 36] Additionally,
advocates noted that having skilled interpreters is especially
important for deaf children in regular classrooms because they rely on
these interpreters to accurately convey to them what is being taught
in the classroom.
Limited Information and Resources are Challenges to Providing
Appropriate Interventions to Children:
Parents May Lack Information on How to Address the Specific Needs of
Their Children:
Experts told us that parents do not always have access to information
on the full range of available communication options. Several said
that the first service provider with whom parents consult after their
child is identified as having hearing loss can have a significant
influence on the choices parents make, especially if they do not
receive balanced information on a range of options. For example, if
the family is first referred to an audiologist, experts were concerned
that parents would choose a cochlear implant for their child rather
than continue learning about other options such as sign language.
Some experts we interviewed were also concerned that parents of deaf
and hard of hearing children may struggle to understand the
information needed to make language and communication decisions for
their children. The majority of these children are born to hearing
parents, and as such, experts commented that families often do not
know how to address the specific needs of their children. For
instance, several officials we spoke with noted that many parents do
not understand the importance of enrolling their children in early
intervention services. To illustrate, 2008 data from CDC show that
about 24 percent of children with a hearing loss eligible for early
intervention services did not enroll in them.[Footnote 37] As noted
previously, early intervention services can have a significant impact
on the development of a child.
Efforts to help parents make informed decisions for their deaf and
hard of hearing children vary. For example, Colorado officials said
state law requires cases of infants identified with a hearing loss to
be referred to a hearing resources coordinator. This coordinator may
meet with the family, explain the communication and service options
available to the child, and refer the child to follow-up services.
Similarly, Washington state officials told us that their state uses
family resource coordinators to provide families with objective
information about options and help them access services. In contrast,
a national group of educators told us that most states lack a
centralized contact and do not track children to ensure they receive
follow-up services after being identified.
In addition to state efforts, some federal requirements concerning
educating parents also exist. IDEA requires each state to have a
public awareness program focused on the early identification of
infants and toddlers with disabilities and a central directory that
includes information on early intervention services and resources in
the state. Additionally, Education funds Parent Training and
Information Centers across the nation to provide parents of children
with disabilities--including those who are deaf and hard of hearing--
with training and information on working with early intervention and
special education providers to meet the needs of their children.
Agencies are Taking Steps to Address Data Limitations That Hinder
Evaluation of Early Interventions:
Limited data may hinder the ability of states to evaluate the
effectiveness of early intervention programs for deaf and hard of
hearing children. The EHDI law directs HRSA to award grants or form
cooperative agreements with states to monitor, among other things, the
effectiveness of early interventions for children with hearing loss.
Similarly, the law calls on CDC to award grants or form cooperative
agreements to provide technical assistance with data collection for
EHDI programs and to study the effectiveness of early intervention
programs. State EHDI programs currently collect some outcome data,
such as the number of children who are eligible for and enroll in
early intervention. However, because early intervention services are
provided under IDEA Part C, EHDI programs generally do not have access
to the information on individual children needed to evaluate these
interventions. State IDEA Part C programs are required to collect some
outcome data on the children they serve. For example, state Part C
programs collect information on the acquisition and early use of
language among infants and toddlers receiving services as well as the
number of children who receive assistance to transition out of Part C
early intervention into Part B special education services. According
to the National Center for Hearing Assessment and Management (NCHAM),
such data could help state EHDI programs evaluate early intervention
outcomes, but federal privacy laws and regulations may prohibit state
EHDI programs from obtaining these data from state Part C programs.
For instance, NCHAM states that IDEA Part C regulations prohibit
programs from sharing personal information about children with anyone
who is not a participating Part C service provider without written
consent from parents.[Footnote 38]
Federal agencies are taking a number of steps to help state EHDI
programs obtain data they need on early intervention outcomes. For
example, CDC is funding a study in a limited number of states to
explore the feasibility of creating data management systems that
enable states to collect data on developmental outcomes for deaf and
hard of hearing children. The results of this study should be
published by the end of fiscal year 2011, and CDC told us that the
principal investigator has applied for additional funding in order to
continue work in this area. Additionally, CDC, HRSA, and Education
have provided technical assistance to NCHAM in identifying a number of
recommended practices for helping state EHDI and Part C programs share
data in a manner that is consistent with applicable privacy
restrictions. These practices include implementing memorandums of
agreement between EHDI and Part C programs specifying procedures for
obtaining consent from parents to allow agencies to share data about
their children.
Shortages of Qualified Professionals and the Availability of Resources
May Hinder Schools from Providing Appropriate Services:
Experts told us that early intervention service providers and schools
have trouble attracting and retaining qualified staff. Several of them
told us that schools and service providers have difficulty retaining
teachers, interpreters, and other staff because these professionals
can receive better pay outside of the education system. Experts also
told us that there is a shortage of teachers for the deaf and that the
number of training programs for these professionals is decreasing.
Poorly trained interpreters can also be a barrier to student learning
because not all states have proficiency requirements for interpreters.
For example, officials in Colorado said the state requires educational
interpreters to demonstrate competency by meeting a minimum score on a
proficiency test, whereas officials in Washington state told us that
they have no comparable requirement for interpreters. More generally,
officials from the Registry of Interpreters for the Deaf (RID) told us
that according to published research, only about 20 percent of
individuals taking the Educational Interpreter Performance Assessment
(EIPA)[Footnote 39] meet state standards or RID's standards.
Parents, educators, and advocates agree that while decisions about a
child's education should be based on his or her unique needs as
required by IDEA, the cost or availability of services often
determines what a child receives. Some of these stakeholders said that
schools may be hesitant to provide particular special education
services because the costs incurred are prohibitive. For example, a
school district may have to pay tuition for a child if the child
attends a program outside the school district in order to have his or
her needs met. Also, educators and advocacy groups said schools may
prefer to place children in a program the school already offers in
order to keep down costs. However, IDEA requires schools to provide an
individualized education to children and to obtain input from a team,
including knowledgeable school staff and parents, when making
decisions about how to meet a child's needs. Additionally, IDEA
requires school districts and states to provide recourse for parents
who do not agree with individualized education program decisions for
their child, including the ability to seek a due process hearing.
Experts also noted that providing services in rural areas is
especially challenging. Hearing loss occurs in a small percentage of
children and as such, there may be few deaf children in a given area.
One expert noted that in some rural areas, it is not uncommon to have
only one or two deaf children per county. In these cases, children may
not have access to the same level of expertise or services as children
in urban areas. For example, a Washington state official said that a
rural county in that state had only one special education teacher to
serve children with a range of disabilities and the one available
speech-language therapist did not have a background in hearing loss
issues.
Concluding Observations:
The newly reauthorized EHDI law acknowledges the importance of early
access to services for children with hearing loss, in part, by
encouraging states to increase follow-up rates for newborns and
infants who fail a hearing screening. Meeting the needs of deaf and
hard of hearing children requires an approach that begins early and is
tailored to each child's needs. Given the impact that early
intervention can have on a child's development and future self-
sufficiency, and the level of federal funding devoted to it, the
evaluation of the effectiveness of early intervention is crucial. The
federally funded effort to facilitate these state evaluations is an
important step and may, over time, help inform the effectiveness of
early interventions for deaf and hard of hearing children.
Agency Comments:
We provided a draft of this report to Education and HHS for review and
comment. Both agencies provided technical comments, which we
incorporated into the report, as appropriate.
We are sending copies of this report to the Secretaries of Education
and HHS, relevant congressional committees, and other interested
parties. In addition, the report will be available on GAO's Web site
at [hyperlink, http://www.gao.gov].
If you or your staff have any questions about the report, please
contact me at (202) 512-7215 or scottg@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff that made major contributions
to this report are listed in appendix IV.
Signed by:
George A. Scott, Director:
Education, Workforce, and Income Security Issues:
[End of section]
Appendix I: Scope and Methodology:
To obtain information on the extent of hearing loss among children in
the United States, we analyzed recent available data on hearing loss
in children from hearing tests and three Department of Health and
Human Services' (HHS) surveys from 2005 to 2009. Specifically, we
analyzed hearing test data from the Early Hearing Detection and
Intervention program on newborns and infants up to 12 months and from
the National Health and Nutrition Examination Survey's hearing
examinations of 12-17 year olds. We also analyzed survey data from the
National Health Interview Survey, National Health and Nutrition
Examination Survey, and the National Survey of Children's Health (see
table 3). We evaluated these federal surveys for methodological rigor,
as well as to determine the extent to which the data could be used to
offer a national perspective on children with hearing loss. We
determined that the data were sufficiently reliable for our purposes.
Because the survey data were collected using generalizable,
probability samples, this sample is only one of a large number of
samples that might have been selected. Since each sample could provide
different estimates, we have used 95 percent confidence intervals to
show the precision of our results. All percentage estimates used in
this report have 95 percent confidence intervals of within plus or
minus 4 percentage points, unless otherwise noted.
Table 3: National Surveys of Children with Hearing Loss:
Survey: National Health Interview Survey;
Purpose: To serve as the principal source of information on the health
of the civilian noninstitutionalized population of the United States;
Age group analyzed[A]: Children aged 0-17 years;
Web sites, as of April 12, 2011: [hyperlink,
http://www.cdc.gov/nchs/nhis.htm].
Survey: National Health and Nutrition Examination Survey;
Purpose: To assess the health and nutritional status of adults and
children in the United States, through a combination of interviews and
physical examinations;
Age group analyzed[A]: Interview surveys of children aged 0-17;
hearing examinations of youth 12-17 years;
Web sites, as of April 12, 2011: [hyperlink,
http://www.cdc.gov/nchs/nhanes.htm].
Survey: National Survey of Children's Health;
Purpose: To examine the physical and emotional health of children;
Age group analyzed[A]: Children aged 0-17 years;
Web sites, as of April 12, 2011: [hyperlink,
http://www.cdc.gov/nchs/slaits/nsch.htm].
Source: GAO analysis of HHS surveys.
[A] For the purposes of our analysis.
[End of table]
To identify factors associated with the development of language and
literacy for deaf and hard of hearing children, we spoke to a variety
of national experts, representing educators, parents, and the deaf
community, and solicited written comments from a variety of national
organizations representing a spectrum of views on deaf education (see
table 4).
Table 4: Organizations Interviewed or Providing Written Input:
Organization:
Alexander Graham Bell Association for the Deaf and Hard of Hearing.
Organization:
National Association of the Deaf.
Organization:
American Society for Deaf Children.
Organization:
National Cued Speech Association.
Organization:
Convention of American Instructors of the Deaf.
Organization:
Registry of Interpreters for the Deaf.
Organization:
National Association of State Directors of Special Education.
Organization:
Conference of Educational Administrators of Schools and Programs for
the Deaf.
Organization:
American Speech-Language-Hearing Association.
Organization:
The Laurent Clerc National Deaf Education Center at Gallaudet
University.
Organization:
Center for ASL/English Bilingual Education and Research.
Organization:
Hands & Voices.
Organization:
The Association of College Educators-Deaf and Hard of Hearing.
Organization:
American Academy of Audiology.
Source: GAO.
[End of table]
We searched numerous databases--including the Education Resources
Information Center, the Cumulative Index to Nursing and Allied Health
Literature, Electronics Collections Online, ProQuest, and numerous
social science and medical literature databases on the Dialog platform-
-in order to identify recent studies on factors that have been shown
to promote language and literacy development for deaf and hard of
hearing children. We also consulted with national experts to identify
relevant studies. As a result, we identified 159 studies published
from 2005 through 2010. We limited the scope of our work by looking at
studies that met the following criteria: (1) original research
published since 2005, (2) based in the United States, (3) included
five or more participants, and (4) related to a single disability.
Through further review, we found that 26 published studies fell within
our scope. Therefore, our results are not an exhaustive or historical
treatment of the topic. We conducted detailed reviews of these 26
studies. Our reviews entailed an assessment of each study's research
methodology, including its research design, and analytic techniques,
as well as a summary of each study's major findings and conclusions.
We also assessed the extent to which each study's data and methods
support its findings and conclusions.
To identify the challenges that exist to providing appropriate
interventions for deaf and hard of hearing children, we reviewed
relevant federal laws and regulations for the Early Hearing Detection
and Intervention program and the Individuals with Disabilities
Education Act (IDEA), and interviewed federal officials responsible
for administering these programs. We also spoke to a variety of
national organizations and conducted site visits to Colorado,
Massachusetts, and Washington state to learn more about the
experiences educators and others have had with educational and other
services for deaf and hard of hearing children. We selected these
states because they vary in terms of the percentage of deaf and hard
of hearing children educated in regular classrooms, the educational
focus of their state school for the deaf,[Footnote 40] and their
geography. During these visits, we solicited input from a variety of
groups and individuals, including state agencies responsible for
overseeing IDEA Part C and Part B programs, school district and school
administrators, and teachers. We visited a variety of schools
encompassing differences in setting (residential, regional programs,
children in self-contained classrooms, and children in regular
classrooms) and mode of communication (sign language and auditory or
oral). In addition, we interviewed 28 parents of deaf and hard of
hearing students during our site visits to learn about their
experiences and the challenges they face. Local organizations within
the states we visited organized meetings of parents who volunteered to
meet with us.
We conducted this performance audit from March 2010 to May 2011 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
[End of section]
Appendix II: Summary of Key Provisions of IDEA Part C and Part B
Programs:
Who is eligible for services?
Part C: An infant or toddler with a disability, under 3 years of age,
who is experiencing a developmental delay or has a diagnosed condition
that has a high probability of resulting in a developmental delay;
Part B: A child, aged 3-21, with a disability that falls into at least
1 of 10 categories, including hearing impairments, that adversely
affects the child's educational performance, and as a result is
determined to require special education services.[A]
What is included in a child's individualized family service plan or
individualized education program?
Part C: An individualized family service plan should include, among
other things, a written assessment of the child's development,
acknowledgment of the family's priorities, measurable outcomes and
results for the child, and the specific early intervention services to
be provided;
Part B: An individualized education program should include, among
other things, a written assessment of the child's level of performance
and academic achievement; measurable annual goals, including academic
goals; and the special education services and accommodations to be
provided.
Where does a child receive services?
Part C: To the maximum extent appropriate, early intervention services
should be provided in a child's natural environments, including the
home, and community settings where children without disabilities
participate;
Part B: Under the principle of least restrictive environment, to the
maximum extent appropriate, children with disabilities should be
educated with children who are not disabled.
Source: GAO analysis of IDEA, as amended, and implementing regulations
found at 34 C.F.R. Part 303 (Part C) and 34 C.F.R. Part 300 (Part B).
[A] The 10 categories are intellectual disabilities, hearing
impairments (including deafness), speech or language impairments,
visual impairments (including blindness), serious emotional
disturbance, orthopedic impairments, autism, traumatic brain injury,
other health impairments, and specific learning disabilities.
[End of table]
[End of section]
Appendix III: National Survey Estimates of Hearing Loss for Children
Aged 0-17:
Survey: National Health and Nutrition Examination Survey;
Years: 2005-2008;
Survey question: Which statement best describes {the sample child's}
hearing (without a hearing aid)? Would you say {your/his/her} hearing
is excellent, good, that {you have/s/he has} a little trouble,
moderate trouble, a lot of trouble, or {are you/is s/he} deaf?;
Percentage of children, Aged 0-11, experiencing at least a little
trouble hearing or told they had hearing problems: 3.3%;
Percentage of children, Aged 12-17, experiencing at least a little
trouble hearing or told they had hearing problems: 5.3%.
Survey: National Health Interview Survey;
Years: 2008-2009;
Survey question: Which statement best describes {the sample child's}
hearing without a hearing aid: Excellent, good, a little trouble
hearing, moderate trouble, a lot of trouble, or is {the child} deaf?;
Percentage of children, Aged 0-11, experiencing at least a little
trouble hearing or told they had hearing problems: 2%;
Percentage of children, Aged 12-17, experiencing at least a little
trouble hearing or told they had hearing problems: 2.5%.
Survey: National Survey of Children's Health;
Years: 2007;
Survey question: Has a doctor or other health care provider ever told
you that {the sample child} had hearing problems?;
Percentage of children, Aged 0-11, experiencing at least a little
trouble hearing or told they had hearing problems: 2.9%;
Percentage of children, Aged 12-17, experiencing at least a little
trouble hearing or told they had hearing problems: 3.1%.
Source: GAO analysis of HHS surveys.
[End of table]
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
George A. Scott, (202) 512-7215 or scottg@gao.gov:
Staff Acknowledgments:
Clarita Mrena (Assistant Director), Avani Locke (Analyst-in-Charge),
Daniel R. Concepcion, and Alana Miller made significant contributions
to all aspects of this report. Jean McSween helped develop our
methodology and reviewed relevant research. Ying Long, Karen O'Conor,
and Vanessa Taylor analyzed data, and Leia Dickerson and Ashley McCall
assisted with our literature search. Kathleen van Gelder provided
writing assistance, and James Bennett helped develop our graphics.
Also, Jessica Botsford provided legal assistance and Ashanta Williams
verified the material in this report.
[End of section]
Footnotes:
[1] The phrases "deaf and hard of hearing" and "children with hearing
loss" are used interchangeably throughout the report.
[2] Carol Bloomquist Traxler, "The Stanford Achievement test, 9TH
Edition: National Norming and Performance Standards for Deaf and Hard-
of-Hearing Students," Journal of Deaf Studies and Deaf Education, vol.
5, no. 4 (fall 2000): 337-48.
[3] Experts include the Centers for Disease Control and Prevention
(CDC), American Speech-Language-Hearing Association, Boys Town
National Research Hospital, and Johns Hopkins Medicine. CDC also
identifies a fourth type of hearing loss--Auditory Neuropathy Spectrum
Disorder, where damage to the inner ear or hearing nerve prevents
sound that enters the ear normally from being easily understood by the
brain.
[4] The American Speech-Language-Hearing Association cites the
following hearing loss classification system, with loss measured in
decibels (dB HL): normal hearing loss falls from negative 10 to 15 dB
HL, slight loss from 16 to 25 dB HL, mild loss from 26 to 40 dB HL,
moderate loss from 41 to 55 dB HL, moderately severe loss from 56 to
70 dB HL, severe loss from 71 to 90 dB HL, and profound loss of 91 dB
HL or more. According to the Centers for Disease Control and
Prevention, a person with mild hearing loss may hear some speech
sounds but find soft sounds difficult to hear whereas someone with
profound hearing loss will not hear any speech and only very loud
sounds.
[5] Testimony of James F. Battey Jr., M.D., Ph.D., Director, National
Institute on Deafness and Other Communication Disorders, before the
Subcommittee on Labor, Health and Human Services, Education, and
Related Agencies, U.S. Senate Committee on Appropriations (Mar. 26,
2007).
[6] Other assistive technologies, such as an FM system, can help deaf
and hard of hearing children communicate in the classroom by sending
sound from someone speaking into a microphone to a person wearing the
receiver, and can be used in conjunction with hearing aids.
[7] Bone-anchored hearing aids may be used by children who are unable
to wear a hearing aid in or behind the ear.
[8] 42 U.S.C. § 280g-1. CDC was appropriated about $10.9 million for
EHDI in fiscal year 2009. The same year, HRSA's hearing screening and
intervention program was funded at $19 million.
[9] The committee is composed of members of the Alexander Graham Bell
Association for the Deaf and Hard of Hearing, the American Academy of
Pediatrics, the American Academy of Audiology, the American Academy of
Otolaryngology-Head and Neck Surgery, the American Speech-Language-
Hearing Association, the Council on Education of the Deaf, and the
Directors of Speech and Hearing Programs in State Health and Welfare
Agencies.
[10] According to the CDC, the agency does not establish criteria for
passing the hearing screening.
[11] Early Hearing Detection and Intervention Act of 2010, Pub. L. No.
111-337, 124 Stat. 3588. The program also aims to develop efficient
models to ensure that newborns and infants who are identified with a
hearing loss through screening receive follow-up by a qualified health
care provider. The EHDI law was first enacted as part of the
Departments of Labor, Health and Human Services, and Education Fiscal
Year 2000 Appropriations Act, Pub. L. No. 106-113, Appendix D, Title
VI, 113 Stat. 1501, 1501A-276 (1999) and was subsequently added as
amendment to the Public Health Service Act by section 702 of the
Children's Health Act of 2000, Pub. L. No. 106-310, Div. A, Title VII,
114 Stat. 1101, 1120.
[12] IDEA was originally enacted as the Education for All Handicapped
Children Act, Pub. L. No. 94-142, 89 Stat. 773.
[13] Individuals with Disabilities Education Improvement Act of 2004,
Pub. L. No. 108-446, 118 Stat. 2647. IDEA, as amended, is codified at
20 U.S.C. § 1400 et seq.
[14] In fiscal year 2008, the Part C program was funded at $436
million.
[15] In fiscal year 2008, the Part B program was funded at $10.95
billion.
[16] In addition to IDEA, other laws support the educational needs of
children with disabilities, including children who are deaf or hard of
hearing. Section 504 of the Rehabilitation Act of 1973 (Section 504)
prohibits entities that receive federal financial assistance,
including public schools, from discriminating against otherwise
qualified individuals with disabilities. Title II of the Americans
with Disabilities Act of 1990, as amended, prohibits discrimination on
the basis of disability by public entities, including public schools,
regardless of whether they receive federal financial assistance. In
general, Section 504 and Title II requirements are similar.
[17] Education requires state Part C programs to report on, among
other things, the percentage of children exiting Part C who receive
timely transition planning to support the child's transition to
preschool and other community services by the age of 3. Transition
planning includes documentation of appropriate transition steps and
services for a child, as well as notification of school districts and
a transition conference for children potentially eligible for Part B
services. Part B programs are required to report to Education on the
percentage of children referred by Part C prior to age 3, who are
found eligible for Part B, and who have an individualized education
program developed and implemented by their third birthdays.
[18] 20 U.S.C. § 1436 and 34 C.F.R. § 303.342 and § 303.343.
[19] 20 U.S.C. § 1414(d)(1) and 34 C.F.R. § 300.321 and § 300.324.
[20] States must also include procedural safeguards in their programs,
such as a right to due process hearings and the right to appeal to
federal district court.
[21] These data represent the 50 states only. More than 79,000 deaf
and hard of hearing children in the 50 states, the District of
Columbia, schools of the Bureau of Indian Education, and the U.S.
territories received IDEA Part B services as of fall 2008.
[22] This statistic represents prevalence in the 45 states for which
data were available. Alabama, California, Georgia, Nevada, and New
York were not included in this analysis.
[23] Infants may be screened for hearing loss more than once; for
infants who received multiple screenings, this statistic is based on
the results of their most recent screening test.
[24] The families of most infants without a documented diagnosis could
not be contacted or were unresponsive (about 82 percent), while other
infants had a diagnosis in process (about 9 percent), died or had a
parent who refused further testing (about 5 percent), or were
nonresidents or moved out of state (about 4 percent).
[25] Pub. L. No. 111-337, § 2, 124 Stat. 3588 (codified at 42 U.S.C.
280g-1(a)(3)).
[26] The most recent year for which hearing test data are available
for children in this age range is 1994, when data were collected on
children aged 6 to 19. Although existing federal hearing screening and
testing programs do not currently cover children of all ages, states
may mandate hearing tests for these children. For example, according
to the Colorado Department of Education, Colorado requires that
children in kindergarten and grades 1-3, 5, 7, and 9 are tested for
hearing loss.
[27] The surveys include the National Health Interview Survey (NHIS),
National Survey of Children's Health (NSCH), and National Health and
Nutrition Examination Survey (NHANES) household interview data. For
NHIS and NSCH, a responsible adult, such as a parent or guardian who
is knowledgeable about a child's health status, served as the survey
respondent. For NHANES, an adult reported information on behalf of
children younger than the age of 16.
[28] The National Health and Nutrition Examination Survey is used to
assess the health and nutritional status of children and adults in the
United States through a combination of interviews and physical
examinations. For the purposes of examining data on children, we
limited our analysis to 12-17 year olds only. See appendix I for more
information.
[29] An estimated 99 percent of 12-17 year olds had hearing ranging
from normal to mild loss and less than an estimated 1 percent
experienced severe or profound loss.
[30] For poverty status, we compared 12-17 year olds from families
with income below 200 percent of federal poverty guidelines and at or
above 200 percent of the guidelines. For race, we compared non-
Hispanic white children and non-Hispanic African-American children. We
selected these races due to the limited sample sizes available by race.
[31] Marianne Ahlgren, Julie Jodoin-Krauzyk, Mary Jane Johnson,
Deborah Topol, Richard Tucker, and Betty Vohr, "Early Language
Outcomes of Early-Identified Infants With Permanent Hearing Loss at 12
to 16 Months of Age," Pediatrics, vol. 122, no. 3 (2008).
[32] Carol McDonald Connor, Holly K. Craig, Krista Heavner, Stephen W.
Raudenbush, and Teresa A. Zwolan, "The Age at Which Young Deaf
Children Receive Cochlear Implants and Their Vocabulary and Speech-
Production Growth: Is There an Added Value for Early Implantation?"
Ear and Hearing, vol. 27, no. 6 (2006).
[33] Amy R. Lederberg and Patricia E. Spencer, "Word-Learning
Abilities in Deaf and Hard-of-Hearing Preschoolers: Effect of Lexicon
Size and Language Modality," Journal of Deaf Studies and Deaf
Education, vol. 14, no. 1 (2009).
[34] For the committee's policy, see Pediatrics, vol. 120, no. 4
(2007).
[35] Deaf Students Education Services; Policy Guidance, 57 Fed. Reg.
49,274 (Oct. 30, 1992).
[36] National Association of State Directors of Special Education,
Inc., Meeting the Needs of Students Who Are Deaf or Hard of Hearing:
Educational Services Guidelines (Alexandria, Va, July 2006).
[37] 2008 CDC EHDI Hearing Screening & Follow-up Survey. These data
were reported from 44 states.
[38] National Center for Hearing Assessment and Management, The Impact
of Privacy Regulations: How EHDI, Part C, & Health Providers Can
Ensure that Children & Families Get Needed Services (Logan, Utah, May
2008).
[39] The EIPA test was developed by the Boys Town National Research
Hospital and uses skilled deaf and hearing raters to provide
diagnostic services for individual interpreters, states, educational
settings and school districts. RID considers a score of 4.0 or higher
on the EIPA as qualifying for RID certification.
[40] Massachusetts does not have a state school for the deaf.
[End of section]
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