Infant Hearing, Intervention, and Childhood Hearing Loss: Interview with Brian J. Fligor, ScD
Douglas L. Beck, AuD, spoke with Dr. Fligor about his new book on childhood hearing loss, early intervention and more.
Academy: Hi, Brian! As always, great to chat with you.
Fligor: Thanks, Doug. Good to speak with you, too.
Academy: And let me be among the first to say I have read your new book, I think it's great, it fills a niche, and congratulations! Rather than creating a new text about hearing loss, this one is written for parents, and it's more about understanding and managing hearing loss in a child, and the many interactions across and through the family. Is that a fair assessment?
Fligor: Yes. That's the idea. I wanted to write to the parents about how to grow a healthy family and a healthy child. As you know, Doug, of course the child with hearing loss is the patient of the pediatric audiologist, and so too, are the parents (and/or caregivers).
Academy: One of the great concepts you introduce early in the book is the "citizen of the world" idea. Can you explain that, please?
Fligor: Sure. That idea comes from Patricia Kuhl, PhD, as she was doing work in language acquisition and publishing in the psychology literature as long ago as the early 1980s. Her idea was that the typically developing child under age 6 months or so, is usually able to differentiate virtually all of the phonemes in all of the languages of the world, and as the child grows and matures, their repertoire of phonemes is grossly reduced to their "native language." So then, a child who is still a citizen of the world can identify and respond to Japanese, Arabic, English and French, but as the child focuses more and more on their own native language, they lose some of the ability to discriminate between phonemes in foreign languages.
Academy: Which supports the idea that early intervention for hearing impaired and deaf children is of significant importance, as we want to expose the child to their native language as soon as possible—not to obliterate the identification of other languages, but to assure their brain is exposed to sounds that will be dominant throughout their lifetime.
Fligor: Exactly. So the bottom line is we need to make sure early intervention occurs at a time based on brain development milestones, and of course, we want to be sure to provide sound when the brain is prepared to listen, so as to develop and nurture speech and language acquisition.
Fligor: Right, and of course the Joint Committee for Infant Hearing (JCIH, 2007 and 2012) described these issues in detail. The JCIH introduced the "1-3-6 EHDI Plan" which sets the benchmark that all babies should be screened by 1 month. Children who do not pass the screenings, should have diagnostic audiological evaluation no later than 3 months of age, and for infants with permanent hearing loss, early intervention should start no later than 6 months of age, and family-centered early intervention should be initiated at this time. To be clear, when I say "every baby" I'm actually referring to the JCIH benchmark which is 90% of all babies, as unfortunately, 100 percent is just not realistic. Actually, you did an interview with Christie Yoshinaga, which nicely reviewed the JCIH releases.
Academy: Right, she is such a joy to work with and she really is a fountain of knowledge!
Fligor: Absolutely. Christine has taught all of us the importance of newborn hearing screenings as the entry into family-centered intervention for the children who need us most. Further, we know that late onset of hearing loss can occur after the child has been screened, and so we also need to be aware of this and make sure that if late changes occur, they are addressed in a timely manner. So then, given a delayed onset, it needs to be diagnosed within 45 days of onset, and intervention needs to be initiated within another 45 days.
Academy: And of course with regard to timely intervention, it is to be unbiased, and it assures that the appropriate people are available to review, explain and implement the family's choice?
Fligor: Yes. And this is not an easy thing for all professionals, as we all have our personal preferences and biases across modes of communication such as American Sign Language (ASL) versus, perhaps, spoken language. That is, if the family chooses ASL, a qualified ASL instructor must be made available to work with the family and the child, and to be clear, the provider must be fluent in ASL.
Academy: Yes, that can be difficult if the family chooses a path different from the personal preference of the professional. Of course, it really is important to respect the choices of the family, and to make sure that whatever they choose is maximally provided for their child.
Fligor: Right, as one of the parents I interviewed for this book said to me "The question is not which is easier, ASL or cochlear implants, the issue is, how do you want to communicate with your child, because when it comes to teaching a deaf child language, there is no getting out of hard work…"
Academy: That's a profound statement, and of course the family, the child and their needs trump everything else, no doubt. However, if one were to ask a different question, such as "At which hearing level in decibels, is a child four times more likely to succeed with a cochlear implant than a hearing aid" the answer is very different.
Fligor: You must be referring to Lovett, Vickers, and Summerfield?
Academy: Exactly. Lovett, Vickers, and Summerfield (2015) examined the decibel level at which point a child is four times more likely to excel with cochlear implants (CIs) than hearing aids. They determined a mean 4FPTA of 80 dB HL is the point. Of note, this is a different point than that currently described by the FDA. The FDA approves CIs for children ages 12 to 23 months given a 3FPTA of 90 dB or greater. And so given this information and the other developments in the scientific literature, such as the scientific inquiry into should we fit CROS, bi-CROS and Bone Anchored solutions, and what should we recommend given a severe-to-profound unilateral hearing loss and more, it's sometimes very difficult to be objective and unbiased!
Fligor: Yes, you've hit the nail on the head. When we had less knowledge, just like all people and all professions, it was very easy to choose the answer we personally preferred….but in 2015 and moving into the future, we have amazing peer-reviewed findings, which sometimes (perhaps often!) contradict what we do traditionally or clinically—and so to keep it unbiased and family-centered is not particularly easy!
Academy: The question of what to do for the child with a profound unilateral hearing loss is particularly interesting to me, as I've been working with cochlear implants for more than 30 years.
Fligor: Yes—the "go to" answer has previously been FM systems and perhaps a hearing aid and more, but in 2015, that child may wind up with a cochlear implant! That's not to say one is better than the other, or which child should or shouldn't get an implant—and let's be clear the FDA Guidelines don't go there, but yes, many people, and indeed some children are getting cochlear implants in light of a unilateral severe-to-profound hearing loss.
Academy: The literature on this has been astounding, and it wouldn't surprise me if we see a reshuffling of cochlear implant candidacy guidelines in the next year or two. We'll place some related links at the end of this interview.
Fligor: Yes, thanks. The thing to understand is we need to keep looking and examining and researching, because the conclusions we drew yesterday, may not be the conclusions we would arrive at today, given the contemporary research.
Academy: Brian, it's been a pleasure chatting with you. Thanks so much for your time, and I urge our colleagues and the parents of the children we work with to get a copy of the book, to read it, and to work with their audiologist to best understand the messages, the information and the opportunity.
Fligor: Thanks, Doug. I appreciate your interest in the book, and thanks for your time, too!
Brian J. Fligor ScD, PASC, is the chief audiology officer at Lantos Technologies. He is also president of Boston Audiology Consultants, adjunct instructor at Northeastern University and Salus University, and author of Understanding Childhood Hearing Loss – Whole Family Approaches to Living and Thriving. His book can be ordered through Amazon or directly from the publisher, Roman and Littlefield.
Douglas L. Beck, AuD, Board Certified in Audiology is the Web content editor with the American Academy of Auidology.
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