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Chen, D. (2000). Identifying vision and hearing problems in infants with disabilities. IDA News,27(3), 1-3.
Identifying Vision and Hearing Problems in Infants with Disabilities
Deborah Chen, Ph.D.
Vision and hearing are such primary avenues for learning that infants who have developmental delays or disabilities should receive comprehensive ophthalmological and audiological evaluations. Unfortunately, this is not common practice. Without accurate information about the status of an infant's vision or hearing, service providers cannot be confident that they are providing the most appropriate interventions to promote early development. A child's inattentiveness to certain activities or delay in speech and language development may be influenced by an unidentified vision or hearing problem, rather than solely due to an obvious motor or developmental delay. Research indicates that infants who are eligible for early intervention services are more likely to have a vision impairment or a hearing loss than infants without disabilities. Children who have developmental delays, cerebral palsy, or Down syndrome have a higher incidence of refractive errors and other ophthalmological problems than children without disabilities. About 70 percent of children with visual impairments have an additional disability. Over 75 percent of children with Down syndrome have a hearing loss, and over 35 percent of children with hearing loss have an additional disability. Further, ear infections, which can cause a fluctuating hearing loss, is a common occurrence in infancy. These statistics emphasize the need for infants with developmental delays or disabilities to receive audiological and ophthalmological evaluations and the importance of an interdisciplinary approach to early intervention services.
The purpose of this article is to provide questions that early intervention service providers can use to guide their review of medical records, their interviews with families, and their systematic observations of infants. This way, service providers may identify high risk indicators associated with visual impairment or hearing loss and refer these infants for additional evaluation, as needed.
Family Interview and Medical Records
1. Has the infant had ophthalmological and audiological evaluations?
If yes, what tests were conducted and what were the results? If the infant was identified as having a visual impairment or hearing loss, what services and interventions have been provided to address these needs? It is important to find out test results, whether any recommendations were made and acted upon, whether the family has any questions and concerns, and when a follow-up evaluation should be scheduled.
2. Does anyone in the family have a visual impairment or hearing loss?
If these problems are related to hereditary factors, the infant should receive comprehensive audiological and ophthalmological evaluations.
3. Is there any problem in the infant's prenatal or birth history that is associated with hearing loss?
These factors include prenatal exposure to certain maternal infections (e.g., toxoplasmosis, syphilis, rubella, cytomegalovirus, herpes), prematurity, hypoxia,
an Apgar score of 3 or less at 5 minutes after birth, a hyperbilirubinemia level requiring transfusion, prolonged medical ventilation or prolonged use of ototoxic medication.
4. Is there any problem in the infant's prenatal or birth history that is associated with visual impairment?
These factors include prenatal exposure to certain maternal infections (e.g., toxoplasmosis, syphilis, rubella, cytomegalovirus, herpes, HIV, chicken pox), prematurity, hypoxia, and abnormal prenatal brain development (Teplin, 1995).
5. Does the infant have a diagnosis that is associated with hearing loss?
These diagnoses include head trauma, cerebral palsy, specific syndromes (e.g. CHARGE, Down, Fetal Alcohol, Goldenhar, Hurler, Norrie, Refsum, Trisomy 13, Waardenburg), certain childhood infections (e.g., bacterial meningitis, mumps, measles) and particular neurodegenerative disorders (e.g. neurofibromatosis, Tay-Sach, Niemann-Pick disease).
6. Does the infant have a diagnosis that is associated with visual impairment?
These diagnoses include head trauma; cerebral palsy; specific syndromes (e.g., CHARGE, cri du chat, Down, Fetal Alcohol, Goldenhar, Hurler, Lowe, Marfan, Norrie, Refsum, Trisomy 13, Usher); bacterial meningitis; and particular neurodegenerative disorders (e.g., neurofibromatosis, Tay Sach).
7. Does the infant have frequent ear infections, earaches, or discharge from the ears?
Middle ear infections or otitis media can cause a mild, fluctuating hearing problem that may influence the infant's ability to develop language and comprehend speech. Some infants have ear infections but show no symptoms; while others may seem tired, sick, or unresponsive to sound.
8. Are the infant's face and ears normal in appearance?
High risk signs for hearing loss include cleft lip or palate; malformations of the face, head or neck, or ears.
9. Are the infant's eyes normal in appearance?
High risk indicators of vision problems include a drooping eyelid that covers the pupil, abnormal eye shape or structure, absence of a clear dark pupil, and persistent redness in the conjunctiva that is normally white, and persistent tearing without crying.
Other indicators include jerky eye movements (nystagmus), an absence of eyes moving together, or a sustained eye turn after the infant is 4 to 6 months old.
10. How does the infant respond to different types of auditory stimuli?
Depending on the type and severity of the hearing problem, an infant may attend inconsistently to sounds, respond to some sounds and not to others, or may not respond at all. Infants with mild or moderate hearing losses may still demonstrate early listening behaviors such as attention or alerting to sounds, i.e., changes in facial expressions, vocalizations, or in activity and discrimination and recognition, i.e., responding differently to familiar and unfamiliar voices; imitating vocalizations; responding to familiar words (e.g., name, "no", songs). However, without early identification and appropriate intervention, even a mild or moderate hearing loss will have a negative effect on the infant's language development and speech comprehension, particularly when the infant has additional special needs.
11. How does the infant respond to different types of visual stimuli?
Depending on the type and degree of visual impairment, children show a preference for brightly colored or black and white objects. They may seem to pay more attention if the objects are presented at particular distances or positions. Some children with visual impairment may be very sensitive to bright light and may squint or close their eyes. Infants with visual impairment may still show attending or alerting behaviors by smiling, looking, reaching, or orienting toward a preferred object or person; and discrimination, recognition, and examining behaviors by differentiating between familiar and unfamiliar people and objects and indicating preferences. However, without early identification and appropriate intervention, a child who has a visual impairment will have more difficulty discriminating, recognizing, and understanding pictures and letters, particularly if this child has additional special needs.
12. Does the infant produce vocalizations that are typical for his or her age?
By 12 months, infants make a variety of sounds and use a few words. A hearing problem may result in limited vocalizations; abnormal voice, intonation, or articulation; or delay in speech development.
13. Does the infant have an unusual gaze or head position when looking at something or someone?
In order to see better, an infant with a visual impairment may turns his or her head in certain positions to look at an object, holds object close to eyes or moves head close to the object, or seem to look beside, under, or above the object of attention.
14. Does the infant demonstrate visually guided behaviors that are typical for his or her age?
High risk indicators of visual impairment include lack of eye contact, visual fixation or following by 3 months of age and an absence of accurate reaching for objects by 6 months old.
If an infant has a medical history, diagnosis, physical appearance, or behaviors that are risk indicators of visual impairment or hearing loss, then early intervention service providers should discuss these concerns with the child's family and with relevant program staff (e.g., a nurse, speech and language therapist, and teachers certified in visual impairment or deaf and hard of hearing specializations) to determine the appropriate steps and possible interventions. To achieve the goal of promoting early development, early intervention services must ensure that infants with developmental delays or disabilities have access to comprehensible sensory information. Early identification of vision and hearing problems is a significant first step.
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