Trajectory of hearing loss in children with unilateral hearing loss.

Introduction: The aim of this study was to quantify the amount of deterioration in hearing and to document the trajectory of hearing loss in early identified children with unilateral hearing loss (UHL). We also examined whether clinical characteristics were associated with the likelihood of having progressive hearing loss. Methods: As part of the Mild and Unilateral Hearing Loss Study, we followed a population-based cohort of 177 children diagnosed with UHL from 2003 to 2018. We applied linear mixed models to examine hearing trends over time including the average amount of change in hearing. Logistic regression models were used to examine the relationship between age and severity at diagnosis, etiology, and the likelihood of progressive loss and amount of deterioration in hearing. Results: The median age of the children at diagnosis was 4.1 months (IQR 2.1, 53.9) and follow-up time was 58.9 months (35.6, 92.0). Average hearing loss in the impaired ear was 58.8 dB HL (SD 28.5). Over the 16-year period, 47.5% (84/177) of children showed deterioration in hearing in one or both ears from their initial diagnostic assessment to most recent assessment including 21 (11.9%) who developed bilateral hearing loss. Average deterioration in the impaired ear ranged from 27 to 31 dB with little variation across frequencies. Deterioration resulted in a change in category of severity for 67.5% (52/77) of the children. Analysis for children who were followed for at least 8 years showed that most lost a significant amount of hearing rapidly in the first 4 years, with the decrease stabilizing and showing a plateau in the last 4 years. Age and severity at diagnosis were not significantly associated with progressive/stable loss after adjusting for time since diagnosis. Etiologic factors (ENT external/middle ear anomalies, inner ear anomalies, syndromic hearing loss, hereditary/genetic) were found to be positively associated with stable hearing loss. Conclusion: Almost half of children with UHL are at risk for deterioration in hearing in one or both ears. Most deterioration occurs within the first 4 years following diagnosis. Most children did not experience sudden "large" drops in hearing but more gradual decrease over time. These results suggest that careful monitoring of UHL especially in the early years is important to ensure optimal benefit from early hearing loss detection.

Auditory and language outcomes in children with unilateral hearing loss.

OBJECTIVES: Children with unilateral hearing loss (UHL) are being diagnosed at younger ages because of newborn hearing screening. Historically, they have been considered at risk for difficulties in listening and language development. Little information is available on contemporary cohorts of children identified in the early months of life. We examined auditory and language acquisition outcomes in a contemporary cohort of early-identified children with UHL and compared their outcomes at preschool age with peers with mild bilateral loss and with normal hearing. DESIGN: As part of the Mild and Unilateral Hearing Loss in Children Study, we collected auditory and spoken language outcomes on children with unilateral, bilateral hearing loss and with normal hearing over a four-year period. This report provides a cross-sectional analysis of results at age 48 months. A total of 120 children (38 unilateral and 31 bilateral mild, 51 normal hearing) were enrolled in the study from 2010 to 2015. Children started the study at varying ages between 12 and 36 months of age and were followed until age 36-48 months. The median age of identification of hearing loss was 3.4 months (IQR: 2.0, 5.5) for unilateral and 3.6 months (IQR: 2.7, 5.9) for the mild bilateral group. Families completed an intake form at enrolment to provide baseline child and family-related characteristics. Data on amplification fitting and use were collected via parent questionnaires at each annual assessment interval. This study involved a range of auditory development and language measures. For this report, we focus on the end of follow-up results from two auditory development questionnaires and three standardized speech-language assessments. Assessments included in this report were completed at a median age of 47.8 months (IQR: 38.8, 48.5). Using ANOVA, we examined auditory and language outcomes in children with UHL and compared their scores to children with mild bilateral hearing loss and those with normal hearing. RESULTS: On most measures, children with UHL performed poorer than those in the mild bilateral and normal hearing study groups. All children with hearing loss performed at lower levels compared to the normal hearing control group. However, mean standard scores for the normal hearing group in this study were above normative means for the language measures. In particular, children with UHL showed gaps compared to the normal hearing control group in functional auditory listening and in receptive and expressive language skills (three quarters of one standard deviation below) at age 48 months. Their performance in receptive vocabulary and speech production was not significantly different from that of their hearing peers. CONCLUSIONS: Even when identified in the first months of life, children with UHL show a tendency to lag behind their normal hearing peers in functional auditory listening and in receptive and expressive language development.

Service Preferences of Parents of Children With Mild Bilateral or Unilateral Hearing Loss: A Conjoint Analysis Study.

OBJECTIVE: Universal newborn hearing screening results in substantially more children with mild bilateral and unilateral hearing loss identified in the early years of life. While intervention services for children with moderate loss and greater are generally well-established, considerable uncertainty and variation surrounds the need for intervention services for children with milder losses. This study was undertaken with parents of young children with permanent mild bilateral and unilateral hearing loss to examine their preferences for characteristics associated with intervention services. DESIGN: Conjoint analysis, a preference-based technique, was employed to study parents' strength of preferences. Using a cross-sectional survey that consisted of eight hypothetical clinic scenarios, we invited parents to make a discrete choice (to select one of two or more different services) between available services with different characteristics. The survey was informed by qualitative interviews conducted for this purpose. The questionnaire was administered to parents receiving intervention services in the province of Ontario, Canada, who were enrolled in a mixed-methods longitudinal study examining outcomes in early-identified children with mild bilateral/unilateral hearing loss. Data were analyzed using a generalized linear model (probit link) to identify attributes of interest for the respondents. Characteristics of the children were entered into the model to control for differences in age of diagnosis, sex, laterality of hearing loss, and hearing aid use. RESULTS: A total of 51 of 62 invited parents completed the questionnaire. All four attributes of care that were included in the survey were found to be statistically significant, that is, parents valued support for amplification, support for speech-language development, emotional support, and communication from professionals. Analysis showed greater preference for enhanced levels relating to support for speech-language development than for support for amplification. Preference for attributes relating to emotional support and communication were also greater than for support for amplification use. CONCLUSIONS: Conjoint analysis was used to quantify parents' preferences for service attributes. Parents' values provide insights into the aspects of a service model that should receive consideration in the development of intervention programs for young children with mild bilateral or unilateral hearing loss and their families. Although parents of young children with mild bilateral or unilateral hearing loss valued several components of care, they indicated a clear preference for speech-language support compared with support for amplification use.

Parent Report of Amplification Use in Children with Mild Bilateral or Unilateral Hearing Loss.

BACKGROUND: Amplification is considered to be one of the most important interventions for children with hearing loss. However, achieving consistent use of hearing technology in young children is an important problem, particularly when hearing loss is of mild degree. Little information is available about amplification use specifically for children with mild bilateral or unilateral hearing loss when such losses are targeted and identified early because of the availability of newborn hearing screening. PURPOSE: We examined amplification use in a contemporary cohort of early-identified children with mild bilateral and unilateral hearing loss. RESEARCH DESIGN: As part of the Mild and Unilateral Hearing Loss in Children Study, we collected parent reports on their child's use of amplification during the preschool years. STUDY SAMPLE: A total of 69 children (38 unilateral and 31 bilateral mild) enrolled in the study from 2010 to 2015. Children entered the study at various ages between 12 and 36 mo of age and were followed up to age 48 mo. The median age of the children at enrollment was 16.5 mo (interquartile range [IQR] = 9.5, 26.8). Hearing loss was confirmed in these children at a median age of 3.6 mo (IQR = 2.4, 5.7). DATA COLLECTION AND ANALYSIS: Baseline characteristics related to the child and family were collected through an intake form at study enrollment. Data on amplification fitting and use were collected via parent questionnaires at each assessment interval. Information from parent questionnaires was summarized descriptively and amplification use was grouped into categories. Through logistic regression, we examined the relationship between amplification use and laterality of hearing loss, sex, and maternal education. RESULTS: Amplification was recommended for 59 (85.5%) children at a median age of 6.5 mo (IQR = 3.6, 21.2) and children were fitted at a median age of 10.9 mo (IQR = 6.0, 22.1). Based on parent report, hearing aid use was consistent for 39 (66.1%) of 59 children who had amplification recommended. Parent questionnaires showed very little change in use for most of the children over the study period. More children with bilateral hearing loss used their amplification consistently than those with unilateral hearing loss. After adjusting for maternal education and sex of the child, the odds for consistent use in children with mild bilateral loss was almost seven times higher (odds ratio = 6.75; 95% confidence interval = 1.84, 24.8) than for those with unilateral loss. CONCLUSIONS: Although 85.5% of children with mild bilateral or unilateral hearing loss received amplification recommendations, only two-thirds achieved consistent use by age 3-4 yr based on parent report. Children with mild bilateral loss were more likely to use amplification during the preschool years than those with unilateral loss.

Children With Mild Bilateral and Unilateral Hearing Loss: Parents' Reflections on Experiences and Outcomes.

Children with mild bilateral and unilateral hearing loss are now commonly identified early through newborn hearing screening initiatives. There remains considerable uncertainty about how to support parents and about which services to provide for children with mild bilateral and unilateral hearing loss. The goal of this study was to learn about parents' experiences and understand, from their perspectives, the impact of hearing loss in the mild range on the child's functioning. Parents of 20 children in Ontario, Canada, participated in the study. The median age of identification of hearing loss was 4.6 months (interquartile range: 3.6, 10.8). Parents appreciated learning early about hearing loss, but their experiences with the early process were mixed. Parents felt that professionals minimized the importance of milder hearing loss. There was substantial uncertainty about the need for hearing aids and the findings suggest that parents need specific guidance. Parents expressed concerns about the potential impact of hearing loss on their child's development, particularly at later ages.

Communication Development in Early-Identified Children With Mild Bilateral and Unilateral Hearing Loss.

PURPOSE: This clinical focus article provides preliminary findings from a multicenter longitudinal study investigating auditory and communication development in children with mild bilateral or unilateral hearing loss of any degree. METHOD: A total of 100 children (55 with mild bilateral or unilateral hearing loss and 45 with normal hearing) underwent 1 or more assessments from a battery of auditory and language measures. RESULTS: Children up to age 4 years demonstrated auditory and language skills similar to those of children with normal hearing. CONCLUSIONS: Factors that affect outcomes in communication development will be explored as additional data are collected in this ongoing study.

Mild bilateral and unilateral hearing loss in childhood: a 20-year view of hearing characteristics, and audiologic practices before and after newborn hearing screening.

OBJECTIVES: There is some evidence that the presence of even mild degrees of hearing loss and unilateral loss in early childhood can negatively affect typical development. Consequently, the identification of all children with permanent hearing loss including those with milder degrees of hearing loss is currently targeted through some newborn hearing screening initiatives. The objectives of this study were to document the proportion of children identified with mild bilateral or unilateral hearing loss (MBUHL) before and after the implementation of a universal newborn hearing screening program (UNHS). A second objective was to examine the clinical characteristics and audiologic management of this population of children. DESIGN: This population-based study involved an analysis of data on children with hearing loss; these data had been collected prospectively over a 20-year period from 1990 to 2010 in a publicly funded pediatric teaching hospital in Canada, which provided diagnostic audiology services for all children in the region. The proportion of all children with hearing loss identified with MBUHL before and after implementation of UNHS and their clinical profiles were documented. Data related to amplification use were also retrospectively extracted from detailed medical chart reviews to investigate clinical recommendations regarding amplification and subsequent use of hearing devices. Factors affecting amplification decisions and amplification use were examined. RESULTS: A total of 381 of 823 children (46.3%) aged 0 to 18 years who were identified with permanent nonacquired hearing loss presented with MBUHL. The proportions identified were similar in the pre- and post-UNHS periods (p = 0.207). Before UNHS children were identified at a median age of 5.0 years (interquartile range: 3.6 to 7.0) compared with a median of 0.8 years, (interquartile range: 0.3 to 2.3) post-UNHS. Progression of hearing loss was documented for 22% of all children, and for the group identified since UNHS, 32.4% experienced deterioration in hearing thresholds. Although 87.2 % of children received recommendations for amplification, more than 50% experienced considerable delay from identification to amplification. Age at identification and severity of hearing loss in the better ear were associated with amplification decisions for bilateral but not unilateral loss. CONCLUSIONS: MBUHL constitutes almost half of childhood hearing loss. UNHS has lowered age of confirmation of MBUHL by 4 to 5 years. Delay to amplification suggests uncertainty of the benefit of intervening early for these losses. Further research is required to determine the effects of early-identified MBUHL on children's development and to document the benefits of early amplification.

Comparison of outcomes in children with hearing aids and cochlear implants.

OBJECTIVES: The purpose of this study was to document the performance of a group of children with moderately severe to severe hearing loss who use hearing aids on a range of speech recognition, speech-language, and literacy measures and to compare these results to children with severe to profound hearing loss, who have learned language through cochlear implants. METHODS: This study involved 41 children with bilateral sensorineural hearing impairment, aged 6-18 years. Twenty children had moderately severe/severe hearing loss and used hearing aids, and 21 had severe to profound hearing loss and used cochlear implants. Communication and academic skills were assessed using speech recognition tests and standardized measures of speech production, language, phonology, and literacy. RESULTS: The two groups did not differ in their open-set speech recognition abilities or speech production skills. However, children with hearing aids obtained higher scores than their peers with cochlear implants in the domains of receptive vocabulary, language, phonological memory, and reading comprehension. The findings also indicate that children with moderately severe or severe hearing loss can develop spoken language skills that are within the range expected for normal hearing children. CONCLUSIONS: School-aged children with moderately severe and severe hearing loss performed better in several domains than their peers with profound hearing loss who received cochlear implants between age 2 and 5 years. Further research is required to evaluate the benefits of hearing aids and cochlear implants in children with hearing loss who are diagnosed and receive intervention within the first year of life.

A descriptive analysis of language and speech skills in 4- to 5-yr-old children with hearing loss.

OBJECTIVE: Early intervention through hearing aids (HAs) and cochlear implants (CIs) aims to reduce the negative effects of childhood hearing loss and to promote optimal communication development over time. The primary goal of this study was to examine the communication outcomes of children with CIs and children with HAs at age 4 to 5 yrs and to consider their spoken language skills relative to a group of typically developing hearing peers. DESIGN: In this multicenter observational study, communication results were obtained for a total of 88 children at age 4 to 5 yrs. Participants were recruited from three clinical programs in two cities in the province of Ontario, Canada. This study was undertaken shortly after the introduction of a new provincial population screening initiative and included both children who were screened and not screened for hearing loss. The study sample comprised 51 children with sensorineural hearing loss and 37 children with normal hearing. Of the 51 children with hearing loss, 26 used CIs and 25 used HAs. The degree of hearing loss ranged from mild to profound. All children were enrolled in rehabilitation programs focused on oral language development. Children's language skills were assessed with an extensive battery of child- and parent-administered speech and language measures. RESULTS: Assessment of language skills showed no significant differences between the children with severe to profound hearing loss using CIs and children with varying degrees of hearing loss using HAs. However, children with HAs showed better articulation skills. Overall, both groups of children obtained scores on communication measures that were lower than their hearing peers. The number of children with hearing loss who obtained spoken speech-language scores within 1 SD of normative populations ranged from 65 to 86% depending on the test measure. Children with average hearing loss of 70 dB HL or better generally obtained scores on all measures in line with those of age-matched norms while scores were quite variable for children with severe and profound hearing loss. Factors influencing performance in children with hearing loss included degree of hearing loss (pure-tone average) and parent education. Age at diagnosis of hearing loss was not a significant predictor of speech-language outcomes in this study. CONCLUSIONS: Results indicated that overall, children with all degrees of hearing loss who were fit with hearing technology and who received auditory-based rehabilitation services during the preschool years demonstrated the potential to develop spoken language communication skills. As a group, children with CIs and children with HAs did not differ significantly on language abilities although there were differences in articulation skills. Their performance at age 4 to 5 yrs was delayed compared with a group of hearing peers. The findings reinforce the need for research to identify factors that are likely to lead to age-appropriate communication skills for preschool-age children with hearing loss.

Clinical practice for children with mild bilateral and unilateral hearing loss.

OBJECTIVE: Historically, children with mild bilateral and unilateral hearing loss have been reported to experience difficulties related to language and academic functioning. In the context of Universal Newborn Hearing Screening, there is an increasing focus on determining optimal clinical interventions for this population of children. The objectives of this study were to determine the prevalence of mild bilateral or unilateral hearing loss identified in a clinical population from 1990 to 2006 and to document clinical practices related to recommendations and uptake of amplification. DESIGN: This population-based study consisted of a detailed retrospective chart review of all children identified with mild bilateral or unilateral hearing loss in a Canadian pediatric center between 1990 and 2006. Hearing loss and patient characteristics were extracted to describe the clinical population. Amplification recommendations and uptake of amplification were documented. Clinical decisions regarding amplification practices were explored as a function of age of identification and severity of hearing loss. RESULTS: A total of 670 children were identified with permanent hearing loss during the 16-yr study period, of which 291 were presented with a mild bilateral or unilateral hearing loss. Detailed reviews of the 255 available medical charts showed that at diagnosis, 178 children presented with mild bilateral, 31 with mild bilateral high frequency, and 46 with unilateral hearing loss. Eighty percent of children had been referred through conventional medical processes before the implementation of universal hearing screening and 20% had been exposed to screening. The average age of identification for the entire group was 54.2 mos (interquartile range, 30.1 to 76.9 mos). Amplification was prescribed for 91.4% of children but there was considerable delay from confirmation of hearing loss to amplification for both children identified with and without screening. Overall, 54.1% received an initial recommendation for amplification and a further 37.3% received a recommendation more than 3 mos after hearing loss confirmation. Practice patterns varied according to category of hearing loss with 60.1% of children with mild bilateral hearing loss receiving an initial recommendation compared with 26.1% of those with unilateral hearing loss. Clinical decision making relative to amplification needs was also changed during the course of audiologic care. The decision to amplify was significantly related to age at identification and degree of hearing loss in the mild bilateral group but not in the unilateral group. Although, more than 90% of children received a recommendation for amplification, chart documentation revealed that less than two thirds of children consistently used their amplification devices. Use of amplification did not vary among children with mild bilateral, mild bilateral high frequency, and unilateral hearing loss. CONCLUSIONS: : This research suggests that there is considerable uncertainty related to clinical recommendations of intervention for this population of children. The impact of parental indecision regarding the benefits of amplification is unknown. Further studies are required to document the potential benefits and factors affecting amplification recommendations and use in the current practice environment where children with mild bilateral or unilateral hearing loss are identified early through newborn hearing screening.

Bilateral paediatric cochlear implants: a critical review.

A recent trend has been the implantation of bilateral cochlear implants (CIs) for children with severe to profound hearing loss. A review of available research on bilateral CIs was conducted to determine the support for this trend. A replicable review was undertaken to evaluate published research studies that examined the effectiveness of bilateral paediatric cochlear implantation. Databases, reference lists, and journals were searched for relevant documents using a pre-determined search protocol. Twenty-nine articles met the review's inclusion criteria and were retrieved and reviewed. This review adds to the previously published reviews on the topic by identifying additional paediatric studies. Sound localization and speech recognition in noise appear to be improved with bilateral compared to unilateral cochlear implants. Similarly, evoked potential measures suggest improved morphology when the second CI is implanted early. Well-designed and controlled studies that explore a variety of outcomes including cost-effectiveness, quality of life, speech, language, and psycho-educational measures should be further explored in order to provide additional support for parents and clinicians confronted with the bilateral cochlear implant decision.

Pediatric cochlear implantation: how much hearing is too much?

Audiologic candidacy criteria for determining cochlear implantation candidacy in children are evolving. The objective of the study was to examine clinical practice related to the cochlear implantation of children who typically do not meet audiologic criteria for this technology. Practitioners' perspectives on the process and the factors influencing candidacy decisions were explored through focus group interviews with hospital and school-based practitioners. The interviews were analysed using qualitative techniques to identify key issues. The findings from the interviews informed a questionnaire which was sent to all cochlear implant centers in Canada to further examine clinician views and experiences with this special population. Responses were collected from 11 of the 12 centers and indicated that children with hearing outside typical criteria were receiving implants. The definition of 'borderline' varied across the programs from approximately 70 dB HL to less than 90 dB HL. All centers emphasized the importance of considering factors beyond the child's audiometric thresholds in candidacy decision-making.

Parents' needs following identification of childhood hearing loss.

PURPOSE: Appropriate support for families of children diagnosed with hearing impairment may have a direct impact on the success of early hearing detection and intervention programs in reducing the negative effects of permanent hearing loss. We conducted a qualitative study to explore parents' needs after learning of their child's hearing loss to better understand the important components of service delivery from families' perspectives. METHOD: Semistructured interviews were conducted with 17 families (21 parents) of preschool children in 4 centers in Ontario, Canada. Parents of children identified by neonatal screening as well as those identified through traditional referral routes participated. We asked parents to share their perceptions of the strengths and gaps in the care system. RESULTS: Although the majority of parents were satisfied with the range and quality of audiology and therapy services available, they identified gaps in the areas of service coordination, availability of information, and the integration of social service and parent support into the system. Access to audiology services appears to have been facilitated for children who were systematically screened. CONCLUSIONS: The findings provide insights into the services most valued by families. These findings highlight the importance of eliciting parents' perspectives in designing optimal care models for children and families.

Parents' preferences for services for children with hearing loss: a conjoint analysis study.

OBJECTIVE: Early identification of permanent childhood hearing loss through universal newborn hearing screening is rapidly becoming a standard of care. However, it is well recognized that hearing screening must be embedded within a comprehensive system of rehabilitation and parent support services. This study was undertaken with parents of young children with permanent hearing loss to examine their preferences for characteristics associated with intervention services. A secondary goal was to explore whether preferences may differ according to patient subgroups. DESIGN: Conjoint analysis, a preference-based economic technique, was used to investigate parents' strength of preferences. A cross-sectional survey that consisted of hypothetical clinic scenarios was developed based on information from qualitative interviews with parents. The questionnaire was administered to parents receiving intervention services in the province of Ontario, Canada, shortly after the implementation of a universal hearing screening program. The sample was recruited from three different clinical programs. RESULTS: A total of 48 of 75 respondents completed the questionnaire, a response rate of 64%. The participants varied by screening status of the child (25 screened, 23 not screened), type of device (23 hearing aids, 25 cochlear implants), and region. All five characteristics of care that were selected for inclusion in the survey were found to be statistically significant attributes of services: coordinated services, access to parent support, access to information, frequency of services, and location of services. Parents showed a preference for clinic-based rather than home-based services. Preferences toward once a week therapy services rather than services two to three times weekly were also found. In particular, parents valued service models that consisted of well-coordinated care with access to support from other parents. Differences in respondents according to hearing screening status (screened or unscreened), type of hearing device (hearing aid or cochlear implant), or region (Ottawa or Toronto) did not seem to affect parents' preferences for attributes of care. CONCLUSIONS: Conjoint analysis is a useful technique for quantifying parents' preferences for care. The values expressed by parents provide insights into the aspects of a service model that should receive consideration in the development of programs for young children with hearing loss and their families.

The impact of newborn hearing screening on communication development.

OBJECTIVE: Universal newborn hearing screening has become standard practice in many countries. The primary goal of this study was to assess the impact of early identification of permanent childhood hearing loss on oral communication development. SETTING: Participants were recruited from three clinical programmes in two cities in the province of Ontario, Canada. The study sample was born during two consecutive periods of newborn hearing screening. The first period, prior to 2002, was targeted on high-risk infants only, and the second, from 2002, included both high- and standard-risk infants (universal newborn hearing screening - UNHS). All children were enrolled in rehabilitation programmes focused on oral language development. METHODS: In this multicentre observational study, 65 children under the age of five years with onset of hearing loss before six months of age, 26 identified through systematic newborn screening (14 through targeted screening and 12 through UNHS) and 39 without screening, were assessed with an extensive battery of child- and parent-administered speech and language measures. The degree of hearing loss ranged from mild to profound with 22 children in the mild, moderate and moderately severe categories and 43 in the severe and profound categories. Data are reported for the three-year study period. RESULTS: The screened group of children was identified at a median age of 6.6 (interquartile range, 3.0-8.2) months and children referred from sources other than newborn screening were diagnosed at a median age of 16.5 (interquartile range, 10.2-29.0) months. Assessment of oral communication development showed no significant difference between the screened and unscreened groups. The communication outcomes for children identified before 12 months of age did not differ from those of later identified children. CONCLUSIONS: Systematic screening of newborn hearing results in earlier identification and intervention for children with permanent hearing loss. Superior language outcome following newborn screening was not demonstrable in the setting of this study.

Parents' perspectives on the impact of the early diagnosis of childhood hearing loss.

Newborn hearing screening has been widely implemented to improve outcomes for children with permanent hearing loss. This study examined benefits beyond those typically measured clinically, by exploring parents' perceptions of the effects of early/late identification of hearing loss. The parents of 17 children in Ontario, Canada, participated in the study. Seven children were identified through systematic screening and ten through traditional referral practices. All children were in oral rehabilitation programs. The study adopted a qualitative approach, examining parent's views through individual interviews. Purposive sampling was used to select a diverse group of parents to allow a broad range of perspectives to emerge. Benefits of early identification included improved communication development and early access to hearing. Negative aspects of late identification included regret for the family and family stress around the child's language gap. Although, screening programs may offer a seamless transition to audiology services, the transition to intervention services appeared less fluid for some families. Overall, parents strongly support infant hearing screening and identify benefits that are not easily quantifiable through traditional clinical measures.

Fitting audiology within the population health perspective.

The population health perspective has become increasingly apparent in the medical, public health, and policy literature. This article emphasizes the value of applying the population health perspective and associated frameworks to the rehabilitative sciences and particularly to the field of audiology. Key components of the population health perspective--including the determinants of health, the importance of evidence-based practice, and the value of transdisciplinarity--are used to illustrate the relevance of population health to the field of audiology. Using these key concepts from a population health framework and examples from audiology, the adoption of a population health perspective is proposed.