Promoting Early Identification and Intervention for Children who are Deaf/Hard of Hearing,
Children with Vision Impairment, and Children with Deaf-Blind Conditions
These documents were developed by the Ohio Center for Deafblind Education to support Early
Intervention providers’ effective recognition of and provision of support to children with hearing
loss, children with vision loss, and children who are deaf-blind. These documents are intended
to supplement current processes within Help Me Grow and can be used to systematically
ensure children receive the specialized services when appropriate and that team members are
aware of the child’s needs related to hearing and/or vision.
Early Intervention (EI) providers can play a critical role in the identification of hearing and vision
difficulties in young children, thus allowing access services and improving child and family
outcomes.
By the very nature of having a developmental concern, children enrolled within Part C
Programming (Early Intervention services) are at higher risk for having a hearing loss or vision
loss. This is likely related to the fact that risk factors which can contribute to developmental
delay (such as prematurity, congenital infections, and certain genetic syndromes) may also put
children at risk for hearing loss and/or vision loss. Hearing loss and vision impairment can
impact various domains of development. Children with hearing loss and vision loss have unique
needs and require adaptations to intervention strategies. There are higher rates of
developmental delays in children who are deaf/hard of hearing (approximately 40%)1-3 and in
children with vision impairment (up to 66%)4-7.
Furthermore, some children have both hearing loss and vision loss (deaf-blind) which further
complicate intervention strategies. These children benefit from early specialized services.
Individuals with Disability Education Act (IDEA)8 specifically defines Deaf-blindness as
“concomitant hearing and visual impairments, the combination of which causes such severe
communication and other developmental and educational needs that they cannot be
accommodated in special education programs solely for children with deafness or children with
blindness”. However, the diagnosis of these concerns, whether for vision or hearing, or the
recognition that both are occurring can be delayed due to a number of barriers9-12. The goal of
these tools is to decrease the age of identification of hearing and vision impairments thus
improving access to appropriate interventions to help children meet their potential.
Overall best practices:
 Recognition is the first step towards accessing specialized services.
 Integration of expertise within the context of services is essential for optimal outcomes
for children.
 When transitioning to Part B programming, children with hearing loss, vision loss and
children who are deaf-blind, it is essential for the EI team to describe the impact of
specialized services for the child’s needs which impact the educational setting.
 A strengths based approach is essential.
Deaf/HH best practices
Definition: Based on the Ohio Department of Education13: "Deafness" means a hearing
impairment that is so severe that the child is impaired in processing linguistic information
through hearing, with or without amplification that adversely affects a child's educational
performance and "Hearing impairment" means an impairment in hearing, whether permanent or
Wiley S, Parnell L, Belhorn, T. “Promoting Early Identification and Intervention for Children who are Deaf/Hard of
Hearing, Children with Vision Impairment, and Children with DeafBlind Conditions” The Journal of Early Hearing
Detection and Intervention 2016 (in press)
fluctuating, that adversely affects a child’s educational performance but that is not included
under the definition of deafness in this rule.
Early Identification:
 Early identification and intervention is associated with improved language, socialemotional, and academic outcomes14-18.
 Universal Newborn Hearing Screening programs do not identify all children with hearing
loss (due to screening equipment thresholds and the possibility of late-onset or
progressive hearing loss). Therefore, a high level of suspicion is important to identify
hearing loss in all children19. Resources for accessing audiology services include:
o Ohio Department of Health Audiology Directory
http://www.helpmegrow.ohio.gov/~/media/HelpMeGrow/ASSETS/Files/Professio
nals%20Gallery/Infant%20Hearing/Infant%20Hearing%20Resources/Pediatric%2
0Audiology%20Facilities%20Directory%202014%20County%20Listings.pdf
o National resource: Early Hearing Detection & Intervention - Pediatric Audiology
Links to Services (EHDI-PALS) http://ehdipals.org/
 Infants and children of any age or developmental abilities can have their hearing
evaluated by audiologists knowledgeable in pediatric hearing.
 Children with an identified hearing loss should be reported to the Ohio Department of
Health at any time during their enrollment in Early Intervention20.
 Children who are identified with a hearing loss should have their vision evaluated by an
ophthalmologist knowledgeable in pediatrics19.
Early Intervention:
 Permanent hearing loss of any degree or type is an established condition which
automatically implies eligibility for Help Me Grow Services in Ohio20.
 Within Ohio, the Regional Infant Hearing Program22 provides specialized services and
should be included on the IFSP of all children with known hearing loss20.
 Best practices for intervention for children who are Deaf/Hard of Hearing have been
established by the Joint Committee on Infant Hearing22.
VI best practices
Definition: Based on the Ohio Department of Education13
(http://cisam.ossb.oh.gov/VIGuidance.php) “Visual impairment” including blindness means an
impairment in vision that, even with correction, adversely affects a child’s educational
performance.
a. The term visual impairment includes both partial sight and blindness.
b. The term visual impairment does not include a disorder in one or more of the basic
psychological processes, such as perceptual disabilities, brain injury, minimal brain dysfunction,
dyslexia and developmental aphasia. 3301-51-01 (B)(10)(d)(xiii)
Early Identification:
 Recognizing risk factors and visual behaviors in young children can improve early
identification of vision impairment23.
 A child’s ophthalmological report will provide the foundation for understanding the child’s
underlying vision concerns. Children with cortical vision impairment have a brain-based
reason for their vision difficulties (with a normal eye exam). This sometimes requires a
neurologist or ophthalmologist with specific expertise in this type of vision impairment to
recognize and identify the vision loss.
Wiley S, Parnell L, Belhorn, T. “Promoting Early Identification and Intervention for Children who are Deaf/Hard of
Hearing, Children with Vision Impairment, and Children with DeafBlind Conditions” The Journal of Early Hearing
Detection and Intervention 2016 (in press)


A functional vision assessment is essential and can guide interventions to account for
the child’s visual skills.
Children with vision impairment should have an evaluation of hearing as a hearing loss
would impact access to information and alter intervention strategies
Early Intervention:
 Vision loss is an established condition which automatically implies eligibility for Help Me
Grow Services in Ohio20.
 Specialized services are important to guide a child’s programming8.
 While vision services (vision specialists, orientation and mobility) are somewhat limited
across the state, it is important to link children with service providers closest to the
family’s home. School districts may also be aware of services for the family’s
geographic location.
Deaf Blind best practices
Definition: The definition of “deaf-blind” includes children of any degree or type of hearing loss
and any degree or type of vision impairment. A child does not have to be totally deaf and totally
blind to receive this educational category.
By the Ohio Department of Education13, the definition of “Deaf-blindness" means concomitant
hearing and visual impairments, the combination of which causes such severe communication
and other developmental and educational needs that they cannot be accommodated in special
education programs solely for children with deafness or children with blindness.
Early Identification:
 Early identification of children who are deaf-blind can allow families and intervention
specialists to develop appropriate team support for needs and access therapeutic specialists
to address both developmental and educational needs.
 Reporting children who are deaf/blind to the Ohio Deafblind Center for Education’s census24
allows continued national and state support and assistance for children with this low
incidence condition as well as provides a mechanism to initiate technical assistance and
supports for the families and early intervention providers.
Early Intervention:
 Children who are deaf-blind are considered as having an established condition which
automatically implies eligibility for Help Me Grow Services in Ohio21.
 The integration of specialized hearing and vision services are important to guide a child’s
programming.
 Accessing technical assistance from the Ohio Deafblind Center for Education25 can
facilitate a team approach to a child’s needs.
 When transitioning to Part B programming, children with hearing loss, vision loss and
children who are deaf-blind, it is essential for the EI team to describe the impact of
specialized services for the child’s needs which impact the educational setting8.
Wiley S, Parnell L, Belhorn, T. “Promoting Early Identification and Intervention for Children who are Deaf/Hard of
Hearing, Children with Vision Impairment, and Children with DeafBlind Conditions” The Journal of Early Hearing
Detection and Intervention 2016 (in press)
Risk factors and behaviors suggesting a possible vision and/or hearing concerns
in young and school-aged children
Child with Risk Factors for
Vision Impairment:
Low birth weight (<3 pounds)
Cerebral palsy
Head Trauma
Hearing Loss*
Hydrocephalus/Shunt
Meningitis/Encephalitis
Congenital infections (such as CMV)
Retinopathy of Prematurity
Seizures
Syndrome associated with vision concerns
Delayed motor milestones
Child has concerning vision behaviors:
Any time:
Does not look at faces, give eye contact
Rubs eyes
Squints/closes eyes/cries, turns away from bright
lights
Tilts/turns head to look
If not occurring by 3 months of age
Does not notice objects above or below the head
Notices objects only on one side
Does not notice objects above or below head
If not occurring by 5-6 months of age
Doesn’t visually follow moving objects
Doesn’t reach for objects
Over or under-reaches for objects
Seems unaware of self in mirror
Seems unaware of distant objects
Older Ages
Covers or closes one eye when looking
Does not look at pictures in books
Holds books or objects close to eyes
Stops and steps/crawls over changes in floor texture
or color
Trips over/bumps into things in path
Child has notable eye concerns:
Child with Risk Factors for Hearing Loss
Speech/Language Delay
Parental concern about hearing
Family History of Hearing Loss
Prematurity/NICU > 5 days
Congenital Infection (such as CMV)
Bacterial meningitis
Craniofacial abnormalities
Syndromes associated with hearing loss
Ototoxic medications (gentamycin, lasix,
chemotherapy)
Head Trauma
Child has concerning
listening/speaking:
Does not look attend to voices, sounds (all children
with autism spectrum disorder should have a
definitive hearing evaluation)
Asks “what” or “huh” a lot
Asking for people to repeat what they have said
Talking too softly or too loudly
Favoring one ear/turning one ear to a speaker or the
TV
Difficulty localizing sounds (i.e. calling the child from
another room and the child not knowing where to
look)
Having to face the person talking to understand what
is being said
Speech delay
Language delay
Articulation problems which are not improving
Concerns about behavioral compliance
Distractibility
Child has notable physical concerns:
Child has a known vision impairment
Frequent ear infections
Child has a cleft lip/palate
Child has skin tags or pits in the front of the ear
Shape of ear is abnormal
White patches of skin or white patches of hair
Kidney problems
Heart problems
Child has a known hearing loss
Far-away look in eyes
Cloudy or milky appearance of eyes
Droopy eye lid(s) (ptosis)
Jerky or wiggling eyes (nystagmus)
Random eye movements
Squinting, excessive blinking
Unequal
pupil
Wiley
S, Parnell
L,size
Belhorn, T. “Promoting Early Identification and Intervention for Children who are Deaf/Hard of
Watery,
red, irritated
eyesImpairment,
or eyelids and Children with DeafBlind Conditions” The Journal of Early Hearing
Hearing,
Children
with Vision
Detection and Intervention 2016 (in press)
Next Steps if a child has concerns about vision or hearing
Provider/Parental Concerns of
Vision (based on observations,
interview or ASQ results,
presence of risk factors, failed
vision screen)
Provider/Parental Concerns of
Hearing Loss (based on
observations, interview or ASQ
results, presence of risk factors,
failed hearing screen)
Discuss with family, team,
implement appropriate
referrals for
comprehensive eye exam
by ophthalmologist
knowledgeable in pediatric
vision concerns
Discuss with family, team,
implement appropriate
referrals for
comprehensive hearing
evaluation by pediatric
audiologist
Obtain and review
ophthalmological report
Obtain and review
audiology report
Medically Identified Vision
Impairment
(based on confirmatory
ophthalmology evaluation)
Medically Identified Hearing
Loss
(based on confirmatory audiology
evaluation)
Proceed with steps to determine
educational impact and services
(next page)
Proceed with steps to determine
educational impact and services
(next page)
Vision is normal or correctible
with glasses
Hearing is normal
Monitor for vision, hearing concerns, changes
Wiley S, Parnell L, Belhorn, T. “Promoting Early Identification and Intervention for Children who are Deaf/Hard of
Hearing, Children with Vision Impairment, and Children with DeafBlind Conditions” The Journal of Early Hearing
Detection and Intervention 2016 (in press)
What to do for children with known
vision impairment and/or hearing loss
Essential steps for children with
confirmed vision impairment impacting
educational needs
Essential steps for children with
confirmed hearing loss impacting
educational needs
Obtain Ophthalmology report
and recommendations
Obtain Audiology report and
recommendations
Obtain Functional Vision
Assessment (to understand
impact on educational needs and
strategies to employ
educationally)
Obtain Functional Listening
Evaluation
Add appropriate Hearing
Services and accommodations
to IFSP/IEP (i.e. Educational
Audiology, Teacher of the
Deaf/HH, communication needs)
Add appropriate Vision Services
(i.e. VI, O&M) and
accommodations to IFSP/IEP
Communicate to all team
members, vision accommodations
needed
Provide
resources
for FamilyFamily
Support
Communicate to all team
members, hearing
accommodations needed
Monitor for changes in hearing
Monitor for changes in vision
Ensure Part C and Part B
References:
programming includes needs
related to vision on
IFSP/IEP/transition plan
Ensure Part C and Part B
programming includes needs
related to hearing on
IFSP/IEP/transition plan
Evaluate and monitor for hearing
loss (hearing screening results,
audiology report)
Evaluate and monitor for vision
loss (ophthalmology evaluation)
If DeafBlind
Refer to State Center for
Deafblind Education if identified
with hearing loss of any degree
(unilateral or bilateral)
Refer to StateCenter for
Deafblind Education if identified
with vision loss in addition to
hearing loss
Consider DeafBlind as
appropriate educational category
Monitor for changes in hearing
Monitor
forwho
changes
in vision
Wiley S, Parnell L, Belhorn, T. “Promoting Early Identification and Intervention
for Children
are Deaf/Hard
of
Hearing, Children with Vision Impairment, and Children with DeafBlind Conditions” The Journal of Early Hearing
Detection and Intervention 2016 (in press)
National and State Resources
Resource
Description
Ohio Center for DeafBlind Education
Providing services in Ohio for individuals birth
through 21 years with deafblindness including free
collaborative technical assistance to families,
education personnel and service providers through
training and information dissemination
National technical assistance center funded by the
federal Department of Education. NCDB includes
several national initiatives, as well as a diverse library
of resources and information for families and
professionals. Resources also available in Spanish.
National association with large network of families
focusing on Deaf-Blind issues. Provides opportunities
to connect with other families, and well as online
learning, resources, and shared stories.
Basic information, and a collection of resources
including state specific for deaf-blind children
The Center for Instructional Supports and Accessible
Materials (CISAM) is a statewide project serving
students with print disabilities, including students
who are blind and visually impaired.
Campaign by the National Deaf-Blind Equipment
Distribution Program. Provides technology, training,
and resources to individuals who qualify.
Program offering in-home support, as well as a
resource manual for families with infants, toddlers
and pre-schoolers, age birth to five, with sensory
impairments and additional disabilities.
School for the blind with expertise in serving children
who are DeafBlind, library of webinairs and resources
Foundation committed to ensuring individuals with
vision impairments have equal access and
opportunities.
A checklist for parents and professionals to help
identify children who need referral for possible vision
problems
National Center on DeafBlindness
National Family Association for
DeafBlind
Center for Parent Information and
Resources, DeafBlindness
Ohio School for the Blind Center for
Instructional Supports and Accessible
Materials
iCanConnect
Ski-HI Institute IN-home Sensory
Impaired Training and Education
Perkins School for the Blind
American Foundation for the Blind
Taking a Look Checklist: A First Step
in Vision Assessment for Ohio’s
Infants and Toddlers
Regional Infant Hearing Programs
State Early Intervention Program in Ohio serving
children birth to three with permanent hearing loss of
any type and degree.
Early Hearing Detection &
Intervention - Pediatric Audiology
Links to Services (EHDI-PALS)
Information, resources, and services directory for
finding audiology services for children with hearing
loss
Hands and Voices
Parent-driven support organization for families of
children with hearing loss, providing unbiased
support and information regarding all methods of
communication.
URL
www.ohiodeafblind.org/
https://nationaldb.org
http://nfadb.org/
www.parentcenterhub.org/reposi
tory/deafblindness/
http://cisam.ossb.oh.gov/
www.icanconnect.org/
http://skihi.org/INSITE.html
www.perkins.org/
www.afb.org
https://www.google.com/search?
q=taking+a+look+checklist+ohi
o&ie=utf-8&oe=utf-8
www.odh.ohio.gov/~/media/Hel
pMeGrow/ASSETS/Files/Profes
sionals%20Gallery/Infant%20He
aring/RHIP%20MAPS/FY14%2
0RIHP%20mapcontact%202013
2014.ashx
http://ehdipals.org/
www.handsandvoices.org/
OhioChapter :
www.ohiohandsandvoices.org/
Wiley S, Parnell L, Belhorn, T. “Promoting Early Identification and Intervention for Children who are Deaf/Hard of
Hearing, Children with Vision Impairment, and Children with DeafBlind Conditions” The Journal of Early Hearing
Detection and Intervention 2016 (in press)
References:
1) Gallaudet Research Institute. Regional and National Summary Report of Data from the 2009-2010 Annual
Survey of Deaf and Hard of Hearing Children and Youth. 2011.
http://research.gallaudet.edu/Demographics/2010_National_Summary.pdf accessed 6/23/15.
2) Nikolopoulos TP, Lioumi D, Stamataki S, O’Donoghue GM. Evidence-based overview of ophthalmic disorders in
deaf children: a literature update. Otology and Neurotology 2006: 27:S1-24, discussion S0.
3) Szymanski, C. A., Brice, P. J., Lam, K. H., & Hotto, S. A. Deaf Children with Autism Spectrum Disorders. J
Autism Dev Disord, 2012 42(10), 2027-2037. doi: 10.1007/s10803-012-1452-9.
4) Hatton, DD, Bailey, DB, Burchinal, MR, Ferrell, KA. Developmental Growth Curves of Preschool Children with
Vision Impairments. Child Development 1997 68 (5) 788-806.
5) Rahi, JS, Cable,N and the British Childhood Visual Impairment Study Group Severe visual impairment and
blindness in children in the UK Lancet 2003; 362: 1359–65.
6) Mervis, CA, Boyle, CA and Yeargin-Allsopp, M. Prevalence and selected characteristics of childhood vision
impairment. Developmental Medicine & Child Neurology, 2002: 538-541.
7) Mervis, CA, Yeargin-Allsopp, M, Boyle, C Aetiology of childhood vision impairment Metropolitan Atlanta 19911993 Paediatric and Perinatal Epidemiology 2000 14, 70-77.
8) US department of Education, IDEA web-page
http://idea.ed.gov/explore/view/p/%2Croot%2Cregs%2C300%2CA%2C300%252E8%2C (accessed 6/23/15).
9) Liu, C,Farrell, J, MacNeil, JR, Stone, S, Barfield, W. Evaluating Loss to Follow-up in Newborn Hearing
Screening in Massachusetts Pediatrics 2008 121 (2) e1.
10) Chapman, DA, Stampfel, CC, Bodurtha, JN, Dodson, KM, Pandya, A, Lynch, KB, Kirby, RS. Impact of CoOccurring Birth Defects on the Timing of Newborn Hearing Screening and Diagnosis American Journal of
Audiology 2011: 20, 132-139.
11) Mark, H, Mark, T. Parental Reasons for Non-Response Following a Referral in School Vision Screening J of
School Health 1999: 69 (1) 35-38.
12) Williams, S, Wajda, BN, Alvi, R, McCauley,C, Sarah Martinez-Helfman, S, Levin, AV.
The challenges to ophthalmologic follow-up care in at-risk pediatric populations. J AAPOS 2013;17: 140-143.
13) Ohio Department of Education website http://education.ohio.gov/Topics/Special-Education/Federal-and-StateRequirements/Procedures-and-Guidance/Evaluation/Definition-of-a-Child-with-a-Disability (accessed 6/23/15).
14) Yoshinaga-Itano C, Sedey AL, Coulter DK, Mehl AL. Language of early- and later-identified children with
hearing loss. Pediatrics 1998 102(5): 1161-71.
15) Moeller, MP. Early intervention and language development in children who are deaf and hard of hearing.
Pediatrics 2000 106(3) e43.
16) Kennedy, CR, McCann, DC, Campbell, MJ, Law, CM, Mullee, M, Petrou, S, Watkin, P, Worsfold, S, Yuen, HM,
Stevenson, J. Language ability after early detection of permanent childhood hearing impairment. New England
Journal of Medicine 2006 18;354(20): 2131-41.
17) Vehaert, N, Willems, M, Van Kerschaver, E, Desloovere, C. Impact of early hearing screening and treatment
on language development and education level: evaluation of 6 years of universal newborn hearing screening
(ALGO) in Flanders, Belgium. International Journal of Pediatric Otorhinolaryngology 2008 72(5); 599-608.
18) Meinzen-Derr, J, Wiley, S, Choo, DI. Impact of early intervention on expressive and receptive language
development among young children with permanent hearing loss. American Annals of the Deaf 2011
155(5):580-91.
19) Joint Committee on Infant Hearing Year 2007 Position Statement: Principles and guidelines for early hearing
detection and intervention programs. Pediatrics 2007; 120:898-921.
20) Ohio Department of Health: Infant Hearing Resources: Ohio audiologists by County
Chapter 3701-8 Help Me Grow Program Rules and Regulations website: http://codes.ohio.gov/oac/3701-8
(accessed 6/23/15).
Appendix website: http://codes.ohio.gov/pdf/oh/admin/2015/3701-8-07_PH_FF_A_APP1_20140725_0811.pdf
(accessed 6/23/15).
21) Ohio Department of Health: Infant Hearing Resources, Regional Infant Hearing Programs
http://www.helpmegrow.ohio.gov/~/media/HelpMeGrow/ASSETS/Files/HMG%20Resources/Infant%20Hearing
%20Program/FY15%20RIHP%20mapcontact%2020142015.pdf (accessed 6/23/15).
22) Joint Committee on Infant Hearing: Supplement to the JCIH 2007 Position Statement: Principles and Guidelines
for Early Intervention After Confirmation That a Child Is Deaf or Hard of Hearing Pediatrics 2013 131(4) e1324 e1349.
23) Taking a Look Checklist: A First Step in Vision Assessment for Ohio’s Infants and Toddlers
http://infocenter.lys.org:8081/HMG%20Forms/Vision%20screening%20English.pdf (accessed 6/23/15).
24) The Ohio Center for Deafblind Education Census website: https://www.ohiodeafblind.org/census/register.cfm
(accessed 6/23/15).
25) The Ohio Center for Deafblind Education website http://ohiodeafblind.org/ (accessed 6/23/15).
Wiley S, Parnell L, Belhorn, T. “Promoting Early Identification and Intervention for Children who are Deaf/Hard of
Hearing, Children with Vision Impairment, and Children with DeafBlind Conditions” The Journal of Early Hearing
Detection and Intervention 2016 (in press)