Dr. Ross on Hearing Loss
Some Reflections on Early Childhood Deafness
by Mark Ross, Ph.D.
In preparing for this presentation, I couldn’t help but recall the number of similar symposiums I’ve either attended or presented at over the past forty years or so. Lots of them. Looking at the titles of the papers in this meeting, in some ways it looks like very little has changed over this period, that we seem to be covering the same ground over and over. Well, we are and we aren’t. Of course, early detection and management considerations still take center stage, as they should. What’s different now, in spite of the similarity in paper titles, is the confluence of new legislative mandates and technological advances that directly affect both detection and management. In other words, we not only know a lot more, but we are also required to do lots more. In the following pages, we’re going to be reading much about what we are now able to do, particularly in regards to newborn screening programs, outcome measures, amplification options, and the impact of the relatively new player in this game, cochlear implants. As we consider these new developments, I suggest that we keep in mind that in perhaps the most significant areas of all, very little has changed. What I’d like to do in these pages is reflect both on what I believe has changed since Dave Luterman, in whose honor this symposium was held, and I first entered this field and what has not. First, some comments on what hasn’t changed.
What hasn’t changed is the reaction of parents when they are first informed that their child is deaf. Parents still go through the stages of disbelief, denial, anger and grief that they’ve always gone through. For them, this is a one-time, unexpected event, the first time in history it has ever happened - because it happened to them. Few such parents have had any experience with deaf people. They know nothing about all the age-old controversies, all the choices that we’re going to be asking them to make. At this stage, what they have swirling around in their minds is the death of their initial dreams, their groping attempts to come to terms with what they perceive is a tragic reality, and their feelings of complete inadequacy to meet all the confusing and currently undefined challenges they are going to be required to face. What we have to do is help them understand that their child should still be a source of joy and satisfaction, whose future can still be as rich and fulfilling as any hearing child. This hasn’t changed.
What also hasn’t changed is the need for parents to share their feelings with other parents of children with hearing loss. We know that the emotional support that professionals can provide parents at this time is not nearly what parents can provide each other. While this need has always been with us, it was the exception more than the rule years ago for it to be recognized as a vital component of any management program for young hearing-impaired children. This is one area that has changed tremendously in the past forty years, in great part because of the work done by David Luterman. For all of this period, through his books, lectures, and clinical work, he has taught us to respect and trust the parents of the children we see in our clinics. If this emphasis seems obvious now, it is in large part because he, and a few other pioneers like him, have done their work so well.
The need for skilled professionals to work with the children and their parents also hasn’t changed. Such professionals still need specialized training and experience, beyond that offered in the typical Audiology, Speech-Language Pathology, or Education of the Deaf programs. Some of the responsibilities and roles between these three groups overlap and some are in dispute. There should be no dispute, however, regarding a competency base formulation, i.e. whoever takes on any role with young hearing-impaired children be the group that can demonstrate the appropriate background training. Clearly, however, the issue here is exactly how “appropriate” is defined. For example, as an audiologist, my definition of “appropriate” is going to be different from that of a teacher of the deaf who routinely advocates ASL as the first language for children with hearing loss. You would think that after all this time we should be able to reach some kind of consensus regarding the training, background, and skills of the professionals who work with young hearing-impaired children and their families. From what I see, it doesn’t look like we have reached this point yet.
Clinicians dealing with parents of hearing-impaired children still have to be able to relate to them in a sensitive, compassionate and honest manner. Can clinicians be trained to be both academically competent and humanly sensitive? I suspect the answer that Dave Luterman would give would be “yes”, given the fact that most people who elect to work with such children are somewhat self-selected to begin with. Nevertheless, no matter how knowledgeable, compassionate and experienced we may be, no matter how many deaf children we may have seen in our careers, the tendency to fall into a routine, management mode is a continuous battle. No child and his/her parents are “routine”; all require our respect as unique human beings. And while of course we must take pride and gain satisfaction from our work, at the same time we have to accept the humbling notion that this is not about us, but about parents and their children with hearing-impairment. No matter what our personal biases are – and we all have them to some extent – we still required to respect the authority of the parents in having the final say regarding the management of their child. Our role is to lay out, as objectively as we can, the various educational and communication options.
Even though the children we see in our clinics are younger than we’ve ever seen them before, the management issues they present are exactly the same as they were 40 years ago. We still have to ask why we are doing this? Why are we so focussed on early detection and early management. What do we hope to accomplish? What are our goals? These are not trivial questions. They embody an implicit assumption that an untreated hearing loss will have a profound impact on a child’s development, but that the usual consequences can be ameliorated with an early and effective management program. Essentially, we are denying the point of view that a profound hearing loss is a “normative” condition akin to ethnicity - else why provide such programs? Rather, what we are implying through our clinical efforts is that a hearing loss is a condition that society has a responsibility to address. Which leads me to my next point, which may appear to be simplistic, but isn’t really.
In every area where some sort of therapy is conducted, it is necessary that the clinician define the condition as precisely as possible. In this case, because we are working with children who have a hearing loss, we have to address the fundamental fact that this condition varies widely in a number of dimensions. It follows, therefore, that we need to know as much as we can about the type and configuration of the hearing loss because much of our therapeutic efforts are grounded on – or should be - on this information. Of course every child is unique with different personalities, aptitudes and possibilities. And of course, we must “tailor” our approach to an individual child; all this is understood. Too often, however, we seem to deal with such children as if they were a homogenous group in the one dimension that has brought them to our attention in the first place – the extent and nature of their hearing loss. Obviously, therefore, one major component of any early management program has to be a focus on maximizing the use of the residual hearing. Indeed, it’s my contention, that one of the most important capabilities a child brings to the therapy process is the extent of residual hearing she or he possesses.
Let’s pause for a moment to consider residual hearing. It is a term that I’ve used for many years, but recently was asked again to define it. We all know what a hearing loss is, and we are aware that a total hearing loss is a relatively rare occurrence. Residual hearing refers to what hearing remains rather than what is lost. It’s where we hope to package amplified sound to permit children as much access to the auditory channel as we can. It’s the range between a person’s thresholds and the highest level of sound pressure appropriate to deliver. I like the term because it has positive rather than negative implications, as it implies that the auditory channel is still capable of making some of its biological contribution to the welfare of the human being.
Although obviously the absence of residual hearing does not make anyone less a human being, or incapable of living a rich and fulfilling life - and I really do want to stress this point - the sense of hearing ordinarily does play a vital role to play in human development and interactions. When we think of audition, we most often think of the sensory basis for auditory-verbal language development – undoubtedly its most important function. Through many years of research and clinical experience, we know that even a little bit of residual hearing can contribute to communicative and linguistic development. What is less often appreciated, however, is that residual hearing can do more than foster performance in these communicative dimensions.
The auditory sense provides a channel to the brain that not only informs us about the world around us, but also enriches our overall perception of the world. By being immersed in a three-dimensional acoustic sphere, we are able, consciously or unconsciously, to adapt to and feel part of our immediate surroundings. We are able to identify potentially dangerous or significant unseen events because we can selectively “tune in” to the sound waves that surround us. Unlike our eyes, our ears are always “open” to receive stimuli and thus we are able to continuously monitor our surroundings through this auditory connection. Just because someone has a hearing loss does not mean that he or she need be deprived of all the non-linguistic contributions that audition can make. As long as a person possesses any residual hearing at all, some potentially significant sensory information from the auditory channel can still be obtained.
Some of us older folks may recall an auditory hierarchy concept first described by Ramsdell after World War II. After many experiences with newly deafened servicemen, he realized that many of their complaints transcended their apparent communication problems, but dealt with their inability to hear background sounds, sounds that previously they were not even consciously aware of. They would often complain that the world seemed “dead”. Ramsdell postulated that their reaction reflected the loss of the lowest level on the hierarchy, the primitive or background level of hearing. He believed that these background sounds served to psychologically “couple” people to the world around them. While people may not be consciously aware of sounds at this level, they are still present and still being processed by the brain. When some sound event emerges from this background, such as a shouting voice or an emergency vehicle siren, then it would be considered the second stage in his auditory hierarchy, the signaling or warning level of hearing. I like to consider these two lowest levels as appropriate therapy goals relevant to any child with any degree of residual hearing, no matter what mode of communication is used primarily.
Everyone once in a while I hear someone, usually from the Deaf community, denigrating the very concept of residual hearing. I find this a rather sad and rather self-defeating position. Adults who do not hear, or choose not to hear, have the power and authority to make their own decisions regarding the use, or non-use, of their own (and their children's) residual hearing. Having never experienced auditory sensations, or having experienced them but finding the occasions unpleasant or irrelevant, these adults are free to ignore any residual hearing they possess. They do not have the right to make this decision for other people’s children, particularly for those who cannot make their own informed judgments regarding the potential value of hearing in their lives. Note that this is not an argument for or against any communication mode for children. It is an assertion that no professional or educator should deny young children a reasonable opportunity to use their own residual hearing. To do so, imposes one's personal values on a very fundamental sensory inheritance of other human beings.
I guess I shouldn’t be surprised by this attitude. This is an area that has, in one sense or another, been polarized for over 200 years, going back to the original “oral versus manual” controversies. I do understand the desire of profoundly deaf people to form a community based on a common language and life-situation. What I don’t understand is why this has to preclude the use of residual hearing, for whatever benefits it can confer. Why is it necessary to disparage the value of some acoustic connection to the world in order to express one’s loyalty to this community? Why should one preclude the other? Obviously, not all Deaf people take this point of view, and I don’t want to be guilty of further polarizing the situation. Still, it’s an attitude that as professionals we should explicitly address. I have to admit that as a hard of hearing person with a severe to profound hearing loss, I take this attitude very personally. I, and other hard of hearing people, value our residual hearing very highly and we work very hard to maximize its use in every communicative situation. To see it dismissed so blithely devalues what we hold very dear.
Of all the changes that have taken place in the last forty years that have impacted upon people with hearing loss, I think the advent of cochlear implants has to rank as the most portentous. For the first time in history, we are able to provide usable auditory sensations to people with profound and total hearing losses. For the first time, we have a truly auditory option for people who we previously had only visual options, either oral or manual. That the device has had a major impact on all people who are professionally or personally involved with young hearing-impaired children needs no elaboration from me. I cannot recall any development getting more coverage, both on TV and in all print media. Hardly a week seems to go by without some story on this device, most dramatically as they concern young children. It’s not my role to provide a technical discussion or to review results; what I would like to do is discuss its impact on families and on the Deaf community.
In the past few years, there have been quite an intensive discussion regarding the consequences of the implant, on the internet and in all the print media. Most recently, this now includes an intensive, thoughtful and continuing dialogue in the current issues of the Hearing Health magazine from a number of different contributors holding different perspectives. These discussions reveal a great fear among many people in the Deaf Community, as well as those allied with this community, that the spread of implants means the end of the Deaf community and the Deaf culture. Thousands of children have already been implanted, at earlier and earlier ages, and it seems to be a process that is feeding on itself. The more children there are who receive implants, the more it becomes a routine clinical procedure, the more popular and acceptable the procedure becomes. The Deaf community fears, and rightly so, that the cochlear implant is, and will be, draining off many of their potential members. They believe that these children will be lost to them and that the future viability of the community is now questionable..
This is not a development that can be viewed with moderation and equanimity by those whose lives and life styles are inextricably woven into their Deaf identity. It is only in relatively recent years that Deaf people have achieved acceptance in our society - albeit not complete acceptance – and free to engage in whatever personal, social, vocational and civic activities they choose. To an amazing extent, many Deaf people have surmounted the impact of their deafness and are able to lead rich and fulfilling lives. From an historical perspective, it wasn’t too many years ago that Deaf people were denied to right to vote, to testify in legal cases, to receive an inheritance, or to acquire an education. It is this very proud history, and the currently hard-won status, that appears to be threatened by the advent of the cochlear implant. From this perspective, the reaction of many people in the Deaf community is perfectly understandable. What for many of us is a miraculous device, to them is a sword of extinction hovering over their community’s head. Without a community, without a critical mass, how can there be a Deaf culture? To be quite honest, I do believe that their fears are well founded, that the cochlear implant can threaten the future viability of the Deaf community. At the least, it will change it in some presently unforeseen ways.
In their fears, however, some Deaf people have made extreme and unsupported statements regarding the cochlear implant. Objections range from “it doesn’t work anyway”, it “causes lots of medical problems”, to questioning the right of parents to artificially (i.e. through surgery) to change the future identity of the child. I’ve read some comments equating the implant with genocide or a holocaust, statements that I personally find very offensive. It seems that trying to reach some kind of balanced view on this issue is even more difficult than trying to reconcile the old oral and manual controversies! Those arguments have been played out for several hundred years with little impact upon the initial views of the people involved. The difference that implants have wrought in this argument is that results with them far exceed that obtained with the classical visual-oral approach. Deaf children are becoming effective auditory-verbal communicators because of the implant. This fact undermines much of the previous traditional objections against oral communication, those that dealt with the difficulty in succeeding with a traditional visual-oral approach.
This is not an area, however, that we have the luxury of postponing decisions. It is not an issue that we can continue to debate until somehow the “truth” emerges. It is not just a question of the current reality, i.e. lots of kids are now being implanted, but also of the nature of the auditory system. If the procedure is going to done at all, then it should be as early as possible. We need to provide a developmental approach to therapy rather than a remedial approach. This means providing auditory-verbal experiences early in a child’s so that we can take advantage of the normal linguistic developmental pattern as well as preclude the impact of possible auditory sensory deprivation effects. However, there are some qualifications we should keep in mind when children receive cochlear implants.
First, a cochlear implant is not a panacea. It does not replace a normal ear. No parent should enter this process believing that this device will completely “fix” a child’s hearing loss. Second, we still don’t have any good way of accurately predicting just how well an individual child will do with an implant. Some do amazingly well, while others do not (just about all, however, can realize some degree of usable auditory access). Third, it is unlikely that the full potential of an implant can be realized without concurrent and appropriate therapy. And fourth, this last point implies that all concerned with the child, school and parents, be fully committed to do whatever is necessary to realize this potential. One cannot implant a child and wait for the “miracle” to occur.
The most important question we have to ask here is who are the ones empowered to decide on an implant for an individual child? In our society, it is the parents who have the legal and moral right to make this decision. But in our society, too, parents do not have an unlimited right to take actions that potentially endanger the life and welfare of their child. Do implants fall in this category? Hardly, and though there are some who say they do, in my opinion this is clearly a extremist position tainted with a lot of self-interest.
It is the parents, then, who must choose whether or not their child should be “treated” with a cochlear implant. Of course, they should be informed of all the management options, in as objective and comprehensive manner as possible. However, the reality of the situation is that the majority of the parents will probably select the option they are most familiar with, the one that permits their child to enter their world. Functionally, and this should be made clear to the parents, the child will operate as a hard of hearing person rather than someone with perfectly normal hearing. What we can’t do, and what we have no right to do, is to ask parents to make decisions for their child based on what will ensure the future of the Deaf community.
Some Deaf people will argue passionately that they’re only recommending what it best for a child, that it is the child’s interest that is at stake here and not the parents. I do not question the sincerity of these beliefs. What I do question is the conclusion that a child’s best interest can be attained by linguistically and psychologically separating the child from his or her natural parents. This argument would have much more force if we were still in the era of single channel, relatively crude cochlear implants. That’s not the case any more. As I already commented, children with implants should be able to function as hard of hearing people in an auditory-verbal world. And as a hard of hearing person, I can personally testify to the profound differences there are between being deaf, and depending primarily upon a visual mode of communication, and being hard of hearing, and requiring a primarily auditory-verbal communication mode.
It could be, of course, that I’m also describing a rather extreme position, an assumption that children who receive implants will automatically identify with the hearing world and not the Deaf world. The real world presents many more shades of gray than this polar formulation suggests. Many children who are implanted are continuing their education in a total communication (TC) program. In the course of it, they learn sign language and, eventually, particularly as they get older, may prefer to identify closely with the Deaf community. That is also a choice, one that they have every right to make for themselves.
The practical therapy question is whether a child can receive the full benefit of a cochlear implant if they are consistently and primarily exposed to simultaneous communication. Actually, this is the same question that we have asked for many years, but dealing with hearing aids rather than implants. All of us involved in this area have opinions, often expressed stridently and with a great deal of emotion, but with precious little experimental evidence. For myself, I would say it depends. The way I’ve seen TC practiced for the past 30 years, the children are not receiving a complete and correct language sample in any form, either oral or sign. One can’t build a competent language user in two languages when the input for both is impoverished and incomplete.
Is it possible to provide a sufficient quantity and quality of auditory-verbal inputs for a child to reach maximum capabilities in the auditory-verbal mode, and then do the same in a sign mode? I’d say yes, but this argues for an alternate rather than a simultaneous approach, one that provides sufficient exposure in each mode separately. I do believe that there are some children out there, either wearing cochlear implants or hearing aids, who are competent language users in both the oral and sign modes. How many there are and how they arrived at this happy state are not questions we can now answer. We all have anecdotal reports, plus lots of personal observations filtered through our own belief system. What does seem apparent is that implanted children do require an auditory-verbal focus for at least some presently undefined portion of each day. The auditory system has to be stimulated in some unambiguous fashion, the auditory experiences have to be associated with experiential events, in order for maximum auditory-verbal development to occur.
Cochlear Implants and Hearing Aids
After saying all these nice things about implants, what I have to say now may be a bit confusing. And that is, I resent them. Or rather, I’m a bit envious of all the attention they’re getting. After working with hearing aids for more than forty years, I find myself a bit overwhelmed by a focus on implants that we never saw with personal amplification, our more conventional mode of providing auditory access for children with hearing loss. In the entire world, there are perhaps 5000 children wearing cochlear implants. Anybody want to hazard a guess on how many children use hearing aids? I don’t know, but if I said about one hundred times more I don’t think I’d be too far off. If we look at the literature in the past ten years, I would also be willing to bet that articles concerning children with implants are at least as numerous as those dealing with children wearing personal hearing aids. This is quite an imbalance.
Does this paucity of professional literature concerning children wearing hearing aids mean that we’ve answered all the questions regarding personal amplification? That we know what to do and how to do it? That we’re able to ensure that every child who receives any type of personal amplification is making the most use of his or her residual hearing? It would be the brave and foolish person indeed who would dare make that assertion! So how do we explain the popularity of cochlear implants? Part of its current popularity is well understood: they can do things for some people that hearing aids cannot. In that, they are a truly new and, to my mind, almost miraculous device. They can make the deaf hear! But another part of the reason is that the process includes and is fostered by high-status individuals in our society, the surgeons, rather than traditional clinicians, educators and parents. The medical community has adopted the implant as a legitimate extension of its usual responsibilities for patients.
What I’d like to see is all care that goes into their selection, all the frequent follow-ups for mapping and for assessing performance status, all the careful longitudinal research, all the organized programs available to parents, also be applied to children wearing hearing aids. And that’s why I’m so envious. Not to deny the need for a comprehensive therapy and follow-up program for children with implants, but to assert that children wearing personal amplification require the same services. In my optimistic moods, I keep thinking that we’re going to see a “trickle down” effect, where children wearing hearing aids will begin to receive the same attentions as those wearing implants. In my more pessimistic modes, which unfortunately I also think more realistic, I believe that we’re still going to be facing the same battles we always did in regards to ensuring appropriate amplification for children. Which is sad, considering how much more we know now about providing amplified sound for young children.
Cochlear implants are not the only thing that’s new in recent years. Ironically, at the same time cochlear implants are threatening to siphon off future member of the Deaf community, recent changes in terminology may well foster an increase the number of people in this community. Where will they come from? From the ranks of potentially hard of hearing people. Let me explain what I mean by this assertion.
In previous years, the labels “deaf” and “hard of hearing” were most often employed as subcategories of the term “hearing-impaired”, used generically to refer to anybody with any auditory disorder. Some Deaf people and their supporters objected to the term “hearing-impaired” because in their mind it had several negative connotations. For one, they did not believe that their auditory status should be characterized as “impaired” when for them it was a normative condition. The fact that they were unable, or unwilling to hear, was considered a component of their identity, that they were primarily part of a visual and not auditory world. The other objection was their judgment that the term carried an implication that the person was “impaired”. I don’t know where this interpretation came from. I can’t ever remember anyone using the term as a direct or implied commentary on the human status of a deaf person. I know that I’ve done quite a bit of writing on this topic myself over the years, and the label always referred only to a person’s hearing condition.
Because of these reasons, however, and regardless of their merits, this generic usage of the label “hearing-impaired” now appears to be in disfavor. Now we see the term “deaf and hard of hearing” being employed instead. In part, the term is being used as a substitute generic label, to refer to all people with hearing loss, and partly apparently to reflect an extension of the original mission of agencies that heretofore only ostensibly dealt with “deaf” people. Thus, a number of organizations, agencies and educational settings at the national, state and local levels have recently relabeled themselves to include the term “hard of hearing” as well as “deaf”. Thus, state commissions originally called “State Commission for the Deaf” are now often titled “Commission for the Deaf and Hard of Hearing”. Vocational Rehabilitation agencies now claim as their mission to service both “deaf and hard of hearing” people as clients. Local, regional, and national educational programs, from the elementary to the college level, are ostensibly designed to assist both “deaf and hard of hearing students”, while teacher training programs presume to prepare future professionals teach all students falling into the both categories. Even the Alexander Graham Bell Association for the Deaf now includes “hard of hearing” in its title. Well, so what? Does this label make a difference?
I believe it does for two reasons. The first is that although the label of an agency or institution may have changed, from what I can see the services and actual functions are still basically the same. Thus, the need for interpreters, notetakers, and real-time captioning are stressed for the deaf clients, as well they should be, but not assistive listening systems or acoustical modifications for their hard of hearing clients. The second reason, and the one most germane in this context, is how this generic classification plays out with children in schools.
There are many educational programs in this country that purport to serve both deaf and hard of hearing students. However, from the elementary to the post-secondary levels, a number of such programs only provide one educational philosophy for any child with a known hearing loss regardless of severity. Almost always in these classrooms, a Total Communication (TC) program is the one employed. While theoretically, hard of hearing children (or those potentially so, given appropriate auditory management) should also receive the auditory access they require in a TC program, in reality the auditory-oral mode is often given short shrift. Because the teacher is simultaneously signing while speaking, the oral language component is rarely complete and grammatical. Hearing aids and auditory training systems are not monitored and sometimes not even used. In some schools that claim to care for both deaf and hard of hearing students, American Sign Language (ASL) with "voice-off" is the instructional language. While perhaps not explicitly forbidden, the value system developed in such schools often discourage the use of audition.
These are the kinds of educational experiences that, I believe, can and do “create” functionally deaf people from audiologically hard of hearing children. This is where the future recruits to the Deaf community will come from. None of this is malicious, none of it is done without the best of intentions. Leaders of the Deaf community know very little about hearing, though they undoubtedly know quite a bit about its absence. They may truly believe that hard of hearing children “belong” to the Deaf community, that they will be happier as part of a visual world than struggling as a hard of hearing person in the hearing world. Again, we see the polarity which so bedevils this issue. The only real issue here should be the full use of whatever residual hearing a child possesses, leaving the question of their future social and cultural identity something for them to decide when they’re ready.
In a way the lumping together of deaf and hard of hearing people is understandable, simply because both deaf and hard of hearing people display auditory deficiencies of some degree or another. In actuality, however, in spite of some overlapping needs and the presence of some people who fall into a “gray” area, these groups are fundamentally very different. From the viewpoint of some leaders in the Deaf community, however, there is clearly an advantage to this combined label in that it appears to increase their constituency from 2 to 26 million people. This larger number is much more likely to influence politicians and bureaucrats when they determine policy and allocate resources. To assert that one is representing 26 million people puts one in a much more powerful and influential position than claiming to represent the interests of only two million people nationally.
As a society we can reduce many of the problems if we simply refine or define our terminology more precisely. How we label an entity often influences treatment; individual differences are easily lost in diagnostic labels that are too inclusive. We should not be surprised if audiologically hard of hearing children, labeled or treated as deaf, who attend schools for the deaf and socialize primarily with deaf children, often identify and function as members of the Deaf community. Above all, it must be understood that “hard of hearing” is not some subcategory of “deaf”, but rather a different disability with its own implications and needs. If the services of some agency are designed in fact to respond only to the needs of deaf people, then its mission should be restricted to this population. If the agency purports to care for hard of hearing people as well, then this fact should be explicitly reflected in the services that are offered. What is unsupportable is the deceptive claim that both “deaf and hard of hearing” people are being cared for by an agency or institution when in reality only services appropriate for deaf people are being provided – for all the clients, both deaf and hard of hearing.
It is well for us to always keep in mind why we are involved with the early detection and management of children with hearing loss. If these activities did not make a difference in a child’s ultimate adjustment and performance, we wouldn’t be doing this. One consensus we can claim to have reached concerns the need to identify the presence of a hearing loss early in life, that the sooner we enroll children and parents in some kind of therapeutic program, the better off they eventually will be. For the first time in history, we now have both the forces of law and technology on our side. We can identify the children through impressive newborn hearing screening tools, and we can bring to bear the kinds of sophisticated technology we could not even dream of years ago. What hasn’t change, however, and what must always remain the highest priority in our activities is the need to be respectful of the parents and the children. What I mean by this is that it has to be their needs that take priority; that it is the parents and ultimately the children who will define and decide their own life’s course; and that our role is not to direct them or to impose our values on them, but to serve as their agents while they work out their own future.