Language and Literacy Outcomes for Children Who are Deaf and Hard of Hearing in the State of Georgia
Report to the Governor and General Assembly September 2019
Presented by the Georgia Commission for the Deaf or Hard of Hearing
as required by OCGA 30-1-5

Co-Authored by:

Stacey Tucci, PhD Georgia Department of Education State Schools Division Language and Literacy Initiative Coordinator

Jeannine Galloway, MPH Georgia Department of Public Health Maternal and Child Health Director Health Promotion Division

Kelly Jenkins, MBA Georgia Department of Education State Schools Division Language and Literacy Initiative Consultant

Judith Kerr, MPH Georgia Department of Public Health Child Health Screening Program Senior Manager Child Health Services

Heidi Evans, PhD Georgia Department of Education

Maternal and Child Health Section Division of Health Promotion

Director, Georgia PINES Georgia Parent Infant Network for Educational Services

Brandt Culpepper, PhD, CCC-A Georgia Department of Public Health Early Hearing Detection and Intervention

Jessica Bergeron, PhD Georgia Department of Education State Schools Division

Team Lead Maternal and Child Health Section Division of Health Promotion

Director of Mobile Audiology Program

Lisa Pennington, MS, MA, LPC

Michael Lo, MSPH Georgia Department of Public Health Child Health Screening Epidemiologist Maternal and Child Health Epidemiology Unit

Georgia Department of Public Health Deputy Director, Early Intervention Maternal and Child Health Section Division of Health Promotion

Epidemiology Section Division of Health Protection

Jennie Couture Georgia Department of Early Care and Learning

Bright from the Start

Practice and Support Services Director

For more information:

Georgia Commission for the Deaf or Hard of Hearing Mr. J. Comer Yates, Chairperson https://dhs.georgia.gov/georgia-commission-deaf-or-hard-hearing
Katherine Cadena Manager, Limited English Proficiency and Sensory Impaired Program Office of Communications Georgia Department of Human Services 404.657.5244 (0) 404.326.7710 (M) Katherine.cadena@dhs.ga.gov

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Rationale for Report and Legislative Charge.................................................................................. 4 Executive Summary ........................................................................................................................ 5 Georgia's Children Who Are DHH Key Transactions Map ......................................................... 12 Georgia's Ecosystem for Children who are DHH ........................................................................ 13 Framing the Population................................................................................................................. 14
Data Challenges........................................................................................................................ 14 The DHH Language and Literacy Dashboard.......................................................................... 28
Transaction 1: Newborn Hearing Screening and Rescreen Birth to 1 month ................... 29 Transaction 2: Diagnosis By 3 months .............................................................................. 29 Transaction 3: Early Hearing Orientation Visit By 6 months ........................................... 29 Transaction 4: Early Intervention 6 months to 3 years ..................................................... 29 Transaction 5: Transition Meeting 3 years ....................................................................... 34 Transaction 6: Preschool Services 3 to 5 years................................................................. 34 Transaction 7: School Instruction 5 to 8 years.................................................................. 34 Recommendations......................................................................................................................... 37 Thank You to Governor Kemp and Georgia's General Assembly ............................................... 41 Appendix A: Appointees for the Georgia Commission for the Deaf or Hard of Hearing (GCDHH)...................................................................................................................................... 42 Appendix B: Appointees for the Multiagency Task Force ........................................................... 43 Appendix C: Appointees for Stakeholder Advisory Committee .................................................. 44 Appendix D: OCGA 30-1-5 Deliverables Detailed Description .................................................. 45 Appendix E: Current Service Provision by Agency ..................................................................... 49 Appendix F: Georgia Milestones Grade 3 English Language Arts Assessment Reading Proficiency Category Descriptions ............................................................................................... 54 Appendix G: ACT 462................................................................................................................. 55 Appendix H: Glossary of Terms ................................................................................................... 64

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Rationale for Report and Legislative Charge
On May 8, 2018, Act 462 was signed into law effectively amending Chapter 1 of Title 30 of the Official Code of Georgia Annotated (OCGA) by revising Code Section 30-1-5. This legislation was sponsored by Representative Penny Houston and Senator P.K. Martin, both longtime advocates for Georgia's Deaf and hard of hearing (DHH) community. The revisions stipulate ten, key deliverables listed below which aim to improve the language and literacy outcomes for Georgia's children who are DHH. One of the key deliverables required by this legislation is for the Georgia Commission for the Deaf or Hard of Hearing (GCDHH) to deliver a report to the governor and General Assembly annually in order to measure progress towards age-appropriate language and literacy outcomes for children who are DHH:
A report detailing the provision of early intervention (EI) and school-age services and the language and literacy outcomes for children who are Deaf or hard of hearing between the ages of birth and eight years shall be completed on or before September 1, 2019, and a similar report shall be completed on or before
September 1 every year thereafter. Such report shall be jointly authored by the Department of Public Health, the Department of Early Care and Learning, and the Department of Education and approved by the commission (GCDHH) and the advisory committee. The commission shall make the report available to the public on its website and present this report to the governor and General Assembly no later than
September 15, 2019, and every September 15 thereafter. Act 462, lines 272-280

Below are the key deliverables stipulated by OCGA 30-1-5. More detailed information for each deliverable is available in Appendix D on page 45.

OCGA 30-1-5 Deliverable

ACT 462 Reference

1. Changes to the GCDHH 2. Establishment of Multiagency Task force 3. Establishment of Stakeholder Advisory
Committee 4. Georgia Testing Identifier (GTID) process and
implementation

Lines 58 to 36 Lines 137 to 176 Lines 177 to 215
Lines 244 to 271

5. Web and print based parent/professional resource
6. Create List of Developmental Milestones 7. List and Implementation of biannual Language
and Literacy Assessments 8. Development and Implementation of an
Individualized Child Report (birth to literacy) 9. Interagency Collaboration, Provision of
Seamless Services and Data Sharing from birth through high school graduation 10. Annual Legislative Report

Lines 222-226 Lines 216 to 221 Lines 227 to 233 Lines 234 to 237 Lines 244 to 255
Lines 272 to 280

Status Complete Complete Complete Ongoing
In process In process In process Not Started Ongoing
Complete

Page # in Appendix p. 45 p. 45 p. 45
p. 45
p. 46
p. 46 p. 47
p. 47
p. 48
p. 48

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Executive Summary
The Problem Today in Georgia, only 34% of all students are reading proficiently by the end of third grade.1 For the 2017-18 school year, less than 14% of children with a primary Special Education (SPED) eligibility of Deaf or hard of hearing (DHH) achieved reading proficiency by the end of third grade.2 For these children who are DHH, language and literacy outcomes are nothing short of a public health crisis. As 85% of a child's brain development occurs by age five, appropriate and accessible early intervention services and preschool programs are a necessity for optimal outcomes during this critical developmental window.3 Academic challenges for children who are DHH do not end in the third grade. In fact, these challenges become significantly more difficult to address as children progress through their school career.
The Get Georgia Reading Campaign, created by former Governor Nathan Deal and First Lady Sandra Deal and supported by Governor Brian Kemp and his administration, has a goal of ensuring all children in the state are on a path to reading proficiently by the end of third grade by 2020.4 Research shows that children who do not read proficiently by the end of third grade are more likely to drop out of high school. In addition, they are more likely to experience poor health, have discipline problems, perform poorly in eighth grade math and become teen parents.5 85% of juvenile offenders have reading challenges, and three out of five adults in our nation's prisons are illiterate.6
Georgia's children who are DHH have both the ability and the right to achieve every educational outcome that children with typical hearing can achieve. Access to early diagnosis and appropriate early intervention services are prerequisites for later achievement. While 96% of babies who were born in 2017 were reported as screened for hearing loss by one month of age, only 32% of the babies identified as needing a full diagnostic hearing exam were reported to have received the exam by three months of age.7 Furthermore, just 41% of babies born in 2017 and diagnosed as DHH received a home visit from an early intervention specialist by six months of age.8

1 Georgia Milestones ELA, 2017. http://getgeorgiareading.org/wp-content/uploads/2016/09/July-2017GGR_NarrativeBook-1.pdf 2 Georgia Department of Education, Grade 3 Milestones End of Grade English Language Arts Assessments for Deaf
or Hard of hearing Students Receiving Special Education. School Year 2017-18 Milestones End of Grade Assessments. Total number of third graders tested was 131 with 18 testing at or above grade level and 113 testing
below grade level. 3 Georgia Early Education Alliance for Ready Students. http://geears.org/wpcontent/uploads/2011/05/GEEARSFactSheet.pdf 4 Reference http://getgeorgiareading.org/framework-overview/ & http://getgeorgiareading.org/cabinet/gov-brian-
kemp/ for more information 5 http://getgeorgiareading.org/framework-overview/ 6 https://www.literacyprojectfoundation.org 7 State Electronic Notifiable Disease Surveillance System (SendSS) for newborn hearing screening/rescreen,
diagnosis, and EHOS visit data 8 Babies Information and Billing Services (BIBS) repository for Part C early intervention enrollment data

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Success is dependent upon equitable access to appropriate hearing screenings and audiological care, educational settings and educational professionals who use evidence-based instruction and curriculum/intervention materials. Today, far too many children in Georgia who are DHH are not proficient in language or literacy largely due a lack of access to services (i.e., the zip code lottery - the location in which a child resides determines the access a child has to timely and appropriate resources and services).
Additionally, there is an economic cost associated with not meeting the language and literacy needs of children who are DHH. The lifetime educational cost of hearing loss has been estimated at $115,600 per child over the course of their educational career. 9 10 In addition, unidentified and unmanaged hearing loss results in a loss of household income of up to $30,000 per year which results in a negative economic impact for Georgia due to unrealized taxes.11
The Solution This report marks the first time that there has been an aggregate count of the number of children receiving Special Education (SPED) services under a primary eligibility of DHH from birth to 12th grade. While this may seem like a small success, it is a necessary step towards understanding the scope of the problem (i.e., identifying gaps in service delivery and reporting) and more effectively serving this population. The goal of OCGA 30-1-5 as amended by Act 462 is to create an individualized, child-focused system that supports a seamless provision of services for children and families as they move through the seven key transactions necessary for age appropriate language and literacy outcomes. This requires a radical change in adult behavior as it relates to supporting a statewide ecosystem of caregivers and professionals responsible for the individual language and literacy outcome for each child who is DHH in Georgia.
The completion of this initial legislative report is a critical first step towards an actionable individualized birth to literacy plan for every child who is DHH in the state. While some states designate one lead agency for all ages of children who are DHH, Georgia tasks multiple state agencies with providing early intervention and education for children who are DHH.
As required by OCGA 30-1-5 as amended by Act 462, a multiagency task force was assembled to promote transparency, require data sharing, and support ongoing collaboration to improve language and literacy outcomes for all children who are DHH. For the year one report, the multiagency task force consolidated thought leaders from the Department of Public Health (DPH), the Department of Education (DOE) and the Department of Early Care and Learning (DECAL), and data from six different agency databases in order to consider the following questions:

9 Grosse defines hearing loss as bilateral hearing loss of 40 HL dB or greater. Note that EHDI defines hearing loss as
unilateral and bilateral loss of 15 dB HL or greater average for 500Hz to 400Hz. 10 Grosse SD. Education cost savings from early detection of hearing loss: New findings. Volta Voices 2007;14(6):38-40. https://www.cdc.gov/ncbddd/hearingloss/data.html 11 Better Hearing Institute. The Impact of Untreated Hearing Loss on Household Income
Hearing Aid Assistance Tax Credit. http://www.hearingaidtaxcredit.org/index-jump1.cfm

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1. What does a child who is DHH need in order to achieve proficient language and literacy by third grade? The task force developed the Georgia's Children Who are DHH's Language and Literacy Transaction Map which outlines seven key transactions from birth to third grade necessary in order to achieve proficient literacy by the end of third grade (p. 12).
2. What are the current resources available in Georgia today for children who are DHH? A comprehensive list of all current service provisions in both the public and private sector was consolidated in Appendix E (p. 49) in order to identify gaps in service provision.
3. Who are the key influencers in ensuring that a child who is DHH meets the key transactions required to achieve proficient literacy by the end of third grade? The task force developed Georgia's Ecosystem for Children who are DHH which documents all influencers including the General Assembly who must be considered and empowered to help children who are DHH complete critical language and literacy transactions (p. 13).
4. How large is the population and what are the characteristics of children who are DHH? Are there additional geographic or socioeconomic barriers to consider? The task force consolidated data from multiple agencies to address this question in the Framing the Population section of this report on page one. The data indicate:
The state significantly underestimates the true DHH child population. There are approximately 2,326 students from birth to 12th grade receiving special
education services with a primary eligibility of DHH. Approximately 50% of children who are DHH live outside of metro Atlanta. 58% of counties report five or fewer students who are DHH. 40% of children who are DHH are in the critical age window for early intervention
and school-age services that support language and literacy proficiency. 90% of children who are DHH receive services in a home or local school setting. 69% of children who are DHH are economically disadvantaged. A higher percentage of non-metro Atlanta (75%) and State Schools (78%) students
who are DHH are economically disadvantaged when compared to metro Atlanta students who are receiving special education (SPED) services with a primary eligibility of DHH (62%). 64% of children who are receiving SPED services with a primary eligibility of DHH fall within the following race/ethnicity groups: Black, Hispanic, Asian, and Two or More Races. Students who are Black, Hispanic, Asian, and Two or More Races are overrepresented in the State Schools when compared to the General Education population and the SPED DHH population in local school districts.

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5. What is the current state for children who are DHH in terms of language and literacy acquisition, and how will we measure success? The task force developed the DHH Language and Literacy Dashboard as a child focused measurement of language and literacy outcomes for every transaction in the Transaction Map. Data indicate that children who are DHH are "lost" at every transaction point. The data indicate (p.28):
96% of babies born in 2017 (124,893 of 130,006) were reported as having completed the screening transaction within the critical period of completion (i.e., screened by one month).
32% of babies born in 2017 who were screened and referred for a full diagnostic evaluation (505 of 1,561) were reported as receiving one within the critical period of completion (i.e., diagnosed by three months).
41% of babies born in 2017 and reported as DHH (98 of 241), received an early hearing orientation (EHO) visit within the critical period of completion (i.e., by six months).
69% of babies enrolled in the Georgia PINES SKIHI program which provides early intervention for children who are DHH (172 of 250) were enrolled within the critical period of completion as of June 2019 (i.e., enrolled by the age of six months).
44% of babies who are DHH and enrolled in the Georgia PINES SKIHI program (110 of 250) as of June 2019 are meeting or exceeding age appropriate receptive language milestones.
31% of babies who are DHH and enrolled in the Georgia PINES SKIHI program (78 of 250) as of June 2019 are meeting or exceeding age appropriate expressive language milestones.
Data on the transition from early intervention to preschool services specifically for children who are DHH are not currently available.
14% of children receiving SPED services with a primary eligibility of DHH (18 of 131) are reading proficiently by the end of third grade for academic year 2017-18.
6. How do we help children who are DHH who are "lost by the ecosystem"? Children who are "lost by the ecosystem" are children who do not complete the seven key transactions necessary for literacy proficiency by the end of third grade. The multiagency task force will focus on these "lost" children in the upcoming year. These "lost" children are those who are DHH: Who are never diagnosed either at birth or school-age. Who are diagnosed but not reported to the Georgia Department of Public Health (DPH). Who are diagnosed but do not complete various transaction points. Who have a late onset hearing loss or a congenital hearing loss which is not identified by the newborn hearing and/or school entry hearing screen. Who are not identified as DHH because the Georgia Department of Education (DOE) only identifies children who are DHH who are receiving SPED services with a primary eligibility of DHH.

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7. How do we identify and help our most vulnerable children who are DHH? Children who are DHH who enter the ecosystem but are not reaching age appropriate language and literacy milestones beginning at birth are at great risk of not achieving reading proficiency by the end of third grade. The task force identifies these children using data collected in this report.
8. What are the recommendations for next year, and how do we focus our efforts based on the findings in this report? The issues below have been identified as priorities for the multiagency task force to address over the next 12 months. The task force will deliver an actionable, measurable, collaborative plan in 2020 which will serve as a roadmap towards proficient language and literacy by the end of third grade for the state's children who are DHH. This collaborative plan will focus on:
A request for a letter jointly authored by Governor Kemp, the GCDHH and the DPH to birthing hospitals and audiologists reinforcing the legal reporting requirements for initial hearing screening and outcomes of a diagnostic evaluation within seven days to ensure prompt enrollment into early intervention.
Consideration of legislation which would require periodic school-age hearing screenings.
Allocating an annual budget for the GCDHH. Holding an open house and ribbon cutting ceremony at the State Capitol for the
Mobile Audiology Unit. Creating a list of developmental milestones for children who are DHH. Implementing biannual language and literacy assessments for every child who is
DHH. Developing a web and print based parent and professional resource. Creating a process to identify all children who are DHH from birth to 21 and
developing and implementing a birth to literacy individualized child plan for every child who is DHH in Georgia. Identifying and developing a plan to reclaim children "lost by the ecosystem". Increasing the rate of diagnosis within both the infant and school-age population. Closing the gap in services within the early intervention and preschool population for children who are DHH. Addressing the impact of socioeconomic status on early diagnosis, early intervention and the provision of services to children who are DHH. Extending services for children who are DHH into rural Georgia. Evaluating the accessibility of Hearing Diagnostic Centers outside of the metro Atlanta area. Increasing compliance and timeliness of data reporting so that diagnosis and early intervention can occur as soon as possible. Identifying the scope of current resources and addressing the identified lack of resources for students who use ASL, spoken language or a combination of both. Collecting data on the transition meeting and considering the inclusion of early interventionists with a specialty in DHH education. Delivering the 2020 annual report.

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The Future Serving the DHH population can be challenging given its low incidence which is compounded by an even smaller population outside of major metro areas as well as significant socioeconomic barriers. However, research clearly shows that children who are DHH who have been identified in early infancy, enrolled in early intervention by six months and who have received appropriate intervention services (especially in their early years) will be on a path to later academic success in the school-age years.12
The Centers for Disease Control and Prevention (CDC) Early Hearing Detection and Intervention (EHDI) recommends that infants be screened for hearing loss before one month of age, diagnosed with hearing loss before three months of age, and enrolled in early intervention before six months of age.
However, it is critical to recognize that infants can and should receive diagnosis and early intervention services much sooner than is recommended by the 1-3-6 model. According to Harvard University's Center on the Developing Child, in the first few years of life, more than one million new neural connections form every second. 13 There is no way to overstate the lost human potential represented by an infant not meeting these three and six month milestones.
The Access to Language (AtL) initiative at Grady Hospital has been developed in collaboration with The Atlanta Speech School, the DPH, Children's Healthcare of Atlanta, and Talk With Me Baby to ensure that every infant with hearing loss at Grady Hospital is diagnosed and in early intervention within the first 14 days of life if possible. A reported early success of the AtL initiative: an infant was screened and diagnosed with hearing loss by one month of age and scheduled for a hearing aid fitting within 41 days of birth. This initiative is identifying barriers to early diagnosis and early intervention and is considering approaches to scale solutions to every birthing hospital/center in the state.
It is important to recognize that there are many excellent early intervention and educational resources in Georgia for children who are DHH and their families. In addition, there are children who are DHH in general education settings in both public and private schools displaying proficient language and literacy. However, these children are not currently identified as students who are DHH by the DOE which makes it difficult to learn from their successful outcomes. Even though many resources and services are available to Georgia's children who are DHH, children who are DHH are still experiencing epidemic levels of language and literacy delays which are untenable for this relatively small but high potential population.
While there is much work to be done, this is an exciting time to be working for children who are DHH in Georgia. As mentioned above, current legislation has provided a critical foundation for
12 Moeller, M.P. (2000). Early intervention and language development in children who are deaf and hard of hearing. Pediatrics, 106(3), E43. (here's the abstract: https://www.ncbi.nlm.nih.gov/pubmed/10969127) Yoshinaga-Itano, C., Sedey, A.L., Coulter, D.K., & Mehl, A.L. (1998). Language of early- and later-identified children with hearing loss. Pediatrics, 102(5), 1161-1171. https://www.ncbi.nlm.nih.gov/pubmed/9794949) 13 Center on the Developing Child. Harvard University. Harvard's Center on the Developing Child. https://developingchild.harvard.edu/science/key-concepts/brain-architecture/

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interagency collaboration and service provision focused on the needs of the individual child. Annual reports will continue to measure the task force's progress towards language and literacy proficiency for children who are DHH as well as to identify and measure specific opportunities for improvement through actionable recommendations from the GCDHH.

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Georgia's Children Who Are DHH Key Transactions Map
The transaction map below provides guidance for families on their journey from birth to literacy. Seven key transactions are identified based on best practices (as determined by the Joint Committee on Infant Hearing (JCIH), the CDC, the DPH, the Department of Early Care and Learning (DECAL), and the DOE) and are presented in chronological order along with a brief description of what should occur within each transaction as well as the critical period for completion.14 If the state ensures every child who is DHH can complete these transactions in a timely and coordinated manner, Georgia children who are DHH will be able to achieve proficient language and literacy skills in significantly greater numbers. This report will quanitify the fall out of children who are DHH at each transaction point contingent on data availability

14 Catts, H. W., Fey, M. E., & Proctor-Williams, K. (2000). The relationship between language and reading: Preliminary results from a longitudinal investigation. Logopedics Phoniatrics Vocology, 25, 3-11. & Dickinson, D. K., McCabe, A., & Essex, M. J. (2006). A window of opportunity we must open to all: The case for preschool with high quality support for language and literacy. In D. K. Dickinson & S. B. Neuman (Eds.), Handbook of early literacy research (Vol. 2, pp. 11-28). New York: Guilford Press. & Easterbrooks, S., Lederberg, A., Miller, E., Bergeron, J., & Connor, C. (2008). Emergent literacy skills during early childhood in children with hearing loss: Strengths and weaknesses. Volta Review, 108, 91-114.

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Georgia's Ecosystem for Children who are DHH
The Georgia ecosystem for children who are DHH is comprised of many public and private resources and influencers available to assist children who are DHH and their families. For the purposes of this report, an "ecosystem" is a community of interacting agencies, influencers, resources and supports with the child and family as its focus. Currently, not all Georgia families have equitable access to ecosystem services and resources. When evaluating improvement opportunities, it is important to consider every influencer. These influencers must be working together to deliver comprehensive, appropriate, and consistent information and services that place the child and the family at the center of the work. For example, excellent parent capacity building early intervention services may exist in the state, but if newborn hearing screeners or pediatricians are not aware of them, the child and the family will not benefit. It is also important to note that all influencers in the Georgia ecosystem are not currently included in the task force work; inclusion of all influencers will be an area of focus in year two.
Although they should be at the center of the ecosystem, children and their families are often overlooked when it comes to analyzing service provision efficacy. Even the most robust ecosystem will not promote positive outcomes for children who are DHH if their primary caregiver cannot access services and resources or is unable to support language and literacy development. A detailed view of currently available state services by agency is outlined in Appendix E. The task force's ultimate goal is to realign the state's existing services to the individual child and to develop an individualized child plan for every child who is DHH.

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Framing the Population
Data Challenges Due to state and federal privacy laws (e.g., the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Family Educational Rights and Privacy Act of 1974 (FERPA)), family and child/student data cannot be publicly reported unless the data are de-identified and aggregated. Data sample sizes must meet state privacy regulations (n5 for the DPH and n15 for the DOE) to be eligible for public report. This can be a challenge to public reporting as the DHH population occurs at a low incidence.
The DPH is reliant on birthing hospitals and audiologists to report children who are DHH upon completion of a diagnostic evaluation. The state mandates reporting within seven days upon diagnosis, but currently only 62% of children identified as DHH were reported within this seven day window.15 Late reporting delays data collection which makes it difficult to measure the success of improvement efforts and to ensure prompt enrollment into early intervention.
It is important to note that Georgia is unique in that hearing loss is considered a public health "reportable condition" meaning every child up to age five must be reported to the DPH if they are suspected of or are diagnosed with a permanent hearing loss. This is not the case in most states and is a relative strength in our state.
The DOE defines students as DHH only if they are receiving SPED services with a primary eligibility of DHH. As a result, the data analysis in this report does not include data for children who are DHH who are:
1) Never diagnosed with hearing loss (i.e., lost by the ecosystem). 2) Diagnosed but never reported with a DHH diagnosis to the DPH by the birthing hospital
or audiologist. 3) In general education settings with or without a 504 Plan. 4) In special education settings with a secondary or tertiary eligibility of DHH. 5) In private school, healthcare or clinical settings (non-Part C) with or without a 504 Plan. 6) Served under a SPED eligibility category of DeafBlind (DB). The year two report will
include data and recommendations for this group of children.
Due to this lack of complete data collection between public and private partners, the state significantly underestimates the true DHH child population. In addition, Georgia does not currently mandate periodic school hearing screenings. As a result, many school-age children with hearing loss are not diagnosed. A diagnosis of hearing loss is required to receive SPED services. It is imperative that the state receive accurate population numbers so that the deployment of appropriate support and resources is possible. Comprehensive, timely, and accurate data collection and compliance in reporting represents opportunities for improvement as listed in the recommendations section of this report.

15 The Georgia Department of Public Health. https://dph.georgia.gov/testing-and-reporting-unhsi https://dph.georgia.gov/sites/dph.georgia.gov/files/DPH%20ND%20Reporting%20Poster_032414.2.1.2016.pdf https://dph.georgia.gov/nbs-policies-and-procedures

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The current infrastructure of the state ecosystem requires children who are DHH and their families to engage with three separate state agencies (i.e., the DPH, the DECAL, and the DOE) from birth to 12th grade. Related data are stored in at least six different databases. These databases do not currently communicate with one another. As a result, data entry rules and identification numbers differ from database to database often requiring manual data collection and data entry. Even within certain agencies, data sharing can be a challenge. As a result, data for this report were pulled manually, and limitations are noted when necessary.
Due to data limitations and availability, there are varying sample sizes for the figures in this report as follows.:
Figures 1-3 and 5-6 combine data from Georgia PINES (the DOE early intervention provider for children birth to three years who are diagnosed as DHH. Georgia PINES does serve a small number of older children between four and five years of age who typically have been referred to early intervention services later) and the DOE (Preschool to 12th grade students with a primary eligibility of DHH) resulting in an n=2,326.
Figures 7-10 represent data from the DOE only (Preschool to 12th grade students with a primary eligibility of DHH) resulting in an n=2,077.
Transactions 1-3 on the dashboard include data from the EHDI program from the DPH with various sample sizes dependent upon transaction.
Figures 11-13 include data from Georgia PINES resulting in an n=250. Figure 14 represents data from the DOE for third grade students with a primary eligibility
of DHH resulting in an n=131.

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Demographics of Children who are DHH The following figures represent the population of children with a primary eligibility of DHH by several demographic categories including age, geographic location, race/ethnicity, and socioeconomic status.
Figure 1. Population of students who are DHH Approximately 2,326 receiving special education (SPED) with a primary eligibility of DHH. According to the DOE, there are approximately 2,326 children from birth to 12th grade receiving public services through the DOE who have a primary SPED eligibility of DHH. Again, this number significantly underestimates the true DHH child population as it does not include the subgroups of the DHH student population listed on page 14 of this report.

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Figure 2. Children who are DHH by Geographic Location 50% live outside of metro Atlanta. Approximately half of Georgia's children who are DHH live outside of the metro Atlanta area (as defined by the official tourism guide for Atlanta). National data indicate that rural areas are often underserved by the health/medical/education sector and struggle to provide appropriate services due to difficulties in recruiting licensed professionals.16 In many non-metro Atlanta counties, services for children who are DHH are limited or nonexistent. Without early intervention, these children experience delays in language and literacy.

16 April 12, 2017. Sibon-Macarro, Teresa. Rural Perspectives of Models, Services, and Resources for Students with Hearing Impairments. https://journals.sagepub.com/doi/abs/10.1177/875687051403300404?journalCode=rsqa&

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Figure 3. Geographic Location and the Impact on Children Who are DHH 58% of Counties report five or fewer students who are DHH. There are 159 counties and 181 local school districts in Georgia. 58% of Georgia counties report five or fewer children who are DHH, and 21% do not report any children in SPED with a primary eligibility of DHH. It is important to note that in some instances a county may include more than one school system (e.g., Lowndes County has Valdosta City Schools and Lowndes County Schools, Cobb County has Marietta City Schools and Cobb County Schools).

Lack of Audiological Screening and Audiological Care Services Children must first be diagnosed with hearing loss in order to be eligible for SPED services. Simply put, without a diagnosis, the state cannot serve children who are DHH. Georgia mandates newborn hearing screenings, and as a result 96% of babies born in 2017 were screened by one month of age.17 However, Georgia does not mandate ongoing, periodic screening for school-age children after initial entry into the public school system. As a result, many children who have late onset hearing loss or progressive loss are never diagnosed. Other states such as Florida, South Carolina, and Colorado mandate periodic school-age screenings, and the multiagency task force recommends further study into this issue with a potential recommendation of introducing legislation mandating periodic school-age screening statewide.

17 2017 CDC EHDI Hearing Screening and Follow-up Survey (HSFS) Version 2

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Figure 4. Lack of Hearing Diagnostic Centers in rural Georgia. Figure 4 shows the location of known infant hearing diagnostic centers in the state by county. Infants who do not pass their hearing screening at birth must then receive a full diagnostic evaluation in order to be diagnosed as DHH. The significant lack of diagnostic centers is a contributing factor to the low number (i.e., 32%) of infants receiving a full diagnostic evaluation within the critical completion period (i.e., by three months of age).18 Further investigation into the lack of audiological diagnostic services is a key recommendation in this report.

18 2017 CDC EHDI Hearing Screening and Follow-up Survey (HSFS) Version 2

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Lack of Educational Services In addition to health services, there is also a lack of educational services for children who are DHH. It is not uncommon for children who are DHH who reside in non-metro counties to receive school instruction from a teacher who is not certified to teach children who are DHH. Children who are DHH who use American Sign Language (ASL), often do not receive appropriate services related to ASL interpreting due to a lack of resources or an inability of the school district to fill staff positions with certified professionals. At the time of this report, only two schools educating children who are DHH who use ASL are known to require ASL proficiency standards for their teachers (e.g., the Georgia Department of Education State Schools Atlanta Area School for the Deaf (AASD) and Georgia School for the Deaf (GSD)). However, AASD is a day school located in Clarkson, GA and therefore requires a long daily commute for non-metro residents. GSD is a residential school (with a day school option) located in Cave Springs, GA. Thus, geographic challenges limit attendance for many potential students for whom the State Schools may be the most appropriate school placement.
A parallel, statewide lack of access to certified professionals using the Auditory Verbal (AV) approach exists for students using Listening and Spoken Language. The Atlanta Speech School is the only school that provides AV language instruction in a classroom setting (serving ages 18 months through Pre-Kindergarten). In addition, the Auditory Verbal Center provides AV therapy in a clinical setting with locations in Macon and Atlanta (though teletherapy services are available). Many families drive long distances to access AV services. Both the Atlanta Speech School and the Auditory Verbal Center are private settings. There is a lack of AV services in the public school system.
One of the key recommendations of the task force is to evaluate the lack of publicly available ASL and AV resources for children who are DHH throughout the state.

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Figure 5. Children who are DHH by Age 40% are in the critical age window for intervention. 11% of children diagnosed as DHH are infants and toddlers ages 0-3. (It is important to note that Georgia PINES may serve children up to age 5. Children 4-5 years are a small percentage of those served by Georgia PINES, and services are generally provided when a child is late enrolled to the program.) Georgia PINES is a free, state-supported early intervention program that provides critical services for children who are DHH. Approximately 30% of children with a primary SPED eligibility of DHH are between Preschool and 3rd grade (three years to eight years).

Approximately 40% of children with a primary SPED eligibility of DHH are between birth and eight years of age (3rd grade) a key window for early intervention for language and literacy. According to Get Georgia Reading, "the end of 3rd grade marks the critical time when children shift from learning to read to reading to learn. Children unable to make this shift face serious barriers for future learning because they can't grasp half of the printed fourth-grade curriculum and beyond, including math and science. As a result, these children fall even further behind".19
Therefore, current legislation requires the multiagency task force to implement language supports through the use of specifically designed assessments. These assessments are formative in nature and are to be used as benchmark data to support language acquisition and usage. They will be of low cost to no cost to local school districts and other providers that serve children who are DHH. In addition, an individualized child plan will be created for every child who is DHH, which will empower families and professionals to ensure children are meeting these milestones.

19 http://getgeorgiareading.org/framework-overview/

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Figure 6. Children who are DHH by Educational Setting 90% are receiving services in the home (i.e., early intervention) or local school setting (i.e., school-age services). An overwhelming majority of children with a primary SPED eligibility of DHH are enrolled in home-based early intervention services via Georgia PINES or are receiving SPED services via their local school district as opposed to the State Schools for the Deaf (i.e., GSD and AASD). The State Schools have a combined enrollment of 213 children who are DHH which represents less than 10% of the reported DHH child population.

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Figure 7. Children who are DHH and Economic Disadvantage 69% of children who are DHH are Economically Disadvantaged. Almost 70% of children with a primary SPED eligibility of DHH are economically disadvantaged students (EDS) as defined by the DOE. Georgia defines EDS as students who are eligible for a free or reduced price lunch meal (FRM). For schools with federal waivers, all students are classified as economically disadvantaged; these data are collected as part of the student record. A family's economic resources have a significant impact on their ability to access services for their child who is DHH.20

20 April 12, 2017. Sibon-Macarro, Teresa. Rural Perspectives of Models, Services, and Resources for Students with Hearing Impairments. https://journals.sagepub.com/doi/abs/10.1177/875687051403300404?journalCode=rsqa&

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Figure 8. Geographic Location and the Connection to Economic Disadvantage among children who are DHH A greater percentage of children who are DHH who attend nonmetro Atlanta schools and the State Schools are economically disadvantaged. The figure below shows that families residing in non-metro Atlanta areas have a higher percentage of children who are economically disadvantaged. 75% of non-metro Atlanta families are defined as economically disadvantaged compared to 62% of families in the metro Atlanta area. Students in the State Schools are also more likely to fall into this category. In 2018, approximately 68% of all children with a primary SPED eligibility of DHH from preschool through third grade were considered economically disadvantaged. This represents a slight decline from 72% in both 2016 and 2017.

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Figure 9. Children who are DHH by Race and Ethnicity 64% of children who are receiving SPED services with a primary eligibility of DHH fall within the following race/ethnicity groups: Black, Hispanic, Asian, and Two or More Races. For the general student population, optimal child outcomes are tied to early intervention and school-age services that are responsive to diverse home languages and cultural identities.21 22 23 It is important to understand the racial and ethnic composition of children who are DHH as the same likely holds true. Recruitment of bilingual professionals is an ongoing challenge that may affect optimal service delivery and warrants further research.

21 Martin, M. & Vaughn, B. Cultural & Global Competence: The Nuts & Bolts of Diversity & Inclusion.
https://diversityofficermagazine.com/cultural-competence/cultural-competence-the-nuts-bolts-of-diversity-inclusion-
2/ 22 Pratt-Johnson, Y. (2006). Communicating Cross-Culturally: What Teachers Should Know.
http://iteslj.org/Articles/Pratt-Johnson-CrossCultural.html 23 Nieto, S. Teaching Diverse Students Initiative. https://www.tolerance.org/

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Figure 10. Children who are DHH Compared to General Education Population by Race/Ethnicity There is racial/ethnic disparity dependent on school placement setting for children who are DHH Disparities between race and ethnicity are evidenced when broken out by school placement. The DHH SPED population within local schools (not including State Schools) mirrors statewide student enrollment in terms of racial/ethnic composition. However, when the DHH SPED racial/ethnic composition in local school systems is compared to State Schools, a significant difference is revealed. The trend lines in Figure 10 clearly illustrate that a disproportionate number of Black and Hispanic children attend the State Schools when compared to the statewide student population and DHH SPED population within local schools. This requires further research.

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In summary, the data show the following with regards to children/students receiving SPED services with a primary eligibility of DHH:
The state significantly underestimates the true DHH child population. There are approximately 2,326 students from birth to 12th grade receiving SPED with
a primary eligibility of DHH. Approximately 50% of children receiving SPED with a primary eligibility of DHH
live outside of metro Atlanta. 58% of counties report five or fewer students who are DHH and receiving SPED with
a primary eligibility of DHH. 40% of reported children receiving SPED with a primary eligibility of DHH are in the
critical age window for early intervention and school-age services that support language and literacy proficiency. 90% of children receiving SPED with a primary eligibility of DHH receive services in a home or local school setting. 69% of reported children receiving SPED with a primary eligibility of DHH are economically disadvantaged. Among children receiving SPED with a primary eligibility of DHH, a higher percentage of non-metro Atlanta (75%) and State Schools (78%) students are economically disadvantaged when compared to metro Atlanta students (62%). 64% of reported children who are receiving SPED services with a primary eligibility of DHH are Black, Hispanic, Asian and two or more races. Students who are Black and Hispanic are overrepresented in the State Schools when compared to the General Education population and the SPED DHH population in local school districts.
The DHH child population is complex and difficult to accurately identify. However, it is clear that certain factors such as race/ethnicity, geographic location, and economic disadvantage likely play a role in child outcomes. In addition, the unequal distribution of children who are DHH across the state results in a lack of critical services for over half of the DHH child population. A key recommendation of the multiagency task force is to further study this disparity and to create an action plan to address this issue.

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The DHH Language and Literacy Dashboard
In order to determine the current state of language and literacy outcomes for children who are DHH and to measure future progress, a DHH Language and Literacy Dashboard was developed. Success metrics are matched to each of the key transactions in the transaction map (page 12) to ensure appropriate, child-focused measurement. For this year's report, all data were not available.
While a dashboard of aggregate data is helpful to evaluate the current state of children who are DHH, the ultimate goal is to move towards a comprehensive, child-focused view as we measure opportunities for both ecosystem level and individual child level improvement and progress. Eventually, every child who is DHH in Georgia will have access to his/her own dashboard measuring his/her individual progress from birth to literacy with specific steps on how the state ecosystem can help him/her achieve their full potential. Age appropriate language and literacy outcomes for a child who is DHH are optimized when key transactions are met by a certain age. The ages below represent upper thresholds for optimal language and literacy outcomes based on best practices.

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Transaction 1: Newborn Hearing Screening and Rescreen Birth to 1 month
On April 13, 1999, the Universal Newborn Hearing Screening law was signed and is arguably one of the most influential pieces of legislation impacting outcomes for children who are DHH in Georgia. In 2014, Georgia added newborn hearing screening to the mandatory conditions an infant is screened for at birth under Georgia Rule 511-5-5. The revised rule mandates screening and reporting of individualized results for all newborns as well as reporting of follow-up testing of newborns with an initial refer result. The required timeframes for reporting individualized hearing screening results are aligned with best practices established by JCIH 2007 recommendations, Healthy People 2020, the CDC, the Health and Research Services Administration (HRSA), the National Institutes for Health (NIH) and professional guidelines. These specify that all babies should be screened for hearing loss by no later than one month of age. As a result, 124,893 out of 130,006 (or 96%) of babies born in Georgia in 2017 were reported as completing the screening transaction within the critical period of completion (i.e., were screened by one month). Another 3,275 babies were reported to have received a screening for hearing loss after the critical period of completion (i.e., after one month of age), resulting in 1,838 infants born in 2017 who do not have a reported newborn hearing screening.
Transaction 2: Diagnosis By 3 months
As stated earlier, successful language and literacy outcomes are inextricably tied to an early diagnosis of hearing loss. Best practices recommend a diagnostic evaluation as soon as possible but no later than three months of age for any child who does not pass the initial screening or rescreen. Of the babies born and screened in 2017, 1,561 babies were referred for a full diagnostic evaluation (i.e., did not pass previous screenings). Of these babies, 505 or 32% were reported as receiving a diagnosis within the critical period of completion (i.e., three months). Another 45 babies were reported to have received a diagnosis after the critical period of completion (i.e., after three months of age). This leaves approximately 1,011 babies born in 2017 who were reported as not passing their initial screenings but did not have a reported follow-up diagnostic evaluation.
Transaction 3: Early Hearing Orientation Visit By 6 months
After diagnosis, the family has the option to meet with an Early Hearing Orientation Specialist (EHOS) in order to learn about early intervention and language development options including resources available across the state. This transaction should be completed by no later than six months of age. According to the DPH, of the 241 babies born in 2017 and reported as DHH, 98 babies or 41% received an early hearing orientation (EHO) visit within the critical period of completion (i.e., by six months).
Transaction 4: Early Intervention 6 months to 3 years
The state provides early intervention services to children who are DHH via two different programs in two different agencies Babies Can't Wait (BCW) via the DPH and Georgia PINES via the DOE. Families have the option to enroll in one or both programs with the ideal option of being served by both. BCW offers enrolled families safeguards and protections in accordance

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with federal legislation, the Individuals with Disabilities Education Act (IDEA), to include a sliding fee scale and timely transition from Part C services (i.e., early intervention services) to Part B services (i.e., school-age services) by age three. Georgia PINES provides free services in conjunction with BCW services or as a stand-alone provider. The critical benefit of the Georgia PINES program is that all families have access to early intervention experts who are specifically trained to work with children who are DHH.
Babies Can't Wait The Department of Public Health Babies Can't Wait (BCW) provides early intervention for babies birth to age three who have disabilities including children diagnosed with unilateral or bilateral hearing loss. In fiscal year 2017-2018, 18,493 children and their families were served by BCW and 240 of these were children who are DHH. Eligible children and their families receive a minimum of four service coordination visits each calendar year. In addition, families may receive weekly services such as special instruction, occupational therapy, physical therapy, and speech-language therapy as determined by individual needs identified in the Individualized Family Service Plan (IFSP).
Because BCW interventionists work with a wide range of children with disabilities and are not specifically trained to work with children who are DHH, BCW refers children with sensory disabilities (i.e., DHH, DeafBlind (DB), Vision Impairment (VI), DHH with other disabilities, and VI with other disabilities) to Georgia PINES. Georgia PINES provides additional services and Deaf Mentor services specific to the unique needs of a child who is DHH.
Best practices recommend that babies diagnosed with hearing loss should be enrolled in early intervention services as soon as possible, but no later than six months of age. According to the DPH-Babies Can't Wait, of the 221 eligible babies born in 2017 and diagnosed with hearing loss, 78 or 35% were enrolled in Part C Early Intervention services before six months of age.
Georgia PINES The DOE Georgia PINES is the statewide early intervention program funded by the Division of State Schools at the DOE. The Georgia PINES program works exclusively with families with young children with sensory disabilities at no cost to the family. Families may receive up to 72 home visits per calendar year. There are four disability-specific programs within Georgia PINES:
(1) SKIHI - early intervention program for children who are DHH (2) VIISA - early intervention program for children with VI which may include children who are DB (3) INSITE - early intervention program for children who are DHH, VI, or DB and who have additional disabilities (4) Deaf Mentor - early intervention program that supports families learning visual communication strategies, Deaf Culture, and American Sign Language
As of June 2019, 250 children who are DHH were enrolled in early intervention services through the Georgia PINES SKIHI program. For the purposes of the year one report, only data from the SKIHI program will be reported. Data from other Georgia PINES programs will be included in the year two report.

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Figure 11. Age at referral to Georgia PINES SKIHI Early Intervention Program 69% of children enrolled in Georgia PINES are completing enrollment within the critical time (i.e., no later than six months of age). 69% of babies receiving services from Georgia PINES were enrolled by the age of six months. This means of the babies who are referred to Georgia PINES, 172 babies completed the enrollment into the early intervention transaction within the optimal timeframe. 31% or 78 babies were enrolled after six months of age (i.e., they did not meet the enrollment into the early intervention transaction within the optimal timeframe).

Receptive and Expressive Language
Speech and language are different skills. Speech refers to how one produces sounds and words. Speech includes: articulation, voice, and fluency. Language can be spoken (e.g., English and Spanish) or signed (e.g., American Sign Language, British Sign Language, French Sign Language). Some children who are DHH will learn spoken language(s), some will learn sign language, and some will learn multiple languages. No matter what language(s) they may learn, many children who are DHH exhibit language delays that result in later academic delays including reading. Language refers to the words/signs we use and how we use them to share ideas and get what we want. Language includes understanding what words/signs mean, understanding how to make new words/signs, understanding how to put words/signs together, and knowing what one should say/sign at different times. Receptive language is the ability to understand words/signs and language (e.g., understanding a question).

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Expressive Language is the ability to use words/signs and language (e.g., asking a question). Expressive language at the age of three years is a predictor of later reading proficiency.24 Figure 12. Receptive Language and Children who are DHH 110 children (or 44%), who are DHH who are enrolled in the Georgia PINES SKIHI program, are meeting or exceeding age appropriate receptive language milestones. Another 30 (or 12%) children are scoring within one to three months of age appropriate receptive language. However, a total of 140 children (or 56%), who are DHH who are enrolled in Georgia PINES, are not meeting age appropriate milestones. Children who are DHH who do not achieve age appropriate language during the early intervention years are at risk for later language and literacy delays.

24 2013. Durand, Vanessa N. Effects of early language, speech, and cognition on later reading: a mediation analysis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3759794/

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Figure 13. Expressive Language and Children who are DHH 78 children (or 31%) who are DHH who are enrolled in Georgia PINES are meeting or exceeding age appropriate expressive language milestones. Another 41 children (or 16%) are scoring within one to three months of age appropriate expressive language. However, a total of 172 children (or 69%) who are DHH who are enrolled in Georgia PINES are not meeting age appropriate milestones. Children who are DHH who do not achieve age appropriate language during the early intervention years are at risk for later language and literacy delays.

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Transaction 5: Transition Meeting 3 years
The transition meeting occurs when a child enrolled in BCW services transitions out of IDEA Part C services (i.e., early intervention services) into IDEA Part B services (i.e., public-school services). The transition meeting is an opportunity for the IFSP team to come together to discuss next steps in preparing the child and family to transition into public school services. Part B representatives may be invited to the transition meeting to discuss preschool options available through the local school system if an initial evaluation shows the child qualifies for SPED services. Since Georgia PINES is not an official IDEA Part C/BCW provider and sensory support services through Georgia PINES are typically listed as "Other Services" on the IFSP, the transition meetings have not typically included the Georgia PINES early interventionists. Uncoordinated services between BCW and Georgia PINES and a lack of inclusion of the Georgia PINES interventionist in the transition meeting may result in children who are DHH not being appropriately identified by their local school system and not receiving appropriate schoolage services.
For those families who have elected not to enroll in BCW and have received services solely from Georgia PINES, the IDEA Part C mandates do not apply. This may result in these children not completing the transition meeting. BCW and Georgia PINES are working to strengthen their collaborative relationship. Data from BCW were not available for this transaction at the time of this report but will be included in the year two report.
Transaction 6: Preschool Services 3 to 5 years
The preschool years can result in a gap in public services and a subsequent lack of progress for children who are DHH. Some children who are DHH will be eligible for IDEA Part B services (i.e., school-age services). These include a SPED preschool classroom between the ages of three and five years that may or may not have a teacher certified to work with children who are DHH and/or other supplemental services. The Department of Early Care and Learning (DECAL) provides a free, lottery-funded 4-year-old preschool program. For children who are DHH and not eligible for these preschool services, there are no other public options that are DHH specific. Data were not available for this transaction at the time of this report but will be included in the year two report.
Transaction 7: School Instruction 5 to 8 years
The current measure of success for the Georgia ecosystem is the percentage of children who are DHH who read proficiently by the end of third grade. All Georgia public school districts administer the Georgia Milestones English Language Arts Assessment at the end of 3rd and 8th grades. There are four categories of reading proficiency on the Georgia Milestones English Language Arts Assessment. Please see the table with a detailed explanation of reading categories in Appendix F.

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Figure 14. Significantly more children who are DHH who are receiving SPED services with a primary DHH eligibility score in the lowest reading proficiency category (beginning reader) on the Grade 3 Georgia Milestones English Language Arts assessment than in any other proficiency category.
Figure 14 illustrates the number of students who are DHH in each of the four reading categories (e.g., distinguished reader, proficient reader, developing reader, and beginning reader) on the Grade 3 Georgia Milestones English Language Arts Assessment for academic years 2015-16, 2016-17, and 2017-18. Significantly more children who are DHH score in the beginning reader category: 2015-16 91 students out of 138 (or 66%), 2016-17 85 students out of 137 (or 62%), and 2017-18 86 students out of 131 (or 66%).
For the most current school year of 2017-18, only 18 children out of 131 (or 14%) of the children who receive SPED services with a primary eligibility of DHH through local school systems, the State Schools for the Deaf, and state-supervised charter schools read on-grade-level by the end of third grade. This means 113 children out of 131 (or 86%) are not reading proficiently by the end of third grade. As shared in the introduction of this report, on-grade-level reading in the third grade is a major predictor of future academic success as well as adult outcomes.
It is important to note that these data do not include children who are DHH in General Education settings (without SPED services) who may be reading proficiently.

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In summary, the data above indicate the following with regards to children/students receiving SPED services with a primary eligibility of DHH:
96% of babies born in 2017 (124,893 of 130,006) were reported as having completed the screening transaction within the critical period of completion (i.e., screened by one month).
32% of babies born in 2017 (505 of 1,561) were reported as receiving a diagnosis within the critical period of completion (i.e., diagnosed by three months).
41% of babies born in 2017 (98 of 241) and reported as DHH, received an early hearing orientation (EHO) visit within the critical period of completion (i.e., by six months).
69% of babies enrolled in Georgia PINES SKIHI program as of June 2019 (172 of 250) were enrolled within the critical period of completion (i.e., enrolled by the age of six months).
44% of babies who are DHH and enrolled in the Georgia PINES SKIHI program (110 of 250) as of June 2019 are meeting or exceeding age appropriate receptive language milestones.
31% of babies who are DHH and enrolled in the Georgia PINES SKIHI program (78 of 250) as of June 2019 are meeting or exceeding age appropriate receptive language milestones.
Data on the transition from early intervention to preschool services specific to children who are DHH are not currently available.
14% of children receiving SPED services with a primary eligibility of DHH (18 of 131) were reading proficiently at the end of 3rd grade for the academic year 2017-18.

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Recommendations
There is a need for a long-term collaborative plan which will prioritize and address the key issues identified in this report. This plan should be created by the DPH, the DOE and the DECAL and should include feedback from all influencers in the DHH ecosystem.
For year two, the task force will focus primarily on children in SPED with a primary eligibility of DHH who have been "lost by the ecosystem" as defined in this report. These are children who are not connected to any state agency. The GCDHH will reclaim these children through working with the multiagency task force and stakeholder advisory committee.
1. The multiagency task force will focus on specific deliverables as required by Act 462 in order to: a. Develop an actionable, long-term plan to ensure continued collaboration between the GCDHH, the multiagency task force, and the stakeholder advisory committee including data sharing from birth through high school graduation in order to ensure every child who is DHH is on a path to reading proficiently by the end of 3rd grade. b. Create a list of developmental milestones for children who are DHH. c. Implement biannual language and literacy assessments for every child who is DHH. d. Develop a web and print based parent/professional resource. e. Create a process to identify all children who are DHH from birth to 21 and develop and implement a birth to literacy individualized child plan for every child who is DHH in Georgia. f. Deliver the 2020 Annual report.
2. The Collaborative Plan will consider the following key issues discussed in this report in order to: a. Identify and develop a plan to reclaim children "lost by the ecosystem". b. Close the gap in services within the preschool population for children who are DHH. Collaboratively develop a DECAL-approved (i.e., Quality Rated Program approved) Professional Learning Course that Childcare Providers serving the Preschool population (i.e., 3-5 years of age) can access to support implementation of evidence-based instructional supports for children who are DHH. c. Address the impact of socioeconomic status on early detection, intervention and the provision of services to children who have hearing loss. The data in this report suggest a disparity in the provision of services for children who are DHH dependent on race/ethnicity and economic status. The multiagency task force will complete a detailed analysis and collaborate with other state agencies who address larger social issues to identify synergies and actionable solutions. d. Extend services for children who are DHH into rural Georgia. The data in this report demonstrate that 50% of our children who are DHH live outside of metro Atlanta (i.e., outside of the areas where services are typically available). The multiagency task force will evaluate the accessibility of Hearing Diagnostic Centers outside of the metro Atlanta area. In addition, the multiagency

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task force will work with the DOE State Schools Division Mobile Audiology Program (MAP) to deploy a fully outfitted mobile audiology unit to rural areas to provide screening, audiological care, early intervention and hearing aids to children who are DHH. Lastly, the multiagency task force will explore telehealth and teletherapy options to extend services into rural areas where medical/educational resources are scarce. The Mobile Audiology Program (MAP) is scheduled to launch in early 2020. e. Increase compliance and timeliness of data reporting to ensure prompt enrollment into Early Intervention. f. Identify and address resource gaps for students who use ASL, spoken language or a combination of both. g. Collect data on the transition meeting and consider the inclusion of early interventionists with a specialty in DHH education. h. Explore options to provide statewide support to the local school systems that are serving the majority of the DHH student population.
The scope of the work above is broad and deep and will require the support of the governor and the General Assembly in order to be fully addressed. The GCDHH respectfully requests that the following be considered by the governor and General Assembly:
1) Objective: To improve timeliness of diagnosis and prompt enrollment into early intervention for children who are DHH from birth to 8th grade Georgia must receive a diagnosis for children who are DHH in order to address their early intervention and educational needs. Quite simply, if children cannot be identified as DHH through newborn and shool-age screening and diagnostic evaluations, the state cannot provide children who are DHH with the resources they need to ensure 3rd grade literacy proficiency. The GCDHH, in conjunction with the multiagency task force, recommends the following action from Governor Kemp and the General Assembly:
a) Letter from Governor Kemp to birthing hospitals and Audiologists reinforcing O.C.G.A. 31-1-3.2 and 31-12-2 which require the reporting of initial hearing screening results and the results of a diagnostic evaluation for children birth five years within a seven day reporting window The current law requires that birthing hospitals/centers report hearing screening results on every infant. The law also requires that the results of all diagnostic hearing evaluations be reported within seven days. While 96% of babies born in 2017 were reported as receiving a newborn hearing screening by one month of age, only 32% of the babies who did not pass this screening were reported as receiving a follow up diagnostic test by three months of age. Of 1,437 diagnostic evaluations reported to the DPH in 2017, only 892 or 62% were reported within seven days of the evaluation (range: 0-846 days). It is critical that birthing hospitals/centers are timely in their report of initial screening results and that audiologists report children with confirmed hearing loss to the DPH within the mandatory seven day window so that parents can receive timely access to early intervention when

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appropriate.25 Timely diagnosis is the most critical step in the birth to literacy process because diagnosis is the entry point into the Georgia DHH ecosystem. Without a diagnosis of hearing loss, children who are DHH and their families are not eligible for early intervention or later school-age services specific to children who are DHH.
b) Consideration of legislation which would require periodic school-age hearing screenings Currently, Georgia does not mandate ongoing, periodic hearing screening for school-age children after initial entry into the public-school system. As the incidence of childhood hearing loss increases from 1 per 300 at birth to 3 per 300 among school-age children, a lack of school-age hearing screenings results in a significant number of children who are DHH with a missed diagnosis. Other states such as Florida26, South Carolina27, and Colorado28 recommend hearing screenings as often as grades K, 1, 2, 3, 5, and 7. The GCDHH will research the availability and occurrence of school-age hearing screenings in allignment with the recommendatons of the American Academy of Audiologists (AAA) and the American Academy of Pediatrics (AAP). The multiagency task force recommends researching the potential legislation over the next few months and recommending legislation for the upcoming legislative session if appropriate.
2) Allocation of an annual budget for the GCDHH Currently, there is not an associated budget for the work of the GCDHH beyond interpretive services for quarterly meetings which are funded by the Georgia Department of Human Services. Due to the renewed focus on children who are DHH, the GCDHH has identified a great deal of work which must be evaluated and implemented in order to improve language and literacy outcomes. Therefore, the GCDHH requests reconsideration of the annual budget to be commensurate with that of other state Commissions. If amenable, the GCDHH will create a recommended budget for 2020 for the governor and General Assembly's consideration. Funds would be used to hire staff to assist the task force in meeting the above goals.
3) Hold an open house and ribbon cutting ceremony at the State Capitol for the Mobile Audiology Unit The GCDHH would like to hold an open house and ribbon cutting ceremony at the State Capitol in February 2020 that enables the governor and legislators to see the impact of this program which will provide much needed services to families with children who are DHH
25 The Georgia Department of Public Health. https://dph.georgia.gov/testing-and-reporting-unhsi https://dph.georgia.gov/sites/dph.georgia.gov/files/DPH%20ND%20Reporting%20Poster032414.2.1.2016.pdf https://dph.georgia.gov/nbs-policies-and-procedures 26 2011 Florida Statute 381.0056 https://www.flsenate.gov/Laws/Statutes/2011/381.0056?fbclid=IwAR25oWwiq9FzAsGkamOBt7o5THbUvma1pQJV4Iqz0klKy2us5ORVp45hjs 27 South Carolina. All students in grades K, 1, 2, 3, 5 and 7. https://www.scdhec.gov/sites/default/files/docs/Health/docs/SC%20School%20Nurses%20 Mass%20Screening%20Recommendations%20201718.pdf?fbclid=IwAR2tGgBW2h_9eOY8gJITym1kuA78ZnEo7EvqbPKsA1SuxVXLNivsF6MYyo0 28 Colorado. Statute C.R.S. 22-1-116 K, 1, 2, 5, 7 and 9. http://www.lpdirect.net/casb/crs/22-1-116.html

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throughout the state. This will also be an opportunity to present an abbreviated version of this report.
There is an economic cost associated with not meeting the language and literacy needs of children who are DHH. As stated earlier, the lifetime educational cost of hearing loss has been estimated at $115,600 per child over the course of their educational career.29 In addition, unidentified and unmanaged hearing loss results in a loss of household income of up to $30,000 per year which results in a negative economic impact for Georgia due to unrealized taxes.30 The deliverables above will be evaluated for efficacy as well as potential cost savings to the state.
While the incidence (i.e., rate of occurrence) of children who are DHH may be low when compared to other child populations, it is imperative that the state strive to reach a point where every child who is DHH is diagnosed promptly and is receiving every resource he/she needs in order to reach his/her full potential starting with age appropriate language and culminating with reading proficiency by the end of third grade.
The state has access to a vast amount of technology, resources, and education that should be used to propel children who are DHH to their full potential; it is unacceptable that so many children who are DHH are lost by the ecosystem and vulnerable to significantly delayed outcomes. In an effort to increase the number of children who are DHH who are meeting and/or exceeding language and literacy milestones, the multiagency task force will continue to work together in order to prioritize and implement actionable programs.

29 Grosse SD. Education cost savings from early detection of hearing loss: New findings. Volta Voices 2007;14(6):38-40. https://www.cdc.gov/ncbddd/hearingloss/data.html 30 Better Hearing Institute. The Impact of Untreated Hearing Loss on Household Income
Hearing Aid Assistance Tax Credit. http://www.hearingaidtaxcredit.org/index-jump1.cfm

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Thank You to Governor Kemp and Georgia's General Assembly
This annual report on the current state of Georgia's children who are DHH is leading the country in terms of striving for age appropriate language and literacy outcomes for children who are DHH. While many states report statistics on children who are DHH, Georgia is focusing on developing a collaborative plan specific to language and literacy for children who are DHH. To date, the bar has been set far too low for children who are DHH. Subpar outcomes have become the norm and are often considered intractable and thus acceptable.
This legislative report is an accomplishment in and of itself representing the combined work of multiple agencies and a renewed statewide focus on children who are DHH. However, if the state continues to simply report data on an annual basis, the state will have failed these children completely. Simply monitoring the DHH child population and connected outcomes without an orchestrated effort to implement real change in the ecosystem is futile.
This report as well as the key deliverables would not have been possible without the support of former Governor Nathan Deal and First Lady Sandra Deal, former DPH Commissioner Dr. Brenda Fitzgerald, interim DPH Commissioner Dr. Patrick O'Neal, and current DPH Commissioner Dr. Katheleen Toomey, GaDOE Superintendent of Schools Richard Woods and GaDOE State Schools Division Director Dr. Kenney Moore as well as Governor Kemp and our legislative sponsors, Senator P.K. Martin and Representative Penny Houston. In addition to Act 462, both sponsors also introduced The Hearing Aid Coverage for Children Act which was signed into law on May 8, 2017 and has improved access to hearing aids for many children who are DHH in the state. Additional thanks to Christine Murdock, Deputy Director of the Georgia House Budget and Research Office, for her support of the Mobile Audiology Program (MAP) and Vice Chairman Tim Echols, Deborah Flanagan, Leon Bowles, and Tonika Starks of the Public Service Commission, for their support of the Lighthouse Soundwaves Pediatric Hearing Aid Program as well David Paule, Executive Director of the Georgia Lion's Lighthouse Foundation. Lastly, a generous thank you to Governor Kemp for his continued commitment to Get Georgia Reading and every child's right to literacy.
This is an exciting time to be working for the future of Georgia's children who are DHH. The Georgia Commission for the Deaf or Hard of Hearing, the DPH, the DECAL, and the GaDOE thanks each of you for your time and commitment to Georgia's children who are DHH. The Commission's and the multiagency task force's aim is to deliver an actionable and measurable collaborative plan in 2020 which will serve as a roadmap towards language and literacy proficiency for all of the state's children who are DHH.

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Appendix A: Appointees for the Georgia Commission for the Deaf or Hard of Hearing (GCDHH)

The GCDHH is comprised of 12 members, ten of whom are appointed by the governor. The Senate Committee on Assignments appoints one member, and the Speaker of the House of Representatives appoints the final member. The GCDHH serves as the principal agency of the state to advocate on behalf of persons who are DHH by working to ensure those persons have equal access to the services, programs, and opportunities available to others. The GCDHH assists children who are DHH and their parents in advocating for equal access to services, programs, and opportunities, advises the governor, General Assembly, Commissioner of Human Services, and the Commissioner of Community Health on the development of policies, programs, and services affecting people who are DHH and on the use of appropriate federal and state moneys for such purposes.

Position DHH adult ASL DHH adult English DHH adult English and ASL Deaf-Blind Adult Late deafened (after 18 years) Parent of DHH Child English Parent of DHH Child ASL Otolaryngologist or Audiologist Private Provider of Services for DHH Person involved w/Programs for DHH At Large
At Large *Current Chairperson

Appointee Governor Governor Governor Governor Governor Governor Governor Governor Governor Governor Senate Committee on Assignments Speaker of the House GCDHH votes

Current Commissioner Jimmy Peterson Jennifer Clark Ellen Rolader Dana Tarter Jim Lynch Kelly Jenkins Deshonda Washington Dr. Jiovanne Hughart Comer Yates* Dr. Amy Lederberg Dr. Chip Goldsmith
Dr. Beth Lytle Comer Yates*

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Appendix B: Appointees for the Multiagency Task Force

Created within the GCDHH is a multiagency task force for the purposes of establishing a system of collaborative governance responsible for:
making recommendations to the General Assembly and the governor regarding essential improvements to the statewide system of developmental and educational services that support age appropriate language and on-grade-level literacy proficiency for children who are DHH from birth to third grade,
engaging with stakeholders at the Department of Public Health (DPH), the Department of Early Care and Learning (DECAL), and the Department of Education (DOE) to ensure a seamless, integrated system of care from birth to literacy for children who are DHH, and
developing and supporting interagency practices and policies that support the implementation of individualized birth to literacy plans for each child who is DHH.

Position Chairperson of GCDHH Executive Director of Task Force
The DOE Direct authority over Deaf Education The DPH Direct authority over Early Intervention
The DECAL Authority over Preschool Programs The DPH State EHDI Coordinator The DPH Direct Responsibility over Data Management The DOE Direct Responsibility over Data Management State Board of Education Member Georgia Technology Authority

Current Representative Comer Yates Atlanta Speech School Executive Director Dr. Stacey Tucci The DOE Language and Literacy Initiative Coordinator Dr. Kenney Moore Division of State Schools Superintendent LaToya Osmani Health Promotions Director Jeannine Galloway Maternal and Child Health Director Judith Kerr Child Health Screening Program Manager Lisa Pennington Babies Can't Wait Director Jennie Couture Practice and Support Services Director
Dr. Brandt Culpepper Early Hearing Detection and Intervention Team Lead Michael Lo EHDI Epidemiologist
Levette Williams Chief Privacy Officer
Scott Johnson State Board of Education Chair Steve Nichols Chief Technology Officer Nikhil Deshpande Chief Digital Officer Cameron Fash Director of Intergovernmental Relations

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Appendix C: Appointees for Stakeholder Advisory Committee

A stakeholder advisory committee was created to provide information and guidance to the multiagency task force regarding the following deliverables:

(1) a list of developmental milestones necessary for progressing toward age appropriate language and English literacy proficiency by the end of third grade (2) a comprehensive and accurate web and print based resource for parents and professionals (3) a list of currently available assessments appropriate for evaluating an individual child's progress towards age appropriate language and English literacy proficiency (4) an individual report of a child's current functioning, developed in collaboration with professionals and the parents or caregivers, that will be used for the purpose of monitoring a child's progress toward age appropriate language and English literacy proficiency by the end of third grade

The stakeholder advisory committee is comprised of 13 members appointed by the GCDHH based upon the following criteria for each member as described in the table below.

Position
Parent of DHH Child under 10 ASL (child's language) Parent of DHH Child under 10 Spoken English (child's language) Parent of DHH Child under 10 English as second language (home language) DHH Adult ASL DHH Adult Spoken English Early Interventionist ASL Early Interventionist Spoken English Early Interventionist non-Metro Area Teacher Spoken English, non-Metro School Teacher ASL and Spoken English Deaf Teacher ASL, State School for the Deaf Teacher Spoken English, Metro School Pediatric Audiologist

Current Representative Krystle Wilson Katie Hope Lauren Sangaline
Vyron Kinson Jonathan Brilling Lisa Collis Debbie Brilling Dr. Heidi Evans Kathy Lyons Cherie Wren Wende Grass Lesley Cauble Dr. Jill Maddox

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Appendix D: OCGA 30-1-5 Deliverables Detailed Description
A synopsis of the key deliverables required is as follows with line references from ACT 462:
Completed: The first three deliverables are related to identifying and assembling the individuals responsible for the remainder of the work as required by this legislation.
1. Changes to the Georgia Commission for the Deaf or Hard of Hearing (GCDHH) lines 58 to 136 a. The commission's name was changed from the Georgia Commission on Hearing Impaired and Deaf Persons to the Georgia Commission for the Deaf or Hard of Hearing in keeping with standard terminology. The website (https://dhs.georgia.gov/georgia-commission-deaf-or-hard-hearing) was updated to reflect this change. b. The GCDHH was expanded from seven to 12 members and the composition of appointees was altered to better reflect the DHH community in Georgia.
2. Multiagency Task Force Establishment and Responsibilities lines 137 to 176 A task force was created to foster interagency collaboration with the charge of making recommendations to the governor and General Assembly with the goal of improving language and literacy outcomes for children who are DHH. The first quarterly meeting of the multiagency task force took place on October 9, 2018.
3. Establishing the Stakeholder Advisory Committee lines 177 to 215 A stakeholder advisory committee was also created to collect authentic information from the families, educators, and professionals who serve children who are DHH. These individuals were appointed on April 12, 2019 by the GCDHH.
Short-Term Deliverables (One Year): The following deliverables are expected to be completed within the next year. Responsibilities for each deliverable are noted.
4. List of Developmental Milestones lines 216 to 221 Responsibility of Task Force Current State: Today there is no recognized list of developmental milestones for children who are DHH from birth to third grade. Milestones exist from different agencies with regards to the ages they serve, but a consolidated list and collaborative review of these milestones is needed in order to monitor children who are DHH's progress towards age appropriate language and literacy.
Deliverable Required: The task force is charged with delivery of a list of developmental milestones necessary for progressing towards age appropriate language and literacy by third grade with consideration given to the challenges specific to children who are DHH and their families in Georgia.

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5. GTID Process and Implementation lines 244 to 271 Responsibility of Task Force Current State: Today, individual data resources (i.e., program specific databases) within each state agency are separate, and in general, data is not efficiently or effectively transferred from one database to another. To date, six separate state-level databases have been identified in addition to databases in each local school district. This disintegration of data is to the detriment of individual children who are DHH as it results in a fragmented view of their progress in aggregate. There is no common identifier linking children who receive services via the DPH to those who transfer to the DOE. As a result, it is impossible to evaluate whether process improvements in one agency impact the individual child outcomes in other agencies. It is also currently impossible to deliver an individualized child plan as we cannot specifically identify an individual child as they move through the entire state system.
Deliverable: The DOE utilizes the Georgia Testing Identification Number (GTID) to identify and map the progress of every child enrolled in public school. With the passage of Act 462, the DOE is now able to assign GTIDs at the time of diagnosis through a collaborative process with the EHDI and BCW programs at the DPH. With this early assignment, it will be possible to monitor a DHH child's progress from diagnosis (possible in infancy) until they exit the public-school system at age 21. As of January 2019, the DPH and the DOE have implemented the first step in early GTID assignment. However, this process is manual and additional steps are necessary to follow state and federal privacy statutes as well as parent consent requirements. The task force proposes ongoing implementation will be necessary to utilize the GTID process to establish the individualized child plan required in OCGA 30-1-5. Because agency databases are not linked at this time (with the exception of the DOE's Statewide Longitudinal Database (SLDS) and local school district databases), a manual process has been developed with the end goal being a fully automated process.
Longer Term: 6. Parent Resource lines 222-226 Responsibility of Task Force Current State: One challenge families face when they learn that their child is DHH is understanding and acting on the overwhelming information regarding the state and private resources available. In addition, this information is often inconsistent and at times inaccurate. Parents must visit multiple websites (for those families living in areas without consistent internet service, this poses a significant barrier to access) and often receive many individual resources from multiple providers who often do not collaborate in an effective manner. This piecemeal service delivery is overwhelming for families and does not support the efficient and timely service delivery necessary for optimal language and literacy development.
Deliverable: A web and print based resource will be created for both parents and professionals so that they can monitor each DHH child's individual progress towards language and literacy proficiency. The website will address the specific needs of children who are DHH who may use multiple communication modes (e.g., American Sign Language (ASL), Spoken Language, and home language). The DOE has engaged the Georgia Technology Authority (GTA) in the first phase of this project.

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7. Implementation of biannual Language and Literacy Assessments lines 227 to 233 Responsibility of Task Force Current State: Today, assessments of children who are DHH's language and literacy progress is inconsistent, at times inappropriate, and in some cases not administered at all. Different agencies and service providers use different assessments and may administer these assessments in different ways. Additionally, assessments are not monitored or evaluated in a standardized method, and they are not stored in a localized, central database which presents a challenge in monitoring and responding to individual and population level language and literacy progress.
Deliverable: The Stakeholder Advisory Committee must submit a comprehensive list of recommended (existing) assessments to the GCDHH for approval as follows:
Language Assessments: English, American Sign Language, and Home Language (e.g., Spanish) from birth to three years and English and American Sign Language from pre-kindergarten to third grade (this does not suggest that all children who are DHH will need both English and ASL, instead that some children will need only English assessments, some children will need English and ASL assessments, and some children will need only ASL assessments).
Literacy Assessments: preliteracy skills assessments from three to five years and literacy skills assessments from kindergarten to third grade.
The assessments must be chosen from already existing assessments.
Ongoing: 8. Interagency Collaboration, Provision of Seamless Services and Data Sharing from birth through high school graduation lines 244 to 255 Current State: As current databases and agency roles and responsibilities are independent, data sharing and collaboration has not been a priority. As stated earlier, states in which one agency has responsibility for a DHH child's outcome from birth to 21 often have a much higher outcome at third grade as well as at the post-secondary level. This indicates that collaboration between the three agencies which influence DHH child outcomes is paramount.
Deliverable: Collaboration is ongoing. As long as children who are DHH are identified, the need for collaboration which includes data sharing, multiagency process improvements and monitoring with the focus being on the child is necessary. This legislative requirement of collaboration will result in future improvement efforts which will be reported on an annual basis. Of course, the development of our children who are DHH does not end in third grade. The requirement of data sharing from birth to 21 will set the foundation for moving towards the realization of every DHH child in Georgia reaching his/her fullest potential and becoming a productive and fulfilled citizen.

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9. Individualized Child Report lines 234 to 237 Responsibility of Task Force Current State: While children with a primary eligibility of DHH educated in the public sector have Individualized Education Plans (IEPs) or IFSPs, they are often not aligned towards providing resources that will result in language and literacy acquisition.
Deliverable: This deliverable will result in parents and caregivers alike being informed of the potential of children who are DHH to develop language and literacy and will ensure that accommodations provided will allow children to demonstrate literacy proficiency by the end of third grade.
10. Annual Legislative Report lines 272-280 Responsibility of the DPH, the DOE and the DECAL and delivered by the GCDHH Current State: Previously, there has been no documentation on the current state of DHH children's language and literacy outcomes nor the improvements and recommendations necessary to improve them.
Deliverable: An annual report will promote transparency, require data sharing and support ongoing collaboration to improve language and literacy outcomes for children who are DHH. Future reports will also deliver recommendations and resource requirements necessary for achieving these outcomes.

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Appendix E: Current Service Provision by Agency
Birth to Three years of age Early Hearing Detection and Intervention Program (EHDI) the DPH
Screening all newborns for hearing loss at birth (i.e. Universal Newborn Hearing Screening, UNHS)
Ensuring all newborns who do not pass the initial hearing screening be rescreened by one month of age
Ensuring that all newborns who do not pass the rescreen receive a full diagnostic evaluation by three months of age
Ensuring that babies diagnosed as DHH are enrolled in early intervention by six months of age
Follow-up of babies through the EHDI process is conducted by the State EHDI Coordinator and 18 District EHDI Coordinators located in each of Georgia's 18 Public Health Districts
Babies Can't Wait (BCW) The Department of Public Health BCW provides early intervention for babies, birth to age three, who have disabilities including children diagnosed with unilateral or bilateral hearing loss. In Fiscal Year 2017-18, 18,493 children and families were served by BCW and 240 of these were children who are DHH. Eligible children and their families receive a minimum of four Service Coordination visits each calendar year and based on individual need as identified in the IFSP, can receive weekly services such as special instruction, occupational therapy, physical therapy, and speech-language therapy.
Georgia Loaner Hearing Aid Bank the DPH The loaner hearing aid bank program loans hearing aids to children for six months with the option of a six-month extension. Specifics of the program are as follows:
There are no requirements other than an audiogram No financial commitment for the parent Aids are shipped to an audiologist to program and fit Pediatric care kit sent with all aids Audiologist is paid for fitting ($150/aid) and one ear mold per aid by the health district Audiologist is given a FedEx label to return the aids (no cost to the audiologist) Aids are returned to the Auditory Verbal Center (AVC) AVC will clean and check aids for future use AVC logs and tracks aids
Georgia PINES The DOE Provided under the DOE (Division of State Schools), Georgia PINES provides disability-specific early intervention services for children with diagnosed sensory disabilities (hearing and/or vision loss, as well as those with additional disabilities). For the purposes of this report, information will be specific to those children served via the Georgia PINES SKIHI program, which focuses specifically on children for whom hearing loss is their primary/only area of need. Currently, there are 250 children who are DHH in 69 counties receiving services from the Georgia PINES

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program. In some circumstances, Georgia PINES serves a very small number of children ages four to five who are typically late identified. Children and their families are eligible to receive:
Up to four home visits a month/48 home visits per year from an Early Intervention Service Provider with specialized training in early language development strategies specific to children who are DHH
Up to three home visits a month/36 home visits per year from a Deaf Mentor who is a college-degreed Deaf adult who has received specialized training in Early Intervention as related to visual language, American Sign language (ASL) and Deaf Culture
All services are provided without charge to families with children who have a diagnosed hearing loss
Birth to 19 years of age Georgia Lions Lighthouse Pediatric Hearing Aid Program Public Service Commission (PSC) The Sound Waves Pediatric Hearing Aid Program is administered by the Georgia Lions Lighthouse Foundation in the belief that no child should be denied hearing aids due to the inability to pay. Through funding from the Telephone Relay Service (TRS) fund granted by the Georgia Public Service Commission, children from birth to 19 years old who are uninsured or underinsured may be provided hearing aids and three years of ongoing audiological care at a very low cost. Sound Waves served 42 families in 2017, 35 families in 2018 and 19 families through June 2019.
Birth to 21 years of age Georgia Hands & Voices (GA H&V) Guide by Your Side Program (GA H&V GBYS) the DOE & the DPH GA H&V is a nonprofit group comprised of six parent guides and a program director who serve 173 families statewide. Eligible children and their families receive the following:
Free services for one year and access to the state chapter thereafter A Parent Guide for the first year who will help the family gather resources including, but
not limited to, early intervention services, technology, language options, and therapies. All Parent Guides have children who are DHH, allowing them to provide authentic peerto-peer support and guidance Free attendance to all seasonal events hosted around the state Free access to all social media resources that aim to connect families on similar journeys Transition into the GA H&V chapter for continued support, resources, and connection with other families that have children who are DHH for an annual membership fee of $25
Birth to 5 years of age Bright from the Start - The Georgia Department of Early Care and Learning (DECAL) Bright from the Start is responsible for meeting the childcare and early education needs of Georgia's children and their families. Several programs are under the DECAL umbrella:
Georgia's Pre-K Program serves approximately 80,493 children. Children with disabilities are included in all programs and 167 inclusion classrooms have been established to provide additional support to children with more complex needs. These

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classes have lower enrollment and increased staff to allow individual needs to be met. This past school year Georgia's Pre-K served 3,078 children with IEPs. (No data is collected regarding the eligibility categories that the IEPs fall under), Licensing Program for childcare centers and home-based childcare programs, Georgia's Childcare and Parent Services (CAPS) childcare subsidy program, Federal Nutrition Programs, Quality Rated Georgia's community powered childcare rating system, Head Start State Collaboration Office distributes federal funding to enhance the quality and availability of childcare and works collaboratively with Georgia childcare resource and referral agencies and organizations throughout the state to enhance early care and education, and Georgia's Cross Agency Child Data System (CACDS) aligns critical data from programs and services for children zero to five and their families. The purpose of the system, is to identify services gaps, create opportunities for analysis and research, and provide an integrated and aligned approach to demonstrate how the state is meeting the needs of its youngest learners. Data is sent to the system from four partners currently, three state agencies and Head Start grantees across the state. All participating programs are represented by a Governance Committee that meets regularly to discuss priorities for Georgia's CACDS (www.gacacds.com)
The participation data included in CACDS is historical in scope with the most recent data reporting on the enrollment year July 1, 2017 June 30, 2018. Data is currently available on www.gacacds.com. This same data is visualized using Tableau in partnership with the Get Georgia Reading Campaign: https://public.tableau.com/views/GACACDS_age/Story?:embed=y&:display_count=yes&publis h=yes:showVizHome=no#2
School-Age (Age Two to High School Graduation) Georgia Hands & Voices Advocacy Support & Training (ASTra) Program the DPH (EHDI) A parent-driven, nonprofit organization that provides free, educational advocacy, and support to parents and professionals concerning IDEA, Section 504, and additional state and federal laws regarding education. There are currently three advocates who have a total of 102 families on their caseload and have attended 17 IEPs since 1/1/19. Eligible children and their families receive:
Training on educational law and how to effectively advocate for their child An advocate to assist them with IEPs, IFSPs, and transition services Additional services and supports, as needed
School-Age (Age Two to High School Graduation) Atlanta Area School for the Deaf (AASD) The DOE Located in Clarkson, Georgia, AASD enrolled 179 students Prekindergarten 12th grade in the 2017-18 school year. A public day school, AASD provides an English/ASL bilingual learning environment.

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Services other than the typical classroom instruction include:
Audiological services Speech language services Psychological & socio-emotional services/supports (this includes psychological &
academic evaluations) Transition planning services (this includes a partnership with GVRA) academic intervention support Work-Based Learning program CCART program (College and Career Academy: Ready for Transition program) CTAE program offering six CTAE pathways Family Engagement support including support for Spanish-speaking families Afterschool programs (e.g., tutoring, driver education classes, enrichment activities,
sports, etc.) Toddler Program (in partnership with GA PINES) for 2-year old toddlers ASL Community Classes for families and community members
Georgia School for the Deaf (GSD) The DOE Located in Cave Spring, Georgia, GSD enrolls approximately 80 children Prekindergarten 12th grade. A public day/residential school, GSD provides an English/ASL bilingual learning environment.
Services include (other than the typical classroom instruction): Audiological services Speech language services Psychological & socio-emotional services/supports (this includes psychological & academic evaluations) Transition planning services (this includes a partnership with GVRA) Academic intervention support Work-Based Learning program CCA program (College and Career Academy) CTAE program offerings Family engagement support including support for Spanish-speaking families Afterschool programs (e.g., tutoring, driver education classes, enrichment activities, sports, etc.) ASL community classes for families and community members
Local School Districts The DOE There are currently 181 school districts, large and small, across the state containing over 2,200 schools that employ over 114,800 teachers who educate approximately 1.6 million students. Local school districts are required to provide services for students in general education and special education settings in accordance with state and federal education laws including IDEA.

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Privately Available (known) Resources Include: The Atlanta Speech School (Katherine Hamm Center) A private school located in Atlanta that partners with families/individuals who are developing listening and spoken language. The school offers individual Auditory Verbal Therapy sessions for all ages (birth - 99), and classroom environments for Toddlers (18 months) through PreKindergarten. The Atlanta Speech School enrolled 63 children in the 2018-19 school year and offers opportunities for financial aid. The Auditory Verbal Center A family education program for families seeking a listening and spoken language outcome by providing weekly Auditory Verbal therapy sessions until the child is age appropriate expressively and receptively as compared to a typically hearing peer. The AVC serves children with any degree of hearing loss as well as those with multiple disabilities starting as young as two months old. In 2018, the AVC served 167 children. The center accepts Medicaid, all CMOs, and private insurance, in addition to providing financial assistance to those in need. There are locations in both Macon and Atlanta in addition to teletherapy services. Children's Healthcare of Atlanta (CHOA) offers a comprehensive audiology treatment program for infants, children and young adults with mild to profound hearing loss. CHOA's pediatric otolaryngologists (ear, nose and throat doctors, or ENTs), audiologists (hearing specialists) and therapists offer a full range of audiology diagnostics and treatment services including evaluation, treatment, auditory-verbal therapy, and newborn screening. Pediatric ENT of Atlanta (PENTA) is the largest private, non-academic practice in the nation devoted exclusively to pediatric ENT medical care including implantable hearing devices (e.g., cochlear implants and bone-conduction implants), mastoid and middle ear surgery, hearing screenings, hearing loss evaluation and management, conventional hearing aids, and otitis media diagnosis and treatment. 20/20 Hearing (www.2020hearing.org) is a nonprofit hearing aid assistance program that provides hearing aids at no cost to eligible families. Let Georgia Hear (www.letgeorgiahear.org) is a parent advocacy group working to improve access to hearing aids for children in Georgia.

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Appendix F: Georgia Milestones Grade 3 English Language Arts Assessment Reading Proficiency Category Descriptions

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Appendix G: ACT 462

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Appendix H: Glossary of Terms
1-3-6 EHDI Guidelines National best practices/guidelines established by EHDI encouraging screening by one month of age, diagnosis of hearing loss by three months of age, and entry into early intervention (EI) services by six months of age.
504 Plan The 504 Plan is a plan developed to ensure that a child who has a disability identified under the law and is attending an elementary or secondary educational institution receives accommodations that will ensure their academic success and access to the learning environment.
AAA American Academy of Audiology
AAP American Academy of Pediatrics
ASL American Sign Language
AtL Access to Language (AtL) initiative at Grady Hospital
ASTra Program Advocacy Support & Training (ASTra) Program Program available through Georgia Hands and Voices which provides parents with training on educational law and how to effectively advocate for their child, an advocate to assist them with IEPs, IFSPs and transition services and additional services and supports as needed.
BCW Babies Can't Wait Provides services to improve developmental potential of infants and toddlers birth to age 3, with developmental or chronic health conditions. Provided under the DPH.
BIBS Babies Information and Billing Services web based central repository of case management data on children enrolled in and served by BCW.
BVI Blind - Visually Impaired
CACDS Georgia's Cross Agency Child Data System (CACDS) aligns critical data from programs and services for children zero to five and their families. The purpose of the system, is to identify services gaps, create opportunities for analysis and research, and provide an integrated

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and aligned approach to demonstrate how the state is meeting the needs of its youngest learners. Data are sent to the system from four partners currently, three agencies and Head Start grantees across the state. All participating programs are represented by a Governance Committee that meets regularly to discuss priorities for Georgia's CACDS (www.gacacds.com).
CDC Centers for Disease Control and Prevention
DHH Deaf or hard of hearing - A student who is Deaf or hard of hearing is one who exhibits a hearing loss, whether permanent or fluctuating, that interferes with the acquisition or maintenance of auditory skills necessary for the normal development of speech, language, and academic achievement. [Refer to 34 CFR 300.7 (3), (5)]
DB Deafblind
DECAL The Department of Early Care and Learning Also referred to as Bright from the Start, Georgia Department of Early Care and Learning is responsible for meeting the child care and early education needs of Georgia's children and their families.
DOE The Georgia Department of Education Oversees all aspects of public education in the state. The DOE is also responsible for the education of DHH children ages 3 - 22. Includes Atlanta Area School for the Deaf and Georgia School for the Deaf.
DPH The Georgia Department of Public Health Lead agency in preventing disease, injury and disability; promoting health and well-being; and preparing for and responding to disasters from the health perspective. Includes Maternal and Child Health (MCH) which oversees newborn screening and Early Hearing Detection and Intervention (EHDI) which provide services for DHH children birth to 3.
EHDI Early Hearing Detection and Intervention Provided under the DPH, EHDI maintains and supports the statewide screening and referral system. This includes screening for hearing loss in the birthing hospital; referral of those who do not pass the hospital screening for rescreening;

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diagnostic audiological evaluation as appropriate as well as linkage to appropriate intervention for those babies diagnosed with hearing loss.
EI Early Intervention The provision of services to babies and young children with developmental delays and disabilities and their families. May include speech therapy, physical therapy, and other types of services.
FERPA The Family Educational Rights and Privacy Act of 1974 (FERPA) is a federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education.
Georgia Hands and Voices - A parent driven non-profit organization that provides peer to peer support to families of children who are deaf or hard of hearing regardless of communication modality. Children are served from birth-21.
Georgia PINES Georgia Parent Infant Network for Educational Services Early Intervention program for families of children birth to three years with a diagnosed hearing loss and/or visual impairment. Georgia PINES' Sensory Kids Impaired Home Intervention (SKI-HI) program provides weekly services for children who are DHH. Georgia PINES may serve children up to age 5. Children 4-5 years are small percentage of those served by Georgia PINES and typically occurs when a child is late enrolled to the program.
GCDHH Georgia Commission for the Deaf or Hard of Hearing Created in 2007 to advocate for DHH persons, work with state and federal agencies to promote economic development for DHH persons and to recommend legislation to the governor and General Assembly.
GENED General Education
Georgia Milestones English Language Arts (ELA) Assessment A comprehensive, summative assessment program spanning grades 3 through high school which measures how well students have learned the knowledge and skills outlined in the state-adopted content standards in English Language Arts.

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Georgia Pathway to Language and Literacy A group of stakeholders founded Georgia Pathway in 2010 to advance the literacy proficiency of Georgia's children who are Deaf or hard of hearing (DHH).
GKIDS Georgia Kindergarten Inventory of Developing Skills A year-long, performancebased assessment used to provide teachers with information about the level of instructional support needed by individual students entering kindergarten and first grade. GKIDS data is recorded based on the school system's curriculum map or report card schedule. Individual student reports are generated at the end of the year based on the data the teacher has entered throughout the year.
GLRS The Georgia Learning Resources System Network of 18 regional programs that provide training/resources to personnel and parents of students with disabilities to support academic achievement and post-secondary success. Provided under the DOE.
GTA The Georgia Technology Authority Manages delivery of IT infrastructure services to the 85 Executive Branch agencies.
GTID Georgia Testing Identifier A unique, unchangeable, random ten-digit number assigned on a permanent basis to each student enrolled in a publicly funded K-12 Georgia school or program.
Healthy People 2020 - Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. For 3 decades, Healthy People has established benchmarks and monitored progress over time in order to encourage collaborations across communities and sectors, empower individuals toward making informed health decisions and ensure the impact of prevention activities. https://www.healthypeople.gov
HIPAA Health Insurance Portability and Accountability Act of 1996 is federal legislation that provides data privacy and security provisions for safeguarding medical information.

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HRSA Health Resources and Services Administration The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, is the primary federal agency for improving health care to people who are geographically isolated, economically or medically vulnerable.
IDEA Individuals with Disabilities Education Act Passed in 1975, IDEA proposes to provide free, appropriate public education (FAPE) to children with disabilities and to give parents a voice in their child's education. Part C of IDEA is a federal program that assists states in providing early intervention services to infants and toddlers with disabilities from birth until age 3. Part B of IDEA governs how special education and related services are provided to school-age children ages 3-22.
IEP Individualized Education Program Framework for determining the meaning of the term a free, appropriate public education (FAPE) in the least restrictive environment (LRE), which is developed and reviewed annually and must be in effect at the beginning of each school year in accordance with IDEA (Individuals with Disabilities Education Act). This is an education document for children from three to 22 years of age.
IFSP Individual Family Service Plan Serves children birth to three years of age with a focus on family involvement. When a child moves from BCW to special education, the IFSP is replaced by an IEP.
INSITE An early intervention program for children who are DHH, VI, or DB and who have additional disabilities and administrated through Georgia PINES.
JCIH - Joint Committee on Infant Hearing National committee within the American SpeechLanguage-Hearing Association which addresses issues that are important to the early diagnosis, intervention, and follow-up care of infants and young children with hearing loss. Created the 1-36 Guidelines.
LSLS Listening and Spoken Language Specialist Certification Awarded by the AG Bell Academy which is the global leader in Listening and Spoken Language Certification. The requirements for the Listening and Spoken Language Specialist (LSLS) Certification set

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universal professional standards for knowledge and practical experience providing listening and spoken language intervention for children who are DHH and their families.
NIH National Institutes of Health
Part B Services Provision of services for children with special needs from three years to 21 years as specified by IDEA.
Part C Services Provision of services for children with special needs from birth through age two as specified by IDEA.
RESAs Regional Educational Service Agencies 16 agencies strategically located in service districts throughout the State of Georgia. The agencies were established for the purpose of sharing services designed to improve the effectiveness of the educational programs of the member school systems.
SendSS State Electronic Notifiable Disease Surveillance System the DPH's information system for reporting screening, laboratory, and diagnostic results for notifiable diseases, including permanent hearing loss in children birth to five years of age.
SI Sensory Impairment
SLDS Statewide Longitudinal Data System (SLDS) - The Statewide Longitudinal Data System is designed to help districts, schools, and teachers make informed, data-driven decisions to improve student learning. SLDS is a free application that is accessed via a link in the district's Student Information System (SIS). It provides districts, schools, and teachers with access to historical data, including Assessments, Attendance, Enrollment, Courses, and Grades beginning with the 2006-2007 school year.
SPED Special Education

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TWMB Talk with Me Baby A collaboration of six leadership organizations including the DPH, the DOE, and the Campaign for Grade Level Reading working to bring the concept of language nutrition into public awareness and to educate caregivers on the importance of talking with their baby every day. This program is not specific to DHH children.
TDHH Teacher of the Deaf/Hard of hearing
UNHS Universal Newborn Hearing Screening 1999 Georgia law requires that no fewer than 95% of all newborn infants born in hospitals in the state be screened for hearing loss at birth and that local birthing hospitals and audiologists must report data to DPH/EHDI when infants do not pass the initial hearing screen or are diagnosed with hearing loss.
VCSL Visual Communication and Sign Language Checklist A developmental checklist of visual (ASL) language development.
VI Visually Impaired
VR Vocational Rehabilitation - A set of services offered to individuals with mental or physical disabilities designed to enable them to attain skills, resources, attitudes, and expectations needed to gain employment.

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