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CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) convenes the July, 1999 EARLY HEARING DETECTION AND INTERVENTION AD HOC GROUP TELECONFERENCE The verbatim transcript of the EHDI Ad Hoc Group Teleconference convened at 2:00 p.m. on Tuesday, July 6, 1999 Table of Contents I. Welcome and Announcements II. Legislative
News III. Families of Deaf and
Hard of Hearing Children: Advice to Professionals IV. Update from AHCPR,
Preventive Services Task Force V. Summary of CDC/Gallaudet
Genetics of Hearing Workshop JUNE HOLSTRUM: Hello, everyone. I hope you all had a great holiday weekend. I'm June Holstrum from the Centers for Disease Control and Prevention. Welcome to our July teleconference on Early Hearing Detection and Intervention and thank you for joining us. Please remember to mute your microphone when you're not talking. Today's conference is being recorded and the transcript will be available on the Internet. Before we begin our scheduled program, are there any questions, announcements, or updates from any of our listeners? IRENE FORSMAN: June, do you want to hear about the implementation guide here? JUNE HOLSTRUM: Yes we do. Go ahead, Irene. IRENE FORSMAN: For some months, nearly a year now, at the Maternal and Child Health Bureau, we have been working with Carl White on the production of an implementation guide for universal newborn hearing screening. The guide is now finished in multi-color. It is at our clearinghouse and it is being mailed out to all birthing hospitals in the country through the state Title V programs. There is considerably more of a distribution list than that. The guide is being mailed to all the state contacts, to the FICC people, to Part C coordinators, and to all of our regional offices. I have asked that the clearinghouse not release it until we get through with our mailing, but for those of you who want to call and leave a request, the number is 703/821-8955. That's it. JUNE HOLSTRUM: Thank you, Irene. I'm glad you brought that up and I'm glad that it's finally ready. We'll look forward to receiving it. Any questions for Irene? (NO RESPONSE WAS HEARD) Any other updates or announcements from anyone else? (NO RESPONSE WAS HEARD) We have one announcement from CDC, and that's that we have a new web address. The new address is www.cdc.gov/nceh/programs/CDDH/ehdi.htm. The only change is that we have added "CDDH," which stands for Child Development Disability and Health, which is the name of our new division here. Our sources tell us that there are now twenty-one states with legislation on universal newborn hearing screening. Since our last conference, I believe New York, Illinois, Maryland, Missouri, Massachusetts, Indiana, and Wyoming have new legislation. With us today, we have Susan Brannen from New York who has agreed to tell us a bit about the New York legislation. If anyone from any of the other states would like to talk about their bill, we'd be happy to hear from you as well. So go ahead, Susan, if you're there, and tell us about New York. (NO RESPONSE WAS HEARD) JUNE HOLSTRUM: Is there anyone from New York that would like to speak about the bill? FRAN STEVENS: Hi, June. This is Fran Stevens. I know Susan was planning on being on the call, but I'll tell you what, let me start and if she comes on, I'm going to be more than happy to give the floor over to her because she knows about the kind of lobbying that went on to get the bill passed. I'm happy about the bill and I've got my cautions as well because it doesn't say "universal" and it's not a mandate. It was the only way we appeared to be able to get the bill through in New York. So what it does, it recommends that hospitals screen babies as early in life as possible and it charges the administrator in charge of the hospital, to either administer such a program (and here's the part that's a little bit iffy) or to provide for referral of the newborn to obtain such a service. So I think it is a step in the right direction. I would be hard-pressed to call this the universal newborn legislation. On the other token, it might move us forward. So it does designate that the health department is responsible for establishing this program. So it appears to me that in consultation with groups around the state that we will, in fact, develop some kind of a program that will administer newborn hearing screenings, again, without the -- Like I said, there's no such word as "mandated" in here and there's no such word as "universal," but it will get us started. So I think that's all I can say in a nutshell. Susan certainly knows about the kind of lobbying that the New York State Speech, Language and Hearing Association went through to even get it this far. So it's kind of a mixed blessing. JUNE HOLSTRUM: Well, it sounds like it's a good start anyway. FRAN STEVENS: It's a good start. JUNE HOLSTRUM: Anyone have any questions for Fran? MARILYN SASS-LEHRER: Yes, I do. This is Marilyn Sass-Lehrer. When does this take effect? FRAN STEVENS: It takes effect in April of the year 2000, April 1. MARILYN SASS-LEHRER: Okay. Thank you. KIM OLLER: This is Kim Oller from the University of Maine. I was just wondering what proportion of infants in the State of New York are currently being screened, or do you have a good estimate of that? FRAN STEVENS: We don't know that. It's one of the things that I am proposing that we find out because it will really assist us with trying to figure out how to pay for this. I have proposed that we actually conduct a statewide survey. Our seven hospitals that were the demo sites were actually screening about ten percent of the population, but I know that there are many, many hospitals with NICU's that are screening their NICU population on top of that ten percent. So if I had to take a real wild guess, my guess might be (and I don't have any was of verifying this yet until I send out my survey) twenty percent, but, again, that's a wild guess. JUNE HOLSTRUM: Anymore questions for Fran? BARBARA RAIMONDO: I have one. This is Barbara Raimondo from Maryland. Is there any language in the bill about intervention or linkages with existing programs, anything like that? FRAN STEVENS: A little bit. It says the program shall provide for follow-up screening, including referrals for screening or care. BARBARA RAIMONDO: But not educational intervention? FRAN STEVENS: Well, it doesn't specify educational intervention. It calls it "care." That care could be almost anything from medical to educational to a combination. So I think it will depend, then, on how we define the term "care," and I hope that the group that we pull together to do this will assume that the legislators meant this as broadly as possible. BARBARA RAIMONDO: Okay. Thank you. JUNE HOLSTRUM: Do we have any other state representatives that would like to talk a little bit about their states since we have so many new states that have gotten some legislation since we've last talked? (NO RESPONSE) Our next speaker is Dr. Marilyn Sass-Lehrer. Marilyn is a professor in the Department of Education at Gallaudet. Her topic is "Families of Deaf and Hard-of-Hearing Children: Advice to Professionals." Go ahead, Marilyn. MARILYN SASS-LEHRER: I'd like to begin by introducing myself and my colleagues I am a professor at Gallaudet University-in the Department of Education and the director of the Family Centered Early Education specialization in teacher preparation. Kay Meadow-Orlans, is Professor Emeritus at Gallaudet and currently working as a Scientific Review Administrator in the Center for Scientific Review at the National Institutes of Health. Donna Mertens, is a faculty member in the Department of Educational Foundations and Research also at Gallaudet and past president of the American Evaluation Association. Donna, I believe is on line with us today, Donna are you there? DONNA MERTENS: Yes, I'm here. MARILYN SASS-LEHRER: Donna, please feel free to jump into the conversation at any time. In addition to Donna, two graduate students, Kim Scott-Olson, now a family educator at Kendall Demonstration Elementary School on Gallaudet's campus and Selena Steinmetz, a recent graduate of the Family Centered Early Education program have worked with us. All five of us have been involved in a national study of families with young children who are deaf and hard of hearing (d/hh). Our research project began in the spring of 1996. We began this research because we believed there was a lack of information about families' experiences from the time they suspected that their child had a hearing loss through their early intervention years and their transition to preschool. We were struck by the many changes that had occurred in the field of deaf education - especially the technological advances which were showing great promise in identifying hearing loss at birth. We believed that it was critical to understand, from the family's perspective, what families were going through. We were interested in learning more about the experiences of families - from suspicion, to diagnosis including their experiences with early intervention professionals and services, and the advice they have for professionals. Our research has been funded, in part, by Gallaudet University through priority research and small research grant awards. For the purpose of today's teleconference, I thought I would provide you with an overview of our research...what we have done so far, some of our findings which we believe have implications for the provision of services, and what our future plans include. In the spring and summer of 1996, we conducted a national survey of parents whose children were enrolled in programs providing services for deaf and hard of hearing children. The survey was designed for parents whose children were 6 and 7 years old. We selected this age because we believed that by 6 or 7 all children with hearing loss, even those whose hearing loss was mild would have been identified by this time, and yet, families' early experiences would still be fresh in their minds. The purpose of the national survey was to collect information on: 1) Age at which hearing
loss was identified and intervention services started The survey was completed by just over 400 parents in 39 states plus the District of Columbia. Responses received very closely matched the demographic and geographic characteristics of the population of children in this age group (as determined by Gallaudet's Center for Assessment and Demographic Studies) - with just a few exceptions. A summary of the survey was published in the American Annals of the Deaf. Donna, do you have the complete reference? DONNA MERTENS: The American Annals for the Deaf, Volume 142, Number 4, 1997 beginning on page 278 through page 293. The article includes a copy of the entire survey form that we used. MARILYN SASS-LEHRER: Thanks, Donna. The purpose of the survey was to collect information on the age at which hearing loss was identified and the kinds -- and the age at which intervention services began. We also were interested in finding out what kinds of intervention services families were receiving and their level of participation in those services. We were interested in finding out how satisfied they were with the services that they received and their sources of support. We asked them questions to get at their views on deafness, the level of stress that they might have felt during the time of diagnosis and early intervention, and we were also interested in finding out how they assessed their child's social/emotional development and their child's progress in language. The survey was completed by just over four hundred parents, and we had responses from thirty-nine states, plus the District of Columbia. We were quite pleased that our responses very closely matched the demographic and geographic characteristics of the population of children in this age group from the Center for Assessment of Demographic Studies. While we did have a few exceptions, our sample closely matched what we know about this age group of d/hh children. In order to obtain a greater understanding of parental experiences, focus groups and telephone interviews were conducted following the analyses of the survey data. Initially, forty (40) hearing parents were selected at random from the parents who had participated in the national survey. After preliminary analyses of these data B we realized the richness of the information that we were getting and decided to expand the interviews to focus in depth on families with unique situations. Our first set of interviews focused on families whose children were hard of hearing - we were interested in seeing how these families' experiences differed from families whose children were deaf. Next, we interviewed families in which both parents were either deaf or hard of hearing. We have analyzed these data and have some interesting differences in perspectives and advice. We have partially completed interviews with families whose children have multiple disabilities; families who have elected cochlear implant surgery, and families who are non-white - English speaking. We hope to be able to complete interviews with these other families in the near future. For the purpose of the teleconference, I have selected just a few of the many interesting findings to share with you. We were interested in finding out the age at which parents first suspected a hearing loss, when it was confirmed, and then when early intervention services were first received. We found that hearing loss was discovered quite late. We found, on average, that hearing parents in our survey suspected a hearing loss on average at about seventeen months. The confirmation of the hearing loss, however, did not happen for another five months. We found that parents of children who were hard-of-hearing, didn't even suspect a hearing loss until, the children were twenty-two-and-a-half months (on average), and confirmation of the loss was not until twenty-eight months. That's a full year later than parents who had deaf children. Parents with deaf children suspected a hearing loss at around ten months and confirmation was at fourteen months. Deaf parents suspected a hearing loss much, much earlier, by four months of age, and the confirmation of a hearing loss was by nine months. So, clearly, there is a great need for early hearing screening, and it will be interesting to see how the age of identification of hearing loss moves downward as more and more states implement screening programs. We found another long delay from the time that the hearing loss was confirmed to the time that families enrolled in early intervention programs. This is an important point. The families in our study waited almost one full year from the time at which the hearing loss was confirmed until families and children were enrolled in an early intervention program. Although some isolated services begin earlier, for example, many children receive hearing aids, auditory training, speech services or sign language several months after the confirmation, it often takes families quite a while to actually get into an early intervention program. For hard-of-hearing children, the time from the diagnosis of the hearing loss to beginning services was less than for deaf children. However, hard of hearing children still did not begin early intervention programs until they were, on average, three years old. We asked parents to rate their children's language performance. Children who are hard of hearing scored significantly higher than children who are deaf. Deaf parents ratings of their children's language was higher than hearing parents ratings. And hard of hearing children without additional disabilities scored higher than hard of hearing children with disabilities. In regard to social development, about 10% of the parents responding to the survey reported that their children had behavior problems that Amight affect development or education@. In our interviews, several parents reported that they initially suspected that their children had behavioral problems, but later realized that there was a hearing loss. Some parents reported punishing their child for not listening and not responding before the hearing loss was identified. Hearing loss was often misunderstood as a behavior or language delay, and parents reported feeling guilty when they discovered a hearing loss. Parents indicated a desire for more information and support in the areas of social development and behavioral guidelines for children with hearing loss. We discovered from our survey that parents were generally satisfied, in fact, very satisfied with the services that they received. However, we found that some of the parents were less satisfied, significantly less satisfied. In our survey, parents who were not white -- and deaf parents particularly indicated that they were less satisfied with the services they received than hearing families. It may be that service providers need to develop more sensitivity and be more responsive to unique needs of families. In our interviews with parents, we asked them what concerns they had when their child's hearing loss was first discovered.. Many parents told us that they never suspected a hearing loss. They assumed a behavioral problem or a language delay. They felt that professionals often dismissed their concerns, and that some professionals accused them, particularly mothers, of being overly worried or anxious, and one of the mothers said that her doctor told her that it was all in her head. The professionals, they told us, tend to reject a hearing problem, and that parents want to believe that the professional is right, and that there is nothing wrong. This, they say, prolongs and delays their response and postpones their seeking of support and intervention. Parents complained that the information they received from professionals was often incomplete, or biased. They told us that professionals seemed to give them only the information that they think that parents are ready for. In other words, professionals sometimes withhold information instead of giving them all the information and leaving it up to parents to decide how to process that information. Parents said that decisions, in general, are very difficult to make because of all the controversies in the field and among the professionals. It was interesting that when we looked at deaf parents' responses to the questions about their concerns and issues, they had a different view. It appears that deaf parents were less concerned about the professionals' responses and were more concerned about educational and social opportunities for their children. Deaf parents said that they were concerned that the educational programs are not challenging enough for their children, and that their kids are not receiving what they would consider to be age-appropriate programs and experiences. They wanted more emphasis on academics, specifically reading, early literacy. They wanted to be sure that their children had deaf friends, that there were deaf adults in the early intervention and preschool programs for their children to look to as role models, and they wanted their kids to have the same opportunities as hearing children in terms of outside-of-school experiences. They wanted their kids to be able to communicate with both hearing and deaf people. Some of the deaf parents we interviewed complained that there are not enough good interpreters. Professionals, they said, often lack skills to be able to communicate directly with them, and this has a negative impact on their ability to develop positive relationships and interactions with many professionals. We asked the parents to share their advice for professionals. Generally, what we found from the hearing parents' comments fell into four very broad areas. (We do have a list of very specific advice as well). Here's what they told us: First, professionals need to listen to parents. That is, professionals must learn to listen to their concerns. When we asked one parent if she had any advice for professionals, she at first was speechless. She said, AWow, nobody has ever asked me that before." Now, that is really something. Often professionals do not take the time to find out what it is that's really of concern to parents. Other parents told us that professionals need to respect us." There was a theme that ran through the responses which indicated that parents often feel that professionals look down upon parents. Some parents are particularly worried and concerned about other parents who may have limited education, language, or resources. They think that professionals may not treat all families equally. Another theme in the area of advice was that not all professionals have adequate knowledge about hearing loss, or resources available for parents. One parent said that professionals just don't have the information that they should, and it may not be until much later that the parents, on their own, get the information that they should have had much earlier. One other theme that we heard was, again, "Tell us everything". The professionals need to tell parents everything and not withhold information because the professionals think parents don't understand or that they're not ready." From the deaf parents' perspective, they had many of the same suggestions and advice, but in addition, they wanted more parental involvement in decision-making. They told us that they felt left out of the decision-making process. Deaf parents, they believe, have a lot to offer -- particularly during the early years, and that they're not often consulted. Another theme was the professionals need to improve their sign language so that they can communicate with not only deaf parents but other deaf adults. They felt that this was critical. Finally, deaf parents told us that professionals do not have high enough expectations for deaf children. In general, professionals need to raise their expectations for deaf children. They told us that professionals do not always consider what is age or developmentally appropriate for children. I could go on and on, but I think I'm going to stop there. Donna and I have just completed a chapter in a book that should be out soon. The name of the book is "The Deaf Child in the Family and at School". We've summarized the comments from these initial interviews with families. The book is being published, by Ehrlbaum and edited by Spencer, Erting and Marshark. The title of the chapter is "Sensitivity in the Family, Professional Relationship: Parental Experiences in Families with Young Deaf and Hard-of-Hearing Children." BARBARA YOUNG: This is Barbara Young. Could I ask a couple of quick questions? Very exciting information. Could you tell me what the response rate was? MARILYN SASS-LEHRER: Donna, do you want to respond to that? DONNA MERTENS: We went through the program administrators and asked them to give them to their parents. So we don't have an accurate number of how many surveys were actually given to parents or who received them. We did distribute one thousand one hundred and forty-seven. They were mailed to the participating programs. We don't know how many actually were given to parents, but we know that four hundred and four came back to us. So a thirty-five percent response rate, which we realize is not real high, but that's why we did the comparison back to the Center for Assessment of Demographic Studies database, to see where we were in relation to the national database. BARBARA YOUNG: The other question is just -- there might be another, what seems to me, very exciting alternative hypothesis for what should happen. You said obviously this means we should have universal newborn hearing screening -- That's one -- but I wondered, it could also maybe imply that education could go a long ways. Obviously, deaf parents know what to look for and they were identifying it at four months as opposed to seventeen months and twenty-eight months. So it sounded to me like you also have some very strong suggestion that perhaps educating parents about what to look for, and professionals, too, might go a long ways in supplementing whatever else is going on. MARILYN SASS-LEHRER: Right. I think that's a very good point. But, one thing that I found very interesting was that while deaf parents who had deaf children were, quick to identify a hearing loss, that was only true if their children were deaf. If these Deaf parents had children who were not deaf but hard-of-hearing, it took them a much longer time. I found that very interesting, that even though they knew what to look for, some hearing losses, especially mild and moderate hearing losses, are not easy to detect. Certainly, it's helpful for parents to have some guidelines, but without specific instruments to identify and to confirm a hearing loss, some hearing losses would still go unrecognized. DONNA MERTENS: I think you do have a good point about listening to the deaf parents who have that life experience and understanding of what it means to be deaf and what it means to have a deaf child. Their words to us took on a very different tone than the hearing parents. I mean, it was always, "Well, we didn't really care if they were hearing or deaf. We kind of assumed they might be deaf and that's okay." You know, whether or not the child can hear is not particularly a strong emotional trigger the way it is with hearing parents, because if they assume the child might be deaf, then that's an okay thing. Whereas, with a lot of hearing parents, it's extremely emotional when you find out that your child has a hearing loss. So their advice to hearing parents was to "love the whole child." Deaf parents stress that this is a child first who happens to have a hearing problem, and not, it's a hearing loss that must be fixed, and it's not the end of the world. JUNE HOLSTRUM: Marilyn, thank you so much for that valuable report. Could you or Donna you tell us again about when the deaf child book will be coming out? DONNA MERTENS: We're supposed to get our page proof this August and it's supposed to be out before the end of the year. JUNE HOLSTRUM: Great. We'll look forward to that. Are there any other questions for Donna or Marilyn? (NO RESPONSE) If not, Our next speaker is from the Agency for Health Care Policy and Research. David Atkins is going to provide us an update on the U.S. Preventive Services Task Force. David, are you with us? DAVID ATKINS: I've just been asked to update this group on where things are with the U.S. Preventive Services Task Force. As some of you may know, when the U.S. Preventive Services back in '95, looked at the issue of universal newborn hearing screening, although they recommended screening for high-risk infants, they concluded the evidence for universal screening wasn't sufficient to recommend either for or against it. There's obviously been a lot of new data since then. So this was rated a high priority. The review for this is being done by a collaborative group out at Oregon -- OHSU, the Oregon Health Sciences University there, and some pediatricians and an audiologist at University of Washington and Group Health Collaborative at Pugent Sound. We're expecting a draft report of the evidence at our September meeting and we hope after that, we'll draft a policy statement which we will then circulate widely for peer review. We'd obviously like to take advantage of many of the people on this call to serve as expert reviewers. The problems in '95 from the perspective of the Task Force, again, with respect to the Task Force (inaudible) for prevention issues has always been sort of the -- We look at a range of preventive services delivered primarily in the primary care setting, although newborn screening obviously is someone outside that. Again, taking the perspective of (inaudible) and are the benefits of (inaudible) clearly outweigh (inaudible) do not explicitly look at costs, though costs and cost-effectiveness will probably be seeing increasing attention (inaudible) Task Force, although I don't expect that it'll ever become the official basis for recommending or not recommending something. (Inaudible) The data supporting the benefit of early identification (inaudible) had numerous methodological problems and I think clearly (inaudible) and perhaps others (inaudible) some of the potential biases in the studies. (Inaudible) have a lot of data from existing programs. There were concerns about the potential (inaudible) between consequences of (inaudible). Again, that's another area where we have (inaudible) -- I do not have any -- I haven't seen any (inaudible) other than the areas (inaudible) key issues. We hope early this fall to have some draft materials to circulate for outside input. JUNE HOLSTRUM: Okay. Thank you, David. Are there any questions? (NO RESPONSE) Our last, and certainly not our least, speaker is Kim Van Naarden who will give us a summary of the CDC/Gallaudet Genetics of Hearing Workshop that we held here in Atlanta on June 7th. Go ahead, Kim. KIM VAN NAARDEN: Hi. Good afternoon. So last month on June 7th, CDC and Gallaudet University co-sponsored a workshop on the Genetics of Congenital Hearing Impairment here in Atlanta, Georgia. First off, we'd like to thank Gallaudet University, especially Kathleen Arnos and Brandt Culpepper, as well as NIDCD and members of the scientific community for their input in formulating the agenda for the one-day workshop. The partnership between CDC and Gallaudet was a key component of the workshop, ensuring adequate representation from each vested stakeholder. The seventy participants in the workshop included representation from public health professionals, clinical and molecular geneticists, audiologists, ethicists, genetic counselors, various members of the deaf and hard-of-hearing communities, universities, private organizations, and state and local representatives involved in newborn hearing screening programs. The main objectives of the workshop were to build upon these partnerships, to discuss the ethical ramifications of genetic research and hereditary hearing loss, to explore the public health role and significance of population-based research in the genetics of hearing impairment, as well as to discuss the various strategies for how to conduct this type of population-based research. So I'd like to provide a brief summary of the content of the workshop. From the presentations and comments of the workshop, three main areas emerged centered around population-based, rather than clinical-based strategies. First, the distinction between genetic research, testing, and screening is crucial. The point of this distinction is to clarify what is meant by public health, population-based research rather than genetic or clinical research. Two, the importance of the involvement of the deaf and hard-of-hearing communities and other stakeholders in formulating the public health research agenda. Third, the needed development of population-based research to further understand the many aspects of the genotype/phenotype relationship, including both gene-gene and gene-environment interactions. The afternoon panel discussion was entitled, "Potential Strategies for Epidemiologic/Population-Based Research in the Genetics of Congenital Hearing Impairment - How do we get from here to there?" Various considerations were discussed based on previous and current experiences in the field. Most of these experiences were primarily related to genetic research on the Connexin 26 mutations for nonsyndromic autosomal recessive sensorineural deafness. One, based on the recent evidence of varying phenotypes related to a single genotype, prospective studies to investigate environmental modifiers, gene-environment interactions, progressive and late-onset hearing losses, expression in other tissues, as well as to provide a better understanding of the pathophysiology of the ear need to be conducted. Second, existing databases containing serial audiograms need to be preserved and potentially utilized to provide further information on phenotypic variations. Third, newborn hearing screening tracking systems may provide a population-based database for conducting studies on the genetics of hearing impairment. Fourth, the usage of Guthrie blood spots, while easily analyzed for genetic mutations, have proven to be somewhat difficult to obtain, which was evidenced and discussed by the Rhode Island Department of Health and the Boston University collaboration to study Connexin 26 mutations. Five, further support and recruitment of deaf individuals in the medical and science research communities for leadership in the field of genetic research is needed. The official proceedings for the workshop will be available on the CDC web site for the Division of Child Development Disability and Health. The information from the workshop published on the web site will include the presentations of the invited speakers, the list of participants, a transcript of the afternoon panel discussion session, as well as the official summary and recommendations put forth by our division. So you can locate the web site at http://www.cdc.gov/nceh/programs/CDDH/ehdi.htm, which is the same site that June mentioned earlier. Are there any question? (NO RESPONSE WAS HEARD) Thank you. JUNE HOLSTRUM: Thank you, Kim. Before we close, are there any last comments, questions, announcements, or information on legislation from any of our listeners? KIM OLLER: Perhaps we could get a little update -- June, this is Kim Oller again -- regarding states that are still very actively involved. I can mention that Maine had a bill up this year and it has been postponed due to the legal necessity of an insurance review that the proposers of the bill were unaware of, even the legislative proposers, until the last minute, but I'm interested in what other states are in this sort of one-year waiting cycle. JACKIE CUNDALL: Many states submitted -- This is Jackie Cundall in Tennessee. Tennessee did have some legislation on, but it also was kind of (inaudible), but we do (inaudible) -- JUNE HOLSTRUM: Jackie, are you still there? We've lost contact. JACKIE CUNDALL: Yeah, I'm here. JUNE HOLSTRUM: Okay. We lost what you said completely. JACKIE CUNDALL: Oh. I just said that we did have some legislation, but it was also sidetracked and sidelined, but we do propose to try again. JUNE HOLSTRUM: I understand North Carolina and Oregon are fairly close, too. Any other states out there that would like to speak about their states? (NO RESPONSE WAS HEARD) I apologize for all of our interference. We'll try to get it cleared up. That's our program for today. Our next meeting will be September 7th. Thank you for joining us and we'll talk to you in September. Bye-bye. [Whereupon, the teleconference was concluded at approximately 2:50 p.m.] |