Getting Started with Audiologic Rehabilitation Audiologic Rehabilitation for Children and Educational Audiology SPA 6581 – Spring 2015 Lecture Date: 01/06/2015.

Getting Started with Audiologic

RehabilitationAudiologic Rehabilitation for Children and Educational

AudiologySPA 6581 – Spring 2015

Lecture Date: 01/06/2015

Topics• Background• Review syllabus and course requirements • Audiology Scope of Practice regarding AR• Neurological Foundations of Listening and Talking • Getting started with Aural Habilitation• The Auditory System• Effects of Hearing Loss on Development of

Speech and Language

A Hybrid• Dually certified by ASHA as a SLP and an AuD• Specific clinical interests include: cochlear

implants, auditory verbal therapy, incorporating speech and audiology, investigating and demonstrating the habilitative aspect of audiology, interdisciplinary teams

• Positions held in speech and audiology: public school systems (elementary through high, total communication programs, oral communication programs), special education schools, group homes, residential facilities, home health, private practice, ALF and SNF, and cochlear implant teams.

Recommended Resource Texts

• Cole, E. B., & Flexer, C. (2007). Children with hearing loss: Developing listening and talking birth to six. San Diego, CA: Plural Publishing, Inc.

• Deconde Johnson, C., & Seaton, J. B. (2012). Educational

audiology handbook. (2nd ed.). Clifton Park, NY: Delmar Cengage Learning.

• Ling, D. (2002). Speech and the hearing-impaired child: Theory and practice. (2nd ed.). Washington, DC: Alexander Graham Bell Association for the Deaf and Hard of Hearing.

• Ling, D., & Ling, A. H. (1978, 1980, 1985). Aural habilitation: The foundations of verbal learning in hearing-impaired children. (3rd ed.). Washington, DC: AG Bell Association for the Deaf, Inc.

“The most debilitating consequence of onset of

hearing loss in childhood is its disruption to learning speech and language.”

-ASHA

What’s the difference?

Habilitation vs. Rehabilitation

Why does the differentiation matter?

How might it aid you?

Audiologic HabilitationAudiologic (Hearing) (Re)Habilitation is the process of

providing training and treatment to improve hearing for those who are hearing impaired.

or

Audiologic/Aural rehabilitation (AR) is an ecological, interactive process that facilitates one’s ability to

minimize or prevent the limitations and restrictions that auditory dysfunctions can impose on well-being and

communication, including interpersonal, psychosocial, educations, and vocational functioning.

AR Today• “…Client-centered rehabilitation model that

promotes successful adherence to treatment recommendations and professional accountability.”

• Each child and family should have an individualized aural (re)habilitation plan. o Who comes up with that plan?

• The scope of practice of AR has expanded such that not all aspects of AR are as likely to be addressed by either an audiologist or a speech-language pathologist as they were 20 years ago.

Routine Aspects of ARExpanded Range and Increased Complexity

• More Recent View: o Assessment measures

o Educational, behavioral, technological, and counseling intervention procedures

o Ongoing client-clinician interaction• Evaluate and monitor

progress

• AR is NOT just limited to: o Speechreading

o Auditory training

o Hearing aid orientation

o 30 day trial period

Focus of AR Services• Training in auditory perception• Improving speech• Developing language• Managing Communication

o Pragmatics

• Managing hearing aids and assistive listening deviceso Making the best use of personal amplification deviceso Exploring assistive deviceso Adjusting to hearing loss

• May incorporate visual cues

Services Depend On…Chronological age

Age of onset of hearing loss

Age at which the hearing loss was diagnosed

Severity/extent of the hearing loss

Type of hearing loss

“Hearing age”

Communication Mode

Others?

Service ModelsIndividualized

Small groups

Combination of both

Therapist/patient dynamic

Therapist/parent/patient dynamic

Members of AR Team

Other Potential Members:• Office Staff• Administrative

Support• Social Worker• Group Home

Managers• Pediatrician• Psychologist• Others?

Primary Members:• The PATIENT and the

FAMILY/Caregivers• Otolaryngologist (ENT)• Audiologist• Speech-Language Pathologi

st• Listening and Spoken

Language Specialist• Hearing Therapist• Early Interventionist• Educators

o Itineranto Mainstreamo Teacher of the Deaf

Quote from the 70sMy how far we’ve come! …or have we?

“People who have all the skills required for work in parent-centered habilitation are rare. Most

specialist teachers of hearing-impaired children have too little knowledge of speech science,

audiology, and counseling; most audiologists have insufficient background in child development,

speech science, language acquisition and education; and most speech pathologists have few, if any, skills relating to audiology, education, and

the speech acquisition problems of hearing-impaired children.”

(Ling & Ling, 1978)

Is Coursework Enough?

The interdisciplinary nature of AR, particularly in the area of pediatrics where speech and language intervention is crucial, supports the need for additional training/coursework beyond the current minimal requirements for certification for either audiology or speech-language pathology!

Professional Expertise

Educators

Speech PathologyAudiology

Aural Habilitation

and Education

(Ling & Ling, 1978)

Roles of Professionals• Audiologists and Speech-Language Pathologists

roles may be: o Complementaryo Interrelatedo Overlapping

• Both Audiologists and Speech-Language Pathologists bring specific knowledge and skills to the ongoing facilitative process of AR.

Basic Areas of Knowledge and Skills:

Audiologists• Basic Communication

Processeso Anatomic and physiologic basis

for normal development and use of speech, language, and hearing

o Physical bases and processes of the production and perception of speech and hearing

o Linguistic and psycholinguistics variables related to the normal development and use of speech, language and hearing

o Dynamics of interpersonal skills, communication effectiveness, and group theory

• General Knowledgeo General psychologyo Human growth and

developmento Psychosocial behavioro Cultural and linguistic

diversityo Biological, physical, and social

scienceso Mathematicso Qualitative and quantitative

research methodologies

Specific Areas of Knowledge and Skills: Audiologists

• Auditory System Function and Disorders• Developmental Status, Cognition, and Sensory

Perception• Audiologic Assessment Procedures• Speech and Language Assessment Procedures• Evaluation and Management of Devices and Technologies for

Individuals with Hearing Impairment• Effects of Hearing Impairment on Functional

Communication• Effects of Hearing Impairment on Psychosocial,

Educational, and Occupational Functioning• AR Case Management• Interdisciplinary Collaboration and Public Advocacy• Hearing Conservation/Acoustic Environments

Basic Areas of Knowledge and Skills:

SLPs• Basic Communication

Processes:o Anatomic and physiologic

bases for the normal development and use of speech, language, and hearing

o Physical bases and processes of the production and perception of speech and hearing

o Linguistic and psycholinguistic variables related to the normal development and use of speech, language, and hearing

o Dynamics of interpersonal skills, communication effectiveness, and group theory

• General Knowledge:o General psychologyo Human growth and

developmento Psychosocial behavioro Cultural and linguistic

diversityo Biological, physical, and social

scienceso Mathematicso Qualitative and quantitative

research methodologies

Specific Areas of Knowledge and Skills: SLPs

• Auditory System Function and Disorders• Developmental Status, Cognition, and Sensory Perception• Audiologic Assessment Procedures• Assessment of Communication Performance• Devices and Technologies for Individuals with

Hearing Loss• Effects of Hearing Loss on Psychosocial,

Educational, and Vocational Functioning• Intervention and Case Management• Interdisciplinary Collaboration and Public Advocacy• Acoustic Environments

Professional Expertise

Educators

Speech PathologyAudiology

Aural Habilitation

and Education

Parents

Scope of Practice• American Academy of Audiology• American Speech-Language-Hearing Association

• Who is responsible for providing, facilitating, maintaining, and evaluating aural habilitation services? o Teacherso Clinicians

• Audiologists, Speech-Language Pathologists, Listening and Spoken Language Specialists

o Educational Administratorso Parents

• What other services are within the scope of practice of audiology? o Did you know… “Audiologists may perform speech or language screening, or other

screening measures, for the purpose of initial identification and referral of persons with other communication disorders.” AAA 2004(American Academy of Audiology,

2004)(American Speech-Language-Hearing Association, 2004)

http://www.audiology.org/resources/documentlibrary/Pages/ScopeofPractice.aspx


http://www.asha.org/policy/SP2004-00192/

Scope of Practice: How prepared are we?• Did you know…

o “Audiologists may perform speech or language screening, or other screening measures, for the purpose of initial identification and referral of persons with other communication disorders.”

o “The audiologist is the professional who provides the full range of audiologic treatment services for persons with impairment of hearing…”

o “The audiologist provides assessment, counseling, and ALL aspects of audiologic treatment including auditory training, rehabilitation…”

o “The audiologist…is a source of information for family members, other professionals, and the general public. Counseling regarding hearing loss, the use of amplification systems, and strategies for improving speech recognition is within the expertise of the audiologist.”

o “The audiologist’s scope includes participation in the development of an Individual Education Plan (IEP) for school-age children or an Individual Family Service Plan (IFSP) for children from birth to 36 months old.”

(American Academy of Audiology, 2004)(American Speech-Language-Hearing Association, 2004)

• A few more…o The audiologist provides counseling regarding the effects of hearing loss on

communication and psycho-social status in personal, social, and vocational arenas.

o The scope of practice for audiologists includes screening for speech, orofacial myofunctional disorders, language, cognitive communication disorders, and/or preferred communication modalities that may affect education, health, development, or communication, and may result in recommendations for rescreening or comprehensive speech-language pathology assessment or in referral for other examinations or services.

o The audiologist is responsible for the provision of comprehensive audiologic rehabilitation services, including management procedures for speech and language habilitation and/or rehabilitation for persons with hearing loss or other auditory dysfunction, including but not exclusive to speechreading, auditory training, communication strategies, manual communication, and counseling for psychosocial adjustment for persons with hearing loss or other auditory dysfunction and their families/caregivers(American Academy of Audiology,

2004)(American Speech-Language-Hearing Association, 2004)

“Most hearing-impaired children can learn to speak and understand spoken language if they are given adequate

opportunity to do so. Adequate opportunity can be provided only if

those concerned with the child’s care – parents, teachers, clinicians, and

administrators – are aware of, and exploit, the conditions that contribute

to verbal learning.”

(Ling & Ling, 1978)

Neurological Foundations:Listening and

Talking

Amazing Brains!• Auditory experience in utero and infants with

normal hearing• “We hear with the brain – the ears are just a way

in.” • How do auditory pathways mature?• Neuroplasticity• Secondary Auditory Association areas in the

cortex• Developmental Synchrony• Invisible Acoustic Filter

Typical Infants• At birth, infants prefer their mother’s speech and

they even prefer songs and stories heard before birth.

• Infants are born with 20 weeks of listening experience.o Cochleae are formed and functional by the 20th week of gestation

• So why do we care so much about early identification of hearing loss? o Experience with sound is available to the infant in uteroo Newborns with hearing loss have already missed what?

• 20 weeks of listening!

“We have time, the baby is only 6 months

old…”• What do you think about that statement?• In the first 6 months of life, babies can discriminate many speech

sounds, even those not heard in their home-spoken language(s). • By the end of the first year, there is a functional reorganization of

the brain to distinguish phonemes specific to language(s) heard daily.

• This neural reorganization improves and tunes the phonetic categories required for the infant’s language and attenuates those phonemic distinctions not required for the infant’s mother tongue.

• Infants use their phonetic categories as the foundation for learning new words. Phonetic distinctions guide new word learning by 17 months of age.

• What does that mean for listening experience in infancy? o It is critical for the development of both speech and language in young children, and a strong

language base is essential for reading.

Reading & Higher Order

Language Use

Lexical-Semantic Use

Phonological Processes

Phonetic Categories

Listening Experience

32

Lois Bloom and Margaret Lahey’s Model of

Communication – 1978

Model of Language• Bloom and Lahey (1978)

o Three aspects of language were identified: • language form (syntax, morphology, and

phonology)• language content (semantics)• language use (pragmatics)

• Lois Bloom and Erin Tinker added the following as factors influencing language development:

• effort• engagement

34

Essential Areas of Language

How Much is Necessary?

• In order to obtain adequate language development, how much listening experience is necessary?

• The first three years of experience put in place a trajectory of vocabulary growth and the foundations of analytic and symbolic competencies that will make a lasting difference to how children perform in later years.

• ALL infants and children require a great deal of listening experience in order to develop age appropriate auditory and spoken language skills.

Importance of Early Identification

• Newborn infant screening programs and Newer technology

o These both allow access to critical auditory brain centers during times of maximum neuroplasticity

o Auditory language enrichment can be provided during critical periods of maximum brain neural plasticity – the first few years of life (Sharma, Dorman, & Spahr, 2002; Sharma et al., 2004; Sharma, Dorman, & Kral, 2005).

Auditory Neural Development

• “We hear with the brain – the ears are just a way in.”

• How do auditory pathways mature?o Full maturation of central auditory pathways is a precondition for the normal development

of speech and language skills in children, whether or not they have a hearing loss

• Neuroplasticityo Brain’s availability and malleability to grow, develop, and alter its structure as a function of

external stimulation. o Why is neuroplasticity important?

• Today’s babies and young children who are born deaf or hard of hearing have incredible possibilities for achieving higher levels of spoken language, reading skills, and academic competencies than were available to most children in previous generations.

• Secondary Auditory Association Areaso Cortical levelo Not fully developed until a child is about 15 years old

• Limited time period of optimal neural plasticity (greatest during the first 3 ½ years of life)

• Studies in brain development show that sensory stimulation of the auditory centers of the brain is critically important, and influences the actual organization of auditory brain pathways.

• Neural imaging has shown that the primary and secondary auditory areas are most active when a child listens and when a child reads.

• Phonological or phonemic awareness, which is the explicit awareness of the speech sound structure of language units, forms the basis for the development of literacy skills.

Rapid Development in Infants

• What is required to keep up with the rapid brain development in infants? o PROMPT interventiono …remember…not just identification, but INTERVENTION

• Early amplification or implantation stimulates a brain that is in the initial process of organizing itself, and is therefore more receptive to auditory input, resulting in greater auditory capacity. o However, this only provides the access to sound…

Access, Access, Access• Access will allow for experiences, which will allow for

“programming” of those critical and powerful auditory centers of the brain with acoustic detail and will expand children’s abilities to listen and learn spoken language.

• Early and ongoing intervention is essential. NOT JUST IDENTIFICATION. That is just the first step!

• Important neural deficits have been identified in the higher auditory centers of the brain due to prolonged lack of auditory stimulation.

• The auditory context is directly involved in speech perception and language processing in humans.

Neural Maturation• In order for auditory pathways to mature,

acoustic stimulation must occur early and often because normal maturation of central auditory pathways is a precondition for the normal development of speech and language skills in children.

• Audiologists are critical!o Fitting personal devices which allow for accesso Fitting these devices appropriatelyo Direct, repetitive auditory skills instruction as part of an effective

family-based early intervention program is criticalo EXTRA auditory stimulation is necessary

“A brain can only organize itself around

the sensory stimulation that it receives.”

Impact of the Absence of Sound

• The brain reorganizes itself to receive input from other senses, primarily vision. o Cross-Model Reorganization

• This process actually reduces auditory neural capacity.

We can’t just stop at access!

• Hearing vs. Listening

• “We hear with the brain – the ears are just a way in.”

• Hearing is acoustic access to the brain. o Improves the signal-to-noise ratio by managing the environment and

utilizing hearing technology

• Listening is attending to acoustic events with intentionality.

Intervention Models• Developmental

• Remedialo Not in harmony with normal developmento We need to undo the neural organization that the brain has initially

acquired and reorganize the brain around different stimuli. o This model takes longer and has reduced outcomes. Why?

• The child is now neurologically and psychosocially out of synchrony with the typical developmental process.

Cumulative Practice• What is it?

o Each practice opportunity builds on the last one.

• Mastery of any developmental skill depends on cumulative practice.

• Why do we care about this?o The more delayed the age of acquisition of a skill, the farther behind

children are in the amount of cumulative practice they have had to perfect that skill.

• Another way to think of it…Cumulative Auditory Practice.

Cumulative Practice• Other developmental skills (walking, crawling)

o How do they learn these skills? They practice.

• Delayed auditory development leads to delayed language skills which will necessitate using a remedial rather than a developmental paradigm.

Developmental Synchrony

• Humans are programmed to develop specific skills during certain periods of development.

• If those skills can be triggered at the intended time, we will be operating under a developmental and not a remedial program. o That is…skills mastered as close as possible to the time that a child is

biologically intended to do so result in developmental synchrony

• Intervention later in life is out of harmony with the typical developmental process.

Normal Speech and Language

Development

Normal Development• Based on the age by which most monolingual

speaking children will accomplish identified milestones

• All items in a category are not typically mastered until reaching the upper age in the age ranges.

• Why important? o Not just so you know what abnormal development is…o To aid in counseling a family regarding progress

• Other than… “Little Johnny is doing good!”

Normal DevelopmentHearing, Understanding and Talking

Birth to 3 months

4-6 months

7 months to 1 year

1 year to 2 years

2 years to 3 years

3 years to 4 years

4 years to 5 years

(American Speech-Language-Hearing Association, 2012)

Audition

Speech

Language

Birth to 3 MonthsHearing & Understanding Talking

Startles to loud sounds Makes pleasure sounds (gooing, cooing)

Quiets or smiles when spoken to Produces different cries for different needs

Seems to recognize caregivers voice and quiets if crying

Smiles when sees caregiver

Increases or decreases sucking behavior in response to sound


4 to 6 MonthsHearing & Understanding Talking

Moves eyes in direction of sounds Babbling sounds more like speech; many different sounds (p, b, and m)

Responds to changes in the tone of caregivers voice

Chuckles and laughs

Notices toys that make sounds Vocalizes excitement and displeasure

Pays attention to music Makes gurgling sounds when left alone and when playing with you


7 Months to 1 YearHearing & Understanding Talking

Enjoys games like peek-a-boo and pat-a-cake

Babbling has both long and short groups of sounds (tata upup bibibibi)

Turns head to look in the direction of sounds

Uses speech or other sounds (not only crying) to get and keep attention

Listens when spoken to Uses gestures for communication (waving, holding arms to be picked up)

Recognizes words for common items (cup, book, juice, milk)

Imitates different speech sounds

Begins to respond to requests (Come here, want more?)

Has one or two words (hi, dog, dada, mama) around first birthday, although sounds may not be clear


1 Year to 2 YearsHearing & Understanding Talking

Points to some body parts when prompted

Produces more words every month

Follows simple directions and understand simple questions (Where’s your shoe?)

Uses some one- or two- word questions (Where kitty? Go bye-bye?)

Listens to simple stories, songs, and rhymes

Puts two words together (more cookie, mommy juice)

Points to pictures in a book when named

Uses many different consonant sounds at the beginning of words


2 Years to 3 YearsHearing & Understanding Talking

Understands differences in meaning (go/stop, in/on, big/little, up/down)

Has a word for most everything

Follows two requests (Get the cup and put it on the table.)

Uses two- or three- words to talk about and ask for things

Listens to and enjoys hearing stories for longer time periods

Speech is understood by familiar listeners most of the time

Often asks for or directs attention to objects by naming them



Hears you when you call from another room

Talks about activities at school or at friends’ homes

Hears television or radio at the same loudness level as other family members

People outside of the family usually understand the child’s speech

Answers simple WH questions (who, what, where, and why)

Uses a lot of sentences that have 4 or more words

Usually talks easily without repeating syllables or words



Pays attention to a short story and answers simple questions about them

Uses sentences that give lots of details

Hears and understands most of what is said at home and in school

Tells stories and maintains topic

Communicates easily with other children and adults

Says most sounds correctly except a few like l, s, r, v, z, ch, sh, th

Says rhyming words

Names some letters and numbers

Uses the same grammar as the rest of the family


(Talking Child, LLC, 2003)




Vocabulary• How is vocabulary learned?

• 18 months = 10 to 15 words• 24 months = 45 words• 2 years = 150 words• 3 years = 300 to 400 words• 3 to 4 years = 600 to 1000 words• 4 to 5 years = 1000 to 1600 words• 5 to 6 years = 1500 to 2100 words


Vocabulary: Food For Thought

• Average number of words per house addressed to children by parents (Hart & Risley, 1999): o 2100 in a professional familyo 1200 in a working-class familyo 600 in a welfare family

• How does the vocabulary differ among families? o Professional and working-class families

• More varied vocabulary, complex ideas, subtle guidance, and positive feedback

Typical Speech Intelligibility

Approximate Age % Understood by Parents

18 months A typical child is 25% intelligible

2 years A typical child is 50-70% intelligible

3 years A typical child is 80% intelligible

4 years A typical child is 90% intelligible


“The Invisible Acoustic Filter Effect”

• Hearing loss

• This filter, “distorts, smears, or eliminates incoming sounds, especially sounds from a distance – even a short distance.”

• Hearing is not an isolated activity. Everything else is built upon hearing

• Hearing loss itself is invisible and can be easily ignored or underestimated. o Only the negative effects of hearing loss are visible. o Name some.

“The earlier and more efficiently we can allow a child access to meaningful sound with subsequent direction of the child’s attention to sound, the better opportunity that child will have to develop spoken language, literacy, and academic skills.”

Hearing is the Foundation

Hearing

Spoken Language

Reading and

Writing

Academics

Professional

Flexibility

“What is your vision for your child?”

• Every parent has a vision for their child…even if they haven’t vocalized it yet.

• Why is this important?

• 95% of children with hearing loss are born into hearing and speaking families.

• What will it take to reach that vision the parent has for their child?

Developing Listening and Talking: What it

Takes!• Early identification and intervention • Vigilant and ongoing audiologic management• Immediate and consistent auditory brain access via

technology• Guidance from a professional who is highly

qualified in the development of listening and speaking, through techniques of parent coaching

• Following the professional’s coaching with daily and ongoing formal and informal auditory, language, cognitive, and literacy enrichment.

• Integration and use of auditory strategies into all-day, everyday interactions with the child

“How to Grow Your Baby’s Brain”

• 8. Read aloud• 9. Sing and read

nursery rhymes• 10. Name objects• 11. Describe: sound,

look, and feel• 12. Prepositions• 13. Similar and

Different• 14. Describe sequences• 15. Familiar stories

• 1. Quiet and close• 2. Consistent use of

technology• 3. Device checks and

troubleshooting• 4. FM system• 5. Focus on listening• 6. Joint focus of

attention• 7. Clear speech and

sentences

It’s Not Just About Speech and Language!Hearing Functions• Unconscious Function

o Most primitive function of hearingo Carries auditory background and sounds that serve to identify a

locationo Own biological sounds

• Signal Warning Functiono Monitoring the environmento Distance hearingo Incidental information

• Can teach a child how to start conversations, make requests, problem solve, negotiate, compromise, joke, tease, and use sarcasm

• Spoken Communication Function

Audiology• How well can you counsel a family?

• The hearing system

• Types of Hearing Tests

• Degrees of Hearing Loss

• Causes of Hearing Loss in Children

• Audiograms

“With the technology and early auditory intervention

available today, a child with a hearing loss can

have the same opportunity as a typically hearing child

to develop spoken language, reading, and

academic skills.”

References• American Academy of Audiology. (2004). Scope of practice . Retrieved from


• American Speech-Language-Hearing Association. (2012).How does your child hear and talk?. Retrieved from http://www.asha.org/public/speech/development/chart.htm

• American Speech-Language-Hearing Association. (2001). Knowledge and skills required for the practice of audiologic/aural rehabilitation [Knowledge and Skills]. Available from www.asha.org/policy.

• American Speech-Language-Hearing Association. (2004). Scope of practice in audiology [Scope of Practice]. Available from www.asha.org/policy.

• Cole, E. B., & Flexer, C. (2007). Children with hearing loss: Developing listening and talking birth to six. San Diego, CA: Plural Publishing, Inc.

• Deconde Johnson, C., & Seaton, J. B. (2012). Educational audiology handbook. (2nd ed.). Clifton Park, NY: Delmar

Cengage Learning.

• Ling, D. (2002). Speech and the hearing-impaired child: Theory and practice. (2nd ed.). Washington, DC: Alexander Graham Bell Association for the Deaf and Hard of Hearing.

• Ling, D., & Ling, A. H. (1978, 1980, 1985). Aural habilitation: The foundations of verbal learning in hearing-impaired children. (3rd ed.). Washington, DC: AG Bell Association for the Deaf, Inc.

• Talking Child, LLC. (2003). Child language development. Retrieved from http://www.talkingchild.com/chartvocab.aspx

• Talking Child, LLC. (2003). Intelligibility guidelines. Retrieved from http://www.talkingchild.com/chartintel.aspx

• Talking Child, LLC. (2003). Speech and articulation development chart. Retrieved from http://www.talkingchild.com/speechchart.html

Getting Started with Audiologic Rehabilitation Audiologic Rehabilitation for Children and Educational Audiology SPA 6581 – Spring 2015 Lecture Date: 01/06/2015.

Documents

hearing association

hearing loss

hard of hearing

hearing technology listening

clearamerican speechlanguage

plural publishing

san diego

hearingimpaired children