NECHEAR Family Support: The Role of the Pediatric Audiologist Karen M. Ditty, M.S. Texas ENT Specialists, P.A. Antonia Brancia Maxon, Ph.D. Diane Brackett,

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Family Support: The Role of the Pediatric Audiologist

Karen M. Ditty, M.S.Texas ENT Specialists, P.A.

Antonia Brancia Maxon, Ph.D.Diane Brackett, Ph.D.

New England Center for Hearing Rehabilitation354 Hartford Tpke.

Hampton, CT 06247860-455-1404

[email protected]

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Parental Reaction (Luterman)

• Mourning “the lost normal child” – Shock– Recognition– Denial– Acknowledgment– Constructive action

• Parental Expectations

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Parental Reaction (Luterman)

• Audiologist’s role– Understand where parents are in process– Consider amount of information they can

handle at any given time– Repeat information– Consider culture

• Culture, community, access

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Parental Reaction (Luterman & Maxon)

• Parents are overwhelmed

• Long term vs. short term goals

• “Fixing” the problems

• Where does child “belong?”

• “Taking care of” the child

• How the family changes

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What is the pediatric audiologist’s role in diagnosis and intervention ?

Explaining hearing, hearing loss and amplification

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Auditory Development

Skill Age BehaviorLocalization 6 mos Head turn to source

Min Aud Angle 6-18 mos Decreases 15-40

Detect duration

differences <6 mos <= 20 msec

Pitch perception <6 mos large for detection

Speech perception 1 month VOT can be made

2 mos Falling vs. rising F0

9-18 mos Prefer highly novel

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Speech Signal Discrimination

• Learning about inflection– angry vs. soothing– question vs. statement

• Learning about intensity– loud vs. soft– near vs. far

• Perceptual categories– consonants– vowels

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Auditory Connections

• Objects make specific sounds• Important people make specific sounds• Food preparation has specific sounds• Toys, pets, etc. make specific sounds• Auditory feedback loop critical

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What is the pediatric audiologist’s role in early intervention?

Understanding and explaining typical spoken language

development

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What is progress?

Define the area of communication you are talking about….

- auditory skills

- speech

- spoken language

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How does language develop in normally hearing children?

• Listening, speech, and language develop simultaneously.

• Meaning is established by hearing sounds, words, phrases used in a particular situational context.

• Refinement of skills occur by comparing one’s own production with a model.

• Spoken language development continues into adolescence.

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How does spoken language develop in children with hearing loss?

The same way if the child has access to spoken language through appropriate sensory device..

• Listening, speech, and language simultaneously.• Meaning = hearing in context• Refinement occurs with comparison to a model.• Spoken language development through teens.

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BUT……..• It is difficult to provide sufficient audible

exposure to language in totally natural situations

• The parent/therapist needs to purposely increase exposure to spoken language to counteract the many times that it is “masked” by noise or distance.

• The “conscious” process of ensuring reception and understanding begins at identification and continues through adolescence.

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EXPECTATION• Children who grow up using appropriate

sensory devices have the potential to develop superior spoken language skills.

• Achievement of that potential is dependent on:– quality of the auditory information – dependence on auditory information– input from parents/therapists/children– high expectations

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What is the pediatric audiologist’s role in early intervention?

Basic principles of early intervention

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Service Provision

• Families should have equal access to a coordinated program of comprehensive services that:

– foster collaborative partnerships

– are family centered

– occur in natural settings

– recognize best practice in early intervention

– are built on mutual respect and choice

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Audiologic Habilitation

• Pediatric audiologist– expertise in infant hearing aid selection and

fitting– expertise in using appropriate pediatric testing

equipment and methods– experience working with infants and their

families– flexibility in scheduling

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Audiologic Habilitation

• Pediatric aural rehabilitationist– expertise in

• infant development• infant auditory development• infant speech and language acquisition

– experience working with infants and their families

– flexibility in scheduling

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What is the pediatric audiologist’s role in early intervention?

Supporting family’s understanding of language choices

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Communication Modality

• Spoken language options– auditory-verbal

• use amplified residual hearing to learn to listen, comprehend spoken language

• uses auditory input only

– oral/aural • use amplified residual hearing to acquire spoken

receptive and expressive language • uses auditory input with speech reading when

necessary

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Communication Modality

• Spoken language options– cued speech

• use hand configurations and positions to assist in identifying and discriminating among visible speech sounds

• uses auditory input when possible

– total communication• use all means of communication (sign, auditory) to

acquire spoken language - e.g., Signing Exact English

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Communication Modality

• American Sign Language– A separate language - not based on spoken

English– Use hand signs and finger spelling to acquire

language with its own vocabulary and syntax– Does not use auditory input

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What is the pediatric audiologist’s role in early intervention?

Helping families understand and select sensory devices

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Purpose of Amplification

• Accessing the Speech Signal

• Speech must be well above detection within an appropriate dynamic range

• Maximal exposure to speech spectrum

• Maximizing use of residual hearing• Develop/maintain auditory feedback loop

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Amplification Candidacy

• Any child with any degree of hearing loss is a candidate for amplification

• Without amplification– with 15 dB HL thresholds 98% of everyday speech is

received– with 40 dB HL thresholds 50% of everyday speech is

received– with 55 dB HL thresholds 5% of everyday speech is

received

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Pediatric Amplification Fitting

• Initiate amplification process immediately after diagnosis or change in hearing levels

• Select, fit and validate amplification with clinical and functional evaluations

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Pediatric Hearing Aid Fitting/Validation

• Ongoing process with flexible instrument• Clinical measures

– More audiological data - setting adjustment

• Observe behaviors, communication, environment– Audiologist– Family– Service providers

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Pediatric amplification fitting

• Audiologist should use real-ear measures

• Audiologist should use prescriptive fitting

• Audiologist should have experience with functional measures of benefit

• Audiologist should have scheduling flexibility and understand the need for immediacy of fitting

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What is the pediatric audiologist’s role in early intervention?

Helping families understand problems and daily use of

amplification

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Practical Problems

Problem SolutionMaintaining BTE Huggies, Strap holder, clips

Removing batteries Battery door lock

Changing volume Volume cover, deactivate volume

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Issues with Amplification

Behavior Problems SolutionsBlinking, flinchingOutput/gain too Decrease output

to loud sounds high; tolerance prob. or gain

Pulling out earmolds Not used to molds Use “huggies”

or strap

Poorly fitting molds Remake or refit

Sore ears- allergic Remake with hypoallergenic

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Issues with Amplification

Behavior Problems SolutionsFeedback Inappropriate settings Reprogram

Cerumen plug Medical treatment

Poorly fitting mold Remake

OME Medical treatment

Pulling on or chewing Cords too obvious String cords

cords behind back, through clothing;

decrease length

Not responding to Poor high frequency Change settings;

high pitches amplification modify earmolds;

frequency trans.

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Issues with Amplification

Behavior Problems SolutionsBlinking, startling Over amplification in Reduce low gain;

to low pitches low frequencies change FRC, h.a.

Poor responses to Not a full-time user; Work to better use

sounds Cannot use traditional Consider CI

amplification

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What is the pediatric audiologist’s role in early intervention?

Helping families understand candidacy for cochlear implants

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UNHS affects the age of cochlear implant candidacy identification

• Bilateral severe to profound sensorineural hearing loss

• Infant/toddler cannot benefit from traditional amplification

• 12 months old is recommended lowest age.

• Some surgeons are implanting younger infants.

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Factors that Facilitate CI Success

• Parents know about hearing loss and accept long-term problems

• Parents understand the implant is not a cure

• Parents are committed to implant use

• Parents are committed to therapy

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Factors that Facilitate CI Success

• Family has access to therapy and mapping facilities

• Family is motivated

• One parent at home - minimal day care

• The household is organized

• Child is vocalizing

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What is the pediatric audiologist’s role in early intervention?

Helping families understand problems and daily living with a

cochlear implant

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Information Needed by Parents

• Parents wanted most information prior to surgery, but wanted continued informational support post-implant

• Parents felt emotional support was most lacking

• Majority of parents felt there needed to be a professional liaison between CI center and educational program (Most and Zaidman-Zait, 2003)

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Information and Follow-up for Parents

• Cochlear implant orientation and ongoing support for all care providers

• On-going mapping after initial stimulation – When changes in responses to sound are seen– When changes in vocal/verbal output are seen

• On-going service by early intervention provider

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Practical Problems

Problem SolutionMaintaining headpieceHuggies, Strap holder, clips

Chewing on cords Stringing wires behind

and headpieces

Changing volume Locking volume control

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Issues with Cochlear Implants

Behavior Problems SolutionsBlinking, flinchingCs, Ms too Decrease thoseto loud sounds high; facial nerve levels, turn off

stimulation electrodes

Red, sore spot Magnet strength Change magnetsunder headpiece too much Use moleskin

Not responding to Inadequate high Change Ts, Cs/Ms;high pitches frequency stimulation change frequency

table

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Issues with Cochlear Implants

Behavior Problems Solutions

Not responding to Inadequate low Change Ts, Cs/Ms;

high pitches frequency stimulation change frequency

table

Soft voice Over stimulation Change Ts/Cs

Loud Under stimulation Change Ts/Cs

Poor voice quality Inadequate stimulation Change settings

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What is the pediatric audiologist’s role in early intervention?

Helping families understand life transitions

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Transitions: Parent Perspective

• There are always transitions in life

• There are always options in the transition periods

• Knowing options and goals helps through the process

• There is more than one way to get through the transition with a positive outcome

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Transitions

• Early Intervention to School System

• Elementary to Middle School

• Middle School to High School

• Life After High School

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Referral to and Enrollment in Early Intervention

• Know established IDEA Part C (0-36 months) guidelines in state

• Know child eligibility criteria– automatic enrollment - diagnosed condition

– significant developmental delay

– know state guidelines for selecting a program

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Enrollment in Early Intervention

• Develop Individualized Family Service Plan (IFSP)– All services

• speech and language development• auditory development• assistive technology

– Goals and objectives– Timelines

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Components of IFSP for I/T with Hearing Loss

• Amplification provision– parent education

• Audiological monitoring• Development of auditory skills• Communication development

– listening skills - speech perception– speech production– language development

• Monitoring middle ear status

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Language Development: Determining what children need to know at various

ages

• Need to determine– Interactors

• Adults exposed to• Children exposed to

– Situations• home• school• community

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Leaving Early Intervention

• Helping parents understand differences in LEA and EI approaches

• Working toward a smooth transition

• Ensuring good services continue

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“What’s the difference”

Goals of Birth to Three• Strengthen families to

meet the developmental and health-related needs

of their infants and toddlers who may have

delays or disabilities• Families must be involved

with the process to develop the IFSP

Goals of Special Education

• Educate the child with a delay or disability

• Families must be members of the PPT meetings that make

decisions on the education of their child

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Timeline

• Referral to LEA

• Investigate– word of mouth, phone calls to Special Education

Director, Teacher of the Hearing Impaired, or other people in the school system with which you are familiar

• Observe preschools– neighborhood preschools, Special Education

Preschools, preschools for children with hearing impairment

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Things to consider

• Services– individual therapy– center-based or school

based– consultations

• Assistive Technology– FM– MAP adjustments

• Classroom Environment– acoustics– teaching style– language of other

students– willingness of teacher

to make modifications (if not already)

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Things to consider• Part time preschool - is your child able to be

home for the rest of the day or is another preschool or daycare involved? Availability of full-time preschool?

• Extended school year• In-service Training

– technology – classroom modifications– teaching styles

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Elementary to Middle School Transition

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Middle School Language

Adults Children Environment

parents siblings home

family

------------ ------------- -----------

teachers classmates (20+) school

------------ ------------- -------------

coach team sports fields

social group (3+) community

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Differences

• Moving from a sheltered environment to less protection

• Multiple teachers– Teachers are still working with a restricted

number of students

• More “specials” options– Foreign language– Shorter length of time during year

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Teachers

• Modifications become extremely important– Repeat, rephrase, direct lessons, etc.

• Willing to use an FM system– Microphone technique– Pass around microphone

• Want to have input into the teachers (team) that are selected

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Academics

• More content harder language

• Higher expectations for getting information without “spoon feeding”

• Where does the paraprofessional fit?

• Scripting really critical

• What classes do you give up for special services

• Communication demands

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Potential Issues

• The “dread FM”– It can never be too small or too invisible

• Adolescence– Socialization - old friends change– Still a limited number of groups– Everyone should be the same– Separating “typical” from hearing loss

problems

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Middle School to High School

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Differences

• Higher expectations– More student independence– Less family input– Less written information sent to family

• More rooms – Need to ensure good listening conditions– Specials: new vocabulary, noise

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Teachers

• More difficulty finding teachers who will readily make modifications

• Different teacher for every subject– Each teacher responsible for many more

students– Teacher does not know each child as well

• Willing to use an FM system– May not “get” the need for it

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Teachers

• They need more in-service training, but they have less time for it

• More difficult to get team meetings organized

• Less likely to notice changes

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Academics

• More content harder language

• Foreign language

• Levels of classes

• How does the paraprofessional work at this level?

• Note taking - listening and writing at the same time

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Academics

• Having a note taker

• Literature vs reading

• College preparation vs vocational

• Interaction demands of classes

• Communication demands of the classes

• Written demands of the classes

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Potential Issues

• Sports can be a form “automatic” social groups

• More social groups to choose from - likely to find a comfortable fit

• More choices for different interests

• School-related social interactions take place in noise, e.g., cafeteria

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High School Language

Adults Children Environmentparents siblings home

family

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teachers classmates (20+) school

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coach team sports fields

social group (3+) community

1:1 social community

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Life After High School

and the beat goes on