Maximizing Auditory Slides

8/10/2019 Maximizing Auditory Slides

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Maximizing Auditoryand Speech Potential for

Deaf and Hard-of-Hearing

Children


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Course Objectives

Today well cover a lot of territory about hearing loss in children.You may be surprised to know that congenital hearing lossaffects between 1 to 3 per 1,000 live births, making it the mostcommon anomaly in newborns.

Well discuss the profound impact of hearing loss on the childs life,

as well as review the wide range of interventions now available.

Perhaps most important, well talk about the communicationoptions available to deaf and hard-of-hearing children, and how tomaximize a deaf or hard-of-hearing childs ability to listen and speak.

Many parents and professionals have assumed that the only optionis sign language, and do not know that almost all deaf and hard-of-hearing children can learn to listen and to speak through oral deafeducation, which gives them many advantages in a hearing world.It is important to note that 90 percent of deaf children are born tohearing parents.

Maximizing Auditory and Speech Potentialfor Deaf and Hard-of-Hearing Children

Good morning, and thank you for asking me here today to talkabout maximizing auditory and speech potential for deaf andhard-of-hearing children.

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Early InterventionEarly identification and intervention are the most importantfactors for maximizing auditory and speech potential for deafand hard-of-hearing children.

As you will learn today, the first six months are crucial. Childrenwhose hearing loss is identified by six months of age developsignificantly better language skills than children identified later.

They achieve more academically and they have an easier timefunctioning in society. Many can manage their day-to-day

interactions independently, without the help of an interpreter.

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Facts: Risk Factors for Hearing Loss -Birth to 29 days

What causes hearing loss?

In about 50 percent of all cases, the cause of a childs hearing loss isnot known or identifiable. Risk factors include:

Known genetic factors in 25 percent of cases. However, mostgenetic deafness is recessive and 90 percent of deaf and hard-of-hearing children are born to parents who have normal hearing.

In utero infections such as cytomegalovirus can cause hearing loss.

Other anomalies are associated with deafness, including craniofaciaanomalies.

Birth weight under 3.3 lbs

Hyperbilirubinemia requiring exchange transfusion

Ototoxic medications

Apgar scores of 0-4 at 1 minute or 0-6 at 5 minutes

When any of these risk factors are present, the childs hearingshould be screened immediately, and in the presence of somefactors, tested at 6-month intervals until the child is 3 years of age.

Of course, it is always recommended to test all newborns because othe benefits of early intervention.

Facts: Hearing Loss Incidence

As I mentioned, hearing loss is the most common birth anomaly.Occurring in 1 to 3 per 1,000 live births, its 20 times more

common than phenylketonuria, for which newborns are routinelyscreened. It is twice as common as phenylketonuria,hypothyroidism, sickle cell disease, and galactosemia combined.

Hearing loss also occurs after birth due to causes includingautoimmune inner-ear disease, meningitis, maternal viral infectionduring pregnancy, or ototoxic drugs given after birth.

Despite the frequency of hearing loss in children, many pediatricprofessionals are unaware of the advances in hearing testing,technology, and the many communication options available todeaf and hard-of-hearing children.

A survey conducted last year found that while half of pediatricianshad heard of oral deaf education, only 30 percent were aware ofprograms in their community. More than 90 percent believed thatsign was the primary method used by deaf and hard-of-hearingchildren to communicate.

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The Case for Early Diagnosis and

InterventionSome of those consequences include damage to the parent-childbond and behavioral problems, as well as delays and problems withlanguage acquisition.

Lets look at these in more detail.

Facts: Diagnosis and Intervention Lag

Although hearing loss is the most common birth anomaly,universal screening has only recently begun in some states. As aresult, babies are often 1, 2, 3, or even 4 years old before they arediagnosedon average 13-22 months of age, depending on theseverity of the loss.

Parental concern is a very important clinical indicator that there isa problem, and should be taken as seriously as any other risk factor.

Often there is a lag of several months after parents bring theirconcern to a physician before the physician tests the childs hearing.

Physiological tests of hearing can identify and diagnose infanthearing loss very early. No child is too young to have a hearing test.

The lag in diagnosis and treatment can have serious consequencesfor the child.

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Facts: Risk Factors for Hearing Loss -29 days to 2 years

Parent/caregiver concern regarding hearing, speech, language,and/or developmental delay

Bacterial meningitis and other infections associated withsensorineural loss

Head trauma associated with loss of consciousness or skull fracture

Stigmata or other findings associated with a syndrome known toinclude hearing loss

Ototoxic medications

Recurrent or persistent otitis media with effusion for at least 6months

Family history of hearing loss

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The Case for Early Diagnosis andIntervention

Early childhood is a critical time for language development, butuntil recently we didnt realize HOW early and HOW critical. As itturns out, the first 6 months are perhaps the most important.

To determine whether early intervention with children with hearing

loss made a difference in language development, Yoshinaga-Itanoand colleagues from the University of Colorado compared thereceptive and expressive language abilities in children with hearingimpairment with those of children with no hearing loss.

The study found that scores were significantly higher when thechildren were diagnosed and intervention started before 6 monthsof age.

This is reflected in the Yoshinaga-Itano results charted here.


InterventionA child with hearing loss does not respond in the same way ashearing children do. For instance, he or she may not turn towardpeople who are talking to him or her. When the hearing loss hasnot been diagnosed, parents and other people often interpret thisas an emotional problem instead of a physical problem.

Parents may assume problems with the relationship, withtheir parenting, or with the childs emotional style instead ofsuspecting hearing loss.

A hard-of-hearing or deaf child may use hitting or aggression to geta point across or gain attention, or out of frustration at beingunable to communicate. Some children may withdraw as a resultof a lack of communication skills.

If not diagnosed until the child is 2 or 3 years old, the emotionaland social damage can be longstanding.

Ironically, the child most likely to be diagnosed and treated is theprofoundly deaf child. Yet the child with mild to moderate hearingloss may suffer the same issues and bonding problems.

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Screening Protocols

Because hearing loss is the most common birth anomaly, andbecause early intervention is so critical for language developmentand socialization, every hospital should institute a universal protocolto screen for hearing loss.

Universal screening can be conducted for less than $30 per baby,including hardware cost, disposables, and the screeners time to

conduct the test.


InterventionWhat was particularly striking in the Yoshinaga-Itano study is thatin children with normal cognitive abilities, the statistical difference

was independent of age, gender, ethnicity, communication mode,degree of hearing loss, socioeconomic group, or the presence orabsence of other disabilities. The only meaningful difference wasthe age of diagnosis and intervention.

Those first 6 months give the child the chance to develop languagenormally, instead of playing catch up.

Screening Protocols

Routine newborn screening is not the whole story, however.Genetic hearing loss may not be present at birth, but may developin the months after.

And as we discussed earlier, other causes, such as hearing loss dueto ototoxic medications, can occur later. So there are other times

when children should be tested.

Parental concern should be considered a valid factor that there isa hearing loss, and a child should be tested immediately if theparent suspects a hearing problem.

If there are risk factors such as family history or low Apgar scores,the child should be tested even if there are no obvious othersymptoms.

If there is a question about the results of initial testing, additional

tests should be scheduled at 3- or 6-month intervals.

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Auditory and Language Milestones

At 6 to 12 months, the child should be babbling, repeatingsyllables like ma-ma-ma, and using pointing and facial gesturesto communicate.

A 12-month old may only be speaking a few words, but shouldbe playing with sounds to make adult-like speech patterns, andtypically understands 50 words or so. The child should knowhis or her own name, understand no, and understandsimple directions.

Between 18 months and 36 months, most children experiencevery rapid development of speech. By 3 years, a child will knowthousands of words, make short sentences, and sing songs.

Children who miss these milestones should be tested again for

hearing loss.

Auditory and Language Milestones

An infant who has tested normally, but who misses majordevelopmental milestones should be tested again.

Newborns should startle to loud and sudden sounds.

By 2 to 3 months, the child should laugh, form sounds in the backof the mouth, recognize familiar voices, and distinguish changes intone of voice, for instance, a question or a happy statement.

A child of 4 to 6 months ought to turn his or her head toward asound to find the source. The child also should start makingsyllable-type noises, putting vowels and consonants together,and simply make noises of all types.

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Audiology

The audiologist uses a range of tests, often over a period of monthsor years, to pinpoint the exact type and severity of hearing loss.Some of these are passive tests that can be administered withoutactive participation on the childs part. Some tests must be post-

poned until the child is old enough to respond actively.Severity of hearing loss is classified as mild from 25-40 dB,moderate 41-70 dB, severe 71-90 dB, and profound is anythingmore than 90 dB. The audiologist can also identify whichfrequencies are affected.

Profound loss does not mean total absence of hearing, which is infact very rare.

Screening Protocols

Taking immediate action when you suspect a hearing loss is

important because every day missed is a day that languageacquisition is affected.

As soon as a screening indicates a problem or you suspect a problem,the childs hearing should be thoroughly checked by an audiologist

with pediatric training. The audiologists pediatric experience isessential, because testing children and infants is very different fromtesting adults who are losing their hearing, and requires specialtraining.

When hearing loss is identified, a medical work-up, usuallyperformed by an otolaryngologist, should occur to determinecause and possible treatment options.

Hearing aids can and should be prescribed and fitted as soon as thehearing loss is diagnosed, even on tiny newborns. There is no benefitto waiting. Hearing aids alone are not a quick fix. Parents andprofessionals need to work closely with children to help themmake sense of sound.

Parents also need time to mourn, adjust, learn, and immersethemselves in the skills and knowledge theyll need. Some periodof adjustment is to be expected. However, parents who hesitate for

more than a month or two may need help to get moving, becausetheir denial can have long-term consequences for the child.

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Audiology

The active tests of a childs hearing require special training and skillon the part of the audiologist to interpret and understand thechilds reactions.

In Behavioral Observational Audiometry (BOA), the audiologistwatches the babys face and changes in behavior in response to aseries of sounds.

In Visual Reinforcement Audiometry (VRA), the audiologistdirects the child to a toy that lights up or moves when the childlooks at it in response to a sound.

In Play Audiometry, the audiologist teaches the child to respondwith a particular action when he or she hears a sound.

All of these tests are done with speech sounds and pure tones atdifferent pitch and loudness levels to obtain the most completemap possible of the range and severity of the childs hearing loss.

Audiology

Passive tests are ideal for small children because they dont requirecooperation. These tests can be conducted on children as early asone or two days after birth.

Auditory Brainstem Response (ABR) uses electrodes to test aninfants brain response to a series of sounds including differentfrequencies and clicks. Babies older than 4 months may needsedation, not because the test is painful, but to keep them still.

ABR tests the entire auditory pathway.

The Otoacoustic Emission (OAE) test uses a probe to measureechoes from the inner ear in response to sound. A normal cochleacreates its own sound in response to sound entering the ear. OAEtests this function of the cochlea.

Tympanometry measures the movement of the eardrum and theability of the middle ear to conduct sound to the inner ear.

Acoustic reflex tests for a normal reflexive response to loud noises.

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Hearing Technology Today

Hearing technology has improved dramatically in the past 10 yearsand continues to become more powerful and sophisticated.

Even profoundly deaf children can benefit from hearing aids today,whereas 20 or 30 years ago, the available aids often did not provideenough amplification. In addition, todays aids can be tuned to thechilds specific hearing profile.

The range of options for different children and different situationsincludes hearing aids, FM systems and cochlear implants, each of

which well review in greater detail.

The critical point to remember is that even though it is powerfuland effective, the technology is not a solution by itself. Hearing andspeech must be taughtthe technology does not make hard-of-hearing and deaf children into normal-hearing children.

Audiology

This familiar sounds audiogram is designed to explain a childshearing loss to families in terms that they can better understand.It is used to show the frequencies affected and the severity of theloss, as well as what the aided potential is with hearing aids.

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Hearing Techology TodayHearing aids work like tiny amplification systems. They receivesound and amplify it at each frequency to make the most of thechilds residual hearing.


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There are three basic types of hearing aids and many variationsamong them. There are benefits and drawbacks to each, anddifferent aids may be appropriate for different children.

Analog aids can be made more powerful than digital aids, and areoften the best choice for profoundly deaf children. However, theymake some static noise even when its quiet, which can bedistracting for children with mild hearing loss.

Programmable aids are easier to tailor to a childs hearing profilethan conventional aids are.

Digital aids offer the most precise control, and are silent when itsquiet, but they are not as powerful as analog aids, so they may notbe ideal for children with the most profound loss.

The services of an experienced pediatric audiologist are required torecommend the appropriate amplification device.


Fitting children with hearing aids is not a one-time event.It takes time and patience.

Since the patients are generally pre-verbal, observation and deductionwill be required. The audiologists observations at the childsappointments are important, but time-limited. Therefore, theparents ability to notice and discuss the childs response isimportant in fitting aids. Encourage parents to take notes andbring them to appointments.

Parents may need to work with several different types of aids overtime to find the one that works best for their child. A daily, weekly,

and monthly maintenance routine is important to ensure thatyoung children are getting the benefit of the aid. Batteries go bad,peanut butter gets in the amplifier, cords break, etc. At any giventime, only half of small childrens aids are working.

Children may find aids distracting or try to take them out at first.Parents may feel embarrassed or experience emotions and need toprocess these normal feelings.

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Cochlear Implants

Cochlear implants offer dramatic benefits to many children whosehearing aids dont supply sufficient amplification to learn to developspoken language efficiently. Different from hearing aids that amplifysound to the middle and inner ear, cochlear implants send electrical

signals directly to the inner ear and stimulate the auditory nerve.This is accomplished by surgically implanting an electrode arrayin the cochlea. The external component of the cochlear implantconsists of a headpiece with a microphone and a speech processor(usually body worn).

The speech processor converts acoustic information entering themicrophone into electronic codes, which are then transmittedthrough the skin to the implanted cochlear stimulator and onto theelectrode array. The electrodes stimulate the nerve endings withinthe cochlea, which send a stimulus to the brain and is interpreted

as sound.


FM systems consist of a wireless microphone that is worn by onepersonusually a parent or teacherthat transmits sound to thechild, who wears a receiver. FM systems overcome problems ofdifficult listening situations, such as a noisy environment ora distance.

FM systems can work as a hearing aid, and also focus and clarifythe sound of the speaker using the microphone consistently.

FM systems can be very useful when a baby is little and needsaccess to consistent sound to learn to use the sense of hearing.

They are traditionally used in schools to overcome the noisyclassroom environment.

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Communication Options

Although American Sign Language has developed a high profileover the past decade, there are other communication options forthe deaf or hard-of-hearing child that parents and professionalsmust be made aware of.

Today, deaf and hard-of-hearing children have options, includinglearning to listen and speak.

Parents have the ultimate responsibility and the right to choose thecommunication option that they feel is right for their child andtheir family.

Cochlear Implants

Children may be candidates for cochlear implants if they have abilateral severe to profound hearing loss, and have received marginalbenefit from their amplification after at least six months of use.

As we learn more from the success of the earliest implants, cochlearimplants are becoming more common in younger children.

Cochlear implants are FDA-approved for children 12 months andolder, although there are now many cases of children receivingcochlear implants as early as 9 months of age.Slide 27

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Cued speech is intended to help the deaf person by providing visualcues from the speaker for the sounds they are producing as theyspeak. These cues help to clarify what is being spoken. The cuesare not sign language, and have no meaning without the verbalcontext, but clarify the specific sound being made.


Auditory oral and auditory verbal are two slightly differentmethodologies with the same basic goal: to enable deaf orhard-of-hearing children to learn to listen and speak andfunction independently in a hearing world. Both make use ofavailable technologies to aid the childs ability to listen, always inconjunction with a comprehensive education program that isdevelopmentally appropriate for the child. Ill discuss them todayusing the term, oral deaf.

Oral deaf education also focuses on the cognitive domain of eachchild in order to promote thinking skills. All of these domains will

greatly enhance the childs educational future. Studies have shownthat spoken language acquisition has a positive effect on literacy.

Oral deaf educators teach children listening, speaking, and thinkingskills in addition to academic topics. They also teach parents, family,and friends how to interact with the deaf or hard-of-hearing childto support language development through strategies that enhancelistening and speaking.

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Total communication combines auditory training with SigningExact English, or SEE. SEE is a manual code for English that hasthe same vocabulary and syntax.

Total communication has a disadvantage in that most hearing peopledo not understand the signs, so it may limit the childs ability tocommunicate with the hearing world.

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ASL is sound-free. It is its own language, with unique syntax andgrammar, communicated by gesture and facial expression, and it isnot English.

Some people advocate teaching ASL over spoken language becauseit is more natural or easy for the deaf or hard-of-hearing infant tolearn. There is a large pool of ASL speakers, including resources atschools and universities.

ASL is not spoken or understood by most hearing people, whichposes a challenge to the ASL speaker who wants to simply buy ahamburger or ask directions.

In addition, because literacy is based on auditory, rather than visualpathways, it is more challenging for speakers of ASL to learn toread, and literacy among ASL speakers has historically been low.

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Oral Deaf Education: Team Approach

The success of oral deaf education depends on the skills and

cooperation of an extended team of professionals, family,and friends.

The child and family are at the core, doing the daily work ofimproving listening and verbal skills, and choosing andmanaging the rest of the team.

The pediatrician and ENT specialist have roles in monitoring thechilds auditory health in addition to other health issues of childhood.

Audiologists and speech pathologists provide specialized technicalexpertise in diagnosing and treating the hearing loss, and working

with the child and his or her parents to develop listening skills.

Oral deaf educators use specialized teaching techniques to teachlanguage skills along with academic subject matter.


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Oral Deaf Education

Social interaction is the motivation every child has to learn and grow.

All family and friends should be invited and taught the skills theyneed to communicate with the deaf or hard-of-hearing child.

Siblings can be excellent motivators and teachers. Grandparentsmay have time and patience to share.

Involving the entire family not only is good for the child, but alsogives the parents a much-needed break.Slide 34

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Oral Deaf Education

Though many pediatricians have deaf or hard-of-hearing patients,few know the options for children with hearing loss. A recent studyfound that 90 percent of pediatricians believe that the primarymodality is ASL. Only about 1 in 3 knows of oral deaf resources intheir community.

Its important to have those resources ready, because parents will

turn to you for referrals.

The ENT specialist is essential in the diagnostic process,determining cause and possible treatment options and working

with the pediatric audiologist to provide the appropriateamplification device to maximize the childs listening potential.


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Oral Deaf Education

The pediatric audiologist is the testing and hearing technologyexpert. As we discussed, audiologists can pinpoint the degree ofhearing loss and the frequencies that are affected. Audiologists

work with families to find the right hearing aids and to fine-tunethem to the childs needs.

The speech and language pathologist teaches the child the skills heor she will need to listen, attach meaning to sound, and developspeech skills. These professionals also work with parents and familyto teach effective communication skills for use with the child.

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Oral Deaf Educators

Oral deaf educators teach the whole child at each developmentallevel, while supporting speech, listening, and language acquisitionand preparing the child for regular education. When appropriate,oral deaf educators teach all academic subjects and prepare childrento move into mainstream schooling.

Oral deaf educators are often one of the best networking resourcesfor parents.

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Conclusion: Remember These Key Points

As pediatricians, what do you need to remember?

Hearing loss is the most common birth anomaly by far, andhas enormous consequences for the child. Advocate foruniversal testing at your facilities.

Children can be tested in the first days after birth, and hearingaids fitted immediately. Research shows that there is anenormous benefit to intervention before 6 months of age.

Technology does not fix hearing. Technology gives the child thebest opportunity to listen and develop spoken communication,

which must be supported with the right education over time.

Even children with profound hearing loss can learn to listenand speak and communicate with hearing family members,friends, and peers.


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Conclusion (For physician audience)

You may be the parents first or only source of information aboutoral deaf education. Make a point to keep a file on resources suchas pediatric audiologists, oral deaf educators, and speech therapistsso that you can help your patients achieve all they can.

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Conclusion (Alternate slide fornon-physician audience)

You may be the parents first or only source of information aboutoral deaf education. Make a point to keep a file on resources suchas pediatric audiologists, oral deaf educators, and speech therapistsso that you can help your patients achieve all they can.

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Maximizing Auditory Slides