Slide 2 Sound Start for Communication Michelle King, AuD., CCC-
A Amy Vissing, BSN, M.S., CCC-SLP Slide 3 Cabinet for Health and
Family Services Objectives Describe importance of Early Hearing
Detection and Intervention (EHDI) in relation to maximizing
communicative competence and literacy Describe how hearing
screening differs from diagnostic hearing assessment Discuss
importance of early speech/language intervention to promote
communicative competence and literacy skills List how
environmental, socio-economic and parental education discrepancies
can effect development of optimal communicative competencies. Slide
4 National EHDI Goal The goal of EHDI is to maximize linguistic and
communicative competence and literacy development for children (who
are hard of hearing or deaf) Some infants are born listeners, and
others need our help Slide 5 Cabinet for Health and Family Services
Facts about Infant Hearing Hearing begins prior to birth
Nationally, 3-6 out of every 1000 births have congenital hearing
loss KY has 55,000 births/yr - - - we would expect 165-330 babies
would be identified with hearing loss annually. In 2008, we
identified 55 children born in that year with permanent childhood
hearing loss (PCHL). 50% of infants born with hearing loss have no
other identified risk indicators for hearing loss. The auditory
cortex is hard-wired by 1 st birthday. Late identification of
hearing loss or lack of early intervention services can negatively
impact development and academic achievement. Slide 6 Cabinet for
Health and Family Services THAT WAS THEN THIS IS NOW Hi - Risk
Registries and Voluntary UNHS Referred if not talking 12-18 mos
Critical period for Language Learning 2-3 years Diagnosed 18 mos to
3 years using behavioral audiometry Intervention following
diagnosis F/U testing every 6 mos Testing behavioral HAB tech- CI
at 2 years Mandated UNHS prior to hospital discharge EHDI Referred
at hospital discharge Critical period for Language Learning before
6 mos. of age. Diagnosed before 3 mos. of age Intervention before 6
mos. of age F/U testing frequently dependent upon age/growth OAE,
ABR and behavioral CI FDA 1 yr. Possible at 6 mos (special
circumstances) Slide 7 Cabinet for Health and Family Services Why
is Early Identification of Hearing Loss so Important? Congenital
hearing loss interferes with the most basic human need,
Communication. Hearing loss is the most frequent birth defect There
is a narrow window of brain development for language. Undetected
hearing loss has life long negative impact consequences Newborns
identified w/ hearing loss can receive intervention services before
6 months. Intervention by 6 months boosts language development to
near normal rates. Cost of education is reduced Life time
achievement & earning potential is increased by early
intervention Slide 8 Cabinet for Health and Family Services JUST IN
TIME: 1-3-6- PLAN NEWBORN HEARING SCREENING BEFORE 1 MONTH OF AGE
DIAGNOSTIC AUDIOLOGICAL FOLLOW-UP BEFORE 3 MONTHS OF AGE ENROLLMENT
IN EARLY INTERVENTION BEFORE 6 MONTHS OF AGE Slide 9 Cabinet for
Health and Family Services Hearing Screening Screening, a colander
to identify kids with hearing loss Pass/Refer Relatively quick
Relatively Cheap Acceptable refer rate and false positives Slide 10
Cabinet for Health and Family Services AABR & OAE Slide 11
Cabinet for Health and Family Services Typical Mild Moderate Severe
Profound Slide 12 Cabinet for Health and Family Services Can UNHS
Miss Hearing Loss That is Present at Birth? It is possible to have
mild or minimal hearing loss at birth and pass UNHS Screening
programs needs to achieve a low false-alarm rate and a high hit
rate Goal is to have few children referred for additional, more
expensive testing who do not need it and those who are referred
have a high likelihood of having hearing loss Slide 13 Cabinet for
Health and Family Services Otoscopy ear canal Ear Drum Tympanometry
Ossicles Cochlea Otoacoustic Emissions (OAE) Acoustic Reflexes
Auditory nerve Auditory Brainstem Response (ABR) Pediatric
Audiologic Test Battery Slide 14 Cabinet for Health and Family
Services How Hearing is Evaluated Otiscopic inspection Visual
Reinforcement Audiometry (VRA) Play Audiometry Behavioral
Observation Audiometry (BOA) Conventional Audiometry Tympanometry
Acoustic Reflex Testing Otoacoustic Emission Testing (OAE) Auditory
Brainstem Response Testing (ABR) Slide 15 Cabinet for Health and
Family Services OAE RESULTS Slide 16 Cabinet for Health and Family
Services AUDITORY BRAINSTEM RESPONSE Auditory Brainstem response.
Measures how sound is neurally transmitted from the level of the
cochlea to the lower brainstem or how the ear and brain work
together. Not a true test of hearing. Traditional (click)Tests only
the high pitches (2-4K freq region S-T) Frequency specific ABR is
what is needed as a confirmation of other testing, prior to fitting
amplification, especially on the hard to test. Slide 17 Cabinet for
Health and Family Services ABR RESULTS: Slide 18 Cabinet for Health
and Family Services Auditory Neural Pathway Central Auditory
Pathway Slide 19 Cabinet for Health and Family Services TYPES OF
HEARING LOSS CONDUCTIVE SENSORI NEURAL MIXED AUDITORY DYSYNCHRONY
CENTRAL AUDITORY PROCESSING Slide 20 There are no more secrets to
early learning This is why and how Early Intervention REALLY
works.. Slide 21 ITS ALL ABOUT THE BRAIN Cabinet for Health and
Family Services Determining hearing status is not about the ears;
its about getting the auditory input to the brain! If warranted:
hearing aids, FM systems and cochlear implants are not about the
ears are hearing loss but about improving auditory input to the
brain! Slide 22 Cabinet for Health and Family Services Brain Relies
on Auditory input to Initiate Neuro-growth (enhancement) Slide 23
Cabinet for Health and Family Services The Auditory Window Hearing
begins prior to birth The auditory cortex is wired by 1 st birthday
By 6 months of age, Language dependant auditory maps are apparent
in children. These maps are completed by 12 months. These maps
train all subsequent language learning attempts, explaining why 2
nd language learning can be so difficult Slide 24 NEUROLOGICAL
ISSUES We hear with the brain -- the ears are just a way in! Whats
the big deal? Hearing loss keeps sound from reaching the brain.
Human beings are rich in auditory brain tissue But children cant
listen like adults! Why? 1) the higher auditory brain centers are
not fully developed until a child is about 15 years old, 2) and
children cannot perform sophisticated automatic auditory cognitive
closure. Therefore, all infants and children need a quieter
environment and a louder signal than adults. Slide 25 Auditory
Access to the Brain Hearing is a first-order event for the
development of spoken communication and literacy skills. Anytime
the word hearing is used, think auditory brain development!!
Acoustic accessibility of intelligible speech is essential for
brain growth. Signal-to-Noise Ratio is the key to hearing
intelligible speech. Our early intervention protocols and classroom
environments must take into consideration the listening
capabilities and limitations of ALL children. Slide 26 Cabinet for
Health and Family Services The Big Picture Goal Age appropriate
language literacy by school age. Difficult to happen with late
identification of hearing loss Early and critical connections in
the brain are missed Slide 27 Cabinet for Health and Family
Services TO DEVELOP LANGUAGE IN INFANTS BEGIN WITH THE BRAIN Slide
28 Neurological & Developmental Foundations of Speech
Acquisition Brain Weight: Function: Brain size gives humans
capacity to grasp complex patterns. Growth: from 25% adult weight
at birth to 80% first few years of life. Selective Elimination:
Function: extra cell connections used for speech learning are
strengthened and retained when used and eliminated if unused.
Growth: ~1/3 cells lost between birth - adulthood. Occurs in
sensory areas first and later in cortical function. Cabinet for
Health and Family Services McLeod & Bleile ASHA 2003 Major
aspects of brain development occur as child interacts with the
environment: Slide 29 Neurological & Developmental Foundations
of Speech Acquisition Growth & Elaboration: Function:
Environment stimulates growth of cell connections needed for speech
learning. Growth: Enriched environment promotes increase
synapses/neuron. Environmental deprivation decrease # of cell
connections. Myelin Sheaths: Function: white fatty substance on
axons insulates and speeds transmission of signals. Critical for
gross and fine motor movements. Growth: Myelination begins ~3
months before birth. Peak growth birth-end first year of life.
Continues until adulthood. Slide 30 Neurological &
Developmental Foundations of Speech Acquisition Wernickes Area:
Function: Functional region in left temporal lobe critical for
language comprehension. Growth: Peak # cell connections during 1 st
half of 1 st year of life. Achieve mature # cell connections during
2 nd half of 1 st year of life. College educated > dendritic
connections in Wernickes than high school educated > persons
with less than high school education. Brocas Area: Function:
Functional region in left frontal hemisphere controls speech.
Growth: Density of cell connections does not peak until 15 months.
Does not reach mature number of connections until age 6-8 years old
Cabinet for Health and Family Services Slide 31 Neurological &
Developmental Foundations of Speech Acquisition Hippocampus:
Function: Critical to working memory. Speech activities memory
retention and word retrieval. Growth: Develops after birth,
especially during 2 nd year of life. Prefrontal Cortex: Function:
Critically important to many cognitive functions that underlie
speech reasoning, planning, judgment, and attention. Growth: Cell
connections develop slowly throughout childhood and do not mature
until after adolescence. Cabinet for Health and Family Services
Slide 32 Timing is everything Window For:Wiring Window Enhancement
Window Further Enhancement Emotional Intelligence 0-48 months4-8
years At any age Motor Development 0-24 months2-5 years Decreases
with age Vision 0-24 months2-6 months Early Sounds 4-8 months8
months- 10 years Music 0-36 months3-10 years Thinking skills 0-48
months4-12 years At any age Reading Skills 0-24 months2-7 years At
any age Second Language 0-60 months6-10 years Decreases with age
Slide 33 Arguments for Early Intervention Betty Hart & Todd
Risley The Early Catastrophe: The Million Word Gap by Age 3 Jack
Shonkoff, Andrew Garner, et. al. The Lifelong Effects of Early
Childhood Adversity and Toxic Stress Medical Case for Early
Intervention Cabinet for Health and Family Services Slide 34 The
Early Catastrophe: The 30 Million Word Gap by Age 3 Longitudinal
Study Betty Hart and Todd Risley Focus Build everyday language used
by children Evaluate the growth of that language Method Observation
of 42 families: 1 hr/mo from 7mo-3yr 13 high-income 10 middle
socio-economic status 13 low socio-economic status (6 on welfare)
Cabinet for Health and Family Services Slide 35 The Early
Catastrophe: The 30 Million Word Gap by Age 3 Results 86-98% of
words used by age 3 are derived from parents vocabulary Other
similarities between child and parent Average utterances per hour
Average different words used per hour Children from welfare
families provided experiences (words heard per hour) of working
class and experiences of professional families Professional family:
6 encouragements/1 discouragement Working class: 2 encouragements/1
discouragement Welfare family: 1 encouragement/2 discouragements
Cabinet for Health and Family Services Slide 36 The Early
Catastrophe: The 30 Million Word Gap by Age 3 Follow-up: 29/42
families 3 rd grade Findings at age 3 predictive of: Vocabulary
Language development Reading comprehension Cabinet for Health and
Family Services Slide 37 The Early Catastrophe: The 30 Million Word
Gap by Age 3 Implications: Intervention after age 3: Lack of
knowledge & skill Approach to further experience Amount and
diversity of past experience influences new experiences Less
possibility for change the longer intervention is delayed Cabinet
for Health and Family Services Slide 38 The Lifelong Effects of
Early Childhood Adversity and Toxic Stress Positive Stress: Brief
and mild-moderate in magnitude: i.e. dealing with frustration,
getting immunization, coping with the first day at child care
Caring, responsive adult helps child cope Growth-promoting element
of normal development Tolerable Stress: Non-normative experiences
that present a greater magnitude of adversity or threat: i.e. death
of family member, serious illness or injury, divorce, natural
disaster, act of terrorism Tolerable to the extent that protective
adult relationships facilitate the childs adaptive coping and sense
of control Reduced physiologic stress response and promote return
to baseline status Cabinet for Health and Family Services Stress
Responses in Young Children Slide 39 The Lifelong Effects of Early
Childhood Adversity and Toxic Stress Toxic Stress: Results from
strong, frequent, or prolonged activation of the bodys stress
response systems Absence of buffering protection of a supportive,
adult relationship Risk factors: child abuse or neglect, parental
substance abuse, maternal depression Disruption of brain circuitry
and other organ & metabolic functions Results in anatomic
changes and/or physiologic dysregulations Later impairments in
learning and behavior Chronic stress-related physical and mental
illness Cabinet for Health and Family Services Slide 40 Toxic
Stress and the Developing Brain Cabinet for Health and Family
Services Altered size and neuronal architecture of: Amygdala:
visceral and motor response to aid in coping with stress
Hippocampus: converts content of working memory in prefrontal
cortex into long-term memory Prefrontal Cortex : regulates
thoughts, actions, and emotions extensive connections with other
brain regions Persistent elevated levels of stress hormones lead to
permanent changes in brain structure and function Slide 41 Toxic
Stress and the Developing Brain Cabinet for Health and Family
Services Functional Consequences Increased fear and anxiety
Impaired memory and mood control Problems in the development of
linguistic, cognitive and social- emotional skills Weak foundation
for later learning, behavior, and health Poor development of
executive function skills Decision-making Working memory Behavioral
self-regulation Mood and impulse control More reactive to mildly
adverse experience and less capable of effectively coping with
stress Slide 42 Lifelong Impairments in Physical and Mental Health
Link between early adversity and a wide range of health threatening
behaviors Alcohol use at a younger age Tobacco use Illicit drug
abuse Obesity Promiscuity Difficulty maintaining supportive social
networks resulting in a higher risk for: School failure Gang
membership Unemployment Poverty Homelessness Violent crime
Incarceration Becoming single parents Less likely to provide stable
supportive relationships to protect their own children from toxic
stress Cabinet for Health and Family Services Slide 43 Lifelong
Impairments in Physical and Mental Health Biological Manifestations
Alterations in immune function Increases in inflammatory markers
Cardiovascular disease Viral hepatitis Liver cancer Asthma COPD
Autoimmune diseases Poor dental health Depression Cabinet for
Health and Family Services Slide 44 Economic Impact Multiple
dimensions of cost Quality of community life Health Skills of
nations workforce Ability to participate in global economy
Economists argue for Early and sustained investments in early care
and education programs Particularly for children whose parents have
limited education and low income Cabinet for Health and Family
Services Slide 45 Activities to Encourage Speech Development ASHA
Birth 2 years Encourage vowel-like and consonant- vowel sounds
Reinforce eye contact Respond with speech Imitate vocalizations
using different patterns of emphasis Imitate laughter & facial
expressions Teach baby to imitate Throw kisses Clapping Finger
games Peek-a-boo Slide 46 Activities to Encourage Speech
Development Talk When you are bathing, feeding, dressing your baby
What you are doing Where you are going What you will do when you
arrive Who you will see Identify colors Count items Use gestures to
convey meaning Introduce animal sounds with specific meaning
Acknowledge attempts to communicate Expand on single words Read
Slide 47 Activities to Encourage Speech Development 2-4 Years Use
speech that is clear and simple model for child Repeat what your
child says Indicate you understand Build on what was said Use baby
talk only if needed to convey a message When accompanied by the
adult word: din-din and dinner Slide 48 Activities to Encourage
Speech Development Scrapbook familiar and favorite things Group
into categories Mix and match to create silly pictures Talk about
what is wrong and ways to fix it Count items in a book Help your
child understand and ask questions Play yes-no games Ask questions
such as Are you a boy? Can a pig fly? Encourage your child to make
up questions and try to fool you Ask questions that require a
choice Do you want orange or blue? Slide 49 Activities to Encourage
Speech Development Expand vocabulary Name body parts Identify what
you do with them Sing simple songs and recite nursery rhymes Shows
rhythm and patterns of speech Place familiar objects in a container
Have your child remove the object Tell you what it is called How to
use it Use photographs of familiar people and places Retell what
happened or make up a story Cabinet for Health and Family Services
Slide 50 About the Commission Our Mission: To enhance the quality
of life for Kentuckys children with special health care needs
through service, leadership, advocacy, education, and
collaboration. Our Vision: To be the visible leader in supporting
the highest quality of life for Kentuckys children with special
health care needs and their families through collaboration and
creation of a more accessible community based system of support.
Slide 51 Eligibility Resident of Kentucky Less than 21 years old
Has a condition usually responsive to medical treatment that is
covered by the Commission Meets financial guidelines based on
income Slide 52 Commission Clinics Asthma (Severe) Cardiology
Cerebral Palsy Cleft Lip & Palate Craniofacial Cystic Fibrosis
Eye Hand Hemophilia Neurology Neurosurgery Orthopedic Otology
Rheumatology Scoliosis Spina Bifida Slide 53 Commission Offices
Slide 54 Services Provided Care Coordination Hospitalization
Physician Services Surgery Hearing Tests Physical Therapy
Occupational Therapy Speech Therapy Lab Tests/X-rays Interpretation
Medical Supplies/DME Medication Management Dental Transportation
Nutritional Supplements Orthodontia Slide 55 Direct Care Clinics
offer multi-disciplinary care Team approach for management of
complex conditions Access to nutritional services, social services,
and care coordination Augmentative services as appropriate Physical
therapy Occupational therapy Speech/language therapy Slide 56 EHDI
/ Audiology EHDI - Focus on early identification and intervention
of children with hearing loss critical to preventing problems with:
Communicative Competence Literacy and Academic achievement
Social/emotional development Comprehensive Audiology program which
includes: Hearing conservation Testing Hearing aid fittings
Programming for cochlear implants Slide 57 Cabinet for Health and
Family Services Question? Discussion?
