ROUGH EDITED COPY

2016 EHDI Annual MeetingTopical Session 2Pacific Salon 2

ASSESSMENT AND INTERVENTION FOR CHILDREN WITH MILD-MODERATE-SEVERE HEARING LOSS

2:00 p.m.March 14, 2016

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* * * * *This is being provided in a rough-draft format. Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings.

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>> BRITTNEY SPROUSE: So we'll go ahead and get started. Can everyone hear me okay? I apologize, I am getting over a cold where I lost my voice last week so if I stop here and there for water I apologize in advance for that. I'm Brittney, I'm a pediatric audiologist at the University of Chicago Medicine former children's. So I recently joined the Chicago team a little over a year ago. I was previously practicing in Ohio at a Children's Hospital a little over six years there so a little bit about my background. So the topic we're going to talk about today is the assessment and intervention really focusing on children that fall into this mild-moderate-severe category. A little bit about the course overview here, looking at this neurodevelopmental emergency that exists when we identify a child with a mild-moderate-severe hearing loss. Looking at that relationship between hearing loss and the auditory brain development and identifying how this affects our assessments, our intervention as we're working with these children and their families reviewing ways we can facilitate overcoming neurodevelopmental emergencies.

Can I just get a sense of who's in the room. How many are audiologists? And speech therapists? Early Intervention providers?

Parents? Any physicians? And anyone else that I missed? Well, thank you for joining me today. So why is this important? Well, everyone knows that when we think about hearing loss, we

can relate to this neurodevelopmental emergency so when we look at why this is important, we have to talk about what does that mean? What is a neurodevelopmental impairment or disorder? So it's really looking at anything that's affecting the brain development, and that can be emotions, learning disabilities, can affect cognition, motor skills, self-control, memory, and when we think about hearing loss, it falls into that category.

So why is that important again? We have to think about: How do we hear? And simply put, we think about: We hear with the brain. The ears are just a way in so we have the cochlea, our sensory organ so it gives us that sensitivity and detection of sound. Taking it on to the auditory nerve which is the pathway for that detection on to interpretation. And the interpretation happens at the brain so we hear with our brain. So when we think about how we're talking to families, counseling parents, working with other providers it's really important that we focus on this topic, and when we talk about hearing, that we're talking about hearing with the brain.

Then more importantly we have to talk about neuroplasticity and as we talk about again this hearing with the brain and understanding the importance of neuroplasticity what does that look like when we're working with children? So we know that it's the ability for the brain to change with learning, and when we think about early learning, early exposure to sound, we can think about how children are exposed to sound in utero so they can actually start to hear around 20 weeks of gestation, so the long and short is, our ears are kind of pre-wired for this sensory information. We're pre-wired for hearing, and when we look at children who have been identified with a hearing loss, we're already starting off a little bit behind with that exposure so we're thinking starting at 20 weeks gestation where they're hearing in utero, and then now after birth, we've identified a hearing loss. Depending on how much time it takes for that hearing loss to be identified, that's more and more time they're kind of missing out on this information. So in some ways we're already starting off behind, especially when we're looking at the goal of spoken language.

So again, language is the key there, but when we're focusing on our children that are falling more into this category with more residual hearing, and if the family's goal is to develop spoken language, we're starting off a little bit behind with that, so the importance of this talk and this topic is really every child who's identified with a hearing loss, no matter how mild, minimal, depending how you want to phrase that, really warrants this proactive intervention, so that's when we talk about this neurodevelopmental emergency.

So research has already illustrated that our children who fall

into the severe to profound category that particularly are using cochlear implants are achieving huge outcomes with their spoken language. When we turn that and look at our kids that are using like the Baha, the Contra Pro, or hearing aids, they're not necessarily making those same strides. We have limited research really in that field, and a lot of the research we have [ Inaudible ] but we're still seeing the same thing, that our kids are still performing sometimes at lower levels, whether that's with their reading, their math scores so we have to take this into account when we hear working with children with more residual hearing that this is still that neurodevelopmental emergency so it's pretty easy as providers, parents, when we're working with these families that we have a child that has a severe to profound hearing loss, automatically it just kind of strikes us absolutely we need to do this, these are all the steps, there's a lot of eyes watching that child.

It's not necessarily the same reaction that we get when we're identifying a mild hearing loss or mild to moderate or even if it's very minimal, maybe 25 decibels things like that. I'd encourage you as you're working with these children and working with these families that really hearing loss in general warrants all this proactive intervention and assessment as we're working with them. It doesn't have to be to that severity of a severe to profound loss in order for us to get moving, get the ball rolling and talking about how important it is when we look at this neurodevelopmental emergency.

The feel free to stop me if you have questions or things like that as I'm talking.

So when we look at a neurodevelopmental emergency and how this plays into hearing loss, it's really because we have this optimal time, this critical language learning speared, that we have to worry about. That happens between birth to 3. And really that first year of life. And so again, the more that we can early identify these children, we have our newborn hearing. How many times has a family or me as an audiologist show up at my doorstep at 8 months, 6 months, last week I had a 14 month old that never followed up from a referral from their newborn hearing test so when we look at this critical language learning period, we're at 14 months and now we have to worry about what kind of information can we get with this individual. Are we going to [ Inaudible ] the procedure for testing if we're not able to capture that behaviorally right now. Thankfully we're able to get a normal hearing test for both ears but again when that shows it up on our doorstep looking at how much time has passed and when we look focusing back at the critical language learning period and the birth to 3 and focusing on that first year of life, we have to get moving so we also when we're thinking about this and

counseling families we really have to stress the importance of making these auditory connections and making them over and over and over, and again we have to have access. We have to know who these children are, and if we've identified a hearing loss we have to have a way to get in. When we think about hearing and hearing with the brain we have to have a way for all that sound input to get in and get in consistently so they can continue building auditory connections.

So this is kind of an image that comes to mind when I'm thinking and counseling with families and we really need the appropriate technology and they need the input to be accessible. Add that to this enriched auditory exposure and that's going to equal our auditory brain development. So again I keep repeating this over and over, that's this neurodevelopmental emergency so when we think of a hearing loss again if we're focusing on a child with more residual hearing and we're focusing on goals of developing spoken language, hearing loss acts as a barrier. It acts as a barrier in order for that brain to have access to this information. So when we think technology, they're brain access tools. That's one way to think about the hearing aids, osseo-integrated devices, cochlear implant. So when we're building our auditory brain development, we're strengthening these neural connections. We have to deliver a clear, consistent, salient signal.

Sorry, I lost my train of thought there.So we're delivering this clear, salient, consistent acoustic

signal, and so again focusing on the critical language learning period, all that's happening during the first few months of life. When we think of the brain development and how if we're not exposed to this over and over, the brain will actually reorganize, and so sometimes when we think of the auditory portion, it can actually be taken over by other senses, like the visual system, things like that. And so it's really important to have this early access, early identification.

Here we go. So as we talk about this neurodevelopmental emergency and the critical language learning period, we have to think about the areas that are impacted with a child when we're talking about hearing and hearing loss. So some of these areas fall into auditory skill development, looking at their speech and language, their academic achievement, social elements, looking at their future, and so these are not all of the elements. These are just some that I'm highlighting for you today as we're talking about this.

And really looking at children with more residual hearing, and by knowing and understanding what's impacted, we as providers can alter our assessment and our intervention to best meet the needs of children with hearing loss, particularly those, again, that

have more residual hearing.So how do we do that? Looking at the hierarchy of auditory

skill development, by examining these components again, we can implement that into our assessment and our intervention. So when I think about this kind of diagram, we're looking at detection as the lowest on the form there, so the presence and absence of sound. What does that mean to me as an audiologist? Well, it affects what I'm doing not only in the testing but it affects how I'm programming their equipment, and so if my end goal is just for this child to detect the presence or absence of sound, I'm missing the mark. We're missing a lot of information, and so it's going to be very difficult to build and grow on that auditory cortex if I'm not doing more than that, if I'm only looking at the end goal being the detection.

And so sometimes when I talk to other providers or even when we're working with families and we're showing them the test results or looking at the audiogram, sometimes the focus can be on that detection. Of course, that's important. That's where we're starting but we have to have an end goal. We have to look farther than that. We have to be moving forward so with our young kids absolutely that may be the only information that we're able to gather but again we have to keep building on that and moving forward, so moving on to discrimination, when it's age appropriate, again recognition, looking at closed set identification, looking at open set and then on to comprehension so that really falls on me as a provider, working with the child's team, making sure that we not only detect sound but we're able to move forward with that.

So if I put them in the test booth and let's say I'm doing functional listening if I'm only concerned about whether they detect the S sound I may be missing whether they can discriminate the S from the SH or again if there's similar sounding words if they're able to actually pick up on that information. So again looking at how does all of this, in this auditory hierarchy, how can we implement that into what we're doing as we're assessing these children.

So another area is of course the speech and language again when we're focusing on developing spoken language as a goal, we're working with these children so there can certainly be a delay with their expressive and recessive language, communication skills. When we look at vocabulary can actually develop more slowly so again relating all this back to brain development and how it connects with hearing loss.

So their vocabulary can develop more slowly. They may have increased difficulty with words that have double meaning. For example, the word bank. Is it an actual bank where you're getting money? You mean a bank by a river bed? Things like

that. Again, if we're not having these discussions with their families, with the children, with the providers, we may be missing this information and we may be missing again how we're assessing and what type of intervention and treatment we're putting into place. I can't tell you how many times we'll have a child, an older kid telling a story and they'll give us an example how long they thought the word meant this. If it's a double meaning they have one of those meanings but they've missed there's a whole other side for that word.

Another thing they may have difficulty with is listening at more abstract words, so before, in addition to, things like that, versus concrete words like hat, ball, red. Again we have to be in communication with our other providers and with the whole team, whether it's the parents, Early Intervention providers, the therapists, the academic team, in order to have this information because all this also impacts again me as a provider as an audiologist, how programming their cochlear implant. How [ Inaudible ], if we're missing these words, these sounds, if we're having difficulty with similar sounding words, is there anything that I can do to make that easier? But part of that is including that and incorporating that into my testing and effectiveness.

As we look at vocabulary we know that that gap widens as the child gets older, and sometimes if there has been no intervention, or let's say if a child has a mild loss that may be more at risk academically, they may not have all these interventions in place and so sometimes we may be missing how much or how big that gap is getting and depending on how much management or intervention is in place that gap is going to continue and sometimes we can't overcome that gap. So those are things we have to look at not only right now but down the road.

It's important to make sure they're hearing sounds. Can they hear the S, can they hear the C. All of these things we have to incorporate as we're working and treating these kids especially that have more residual hearing.

So of course we have to talk about their academic achievement so I touched on that a little bit as we're focusing on speech and language, looking at vocabulary, word learning, things like that. When we look at just academic achievement overall, research has actually showed that kids who fall into the mailed to moderate are at more of an academic risk than kids who have a severe to profound loss. I think it comes back to not as many interventions in place, not as many eyes watching that child. It's not seen as this neurodevelopmental emergency. It's not something that kind of invokes so much more care and attention on that child in comparison to one that falls into that severe to profound category.

So they can have difficulty across all areas. We see increased difficulty with reading, writing, even mathematical concepts. They may do well with numbers themselves but when we make it harder problem solving, anything that has more to do with the reading and writing component. That's the main areas that our kids are struggling with that have a hearing loss. And so when we look at comparing this mild to moderate group with the severe to profound counterpart, they actually found that they're 1 to 4 times below what their severe to profound counterparts are performing at. So not only are we possibly falling behind in comparison to our normal hearing peers, now when we compare this group with more residual hearing with a group in that severe to profound category, they're still performing poorer.

And then as we talked about, academic achievement, we can't touch on that without speaking on the importance of literacy. And so when we look at these early listening experiences, that's what lays the foundation for the development of spoken language and literacy.

A child needs about 5 to 6 years of consistent input in order to be ready to learn to read. And so that's a lot of time and that's a lot of information, so when we look at some of these children that may fall into a child or borderline category, where maybe they're not wearing any amplification or there's no FM in place or things like that, and we're unsure of how much information is being missed that's a lot of time. That's a lot of time we have to play catch-up with if we're thinking or we know and research says we need about 5 to 6 years of this consistent input over and over, in order to just be ready and prime to learn to read.

So again just making sure that as you're working and looking at all of these children, that we're defining it as this neurodevelopmental emergency so that we can put more interventions, more assessments in place, and be more proactive with these children.

And then when we look at interaction with friends, it's actually one of the primary ways to expand a child's vocabulary, their attention span, their memory. So those are all again recommendations that we can make as we're working with families. As Early Intervention provider, we're looking at the home at children, reading, exposure to books and friends. We know that writing is stemming from that.

Then when we look at kind of social and the future of what they -- what their opportunities are, what they have access to, again the research is showing that our children that are falling into this mild to moderate category can feel isolated. Sometimes they may be the only child in their school who has a hearing loss. They may be the only child around them who's wearing any

type of amplification. Again, this can happen with our children that are in that severe to profound category but really focusing on sometimes kids with more residual hearing are overlooked because they can hear. Even if they're not wearing their technology, they can hear.

And so if they're interacting with their teachers, their friends, they may not be putting communication strategies in place, again because it appears like they're hearing, and they do hear, but how much of that information are they missing? When we look at again taking it a step further in their academic achievement, are they able to comprehend those abstract concepts? How are they following directions? How much do they rely on their visual input? Things like that.

So it's really important to be sensitive to these issues and making sure we're putting systems in place to address this, knowing that there's already research that supports that they can have this isolation they may feel, whether that's socially  and that can map in the home, so we also want to look at: How does this impact their future, their vocation, their career choices? What kind of things can we put in place starting from a young age so they have all these opportunities down the road and for their future?

So what's next? Now that we have all of this information, now that we have identified that hearing loss falls into this neurodevelopmental emergency, where do we go? How do we help them? What can we do again as providers, as parents? So again, most of our children with hearing loss need to make up for lost time and certainly if there's been any type of delay in their diagnosis or identification of a hearing loss, we can't afford to miss anymore more so we have to incorporate all this knowledge and information into our settlement and intervention and treatment of working with these children who have more residual hearing.

So to do that, I want to look at these four key areas. Again, there are plenty, but these are the four that I'm going to focus on today. So by examining these four key areas, looking at providers, looking at technology, Early Intervention, and families, how can we overcome this neurodevelopmental emergency? It's not going away, but what can we do to help this? What can we do to prevent what we already know that's happening with their brain development, to continue making forward progress?

So the first category I want to focus on is the provider. So access, very simple. The family has to have access to a provider in order to get the diagnosis. And so when we look at access we have to talk about early identification, and how does this play into meeting the 1-3-6 model? So access is not just being able to have the diagnostic test done after the screening. It's also

finding a pediatric audiologist.So as I transitioned from the state of Ohio moving to

Illinois, we're finding that there's limited pediatric audiologists outside of the Chicago area, making it very difficult for families to find someone who's knowledgeable in working with a child with hearing loss, who's comfortable completing whether it's the ABR, looking at the protocols that they have in place. And so those are all again just really important factors that we have to keep in mind, that can contribute to that time that we may be off the air, that time that they may not have this clear consistent salient signal. Again as providers we have to look at: What is our protocol? How are we working with these children? What kind of things are we putting in place? And making sure that we're providing that evidence-based care to our families.

Communication. We have to talk with each other. We have to communicate with the families. We have to communicate with all of the providers on the child's team. That's really important again in making sure that we're hitting all of these marks.

Looking at what other additional resources we can provide to the family. What other ways can we get them connected? What other referrals do they need? Sometimes we're the gatekeeper. Sometimes we're the first person as an audiologist they may see. They may not have been to a Speech Therapist. They may not have Early Intervention in place, so it's certainly our job to help connect them, help connect the families with this and then providing them with the information so that they can make appropriate decisions for their child.

And so when we look at the education and counseling piece, part of that also falls on educating and counseling from day one, making sure that the families and the parents understand: What does this mean? And so I relay that all back to the previous information of really tying hearing into the brain and brain development. And I can tell you from counseling families over and over, that speaks volumes. That gets attention.

If I talk about hearing as just hearing loss, and certainly if I'm talking about a child that has more residual hearing where they're seeing their child hears them with no amplification. I have to switch gears and take it a step further in talking about the brain development and the effects of this and what we're looking at outside of again whether that child can just detect whether someone was talking to them, whether they're missing a few pieces of information here and there. I would encourage you as you're working with these families to really change gears in what we're talking about and stressing this notion of neurodevelopmental emergency.

When we're talking about education I have to make sure they

understand the test results, making sure they understand what the audiogram is because they're going to be able to advocate for their child in ways that I can't. They're going to be able to advocate for their child in scenarios where we're not necessarily around so giving them the tips and the tools to have that information, making sure that they understand all of this.

And then getting the family involved and that means from day one, participating, whether it's trying to get the ABR, giving them appropriate recommendations on how to keep the baby asleep for testing, how to decrease that frustration, things like that. Whether it's coordinating appointments so there's less travel to and from our facility, getting them involved whether we're in the test booth, bringing toys from home if that works better for the child. Not testing around nap time, whatever we can do, really partnering with the family from day one.

And then I just think that this really sums up a lot for me that not all acoustic information is specific enough and not all speech perceptual systems are complete enough to allow the communication process to occur uninterrupted.

And so this to me just kind of sums up the importance of why we have to focus on the children that have more residual hearing because we don't know what all of that information that's coming in if they're not wearing any type of amplification or we have no interventions in place and we're working with individuals that don't have a complete system. And so we can't just rely on, that's good enough. Or they hear enough. We have to take it a step further and have to look at the bigger picture so listening is an active and it's not a passive process for children with hearing loss. So their systems again are still being developed and it's not complete yet so we can't rely on using that. We have to be able to provide more.

So another category or another key would be looking at technology. Making sure that again the goal and the route the family is taking that we have appropriate technology, that they're fit in a timely manner. We have so many children that are on wait lists in order to get their hearing needs or their [ Inaudible ], and even a wait list to get their cochlear implants so when we look at fitting the appropriate technology again I think that also goes back to making sure that they have access to pediatric providers, making sure they have access to people who are knowledgeable about what they're fitting, what's important, what kind of things to look for, whether it's the specific manufacturer, whether it's warranties, having tamper resistant battery doors. I can't tell you how many times a child will come in that's 2 and we don't have a tamper resistant battery door. It's never been a topic that was discussed with the family.

So again, these are just little pieces that play a bigger role at making sure the family has that access, making sure the child has appropriate amplification. There are plenty of times that a child who has maybe a more moderately severe loss, maybe their amplification is better fit for someone with a mild or borderline cost. If the family paid out of pocket or the device isn't covered by insurance, it can make it very difficult swapping out for another device so having that communication, that close relationship so we can make sure all these kids get the appropriate amplification, that they're fit as early as possible. Also does the facility have access to loaner equipment? If the child is off the air which they have been all the time for different reasons how quickly can we get them back on the air? Whether it's a loaner device or even just a replacement of what that equipment is.

And then looking at assistive technologies. What age or stage do we introduce that? And there's different philosophies in the audiology world. We have no consensus at what point you introduce an FM system. At what point do you introduce [ Inaudible ] technologies but I would definitely encourage having that conversation, looking at that child's scenario because noise is noise. Whether they're sitting in a day care, whether they're sitting in a preschool so we have to make sure even if we're not introducing some of these technologies, that we're looking at how we can help the child. How can we make sure they're getting nice clear, salient signals? So it may just be training, education with their day care providers in how to interact with that child. Looking at the noise. Where can we eliminate it? We know that it's not going away in all scenarios but having that conversation, having that education, training individuals on what to look for with that.

And then of course, having consistent device use because again if we don't have the technology on all the time, and certainly if we're looking at a child who has more hearing loss, we're not sure how much of that information is getting in. We can say for a fact it's not all going in but we can't say how much are we missing. Are we missing those soft sounds in again that S, the P, PH. Things like that.

We want to make sure we're stressing the importance of that consistent device use, because when we're looking at children who have normal hearing, they don't get to take their ears off. They don't get to take a break from that. So if we have what we call our data logging, and how long is that technology on? Sometimes with our little ones, it may be just a few hours. Sometimes it's under one. There are cases where it's a zero point something so having that conversation and that education and looking at what that goal is, eyes open, ears on philosophy. Part of that is

again starting that conversation from the beginning, stressing that importance, looking at the bigger picture and talking about hearing with the brain.

Another category or third category is Early Intervention. Yes?

[ Off Microphone ]I do try to talk about technology because I know there are

kids that are using a Baha or [ Inaudible ] that are still falling into this mild-moderate-severe category so [ Inaudible ] those. Then there are kids that are as our cochlear implant criteria is changing and we have hybrid devices where you don't have to fall into the severe to profound category technology is looking different. Technology means something different than even a year ago, 5 years ago so you may have a child with an implant on one side and the hearing aid on the other. But they may be [ Inaudible ], using hybrid technology or input [ Inaudible ] osseo-integrated devices and I really think with that category that kind of population we don't necessarily talk about them as much. We talk about the [ Inaudible ]. We talk about hearing aids. When we look at the Baha and the Ponto, we don't have a lot of research kind of up to date with that information and how are those kids doing. It doesn't have to be necessarily atresia. It could be a child that's had a lot of [ Inaudible ] and now they have this [ Inaudible ] going on or maybe they have active drainage. I have several kids that are falling into this permanent conductive hearing loss category but they have this active draining ear, and so putting a hearing aid on isn't really the best action for that. But again making sure that we're giving them the best access. Making sure we're able to build and grow their brain and when we look at the hearing and talking about brain development. Did that help? Any other questions?

When we look at Early Intervention focusing on referring them early, it makes sense. It's in the name so look at Early Intervention, the birth to 3 population, but making sure that that referral is happening even if it's not again if it's not coming from me, if it's one of my other team members, making sure that they're referred for this program. Also when we look at once they're in the program what are the services? So it's not enough for me again as audiologists to say okay, you're in Early Intervention, great, all is well and taken care of but finding out what does that mean? What does that look like? How often are they receiving services? What services are they receiving?

Are they working with anyone on the Early Intervention team that worked with a child with a hearing loss. That's not always the case depending where they're located. I have several kids where maybe they were already in Early Intervention. Then they

get the diagnosis of hearing loss, and it's actually harder to start introducing the services, because they've already had their evaluation, and we're trying to add something to it, and their team may not be ready to do that. Or the next scheduled time [ Inaudible ] doesn't happen for another couple months or maybe even six months for the re-evaluation, so really having that communication, really talking with all of the those providers so that you understand what's going on and what's happening and not just leaving it at their end goal. And moving it off to the side there.

And then I would say the most important is the family. As I talked about before, having access. Making sure that our families have access to pediatric providers. Making sure they have access to a provider who's familiar with working with a child who has a hearing loss. Looking at the education, the counseling and the support. Making sure that they understand the test results, making sure they have the support on again having this new diagnosis of a hearing loss and what kind of needs do the parents, what do they need? That? And learning this new information.

Looking at consistent device use, stressing the importance of again kind of the eyes open, ears on, making sure that whatever difficulties or challenges whether it's teething, whether it's ear infections, whether it's [ Inaudible ] and you want to take them out, what kinds of things can we do to help overcome that? And having those conversations and really what helps me is being realistic with families. There's going to be a time that the devices are coming off. There's going to be hurdles with this. That's okay. That's normal.

Again, looking at our end goal, looking at how we're trying to move forward. Looking at the overall, the bigger picture and I can tell you when I talk to families about hearing with the brain, and even though we're struggling with maybe the child is pulling the device off, sometimes that helps with fighting a little bit more and putting them back on, versus again focusing on how much they can hear without the device. And focusing on what we're giving them, what we can do by putting on this device, by giving them access to this, by giving them this nice consistent signal so again we can strengthen the vocabulary, we can decrease the gap, we can overcome these other achievement areas that we know they're at risk for already just by having a hearing loss. So yes? Go ahead.

[ Off Microphone ]Absolutely. I think that's a struggle that we all have, for

sure.[ Off Microphone ][ Captioner not able to hear comment ]

Absolutely, yeah. And I think there are so many times in audiology that we try not to relate to kind of ophthalmology, optometry, things like that, but I think that's a perfect example when we're looking at, you have a picture and how nice and clear it can be when you put the glasses on. And maybe again when you take the glasses off it gets a little blurry or maybe you can pick out that there's red in there and there's blue and how much clearer can it be by using that kind of a system with the glasses. So I think that's a great example.

I think again for me focusing on: How am I talking about the hearing? And not focusing on what they can hear without the device and really putting the focus on: What are they missing? And when we think about a child that's in this birth to 3, they can't tell us what they're missing [ Inaudible ]. They don't know that they're missing that information and so sometimes what's been helpful for me in counseling is really shifting that gear of: Okay, that's great that they can hear, that's great that they can detect that. I don't doubt any of that information.

I care about what they're missing and even if they're only missing this one piece, if they're missing that one piece over and over, what does that look like down the road? What does that look like a year from now? When we talk about getting them kindergarten ready and getting them ready and primed for reading, again if we're missing this information, even if it's just a little bit, we know that they may be starting off behind. Now we're just putting more of that so sometimes just having more of that conversation. It may be more than one conversation. And I think it also has to be a team approach.

It has to be a consistent message as we're working with them and part of that comes with having the communication with the child's provider, their speech Therapist, their Early Intervention provider that we're sending the information that this is important and this is why it's important and these are the effects we have, if our goal is spoken language, this is what it takes to get there. Even if we're starting off behind we don't want to make it that much harder and that much more difficult for the child.

So having more of those open conversations but then also I think you have to not be afraid to have the difficult conversation. So having it, starting off, engaging the whole group, but then also really when you're working with a family, talking about, if this is what your goal is, this is how we get there, and then working with them on what the those goals are, and having the family be an active participant in that in setting the goals and looking at.

I try to talk to families about: I'm not just concerned about

right now. I'm also looking at the future. So when I talk about the testing we're getting, whether we have a change in hearing, the programming, it's not just right here, not just this moment. This is very fluid. Things are going to change.

The goal, the intervention, the assessment that we're putting in place right now is not going to be the same 6 months from now. Might not be the same a year from now so I have to look at the bigger picture and it's part of my job to do that.

[ Inaudible ][ Off Microphone ][ Captioner unable to hear comment ]That's great.[ Off Microphone ]Another thing that I may do in the booth -- so keep this kind

of the most important -- I may not care about that functional gain of whether they're hearing those different tones but sometimes we may play those sounds with the family in the booth so that they can hear again having that simulation, but it may not be a tool that I'm using to make changes on but it may be something that I use that okay, this is how loud this had to be in order for them to detect this, in order for them to even hear that something was going on even with mild or moderate hearing loss. So kind of incorporating that in the conversation, even if it's not a part of kind of like my assessment.

In the back. [ Off Microphone ][ Inaudible ] I think what's helpful, what's been helpful, for

me is having them introduced to somebody else with hearing loss. Sometimes I find kids who are more reluctant to wear it are kids who are the only one in their classroom, they're the only one in their school, so figuring out ways we can introduce them to other teens who preferably a teen that's wearing their devices, with that, to have those -- to have that conversation.

No one else can sell you on the importance of having it like somebody else who is already doing it every day. Talking to them about what worked for them, what their struggles are, what works well, what doesn't work well, so finding some of those opportunities, whether it's camps, whether it's -- we host kind of a hearing loss event and we try to host that [ Inaudible ] so families cannot only connect with each other so also the kids can connect with each other and making sure with people with the world of social media getting them to be able to connect with each other is a lot easier in comparison to what it used to be. But I feel like that has been probably one of the most helpful things in working with -- I feel like it usually starts around 5th, 6th grade that we do that.

Also starting those conversations early on with the families,

with the child, helping them advocate for themselves, helping them feel empowered with it and so those are conversations that we can have from Day One of diagnosis and getting started with their amplification of how do we build those skills in our little ones so that when we get to 5th grade and 6th grade they don't feel like they're the only ones wearing a device or whatever the issue is, that maybe we kind of put some of these things in place to kind of work on that barrier.

[ Off Microphone ]Absolutely, I would agree. Did anyone else have suggestions

on what's worked for them? [ Off Microphone ] Absolutely.[ Off Microphone ]I would agree.[ Off Microphone ]Thin I know there's the [ Inaudible ] out there. That's also

something that's been great to use in classroom settings, to help with other kids understanding what's going on but it's also useful with parents.

[ Off Microphone ]That's great. I think using any of these tools again just

getting across and stressing the importance of this particularly again when we're focusing on our kids that have more of that residual hearing loss and as we're finishing up here as we're focusing on the families and just making sure that they understand and they're educated, it may take three times more exposure for that child to learn a new word or a new concept so again if we're not using any type of amplification, if we're not putting proper intervention in place it's going to make it that much harder for the child to learn those new words, those new concepts and even think about literacy, learning to read.

So the last thing, if you're not as familiar coming from the University of Chicago, I get to work with [ Inaudible ], one of our pediatric ENTs so when we look at the 30 million word project, this is kind of the main focus as we tie it into kids with hearing loss, three Ts. Talk more, tune in and taking turns and really stressing that to again anyone who's working with that child. The parents, Early Intervention providers, me as an audiologist. So talking more to the child, tuning into what they're focused on, and taking turns as you're interacting.

And so that's certainly something as I look at a provider as an audiologist, those are things that I can put into place, I can model that even during our appointment, so whether it's half an hour or hour session as I'm interacting with their baby, those are things that I can do is we're working with the [ Inaudible ], a 3-year-old that's getting into all of the toys again focusing

on tuning into what they're into so that we can get more of this language and giving them more exposure and just again talking about how important this is from Day One and stressing that importance over and over as we're working with the family.

That's my contact information. Any other questions or input? [ Off Microphone ] I think it's kind of two-fold. We have the kids that are

getting -- we're talking about the children who are in this mild to moderate and performing one to four times lower than kids in the severe to profound. I think it goes into we have a category of kids that are getting cochlear implants, and so they're able to have kind of better access, as well as then you have the category that are using sign language so they have language and when we look at our kids in this mild-moderate, if they're not using technology or amplification, if we don't have these interventions in place, we already know that they're missing a lot of this information. We know that they have difficulty with these abstract concepts. We know that they're having trouble with similarly sounding words and words with double meaning and things like that.

So when we look at their language, it's still falling 1 to 4 times below compared to their counterparts. And so again, that just kind of ties in why we have to stress the importance of this because these kids are at-risk so sometimes they're more at risk because they get overlooked, because they can hear without use of their technology, or it's not as important that they have it on.

There are some kids that fall into the mild category where maybe they're only wearing their hearing aid while they're at day care, or at preschool but then when they come home they go off or on the weekends they're off. Again stressing this importance across the board and starting kind of from day one with that information.

Any other comments or questions?Well, thank you so much for your time.[ Applause ][ End of session ]

* * * * *This is being provided in a rough-draft format. Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings.

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