1. Family Support: The Role of the Pediatric Audiologist
Karen M. Ditty, M.S.
Texas ENT Specialists, P.A.
Antonia Brancia Maxon, Ph.D.
Diane Brackett, Ph.D.
New England Center for Hearing Rehabilitation
354 Hartford Tpke.
Hampton, CT 06247
NECHEAR

2. Parental Reaction (Luterman)
Mourning “the lost normal child”
Shock
Recognition
Denial
Acknowledgment
Constructive action
Parental Expectations
NECHEAR

3. Parental Reaction (Luterman)
Audiologist’s role
Understand where parents are in process
Consider amount of information they can handle at any given time
Repeat information
Consider culture
Culture, community, access
NECHEAR

4. Parental Reaction (Luterman & Maxon)
Parents are overwhelmed
Long term vs. short term goals
“Fixing” the problems
Where does child “belong?”
“Taking care of” the child
How the family changes
NECHEAR

5. Explaining hearing, hearing loss and amplification
What is the pediatric audiologist’s role in diagnosis and intervention ?
Explaining hearing, hearing loss and amplification
NECHEAR

6. Auditory Development Skill Age Behavior
Localization 6 mos Head turn to source
Min Aud Angle 6-18 mos Decreases 15-40
Detect duration
differences <6 mos <= 20 msec
Pitch perception <6 mos large for detection
Speech perception 1 month VOT can be made
2 mos Falling vs. rising F0
9-18 mos Prefer highly novel
NECHEAR

7. Speech Signal Discrimination
Learning about inflection
angry vs. soothing
question vs. statement
Learning about intensity
loud vs. soft
near vs. far
Perceptual categories
consonants
vowels
NECHEAR

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

9. What is the pediatric audiologist’s role in early intervention?
Understanding and explaining typical spoken language development
NECHEAR

10. What is progress?
Define the area of communication you are talking about….
- auditory skills
- speech
- spoken language
NECHEAR

11. How does language develop in normally hearing children?
Listening, speech, and language develop simultaneously.
Meaning is established by hearing sounds, words, phrases used in a particular situational context.
Refinement of skills occur by comparing one’s own production with a model.
Spoken language development continues into adolescence.
NECHEAR

12. How does spoken language develop in children with hearing loss?
The same way if the child has access to spoken language through appropriate sensory device.
Listening, speech, and language simultaneously.
Meaning = hearing in context
Refinement occurs with comparison to a model.
Spoken language development through teens.
NECHEAR

13. BUT……..
It is difficult to provide sufficient audible exposure to language in totally natural situations
The parent/therapist needs to purposely increase exposure to spoken language to counteract the many times that it is “masked” by noise or distance.
The “conscious” process of ensuring reception and understanding begins at identification and continues through adolescence.
NECHEAR

14. EXPECTATION
Children who grow up using appropriate sensory devices have the potential to develop superior spoken language skills.
Achievement of that potential is dependent on:
quality of the auditory information
dependence on auditory information
input from parents/therapists/children
high expectations
NECHEAR

15. What is the pediatric audiologist’s role in early intervention?
Basic principles of early intervention
NECHEAR

16. Service Provision
Families should have equal access to a coordinated program of comprehensive services that:
foster collaborative partnerships
are family centered
occur in natural settings
recognize best practice in early intervention
are built on mutual respect and choice
NECHEAR

17. Audiologic Habilitation
Pediatric audiologist
expertise in infant hearing aid selection and fitting
expertise in using appropriate pediatric testing equipment and methods
experience working with infants and their families
flexibility in scheduling
NECHEAR

18. Audiologic Habilitation
Pediatric aural rehabilitationist
expertise in
infant development
infant auditory development
infant speech and language acquisition
experience working with infants and their families
flexibility in scheduling
NECHEAR

19. What is the pediatric audiologist’s role in early intervention?
Supporting family’s understanding of language choices
NECHEAR

20. Communication Modality
Spoken language options
auditory-verbal
use amplified residual hearing to learn to listen, comprehend spoken language
uses auditory input only
oral/aural
use amplified residual hearing to acquire spoken receptive and expressive language
uses auditory input with speech reading when necessary
NECHEAR

21. Communication Modality
Spoken language options
cued speech
use hand configurations and positions to assist in identifying and discriminating among visible speech sounds
uses auditory input when possible
total communication
use all means of communication (sign, auditory) to acquire spoken language - e.g., Signing Exact English
NECHEAR

22. Communication Modality
American Sign Language
A separate language - not based on spoken English
Use hand signs and finger spelling to acquire language with its own vocabulary and syntax
Does not use auditory input
NECHEAR

23. What is the pediatric audiologist’s role in early intervention?
Helping families understand and select sensory devices
NECHEAR

24. Purpose of Amplification
Accessing the Speech Signal
Speech must be well above detection within an appropriate dynamic range
Maximal exposure to speech spectrum
Maximizing use of residual hearing
Develop/maintain auditory feedback loop
NECHEAR

25. Amplification Candidacy
Any child with any degree of hearing loss is a candidate for amplification
Without amplification
with 15 dB HL thresholds 98% of everyday speech is received
with 40 dB HL thresholds 50% of everyday speech is received
with 55 dB HL thresholds 5% of everyday speech is received
NECHEAR

26. Pediatric Amplification Fitting
Initiate amplification process immediately after diagnosis or change in hearing levels
Select, fit and validate amplification with clinical and functional evaluations
NECHEAR

27. Pediatric Hearing Aid Fitting/Validation
Ongoing process with flexible instrument
Clinical measures
More audiological data - setting adjustment
Observe behaviors, communication, environment
Audiologist
Family
Service providers
NECHEAR

28. Pediatric amplification fitting
Audiologist should use real-ear measures
Audiologist should use prescriptive fitting
Audiologist should have experience with functional measures of benefit
Audiologist should have scheduling flexibility and understand the need for immediacy of fitting
NECHEAR

29. What is the pediatric audiologist’s role in early intervention?
Helping families understand problems and daily use of amplification
NECHEAR

30. Practical Problems Problem Solution
Maintaining BTE Huggies, Strap holder, clips
Removing batteries Battery door lock
Changing volume Volume cover, deactivate volume
NECHEAR

31. Issues with Amplification
Behavior Problems Solutions
Blinking, flinching Output/gain too Decrease output
to loud sounds high; tolerance prob. or gain
Pulling out earmolds Not used to molds Use “huggies”
or strap
Poorly fitting molds Remake or refit
Sore ears- allergic Remake with hypoallergenic
NECHEAR

32. Issues with Amplification
Behavior Problems Solutions
Feedback Inappropriate settings Reprogram
Cerumen plug Medical treatment
Poorly fitting mold Remake
OME Medical treatment
Pulling on or chewing Cords too obvious String cords
cords behind back, through clothing;
decrease length
Not responding to Poor high frequency Change settings;
high pitches amplification modify earmolds;
frequency trans.
NECHEAR

33. Issues with Amplification
Behavior Problems Solutions
Blinking, startling Over amplification in Reduce low gain;
to low pitches low frequencies change FRC, h.a.
Poor responses to Not a full-time user; Work to better use
sounds Cannot use traditional Consider CI
amplification
NECHEAR

34. What is the pediatric audiologist’s role in early intervention?
Helping families understand candidacy for cochlear implants
NECHEAR

35. UNHS affects the age of cochlear implant candidacy identification
Bilateral severe to profound sensorineural hearing loss
Infant/toddler cannot benefit from traditional amplification
12 months old is recommended lowest age.
Some surgeons are implanting younger infants.
NECHEAR

36. Factors that Facilitate CI Success
Parents know about hearing loss and accept long-term problems
Parents understand the implant is not a cure
Parents are committed to implant use
Parents are committed to therapy
NECHEAR

37. Factors that Facilitate CI Success
Family has access to therapy and mapping facilities
Family is motivated
One parent at home - minimal day care
The household is organized
Child is vocalizing
NECHEAR

38. What is the pediatric audiologist’s role in early intervention?
Helping families understand problems and daily living with a cochlear implant
NECHEAR

39. Information Needed by Parents
Parents wanted most information prior to surgery, but wanted continued informational support post-implant
Parents felt emotional support was most lacking
Majority of parents felt there needed to be a professional liaison between CI center and educational program (Most and Zaidman-Zait, 2003)
NECHEAR

40. Information and Follow-up for Parents
Cochlear implant orientation and ongoing support for all care providers
On-going mapping after initial stimulation
When changes in responses to sound are seen
When changes in vocal/verbal output are seen
On-going service by early intervention provider
NECHEAR

41. Practical Problems Problem Solution
Maintaining headpiece Huggies, Strap holder, clips
Chewing on cords Stringing wires behind
and headpieces
Changing volume Locking volume control
NECHEAR

42. Issues with Cochlear Implants
Behavior Problems Solutions
Blinking, flinching Cs, Ms too Decrease those
to loud sounds high; facial nerve levels, turn off
stimulation electrodes
Red, sore spot Magnet strength Change magnets
under headpiece too much Use moleskin
Not responding to Inadequate high Change Ts, Cs/Ms;
high pitches frequency stimulation change frequency
table
NECHEAR

43. Issues with Cochlear Implants
Behavior Problems Solutions
Not responding to Inadequate low Change Ts, Cs/Ms;
high pitches frequency stimulation change frequency
table
Soft voice Over stimulation Change Ts/Cs
Loud Under stimulation Change Ts/Cs
Poor voice quality Inadequate stimulation Change settings
NECHEAR

44. What is the pediatric audiologist’s role in early intervention?
Helping families understand life transitions
NECHEAR

45. Transitions: Parent Perspective
There are always transitions in life
There are always options in the transition periods
Knowing options and goals helps through the process
There is more than one way to get through the transition with a positive outcome
NECHEAR

46. Transitions Early Intervention to School System
Elementary to Middle School
Middle School to High School
Life After High School
NECHEAR

47. Referral to and Enrollment in Early Intervention
Know established IDEA Part C (0-36 months) guidelines in state
Know child eligibility criteria
automatic enrollment - diagnosed condition
significant developmental delay
know state guidelines for selecting a program
NECHEAR

48. Enrollment in Early Intervention
Develop Individualized Family Service Plan (IFSP)
All services
speech and language development
auditory development
assistive technology
Goals and objectives
Timelines
NECHEAR

49. Components of IFSP for I/T with Hearing Loss
Amplification provision
parent education
Audiological monitoring
Development of auditory skills
Communication development
listening skills - speech perception
speech production
language development
Monitoring middle ear status
NECHEAR

50. Language Development: Determining what children need to know at various ages
Need to determine
Interactors
Adults exposed to
Children exposed to
Situations
home
school
community
NECHEAR

51. Leaving Early Intervention
Helping parents understand differences in LEA and EI approaches
Working toward a smooth transition
Ensuring good services continue
NECHEAR

52. “What’s the difference”
Goals of Birth to Three
Strengthen families to meet the developmental and health-related needs of their infants and toddlers who may have delays or disabilities
Families must be involved with the process to develop the IFSP
Goals of Special Education
Educate the child with a delay or disability
Families must be members of the PPT meetings that make decisions on the education of their child
NECHEAR

53. Timeline Referral to LEA Investigate Observe preschools
word of mouth, phone calls to Special Education Director, Teacher of the Hearing Impaired, or other people in the school system with which you are familiar
Observe preschools
neighborhood preschools, Special Education Preschools, preschools for children with hearing impairment
NECHEAR

54. Things to consider Services Assistive Technology Classroom Environment
individual therapy
center-based or school based
consultations
Assistive Technology FM
MAP adjustments
Classroom Environment
acoustics
teaching style
language of other students
willingness of teacher to make modifications (if not already)
NECHEAR

55. Things to consider
Part time preschool - is your child able to be home for the rest of the day or is another preschool or daycare involved? Availability of full-time preschool?
Extended school year
In-service Training
technology
classroom modifications
teaching styles
NECHEAR

56. Elementary to Middle School Transition
NECHEAR

57. Middle School Language
Adults Children Environment
parents siblings home
family
teachers classmates (20+) school
coach team sports fields
social group (3+) community
NECHEAR

58. Differences Moving from a sheltered environment to less protection
Multiple teachers
Teachers are still working with a restricted number of students
More “specials” options
Foreign language
Shorter length of time during year
NECHEAR

59. Teachers Modifications become extremely important
Repeat, rephrase, direct lessons, etc.
Willing to use an FM system
Microphone technique
Pass around microphone
Want to have input into the teachers (team) that are selected
NECHEAR

60. Academics More content harder language
Higher expectations for getting information without “spoon feeding”
Where does the paraprofessional fit?
Scripting really critical
What classes do you give up for special services
Communication demands
NECHEAR

61. Potential Issues The “dread FM” Adolescence
It can never be too small or too invisible
Adolescence
Socialization - old friends change
Still a limited number of groups
Everyone should be the same
Separating “typical” from hearing loss problems
NECHEAR

62. Middle School to High School
NECHEAR

63. Differences Higher expectations More rooms More student independence
Less family input
Less written information sent to family
More rooms
Need to ensure good listening conditions
Specials: new vocabulary, noise
NECHEAR

64. Teachers
More difficulty finding teachers who will readily make modifications
Different teacher for every subject
Each teacher responsible for many more students
Teacher does not know each child as well
Willing to use an FM system
May not “get” the need for it
NECHEAR

65. Teachers
They need more in-service training, but they have less time for it
More difficult to get team meetings organized
Less likely to notice changes
NECHEAR

66. Academics More content harder language Foreign language
Levels of classes
How does the paraprofessional work at this level?
Note taking - listening and writing at the same time
NECHEAR

67. Academics Having a note taker Literature vs reading
College preparation vs vocational
Interaction demands of classes
Communication demands of the classes
Written demands of the classes
NECHEAR

68. Potential Issues Sports can be a form “automatic” social groups
More social groups to choose from - likely to find a comfortable fit
More choices for different interests
School-related social interactions take place in noise, e.g., cafeteria
NECHEAR

69. High School Language Adults Children Environment parents siblings home
family
teachers classmates (20+) school
coach team sports fields
social group (3+) community
1:1 social community
NECHEAR

70. Life After High School and the beat goes on
NECHEAR