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Understanding Hearing Loss

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1 Understanding Hearing Loss
Welcome to “Understanding Hearing Loss.” This module provides introductory information regarding how a hearing loss is determined and how that loss impacts a child’s education. This module was developed by the North Dakota School for the Deaf Outreach Department. The North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing is a state agency and a division of the North Dakota Department of Public instruction. Compiled by the North Dakota School for the Deaf/ Resource Center for Deaf and Hard of Hearing’s Outreach Department (3/2013)

2 North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department
The presentation is intended to serve as a resource for parents, teachers and other professionals who want to gain a greater understanding of the impact a hearing loss has on a child’s education. Topics included in this module are: how the ear works; developmental hearing milestones, types of hearing loss, audiological assessments, the audiogram, introductory information on hearing aids, cochlear implants, and other assistive listening devices, as well as the range of options for communication systems.

3 Typical Hearing Drawing from SKI*HI
North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department This diagram illustrates how the ear processes speech and other environmental sounds. These sounds enter as waves and pass through the ear canal to the eardrum located at the end of the ear canal. The sound waves cause vibrations in the eardrum and the ossicular chain, the three bones in the middle ear: the malleus, incus and stapes (also known as the hammer, anvil and stirrups). The snail shaped portion of the inner ear is known as the cochlea. It changes the incoming accoustical sound signals into electrical signals the brain can translate. The sound waves cause the fluid and hair cells in the cochlea to move. The hair cells vibration stimulates the nerve fibers of the auditory nerve. The sounds coming into the ear determine which hair cells respond. The hair cell responses create signals that become nerve impulses which are carried to the brainstem by the acoustic nerve ( the eighth cranial nerve). From the brainstem the nerve impulses continue on to the auditory processing centers within the brain which creates the perception of sound. Drawing from SKI*HI

4 Conductive Hearing Loss
An obstruction in the outer and/or middle ear blocks the transmission of sound. Medical and/or surgical treatment may reduce or eliminate this type of hearing loss. North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department A hearing impairment can be diagnosed as conductive, sensorineural, or mixed. A conductive hearing loss occurs when an obstruction in the outer or middle ear blocks the transmission of sound to the inner ear. Like an earplug, this type of hearing loss diminishes the loudness, but not the clarity, of the sound reaching the inner ear. Conductive hearing impairments may be treated medically. Drawing taken from

5 Causes of Conductive Hearing Loss
The ear canal is missing or occluded (obstructed). Allergies The bones in the ossicular chain are broken or calcified. North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Middle ear infections or fluid in the middle ear are common causes of conductive hearing loss. Other conditions that may produce this type of hearing impairment include: a hole in the eardrum, excessive wax buildup, a foreign body in the ear canal, or a malformation of the outer ear, ear canal, or middle ear. Young children who experience chronic middle ear infections and/or extended periods of congestion often exhibit developmental delays in language and speech acquisition.

6 Sensorineural Hearing Loss
Are commonly a result of a damaged cochlea and/or auditory nerve. May improve with hearing aids or cochlear implants. Require auditory training. North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department A sensorineural hearing loss most commonly results from damaged or absent cochlear hair cells and/or atrophied auditory nerve fibers. Cochlear hair cells are “tuned” to specific pitches. In normal hearing, when sounds in the hair cells’ frequency range reach them, these cells stimulate the auditory nerves that lie below them. Damaged cochlear hair cells or the absence of any hair cells “attuned” to a particular range of volume or pitch reduces the amount of stimulation to the auditory nerve fibers. Lacking stimulation, these fibers eventually atrophy. Children with sensorineural hearing loss experience difficulties with sound clarity and hearing sensitivity. A sensorineural hearing loss cannot be medically repaired. Drawing taken from

7 Causes of Sensorineural Hearing Loss
Diseases during pregnancy Heredity Childhood diseases (mumps, measles, chicken pox) Viral infections (meningitis, encephalitis) Prolonged high fever Physical damage to head or ear Exposure to excessive or intense noise (loud music, gunfire, etc.) North Dakota School for the Deaf Outreach Department Nearly 50% of all diagnosed sensorineural hearing losses have no known cause. Many suspected contributors to sensorineural hearing loss include: diseases during pregnancy, heredity, childhood diseases (mumps, measles or chicken pox), viral infections (meningitis or encephalitis), prolonged high fever, any physical damage to the head or ear, or exposure  to excessive or intense noise ( loud music, gunfire, etc.).

8 Mixed Hearing Loss A combination of conductive and sensorineural components: Blockage in the outer or middle ear AND Damaged inner ear (cochlea) or auditory nerve North Dakota School for the Deaf Outreach Department A child receives a diagnosis of a mixed hearing loss when they have a combined conductive and sensorineural impairment. Most commonly this type of hearing loss results from a blockage in the outer and/or middle ear, (the conductive impairment) and damage to the inner ear (cochlea) and/or auditory nerve (the sensorineural impairment). Many children with a sensorineural hearing loss have experienced chronic middle-ear infections; a susceptibility that makes mixed impairments somewhat more common. A mixed hearing loss reduces or eliminates a child’s access to sounds, including speech. A diminished hearing sensitivity impacts the child’s development of speech and language.

9 Warning Signs for Infants
Birth to 4 months: awakens or startles at loud noises? calm at the sound of a familiar voice? 9 to 15 months: babble a lot of different sounds? respond to his/her name? respond to changes in your tone of voice? say "ma-ma" or "da-da"? understand simple requests? repeat some sounds you make? use his/her voice to attract attention? 4 to 9 months: turn eyes toward source of sounds? notice rattles and other sound-making toys? cry differently for different needs? make babbling sounds? seem to understand simple word/hand motions such as "bye-bye" with a wave? 15-24 months: point to familiar objects when they are named? listen to stories, songs and rhymes? follow simple commands? use several different words? point to body parts when asked? name common objects? put two or more words together? North Dakota School for the Deaf Outreach Department According to current research, the most critical period for speech and language development occurs between birth and age four. The chart above provides parents with the developmental milestones for hearing and language development during the first 24 months. Parents in their role as their child’s first teacher often are the first to suspect their child may have a hearing loss. Early detection of a hearing loss is critical during this important developmental period. Parents should not hesitate to report any concerns or observed delays in their child’s hearing or language development to their pediatrician. It is never too early to ask for a thorough hearing evaluation for an infant or toddler.

10 Warning Signs for Preschool & Older Children
Does the child: need the TV volume to be excessively high? respond inappropriately to questions? fail to reply /respond when called? watch others to imitate what they are doing? have articulation problems or speech/language delays? have problems academically? complain of earaches, ear pain or head noises? have difficulty understanding what people are saying? seem to speak differently from their same age peers? North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department This slide contains a list of warning signs for Preschool and Older Children. Parents should monitor children of all ages for any sign of a hearing loss. Just because a child may exhibit any of the behaviors listed in this slide, parents should not assume automatically that their child has a hearing loss. However, when any of these behaviors or a combination of behaviors occur over an extended period of time, or when any suspicion arises that a child is having difficulty hearing, parents should consider scheduling a thorough hearing evaluation with an audiologist as soon as possible.

11 Audiologic Assessments
Otoacoustic Emissions Test (OAE) Auditory Brainstem Response Test (ABR or BAER) Conventional Behavior Tests Tympanometry North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department When a child receives a diagnosis of a hearing loss, regular visits to an audiologist become routine. An audiologist tests hearing, recommends and/ or provides appropriate assistive hearing devices, and/or referrals to other medical personnel for further evaluations. Common audiologic assessments used to diagnose or determine the extent of a hearing loss include: Otoacoustic Emissions Test (OAE), Auditory Brainstem Response Test (ABR or BAER), conventional behavioral audiometry and tympanometry. Parents should be given an explanation of the type of assessments that will be administered during the hearing evaluation as well as the information generated by those assessments.

12 Otoacoustic Emissions (OAE) Test
North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department One of the techniques used to test a child’s hearing at any age is an Otoacousic Emissions (OAE) test. The OAE test measures the response of the cochlea’s sensory cells to sound. A small probe placed in the ear canal delivers a soft click and then measures the echo. A normally functioning cochlea produces a measurable echo (an OAE). The absence of a measurable echo indicates a minimum 30 dB HL which may be conductive or sensorineural. photo from Cataract Foundation Philipines, Inc.

13 Conventional Behavioral Hearing Tests
North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department A conventional behavior hearing test enables the audiologist to evaluate the child’s hearing in: the inner ear; each ear separately and/or both ears simultaneously. During this test, a device called an audiometer delivers sounds at different volumes and pitches through headphones, ear probes or speakers to the child. The child’s responses to those sounds can be as simple as widening the eyes or as complex as performing a designated task each time a sound is perceived. The results of the hearing test are displayed on a graph called an audiogram. From the audiogram, the audiologist can determine the degree (mild to profound) and type of hearing loss (sensorineural, conductive or mixed). photo from

14 Auditory Brainstem Response (ABR) Test
North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department An absence of behavioral responses during a hearing evaluation may warrant the administration of an Auditory Brainstem Response (ABR) test. This test does not require cooperation from the child and is easily and reliably performed when the child is asleep. Electrodes, placed at selected points on the head, objectively measure the child’s neural responses to sounds. The electrical activity in the auditory nerve and the hearing centers in the brainstem produces a waveform record which the audiologist examines and interprets throughout the test. These records provide a general picture of the child's overall hearing sensitivity and information about any type or degree of hearing loss. photo from

15 Tympanometry North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department An audiologist routinely performs a tympanometry which assesses the function of the middle ear, not hearing acuity. During the test, a rubber tip probe connected to a tympanometer is inserted into the ear canal. The tympanometer generates tones and measures the eardrum movements in response to the tones and the air pressure changes. These measurements are recorded on a graph called a tympanogram. The test results provide important information about the functioning of the eardrum and the middle ear system. Optimal functioning of the middle ear system is important to ensuring that the child does not experience an additional decrease in hearing. photo from

16 Understanding Audiograms
North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Drawing from The audiologist uses a graph, called an audiogram, to represent the sounds heard during a hearing evaluation. The audiologist plots an individual’s hearing thresholds, the softest and loudest sounds the individual hears, on the audiogram.

17 HIGH PITCH LOW PITCH FREQUENCY IN CYCLES PER SECOND (HZ) 125 250 500
1000 2000 4000 8000 LOW PITCH HIGH PITCH North Dakota School for the Deaf Outreach Department NOTE TO ANNOUNCER: Wait for audio tones to finish before narrating Numbers across the top of the audiogram represent frequency (or pitch), going from a low (125Hz) to very high (8000Hz). FREQUENCY IN CYCLES PER SECOND (HZ)

18 SOFT LOUD HEARING LEVEL (dB HL) 10 20 30 40 50 60 70 80 90 100 110 120
10 20 30 40 50 HEARING LEVEL (dB HL) 60 70 North Dakota School for the Deaf Outreach Department 80 NOTE TO ANNOUNCER: Wait for audio tones to finish before narrating The numbers down the left side of the audiogram represent the volume ( or loudness), or decibel (dB) level of sounds. Starting at the top of the audiogram, the numbers represent a progression from very quiet sounds to very loud, and quite possibly, dangerous decibel levels. 90 100 LOUD 110 120

19 Average Loudness Levels
Drawing from North Dakota School for the Deaf Outreach Department This audiogram illustrates the average volume (loudness) and pitch ranges of commonly heard sounds.

20 Audiogram symbols North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department A hearing sensitivity assessment measures the air conduction of sounds using headphones or speakers. Sounds of different frequencies and intensities are transmitted through the air to the inner ear. Each ear’s responses to the sounds are recorded on the audiogram by different symbols, “X” for the left ear and “O” for the right ear. Sounds that are inaudible or quieter than a child's hearing thresholds are recorded using numbers that are smaller than the “X” and “O” on the audiogram. By the same token, sounds that are greater than the child’s threshold levels will be recorded underneath the “X” and “O” responses. When one ear has better hearing than the other, certain sounds may be audible only in that ear. In this case, sounds falling between the recorded “X” and “O” responses represent the audible sounds the more sensitive ear can hear. When responses to sounds are not obtained using the earphones, speakers may be used. These responses will be recorded using an “S” or some other designated symbol to represent the range of sounds each or both ears can hear. An arrow at the bottom of the symbol denotes that the child did not respond to that sound.

21 Audiogram from http://www.merckmanuals.com
Bone Conduction North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Audiologists have another method of assessing hearing sensitivity. A special headset called a bone-conduction oscillator presents sounds and then measures the audible sounds using a process called bone conduction. Bone conducted hearing occurs when the oscillator vibrates against the mastoid bone behind the ear. These vibrations in turn directly stimulate the inner ear. The inner ear, or bone-conducted, responses are recorded on an audiogram using the following symbols “<“ “>” “[“ “]”. Audiogram from

22 Drawing from http://www.babyhearing.org
Degree of Hearing Loss North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Drawing from An audiologist uses audiograms from various assessments, a tympanogram and medical evaluations to determine what type of hearing loss a child has (conductive, mixed or sensorineural). The color coding of this audiogram indicates the decibel range for normal hearing and each degree of hearing loss: mild, moderate, severe and profound. Audiologists classify the slightest degree of hearing loss as mild and the most significant degree as profound. Different degrees of hearing loss create unique sets of needs and questions regarding the impact of the loss on the child and how to address it most effectively. Knowing and understanding the implications associated with a child’s degree of hearing loss improves the communication between parents, professionals and specialists as well as the parents’ access to appropriate information and services.

23 Amplification Photo from Advanced Bionics
North Dakota School for the Deaf Outreach Department Amplification devices that increase the range of perceptible sounds for a child with a hearing loss are available. The most familiar amplification devices are hearing aids and cochlear implants. An audiologist may have the child wear one of these devices during a hearing test. From the audiogram produced with the amplification device, the audiologist is able to determine the thresholds of sound the child will be able to hear when wearing the device. Parents should be aware that not every child is a candidate for every device. The child’s degree and type of hearing loss are the main factors the audiologist will use to determine which device is the most appropriate for the child. Photo from besthearingaidsguide.info Photo from

24 Hearing Aids Amplify sounds
Allow sound to travel the “normal” route through the ear North Dakota School for the Deaf Outreach Department Obtaining amplification is the first and most important step in the habilitation or rehabilitation of a child with a hearing loss. Hearing aids increase the loudness of sounds so that the child is able to hear previously inaudible sounds. Improving a child’s audition promotes speech and language development, as well as increased awareness of environmental sounds. Sound awareness and perception are important to children with a severe or profound hearing loss and/or users of sign language . Since the auditory channel’s primary role is a learning modality, it is important that children with any type of hearing loss have multiple opportunities to learn using this channel.

25 Hearing Aids CANNOT Restore sound’s natural quality (sounds may be perceived as “mechanical’ or “tinny”) -which will affect listening to music Improve hearing when background noise is present or with simultaneous conversations Amplify only what a child wants to hear North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department For a child with a damaged inner ear, hearing aids will not improve the clarity of sounds; they only make sounds louder. However, sounds loud enough to be perceived by impaired ears can promote the development of a child’s auditory skills.

26 Hearings Aids Can Make soft sounds louder, make listening to speech more comfortable and easier to understand Improve hearing in social situations that were previously difficult (church, social groups, etc.) Improve hearing at high pitches (promoting an awareness of environmental sounds and increased understanding of speech) Improve comfort with social interactions and events North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Having realistic expectations about the benefits a hearing aid can provide is important. Hearing aids amplify sounds to make them audible; however, sounds will still be distorted for children with a sensorineural hearing impairment.

27 How a Hearing Aid works North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department The previous slides discussed what hearing aids can be expected to do; the next slides will describe how they work and what they look like. Hearing aids are battery operated amplifiers of sound. The hearing aid’s tubing and ear mold have been designed to hold it in place and direct the sound down the ear canal. The hearing aid’s microphone detects sound and sends it electronically to the amplifier. As its name implies, the amplifier increases the sound level to match the child’s hearing loss. The amplified sound is sent electronically to the receiver and converted from an electrical signal into acoustical energy. This energy is transmitted through the ear hook, tubing and ear mold into the ear canal. The volume of sound entering the ear canal should be adjusted to the audiologist’s recommended level.

28 What do Hearing Aids look like?
North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Two factors, age and the type of hearing loss, are used to determine which type of hearing aid will provide the most benefit to the child. The most suitable hearing aids for young children are the snug fitting behind-the-ear models held in place by a individually designed ear mold. Older children with a mild to moderate hearing loss may be able to choose in-the-ear or in-the-canal hearing aids which do not have a behind the ear piece. Today, hearing aids can be fun and fashionable as well as functional. Conventional aids and ear molds are made in a variety of colors ranging from flesh-colored tones to bright colors. Some molds even come with sparkling stars. This slide shows a small selection of currently available hearing aids and ear molds. photo from

29 Cochlear Implants North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Children with a severe to profound sensorineural hearing loss, who do not benefit from hearing aids, may benefit from having a cochlear implant (CI). These implants do not give the child normal hearing, but they do provide the child with important sound information. Children receiving an implant will need instruction on the use of the sound stimulation their implant creates. Learning to use sound stimuli requires intensive auditory training, a slow and difficult process for any child; but, especially for those who have little or no prior experience with sound. photo from

30 What is involved with CIs?
Surgery and an overnight hospital stay A healing period before the external devices are connected Numerous follow up appointments To map and program the device To receive extensive auditory training North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Cochlear implants require surgery and a one-night stay in the hospital. After several weeks, the external devices are connected. Once the devices have been connected, numerous appointments with the audiologist will follow. In addition to mapping and programming the device, the audiologist provides the extensive auditory training the child needs to benefit from the implant . This training is most effective when incorporated within an instructional program that emphasizes the development of auditory skills and speech. Family involvement is an essential component in the successful development of auditory, speech and language skills.

31 Image from Cochlear, Ltd.
Parts of an implant Internal part – C. Electrodes North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Image from Cochlear, Ltd. Cochlear implants completely bypass the outer and middle ear to directly stimulate the auditory nerve. A series of electrodes surgically implanted into the cochlea are then connected to a receiver/stimulator implanted in the bone behind the ear. In addition to the implants, the child must wear a set of external components: a speech processor, an over the ear microphone, and a transmitting coil connected magnetically to the internal receiver/stimulator. External Parts – A. Speech Processor B. Transmitting Coil

32 Taken from www.ent.uci.edu. Photo from Cochlear, Ltd.
How an implant works North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Taken from Photo from Cochlear, Ltd. The diagram in this slide visually depicts how a cochlear implant works. The microphone in the speech processor collects the sound and sends it via a cord to the transmitting coil. Next, FM radio transmissions send the information from the transmitting coil to the receiver/stimulator implanted behind the ear. The receiver/stimulator activates the electrodes that correspond to the encoded sound signals which then stimulate the auditory nerve fibers lying beneath them. Finally, the stimulated auditory nerve fibers carry the message to the brain, where the sound is interpreted.

33 Eligibility Criteria for Cochlear Implant
No benefit from hearing aids At least one year of age Family and educational support Absence of medical restrictions Cochlea and auditory nerve are present North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department As stated previously, children should receive hearing aids promptly after a hearing loss is detected. For children who do not benefit from hearing aids, a cochlear implant might be an option. Currently, the Food and Drug Administration states a child must be one year of age to be a candidate for a cochlear implant. Audiologists have criteria to determine whether a child is an appropriate candidate for a cochlear implant. These criteria include: ability to hear and understand sound with a hearing aid; family and educational support; motivation to communicate using speech; absence of medical restrictions; presence of a cochlea and auditory nerve; and, educational placement following implantation. Prior to implantation, parents should consider obtaining an assessment of their child’s nonverbal intelligence or developmental level and his/her ability to learn language. These assessment results should be compared to those of other hearing impaired children. When a child with acquired speech and language experiences a sudden hearing loss, the required period of hearing aid use prior to consideration for an implant may be waived. Sudden-onset deafness in a child who has acquired language will impact that child differently than a child born deaf. In short, children are unique and have individual needs. Each must be evaluated individually to determine whether they are good candidates for an implant.

34 Bone Conduction Hearing Aid
North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Children with a conductive hearing impairment may not be able to wear a conventional hearing aid due to the ear’s physical condition. In those cases, a bone-conduction hearing aid may be recommended. This special type of hearing aid directly stimulates the inner ear and bypasses the damaged outer and/or middle ear. A bone conduction hearing aid consists of a microphone, receiver, amplifier and bone-conduction vibrator attached to a headband. The headband securely positions the vibrator on the bone behind the ear which allows the vibrator to stimulate the inner ear. photo from

35 Bone Anchored Hearing Aid (Baha)
North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Some children with chronic ear infections, congenital external auditory canal atresia and single sided deafness do not benefit from conventional hearing aids. One option parents may consider is a bone-anchored hearing aid (Baha). A Baha system has three parts, a titanium implant, an external abutment, and a sound processor which transmits sound through a pathway that bypasses the external auditory canal and middle ear. The external abutment attaches to a surgically placed titanium implant which eventually becomes part of the skull bone. The Baha components capitalize on natural bone’s ability to transmit sound. Using a process known as direct bone conduction, the sound processor transmits sound vibrations through the external abutment to the titanium implant. The child hears when the vibrations to the implant create additional vibrations within the skull and inner ear to stimulate the inner ear’s nerve fibers. Image from

36 photo from http://hearingtherapyaustralia.com
Vibro-tactile Aid North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department For children who experience a total hearing loss or for some reason are not good candidates for a CochlearTM Implant, consideration should be given to wearing a vibro-tactile aid (VTA). A VTA assists children with developing an awareness of sounds and distinguishing between sounds of different pitches and loudness. For example a child using a VTA will be able to distinguish the difference between a door knock and a telephone ring. The VTA receiver collects sounds and converts them into electrical signals. The signals are transmitted via a wire to a vibrator on the child’s wrist or chest. The sound’s pitch determines which locations on the skin receive the electrical signals’ vibration. Louder sounds will be felt as stronger vibrations than quieter sounds. Conventional hearing aids may be worn in conjunction with VTAs. In order to receive the maximum benefit from a VTA, a child must receive training. There are several models of VTAs from which to choose. The models vary from one, two or seven channels. Usually, a one or two channel VTA is worn on the wrist. The two channel model which transmits high and low frequency information can be worn on the chest as well. Children often wear the seven channel VTA on their chest. Children who experience sudden deafness may use a VTA while they wait for a CochlearTM Implant. Using a VTA helps beginning lip readers learn the skill more quickly because they can feel the consonants that cannot be detected on the lips. photo from

37 Assistive Listening Device (ALD)
A child with a hearing loss may benefit from an Assistive Listening Device (ALD). The ALD increases the child’s ability to hear sounds in an auditorium or classroom by Reducing background noise. Making faraway sounds seem closer. North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department A child with a hearing loss may benefit from using an Assistive Listening Device (ALD). These systems direct sounds to the ears which improves the child’s hearing in large areas, like an auditorium or a classroom. They reduce background noise and make faraway sounds seem closer. Assistive listening devices have become popular because they improve the hearing of every child not just those with hearing losses.

38 Assistive Listening Devices
Personal FM System Soundfield FM System North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Delivers speech from a speaker’s microphone to the ears of the person with a hearing loss Delivers speech from a speaker’s microphone to speakers placed strategically throughout the room Personal FM systems require the FM microphone to be placed next to the sound source (e.g., a speaker, other participants or a TV). The microphone uses radio waves to deliver the sound source’s speech directly to the ears of the child with a hearing loss. By eliminating background noise, these systems transmit the clearest and most consistent pattern of the speaker’s voice. Having a second microphone available for additional sound sources makes managing the Personal FM system easier. Soundfield FM systems function like a public address system. An FM wireless microphone located near the sound source collects, amplifies, and transmits speech sounds to the room via one or more strategically placed speakers. This type of ALD benefits an entire room because it improves the sound’s clarity and reduces background noise. Children having a hearing loss report that this type of ALD does not provide the same sound clarity or volume as the personal FM system. When selecting assistive technology, the child and their family must understand the technology’s purpose and its intended benefits to the child with a hearing loss. The child should be given time to learn how to operate the technology and evaluate its usefulness for him/her. Finally, it is important to ensure that technical and audiological support are available for both of these ALD systems.  Technical malfunctions and breakdowns do occur.

39 Educational Implications
Communication Language Speech Social Emotional Behavior Reading Academic Daily Living Career North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Any degree of hearing loss affects a child’s development, especially their ability to communicate. These children commonly experience delays in the development of language and speech sounds. Children with speech and language skill deficits frequently engage in attention seeking behaviors that negatively impact their social interactions. Inevitably, their inability to obtain and maintain age-appropriate peer relationships leads to a predictable consequence, social and physical isolation. Within the educational setting, the social and physical isolation experienced by children with poor communication skills and attention seeking behaviors continues. Children with poor communication skills and behavioral deficits frequently spend less time in academic instructional settings and more time suffering disciplinary consequences for their behavior. Any reduction in academic instructional time creates a potentially corresponding decrease in academic achievement which over the course of their school enrollment diminishes their prospects for becoming gainfully employed. Failure to obtain and sustain gainful employment reduces their ability to become self sufficient and independent.

40 Communication Options
Auditory Oral Auditory Verbal Cued Speech Total Communication American Sign Language North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department The following slides provide a brief description of communication methods used with children who have a hearing loss. Parents should become aware of and research the different options for teaching language and communication skills as well as the professionals trained in the various approaches. Some professionals have training in only one method, while others have been trained in multiple methods and as a result possess a wider repertoire of treatments from which to select. Parents should select the approach and professional that best fits their child and family; however, neither selection is irrevocable. Parents should monitor their child’s progress and not be afraid to consider trying a different method when their child shows limited or no progress after several months of consistent instruction on an elemental skill or a building block for more a more advanced skill. Establishing an effective communication system between family members and the child with a hearing loss must be the ultimate goal.

41 Auditory-Oral Programs
GOAL: To encourage speech Auditory-Oral programs combine: residual hearing, lip reading, hearing aids, cochlear implant (s) and/or other amplification devices. North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Auditory- Oral programs use a combination of residual hearing (remaining hearing), lip reading, hearing aids, cochlear implant/s and /or an FM system to encourage speech development. Incorporating tactile methods into the auditory-oral program enables the child to feel the sounds of speech. Although a portion of the instruction may require the child’s listening skills alone, it does permit the use of supplemental visual cues to promote optimal understanding of spoken language. Auditory- Oral programs do not recommend the use of sign language during instruction.  

42 Auditory Verbal Programs
GOAL: To teach listening and speaking using hearing aids, cochlear implant and/or other amplification devices. No use or emphasis of sign language or speech reading. Parents training: methods incorporating listening and language use within daily routines. North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department The Auditory-Verbal approach emphasizes teaching children how to listen and speak using their hearing aids, cochlear implant/s, and/or FM unit. Instruction does not emphasize or use sign language or speech reading. Auditory-Verbal programs require a high degree of parent involvement. During child therapy sessions, an Auditory-Verbal therapist guides the parents in encouraging and developing their child’s speech as well as helping the child understand sound and spoken language. This training provides parents with strategies for incorporating listening and language use into daily routines.

43 Cued Speech GOAL: To teach speaking through the use of amplification, lip-reading and cues from the hand shape system. North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Cued Speech teaches children to read speech using a visual system of eight simple hand movements (cues) around the face. Each cue alerts the child to the differences in the pronunciation of spoken words that look exactly the same on the mouth (e.g., pan, man). Classes for Cued Speech require trained teachers or therapists and a significant amount of time for practicing cues to develop proficiency using them.

44 Total Communication speech, sign language, auditory training,
GOAL: To teach speech using all modes of communication: speech, sign language, auditory training, speech reading finger spelling. North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Initially, defined as a philosophy that incorporated using all modes of communication (i.e., speech, sign language, auditory training, speech reading and finger spelling), Total Communication, has become more commonly referred to as Simultaneous Communication (signing while talking).  As a philosophy, Simultaneous Communication led to the development of manual systems representing spoken English (i.e., Signing Exact English, Signed English) that can be used simultaneously with oral speech. The goal of Total Communication is to use every method available to develop a communication system for a child with a hearing loss.

45 American Sign Language (ASL) (Bilingual/Bicultural)
GOAL: To teach a visual language Used by persons defined as culturally Deaf in the United States and Canada. Has a distinct grammar and word order. (Often English is learned as a second language). Incorporates eyes, hands, facial expressions and body movements. North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department American Sign Language ,a fully developed, visual language, is used widely in Deaf communities in the United States and Canada. Unlike English, which has a spoken and written form, ASL is a visual-gestural language. In order for the child to develop proficiency in this mode of communication, family members must learn and become proficient in ASL as well. ASL has its own grammar and syntax. Because its syntax does not follow English word order, speaking English and signing ASL simultaneously will not convey the same meaning. (ASL: Food store I go will.  English: I will go to the grocery store.) 

46 Accommodations Use draperies on windows
NOISE CONTROL Use draperies on windows Use low, acoustically controlled ceilings Reduce noise from lights, fans, heaters, etc. Use carpeting on floors and walls to absorb sound Use auditory training equipment to enhance the child’s listening LIGHTING CONTROL Use draperies to control sun glare Provide adequate ceiling lights North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Both noise and lighting may impact a child’s ability to hear and visually process information. Common accommodations include modifying the physical environment using acoustical ceiling tiles, carpeting, thick curtains, rubber tips on furniture legs, and proper maintenance of the ventilation and lighting systems, as well as doors and windows can help with hearing and vision. These modifications reduce unnecessary noise and distractions in the room. Shadows on a speakers face make it difficult for a child with a hearing loss to lip read or understand speech. To avoid this situation, ensure that the child with a hearing loss sits with his/her back towards the light source (a window or door) and not the speaker. A child with a hearing loss must have adequate lighting at all times and in all locations.

47 Accommodations SEATING ARRANGEMENTS Ensure a clear view of the speaker’s face – essential to following discussions and lectures Allow seating changes as activities change Seat with the better ear turned toward the speaker VISUAL AIDS Make language and information visible-Use chalkboard, overhead projector, written labels, captioned films, etc. North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Seating arrangements should be determined by the child’s needs. Optimal seating for the child with a hearing loss should be: near the front of the room to maintain visual access to the speaker. Sitting off to one side also allows greater access to the majority of the participants in the room during discussions. During group activities, encourage the child to watch the faces of the other people when they speak. Semi-circle seating can be especially helpful. If the child with a hearing loss has a “better” ear, seat the child with the better ear turned towards the speaker. Using visual aids as much as possible is helpful for children with a hearing loss. Visuals help fill in missed information and alert the child to topic changes or transitions during discussions. During movies don’t dim the lights. Dimmed lights make it difficult for the child with a hearing loss to read the speaker’s lips and causes them to miss information shared during the film.

48 Communication Tips Choose a quiet environment.
Get the child’s attention before speaking. Do not cover mouth when speaking. Look directly at communication partner. Maintain eye contact. State the topic of discussion at the beginning of the conversation. North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department These tips allow children with a hearing loss to effectively use their residual hearing and visual cues to gather as much information as possible. Some children with a hearing loss have difficulty identifying the origination or direction of sounds. Others may hear sounds, but may not be able to recognize the spoken words. Children should be asked for guidance in making the communication easier and more effective. Initially parents and teachers may find it takes a conscious effort to remember these suggestions and ensure that accommodations are in place for the child. Choose a quiet environment. Trying to communicate in locations or at times when lots of noise or visual activity is occurring will become difficult . Turn off the TV, radio or an appliance that is creating background noise or consider moving to a different location to have a conversation. Get the child’s attention before speaking using acceptable methods like waving a hand or a light touch on the shoulder or arm. Keep the speaker’s mouth visible when talking. Covering the mouth with a hand, long mustache or beard will limit child’s ability to get information. Do not talk when eating or chewing. Look directly at the child when speaking, even when an interpreter is present. Maintain eye contact, especially when giving instructions. Do not walk around the room or turn away from the child. State the topic of discussion at the beginning of the conversation. When topics change, make sure the child is aware that a new topic is being discussed.

49 Communication Tips Speak clearly, at a normal pace. Do not shout.
When spoken words are not heard Repeat statements, then Re–phrase Be patient- take time to communicate. Be aware of fatigue. North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department Speak clearly, at a normal pace. Rapid talkers will need to slow their speaking rate. Initially, do not over exaggerate or slow the rate of speaking. If the child continues to experience difficulty with understanding the speaker’s speech, the speech rate should be slowed even more. Consider breaking sentences into smaller units. Check for understanding often. Do not shout. A loud voice may increase distortion or give the impression you are angry. Shouting does not improve comprehension. When child cannot hear the spoken words, try repeating the statement, then re–phrase the statement and if necessary use short, simple sentences. Be patient -take time to communicate. Saying “never mind” or “it’s not important,” gives the child with a hearing loss the impression they are not important. Be aware of fatigue. Children who are Deaf, Hard of Hearing, or DeafBlind must work harder to communicate than those with hearing. Be aware they may tire easily and need breaks.

50 for more educational strategies…
Contact the North Dakota School for the Deaf in Devils Lake 1401 College Drive N., Devils Lake, ND or (701) or one of their outreach offices listed below. Minot Memorial Building 500 W. University Avenue Minot, ND (701) Grand Forks 1401 College Drive N. Devils Lake, ND (701) Bismarck 418 East Broadway Suite 228-B Bismarck, ND (701) Fargo th Avenue N. P.O. Box 5036 Fargo, ND (701) North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department For specific educational strategies, contact the North Dakota School for the Deaf in Devils Lake or one of its four Outreach Offices serving the four corners of North Dakota with offices in Minot, Devils Lake, Bismarck and Fargo.

51 Resources North Dakota School for the Deaf (NDSD) www.nd.gov/ndsd/
North Dakota Interagency Project for Assistive Technology (IPAT) Described and Captioned Media (DCMP) North Dakota School for the Deaf/Resource Center for Deaf and Hard of Hearing Outreach Department The North Dakota School for the Deaf is the state’s designated resource center on hearing loss for all citizens of North Dakota. It is a great place to begin researching information on hearing loss. Information on assistive technology that may be appropriate for people with hearing loss can be obtained from the North Dakota Interagency Project for Assistive Technology or IPAT. IPAT also manages the Telecommunications Equipment Distribution Service which provides individuals with specialized telephones to match their hearing loss. The eligibility criteria for the program includes: 1) difficulty using the telephone due to a severe hearing loss, speech impairment or physical disability, and 2) requested/applied for or have phone service in the home, 3) be a North Dakota resident age 5 or over, 4) meet income limits (see application online), and 5) certified as unable to use a telephone readily purchased from a retail store by a physician, audiologist, hearing instrument specialist, speech language pathologist, or other appropriate professional. Described and Captioned Media, a service funded by the U.S. Department of Education, is administered by the National Association of the Deaf. This free-loan program provides available described and captioned educational media to students who are deaf, blind, hard of hearing, visually impaired, or deaf-blind. Captioning makes educational media accessible to the deaf and hard of hearing whereas description provides accessibility to the blind and visually impaired.


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