2. Sound Start for Communication Michelle King, AuD., CCC- A Amy Vissing, BSN, M.S., CCC-SLP

3. Cabinet for Health and Family Services Objectives Describe importance of Early Hearing Detection and Intervention (EHDI) in relation to maximizing communicative competence and literacy Describe how hearing screening differs from diagnostic hearing assessment Discuss importance of early speech/language intervention to promote communicative competence and literacy skills List how environmental, socio-economic and parental education discrepancies can effect development of optimal communicative competencies.

4. National EHDI Goal “The goal of EHDI is to maximize linguistic and communicative competence and literacy development for children (who are hard of hearing or deaf”) Some infants are born listeners, and others need our help

5. Cabinet for Health and Family Services Facts about Infant Hearing Hearing begins prior to birth Nationally, 3-6 out of every 1000 births have congenital hearing loss KY has 55,000 births/yr - - - we would expect 165-330 babies would be identified with hearing loss annually. In 2008, we identified 55 children born in that year with permanent childhood hearing loss (PCHL). 50% of infants born with hearing loss have no other identified risk indicators for hearing loss. The auditory cortex is hard-wired by 1 st birthday. Late identification of hearing loss or lack of early intervention services can negatively impact development and academic achievement.

6. Cabinet for Health and Family Services THAT WAS THEN … THIS IS NOW Hi - Risk Registries and Voluntary UNHS Referred if not talking 12-18 mos Critical period for Language Learning 2-3 years Diagnosed 18 mos to 3 years using behavioral audiometry Intervention –following diagnosis F/U testing every 6 mos Testing – behavioral HAB tech- CI at 2 years Mandated UNHS prior to hospital discharge –EHDI Referred at hospital discharge Critical period for Language Learning before 6 mos. of age. Diagnosed before 3 mos. of age Intervention before 6 mos. of age F/U testing – frequently dependent upon age/growth OAE, ABR and behavioral CI – FDA 1 yr. Possible at 6 mos (special circumstances)

7. Cabinet for Health and Family Services Why is Early Identification of Hearing Loss so Important? Congenital hearing loss interferes with the most basic human need, Communication. Hearing loss is the most frequent birth defect There is a narrow window of brain development for language. Undetected hearing loss has life long negative impact consequences Newborns identified w/ hearing loss can receive intervention services before 6 months. Intervention by 6 months boosts language development to near normal rates. Cost of education is reduced Life time achievement & earning potential is increased by early intervention

8. Cabinet for Health and Family Services JUST IN TIME: 1-3-6- PLAN NEWBORN HEARING SCREENING BEFORE 1 MONTH OF AGE DIAGNOSTIC AUDIOLOGICAL FOLLOW-UP BEFORE 3 MONTHS OF AGE ENROLLMENT IN EARLY INTERVENTION BEFORE 6 MONTHS OF AGE

9. Cabinet for Health and Family Services Hearing Screening Screening, a “colander” to identify kids with hearing loss –Pass/Refer –Relatively quick –Relatively Cheap –Acceptable refer rate and false positives

10. Cabinet for Health and Family Services AABR & OAE

11. Cabinet for Health and Family Services Typical Mild Moderate Severe Profound

12. Cabinet for Health and Family Services Can UNHS Miss Hearing Loss That is Present at Birth? It is possible to have mild or minimal hearing loss at birth and pass UNHS Screening programs needs to achieve a low false-alarm rate and a high “hit” rate Goal is to have few children referred for additional, more expensive testing who do not need it and those who are referred have a high likelihood of having hearing loss

13. Cabinet for Health and Family Services Otoscopy ear canal Ear Drum Tympanometry Ossicles Cochlea Otoacoustic Emissions (OAE) Acoustic Reflexes Auditory nerve Auditory Brainstem Response (ABR) Pediatric Audiologic Test Battery

14. Cabinet for Health and Family Services How Hearing is Evaluated  Otiscopic inspection  Visual Reinforcement Audiometry (VRA)  Play Audiometry  Behavioral Observation Audiometry (BOA)  Conventional Audiometry  Tympanometry  Acoustic Reflex Testing  Otoacoustic Emission Testing (OAE)  Auditory Brainstem Response Testing (ABR)

15. Cabinet for Health and Family Services OAE RESULTS

16. Cabinet for Health and Family Services AUDITORY BRAINSTEM RESPONSE Auditory Brainstem response. Measures how sound is neurally transmitted from the level of the cochlea to the lower brainstem or how the ear and brain work together. Not a true test of hearing. Traditional (click)Tests only the high pitches (2-4K freq region S-T) Frequency specific ABR is what is needed as a confirmation of other testing, prior to fitting amplification, especially on the hard to test.

17. Cabinet for Health and Family Services ABR RESULTS:

18. Cabinet for Health and Family Services Auditory Neural Pathway Central Auditory Pathway

19. Cabinet for Health and Family Services TYPES OF HEARING LOSS CONDUCTIVE SENSORI NEURAL MIXED AUDITORY DYSYNCHRONY CENTRAL AUDITORY PROCESSING

20. There are no more secrets to early learning… This is why and how Early Intervention REALLY works…..

21. IT’S ALL ABOUT THE BRAIN Cabinet for Health and Family Services Determining hearing status is not about the ears; it’s about getting the auditory input to the brain! If warranted: hearing aids, FM systems and cochlear implants are not about the ears are hearing loss but about improving auditory input to the brain!

22. Cabinet for Health and Family Services Brain Relies on Auditory input to Initiate Neuro-growth (enhancement)

23. Cabinet for Health and Family Services The Auditory Window Hearing begins prior to birth The auditory cortex is wired by 1 st birthday By 6 months of age, Language dependant auditory maps are apparent in children. These maps are completed by 12 months. These maps train all subsequent language learning attempts, explaining why 2 nd language learning can be so difficult

24. NEUROLOGICAL ISSUES We hear with the brain -- the ears are just a way in! What’s the big deal? Hearing loss keeps sound from reaching the brain. Human beings are rich in auditory brain tissue – But children can’t listen like adults! Why? 1) the higher auditory brain centers are not fully developed until a child is about 15 years old, 2) and children cannot perform sophisticated “automatic auditory cognitive closure”. Therefore, all infants and children need a quieter environment and a louder signal than adults.

25. Auditory Access to the Brain Hearing is a first-order event for the development of spoken communication and literacy skills. Anytime the word “hearing” is used, think “auditory brain development”!! Acoustic accessibility of intelligible speech is essential for brain growth. Signal-to-Noise Ratio is the key to hearing intelligible speech. Our early intervention protocols and classroom environments must take into consideration the listening capabilities and limitations of ALL children.

26. Cabinet for Health and Family Services The Big Picture Goal Age appropriate language literacy by school age. –Difficult to happen with late identification of hearing loss –Early and critical connections in the brain are missed

27. Cabinet for Health and Family Services TO DEVELOP LANGUAGE IN INFANTS – BEGIN WITH THE BRAIN

28. Neurological & Developmental Foundations of Speech Acquisition Brain Weight: –Function: Brain size gives humans capacity to grasp complex patterns. –Growth: ↑ from 25% adult weight at birth to 80% first few years of life. Selective Elimination: – Function: extra cell connections used for speech learning are strengthened and retained when used and eliminated if unused. –Growth: ~1/3 cells lost between birth - adulthood. Occurs in sensory areas first and later in cortical function. Cabinet for Health and Family Services McLeod & Bleile – ASHA 2003 Major aspects of brain development occur as child interacts with the environment:

29. Neurological & Developmental Foundations of Speech Acquisition Growth & Elaboration: –Function: Environment stimulates growth of cell connections needed for speech learning. –Growth: Enriched environment promotes increase synapses/neuron. Environmental deprivation decrease # of cell connections. Myelin Sheaths: − Function: white fatty substance on axons – insulates and speeds transmission of signals. Critical for gross and fine motor movements. − Growth: Myelination begins ~3 months before birth. Peak growth birth-end first year of life. Continues until adulthood.

30. Neurological & Developmental Foundations of Speech Acquisition Wernicke’s Area: –Function: Functional region in left temporal lobe – critical for language comprehension. –Growth: Peak # cell connections during 1 st half of 1 st year of life. Achieve mature # cell connections during 2 nd half of 1 st year of life. College educated > dendritic connections in Wernicke’s than high school educated > persons with less than high school education. Broca’s Area: –Function: Functional region in left frontal hemisphere – controls speech. –Growth: Density of cell connections does not peak until 15 months. Does not reach mature number of connections until age 6-8 years old Cabinet for Health and Family Services

31. Neurological & Developmental Foundations of Speech Acquisition Hippocampus: –Function: Critical to working memory. Speech activities – memory retention and word retrieval. –Growth: Develops after birth, especially during 2 nd year of life. Prefrontal Cortex: –Function: Critically important to many cognitive functions that underlie speech – reasoning, planning, judgment, and attention. –Growth: Cell connections develop slowly throughout childhood and do not mature until after adolescence. Cabinet for Health and Family Services

32. Timing is everything Window For:Wiring Window Enhancement Window Further Enhancement Emotional Intelligence 0-48 months4-8 years At any age Motor Development 0-24 months2-5 years Decreases with age Vision 0-24 months2-6 months Early Sounds 4-8 months8 months- 10 years Music 0-36 months3-10 years Thinking skills 0-48 months4-12 years At any age Reading Skills 0-24 months2-7 years At any age Second Language 0-60 months6-10 years Decreases with age

33. Arguments for Early Intervention Betty Hart & Todd Risley The Early Catastrophe: The Million Word Gap by Age 3 Jack Shonkoff, Andrew Garner, et. al. The Lifelong Effects of Early Childhood Adversity and Toxic Stress –Medical Case for Early Intervention Cabinet for Health and Family Services

34. The Early Catastrophe: The 30 Million Word Gap by Age 3 Longitudinal Study –Betty Hart and Todd Risley Focus –Build everyday language used by children –Evaluate the growth of that language Method –Observation of 42 families: 1 hr/mo from 7mo-3yr 13 high-income 10 middle socio-economic status 13 low socio-economic status (6 on welfare) Cabinet for Health and Family Services

35. The Early Catastrophe: The 30 Million Word Gap by Age 3 Results –86-98% of words used by age 3 are derived from parent’s vocabulary –Other similarities between child and parent Average utterances per hour Average different words used per hour –Children from welfare families provided ½ experiences (words heard per hour) of working class and ⅓ experiences of professional families –Professional family: 6 encouragements/1 discouragement Working class: 2 encouragements/1 discouragement Welfare family: 1 encouragement/2 discouragements Cabinet for Health and Family Services

36. The Early Catastrophe: The 30 Million Word Gap by Age 3 Follow-up: 29/42 families 3 rd grade Findings at age 3 predictive of: –Vocabulary –Language development –Reading comprehension Cabinet for Health and Family Services

37. The Early Catastrophe: The 30 Million Word Gap by Age 3 Implications: Intervention after age 3: –Lack of knowledge & skill –Approach to further experience Amount and diversity of past experience influences new experiences Less possibility for change the longer intervention is delayed Cabinet for Health and Family Services

38. The Lifelong Effects of Early Childhood Adversity and Toxic Stress Positive Stress: –Brief and mild-moderate in magnitude: i.e. dealing with frustration, getting immunization, coping with the first day at child care –Caring, responsive adult helps child cope –Growth-promoting element of normal development Tolerable Stress: –Non-normative experiences that present a greater magnitude of adversity or threat: i.e. death of family member, serious illness or injury, divorce, natural disaster, act of terrorism –Tolerable to the extent that protective adult relationships facilitate the child’s adaptive coping and sense of control –Reduced physiologic stress response and promote return to baseline status Cabinet for Health and Family Services Stress Responses in Young Children

39. The Lifelong Effects of Early Childhood Adversity and Toxic Stress Toxic Stress: –Results from strong, frequent, or prolonged activation of the body’s stress response systems –Absence of buffering protection of a supportive, adult relationship –Risk factors: child abuse or neglect, parental substance abuse, maternal depression –Disruption of brain circuitry and other organ & metabolic functions –Results in anatomic changes and/or physiologic dysregulations Later impairments in learning and behavior Chronic stress-related physical and mental illness Cabinet for Health and Family Services

40. Toxic Stress and the Developing Brain Cabinet for Health and Family Services Altered size and neuronal architecture of: –Amygdala: visceral and motor response to aid in coping with stress –Hippocampus: converts content of “working memory” in prefrontal cortex into long-term memory –Prefrontal Cortex : regulates thoughts, actions, and emotions – extensive connections with other brain regions Persistent elevated levels of stress hormones lead to permanent changes in brain structure and function

41. Toxic Stress and the Developing Brain Cabinet for Health and Family Services Functional Consequences ─ Increased fear and anxiety ─ Impaired memory and mood control ─ Problems in the development of linguistic, cognitive and social- emotional skills ─ Weak foundation for later learning, behavior, and health ─ Poor development of executive function skills Decision-making Working memory Behavioral self-regulation Mood and impulse control ─ More reactive to mildly adverse experience and less capable of effectively coping with stress

42. Lifelong Impairments in Physical and Mental Health Link between early adversity and a wide range of health threatening behaviors –Alcohol use at a younger age –Tobacco use –Illicit drug abuse –Obesity –Promiscuity Difficulty maintaining supportive social networks resulting in a higher risk for: –School failure –Gang membership –Unemployment –Poverty –Homelessness –Violent crime –Incarceration –Becoming single parents Less likely to provide stable supportive relationships to protect their own children from toxic stress Cabinet for Health and Family Services

43. Lifelong Impairments in Physical and Mental Health Biological Manifestations Alterations in immune function Increases in inflammatory markers –Cardiovascular disease –Viral hepatitis –Liver cancer –Asthma –COPD –Autoimmune diseases –Poor dental health –Depression Cabinet for Health and Family Services

44. Economic Impact Multiple dimensions of cost –Quality of community life –Health –Skills of nation’s workforce –Ability to participate in global economy Economists argue for –Early and sustained investments in early care and education programs –Particularly for children whose parents have limited education and low income Cabinet for Health and Family Services

45. Activities to Encourage Speech Development ASHA Birth – 2 years Encourage vowel-like and consonant- vowel sounds Reinforce eye contact –Respond with speech –Imitate vocalizations using different patterns of emphasis Imitate laughter & facial expressions Teach baby to imitate –Throw kisses –Clapping –Finger games –Peek-a-boo

46. Activities to Encourage Speech Development Talk –When you are bathing, feeding, dressing your baby –What you are doing –Where you are going –What you will do when you arrive –Who you will see Identify colors Count items Use gestures to convey meaning Introduce animal sounds with specific meaning Acknowledge attempts to communicate Expand on single words Read

47. Activities to Encourage Speech Development 2-4 Years Use speech that is clear and simple – model for child Repeat what your child says –Indicate you understand –Build on what was said Use baby talk –only if needed to convey a message –When accompanied by the adult word: “din-din and dinner”

48. Activities to Encourage Speech Development Scrapbook familiar and favorite things –Group into categories –Mix and match to create silly pictures –Talk about what is wrong and ways to “fix it” –Count items in a book Help your child understand and ask questions –Play yes-no games –Ask questions such as “Are you a boy?” “Can a pig fly?” –Encourage your child to make up questions and try to fool you Ask questions that require a choice –“Do you want orange or blue?”

49. Activities to Encourage Speech Development Expand vocabulary –Name body parts –Identify what you do with them Sing simple songs and recite nursery rhymes –Shows rhythm and patterns of speech Place familiar objects in a container –Have your child remove the object –Tell you what it is called –How to use it Use photographs of familiar people and places –Retell what happened or make up a story Cabinet for Health and Family Services

50. About the Commission Our Mission: To enhance the quality of life for Kentucky’s children with special health care needs through service, leadership, advocacy, education, and collaboration. Our Vision: To be the visible leader in supporting the highest quality of life for Kentucky’s children with special health care needs and their families through collaboration and creation of a more accessible community based system of support.

51. Eligibility Resident of Kentucky Less than 21 years old Has a condition usually responsive to medical treatment that is covered by the Commission Meets financial guidelines based on income

52. Commission Clinics Asthma (Severe) Cardiology Cerebral Palsy Cleft Lip & Palate Craniofacial Cystic Fibrosis Eye Hand Hemophilia Neurology Neurosurgery Orthopedic Otology Rheumatology Scoliosis Spina Bifida

53. Commission Offices

54. Services Provided Care Coordination Hospitalization Physician Services Surgery Hearing Tests Physical Therapy Occupational Therapy Speech Therapy Lab Tests/X-rays Interpretation Medical Supplies/DME Medication Management Dental Transportation Nutritional Supplements Orthodontia

55. Direct Care Clinics offer multi-disciplinary care Team approach for management of complex conditions Access to nutritional services, social services, and care coordination Augmentative services as appropriate –Physical therapy –Occupational therapy –Speech/language therapy

56. EHDI / Audiology EHDI - Focus on early identification and intervention of children with hearing loss critical to preventing problems with: –Communicative Competence –Literacy and Academic achievement –Social/emotional development Comprehensive Audiology program which includes: –Hearing conservation –Testing –Hearing aid fittings –Programming for cochlear implants

57. Cabinet for Health and Family Services Question? Discussion?