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Case Study by Kristin Knight and Sara Martello

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1 Case Study by Kristin Knight and Sara Martello
This is a case study of the following student (name has been changed) Chance is a 6 year-old male who is 2 years post cochlear implantation. Prior to implantation, Chance had a severe-to profound bilateral, sensori-neural hearing loss. With his implant, Chance can hear sounds in the normal conversational range. He has, however, failed to develop speech and language skills commensurate with his auditory ability. He is mainstreamed in kindergarten for ½ day and returns to deaf education resource teacher for the last half of the day. Chance is having trouble maintaining social interactions in the classroom and is missing out on key vocabulary words in the teaching units. The goals/objectives of this case include he following: Clearly describing to Chance’s parents and classroom teacher the implications of his hearing loss Researching Chance’s learning capabilities in order to place him in the least restrictive and best learning environment.

2 Audiological Evaluation
Interpretation: Prior to implantation Chance had a severe to profound, bilateral, sensorineural hearing loss. To the right are the typical audiogram symbols that are used: Some other helpful symbols to know are: A: aided score (this is how the student heard with his hearing aid on) C: cochlear implant score (this is how the student did with his/her cochlear implant on) Other helpful terms to know: SDT: speech detection threshold - The SDT is the lowest/softest level at which the individual can detect speech, not understand it (The individual just needs to know that sound is present) SRT: speech reception threshold -  The SRT is lowest/softest level at which the individual can repeat 50% of spondee words (ex. cowboy, hotdog)

3 Audiological Evaluation: (continued) Explanation of Terms
Degree of Loss: Severe to Profound -This means that without amplification, Chance may have trouble hearing sounds like a dog barking, a vacuum, a baby crying. Chance will have trouble hearing all of the speech sounds. His loss is at the point where speech sounds cannot be picked up auditorally. Type of Loss: Bilateral- Sensorineural -Bilateral means in both ears -A sensorineural loss is a hearing loss due to dysfunction in the inner ear, 8th nerve, or the central auditory pathway. A sensorineural loss results in distorted sounds. Chance’s Audiogram: Chance’s audiogram shows his hearing while he is wearing his cochlear implant. His audiogram shows that he is within the normal range of hearing (0-25 dB) Chance’s SDT is 20 dB. This means that Chance can detect sound at 20dB. Chance should be able to hear all of the speech sounds, and sounds such as a baby crying, a vacuum, a dog barking, etc.

4 Chance’s Audiogram

5 Explanation of Chance’s Loss to Classroom Teacher
Degree of Loss: Severe to Profound -Because Chance has a severe to profound hearing loss, he cannot hear anything above the blue section in the audiogram picture above without his implant. For example, he cannot hear any of the speech sounds as they are listed in the yellow and green areas (ex. speech sounds, birds chirping, people whispering,etc) . Because Chance has a severe to profound hearing loss, he cannot hear anything above the blue section in the audiogram picture at right. For example, he cannot hear any of the speech sounds as they are listed in the yellow and green areas.

6 Explanation of Chance’s Loss to Classroom Teacher (continued)
Type of Loss: Sensorineural hearing loss (or nerve-related deafness) involves damage to the inner ear caused by aging, pre-natal and birth-related problems, viral and bacterial infections, heredity, trauma, exposure to loud noise, or a benign tumor in the inner ear.  Almost all sensorineural hearing loss can be effectively treated with hearing aids. A sensorineural loss affects the inner ear. The area of the inner ear is highlighted in the picture at right in purple. Bilateral hearing loss: hearing loss in both ears

7 Explanation of Chance’s Cochlear Implant to Classroom Teacher
Chance’s Cochlear Implant: A cochlear implant is an artificial hearing device, designed to produce useful hearing sensations by electrically stimulating nerves inside the inner ear. At left, The internal component of the cochlear implant

8 Continued Explanation of the Cochlear Implant to Classroom Teacher
Here’s a quick explanation of how a cochlear implant works: -Speech and other sounds are picked up by the microphone and sent to the speech processor. The processor codes the sounds into an electrical signal which is sent via a cable to the transmitting coil. The coil passes the signal through the skin to the implant which transforms the signal to electrical pulses. The pulses pass from the electrode array and stimulate hearing nerve fibers within the cochlea. -The speech processor does not just make sounds louder as does a hearing aid. Instead, it selects out some of the important information in the speech signal and then produces a pattern of electrical pulses in the patient's ear. This pattern is selected to sound as close as possible to the original speech sound. It is not possible to make sounds completely natural, because there are only 22 electrodes that are replacing the function of tens of thousands of hair cells in a normally hearing ear. -The electrical patterns are different for each person and need to be programmed into the speech processor by a trained clinician. The differences arise because the electrodes are not always in the same position relative to the surviving nerves and the nerves vary in sensitivity to electrical currents. The clinician must measure the lowest and greatest current for every electrode to determine the softest and loudest sounds that will be heard. The different electrodes produce sounds with different pitch. The speech processor combines sounds on different electrodes with different loudness, to build up something as close to the original sound as possible. The external components of the cochlear implant

9 The Process of Hearing With a Cochlear Implant
Sounds and speech are detected by the microphone. The information from the microphone is sent to the speech processor. The speech processor analyzes the information and converts it into an electrical code. The coded signal travels via a cable to the transmitting coil in the headset. Radio waves from the transmitter coil carry the coded signal through the skin to the implant inside. The implant package decodes the signal. The signal contains information that determines how much electrical current will be sent to the different electrodes. The appropriate amount of electrical current passes down the appropriate lead wires to the chosen electrodes. The position of the stimulating electrodes within the cochlea will determine the frequency or pitch of the sounds. The amount of electrical current will determine the loudness of the sounds. Once the nerve endings in the cochlea are stimulated, the message is sent up to the brain along the hearing nerve. The brain can then try to interpret the stimulation as a meaningful sound. (http://www.medoto.unimelb.edu.au/info/implant2.htm)

10 Recommendations for Classroom Teacher
Repeat key concepts/phrases/words   Have visuals for key concepts as often as possible o       Board notes o       Handouts o       Glossaries o       Course books o       Multimedia materials o       Closed captioning ·        Repeat other student responses ·        Be a good listener to your student o      Allow processing time o      Repeat child’s utterance to ensure you understand their point ·        Use a variety of examples in a variety of situations Write assignments on the board Allow flexibility o       Hard of hearing student may give inappropriate answers due to a break down in the message. o       Make sure they understand the question before they are expected to give an answer (watch their facial expressions—this will indicate confusion) Be knowledgeable about students auditory devices o       Students may fiddle with auditory devices and may try to tell you what’s wrong. o       Being knowledgeable about the auditory devices could allow you to fix it faster. Be aware of surroundings o       Preferential seating—hard of hearing students may need to sit up front and close to the teacher o       Lighting—try not to stand in front of lights or window as they cause your face to go in shadow. Make sure there is enough light in the classroom for the student to be able to see the teacher o       Outside noise—hard of hearing students may have trouble understand with a lot of outside noise Speak naturally o       Talking very loudly or over-enunciating makes it harder for your student to understand

11 Checklist for Deaf Educator to Take when Evaluating the Regular Education Classroom An Assessment of the child’s Learning Environment Environment: Acoustics of the classroom Satisfactory (circle one) Satisfactory Good Terrible Outside Noise Loud Controllable None present Seating Arrangement Traditional Rows Groups of 4 or more desks U-Shape Other: _____ Lighting Teacher Behavior Uses of the following: (check if used) Visual Examples Assistive technology Vocabulary/Language Level High Appropriate/Grade Level Low Teacher’s volume Loud Normal soft Key concepts Repeats Does not repeat Teacher’s position while teaching Facing the students Not facing the students

12 Examples of what Chance may be doing in the classroom
*Child may adjust implant volume level -This may be because the child is still getting used to listening *Child might complain about their implant -This could be because the child needs to get their map (implant wiring) changed * Child may be daydreaming - This could be because the battery may be dead or the implant may be broken * Child could experience facial ticks - This could be because of the strength of the cochlear implant electrical pulses *Child may need to take off their implant for particular activities -          Static electricity can damage these children’s hearing devices (ex. plastic slides, trampolines, tumbling mats, parachutes, playing in plastic balls or tubing, magnets or balloons) *Child still may be having trouble understanding speech Having a cochlear implant does not make a person hearing. They are not hearing sounds but getting sound through electrical impulses

13 Communication Unit For Chance
State Goal 4: Listen and speak effectively in a variety of situations.  Standard: Listen effectively in formal and informal situations.  Speech Objective Given a question from the teacher, the student will verbally answer using speech with zero speech errors.  Speechreading Objective When presented with five one-word-named toys, Chance will pick up each toy as its name is mouthed by the teacher, using only speechreading cues (no auditory input) with 100% accuracy.  Speech Perception (Auditory Training) Objective Given teacher-presented words through a listening hoop, Chance will repeat each of the 6(7) Ling Sounds with 100% accuracy.  Receptive Language Objective When presented auditorally with simple vocabulary words, Chance will point to the matching object or picture of the word(s) with 5 out of 6 correct.  Expressive Language Objective When presented with three snack choices, Chance will demonstrate which he would like by using his voice to name it without speech errors.

14 Annual Goals and Objectives for Chance
IEP Goals *The student will have improved vocabulary recognition through speech and hearing in teaching units. Short -term Objectives: 1.      Given proper instruction, the student will correctly identify 5 out of 7 vocabulary words within each unit. 2.      Give exposure to a basal story, the student will circle at least 5 vocabulary words that had been covered in class. *The student will improve social interactions within the mainstream and resource classrooms. Short-term Objectives: 1.      Given social time, the student will initiate conversation with at least 3 classmates per day. 2.      During appropriate discussion times, the student will maintain conversation with classmates by responding appropriately to peers comments for at least 3 exchanges per student. *The student will improve speech skills inside and outside the classroom in order to match his auditory abilities. Short-term Objectives 1.      Given various environmental sounds, the student will correctly name them with at least 5 correct. (ex. dog barking =dog, siren = firetruck) 2.      Given a correct teacher model, the student will repeat the model with 100% accuracy. Annual Goals The student will have improved vocabulary recognition through speech and hearing throughout teaching units. The student will improve social interactions within the mainstream and resource classrooms. The student will improve speech skills inside and outside the classroom in order to match his auditory abilities.

15 Adverse Effects/Educational Needs
*The student will have improved vocabulary recognition through speech and hearing throughout teaching units. Adverse Effect: Hearing loss adversely affects Chance’s language and learning abilities. Educational Need: The information will need to be presented at student’s specific instructional level *The student will improve social interactions within the mainstream and resource classrooms. Adverse Effect: Chance’s impaired hearing abilities adversely affect his interactions with students or other peers. Educational Need: Teachers and other educational leaders will need to provide more comfortable situations for social interactions and go through social skills training to better help Chance. *The student will improve speech skills inside and outside the classroom in order to match his auditory abilities. Adverse Effect: Hearing loss adversely affects speech perception. Educational Need: The student will need to be in a more acoustically controlled environment

16 Letter to Parents Dear Parents,
Wow! I can’t believe a month of school has already past! Time flies when you are having fun. I just wanted to send out a letter to explain my role in the education of your child with a description of a typical session with your child. Officially, I am an itinerant teacher for deaf and hard of hearing students. I provide direct services to your son Chance 3 times a week. This means I work directly one on one with your son on improving his listening, speech and language skills. A typical session might include: checking that his implant is functioning properly, discussion of what is going on in his classes, overview of vocabulary that he is having difficulty with, and working to improve his speech and language skills. With that said I have seen great improvements from Chance in the areas of speech and language and especially listening. For example, Chance just recently was able to recognize the connection of the sound of an ambulance siren to the picture of an ambulance. This shows improvement because he has made the visual and auditory connection: Chance says the words, and is able to come up with the word without a teacher model. These and other similar connections prove that Chance is making progress with his listening, speech and language skills. Chance is also able to say 5 vocabulary words using intelligible speech after small amount of speech therapy. To help Chance to continue to make progress it is imperative that we work together as a team. There are a variety of ways to help him generalize sounds, speech, and listening skills from school to home. Every event can be a language lesson. For example, we are working on the “m” sounds. Perhaps you could make muffins together and talk about the “m” sound. Another suggestion would be to point out any object that has the “m” sound in it at home. For example: mom, movie, make your bed, Max your dog, etc. I appreciate your help and your willingness to work together to support Chance’s learning experience. Should you have any questions or suggestions please do not hesitate to call me. I am very excited to see Chance’s progression over the course of the remaining school year. Thank you! Sincerely, Teacher name __________________________

17 References Smith, M.D. (1997).The are of itinerant teaching for teachers of the deaf & hard of hearing, Butte Publications, Inc. Hillsboro, OR.


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