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When Hearing Loss Occurs with Multiple Disabilities Jackson Roush, Ph.D. Professor and Director Division of Speech and Hearing Sciences The University.

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Presentation on theme: "When Hearing Loss Occurs with Multiple Disabilities Jackson Roush, Ph.D. Professor and Director Division of Speech and Hearing Sciences The University."— Presentation transcript:

1 When Hearing Loss Occurs with Multiple Disabilities Jackson Roush, Ph.D. Professor and Director Division of Speech and Hearing Sciences The University of North Carolina School of Medicine 2004 National Conference on Early Hearing Detection and Intervention

2 Acknowledgements Maria Luisa Escolar Meredith Holcomb Patricia Roush

3 Topics Etiology of HL and Multiple Disabilities Disabilities that Occur with Deafness Implications for Audiologic Management Role of the Medical Home Implications for Educational Management Parent/Family Perspectives

4 Etiology of Hearing Loss and Multiple Disabilities

5 Causes of HL in Children Genetic (50%) 70% autosomal recessive 15% autosomal dominant 15% all other types of inheritance Non-Genetic (25%) Unknown (25%)

6 Congenital Anomalies and In Utero Infections Charge Syndrome In Utero Infections CMV Herpes Rubella Syphyllis Toxoplasmosis

7 Postnatal/Acquired Conditions Low birth weight / Hypoxia Ototoxicity Hyperbilirubinemia Meningitis

8 Progressive Diseases Metabolic Disorders e.g. Hurler syndrome Progressive Neurological Diseases e.g. Friedreichs Ataxia Sensory Neuropathies Charcot-Marie-Tooth Syndrome

9 Multiple Disabilities that Occur with Hearing Loss

10 Disabilities That Occur with Deafness (%) Deafness with No Other Disabilities 60.1 Learning Disability10.7 Intellectual Disability9.8 Attention Deficit Disorder (ADD/ADHD) 6.6 Blindness and Low Vision3.9 Cerebral Palsy3.4 Emotional Disturbance1.7 Other conditions12.1 Gallaudet Research Institute, Jan 2003

11 Intellectual Disability (10%) Largest Group: Down Syndrome Most children with intellectual disabilities have HL in one or both ears Some estimates approach 80% Intellectual disabilities affect language, learning, socialization Intellectual disabilities are exacerbated by hearing loss

12 Learning Disabilities (11%) The DSM-IV definition IQ-achievement discrepancy four types of learning disorders: reading, written expression, mathematics, and learning disorder not otherwise specified Domain-based Focus on cognitive abilities, phonological awareness, listening comprehension, word retrieval

13 Learning Disabilities (cont.) Described for over 100 years but remarkably little research Each child is unique Unable to use traditional research methods Educational Challenges programs that provide structured intervention specific, clearly stated objectives, focusing on the individual strengths and needs of each child.

14 Attention Disorders (7%) ADD/ADHD (5% in general population) Inattention Distractibility Impulsivity Hyperactivity Can interfere with all aspects of development Educational achievement socialization Parents and teachers may over-identify Need for Comprehensive Medical Evaluation Medication for AD

15 Visual Impairment (4%) Genetic Syndromes Usher (Types I and II) Goldenhar Oculo-Auricular-Vertebral Congenital / Perinatal Charge, CMV, meningitis

16 Deaf-Blindness Child cannot be accommodated in special education programs designed for children with deafness or blindness. Approx 11,000 deaf-blind children in U.S. Most have severe developmental disabilities (CI)

17 Cerebral Palsy (3.4%) Three Main Forms Spastic CP stiff, difficult movement Athetoic CP involuntary and uncontrolled movements Ataxic CP disturbed sense of balance, position in space, and overall lack of coordination Classification made according to the age of diagnosis 70% of CP occurs prior to birth (prenatal) 20% occurs during the birthing period (perinatal) 10% occurs during the first two years of life (postnatal) Remarkably little research on HL in CP

18 Implications for Management

19 Audiologic Assessment Many of same components Test battery Coordination of multiple disciplines Delays can be prevented by competent, proactive management

20 Physiologic Measures (ABR, ASSR, OAE, Immittance) To define nature/degree of HL Sedation More likely to be needed Communication with medical staff is critical O.R. Evaluation When there are respiratory risks More expensive but worth it to achieve timely follow-up Communication with medical staff enables multiple procedures (e.g. earmolds)

21 Behavioral Assessment Begins with VRA, developmental age of ~six months Multiple disabilities should not preclude attempts to obtain behavioral assessment You dont know until you try; results can be surprising Modifications often needed Infant seat; head support; careful observation Begin with sound field but individual ear data needed as soon as possible Consider use of childs earmolds w/ insert receivers

22 Goal of Diagnostic Assessment To obtain the info needed to proceed with hearing aid selection and fitting Approximation of HL degree and configuration Need accurate estimate of low and high frequencies Children with multiple disabilities tend to be later diagnosed and fitted Need to identify centers with the experience and institutional support to manage these children well

23 Hearing Aid Selection / Fitting Special challenges, even so… Prescriptive methods (e.g. DSL) combined with appropriate diagnostic assessment allows for timely HA fitting Adjustment of output level especially critical for children with multiple disabilities

24 Considerations in the Pre- selection Process Input from teachers parents and professionals information about home and school environments Physical limitations likely to affect the use of hearing technology Behavioral issues relevant to hearing aid use. Tharpe, 2004

25 Considerations in HA Selection Flexibility in hearing aid circuitry Retention devices Volume control covers FM may be useful for young children on ventilators Remote controls for children with poor head control Multiple care providers necessitate easy operation/maintenance of devices

26 Close Follow-up is Essential 1 month Every 3-4 months On-going diagnostic assessment On-going electroacoustic analysis On-going monitoring for OME Health implications Hearing aid implications

27 Assessment of Aided Performance Formal and Informal Referral for Cochlear Implant At one time, children with MD not considered CI candidates Many centers will – if no medical contraindications and reasonable chance of benefit Success may need to be defined differently

28 Implications for the Medical Home The medical home is an approach to health care services where the care is accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally competent (JCIH, 2000; AAP, 1992) Usually pediatric or primary care office Most pediatricians have limited experience with SNHL Need to make recommendations clear and specific Be sure to inform re: initial diagnosis and send reports

29 Assessment and Planning Referral for Multidisciplinary Team Evaluation Individualized Family Service Plan (IFSP) ENT, Ophthalmology, and Genetics Medical management takes priority initially, but a well coordinated team approach must be established as soon as possible Team approach reduces the logistical challenges faced by families

30 Implications for Educational Placement and Services Special challenges Placement decisions often based on a categorical view of disabilities Failure to consider individual uniqueness Failure to consider implications of deafness

31 Guiding Principles (Ewing and Jones, 2003) 1) Every child is capable of learning even when disabilities are multiple and severe 2) Peer acceptance and social relations are essential for all children including those with multiple disabilities 3) Families and communities are critical to success 4) Service delivery based on a transdisciplinary model results in better coordination and sharing of knowledge and resources

32 Communicating with Families Children with multiple disabilities pose many challenges for professionals Focus on areas of expertise and specialization is needed, but Need to consider implications for family Families are profoundly affected by a child with special needs, especially when the history includes developmental disabilities and serious illness.

33 Parent / Family Perspectives

34 Josh (CHARGE Syndrome) Required resuscitation immediately after birth Spent the first weeks of his life in the Newborn Intensive Care Unit, multiple surgeries, intubation and tube feeding. Within weeks of his birth, Joshs family was told that he had congenital heart disease, a seizure disorder, an immune deficiency, facial and vocal cord paralysis, visual impairment, mental retardation, and a severe hearing loss

35 Having a child with disabilities affects the entire family. It is something we live with every minute of every day. The simplest things that happen every day remind us of the fact that were different

36 The best thing professionals can do is admit they dont have all the answers, and that no one else does either.

37 Give power to families by reminding them that they are the experts on their child, because they are with the child every day and most professionals only see them in the clinic

38 Even other families with children who have disabilities cannot know what its like for another family. Many professionals recommend involvement in family support programs, but its important they realize this doesnt solve all the problems

39 It took me a long time to seek support outside my own immediate family. I was still grieving the loss of my perfect child, and I didnt want to share that heartbreak with strangers.

40 Everyone is different, and everyone needs to seek support in their own time. Professionals can help by reminding families that support is available if they need it.

41 Your patience and understanding is even more valuable than anything you can fix.

42 Conclusions Nearly 40% of children with HL have one or more disabilities; some include severe illness Dx and Intervention can occur on a timely basis but it takes competent and proactive audiologic management - and advocacy when needed Children should not be defined by their disabilities Well coordinated teamwork is critical The pediatrician needs to be informed and included Communication and support for families is paramount Every child deserves an opportunity to hear

43 Thank you.


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