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NECHEAR Family Support: The Role of the Pediatric Audiologist Karen M. Ditty, M.S. Texas ENT Specialists, P.A. Antonia Brancia Maxon, Ph.D. Diane Brackett,

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Presentation on theme: "NECHEAR Family Support: The Role of the Pediatric Audiologist Karen M. Ditty, M.S. Texas ENT Specialists, P.A. Antonia Brancia Maxon, Ph.D. Diane Brackett,"— Presentation transcript:

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

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

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

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

5 NECHEAR What is the pediatric audiologists role in diagnosis and intervention ? Explaining hearing, hearing loss and amplification

6 NECHEAR Auditory Development SkillAgeBehavior Localization6 mosHead turn to source Min Aud Angle6-18 mosDecreases Detect duration differences<6 mos<= 20 msec Pitch perception<6 moslarge for detection Speech perception1 monthVOT can be made 2 mosFalling vs. rising F mosPrefer highly novel

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

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

9 NECHEAR What is the pediatric audiologists role in early intervention? Understanding and explaining typical spoken language development

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

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

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

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

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

15 NECHEAR What is the pediatric audiologists role in early intervention? Basic principles of early intervention

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

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

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

19 NECHEAR What is the pediatric audiologists role in early intervention? Supporting familys understanding of language choices

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

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

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

23 NECHEAR What is the pediatric audiologists role in early intervention? Helping families understand and select sensory devices

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

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

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

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

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

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

30 NECHEAR Practical Problems ProblemSolution Maintaining BTEHuggies, Strap holder, clips Removing batteriesBattery door lock Changing volumeVolume cover, deactivate volume

31 NECHEAR Issues with Amplification BehaviorProblemsSolutions Blinking, flinchingOutput/gain tooDecrease output to loud soundshigh; tolerance prob.or gain Pulling out earmoldsNot used to moldsUse huggies or strap Poorly fitting molds Remake or refit Sore ears- allergicRemake with hypoallergenic

32 NECHEAR Issues with Amplification BehaviorProblemsSolutions FeedbackInappropriate settingsReprogram Cerumen plugMedical treatment Poorly fitting moldRemake OME Medical treatment Pulling on or chewingCords too obviousString cords cordsbehind back, through clothing; decrease length Not responding toPoor high frequencyChange settings; high pitchesamplificationmodify earmolds; frequency trans.

33 NECHEAR Issues with Amplification BehaviorProblemsSolutions Blinking, startlingOver amplification in Reduce low gain; to low pitcheslow frequencieschange FRC, h.a. Poor responses toNot a full-time user;Work to better use soundsCannot use traditionalConsider CI amplification

34 NECHEAR What is the pediatric audiologists role in early intervention? Helping families understand candidacy for cochlear implants

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

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

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

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

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

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

41 NECHEAR Practical Problems ProblemSolution Maintaining headpieceHuggies, Strap holder, clips Chewing on cordsStringing wires behind and headpieces Changing volumeLocking volume control

42 NECHEAR Issues with Cochlear Implants BehaviorProblemsSolutions Blinking, flinchingCs, Ms tooDecrease those to loud soundshigh; facial nervelevels, turn off stimulationelectrodes Red, sore spotMagnet strengthChange magnets under headpiecetoo muchUse moleskin Not responding toInadequate high Change Ts, Cs/Ms; high pitchesfrequency stimulationchange frequency table

43 NECHEAR Issues with Cochlear Implants BehaviorProblemsSolutions Not responding toInadequate low Change Ts, Cs/Ms; high pitchesfrequency stimulationchange frequency table Soft voice Over stimulationChange Ts/Cs LoudUnder stimulation Change Ts/Cs Poor voice qualityInadequate stimulationChange settings

44 NECHEAR What is the pediatric audiologists role in early intervention? Helping families understand life transitions

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

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

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

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

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

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

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

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

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

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

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

56 NECHEAR Elementary to Middle School Transition

57 NECHEAR Middle School Language Adults Children Environment parentssiblings home family teachersclassmates (20+) school coach team sports fields social group (3+) community

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

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

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

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

62 NECHEAR Middle School to High School

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

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

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

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

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

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

69 NECHEAR High School Language Adults Children Environment parentssiblings home family teachersclassmates (20+) school coach team sports fields social group (3+) community 1:1 social community

70 NECHEAR Life After High School and the beat goes on


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