1. Perry C. Hanavan, Au.D. Audiologist
Introduction to AR
Perry C. Hanavan, Au.D.
Audiologist

2. Auditory Experience

3. TED Talk Establishing a Sound Foundation
Dr. Karl R. White is a Professor of Psychology at Utah State University and the founding Director of the National Center for Hearing Assessment and Management (NCHAM).
Recognized as one of the world's leading authorities on early identification and treatment of hearing loss in infants and young children.
He has hundreds of publications and presentations at scholarly meetings, and has been invited to more than 30 countries to assist in the implementation of newborn hearing screening and intervention programs. 

4. National Goal – Early Hearing Detection and Intervention (EHDI)
1:3:6

5. Percent of Newborns Screened for Hearing Loss in U.S.

8. Vocabulary Development

9. Hart & Risley, 1995

10. Dana Suskin, MD

11. Birth of a Word Birth of a Word
Deb Roy, MIT researcher, wanted to understand how his infant son learned language
Wired house with video cameras to catch every moment (with exceptions) of his son's life
Parsed 90,000 hours of home video to watch "gaaaa" slowly turn into "water"
Data-rich research for how we learn

12. The Linguistic Genius of Babies
Patricia Kuhl, PhD
How babies learn one language over another
by listening to the humans around them and "taking statistics" on the sounds they need to know.
The Linguistic Genius of Babies

13. Neuroplasticity
Childhood hearing loss is a neurodevelopmental emergency!
Without early access to consistent intelligible speech, the auditory centers of the brain will not develop and normal intrahemispheric connections
Auditory Access!
Children hear 46 million words by age 4 years
Hear 46 million words by 4 years of age (Risley and Hart)
Listening 20,000 hours to learn to read…listening at least 12 hour days for 1,667 days (Dehaene)
Auditory exposure to learn new words and concepts increased up to 3 times necessary for children with hearing loss

14. Case Studies
Newborn identified at birth with connexin 26, severe to profound bilateral hearing loss, normal hearing parents
Newborn identified at 2 years with rapidly progressive bilateral SNHL, parents have a profound loss
Seven year old recently identified with unilateral severe SNHL
Middle school male with normal hearing but auditory processing problem in noise
Fourteen year recently survived bacterial meningitis resulting in bilateral SNHL
Dad, suffered sudden onset mild bilateral SNHL
Grandmother, slow progressive bilateral SNHL

15. Impact of HL on Quality of Life
Physical health
Emotional & mental health
Other’s perceptions of a person’s mental acuity
Social skills
Family relationships
Self-esteem
Work & school performance
Dementia in elderly
Household income by up to $12,000/year

16. Some Historical Landmarks Regarding AR in Audiology
Genesis in WWII (1942)
Audiologists Dispense Hearing Aids (1978)
WHO Classification (1980)
Cochlear Implants (1984 – FDA approval)
Early Newborn Identification (1990 – Joint Comm)
Communication Therapy (1990+)
Neural Plasticity of the Auditory System (1995+)
WHO Classification (ICF, 2001)
Hearing Assistance Technologies (HAT) (2000+)

17. Question
Does AR increases income for persons with hearing loss? Yes No

18. Hearing Loss and Impact on Household Income
Kochkin, S (2010).The Hearing Journal. 63(10):19-24,26,28.

19. Treated Vs. Untreated HL Impact on Household Income
Kochkin, S (2010).The Hearing Journal. 63(10):19-24,26,28.

20. Mild HL Linked to Brain Atrophy in Older Adults
Early intervention could prevent slide toward speech comprehension difficulties
Research suggests that hearing sensitivity has cascading consequences for the neural processes supporting both perception and cognition

21. Definitions Auditory Training Aural Rehabilitation
Audiological Rehabilitation
Speechreading
Lipreading
Communication Rehabilitation
Habilitation
Rehabilitation

22. AR Definition
“The assessment, intervention, and management of communicative consequences of hearing loss”
(unknown author)

23. ASHA
Aural rehabilitation refers to services and procedures for facilitating adequate receptive and expressive communication in individuals with hearing impairment. (ASHA, 1984, p. 37)
Audiologic/aural rehabilitation (AR) is an ecological, interactive process that facilitates one's ability to minimize or prevent the limitations and restrictions that auditory dysfunctions can impose on well-being and communication, including interpersonal, psychosocial, educational, and vocational functioning.
(American Speech-Language-Hearing Association. (2001). Knowledge and Skills Required for the Practice of Audiologic/Aural Rehabilitation [Knowledge and Skills)

24. David Hawkins Anything that facilitates: 1) hearing,
2) understanding of hearing loss,
3) coping strategies,
4) acceptance of hearing loss, and
5) involving communication partners.
(Hawkins, D. 2003)

25. Mark Ross
Any device, procedure, information, interaction, or therapy which lessens the communicative and psychosocial consequences of a hearing loss.
Ross, M., JARA, 1997

26. McCarthy & Culpepper
The purpose of an aural rehabilitation program is to focus on assisting hearing-impaired individuals in the realization of their optimal potential in communication, which is needed in educational, vocational, or social settings.
McCarthy & Culpepper, AJA, 1987, p. 305

27. Houston & Montgomery
"…the goal of aural rehabilitation for the adult is ambitious – to increase the likelihood, the level, of successful communication over the client’s lifetime."
Houston, K.T., and Montgomery, A.A. Auditory-visual integration: A practical approach. Seminars in Hearing, 18 (2), 1997.

28. JP Gagné
“Aural rehabilitation is aimed at restoring or optimizing a patient’s participation in activities that have been limited as a result of a hearing loss and also may be aimed at benefiting communication partners who engage in activities that include person with hearing loss.” Gagné JP. Ear and Hearing. 2000, p36.

29. Arthur Boothroyd, Ph.D.
“Adult aural rehabilitation is here defined holistically as the reduction of hearing-loss-induced deficits of function, activity, participation, and quality of life through a combination of sensory management, instruction, perceptual training, and counseling.
Boothroyd A, Trends in Amplification, 2007, p63.

30. Aural Rehabilitation
Intervention aimed at minimizing and alleviating the communication difficulties associated with hearing loss.
(Tye-Murray N. Foundations of Aural Rehabilitation (video)

31. Audiologic Rehabilitation
“Any activity, method, resource, technology, and/or device that facilitates and/or enhances communication and participation in activities.”
Hanavan, PC, 2010

32. Conversational Fluency
“…relates to how smoothly conversation unfolds”
“the book’s central theme”
Tye-Murray N, Foundations of Aural Rehabilitation, p2. and preface, p ix.

33. Hearing-Related Disability
“…a loss of function imposed by hearing loss. The term denotes a multidimensional phenomenon.”
Tye-Murray, Foundations of Aural Rehabilitation, p2.

34. Summary of Definitions of AR and WHO 1980
Often describes approaches rather than objectives/goal
Hearing and communication oriented
Medically oriented: eliminate (treat)
prescribe (cure)
(International Classification of Impairments, Disabilities and Handicap – ICIDH, WHO, 1980): Adapted from Gagne JP, 2007 ARA Institute, Louisville, KY.

35. International Classification of Functioning, Disability and Health (ICF: WHO, 2001)
Health Condition
(disorder/disease)
Body Structures
& Functions
Participation
(participation restriction)
Activities
(activity limitation)
Environmental Personal
Factors Factors

36. ICF (WHO: 2001)
Disabilities is an umbrella term, covering impairments, activity limitations, and participation restrictions.
Thus disability is a complex phenomenon, reflecting an interaction between features of a person’s body and features of the society in which he or she lives.

37. Question
Does “hearing impairment” means deaf, only? Yes No

38. ICF (WHO: 2001)
Hearing impairment is a broad term used to describe the loss of hearing in one or both ears. There are different levels of hearing impairment:
hearing impairment refers to complete or partial loss of the ability to hear from one or both ears. The level of impairment can be mild, moderate, severe or profound;
deafness refers to the complete loss of ability to hear from one or both ears.

39. ICF (WHO: 2001)
Impairment is 'a loss or abnormality of body structure or physiological or psychological function' Activity limitation is 'the nature or extent of functioning at the level of the person' Participation restriction is 'the nature or extent of a person’s involvement in life situations in relation to impairment, activities, health conditions, and contextual factors’ Health-related Quality of Life is 'the functional effect of an illness and its consequent therapy upon the patient.' Satisfaction is the subjective assessment by the patient that his/her needs or expectations have been met.

40. Applying WHO Taxonomy to HL
Anatomy and physiology: Physical and functional integrity, including integrity of outer ear, middle ear, cochlea, neural pathways to the brain, and the brain itself. A major concern is with the status of the cochlea. With older patients, integrity of neural structures is important.
Function: Includes hearing threshold, dynamic range, frequency range, spectral and temporal resolution, acoustic pattern discrimination, direction and distance perception, attention, auditory working memory, processing speed, and ability to listen in noise.

41. Applying WHO Taxonomy to HL
Activity: The use of this capacity—the things one wants or needs to do with hearing in the real world. Examples include being alerted by sound, monitoring the environment, recognizing and localizing events and deducing their significance, monitoring and controlling one's own speech, and enjoying auditory experiences. The activities of most concern, however, are perceiving the speech of others and engaging in spoken language communication.
Participation: The contribution of these activities to daily life, include social interactions and relationships, employment, leisure, learning, control, creativity, etc.

42. ICF (WHO: 2001)
Psychological factors pertains to attitudes, self-image, motivation and assertiveness, etc. Social factors are the viewpoint of society

43. Model of Hearing-Related Disability
Listening aids
Lifestyle
Hearing Impairment
Communication activity limitations
Participation restrictions
Frequent communication partner(s)
Physical environment
Psychosocial factors
Tye-Murray N, Foundations of Aural Rehabilitation, p4.

44. Services Included in AR Plan
Diagnosis & quantification of hearing loss
Hearing assistance technologies
Auditory training
Communication strategies training
Informational/educational counseling
Personal adjustment counseling
Psychological support
Communication partner training
Speechreading training
Speech-language therapy
Inservice training

45. Question Which is provided by educator of the deaf and/or SLP?
Aural rehab
Audiologic rehab
Physical therapy

46. Aural Rehabilitation vs. Audiologic Rehabilitation
Broad breadth of services
Variety of professional providers
Audiologic Rehabilitation
Narrow breadth of services
Audiology professional providers

47. Roles Audiologist: Audiologic Rehabilitation SLP/EDHH: Aural Rehab
Audiologic diagnostic evaluation
Fitting, dispensing and evaluation of hearing aids
Mapping cochlear implants
Evaluating, fitting and dispensing HAT
Evaluating speech/language receptive and expressive abilities
Treatment of speech/language disorders
EDHH provides curriculum

48. Rehabilitation vs. Habilitation
Restore lost function
Adults
Acquired hearing loss
Habilitation
Develop skill not present beforehand
Infants/children
Congenital or pre-lingual onset

49. AR Service Locations University/College Private Practice Hospital
Community Center
Otologist’s office
Public/Private School
Self-help groups
School for the Deaf
Internet
Home with computer

50. AR Providers Audiologist Speech Language Pathologist
Educator of the Deaf
Communication Partner

51. Other Team Members ENT Parents Regular classroom teachers Psychology
Geneticist
Other specialties as necessary

54. Definition of Terms in Survey

55. Traditional Variables
Time of Onset
Degree of Loss
Type of Loss
Etiology

56. Question Which is not a traditional variable for hearing loss?
Time of Onset
Rapidity of progression of hearing loss
Degree of Loss
Type of Loss
Etiology

57. Other Variables Progressive Acceptance Family support
Time of identification
Time for implementation of AR
Intelligence
Motivation

58. AR vs. Age of Client Newborns Preschoolers Grade school Middle school
High school
Post secondary
Young adults
Middle age
Old age

59. Hearing Loss Incidence
36 million persons in US have HL
4,000,000 babies born in US annually
1/1000 to 6/1000 born with HL
1 in 10 by age 60
Third most prevalent chronic problem in older persons
1.3% of children who receive special ed services were hard of hearing or deaf
5% of world’s population, about 360 million people, including 328 million adults and 32 million children, have disabling hearing loss

60. Hearing Loss Projections
Kochkin, S. MarkeTrak VII: Hearing Loss Population Tops 31 Million People, The Hearing Review, Vol. 12(7) July 2005, pp

61. Time of Onset Congenital Prelingual Postlingual Deaf/deaf Deafened
Adventitious
Sudden
Progressive

62. HL Prevalence and Age

63. Degree of Hearing Loss Minimal Mild Moderate Moderately Severe Severe
Profound

65. Common Etiologies
Most of the hearing loss is genetic with over 30 autosomal recessive (70-80%), dominant (23-30%) and X-linked (2-3%) forms.
A large proportion (60-75%) of nonsyndromic hearing loss in children has been localized to defects in a single gene, Connexin 26 (Cx26) on chromosome 13q11-12.
A variety of mutations have been described in this gene with a 35delG hotspot mutation representing over half of the defects in Caucasians.
Recently, other links with deafness and connexin has been established

66. Autosomal Recessive Non-Syndromic HL

67. Question The Amy Tan Syndrome? Treacher-Collins BOR Pendred Stickler
Usher

68. Common Syndromes Associated with Hearing Loss
Name of syndrome
Other features that may occur (besides hearing loss)
Alport
Kidney problems
Branchio-oto-renal (BOR)
Neck cysts and/or ear tags and kidney problems
Jervell and Lange-Nielsen
Heart problems
Pendred
Thyroid enlargement or low thyroid function
Stickler
Unusual facial features, cleft palate, eye problems (nearsightedness, cataracts, or retinal detachment,) arthritis, heart problems
Usher
Progressive blindness
Waardenburg
White patch of hair or light-colored skin patches; eyes of two different colors, or bright blue eyes, or widely spaced eyes

69. Jervell and Lange-Neilsen Syndrome
Profound SNHL
Prolongation of QT interval on EKG
May develop arrhythmias resulting in sudden death
Autosomal recessive inheritance
Mutations in KVLQT1gene on chromosome 11p15 and KCNE1gene on chromosome 21q22
Potassium channel genes

70. Waardenburg Syndrome Hearing loss approximately 20%
Pigmentation abnormalities of skin and hair
Lateral displacement of medial canthi of eye
Heterochromia of iridi

71. Branchio-Oto-Renal Syndrome (BOR)
Hearing loss 93%
Mixed hearing loss 52%
Conductive hearing loss 33%
Sensorineural 29%
Pre-auricular pits 82%
Branchial fistulae 49%
Cupped or mildly altered auricle 36%
Renal abnormalities 67%

72. Treacher Collins Syndrome
Conductive hearing loss 50%
Malformed ossicles
Malformation of auricle
Very small jaw and chin (micrognathia)
Malar hypoplasia
Down slanting palpebral fissures
Defects of lower eye lids

73. Cytomegalovirus (CMV)
Leading cause of non-syndromic HL (1/3rd)
Hearing loss, often delayed onset, can fluctuate
Small for gestational age
Growth failure
Skin rashes 
Enlarged abdominal organs
Blood count abnormalities
Reduced head growth
Developmental delay

74. Comorbidities Comorbidity is the -
presence of one or more disorders or diseases in addition to the primary disease or disorder; or
effect of disorders or diseases
Children with congenital SNHL have a relatively high incidence of comorbid conditions, either congenital or acquired

76. Etiologies Genetic Bacterial/viral Metabolic Trauma Ototoxic Cancers
Autosomal, x-linked, mitochondrial, non-syndromic, syndromic
Bacterial/viral
Metabolic
Trauma
Ototoxic
Cancers
Vascular disorders
Myelization

77. Type of Loss Conductive Sensorineural Mixed
Auditory Processing Disorder

78. AR Service Plans Adult Child Home Home Social/ Social/ Educational
Extracurricular
Home
Vocational
Social/
Avocational
(Tye-Murray, 2009, p 16)

79. AR Services Services for persons with hearing loss
Served
Unserved
Underserved
Lack of services due to
Lack of outreach and immediate or extended support services
Attitudes of service delivery personnel
Lack of adequate reimbursement for AR
Communication and environmental barriers
(Tye-Murray, 2009, p 14)

80. Cost-Effectiveness and Costs
Cost-effectiveness is the relationship between the money spent and the benefits accrued Cost is the actual expense for providing Examples: Trends in Educational Placement and Cost-Benefit Considerations in Children With Cochlear Implants

81. Reimbursement
Medicare U.S. Social Security program that reimburses hospitals and physicians for medical care provided to qualified persons 65 years or older (federal program) Medicaid U.S. Title XIX program under the Social Security Act that is jointly funded by the federal and state governments that reimburses healthcare providers Private insurance plans (some provide for services while others do not) IDEA youth birth to twenty-one who qualify Out of pocket payment

82. Triad of Evidence-Based Practice
Evidence-Based Practice. Developed with Keith Posley, MD, Stanford Medical ... medresidents.stanford.edu

83. Evidence-Based Practice
EBP is “the integration of best research evidence with clinical expertise and patient values Levels of evidence to support EBP Five-step approach (Canadian Cochrane Network/Centre Affiliate Representatives)

84. Question
How many persons that could benefit from wearing hearing aids in the U.S. have hearing aids?
1 in 5
1 in 3
1 in 4
1 in 6

85. Hearing Aid Use
Only 1 in 4 wear hearing aids who could benefit from amplification
S. Kochkin. MarkeTrak VIII: 25 year trends in the hearing health market. The Hearing Review, Vol. 16 (11), October 2009, pp

86. Other Areas of AR Auditory processing disorders Tinnitus Hyperacusis
Vestibular and balance disorders

87. AR Professional Organizations
AAA (American Academy of Audiology)
AAS (American Auditory Society)
AG Bell Association
ARA (Academy of Rehabilitative Audiology)
ASHA (American Speech Language Hearing Association)
EAA (Education Audiology Association)
ISA (International Society of Audiology)

88. AR Foundations
DRF (Deafness Research Foundation)

89. Consumer Organizations
HLAA (Hearing Loss Association of America)
Hearing Loss Web
ALDA (Association of Late-Deafened Adults)
Hands & Voices

90. Terminology: Hearing Loss
NAD
Deaf-mute, deaf and dumb, hearing impaired terminology
d/Deaf
Wikipedia
Hearing Loss Association of America
“Hard of Hearing,” “Hearing Impaired” or “Deaf”—Which Is Correct?

91. Kiersey

92. Circle of Courage
Belonging
Independence
Generosity
Mastery