1. Audiologic Rehabilitation for Children
July 20, 2010

2. Rehabilitation Settings and Providers
Differ according to type of hearing loss and when the loss was identified.
Differs according to age groups (preschool, school-age)
Auditory verbal: everything done through audition; parent drive,, everything done through listening
-premise is to build the listening D

3. WHAT IS A COCHLEAR IMPLANT?
Electronic prosthetic device
Surgically implanted in the scali tympani of the cochlea
Bypasses damaged hair cells in the cochlea
Electronically stimulates auditory neural elements that do not respond to acoustic stimulation with hearing aids
Bypasses damaged hair cells.
They do not regenerate
More accepted now
Bilateral impants: new within the past 10 years
-common now

4. BASIC COMPONENTS External Microphone Speech Processor
Battery Component
Coil/transmitter
Receiver/Stimulator
Magnet for Retention
Implanted Electrode array
Need to work on the isde of the impant
Be aware of where microphone is
Where are they in terms of using ci with verbal lang

5. HOW DOES IT WORK?
External microphone converts incoming sound into electrical signal
Speech processor converts electrical signal into a digital code (speech processing strategy)
Signal is transmitted across the skin
Aud. Programs the programs
-needs to go in for mapping or new program
-aud can put in more than one program at a time
-can give progressive programs (less access or more access to sound): give them these because may be overstimulated (why don’t start at P3)
-can give environmental programs

6. HOW DOES IT WORK?
Implanted cochlear stimulator receives the coded signal and delivers it to the electrode array
Electrodes stimulate cochlear neurons
Bypasses damaged hair cells
Nerve impulses are sent along the auditory pathways to the cerebral cortex
Allows the brain to perceive sound

7. MAPPING Term utilized for programming external device
Occurs approximately 4 weeks after surgery
Laptop computer utilized
Objective measures utilized
Progressive maps
Plateau/stabilization: when program gets too soft they stabilize and plateau at that one
Regular maintenance schedule
Goal is to get them in normal range of hearing
Used to be 4 weeks post op
-children’s hospital does 2
Some reluctant to get ci bc it wipes away any hearing left
Speech usually telegraphic, taught and nasally

8. FREQUENCY IN HERTZ (Hz) 10 CI CI CI 20 dB HL CI CI 30 40 A A A 50 60
HA audiogram are still similar to hearing loss
-it amplifies sound and can switch from low freq to high freq sounds
That is a good aidiogram with an implant
-want to get a straight line
-goal is to get into normal range in the speech banana
-once in this range it is a manner of maintaining that
After get this then comes work on which sounds are what and how to use them
Job is to teach them how to liste, disciminate, idenitify, and comprehend sound(what language is) A 70 A 80 90 NR NR NR
100

9. Video Clip (40 minutes) : Acoustics of Sound
Need to understand acoustics of sounds
Mihgt catch it at F2 or F3 frequency and not F1
The Ling Sounds
Speech banana
Know to be able to look at aided audiogram and know which sounds you have access too
-helps with knowing speech patterns
-high frequency sounds are new to their brain so may need help with this
-all sounds in environment is now increased; all sounds are new so brain is hearing all this auditory info but doesn’t know how to filter yet
-work how to discriminate sounds and recognize what is important

10. PREDICTIVE FACTORS Medical conditions Communication strategies
Language development
Mode of education
Family support/dynamics
Developmental delay
Adolescents – poorer prognosis
Variability exists
Are their other things other than hearing impairments
Anything else going on that may controbulte to speech nad language disorder
-while ago they were not implanted bc they had multidisorders
-multihandicapped childrne are implanted within the past 10 years
More set up for spoken language than child who was 9 just hearing the sounds
Set up reality of not being able to have expressive language and speech intelligibility bc of age and limit of sounds
Mode of education: is this child that used sign language all life or verbal language
Family support: realize they have missed 3 appt and social services is telling them they have to get evaluated
You look at that for predictive factors
Priorities are not right when it comes to child’s hearing aids
Dynamics of family
Developmental delay: cognitive delays
Adolescents: gone long without speech and psychology of the child
If adolescent does not want this
If parent says they have to get it and they don’t want it
Variability: somethijng happens and that changes the outcome

11. TEAM APPROACH Surgeon Audiologist Auditory Verbal Therapist
Speech/Language Pathologist
Nurse/O.R. Staff
Educator
Early Interventionist
Coordinator/Case Manager
Administrative

12. Yes! SLPs Need to Know Pre-CI Audiograms are Important
Always get most the most updated audiogram!!!
Need to know hearing before ci
- And always want most recent audiogram

13. Communication, Communication, Communication
You and the audiologist will work together to get the best program for your client.
You can help with ease of programming and adjustment to new programs with young children.
You provide valuable information to the audiologist about your client’s functional use of his/her implant.
You ar eat the front line
-you notice if there is something that isn’t right
You and audiologist talk together and let them know if something may need to be fixed
-audiologist may say client doesn’t understand soft and loud
-so may work on soft and loud in therapy
-chikd;s functional use of impant (altering speech based on what he hears)

14. Adjusting to the Cochlear Implant
You are usually on the “front line”.
Advising parents about saturation.
Talk about realistic expectations.
You provide lots of encouragement and education!!!
Pointing out the gains in auditory skills that you see.
Letting them know what is typical “tolerance issues”.
Explain to parent that he hears but doesn’t understand what he is hearing (not processing)
Saturation: don’t hear sound because they need to move up; you get used to sounds
-tell parent to tell you hwne it looks like they can hear again
-brain gets used to sound and it is less stimulus to them
Keep in mind that infant doesn’t notice different sounds until one year

15. Remember!!!!
Every client is different and comes to you will a diverse background (language, social environment, hearing, personality, family).

16. Keep in mind that a your client’s ability to receive the sounds of speech is only the first step…….
Very Important to know have your client’s most recent CI audiogram.
They can hear sound but doesn’t know what sound means
Perception of speech is not the same as processing, discirmination, and comprehending speech
-just bc percieve speech it doesn’t mena they understand speech -
This is just the first step

17. Why do we address auditory skills in therapy?
In both children and adults, we use it to fully develop their use of available sounds.
This is their weak sense, work where they have to work on certain things so take away others
In children, effective listening becomes their foundation for the development of spoken language.
This is what all children use for spoken lang devel.
Give two sounds are they the same or different first thing we work on: discrimination
Children just learn language
-childrne learn through their environment
-teaching them to be good listeners

18. Auditory Skills?
You need to know where your client’s auditory skills fall in the hierarchy. Each therapy session will be diagnostic in nature.
Need to know what they can and cannot hear and where they are with hearing
Normal children move very quickly through auditory stages
-children with other issues move more slowly

19. Basic Stages of Auditory Development
Comprehension Identification Discrimination Detection
First need to detect the sound
First detect the ling sounds: they are across diff frequencies /u,i,a,s,S/
-for baby you have to do sound detection tasks: when you talk with audiologist
Discriminate:

20. The awareness of whether a sound is present or not
Detection
The awareness of whether a sound is present or not
Detection activities should be…
Motivating
Simple and quick
Age appropriate
Varied
When you hear it put it into the bucket
-might need to do hand over hand at first

21. Auditory Attention Also work on generalizing auditory attention.
Must be established as a foundation for learning to listen
Timers
Name calling
Eventually the child will alert to environmental sounds and speech without cues
Not on basic hierarchy
Detect sound and once you detect you have to attent to sound
-need to teach to attend sound in environment
-hold attention to important sounds
Putting attention to auditory information
Want them to ask you to label what they are hearing
Tell adult to listen for sounds and to go find out what it is

22. Detection: Conditioned Response Activities
Should be…
Motivating
Simple and quick
Age appropriate
Varied
Activity Suggestions
Balls, puzzles, mechanical banks, stacking toys, peg boards, black towers, beanbag or ball toss, stringing beads, letters in a mailbox…..
They hear it they do something

23. Discrimination Distinguishing differences between sounds
The listener's ability to tell whether two sounds are the same or different.
Whether 2 sounds are the same or different

24. Keep in mind the Acoustic Contrasts within the Discrimination Task
From Easiest to Most Difficult
Suprasegmentals
Syllable Length
Vowel Differences (bat, bet, boot)
Manner of Production Differences (t vs. sh)
Voicing Differences ( p vs. b)
Place of Production Differences (k vs. t)
Learning to listen sounds
Some sounds are easier than other sounds to tell the difference of
Suprasegmental: intonation, prosody, tone, pitch, rhythm of speech
-some with sever to profound loss missed all this why they are monotone
Learning to listen sounds: airplane sound ahhhhhhaaaaaa
Boat: bababababaaaa
Long continuous: mooooooo
Syllable length
-am I saying ball bat or butterfy
Recognizing words that differ by vowels
Manner of production: fricative, stop, affricate, nasal, liquid
-recognizing manner of differences
-shoe, knew, boo
-words are the same except for manner of production
Voicing diff: manner and place of production is same but change voice
Place of production:
-where placing sound

25. A person's ability to recognize a sound and then label it
Identification
A person's ability to recognize a sound and then label it
With words or sounds
Recognize it and label it
Hears a bird and says that’s a bird
Just because they repeat something doesn’t mean they know what they are saying
Imitation doesn’t mean they understand it
Teach them the task then ask them listen “pen” and they grab it that is identification

26. Comprehension
A person’s ability to understand the meaning of the spoken message
This level requires that the person have a certain degree of semantic and syntactic language development
Bc it involves them understnading sent and being able to answer questions
Dahlia doesn’t have semantic and syntactic language to asnwer her
-expressive is lacking
-receptive is fine

27. Auditory Attention Also work on generalizing auditory attention.
Must be established as a foundation for learning to listen
Timers
Name calling
Eventually the child will alert to environmental sounds and speech without cues

28. Always keep in mind the variables that affect how challenging a therapy task is for your client.
For any child with language issue

29. What is your Listening Set?
Closed Bridge Open
Closed: they have a finite number of options to answer, field of choice, have to hold info in their memory
Bridge: not quite totally open or closed, three pictures and might say” he is wearing a blue shirt and have three boys wearing diff colors, I am going to tell you something about what someone is wearing, I am going to tell you something that you might hear at a doctor’s office; context clue
Open: only one choice, no idea what you are going to ask them, most difficult level, what are you going to do Friday night?
If they ar enot getting it at this level and if they are getting 100% one setp down there is something in the middle there may be cues to add or take away

30. What are the contents of your set?
Keep in mind….
The familiarity of the vocabulary
How the items acoustically contrast each other
The number of key words being used and where they are placed
The linguistic complexity of what you are presenting
More familiar to what you are used too
Levels of discrimination
Things are eaier to understand at the end of a sentence then embedded
Are you suing simle sent structure

31. How are you presenting the stimulus items?
What is your rate of speech?
Are you using acoustic highlighting?
Is there background noise?
Acoustic highlighting: pausing before the word, sing songy, somehow highlighting the sound of it
Background noise: might have to move them or you might need to schedule therapy session when not in lunch time

32. Ling 6 Sounds What are they? Why do I need to use them?
When do I use them?
A behavioral listening check to determine a cochlear implant’s effectiveness.
The sounds ah, ee, oo, sh, s, and mm indicate a child’s ability to detect all aspects of speech as these six sounds encompass
the frequency range of all phonemes.
This check can be used to determine what sounds the student is able to detect, discriminate, and identify
Rep the sounds within the speech banana: if they can hear and repeat these sounds it’s a good indicator they are hearing wihtin a speech range
-initally for detection use them to discriminate , and use them for identification
-after this only use them at the beginning of every session to make sure hearing is up and working

33. Ling 6 Sound Test OO EE AH S SH MM Also….absence of sound
Developed by Daniel Ling
Used for detection, discrimination and then identification
Will serve as a diagnostic indicator and help you detect when something is not right or different with the way the person is hearing from the CI
Should begin sitting next to the child, move to 3 feet then to 6 feet.
By including the absence of a sound it teaches the child to indicate when they don’t hear anything.
A child with normal hearing can hear all of these sounds at twenty feet.
Remember to presetn these in varying order.
Because they ned to know what it sounds like when something is wrong with HA or CI and they can’t hear

34. Sound-Word Associations
These are used to teach the skill of listening to the younger child
They differ greatly in terms of duration, intensity and pitch.
Can be taught through a variety of different toys, pictures, craft items, stamps and everyday objects
Learning to listen sounds
suprasegmentals

35. Sound-Word Associations
Many of these associations are commonly used in traditional, early language therapy
Once the child learns the associated sound then the true word is given
Teaching them to learn to listen
Be consistant

36. Transitioning Between Visual and Auditory
Auditory Information
Visual Clarifier
Reduces dependence on visual clues.
Auditory sandwhich: switch btwn sign and lsitneing
Embedd what you are doing in auditory
-can you get me the purse an dthey don’t get it
-give me the thing you put your money in
-or if took hand away from mouth and say it so they are able to speech read
-ok so you used visual but always go back to auditory
Now that you know what im saying listen to what I am saying
Can be written speech reading, a sign

37. Sound-Word Associations
These are used to teach the skill of listening to the younger child
They differ greatly in terms of duration, intensity and pitch
Many of these associations are commonly used in traditional, early language therapy
Once the child learns the associated sound then the true word is given
Can be taught through a variety of different toys, pictures, craft items, stamps and everyday objects

38. Some Examples of Sound-Word Associations
Up, up, up, weeee
Mooooo
Ahhhhhhhhh
(rising and falling intonation)
Listening for Littles,1997

39. Some Examples of Sound-Word Associations
Up, up, up, weeee
Mooooo
Ahhhhhhhhh
(rising and falling intonation)
Listening for Littles,1997

40. Keep in mind……. Imitation is not identification Closed versus open set
Complex closed sets may be easier than single word in a open set
A “bridge set” may be used to connect between closed versus open sets
Content and presentation determine the level of challenge

41. When they don’t get it the first time….
Acoustically highlight the key word
Model a similar question with another person
Use familiar information and vocabulary to introduce words
Use descriptions
Keep in mind that imitation does need mean comprehension.
Imitation does develop the auditory feedback loop which is important for matching speech productions to sounds that are heard.
Model: Parent is in the room.
-what color is your shirt?
Then ask mom: what color is your shirt? Mom says correct asnwer blue
-then they get what you were asking
Familiar info: might talk about something that they know the vocab already
Use descriptions: something you put on your shoulder, you put your wallet in it, money, you wear it
-they may get that youwere talking about a purse

42. Listening Hoop Instructions on assembly provided Materials needed
Embroidery hoop
Stereo speaker cloth

43. Therapy Materials and Ideas
Lots of great stuff is on the internet now!!!!!!
Therapy Materials
Free On-line Training
Med el:soundscape

44. Video Clip (59 minutes) : Principles and Practice Of CI Rehab
Hope courses: cochlear company, free
Listening room: advanced bionics

45. Let’s look at some pediatric therapy……
Warren
Listening therapy
Baby a lot of sound awareness stuff
-teacht he parents how to help the children
Detection: listen and put block on when hear sound
What color is that? Identification
What goes quack quack quack? Child idenitfies duck
Closed: but big bc only a certain number you can choose from
Auditory verbal therapy is a lot of teachign the parent