1. Audiological Management: What Everyone Needs to Know Antonia Brancia Maxon, Ph.D., CCC-A 1, 2 Kathleen Watts, M.A. 2 Karen M. Ditty, Au.D., CCC-A 2 1 New England Center for Hearing Rehabilitation Hampton, CT 2 National Center for Hearing Assessment and Management Logan, UT

2. Faculty Disclosure Information In the past 12 months, we have not had a significant financial interest or other relationship with the manufacturer of the product or provider of the services that will be discussed in our presentation. This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA.

3. Pediatric Audiology Training UNHS successful across the U.S. Created a need for pediatric audiologists –need knowledge and experience to work with very young infants and their families –large enough pool does not exist

4. NCHAM Audiology Courses NCHAM developed two courses to train audiologists. –Course ONE covers the diagnosis of hearing loss in infants –Course TWO covers the provision of appropriate follow-up management ongoing audiological evaluation hearing aid selection and fitting cochlear implants

5. Course Two Ongoing Audiological Assessment Originally designed for audiologists Course information is also critical for : –early intervention providers –medical professionals working with young children –parents

6. What Other Professionals and Parents should know about Audiologists Not all Audiologists are equally trained to work with infants and toddlers. –Not all Audiologists are familiar with clinical protocols for young infants. –There is an inadequate number of audiologists with pediatric expertise. Some audiological facilities lack equipment needed to assess young infants.

7. Basics of Ongoing Audiological Assessment Behavioral audiological evaluation –necessary and appropriate for infants and toddlers with hearing loss Prescriptive methods for selecting, fitting and validating hearing aids for infants and toddlers Appropriate methods for determining cochlear implant candidacy and outcomes for infants and toddlers

8. J. Gravel, NCHAM 2005 Audiological Assessment of Infants Characterize: Hearing loss degree, type, configuration Purpose: Initiate appropriate intervention and establish baseline for monitoring hearing overtime

9. J. Gravel, NCHAM 2005 Visual Reinforcement Audiometry (VRA) Appropriateness established in 1960s Methods standardized in 1970s Widely used in clinics Valid and reliable procedure for infants and toddlers from 5 through 24 months.

10. J. Gravel, NCHAM 2005 Visual Reinforcement Audiometry (VRA) Conditioned response Child hears a sound and learns it will be followed by a visual reinforcement Basic head turn (to sound) response is increased by use of the reinforcer (lighted and/or moving toys) Reliable responses result in a good consistent audiogram

11. J. Gravel, NCHAM 2005 Suggested VRA Protocol (Gravel, 2000) Reinforcers located 90 0 to one side –multiple toys behind smoked Plexiglas Condition head turn response using speakers in the test booth (sound field) Use signal and silent presentations –measure thresholds using typical procedures After sound field testing completed –bone conduction or insert earphones used –depends on sound field results

12. J. Gravel, NCHAM 2005 Suggested VRA Protocol (Widen, 2000) Reinforcers located 90 0 on both sides –two toys on each side Infant seated on parents lap Two testers Condition head turn response using insert earphones Use signal and silent presentations –measure thresholds at 1K, 2K, 4K Hz and speech

13. J. Gravel, NCHAM 2005 Use of Earphones in VRA Procedures Younger infants retain earphones better than older ones Most difficult age range is 24 - 30 months Insert earphones are better –more comfortable –not easily dislodged with movement –better for hearing aid selection

14. J. Gravel, NCHAM 2005 Scheduling the VRA Visit To maximize the chance of getting a good complete test (and audiogram) –childs development –childs health –childs temperament

15. Seewald and Moodie, NCHAM 2005 Hearing Aid Selection: What the Audiologist Wants to Know That the audiologist has achieved a good match between the amplification characteristics (gain, output, frequency response) of the hearing aids and the auditory characteristics of infants so that the use of residual auditory capacity can be maximized.

16. Seewald and Moodie, NCHAM 2005 Hearing Aid Selection: Measurements Assessment –Measure the infants ear acoustics – important because infants have small ear canals and hearing aid manufacturers use adult ear canals (as measured in a coupler) to determine hearing aid characteristics –Determine Real Ear to Coupler Differences (RECD) – the difference between what the hearing aid will produce in an infants ear as compared to the coupler measurements.

17. Seewald and Moodie, NCHAM 2005 RECDs in Infants: Key Points RECDs in infants and toddlers differ significantly from average adult values. RECDs vary from infant to infant. RECDs will vary for a given infant over time. The pediatric audiologists should determine RECDs before initial fitting and regularly over time.

18. Seewald and Moodie, NCHAM 2005 RECDs : More Points RECDs have large individual variability regardless of age. RECDs from foam eartips and earmolds have very different shapes and are not interchangeable. Age-appropriate average RECDs may be used when measurement is not possible. The pediatric audiologists should always consider RECDs when fitting hearing aids.

19. Seewald and Moodie, NCHAM 2005 Hearing Aid Selection Minimally, the fitting method employed to determine hearing aid characteristics should be audibility based - with the goal to provide audibility of an appropriate amplified long-term average speech spectrum. That is, the hearing aid should present all components of speech at a level that the infant can hear.

20. Seewald and Moodie, NCHAM 2005 Hearing Aid Verification What the hearing aid can produce (electroacoustic performance) should match what was predicted from the infants real ear measurements and the RECDs.

21. Maxon, NCHAM 2005 Cochlear Implants: Options Three companies approved by FDA –Internal devices for each –Speech processors for each Body-worn Behind-the-ear Assistive device compatibility –Speech processing strategies for each –Bilateral considerations

22. Maxon, NCHAM 2005 Cochlear Implant Candidacy Infant cannot benefit from traditional amplification No medical contraindications Family is aware of benefits and limitations

23. Maxon, NCHAM 2005 Cochlear Implant Mapping When and why to map Basic measurements –Thresholds –Comfort levels Rehabilitative mapping –Perceptual validation of the map Optimizing the map

24. Maxon, NCHAM 2005 Cochlear Implant Outcomes Why implant early –Earlier implantation results in less negative impact from severe to profound hearing loss Speech and language development follows typical development with good EI and parental input –No significant medical contraindications –With early identification families are prepared for follow-up management.

25. Maxon, NCHAM 2005 Referral and Enrollment in EI The pediatric audiologist and parents know the established Part C guidelines for the state. The pediatric audiologist and parents know the child eligibility criteria –automatic enrollment – diagnosed condition –significant developmental delay The pediatric audiologist and parents know the state guidelines for selecting a program

26. Maxon, NCHAM 2005 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 –language development –speech production Monitoring middle ear status

27. The information in this presentation should be shared with EHDI providers and families so that they can make well-informed decisions regarding the services being provided for children with hearing loss.

28. Resources on the Web Joint Committee for Infant Hearing http://www.jcih.org/history.htm National Center for Hearing Assessment and Management www.infanthearing.org Boystown National Research My Babys Hearing www.babyhearing.org