Beyond the soundproof booth: Beyond the soundproof booth: the audiologist in the the audiologist in the

development of children’s development of children’s language and cognitionlanguage and cognition

Carolina Leal

Audiological Scientist

St Thomas’ Hearing Implant Centre

SWEDCM Conference 2015

St Thomas’ Paediatric St Thomas’ Paediatric Hearing Implant Centre Hearing Implant Centre

• Established 1996

• Over 400 paediatric Cochlear Implant surgeries

• Other implants: BAHA, MEI, Soundbridge, Bonebridge, ABI

• Diverse, multidisciplinary team – ENT surgeons, Audiological Scientists, SaLTs, ToDs, Psychologists, Hearing Therapist, ATOs, Administrators

• Development of functional communication and language is priority

• Communication modes (BSL level 4, AVT specialists)

• Embrace Deaf culture and the views of deaf adults

• Guided by family’s desired outcome

Understanding the family’s Understanding the family’s experienceexperience

• 90% deaf babies are born into families with no experience, or history, of childhood deafness (www.hearing.screening.nhs.uk)

• Working with a diverse/multicultural population: 22% London homes speak another main language alongside English (Census, 2011)

• Families get information and different opinions from professionals across a variety of fields

• Misconceptions + Misinformation + Mixed messages = Frustrated families

• Audiologists – the first point of contact

• Families have long term goals for their child:

“Where will my child be at age 3, 5, 20? Able to talk? Mainstream school?”

“What do we need to do to get there...?”

And the world is changing fast...And the world is changing fast...

• We live in a world that demands high levels of communication and literacy

• We are treating children who will take charge in the world of 2030, 2040, and 2050… not in the world of 1970 or 1990 or even 2016 (Carol Flexer)

• Today’s patient, tomorrow’s prime minister – how can we positively influence children’s language and cognitive development (Stiles, BAA 2014)

State-of-the-art technologyState-of-the-art technology

Access to soundAccess to sound

PTA not good predictor of

• Vocabulary

- Davis et al (1986)- Moeller (2000)

• Word Learning

- Gilbertson & Kamhi (1995)- Davis et al (1986)

• Language

- Ramkalawan & Davis (1992)

Detection versus AudibilityDetection versus Audibility

Pure Tone Average

(PTA)

• Frequencies have equal weighting

• Defines minimal detectable signal

• Does not infer discrimination or predict benefit from amplification for speech understanding

Speech Intelligibility Index

(SII)

• Frequency weighting incorporates importance to speech understanding

• Defines audibility of information in speech

• Predicts potential benefit from amplification for speech

The aided SII and language The aided SII and language outcomes in childrenoutcomes in children

• SII better predictor than PTA for language outcomes in children with HAs

• Aided SII ≤ 65% - risk for delays in vocabulary development

• Aided SII may become a useful benchmark in determining CI candidacy

• Higher aided SII associated with more accurate word recognition, non-word repetition and larger receptive vocabulary

• Aided SII more sensitive than PTA at predicting lexical abilities of children who wear HAs

N.B.: Age appropriate lexical development is thought to be critical for later attainments in syntax (Tomasello, 2000) and reading (Stanovich, 1986)

Stiles et al., 2012

The aided SII and language The aided SII and language outcomes in childrenoutcomes in children

McCreery et al., 2015 (in press)McCreery et al., 2015 (in press)

Planned audibilityPlanned audibilityThere’s no finer investment for any community than putting language into

babies (Derek Stiles, BAA 2014)

Technology selection (HA / BAHA / CI)

Target / programming strategy selection

Programming / MAPping

Verification

Planned audibilityPlanned audibility

Unaided

Aided

• Thresholds/Severity

• PTA / SII

• Speech understanding

Select device and targets/strategies, knowing they do not restore normal hearing

• REAR

• Aided SII

• Aided speech understanding

• Aided θ

Job done!

Really?

Audiologist

Consistent accessConsistent access• Data-driven learning

• Learning opportunities

• Common denominators

Look at the cat

Naughty cat!

Cat, cat, cat!

What a pretty cat!

Consistent accessConsistent access

• Consistent device use is the biggest predictor of a good outcome

• Children need to be constantly exposed to language

• Inconsistent use of amplification is similar to a fluctuating hearing loss

• Children with hearing loss require 3x the exposure to learn new words and concepts (Pittman, 2008)

Time A

dequ

ate

Inpu

t

Consistent accessConsistent access

• Verifying consistent access– Interviewing– Data-logging

• Educating about consistent use of amplification– First two years are most challenging

• St Thomas’ hearing aid / CI / BAHA retention box (Library)

Child related

• Pulling out/falling off

• Ear infections

Environment

• Car seats• Outdoor play

Parent related

• Loss prevention• Adjustment

(Moeller, 2009)

CollaborationCollaborationReport writing:

• Usable information to other professionals– Degree of loss– Speech recognition / SII

• Contextualise the added benefit

• Emphasize aided prognosis

Reporting Audibility:

“Bob is a 5 year-old boy with mild to moderate SNHL. Bob wears BTE hearing aids. Without amplification Bob has access to 23% of speech cues at normal conversational speech level. With hearing aids in place, in best listening conditions, Bob has access to 84% of speech cues at normal conversational levels. In ideal listening environments with hearing aids on and additional visual cues, Bob is expected to have minimal communication difficulties. In more adverse environments, Bob may require additional support, i.e. FM system.”

CollaborationCollaboration

Siblings /Extended

Family

GP

Psychologist

ENT / AVM Audiologist

ToDEduc Audiologist

SaLT

Teacher

Parent

Child

Collaboration (family)Collaboration (family)Why parent education?

• The linguistic environment at home best predicts the child’s language and IQ outcomes – for all children (Quittner et al 2013)

• The quality of relationships and the learning environments for babies & toddlers is critically important

• Children learn through being engaged, doing, watching and Copying

(The US National Institute of Child Health and Human Development)

• Mother’s interactions had significant impact on implanted child’s language development

(Desjardin et al 2007)

• Given that parents of special needs children often experience excess stress, they may be susceptible to negative outcomes

(Asberg et al 2008)

At St Thomas’…At St Thomas’…• Information Sessions (1st appt)

– Parent / extended family and local professionals

• Early Interaction and Language Facilitation (Look who’s talking!)

1st: parent-only group education session

– early interaction and communication skills

– how parents can facilitate these in everyday FUN situations

2nd: session attended by parents and their children

– opportunity to practise new skills and strategies

– real time video feedback given by a SaLT

• Music and Language groups– ‘baby beats’ - for infants and toddlers

– ‘musical journey through the rainforest’ - for nursery and school age children

Random variablesRandom variables

• Intellect– Intellectual potential– Other disabilities– Language/logic

• Temperament– Intro-/extraversion– Curiousity– Bravery

• Access to service– Time of intervention– Socio-economic factors – Environment

• Nutrition• Quality of schooling

• Cultural values– Education/literacy– Community– Religious/family rituals

Audibility

Opportunity to socialise /

interact Professional collaboration

Consistent use of

technology

The audiologist challenge: take your role The audiologist challenge: take your role beyond the soundproof booth!beyond the soundproof booth!

ReferencesReferences Asberg KK, Vogel JJ, Bowers CA. Exploring correlates and predictors of stress on parents of children who are deaf:

Implications of perceived social support and mode of communication. Journal of Child and Family Studies. 2008; 17:486-499

Boons, T., De Raeve, L., Langereis, M., Peeraer, L., Wouters, J., & Van Wieringen, A. (2013). Expressive vocabulary, morphology, syntax and narrative skills in profoundly deaf children after early cochlear implantation. Research in developmental disabilities, 34(6), 2008-2022.

Briscoe, J., Bishop, D. V., & Norbury, C. F. (2001). Phonological processing, language, and literacy: a comparison of children with mild‐to‐moderate sensorineural hearing loss and those with specific language impairment. Journal of Child Psychology and Psychiatry, 42(3), 329-340.

Colin, S., Leybaert, J., Ecalle, J., & Magnan, A. (2013). The development of word recognition, sentence comprehension, word spelling, and vocabulary in children with deafness: A longitudinal study. Research in developmental disabilities, 34(5), 1781-1793.

Desjardin JL, Eisenberg LS. Maternal contributions: supporting language development in young children with cochlear implants. Ear Hear. 2007;28:456-469.

Edwards, L., Figueras, B., Mellanby, J., & Langdon, D. (2011). Verbal and spatial analogical reasoning in deaf and hearing children: the role of grammar and vocabulary. Journal of deaf studies and deaf education, 16(2), 189-197.

Hornsby, B. W. Y. (2004). The Speech Intelligibility Index: What is it and what’s it good for? The Hearing Journal, 57, 10–17.Killion, M. C., & Mueller, H. G. (2010). Twenty years later: A NEW Count-The-Dots method. The Hearing Journal, 63, 10–17.Lee, Y., Yim, D., & Sim, H. (2012). Phonological processing skills and its relevance to receptive vocabulary development in

children with early cochlear implantation. International journal of pediatric otorhinolaryngology, 76(12), 1755-1760.Moeller, M. P., Hoover, B., Peterson, B., & Stelmachowicz, P. (2009). Consistency of hearing aid use in infants with early-

identified hearing loss. American Journal of Audiology,18(1), 14-23.Moeller, M. P., McCleary, E., Putman, C., Tyler-Krings, A., Hoover, B., & Stelmachowicz, P. (2010). Longitudinal development of

phonology and morphology in children with late-identified mild-moderate sensorineural hearing loss. Ear and hearing, 31(5), 625.

Pittman, A. L. (2008). Short-term word-learning rate in children with normal hearing and children with hearing loss in limited and extended high-frequency bandwidths. Journal of Speech, Language, and Hearing Research, 51(3), 785-797.

Pittman, A. L., Lewis, D. E., Hoover, B. M., & Stelmachowicz, P. G. (2005). Rapid word-learning in normal-hearing and hearing-impaired children: Effects of age, receptive vocabulary, and high-frequency amplification. Ear and hearing,26(6), 619.

Stiles, D. J., Bentler, R. A., & McGregor, K. K. (2012). The Speech Intelligibility Index and the Pure-Tone Average as Predictors of Lexical Ability in Children Fit with Hearing Aids. Journal of Speech, Language, and Hearing Research, 55, 764–778. doi:10.1044/1092-4388(2011/10-0264)

THANK YOU!THANK YOU!

Acknowledgements:

– St Thomas’ Hearing Implant Team, especially Alice Montgomery (SaLT)

– My grateful thanks to Dr Derek Stiles, for his input and Dr Ryan McCreery for allowing reproduction of their unpublished research data

Carolina.leal@gstt.nhs.uk