NECHEAR Family Support: The Role of the Pediatric Audiologist Karen M. Ditty, M.S. Texas ENT...
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Transcript of NECHEAR Family Support: The Role of the Pediatric Audiologist Karen M. Ditty, M.S. Texas ENT...
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 Rehabilitation354 Hartford Tpke.
Hampton, CT 06247860-455-1404
NECHEAR
Parental Reaction (Luterman)
• Mourning “the lost normal child” – Shock– Recognition– Denial– Acknowledgment– Constructive action
• Parental Expectations
NECHEAR
Parental Reaction (Luterman)
• Audiologist’s 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
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
NECHEAR
What is the pediatric audiologist’s role in diagnosis and intervention ?
Explaining hearing, hearing loss and amplification
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Auditory Development
Skill Age BehaviorLocalization 6 mos Head turn to source
Min Aud Angle 6-18 mos Decreases 15-40
Detect duration
differences <6 mos <= 20 msec
Pitch perception <6 mos large for detection
Speech perception 1 month VOT can be made
2 mos Falling vs. rising F0
9-18 mos Prefer highly novel
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
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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
NECHEAR
What is the pediatric audiologist’s role in early intervention?
Understanding and explaining typical spoken language
development
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What is progress?
Define the area of communication you are talking about….
- auditory skills
- speech
- spoken language
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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 one’s own production with a model.
• Spoken language development continues into adolescence.
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.
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.
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
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What is the pediatric audiologist’s role in early intervention?
Basic principles of early intervention
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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
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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
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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
NECHEAR
What is the pediatric audiologist’s role in early intervention?
Supporting family’s understanding of language choices
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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
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
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
NECHEAR
What is the pediatric audiologist’s role in early intervention?
Helping families understand and select sensory devices
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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
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
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
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
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
NECHEAR
What is the pediatric audiologist’s role in early intervention?
Helping families understand problems and daily use of
amplification
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Practical Problems
Problem SolutionMaintaining BTE Huggies, Strap holder, clips
Removing batteries Battery door lock
Changing volume Volume cover, deactivate volume
NECHEAR
Issues with Amplification
Behavior Problems SolutionsBlinking, flinchingOutput/gain too Decrease output
to loud sounds high; tolerance prob. or gain
Pulling out earmolds Not used to molds Use “huggies”
or strap
Poorly fitting molds Remake or refit
Sore ears- allergic Remake with hypoallergenic
NECHEAR
Issues with Amplification
Behavior Problems SolutionsFeedback Inappropriate settings Reprogram
Cerumen plug Medical treatment
Poorly fitting mold Remake
OME Medical treatment
Pulling on or chewing Cords too obvious String cords
cords behind back, through clothing;
decrease length
Not responding to Poor high frequency Change settings;
high pitches amplification modify earmolds;
frequency trans.
NECHEAR
Issues with Amplification
Behavior Problems SolutionsBlinking, startling Over amplification in Reduce low gain;
to low pitches low frequencies change FRC, h.a.
Poor responses to Not a full-time user; Work to better use
sounds Cannot use traditional Consider CI
amplification
NECHEAR
What is the pediatric audiologist’s role in early intervention?
Helping families understand candidacy for cochlear implants
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.
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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
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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
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What is the pediatric audiologist’s role in early intervention?
Helping families understand problems and daily living with a
cochlear implant
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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)
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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
NECHEAR
Practical Problems
Problem SolutionMaintaining headpieceHuggies, Strap holder, clips
Chewing on cords Stringing wires behind
and headpieces
Changing volume Locking volume control
NECHEAR
Issues with Cochlear Implants
Behavior Problems SolutionsBlinking, flinchingCs, Ms too Decrease thoseto loud sounds high; facial nerve levels, turn off
stimulation electrodes
Red, sore spot Magnet strength Change magnetsunder headpiece too much Use moleskin
Not responding to Inadequate high Change Ts, Cs/Ms;high pitches frequency stimulation change frequency
table
NECHEAR
Issues with Cochlear Implants
Behavior Problems Solutions
Not responding to Inadequate low Change Ts, Cs/Ms;
high pitches frequency stimulation change frequency
table
Soft voice Over stimulation Change Ts/Cs
Loud Under stimulation Change Ts/Cs
Poor voice quality Inadequate stimulation Change settings
NECHEAR
What is the pediatric audiologist’s role in early intervention?
Helping families understand life transitions
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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
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Transitions
• Early Intervention to School System
• Elementary to Middle School
• Middle School to High School
• Life After High School
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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
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Enrollment in Early Intervention
• Develop Individualized Family Service Plan (IFSP)– All services
• speech and language development• auditory development• assistive technology
– Goals and objectives– Timelines
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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
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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
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Leaving Early Intervention
• Helping parents understand differences in LEA and EI approaches
• Working toward a smooth transition
• Ensuring good services continue
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“What’s 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
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
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)
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
NECHEAR
Elementary to Middle School Transition
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Middle School Language
Adults Children Environment
parents siblings home
family
------------ ------------- -----------
teachers classmates (20+) school
------------ ------------- -------------
coach team sports fields
social group (3+) community
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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
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
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
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
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Middle School to High School
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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
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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
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
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
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
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
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High School Language
Adults Children Environmentparents siblings home
family
------------ ------------- -----------
teachers classmates (20+) school
------------ ------------- -------------
coach team sports fields
social group (3+) community
1:1 social community
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Life After High School
and the beat goes on