Family Support: The Role of the Pediatric Audiologist

1. 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 Rehabilitation 354 Hartford Tpke. Hampton, CT 06247 860-455-1404 nechear@snet.net NECHEAR

2. Parental Reaction (Luterman) • Mourning “the lost normal child” • Shock • Recognition • Denial • Acknowledgment • Constructive action • Parental Expectations NECHEAR

3. 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

4. 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

5. What is the pediatric audiologist’s role in diagnosis and intervention ? Explaining hearing, hearing loss and amplification NECHEAR

6. Auditory Development Skill Age Behavior Localization 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

7. 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 NECHEAR

8. 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

9. What is the pediatric audiologist’s role in early intervention? Understanding and explaining typical spoken language development NECHEAR

10. What is progress? Define the area of communication you are talking about…. - auditory skills - speech - spoken language NECHEAR

11. 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

12. 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

13. 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

14. 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 NECHEAR

15. What is the pediatric audiologist’s role in early intervention? Basic principles of early intervention NECHEAR

16. 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 NECHEAR

17. 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 NECHEAR

18. 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

19. What is the pediatric audiologist’s role in early intervention? Supporting family’s understanding of language choices NECHEAR

20. 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

21. 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

22. 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

23. What is the pediatric audiologist’s role in early intervention? Helping families understand and select sensory devices NECHEAR

24. 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

25. 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

26. Initiate amplification process immediately after diagnosis or change in hearing levels Select, fit and validate amplification with clinical and functional evaluations Pediatric Amplification Fitting NECHEAR

27. 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

28. 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

29. What is the pediatric audiologist’s role in early intervention? Helping families understand problems and daily use of amplification NECHEAR

30. Practical Problems Problem Solution Maintaining BTE Huggies, Strap holder, clips Removing batteries Battery door lock Changing volume Volume cover, deactivate volume NECHEAR

31. Issues with Amplification Behavior Problems Solutions Blinking, flinching Output/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

32. Issues with Amplification Behavior Problems Solutions Feedback 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

33. Issues with Amplification Behavior Problems Solutions Blinking, 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

34. What is the pediatric audiologist’s role in early intervention? Helping families understand candidacy for cochlear implants NECHEAR

35. 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. NECHEAR

36. 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 NECHEAR

37. 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 NECHEAR

38. What is the pediatric audiologist’s role in early intervention? Helping families understand problems and daily living with a cochlear implant NECHEAR

39. 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) NECHEAR

40. 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

41. Practical Problems Problem Solution Maintaining headpiece Huggies, Strap holder, clips Chewing on cords Stringing wires behind and headpieces Changing volume Locking volume control NECHEAR

42. Issues with Cochlear Implants Behavior Problems Solutions Blinking, flinching Cs, Ms too Decrease those to loud sounds high; facial nerve levels, turn off stimulation electrodes Red, sore spot Magnet strength Change magnets under headpiece too much Use moleskin Not responding to Inadequate high Change Ts, Cs/Ms; high pitches frequency stimulation change frequency table NECHEAR

43. 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

44. What is the pediatric audiologist’s role in early intervention? Helping families understand life transitions NECHEAR

45. 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 NECHEAR

46. Transitions • Early Intervention to School System • Elementary to Middle School • Middle School to High School • Life After High School NECHEAR

47. 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 NECHEAR

48. Enrollment in Early Intervention • Develop Individualized Family Service Plan (IFSP) • All services • speech and language development • auditory development • assistive technology • Goals and objectives • Timelines NECHEAR

49. 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 NECHEAR

50. 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 NECHEAR