case study about hearing loss in adults and children

Case 1.

Mr. Gandalf Grey is 82 years old and has arrived for an audiological appointment with you. You are working on a case history intake and he points to his ear and tells you, “I can’t hear anything anymore.” While you are testing him, you give him a break while you clean up the results to start counseling. He looks at you and says,” no one wants to talk to a dumb old man anymore.” His audiogram is shown above. His speech understanding at PBmax is 72% for the right ear and 60% for the left ear.

Mr. Gandalf Grey was accompanied by his daughter who thinks a hearing aid would benefit him greatly in his daily living. She is concerned about his quality of life and the frustration he has been demonstrating with unsuccessful communication. He would be a first-time hearing aid wearer. He has some dexterity issues. He has been isolating himself more and more from social activities. They have a large family and he is often in group settings, out to dinner, attending his grandchildren’s events. He used to be extremely active with his church community.

How would you explain Mr. Gandalf Grey’s audiogram? (1 points)

Mr. Gandalf Grey is interested in pursuing amplification. Based on the case history you have in front of you, suggest a possible hearing aid style for him. Explain why you suggested that hearing aid. (1 point)

What would your approach be toward hearing aid orientation for Mr. Gandalf Grey and his daughter? (Discuss how much information you would share and when). (2 points)

Mr. Gandalf Grey is interested in pursuing amplification. He has heard about some research about a low cost option, something similar to hearing aids. What is he talking about? How would answer his questions based on EBP? (2 points)

What other technology you might consider for Mr. Gandalf Grey in addition to hearing aid use? Why? (1 point)

In sharing information to Mr. Gandalf Grey, you may want to provide some counseling to his daughter as well (or any other family member who attends his appointments with him). What are Grice’s maxim’s of conversation? Why are they important to share?(2 points)

Case 2.

How would you explain Peregrin’s results to his mother who is accompanying him? (1 point)

What might you suspect is going on with Peregrin, if it is indeed an audiologic issue? (1 point)

Would you recommend a hearing aid or ALD for Peregrin? Why? (2 points)

How would this change if Peregrin was not 10 years of age but 6 years of age? Why? (2 points)

Case Study 2: SPPA 325 Spring 19
Name: Wilson.S
Section:002
The case study is worth 10% of
your final grade.
Case 1.
Mr. Gandalf Grey is 82 years old and has arrived for an audiological appointment
with you. You are working on a case history intake and he points to his ear and
tells you, “I can’t hear anything anymore.” While you are testing him, you give
him a break while you clean up the results to start counseling. He looks at you and
says,” no one wants to talk to a dumb old man anymore.” His audiogram is shown
above. His speech understanding at PBmax is 72% for the right ear and 60% for the
left ear.
Mr. Gandalf Grey was accompanied by his daughter who thinks a hearing aid
would benefit him greatly in his daily living. She is concerned about his quality of
life and the frustration he has been demonstrating with unsuccessful
communication. He would be a first-time hearing aid wearer. He has some
dexterity issues. He has been isolating himself more and more from social
activities. They have a large family and he is often in group settings, out to dinner,
attending his grandchildren’s events. He used to be extremely active with his
church community.
1. How would you explain Mr. Gandalf Grey’s audiogram? (1 points)
2. Mr. Gandalf Grey is interested in pursuing amplification. Based on the case
history you have in front of you, suggest a possible hearing aid style for him.
Explain why you suggested that hearing aid. (1 point)
3. What would your approach be toward hearing aid orientation for Mr.
Gandalf Grey and his daughter? (Discuss how much information you would
share and when). (2 points)
4. Mr. Gandalf Grey is interested in pursuing amplification. He has heard about
some research about a low cost option, something similar to hearing aids.
What is he talking about? How would answer his questions based on EBP?
(2 points)
5. What other technology you might consider for Mr. Gandalf Grey in addition
to hearing aid use? Why? (1 point)
6. In sharing information to Mr. Gandalf Grey, you may want to provide some
counseling to his daughter as well (or any other family member who attends
his appointments with him). What are Grice’s maxim’s of conversation?
Why are they important to share? (2 points)
7. What are some “non-technological” recommendations you might make to
Mr. Gandalf Grey? (1 point)
Case 2.
The audiogram above is for Peregrin Took who is 10 years of age. Peregrin’s
classroom teacher complains that he is easily distracted in class, and does not
follow oral instructions. Peregrin’s mother reported that Peregrin appears very tired
by the end of the day, when he returns home from school. She added that he says,
“huh” all the time, especially when he is watching TV or playing with his siblings.
Peregrin passed his newborn hearing screening, as well as every other school
hearing screening conducted thus far. His mother is very concerned since his
schoolwork is suffering. Based on recommendations from the school psychologist,
Peregrin has been tested for ADHD, and his scores on the ACPT (the test
conducted for ADHD) were well within the acceptable limits. He has no other
known medical history or behavioral issues. He has been referred for an audiology
appointment now, but his mother is skeptical. “After all, he has passed every
hearing test so far!” she said to the audiologist at the beginning of the appointment.
1. How would you explain Peregrin’s results to his mother who is
accompanying him? (1 point)
2. What might you suspect is going on with Peregrin, if it is indeed an
audiologic issue? (1 point)
3. What clues from the audiogram and Peregrin’s behavior lead you to this
conclusion? (2 points)
4. Would you recommend a hearing aid or ALD for Peregrin? Why? (2 points)
5. Name 4 accommodation strategies that can be employed by the teacher in
the classroom to optimize Peregrin’s performance. (2 points)
6. How would this change if Peregrin was not 10 years of age but 6 years of
age? Why? (2 points)
4/24/2019
Detection and Confirmation of
Hearing Loss in Children
Aural Rehabilitation for infants,
toddlers, and school-age children
Spring 2019
SPPA 325
Nirmal Srinivasan, Ph.D.
SNHL in pediatric population
SNHL most common birth defect in US
3/1000 babies have significant HL when born (NIH 2013; White 1996)
Increases to 6/1000 by the time they begin school (ASHA, 2013)
• Pre-lingual hearing loss
• Birth to three years of age critical speech and language development
• If a child with significant hearing loss receives intervention early on
—> much better chance of developing communication skills
Detection of HL
Universal Newborn Hearing Screening (UNHS)
1999: federal Newborn Infant Hearing Screening and Intervention Act to
develop screening and intervention services
2007: > 40 states & DC enact legislation requiring newborn screening
(Centers for Disease Control and Prevention, 2007)
About 95% of babies in the United States are screened before going home
from the newborn nursery (White et al, 2010)
Today:
Every state and territory in the United States has now established an Early
Hearing Detection and Intervention (EHDI) program
Every child born with a permanent hearing loss is identified before 3
months of age and provided with timely and appropriate intervention
services before 6 months of age.
1
4/24/2019
Research supporting UNHS
• When hearing loss identified by six
months or age or younger, the prognosis
for good language, speech, and socialemotional skills improves greatly
• Better language means less parental stress
• Language similar to the child’s
nonverbal cognitive development
• Language development
• Low to average as compared to children with
normal hearing through five years of age
What happens when infant…
Passes
Fails/Refer to
• Monitor hearing and language
milestones
• Audiological assessment
• Consideration of risk factors
• Otolaryngological examination
Risk Factors for HL (Joint Commission on Infant
Hearing (JCIH), 1994)
Low birth weight (less than 3.3 lbs)
Family history of HL
In utero infections such as
cytomegalovirus (20-30% of
childhood hearing loss), rubella, or
herpes
Ototoxic medications
Low Apgar scores
Need for use of a ventilator for 5 days
or longer
Craniofacial anomalies
Bacterial meningitis
Hyperbilirubinemia (severe
jaundice) at levels that require an
ex-change transfusion
APGAR (Appearance, Pulse, Grimace, Activity, Respiration) is a quick test performed on a baby at 1 and 5 minutes after birth. The 1minute score determines how well the baby tolerated the birthing process. The 5-minute score tells the doctor how well the baby is doing
outside the mother’s womb. The test may rarely be done 10 minutes after birth.
2
4/24/2019
Hearing test
• Method dependent on child’s age
• Follow-up testing two to four times per year
• Audiologist counsels parents about test results
• Provide opportunity to ask questions
• Establish follow-up schedule
Screening is designed to detect hearing loss of 30 to 40 dB HL
in the frequency region of about 500 to 4,000 Hz
Baby “passes” test
HL not suspected presently
Even if a baby passes the newborn screening test, a speech and
hearing professional might want to alert parents to watch for the telltale signs of HL
Monitor speech and hearing “milestones”
especially if risk factors are present!
Delayed onset HL
If risk factors present, retest at age 6m & every 6m until age 3 years
(JCIH 2000)
Baby “refers” on test
HL suspected
Follow-up evaluation ASAP
Complete audiological & medical examination
JCIH (2000): 1-3-6 guideline
Screen by 1 month
Confirm presence of HL by 3 months
(Re)habilitation services to be provided by 6 months
3
4/24/2019
Objective Tests to Confirm HL
• Auditory brainstem response (ABR)
• Otoacoustic emissions (OAE)
Auditory brainstem response (ABR)
• Most comprehensive test for identifying infants
• Birth through five months of age
• Electrophysiological
• Elicit brainwave activity
• Performed on sleeping child
• Measured in terms of latency
• Wave V correlates to 1500 to 4000 Hz
Otoacoustic emissions (OAE)
•
•
•
•
•
Spontaneously emitted sound
Screen for newborns other than audiologist
Pass/Refer
Tests 2000, 3000, 4000, and 5000 Hz
Record OAEs for hearing better than 30 to 40 dB
Distortion Product OAE (DPOAE)
Acoustic energy created by stimulating the ear with two
simultaneous pure tones (f1 and f2) which results in energy
created at several frequencies that are combinations of the two
pure tones. DPOAEs entail the measurement of 2f1-f2
Transient Evoked OAE (TEOAE)
Means to access the integrity and function of outer hair cells by
presenting brief clicks
Low level acoustic response emitted by cochlea is measured
4
4/24/2019
Behavioral Tests to Confirm HL
Behavioral/Observational Audiometry (BOA)
Visual Reinforcement Audiometry (VRA)
Conditioned Play Audiometry (CPA)
Standard Audiometry
Behavioral observation audiometry (BOA)
• Audiologist presents a stimulus
and then observes child’s responses
•
•
•
•
Infants 0-3 months
Does not test hearing thresholds
Responses vary among babies
Habituation to sound can be problematic
during BOA
• Can reliably only eliminate the possibility of
profound hearing loss
Visual reinforcement audiometry (VRA)
• A method of audiometric testing for young children that entails providing an
acoustic signal and reinforcing a head turn with a light stimulus or an activated
and illuminated toy reinforcement.
• Child is tested in a soundbooth and stimuli are presented via an audiometer
• Six months to two and one-half years of age
• Child is conditioned to look towards a lit box that has a moving toy (e.g., monkey with
cymbals) or at a video stimulus, taking advantage of a child’s natural tendency to look
towards sound and to seek positive reinforcement
• Able to obtain individual ear information
• Based on operant-conditioned response
• https://www.youtube.com/watch?v=BB8dnQbFnTo
5
4/24/2019
Conditioned play audiometry (CPA)
• Method of testing children 2 ½ years and older in which the child is trained to
perform a task in response to presentation of a sound
• Audiologist presents sound via an audiometer to a child who is in a soundbooth
• “Wait and listen” behavior
• Use familiar toys
• E.g., puzzles, blocks
• Can also use for speech testing
• https://www.youtube.com/watch?v=LPywSJQ-D1E
Health care follow up
If HL identified, child referred to other health care professionals
and/or for additional audiological testing to
Determine etiology
Determine whether additional concerns are present besides hearing loss
6
4/24/2019
Causes of hearing loss in children
Idiopathic (25%)
Arises suddenly and the cause
is unknown
Non-genetic (25%)
Prenatal, perinatal or postnatal
Genetic (50%)
Syndromic (30%)
Non-syndromic (70%)
Prenatal
Occurs before birth
Perinatal
Occurs at birth
Postnatal
Occurs after birth
Prenatal – Before birth
Intrauterine infections,
including rubella,
cytomegalovirus, and
herpes simplex virus
Rh incompatibility
Prematurity
Maternal diabetes
Parental radiation
Toxemia
Perinatal – During birth
Anoxia
which may be caused by a prolapse of the umbilical cord and a subsequent blockage of
blood to the infant’s brain
Although rare, the use of forceps during birth may
cause damage to the cochlea
Postnatal – After birth
Infections such as:
Meningitis, measles, encephalitis, chicken pox, influenza, and mumps
A condition in pregnancy, also known as preeclampsia (or preeclampsia) characterized by
abrupt hypertension (a sharp rise in blood
pressure), albuminuria (leakage of large
amounts of the protein albumin into the urine)
and edema (swelling) of the hands, feet, and
face.
Syphilis
Use of ototoxic drugs
25% of bilateral childhood HL is postnatal
(Weichbold, Nekahm-Heis, & Weizl-Mueller,
2007): good motivation for continued surveillance
of children after they leave the newborn nursery,
particularly those at risk for HL.
Genetic HL
Mode of inheritance
Autosomal dominant
Most of them are part of a syndrome
Requires one parent to have the affected gene
Waardenburg Syndrome (WS) – varying degrees of SNHL, pigmenraty discolorations of the skin,
white forelock in the hair, tow irises of the eyes being different color.
Autosomal recessive
Requires both parents to have the affected gene
Usher Syndrome may be born with normal hearing or a degree of SNHL and experience progressive
HL as they age, develop retinitis pigmentosa
X-linked
Genes carried on the X chromosome, or the sex chromosome
Alport Syndrome
progressive SNHL, renal disease, and ophthalmologic involvement. HL usually
manifests in the second decade of life.
Syndromic: presence of associated findings
HL as a result of a single cause and institute a distinct clinical entity
Non-syndromic: no other associated findings
Table 12-3 has examples of other syndromes that may affect hearing
7
4/24/2019
Conductive & Mixed Losses
otitis media: inflammation of ME, often associated with fluid buildup
Other causes anomalies of the external ear canal (such as atresia),
tympanic membrane or ossicles, and congenital cholesteatoma
fluid may or may not be contaminated with infection
mild or moderate conductive hearing loss, particularly in the low
frequencies
can accentuate the amount of HL in the presence of an existing
sensorineural loss
Risk factors for Otitis Media
• Between the ages 6 and 24 months
• Eustachian tube malfunction of anomaly (e.g., as might occur with
Down Syndrome)
• Impaired immunologic status (e.g., AIDS)
• Male
• Bottle fed as opposed to breast fed
• Native American
• Placement in a daycare center
• Poverty status
Symptoms of Otitis Media
• Inattentiveness
• Reduced ability to discriminate speech
• Wanting the television turned up more loudly than usual
• Hands pulling the ear lobes
• Undue fatigue
8
4/24/2019
Conductive & Mixed Losses
Academic performance may suffer in the early grades if children
with otherwise normal hearing suffer from chronic otitis media
(Golz, Netzer, & Westerman, 2005)
Otitis media in the early years puts children at risk for reduced
consonant inventories, delayed babbling, and smaller expressive and
receptive vocabularies, although these effects may disappear if the
otitis media is resolved (see Shriberg et al., 2000)
Other Health Related Issues
Nearly 40% of children with hearing loss suffer another disability
Intellectual disability
Cognitive delays
learning disabilities
Behavioral or psychiatric disorders
Attention deficit disorder
Renal disease
Cerebral palsy
Autism
Table 12-4 has more conditions that may co-occur with hearing loss
Other Hearing Related Concerns
CAPD (Central Auditory Processing Disorder)
Auditory Neuropathy Synchrony Disorder (ANSD)
Tinnitus
9
4/24/2019
CAPD
• Central cause
• Not peripheral hearing loss
• Transmission of signal from brainstem to cerebrum is impaired
• Causes
• Known Head trauma, neuromaturational delays in the CANS, degenerative diseases (e.g., MS),
exposure to neurotoxic substances, seizure disorders (e.g., Landau Kleffner syndrome), brain tumors, or
autism
• or may not know cause
• Difficult to diagnose
• Child will have difficulty with:
•
•
•
•
•
•
•
•
Localizing sound
Auditory discrimination
Recognizing auditory pattern
Associating meaning to sound
Listening in noise
Understanding distorted signal
Music rhythm and melody
Auditory memory
Behaviors and Characteristics of patients with APD
• Says “huh” or “what” a lot
• Trouble listening in noise
• Responds inappropriately in the classroom
• Reluctant to participate in class discussions
• Difficulty following multi-step directions (poor auditory memory)
• Seems to have a hearing loss but audiograms are normal
• Teacher concern about hearing and listening abilities
• Poor reading and spelling skills
• Fatigue – noted in heavy listening environments (school)
James W. Hall, Introduction to Audiology Today (2014)
ASHA (1996, 2005) recommends that APD diagnosis should
be based on a number of indices:
• history (family history, speech & language…)
• systematic observation of auditory behavior using questionnaires
or checklists
• audiological test procedures including pure tone, speech and
immittance audiometry
• speech-language pathology assessment
• a range of tests of central auditory function
10
4/24/2019
Some of the many variables potentially confounding
an accurate diagnosis
Issues to be addressed before Clinical Assessment
• Children under the age of 7 years
• Children with English as a second language
• Children with low cognitive intelligence
• Children with language disorders
ANSD
• Affects peripheral auditory system
• Usually mild to moderate hearing loss
• Present OAEs
• Abnormal or absent ABR
• Poor word recognition, poorer than that which would be predicted by
their audiological thresholds
• Most likely cause either impaired inner hair cell functioning or faulty
connections to the auditory nerve
• Sometimes associated with
• Jaundice, premature birth, anoxia at birth, and family genetics (CharcotMatieoTooth syndrome and Friedreich’s ataxia)
Parent Counseling
Between 90 and 95% of children who have a
severe or profound SNHL have NH parents
(Northern & Downs, 1991)
much to learn about HL & AR!
• A family-centered approach
• Family systems theory recognizes that people do
not live in a vacuum. A family consists of
interdependent individuals, none of whom can be
understood in isolation from the family system.
An apt analogy is a mobile: If you move one
component of the system, the rest of the system is
affected. If homeostasis occurs, all components
come to rest.
• Parents
• Siblings
• Extended family
11
4/24/2019
Sequential stage model of grieving
• Shock and denial
• Guilt
• Bargaining
• Anger
• Depression and/or detachment
• Acceptance (the work begins)
Circular pathways models of grieving
• Includes many sequential stage reactions.
• Grieving experience as an enduring cyclical
process.
• Positive pathway: incorporate hope, take on
future with optimism.
• Negative pathway: regularly lapsing into
despair or anger, protest.
Infants and Toddlers
12
4/24/2019
Introduction
• When a child is diagnosed with a hearing loss, an aural rehabilitation
plan should be put into place, with a goal of early intervention
• Goals of early intervention:
• Enhancing development
• Minimizing possibility of developmental delay
• Enhancing accommodation of child’s needs
The Individualized Family Service Plan (IFSP)
An Individualized Family Service Plan is a federally mandated plan
for children age birth to 3 years that ensures appropriate earlyintervention services for infants and toddlers and their families.
The plan should take into account a child’s current level of
development, the family’s resources and priorities, goals and services
necessary for achieving the goals, and a time course.
Plan is for entire family, with parents playing an active role in
development
IFSP development
• A written document developed by a team, including the family, that:
• Summarizes the child’s present levels of physical, cognitive, communication, social,
emotional, and adaptive development, based on objective criteria
• Identifies family’s resources, priorities, and concerns related to enhancing the child’s
development
• Specifies major outcomes expected and the criteria, procedures and timelines to be used in
monitoring progress
• Describes early-intervention programs and services necessary to meet needs and
objectives
• Specifies dates for initiation of services and the anticipated duration of services
13
4/24/2019
Communication Mode
• Modes include:
•
•
•
•
Spoken language
Manually coded English
Sign of the Deaf Community
Cued Speech
(Gallaudet Research Institute, 2011)
Communication Mode – ASL
Manual system of communication
Different grammar than spoken English.
One ASL sign might represent a concept that would require many English words
to express.
Facial expressions and body language can impart a variety of meanings to the
signs.
Manual system of communication expressed by the hands through:
Configuration
Orientation
Location in space
Movement
14
4/24/2019
Communication Mode: Manually coded English
• Comprised of manual signs
corresponding to the words of
English, sharing syntactic
structures.
• Person speaks simultaneously
while signing.
• Called Total Communication,
the child uses every available
means to receive a message,
including sign, residual
hearing, and lipreading.
• Can fingerspell those words
that do not have a sign
Communication Mode: Aural/Oral
• Same language used by those with normal hearing
• Child will speak messages and use speechreading to receive
messages
• Children using a multisensory approach use both vision and
hearing to recognize speech
• In small pockets, a unisensory approach is advocated, where
reliance on the visual speech signal is not encouraged
Communication Mode: Cued Speech
• Uses phonemically-based hand
gestures to supplement
speechreading.
• Talker speaks while cueing the
message.
• Individually, the hand signals are
uninterpretable. They are used to
distinguish viseme members.
• Has been adapted to more than
60 languages.
15
4/24/2019
Selecting a Communication Mode
no definitive answers as to the best way to go
it is likely that the best route is different for different children
Markides (1988) found that children from an aural/oral-emphasis education
program were more likely to achieve better speech intelligibility than children
from total-communication programs, and their speech intelligibility was less
likely to deteriorate over time.
Dornan et al. (2008) found that a group of 29 children who have severe and
profound hearing losses, and who were between the ages of 2 and 6 years at
the time of their study, showed the same amount of progress in their speech
and language skills over the course of 9 months as NH children
incorporating aural and oral provided better speech intelligibility abilities and
if aural information was utilized at an early age, S/L skills were progressing
just like a normal hearing child
Listening Device
The goal of providing a listening device is to provide the infant or
toddler with maximum access to the speech signal at a listening level
that is safe and comfortable
• Amplification
• Hearing aids received as early as four weeks of age
• Even children ideal for cochlear implants must first undergo a trial period with
a hearing aid.
• The five steps of the amplification process are selection, verification,
orientation, validation, and follow-up.
Listening device — Cochlear Implants
• FDA guidelines endorse for children as young as 12 months (profound
hearing loss) and children 18-plus months (severe to profound hearing loss).
• Candidacy is determined by hearing loss degree.
• Stages: initial contact, counseling, formal evaluation, surgery, fitting,
follow-up, and aural rehabilitation
16
4/24/2019
Early-intervention program
• Ideally begins as soon as the permanent hearing loss is confirmed and
includes receipt of a listening aid
• Families may receive a list of all of the available programs in the
geographic area and/or be referred to a statewide early-intervention
system.
• Options will vary.
Types of Early intervention programs
• Center-based program: children attend weekly therapy for a set
number of hours.
• Home-based programs: early-intervention specialist visits the infant’s
home and provides instruction to the parents and child.
Parental support
• Parental instruction can create a dual benefit:
• It may promote the child’s development.
• It may promote the parent’s sense of self-efficacy and increase family wellbeing.
• The intervention team will provide parental support throughout early
intervention.
• Informal Instruction
• Provided, irregularly, as clinicians observe parent-child interactions.
• Clinician should be tactful, provide respect for parents, and avoid being
overly negative.
• Formal Instruction
• Might follow specific stages of didactic instruction, guided learning, and
real-world practice.
17
4/24/2019
Four design principles of Auditory Training (AT)
Auditory Skill Levels:
• Sound awareness (not for speechreading training)
•
play peek-a-boo; play musical chairs’ march to the beat of a
drum
• Sound discrimination
•
Play a game with toy animals – cow says “moo” sheep says
“baa”; Play a same or different game (“boy boy” vs “boy
toy”
• Identification
•
Play the game Candyland and listen for the names of the
colors; Play Go Fish (give me your sevens” give me your
twos”)
• Comprehension
•
Listen to a read-aloud story; Play I Spy
Page 403 – 406 has examples of formal and informal training programs
School-Age Children
Introduction
• Preschool begins at three-to-four years of
age for children with hearing loss.
• At preschool, child:
• Likely used a listening device
• Typically had early intervention service
18
4/24/2019
School-age population
• Develop the following items:
• Multidisciplinary team: a group of professionals with different expertise who
contribute to the assessment, intervention, and management of a child (e.g.,
audiologist, speech-language pathologist, classroom teacher, psychologist)
• Education plan
• Aural rehabilitation intervention strategy
Creation of an Individualized Education Plan (IEP)
Creation of an Individualized Education Plan (IEP)
• IEP’s include (cont.):
•
•
•
•
•
•
Anticipated duration of services
Criteria to determine if objectives are achieved
Procedures to determine if objectives achieved
Schedules for review
Assessment information
Placement justification statement
19
4/24/2019
Example: Present level of academic performance
• Froddo is a curious boy who enjoys variety
• Grades range from B’s to C’s
• Responds well to visual aids, hands-on activities, and novelty
• Experiences moderate difficulty in working independently, and often requires
teacher encouragement to complete an assignment
• Recognizes common words during reading class and is performing just below
grade level on reading comprehension tests
• Enjoys listening to stories and appears to have good auditory comprehension
with the use of his cochlear implant
• Math is his strength, and he is able to add and subtract 3- and 4-digit numbers
20
4/24/2019
The multidisciplinary team
• All professionals providing expertise to IEP conduct evaluation,
intervention, and management
• Professionals include:
• Audiologist
• Speech-language pathologist
• School personnel, including teacher, itinerate teacher, psychologist, resource
room teacher
• Parents
The audiologist
• Roles
•
•
•
•
•
•
•
Test hearing and speech
Maintain listening device and ALDs
Assess central auditory function
Assess classroom acoustics and make recommendations
Provide auditory and speechreading training
Consultation
Possibly, sign language instruction
The speech-language pathologist
• Roles
• Assessment speech, language, literacy, and speechreading skills
• Possess knowledge of listening devices and ALDs
• Provide direct speech-language and speech perception therapy, and auditory
training
• Consultation with parents
• Possibly, sign language instruction
21
4/24/2019
The classroom teacher
• Roles
• Provide academic instruction
• Provide assessment and diagnosis
• May or may not possess
experience or a background in deaf
education
• Make modifications to regular
education curricula
• Manage learning environment
• Manage student behavior and
social skills
The psychologist
• Roles
• Implement psychoeducational assessment
• Assess intelligence
• Verbal and nonverbal skills
• Written language, reading, and arithmetic skills
• Visual-motor, memory, and multimodal integration
• Social-emotional, attention, and behavior skills
The interpreter
• Roles
• Provides preferred mode of communication
• Serves as member of multidisciplinary team
• Enhances communication and social interactions
22
4/24/2019
The itinerant teacher
• Roles
• One-on-one instruction
• Supplements classroom instruction
• Provides pre-teaching
IEP Goals
• IEP goals must adhere to DARTS:
• Demonstrable or Measurable
• Achievable
• Realistic
• Time-related
• Specific
School and classroom placement
• School placement:
• Options include:
• Public
• Private
• Day
• Classroom placement
• Can be:
• Self-contained
• Mainstream
• Mixed
23
4/24/2019
Determining classroom placement
Appropriate Format Accomodations
•
•
•
•
•
•
•
•
•
•
•
Abbreviated assignments
Alternative test format
Content enhancement and reduction
Copies of class notes
Extra credit
Flexible scheduling
interpteter
Language simplification
Modified grading
Paraphrasing
Study guides
Amplification and Assistive Listening Devices
• FM devices are typical in classroom settings
•
•
•
•
•
Personal microphones (teacher only)
Environmental microphones (whole classroom)
In personal set-up, teacher wears microphone
Student wears receiver
Audiologist serves as resource for teacher to ensure comfort with system
24
4/24/2019
Classroom acoustics
• Background noise
muffles and distorts
speech
• Reverberation
• Signal reflected from
walls, floor, or ceiling
• Impacts speech
recognition
• Magnifies noise
• Strategies for reducing
classroom noise
• Carpeting
• Rubber tips on chair and
desk legs
• Acoustical panels,
flannel, etc. on walls
• Window treatments
• HVAC modifications
• Reduced overall room
size
• Low ceilings
Other services
• Other services could include:
•
•
•
•
Class in-service
School in-service
Psychosocial support
Communication strategies training for both parent and child
Classroom in-service
• Content may include:
•
•
•
•
The sense of hearing
Anatomy of the ear (with a model)
How to talk so you are easy to understand
Hearing aids (cochlear implants) and assistive listening technology
• Activity: How speech sounds with a hearing loss
• Activity: Simple signs; e.g., “turtle”, “fish”, “elephant”, the manual alphabet
25
4/24/2019
School in-service
• Content may include:
•
•
•
•
•
•
Hearing loss levels
Implications for academic achievement
Social-emotional impact of hearing loss
Hearing aids (cochlear implants) and assistive technology
Visual aids and note-taking
Communication strategies (e.g., importance of speaking with clear speech and
expressive facial and body gestures)
• Importance of ensuring that the student understands what is being taught and is
included in all classroom activities
• Appropriate format accommodations
Mental health and psychosocial support
• Children with significant hearing loss may have a
higher likelihood of psychosocial problems than
those with normal hearing
• Lower levels of self-perceived social acceptance
• Fewer close friendships
• Impaired ego development
• There are several check-lists available to examine
children in terms of social skills (e.g.,
“Demonstrates pride and confidence in their skills
and accomplishments”; “Respects others’ opinions
and points of view, even if different from their
own”)
Communication strategies training for parents
• Parents often do not possess detailed knowledge of communication
strategies, even though they live with their child
• Parents might receive instruction on the optimal ways to repair
communication breakdowns when they are the talker, using expressive
repair strategies such as rephrasing, simplifying, elaborating, and
building-from-the-known
26
4/24/2019
Receptive repair strategies
• Ask children to repeat the message
• Encourage them to provide more information (Tell me more . . .)
• Restate what they might have said (I think you said . . .)
• Ask them to alter the delivery of their messages (Slow down a little . . .)
• Go with the flow, in the hopes that you will eventually understand (How
about that ! I see and then what happened . . . ? )
Communication strategies training for children
• Children with hearing loss also
may benefit from communication
strategies training.
• Training is typically taught to
children in the higher grades of
elementary school or in junior
high school or high school
• Similar model as for adults:
Formal instruction (e.g., watch the
talker’s face, identify key points) ,
guided learning (role-playing in
class), real-world practice (asking
school secretary for supplies)
Children who have mild or moderate hearing
loss or unilateral hearing loss
• May have difficulty listening in noisy and reverberant classrooms
• May miss out on incidental learning when good ear is turned away
• May exhibit inattentive listening and may be accused of “selective
listening”
• May fatigue more quickly
• May have academic delay
• May be at risk for language delay and mild articulation errors
• Will benefit from favorable seating
• May benefit from amplification and a soundfield FM system
27
4/24/2019
Incidence and services
Unilateral Hearing Loss
• One in 40 children
• May not receive an IEP
• Only about half try some form
of amplification or FM system
• Higher likelihood of receiving
speech-language therapy and
special education
• Higher incidence of behavioral
problems
Mild Hearing Loss
• About 15% of children in
the USA
• Thanks to newborn
screening, they are being
identified at an earlier age
than previous decades
• Many receive hearing aids
• Many receive an IEP
Final remarks
• An Individualized Education
Plan (IEP) must be flexible and
be updated on a regular basis
according to the child’s progress
• Many times parents must serve
as advocates for their child and
lobby for services
28
4/15/2019
Aural Rehabilitation for the
Elderly / Adults
Spring 2019
SPPA 325
Nirmal Srinivasan, Ph.D.
Outline
• Myths about ageism
• Designing AR Plan
• Adaptations required during audiologic testing
• Overall health changes
• Impact of hearing loss on AR
• Outcomes Assessment
The Aging Society
Elderly represent fastest growing segment in American society
Presently, 12% of the population > 65 years
Balloon to 20 % in 2030
In the US, more persons > 65 than < 25 years of age Implication of these numbers for aural rehab? Increased case load for audiologists/SLPs 1 4/15/2019 Counties With the Largest, Smallest Shares of Seniors (65+) https://www.pewresearch.org Sixty Five Plus in the United States https://www.seniorcare.com/featured/aging-america/ Myths of Age-ism • How do we describe the elderly? • Aging Stereotypes Aren’t a Punchline • https://www.youtube.com/watch?v=xz6Sk3KjQbY • Millennials Show Us What ‘Old’ Looks Like • https://www.youtube.com/watch?v=lYdNjrUs4NM 2 4/15/2019 Myths of Ageism • Senility/poor memory • Rigid, can’t learn new things • Not as smart • Frail and sick • Poor • Unproductive • Depressed and lonely • Dependent on others Shenk, H. & J. Dancer (2006). Mythical Battles in Audiology: Part IV: Ageism and Stereotypes of Aging. Advance for Speech-Language Pathologists Audiologists, What’s the big deal? • Baby Boomers • 1946-1964 • Retiring currently • Largest volume of elderly in U.S to date 82% belong to at least one social media site, with Facebook being the most popular and Twitter and Instagram much less so 13% use LinkedIn, about the same rate as adults who are between the ages of 18 and 29 They are 19% more likely to share content with others than is any other age demographic They tend to take action based on what they learn from social media, often seeking more information They spend more time online than millennials and out- spend them online by 2:1 They own 40% of Apple products • From 2010-2030, the baby boomers are retiring • this will be the largest volume of elderly people this country has EVER seen • concern is that there aren’t enough practitioners/money/infrastructure to handle it well Immersion Active, 2017; Liquid Lock Media, 2017 Peripheral Presbycusis A global term used to refer to hearing loss associated with the aging process Does not refer to a single pathology but is typically diagnosed when an older person presents a high-frequency hearing loss To date, no medical treatments exist to reverse age-related hearing loss, other than cochlear implants Physiologic causes Neural loss of sensory cells and supporting cells, nerve fibers, and neural tissue Metabolic or Strial a change in the blood supply to the cochlea 3 4/15/2019 Peripheral Presbycusis • Loss increases with age • Sloping, high frequency loss • Affects 30% over 65 years of age • Affects 50% between 75 to 79 years of age • Males suffer greater loss than females • Speech recognition abilities decline • Background noise further decreases speech recognition, more so than for young adults Average audiograms for groups of females (n = 1,358) and males (n = 935) at half-decade intervals between the ages of 60 and 84 years. Modeled after Mills et al. (2006, p. 16) Consequences • If left untreated, presbycusis can affect overall quality of life • Negative emotional consequences, including an increase in negative feelings, such as depression, paranoia, hopelessness, and grief • Negative social consequences, including an avoidance of social activities and stigmatization by others and self • Cognitive decline Central Presbycusis Who and when 12% of people over the age of 74 years What Hearing loss characterized by normal thresholds (