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How can providers Collaborate to Optimize Outcomes for Children who are hard of Hearing

Consistency of auditory success
Early Intervention Services

Universal born Hearing Screening

98% of children born in US get this, other 2% are home births
Before this HL was diagnosed between 2-5
At the beginning it wasn't thought of as cost effective

Birth-3 Early Childhood Education Programs

Designed to address HL and help children with better outcomes in general education program

Outcomes of Children with Hearing Loss

Want to know about services provided to children who are hard of hearing
Only had this one disability

Data Collection and management

Family Interview
Audiology Service provider Survey
Services and Provider Survey

Professional Development with OCHL

61% had continuing education
A wide range of a one day seminar to university courses
English is primary language
No secondary disability

Ling Six Sounds


Increase comfort levels with HA management for SLPs

Specific training programs
Continue education in uncomfortable areas
Ask Audiologist


Ling's 6 Sounds
Check Batteries
Do this daily

Educating Parents

Tell them to educate others in child's life about troubleshooting
Want parent to be knowledgeable on HA


Identify and fit amplification early
Use best practice for evaluations, verifications, fittings, etc
Monitor HA use with data logging and consistency rating

Collaborative Strategies to support HA use

Data logging and consistency ratings
Speech perception
Regular contact with service providers

What is Telepractice

Provision of a professional service over geographical distances by means of modern technology
Skype like service
Skype is NOT HIPAA complient

Increase in Telepractice

Further a child is from audiologist the longer the delay in getting HA and CI
Shortage of experienced individuals

Benefits of Teletherapy

Provides access to qualified providers
Decrease trvel constraints
Birth-3 services should be provided at home
Reduces number of cancellations
Increase of family centered coaching

Limitations of Teletherapy

Access to high speed internet and computer
Feeling comfortable with technology
Quiet environment at home
Access to materials

Preparing for Tele-therapy Sessions

Create listening environment
Select instructional material

Paradise's View on UNHS

Not the best
Not cost effective
Forced audiologists to identify the problem with identifying HL at birth and how to improve UNHS

Arguments Against UNHS

Most infants with SNHL are high-risk in NICU
False Positive could have negative impact on parent-infant bonding and long term psychosocial consequences
Insufficient facilities and professionals to provide follow-up care
Some HL are late-onset this gives parents false hope
Can deal with first 3 bottom still a problem

Increase in UNHS is Due To

Growing body of research supporting feasibility and efficacy
Increased Federal Funds
Technology Advances
False-Positive Rate is low

Objective Tests

0-6 months
Baby can lie there and do nothing

Visual Reinforcement Audiometry

6-24 Months
Behavioral Tests, kid turns their head to auditory stimulus
20-30 minutes
Assesses auditory perception
Via speakers better ear responds
Need motor skills to turn head

Conditioned Play Audiometry

24-60 months
Hear a beep drop a block
Make this FUN for children
20-30 minutes
Child conditioned to perform action in presence of stimuli
Ear specific and assesses auditory perception

Black Hole

about 18-24 months
No mans land
Kid to mature by VRA but to immature for CPA

Otoacoustic Emmisions

5 minute test
Measure OHC response to stimulus
Ear Specific
Have to be quiet for administration
May miss mild HL or auditory neruopathy

Auditory Brainstem Response (Brainstem Auditory Evoked Response)

15 minute test
Electrophysiologic measure of brainstem
Ear Specific
Patient needs to be quiet

OAE Procedure

Small probe containing sensitive microphone in EC
Probe presents stimulus and microphone detects response of OHC

ABR Procedure

Audiologist places 4-5 electrodes on infants head
Present different levels of sound
Electrical Activity of brain is recorded and represented as waveform
Look at Wave 5
Can be done with AC and BC


OAE first
ABR Second
Two ABR's is best

Behavioral Tests

Gold standard
Visual Response Audiometry
Conditioned Play Audiometry

Conventional Tests

4 years and above
30 minutes
Child instructed to raise hand
Ear Specific
Traditional Audiogram

SLPs Role

Develop listening skills
Practice developing a conditioned response


Children identified before 6 months have better language outcomes than children identified after 6 month

EHPI 1-3-6

1 month of age have hearing screening
3 months of age have HL confirmed
6 months of age begin early intervention

Between 3-6 months have HA fitted

OCHL and 1-3-6

32% met all benchmarks on time
Lowest area was 3 months where only 70% met that benchmark

Causes for Delay of HL Confirmation

Multiple ABRs
Recurrent middle ear infections
ABR was near normal

Reasons for Delay in UNHS Test

Multiple re screenings
Family chose to wait
Family assured that equipment wasn't working
Delayed because of ME problems

Causes for Delay in HA Fitting

HA not initially recommended
Difficulty obtaining clinic appointment for HA fitting
Family decided not to proceed with HA fitting right away

How are Delay's in 1-3-6 Addressed

Professional priorityfor children at "benchmark" appoinments
Education resource for professional and families
Follow-up incase of ME issue
Effects on mild HL or unaided HL on communication development
Communication between professionals about where family is on EDHI timeline
Support at risk families

Importance of Early Identification

Most common birth condition affecting development
3 in 1000 births
93% of children with HL are born into hearing families

Risk Factors of Congenital HL

Family History of HL
In utero Infection
Craneofacial Anomalies
Low birth weight
Ototoxic medicine
Low ApGAR scores
Extended NICU stay of greater than 5 days
Fungal Infection

Challenges in Screening

Standardized methodology, reporting system evaluation
Each state can't regulate another
Rural states vs urban states

Informal Assessment

Calculating MLU
Calculating TTR
Speech inventory (vowels and consonants)
Word Shapes
Voice; Sign Ratio
Sign Frequency/Depth Vocabulary
Turn Taking Skills

Formal Assessments

Auditory Access
Auditory Skills
Speech Production Repetoire
Language: Receptive and Expressive
Cognitive behavioral, emotional health statues

Communication Options

Critical Decision: "Cost" "Benefit"
May need to be flexible
More demand from families for oral/AVT
Consider what works for the family
You want FLUENCY

According to the Authors what is a Reason for limited collaboration between SLPs and AuDs

There is a limited number of educational audiologists in the US

In the survey, what was the most frequent response for how often SLPs performed HA listening checks for clients


According to IDEA How often should HA Checks be Performed


How SLPs feel for troubleshooting according to the survey


Which Type of Equipment were SLPs Least Confident Troubleshooting

Cochlear Implants

What was a limitation in the McCormick et al. Study

Low response rate may have resulted in an unrepresentative sample of school based SLPs

What percentage of SLPs do not have access to educational audiologists


What is a feasible option in improving collaboration between SLPs and AuDs according to McKormik et al

Joint participation on students IEP teams

What was the primary advantage of using Skype for telepractice services for the Sound Beginnings Program in Utah

Relatively stable audio and visual signs

Issues that may arise during telepractice sessions

Inconsistent bandwidth
Poor AV signal
Visual Glare or Darkness
Signal Interference

Utah Sound Beginnings Model for telepractice, one goal is that the service provider is the

Coach for the family during the intervention session

Benefits of Teleintervention

Parents take an active role in therapy
Fewer cancelations
Sessions can be recorded for other family member use

Limitations of Teleintervention

Technologic issues
Behavioral issues of the child

Why is the coaching process an integral component of the iHear Program

The coaching process encourage parents to be more involved in intervention which has a positive impact on child language development

Stedler-Brown reports that one of the challenges in implementing telepractice is that it is difficult to continue providing the services are initial grant funding runs out, what does she suggest as a way to sustain telepractice service

Engage multiple local, state, and federal agencies in continued funding

As of 2003 why was there little prospective research on outcomes of infants and toddlers with HL

Until around the 1990s the average age of identification of HL was 2 years

What areas of language development was significantly different between screened and no screened groups according to Yoshinga-Itano

Speech Production

In the section on cognition and language, the authors describe a seminal study by Yoshinaga what was the primary finding

Early identified children with additional disabilities had language outcomes that were similar to late-identified children with no disabilities

Advantages gained by early identified only occur in children who are exposed to an auditory-oral intervention approach


Majority of children in Holte et al met all 1-3-6 guidelines for kids who fail the UNHS

False, only about 1/3 met all guidelines

Which of the following makes it difficult to get families to follow up, after their child fails UNHS

They see their infant responding to sounds and think there isn't a problem with their hearing

Which of the following isn't a finding from Holte

Severity of HL affects timeliness of service delivery (Confirmation of HL, HA fitting, entry in early intervention)

Most common reason for delay in EDHI Process

Multiple rescreenings

Looking at maternal education level data in Table 2 of Fulcher, what generalization can you make about this particular sample of children with HL

It was an advantaged sample of children

Children in the Fulcher study who failed to attend therapy or didn't wear aids were excluded. What did the exclusion have with determining effects of auditory verbal therapy on language outcomes

Biases results in favor of AVT

Example of a non-malleable factor

Degree of HL

Results suggested that early-identified children with severe HL outperformed late-identified children with mild HL


Limitations of Fulcher Study

High maternal education level
EI Group had access to better technology

Josie, age 23 months, is beginning to combine words. She primarily uses phrases such as "big cookie" and "silly doggie" in her interactions at home. What type of semantic syntactic word classes has Josie mastered?

Attribute + Entity

For a young baby, according to Easterbrooks and Estes, the main brain task that is important is:


Jamal is a 15 month old with ly diagnosed severe to profound bilateral SNHL. You just saw him for an audiological appointment. During the evaluation, you heard him verbally producing: "ee", "uh oh", and "baba" for mama. You might expect him in a few months to produce which of the following first?

Different vowels and consonant strings
Conversational babble/jargon

LI children with HL

Slow mappers

Incidental learning is critical for generalizaiton and has greatest importance for school-aged children


A 3-4 year old child is responsive to a wide variety of sounds at approximately what sound level?

10 dB HL

Federal law requires an IFSP for infants and toddlers with disabilities. If you were working with a baby with hearing loss, which of the following information might be provided on the IFSP?

Assessments conducted with the child
Related services this child might qualify for
Transition Planning

One problem with born hearing screening not identifying children with true hearing losses may be:

born hearing screening may result in false negatives

born hearing screening identifies hearing loss in about how many out of every 1000 borns


JCIH guidelines has the intended goal of 1) identification of hearing loss and 2) initiation of services by what ages?

3 months, 6 months

"Finger to ear" cue might be useful to bring a baby's attention to an ambulance sound, or other environmental stimuli.


Nursery rhymes, fingerplays, and children's songs can be useful to teach vocabulary as well as the rhythm in the language on a receptive level. They are also useful expressively to aid the child in developing auditory closure abilities.


Jason, age 16 months, has been using his hearing aids since he was 8.5 months old. Which of the following listening tasks is he most likely engaged in?


Hallmark behaviors of preinflected stage include

Usage of 2-3 words without tense and number
Utilization of a pointing gesture
Increase usage of prominent intonational pattens by family members, teachers, and care givers

Mothers speak more slowly to their infants (motherese) because babies have shorter temporal resolution than older children and adults


Welcome to Holland

Get told you are going to Italy
You plan for this trip and places you will see
Plane actually takes you to Holland
People may be disappointed because they were expecting Italy and got Holland instead

Emily Perl Kingsley

Wrote for Sesame Street
Had a son with Down Syndrome
Introduced a disabled character to Sesame Street

Pre-Assessment of Children with HL

Key assumed knowledge: ND acquisition information relative to: Auditory status and abilities
Amplification type
Speech Development
Receptive and Expressive Language

Pre-Assessment ABCs

Appliances: HA, CI, Glasses, braces, etc
Behavior: Appropriate? Busy? Shy
Communication: Modality? Success?

Support: Who is supporting the child

Initial Diagnosis of Child

Not easy to test/quantify infants
Reacquires multiple testing and evaluations
Consistency in response is important
need to think of time of test is it normally feeding/nap time for child

Modality Issues

Receptive and Expressive modality needs to be clarified by examiner: Helps verify what the family wants
Clinician needs to support the decision they have made

What we know to be true about HL in children

Identify by 6 months of age:consistently outperform later identified children on measures of language severity of HL doesn't matter
Age of enrollment in interventions is significant predictor of vocabulary and verbal reasoning at age 5
According to Moeller before 11 months shows significant improvement in EI


What concern does the family have
How does it affect child's function
Are their other issues

Normal Developmental Model

Where does the child fall with Normal Hearing child at the same age

Discrepancy model

How far are they behind hearing peers

Transdisciplinary Model

Across many disciplines (motor skills, social skills, etc)
You aren't licensed to evaluate these

Educational Model

Where the child is compared to milestones

Medical Model

Hearing will not be restored
Work with all disabilities

An infants first smile occurs during 6 weeks when others talk to it


A 3 year old can catch a ball with their arm out straight


Joint referencing is developed at approximately age 3

False, it is developed earlier in ND children

First steps and words occur at 9 months

False, occur typically at 12 months

A 3 year old can build a 10 block tower


4 year olds can cut shapes with scissors

False, Fine motor skills are not that developed yet, maybe true for a child that signs

2 year olds can blow bubbles

False, They do not have the coordination or breath support

6 month old can anticipate the language and can respond appropriatly


Conversational Turn taking occurs at one year

False, it occurs at 6 months

5 year olds know their letters and are beginning to "read"


Looking at the whole child

Prevalence of additoinal disabilities with HL
No additional disability=60.1%
Intelectual Disability=9.8%
Learning disability=10.7%
Vision Impairment=3.9%
Emotional Disability=1/7%

Assessment Categories

Audiological Status
Auditory Skills
Speech production

Audiological Status

Verification of HL: Is there a change in the audiogram
Equipment: Major or minor changes

Auditory Skills

Different than audiologic information
Erber's Model

Erber's Model


Easier Auditory Variables

Closed Set
Small Set
Linguistic Complexity
Acousticaly Dissimilar
High Context
Positive SNR

More Complex Auditory Variables

Open Set
Large Set (5+)
Sentence Level/Conversation
Acoustically similar
Low context
Competing Stimuli

Speech Assessment Framework

Always bear in mind developmental expectations for speech as well as auditory perceptual abilities: Compare CI vs HA
Think of Speech Production

Speech Production


HH Child Speech Skills

Speech intelligibility is related to degree of hearing loss
More variable above 90 dB HL
Mild to moderate loss have similar problems to ND
Problems with low intensity high frequency sounds

Severe to Profound HL Speech Characteristics

Consider residual hearing, in general poorer hearing leads to less speech produciton
20% speech inteligibility

Suprasegmental Speech Characteristics

Speaking Rate
Breath Control
Voice Quality


Equal n word, inappropriate stress consider physical componants

Speaking Rate of HH person

Within word/ word pauses 1.5-2 times slower


Speaker with profound HL do not demonstrate this

Breath control

Poor breathing patterns, fewer syllables per breath, breathy voice

Voice Quality

Pitch variations/breaks
Cul De Sac resonances

Segmental Speech Characterisitcs

Vowel production errors
Consonant Production Errors

Vowel Production Errors


Consonant Errors

Voice/Voiceless confusion

Research has demonstrated that children with hearing loss who are implanted before five years of age have the potential for age-appropriate English language abilities.


When testing children with hearing loss, SLPs often have to supplement language testing with measures standardized on children with normal hearing.


Speech intelligibility is directly related to degree of hearing loss, and the greatest variability occurs for children whose hearing loss is at or exceeds 75 dB HL.


Carney showed in her research that the average speech intelligibility of children whose hearing loss falls in the severe to profound range can range from 0-100% but averages only 20%. Recent research (Chin and Kaiser, 2000) revealed that children with cochlear implants who are given the GFTA perform within normal limits when compared to hearing peers.


The auditory-oral approach and the auditory-verbal approach emphasize the use of sensory aids (as needed) and the role of parents in promoting learning at home.


In a bi-bi second language approach, English is developed as a second language via the written form and access to individuals with fluency in ASL in the DEAF culture is important.


Which of the following is TRUE regarding children with hearing impairment's early vocalizations?

Their canonical babbling is delayed in frequency and diversity

Libby, age 6, communicates via TC. Her mom wants you to assess Libby's receptive sign vocabulary. You decide to use which formal measure?

Carolina Picture Vocabulary Test

Jacob, age 3, has a mild sloping to moderately severe bilateral SN hearing loss. We might anticipate he would have trouble producing which of the following words?


Preschool children with hearing loss often struggle with mapping language into everyday routines. This can be due to

Limited schema about the event or routine
Less access to language of parents, siblings, and caregivers
Fewer incidental learning opportunities

A landmark study on language acquisition on preschoolers with hearing loss revealed which of the following as a surprise finding?

Late identification with normal cognition scored essentially equal to early identification with low cognition.

What are factors that have significantly changed the speech and language outcomes for children with hearing loss.

Early Identification
Increased Client Diversity

By what age does a typically developing child with normal hearing learn to discriminate the sounds of their native language?

6 months

Gregg, age 11, has a profound hearing loss and voicing problems when he talks. Name one perceptual problem we might hear in Gregg's speech attempts if he has sufficient vocal fold adduction.

Hypo/Hyper Nasality

Gregg, age 11, has a profound hearing loss and voicing problems when he talks. Name one perceptual problem we might hear in Gregg's speech attempts if he has insufficient vocal fold adduction.


The OCHL study is an epidemiological study conducted from three universities that hopes to inform practices that lead to differences in outcomes for children who are deaf.


Most students who are identified in school-aged hearing conservation programs demonstrate sensorineural hearing loss.


What is the recommended interval for assessing hearing in children aged birth to three years?

3 months

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