Other People’s Ideas
Calvin Staples, MSc, will be selecting some of the more interesting blogs from HearingHealthMatters.org which now has almost a half a million hits each month. This blog is the most well read and best respected in the hearing health care industry and Calvin will make a regular selection of some of the best entries for his column, Other People’s Ideas.
By the time this blog submission is read, the beautiful summer nights will be a distant memory. As the days become shorter and my kids check off their lists in preparation for another academic school year, I thought I would return to a previous blog topic; Hearing in the Classroom! For clinical audiologists, the start of school usually means a rush of children into our clinics for appointments for routine hearing tests, requested by teachers or parents concerned about the listening skills of the little ones, as well as hearing aid checks and repairs. I have recently wondered, are schools across the country requesting hearing tests for incoming kindergarten children? Maybe our readers could let us know? Enjoy the blogs!
As we keep saying, things keep changing (for the better) for children with hearing loss. As we keep saying, “It’s not the same old deafness.” Prior to the initiation of newborn hearing screening the age of identification of hearing loss in children was around two years of age. As a result, babies were not fit with hearing aids until well after their peers started to listen and talk. Now almost all babies are identified at birth and fit with hearing aids within a couple of months of age. Data from Tomblin, the LOCHI studies, and others indicates that fitting hearing aids early has a significant positive impact on outcomes.
Tomblin et al, Ear and Hearing 2015, did a longitudinal analysis of language abilities for children with hearing loss. They were trying to identify which factors influence language growth in children who are fit with hearing aids. They looked at whether speech was audible through the hearing aid and how many hours a day children wore their hearing aids. The study looked at several language abilities for both children with hearing loss and typical hearing peers.
What do we know?
The study showed that compared to children with typical hearing, children with hearing loss had poorer language abilities than their peers. And, as expected, the more severe the hearing loss, the greater the language delay. However, the most significant finding was that the amount of audible speech through hearing aids and how much the children used the hearing was critical. Children with better audibility had language 2/3 of a standard deviation above that of children with poor audibility.
Is speech audible?
Children with good audibility had significantly better language. This should be no surprise but it is a very important piece of information. What does this mean for clinicians? It means that we must be absolutely that the children we work with are hearing well enough.
How many hours a day do you need to hear?
Even with the best technology children with hearing loss will be missing some things. For them to successfully learn to listen, children need to hear all day long. Let’s remember that typical hearing children hear 24 hours a day. Children who use technology only 4 hours a day will take 6 years to hear what a typical hearing child hears in one year. So, we need to help families understand that full time use of technology is critical. In the Tomlin et al study, children who wore technology 10 hours/day had more positive language trajectories than children who wore technology less than 10 hours/day.
Why we need to hear soft speech
Much of the language kids learn (about 80%) they learn by overhearing conversation around them. This incidental learning will not be loud – it will be at a soft level. We need to be sure that our kids are hearing at soft levels if they are going to be able to take advantage of incidental learning.
How do you know if a child is hearing well?
It is critical that we start off using electroacoustic measures and are certain that children are reaching target gains with hearing aids. But that is not sufficient. How do we know that children are receiving enough auditory stimulation to develop the auditory brain and to hear soft speech? Only by testing!! In addition to real ear measures it is critical to obtain aided thresholds. WE NEED TO SEE AN AIDED AUDIOGRAM FOR EACH EAR SEPARATELY AND IT NEEDS TO BE AT THE LEVEL OF THE SPEECH STRING BEAN. If children are hearing at the string bean, they will hear normal conversation (at about 45-50 dB HL) and soft speech (at about 30-35 dB HL). They will still have some problems hearing in noise (as do typical hearing people I might point out) but if they can hear soft speech children have a very good possibility of hearing what they need to hear to develop language.
Take away message
The amount of audibility received from technology is a critical predictor of language ability. In addition, professionals can and should monitor the amount of hearing aid use. Parent report as well as technology monitoring can provide information to the audiologist who can then counsel families to help them understand why children need to have technology on their ears every waking hour and why it is critical that they return to the audiologist often to be sure that the technology is doing what it needs to do.
Explain the effects of hearing loss to teachers and other school staff
Most people think that once you fit a child with hearing aids the hearing loss should be cured. Hearing aids are not like eyeglasses. They help a lot but they do not solve all listening problems. Teachers need to understand that, even with the very best technology, children with hearing loss will have some problems in the classroom so it is essential that they do their best to maximize function. They need to understand the effects of distance and noise and they need to understand that they need to check that children are hearing all day long.
Children with hearing loss should be seated where they can both hear and see the teacher. But keep in mind they also need to see and hear their peers. For young children, during circle time, a seat in the middle is ideal. For older students, seating over to the side about 1/3 back from the front will allow them to scan the room and see who is talking in order to move focus. Students should be allowed to move about the room as the teacher moves, or as activities change.
At the start of the school day and, for young children, at least once again during the day, someone needs to check that all the technology is working. Children, especially young children, are not good reporters. They do not always know when the equipment is not working optimally. Check listening daily when the child can hear but not see the talker.
- Have the child repeat Ling sounds in random order:
- /ah/, /uu/, /eee/, /mmm/, /sh/, /ss/
- Say some individual words for the child to repeat
- Ask some questions that the child cannot anticipate. (What color shirt is John wearing?)
Make sure the teacher knows who to call if there is a problem.
Note: give the teacher a listening tube so the teacher can listen to hearing aids to see if they are working if the child does not hear. The problem may be just a dead battery.
Using a remote microphone
Children will hear best when they are close to the person who is talking and when it is quiet. Since students are often not within a few feet of the person who is talking in a classroom and since classrooms are seldom quiet, it is essential that any child with a hearing loss use a remote microphone system for all academic situations. Note: they are also very useful for situations outside of school such as ballet class, sports, religious instruction etc.
Teachers should have the microphone ‘on’ when talking to the student with hearing loss and mute it when talking to other students in a situation when the child with hearing loss does not need to hear. When possible, there should be a pass microphone which can be used like a talking stick so that other students in the class can speak directly into the microphone. If there is no pass microphone, teachers need to repeat comments of other students so the child with hearing loss can know what is happening in the classroom discussion. Teachers should use the student’s name when calling on a student so the child with hearing loss can find the student easily and look and listen. During small group work, give another child in the group the remote microphone or place it in the middle of the table so the child with hearing loss can hear small group discussion.
Check for understanding
It is important to be sure that the child with hearing loss understands classroom discussion. Asking “do you understand” is not enough. Very few children will admit to not understanding. Ask critical questions to confirm understanding.
Keep the classroom quiet
Furniture makes noise. Footies or used tennis balls on legs of all movable chairs and tables will reduce the noise. Windows and doors should be shut to reduce outside noise. Classroom rules should include that only one person talks at a time and that there is no walking around or using pencil sharpeners or other noisy things during lessons.
Cue the student
The teacher should call the student’s name to get his attention or to comment on a change of subject. It is also helpful to call the name of a child who is going to make a comment instead as well as pointing so the child with hearing loss can know where to look to see who is speaking.
Provide written instructions
All assignments and homework should be provided in written form so there is no confusion about what the assignment is. During class, if students are being asked to turn to a particular page or book, write that on the whiteboard.
Additional wait time
Children with hearing loss may need additional wait time to help them understand the message. Just give them a few extra minutes.
Children with hearing loss will benefit from extended test time, usually 1 ½ times the typical test time. In addition, if any information on the test is spoken, it is essential to be sure that they heard it. The teacher should be close by and the room should be quiet. Preferably, testing should be conducted in a quiet room.
Teacher of the Deaf services
All children with hearing loss will benefit from academic assistance. Teachers of the deaf should preview vocabulary of new material before they are presented in the classroom and review the vocabulary and concepts with the student after presentation. In that way children with hearing loss can keep up with their classmates. Do not let a school tell you that because a child is doing “well enough” they do not need preview and review. Every child with hearing loss needs these services. Some may do well with one or two sessions a week and others will need TOD services daily.
Every child with hearing loss should have speech-language-listening therapy unless there are no areas of weakness. While a child’s overall score on a standardized test may be within the average range, if he or she has some areas of weakness in language testing, therapy is still essential. Without it, the child will just drop farther and farther behind. Therapy should include developing listening skills so the child can use audition to learn. Ideally this should be conducted by a therapist skilled in auditory verbal practice.
Every school should have an educational audiologist who can monitor equipment on a regular basis and who can assist school staff in understanding hearing loss and maximizing auditory performance for children with hearing loss. Depending on the number of children with hearing loss in the school district, this may be a full time or part time person. At least in the beginning of the school year, the educational audiologist should come in on a regular basis, at least every few weeks. If all is well, services may be needed less frequently as the year goes on.
It is not easy to listen all day long when you have a hearing loss. Children need listening breaks during the day when it is not essential that they be “on”. As the day goes on, listening becomes more exhausting and so, if possible, critical subjects should be scheduled in the morning before listening fatigue sets in. Listening break may be quiet time working at the desk or study time. Lunch is likely not a listening break since they will want to talk to their friends.
High expectations are critical
Everyone working with a child with hearing loss needs to believe that the child can and will do well and work toward that goal. “It’s good enough for a child with hearing loss” is just not acceptable. Kids with hearing loss can and do very well in school and in life. But that only happens when we all do our part.
Please click on the article title to read David’s blog.
The National Acoustics Laboratory in Australia under the supervision of Dr. Teresa Ching has conducted the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study over a period of years. In Australia, all children with hearing loss are followed by Australia Hearing, so collecting data on performance of children with hearing loss is easier. All children receive evidence based audiology and habilitative services. Children are monitored carefully over time. Audiology tests are well organized. Hearing aids are fit using prescriptive targets and are monitored to be sure that they are meeting prescribed targets. All children receive hearing aids and cochlear implants as needed with no cost to families (wow! – ideal). All have complete language, literacy, and social skills evaluations in addition to audiological evaluations.
Because all children throughout the country are monitored by the same agency, it is possible to really evaluate many aspects of development for children with hearing loss. Every child is monitored. There is no selection bias in research. Children will be monitored over a long period of time and should provide outstanding data to help us understand what makes a child successful.
468 children are participating in the LOCHI studies. 305 use hearing aids and 163 use cochlear implants. Some of the cochlear implant students are bilateral and others bimodal. Here is what has been learned so far.
- Fit technology early and fit it right – not a surprise. Although this appears obvious, it is important that we recognize that this is really critical. The LOCHI data shows that for children with severe hearing loss, outcomes decrease by 0.3 SD when hearing aid fitting is delayed from 6-12 months and another 0.3 SD when delayed to 24 months. Similar results are observed for children with moderate hearing loss. These data confirm the need for accurate early fitting of technology and should push EDHI providers to encourage parents to fit technology early and to use it full time. Children fit later are delayed and the time cannot be made up. The LOCHI data also demonstrated that is critical to verify the output of hearing aids using RECD and probe microphone measurements. Meeting target gains is critical.
- Cochlear implantation needs to happen early. Children who received CI’s early performed better. A delay of 6-12 months resulted in a decrease of 0.7 SD in language outcomes with an additional 0.4 SD reduction for children implanted from 12-18 months and another 0.3 SD for children implanted between 18-24 months. This data makes the best case so far for implanting children before their first birthday. CI teams, auditory verbal practitioners, speech-language pathologists and educators, need to push to get children who are not doing well implanted early.
- Monitoring language outcomes – A significant goal of the LOCHI studies was to try and determine prognostic factors that could be used to predict how children with hearing loss are progressing to enable them and us to identify intervention that might be needed early to improve progress. They identified the PEACH as an excellent tool to provide the necessary information. The PEACH (Parents Evaluation of Aural/Oral Performance of Children with Hearing Loss) questionnaire was found to be a good predictor. The PEACH is designed to evaluate how children with hearing loss communicate in every day situations. Testing showed that children who had poorer Peach scores before 12 months of age had poorer outcomes at 5 years of age. This may actually be good information. If we can identify children at risk early on, it may be possible to modify intervention so that we can improve outcomes.
- ANSD – Of the 40 children with ANSD in the LOCHI studies, there was no significant difference in language outcomes at 5 years of age when compared to other children with hearing loss. This is very exciting and hopeful information. It means that, with appropriate management, children with ANSD can have good outcomes. The NAL uses speech-evoked cortical responses to determine if hearing aids should be fit on children with ANSD, and to determine if they are likely to benefit. If it is determined that they are not likely to benefit, they are moved quickly to cochlear implants. Results are reported to be excellent if hearing aids are fit by 6 months and cochlear implants fit by 12 months.
- Language stimulation – The LOCHI study confirmed what was found in the earlier Hart and Risley study in 1995. Children whose mothers have higher education have better language outcomes. The reason for this is not clear. Perhaps mothers with higher education levels are talking to their children more. Perhaps mothers with less income do not understand the need for intensive language stimulation, or perhaps their lives are overwhelming and they cannot manage the additional stimulation needed by their children with hearing loss. What is clear is that EDHI programs need to recognize that language stimulation is critical and help families provide more and more.
- Literacy – The value of good literacy skills cannot be underrated. Children who do not have good literacy skills have problems learning and are underemployed. The LOCHI study demonstrated that phonologic awareness made a significant contribution to a child’s ability to read. The study controlled for for variations in receptive vocabulary, cognitive skills and other demographic variables. The ability to both break down words ( breakdown book into /b/, /u/, /k/) and rhyme words (cat, bat, hat, mat) are critical for literacy. Children with difficulties in phonologic awareness had difficulties in literacy. Providing early intervention skills to improve phonologic awareness can significantly improve literacy.
- Communication mode – Certainly a hot topic. Three fourths of the LOCHI families chose spoken language and the remaining chose total communication. The LOCHI researchers had no direct tie to any communication mode so the results should be considered reliable and unprejudiced. The language outcomes for children using spoken language were significantly higher than those using total communication. Since more than 95% of the children were born to hearing parents the families natural mode of communication was spoken language so they were more easily able to provide spoken language stimulation to their children. Families who chose sign language were learning a new language while trying to provide language stimulation to their children.
- 37% of children in the LOCHI study had additional disabilities. Children with additional disabilities had poorer language outcomes compared to children with no other disabilities. While this data is not surprising, it is critical. It is a reminder that all children with hearing loss need to be followed by a multidisciplinary team of professionals who can evaluate children for additional disabilities and provide whatever additional services are needed. The team should include speech-language pathologists familiar with language and literacy issues for both normal hearing and hearing impaired children, as well as physicians, psychologists physical and occupational therapists, and teachers. The group needs to work as a team planning for children in order for children to succeed.
What have we learned? We need to thank Dr Teresa Ching and the staff of the National Acoustics Laboratory for doing this excellent work. They have helped us to understand how important it is to move quickly to provide children with appropriately fit technology and habilitation. Fit hearing aids early and be sure they meet real ear goals. (I would add that we should validate test results in addition to using real ear. We need to use behavioral testing to assure that children are hearing what they need to hear. Monitor progress using the PEACH or another similar questionnaire. If a child is not making sufficient progress with hearing aids, fit cochlear implants early. Help parents learn to talk talk talk talk talk. Develop literacy skills early. We owe it to children with hearing loss to assure that they can be whomever they want to be.