Children with Cochlear Implants The New Generation

1. Children with Cochlear Implants The New Generation Molly Lyon, M.A., CCC-A/SP LSLS AVEd Via Christi Hospitals January 21, 2011

2. Goals • Participants will learn about the development of the auditory cortex and the window of opportunity • Participants will gain knowledge of the development of listening skills in children

3. Goals • Participants will learn about auditory assessments and the development of appropriate objectives • Participants will become knowledgeable of expected auditory outcomes and recognize red flags

4. A New Decade • Identification: UNHS • Habilitation: Technology • Certification: LSLS • Education: Impact on programs

5. National Goal – Early Hearing Detection and Intervention (EHDI) • 1-3-6 • Screen hearing by one month • Confirm hearing loss by three months • Early intervention by six months

6. Percent of newborns screened for hearing loss

7. Listening and Spoken Language Specialist Certification • Ensures professional has experience and knowledge in developing spoken language in children with hearing loss • Fall 2010, 600 LSL specialists in the country • Auditory Verbal Therapist (AVT) or Auditory Verbal Educator (AVEd) • Application process through AG Bell Academy • Continuing Education/Coursework • Mentoring • Examination

8. A “tsunami” is occurring (Brown 2006) • North Carolina data: In 1995, 40% of families chose spoken language outcomes compared to 60% who chose a form of manual communication • In 2005, 85% of families chose spoken language outcomes

9. Bergen County, NJPublic School Program (Murphy 2009) • 1997, 16% of elementary age and no secondary level students in the DHH program were pursuing a spoken language outcome • 2009, 73% of elementary and 68% secondary level students are learning through spoken language • An additional 100 students returned to their own home districts because of readiness to be mainstreamed

10. Prenatal Hearing Research • Human cochlea has normal adult function after 20th week of gestation • Fetuses can hear a mother’s voice, but sound lacks tone because of attenuated high frequencies (Querleu, Renard, and Crepin, 1981)

11. Age 0 • At birth, infants have heard sounds for four months - fluid-borne, but still true hearing • At birth, infants can discriminate a mother’s voice and show a preference to that voice (Decasper and Fifer, 1980)

12. Neonatal Hearing Research • Neonates are responsive to the rhythm of speech and will move in synchrony (Condon and Sanders, 1974) • 1 to 4 month old infants can discriminate linguistic stress, location, fundamental frequency, intensity and duration (Spring and Dale, 1977)

13. Neonatal Hearing Research • 1 month old infants can discriminate the difference between a voiced and voiceless consonant feature (pa vs. ba) (Eimas, et. al., 1972) • Lower frequencies tend to have a soothing or inhibiting effect, while higher frequencies tend to create more distress (Eisenberg, 1970)

14. Neonatal Hearing • There is an orderly development of auditory responses in infants between 4 and 16 months • A normal hearing alert infant will respond in a predictable manner in accordance to mental age • The type of responses obtained are age specific depending on maturation of the infant

16. Auditory Behavior IndexMcConnell and Ward (1967)

18. Neuroplasticity The brain’s availability and malleability to grow, develop and alter its structure as a function of external stimulation (C. Flexer)

19. Really?

20. Building Auditory Capacity • Current technologies provide auditory stimulation to children who have hearing loss • Current technologies take advantage of the neuroplasticity of the infant brain to “hard wire” efficient auditory brain pathways

21. Absence of Sound • Neural deficits occur • Brain reorganizes itself to receive input from other senses, primarily vision • “Cross-modal” reorganization – reduces auditory neural capacity

22. The Window is Small Neuroplasticity is greatest in the first 3 ½ years of life… • The goal of early auditory intervention is to maintain a child’s ability to learn through a developmental model • “Developmental synchrony”

23. Hearing vs. Hearing loss • Listening skills are acquired in normal hearing infants transparently • Children with hearing loss achieve listening skills commensurate with • Effectiveness of hearing technologies, • Experience, and • Expectations

26. Sample of a Vowel Chartboot-book-bone-ball-box-bye-bun-bella-bird-bad-bed-bake-bit-bee

27. Impact of Hearing Loss on Phonological Processes • Vowel substitutions • Deletion of unstressed syllable – “di(na)sour” • Deletion of initial syllable of word – (e)lephant • Vowel insertion - “cuppa” for “cup” • Cluster reduction – “fower” for “flower” • Final consonant sound deletion – “cu” for “cup”

28. Plurals Sounds like “s” (cats) Sounds like “z” (dogs) Sounds like “es” (horses) Suffixes and Prefixes Friendly, happiness Widest, toxic Disable, misbehave At-Risk Language Components in Children with Hearing Loss

29. Past tense Sounds like “t” (walked) Sounds like “d” (bobbed) Sounds like “ed” (beaded) Possessives The cat’s mitten The truck’s wheel At-risk Language Components, Cont.

30. Copulas/Connecting words Is Of Have If Present progressive Going Swimming Pronouns and 3rd person He, his She, her It Vocabulary! At-risk Language Components, Cont.

31. The Early CatastropheHart and Risley, 1995

32. Words Understood Note: Between ages 5 and 6, children are learning about 28 words a day

33. Developmental Technology – HA/CI Early intervention Parent education Developmental curriculums Minimal didactic instruction Remedial Technology – HA/CI Early intervention Parent education Listening hierarchy curriculums Didactic instruction Children with Hearing Loss –Two Listening Paradigms:

34. Listening Hierarchies Two listening approaches: - Focus on processing language and cognition – HOW audition is used - Focus on the complexity of the auditory signal – the nuts and bolts

35. The Stages of ListeningListen, Learn and Talk, 2005 • Sound Awareness • Responds to music • Notices acoustic feedback • Indicates when hearing aid/cochlear implant is not working

36. The Stages of ListeningListen, Learn and Talk, 2005 • Associating Meaning to Sound • Begins to recognize familiar phrases • Learning to listen to sounds • Recognizes own name

37. The Stages of ListeningListen, Learn and Talk, 2005 • Imitation and Expansion • Child imitates language which has been modeled • Imitates mother’s babble play • Calls back and forth in calling games • Remembers and approximates sentences

38. The Stages of ListeningListen, Learn and Talk, 2005 • Auditory Comprehension • Process and recall language • Auditory memory • Identifies sound parameters: onset, loudness, speed • Discriminates vowels, words, and phrases

39. The Stages of ListeningListen, Learn and Talk, 2005 • Advanced Listening Skills • Localization • Distance listening • Background noise • Taped speech • Telephone • Auditory memory and sequencing

40. Incidental Learning is Important • Developmental paradigm • Let the natural happen • Provide natural opportunities to listen • Use everyday experiences and routines • Given adequate audition, speech and language milestones are obtainable

41. Incidental Learning:What Needs to Happen • Assistive technology is worn 100% • Assistive technology is appropriately fitted • Determine distance hearing ability • Listening opportunities are meaningful • Speech is slow and interesting • Repeat, repeat, repeat • Background noise is minimal

42. Evidence of Incidental Learning • Child repeats something overheard in a conversation • Child uses a new word without being directly taught • Questions something heard on the radio • Re-auditorizes by “thinking out loud”

43. Signature Auditory Behaviors • Reporting dead batteries, no sound, bad sound • Asking to wear implant/hearing aid • Reporting FM interference* • Child says “What?” • Signs of incidental learning • Overhears conversations • Reauditorizes by “thinking out loud”

44. Norm Referenced Speech and Language Assessments • Used to guide instruction and monitor growth • Annual assessment is standard protocol with deaf and hard-of-hearing children • Target deficit areas • Goal is to close any existing gap • Auditory goals are needed if skills do not support incidental learning

45. Ling Six Sounds:mm oo ah ee sh s These six sounds provide information covering the entire speech spectrum The seventh sound – silence: - reduces child’s concern for sounds “not heard” - adds honesty

47. Ling Sounds Ling Sounds can provide information on: • Distance (speech bubble) • Detection • Segmental discrimination • Troubleshooting • Separate ear functioning

48. Framework for Auditory Evaluation and Training • Norman Erber, 1982 • Glendonald Auditory Screening Procedure (GASP!) • Detection • Discrimination (same or different) • Identification • Comprehension

49. Auditory Skills Hierarchy • Reflexive • Detection (Awareness) • Pattern (Suprasegmental) • Word discrimination (Segmental) • Vowel discrimination • Consonant discrimination • Connected speech

50. Reflexive Response • Eye blink • Moro response • Involuntary response to sound • Typically observed only to loud sound • Assessed through observation