Leigh Matthews, M.A., CCC-SLP

1. Information and Strategies for SLPs Working with Students with Hearing ImpairmentRegion IV PresentationApril 17, 2013 Leigh Matthews, M.A., CCC-SLP

2. Purpose • To explain and emphasize the importance of recognizing a hearing loss • To provide some interesting information about hearing impairment, sign language, deaf culture • To provide some techniques for evaluation, that are different from a more conventional evaluation • To provide some ideas for treatment

3. Hearing Impairment • Hearing loss is one of the most common disability conditions at birth • Three out of every 1,000 babies are born with permanent hearing loss • About 90% of hearing-impaired children are born to hearing parents • Hearing loss is typically identified at 12-25 months, although 22 states have newborn hearing screenings available. • Approximately 14.9% of US children have low-frequency or high-frequency hearing loss of at least 16 dB hearing level in one or both ears. Region 4 Special Education Solutions

4. Hearing Impairment • Mild: (26-45dB) Child may have difficulty with faint or distant speech, may need modifications in the classroom, may miss certain consonants in speech due to some high frequency speech sounds • Moderate: (46-65dB) Child may understand conversational speech at a short distance in a structured setting, may miss 50% of conversation if background noise is present, will exhibit limited vocabulary, immaturity in syntax and pragmatics, and reduced speech intelligibility. May need classroom modifications and special education services. • Severe: (66-86+) Child may hear loud voices or environmental sounds but is more aware of vibrations; vowels may develop before consonants; speech and language will not develop spontaneously if loss is pre-lingual, quality and intelligibility of speech is atonal, child may rely on visual cues and gestures to communicate. Will need modifications in the classroom and/or special education services.

5. Audiogram www.wikipedia.com

6. p h g ch sh l a j mdb o r n ng e i AUDIOGRAM OF FAMILIAR SOUNDS FREQUENCY IN CYCLES PER SECOND (HZ) 125 250 500 1000 2000 4000 8000 0 10 z v f th 20 s 30 40 50 u HEARING LEVEL (dB HL) 60 70 80 90 100 110 120 Provided by: Northwest Harris County Cooperative for the Hearing Impaired

7. Assistive Technology and Assistive Listening DevicesAmplification • Hearing Aids – Usually worn behind the ear; a child may have one or two hearing aids, depending on his or her loss and need. • Cochlear Implants (CI) - an electronic device consisting of electrodes placed in the cochlea to provide electrical stimulation to nerve fibers and a mini-processor implanted behind the ear. Externally, the patient wears a transmitter which contains the sound processor and microphone. Hearing from a cochlear implant is “digital hearing”. • FM – frequency modulation – microphone, transmitter, receiver • Portable Sound Field System

8. Listen Around the Clock • Early intervention is so important! Babies born with normal hearing are exposed to noise, sounds, language even before they are born. With mandatory newborn hearing screenings, now hearing impairment present at birth can be identified. With proper follow up, it is possible that the baby with the hearing impairment would not have to lose much time being exposed to these noises, sounds and language. Much of what we learn is incidental learning – we learned it by listening. Many things we know we weren’t taught; we just heard one thing and heard another, and things began to fit together. Not so with children with hearing impairment. Much of what they need to learn must be directly taught to them. (AGBell handout “Listen Around the Clock”)

9. Programming Possibilities • Special Education support at home campus - Combinations of time in general education and special education (such as time in the resource class, in speech therapy, etc.) • Indirect services from AI-certified teacher at home campus • Direct services from AI-certified teacher at home campus • Intensive services at designated self-contained site campus - Most of the day spent in special education classroom (i.e. “self-contained”) because the modifications to the curriculum require it. • During time in the special education classroom a variety of services may be accessed – including time with an AI Itinerant teacher. • Regional Day School Program for the Deaf (RDSPD) – • Texas School for the Deaf (residential in Austin)

11. Sign Language

12. Examples of Sign LanguageScripts for Videos of Each • American Sign Language (ASL) • Hello. Name me what? • Dennis last nameDavino. • want inform program what? • Interpreter train. • for for? Interpret • work where? School all • program where? CypressCollege • class class many variety different look can • start when? Week Aug 22, 2005 • come on. • Contact Signs/Pidgin Signed English (PSE)/Conceptually Accurate Signed English (CASE) • Hello, • My name Dennis Davino • Welcome Cypress College educate interpret train program • Look class class we are plan plan • Our class start week Aug 22nd, 2005 • Hope see there • Signing Exact English (SEE) • Hello. My name is Dennis Davino. Welcome to the Cypress College Educational Interpreter Training Program. Look at the classes we are planning. Our first classes begin the week of Aug 22nd, 2005. Hope to see you there.

13. Auditory-Verbal Approach Auditory-Verbal programs follow a set of guiding principles and practices to help the child with hearing-impairment maximize the use of their residual hearing. Using amplification gives the child an opportunity to learn to listen, so that he or she can process and use spoken language. These programs emphasize: • Early identification of hearing loss and pursuing maximum potential for amplification • Helping the child understand the meaning of any sounds he or she hears • Helping the child learn and respond in the same way hearing children would • Helping the child participate academically and socially with hearing peers • Depends upon high parent involvement

14. Lots of Listening Before Talking! Stages of Listening and Talking handout Estabrooks, Warren. Cochlear Implants for Kids. Washington, D.C.: Alexander Graham Bell Association for the Deaf and Hard of Hearing, 1998. Print.

15. The Auditory BrainCarol Flexer “Hearing loss isn’t about ears – it’s about the brain. We hear with the brain. We are organically designed to listen and talk. But those areas of the brain must be stimulated (via technology).” She explains how basic neural research now shows data that supports the necessity of stimulating auditory brain centers. Greatest neurologic plasticity is the first 3 years of life. Children with hearing loss need 3 times as much exposure to information/concepts as compared to hearing kids. “Muddy in leads to muddy out. Kids can only “close” a word they already know.” She adds that unknown information should be given in pull-out. Known/carryover can be done (maybe) in inclusion.

16. Want your child to read? Carol Flexer

17. The Language you Think with….

18. Mode of Communication • We are required by law to determine the child’s primary mode of communication during the evaluation. • Continuum of Total Communication to total Oral communication….. • The SLP is in charge of Communication - your first responsibility with any kind of evaluation - in the schools, clinic, hospital, etc. is to figure out how the child communicates.  This includes what oral communication the child can comprehend. •  If the child normally wears hearing aids, be sure he or she is wearing them for the evaluation.  If he or she uses an FM in the classroom, part of your listening comprehension assessment may be to describe how much higher his or her comprehension is using the FM; do some informal comparisons in your evaluation. This is also information that the child’s audiologist could and should provide.   • In the case that the child needs hearing aids, they are perpetually lost, or Medicaid hasn’t come through, or....then do go ahead and evaluate his or her listening and overall communication.  

19. EvaluationStandardized Tests Most standardized tests are not normed on the hearing-impaired population. Be sure to follow standard procedures for each standardized test, and if the test is not normed on the hearing impaired, don’t report the score. You can use it as a criterion-reference measure; use it to collect data and establish a baseline so you can measure progress with the same measure at a later date. The OWLS (pg. 140 of the manual) and the CASL (pg. 146) had a group of hearing impaired subjects in their standardization groups On these tests, the HI group scored about 15 points lower.

20. Evaluation of Auditory Comprehension When evaluating children with hearing loss, it is important to use hierarchies. • Listening, Speech and Language Skill Development Checklist – UT Dallas Callier Center • Listening Skills Scale for Kids with Cochlear Implants – Warren Estabrooks • Auditory-Verbal Ages and Stages of Development – Warren Estabrooks • DASL – Developmental Approach to Successful Listening by Gayle Goldberg Stout and Jill Van ErtWindle • Placement and Readiness Checklist – www.handsandvoices.org • Listening vs. Comprehension – Keep in mind you are teasing out the specific skills of listening. So you want to go through the stages of discrimination, distance and directional listening, as well as listening in noise, and auditory memory and sequencing.

21. Comprehension Evaluation cont’d In the case you would need to evaluate • Sign Language • Lip reading The AI teacher would assist. Reading comprehension is the final comprehension component. You may not directly evaluate this, but you should know the results of the reading testing and be able to help figure out where/why it breaks down.

22. Evaluation of Expression • Keep in mind the Estabrooks/Pollack “Stages of Listening and Talking”…lots of listening before talking. Be sure you’ve addressed any holes in the early listening skills. • Remember you are to establish the mode of communication. In the area of expression, that will include a qualitative/quantitative look at the child’s non-speech communication. • Don’t be tempted to take the easy road....articulation:) Often that overlooks the underlying problem of auditory discrimination or some other audition-related issue. You must attack that issue before working on the speech - and often the speech will come easily without a lot of work, once the auditory piece is in place. These kids are very often language disordered - you will be the one to diagnose that.

23. Evaluation of Expression • Classroom Observation • Language Sampling • Language Sampling • Language Sampling • Another classroom observation – different setting or activity. • Standardized tests if appropriate – OWLS, possibly CASL, CELF. Check for HI norms. If not, do not score, but use information informally for baseline. • CASLLS – Cottage Acquisition Scales for Listening, Language & Speech Excellent resource for analyzing language samples. Contains five forms for checking skills: Pre-Verbal, Pre-Sentence, Simple Sentence, Complex Sentence, and Sounds and Speech. • Written Expression – Consider doing your own informal evaluation, especially if the child uses writing to communicate everyday.

24. Language Sampling • Have a set of pictures, cards, etc. ready to go. Develop a system… • 50-100 utterances • Need narration and description – do picture description as well as procedural description with or without pictures. • Sample constantly. Use simple form and keep with the child’s progress notes to remind you to do it. • Imperative that you write what was said, not what you assumed was said. • Parent could bring in videotape and you could analyze together. • Include note about context to show intent and check pragmatics

25. Articulation Consider Daniel Ling’s work with students who were deaf and compare to normal speech development…. As the child develops a phonetic level skill (i.e. being able to vocalize freely on demand), he develops a related phonological skill(i.e. vocalizing as a means of communication). This proceeds through the 7 stages of speech acquisition. The phonetic stages are vocalizing, suprasegmentals, vowels and diphthongs produced with voice control, consonants by manner with all vowels, consonants by place with all vowels, consonants by voicing with all vowels, initial and final blends. The phonological levels progress from vocalizing for communication to different voice patterns, to using different vowels to approximate words to clearer words, phrases, sentences, to intelligible speech.

26. AI Assessment • Keep in mind that you will be the only one assessing listening (not reading) comprehension, and speaking (not writing). At the home school, the AI teacher will focus on reading and writing, and unless the child is very young, will most likely not spend a lot of time on listening and oral language. And your work in therapy nearly always will be about building some listening skills and verbal expression. You must know the hierarchy - what comes first. Auditory hierarchies and language sampling!! • Your evaluation should include some trials with accommodations. For example, you will need to evaluate how far away a speaker can be before comprehension at a certain level breaks down. • Communication Assessment (Part C) - Use information from the Speech and Language Evaluation to complete. Or become best buddies with a good AI teacher and she will do it for you:) It’s just a form. One of its main functions is to report Mode of Communication and to assist with determining a baseline of where the child is functioning with communication.

27. How should I write-up my evaluation???? Billy has been diagnosed with a mild- moderate hearing impairment and wears bilateral hearing aids. He uses an aural/oral mode of communication. The current evaluation shows that when wearing his hearing aids, he can understand two-step commands in a quiet environment, listen to a short paragraph and answer simple yes/no questions if given content set-up before the paragraph was read to him, and discriminate rhyming/non-rhyming words. He is unable to hold more that 3-4 words or numbers in his working memory at one time, needs repetition of longer information, and may need simplification of more complex sentence structure or word forms. His comprehension significantly decreases in the presence of noise. He uses speech with approximately 80% intelligibility to express his needs, comments, and questions/answers. His language output consists of sentences 7-10 words in length with accurate word order and simple or compound structure. His vocabulary variety is limited, and he does not use many descriptive words or complex verb forms.

28. Accommodations • Use of visual aids • Preferential seating • Clear visual pathway to the teacher • Monitor use of amplification device • Assistive Technology • Clarification of vocabulary • Use of an interpreter • Additional time for responses • Note-taking assistance • Provide opportunities to interact with peers and include them in all class activities

29. Treatment • Spend a lot of time at the beginning giving information and explaining techniques to the teachers working with the student. Use the hierarchies. Educate them on normal language development. Let them see where the comprehension breaks down. Brainstorm techniques/accommodations to use; hopefully you have assessed the effectiveness of these with the student. Demonstrate for the teacher. • Remediation vs. Compensation - there is a time to remediate and a time to compensate.  Usually they are done concurrently.  Don’t withhold compensatory strategies while you wait for remediation!!  For example, you may expect some improvement in even severely impaired speech with your remediation techniques; however, in the meantime, teach the child how to functionally express himself or herself. • Therapy techniques would include sound discrimination work, auditory sequencing and memory exercises, practice with comprehension of sentences containing progressively higher levels of vocabulary and syntactic complexity, practice sentence or word comprehension with and without lip-reading, and practice with difference background noise levels or different distances from sound source. • IEPs are not treatment plans

30. Treatment • Treatment goes on all day. Use words from the school – in the hallway, in the classroom. Practice listening to them, using them, finding them, writing them. Practice same things over and over. Repetition so important. Consider individual file boxes. • Play – dollhouse, ordering from “restaurant”, • Guessing game – set up objects behind a screen, listen to description, • I’m going on a camping trip and I’m taking my….(auditory memory) • Roald Dahl books • Listening for Littles – WordPlay Publications • Categories and descriptions – how are a sock and a shoe alike? How are they different? This skill is a prerequisite for the 20 Questions Game

31. Treatment • Rhymes and Songs • Reading aloud to the child. Have him or her follow with his or her finger. • Absurd or silly pictures – SLP read or describe using an incorrect word (“log” for “dog”) and the student must correct him as he says it. • Sentence or word dictation • Word families and rearranging phonemes…how many sounds in this word? How many words in this sentence? • Critical elements – “two black cats” contains 3 critical elements. Keep track of the level of the student and progressively build. • Pronouns and prepositions – work on during story retelling with objects. “She took her shoes off and put them under the bed.” • Auditory closure – remember to teach the set before practice. Can make a game of taking turns saying one word without a sound and the other one guessing it.

32. Listening Checks • For hearing aids and cochlear implants to work effectively, teachers need to make sure that hearing aids and cochlear implants are working at all times. This is called a ‘listening check’. • Teachers: Perform listening checks when the student first comes to school, after recess/PE, and any other time you have concerns. • SLPs: Perform listening checks before therapy and any other time you have concerns. • Listening checks are absolutely critical for success!

33. Say It! It is always important to have the child say or approximate the words you or the teacher are teaching/working on. Even the child with severe articulation must be encouraged and taught how to at least approximate the sounds in words.  This will increase both auditory and reading comprehension and written expression. Research shows that phonemic awareness is strongly linked to reading success. And, manipulating the phonemes of a word has been highly successful in producing better reading skills. An SLP can teach the child the phonemes of a word…/f/ /o/ /n/…phone…3 sounds, 5 letters. Now replace the /f/ with /b/…what word do you have? This relates to the IEP this child will surely have about reading on grade level!

34. Beverly Trezek’s work and Visual Phonics According to the National Reading Panel (2000), balanced and effective reading instruction contains five essential components: • Phonemic awareness • Phonics • Fluency • Vocabulary • Comprehension Trezek page 77 All children, “including those who are hearing impaired, must understand the connection between the phonemes of the language and the graphemes of print.” Visual Phonics provides a visual representation (with the hand) of all 42 phonemes in the spoken English language. Therefore, a hearing-impaired student can “see” how the word sounds, and when he or she learns most of the possible graphic representations of those sounds, can spell and read!

35. Dismissal Issues listening writing

36. Resources • www.advancedbionics.com • http://www.agbell.org • www.cochlear.com • www.handsandvoices.org • http://www.listen-up.org • www.medel.com • http://www.nidcd.nih.gov/Pages/default.aspx • www.parentpals.com • www.sunshinecottage.org • http://www.welisteninternational.com/AV_PRACTICE_TODAY.pdf • Estabrooks, Warren. Cochlear Implants for Kids. Washington, D.C.: Alexander Graham Bell Association for the Deaf and Hard of Hearing, 1998. Print. • Trezek, Beverly J. Reading and Deafness: Theory, Research, and Practice. Canada: Delmar, Cengage Learning, 2010. Print The DASL II Cochlear Corporation400 Inverness Drive SouthSuite 400Englewood Colorado 80112USAToll Free: 1-800-523-5798Telephone: 1-303-790-9010Fax: 1-303-792-9025 The Part Number is FUZ041.  leighmatthews85@gmail.com • For further information about services for students who are Deaf/Hard of Hearing please contact: Sandra ConnatserRegion 4 ESCsconnatser@esc4.net 713-744-6329