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25 Red Flags: Identifying and Managing Barriers to the Child’s Optimal Auditory Development
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
25.4.2 Checking Technology
Eective intervention is impossible without appropriate and
functioning technology. Technology must be aggressively monitored and checked correctly and thoroughly on a daily basis
by the adults who have appropriate listening technology (HA
stethoscope, CI earbuds, CI listening check) to determine when
the child’s technology is not functioning and to troubleshoot for
issues such as a dead battery, a broken device, or intermittent
use. Audiologists must make responding to equipment issues
a priority by quickly facilitating repairs, replacement, and/or
loaner equipment.
Pearl
All clinicians working with a child need to be able to monitor
performance with technology daily and immediately refer to the
audiologist if the child is not hearing well.
25.4.3 Parental Support for Eective
Intervention
Parents must find knowledgeable, experienced professionals
and actively participate in all intervention. Full participation in
their child’s intervention enables parents to reinforce all goals
and objectives at home as well as ensure that all family members
and caregivers are also able to do so. Parents must document
observations about the child’s auditory, speech, and language
development so that they can provide feedback to all profes-
sionals. Parents do need to “trust their gut.” If the intervention
and progress do not seem optimal, then they probably are not.
Professionals need to support parents in seeking a second opinion and not feel insulted when parents do so.
to maximize use of auditory input for parents. Expectations in
therapy should be clear. The therapist’s role is to teach carryover
of these expectations into the child’s daily life, allowing parents
to have appropriate and consistent auditory expectations and
knowledge of therapy targets and outcome goals.
25.5 Why Is Careful Monitoring of
Red Flags Important?
Expectations for children with hearing loss should follow normal
developmental patterns. If a child is fitted with appropriate
technology early and receives appropriate therapy, we should
expect 1 year’s development in 1 year’s time. However, if a child
receives technology late or if therapy intervention is not optimal,
development will be impacted. Parents are novices and rely on
professionals for guidance. Parents have reported that they do
not feel professionals from dierent disciplines have the same
expectations for their child’s development. For example, audiologists may not always recognize a concern when auditory verbal
therapists report that a child cannot hear high-frequency pho-
nemes from a distance. When members of dierent disciplines
disagree, parents are put in a dicult position.
Table 25.1 shows the results of a survey of professionals who
work with infants and children with hearing loss.1 The survey
outlines expectations for a baby aided by 3 months or implanted
by 12 months of age. If all clinicians applied this information as a
guideline, all professionals would be using the same criteria for
performance, which would lead to more cohesive expectations
from all interventionists working with the child.
Pearl
If all clinicians applied information about developmental milestones as a guideline, they would all be using the same criteria
for performance, leading to more cohesive expectations from all
interventionists working with the child.
Pearl
Parents should be supported so that they can become strong
advocates and competent medical consumers for their child.
Professionals need to support parents in seeking a second opinion and not feel insulted when parents do so.
25.4.4 Interventionist Support for
Eective Intervention
An auditory focus in therapy or intervention would ensure
that input through sensory modalities other than audition is
minimized; thus, professionals must model and coach strategies
25.6 When Red Flags Point to
Technology as the Source of
the Problem
Speech-language perception issues result from one or more of
four conditions experienced by the child with hearing loss: the
sound was too quiet, too loud, not clear, or the child does not
have sucient language development.
Real-ear measures and CI programming are critical first steps,
but they do not tell us what a child is hearing. Real-ear measures
provide an indication of the sound that is reaching the eardrum,
not the sound that is processed by the auditory brain. The electrically evoked compound action potential (eCAP; e.g., neural
response telemetry [NRT]) provides an indication of how the
271
III Hearing Access Technologies for Infants and Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
cochlear nerve responds to dierent levels of electrical stimulation, but again, it does not inform us of what is being received
by the auditory areas of the brain. Children provide us with
accurate and reliable information about what they hear when
we observe and understand their behavior, when we document
their auditory skill development, when we listen carefully to their
speech production and language, and when we verify their speech
perception through audiologic testing.
Pearl
If a child does not clearly understand spoken language while
wearing technology, something is wrong. The audiologist must
act quickly to identify the source of the problem and modify the
technology to enable the child to comprehend speech.
25.7 Evaluating Audiology Test
Results
25.7.1 Red Flags That Indicate Speech Is
Too Soft
When HAs are not providing sucient amplification or CIs are not
providing sucient stimulation, children will exhibit a variety of
behaviors that should indicate to the professionals and parents
that speech is too soft. A lack of response to sound and a reliance
on visual input are obvious indicators that speech may not be
audible, but other behaviors are often present that provide further
evidence that sound is too soft. Table 25.2 provides a list of spe-
cific behaviors children may exhibit that indicate that speech is
too soft. If the technology is too soft, a child will not have adequate
access to speech and language. In our experience children who are
receiving little benefit from their amplification will often remove
the HAs or CIs because they serve little purpose. Speech perception testing can provide strong evidence that sound is too soft.
If the audiologist suspects that speech is too soft, she must check
that the technology is functioning properly. Unaided pure tone
testing may also be necessary if threshold changes are suspected.
the area or areas of speech that are not clearly audible. Once
audiologic assessments are completed and the results analyzed,
reprogramming of the HAs or CIs may be necessary to improve
access to soft speech, normal conversational speech, and possibly
even loud speech. It is important to note that a poor auditory
response to low-level speech with use of a cochlear implant may
not necessarily imply that stimulation levels are insucient
but rather that input signal processing parameters are not set
appropriately. The programming clinician must have a thorough
understanding of cochlear implant signal processing in order to be
able to determine whether stimulation levels or input processing
parameters should be adjusted.
25.7.2 Red Flags That Indicate Speech Is
Too Loud
From the authors’ clinical experiences and from the reports of
parents and educational professionals, overamplification and,
especially, overstimulation are a growing concern with children.
Moreover, the consequences of overstimulation and overampli-
fication can be extremely detrimental to speech and language
development.
Table 25.3 provides a list of specific behaviors children may
exhibit when speech is too loud. Most children should want
to wear their technology if they hear with it. Any time a child
removes his technology or has a marked startle or involuntary eye
blink or facial stimulation in response to loud sounds, we should
be very concerned. Children who are being overstimulated may
appear to have a shortened attention span, agitated behavior, or
both and exhibit poorly defined borders between their words and
poor voice modulation with high-pitched sounds.
If the audiologist suspects that speech is too loud, she should
ensure that all technology is functioning appropriately. Unilateral
and bilateral assessment of aided speech perception of soft, conversational, and loud speech will provide information about the
intensity levels at which speech is distorting or even becoming
painful. For hearing aid patients, real-ear measurements performed at high intensity levels may provide information about
frequencies that are being overamplified. While loudness scaling
has long been a part of cochlear implant programming, its use
with children should be carefully reviewed. Since hearing adults
8
Table 25.2 When speech is too soft: signs of underamplication or understimulation
Hearing Aids Cochlear Implants
Child consistently removes technology Child consistently removes technology
Turns up volume Turns up volume or sensitivity
Relies on visual input Relies on visual input
Does not turn or respond to name Does not turn or respond to name
Vocalizations do not change with technology Vocalizations do not change with technology
Voice is loud Voice is whispered
Listening/speech/language development is slow or nonexistent Listening/speech/language development is slow or nonexistent
Speech perception is poor at presentation levels consistent with soft
speech (i.e., 50 dB SPL/35 dB HL)
Abbreviation: HL, hearing level.
Speech perception is poor at presentation levels consistent with soft
speech (i.e., 50 dB SPL/35 dB HL)
272
25 Red Flags: Identifying and Managing Barriers to the Child’s Optimal Auditory Development
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Table 25.3 When speech is too loud: signs of overamplication or overstimulation
Hearing Aids Cochlear Implants
Consistently resists or removes technology Consistently resists or removes technology
Turns down volume Turns down volume or sensitivity
Startles, cries, or blinks to loud sounds Startles, cries, or blinks to loud sounds
Has robust responses to very soft sounds Has robust responses to very soft sounds
Is very quiet or withdrawn Is very quiet or withdrawn
Voice is quiet Voice is loud and/or gravelly; voices when whispering
Poor or deviant consonant development Poor or deviant consonant development; produces only vowels and voiced
Receptive language development without expressive language
development
Speech perception at 70 dB HL is poorer (> 12%) than at 50 dB HL Speech perception at 70 dB HL is poorer
Abbreviation: HL, hearing level.
Table 25.4 When speech is not clear: signs of poor clarity
Hearing Aids Cochlear Implants
Relies on visual input Relies on visual input
Poor or unusual voice quality Poor or unusual voice quality
Inappropriate/unusual consonant development Inappropriate/unusual vowel and/or consonant development
Consistent omission/substitution of specic consonants Consistent omission/substitution of specic consonants
Speech production not improving Speech production not improving
Very small or very large dierence between gain for soft and normal
conversation
Speech perception is poor at 35 dB HL, at 50 dB HL, and/or in noise Speech perception is poor at 35 dB HL, at 50 dB HL, and/or in noise
Abbreviation: HL, hearing level.
consonants
Receptive language development without expressive language
development
(> 12%) than at 50 dB HL
Very small or large dierence between T levels and C/M levels
have been shown to be poor raters of loudness,9 it is imprudent
and even unrealistic to assume that children who are profoundly
deaf are able to complete this highly subjective task accurately. On
the other hand, the electrically evoked stapedial reex threshold
(eSRT) provides an excellent indication of upper stimulation levels
that should be appropriate for pediatric cochlear implant recipients. Additionally, audiologists can compare stimulation levels to
the child’s eCAP threshold to identify when the former may be
excessively low or high. The reader is referred to Chapter 22 for
additional information on the use of objective measures as a guide
for programming cochlear implants for children.
Pearl
Overamplication and overstimulation can have deleterious
eects on wearing compliance, speech and language develop-
ment, attention, and behavior.
25.7.3 Red Flags That Indicate Speech Is
Not Clear
When speech is audible, but not clear, children will exhibit
behaviors listed in Table 25.4. Children speak the way they
hear, which means articulation errors may be “hearing” errors.
Thus, because a child’s speech production should be the most
accurate reection of his speech perception, professionals and
parents should make careful and accurate observations and note
the child’s consistent productions, omissions, and substitutions.
After consideration is given for normal developmental patterns,
the remaining errors provide us with significant information
about the child’s speech perception.
For children with hearing loss to acquire good speech produc-
tion and morphemic functions in spoken English, they must be
able
to clearly perceive all of the ~ 44 phonemes of the language.
Although the Ling six-sound test is helpful in determining whether
a child has access across the speech spectrum, it provides us with
a very limited understanding of a child’s phoneme perception.
In a retrospective review of more than 230 cochlear implant
mappings, Hewitt and coworkers10 found that the most common
speech perception errors were not identified by the six phonemes
of the Ling detection test because of the extremely limited
number of consonants that are assessed, and that when a child
has widespread vowel errors, significant global programming
issues may exist. Thus, to ensure that a child is able to perceive
every phoneme in English clearly, identification, not detection,
should be regularly assessed for all phonemes, with emphasis on
consonant perception from distances of 3 feet and 10 feet.
Because audiologists have contact with children for only a small
number of hours every few months or once a year, the majority of
information concerning a child’s speech perception will be documented by LSLSs, SPLs, TODs, and parents. Analysis of phoneme
rors on informal and formal measures and review of a frequency
er
273
III Hearing Access Technologies for Infants and Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
allocation chart for speech phonemes can identify specific frequency bands to be adjusted. While many CI users perform well
if stimulation levels are balanced in loudness across the electrode
array, some will benefit by making needed changes in specific
frequency bands, rather than globally increasing or decreasing all
bands. This can improve speech perception for those sounds that
are not clear to the patient without jeopardizing information that
is already clear. In further analyzing the data, audiologists must
remember to apply their knowledge of basic principles of sound.
Careful analysis of phoneme perception errors and specific programming changes targeted to improve perception can have an
immediate impact on a child’s speech perception and production.
Pearl
Careful analysis of phoneme perception errors (possibly with
the assistance of the LSLS and/or SLP) and specic programming
changes targeted to improve perception can have an immediate
impact on a child’s speech perception and production.
25.7.4 Red Flags That Indicate Speech Is
Not Balanced
The benefits of binaural hearing are well documented.
result of binaural summation, the auditory input from two ears
will be louder and clearer than a monaural input. Furthermore,
the auditory input to both ears should appear balanced to prevent binaural interference, in which the acoustic input from one
device interferes with the ability to receive clear auditory input
from the other device.
While audiologists work to ensure that each ear individually is
fitted with appropriately programmed technology, they must also
determine whether the two devices together provide optimal bin-
aural benefit. When a patient has been utilizing only one device,
the programming, volume, or both of that device will often be elevated to compensate for the lack of binaural summation. Often, HA
programming algorithms automatically provide additional gain if
a fitting is monaural only. However, when the patient receives a
second device, the ability to fit the second device optimally will be
compromised if the output of the first device is not readjusted and
often reduced. When technology is not balanced or when binaural
summation has created an overly loud input, children will often
go to great lengths, such as removing the battery or turning o
the loud or interfering device, to make the sound more tolerable.
Table 25.5 provides examples of behaviors noted in children when
their technology is not binaurally balanced.
With the introduction of a new implant or HA, children should
immediately begin receiving some of the benefits of binaural hearing, even if the listening abilities in the ear with the new device
are just developing. If the loudness is not balanced between the
two devices, only the louder device may be audible, potentially
causing auditory progress in the ear with the new device to be
limited and/or the new device to be rejected.
11,12,13
As a
Table 25.5 When sound is not balanced: signs of unbalanced binaural
technology
Consistently localizes to one direction
Consistently turns one ear to speaker/music/TV
Does not replace one device when it falls o
Startles, blinks, or asks for quiet when putting on second device
Does not indicate when one battery dies
Original HA or CI is not reprogrammed when second is added
Can tell that one device is louder than the other
One of the simplest ways to determine whether a child’s
technology is balanced is to ask, “Which ear is louder, this one or
that one?” The correct answer is “Neither” or “I don’t know.” Even
preschoolers are often able to identify when one device is louder
than the other. By asking the child, “Does this ear need to be louder
or this ear need to be quieter?” the audiologist can obtain infor-
mation to help guide programming changes. (Sometimes, children
need to be encouraged to accept appropriate levels if audibility will
be aected by altering the settings.) If parents or children report
that one device appears to be bothersome, clear evidence of interference may be documented. If the technology is programmed and
balanced appropriately, speech perception scores should improve
in the binaurally aided condition compared with the monaurally
aided condition, especially in the presence of noise.
Pearl
With the introduction of a new implant or hearing aid, children
should immediately begin receiving some of the benets of binaural hearing, even if the listening abilities in the ear with the new
device are just developing. If both devices are reprogrammed
and balanced, the sound quality of both, when worn together,
should be good.
25.8 Conclusions
Dierent professionals can have conicting viewpoints about
a child’s developmental expectations and outcomes. If one
professional has lower expectations, he may discount the input
of others and fail to assess objectively in his area of expertise,
causing collaboration to be adversely aected. Resolution of
legitimate concerns, and ultimately a child’s progress, can be
aected by professionals who have dierent viewpoints and
are not willing to listen openly to colleagues. It is critical that
all clinicians working with children listen with an open ear to
colleagues and to parents. Listening to the children also is essen-
tial; their speech production is a reection of how well they are
hearing.
In a recent survey of experienced professionals working with
children with hearing loss to determine what issues contributed to
a child’s poor progress, the vast majority of interventionists (> 94%)
were “very” or “quite” willing to consider technology as a factor in
274
25 Red Flags: Identifying and Managing Barriers to the Child’s Optimal Auditory Development
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
the child’s poor outcomes.1 The greatest percentage of respondents
ranked inappropriate technology (63.9%) and inappropriate technology settings (64.3%) as most frequently causing problems with
the child’s performance, with resolution of these problems most
frequently leading to improvement in the child’s progress. If technology is so frequently considered a likely factor in a child’s poor
progress, audiologists must be prepared to listen to their colleagues
when such concerns are expressed and accept responsibility for
carefully assessing technology and modifying it as needed.
It is essential that data be collected before making assumptions
about performance. Returning to basic audiologic principles,
audiologists need to test to be certain a child is hearing what we
think she is hearing. Real-ear measures, the eCAP, and the eSRT
are important tools, but they do not tell us what is reaching the
brain. Only behavioral testing of thresholds with technology and
speech perception testing in multiple conditions will validate how
a child is performing.
Audiologists who have appropriate developmental expectations collaborate fully with other interventionists, consistently
assess a child’s ability to perceive speech and language clearly, and
actively pursue appropriate technology fittings and programming
can and will positively impact the development of their young
patients. Inappropriate technology or inappropriate technology
settings are solvable problems. Audiologists can solve them, and
the children we serve deserve to have them solved.
Pearl
Audiologists who have appropriate developmental expectations,
collaborate fully with other interventionists, consistently assess
a child’s ability to perceive speech and language clearly, and
actively pursue appropriate technology ttings and programming can and will positively impact the development of their
young patients.
References
[1] Roteisch S, Madell J, Hewitt J. Developmental expectations with early amplifi-
cation and/or implantation. Presented at the annual convention of the American
Academy of Audiology, Boston; 2012
[2] Connor CM, Craig HK, Raudenbush SW, Heavner K, Zwolan TA. The age at
which young deaf children receive cochlear implants and their vocabulary and
speech-production growth: is there an added value for early implantation? Ear
Hear 2006;27(6):628–644
[3] Geers AE, Nicholas JG, Sedey AL. Language skills of children with early cochlear
implantation. Ear Hear 2003; 24(1, Suppl):46S–58S
[4] May-Mederake B. Early intervention and assessment of speech and language
development in young children with cochlear implants. Int J Pediatr Otorhinolar-
yngol 2012;76(7):939–946
[5] Tait M, De Raeve L, Nikolopoulos TP. Deaf children with cochlear implants before
the age of 1 year: comparison of preverbal communication with normally hearing children. Int J Pediatr Otorhinolaryngol 2007;71(10):1605–1611
[6] Estabrooks W. Auditory-Verbal Therapy and Practice. Washington, DC: Alexander
Graham Bell Association for the Deaf and Hard of Hearing; 2006
[7] Ling D. Foundations of Spoken Language. Washington, DC: Alexander Graham
Bell Association for the Deaf and Hard of Hearing; 1989
[8] Berger J. Overstimulation in children with cochlear implants. Presented at
Cochlear Implant Symposium 2011, Chicago, IL. July 14–16, 2011
[9] Madell JR, Goldstein R. Relation between loudness and the amplitude of the
early components of the averaged electroencephalic response. J Speech Hear Res
1972;15(1):134–141
[10] Hewitt L, Hewitt J, Owen L, Madell J. Analysis of common speech perception
errors prior to cochlear implant MAPping and successful, remedial programming
changes. Presented at ACIA Conference, Baltimore, 2012
[11] Litovsky RY. Review of recent work on spatial hearing skills in children with
bilateral cochlear implants. Cochlear Implants Int 2011;12(Suppl 1):S30–S34
[12] Litovsky RY, Goupell MJ, Godar S, et al. Studies on bilateral cochlear implants at
the University of Wisconsin’s Binaural Hearing and Speech Laboratory. J Am Acad
Audiol 2012;23(6):476–494
[13] Peters BR. Rationale for Bilateral Cochlear Implantation in Children and Adults.
Sydney, Australia: Cochlear Corporation; 2006
Discussion Questions
1. What red ags may be present for children who are not
making optimal progress?
2. Why is carefully monitoring a child’s speech perception and
speech production essential in evaluating the child’s benet
from hearing technology?
3. Why is the monitoring of red ags important for all
professionals?
4. What information can be gleaned from collaboration with
parents and other professionals about the child’s overall
progress?
5. What red ags indicate that the perception of speech through
the child’s technology is (1) too soft? (2) too loud? (3) unclear?
(4) unbalanced?
6. What speech production issues would merit cross-disciplinary
assessment to determine the cause of the child’s errors?
275
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
IV
Educational and Clinical Management of Hearing Loss in
Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
26 Collaborative Team Management of Children with Hearing Loss
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
26 Collaborative Team Management of Children with
Hearing Loss
Jane R. Madell and Carol Flexer
Summary
This chapter uses practical case studies to display various team
management scenarios. The goal of team management is to have
all involved professionals provide services in a coordinated way
to a child with hearing loss and his family. To that end, the roles
of the many critical members of an eective pediatric team
are detailed in this chapter. In order for a team to be eective,
someone has to be in charge, and that team manager likely will
change over the years. This chapter features ways to determine
who is the team manager and highlights ways team members
can communicate for cohesive service delivery.
Keywords
team management, audiologist, medical professionals, social
workers, speech-language-auditory therapist, psychologist,
occupational and physical therapists, educational personnel,
case manager
Key Points
The goal of team management is to have all involved pro-
•
fessionals provide services in a coordinated way and with a
unied philosophy to a child with hearing loss and the child’s
family.
The child and family are always at the center of the team.
•
A system of communication, shared among clinicians and
•
the family, needs to be formulated to provide information
about how a child is performing. Some families have found a
communication notebook, e-mails, or blogs to be useful tools
for sharing information among team members in multiple
settings.
For team coordination to work well, someone must be the
•
case manager; as the child’s needs change over time, the case
manager may change.
Disagreements among clinicians need to be handled in a way
•
that does not involve families in interprofessional disputes.
loss and the child’s family. Sometimes all services are provided by
a single program in one location. In other instances, services are
provided by clinicians working out of dierent programs, including clinicians working in hospital-based audiology programs, in
sc
hools, and in private practices. Whether at one or at multiple
centers, services should be delivered with a unified philosophy
and by clinicians who communicate regularly with each other.
Teaming can be a very positive experience for professionals and
families, in the following ways:
Observations made by one clinician are helpful to other cli-
•
nicians in understanding the child’s overall performance and
behaviors, and can help clinicians rethink and improve their
individual recommendations. For example, a shared observation made by a teacher or speech-language pathologist (SLP)
that a child is not hearing in the classroom or is not hearing
word endings will assist the audiologist in making strategic
changes to the child’s technology. Collaborating with service
providers from other specialties helps clinicians expand their
knowledge base and helps them better understand all children
they serve.
Collaboration with a team provides each professional with a
•
broader view of the eects of hearing loss on the child and the
family.
This chapter will discuss the composition of a team and the
roles of team members. The critical position of the team manager
will be detailed. The chapter will end with four case studies that
illustrate the value of a coordinated team and the recognition
that the role of team manager shifts as the child’s primary needs
change over time.
The composition of the team will be dierent for every child
and will depend on the child’s individual needs (Fig. 26.1).
3,4
26.1 Who Is on the Team?
Multiple professionals are involved in providing services to
children with hearing loss and their families. Even though the
professionals may do their best individually, they do not always
work together as a coordinated team or communicate with each
other when planning and implementing services. As a result,
the totality of services that the child actually receives can be far
from optimal.
The goal of team management is to have all involved profession-
als provide services in a coordinated way to a child with hearing
1,2
Fig. 26.1 The team.
279
IV Educational and Clinical Management of Hearing Loss in Children
Madell et al., Pediatric Audiology: Diagnosis, Technology, and Management, 3rd Ed. (ISBN 978-1-62623-401-7),
copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
26.1.1 Family
Families play an extremely critical role in a child’s success. The
word family is used here in its broadest definition. Family certainly
implies parents, but also can include grandparents, siblings, and
other relatives or caregivers (nannies, etc.) who are involved in a
child’s day-to-day care. Even the most talented group of clinicians
will not be successful in educating a child if the family is not
involved.5 Language learning must take place all day long. Infants
and young children are at home many hours each day.
Pearl
If the family is not conversing and reading with the child for many
hours every day, the child will not reach the outcomes desired by
the family.
A family that has selected Listening and Spoken Language [LSL]
program for their child needs to be responsible for making sure
that the child’s technology is always working optimally. In addition, they need to know how to talk and converse with to the child
o build the child’s cognitive brain centers for spoken language
t
and literacy.
Families that have selected sign language as a communication
mode for their child need to learn/develop a sign language aptitude that far exceeds the level of baby and preschool signs. They
need to communicate with the child using sign language in the
6
same way and at the same level of language complexity used to
communicate with their hearing children in order for the child’s
language to develop to age-appropriate levels.
Table 26.1 provides a list of family responsibilities.
Providing support even for normally developing children is very
often stressful for parents. Children with special needs, including
children with hearing loss, require even more eort on the part of
the family (Chapters 35 and 37). Even though parents are primarily responsible for their child, grandparents and others can be very
he
lpful in providing the necessary assistance.
26.1.2 Audiologist
For every child with hearing loss or auditory processing disorder
(APD), a pediatric audiologist is a key member of the team. Table
26.2 lists the responsibilities of the audiologist.
Because the audiologist sees the child less frequently than
some of the other team members, she can and should observe the
child’s progress over time, including the child’s speech, language,
and auditory development. If the child is not making appropriate
progress, and the audiologist is certain that the child is hearing
optimally with technology, the audiologist needs to discuss concerns with other team members and encourage them to reevaluate
the child’s developmental, listening, and linguistic status.
Once a child enters school, an educational audiologist frequently
joins the team. The educational audiologist will be responsible
for monitoring personal technology in school, selecting and
monitoring assistive technology (including remote microphone
[RM] systems), and teaching school sta how to use the systems
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Table 26.1 Responsibilities of the family
1. Providing intensive language stimulation
2. Controlling noise in the home
3. Transporting child to and from therapy
4. Educating regular education teachers and others about hearing loss and optimal communication with their child
5. Ensuring the child goes to sleep early enough to be bright and alert and ready to learn when at school
6. Checking and assisting with homework
7. Knowing what is happening at school and in therapy to be sure the child is receiving the services he needs
8. Verifying that professionals working with the child have high enough expectations and that the child is doing the best that he can do
Table 26.2 Responsibilities of the audiologist
1. Identifying hearing loss
2. Monitoring hearing loss over time
3. Evaluating auditory behaviors (e.g., sound sensitivities)
4. Evaluating speech perception
5. Selecting and tting amplication technologies (HAs, CIs, osseointegrated implants, RM systems)
6. Monitoring use of technologies to be certain they are providing the necessary benet
7. Evaluating the need for and selection of assistive technologies, including personal RM and classroom listening systems
8. Counseling parents and other team members about hearing loss, auditory brain development, and technology
9. Identifying other auditory problems, such as APD
10. Educating parents, teachers, and others about hearing loss and auditory brain development, the eect of hearing loss on literacy and learning, and
about ways to maximize auditory skills in children with hearing loss and other auditory disorders
Abbreviations: APD, auditory processing disorder; CI, cochlear implant; HA, hearing aid; RM, remote microphone.
Source: Based on Hall JW.
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