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28 The Importance of Early Intervention for Infants and 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.
detectable responses at stimulus presentation levels of 65 and 75
dB SPL in the sound field. In light sleep, no behavioral responses
were observed when broadband, low-, mid-, and high-frequency
noisemakers were presented at high levels. Combining the
unaided CAEP results and behavioral observations, the child
was estimated to have hearing loss of at least 80 dB HL in both
ears. Accordingly, hearing aids were fitted according to the NAL
prescription. After fitting, aided CAEPs were measured showing
responses to /m/ and /g/, but not /t/, presented at 75 dB SPL (Fig.
28.5a). No responses were detected for any of the stimuli at lower
presentation levels. The PEACH score obtained 2 weeks after the
fitting was at 2 SD below the mean of the normative population
(Fig. 28.5b). Accordingly, the hearing levels were re-estimated
to profound loss, and HAs were adjusted to match revised prescriptive targets. Four weeks after the readjustment of hearing
aids, aided CAEPs were evaluated in the soundfield. Ear-specific
aided CAEPs revealed responses to /m/, /g/, and /t/ at 75 dB SPL
in the right ear only. Middle ear problems were reported for the
left ear at this time. The PEACH scores continued to show that the
child’s functional performance was at 2 SD below the normative
mean for his age. Speech therapists reported that the child did
not show detection of the Ling sounds at 1 meter when aided,
and there was no observable progress. In view of the evaluations
of aided CAEPs and PEACH results and the input of the speech
therapists, the family was advised to consider referral for CI
candidacy evaluation before it was possible to obtain reliable
results with visual reinforcement audiometry. The child received
bilateral CIs by 10 months of age.
These two cases serve to illustrate a clinical management
pathway to ensure early fitting and optimizing of amplification for
individual children, and early referral for CI candidacy to ensure
that a child who needs a CI gets it early. The presence of ANSD
is not a condition that precludes early amplification or cochlear
implantation. The evidence-based protocol uses a combination of
objective measurement of CAEPs and behavioral assessment with
the PEACH questionnaire to optimize postdiagnostic management
of children with hearing loss.
Pearl
a
b
Fig. 28.5 Case AN1. (a) Auditory brainstem response testing using
tone bursts as stimuli showed no detectable responses at maximum
presentation levels. Aided cortical auditory evoked potentials testing
showed detectable responses to /m/ and /g/ presented at 75 dB SPL.
Behavioral thresholds obtained at 6 months (corrected age) using
visual reinforcement audiometry are also shown. (b) PEACH scores
at 2.5 and 5 months (corrected age). The solid line represents the
relationship between scores and age for normal-hearing infants, and
the broken lines denote ± 2 standard deviations.
Use objective measurement of CAEPs and behavioral assessment
with PEACH to evaluate the eectiveness of hearing aids. Refer
for CI candidacy if indicated. The presence of ANSD should not
preclude a child from receiving early amplication or cochlear
implantation.
28.5 Conclusion
Current evidence from the LOCHI study attests to the eectiveness of early intervention for improving outcomes of children
with hearing loss. The findings of the study can guide management of childhood hearing loss to maximize the benefit of early
intervention. Following early fitting of HAs and verification of
prescriptive targets, evaluation of the eectiveness of amplifica-
tion for individual children by using objective cortical measures
and the parent-report PEACH scale should be implemented. This
ensures that individual progress with intervention is monitored
and, if indicated, that referral for paediatric CI candidacy evaluation can occur at an early age.
he world for children born with PCHL has changed. With
T
early detection of hearing loss and early intervention, parity of
outcomes between children with hearing loss and those with
typical hearing is within reach. Postdiagnostic intervention needs
to be timely and to be guided by current evidence. The principle
with any treatment/intervention is that we must always evaluate
its eectiveness for each individual, and if it is not eective, have
the courage to change for the better.
In summary, the presence of permanent childhood hearing loss
has a negative impact on children’s developmental outcomes. The
widespread implementation of UNHS makes it possible to detect
301
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.
congenital hearing loss soon after birth, so treatment can begin in
infancy. However, the ecacy of early intervention for improving
outcomes has remained inconclusive. This chapter addresses
the question by drawing on findings from a population-based,
prospective study: the LOCHI study. On average, children who
received earlier fitting of HAs or CIs had better spoken language
by 5 years of age. Better outcomes were also associated with less
severe hearing loss, higher nonverbal cognitive ability, absence of
additional disabilities, higher maternal education level, and use
of an oral mode of communication during early intervention. The
LOCHI study shows that on average, the presence of ANSD did not
significantly inuence outcomes. Further, HAs that were selected
according to either the NAL or the DSL prescription and verified
to match targets using real-ear measures provided adequate
audibility to support language development. This chapter shows
how the evidence can be incorporated in clinical management of
childhood hearing loss to maximize the benefit of early intervention. Current best practice includes fitting HAs in a timely fashion,
verifying that prescriptive targets are matched, and evaluating
the eectiveness of amplification for individual children by using
objective cortical measures and the parent-report PEACH scale.
These processes serve to monitor individual progress with intervention and ensure that pediatric CI candidacy referral can occur
at an early age if indicated.
Discussion Questions
1. What are some of the reasons that explain the equivocal nd-
ings in the literature on the eectiveness of early intervention?
2. Why might a longitudinal study of a single cohort over time
provide stronger evidence than multiple age cohorts in exam-
ining the long-term eectiveness of early intervention?
3. What are some of the factors, in addition to age at interven-
tion, that inuence outcomes of children with hearing loss?
4. How can the clinical pathway for managing children diagnosed
with hearing loss through newborn hearing screening be
streamlined to maximize the benets of early identication?
5. How might the detection of CAEPs and the use of
parent-reported functional performance form part of a rou-
tine evaluation of HA tting in young children?
6. How might the detection of CAEPs and the use of
parent-reported functional performance form part of standard postdiagnostic management of children with ANSD?
7. Why is evaluation of HA eectiveness crucial to maximizing
benets of early intervention?
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303
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.
29 Speech/Language/Auditory Management of Infants and 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.
29 Speech/Language/Auditory Management of Infants and
Children with Hearing Loss
Elizabeth Ying
Advances in amplication technology and early identication
Summary
The primary objective of hearing habilitation and rehabilitation
for children with hearing aids or cochlear implants is continued
development of functional listening skills for spoken language
learning and communication. However, without appropriately
programmed amplification devices, they will gain limited
benefit from habilitation/rehabilitation eorts. This chapter
provides an overview of the systematic progression from the
fitting of amplification to the implementation of evidence-based
speech-language therapy interventions. An initial comprehensive assessment of the child’s communicative competence
is critical to identifying specific training objectives and determining change over time. Recommended assessment protocols
at dierent stages of development are outlined, with particular
emphasis on the components of a functional assessment of
how the child responds to dierent types of speech stimuli, in
contrasting listening environments, which distinguishes the
evaluation of a child with hearing loss from that of his or her
typically developing peer with normal hearing. The remainder
of the chapter addresses intervention and service delivery.
Active parental involvement and close networking between
home, school, and therapy should be established to reinforce
listening and language targets outside of therapy. Provision of
listening experiences, separate-ear and bilateral and in competing background noise, is also described. The chapter concludes
by discussing of how documentation from ongoing diagnostic
training and regularly scheduled comprehensive assessments
should direct future intervention for the individual child with
hearing loss.
Keywords
aural habilitation/rehabilitation, universal newborn hearing
screening, functional listening, assessment, stimulability, acoustic features, telepractice, networking
Key Points
The role of a speech-language pathologist encompasses
•
diagnostic and therapeutic responsibilities for a child who is
deaf or hard of hearing.
The need to assess functional listening distinguishes the
•
communication evaluation of a child with hearing loss from
the communication evaluation of a child with normal hearing.
Audition is the most eective and ecient modality for
•
acquiring and monitoring spoken language skills.
The primary objective of aural habilitation and rehabilitation
•
training is to develop functional listening skills for continued
language learning and enhanced communicative interactions.
•
and intervention have helped more children with hearing loss
to acquire functionally adequate listening and age-appropriate spoken language skills.
Telepractice and smartphone/tablet apps support, not
•
replace, traditional aural habilitation/rehabilitation.
29.1 Role of the Speech-Language
Pathologist
Since passage of the National Institutes of Health (NIH)
Consensus Development Conference in 1993,1 most states now
implement programs of universal newborn hearing screening.
As a result, hearing loss is identified at earlier ages than it was
two decades ago, and more families are seeking assessment and
treatment of the communication deficits accompanying hearing
loss by the time their infant is 1 to 3 months of age.
in technology options (including digital hearing aids [HAs] and
cochlear implants [CIs]), as well as the increased availability
of parent-child-focused early intervention (EI) programs that
emphasize auditory skill development and the comprehension
and use of spoken language, have significantly improved function and performance in children with significant hearing loss.
With EI, age-level receptive and expressive communication skills
by preschool or kindergarten are expected for children identified
at an early age. The positive eects of this EI place unique social
and educational management challenges on professionals and
school systems alike.
It is widely accepted that a Listening and Spoken Language
Specialist (LSLS), or speech-language pathologist (SLP) with
training in developing listening skills, is an integral member of the
interdisciplinary diagnostic team that serves children with hear-
ing loss. Traditionally, findings from an initial speech-language
evaluation yield baseline information about vocabulary, receptive-expressive language functioning, and speech production
stimulability and capability for the child with hearing loss. These
important findings will determine initial training needs and serve
as comparative data for the measurement of therapy benefit and
progress.
The communication profiles of children with any degree of
hearing loss are characterized by a wide variability in functional
listening skills and linguistic competency. Therefore, for any child
with hearing loss, the communication evaluation should encompass a functional listening assessment. This component is needed
to obtain critical information about speech perception abilities
(e.g., the eect of an HA or a CI on the user’s reliance on auditory
input for continued language learning, literacy development, and
enhanced communicative interactions). This functional listening
assessment requirement distinguishes the speech-language
assessment of a child with hearing loss from the communication
assessment of his normal-hearing peers, because formulating and
3
Advances
2
305
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.
implementing aural habilitation/rehabilitation training also fall
within the professional domain of the LSLS or SLP.
Pitfall
Few graduate training programs oer the coursework or prac tical
experiences that are necessary to prepare the average SLP with
skills to work with children with hearing loss. The academic
preparation of an SLP should prepare clinicians to conduct the
evaluation and treatment programs for developing auditory skills
for pediatric patients with hearing loss. Furthermore, SLPs must
be prepared to assume additional responsibilities for the student
with hearing loss who is enrolled in general education settings
(e.g., monitoring amplication, serving as a resource to the classroom teacher and to the teacher of the deaf [TOD] who may be
providing preteaching of classroom vocabulary and content, and
facilitating social interactions). Listening and Spoken Language
Specialists do have the training to provide these services.
29.2 Diagnostic Evaluations
There are two major purposes for conducting speech-language
evaluations and functional listening assessments: (1) to identify
communicative strengths and weaknesses (during the initial
assessment); and (2) to monitor progress over time (during progress assessments). Identifying the purpose of the assessment
is essential to determining the scope of the assessment and in
selecting the most appropriate assessment tools.
Upon receiving a referral for evaluation, it is first absolutely
critical to review the audiologic findings and general case history.
The SLP/LSLS must understand the child’s hearing loss, including
aided and unaided hearing, and be able to perform a listening
check of the child’s technology to ensure that it is working and
that the child has auditory access to the information presented
during assessments.
Language comprehension (encompasses the assessment of the
•
understanding and contingent response to spoken language,
including acting on directions and questions by performing
actions, manipulating objects, pointing to pictures, or verbally
responding)
Expressive language (encompasses the assessment of non-
•
verbal and verbal behaviors produced to convey meaning
intentionally)
Speech production (encompasses the assessment of the artic-
•
ulation of speech sounds in isolation, repeated and alternated
syllables, words, and word combinations, as well as overall
voice quality, prosody, and intonational characteristics)
Pragmatic functioning (encompasses the assessment of how
•
spoken language is used for various communicative purposes,
such as labeling, commenting, requesting, directing, and
questioning)
Performance data yield critically needed information to determine future habilitation and rehabilitation management as well
as educ
ational placement and related services needs.
During the communication assessment, through formal and
informal measures, the SLP or LSLS obtains information about (1)
age of identification
(3) cognitive factors (such as attention span and memory)
environmental considerations, such as everyday communicative
demands and expectations
proficiency.
in the performance of pediatric HA or CI users.
Testing will reveal areas that should be addressed to ensure
there is sucient and appropriate support for the child with
hearing loss, both at home and in school. Considerations such as
consistency of present technology use, realistic understanding of
the impact of hearing loss on language learning, and availability of
aural habilitation and rehabilitation training should be identified
during the initial diagnostic assessment. Most important, it should
be possible to formulate aural habilitation and listening training
objectives and strategies based on the results of a comprehensive
communication evaluation.
11,12
4,5
; (2) previous communication modality6;
9,10
; and (5) parental input/language
These factors account for much of the variability
7,8
; (4)
29.2.1 Initial Assessment
Findings from an initial speech-language evaluation/functional
listening assessment identify areas of strength and weakness in
several skill domains, including:
Phonemic awareness (encompasses assessment of detection,
•
discrimination, and identification of vowel elements and
consonants as they occur in isolation or in dierent positions
within words)
Word recognition (encompasses comparison of open-set word
•
identification under separate ear and binaural listening conditions, in both quiet and noise)
Vocabulary (encompasses the assessment of the understand-
•
ing or expressive use of real words or sound associations
representing real words, e.g., “woof-woof” for “dog”)
29.2.2 Progress Assessments
In contrast, subsequent assessments (routinely occurring at
6-month intervals or annually) provide all of the foregoing,
but also slightly dierent information. Comparative analysis of
performance on criterion-referenced or standardized measures
aords an objective means of monitoring progress and benefit
(of both therapy and technology) for the child who is deaf or hard
of hearing. Subsequent assessments also present the necessary
information for making changes in the child’s aural habilitation/
rehabilitation training.
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29 Speech/Language/Auditory Management of Infants and 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.
29.3 Determining the Focus of
Therapy
Children enter ing the aural habi litation and rehabilit ation process
fall within four major age groupings: infants, preschool-aged,
school-aged, and teenagers. Each of these developmental groups
has distinctly diering diagnostic and training requirements.
Recognizing the unique needs of each group is critical both in
selecting the appropriate diagnostic tools and in interpreting the
test findings and formulating appropriate training programs.
29.3.1 Infants
It is increasingly more common to be asked to conduct a
speech-language evaluation and functional listening assessment
on an infant who has only recently been diagnosed with hearing
loss or who is just beginning an HA trial process. Because of their
young ages, infants exhibit few skills that can be assessed using
standard testing protocols. Therefore, a large part of the evaluation process involves parent questionnaires of observed auditory
and basic communication behaviors. Parental responses on such
questionnaires provide important information about parents’
understanding of the impact of hearing loss on future language
learning and social-communicative interactions as well as par-
ents’ understanding of amplification use and aural habilitation
training on the development of desired skills.
Frequently, the infant or toddler has already undergone some
type of global EI eligibility assessment. Rarely, however, has there
been a systematic attempt during such assessments to observe or
document the auditory responsiveness and stimulability of the
infant or toddler with hearing loss. Generic EI providers may have
limited experience with hearing loss (and even less experience
in determining potential candidates for more advanced technologies, such as remote microphone technology or CIs, as the child’s
primary amplification at home).
EI providers or SLPs often lack the special training or experience to support the necessary preimplant training or to assist in
the infant’s or toddler’s initial acclimation to either HAs or CIs.
In addition, the concept of fast-tracking an infant or toddler for
implantation is often misinterpreted as aording minimal services to the child and family until an implant is fitted, when, in
fact, the early interventionist should be an active participant in
preparing the baby and parents for the implant procedure.
During the HA trial, it is valuable to attempt to establish some
prerequisite communication behaviors while establishing an
awareness of speech and environmental sounds, such as developing visual attending skills, sustained attention to sound-making
toys, and exposure to a variety of low-frequency listening and
vibrotactile experiences.
29.3.2 Preschoolers
The primary component of the evaluation process for the preschool-aged child is to assess the present level of functioning in
9
light of the child’s amplification history and previously delivered
aural habilitation training. If the preschooler with hearing loss
has been fortunate enough to have had some auditory-verbal
training, but achieved minimal gains, the evaluator might assume
that (1) the child has limited potential to use auditory input from
HAs or implants that are currently being used, or (2) the technol-
ogy has not been providing sucient acoustic access to the child’s
b
rain. In contrast, if previous EI programming has been more
visually based or used sign support, one must question whether
there has been sucient focus on auditory skill emergence to
determine ultimate benefit from the HA trial or implant pro-
gram (e.g., perhaps the lack of auditory progress is an artifact of
training as opposed to either a subject-specific or device-related
issue). This communication modality issue becomes particularly
important in borderline cases for a CI (e.g., for children whose
audiograms suggest they should be hearing better with HAs).
At times, potential implant recipients might exhibit behaviors
during formal testing that suggest they are more stimulable (e.g.,
have greater auditory potential) than reported by the parents or
their ongoing speech-language clinicians. This finding would, in
turn, suggest that changes are needed in the preschooler’s aural
habilitation objectives and strategies.
Depending on the child’s age, exploration of present or future
school-based aural habilitation services might also be a component of the evaluation process. When the child with hearing loss
continues to exhibit limited functional listening or oral communication skills, the most appropriate evaluation measures may be
largely parent-report inventories or criterion-referenced assessment tools, keeping in mind that it is critical to include some tool
to assess the nature and consistency of the preschooler’s auditory
and communicative demands.
The recommended protocol for direct observation of the auditory skill emergence of an infant, toddler, or preschooler who is
not yet talking or able to respond on formal diagnostic measures
encompasses exposing the child to a range of noisemakers and
speech, spanning the speech frequency range within interactive
play routines. After a period of exposure, the child’s visual attention should be engaged in play with an alternative manipulative
toy. Then, while his visual attention is averted from the examiner,
these now “familiar” noisemakers or speech stimuli are presented,
and the child’s response is observed. Specific responses could
range from stopping an ongoing action, looking up, moving rhythmically in response to the sound stimuli, visually scanning the
environment to locate the sound source, or attempting to imitate
what was heard. Having knowledge of both the acoustic features
of the sounds presented as well as the normal progression for
auditory skill development will enable the examiner to assess the
appropriateness of the child’s observed behaviors.
9
29.3.3 School-Aged Children
For school-aged children, communication mode (sign language
or total communication versus listening and spoken language/
auditory-verbal) and current communication skills have impact
on both the diagnostic and the therapeutic management of a
child with hearing loss. Potential first-time CI candidates in this
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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.
age group are assumed to have missed the window of opportunity for optimal verbal language learning (unless the referral
for implantation is being made because of a change in hearing).
This may create a need to assess the child’s level of linguistic
competency in her first language (e.g., a manual communication
system). In addition, when the school-aged child is being evaluated for implant candidacy, assessment measures should also be
used to determine whether parents and professionals (who have
often initiated the implant process) have realistic expectations of
the ultimate benefit for the particular implant candidate.
It is expected that the school-aged HA user or CI recipient
can take formal standardized testing, preferably administered in
the child’s primary mode of communication. In addition, if the
present or future educational placement for this child is a regular
classroom setting, it is strongly recommended that tests standardized on children with normal hearing be used rather than tests
standardized on children with impaired hearing. This will provide
a more representative sample of how the skills of the school-aged
student with hearing loss compare with those of her classroom
peers. The results of this evaluation are used to determine the
child’s areas of strengths and weaknesses, to serve as a baseline
from which to measure future progress, and to identify specific
modifications needed in the child’s ongoing aural habilitation and
rehabilitation management.
29.3.4 Teenagers
Teens and parents who enter the evaluation or rehabilitation
process often do so in response to having experienced a change
in hearing status or a failure in some aspect of their social-communicative interactions. If a CI is being considered, the device
may be viewed as a potential cure for deafness unless the family
has been counseled adequately by hearing health care professionals. Other precipitating variables for pursuing a CI in this age
group, however, include obtaining a second CI or simply relaxing
the criteria for implant candidacy.
The requirements of the communication evaluation for a teenager are the same as those for the school-aged child. However, it
is also critical to involve the teen actively in the decision-making
process regarding future amplification devices (including trying
special features of a digital HA, using a remote microphone [RM]
system, or obtaining a CI). Similarly, it is unrealistic to expect that
any progress will be made in the recommended therapy programming without the teen’s motivation and commitment to such
training. If the teen has restricted language skills, it is dicult to
determine whether her limited understanding of the issues will
allow her to oer an informed consent.
Professionals who are actively involved in the diagnostic
and therapy processes with teenagers recognize that teens
who have adjusted to compromised auditory input over many
years may perceive increased or continuous sound from more
contemporary technology as bothersome and aversive. The use
of social-communicative questionnaires, such as the Listening
Inventory for Education (LIFE)13 or the Secondary Screening
Instrument for Targeting Educational Risk (Secondary SIFTER),14
may be useful in assessing whether the teen and parents have
realistic expectations of an amplification device, the listening
environment, or present level of functioning. Similarly, sharing
test results and training strategies throughout the habilitation
and rehabilitation process is motivating. It also ensures that the
teen maintains realistic expectations about her course of management and develops a better understanding of what is needed
f
or her own self-advocacy.
In recent years, there has been a growing group of children from
all developmental groups who reenter the evaluation and hearing
habilitation process to receive a second CI. (Special note should
be made that, ideally, an HA trial has already been completed
as part of the evaluation process for the second CI, involving the
full-time use of an HA in the unimplanted ear.) Particularly if the
teen received an initial implant at a young age, she likely has few
memories of the time commitment or training required to achieve
benefit from the first device. Determining whether the teen and
family have realistic expectations for the second device (com-
pared with the dramatic gains received from the first) is a critical
component of the evaluation procedure for this group. The second
implant can be expected to improve hearing in competing noise,
extend distance hearing, and assist in localization. Some children
may derive little increased benefit in overall speech reception
in quiet, with moderate benefits in noise. Therapeutically, the
challenge lies in devising and motivating an eective protocol for
facilitating integration of the dierent signals initially perceived
from each implant.
29.4 Selection of Test Protocols
The need to ensure accurate reception/perception of verbal test
stimuli distinguishes the test administration for a child with
hearing loss from that of her normal-hearing peers. Accordingly,
all technology must be carefully checked to determine that it is
functioning as intended before any speech-language-listening
assessments are conducted. Assessing functional listening at
the suprasegmental, phoneme, word, and sentence levels is also
a necessary component of a comprehensive speech-language
assessment for this population. Depending on the child’s age,
selected diagnostic protocols may encompass informal and
formal measures. These measures, in turn, might involve
criterion-referenced or norm-referenced tools. The advantage
of norm-referenced diagnostic measures is that they permit
comparison of the child’s performance data to those of typically
developing peers.
The components of a comprehensive communication evaluation should consist of three distinct skill domains: (1) auditory
perception measures in contrasting listening environments; (2)
receptive and expressive language functioning; and (3) speech
production measures in contrasting listening environments. Table
29.115 provides an organizational framework for conducting such
an assessment. Given the wealth of available diagnostic tools, it
is clearly evident that no single test can appropriately meet the
requirements of all of the necessary skill domains. A suggested
protocol of tests has been included in Appendix 29.1 to oer a
model for designing an appropriate diagnostic protocol.
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29 Speech/Language/Auditory Management of Infants and 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.
Table 29.1 Functional listening assessment
Functional Listening Assessment
Background Information
Name: Device: (RE) (LE)
Date: Settings: (RE) (LE)
Listen Alone (Quiet) Listen Alone (Noise)
Linguistic Level RE LE Bin. RE LE Bin.
Suprasegmentals
Phonemes
Words
Sentences
Connected Speech
Listen Alone (Quiet) Listen Alone (Noise)
Linguistic Level RE LE Bin. RE LE Bin.
Suprasegmentals
Phonemes
Words
Sentences
Connected Speech
Speech Production Standard Score Intelligibility
Percentile Rank
Age Equivalent Voice Quality
Resonance
Prosody
Vowels
Consonants
Syllables
Expressive
Verbal Comprehension Standard Score Expressive
Percentile Rank Language
Age Equivalent
Pragmatic Functioning
Abbreviations: LE, left ear; RE, right ear.
Pearl
Supplementary information may be obtained by using an assortment of subtests from various tests to obtain a more representative sample of the child’s level of functioning and management
needs, rather than using one prescribed test completely.
Tests normed on children with typical hearing are preferred.
Using tests normed on children with hearing loss often yields
ceiling-eect scores and an inated view of the child’s present
level of functioning.
(Individuals with Disability Education Act)
altered the delivery of services to children under the age of 3
years. The focus of such services has been modified to address
the social-communicative interactions of the child within family
dynamics and daily home routines. Previously, it was not uncommon for an infant or toddler to be taken to a hospital or clinic
setting, where frequently either the parents were not present in
the session, or they passively observed the therapy session. The
expectation of naturalistic EI programming is that the parents or
caregivers are actively involved in the training sessions, taking
conversational turns and using the clinician’s modeled tech-
16
has substantially
niques for stimulating functional listening and speech-language
skills.11 This commitment to active parental involvement is not
29.5 Service Delivery
The SLP or auditory-verbal practitioner provides direct instructional services to a child with hearing loss, either individually or
within a group setting. The mandate for an early interventionist
to provide services within the child’s natural environment
unique to EI. Quite the contrary, one of the primary tenets of
the auditory-verbal and LSL approaches from their inception
has been the importance of active parental involvement (see
Chapters 27 and 28). Skilled clinicians within clinical settings
have been able to implement naturalistic training tasks eectively to facilitate the child’s acquisition of a target skill (in a
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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.
less distracting environment), with active parent involvement.
The expectation is that because the parents have been actively
involved, they will be able to reinforce the skills within naturally
occurring situations at home.
However, the mere presence of an SLP, LSLS, or early interven-
tionist disrupts the normal parent-child interactions. Parents often
express a lack of confidence in their ability to recreate modeled
routines or to employ modeled strategies eectively when the
interventionist is not there. Telepractice, using Web-based technology that permits two-way simultaneous communication at a
distance, has the potential of ameliorating this disconnect between
the parent and child with hearing loss. This service delivery option
has been suggested as a means of addressing the lack of qualified
professionals in communities with limited auditory-verbal
resources.17 Telepractice also can permit the working parent or an
extended family member or caregiver to be actively involved in
the child’s therapy programming. Target vocabulary, concepts, and
strategies can be discussed with the parents ahead of time, and via
subsequent therapy sessions conducted over FaceTime or Skype,
the SLP, LSLS, or early interventionist can observe and coach the
parents during their interactions with the child.
Similarly, the education initiatives of the 1980s and early 1990s,
which require that the general education classroom must change
to accommodate the individual learning needs of all students, has
most inuenced the delivery of support services to the student
with hearing loss, from the preschool years throughout the college
experience.18 Ideally, instructional exibility should be written
into the child’s Individualized Education Program (IEP), allowing
for push-in and pull-out services as needed. In a push-in delivery
model, the student’s auditory and speech and language training
objectives are provided within the classroom setting; a pull-out
model aords training outside the classroom.
During pull-out therapy sessions, the SLP or LSLS auditory-verbal
practitioner can work in a less distracting environment on areas
of weakness that are dicult to address in a classroom setting
(e.g., resolving specific phonemic confusions or addressing the
child’s preteaching needs). On the other hand, by going into the
classroom environment, the clinician has the valuable opportunity
to observe the imposed communicative demands and teacher-talk
used by the classroom teacher in navigating the students’ behavior
and to engineer social-communicative interactions between peers
and adults while concomitantly addressing the child’s individual
training objectives. Establishing and maintaining some form of
networking between home- and school-based services could
also be addressed through some form of periodic telepractice as
opposed to existing speech books and emails.
Pitfalls
In all service delivery models, care needs to be taken to avoid
•
having the student become overly dependent upon the ser vice
provider, therein fostering less independent functioning in the
classroom than the student is capable of demonstrating.
Familiarity or phobia regarding technology software might
•
discourage families to supplement face-to-face services with
telepractice sessions.
29.6 Components of Hearing
Habilitation/Rehabilitation
Training
In the absence of appropriately programmed HAs or CI sound
processors, limited benefit can be gained from ongoing aural
habilitation/rehabilitation. Therefore, periodic audiologic
assessments are warranted to monitor the auditory status and
to make changes in the device programming for a child with
hearing loss.19 During the early stages of language learning, audiologic testing or device reprogramming is recommended every
3 months.20 However, to benefit optimally from this ongoing
audiologic management, there should be an interactive exchange
between the audiologist and the other clinicians working with
the child.
Because the SLP or auditory-verbal therapist has many opportunities to closely monitor and document the nature of the child’s
phonemic confusions, she could and should share this informa-
tion with the audiologist, who can then optimize modifications
to the HA or speech processor. Current digital HAs and CI sound
processors have numerous features to enhance specific listening
environments. They can be programmed with distinctly diering
programs to capitalize on specific acoustic or perceptual features
to coincide with or facilitate particular training targets (see
Chapters 20, 22, and 24).
Perhaps the most valuable input needed by the audiologist for
device programming is a descriptive analysis of any observed
positive or negative changes in the child’s auditory responsiveness
reported by the clinician, including:
Tolerance to specific sounds or device settings
•
Attention-getting responses
•
Distance listening
•
Phonemic confusions
•
29.6.1 Therapy Environment
The optimal listening and learning environment for any child
acquiring language is a quiet, child-friendly setting that aords a
variety of sensory experiences and permits independent exploration. The structured auditory therapy session can occur within a
range of environments from natural home environments to quiet
or noisy classroom settings or acoustically controlled clinic settings, depending on the purpose of the therapy session. It seems
counterintuitive to attempt to facilitate critical listening in a
distracting environment with competing background noise; however, this may be the purpose of an advanced listening session.
Equally as critical is that auditory therapy should be a
parent-child directive (e.g., actively involving the parent or caregiver in the ongoing training tasks). Regardless of the frequency
of training sessions, it is indisputable that the parents will be the
most consistent source of auditory and speech-language stimulation to the child. It is, therefore, essential to guide the parents
in acquiring skills and strategies for eliciting their child’s optimal
listening, comprehension, and production responses within naturally occurring daily routines.
11,21
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