Please …
register …
help yourself to handouts …
see if you can label parts of the ear while you wait …
sit and relax
Introducing the resource kit Do You Hear What I Hear?
Examined the causes, signs and symptoms of Conductive
Hearing Loss (CHL)
Explored the impact of CHL on children’s development
and educational outcomes
Become familiar with medical approaches to managing
Examined educational approaches for children with CHL,
described in the kit Do You Hear What I Hear?
Developed a plan for ‘Where to from here?’
Context of the CHL Strategy
Dept of Health
and other health
Curriculum Framework
Building Inclusive
Operational Plan
Hearing Loss
Students at
Educational Risk
Speech &
2 Way
Principle of Inclusivity
… means providing all groups of students, irrespective of
educational setting, with access to a wide and empowering
range of knowledge, skills and values … recognising and
accommodating the different starting points, learning rates
and previous experiences … valuing and including the
understandings and knowledge of all groups … providing
opportunities for students to evaluate how concepts and
constructions such as culture, disability, race, class and gender
are shaped.
Curriculum Framework, 1998, p. 17
CHL Resourcing
Consultants (2), Aboriginal Health and Education
(including CHL, Nutrition, Substance Use, Mental
Health, Family Violence) – Statewide
Do You Hear What I Hear? – One kit available to each
school and distributed through professional
development programme
Do You Hear What I Hear?
Intervention Strategies for Aboriginal Children with CHL – research report,
intervention plan and case studies of two focus schools
Resource Book – introduction to CHL; impact of CHL on language,
literacy and social-emotional development; management of CHL in
schools; teaching and learning strategies; profile and screening tool
CD-Rom – as above plus an interactive children’s section
Masters – for activities and a certificate for Breathe, Blow, Cough
Posters (2) – ‘Understanding Middle Ear Infections’ and ‘How to
Avoid Ear Infections’
Order form for kit
Situation of the Ear
Situation of the Ear
Anatomy of the Ear
Hammer, Anvil, Stirrup
Semicircular Canals
Auditory (or Cochlear) Nerve
External Auditory Canal
Inner Ear
Tympanic Membrane
(Ear Drum)
Eustachian Tube
(to nose and throat)
Outer Ear
Middle Ear
Types of Deafness
Conductive Hearing Loss - an impairment to the physical
mechanism of the outer and/or middle ear; occurs as a
result of trauma or Otitis Media (OM); OM is caused by
colds, flu, large adenoids or tonsils, and allergies
Sensorineural Loss – results from damage to the auditory
nerve or the workings of the inner ear
Mixed Loss – combination of conductive and sensorineural
NB: Hearing impairment is not just a simple reduction in auditory
sensitivity. Perceived sounds may be distorted.
Incidence of Conductive Hearing Loss
Specific populations show greater susceptibility –
Aboriginal children, Inuits (Eskimos), Apache and Navajo
Indians, children with particular disabilities; some evidence
of higher prevalence in SE Asian and Hispanic children
(Hasenstab, 1987). Maori children (NZHTA, 1998).
75% to 80% of Aboriginal children on any one day
20% to 25% of European children on any one day
What to do if you suspect a hearing loss
Refer the child for assessment, which will determine:
1. If the child has a hearing loss
2. What the degree and nature of the loss is
3. How the hearing loss can be medically managed
Assessments that are conducted:
Audiometry (1 of 3)
Air conduction screening
- sound goes through middle ear
Masked or unmasked tests
Bone conduction screening
- sound bypasses middle ear
Specialised tests for young children, e.g. Distraction Test
for babies conducted by Infant Health Nurses
Audiogram for normal hearing
Frequency in Cycles per Second (Hz)
Hearing Level in Decibels (dB)
Right ear
Left ear
Interpreting an Audiogram
Frequency in Cycles per Second (Hz)
Hearing Level in Decibels (dB)
Interpreting an audiogram
Audiogram of Familiar Sounds
Mild Hearing Loss
Understanding Degrees of Hearing Loss
Mild (26 – 44 dB)
• Understand conversation at 1 – 1.5m
• May have delayed speech development
• May miss up to 50% class discussion if
speaker not visible
• May need hearing aid
• Will need special education attention
Severe (60 – 89 dB)
May understand speech at <15cm
Hears loud environmental sounds
Will have delayed speech/language
Will need hearing aid
Requires auditory training
Uses vision for additional cues
Speech/language will not develop
spontaneously if loss present before
1 year old
Moderate (45 – 59 dB)
Understand conversation at 0.5m
Will have difficulty at school
Likely to have language delay
Will have poor speech clarity
Will need hearing aid
Will need special education
assistance and probably special
training for listening
Profound (> 90 dB)
• May only be aware of very loud sounds
• Speech and language will be defective
• Visual and gestured cues essential for
• Needs full time special education
• Use of a hearing aid
Assessments that are conducted:
Tympanometry (2 of 3)
Assesses status and function of
middle ear
Looking for the following:
Is the eardrum intact?
Is the middle ear system mobile/immobile/partly mobile?
Assessments that are conducted:
Otoscopy (3 of 3)
Examines the appearance and texture of the eardrum
Screening otoscopy checks for blocked ear canal, state of
eardrum and presence of fluid in middle ear
Diagnostic otoscopy differentiates between the different
types of Otitis Media
Normal Eardrum
Thin and semi-transparent
Pearly-grey appearance
Often some structures within
the middle ear can be seen
A “cone of light” extends
downwards and forwards
from the umbo (where the
eardrum attaches to the
malleus or hammer)
Types of Otitis Media
1. Acute Otitis Media - An acute infection
of the middle ear and eardrum. Starts
suddenly, may be caused by bacteria,
viruses or a combination. Children may
have ear pain, fever, rub or pull their
ears, may be irritable, cry, lose their
appetite, vomit or have diarrhoea.
Eardrum can be bulging and may/may
not be red, and may not move as it
Some children, however, may not
show signs of this infection!
Types of Otitis Media
2. Otitis Media with effusion, ‘Glue ear’ – Fluid in
the middle ear, the consistency of egg white.
Distortion of the eardrum, prominent blood
vessels and bulging in upper half, dullness in
lower half. Outline of malleus (hammer) is
obscured. Fluid levels can be seen behind the
Some children may complain of ear pain, but
don’t have the signs and symptoms of Acute
Otitis Media.
Types of Otitis Media
3. Chronic Supparative Otitis Media, ‘Runny ear’
– Serious and persistent infection. Hole in
eardrum and pus flows from middle ear into
canal. Usually follows untreated or poorly
treated acute middle ear infection. Often occurs
in children under 5 and in children who live in
poverty and poor environmental conditions. Ear
pain not common. Without treatment damage
to middle ear bones will occur and increasing
hearing loss. May also cause serious infections
in mastoid bone and in brain.
Impact of Otitis Media is Multi-Factorial
Age at which the child experienced the first incidence of
Number of incidences under the age of 12 months
Access to good medical intervention
Access to certain types of interactions within the family
Access to audiology and speech pathology
Child’s general health
So what’s it like to have CHL?
Morning Tea
Medical Treatment
Glue ear and infections often clear up without treatment
Antibiotics will help with an infection but will not clear up
the fluid build up that occurs with glue ear
Runny ear does not clear up quickly or easily. The
recommended treatment is twice daily syringing with
Betadine, followed by dry mopping, then drops, for 16
Surgical Treatment
Grommets are recommended
for children who have had
more than 6 infections in a
year or one bout of Otitis
Media lasting more than 3
More Surgical Treatment …
Myringoplasty / Tympanoplasty – patches the eardrum;
not suitable for runny ears
Mastoidectomy – removal of part of mastoid bone and
other parts of middle ear because of erosion by fluid over
long period of time
Middle ear reconstruction
Amplification Options
Behind-the-ear style sits behind ear,
amplified sound travels down a tube into
customised earmold
In-the-ear hearing aids fit inside ear
In-the-canal hearing aids are smaller and
fit the size and shape of ear canal
Completely-in-the-canal hearing aid is
worn deep inside canal and are almost
Other Amplification Options
Hearing hats/head bands – bone conduction
Personal FM systems
Sound Field Amplification Systems
Modes of Communication
Speaking and listening
Reading and writing
Pitch, rhythm and
Gesturing and body
Speech and Language
Speech – the sounds of a language; the ability to pronounce
and distinguish different sounds; and the ability to
coordinate the voice box, lips and tongue to produce sounds
Language – the spoken, written or other symbol system
used to convey (expressive) or understand (receptive)
Communicating without speaking
Oral Language is fundamental …
Speaking and listening provide the foundation for all
language learning and underpin the successful development
of reading and writing skills.
Proficiency in speaking and listening contributes to
children’s abilities to learn effectively in all learning areas.
First Steps: Oral Language Developmental Continuum
Cultural Considerations
Language is the repository of the speakers’ cultural knowledge
and reflects their world view. When we devalue a language we
devalue everything contained within and reflected by it.
The Western school system is set up to reflect a literate
tradition. It assumes all children come to school knowing how
to work with language in a de-contextualised manner. We
need to be aware that children may come to school with rich
language experiences from predominately oral traditions and
Impact of CHL on Speech
and Language Development
Hearing children learn the basics of language passively, by hearing it. This
avenue is not open to children with hearing losses.
Creates a barrier for normal speech development and phonological
Causes delays in the development of a child’s first language and any
additional language, particularly when the hearing loss begins at a very
young age:
Poor vocabulary and semantic organisation
Expressive and receptive language difficulties – language structure, word
endings, grammar, word order etc.
For Aboriginal children, diminished auditory experiences can affect
opportunities for learning about culture, law, relationships, etc. (Clarke,
Impact of CHL on Comprehension
‘Oral comprehension’ relates to the ability to understand the meaning of
what is spoken. Comprehension is dependent upon context, previous
knowledge and experience, sentence length, concepts and attention.
(adapted from Health Department of WA Teacher Modules, 2000)
A child with CHL or a history of CHL probably has:
Difficulty with lengthy or complex instructions
An underdeveloped vocabulary including concepts and
descriptive terms (e.g. in Preprimary will not understand concepts
such as location [over/under…] or size, and descriptive terms [colour,
Difficulty with some questions (e.g. in Preprimary can’t
understand ‘wh’ questions [who, what, when, where])
Impact of CHL on Semantics
Semantics refers to the link between our thoughts and ideas and the
vocabulary and concepts we use to express these thoughts. Semantic
organisation describes how we organise incoming information in order to
make sense of and later retrieve it.
(adapted from Health Department of WA Teacher Modules, 2000 ; Holt & Spitz, 2000)
In Preprimary, a child with CHL or a history of CHL probably:
Has a vocabulary of less than 1500 words
Speaks in sentences of < 3 to 5 words
Doesn’t use language socially
Is slow to learn words and concepts (due to ‘fuzzy’
Impact of CHL on Semantics
Other indicators may be :
Difficulty integrating new information with existing
Limited conceptual understanding
Under-developed receptive and expressive vocabulary
Difficulty retrieving words
Difficulty generating ideas related to a topic
Conversational difficulties
Impact of CHL on Syntax
Syntax or grammar refers to the way we organise words into sentences.
Grammatical rules tell us which words should come before or after others,
the word endings we should use and the way words combine to form
(adapted from Health Department of WA Teacher Modules, 2000 ; Holt & Spitz, 2000 ; Owens 1992)
Problems with forming linguistic categories such as plurals
and tenses
Grammatical errors and unusual word order
Incomplete sentences
Restricted use of describing words (adjectives/adverbs) and
connectors (but, then, because, so …)
Impact of CHL on Narrative
(Oral Texts) Skills
Narratives/Oral texts encompass such genres as stories, reports,
procedures, explanations, recounts and news telling. The common feature
of these genres is the linguistic structures that are used to tell and retell a
series of events in time order.
(Adapted from Health Department of Western Australia Teacher Modules, 2000 ; Holt & Spitz, 2000)
The Western-style narrative structure tends to be linear in
nature and uses a distinct model that may be difficult to
understand for Aboriginal and other CALD students. If a child
has hearing problems they are likely to have additional
problems with story grammar and descriptive vocabulary.
Impact of CHL on Phonological Processing
Phonological processing relates to the ability to use the sounds of a language to
process oral and written language, which allows us to form phonological codes
and access a word stored in our brain’s lexicon. Phonological awareness skills
(explicit awareness of sound structure and ability to manipulate structure of
words) are dependent on phonological processing skills.
Need to hear words to learn words – to ‘map’ words to objects
car? ar? bar? tar? …
Absence of second sound in two-letter blend (eg frog, block)
Absence of unstressed syllable(s) (banana, dinosaur, balloon)
Poor discrimination and identification of sounds
Impact of CHL on Phonological Processing
Australian English speech sounds with which ESL/ESD
speakers frequently are not familiar:
t, d, th
a, e, ir, ai
f, v, b, p, k, g
o, o-e, oo/u, u-e
s, z, sh, ch, j
u, i-e, oi, ai
ee, i, e, a
o, oar, ar, oi, ir
a, ar, u, ow
(Adapted from Making the Jump,
Catholic Education, Kimberley, 1997)
Consider the similarities between these sounds (voice, placement of lips
and tongue). If a child can’t hear a sound correctly he/she will have
considerable difficulty learning to say it correctly, particularly if he/she is
reliant on visual differentiation.
Impact of CHL on Metalinguistic Skills
Metalinguistics refers to the ability to use language to think, talk about, reflect
on and manipulate units of language.
Don’t know how to play with sounds and words, eg rhyming
Don’t know what a ‘word’ is so have difficulty understanding
word boundaries and segmenting sentences into words:
“Ontheweekend”, “smorning”
Impact of CHL on Metalinguistic Skills
Difficulty manipulating words within words (eg take ‘sun’
from sunshine); syllables in words (eg take ‘ing’ from doing);
sounds in words (eg boat has 3 sounds: b / oa / t; take ‘c’ from
coat); and blending sounds to make words (eg s – t – o – p)
Poor understanding that words are arbitrary symbols of a
language system – words usually don’t contain any hint of
their meaning
Problems working out how communication breaks down
Impact of CHL on Pragmatics
Pragmatics relates to the use and functions of language for communication.
Pragmatic awareness is the knowledge of conversational rules and includes
both verbal and non-verbal aspects.
(adapted from Holt & Spitz, 2000 ; Owens 1992)
Children with a hearing difficulties may have problems with:
Entering into a group, requesting, responding and taking
Initiating conversations
Understanding subtle social rules
Accepting others points of view and others’ feelings
Monitoring the listener
Impact of Hearing Loss on Socialisation
Children with hearing difficulties, however, are also likely to
present with social and emotional challenges due to:
Their own frustration and/or the frustration of their peers
Just not “getting it” i.e. the subtleties and unwritten rules of
social exchanges
Consider a child you know who has a
suspected/confirmed hearing loss.
What difficulties have you observed?
What are some strategies that have
been effective with this child?
Summary of Educational Impact of CHL
More than three infections under the age of 12 months is a significant risk factor
Even without a current ear infection children can still suffer the effects of a
history of conductive hearing loss
Poor ability to discriminate sounds in words and to hear words in words;
difficulty chunking words into individual parts; and relationship between own
sound repertoire and written alphabet is tenuous
Language learning difficult; frequently have restricted content, vocabulary,
language and confidence; prediction as a reading strategy is not functional
except with simple or familiar texts
Poor foundation for literacy and without help will fall further behind every year
Socialisation difficulties and behaviour problems are likely
The most debilitating aspects of deafness are secondary to the hearing
impairment itself
Strategies 1 to 6
Strategy 1
Organise your classroom to maximise
learning for children with conductive
hearing loss.
Strategy 2
Increase children’s understanding of
hearing problems.
Strategy 3
Focus on oral language skills as the
foundation for literacy.
Strategy 4
Focus on spoken sound systems.
Strategy 5
Link sounds to the written code.
Strategy 6
Analyse spelling errors to inform teaching.
Strategy 7
Implement a peer tutor program.
Conductive Hearing Loss Screening Tool
Developed by Aboriginal and Torres Strait Islander Education Support Unit
Learning Identifiers
Has learning difficulties
Demands a lot of teacher attention
Short attention span
Poor auditory memory and sequencing
Poor auditory association
Delayed language development
Delayed gross motor
Tends to respond to auditory clues only when given visual clues as well
Physical Identifiers
Behavioural Identifiers
Easily distracted
Appears not be listening
Poor socialisation skills
Often says “what”
Redness around the ear
Rubbing or pulling on the ear
Cupping the ear
Runny ear
Ooze from the ear
Re-occurring ear and chest infections
Complaining of sore ears and throat
Puts head to the side as if to shake out fluid
Mouth breather
Does not respond when asked questions
Responds in inappropriately
Is slow to respond to instructions
Watches other children to see what to do
Asks peers for confirmation what has been said
Sits close to the TV, etc
Sits on the outside so no expectation to participate
Quiet voice
Appears confused when there is a lot of noise
Poor gross motor skills
Is upset by loud or sudden noise
Often tired
Holds ears when there is excessive noise levels
Asks for the volume on the TV to be turned up or down
Speech Identifiers
Speaks in soft or loud voice
Difficulty in understanding speech
Difficulty communicating feelings
Language development below age
Mood changes when there is lots of noise
Has been absent lots of times
Loses interest during story time or direct instructions
Erratic classroom behaviour
Reluctant to participate
Confusion of words
Obvious indication that the child watches your face to lip read
Summary of Key Teacher Behaviours
Teamwork including the AIEO, district CIOs, audiologist/speech
pathologist/psychologist/occupational therapist….
Point of error analysis to understand the strength and weaknesses of a
child’s system.
Practice at the phonological level and oral level before moving into the
written code.
Research has shown that a drill orientation program works well with
young children while the meta approach is most effective with older
Use practice, repetition, buddying, small group work, pre-teaching and
one-to-one tutoring as tools.
Investigate amplification.
Model for Effective Practice in Schools
Curriculum, teaching and
School organisation, ethos
and environment
Whole School Approaches
Partnerships and services
Targeted Approaches for
Targeted Approaches for
Individual Case Work
Health Promoting Schools Framework
Curriculum, teaching
and learning
School organisation, ethos
and environment
Policy, planning and processes
Strategies 1 to 7
Professional development
IEPs …
Collaborative planning
Safe, supportive and inclusive
environment …
Parents, carers, family members; school health;
AIEOs, ALOs, C/MAEs; school psychologists;
specialist teachers; visiting teachers; audiologists;
speech pathologists; medical personnel …
Partnerships and
Where to from here?
your school and/or district and community
further professional development needs
the need for others to acquire knowledge and skills
partnerships that are already in place
opportunities to create new partnerships
Identify the first three steps that need to be taken in your
school community or at a local level to improve outcomes
for children who are experiencing or have experienced
Evaluation Time!
Thank you and close