Children with Cochlear Implants The New Generation Molly Lyon, M.A., CCC-A/SP LSLS AVEd Via Christi Hospitals January 21, 2011 Goals • Participants will learn about the development of the auditory cortex and the window of opportunity • Participants will gain knowledge of the development of listening skills in children Goals • Participants will learn about auditory assessments and the development of appropriate objectives • Participants will become knowledgeable of expected auditory outcomes and recognize red flags A New Decade • • • • Identification: Habilitation: Certification: Education: UNHS Technology LSLS Impact on programs National Goal – Early Hearing Detection and Intervention (EHDI) • • • • 1-3-6 Screen hearing by one month Confirm hearing loss by three months Early intervention by six months Percent of newborns screened for hearing loss Listening and Spoken Language Specialist Certification • Ensures professional has experience and knowledge in developing spoken language in children with hearing loss • Fall 2010, 600 LSL specialists in the country • Auditory Verbal Therapist (AVT) or Auditory Verbal Educator (AVEd) • Application process through AG Bell Academy – Continuing Education/Coursework – Mentoring – Examination A “tsunami” is occurring (Brown 2006) • North Carolina data: In 1995, 40% of families chose spoken language outcomes compared to 60% who chose a form of manual communication • In 2005, 85% of families chose spoken language outcomes Bergen County, NJ Public School Program (Murphy 2009) • 1997, 16% of elementary age and no secondary level students in the DHH program were pursuing a spoken language outcome • 2009, 73% of elementary and 68% secondary level students are learning through spoken language • An additional 100 students returned to their own home districts because of readiness to be mainstreamed Prenatal Hearing Research • Human cochlea has normal adult function after 20th week of gestation • Fetuses can hear a mother’s voice, but sound lacks tone because of attenuated high frequencies (Querleu, Renard, and Crepin, 1981) Age 0 • At birth, infants have heard sounds for four months - fluid-borne, but still true hearing • At birth, infants can discriminate a mother’s voice and show a preference to that voice (Decasper and Fifer, 1980) Neonatal Hearing Research • Neonates are responsive to the rhythm of speech and will move in synchrony (Condon and Sanders, 1974) • 1 to 4 month old infants can discriminate linguistic stress, location, fundamental frequency, intensity and duration (Spring and Dale, 1977) Neonatal Hearing Research • 1 month old infants can discriminate the difference between a voiced and voiceless consonant feature (pa vs. ba) (Eimas, et. al., 1972) • Lower frequencies tend to have a soothing or inhibiting effect, while higher frequencies tend to create more distress (Eisenberg, 1970) Neonatal Hearing • There is an orderly development of auditory responses in infants between 4 and 16 months • A normal hearing alert infant will respond in a predictable manner in accordance to mental age • The type of responses obtained are age specific depending on maturation of the infant Auditory Behavior Index McConnell and Ward (1967) Noise Makers (dB SPL) Speech (HL) 0 - 6 wks 50-70 40-60 6w - 4m 50-60 45 Eye-widening, eye-shift, eyeblink, quieting, beginning rudimentary head-turn by four months 4 - 7m 40-50 20 Head turn on lateral plane toward sound; listening attitude 7 - 9m 30-40 15 Direct localization of sound to side; indirectly below ear level Age Expected Response Eye-widening, eye-blink, stirring or arousal from sleep, startle 9 - 13 m 25-35 10 Direct localization of sound to side, directly below ear level, indirectly above ear level 13 - 16m 25-30 5 Direct localization of sound to side, above and below 16 - 21m 25 5 Direct localization of sound to side, above and below 21 - 24m 25 5 Direct localization of sound to side, above and below Neuroplasticity The brain’s availability and malleability to grow, develop and alter its structure as a function of external stimulation (C. Flexer) Really? Building Auditory Capacity • Current technologies provide auditory stimulation to children who have hearing loss • Current technologies take advantage of the neuroplasticity of the infant brain to “hard wire” efficient auditory brain pathways Absence of Sound • Neural deficits occur • Brain reorganizes itself to receive input from other senses, primarily vision • “Cross-modal” reorganization – reduces auditory neural capacity The Window is Small Neuroplasticity is greatest in the first 3 ½ years of life… • The goal of early auditory intervention is to maintain a child’s ability to learn through a developmental model • “Developmental synchrony” Hearing vs. Hearing loss • Listening skills are acquired in normal hearing infants transparently • Children with hearing loss achieve listening skills commensurate with – Effectiveness of hearing technologies, – Experience, and – Expectations Sample of a Vowel Chart boot-book-bone-ball-box-bye-bun-bella-bird-bad-bed-bake-bit-bee Impact of Hearing Loss on Phonological Processes • • • • • • Vowel substitutions Deletion of unstressed syllable – “di(na)sour” Deletion of initial syllable of word – (e)lephant Vowel insertion - “cuppa” for “cup” Cluster reduction – “fower” for “flower” Final consonant sound deletion – “cu” for “cup” At-Risk Language Components in Children with Hearing Loss • Plurals – Sounds like “s” (cats) – Sounds like “z” (dogs) – Sounds like “es” (horses) • Suffixes and Prefixes – Friendly, happiness – Widest, toxic – Disable, misbehave At-risk Language Components, Cont. • Past tense – Sounds like “t” (walked) – Sounds like “d” (bobbed) – Sounds like “ed” (beaded) • Possessives – The cat’s mitten – The truck’s wheel At-risk Language Components, Cont. • Copulas/Connecting words – – – – Is Of Have If • Present progressive – Going – Swimming • Pronouns and 3rd person – He, his – She, her – It • Vocabulary! The Early Catastrophe Hart and Risley, 1995 Words heard per hour Words heard per week Welfare Working Class Professional 616 1,251 2,153 62,000 125,000 215,000 Words heard per year 3.2 million 6.5 million 11.2 million Words heard by age 4 6.5 million 11.2 million 45 million Words Understood Age 2 years 2.5 years 3 years 4 years 5 years 6 years 7 years No. of Words 300 500 900 1,500 to 2,000 2,500 to 2,800 13,000 20,000 to 26,000 Note: Between ages 5 and 6, children are learning about 28 words a day Children with Hearing Loss – Two Listening Paradigms: • Developmental – – – – Technology – HA/CI Early intervention Parent education Developmental curriculums – Minimal didactic instruction • Remedial – – – – Technology – HA/CI Early intervention Parent education Listening hierarchy curriculums – Didactic instruction Listening Hierarchies Two listening approaches: - Focus on processing language and cognition – HOW audition is used - Focus on the complexity of the auditory signal – the nuts and bolts The Stages of Listening Listen, Learn and Talk, 2005 • Sound Awareness – Responds to music – Notices acoustic feedback – Indicates when hearing aid/cochlear implant is not working The Stages of Listening Listen, Learn and Talk, 2005 • Associating Meaning to Sound – Begins to recognize familiar phrases – Learning to listen to sounds – Recognizes own name The Stages of Listening Listen, Learn and Talk, 2005 • Imitation and Expansion – Child imitates language which has been modeled – Imitates mother’s babble play – Calls back and forth in calling games – Remembers and approximates sentences The Stages of Listening Listen, Learn and Talk, 2005 • Auditory Comprehension – Process and recall language – Auditory memory – Identifies sound parameters: onset, loudness, speed – Discriminates vowels, words, and phrases The Stages of Listening Listen, Learn and Talk, 2005 • Advanced Listening Skills – Localization – Distance listening – Background noise – Taped speech – Telephone – Auditory memory and sequencing Incidental Learning is Important • • • • • Developmental paradigm Let the natural happen Provide natural opportunities to listen Use everyday experiences and routines Given adequate audition, speech and language milestones are obtainable Incidental Learning: What Needs to Happen • • • • • • • Assistive technology is worn 100% Assistive technology is appropriately fitted Determine distance hearing ability Listening opportunities are meaningful Speech is slow and interesting Repeat, repeat, repeat Background noise is minimal Evidence of Incidental Learning • Child repeats something overheard in a conversation • Child uses a new word without being directly taught • Questions something heard on the radio • Re-auditorizes by “thinking out loud” Signature Auditory Behaviors • Reporting dead batteries, no sound, bad sound • Asking to wear implant/hearing aid • Reporting FM interference* • Child says “What?” • Signs of incidental learning • Overhears conversations • Reauditorizes by “thinking out loud” Norm Referenced Speech and Language Assessments • Used to guide instruction and monitor growth • Annual assessment is standard protocol with deaf and hard-of-hearing children • Target deficit areas • Goal is to close any existing gap • Auditory goals are needed if skills do not support incidental learning Ling Six Sounds: mm oo ah ee sh s These six sounds provide information covering the entire speech spectrum The seventh sound – silence: - reduces child’s concern for sounds “not heard” - adds honesty Ling Sounds Ling Sounds can provide information on: • Distance (speech bubble) • Detection • Segmental discrimination • Troubleshooting • Separate ear functioning Framework for Auditory Evaluation and Training • Norman Erber, 1982 • Glendonald Auditory Screening Procedure (GASP!) – Detection – Discrimination (same or different) – Identification – Comprehension Auditory Skills Hierarchy • • • • • • • Reflexive Detection (Awareness) Pattern (Suprasegmental) Word discrimination (Segmental) Vowel discrimination Consonant discrimination Connected speech Reflexive Response • • • • • Eye blink Moro response Involuntary response to sound Typically observed only to loud sound Assessed through observation Detection Child acknowledges sound • Involuntary – Eye widening – Changes in sucking – Head turn • Visual reinforcement audiometry • Voluntary – Conditioned response to sound – Indicate sound on/off • Play audiometry is a conditioned response Suprasegmental • Sounds or speech which vary in rhythm or melody (MRA – melody rhythm accent) • Rhythmic patterns more apparent than pitch • Long-short, loud-soft, high-low differences • Accented words and rising inflection for questions • Children enjoy suprasegmental variations • Parentese Segmental • Auditory events which have the same temporal and intonational patterns • Must have segmental abilities to discriminate speech sounds • Some children may have limited segmental abilities due to incomplete audibility of speech spectrum Connected Speech • The final goal – putting it all together – Rooted in successful acquisition of receptive language skills – Comprehension – Language growth through incidental learning Connected Speech Cautions and Red Flags: • Beware of contextual, situational, and visual clues Ex. “Johnny understands everything I say” (Did he See? Feel? Follow? Anticipate?) Listening Challenges Level of Redundancy • “Put your ______ on your feet.” • “That’s a ______ car!” • “Where’s the ______?” Determining Skill Level: Auditory Assessments Consider Format: • Parent questionnaire • Child elicited response – Imitation – Pointing/Selection Auditory Assessment Examples • Reflexive: Parent questionnaire/observation • Detection: Conditioned response audiogram, Ling Sounds • Suprasegmental: Early Speech Perception Auditory Assessment Examples • Segmental-word: Early Speech Perception • Segmental-vowel: Early Speech Perception, Ling • Segmental-consonant: Minimal Pairs Test, Ling • Connected Speech – Mr. Potato Head Test, Common Phrase Tests Break? Strategies • The best strategy is PREVENTION • Ensure auditory access from the beginning • Hearing technology worn 100% of all waking hours • Control the listening environment • Provide a “listening atmosphere” as learning to listen does not just happen by chance Auditory – Verbal Listening Strategies and Techniques Teresa Caraway, Hearts for Hearing • Be a Director – Direct the child to listen • Be a Birddog – Point out sound: “I hear that!” • Hear It Before You See It: – Auditory first – Direct attention toward the object – Use the handcue Continued • Play by Play – Use familiar phrases – Comment on what child is doing – Be a radio commentator • Keep Them On Their Toes! – Using sabotage – Using others to model Continued • It’s Your Turn! – – – – – – – Expect a response from the child Pause and wait for a response Look expectantly … lean in Use the handcue to indicate a turn Use the parent as a model Use You could say…” Use Auditory Closure Continued • Make it Easier – – – – Control the listening environment Move closer to the child Change task from open set to closed set Use acoustic highlighting – whisper, sing, vary pitch or intonation, emphasize sound or word Continued • Create a Listening Sandwich – Put it back into listening • Beyond the Here and Now – Model and expand the child’s utterances – Provide extensions to the child’s utterances • What Did You Hear? Continued • Help Me But Don’t Tell Me – – – – Label by category Ask for or provide information Provide rhyming words Suggest opposites Learning Listening Skills • Didactic Strategies - Often remedial - Structured - Goal oriented - Provides measurable outcomes - Addresses deficiencies - Is inefficient for learning a native language Why use a Didactic Approach? • Builds skills and confidence in listening • Controlled listening tasks allows for a high rate of success • Helps the child learn and identify meaningful sound differences Why use a Didactic Approach? • Enables child to transfer skills to less favorable listening environments • But, it is NOT needed for young children if able to acquire speech following developmental paradigm Expected CI Progress Central Institute for the Deaf findings: Almost Immediately After Activation - Detection of sound - Detects Ling 6 sounds - Detects environmental sounds 4-6 Month Post Activation • Identifies 35 to 50 words • Names about 75% of these words • Produces approximations of 85% of these words in imitation • Uses single words spontaneously 1 Year Post Activation • Identifies 75-100 words • Produces at least 90% of these words • Understands and produces some early developing two-word combinations • Uses single words, common phrases and expressions spontaneously 15-18 Months Post Activation • A language explosion seems to occur • Vocabulary is learned in a variety of environments • Vocabulary increases to more than 250 words • Comprehension of simple 3-4 word sentences • Uses a variety of 2-word combinations spontaneously Listening and Red Flags Oct. 2008, Cleveland, OH A.M. Robbins • Listening development is a sequence of cumulative skills • Skills build on each other • One skill depends on the acquisition of earlier skills Listening and Red Flags Oct. 2008, Cleveland, OH A.M. Robbins • Early delays often lead to long-term delays • Long-term delays may lead to life-long deficits • Earlier concerns raised, sooner address What is considered a Red Flag? • Red Flag is a reminder: PAY ATTENTION TO THIS • Not a diagnosis of a problem • Not a statement of permanent disability • Data indicate benchmarks are different for CI children depending on age of CI and previous auditory experiences Red Flags – Lack of CI Progress: Group 1: Children implanted age 4 or earlier • Establish full-time device use by 1 month post-implant • Evidence changes in vocalization after 3 months of device use • Alert to name spontaneously 25% of time after 3 months CI experience CI Progress – cont. (Group 1) • Spontaneously alert to name half of time by 6 months of device use • Alert spontaneously to a few environmental sounds after 6 months of use • Performance in booth consistent with real life by 9 months post-CI • Evidence of meaning derived from sound after 12 months of use • Major jump in language after 12 months CI use Auditory Benchmarks for Group 2: CI at 5 yrs or >; some residual hrg; consistent HA use pre-CI; primarily oral communicator • 1 mo post-stim: Full-time CI use • 3 mo post-stim: Understands some words/phrases in closed set • 6 mo post-stim: Understands many words in closed set, spon. alerts to name; understands familiar phrases in everyday situations listening alone • 9 mo post: Spon. recognizes own name vs others • 12 mo post-stim: knows meaning of auditory signals; major jump in language Auditory Benchmarks for Group 3: CI at 5 yrs or >; little or no residual hrg; poor speech perception; highly dependent on sign • 1 mo post-stim: Full-time CI use • 3 mo post-stim: Discriminates PATTERNS of speech • 6 mos post-stim: Understands a few words closed set, alerts to loud sounds –may not know meaning; begins to spon. detect name; • 9 mos post: Know when CI not working • 12 mo post-stim: Understands many words in closed set; may spon. understand familiar phrases in context; Spon. responds to name half of the time; Noticeable improvement in language Red Flag Response reflect amount and length of delay •One-Flag Response: Child is 3 months behind in one skill at an interval (mild concern) • Two-Flag Response: Child is delayed by 6 months or more on multiple skills (serious concern) How to Respond to Red Flags • Share ideas with child’s parents • Confirm child wears CI during waking hrs • Contact CI center regarding possible equipment/programming changes • Assess that home environment creates a need for child to use the skill How to Respond to Two Red Flags In addition to previous suggestions: • Change teaching methods/techniques • Add sensory modality • Consult with a colleague for new ideas • Consider the possibility of additional disabilities Time for Questions? Thanks for LISTENING! Bibliography • Birnholz, J.C., & Benacerraf, B.R. (1983). The development of human fetal hearing. Science, 22, 516-518. • Brown C. (2006). Early intervention: Strategies for public and private sector collaboration. Paper presented at the 2006 Convention of the Alexander Graham Bell Association for the Deaf and Hard of Hearing, Pittsburgh PA. • Cole, E.B., and Flexer, C. (2008). Children with hearing loss: Developing listening and talking birth to six. San Diego, CA: Plural Publishing. • Condon, W.W., & Sander, L.W. (1974). Neonate movement is synchronized with adult speech: Interactional participation and language structure. Science, 183, 99-101. • DeCasper, J.J., & Fifer, W.P. (1980). Of human bonding: Newborns prefer their mothers’ voices. Science, 208, 11741176. • Eimas, P.D., Siqueland, E.R., Juscyzk, P., et al. (1972). Speech perception in infants. Science, 171, 303. • Eisenberg, R.B. (1970). The development of hearing in man: An Assessment of current status. ASHA, 12, 119-123. • Erber, N. (1982). Auditory Training. Wash. D.C.: Alexander Graham Bell Assoc. for the Deaf. • Estabrooks, W. (1998). Cochlear Implant for Kids. Alexander Graham Bell Association for the Deaf. • Flexer, C. (1999). Facilitating hearing and listening in young children (2nd ed). San Diego, CA: Singular Publishing Group, Inc. • Hart, B., & Risley, R. T. (1995). Meaningful differences in the everyday experience of young American children. Baltimore: Paul H. Brookes. • Ling, D. (2002). Speech and the hearing impaired child (2nd ed.). Washington, DC: Alexander Graham Bell Association for the Deaf and Hard of Hearing. • McConnell, F., & Ward, P.H. (1967). Deafness in childhood. Nashville, TN: Vanderbilt University Press • Murphy, C. (2009). Bergen County – A model public school listening and spoken language program. Voices, 16, 22-24. • Northern, J.L., & Downs, M.P. (2002). Hearing in children (5th ed.). Baltimore: Lippincott Williams & Wilkins. • Querleu, Q., Renard, Z., & Crepin, G. (1981). Percepetion auditive et reactivite foetale aux stimulations sonores. Journal de Gynecologie, Obstetrique et Bioligie de la Reproduction, 10, 307-314. • Robbins, A.M. (2005). Clinical red flags for slow progress in children with cochlear implants, Loud & Clear, Valenica, CA: Advanced Bionics:1. • Robbins, A.M., Koch, D.B., Osberger, M.J., ZimmermanPhillips, S., & Kishon-Rabin, L. (2004). Effect o age at cochlear implantation on auditory skill development in infants and toddlers. Archives of Otolaryngology-Head & Neck surgery, 130(5), 570-574. • Sindrey, D. (2002). Listening games for littles (2nd ed). London, Canada: WordPlay Publications.