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
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•
•
•
Identification:
Habilitation:
Certification:
Education:
UNHS
Technology
LSLS
Impact on programs
National Goal –
Early Hearing Detection and
Intervention (EHDI)
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•
•
•
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
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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
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–
–
–
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
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–
–
–
Technology – HA/CI
Early intervention
Parent education
Developmental
curriculums
– Minimal didactic
instruction
• Remedial
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–
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
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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
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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
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•
•
Reflexive
Detection (Awareness)
Pattern (Suprasegmental)
Word discrimination (Segmental)
Vowel discrimination
Consonant discrimination
Connected speech
Reflexive Response
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•
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•
•
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!
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–
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–
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–
–
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
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–
–
–
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
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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.:
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• 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.
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