Auditory Development

1. Auditory Development In Children with Hearing Loss and Additional Disabilities

2. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Purpose of Presentation Discuss strategies for working with children who are learning to listen, and who have special circumstances Multiple Disabilities Motor & Structural Visual Cognitive Language English as a Second Language Auditory Neuropathy ADHD Approximately 70% of children with hearing loss have an additional disability. Reasons for this are varied. Review of pre and post natal history indicates that often we are working with Miracle Babies. Children who without the advances in prenatal care, and postnatal Newborn Intensive Care Units, would otherwise not be with us. An infant�s history in NICU is a significant indicator that the child will have challenges at some point in their lifetime. MULTIPLE DISABILITIES: I have grossly grouped �disabilities� into four categories Motor � includes cerebral palsy, Structural includes every thing from craniofacial anomalies (everything from treacher Collins to Waardenburg and then some. Visual, speaks for itself, and you will/have someone address that. I will address techniques for helping children with vision impairment to learn to listen. Cognitive, remember that many of our students may not qualify for �cognitive� disability, they may not be classified as mild or moderately intellecctually delayed, but are borderline. Language � I will referr to both language delay and language impairment as it relates to audition. ESL � several of our students may have caretakers with all levels of fluency in a language other than English. If the parent does not have a high school diploma, what could their language ability be in their native tongue. Children need good language models, no matter what the language is. AN � is believed to be a dis-synchronous firing of the neurons in the cochlea.Approximately 70% of children with hearing loss have an additional disability. Reasons for this are varied. Review of pre and post natal history indicates that often we are working with Miracle Babies. Children who without the advances in prenatal care, and postnatal Newborn Intensive Care Units, would otherwise not be with us. An infant�s history in NICU is a significant indicator that the child will have challenges at some point in their lifetime. MULTIPLE DISABILITIES: I have grossly grouped �disabilities� into four categories Motor � includes cerebral palsy, Structural includes every thing from craniofacial anomalies (everything from treacher Collins to Waardenburg and then some. Visual, speaks for itself, and you will/have someone address that. I will address techniques for helping children with vision impairment to learn to listen. Cognitive, remember that many of our students may not qualify for �cognitive� disability, they may not be classified as mild or moderately intellecctually delayed, but are borderline. Language � I will referr to both language delay and language impairment as it relates to audition. ESL � several of our students may have caretakers with all levels of fluency in a language other than English. If the parent does not have a high school diploma, what could their language ability be in their native tongue. Children need good language models, no matter what the language is. AN � is believed to be a dis-synchronous firing of the neurons in the cochlea.

3. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Outline Review: How we hear Hearing Instrument Technology Or �They CAN hear you now Audiograms and what they tell us Or � Audiograms and what they don�t tell us Auditory Development Re-Evaluating our Definition of Success Realistic Expectations Techniques Or � Changing �I talk!� into the Nitty Gritty of everyday every moment learning to listen Here�s what wer�re going to do in the next hour and a half. I�m going to rush through the first three. Stop me if you have questions.Here�s what wer�re going to do in the next hour and a half. I�m going to rush through the first three. Stop me if you have questions.

4. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum

5. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum

6. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Amplification Access to sound What sounds: speech spectrum all � some � none Environmental Expect child to hear A word on technology Digital hearing aids Cochlear implants

7. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Hearing Aid Technology & FM

8. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Advanced Bionics Processors If you were implanted with our first, second or third generation cochlear implant systems (implanted between 1991 and 2002), you've seen up to five new sound processor technologies, and a host of other product improvements. These product enhancements enable you to take advantage of new advances that help you get the most out of your cochlear implant. Below, you will see a sample of additional products we are developing for you. New Ear Level ProcessorWe've been listening to users of CII BTE and Platinum BTE processors, who have asked for improved battery life, more attractive styling, and easier usability of their ear-level processor. We are currently gathering input from audiologists and implant users to determine which features are most important for a new ear-level processor. Some of the features that have been noted include :  Low-Profile HeadpieceThe new headpiece substantially smaller diameter and significantly lower profile than the current headpiece used with the CII BTE and Platinum BTE. It will also be significantly lighter and less noticeable. Direct Connect Audio InputThe new audio input interfacing with assistive listening technology. Removing your earhook from processor will be very convenient.  New PowerCel TechnologyThe new PowerCel technology will use improved chemistry to deliver a 28% increase in operating time and provide longer overall life. You can also see how this improvement is being integrated into a new PowerCel for the CII BTE and Platinum BTE by continuing on to the next page. SMALL in size with a soft, flexible shape and low profile, the HiRes 90K benefits both the surgeon and the implant user, and is ideal for infants and young children.SIMPLE for your surgeon to implant. Its thin profile is ideal for minimally invasive surgical techniques. PROVEN CII electronics allow access to HiResolution� Sound. Physical Specifications: Titanium case: 5.5 mm total profile, with only a 2.5 mm prominence. Receiver/transmitter coil: 3-turn gold wire with platinum helix shielding.Magnet: Removing the magnet for MRI is under clinical evaluation.Housing: 28 mm x 56 mm flexible silicone x 5.5. Internal Implant Technical Specifications: Information update rate: 90,000 updates per second Stimulation rate: 83,000 pulses per second Independent output circuits: 16 Information channels: 16 with current HiResolution software Internal Memory Stimulation Strategies: Simultaneous, partially simultaneous, and non-simultaneous options including HiRes (HiRes-P and HiRes-S) and emulation of MPS and CIS with current software. Pulsatile or analog waveforms Monopolar or bipolar coupling (expandable to multi-polar with future software *) Patented HiFocus Electrode: 16 electrode contacts that are designed to focus stimulation toward the nerve fibers Diagnostics: Neural Response Imaging (NRI) Telemetry: Bi-Directional communication link * under development If you were implanted with our first, second or third generation cochlear implant systems (implanted between 1991 and 2002), you've seen up to five new sound processor technologies, and a host of other product improvements. These product enhancements enable you to take advantage of new advances that help you get the most out of your cochlear implant. Below, you will see a sample of additional products we are developing for you.

9. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum FM Advances in Technology

10. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Aided Audiogram They can hear but don�t know what they are hearing They can hear but don�t know what they are hearing

11. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Aided Audiogram, CI Impts of consistent amp Deaf Qualifications for AASD Impossible to predict how someone will do with amplification They can hear but don�t know what they are hearing Impts of consistent amp Deaf Qualifications for AASD Impossible to predict how someone will do with amplification They can hear but don�t know what they are hearing

12. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Motor homunculus A figurative representation of the body map encoded in primary motor cortex in the parietal lobe. Body parts with complex repertories of fine movement, like the hand, require more cortical space in M1, while body parts with relatively simpler movements, like the hip, require less cortical space. Motor homunculus A figurative representation of the body map encoded in primary motor cortex in the parietal lobe. Body parts with complex repertories of fine movement, like the hand, require more cortical space in M1, while body parts with relatively simpler movements, like the hip, require less cortical space.

13. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Audiogram with Ling Sounds Unaided Hearing Aided with hearing aids, and cochlear implants Audiogram, is a graph of hearing sensitivity. It simply tells us the threshold of audibility. It does not tell us what the child understands. Speech Perception: SRT, SAT, Word Discrimination, Open Set, Closed Set All speech perception testing tries to assess in a diagnostic manner how well the individual can repeat what they hear. Unaided Hearing Aided with hearing aids, and cochlear implants Audiogram, is a graph of hearing sensitivity. It simply tells us the threshold of audibility. It does not tell us what the child understands. Speech Perception: SRT, SAT, Word Discrimination, Open Set, Closed Set All speech perception testing tries to assess in a diagnostic manner how well the individual can repeat what they hear.

14. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Auditory Development Within the Brain & Nervous System Auditory Attention > Awareness > Auditory Memory > Auditory Comprehension > Auditory Application Learned behavior Receptive: Reaction > Startle, Attention, Learn associations (What�s that sound? Do I need to react?) Expressive: What does my reaction do for me? FOOD, comfort. Interest, exploring the world. Association from very basis survival to pleasure, needed stimulation such as mouthing. Basics of hearing for communication and language are learned by the first 2 years of life. Acoustic cues for syllable structure, timing of syllables, melody in question forms, anger, etc. grammatical markers-morphemes (plurals, past perfect) When first amplified = Hearing Birthday Miss match of cognitive age : hearing age LEARNED BEHAVIOR Methods, many: Bombardment vs, motherese ...Multisensory! + what is experienced to what is already known Comprehension Auditory Attention > Awareness > Auditory Memory > Auditory Comprehension > Auditory Application Learned behavior Receptive: Reaction > Startle, Attention, Learn associations (What�s that sound? Do I need to react?) Expressive: What does my reaction do for me? FOOD, comfort. Interest, exploring the world. Association from very basis survival to pleasure, needed stimulation such as mouthing. Basics of hearing for communication and language are learned by the first 2 years of life. Acoustic cues for syllable structure, timing of syllables, melody in question forms, anger, etc. grammatical markers-morphemes (plurals, past perfect) When first amplified = Hearing Birthday Miss match of cognitive age : hearing age LEARNED BEHAVIOR Methods, many: Bombardment vs, motherese ...Multisensory! + what is experienced to what is already known Comprehension

15. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Auditory Brain Development - Birth to 5 years What demonstrated? Receptive Expressive How is it developed? Internal & External Forces Motivation Expectation Aud Development Attention >Discrimination, Memory, Comprehension, Application Learned Behavior Hearing Birthday Miss match Cognitive Age : Hearing Age How is this addressed? Learned Behavior, Motivation, It is not enough to slap hearing aids on and say go and you shal hear. Yes they hear but but do not understand and need each stage of auditory development to become Exposure Many methods Multisensory When Each Stage of normal development is Aud Development Attention >Discrimination, Memory, Comprehension, Application Learned Behavior Hearing Birthday Miss match Cognitive Age : Hearing Age How is this addressed? Learned Behavior, Motivation, It is not enough to slap hearing aids on and say go and you shal hear. Yes they hear but but do not understand and need each stage of auditory development to become Exposure Many methods Multisensory When Each Stage of normal development is

16. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Auditory Brain Development � Birth to 5 cont. NOT AUTOMATIC LEARNED BEHAVIOR HEARING, HARD OF HEARING, OR DEAF, with special needs...IS THERE A DIFFERENCE?

17. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Cultural issues aside Remain CHILD focused We are all here as educators who are interested in providing individualized education, individualized development, with no limits on the amount of progress an individual student can make while they experience life and education with us. Language, Speech, Hearing, and or Visual Learning Style Continuum Children with hearing loss, like all learners, process and organize their world along a learning syle continuum ranging from fully visual to fully auditory. One way to monitor progress with amplification is to observe the student�s movements along an auditory-visual continuum, in various listening conditions and with increased listening experience over time. Take the handout: Where are your students now? Think about your present teaching style and place your name above the style you use with your current class(es). Now write your name on the first line where ever you personalyly think you fall on the learning style continuum. Write each studen�ts name where you perceive them to be right now Assignment, Employ Expectations for listening in you classroom, and Other techniques We will discuss. In about 3 � 4 months review this handout and see what progress your students make. You must be willing to move them, and help them learn to use their hearing.Cultural issues aside Remain CHILD focused We are all here as educators who are interested in providing individualized education, individualized development, with no limits on the amount of progress an individual student can make while they experience life and education with us. Language, Speech, Hearing, and or Visual Learning Style Continuum Children with hearing loss, like all learners, process and organize their world along a learning syle continuum ranging from fully visual to fully auditory. One way to monitor progress with amplification is to observe the student�s movements along an auditory-visual continuum, in various listening conditions and with increased listening experience over time. Take the handout: Where are your students now? Think about your present teaching style and place your name above the style you use with your current class(es). Now write your name on the first line where ever you personalyly think you fall on the learning style continuum. Write each studen�ts name where you perceive them to be right now Assignment, Employ Expectations for listening in you classroom, and Other techniques We will discuss. In about 3 � 4 months review this handout and see what progress your students make. You must be willing to move them, and help them learn to use their hearing.

18. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Factors that Affect Progress in Comprehensive Auditory Development Amplification Environment Teaching Child

19. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Amplification: What to Do Wear hearing instrument every day, all day Communicate with audiologist May need a Map (CI) or Program (HA) change Know what child can perceive through device and be aware of changes Report changes to audiologist

20. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Environment Room Acoustics: Poor Signal to Noise Ratio Audiotechnotalk for �sound is bouncing off the walls.� 2001 ANSI Standards for Classroom Acoustics In the mean time�quiet classroom

21. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Child Cognitive deficit Language learning problem Attention � can�t stay on task Oral-motor Poor short-term memory Syndromes & Genetics A word on Syndromes, if your child has a diagnosed syndrome, review expressions, expectations, and remember that there is variable expression.A word on Syndromes, if your child has a diagnosed syndrome, review expressions, expectations, and remember that there is variable expression.

22. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Teaching BUT I TALK!!! Expectation for listening, you must create it, throughout the day Take the training out of auditory training Ten Auditory Processes by L. Daniel. Too global focus on expressive language Environment does not provide enough opportunity for talking and for practice Language too high or too low Not capitalizing on child�s skills and strengths Not focusing instruction on child�s weaknesses Brainstorm ways to create expectations for listening: What�s that sound? Point to your ear, Lean toward student Turn ear toward student Call attention to sound Change the way you teach, if they don�t get it, and you have done it again and again, change what you are doing. Whose problem is it? Take ownership before simply blaming it on the child. Communicate with SLP Build on skills child has Work on skills child needs More emphasis on expressive More opportunity to talk More focused and structured instruction Move in smaller increments Master prerequisite skill before teaching next step� Change the way you teach Whose problem is it? Too global focus on expressive language Environment does not provide enough opportunity for talking and for practice Language too high or too low Not capitalizing on child�s skills and strengths Not focusing instruction on child�s weaknesses Brainstorm ways to create expectations for listening: What�s that sound? Point to your ear, Lean toward student Turn ear toward student Call attention to sound Change the way you teach, if they don�t get it, and you have done it again and again, change what you are doing. Whose problem is it? Take ownership before simply blaming it on the child. Communicate with SLP Build on skills child has Work on skills child needs More emphasis on expressive More opportunity to talk More focused and structured instruction Move in smaller increments Master prerequisite skill before teaching next step� Change the way you teach Whose problem is it?

23. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Auditory development as it is related to speech & language development

24. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Ten Auditory Processes

25. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Ten Auditory Processes

26. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Ten Auditory Processes

27. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Music can (�and is only a small part of auditory integration!) Reinforce active listening skills Stimulate verbal responses Stimulate motor responses Be easily adapted to any age, ability, or culture Release and nurture creativity Be a non-verbal/pre-verbal means of communication Motivate Build a sense of community Music has a very large acoustic spectrum The repetitive nature of choruses and major tune reinforces auditory memory. In children with autism and normal hearing, audition is often the weakest sense. Music helps to make connections for children with frontal lobe problems, where Speech and Sign are fleeting. Music and print or pictures helps make that connection. Music has a very large acoustic spectrum The repetitive nature of choruses and major tune reinforces auditory memory. In children with autism and normal hearing, audition is often the weakest sense. Music helps to make connections for children with frontal lobe problems, where Speech and Sign are fleeting. Music and print or pictures helps make that connection.

28. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Audition, Speech and MusicConnections and Differences SPEECH Intonation Rate Stress Rhythm Duration Produced by voice Speech decoding (temporal) on left auditory cortical regions MUSIC Intonation Tempo Accent Rhythm Duration Produced by voice and instruments Pitch discrimination (frequency) on right cortical regions Music is predictive. Chorous is repeated. Each verse basically follows the same tune. Even Beethoven�s Fifth Symphony, da da da da theme is echoed throughout the entire piece.Music is predictive. Chorous is repeated. Each verse basically follows the same tune. Even Beethoven�s Fifth Symphony, da da da da theme is echoed throughout the entire piece.

29. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Musical Development Neurotypical Children. For children with hearing loss, base this on their hearing age.Neurotypical Children. For children with hearing loss, base this on their hearing age.

30. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Musical Activities Steady Beat Sing/Stop Sing/Hum Pitch Imitation Pitch Discrimination Hold plush toy and tap back to reinforce steady beat. Intervals ___ ma ___ ma Beat competency improves Pat your lap: Hickory Dickory Dock pat the beat Do not clap, requires too much eye had coordination, therefore tapping the body is best. Rhythm is harder Stand on feet and walk. Folk music is best, very repetitive & tells a story Tap body parts & then call out the part Using visual wooden spoon Spoon open mouth and closed. Hold plush toy and tap back to reinforce steady beat. Intervals ___ ma ___ ma Beat competency improves Pat your lap: Hickory Dickory Dock pat the beat Do not clap, requires too much eye had coordination, therefore tapping the body is best. Rhythm is harder Stand on feet and walk. Folk music is best, very repetitive & tells a story Tap body parts & then call out the part Using visual wooden spoon Spoon open mouth and closed.

31. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Building Blocks for Success Expectations Programming Equipment Management Building Blocks for Success Expectations Programming, not just the IEP goals Equipment ManagementBuilding Blocks for Success Expectations Programming, not just the IEP goals Equipment Management

32. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Establishing Expectations Uncertainty Short and long term goals should be discussed early and often Consensus across team May need to use a different �measuring stick� Rate of Progress Augmentative Communication

33. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum The �Cement� 90/10 Concept Experience Teamwork Thinking Team Work: Share what you know about the child with SLP, Audiologist, Parent How does the child express happiness? How does the child express discomfort or fear? Favorite toys & activities Favorite foods What motivates the child What scares the child What is their best time of day? Children with Multiple disabilities Disuss flexible or unusual scheduling options Be prepared for a longer time course Advise regarding optimal positioning Team Work: Share what you know about the child with SLP, Audiologist, Parent How does the child express happiness? How does the child express discomfort or fear? Favorite toys & activities Favorite foods What motivates the child What scares the child What is their best time of day? Children with Multiple disabilities Disuss flexible or unusual scheduling options Be prepared for a longer time course Advise regarding optimal positioning

34. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Equipment Management Considerations for Children with Multiple Disabilities Creativity may be called for in device positioning Traditional options Earmold Otoclip Huggie or Mic Lock Tubing Non Traditional options Hats Huggie Head Contralateral microphone placement Velcro Pin processor to collar

35. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Summary Special children have unique needs. With flexibility, creativity, and teamwork, guided by experience� 1,000,000:1 chance need not be the odds of achieving rewarding use of hearing in challenging cases.

36. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Association Method Mildred McGinnis, 1963, Aphasic Children published by A.G. Bell Association/integration of attention, retention and recall Principles such as Preceptive follows expressive, mastery of material, no prompting. Rote memory builds auditory memory Multi-sensory: Speechread it, Read it, Say it (rote memory builds auditory memory), Listen for it, write it (copy, then memory writing) Instructional content Systematic!!!!! Verticle Elements: Level 1: Phonemes, Syllable drills, Words (broken, Blended), Articles Level 2: Repetivtive Sentnces, Corresponding questions, stories, parts of speech (adjectives, Prepositions, etcl) Level 3 Verbe tenses, direct and indirect disourse, experience stoies, imagination stories, academics Horizontal Elements some are included within th vertical elements Correlaive programs Math, Writing, Calendar, Sensory, etc. Multi-sensory: Speechread it, Read it, Say it (rote memory builds auditory memory), Listen for it, write it (copy, then memory writing) Instructional content Systematic!!!!! Verticle Elements: Level 1: Phonemes, Syllable drills, Words (broken, Blended), Articles Level 2: Repetivtive Sentnces, Corresponding questions, stories, parts of speech (adjectives, Prepositions, etcl) Level 3 Verbe tenses, direct and indirect disourse, experience stoies, imagination stories, academics Horizontal Elements some are included within th vertical elements Correlaive programs Math, Writing, Calendar, Sensory, etc.

37. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Differences in Learners10 vocabulary words Fast learner Day 1 � Introduce all 10 words in conversational setting Day 2 � Check comprehension � child gets all but one or two Day 3 � Child knows all words pretty well Continued practice for mastery

38. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Differences in Learners10 vocabulary words Average Learner Introduce 5 words individually and child says each Add other words gradually next two days Third day child comprehends all words and can name at least half Can name all easily and quickly by end of the week

39. July 20, 2004 Terese I. Huber, MA. CCC-A Georgia Deaf Education Achievement Forum Differences in Learners10 vocabulary words Slow Learner Introduce 3 or 4 words Practice in sets with know words Pull out and practice those child is forgetting Add a new word each day Continue to practice ones already introduced