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Management of Unilateral Hearing Loss for Audiologists and Speech Pathologists. Joey Ford, M.S., CCC-A Megan Friedman M.S., CCC-SLP, LSLS Cert. AVEd. 1978 Northern & Downs Hearing in Children.

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management of unilateral hearing loss for audiologists and speech pathologists

Management of Unilateral Hearing Loss for Audiologists and Speech Pathologists

Joey Ford, M.S., CCC-A

Megan Friedman M.S., CCC-SLP, LSLS Cert. AVEd

1978 northern downs hearing in children
1978 Northern & DownsHearing in Children
  • Audiologists and otolaryngologists are not usually concerned over such deafness [unilateral], other than to identify its etiology and assure parents that there will be no handicap.
what has changed since 1978
What has changed since 1978
  • In the 1980s research really got going in this area.
      • Fowler, 1960; Harford & Barry, 1965
      • Golas & Wark, 1967; Green & Henning, 1969
  • There has been a steady stream of research since the 1980s showing that UHL causes delays and challenges in many areas.
current issues
Current Issues
  • Earlier identification
    • Birth vs. school age
  • Little consensus among professionals
    • Whether to aid at all or how to aid
  • Little research on when to aid
    • Is early better, if so, how early
evidence based practice
Evidence Based Practice
  • Evidence Based Practice is ever changing
    • New research
      • Overwhelming evidence of the detrimental effects
    • New technology
      • Cochlear Baha, Oticon Medical Ponto and ear-level FM
    • More experience
      • Patients who are successful or unsuccessful with each technology and families who say, “I wish we had done this sooner.”
jcih 2007 position statement
JCIH 2007 Position Statement
  • Infants and young children with unilateral hearing loss should also be assessed for appropriateness of hearing aid fitting. Depending on the degree of residual hearing in unilateral loss, a hearing aid may or may not be indicated. Use of “contralateral routing of signals” amplification for unilateral hearing loss in children is not recommended (American Academy of Audiology, 2003). Research is currently underway to determine how to best manage unilateral hearing loss in infants and young children.
impact of unilataral hearing loss
Impact of Unilataral Hearing Loss
  • Localization
    • 2 ears work together to find the source of sound
      • The lost cell phone effect
  • Binaural Squelch
    • The ability of 2 ears to “tune in” to a sound
      • The cocktail party effect
effects of unilateral hearing loss
Effects of Unilateral Hearing Loss
  • Binaural summation
    • Two ears hear sound at a quieter level than each ear individually.
      • This is important for those of us with normal hearing to remember.
  • Head Shadow Effect
    • Lateralized sound is received to one ear as a direct signal, the other ear is in the “head shadow”
      • Low pitch sounds wrap around the head easier than highs
uhl in the real world
UHL in the Real World
  • Speech/Language
  • Cognitive
  • Social
  • Psychological
mcleod upfold taylor 2008
McLeod, Upfold, Taylor, 2008
  • Self-reported difficulties of adults with UHL
    • Emphasis on post-surgical vestibular schwannoma
  • These adults reported significant difficulty
    • Hearing in background noise
    • Hearing when someone was on their “bad side”
    • Localizing sound
      • They also reported more difficulty even when sitting directly across the table from someone.
priwin et al 2007
Priwin, et al, 2007
  • 57 subjects aged 3 to 80 with UHL (max cond)
  • Conversation in quiet
    • 26% had slight to moderate difficulty
  • Conversation with many people
    • 77% slight to moderate difficulty; 14% severe
  • Conversation with one person in traffic noise
    • 63% slight to moderate; 19% severe
  • Localization
    • 47% slight to moderate; 37% severe
signal to noise ratio
Signal-to-noise ratio
  • Normal hearing children require a greater SNR than normal hearing (NH) adults to discriminate speech (Lieu, 2004).
    • Auditory cortex not fully developed
    • better language base
  • Children with UHL require a greater SNR than children with NH (Ruscetta, et al, 2005).
    • Think about your child’s classroom.
    • A child at recess
    • A child at Pump It Up or Chuck E. Cheese
speech and language
Speech and Language
  • Shepard et al., 1981
    • 1250 children in Iowa with hearing loss
    • Academic records were reviewed
    • Preschool through high school
    • Categorized by degree and type of loss
shepard et al 1981
Shepard et al., 1981
  • For children with minimal hearing loss
    • IQ and achievement test scores were only slightly reduced compared to normal hearing peers, if at all.
    • Large gap between language age and chronological age, which increased with grade level
      • By age 8, the vocabulary of some of these children was as much as 3 years behind that of their normal hearing peers.
shepard et al 19811
Shepard et al., 1981
  • Specifically, those with UHL exhibited
    • Smaller vocabulary
    • Less complex sentence structure
  • Incidental learning
    • Over hearing
davis et al 1986
Davis, et al., 1986
  • Evaluated social, academic and communication status of 40 children age 5-18 with losses from mild to moderately severe.
    • Found that their scores on standard audiologic speech perception tests was highly correlated with degree of loss.
    • Similar correlation was not seen between degree of loss and several language measures.
      • Corroborated by Bess & Tharpe 1986, for reading, math and spelling scores of children with unilateral loss only.
educational cognitive impact
Educational/Cognitive Impact
  • Bess, et al., 1998
    • Reviewed the records of 1228 children in grades 3, 6 and 9.
      • 5.4% of those children had minimal hearing loss
      • 30% of the 3rd graders with minimal hearing loss had repeated a grade
      • By 9th grade, 50% had repeated a grade
bess and tharpe 1986
Bess and Tharpe 1986
  • 60 children with unilateral SNHL
  • Reviewed medical & educational records
    • Mean age of ID 5.5 years
    • Etiology: 52% unknown, 24% viruses, 15% meningitis, 8% head trauma
    • Of the 60 children
      • 35% had failed at least one grade
      • 13% got resource help one or more years
      • 20% exhibited behavior problems per teacher report
educational cognitive impact1
Educational/Cognitive Impact
  • Culbertson & Gilbert, 1986
    • Found significant differences between IQ scores of children with severe to profound unilateral SNHL and those with mild to moderate unilateral SNHL.
multi tasking
  • McFadden & Pittman, 2008
    • 10 kids with minimal loss/10 with normal hearing
      • Unilateral, mild bilateral or high frequency
    • Categorized common words (primary task) while completing dot-to-dot games (secondary task)
mcfadden pittman 2008
McFadden & Pittman, 2008
  • The dot rate of both groups decreased similarly when the primary task was introduced
  • The hearing impaired kids performed significantly worse than the normal hearing controls on the word categorization
    • The children may be unable to draw resources from other tasks to respond to a difficult listening situation.
    • They also may be unable to prioritize tasks.
psychosocial impact
Psychosocial Impact
  • Multiple studies going back to Giolas & Wark, 1967, report psychosocial sequelea of unilateral hearing loss.
    • Embarrassment, helplessness, withdraw, aggression, frustration and isolation
  • Stein, 1983
    • Teachers and parents rated behavior
      • 42% aggression and withdraw
      • 37% lower than peers on interpersonal and social adjustment
psychosocial impact1
Psychosocial Impact
  • Bess et al, 1998
    • 6th and 9th graders with minimal hearing loss
    • COOP (Cooperative Information Project Adolescent Chart Method)
      • Assess physical, emotional and social functioning
        • Found significantly more dysfunction for tweens with minimal hearing loss than their normal hearing peers
          • Less energy
          • Tired more frequently
          • Stress
          • Social support
          • Self-esteem
psychosocial impact2
Psychosocial Impact
  • Borton, Mauze & Lieu, 2010
  • Children 6-17 years and their parents
  • Health Related Quality of Life survey
  • Survey had a control group of NH and those with bilateral loss
  • Focus groups for those with UHL
psychosocial impact3
Psychosocial Impact
  • Found that children with UHL had significantly more variance in the social functioning score than children with normal hearing or those with bilateral loss.
  • Both parents and children with UHL rated social functioning lower than children with normal hearing or bilateral loss.
psychosocial impact4
Psychosocial Impact
  • Focus groups found
    • Children didn’t notice differences as much as their parents did.
    • Parents suggested that difficulties got worse as their children aged and got into sports, etc.
    • Parents felt that teachers were not educated about UHL and their children suffered as a result.
    • Assistive technology was seen as a barrier to being “normal”.
psychosocial impact5
Psychosocial Impact
  • Focus Group discussion
    • “[Sometimes I have] hollow moments, where there’s not really anything I can hear. A lot of times I stare off into space, which doubles not being able to hear. So, if I’m not paying attention and there is a lot of noise around or if I’m just not expecting someone to talk to me, I just go completely deaf.
      • Listening Effort
psychosocial effects
Psychosocial Effects
  • Bourland-Hicks & Tharpe, 2002
    • Examined listening effort and fatigue in children with minimal to moderate loss
      • Compared to normal hearing peers there was no difference in fatigue, but significant difference in listening effort for both quiet and noise
right vs left differences
Right vs. Left Differences?
  • Sininger & de Bode, 2008
    • Auditory areas of the right hemisphere (left ear) are specialized for spectral processing of tonal stimuli and music.
    • Areas of the left auditory hemisphere (right ear) are primarily for processing temporally complex and rapidly changing stimuli like speech.
      • Lefties can be opposite (only righties in study)
      • Males more often than females are opposite
        • men=women in study
sininger de bode 2008
Sininger & de Bode, 2008
  • Used gap detection testing of tonal stimuli and noise stimuli in each ear independently
    • The right ear showed an overwhelming advantage for noise.
    • Left ear a smaller advantage for tones.
      • The smaller gap in milliseconds was required to detect a change.
      • True for normal hearing or unilateral loss.
sininger de bode 20081
Sininger & de Bode, 2008
  • Contralateral ear compensation
    • Occurs to some degree in late onset loss
    • Does not occur in congenital/very early onset loss
      • Sininger & de Bode, 2008
sininger de bode 20082
Sininger & de Bode, 2008
  • Children with unilateral loss who have failed at least one grade at school are 5 times more likely to have right ear loss.
    • Oyler, et al., 1988
    • Bess, et al., 1986
    • Klee & Davis-Dansky, 1986
right vs left differences1
Right vs. Left Differences
  • Niedzielski, et al, 2006
  • Evaluated 64 children with UHL
  • Mean age was 11 years
  • Both those with right loss and left loss achieved average intelligence on a full scale IQ test.
  • But, if you look at the scores from each subtest, significant differences exist.
niedzielski et al 2006
Niedzielski, et al, 2006
  • Those with right-sided loss scored signficantly lower on the verbal test compared to those with left-sided loss.
    • Most pronounced in the subtests of similarities, vocabulary and comprehension.
      • Smaller range of concepts, lower skills for learning verbal material and smaller abilities to use acquired knowledge in everyday situations.
niedzielski et al 20061
Niedzielski, et al, 2006
  • Those with left-sided loss scored more poorly on the non-verbal scale.
    • Particulary in the subtests of block design and object assembly.
      • Poorer abilities for analyzing, synthesizing, visual memory, spatial imagination and visual-motor coordination.
management options
Management Options
  • No technology, self advocacy, coping skills
  • Hearing Aid
    • Conventional aid for aidable loss or CROS
  • FM system
    • Ear level
    • Soundfield
  • Cochlear Baha or Oticon Medical Ponto
  • Cochlear Implant – maybe down the road
no assistive technology
No Assistive Technology
  • The most popular option until recently
  • Advantageous positioning
  • Controlling background noise
  • Asking for repeats
  • Utilizing other assistive devices like tape recorders in lectures or borrowing a friends notes
hearing aid
Hearing Aid
  • Conventional Aid
    • Moderately-severe or better hearing
    • Use when appropriate
      • Classroom
      • Dinner party
      • Group Discussion
    • Include auto noise program when possible
    • High non-use rate
cros hearing aid
CROS Hearing Aid
  • Does provide sound from the impaired ear
  • Requires a hearing aid on the normal hearing ear, as well
  • Aid on the normal hearing ear is quite large including DAI door and FM receiver
  • High non-use and return rate
fm system
FM system
  • Designed for classroom use
    • Does very well for it’s intended purpose
      • One speaker
      • Improvement in signal to noise ratio
    • Requires 2 users
      • Speaker and listener to use the equipment consistently and correctly
        • Positioning of mic
        • Correct settings
        • Jewelry, clothing noise, restroom breaks, aside conversations
fm options
FM Options
  • Soundfield
    • Benefits teacher and students with and without loss
    • Stationary
  • Desktop
    • Benefits one or a few students
    • Portable, but with limitations
  • Ear level
    • Very portable and discreet
  • Can be implanted age 5 and over
  • Can be worn on hard or soft headband
  • Provides mic and stimulation on the same side
    • Provides “pseudo stereo hearing”
    • Can be used with any degree of conductive loss or profound unilateral sensorineural loss
  • User is in control of use, volume & program
linstrom silverman yu 2009
Linstrom, Silverman & Yu, 2009
  • 7 adults with adult onset profound UHL
    • Implanted with Baha Compact
  • 20 adults with normal hearing
  • Goal=examine long-term efficacy
    • Speech recognition in noise
    • Subjective satisfaction
    • Assessed at 1 month, 6 months, 1 year post-Baha
linstrom silverman yu 20091
Linstrom, Silverman & Yu, 2009
  • HINT
    • Noise in the front, speech to each side
    • Speech in the front, noise to each side
      • Noise at 65 dBA
    • Significant advantage with Baha when speech was lateralized to the affected ear
      • SNR improved by 3.9 dB in directional mode
      • SNR improved by 3.1 dB in the omnidirectional mode
    • For a performance-intensity function of 10%/dB the omnidirectional Baha yields a 39% gain in speech intelligibility and the directional 31%.
linstrom silverman yu 20092
Linstrom, Silverman & Yu, 2009
  • The Baha had a disadvantage over the unaided condition when noise was delivered to the affected ear, especially in omni mode.
    • The disadvantage was not as great as the advantage seen in the opposite condition.
    • This is a point for patient and family counseling.
linstrom silverman yu 20093
Linstrom, Silverman & Yu, 2009
    • After pooling scores, the Baha condition was significantly better than unaided condition in all but one subtest
      • Background noise*
      • Ease of Communication
      • Reverberation
    • Aversiveness subtest did not show a significant difference, but tended toward Baha creating more unpleasant background noise.
linstrom silverman yu 20094
Linstrom, Silverman & Yu, 2009
  • Single-Sided Deafness Questonnaire
    • 5 point scale
    • Questions
      • Use
        • How many days per week
        • How many hours per day
      • overall quality of life
        • Has it improved due to the Baha
      • situational improvement
        • Talking to one person
        • Listening to music
        • Listening to TV/Radio
linstrom silverman yu 20095
Linstrom, Silverman & Yu, 2009
  • Summary responses
    • Median response scores reveal that the Baha had a positive impact on each item
  • None of the tests in this study changed significantly over time from 1 month to 1 year post Baha fitting.
lin et al 2006
Lin, et al, 2006
  • 23 adults with UHL
  • CROS for 1 month
  • Implanted with Baha
    • Consistently better patient satisfaction with Baha
    • Directional hearing was unchanged with Baha, but was worse with CROS
    • Baha provided significantly better speech recognition in noise.
christensen et al 2010
Christensen, et al, 2010
  • 23 children with implanted Bahas
  • Pre-implant HINT scores
    • 42% @ 0, 76% @ +5 and 95% @ +10
  • Post-implant
    • 82% @ 0, 97% @ +5 and 99% @ +10
  • CHILD scores improved
    • Patient 4.49 to 7.10
    • Parent 4.60 to 6.90
house et al 2010
House, et al, 2010
  • Adults with unilateral loss
    • 68 with Baha, 61 unaided
  • No significant differences on Speech, Spatial and Qualities of Hearing Scale (SSQ)
  • Abbreviated Profile of Hearing Aid Benefit
    • Overall scores were better with Baha
    • Most improvement in Background Noise 17.4%
    • Reverberation subscale improved 13.2%
    • Ease of Communication improved 11.6%
tringali et al 2008
Tringali, et al, 2008
  • Recorded ABRs in 10 adults with implanted Bahas.
    • Adult onset acute profound UHL after vestibular schwannoma removal
    • Stimulus delivered in the free field at 80 dB
      • Recorded from the healthy ear
        • Speaker to the healthy ear with and without contralateral Baha
        • Speaker to the affected ear with and without the Baha
          • Healthy ear occluded
tringali et al 20081
Tringali, et al, 2008
  • When the sound was delivered via Baha wave I was absent and waves III and V were significantly longer than when the non-affected ear was stimulated directly.
    • So, your brain really may actually be able tell the difference between sounds coming into the Baha vs. the ear.
baha ponto1
  • Lots more research corroborates what I have presented today.
  • One or two studies show an improvement in localization, but the vast majority show no statistically significant improvement.
  • All of them show that subjective benefit is much higher than objective audiologic test booth benefit would suggest.
    • This reveals the limitations of test booth measures for unilateral hearing loss.
the right choice
The Right Choice
  • Family and child centered decision
    • Lifestyle
    • Current concern or lack thereof
    • Education and empowerment
      • Whatever choice you make today may not be the right choice tomorrow and we can change at any time.
      • The right choice may be a combination such as Baha and FM.
what we haven t covered
What We Haven’t Covered
  • Neural plasticity
    • Auditory deprivation causes changes in the structure of the neural pathways.
      • Hanss, et al, 2009; Schmithorst, et al, 2005
  • Cochlear implants in unilateral deafness
    • Has been performed on those with debilitating tinnitus
      • All 20 implanted use their CIs all day every day
      • The SSQ improvement was highly significant
      • Hearing in noise improved by 3.8 dB
case example 1
Case Example 1
  • P.F.
    • Head trauma at age 15
    • Right unilateral aidable hearing loss
    • Not interested in amplification
    • Returned to clinic at age 20
    • Fit with a hearing aid – LOVES IT
      • +5 SNR 88% unaided; 100% aided
case example 2
Case Example 2
  • R.F.
    • Prelingual unilateral profound loss
    • Uses no assistive technology
    • Uses environmental adjustments
      • Controlling noise
      • Advantageous positioning
        • Rick on the right
  • Has difficulty localizing sounds
    • Can’t find his ringing cell phone
  • Has difficulty hearing in the car
    • Can’t converse while the radio is on
    • Can’t converse while the window is down
  • Difficulty hearing from a distance
    • Must be very loud for him to hear from another floor.
case example 3
Case Example 3
  • A.C.
    • Six years old
    • Congential unilateral maximum conductive loss
    • Difficulty in school
      • almost qualifies for special services, but not quite
      • Discussion of holding her back last year
    • Difficulty in social situations
      • “I can’t hear the other girls”
      • “I can’t hear on the playground”
  • Used FM in kindergarten, but school personnel thought she no longer needed it
  • Family concerned that she comes home crying because she can’t hear at school
  • Mom reports that Bailey “seems autistic” in noisy places – withdraws, doesn’t seem to know what’s going on around her, can’t seem to engage with others.
  • Family decided to try the ear level FM
  • Bailey loved it from the first moment
    • Described all of the new sounds she was hearing
      • The dog panting
    • She did not like the fact that she could only hear one speaker at a time.
    • She still couldn’t hear the girls on the playground
    • The teacher didn’t always use it or use it properly
  • After her parents saw what a difference the FM made for Bailey, they decided to get the Baha.
  • She wears it on a softband until after her ear reconstruction surgery.
  • Within days she was saying
    • Put the hearing thing on me so I can hear
    • When I don’t have it on everything is quite. When I have it on its louder and they are talking (TV).
  • Still has more difficulty in background noise.
  • They are still having trouble getting buy-in from the school.
  • She is getting speech/language therapy at school and privately with a HI specialist.
  • Her mom told me, “My only regret is not getting it for her a lot sooner.”
  • Teenage boy
  • Unilateral profound SNHL
  • Not interested in Baha
  • Wears CROS
    • Not fond of it, but knows he needs help hearing
  • +5 SNR 80% unaided; 92% with CROS

Individuals with Disabilities Education Improvement Act of 2004 (IDEA)

Typically under Part C children 0 to 3 years with UHL qualify for services whether they have a slight delay, none at all, or a severe delay

Under Part B (section 619) children 3 to 5 years with UHL only qualify for services if their scores fall 1.5 and sometimes 2 standard deviations below normal limits

Often times children with UHL do not qualify for services just at the time when the listening environment and academic needs are becoming more difficult

evaluation process
Evaluation Process

There is no standard set of diagnostic tests at this time for UHL.

The following are suggestions and should be completed over multiple sessions depending on the age of the student


Sit on hearing ear side for best results

Review of most recent audiogram

CELF-4-overall language evaluation

Subtests and item analysis

“swiss cheese” students

PLS-4—overall language evaluation for younger listeners

Cottage Acquisition Scales for Listening, Language & Speech (CASLLS) ~ Sunshine Cottage School for Deaf Children—Criterion Referenced overall language evaluation


Integrated Scales of Development (from Listen Learn and Talk by Cochlear)

Auditory Skills Curriculum Model (John Tracy Clinic)

EOWPVT—expressive vocabulary test

PPVT-IV—receptive vocabulary test

GFTA-2—Articulation test

Conversation/language sample with/without noise

Communication abilities: turn taking, providing enough details, staying on topic, etc.


Audition assessment (with/without background noise)

Model for listening ~ detection, discrimination, identification, comprehension (Estabrooks, 1998).

Listening check using Ling 6 sounds at a distance of 30, 12, and 6 ft. with and without background noise

Informal 1-3 step direction tasks

1-4 item memory/critical element task

Ability to detect and localize sounds

Ability to discriminate between suprasegmentals/prosodic features (pitch, intensity, duration, rate, stress) (Ling, 1976, 1989)


Ability to discriminate between 1 vs. 2 vs. 3 syllable words

Ability to discriminate between words that differ in initial/final consonants by manner, voicing, place (in sentences is easier)

Auditory Perception Test for the Hearing Impaired—Susan Allen

Test of Auditory-Perceptual Skills-3 (TAPS-R)—standardized auditory processing test

Auditory Processing Abilities Test (APAT)--standardized


Parent interview

Pediatric case history form

Do they communicate with peers? Have many friends?

Are they often fatigued?

In general how well do they listen? Do they often misinterpret conversations? Can they follow discussions at the dinner table?

How do they handle noisy environments? (restaurant, sporting events, cafeteria)

Are they able to localize in different environments?

How are their grades?


Other factors to consider

Cognitive abilities

Co-occurring developmental disabilities

Socioeconomic status

Abundance of language stimulation in the home

Quality of child care environment

Recurrent otitis media with effusion

behaviors slp teachers may see
Behaviors SLP/Teachers May See

Avoiding a certain class or activity (especially large group situations) because it is too difficult to hear/understand what others are saying

Fatigue, less energy, complaints of headaches, pains, etc. especially in noisy environments

Limited understanding of humor (riddles, jokes, idioms, slang).

Gives up easily • Daydreaming


behaviors slp teachers may see1
Behaviors SLP/Teachers May See

Social-Emotional behaviors

Misbehaves to get attention typically because they are frustrated

May be aggressive towards peers

Makes fewer initiations with peers

Inappropriate interactions with peers

May miss part or all of a conversation and therefore misinterpret the message, which may lead to a misunderstanding

Isolate themselves in large group activities

Quick change in emotions (sudden crying to giggling)

behaviors slp teachers may see2
Behaviors SLP/Teachers May See

Appears to have selective hearing

When the student is unsure of what to do, especially when given multi-step directions, they will watch and follow peers.

The student may have difficulty listening and completing a task at the same time.

Sounds are often audible to the child, but many times the sound or messages, particularly speech sounds, are not intelligible or understood

Students have to be trained to advocate for their needs and understand and recognize when they are missing a message and how they can receive the message in a better way.

suggested strategies for working with students with uhl
Suggested strategies for working with students with UHL

There is a lack of published guidelines for working with infants and children with UHL


Some one-on-one therapy and some group therapy every week depending on needs of student.

Some auditory-oral training for the SLP would be ideal.

Students must consistently wear/use their hearing devices as long as they are beneficial to the student and programmed appropriately.


Therapist typically sits on the side of the child’s hearing ear unless the therapy session is specifically targeting working on listening in noise.

Ask “What did you hear?” to check for understanding and have the student repeat back word definitions and/or directions

Do not accept one word answers (“tell me in a sentence”)

Speak naturally in a clear voice, at a regular rate. Don’t exaggerate!


Present information, questions, etc. auditory first (hand cue use = a cue to listen!) and then use a visual cue if the student still needs help to understand.

Practice listening in noisy situations (outside, with door open, with radio on, with 2 speaker babble, with 4 speaker babble)

Allow listening breaks if a glazed / flat expression, or inappropriate social behaviors occur

Conduct the Ling 6 (ah, oo, ee, sh, s, m) “test” twice daily to check for proper function of hearing devices


During therapy sessions be sure to get the student’s attention before giving directions.

Ask open-ended questions (To please teachers they will answer yes/no questions with “yes”)

Paraphrase and reword directions etc. if the child does not understand the first time

Incorporate reading as often as possible and be sure to point out new vocabulary and discuss objects in several different ways (synonyms/antonyms).


Encourage the student to be responsible for personal things (including trouble shooting hearing aids, Baha and FM) as well as a responsible listener.

They need to be made accountable for what their peers and teachers say as well as what they themselves produce verbally.

Have the student present on their FM system and hearing devices to the class (i.e. make a power point or demonstrate how their devices work)


A child with a unilateral hearing loss requires close observation and daily informal evaluation to determine their areas of need.

Often times they appear to be functioning at a high level compared to children with greater losses or at a moderate to low level compared to their hearing peers.

They still have difficulty with basic language structures, word meaning, and/ or speech sounds that are often passed over or not noticed in a larger classroom environment or in a group therapy situation.


Students must be encouraged to advocate for themselves at all times. The following are suggestions for students to use throughout their daily activities and should be a part of therapy goals:

*Classroom Behaviors: Strategies for learning in a large group

Focus on your teacher and listen.

Watch the teacher.

Watch whoever is talking.

Raise your hand and wait your turn.

Stay on topic.

Join in group responses.

Use a repair strategy if you don’t understand or you didn’t hear, or check with your neighbor to find out what you missed.

If you can’t see, move.

Sit the correct way.

Keep your hands to yourself.


Repair Strategies: Asking for repetition

Can you repeat that?

I didn’t understand you.

Will you tell me again?

What did you say?


I didn’t hear you.

I don’t know what you said.


Repair Strategies: Asking for clarification

I didn’t understand you.

Can you say that clearer?

Can you say it slower?

Did you say ______?

Did you say “cat” or “bat”?

Can you come closer to me?


Repair Strategies: Asking for more information

What does ____ mean?

I don’t know what ______ means.

Can you tell me what you’re talking about?

Who are you talking to?

From: Self Advocacy: A Curriculum For Creating Independence ~ Carrie Bauza, M.S. --Child’s Voice School



Guide and encourage other staff members to learn more and work with you regarding the strategies on how to best work with the student and what behaviors to look out for

Have a mini inservice at the beginning of the school year to prepare the faculty on how to use equipment.


Have the classroom teacher fill out a questionnaire at the beginning, middle and end of the school year to help monitor classroom behaviors and impressions of student (SIFTER—Screening Instrument for Targeting Educational Risk—K. Anderson).

Ensure there is an understanding of school and classroom rules and that your expectations are the same for all students.

When there are consequences for inappropriate behaviors, check for understanding


Speak one-on-one with student to check for comprehension during instructional times (when possible)

Try to get the student’s attention by calling his or her name before giving instructions/directions (allow noise level in room to decrease—then repeat instructions if necessary).

Have a nonverbal cue that can be used to regain attention (tap on the shoulder followed by eye contact) if the student seems inattentive so that they know to watch whoever is talking.


The teacher repeats answers from other students (saying the name of who asked the question as well) so that the student with hearing loss is sure to hear the answer and better able to participate in group discussions.

Present spelling words and directions in short sentences during test time to help the student discriminate between words

Language and speech should be integrated throughout curriculum, daily routine and individual therapy.


Allow for pre-teaching at home

Provide a list of vocabulary words, spelling words, and upcoming assignments for each subject area, new unit or story that can be reviewed at home—ex. Parents or SLP can check that the student is discriminating between spelling words before the test is given (cake/take etc.)

Have parents explain new words or phrases that are abstract at home so the student is already familiar with terms when they are learning at school.

If possible provide a set of books at home


Classroom Buddy-ex. tell the student when it’s time to line up at the end of recess or it was page 124 in our reading book

Use captioning during movies or videos

Write assignments and directions on board after presenting auditorily (don’t write on board and talk at the same time).

The student may need additional wait time before answering question or following directions especially if they have a right side loss.

  • Use a personal FM system and/or soundfield system during academics, assemblies, specials, etc.
  • Preferential seating in the classroom (front right side if hearing loss is on left side and front left side if hearing loss is on right side)
  • Encourage everyone in the class to ask the meaning of unknown words, or concepts.
  • Environmental and Acoustic Modifications ~ decrease reverberation, background noise, and distance
    • Reduce noise level (rustling papers, ventilation system, pencil sharpener) to help acoustically control the environment
    • Place student in the class that has less “open” class teaching

Use thick window treatments (thick materials)

Area rugs if there is no wall-to-wall carpet

Avoid hard surfaces whenever possible (corkboard)

Use tennis balls or rubber tips on the bottoms of chairs


Use soft seating (bean bag chairs) in play or leisure areas

Use creative artwork such as decorated egg crates, material or rug strips and Styrofoam balls hung from the ceiling to dampen noise levels

Try to keep doors and windows closed

communication with parents home and school
Communication with parents (home and school)

Parents attend a therapy session once a week where they are coached and guided on how to carry-over strategies, techniques, sounds, etc. at home.

Encourage parents to become aware of their child’s listening environments and how to manage them

Reduce “technology” noise in house (TV, background music etc.)

Talk into hearing ear and keep loud noises away from hearing ear

communication with parents
Communication with Parents

Raise your voice slightly and face the child when at a greater distance (walking a child in a stroller)

Play listening games and expand the child’s vocabulary by using multiple adjectives etc.

Involve siblings, family members and friends to practice group activities and games so the child gets more experience with different voices, contexts and distance listening.

communication with parents1
Communication with Parents

Narrate your daily routine and get your child’s attention and make sure that the child is able to listen before talking to them and starting a conversation.

Safety issues with localization.

Encourage parent-to-parent support: Providing parents with contact information for organizations of parents with children who have UHL (list-serves can be helpful)

communication with parents2
Communication with Parents

Keep a notebook that can go between home and school where both parties can ask questions and/or share concerns if face to face meetings or a phone call are not options

Present an unbiased list of intervention approaches that includes information about speech and language development, functional auditory skill development, amplification and visual forms of communication

communication with parents3
Communication with Parents

Share any changes in behavior/health/hearing, social-emotional

Parents get nervous when the SLP or Teacher says everything is fine every day.

The parents may often feel that you might be missing something or not catching issues that may be affecting the students overall education.

goal ideas
Goal Ideas


Sequencing multi-element directions with more difficult concepts (Sit down at your desk, get out your reading book and turn to page 10 or Put the thick blue square behind the empty jug) in noise

Listening to a story one time with no visual cues in noise and

Identifying necessary vs. unnecessary information from stories

Retelling the story/summarizing in sequence using 5 or more sentences

Identify the main idea

Identify the main idea

goal ideas1
Goal Ideas

Imitating a 7-9 word sentence including morphological markers (‘s, s, past tense etc.) without changing word order or omitting any words or word structures.

Identifying 4-5 critical elements in noise. (i.e., Put the bluesquarebehind the emptybasket)

Developing an ability to use their auditory feedback loop by attempting to self-correct articulation and syntax errors in spontaneous verbal productions in structured tasks


Increasing the ability to listen the first time in noise.

Increasing the ability to paraphrase remarks of other speakers in noise.

Discriminating between vowel sounds (mit vs. met or win vs. one)

goal ideas2
Goal Ideas


Asking for repetition, clarification or more information from peers or adults, using repair language, during class discussions when she doesn’t understand (e.g. I didn’t hear, Could you repeat?, I didn’t understand a word., I heard you say _____., Can you tell me what you’re talking about?, What does ____ mean?).

Asking for repetition, clarification or more information from the teacher/therapist when she does not understand a word, direction, or assignment during class time.

goal ideas3
Goal Ideas

Identifying when listening conditions are not optimal and advocating for themselves (ex. Shutting the door, changing seating positions, asking for repetition or clarification)

Demonstrating an ability to troubleshoot problems with Baha, hearing aid and/or personal FM system and notifying teacher/parents/therapist when equipment is not working properly.

Explaining how equipment works to peers and adults.

goal ideas4
Goal Ideas


Increase the ability to understand figurative language (idioms/homophones/jokes)

Identifying novel vocabulary words and asking for a definition/looking them up in a dictionary

Understanding 10 new vocabulary words per reading unit.

goal ideas5
Goal Ideas


Developing her ability to do the following during conversation in the classroom and in a one-on-one setting:

Maintaining topic

Taking 10 turns

Providing appropriate/sufficient details/info.

Checking for listener comprehension (e.g. Do you understand? Do you know what I mean?)

Attending to listener feedback

goal ideas6
Goal Ideas

Providing information in a logical order

Understanding when the topic has changed

Asking appropriate questions in response to a topic

Increasing vocal intensity to a 5 on the Likert Scale (1-5)

Using 10 new vocabulary words per reading unit.

goal ideas7
Goal Ideas


Discriminating between first and then producing the following sounds in all positions of words.

/b/ vs. /d/

/m/ vs. /n/

Producing the following sounds in all positions of words in conversation with 90% accuracy.

/s/ (decrease nasalization)


/l/ blends


Tools for Schools by Advanced Bionics

The Listening Room ( by Advanced Bionic) (Alexander Graham Bell Association/AG Bell Academy)

Otocon, Inc.

Auditory (Cochlear Americas)


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