Risky Business: The Importance of Early Intervention to Infants with Hearing Loss Creating Connections: Strengthening Partnerships Between Families and Providers March 19, 2007 Ann W. Hughes Partnership for People With Disabilities, VCU Debbie Pfeiffer Virginia Department of Education
At Risk! 2 AT RISK! 3 Training Outcomes Participants will: Be able to identify risks related to hearing loss including those in language/communication, cognitive skills, social-emotional growth
Describe early intervention practices that should be used with infants who are deaf and hard of hearing and their families to address at-risk areas Know where to access resources to assist in addressing at-risk areas 4 VDDHH Library Pam Richardson 804-662-9502 1-800-552-7917
www.vddhh.org Whats New Early Intervention 5 Universal Newborn Hearing Screening Universal Newborn Hearing Screening 1998, law passed in Virginia, effective July, 2000 All hospitals test hearing
Results reported to: Parents Childs physician Virginia Department of Health (VDH) 7 Why is Early Identification of Hearing Loss so Important? ~12,000 babies born each year with permanent hearing loss (several of the following slides related to Universal Newborn Hearing Screening are from the National Center for Hearing Assessment and Management [NCHAM]
website) 8 Incidence per 10,000 (NCHAM) 40 30 30 20 12 10
0 11 6 H 5 2 1 Li Sp
Si PK C D ea le ow m c in U kl ft b rin
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9 Why is Early Identification of Hearing Loss so Important? ~12,000 babies born each year with permanent hearing loss Undetected hearing loss can have a negative impact on development. (NCHAM, 2001)
10 Blindness separates people from things. Deafness separates people from people. --- Helen Keller (NCHAM) 11 Grade Equivalents Reading Comprehension Scores of Hearing and Deaf Students
(NCHAM) 10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 Deaf Hearing
8 9 10 11 12 13 14 15 16
17 18 Age in Years Schildroth, A. N., & Karchmer, M. A. (1986). Deaf children in America, San Diego: College Hill Press. 12 Effects of Unilateral Hearing Loss (NCHAM) Normal Hearing Keller & Bundy (1980) (n = 26; age = 12 yrs)
Math Language Peterson (1981) (n = 48; age = 7.5 yrs) Math Language Bess & Thorpe (1984) (n = 50; age = 10 yrs) Social Blair, Peterson & Viehweg (1985)
(n = 16; age = 7.5 yrs) Math Language Culbertson & Gilbert (1986) (n = 50; age = 10 yrs) Math Language Social Average Results Math = 30th percentile Language = 25th percentile
Social = 32nd percentile 0th 10th 20th Unilateral Hearing Loss 30th 40th 50th
60th Percentile Rank 13 Why is Early Identification of Hearing Loss so Important? Hearing loss is the most frequent birth defect. Hearing loss is the most frequent birth defect.
Undetected hearing loss has serious negative consequences. There are dramatic benefits associated with early identification of hearing loss and appropriate intervention. (NCHAM) 14 Language Age in Months Expressive Language Scores for Hearing Impaired Children Identified Before and After 6 Months of Age 35 30 25 20
15 10 Identified BEFORE 6 Months Identified AFTER 6 Months 5 0 13-18 mos (n = 15/8) 19-24 mos (n = 12/16) 25-30 mos
(n = 11/20) Chronological Age in Months 31-36 mos (n = 8/19) (NCHAM) 15 Vocabulary Size for Hearing Impaired Children Identified Before and After 6 Months of Age Vocabulary Size
300 250 200 150 100 Identified BEFORE 6 Months Identified AFTER 6 Months 50 0 13-18 mos (n = 15/8) 19-24 mos
(n = 12/16) 25-30 mos (n = 11/20) Chronological Age in Months (NCHAM) 31-36 mos (n = 8/19) 16 Boys Town National Research Hospital Study of Earlier vs. Later
129 deaf and hard-of-hearing children assessed 2x each year. Assessments done by trained diagnostician as normal part of early intervention program. Language Age (yrs) 6 Identified <6 mos (n = 25) Identified >6 mos (n = 104) 5 4
3 2 1 0 0.8 1.2 1.8 2.2 2.8
Age (yrs) 3.2 3.8 4.2 4.8 Moeller, M.P. (1997). Personal communication , [email protected] 17
18 19 20 Part C Services Part C of the Individuals with Disabilities Education Act (IDEA) Works with infants and toddlers ages birth to three years Work in childs
natural environments 21 How Do We Define At Risk? IDEA 2004 says that any child at risk for significant developmental delays is eligible to receive Part C services. In Virginia, any child with a hearing loss that puts them at risk for developmental delays is eligible for Part C services. We would say that any child with more than a minimal hearing loss is at risk
for delays in many areas. 22 What issues need to be addressed when you meet a family who just learned that their baby is deaf? (Karchmer & Allen, 1999) Psycho-social/social-emotional support Assisting family in: learning about Sensory Devices which and how?
choosing communication methodology supporting language development developing auditory learning environment developing speech skills learning ASL if chosen, & about Deaf culture 23 Who Should be Involved? Service Coordinator OT/PT If approp. Ed. Specialist
In Deafness Child & Family Speech & Language Pathologist Pediatrician/ ENT Audiologist 24 Partnerships Deaf adults
Families of children who are deaf/hard of hearing People representing different communication options 25 Socio-Emotional Development MY IDENTITY 27
Experiences Family Gender Who Am I? Career Ethnicity Abilities/ Attributes 28
Who Am I? I am.. 1.Educator 2.Healthy Influences 1.Worked for over 20 years with schools 2.Sick/hurt as child 29 Effects of Hearing Loss
on Parent-Child Relationship: Prior to diagnosis Reduced communication and interaction Following diagnosis Strong emotions May interrupt process of
attachment 30 Emotional Responses of Family Experiences surrounding the Experiences surrounding the initial diagnosis Profound sense of personal loss Disillusionment Reported blurred memory bewilderment Shock Anger
Guilt Grieving Process 31 VA Guide By Your Side Guide By Your Side (GBYS) is a trademarked family support program of Hands & Voices. In Virginia, GBYS is funded by the Virginia Department of Healths Early Hearing Detection and Intervention Program and coordinated by the Partnership for People with Disabilities at VCU. Connects parents of newly identified children with hearing loss with trained guides (also parents of children who are deaf or hard of
hearing) 32 Identity: What Does Literature Say About People Who Are Deaf and Hard of Hearing ? Reduced communication Perceived lack of acceptance Overprotection
Life Experiences Overindulgence by families Decrease. opportunities to discuss feelings 33 Families can.. Respond to the childs needs consistently. Look at the baby when communicating with her. Use facial expression, body language, and
gesture to promote bonding. Do things at the babys pace. Make funny sounds or actions to amuse baby. Encourage baby to respond back. Practice relaxation techniques to reduce their stress Use infant massage with the baby Listen to music or hum/sing, and dance holding baby. 34 Language/ Communication Development
Communication Options American Sign Language/English as a Second Language) Cued Speech Oral (Auditory-Oral, Aural/Oral) Auditory-Verbal Total Communication 36 Helping Families to Make Informed Decisions
Inform parents of all options (GBYS) View Communication Choices together Provide objective assessment data Consider amount and quality of functional hearing (Oticon & ADA) Observe child and determine the method that seems to fit his needs consider additional challenges As baby grows, it is possible to reevaluate decision Family must be willing and able to use method(s) effectively and consistently (lifestyle and values) 37
Critical Periods for Language Acquisition that age after which not everybody can learn particular aspects of language, especially without explicit instruction (Fischer, 1994) Birth to three years is a critical period for language acquisition 38 Implications for Intervention Try to ensure greatest range of
communication options for the future Encourage consistent use of amplification Reinforce the development of listening skills through play and during daily routines 39 Critical Period for Sign Language Acquisition Native signers (those signing before age 5) outperformed nonnative signers, using ASL Production
Grammatical analysis (Woodward, 1974, 1978; Mayberry & Fischer, 1989) 40 When Does Communication Begin? 41 Early Communication Facial Expression produced by 12 months (hearing and deaf) Use a variety of attentiongetting devices Use gestures
42 Early Communication Help parents tune-in to babys communication cues Teach appropriate responses 43 Help Families to Encourage
Early Communication (SKI HI) Encourage the family to communicate with their infant during daily routines through speech and natural gestures or signs emphasizing important words like diaper, bath, more, bed, dog, drink, bottle, car, etc. Remind parents that all babies need to be exposed to language in a meaningful, socially interactive way during the first year of life for the babys language, communication, cognitive, and social skills to fully develop. Homework: Ask family members to list ways baby tried to communicate during the week. 44
Strategies for Enhancing Language Acquisition Use amplification as early as possible Use visual cues to supplement audition May be necessary to teach visual strategies to hearing parents Deaf parents as models of visual communication strategies 45 Visual Strategies Used To Facilitate Language
Acquisition (all may not appropriate with A-V Method) - Get the attention of the child before speaking/signing (using voice,motion or touch) - Make sure lighting is adequate - Using appropriate facial expression (!), interesting voice (Parentese) Repeat signs or word Dont allow frequency of communication to become annoying during play Use short, simple phrases & sentences
at first Positioning self and object in visual field Moving sign to object or onto child 46 Development of Sign Language Development of Sign Language Receptive sign language development: Develops before expressive skills Able to understand ~50 words/signs before expressing self in sign spontaneously Developmental sequence:
Facial expression Tone of voice (if accessible) Body language Gestures Single words, iconic before abstract Simple phrases or sentences Longer sentences
48 Language Development of Children Using Signs Expressive Language Development: Cooing, gurgling (mostly vowels) Babbling (vocal and manual) Non-verbal communication (facial expression, pulling, pointing, etc.) Baby signing (approximations of adult
signs, sign jabbering and invented sign) True signing (appear at = age w/ hearing peers, or 2-3 mos before) First location, then movement, finally handshape 49 Development of Hearing and Speech Skills 50 Is my baby too young to wear hearing aids?
Audiogram ( Mehr, 2002) 52 Assistive Listening Devices Purpose: to improve the signal to noise ratio (amplify the speakers voice or desirable sound more than background noise) Personal FM Systems Sound Field Systems (used more in classrooms) Loop Systems (not usually used with infants)
53 Cochlear Implant 54 Assist families with HA challenges Feedback When nursing or feeding, turn off aid on that side When baby is sleeping, may remove aids Replace earmolds as infant outgrows them (6 8 wks)
Keeping aids on the baby Critter clips Toupee tape Huggies Ask audiologist to check length of tubing 55 Auditory Development 1.
Awareness of sound 2. Sound has meaning 3. Discrimination 56 Acoustic Highlighting (Simser, AVT) More audible Less Audible No background noise background noise
6 from ear farther from ear Slightly slower rate normal rate Inc pitch variation normal pitch/rhythm Clearer enunciation unclear/unfamiliar Increased repetition no repetition Greater acoustic contrast less varied Simple, short language complex sentences Emphasis on key words no emphasis End of sentencebeginning of sent Closed set open set 57 What Can You Encourage Families to Do?
Become comfortable with listening devices and learn to troubleshoot Develop a schedule if necessary to increase wearing time of hearing aid/fm system/cochlear implant Draw the childs attention to environmental noises throughout the day Ensure that the audiologist is part of your team! 58 Provide enriching listening experiences in the home Add language to babys play routines (ex. - Pair a sound with a toy each time
they play with it (see Sindrey) Speak to baby in an interesting, animated voice. Talk about what baby is playing with or looking at; describe what she sees. 59 Background Noise Activity Close your eyes and list the noises you hear in this room Handout: Reducing background noise in the home 60
Acoustics in the Home Keep television and music off unless that is the focus of the activity Become aware of noise from air conditioner, dishwasher, fans 61 Speech Development Audiogram Showing Speech Banana (Mehr, 2002)
63 Speech Development Suprasegmentals (voice patterns) Vocalization (voice on/voice off) Duration Loudness Pitch
Vowels (e) and diphthongs (oy) Consonants Voiced/voiceless distinctions (d v. t) Consonant Blends (br spl) 64 Auditory-Verbal Method Definition Program that emphasizes development and use of auditory skills Parents/caregivers must be very involved in therapy Must use amplification and/or cochlear implant
Use of speech reading and visual cues discouraged during therapy & home exercises 65 Time to Play! (activities from David Sindreys Listening for Littles, used with his permission) Thinking and Learning If children cant hear, they may depend more on experience & vision Lack of access to incidental
language and learning.demonstrate gaps in language and knowledge 67 EXPOSURE TO INCIDENTAL LANGUAGE Activity Cognition & Language Some skills necessary for language development Cause and effect Symbol representation
Object permanence Interactive turn-taking Joint attention Resources: Developing Cognition in Young Hearing Impaired Children, published by HOPE, Inc. 69 How to Encourage Cognitive Growth Develop language and cognitive skills during play and the normal daily routines: The New Language of Toys, Sue Schwartz Fun to Grow On: Engaging Play Activities for Kids with
Teachers, Parents, & Grandparents , Virginia Morin SKI*HI Curriculum (order through HOPE, Inc.) Follow babys lead; watch her eye gaze and provide language for what she is interested in. Demonstrate different ways to get and hold the babys attention (call babys name, manipulate a toy, use facial expression, imitate your baby, touch baby gently, get in babys field of vision). Use turn-taking, expanding on your childs responses. 70 Theory of Mind
understanding of themselves and other people as beings who think, know, want , feel, and believe. They come to understand that what they think or believe may be different from what another person thinks or believes. They also learn that much of our behavior is motivated or caused by our knowledge and beliefs. (Schick et al) Theory of Mind and Children who are Deaf
Studies have shown delays in understanding of Theory of Mind Implications: Problems in comprehending literature May interfere with development of social interaction skills 73 Children who develop a strong theory of mind: Have improved social skills Show a greater emotional understanding of himself and others
Have better reading skills Have more mature and complex language skills (Used with permission from SKI HI Institute, Copyright 2002.) 74 Parents can help their child develop a strong theory of mind by doing the following: 1. Engage in pretend play 2.
Talk about the past 3. Talk about wants and emotions 4. Taking about understanding misunderstandings (Used with permission from SKI HI Institute, Copyright 2002.) 75
P. 2125 76 Name 2 things you can do to help families encourage: Positive self-identity and healthy socio-emotional development Language/communication development Cognitive development Theory of Mind 77
