The Center for Childhood Communication

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Interdisciplinary Management of Childhood
Hearing Loss CATIPIHLER

• The Center for Childhood Communication

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Eileen Rall, Au.D. - Program Coordinator Louise
Montoya, M.A. - Family Wellness Leigh Partridge,
M.Ed. - Educational Consultant Rebecca Ramirez,
M.S. - Speech/Language Pathology

• The Center for Childhood Communication

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Session Goals

• Discuss the development of an interdisciplinary
  program that was designed to support the
  development of young children with hearing loss.
• Share specific strategies from this program to
• Support psychosocial development
• Describe activities to enhance listening and
  speaking skills in infants and toddlers with
  hearing loss
• Provide educational resources to families and
  professionals
• Describe one system for tracking progress through
  program services

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Keys to Success

• An effective link between health and education
  professionals is needed to ensure successful
  transition and to determine outcomes of children
  with hearing loss for planning and establishing
  public health policy.
• - JCIH 2007
• To achieve improved outcomes form early
  intervention, audiologic practice patterns must
  bridge UNHS programs and early intervention
  programs.
• - ASHA 2004

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CHOPs Assessment and Treatment Implementation
Program for Infants and toddlers with Hearing
Loss - Enhancing (Re)Habilitation
CATIPIHLER
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• Children, from birth to 6 years of age with
• Any degree of permanent hearing loss
• Bilateral and unilateral
• Neural hearing loss (AN/AD)
• Any communication philosophy
• Any type of intervention (HA, CI candidate, FM or
  watching)

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• Children are referred to CATIPHLER when
• Permanent hearing loss is confirmed
• They are in transition to preschool or
  school-aged programs
• There are concerns from the family, intervention
  providers or audiologists in any of the areas
  that the program addresses

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Services

• Newly identified
• Speech-language assessment/therapy
• Support with eligibility for services and
  placement options
• Healthy adjustment/adaptation to hearing loss
• School transition
• Speech-language assessment (review records first)
• Educational consult
• Social-emotional behavioral health assessment -
  PreK
• Red Flag
• Services needed

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Assessment

• Goal - confirmation of permanent hearing loss by
  3 months of age
• Increased upper age limit for unsedated
  procedures
• Staff training quieting test environment
• Protocol for evaluation

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Scenario Baby Never Screened
Risk factor-specific protocols
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Scenario Baby Failed Initial Screen
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http//ihp.mtsinai.on.ca/
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• Flowchart diagram of tone-ABR test sequence (from
  StapellsThe Hearing Journal, November, 2002)

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Pediatric Test Battery
Gravel, 2000 Gravel Hood, 1998
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Management

• Staff training
• Counseling Delivering the Diagnosis
• Management Protocol
• Counseling guidelines
• Baby Bank - loaner amplification systems
• High-quality digital hearing aids
• Integrated FM systems
• Earmolds
• Enhanced tracking of outcomes

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Baby Bank

• Earmold impressions are completed at diagnostic
  visit
• Otolaryngology and Hearing Aid Fitting scheduled
  within one month (earmolds, digital hearing aids,
  integrated FM receivers and care kit)
• FM transmitter can be introduced at 6 week
  follow-up visit

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Baby Bank

• Tracking outcomes
• Speech Intelligibility Index is recorded for soft
  and average speech levels
• Datalogging - HA usage
• Expressive and Receptive Language, Vocabulary and
  Articulation Assessments

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CATIPIHLERSpeech and language component
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Standard Services

• Newly identified
• Periodic auditory/speech/language therapy
  sessions
• School transition
• Speech-language assessment (review records first)
• Red Flag
• Services as needed

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Auditory/Speech/Language Therapy Sessions

• Model techniques for facilitating language
• Provide parent education
• Set appropriate goals
• Monitor progress

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Auditory/Speech/Language Therapy Sessions

• Attendance by service provider(s) is encouraged
• Invitation letter
• Communication of current goals/progress
• Therapist at CHOP is not the childs primary
  therapist

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Parent Education

• Communication Options
• Dream Sheet
• Resources for AG Bell and John Tracy
  Correspondence Course
• Typical Auditory Development
• Typical Receptive/Expressive Language Development
• Typical Speech Development

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Developing Listening in Babies

• Must have understanding of Auditory Hierarchy
• Must know degree/type of hearing loss
• Must be family centered
• Must have understanding of normal development
• Must have understanding of whole child

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Auditory Hierarchy

• Awareness/Detection
• Discrimination
• Identification
• Comprehension

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Auditory Goals/Activities

• Listening Position
• Auditory stimulation with noisemakers
• Localize/Search for sound with noisy toy
• Music on/off
• Door Knock Game
• Respond to Voice/Ling Sounds (ah, oo, ee, m, sh,
  s)

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Auditory Goals/Activities

• Listening Position
• Auditory stimulation with noisemakers
• Localize/Search for sound with noisy toy
• Music on/off
• Door Knock Game
• Respond to Voice/Ling Sounds (ah, oo, ee, m, sh,
  s)

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Auditory Goals/Activities

• Listening Position
• Auditory stimulation with noisemakers
• Localize/Search for sound with noisy toy
• Music on/off
• Door Knock Game
• Respond to Voice/Ling Sounds (ah, oo, ee, m, sh,
  s)

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Auditory Goals/Activities Contd

• Discriminate between familiar phrases
• Learning to Listen Sounds
• Follow simple directions
• Associate meaning to words
• Auditory memory for nursery rhymes or songs

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Auditory Goals/Activities Contd

• Discriminate between familiar phrases
• Learning to Listen Sounds
• Follow simple directions
• Associate meaning to words
• Auditory memory for nursery rhymes or songs

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Auditory Goals/Activities Contd

• Discriminate between familiar phrases
• Learning to Listen Sounds
• Follow simple directions
• Associate meaning to words
• Auditory memory for nursery rhymes or songs

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Speech Goals/Activities for Babies

• Gross motor imitation
• Imitate facial expressions
• Imitate vocalizations
• Vocal turn taking games
• Encourage input of early developing speech sounds
• Imitate duration, pitch, and intensity

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Language Goals/Activities for Babies

• Vocalize with intent
• Respond to name
• Sing along to music
• Increase understanding and use of vocabulary

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CATIPIHLEREducational Support
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Educational Goals

• To educate parents by providing a full range of
  information for all families.
• To collaborate with and provide support,
  training, and resources to professionals who work
  with children having hearing loss.

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• To provide resources concerning
• Hearing Loss
• Communication Options
• Educational Philosophies
• Early Intervention - IDEA
• Classroom Accommodations
• Educational Modifications
• Support Programs
• Advocacy

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Hearing Loss

• Parent Manual BEGINNINGS for Parents of Children
  who are Deaf or Hard of Hearing.
• Published by Beginnings [phone]
  www.ncbegin.com
• Getting Started Resources for Parents and
  Families of Infants and Young Children with
  Hearing Loss. Published by Pennsylvania
  Training and Technical Assistance Network
  [phone] www.pattan.k12.pa.us
• Hearing Loss Parent Information Packet Center
  for Childhood Communication CHOP
• Oticon-Pediatrics Workbook for Parents of
  Children who are Newly Identified as Hard of
  Hearing.
• Melanie Sisson, AuD. 1-888-684-7331.
  www.oticonusa.com

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http//www.cdc.gov/ncbddd/ehdi/ CDROM/index.html
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Communication and EducationalOptions

• Communication Options Educational Placements. A
  Guidebook for Parents by Med-El, www.medel.com
• BEGINNINGS Communication Options
  http//www.ncbegin.org/communication_options/comm_
  options.shtml

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Early Intervention - IDEA

• BEGINNINGS - For Parents of Children Who are deaf
  or hard of hearing. http//www.ncbegin.org/schoo
  l_issues/iep.shtml
• but what about my deaf child? a guide to
  special education in Pennsylvania for parents of
  children who are deaf or hard of hearing
• Parent Education Network. 800-522-5827
  pen_at_parentednet.org
• A Familys Introduction to Early Intervention in
  Pennsylvania Early Intervention Technical
  Assistance (EITA), PATTAN.
• Early Intervention for Children with Permanent
  Hearing Loss Finishing the EHDI Revolution
• by Karl R. White, Ph.D. The Volta Review,
  Volume 106(3)

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Classroom AccommodationsEducational Modifications

• Helpful Hints in the Classroom http//www.ncbegin.
  com/school_issues/classroom.shtml
• General Classroom Modifications
  http//www.ncbegin.com/school_issues/modifications
  .shtml

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Support Programs

• Alexander Graham Bell Association for the
  Deaf www.agbell.org
• American Academy of Audiology www.audiology.org
  /index.htm
• American Society for Deaf Children http//deafc
  hildren.org/
• American Speech-Language-Hearing
  Association www.asha.org
• Auditory-Verbal International www.auditory-ver
  bal.org
• Beginnings for Parents of Hearing Impaired
  Children http//beginningssvcs.com

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Support Programs

• Center for Hearing Loss in Children
  Boys Town National Research Hospital www.boysto
  wn.org/chlc/
• Cochlear Implant Club International www.cici.or
  g
• Cochlear Implant Information Center, Cochlear
  Corp. www.cochlear.com.au/top
• The Council for Exceptional Children www.cec.spe
  d.org
• Educational Audiology Association www.edaud.org
  
• John Tracy Clinic, Correspondence
  Course www.johntracyclinic.org

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Advocacy

• IDEA Advocacy for Children Who Are Deaf or Hard
  of Hearing by Bonnie Poitras Tucker.
  Thomson-Delmar Learning,1997
• Hands and Voices Website, Numerous articles on
  most topics related to deafness, The Pop-Up IEP
  http//www.handsandvoices.org/about/index.htm
• A Familys Introduction to Early Intervention in
  Pennsylvania http//www.pattan.k12.pa.us/files/EI/
  FamilyIntro05.pdf
• Individiuals with Disabilities Education Act
  (IDEA) Guide to Frequently Asked Questions
• Committee on Education and the Workforce, Feb.
  17, 2005
• From the AG Bell Website.

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How is this accomplished?

• Parent Seminars
• Professional Study Groups
• Phone Consultation
• Parent Consultation
• Workshops
• Program Visits
• Family Listserv
• Educator Listserv

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Educational Resource LibraryOn Line and Hard Copy

• Academic Accommodations
• Advocating for your Child
• Amplification
• Auditory Skill Development
• Bilateral Implantation
• Bilingual Issues with Hearing Loss
• Books
• Classroom Acoustics
• Classroom Modifications
• Cochlear Implant Information
• Communication Options
• Daycare Information
• Early Intervention Scope and Sequences in
• Pennsylvania
• Educational Law
• Educational Options
• Evaluation Materials
• Functional Listening Assessments
• Habilitation

• Milestones Speech, Language, Auditory
• Minimal Hearing Loss
• New Jersey Resources
• Normal Speech, Language and Auditory Milestones
• Parent Resources at CHOP
• PowerPoint Presentations
• Preschools and Daycares
• Related Professionals
• Resources for Families
• School Evaluation Form
• Sign Language Resources
• Specially Designed Instruction/ Teaching
  Strategies/Supports/Teacher Hints
• Support Groups / Mentoring Programs
• Technology/ Assistive Technology
• Teen Resources
• Unilateral Hearing Loss
• Websites

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Healthy Adjustment/Adaptation to Hearing Loss

• Families are invited to have a consultation with
  a mental health professional to
• check-in on how the family and child are
  adjusting to their hearing loss
• help families monitor and promote their child's
  healthy social, emotional and behavioral
  development
• provide intervention and/or referrals to help
  during the more challenging times.

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Pre-Kindergarten Social, Emotional, and
Behavioral Check-Up

• For children transitioning from preschool to
  school-age programs, families are invited for a
  "pre-K check-up" focusing on
• The family and child's adjustment to hearing loss
• Communication competence across settings
• The child's behavioral health functioning

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Pre-Kindergarten Social, Emotional, and
Behavioral Check-Up

• Input from the child, family and education
  professionals is solicited
• Families receive information to
• Monitor, promote and intervene with their child's
  behavioral development
• Receive referrals to help during the more
  challenging times

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Pediatric Counseling Guidelines

• Diagnosis
• Birth to Three years
• Three to Six years
• Six to Eleven years
• Eleven through Adolescence

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Guidelines for Audiologists Providing
Informational and Adjustment Counseling to
Families of Infants and Young Children with
Hearing Loss Birth to 5 Years of Age

• Support the development of informed, independent,
  and empowered families
• Audiologists provide information and guidance
  and, as needed, emotional support
• Informational Counseling and Adjustment
  Counseling
• Screening
• Confirmation of Hearing Loss
• Intervention and Habilitation

ASHA, 2008
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Sharing of InformationInformation Counseling
Checklist

• Allows audiologist to
• Document shared
• information
• Re-teach information
• NOT intended as a checklist for review
• Recognize and accommodate different learning
  styles

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Pediatric Counseling Guidelines

• Diagnosis
• Birth to Three years
• Three to Six years
• Six to Eleven years
• Eleven through Adolescence

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Pediatric Counseling Guidelines

• Impact of diagnosis on a family
• Psycho-Social development
• Erik Eriksons model of development
• Development of self-concept (15 mos)
• Development of social skills
• Development of auditory milestones

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Eriksons Stages of Psycho-Social Development

• Trust vs. Mistrust (birth 18 months)
• Autonomy vs. Shame and Doubt
• (18 mos 2 years)
• Initiative vs. Guilt (3 6 years)
• Industry vs. Inferiority (7 11 years)
• Identity vs. Role Confusion (11 21 years)

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Psycho-Social DevelopmentSocial Skills

• Healthy Attachment
• Basic
• Intermediate
• Advanced

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Self-Concept

• An individuals understanding of who they are
• No self
• Self-awareness
• Factual self-concept
• Egocentric view of self-concept
• Self-confidence and self-esteem emerging
• Comparative
• Peer-pressure
• Individuation

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• Developmental Index of Audition and Listening
  (DIAL)
• Functional auditory
• milestones

Palmer and Mormer (1999)
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Psycho-Social Development Eriksons Stages

• Trust versus Mistrust
• (birth 18 months)
• Babies learn to
• Trust their world if they are kept well-fed,
  warm, dry, and receive regular human touch
• Mistrust their world if they are left hungry,
  cold, wet, and unattended

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Psycho-Social Development Eriksons Stages

• Autonomy versus Shame and Doubt
• (18 months 2 years)
• Toddlers want to rule their own actions and
  bodies
• With success develop Autonomy
• With failure develop Shame and Doubt in
  their own abilities

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Self-Concept

• Birth through 14 months
• no sense of self
• Child views themselves as extension of their
  parent/caregiver
• 15 months to 2 years
• Self awareness emerges
• Recognize self in a mirror

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Self-Concept2 - 3 years

• Self concept emerges
• Child identifies themselves as
• A girl or a boy
• A baby or big boy/girl
• A brother or sister or only child
• By religious affiliation
• By ability

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What can be done to support development?

• Evaluate and support access to alerting devices
• Include the child in conversations about hearing
  loss - positive
• Support families in developing relationships with
  other families with children with hearing loss
  and with Deaf /Hard of Hearing (D/HoH) adults and
  older children

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Counseling Guidelines

• Birth to three
• Three to six
• Six to Eleven
• Eleven through Adolescence

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Psycho-Social Development Eriksons Stages

• Initiative versus Guilt
• (3 6 years)
• Initiative
• Increased awareness of self and world outside of
  home
• Eagerly attempts new tasks and play activities
• Successful attempts at new tasks help children
  learn and master many things, which becomes
  self-reinforcing (proud of themselves) and
  self-controlling to gain the approval of adults

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Psycho-Social Development Eriksons Stages

• Initiative versus Guilt
• (3 6 years)
• Guilt
• When attempts result in failure or criticism, the
  child feels
• Guilty
• Incompetent
• Helpless

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Self-Concept3 - 6 years

• Ego-centric thinking
• I am the world and the world is just like me!
• As they develop new skills
• Repetition/Practice Mastery
• Mastery Competence
• Competence Self-confidence
• Self-confidence Self-esteem

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Professional as Coach
Parents teach their child. Professionals support
and coach parents as they teach their child.
Professional
Parent
Child
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Development of Social Skills/Interaction

• Provide information to parents on
• Lack of incidental learning due to hearing loss
• Often deaf/hard of hearing children need specific
  training on basic and more advanced social skills
• Use of social skills books
• Discriminating between Cant Do or Wont Do
  behavior problems
• (Gresham, 1995)

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Frequent Teaching of Social Skills

• For Cant do behavior problems Use Modeling,
  coaching, practice
• For Wont do behavior problems Use behavior
  charts, positive reinforcement, effective praise,
  and noticing (and describing) good behavior
• (Gresham, 1995)

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Examples of Basic Social Skills

• Eye contact
• Smiling
• Listening (for friendship)
• Introducing yourself
• Meeting new people
• Joining a group
• Giving compliments

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What can be done to support development?

• Promote effective communication strategies - for
  all (including YOU!)
• Evaluate and support access to age-appropriate
  activities
• Extracurricular and religious services
• Computers
• Safe outdoor play (bicycle riding)
• telephone
• Talk to families about social skill development
• Foster development of initiative - provide
  opportunities for success

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CATIPIHLERProgram Management Other support
services
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Other Resources

• Collaboration with Otology Clinic
• Support CHOPs Family Health Coverage Program
• Record availability - entry point
• Program Tracking

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Audiological Concern
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Speech and Language Concern
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Behavioral Health Concern
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Educational Concern
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What you can start doing Monday morning

• Develop - refine protocols
• Assessment
• Intervention
• Counseling guidelines
• Loaner amplification systems
• Tracking - spread sheet

• Communication/ collaboration with early
  intervention
• Parent email groups
• Use published resources
• Professional study groups

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Eileen Rall rall_at_email.chop.edu [phone]