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
What’s 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’
• Child’s 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)
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Incidence per 10,000
(NCHAM)
40
30
30
20
5
6
10
11
12
1
2
0
ia
m
U
ne
lA
PK
el
C
le
ck
a
Si
fid
bi
a
in
s
Sp
ct
fe
e
de
m
b
m
ro
Li
nd
Sy
te
n
la
ow
pa
D
or
lip
ft
le
ss
C
Lo
g
rin
ea
H
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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
Reading Comprehension Scores
of Hearing and Deaf Students
Grade Equivalents
(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.
• Undetected hearing loss has serious negative
consequences.
• There are dramatic benefits associated with
early identification of hearing loss and
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)
31-36 mos
(n = 8/19)
Chronological Age in Months
(NCHAM)
15
Vocabulary Size for Hearing Impaired Children
Identified Before and After 6 Months of Age
Vocabulary Size
300
250
200
150
100
50
Identified BEFORE 6 Months
Identified AFTER 6 Months
0
13-18 mos
(n = 15/8)
19-24 mos
(n = 12/16)
25-30 mos
(n = 11/20)
31-36 mos
(n = 8/19)
Chronological Age in Months
(NCHAM)
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
3.2
3.8
4.2
4.8
Age (yrs)
Moeller, M.P. (1997).Personal communication
, moeller@boystown.org
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18
19
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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 child’s
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
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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
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Socio-Emotional
Development
MY IDENTITY
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Experiences
Family
Gender
Who Am I?
Career
Ethnicity
Abilities/
Attributes
28
Who Am I?
• I am…..
• Influences
1. Educator
1. Worked for over 20
years with schools
2. Healthy
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
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
Health’s 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)
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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
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Families can..
• Respond to the child’s needs consistently.
• Look at the baby when communicating with her.
• Use facial expression, body language, and gesture to
promote bonding.
• Do things at the baby’s 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)
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When Does Communication
Begin?
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Early Communication
• Facial Expression produced by 12 months
(hearing and deaf)
• Use a variety of attention-getting devices
• Use gestures
42
Early Communication
• Help parents
tune-in to baby’s
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 baby’s 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
– Don’t 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
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Development of Hearing and
Speech Skills
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“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 speaker’s 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)
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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
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Auditory Development
• 1.
Awareness of sound
• 2. Sound
has meaning
• 3. Discrimination
56
Acoustic Highlighting
(Simser, AVT)
• More audible
• No background noise
noise
• 6” from ear
• Slightly slower rate
• Inc pitch variation
pitch/rhythm
• Clearer enunciation
• Increased repetition
• Greater acoustic contrast
Less Audible
background
farther from ear
normal rate
normal
unclear/unfamiliar
no repetition
less varied
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 child’s attention to environmental
noises throughout the day
• Ensure that the audiologist is part of your team!
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• Provide enriching listening experiences in the
home
• Add language to baby’s 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
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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 Sindrey’s “Listening for Littles”, used with his
permission)
Thinking and Learning
• If children can’t 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 baby’s lead; watch her eye gaze and provide language for
what she is interested in.
• Demonstrate different ways to get and hold the baby’s attention
(call baby’s name, manipulate a toy, use facial expression, imitate
your baby, touch baby gently, get in baby’s field of vision).
• Use turn-taking, expanding on your child’s responses.
70
Theory of Mind
As young children mature, they
develop an 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.)
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P. 2125
76
Name 2 things you can do to help
families encourage:
• Positive self-identity and healthy socioemotional development
• Language/communication development
• Cognitive development
• Theory of Mind
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