ROUGHLY EDITED COPY
2015 EHDI CONFERENCE
Incorporating Lessons from Neurodevelopment to Inform
Clinical Practice: Optimizing Language & Listening Outcome
March 9, 2015, 11:05 A.M.
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CART is standing by. Welcome to EHDI!
"Incorporating Lessons from Neurodevelopment to Inform
Clinical Practice: Optimizing Language & Listening Outcomes."
>> DR. AMY SZARKOWSKI: I think it's time to begin. Whether
I'm ready or not, the time says, let's go. So I'm excited to
see you here and to share the work that I'm doing collectively
with my team. I'm one person, although I'm representing lots of
people, and sometimes I tend to do things a little bit lastminute, but this is a product of almost a year's worth of
collaboration and talking about what this means for our team.
So whether I present that in a way of that or not, there are a
lot of smart people contributing to these ideas today.
This came from -- I work at Boston Children's Hospital. I'm
a psychologist in the cochlear implant team and I work with
speech-language pathologists and C.I.-specific audiologists, and
they were talking about what they look for in kids who are
developing language, and then we had the question, is that
really how the brain works?
And I started to say, maybe we need to think about that.
We're collectively, as a field, the audiologists were saying,
we're looking for these skills and we know that needs to
language. And the speech-language folks said, here's what we
look for and here's what leads to language. And they both have
good outcomes in lots and lots of cases. And yet there are some
children for whom the methods that have been tried haven't been
as successful.
So our thought was, how do we take what we know about the
brain and how might that inform us about ways we might alter our
practice, if need be, for those kids for whom the other methods
aren't quite working?
So what I want you to do before we launch into this, think
about a tough kid that you've worked with, you're a speechlanguage person and they work 90% of the time or you're an AV
therapist or an audiologist and there are kids that they don't
work.
I'm not going to ask you to report on that because that's
embarrassing, but keep in mind the tough kids for whom your
methods haven't exactly worked, and as we go through today's
topic, I hope you'll reflect on that, because hearing aids and
cochlear implants work for many kids who have them, and yet,
sometimes they don't.
What I want to say, this is a signer so it's not about
signing versus spoken language. That's not it. This talk is
about for whom spoken language is a choice and they're using
technology to gain access to sound, and if that's the case, when
does that go wrong, okay?
So it's not about modality, and when I talk about language
and the brain, I want to be clear that the brain can language in
lots of modalities and lots of different languages, but
specifically for those whom are using these technologies and
they're not working. So that's the aim of today's talk, if that
makes sense.
How do we bridge the gap between making sense of sound and
what a child hears? I think everyone here knows, early access
is good, we want to get the input, the sooner the better, all
those things. So we're starting on that page. How can
professionals use science to inform practice? My colleague,
Denise Fournier Eng, will say that people know this stuff and
don't need this horizon.
So if we take it away from discipline-specific training and
what the brain does, how can science address those kids who are
having difficulties making that deep from access to auditory
information, yet not really comprehending language?
So where are you pulling from? My job was to gather the
research and present to you what I found out along the way.
When you do that, you find out you knew less than you thought
you knew, or gosh, I know this and there are gaps. So please
note, I'm not the world's expert on this. I'm the synthesizer.
I'm a point-person.
But we pulled from speech-language pathology, certain
linguistics and medicine and talked about, how can we take out
there to inform better outcomes for kids and our practice
clinically.
We want to move this away from the tug-of-war, we use this
method, you use that method. We are certified, we use speechlanguage, whatever the tug-of-war in those fields. We want to
move away from that. We recognize there are many kids for whom
all of those methods work, and if it's the right match for a
particular kid, we see lots of success and sometimes we don't.
When we don't, how can we pull from outside our regular scope of
practice to improve outcomes for those kids?
So how can we understand the kids for whom traditional
methods haven't worked? Well, we can look at cognitive
liability that is both innate and enriched, teaching parents how
to read with their kids is an enrichment kind of thing that we
know boosts cognitive performance in kids and there are innate
parameters, you're born here or here or wherever the case may
be.
Intelligence plays a role, and if the child was more
motivated or the child was more motivated and they followed
through, that certainly plays a role. And then the caregiver
factors, how much access do they have to resources, children
with disabilities, those all influence how successful we can be
in understanding these traditional methods for speech-language
and for audiology.
But what are some other factors? What else goes into that?
I think sometimes one of the speech-language folks that I work
with will say, we can talk about IQ and talk about AQ but we
can't talk about the X factors. It's hard to say, well, this
child seems like they wouldn't have good outcomes, but they had
the most motivated mother. In a talk, we just heard how a mom
pushed for resources and that makes all the difference.
So we need to consider those and what can we do to foster
those X factors that might be limiting and what can we learn
from those X factors that seem to help kids to thrive? So both,
we're looking at the kids for whom traditional methods don't
help and those that do, what can we learn from them as well?
So in talking with my audiology colleagues, we talked about
the need for discrete auditory skills. As I understand this,
correct me if I am wrong, but this is the ability to decipher
things, to detect small things, so you need to have an awareness
of needing to listen. So sometimes you have a kid that bounces
all over the place and they're unaware that you're asking them
to make a sound that they try to hear and if they can't hear
that, they can't show you they can do that.
Detecting presence of sound is a part of this. So if we're
talking about kids that use hearing aids, cochlear implants, you
want to know if they can detect sounds. Very often, we think
about the ling sounds that goes across the frequency, given
appropriate auditory access, and so that just lets us know, is
that gear working.
And then discrimination of similar sounding phonemes. Can
the child here the difference between an S and Shh or C sound
and what might an audiologist be looking at early on. What we
don't want is for people to get stuck. So absolutely, using the
ling sounds as a method to make sure they have access to those
sounds is important.
Sending six months teaching a child to copy the "A" effect
might be sort of limiting them by focusing on something that is
less brain-based.
In looking at how both speech-language and audiology from
these fields, we've brought this together, it's hierarchical,
you build from here to here to, ta-da! Language comprehension.
Although it isn't this step-wise hierarchical way and it might
work in a different way. So if we think about that, maybe we
need to suspend our 100% dedication to this hierarchical method
if that's not the way the brain processes the information. Does
that make sense? Okay.
Is listening analogous, listening becoming language, is that
analogous to crawling and learning to work? What do you think?
Not really. If you do a checklist, though, let's say you're
looking at a motor development checklist and it says things like
children will roll over at this age, and then they'll crawl, and
then they'll walk, so it sounds like if you're doing a checklist
screening, you crawl and then you walk and then you keep going.
But in fact, there's a whole bunch of things that happen
between crawling and walking. If you have a toddler, you might
recognize that the cruising thing happens for quite some time,
but in addition, there's other stuff, like being able to pick up
your foot and balance for a certain amount of time to put it
down again. You can break it into lots of parts that go from
crawling to walking.
Similarly, I don't think we go from, listen, okay, heard it,
my technology is working, got it, I understand it. There are
ways which it will fall apart and if we're paying attention to
the pay the child was learning, we can help to fill in the gaps
along the way.
In fact, it often works. It's amazing, this brain thing, and
it works for kids, too. They crawl, and then they walk. But if
you have a child that didn't do this, like this and this,
there's delayed time in between or there are other reasons they
didn't crawl, then walk, you realize there are ways to build
support around that for children who need occupational support
or need to learn to walk with AFOs. It can be a natural
process, and for some kids, it's not.
So the listening hierarchy, this lens, which looks great on
my screen and not so much here, is widely used. So when I
showed it to the audiologists, they said, yes, we've seen this.
This is famous, it's been adopted by all the cochlear implant
companies that use cochlear implants in the U.S., they have a
version of this on the home page. Detecting sound,
discriminate, can you hear those distinct things, identification
and imitation and then comprehension. Because you say "cat" and
the child can say "cat," next is not, "I understand full
language."
I'm going to argue that it's not hierarchical and it doesn't
go like this. I think there's a lot of stuff that happens
between here. Between crawling and walking, it happens for
some. For kids who have typical hearing and they have the IQ
and EQ factors, it might look like this. Imitation is not
comprehension, so parents are so excited, the technology is
working, the child is detecting sounds, noticing things in the
environment, and the parents say things and the child copies
those words and it's like, "yes, they've got it!" And the child
may or may not understand what they just said so we need to make
sure we're paying attention to that space between identification
and imitation and comprehension.
It's scaring to challenge the existing hierarchy because it's
so commonly used, so there is a part of me that says, who am I.
But just listen, ask questions later.
So as a team, we came up with this idea of looping back
around. What good speech-language pathologists will do, they'll
check in. This is an idea of how we teach language, but you
might step back a step. I think you got it, but let's step
sideways and see if it works in a different way. But really,
all of these parts need to be there, but a child needs to, first
of all, be responsive. Responsiveness is important. They have
to have accessibility for sound. Again, we're talking about
listening, leading to language learning, not other modalities.
Access to communication, language-listening comprehension,
meaningful exchange. That is an important part too. What
happens, and literally in the brain, it's not just me being
fluffy and psychology-ee, we learn -- in isolation, it doesn't
happen so well, it is important to have meaningful exchange and
what gives children meaningful ways to communicate is that.
What we're doing as professionals makes them less likely to
communicate because it's horrible, one could argue that tends
not to be as successful as engaging the child where they're at
in things that matter to them and using those naturalistic ways
of teaching language and showing language modeling and closing
the loop, making sure they understand and growing their language
both in terms of what's in depth. We don't want to just teach
new vocabulary. We want to teach lots of ways to say the same
thing so it's cool and kids can play with language. All of
those things are also important.
So this is from Denise Fournier Eng, who is from my co-worker
who is supposed to here, and there's communication and language
and comprehensive and all these things that go into that. So
each of those is not a thing. You know, if we just look at the
communication part, what is -- what is involved in
communication?
Well, here are some things that are involved. Visual
attention is required for communication. Looking and pointing.
Vocalizing. All kinds of things. It's not just these,
listening and comprehension, but in fact, each of those has
several discrete skills, if you will, in and of themselves and
when we're teaching kids to be good communicators, we want to
make sure they're attending to those.
Of course, we use curricula to guide us or you want to have
therapy goals or auditory goals, this is what you're hoping the
child can achieve. That makes sense. And yes, we want it as
comprehensive as possible. How can the brain language, and I'm
using that as a verb. How can the brain language, and how can
we communicate.
All right. So sometimes, it can happen. If we get a little
stuck here, we focus and we think, okay, as long as the auditory
pathways are good, we're set. There are a number of times I've
read it's adequate for developing spoken language. Again,
that's that really big leap, I think. Maybe we should write,
access to sound seems to be adequate to hear speech sounds.
They have enough access that they can detect the speech sounds.
I read in the report of a child who has a syndrome with lots
of complications, and I thought, what does that mean for you? I
mean, what I think you're telling me is that the ear gear is
working. The access to sound is present. That's a good
starting place. Right? I don't just pick on audiologists. We
say otolaryngologists among us, and sometimes they don't speak
because of fear of the doctor. So sometimes there are these
estimations made that we should be more cautious about.
So if we move away from the ear works or the gear works,
that's allowing auditory access. So some people will say, well,
you know, temporal lobe, that's where all this stuff happens.
But, in fact, if we look at what are the parts of the brain
involved, it shows there is a lot more going on than detection
of sound. If it's just detection of sound, we can narrow this a
lot. But if it's how does a child comprehend language, the
whole brain lights up. There are lots of things going on and
contributing to that success of the child communicating.
All right. Schema of meaning. In looking at how the brain
understands communication context, here's something that struck
me as really important, because it makes sense that the brain
relies largely on context. The brain actually -- if a child -if they've done this in different ways, so you can set up a
child to have an interaction with a parent, for example, and you
can hook up their brain, monitor their brain before the parent
even says anything and the way the child's brain responds to a
parent talking to them is different than the way the child's
brain primes itself for talking to a teacher.
So what is said is important for comprehension, but also the
speaker and the direction of the conversation. If the brain
knows you're in an exchange, it does it differently than if it
knows you're being spoken to, for example.
Without context, understanding is harder to detect. So if
our aim is comprehension and understanding, maybe we need to
think it's okay to provide context for kids. Part of what
sometimes our therapy approach is to take away context. I'm
going to cover up my mouth and make you tell me what you hear
and I'm not going to give you clues or gestures or anything
that's because the pure way of measuring what your access is.
Not that there's not a purpose for, that I want to say, but
there's a purpose for figuring out what is somebody taking in.
Absolutely. But if the higher aim is communication, then trying
to do therapeutic approaches with kids, we shouldn't necessarily
take away context, because we rely on context, and it's not
cheating, because you do it and I do it too. How I speak today
might be different than I spoke at the bar last night. We alter
the way we present ourselves but how the expectation of how
others perceive us, okay?
So shouldn't it also be the case that when we're working with
kids who are Deaf or hard of hearing and are users of
audiological technology that we're definitely providing access
to sound but we're providing the other clues that help them to
succeed and have successful communication exchanges and social
opportunities which can then make them better at it. Practice
makes kind of better. Not always perfect. Right? But the more
that we provide that context, the better that it can help those
kids to do with that.
So in part, when we're thinking about how do we train these
skills, let's think about that. Context is not cheating.
Providing context cues is not taking away, it's helping their
brain to pull it all together. Does that make sense? Okay.
All right. So early life experiences, we know, help to shape
brain architecture. Charles Nelson Hubbard has done a lot of
work around kids born in orphanages and we know that early
childhood determines how the brain develops, the neurocircuitry
and with plasticities, we know this can change over time.
You've heard about critical periods and sensitive periods,
yes? And this is why the push we need earlier and better
interventions. The earlier, the better, the more the brain can
take it in and make sense of it. So the sensory stuff does need
to happen. We also know the critical period, if it goes beyond
a certain point in time, the development of a full language
system becomes less likely.
We know we can enhance different things, so by providing
different kinds of activities and exposures for kids, we can
change the way the brain connects, and we know that multisensory
integration is an important piece of this. The kid is exploring
and playing and learning in their environment, all of that.
So if we take the brain-based stuff to informed clinic
practice, again, I would argue that, moving away from here only,
to incorporate the whole body, and the child's whole experience
and in their play and all of that, again, I think regardless of
where you're at, I think lots of good people, who are good and
skilled at what they do, they do this naturally. But sometimes
they don't. So if they're not doing that enough, and the tough
kid I asked you to hold in your mind, how do you incorporate
this kind of work to foster this, if that makes sense?
So I went into this project knowing that the brain expects
languaging, languaging as a verb, that the brain takes in input
and wants to make language and make sense of things.
What I didn't know is all of this. That there's experience
expectant and experience dependent ways that it is shaped. It
expects to have adequate nutrition.
It expects to have access
to a caregiver, expects sensory stimulation and language input.
The brain is prime for those things. It means that when the
brain of the new baby is there, it's looking for, actively
seeking, and wanting these inputs.
So we can't necessarily change the person's caregiver, nor
would we want to, but we can help parents to be more engaged in
stimulating with their kids. We can help them in a positive way
to know, you're not just feeding them and changing diapers and
waking up a lot during the night. You are helping the child's
brain grow and this relationship is important.
If you're in the EI field and you've worked with the parent
who has grieved a little bit about the diagnosis that the child
has been given -- and if you're in the EI field, I would imagine
you have -- that we can help parents to connect more with their
kids. We know that attachment has implications for brain
development. Those are important things.
So we don't want to attend only to a discrete listening
trial, but really, how is all of this working together?
Experience-dependent. The quality of the caregiver, the
variability of the input and the quality and quantity of access
to language matters for brain development, and studies have
looked at kids at a year haven't had this, and the implication
is long term, really long term.
When reduced language access is withheld for longer, the
implications are bigger. As a psychologist, I get to see that,
and working with kids in counseling, I see the social and
emotional impact of not having the same kind of care. So we
want to make sure that we're providing that and encouraging
parents to play, to provide access to language in a meaningful
way.
Some parents might feel like it's overwhelming, it's really
hard, how do I do this? I perhaps have an older child and I
read to my child every day and I thought I was a really good
mom, and now, I'm not sure how to do that with this child who
doesn't hear me very well.
So part of the task might be, how do we model, that how do we
teach that, and not just tell parents, you need to read ten
books a day to your child, but help them, see that in context.
Why is it not so important that the child has to learn this
particular book but that the child needs this, they need the
back and forth, they need that meaningful exchange, they need
the idea of waiting for a story, the character says something,
and then what happens next. All of those things help to teach
things like theory of mind and perspective-taking and things
that we want all of our kids to have and to be good at, and it
depends in large part on these kinds of things early on.
So I recommend this article by Mayberry, if you're interested
in this, what expects early language on neuropsychological
functioning. It's not an easy read, but that's how this whole
project is, not so easy. It's fascinating. So I put arrows in
the places, these are the areas that are impacted strongly when
there's reduced early access to language. And in the in terms
of neuropsychology, there's the frontal lobe.
What does the frontal lobe do, anyone, anyone? Attention,
working memory, self-regulation. All of those things. There
are ample studies who show that kids who are Deaf or hard of
hearing are at risk for having reduced functioning. Are they
reduced languaging, verb, or not languaging or how does it allow
the child to self-regulate, to focus in the classroom, to be
participants in their learning experience overall? Okay.
I need clicker. I think I have one. Okay.
So this whole burgeoning field of social science,
fascinating, and showing that the brain requires interaction for
learning. We know that attachment and caring relationships
allow them to produces oxytocin, the bond with the baby, moms,
dads too, look at the faces, get the neurofunction, allowing you
to attend to your child, even when they're throwing up four
times a night and you have to remember how cute they are when
they're cuddly and keeping. I love you. I love you. Oh!
So worth it. It plays on us. It changes our chemistry. And
it does for the child. But the child is not getting the same "I
love you" messages because parents are stressed out about the
diagnosis or stressed out about going to lots of appointments
and struggle with these changes or parents are stressed out
about making choices for their 3-month-old, how many I going to
communicate, where are they going to school, that other parents
perhaps are not facing at that age.
We need to make sure that we're acknowledging and fostering
that, to sing, they can feel the vibration, even without the
gear on, and all of those matter not only for the piece but for
the development of the social and neural part.
We know that empathy isn't just, I understand you, I feel bad
for you, I'm glad I'm not in your shoes, but you have to imagine
yourself in their shoes. Absolutely, empathy requires social
interaction. If you were to look at the literature in the last
three years, coming out of Deaf Studies that looks at theory of
mind, what you would see is that on average, children who
have -- who are Deaf or hard of hearing appear to have reduced
theory of mind relative to children who do not have hearing
loss.
Why might that be? Any thoughts? Reduced over hearing. The
incidental worrying part. You're not accidentally overhearing
things and taking it in. What else? I think sometimes our
expectations are low, too low. Sometimes we have a vocabulary
checklist and if the kids get all those things, we say they're
doing great, and what we haven't thought them are the feeling
words, the academic to teach them to read and do other things
well in the classroom and we don't attend to the touchy-feely
things. We feel it's outside the curriculum and teachers are
overwhelmed, but if we have the families do it too, that would
be one way to foster that.
If -- okay. I'll come back to that.
>> AUDIENCE MEMBER: (Away from mic).
>> DR. AMY SZARKOWSKI: You could be my new best friend.
Gold star! I don't expect you to know these things nor do I
want you to ask me to explain it all. But primary auditory
cortex. This is where the language comes in, right? We hear
and we say, they're hearing. Great. The gear works. The
hearing aid or cochlear implant is successful.
But language goes here, goes back, goes around, and look at
spatial relationships, your understanding of who is that person
who is talking to me. There's all kinds of things. All of
these parts clearly identified in "I took in a sentence, and it
made sense to me." If I heard a sentence and I just heard it,
it would happen here. This is all going on in order to take in
a sentence.
So imagine taking in a whole lecture. Your brain is going
crazy. Okay.
I'd like you to just read this first, and then we'll chat.
And you should break it down and grasp something, but my point
really was, this is what the brain does simultaneously. This is
what it does. If I tell you, language learning is top down and
bottom up, you would nod your heads and say, yeah, yeah, we knew
that. That doesn't sound novel, but the point is not that you
have to understand that whole context, but that's what the brain
does.
So to emphasize that we are doing top-down, understanding,
leading to comprehension, leading to understanding more discrete
things and bottom up, here are these pieces that go together to
lead to something that is more comprehensible. The brain does
it simultaneously. It truly doesn't say, you've had a child.
You can think of it. The ba, ba, the phonemes that add up, but
the child knows what they want to say. The "ba" is the bottle,
and there's meaning and it's not adding the discrete sounds
together but the brain is doing both at the same time.
So the lightning bolt is that we really need interventions
and support that address how the brain works. And my argument
is, as a psychologist talking to early interventionists speechlanguage pathologists, why don't we think outside the box and
say, how can we use brain science to inform us? I'm not asking
everybody to change everything you do, because a lot of what you
do works really well, and when kids have solid cognitive
potential and motivated caregivers, we see good outcomes. When
any of those pieces might not be there, present, or as strong as
could be, then perhaps we should supplement what we do in a
different way.
What I do want to say, too, is that this whole conversation
at Boston Children's Hospital is changed the way we're doing
practice. So the audiologists have said, we've been learning to
this hierarchy thing. That's what they were taught in grad
school. That's what the C.I. programs all say works, and now
they're having to go, woo, all right. So at least three
handouts that they regularly give, we're getting rid of those
and recreating, so it's a really exciting thing. It's not just
me preaching to you saying, "change your practice," but we're
looking at, how can we change our practice in a way that best
supports kids.
One of the audiologists I work with is an audiologist and a
speech-language pathologist, see said it was hard, muddled, if
this, then that, and speech-language pathology, if you do this,
you get your outcome. I said, sorry. But glad you're at the
table and glad that you're opening your mind to doing things
differently to support, again, all of those kids, for those who
it works and for those for whom it has been challenging.
This is meaningful communication, and that's our aim, that
collectively, whichever of those fields you might be in, that
meaningful communication with children who are Deaf and hard of
hearing, that that's a major and overarching goal. In order to
do that, we need to attend to the language and brain, the idea
that the brain is taking in context, do all of the things that
it's doing before.
Who is the speaker? What's the expectation for the back and
forth? What am I supposed to be doing right now? If the
expectation is that I nod and listen, I don't have to engage in
the material in a way that's deep, so that can allow a child to
do less. I think we need to remember this top-down and bottomup approach, that it's neither/nor, it's that whole
comprehensive slide that I made you read all going on at the
same time, and we should be aware of those critical and
sensitive periods, and that's what's driven EHDI programs.
Earlier is better. We know that. But really, does that come
across as just a push to parents? You need to get in there and
you're slacking if they're not by six months, that might be how
it's perceived, but in the state meeting, we talked about, how
do we tell parents we know that? We're doing a good job of
screening and referring.
So scheduled hearing loss, let's get them for an audiologist
exam. Kudos to those involved. If parents don't know why it's
important, part of the lack of follow-up is that. Some might
feel that, it's not my area of practice. If I'm a nurse
practitioner at a birthing hospital who does the screenings,
what do I know? Maybe, collectively, we should be educating
ourselves around that. We want children to have access to
language, want them to be able to communicate and reach their
potential, really, but in kids who are Deaf and hard of hearing,
we need to facilitate that and make sure that happens.
All right. I should have been checking my time along the
way, just to make sure. If I leave too much time for questions,
you might ask a lot. Just kidding. Kind of.
What questions do you have? I'm okay with this being a
discussion. If you don't have questions, but thoughts you'd
like to share, that's okay too. Yes. Sure. So the question
is, can I share some ways that clinical practice is changing
since this is fixed around that.
So with the audiologist, it's that, our plan is to educate
the docs that we work with and have -- with the conversation
around adequate access to sound, they should be able to speak
fine. To have us think about that. What does adequate access
to sound mean? When they say that, the doc who wears a white
coat carries a lot of wait, perhaps more than the speechlanguage therapist who is in the office across hall from me.
So when the doc says they can hear, they're fine, for some
parents, that takes it off the table and they don't need to
follow through with the speech-language pathologist because the
doctor said they're okay. So with the cochlear implant team,
they're already saying, we're not going to give out these
handouts anymore. What should the handouts say about language?
What should we be saying about listening and that it doesn't
really go listening to language but that there are steps in
between where we can foster and provide support.
Another idea is that in our area, there are some folks who
are getting like specialized training in particular types of
speech-language therapy provision, and part of the -- you know,
one of my earlier asides is getting away from the tug-of-war.
This way is best. This way is best. But all of us have areas
where we haven't succeeded as well. How can we work through
that to rise above collectively, and there is a person working
with a speech-language pathologist and working together in a
neat, complementary way, not "I'm right, you're wrong" kind of
thing.
So here is some stuff we're learning about, how the brain
processes language so we can provide these visual supports, and
learning about, what are the reasons for specific tasks. So as
I mentioned, identification of discrete skills. It's important.
It's part of knowing that the ear is working. Ling sounds. Can
you identify those particular sounds. That's important too.
That tells us, is the child getting the whole spectrum of access
to sound.
We also get referrals from kids who have been stuck for eight
months practicing ling sounds that they can't produce, so they
don't want to -- the providers in those cases don't want to move
on because they're stuck there. But that's not how language
works.
So again, if we talk about taking away the hierarchy, you
need to know this, this, and this to get to this, but we now
it's much more circular, okay, maybe they're not having perfect
access to this where maybe there's a fine motor issue and they
can't make the sound, so maybe audiologically, it's okay. But
if your checklist says you have to do these things, then people
really do sometimes get stuck. But if we think comprehensively,
if you're savvy, you might have noticed I had lots of triangles
at the beginning talking about hierarchy, and then there was
looping around and I think it's much more circular. I think
that's how the brain works and that's what we should be doing in
that simple context. Yes.
>> AUDIENCE MEMBER: (Away from mic).
>> DR. AMY SZARKOWSKI: Right. So some of you sitting by
her, I do need to repeat. The comment was, there are a lot of
misconceptions and a lot of audiologists have the hierarchical
model. There are things that need to come first, like
detection. However, if you're thinking of languaging, again, as
a verb, there are lots of ways even if you can't detect a
particular sound, there's language that can happen. So I think
flexibility with those definitions and thinking more in that
holistic way. There was a hand up over here. Let me see, can I
do this? Can I pass the mic? Okay. Paragraph.
>> AUDIENCE MEMBER: So I was wondering if your practice, if
you kind of combine everyone for appointments. At many times a
lot of speech-language pathologists, audiologists, is it
interdisciplinary approach versus one doctor at a time, one
practitioner at a time?
>> DR. AMY SZARKOWSKI: Scheduling. So tricky. It does
happen, and in our team it happens with a speech-language
pathologist and increasingly, the audiologists too. So I joined
an audiologist three or four times for different ways. One is a
10-year-old who has a progressive hearing loss and she's
anxious, so that was more of a psychology kind of focus, so we
can talking about cases that are challenging but also our
thinking how this is evolving.
So I think there's definitely an interdisciplinary approach
and when possible, we try to schedule that. The child may have
three appointments during a day and I see one and the doc sees
one, but we try to get together and give some feedback to the
family, so they feel like, okay, they're working on our behalf.
Yes. I'll come to you.
>> AUDIENCE MEMBER: I think this is a great topic. I've
been working in the field for a very long time, especially with
children with cochlear implants, and the children who have
access to these sounds, but that's just a tool. The sounds are
not is curriculum -- many stick with that, like there's some
magic that comes from being able to repeat them, and that's not
the purpose and never was.
Anyway, what I have seen and I work with grad students now
and what I try to really make them understand is that a child
can have absolutely beautiful speech and sound exactly like a
hearing child and you still cannot assume that this
comprehension is occurring at a higher level.
It isn't just children -- I mean, that's the downside of
having this wonderful technology, isn't it? Especially those of
you who have been in the field a while. We hear speech we never
thought we would hear. We have children with access to sound
that we can't believe they have, but we can't assume they're all
done and all ready to go. It's not really a question. It's
kind of a comment, just to caution people to be conservative, to
be careful that we don't short-change the children and the
families.
>> DR. AMY SZARKOWSKI: A couple of thoughts. Myself and
Denise Fournier Eng have written an article in The Odyssey,
sometimes, expectations are too low. I mentioned that before.
And sometimes expectations -- as long as the gears are in place,
we assume there's understanding and comprehension so the
understanding should be exactly where everybody else's are, so
we make this argument for following and expectations should be
individualized for the child, but high and appropriate. So
setting the bar here, if it's impossible for a given child to
achieve that, isn't fair. So I think being careful around that.
Yes.
>> WOMAN: (Away from mic).
>> DR. AMY SZARKOWSKI: Where can you find that article?
"The Odyssey" magazine, put out by the Clerc Center, coming out
in this month's edition. So the question is, are we starting to
get a better sense of who has a language disorder? Yeah, it
hasn't been delayed access that results in reduced language
skills or is it a disorder? And it really does help clinically
to make more sense. The way you might work with a child with a
learning disability has more with delayed success, filling in
the gaps versus using an alternative approach. I think there's
important stuff that can come from this.
>> AUDIENCE MEMBER: So I'm a surgeon, so obviously, our
approach tends to be okay, if you have a problem. So what I'm
hearing, I think is, a natural progression so -- tell the
students or residents, you know, not all the world is a nail,
just because you have a hammer -- you can't have a fixed
approach that works. But I guess one of the things I hear is,
okay, they can't think of the same way, they have to think
differently. What I'm not hearing is specifically if you've got
this problem, you know, this is the reason and should focus
here. You're saying, well, open it up and think about it, which
I think a mature program, too.
So I guess I haven't got anything particular to say, you know
what, you're having this child, you know, you got an implant
early, audiologically, they seem to be getting all the access,
and yet the performance is behind, check off and things aren't
happening. Language discrete -- how do you know the lack of
language caused the access problem? You've got to read all
these papers you talked about, but I'm not getting anything
particular there that I can carry it out and have it occur.
>> DR. AMY SZARKOWSKI: So I guess one of the take-home
messages would be, who is responsible for checking on these
things? I'm encouraging you to think outside the box. But who
is going to do that? Let's say the child is in a preschool
program, the child is two years old. Part of what we're urging
is for somebody being responsible for checking in on those
things.
If everyone is in place, the situation you described, if all
that is there and they're not succeeding, a lot of people will
say, that's not my thing. I'm doing my piece. Perhaps it's
making a person on the team responsible for a given child to
follow through. Who is going to help the parents think about,
okay, are all these things really being implemented? Some early
intervention rocks and some could use some improvement. So we
need to check in on those things too.
I think you're right and I would be happy to talk to folks
individual -- in a talk of this nature, it's hard to say, here
are all the specific things. My point being, there's lots of
ways in which it could fall down along the way and attending to
those and being aware of them and you're right, it makes sense,
but it also hasn't been widely accepted as the way to think
about it, you know?
I was at the Cochlear Implant Conference in Nashville where
they give seven-minute talks. Yeah, seven minutes. Pretty
fast. And there were several surgeons, several folks on the
medical community talking about things and the person stood up
and said, I want to talk about the elephant in the room. You
are talking about these fabulous outcomes and yet we know there
are kids for whom it doesn't work. And the person said, as long
as our surgical techniques get better, we should be able to
remedy that in the future.
And it was hard, but it led to some great conversations with
the guy who raised that question and my colleagues, but from a
particular discipline you're seeing, that team approach is
super-important, the team saying, this is working all,
audiologically, it's working. Here is where it's falling down.
In a team approach, I feel lucky to be a part of a team with
psychologists and teams on board and there are clinics who
doesn't have that approach. We can figure it out. If you have
the right people on the right teams, we can add to that
conversation and help to contribute. Yeah.
>> AUDIENCE MEMBER: To answer the doctor's question, the
surgeon, I am one of the professionals that realized that and I
am not afraid to say that I am frustrated when I see a child who
is not responding. The ling sounds are not there, so I try to
use songs in which the ling sounds are included to see, can the
child perceive something. And yes, I am frustrated, but I
believe in team work. So if I see that the child is not
responding to language, my first question is, let's go to a
level that I can disregard any pathology.
So my first recommendation is a neurologist. What is
happening? There is something physical preventing the child
from processing, something is interrupted there. Then, the ENT,
the otolaryngologist. I want them to change professionals, to
go for a second opinion. I don't know how many early
interventionists are here, but we are really in that front with
the family and making sure that the family is understanding what
we recommend or we work with them as a team. Thank you.
>> DR. AMY SZARKOWSKI: And the more informed we can be, the
better we can be at the referrals. If you send someone to a
neurologist, but the more educated guesses we can offer, too,
that can help to inform the community. Yeah.
So I just got the two-minute sign, Susan Wiley just made the
comment that she used to be more sequential and if you take care
of the one piece and the next piece it gets too far down the
line so the comprehensive look is important.
If a child has significant motor issues and they're not
producing speech as a motor skill, there's a breakdown there and
I feel that happens a lot so speech-language gets caught on them
producing speech-language sounds and if there's a problem,
there's that whole integrated child part that's important.
I want to thank you as an audience. You've been great. I'll
answer any questions after. Enjoy the conference!
(Applause.)
(End of session at 12:04 p.m.)