Introduction to
AR
Perry C. Hanavan,
Au.D.
Audiologist
Auditory Experience
TED Talk
• Establishing a Sound Foundation
• Dr. Karl R. White is a Professor of Psychology at Utah
State University and the founding Director of the National
Center for Hearing Assessment and Management
(NCHAM).
• Recognized as one of the world's leading authorities on
early identification and treatment of hearing loss in infants
and young children.
• He has hundreds of publications and presentations at
scholarly meetings, and has been invited to more than 30
countries to assist in the implementation of newborn
hearing screening and intervention programs.
National Goal –
Early Hearing Detection and
Intervention (EHDI)
1:3:6
Percent of Newborns Screened for
Hearing Loss in U.S.
Vocabulary Development
Hart & Risley, 1995
Birth of a Word
• Birth of a Word
• Deb Roy, MIT researcher, wanted to understand
how his infant son learned language
• Wired house with video cameras to catch every
moment (with exceptions) of his son's life
• Parsed 90,000 hours of home video to watch
"gaaaa" slowly turn into "water"
• Data-rich research for how we learn
The Linguistic Genius of Babies
• Patricia Kuhl, PhD
• How babies learn one language over another
– by listening to the humans around them and "taking
statistics" on the sounds they need to know.
The Linguistic Genius of Babies
Neuroplasticity
• Childhood hearing loss is a
neurodevelopmental emergency!
– Without early access to consistent intelligible
speech, the auditory centers of the brain will not
develop and normal intrahemispheric connections
• Auditory Access!
• Children hear 46 million words by age 4 years
– Hear 46 million words by 4 years of age (Risley and
Hart)
– Listening 20,000 hours to learn to read…listening at
least 12 hour days for 1,667 days (Dehaene)
– Auditory exposure to learn new words and concepts
increased up to 3 times necessary for children with
hearing loss
Case Studies
• Newborn identified at birth with connexin 26, severe to
profound bilateral hearing loss, normal hearing parents
• Newborn identified at 2 years with rapidly progressive
bilateral SNHL, parents have a profound loss
• Seven year old recently identified with unilateral severe
SNHL
• Middle school male with normal hearing but auditory
processing problem in noise
• Fourteen year recently survived bacterial meningitis
resulting in bilateral SNHL
• Dad, suffered sudden onset mild bilateral SNHL
• Grandmother, slow progressive bilateral SNHL
Impact of HL on Quality of Life
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Physical health
Emotional & mental health
Other’s perceptions of a person’s mental acuity
Social skills
Family relationships
Self-esteem
Work & school performance
Dementia in elderly
Household income by up to $12,000/year
Some Historical Landmarks
Regarding AR in Audiology
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Genesis in WWII (1942)
Audiologists Dispense Hearing Aids (1978)
WHO Classification (1980)
Cochlear Implants (1984 – FDA approval)
Early Newborn Identification (1990 – Joint
Comm)
Communication Therapy (1990+)
Neural Plasticity of the Auditory System (1995+)
WHO Classification (ICF, 2001)
Hearing Assistance Technologies (HAT) (2000+)
Question
Does AR increases income for persons with hearing
loss?
Yes
No
Hearing Loss and Impact on
Household Income
Kochkin, S (2010).The Hearing Journal. 63(10):19-24,26,28.
Treated Vs. Untreated HL
Impact on Household Income
Kochkin, S (2010).The Hearing Journal. 63(10):19-24,26,28.
Mild HL Linked to Brain Atrophy in
Older Adults
• Early intervention could prevent
slide toward speech
comprehension difficulties
• Research suggests that hearing
sensitivity has cascading
consequences for the neural
processes supporting both
perception and cognition
Definitions
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Auditory Training
Aural Rehabilitation
Audiological Rehabilitation
Speechreading
Lipreading
Communication Rehabilitation
Habilitation
Rehabilitation
AR Definition
“The assessment, intervention, and management
of communicative consequences of hearing loss”
(unknown author)
ASHA
Aural rehabilitation refers to services and procedures for
facilitating adequate receptive and expressive communication in
individuals with hearing impairment. (ASHA, 1984, p. 37)
Audiologic/aural rehabilitation (AR) is an ecological,
interactive process that facilitates one's ability to minimize or
prevent the limitations and restrictions that auditory
dysfunctions can impose on well-being and communication,
including interpersonal, psychosocial, educational, and
vocational functioning.
(American Speech-Language-Hearing Association. (2001). Knowledge and Skills
Required for the Practice of Audiologic/Aural Rehabilitation [Knowledge and Skills)
David Hawkins
Anything that facilitates:
1) hearing,
2) understanding of hearing loss,
3) coping strategies,
4) acceptance of hearing loss, and
5) involving communication partners.
(Hawkins, D. 2003)
Mark Ross
Any device, procedure,
information, interaction, or
therapy which lessens the
communicative and
psychosocial consequences of a
hearing loss.
Ross, M., JARA, 1997
McCarthy & Culpepper
The purpose of an aural
rehabilitation program is to focus on
assisting hearing-impaired
individuals in the realization of their
optimal potential in communication,
which is needed in educational,
vocational, or social settings.
McCarthy & Culpepper, AJA, 1987, p. 305
Houston & Montgomery
"…the goal of aural rehabilitation
for the adult is ambitious – to
increase the likelihood, the level,
of successful communication
over the client’s lifetime."
Houston, K.T., and Montgomery, A.A.
Auditory-visual integration: A practical
approach. Seminars in Hearing, 18 (2), 1997.
JP Gagné
“Aural rehabilitation is aimed at restoring
or optimizing a patient’s participation in
activities that have been limited as a
result of a hearing loss and also may be
aimed at benefiting communication
partners who engage in activities that
include person with hearing loss.”
Gagné JP. Ear and Hearing. 2000, p36.
Arthur Boothroyd, Ph.D.
“Adult aural rehabilitation is here
defined holistically as the reduction of
hearing-loss-induced deficits of function,
activity, participation, and quality of life
through a combination of sensory
management, instruction, perceptual
training, and counseling.
Boothroyd A, Trends in Amplification, 2007, p63.
Aural Rehabilitation
Intervention aimed at minimizing and
alleviating the communication difficulties
associated with hearing loss.
(Tye-Murray N. Foundations of Aural Rehabilitation
(video)
Audiologic Rehabilitation
“Any activity, method, resource, technology,
and/or device that facilitates and/or enhances
communication and participation in activities.”
Hanavan, PC, 2010
Conversational Fluency
“…relates to how smoothly
conversation unfolds”
“the book’s central theme”
Tye-Murray N, Foundations of Aural
Rehabilitation, p2. and preface, p ix.
Hearing-Related Disability
“…a loss of function imposed by hearing
loss. The term denotes a multidimensional
phenomenon.”
Tye-Murray, Foundations of Aural Rehabilitation, p2.
Summary of Definitions of AR
and WHO 1980
• Often describes approaches rather than
objectives/goal
• Hearing and communication oriented
• Medically oriented: eliminate (treat)
prescribe (cure)
Disease
Or
Impairments
Disabilities
Handicaps
Disorder
(International Classification of Impairments, Disabilities and Handicap – ICIDH,
WHO, 1980): Adapted from Gagne JP, 2007 ARA Institute, Louisville, KY.
International Classification of Functioning,
Disability and Health (ICF: WHO, 2001)
Health Condition
(disorder/disease)
Body Structures
& Functions
Activities
(activity limitation)
Environmental
Factors
Participation
(participation restriction)
Personal
Factors
ICF (WHO: 2001)
Disabilities is an umbrella term, covering
impairments, activity limitations, and participation
restrictions.
– Thus disability is a complex phenomenon, reflecting an
interaction between features of a person’s body and
features of the society in which he or she lives.
Question
Does “hearing impairment” means deaf, only?
Yes
No
ICF (WHO: 2001)
Hearing impairment is a broad term used to
describe the loss of hearing in one or both ears.
There are different levels of hearing impairment:
hearing impairment refers to complete or partial loss of
the ability to hear from one or both ears. The level of
impairment can be mild, moderate, severe or profound;
deafness refers to the complete loss of ability to hear
from one or both ears.
ICF (WHO: 2001)
Impairment is 'a loss or abnormality of body structure
or physiological or psychological function'
Activity limitation is 'the nature or extent of
functioning at the level of the person'
Participation restriction is 'the nature or extent of a
person’s involvement in life situations in relation to
impairment, activities, health conditions, and
contextual factors’
Health-related Quality of Life is 'the functional effect
of an illness and its consequent therapy upon the
patient.'
Satisfaction is the subjective assessment by the patient
that his/her needs or expectations have been met.
Applying WHO Taxonomy to HL
• Anatomy and physiology: Physical and functional
integrity, including integrity of outer ear, middle ear,
cochlea, neural pathways to the brain, and the brain itself.
A major concern is with the status of the cochlea. With
older patients, integrity of neural structures is important.
• Function: Includes hearing threshold, dynamic range,
frequency range, spectral and temporal resolution, acoustic
pattern discrimination, direction and distance perception,
attention, auditory working memory, processing speed, and
ability to listen in noise.
Applying WHO Taxonomy to HL
• Activity: The use of this capacity—the things one wants or
needs to do with hearing in the real world. Examples
include being alerted by sound, monitoring the
environment, recognizing and localizing events and
deducing their significance, monitoring and controlling
one's own speech, and enjoying auditory experiences. The
activities of most concern, however, are perceiving the
speech of others and engaging in spoken language
communication.
• Participation: The contribution of these activities to daily
life, include social interactions and relationships,
employment, leisure, learning, control, creativity, etc.
ICF (WHO: 2001)
Psychological factors pertains to attitudes,
self-image, motivation and assertiveness,
etc.
Social factors are the viewpoint of society
Model of Hearing-Related Disability
Hearing
Impairment
Listening aids
Lifestyle
Communication
activity
limitations
Participation
restrictions
Physical
environment
Psychosocial
factors
Tye-Murray N, Foundations of Aural Rehabilitation, p4.
Frequent
communication
partner(s)
Services Included in AR Plan
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Diagnosis & quantification of hearing loss
Hearing assistance technologies
Auditory training
Communication strategies training
Informational/educational counseling
Personal adjustment counseling
Psychological support
Communication partner training
Speechreading training
Speech-language therapy
Inservice training
Question
Which is provided by educator of the deaf and/or
SLP?
A. Aural rehab
B. Audiologic rehab
C. Physical therapy
Aural Rehabilitation vs.
Audiologic Rehabilitation
• Aural Rehabilitation
– Broad breadth of services
– Variety of professional providers
• Audiologic Rehabilitation
– Narrow breadth of services
– Audiology professional providers
Roles
Audiologist:
Audiologic Rehabilitation
SLP/EDHH:
Aural Rehab
• Audiologic diagnostic
evaluation
• Fitting, dispensing and
evaluation of hearing aids
• Mapping cochlear implants
• Evaluating, fitting and
dispensing HAT
• Evaluating speech/language
receptive and expressive
abilities
• Treatment of
speech/language disorders
• EDHH provides curriculum
Rehabilitation vs. Habilitation
• Rehabilitation
– Restore lost function
– Adults
– Acquired hearing loss
• Habilitation
– Develop skill not present beforehand
– Infants/children
– Congenital or pre-lingual onset
AR Service Locations
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University/College
Private Practice
Hospital
Community Center
Otologist’s office
Public/Private School
Self-help groups
School for the Deaf
Internet
Home with computer
AR Providers
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Audiologist
Speech Language Pathologist
Educator of the Deaf
Communication Partner
Other Team Members
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ENT
Parents
Regular classroom teachers
Psychology
Geneticist
Other specialties as necessary
Definition of Terms in Survey
Traditional Variables
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Time of Onset
Degree of Loss
Type of Loss
Etiology
Question
Which is not a traditional variable for hearing loss?
1. Time of Onset
2. Rapidity of progression of hearing loss
3. Degree of Loss
4. Type of Loss
5. Etiology
Other Variables
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Progressive
Acceptance
Family support
Time of identification
Time for implementation of AR
Intelligence
Motivation
AR vs. Age of Client
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Newborns
Preschoolers
Grade school
Middle school
High school
Post secondary
Young adults
Middle age
Old age
Hearing Loss Incidence
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36 million persons in US have HL
4,000,000 babies born in US annually
1/1000 to 6/1000 born with HL
1 in 10 by age 60
– Third most prevalent chronic problem in older persons
• 1.3% of children who receive special ed services
were hard of hearing or deaf
• 5% of world’s population, about 360 million
people, including 328 million adults and 32
million children, have disabling hearing loss
Hearing Loss Projections
Kochkin, S. MarkeTrak VII: Hearing Loss Population Tops 31 Million
People, The Hearing Review, Vol. 12(7) July 2005, pp. 16-29.
Time of Onset
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Congenital
Prelingual
Postlingual
Deaf/deaf
Deafened
Adventitious
Sudden
Progressive
HL Prevalence and Age
Degree of Hearing Loss
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Minimal
Mild
Moderate
Moderately Severe
Severe
Profound
Common Etiologies
• Most of the hearing loss is genetic with over 30
autosomal recessive (70-80%), dominant (2330%) and X-linked (2-3%) forms.
• A large proportion (60-75%) of nonsyndromic
hearing loss in children has been localized to
defects in a single gene, Connexin 26 (Cx26) on
chromosome 13q11-12.
– A variety of mutations have been described in this gene
with a 35delG hotspot mutation representing over half
of the defects in Caucasians.
• Recently, other links with deafness and connexin
has been established
Autosomal Recessive
Non-Syndromic HL
Question
The Amy Tan Syndrome?
A. Treacher-Collins
B. BOR
C. Pendred
D. Stickler
E. Usher
Common Syndromes Associated with Hearing Loss
Name of syndrome
Other features that may occur (besides hearing loss)
Alport
Kidney problems
Branchio-oto-renal (BOR)
Neck cysts and/or ear tags and kidney problems
Jervell and Lange-Nielsen
Heart problems
Pendred
Thyroid enlargement or low thyroid function
Stickler
Unusual facial features, cleft palate, eye problems (nearsightedness,
cataracts, or retinal detachment,) arthritis, heart problems
Usher
Progressive blindness
Waardenburg
White patch of hair or light-colored skin patches; eyes of two different
colors, or bright blue eyes, or widely spaced eyes
Jervell and Lange-Neilsen Syndrome
• Profound SNHL
• Prolongation of QT interval on EKG
• May develop arrhythmias resulting in sudden
death
• Autosomal recessive inheritance
– Mutations in KVLQT1gene on chromosome 11p15 and
KCNE1gene on chromosome 21q22
– Potassium channel genes
Waardenburg Syndrome
• Hearing loss
approximately 20%
• Pigmentation
abnormalities of skin
and hair
• Lateral displacement
of medial canthi of
eye
• Heterochromia of iridi
Branchio-Oto-Renal Syndrome (BOR)
• Hearing loss 93%
– Mixed hearing loss 52%
– Conductive hearing loss 33%
– Sensorineural 29%
• Pre-auricular pits 82%
• Branchial fistulae 49%
• Cupped or mildly altered
auricle 36%
• Renal abnormalities 67%
Treacher Collins Syndrome
• Conductive hearing loss
50%
– Malformed ossicles
• Malformation of auricle
• Very small jaw and chin
(micrognathia)
• Malar hypoplasia
• Down slanting palpebral
fissures
• Defects of lower eye lids
Cytomegalovirus (CMV)
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Leading cause of non-syndromic HL (1/3rd)
Hearing loss, often delayed onset, can fluctuate
Small for gestational age
Growth failure
Skin rashes
Enlarged abdominal organs
Blood count abnormalities
Reduced head growth
Developmental delay
Comorbidities
• Comorbidity is the – presence of one or more disorders or diseases in
addition to the primary disease or disorder; or
– effect of disorders or diseases
• Children with congenital SNHL have a relatively
high incidence of comorbid conditions, either
congenital or acquired
Etiologies
• Genetic
– Autosomal, x-linked, mitochondrial, non-syndromic,
syndromic
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Bacterial/viral
Metabolic
Trauma
Ototoxic
Cancers
Vascular disorders
Myelization
Type of Loss
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Conductive
Sensorineural
Mixed
Auditory Processing
Disorder
AR Service Plans
Adult
Home
Vocational
Social/
Avocational
(Tye-Murray, 2009, p 16)
Child
Home
Educational
Social/
Extracurricular
AR Services
• Services for persons with hearing loss
– Served
– Unserved
– Underserved
• Lack of services due to
– Lack of outreach and immediate or extended support
services
– Attitudes of service delivery personnel
– Lack of adequate reimbursement for AR
– Communication and environmental barriers
(Tye-Murray, 2009, p 14)
Cost-Effectiveness and Costs
Cost-effectiveness is the relationship between the money
spent and the benefits accrued
Cost is the actual expense for providing
Examples:
Trends in Educational Placement and Cost-Benefit
Considerations in Children With Cochlear Implants
Reimbursement
Medicare U.S. Social Security program that reimburses
hospitals and physicians for medical care provided to
qualified persons 65 years or older (federal program)
Medicaid U.S. Title XIX program under the Social Security
Act that is jointly funded by the federal and state
governments that reimburses healthcare providers
Private insurance plans (some provide for services while
others do not)
IDEA youth birth to twenty-one who qualify
Out of pocket payment
Triad of Evidence-Based Practice
Evidence-Based Practice. Developed with Keith Posley, MD, Stanford
Medical ... medresidents.stanford.edu
Evidence-Based Practice
EBP is “the integration of best
research evidence with
clinical expertise and patient
values
Levels of evidence to support
EBP
Five-step approach (Canadian
Cochrane Network/Centre
Affiliate Representatives)
Question
How many persons that could benefit from wearing
hearing aids in the U.S. have hearing aids?
A. 1 in 5
B. 1 in 3
C. 1 in 4
D. 1 in 6
Hearing Aid Use
Only 1 in 4 wear
hearing aids who
could benefit from
amplification
S. Kochkin. MarkeTrak
VIII: 25 year trends in the
hearing health market. The
Hearing Review, Vol. 16
(11), October 2009, pp.1231.
Other Areas of AR
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Auditory processing disorders
Tinnitus
Hyperacusis
Vestibular and balance disorders
AR Professional Organizations
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AAA (American Academy of Audiology)
AAS (American Auditory Society)
AG Bell Association
ARA (Academy of Rehabilitative Audiology)
ASHA (American Speech Language Hearing
Association)
• EAA (Education Audiology Association)
• ISA (International Society of Audiology)
AR Foundations
• DRF (Deafness Research Foundation)
Consumer Organizations
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HLAA (Hearing Loss Association of America)
Hearing Loss Web
ALDA (Association of Late-Deafened Adults)
Hands & Voices
Terminology: Hearing Loss
• NAD
– Deaf-mute, deaf and dumb, hearing impaired
terminology
– d/Deaf
• Wikipedia
• Hearing Loss Association of America
• “Hard of Hearing,” “Hearing Impaired” or
“Deaf”—Which Is Correct?
Kiersey
Circle of Courage
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Belonging
Independence
Generosity
Mastery