Information and Strategies for SLPs
Working with Students with Hearing
Impairment
Region IV Presentation
April 17, 2013
Leigh Matthews, M.A., CCC-SLP
Purpose
• To explain and emphasize the importance of recognizing a hearing
loss
• To provide some interesting information about hearing impairment,
sign language, deaf culture
• To provide some techniques for evaluation, that are different from a
more conventional evaluation
• To provide some ideas for treatment
Hearing Impairment
• Hearing loss is one of the most common disability conditions at birth
• Three out of every 1,000 babies are born with permanent hearing loss
• About 90% of hearing-impaired children are born to hearing parents
• Hearing loss is typically identified at 12-25 months, although 22 states
have newborn hearing screenings available.
• Approximately 14.9% of US children have low-frequency or highfrequency hearing loss of at least 16 dB hearing level in one or both
ears.
Region 4 Special Education Solutions
Hearing Impairment
• Mild: (26-45dB) Child may have difficulty with faint or distant speech, may need
modifications in the classroom, may miss certain consonants in speech due to
some high frequency speech sounds
• Moderate: (46-65dB) Child may understand conversational speech at a short
distance in a structured setting, may miss 50% of conversation if background
noise is present, will exhibit limited vocabulary, immaturity in syntax and
pragmatics, and reduced speech intelligibility. May need classroom modifications
and special education services.
• Severe: (66-86+) Child may hear loud voices or environmental sounds but is
more aware of vibrations; vowels may develop before consonants; speech and
language will not develop spontaneously if loss is pre-lingual, quality and
intelligibility of speech is atonal, child may rely on visual cues and gestures to
communicate. Will need modifications in the classroom and/or special education
services.
Audiogram
www.wikipedia.com
125
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0
10
HEARING LEVEL (dB HL)
20
z v
f th
s
p
h
30
ch
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j mdb
n
ng
e i
u
l
o ar
g
sh
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AUDIOGRAM OF FAMILIAR SOUNDS
FREQUENCY IN CYCLES PER SECOND (HZ)
Provided by: Northwest Harris County
Cooperative for the Hearing Impaired
Assistive Technology and Assistive Listening
Devices
Amplification
• Hearing Aids – Usually worn behind the ear; a child may have one or
two hearing aids, depending on his or her loss and need.
• Cochlear Implants (CI) - an electronic device consisting of electrodes
placed in the cochlea to provide electrical stimulation to nerve fibers
and a mini-processor implanted behind the ear. Externally, the
patient wears a transmitter which contains the sound processor and
microphone. Hearing from a cochlear implant is “digital hearing”.
• FM – frequency modulation – microphone, transmitter, receiver
• Portable Sound Field System
Listen Around the Clock
• Early intervention is so important! Babies born with normal hearing
are exposed to noise, sounds, language even before they are born.
With mandatory newborn hearing screenings, now hearing
impairment present at birth can be identified. With proper follow up,
it is possible that the baby with the hearing impairment would not
have to lose much time being exposed to these noises, sounds and
language. Much of what we learn is incidental learning – we learned it
by listening. Many things we know we weren’t taught; we just heard
one thing and heard another, and things began to fit together. Not so
with children with hearing impairment. Much of what they need to
learn must be directly taught to them. (AGBell handout “Listen Around the Clock”)
Programming Possibilities
• Special Education support at home campus - Combinations of time in general education
and special education (such as time in the resource class, in speech therapy, etc.)
• Indirect services from AI-certified teacher at home campus
• Direct services from AI-certified teacher at home campus
• Intensive services at designated self-contained site campus - Most of the day spent in
special education classroom (i.e. “self-contained”) because the modifications to the
curriculum require it.
• During time in the special education classroom a variety of services may be accessed –
including time with an AI Itinerant teacher.
• Regional Day School Program for the Deaf (RDSPD) –
• Texas School for the Deaf (residential in Austin)
Sign
language
Your
“thinking
language”
or combos…
Issues
Auditory
Verbal
Therapy
The
Auditory
Brain
Sign Language
American Sign Language (ASL)
Contact Signs/Pidgin Signed English
(PSE)/Conceptually Accurate Signed English (CASE)
Signing Exact English (SEE)
Examples of Sign Language
Scripts for Videos of Each
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American Sign Language (ASL)
Hello. Name me what?
Dennis last name Davino.
want inform program what?
Interpreter train.
for for? Interpret
work where? School all
program where? Cypress College
class class many variety different look can
start when? Week Aug 22, 2005
come on.
• Contact Signs/Pidgin Signed English
(PSE)/Conceptually Accurate Signed English (CASE)
• Hello,
• My name Dennis Davino
• Welcome Cypress College educate interpret train
program
• Look class class we are plan plan
• Our class start week Aug 22nd, 2005
• Hope see there
• Signing Exact English (SEE)
• Hello. My name is Dennis Davino. Welcome to the
Cypress College Educational Interpreter Training
Program. Look at the classes we are planning. Our
first classes begin the week of Aug 22nd, 2005.
Hope to see you there.
Auditory-Verbal programs follow a set of guiding principles and practices to
help the child with hearing-impairment maximize the use of their residual
hearing. Using amplification gives the child an opportunity to learn to listen,
so that he or she can process and use spoken language. These programs
emphasize:
• Early identification of hearing loss and pursuing maximum potential for
amplification
• Helping the child understand the meaning of any sounds he or she hears
• Helping the child learn and respond in the same way hearing children
would
• Helping the child participate academically and socially with hearing peers
• Depends upon high parent involvement
Lots of Listening Before Talking!
Stages of Listening and Talking
handout
• Estabrooks, Warren. Cochlear Implants for Kids. Washington, D.C.:
Alexander Graham Bell Association for the Deaf and Hard of Hearing,
1998. Print.
“Hearing loss isn’t about ears – it’s about the brain. We hear with the
brain. We are organically designed to listen and talk. But those areas of
the brain must be stimulated (via technology).”
She explains how basic neural research now shows data that supports
the necessity of stimulating auditory brain centers. Greatest neurologic
plasticity is the first 3 years of life.
Children with hearing loss need 3 times as much exposure to
information/concepts as compared to hearing kids.
“Muddy in leads to muddy out. Kids can only “close” a word they
already know.” She adds that unknown information should be given in
pull-out. Known/carryover can be done (maybe) in inclusion.
Phonetic
Categories
Phonologoical
processes
Lexical use
Semantic use
Carol Flexer
Reading and higher
order language use!!
The Language you Think with….
Your home
language
Your
experiences
Your
strengths and
weaknesses
Your
personality
Mode of Communication
• We are required by law to determine the child’s primary mode of
communication during the evaluation.
• Continuum of Total Communication to total Oral communication…..
• The SLP is in charge of Communication - your first responsibility with any
kind of evaluation - in the schools, clinic, hospital, etc. is to figure out how
the child communicates. This includes what oral communication the child
can comprehend.
• If the child normally wears hearing aids, be sure he or she is wearing them for the
evaluation. If he or she uses an FM in the classroom, part of your listening
comprehension assessment may be to describe how much higher his or her
comprehension is using the FM; do some informal comparisons in your evaluation.
This is also information that the child’s audiologist could and should provide.
• In the case that the child needs hearing aids, they are perpetually lost, or Medicaid
hasn’t come through, or....then do go ahead and evaluate his or her listening and
overall communication.
Evaluation
Standardized Tests
Most standardized tests are not normed on the hearing-impaired
population. Be sure to follow standard procedures for each
standardized test, and if the test is not normed on the hearing
impaired, don’t report the score. You can use it as a criterion-reference
measure; use it to collect data and establish a baseline so you can
measure progress with the same measure at a later date.
The OWLS (pg. 140 of the manual) and the CASL (pg. 146) had a group
of hearing impaired subjects in their standardization groups On these
tests, the HI group scored about 15 points lower.
Evaluation of Auditory Comprehension
When evaluating children with hearing loss, it is important to use hierarchies.
• Listening, Speech and Language Skill Development Checklist – UT Dallas
Callier Center
• Listening Skills Scale for Kids with Cochlear Implants – Warren Estabrooks
• Auditory-Verbal Ages and Stages of Development – Warren Estabrooks
• DASL – Developmental Approach to Successful Listening by Gayle Goldberg Stout and
Jill Van Ert Windle
• Placement and Readiness Checklist – www.handsandvoices.org
• Listening vs. Comprehension – Keep in mind you are teasing out the
specific skills of listening. So you want to go through the stages of
discrimination, distance and directional listening, as well as listening in
noise, and auditory memory and sequencing.
Comprehension Evaluation cont’d
In the case you would need to evaluate
• Sign Language
• Lip reading
The AI teacher would assist.
Reading comprehension is the final comprehension component. You
may not directly evaluate this, but you should know the results of the
reading testing and be able to help figure out where/why it breaks
down.
Evaluation of Expression
• Keep in mind the Estabrooks/Pollack “Stages of Listening and Talking”…lots
of listening before talking. Be sure you’ve addressed any holes in the early
listening skills.
• Remember you are to establish the mode of communication. In the area of
expression, that will include a qualitative/quantitative look at the child’s
non-speech communication.
• Don’t be tempted to take the easy road....articulation:) Often that
overlooks the underlying problem of auditory discrimination or some other
audition-related issue. You must attack that issue before working on the
speech - and often the speech will come easily without a lot of work, once
the auditory piece is in place. These kids are very often language
disordered - you will be the one to diagnose that.
Evaluation of Expression
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Classroom Observation
Language Sampling
Language Sampling
Language Sampling
Another classroom observation – different setting or activity.
Standardized tests if appropriate – OWLS, possibly CASL, CELF. Check for HI
norms. If not, do not score, but use information informally for baseline.
• CASLLS – Cottage Acquisition Scales for Listening, Language & Speech
Excellent resource for analyzing language samples. Contains five forms for checking skills: Pre-Verbal, PreSentence, Simple Sentence, Complex Sentence, and Sounds and Speech.
• Written Expression – Consider doing your own informal evaluation,
especially if the child uses writing to communicate everyday.
Language Sampling
Collect
Analyze
Organize
• Have a set of pictures, cards, etc. ready to go. Develop a system…
• 50-100 utterances
• Need narration and description – do picture description as well as procedural description with or
without pictures.
• Sample constantly. Use simple form and keep with the child’s progress notes to remind you to do it.
• Imperative that you write what was said, not what you assumed was said.
• Parent could bring in videotape and you could analyze together.
• Include note about context to show intent and check pragmatics
Articulation
Consider Daniel Ling’s work with students who were deaf and compare
to normal speech development….
As the child develops a phonetic level skill (i.e. being able to vocalize
freely on demand), he develops a related phonological skill (i.e.
vocalizing as a means of communication). This proceeds through the 7
stages of speech acquisition. The phonetic stages are vocalizing,
suprasegmentals, vowels and diphthongs produced with voice control,
consonants by manner with all vowels, consonants by place with all
vowels, consonants by voicing with all vowels, initial and final blends.
The phonological levels progress from vocalizing for communication to
different voice patterns, to using different vowels to approximate
words to clearer words, phrases, sentences, to intelligible speech.
AI Assessment
• Keep in mind that you will be the only one assessing listening (not reading)
comprehension, and speaking (not writing). At the home school, the AI teacher
will focus on reading and writing, and unless the child is very young, will most
likely not spend a lot of time on listening and oral language. And your work in
therapy nearly always will be about building some listening skills and verbal
expression. You must know the hierarchy - what comes first. Auditory
hierarchies and language sampling!!
• Your evaluation should include some trials with accommodations. For example,
you will need to evaluate how far away a speaker can be before comprehension
at a certain level breaks down.
• Communication Assessment (Part C) - Use information from the Speech and
Language Evaluation to complete. Or become best buddies with a good AI
teacher and she will do it for you:) It’s just a form. One of its main functions is to
report Mode of Communication and to assist with determining a baseline of
where the child is functioning with communication.
Billy has been diagnosed with a mild- moderate hearing impairment and
wears bilateral hearing aids. He uses an aural/oral mode of communication.
The current evaluation shows that when wearing his hearing aids, he can
understand two-step commands in a quiet environment, listen to a short
paragraph and answer simple yes/no questions if given content set-up before
the paragraph was read to him, and discriminate rhyming/non-rhyming
words. He is unable to hold more that 3-4 words or numbers in his working
memory at one time, needs repetition of longer information, and may need
simplification of more complex sentence structure or word forms. His
comprehension significantly decreases in the presence of noise. He uses
speech with approximately 80% intelligibility to express his needs, comments,
and questions/answers. His language output consists of sentences 7-10
words in length with accurate word order and simple or compound structure.
His vocabulary variety is limited, and he does not use many descriptive words
or complex verb forms.
Accommodations
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Use of visual aids
Preferential seating
Clear visual pathway to the teacher
Monitor use of amplification device
Assistive Technology
Clarification of vocabulary
Use of an interpreter
Additional time for responses
Note-taking assistance
Provide opportunities to interact with peers and include them in all class
activities
Treatment
• Spend a lot of time at the beginning giving information and explaining techniques to the
teachers working with the student. Use the hierarchies. Educate them on normal
language development. Let them see where the comprehension breaks down.
Brainstorm techniques/accommodations to use; hopefully you have assessed the
effectiveness of these with the student. Demonstrate for the teacher.
• Remediation vs. Compensation - there is a time to remediate and a time to
compensate. Usually they are done concurrently. Don’t withhold compensatory
strategies while you wait for remediation!! For example, you may expect some
improvement in even severely impaired speech with your remediation techniques;
however, in the meantime, teach the child how to functionally express himself or herself.
• Therapy techniques would include sound discrimination work, auditory sequencing and
memory exercises, practice with comprehension of sentences containing progressively
higher levels of vocabulary and syntactic complexity, practice sentence or word
comprehension with and without lip-reading, and practice with difference background
noise levels or different distances from sound source.
• IEPs are not treatment plans
Treatment
• Treatment goes on all day. Use words from the school – in the hallway, in
the classroom. Practice listening to them, using them, finding them,
writing them. Practice same things over and over. Repetition so
important. Consider individual file boxes.
• Play – dollhouse, ordering from “restaurant”,
• Guessing game – set up objects behind a screen, listen to description,
• I’m going on a camping trip and I’m taking my….(auditory memory)
• Roald Dahl books
• Listening for Littles – WordPlay Publications
• Categories and descriptions – how are a sock and a shoe alike? How are
they different? This skill is a prerequisite for the 20 Questions Game
Treatment
• Rhymes and Songs
• Reading aloud to the child. Have him or her follow with his or her finger.
• Absurd or silly pictures – SLP read or describe using an incorrect word (“log” for
“dog”) and the student must correct him as he says it.
• Sentence or word dictation
• Word families and rearranging phonemes…how many sounds in this word? How
many words in this sentence?
• Critical elements – “two black cats” contains 3 critical elements. Keep track of
the level of the student and progressively build.
• Pronouns and prepositions – work on during story retelling with objects. “She
took her shoes off and put them under the bed.”
• Auditory closure – remember to teach the set before practice. Can make a game
of taking turns saying one word without a sound and the other one guessing it.
Listening Checks
• For hearing aids and cochlear implants to work effectively, teachers
need to make sure that hearing aids and cochlear implants are
working at all times. This is called a ‘listening check’.
• Teachers: Perform listening checks when the student first comes to
school, after recess/PE, and any other time you have concerns.
• SLPs: Perform listening checks before therapy and any other time you
have concerns.
• Listening checks are absolutely critical for success!
Say It!
It is always important to have the child say or approximate the words
you or the teacher are teaching/working on. Even the child with severe
articulation must be encouraged and taught how to at least
approximate the sounds in words. This will increase both auditory and
reading comprehension and written expression.
Research shows that phonemic awareness is strongly linked to reading
success. And, manipulating the phonemes of a word has been highly
successful in producing better reading skills. An SLP can teach the child
the phonemes of a word…/f/ /o/ /n/…phone…3 sounds, 5 letters.
Now replace the /f/ with /b/…what word do you have? This relates to
the IEP this child will surely have about reading on grade level!
Beverly Trezek’s work and Visual Phonics
According to the National Reading Panel
(2000), balanced and effective reading
instruction contains five essential
components:
1. Phonemic awareness
2. Phonics
3. Fluency
4. Vocabulary
5. Comprehension
Trezek page 77
All children, “including those who are
hearing impaired, must understand the
connection between the phonemes of
the language and the graphemes of
print.”
Visual Phonics provides a visual
representation (with the hand) of all 42
phonemes in the spoken English
language. Therefore, a hearingimpaired student can “see” how the
word sounds, and when he or she learns
most of the possible graphic
representations of those sounds, can
spell and read!
Functional
communication
Comprehension
listening
reading
Expression
speaking
writing
Resources
• www.advancedbionics.com
The DASL II
• http://www.agbell.org
• www.medel.com
Cochlear Corporation
400 Inverness Drive South
Suite 400
Englewood Colorado 80112
USA
Toll Free: 1-800-523-5798
Telephone: 1-303-790-9010
Fax: 1-303-792-9025
• http://www.nidcd.nih.gov/Pages/default.aspx
The Part Number is FUZ041.
• www.cochlear.com
• www.handsandvoices.org
• http://www.listen-up.org
• www.parentpals.com
• www.sunshinecottage.org
• http://www.welisteninternational.com/AV_PRACTICE_TODAY.
pdf
• Estabrooks, Warren. Cochlear Implants for Kids. Washington,
D.C.: Alexander Graham Bell Association for the Deaf and
Hard of Hearing, 1998. Print.
• Trezek, Beverly J. Reading and Deafness: Theory, Research,
and Practice. Canada: Delmar, Cengage Learning, 2010.
Print
leighmatthews85@gmail.com
• For further information about services for students who are
Deaf/Hard of Hearing please contact:
Sandra Connatser
Region 4 ESC
sconnatser@esc4.net
713-744-6329