Educational Audiology Audiologic Rehabilitation for Children and Educational Audiology SPA 6581 – Spring 2015 Lecture Date: 03/24/15 Educational Audiology The practice of audiology in educational or school settings Topics Educational Audiology Association Student Counseling and Self-Advocacy Roles and Responsibilities of Educational Audiologists Hearing Loss Prevention The Cross-Check Principle in Educational Audiology Classroom Acoustics Case Management and Habilitation Educational Considerations for Students Who Are Deaf and Hard of Hearing Where Are We Headed? Numbers… State 2006-2007 Estimated Population # of Audiologists Employed Alabama 754,110 21 Arizona 1,076,801 63 Arkansas 461,752 4 Florida 2,669,242 60 Hawaii 184,996 0 Mississippi 507,977 1 Oklahoma 588,016 5 Rhode Island 159,214 0 Texas 4,240,524 40 EAA recommends target ratio of one full-time educational audiologist for every 10,000 students What could influence the need for adjusting this ratio? Geographical coverage and Extensive travel time Number of students with hearing loss beyond the expected prevalence Support: secretarial, scheduling, computer Time-intensive services Direct intervention Services to infants, toddlers, and students with multiple disabilities Service provision to regional or self-contained programs designed for multiple students who are DHH Educational Audiology Association EAA International organization Audiologists and related professionals “The mission of the EAA is to act as the primary resource and as an active advocate for its members through its publications and products, continuing educational activities, networking opportunities, and other professional endeavors.” Resources Educational Audiology Association: Educational Audiologists and Cochlear Implants Educational Audiology Association: Minimum Competencies for Educational Audiologists Educational Audiology Association: Recommended Professional Practices for Educational Audiology Educational Audiology Association: Guidelines of the Consensus Panel on Support Personnel in Audiology Roles and Responsibilities of Educational Audiologists Roles of Educational Audiologists Vary depending on other services and personnel available to assist children within the school system Educational audiologists are a member of the educational team Traditional Audiological Activities Service Coordinator Instructional Team Member Consultant Educational Audiologists as Service Coordinators Service coordinator When a student with a hearing loss is not receiving any direct special education services When a student with a hearing loss is receiving multiple special education services Audiologist is the individual responsible for monitoring and managing the educational program for the student, in order to provide appropriate services and classroom accommodations Routine diagnostic audiology services Works with general and special education teachers Works with student, parents, and other relevant individuals Educational Audiologists as Service Coordinators Continued Service coordinator responsibilities (English, 1995): Prepare teachers and other service provides to work with students with hearing loss Ensure that all appropriate services (e.g., SLP, OT, etc.) are coordinated and implemented in a timely fashion Provide ongoing support to teachers and other school staff Monitor student progress Monitor student placement and make recommendations for review and further assessment if needed Support transitions to other grades, schools, and programs Maintain complete and accurate information regarding placement options within the local education agency (LEA), as well as those in the region and state Educational Audiologists as Instructional Team Members Audiologist provides support to the: “Support?” Special education teacher Assessment of the hearing loss General education teacher Other related service professionals Student Parents Understanding of the hearing loss Management of amplification and the student’s learning environment to ensure communication accessibility Direct habilitation In-service Consultation Educational Audiologists as Consultants May provide consultations to ALL teacher, includes those who may not have children with identified hearing losses in their classrooms Teachers may request the following: Information about a child’s hearing sensitivity or auditory processing ability Activities for improving their students’ listening skills Information about how to integrate and reinforce specific auditory skills into the classroom curricula Classroom presentations related to the function of the ear, hearing loss, hearing loss prevention, or deaf culture Information about classroom acoustics Assistance with the use of classroom amplification systems Suggestions for classroom accommodations for standardized testing, as well as general instruction Educational Audiologists in Schools for the Deaf Their role may be limited community support and collaborations rather than screening and identification. Schools for the deaf are typically structured around a Deaf culture environment Why? Requires a unique sensitivity to issues which may not be encountered in public school programs Main goal? Still maximizing audition and listening These audiologists may have to be more creative in designing environments for students to use and practice these skills May have more of an opportunity to provide habilitation What about all of the cochlear implant recipients? Audiologists are a critical resource to help design communication strategies and structure learning in the classroom to maximize outcomes for students Responsibilities of Educational Audiologists Responsibilities may overlap with other school staff (nurses, SLPs, counselors, teachers of the deaf) Identification Hearing loss prevention Assessment Counseling and guidance Habilitation Amplification, cochlear implants, and other assistive technology Responsibilities of Educational Audiologists Identification Assessment Collaborate with community resources to promote awareness of hearing loss, its implications, and programs and services to support children with hearing loss and their families Select and maintain audiometric equipment Provide comprehensive assessments Analyze classroom noise and acoustics Establish, administer, and coordinate programs to identify disorders of hearing and auditory processing Assess central auditory function Provide written & verbal interpretation of assessment, functional implications, and management recommendations Make appropriate referral for further audiological, communication, educational, psychosocial, and medical assessments Train and supervise auditory support personnel What is an Educationally Significant Hearing Loss (ESHL)? Any hearing loss that potentially interferes with access to classroom instruction & impacts a child’s ability to communicate, learn, and develop peer relationships. Responsibilities: Habilitation Recommend methods for improving acoustic accessibility in the learning environment Plan and implement programs related to the care and use of amplification, cochlear implants, and other technology Provide support and training to facilitate auditory skill development Develop and implement treatment plans to facilitate communication competence using speechreading, auditory skill development, communication repair strategies, and other visual support and technology Collaborate with other service providers in selection of appropriate materials Recommend classroom accommodations and instructional modifications to facilitate access to the students’ communication and learning environments Serve as a member of the IFSP and IEP, and instructional teams responsible for educational plans for children with hearing loss Responsibilities Hearing Loss Prevention Establish, manage, and implement hearing conservation programs within the school environment Provide for education about and access to hearing protection devices Amplification, CIs, etc. Evaluate, select, and fit HAT Ensure proper fit and functioning of HAs, CIs, BAHA, and HAT in the educational environment Collaborate with CI centers concerning the evaluation and management of students considering or using cochlear implants Responsibilities Counseling & Guidance Provide information related to the implications and impact of hearing loss to families, caregivers, and students Provide support to students, parents, and caregivers related tot eh educational and psychosocial aspects of hearing loss Provide information to assist students with hearing loss to network with other students with and without hearing difficulties Facilitate communication among families of children and youth with hearing loss Make appropriate referrals to address counseling needs beyond the student’s hearing loss Ethical Considerations Compliance with federal and state laws, regulations, and policies Relations among private and educational audiologists related to the dispensing and management of technology Issues of confidentiality Conflicts of interest Restrictions on information provided to families and caregivers Referral procedures Perceived pressures to compromise recommendations for or against services and technology Educational Audiology Service Delivery Models School Based Contractual Agreement Combined School-Based & Contractual Agreement Telepractice Educational Audiology Service Delivery Models School Based This model is effective only if the audiologist’s caseload is reasonable Contractual Agreement May be less costly and the only means of obtaining audiological services in small or rural districts Many districts limits services in their contracts so that the majority of the services related to the educational support for students with hearing loss are addressed minimally, if at all. Audiologists should emphasize to administrators that a full range of audiology services is required by IDEA (2004). May need to differentiate between educational and clinical audiology services Many districts assume that the audiologist can provide services to an infinite number of students School-Based vs. Contractual Agreement Service Delivery Models School-Based Audiology Services Contracted Audiology Services Direct employee Contract employee Relatively autonomous Completely autonomous Services are typically comprehensive based on job description Services may be limited by scope of contract Peer of other school employees; perceived as “insider” with increased opportunities for collaboration Considered an “outside expert”; collaboration with teachers may be difficult Caseload may be large Caseload can be specified in contract District typically purchases and maintains audiological equipment District not usually responsible for diagnostic audiological equipment Overall cost to district may be less per service Lower capital outlay Often less efficient in small, rural systems with small student population unless part of a regional cooperative Higher cost per service May be appropriate for small, rural systems unless part of cooperative with greater number of students Educational vs. Clinical Audiology Educational Audiology Clinical Audiology Identify hearing loss at earliest age Identify hearing loss at earliest age Diagnose hearing impairment Diagnose hearing and balance impairment Evaluate hearing abilities and skill development to determine hearing function in various communication and learning settings Communicate with physicians, families, and referral sources Select, fit, verify, and validate hearing technology for educational settings Dispense and monitor appropriate amplification for personal use Identify audiological information for educational implications Identify appropriate instructional modifications and accommodations Consult with students, teachers, parents, and other relevant staff regarding hearing and amplification needs Ensure that amplification is working properly in schools Provide or assist with (re)habilitative needs within learning environment Educational Audiology Service Delivery Models Combined School-Based & Contractual Agreement Telepractice This model can be useful when the school-based audiologist is not able to provide services to all of the students within the district or when an audiologist with specialized skills or equipment is needed Relatively new Both audiologists must have: Clearly outlined responsibilities Ability to collaborate to eliminate duplication ASHA (2005), Audiologists PROVIDING Clinical Services Via Telepractice: Technical Report (available from www.asha.org/policy). Contracted arrangement CI mapping EDHI programs Establishing and Expanding Educational Audiology Services in Schools Reimbursement for Educational Audiology Services Dispensing Personal Hearing Instruments Cerumen Management Reimbursement for Educational Audiology Services A number of school systems have implemented third-party reimbursement from Medicaid for audiology as a health related services provided to students under IDEA (2004). Educational Audiologists must be certified as Medicaid providers Permitted by the guidelines from Centers for Medicare and Medicaid Services (CMS) Provided to Medicaid-eligible children Medically necessary Delivered and claimed in accordance with all other federal and state regulations Included in the state Medicaid plan Each state has the authority to: Determine the type, amount, duration, and scope of services Determine state eligibility standards Set rates of payments Administer its own program Training for Educational Audiologists Amplification Educational management of children with hearing loss Mainstreaming Auditory (re)habilitation Working with special populations Sign language counseling Educational referral, followup procedures, and special education eligibility requirements Evaluation of the need for, selection, and maintenance of personal FM and classroom audio distribution systems and other HAT used in educational environments Structure of the learning environment, including classroom acoustics, and implications for learning Training for Educational Audiologists IFSP and IEP planning process and procedures, including interpretation of auditory assessment results and their implications, educational options, and legal issues and procedures Consultation and collaboration with classroom teachers and other professionals regarding the relationship of hearing and hearing loss to the development of academic and psychosocial skills Participation in team management of communication treatment Knowledge of the various communication modes used by individuals who are deaf and hard of hearing Implementation of in-service training for educational staff and support personnel Knowledge of school systems, multidisciplinary teams, and community and professional resources Additional Readings ASHA: Guidelines for Audiology Service Provision In and For Schools Suggested Discipline Responsibilities for Identification, Evaluation, Referral, and Services for Children with Hearing Loss Colorado Department of Education: Listening Requirements for School Audiologists Standards of Practice for Audiology Services in the Schools: Colorado Department of Education Assessment: The Cross-Check Principle in Educational Audiology Cross-Check Principle in Educational Audiology Educational audiologists are seeing an increasing number of children identified with hearing loss at very young ages and with multiple learning challenges Jerger and Hayes (2006) Children should always be diagnosed using a test battery Not just a single measure Functional listening component of assessment battery often falls under the scope of the educational audiologist Assessment Basic Assessment of Hearing Loss Modifications for Special Populations Monitoring Hearing Sensitivity Additional Audiometric Information and Functional Hearing Assessment Assessment of Educational Effects of Hearing Loss Communication of Assessment Results Personal Vulnerability and Safety When standard instructions don’t work… Bright-colored soft toys, bubbles, or stickers Keep materials for activities not in use within easy reach, but out of sight Reinstruct, but remember not to ask… If activity is too interesting to maintain attention to the task, simplify it Change response activity often: Objects dropped or put into a container may need to be out of sight after the child’s response (lids) Ask the child to count beeps Turn over picture or playing cards for each beep Use a soft band for bone-conduction testing Park cars in a garage Place simple puzzle pieces or pegs in holes Assemble Mr. Potato Head Place blocks on board, or checkers on checker board Put coins in a bank Place objects on matching pictures Toss bean bag or small, light balls into a box/basket Put pop-beads together Additional Audiometric Information and Functional Hearing Assessment Speech Recognition for Sentences and Phrases Listening in Noise Speech Recognition with Visual Access The Functional Listening Evaluation Auditory and Listening Development Skills Additional Audiometric Information and Functional Hearing Assessment Speech Recognition for Sentences & Phrases Listening in Noise More realistic in terms of everyday communication as compared with word recognition Critical part of audiological assessment Most do not have normative data, but provide us with information Examples: Word Intelligibility by Picture Identification Sentences (4.5y+) Pediatric Speech Intelligibility Test (3y+) Hearing in Noise Test for Children Word recognition scores obtained in quiet are not reflective of children’s ability to understand speech in classroom Useful in alerting and demonstrating to teachers problems the child may experience Additional Audiometric Information and Functional Hearing Assessment Speech Recognition with Visual Access Auditory and Listening Development Skills Most audiometric speech tests are administered using auditory input alone Some Tests of Auditory Skills: Early Speech Perception Test (ESP) Functional Auditory Performance Inventory (FAPI) Auditory Perception Test for the Hearing Impaired (APT-HI) Cottage Acquisition Scales for Listening, Language, and Speech (CASLLS) Can be used to determine if the child relies on visual cues Can also be helpful to determine if there is an actual lack of understanding, or if speech production is actually decreasing their auditory only word recognition score The Functional Listening Evaluation Need to document a student’s ability to hear in environments other than the soundbooth The Functional Listening Evaluation (FLE) Developed by Johnson and Von Almen (1993) using a paradigm suggested by Ying (1990) and Ross, Brackett, and Maxon (1991) Used to assess the effects of noise, distance, and visual access on a students’ listening abilities Designed to evaluate students in their classrooms Due to room acoustics and individual classroom characteristics 8 lists of words, phrases, or sentences are used in 8 conditions 4 in quiet with close and distance proximities Auditory only and auditory + visual access Same 4 conditions are repeated with background noise present 30 minutes to administer Classroom Acoustics Classroom Acoustics Classroom Acoustics and At-Risk Children Children Adults More vulnerable to the effects of poor classroom acoustics More mature and skillful listeners who rely on their language and life experiences to assist with auditory closure and gaining meaning in less than optimal acoustical conditions More adversely affected by noise and reverberation as central auditory pathways (interhemispheric organization & neural synchrony) do not reach maturity until adolesence Perform better during complex listening tasks Classroom Acoustics and At-Risk Children In every classroom there are children who either have permanent or fluctuating hearing loss or difficulty processing speech and language, and the incidence is more prevalent with younger children. Listening and learning are affected when students cannot hear clearly. Skills involved in auditory processing and learning to read are impacted. Listening and learning problems can be intensified because of excessive noise and reverberation and the loss of intensity of the teacher’s voice over distance or change in directionality. Improving classroom acoustics may require attention to architectural design principles and elements; acoustical modifications; and the use of hearing assistive technologies Classroom Acoustics and At-Risk Children At-Risk Populations for Learning in Poor Acoustical Environments: Young children (<15 years old) Conductive hearing loss History of recurrent otitis media Language or articulation disorder Learning disability or dyslexia English as a second language (ESL) Auditory processing deficit Minimal bilateral sensorineural hearing loss Unilateral sensorineural hearing loss Developmental delays Attention deficits Cochlear implants Auditory neuropathy spectrum disorder (ANSD) Properties of Classroom Acoustics Noise Any auditory disturbance that interferes with what a listener wants or needs to hear Internal building noise, classroom noise, external building noise 3 variables that contribute to speech masking by noise are: Long-term acoustical spectrum of the noise (masking consonants?) Average noise intensity relative to the intensity of speech Fluctuation of noise intensity over time Signal-to-Noise Ratio (SNR) Relationship of the intensity of the following: Auditory signal (i.e., teacher’s voice, etc.) Background noise Young listeners need a quieter listening environment Goal for SNR without hearing loss = +15 dB or more Goal for SNR with hearing loss = even more! Properties of Classroom Acoustics Reverberation Occurs when sound persists in a classroom as a result of repeated reflection from surfaces in or surrounding the enclosed space Warning signs: Hard ceilings without acoustical tiles High ceilings greater than 10 feet Painting ceiling tiles (reduce absorption) Hard surface flooring Lack of sound absorption materials Irregularly shaped classroom Inverse Square Law & Critical Distance The distance from the sound source has a significant effect on the SNR. The direct sound level decreases in linear proportional to the distance between the talker and the listener 6 dB decrease in sound pressure level (SPL) occurs with each successive doubling of distance from the sound source Classroom Acoustical Standards ANSI/ASA S12.60-2002, Acoustical Performance Criteria, Design Requirements and Guidelines for Schools (June 26, 2002) Revision in 2010 Purpose = to assist school planning and design professionals in providing learning environments that allow for good speech communication between teachers and students in classrooms and other learning spaces without the use of electronic amplification systems. Standard is voluntary, unless referenced by state code, ordinance or regulation Looks at: Background Noise Considerations Instructional Equipment Noise Heating, Ventilation, and AC (HVAC), Building Services, and Utility Noise Reverberation Time Noise Isolation Design Requirements Classroom Audio Distribution systems Conformance and Tolerance Verification Which states have adopted the standard? http://www.access-board.gov/acoustic/index.htm New Hampshire Department of Education New Jersey School Construction Board State of Connecticut Ohio School Facility Commission New York City Public Schools Arlington County (VA) Public Schools Classroom Acoustics Resolutions and Guidelines AAA and ASHA both have developed position statements on classroom acoustics Roles of audiologists and acoustical consultants U.S. Green Building Council (2009) Classroom acoustics is a national agenda item for this council Measuring Classroom Acoustics Classrooms of the 21st century are dynamic with active learning environments where the acoustical parameters change by time, the specific learning activity, and other factors (Smaldino, Crandell, & Kreisman, 2005). Specific Procedures to be used in measuring classroom acoustics: Classroom Observation Measuring background noise levels in dBA Measuring or estimating reverberation time Measuring or estimating the SNR Estimation of the critical distance Measuring Classroom Acoustics Classroom Observation Tools Classroom and Student Observation and Assessment Tools Children’s Auditory Perception of Speech (CHAPS) Children’s Realistic Index of Speech Perception (CRISP) Evaluation of Classroom Listening Behaviors (ECLB) Classroom Acoustical Screening Survey Worksheet Fisher’s Auditory Problems Checklist Modeling Classroom Acoustics Listening and Learning Observation Subjective Assessment of Classroom Acoustics Listening Environment Profile Scale of Classroom Listening Behaviors Screening Instrument for Target Educational Classroom Acoustical Modification Efficacy Scale I (CES-I) Classroom Acoustics Documentation Form Role of the Educational Audiologist in Classroom Acoustics Advocacy Acting as an information resource Performing observations and acoustical measurements in classrooms and other learning spaces Collaboration with educational facility planning teams Ensuring acoustical access for special populations Conducting efficacy measurements to determine the need for and benefits from acoustic treatments and modifications, as well as, HAT Case Management and Habilitation Case Management and Habilitation Planning Case Management and Habilitation Implementing Audiological Habilitation Services for Special Populations Inclusions Planning Case Management and Habilitation Service coordination for students with hearing impairment Implies communication and collaboration with more than one service or service provider Clarification of the needs and services for the student with hearing loss Identification of currently available school personnel Arrangements for effective collaboration among service providers Development and implementation of a written communication system Implementing Audiological Habilitation Primary role of educational audiologist in habilitation is to facilitate optimal access to and use of auditory input during the learning process Direct Indirect Management of amplification Development of auditory skills Speechreading Communication repair training Management of environmental barriers to communication Counseling Classroom audio distribution systems and other HAT Teacher collaboration Selection of classrooms and teachers Selection of auditory curricula and materials Facilitation of auditory skill development Information concerning student hearing loss and auditory function Combination Services for Special Populations Unilateral, minimal, or high-frequency losses Students with fluctuating hearing problems APDs ANSD Children with multiple learning challenges Four areas: Amplification and other technology recommendations Strategies for classroom management Development of auditory goals and objectives Monitoring student progress and auditory function Categories of School Accommodations and Modifications for Children with Listening Difficulties Amplification Assistive technology devices Communication Instruction Physical environment Curricula Evaluation Student Counseling and SelfAdvocacy “One of the most difficult facts that students with hearing loss will face is that their hearing loss never goes away.” Karen Anderson Counseling Students with Hearing Loss Service is typically overlooked or referred to another member of the team Teachers are often unaware of student feelings about the impact of the hearing loss on relationships with peers May not always refer the student for counseling By providing information and support in the early years, many adolescent frustrations can be lessened or even avoided Enabling vs. Empowering Remember back to “Family-Centered AR” Tell them where to sit vs. teaching them variables to consider when choosing where to sit Hearing Loss Prevention Planning a Hearing Loss Prevention Program Ongoing Programming Curricular Interface All materials should be reviewed by the teachers before use Ensures developmental appropriateness of the materials and increases teacher support Targeting the School Environment Focus on noise produced within the school environment at each educational level Noise levels in class have ranged from 85 to 115 dB, up to 128 dB in a woodworking class Noise Criteria Standards Make sure to design it with objectives related to general education Consider how much class time the program will take Teacher Involvement Introduction Activities that can be done by the teacher, para, or students Designing a curricular sequence from preschool to highschool OSHA: 90dBA for 8 hours (older) and NIOSH: 85 dBA for 8 hours (newer) Permissible noise exposure criteria for children over a lifetime are unknown, more conservative damage-risk are warranted Architectural Information Hearing Loss Prevention Curricula Preschool Hearing Loss Prevention Program Elementary Hearing Loss Prevention Program Middle School Hearing Loss Prevention Program High School Hearing Loss Prevention Program Preschool Hearing Loss Prevention Program Outcome: Early awareness of need to protect ears and hearing Objective We hear with our ears We need to take care of our ears Loud sound can hurt our ears Content Location and # of ears Sources of sound; loud vs. soft Causes of damaging noise (toys, etc.) Ways to avoid noise damage Elementary Hearing Loss Prevention Program Outcome: Increased awareness of hearing process and danger of loud noise exposure Objective Interface with school’s curricular objectives on hearing (one of 5 senses) Loud noises can damage hearing We can help protect our ears from loud noises Content How the ear transmits sound Damage to the ear cannot be seen but can be temporary or permanent Causes of damaging noise Some rooms and locations are noisier than others Ways to avoid noise damage Middle School Hearing Loss Prevention Program Outcome: Understanding of the implications of damaging noise exposure and need for active use of ear protection in specific situations Objective The inner ear is susceptible to permanent damage from noise Specific strategies can prevent this noise damage from occurring or from increasing Content How the ear works and what part is damaged by noise exposure Noise damage can be permanent but can be prevented; increased loss can also be prevented if a problem already exists Sources of damaging noise exposure Ways to prevent damage from noise Symptoms of excessive noise levels Different surfaces reflect or absorb sound waves High School Hearing Loss Prevention Program Outcome: knowledge necessary for prevention of hearing loss caused by occupational and recreational noise Objective Damaging noise levels can occur in the workplace Laws requiring employers to protect employees from noise-induced hearing loss You can take precautions to prevent noise-induced hearing loss from recreational sources Content Interface with vocational and health curricula Expanded information regarding anatomy of the ear with specific attention to cochlea and cochlear damage Audiogram and configuration associated with noise-induced hearing loss Sources and levels for damage from noise exposure Etc. Numbers… State 2006-2007 Estimated Population # of Audiologists Employed Alabama 754,110 21 Arizona 1,076,801 63 Arkansas 461,752 4 Florida 2,669,242 60 Hawaii 184,996 0 Mississippi 507,977 1 Oklahoma 588,016 5 Rhode Island 159,214 0 Texas 4,240,524 40 References Cole, E. B., & Flexer, C. (2007). Children with hearing loss: Developing listening and talking birth to six. San Diego, CA: Plural Publishing, Inc. Deconde Johnson, C., & Seaton, J. B. (2012). Educational audiology handbook. (2nd ed.). Clifton Park, NY: Delmar Cengage Learning. Educational Audiology Association. (2012). Educational audiology association. Retrieved from http://www.edaud.org/ Educational Audiology Association. (2012). Position statements. Retrieved from http://www.edaud.org/displaycommon.cfm?an=1&subarticlenbr=4 Ling, D. (2002). Speech and the hearing-impaired child: Theory and practice. (2nd ed.). Washington, DC: Alexander Graham Bell Association for the Deaf and Hard of Hearing. Ling, D., & Ling, A. H. (1978, 1980, 1985). Aural habilitation: The foundations of verbal learning in hearing-impaired children. (3rd ed.). Washington, DC: AG Bell Association for the Deaf, Inc.