Aural Rehab Exam 2

Front 1

List of Communication Options

Back 1

ASL (bi-bi)
Auditory Verbal
Cued Speech
Auditory Oral
Total Communication

Front 2

Auditory Therapy

Back 2

Involves an attempt to assist a child or adult with a hearing loss in maximizing the use of whatever degree of residual hearing remains

Front 3

Components of a Communication Model

Back 3

Source or Speaker
Message
Receiver
Feedback
Environment

Front 4

Development of Auditory Skills

Back 4

Newborns possess a functional auditory system that is capable of perceiving auditory stimuli at 20 weeks gestation. Auditory processing skills continue to develop and refine following birth.
Rapid emergence of auditory skills is crucial for the development of speech processing skills and the emergence of speech and language.

Front 5

Range of frequencies the human ear can perceive

Back 5

20-20,000Hz

Front 6

Range of intensity levels the human ear can process

Back 6

0dB SPL- 130dB SPL

Front 7

Average speech intensity when measured at a distance of 1 meter

Back 7

45dB HL

Front 8

Average shout

vs.

Faint speech

Back 8

Average shout: 65 dB HL
Faint speech: about 25 dB HL

Front 9

Spectrum of Speech Frequencies

Back 9

Overall spectrum of speech is composed of acoustical energy from approximately 50 to 10,000 Hz.
Greatest amount of speech energy occurs at frequencies below 1000Hz, attributed largely to the fundamental frequency of the adult human voice.

Front 10

Formant

Back 10

Band of frequencies that are resonated, or boosted in energy, by the vocal tract

Front 11

Segmental Features

Back 11

features associated with individual speech sounds
(Manner, Voicing, Placement)

Front 12

Suprasegmental Features

Back 12

features of speech that are superimposed on phonemes and words (think DIP)

Front 13

Duration of Speech Sounds

Back 13

Duration of individual speech sounds range from 30 to 300 msec
- vowels generally longer than consonants
- overall rate of speech varies considerably from speaker to speaker

Front 14

Sound Perception Components

Back 14

1. Detection- awareness of sound
2. Discrimination- same or different
3. Identification- label what was heard
4. Attention- focus on the message
5. Memory-retain verbal info., combine speech units to derive meaning
6. Closure- fill in the gaps
7. Comprehension- full understanding

Front 15

"Noise"

Back 15

Within the speaker: poor syntax, poor articulation

Within the environment: abnormal lighting, competing visual stimulation, competing auditory stimulation

Within the listener: poor listening skills, poor ATTENDING skills, lack of familiarity with the rules of the language

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When considering auditory training for adults, two general objectives are relevant:

Back 16

1. Learning to maximize the use of auditory and other related cues available for the perception of speech.
2. Adjustment and orientation to facilitate the optimum use of amplification, cochlear implant or tactile device

Front 17

Early Efforts in Auditory Training

Back 17

Raymond Carhart recommended that auditory training for adults should focus on re-educating a skill diminished as a consequence of hearing loss.
Training sessions be conducted in three commonly encountered situations:
1. Relatively intense background noise.
2. The presence of competing speech signal
3. Listening on the telephone

Front 18

Candidacy

Back 18

Most common use of auditory-based therapy is for children with prelingual sensorineural hearing loss.
In recent times, with cochlear implant recipients, for both children and adults.

Front 19

Assessment of Auditory Skills (Children)

Back 19

Includes:
1. Determining whether or not auditory therapy appears warranted.
2. Provides a basis for comparison with post-therapy performance, to assess how much improvement in auditory performance, particularly speech perception, has occurred.
3. Identification of specific areas of auditory perception to concentrate on future training.

Young children- standardized tests but also informal testing and observation are highly relied upon.

Older children- usually more formal, in depth assessment of overall speech perception abilities.

Front 20

Commonly Used Tests (Children)

Back 20

Word Intelligibility by Picture Identification (WIPI)
Northwestern University Children’s Perception of Speech (NUCHIPS)
Ling 6 Sounds Test
Test of Auditory Comprehension (TAC)
Glendonald Auditory Screening Procedure (GASP)
Developmental Approach to Successful Listening (DASL)
Early Speech Perception Test (ESP)
Auditory Perception Test for the Hearing Impaired (APT-HI)

Front 21

Assessment of Auditory Skills (Adults)

Back 21

Formal and informal tests of speech perception are available for use with adults.
Some tasks include:
Monosyllabic word lists
Perception of consonants
Tests which employ sentence-like stimuli with speech babble (recording of several people talking at once)
Ability to perceive connected discourse
Introducing competing noise to a test situation
Use of visual cues (bisensory-using hearing and vision together) to evaluate integrative skills

Front 22

Developmental Approach to
Successful Listening

Back 22

(DASL II)
Highly structured, based on a hierarchy of listening skills
Sound Awareness
Phonetic Listening
Auditory Comprehension

Front 23

SKI-HI

Back 23

Home intervention treatment program for infants and families
Developmentally based auditory-training program
Utilized in conjunction with speech and language stimulation, 4 phases and 11 general skills.
(refer to pages 139-141 in text)

Front 24

Speech Perception Instructional Curriculum and Evaluation (SPICE)

Back 24

Guide for clinicians in evaluating and developing auditory skills in children with severe to profound hearing loss.
Contains goals and objectives associated with 4 levels of speech perception:
Sound detection
Suprasegmentals
Vowel and consonant perception
Connected speech

Front 25

Consonant Recognition Training

Back 25

-relies primarily on an analytic approach to facilitate improved speech production
-incorporates speechreading into a combined auditory-visual approach
-allows for intense drill to occur for a select number of consonants during a relatively short therapy session

Front 26

Communication Training and Therapy

Back 26

-common form of audiologic rehab emphasizing the role of communication strategies and pragmatics to facilitate successful communication
(see Tables 4.12 and 4.13 page 144 in text)
Anticipatory Strategies (e.g.,minimize distance from speaker)
Repair Strategies (e.g.,ask speaker to repeat all or part of a message)

Front 27

Mission of the Auditory-Verbal Approach

Back 27

Help children who are deaf or hard of hearing to learn to use their listening potential to communicate through spoken language.

Front 28

Overview of Auditory-Verbal Option

Back 28

No one system, approach, or communication methodology to meet all the individual needs of the child and family.

When parents choose the A-V approach as their family’s way to manage a child’s hearing loss, they select a method that requires informed and active involvement.

Like no time before in the history, the A-V approach is a viable option for most children with hearing loss.

With advanced technology providing powerful hearing aids and cochlear implants, the majority of children with hearing loss should have access to usable hearing.

Front 29

Listening (A-V Approach)

Back 29

The A-V approach focuses on LISTENING which leads to the natural development of speech and language.

With optimal access to sound, learning to listen and talk can begin immediately and can occur during all waking hours.

Front 30

10 Principles of Auditory-Verbal Therapy

Back 30

1. Promote early diagnosis of hearing impairment in newborns, infants, toddlers, and children, followed by immediate audiologic management and Auditory-Verbal therapy.
2. Recommend immediate assessment and use of appropriate, state-of-the-art hearing technology to obtain maximum benefits of auditory stimulation.
3. Guide and coach parents to help their child use hearing as the primary sensory modality in developing spoken language without the use of sign language or emphasis on lipreading.
4. Guide and coach parents to become the primary facilitators of their child’s listening and spoken language development through active participation in individualized Auditory-Verbal therapy.
5. Create environments that support listening for the acquisition of spoken language throughout the child’s daily activities.
6. Guide and coach parents to help their child integrate listening and spoken language into all aspects of the child’s life.
7. Guide and coach parents to use natural developmental patterns of audition, speech and language, cognition, and communication.
8. Guide and coach parents to help their child self-monitor spoken language through listening.
9. Administer ongoing formal and informal diagnostic assessments to develop individualized Auditory-Verbal treatment plans, to monitor progress and to evaluate the effectiveness of the plans for the child and family.
10. Promote education in regular classrooms with typical hearing peers and with appropriate support services from early childhood onwards.

Front 31

Parental Participation

Back 31

The A-V approach embraces the view that children learn language most easily when actively engaged
in relaxed, meaningful interaction with supportive parents and caregivers.
Parents learn to:
-Model techniques for stimulating speech, language, cognition and communication activities at home.
-Plan strategies to integrate listening, speech, language, cognition and communication into daily routines and experiences.
-Communicate as partners in the therapy process.
-Inform the therapist of the child’s interests and abilities.
-Interpret the meaning of the child’s early communication.
-Develop appropriate behavior management techniques
-Record and discuss progress.
-Understand short and long-term goals.
-Develop confidence in parent-child interactions.
-Make informed decisions.
-Advocate on behalf of their child.

Front 32

Auditory-Verbal Therapy Sessions

Back 32

Cover 4 Areas:
1. Audition
2. Language
3. Speech
4. Cognition

Generally one to one and a half hours long.
Parent or caregiver ALWAYS present.
Therapist models the planned activity and parents carry forth.
Activities planned so easily duplicated at home.
Weekly targets explained to parents. Parents report weekly home outcomes.

Front 33

Auditory-Verbal Techniques

Back 33

Acoustic highlighting (whispering, singing, emphasizing elements in syntax and/or segmental or suprasegmental information)
Repeating exactly what the child says
Asking the child, “What did you hear?”
Moving closer to the microphone
Rewording, providing alternatives
Waiting/pausing for responses
Auditory sandwich
Hand cue

Front 34

Variables Affecting Child’s Progress

Back 34

Age of diagnosis
Etiology of hearing loss
Degree of hearing loss
Effectiveness of amplification device
Effectiveness of audiological management
Hearing potential of child
Health of the child
Emotional state of the child
Level of participation of the family
Skills of the therapist
Skills of the parents
Child’s intelligence
Child’s learning style

Front 35

language

Back 35

Language is a term to describe a system of symbols used as a social tool for the exchange of information.

Front 36

morphology

Back 36

Study of minimal units of language that are meaningful (-s for plural, -ed for past tense)

Front 37

phonology

Back 37

Study of sound systems used in languages

Front 38

syntax

Back 38

Rules of how words are arranged in sentences.

Front 39

semantics

Back 39

Study of word meanings and word relations.

Front 40

pragmatics

Back 40

Functional use of language

Front 41

Factors Affecting Language Acquisition

Back 41

Other handicapping conditions

Predictors

Cultural and linguistic diversity

Early intervention

Cochlear implants

Front 42

Other Handicapping Conditions

Back 42

Nearly 40% of children with hearing loss have other challenges

10.0% learning disabilities
9.1% mental retardation
6.6% attention deficit
4.5% visual impairment
3.2% cerebral palsy
2.0% emotional disturbance
13.3% other

Front 43

Predictors

Back 43

Predictors of early expressive language for children with hearing loss
-Age of identification(before/after 6 mo.)
-Child’s cognitive status
-Presence or absence of one or more additional disabilities

Language abilities cannot be predicted by the degree of hearing loss alone.

Front 44

Cultural and Linguistic Diversity

Back 44

Estimated by 2050, the proportion of individuals from other linguistic and cultural backgrounds will increase by 50% of the total U.S. population
(Caeser & Williams, 2002)

While performing assessments on children with hearing loss whose families have other linguistic backgrounds, it is essential to have interpreters present if the clinician is not proficient in the language as supported by the IDEA.


Family members should not serve as interpreters- risk of bias.

Front 45

Early Intervention

Back 45

Early identified children without other handicapping conditions show age-appropriate language abilities and continue to maintain age-appropriate language abilities. (Yoshinaga- Itano et al., 1998a)

Caution: Some research only looks at vocabulary.

Kindergartners who are i.d. early have conversational skills comparable to normal hearing peers.

Front 46

Cochlear Implant Use

Back 46

1990 FDA approved multichannel cochlear implant use in children


Nicholas & Geers, 2007- implantation at ages 12-16 mo. more likely to achieve age-appropriate language at 4.5 years than if implanted after 24 months.

Dettman et al., 2007; Holt & Svirsky, 2008; Lesinski-Schiedat et al., 2004- higher language skills if implanted before 1 year than those implanted between 1 and 2 years of age.

Geers, Nicholas, and Sedey (2003) evaluated children aged 8 and 9 years; implanted by 5 ½ years

Findings for strongest predictors for language ability:
Greater non-verbal intelligence
Smaller family size
Higher socioeconomic status
Female gender

Front 47

Comparing OC and TC Progrms

Back 47

Better speech production for those in oral communication (OC) programs

Early advantage in receptive communication for those in total communication programs (TC)
(Connor et al., 2000)
Children from OC programs have fewer communication breakdowns
(Tye-Murray 2003)
Keep in mind, much variability in TC programs

Front 48

Language of Children with Hearing Loss
SYNTAX

Back 48

Shorter and simpler sentences
Overuse of certain sentence patterns
Infrequent use of adverbs, conjunctions
Non-English word order
Incorrect usage of irregular verb tense

Front 49

Language of Children with Hearing Loss
SEMANTICS

Back 49

Reduced expressive and receptive vocabulary
Limited understanding of metaphors, idioms, and other figurative language
Difficulty with multiple meanings of words

Front 50

Language of Children with Hearing Loss
PRAGMATICS

Back 50

Restricted range of communicative intents (requests, conversational devices)
Lack of knowledge regarding conversational conventions, such as changing the subject or closing conversations
Limited knowledge and use of communication repair strategies

Front 51

Knowledge of Schema in Preschool Children

Back 51

While experiencing typical sequences of events and communication (dinner, bedtime) the child stores and remembers a body of knowledge, called schema, about the events.
Some children with hearing loss have limited schemata.
(lack of ease in eavesdropping or if family uses sign language, members typically do not always sign as they speak to one another)

Front 52

Early Vocabulary in Preschool Children

Back 52

Classic study by Yoshinaga- Itano, et al. (1998)

Showed advantages in language learning for children whose hearing loss is identified by 6 months of age.

Interesting finding…
Early-identified children with lower cognitive levels achieved the same language levels as late- identified children with higher cognitive skills.

Front 53

Preliteracy and Literacy Issues

Back 53

Low reading and writing proficiency skills for children who are deaf or hard of hearing have been related to limited oral language skills.

Important precursor to reading is phonological awareness. (ability to recognize that words are made up of phonemes, syllables, onsets (h, c, l) and rimes- h(ot), c(ot), l(ot).
A rime is the part of a syllable which consists of its vowel and any consonant sounds that come after it.

Speechreading does not provide enough information for phonological awareness.

Some parents of very young children who are deaf or hard of hearing may unintentionally overemphasize spoken language in the early years and overlook literacy.

Front 54

Language Assessment
and Cautions

Back 54

Communication checklists
Formal Language tests
Communication/language sample analyses

Most assessment tools are standardized for use with children with normal hearing.

Cautions:
Testing language, not listening ability.
If signing, many signs are iconic.
(Show me your nose.)
Formal tests may not provide a true measure of linguistic skills in everyday conversations, which provides linguistic/situational cues.

Front 55

Communication and Language Management

Back 55

Create or participate in experiences that allow for the child to learn about a wide range of events and reasons to communicate about them.
Don’t drill, facilitate!
Adults should be responsive and contingent when facilitating language.
-Bathe the child in language
-Give the child an opportunity to communicate, following his/her lead.

Front 56

Tips in developing conversational skills:

Back 56

Recasting: Correctly reword a child’s comments without changing meaning (“Doggy runned fast.” “Yes, the doggy ran fast.”)

Experiential learning events to develop schema. (If child has a dental appt., first read a book about going to the dentist, talk about what is going to happen, go to the appt., then later have the child retell the experience to someone.)

Sabotoging: Provides opportunities for children to protest, comment, or request. (pretend one can’t open a bottle of bubbles, set the table without any silverware, etc.)

Front 57

Early Vocalizations (Hearing Children)

Back 57

Crying and vegetative sounds (burps, coughs, sneezes)

Cooing and laughing

Reduplicated babbling (dadadada)

Variegated babbling (badabada) with sentence-like intonations

Speech sound combinations called vocables that consistently represent meaning. (ba-ba for bottle)

First words around 12 mo. of age

Front 58

Early Vocalizatons of Infants with Hearing Loss

Back 58

Also coo, squeal, growl and babble

Produce fewer consonant-like sounds from 6-10 months; some rarely babble or stop babbling at this age

Produce greater proportion of velar-back consonants at 12-15 months
(without early intervention/amplification)

Front 59

Speech Intelligibility

Back 59

Intelligibility affects daily conversation and sadly, affects perceptions of a speaker’s cognitive ability and personality. (Most, Weisel, & Matezky, 1998).

Some who are deaf choose not to speak even if they have some intelligible speech.
Intelligibility may be directly related to degree of hearing loss, but much variability.

Better indicators include aided audiometric thresholds and speech perception abilities.

Front 60

Speech Characteristics

Back 60

Children with mild to moderately severe losses (up to 70 dB) generally have intelligible speech with some articulation and phonological errors.
Children with severe-profound losses (>70dB) are more variable in speech intelligibility. Range from 0-100%

Possible errors in:
vowel and diphthong production
consonants
respiration (shallow breaths)
resonance (hyponasality or hypernasality)
phonation (breathy voice quality with inadequate vocal fold adduction, abnormally high fundamental voice frequency, excessive voice intensity and vocal fold resistance.
suprasegmental speech characteristics