Download Optimizing spoken language development in infants and young

Simultaneous bilateral cochlear implantation and auditory-verbal therapy:
Optimizing spoken language development in infants and young children.
Lisa Katz, M.H.Sc., S-LP (C), Reg. CASLPO, LSLS Cert AVT®
Maria Emilia De Melo, M.Fga., S-LP, Aud (C), Reg. CASLPO, LSLS Cert AVT®
Toronto Public Health/ Toronto Preschool Speech & Language Services/ Infant Hearing Program, Toronto, Canada
Simultaneous bilateral cochlear implants are now routinely provided to young children with
severe to profound hearing loss in Toronto, Canada. Bilateral stimulation enables these children
to establish binaural processing and hear with greater ease (Papsin and Gordon, 2008). When
this technology is coupled with early identification and auditory-verbal intervention, children
have optimal chances of benefiting from the sensitive periods of neurological and linguistic
development. As a result, they can achieve their maximum potential in the development of spoken
language.
Auditory-Verbal Therapy
Case Study
Current Skills
The Toronto Infant Hearing Program (IHP) provides the opportunity for all newborn babies to
have their hearing screened. If the infant is diagnosed with a permanent hearing loss, various
services are provided to the family, for example, audiologic management and family support.
The family support worker (FSW) makes referrals to services for growth and development and
communication supports and services. Depending on the family’s needs and expectations for their
child, the FSW refers the family to either a visually based or an auditory based approach.
The following case study serves as an illustration of what nowadays
is considered to be a fairly common profile of a child enrolled in the
Toronto IHP. That is, the child presents with a congenital severe
to profound hearing loss, the hearing loss is identified through
newborn hearing screening and the diagnosis is confirmed shortly
after birth. In addition, the child’s first pair of hearing aids is
obtained shortly after diagnosis, therapy begins early and the
child receives simultaneous bilateral cochlear implants by twelve
months of age.
Auditory-Verbal Therapy (AVT) is an individualized therapy program that facilitates optimal
acquisition of spoken language through listening by infants and young children who are deaf
or hard of hearing. AVT promotes early diagnosis, one-on-one therapy, and state-of-the-art
audiologic management and hearing technology. Parents and caregivers actively participate in
therapy. Through guidance, coaching, and demonstration, parents become the primary facilitators
of their child’s spoken language development. AVT must be conducted in adherence with all ten
principles of the approach (definition adopted by the AG Bell Academy for Listening and Spoken Language®, July 26,
2007 http://www.agbellacademy.org/AuditoryVerbalTherapy.htm).
The child described below was enrolled in auditory-verbal therapy and received services from
a speech-language pathologist who is also Listening and Spoken Language Specialist (LSLS)
certified auditory-verbal therapist and has extensive experience working with infants and children
who are deaf or hard of hearing. As a result of her progress, she has recently been discharged
from receiving weekly therapy services and is currently being monitored.
Background Information
2 years
Gestational age
40 weeks
Age at diagnosis
2 months
Etiology
Unknown
Degree/Type
Bilateral profound sensorineural
1. Promote early diagnosis of hearing loss in newborns, infants, toddlers and children, followed
by immediate audiologic management and Auditory-Verbal Therapy.
Age received hearing aids
2 months
Age started Auditory-Verbal Therapy
4 months
2. Recommend immediate assessment and use of appropriate, state-of-the-art hearing
technology to obtain maximum benefits of auditory stimulation.
Age at implantation
10 months
Hearing technology
Bilateral Nucleus Freedom cochlear
implants simultaneously implanted
3. Guide and coach parents1 to help their child use hearing as the primary sensory modality in
developing spoken language without the use of sign language or emphasis on lip reading.
4. Guide and coach parents to become the primary facilitators of their child’s listening and
spoken language development through active, consistent participation in individualized
Auditory-Verbal Therapy.
Audiogram
6. Guide and coach parents to help their child integrate listening and spoken language into all
aspects of the child’s life.
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7. Guide and coach parents to use natural developmental patterns of audition, speech,
language, cognition and communication.
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.
(Adapted from the principles originally developed by Doreen Pollack, 1970)
The term “parents” also includes grandparents, relatives, guardians, and any caregivers that interact with the child.
*Adapted from the principles of Auditory-verbal Practice. © 2006 A.G. Bell Academy for Listening and Spoken Language®.
1
Factors Impacting Performance
A child’s auditory-verbal progress depends upon a number of variables, such as:
• Timing of hearing impairment
• Effectiveness of audiological management
• Age at diagnosis
• Auditory potential of the child
• Cause, type, and degree of hearing
• Skills and knowledge of the therapist
impairment
• Skills of the parents or caregivers
• Use of hearing aids prior to cochlear
• Child’s learning style and intelligence
implantation
• Emotional state of the family
• Chronological age at cochlear implantation
• Level of participation of the family
• Effectiveness of the hearing technology
Project: Presentation Poster
Client Contact: Lisa Katz (647.212.8710)
Communication Coord: Pauline Jackson
Designer:
Version:
Hassan Akbar
1/5
2/5
Revision meeting date:
3/5
4/5
5/5
Jerry Northern and Marion Downs, From Hearing in Children, (5th Edition, pg. 18),
Lippincott Williams and Wilkins, Baltimore, MD, 2002.
• Answers and asks age
appropriate “Wh-” questions
(e.g., What, Where, and Who).
• Produces age appropriate speech
sounds. Produces word endings • Follows two-step related
spontaneously (e. g., truck, crying,
commands
and wet)
Cognition
Communication
Behaviour
• Performs auditory-cognitive tasks
• Takes turns appropriately
• Understands and uses early
spatial, quantity, and quality
concepts (e.g., up, one, big)
• Has an age appropriate attention
span
• Complies for the duration of the
therapy session (1 hour)
• Exhibits good eye contact
Parent Perspectives
1. About AVT
According to parents interviewed:
2. Challenges Faced
According to parents interviewed:
• “The biggest challenge is to educate people about deafness and to enable them to understand
the fact that our kids have the potential to learn to listen and talk.”
EC Score
-
-
TOTAL
Score
-
145
-
-
-
140
-
-
-
135
-
-
-
130
-
-
-
125
-
-
-
120
X
-
X
-
X-
-
-
110
-
-
-
105
-
100
X
X-
XX
95
10. Promote education in regular classrooms with typical hearing peers and with appropriate
support services from early childhood onwards.
• Localizes and identifies sounds at
all angles and from a distance
• Sings known songs and recites
nursery rhymes
• “AVT has provided me with support and guidance regarding my concerns.”
AC Score
115
8. Guide and coach parents to help their child self monitor spoken language through listening.
• Overhears conversation
• “AVT makes sense as it follows the typical sequence of child development and is carried out in
daily situations.”
PLS- 4 Test Scores
Standard
Scores
150
c
• Uses appropriate suprasegmental • Spontaneously produces five• Understands primary speaker in
features of speech (e.g.,
word approximations with
the presence of background noise
exclamation, question, and
different semantic relations
or a competing message
negation)
(e.g., “Do you want some milk?”)
• Identifies hummed songs
• “AVT has taught me all that I know, from the basics about hearing technology and selecting
appropriate toys to achieving my child’s communication potential.”
One year post activation of the cochlear implants
c
c
Language
• “My therapist has empowered me to advocate for my child and to feel positive about her
future.”
Test Results
5. Guide and coach parents to create environments that support listening for the acquisition of
spoken language throughout the child’s daily activities.
Speech
• “AVT has not only provided me with ongoing guidance regarding the management of my child’s
hearing loss, but also with support in all areas of my child’s development.”
Chronological age
Principles of Practice*
Audition
-
-
XX-
-
-
-
90
-
-
-
85
-
-
-
80
-
-
-
75
-
-
-
70
-
-
-
65
-
-
-
60
-
-
-
55
-
-
-
50
-
-
-
X – January 6, 2009
X – June 10, 2008
X – October 2, 2007
Preschool Language Scale-4 (PLS-4)
The PLS-4 is used to assess receptive and
expressive language skills in infants and
young children. There are two subscales,
Auditory Comprehension (AC) and Expressive
Communication (EC). The PLS-4 also assesses
behaviours considered to be language precursors.
• “Finding a childcare that does not underestimate my child’s potential.”
• “Keeping the cochlear implants on was my biggest challenge. As a baby, she would take them
off and put them in her mouth. Now we are over that and the problem is different…..We both
get frustrated when we have to take them off to swim, bath or play on the slide.”
• “I worry about acceptance when he is older. Others accepting him and he being comfortable
with his difference.”
Conclusion
With the advent of newborn hearing screening and state-of-the-art hearing technology, children
who are deaf or hard of hearing and their families can benefit from auditory-verbal therapy more
than ever. Early diagnosis and intervention enable children to access speech and environmental
sounds, helping to stimulate central auditory pathways which are highly plastic in the first years of
life. As illustrated in the case study, auditory-verbal therapy combined with early simultaneous
bilateral cochlear implantation has facilitated the closure of the gap between the child’s hearing
age and chronological age.
Contact
Toronto Infant Hearing Program
201-225 Duncan Mill Road
Toronto, Ontario, Canada
M3B 3K9
Phone: (416) 338-8255
Fax: (416) 338-8511
TTY: (416) 338-0025
www.tpsls.on.ca
[email protected]
Infant Hearing Program
Speech & Language Program
Blind–Low Vision
Early Intervention Program
The authors wish to recognize the support of the Ministry of Children and Youth Services of Ontario and the support of the team members of the Toronto
Public Health: screeners, support assistants, data entry professionals, program evaluator, and managers. Thank you for your contribution and support.
We dedicate this presentation to the families and their children and to the early childhood professionals in Toronto and the Greater Toronto Area.
Funded by Toronto Public Health, City of Toronto