Download Hearing Aid Fittings on Children Infancy to 5 Years 1

Hearing Aid Fittings on Children
Infancy to 5 Years
Julie Christensen, M.S.
Staff Audiologist
Hearing Aid Fittings on Children
Infancy to 5 Years
Julie Christensen, M.S., CCC-A
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Hearing Aid Fittings on Children
Infancy to 5 Years
What is the primary goal of
putting hearing aids on children?
Promotion of speech and language development
Babble is a building block for word building.
An impoverished inventory of baby sounds may limit early
word learning which may, in turn, delay communication skills
Vocabulary Spurt
No of words
600
400
200
0
0
12
18
24
Age in months
Vocabulary Spurt at 500 words
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Hearing Aid Fittings on Children
Infancy to 5 Years
Vocabulary Spurt
60000
60000
50000
40000
30000
20000
14000
10000
1
75
500
0
Are children and adults fit with
hearing aids in the same way?
Characteristics of the Very Young Listener
• Children use their hearing to learn language
• Smaller ears mean different acoustics and retention
challenges.
• Less audiometric information on children
Case Study: Baby J
• Referred on newborn hearing screen
• Parents brought Baby J to BTNRH at
1 month of age
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Hearing Aid Fittings on Children
Infancy to 5 Years
Unsedated ABR
• 1 month old:
- Normal tympanograms
- Mild high frequency loss in left ear
- Moderate high frequency loss in
right ear
Recommendations – return in 1
month for repeat ABR
Repeat ABR
• 2 months – normal tympanograms
ABR
thresholds
RE
250 Hz
1000 Hz
Clicks
40
40
40
LE
30
40
40 and
?30
LIMITED AUDIOMETRIC INFORMATION
How is behavioral hearing
testing different for a child
compared to an adult?
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Hearing Aid Fittings on Children
Infancy to 5 Years
Anatomy of a behavioral hearing test
•
•
•
•
Tympanograms
Air conduction
Bone conduction
Word recognition
Anatomy of an audiogram
LOW
HIGH
Soft
BONE CONDUCTION
THRESHOLDS
AIR CONDUCTION
THRESHOLDS
KEY
LOUD
Threshold: the softest sound a
person can hear
Complete Audiometric Test
Word Understanding: Presentation
level: 75 dB RE: 96% LE 92%
Normal Tympanograms
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Hearing Aid Fittings on Children
Infancy to 5 Years
Baby J’s Audiometric Information
Click
Word Understanding: Unknown
Normal Tympanograms
What’s next for Baby J?
• Binaural amplification
(took ear imps that day)
Follow-up Appointments
•
•
•
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•
•
ENT evaluation for medical clearance
Fit with loaner aid at 4 months.
Neurosensory Genetics evaluation
Fit with new molds at 7 months of age
Fit with new molds at 9 months of age
Fit with new molds at 11 months of age
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Hearing Aid Fittings on Children
Infancy to 5 Years
Compared to normal hearing adults…
• Children use their hearing to learn
language. They can’t guess at words
they miss.
• Children don’t perform as well in
noise and reverberant rooms.
• Infants and young children can’t give
feedback on hearing aids
Kids need hearing aid targets
designed just for them
Adult targets may not provide enough
speech information: Children may not be
able to monitor their own voice or hear high
frequency speech sounds, which are crucial
for language learning.
Infant Amplification In 8 Steps
1.
2.
3.
4.
5.
6.
7.
8.
Confirm hearing loss
Counseling
Referrals for intervention
Ear Impressions
Selection of Amplification
Fitting and Verification
Hearing Aid Orientation
Follow-up Services
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Hearing Aid Fittings on Children
Infancy to 5 Years
1. Confirm And Monitor
Hearing Loss
Proceed with amplification when…
• Test findings confirm hearing loss
–Presumed permanent hearing loss
–Ruled out acute middle ear
dysfunction
–Parents ready
2. Counseling
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Hearing Aid Fittings on Children
Infancy to 5 Years
Time Frame for Amplification
• Yoshinaga-Itano et al, 1998 Pediatrics
–language abilities significantly
better when intervention begun
at 6 mos. or sooner
Joint Committee on Infant Hearing
(JCIH)
“All infants who do not pass the
birth admission screen…(should)
begin appropriate audiological and
medical evaluations to confirm the
presence of hearing loss before 3
months of age.”
Why is early intervention
so important?
• Vocab skills examined in 112 five year olds
with HL. Verbal reasoning skills examined in
a subgroup of 80.
• Children enrolled by 11 mos of age
demonstrated better vocab and verbal
reasoning scores than later-enrolled
children, regardless of degree of HL.
Moeller MP. Early intervention and language development in
children who are deaf and hard of hearing. (Pediatrics, 2000)
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Hearing Aid Fittings on Children
Infancy to 5 Years
Barriers to Timely Amplification
• Size of the newborn (preemie, LBW)
• Other medical needs supercede or complicate
– Severe medical needs
– Conductive component
• Additional testing for audiological status
• PCP has limited knowledge re: children with HL
• $$$$ for hearing instruments
• Parental acceptance
– Denial or 2nd opinion sought
• Poor access to skilled pediatric audiologist
Limited Economic Resources
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Insurance
Transportation
Child care
Time off from work for appointments
Lack of permanent residence
Language or cultural barriers
Legal status
(Sass-Lehrer 2004)
Causes of Delay, According to Parents
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Need for additional appointments (30%)
Waiting for follow-up appts (19%)
Delays in 3rd party payments (20%)
Child’s health problems (8%)
Difficulties with ear molds (7%)
Seeking second opinion (5%)
Not ready (4%)
Other (7%)
(Sjoblad et al 2001)
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Hearing Aid Fittings on Children
Infancy to 5 Years
Parents’ concern at the
time of hearing aid fitting
I was concerned:
Agree
strongly
Uncertain
Disagree
strongly
about the care and maintenance
of the hearing aids
72
3
23
about what the hearing aids
would look like
61%
4
55
about whether my child would
benefit from hearing aid use
58
6
28
that my child would not be
socially accepted
45
15
39
about what friends and family
would say about the hearing aids
26
6
52
Sjlobad et al 2001
What was your biggest worry when
you child got their hearing aids?
•Learning to talk
•Keeping them on
•Teasing at school
•Losing or breaking them
•Swallowing battery
•Improvement in listening
•Acceptance of hearing aids by child
•Comfort issues
•Keeping them clean and dry
Martin, Stroud & Nicholson, 2005
Early intervention and language
development in children who are deaf and
hard of hearing
• Multiple regressions models to examine the relationship
btw performance and
–
–
–
–
age of enrollment,
family involvement,
degree of HL,
nonverbal intelligence.
• Only 2 significant factors
– family involvement – explained the most variance
– age of enrollment
Moeller MP. Early intervention and language development
in children who are deaf and hard of hearing. (Pediatrics,
2000)
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Hearing Aid Fittings on Children
Infancy to 5 Years
Parental involvement
trumps everything!!!
Talking to parents
•Give the parents time to digest as you go
•Watch parents carefully – use them as a
meter to determine how much information
to give – don’t overwhelm them
•Give them time alone
•Expect to counsel and answer the same
questions over the next twenty years of
following the child
Talking to Parents
• Have handouts ready to take home
• Give them your phone number and
encourage them to call
• Be honest and realistic
• Respect their reactions
• Respect their decisions
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Hearing Aid Fittings on Children
Infancy to 5 Years
"I cannot remember anything they said after the word
‘deaf.’ I had to call the office later and ask for all the
details over again.”
"The biggest mistake I made with my family was to cry all
of my tears before I called them to give them the news. I
knew my parents would be upset by the news, so I
wanted to protect them by acting as if everything was
fine. Because I was so in control and seemed to be
handling it so well, they assumed that I was fine. If I had
been honest with them and let them know how
devastated I was, they would have been much more able
to support me when I really needed it."
My Baby’s Hearing
BTNRH – NIDCD web page: http://www.babyhearing.org/
3. Referrals
Distribution of Conditions that
Occur in Addition to Deafness
Condition
% of Children
No condition in addition to
deafness
60.1
Learning disability
10.7
Intellectual disability
9.8
Attention deficit disorder
6.6
Blindness and low vision
3.9
Cerebral palsy
3.4
Emotional disturbance
1.7
Other conditions
12.1
From Roush et al 2004, based on the Gallaudet Research Institute. Regional and National
Summary Report of Data from the 2001-2002 Annual Survey of Deaf and HOH Children and Youth.
Washington DC: GRI, Gallaudet University; 2003 (N=42,361; 11/9% not reported)
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Hearing Aid Fittings on Children
Infancy to 5 Years
Intervention Referrals
1.
2.
3.
4.
5.
6.
ENT evaluation
Early intervention services
Pediatric Ophthalmology examination
Medical-genetics assessment
Financial assistance, if warranted
Parent to Parent Support
ENT Evaluation
• Rule out treatable causes of HL
• Medical clearance for amplification
• Address wax problems
Early Intervention Services
1. Educational Intervention, including IFSP
(Individual Family Services Plan). Varies
state to state. Typically service
coordinators are in the local school
district. Service coordinators send
patients on to other medical referrals, as
needed.
2. Parent/Infant specialist or Deaf/HOH
Educator
3. Communications Assessment
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Hearing Aid Fittings on Children
Infancy to 5 Years
Ophthalmology Referral
• 3.9% have vision problems
• May depend on vision to assist
communication
Medical-Genetics Referral
Causes of HL in newborns
• 60% genetic
• 40% non-genetic
Joint Committee on Infant Hearing:
“All families of babies with a hearing
loss for whom there is no clear-cut
etiology should be offered an
evaluation with a medical geneticist for
genetic testing and counseling.”
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Hearing Aid Fittings on Children
Infancy to 5 Years
Commonly Heard Responses to
Genetics Counseling Referrals
“We’re not having more children, so it
doesn’t matter what a genetics test tells
us.”
“I don’t need to know what the likelihood
will be of having more children with
hearing loss – it’s not going to stop us from
having them.”
Other things that genetic testing may tell
parents and healthcare professionals:
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Progression of hearing loss
Perilymph gusher, if stapes is disturbed (DFNA1)
Heart problems (Jervell and Lange-Nielsen)
Vestibular abnormalities (Pendred)
Large Vestibular Aquaduct/sudden hearing loss (Pendred)
Thyroid enlargement (Pendred)
Higher sensitivity to ototoxic meds (C.Mitochondrial)
Anemia (Alports)
Kidney problems (Alport and Branchi-oto-renal)
Nerve tumors near the ear (NF2)
Neck cysts (Branchio-oto-renal)
Progressive blindness (Usher)
Skin pigment changes (Waardenburg)
Genetic testing can:
• Allow doctors to make referrals to specialists for
monitoring of potential associated health problems
• Avoid clinical tests to rule out conditions down the
road
• Ease parental guilt by determining the cause of the
hearing loss
• Allow clinicians to develop an treatment strategy
that anticipates future health problems
• Predict the likelihood of having more children with
hearing loss, or of current children having other
children with losses or other symptoms.
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Hearing Aid Fittings on Children
Infancy to 5 Years
Financial Assistance Referrals
• Costs related to HL can be burdensome
• Medically handicapped children’s
programs
• Medicaid
• Service organizations
• Hearing Aid Manufacturers
Parent to Parent Support
Offer parents the opportunity to talk
to the parents of another child with
a similar hearing loss.
Hands and Voices: www.handsandvoices.org
Listen Up!: http://www.listen-up.org/basics.htm
4. Ear Impressions
in an infant ear
1 ½ months old
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Hearing Aid Fittings on Children
Infancy to 5 Years
Ear Impressions & Earmolds
• Proceed when?
– Ears canals clear
– Size adequate
• For earmold (tubing)
• For hearing aid
5. & 6.
Hearing Instrument Selection
Fitting
Verification
Selection Considerations
1. Binaural vs. Monaural
2. Kid-friendly (light alerts, colors, tamperresistant battery doors)
3. Loss/Damage/Repair Warranty
4. Small size
5. FM compatibility
6. Flexibility for changes in hearing
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Hearing Aid Fittings on Children
Infancy to 5 Years
Always Fit Both Ears
• Unless there is a clear contraindication
• To facilitate development of neural
function
• Localization – connecting sounds to
environment
• Even in cases of asymmetrical hearing
until there is evidence that fitting poorer
ear is detrimental to performance
Kid Friendly!
Loss/Damage Warranty
Warranty from the manufacturer (usually 2 yr
loss, 2-3 year repair)
Hearing aid Insurance Companies (ESCO, etc)
Homeowner’s insurance – make sure parents
check on what is covered where.
Some companies don’t cover the
loss if it happens away from
the home.
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Hearing Aid Fittings on Children
Infancy to 5 Years
FM Advantage
• Increases loudness of primary
speaker
• Reduces negative effects of distance,
reverberation, and background noise
Flexibility
• Remember we are working with limited
info!!!
– May have only ABR thresholds
– May have only two or three behavioral
thresholds
– Loss may or may not be progressive
• Need an aid with a range of output and
gain that can grow with the child
What if money isn’t an option?
Should kids drive fully loaded?
Not every advanced option is
appropriate for infants and children.
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Hearing Aid Fittings on Children
Infancy to 5 Years
Directional Microphones
and Noise Reduction:
Practical Issues
Reducing sounds from behind can impact
– Child’s safety
– Child’s ability to “overhear” other talkers in
his environment
’nuff said
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Hearing Aid Fittings on Children
Infancy to 5 Years
What is the primary
goal of verification?
1. To make sure the hearing aids
make speech audible.
2. To make sure the hearing aids
will never be too loud.
Probe Microphone Measures
Speechmap
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Hearing Aid Fittings on Children
Infancy to 5 Years
Speechmap
Speechmap
Speechmap
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Hearing Aid Fittings on Children
Infancy to 5 Years
Speechmap
Speechmap
Speechmap
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Hearing Aid Fittings on Children
Infancy to 5 Years
What if a child
can’t sit for real ear?
Real Ear to Coupler Difference
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Hearing Aid Fittings on Children
Infancy to 5 Years
“Why don’t you repeat my child’s
hearing test, with the hearing
aids on to verify benefit?”
Functional Gain
Testing pure tone and speech
thresholds, in the sound booth,
with the hearing aids on.
Functional Gain doesn’t tell us
1. How well the hearing aids amplify speech
2. How loud the hearing aid will go
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Hearing Aid Fittings on Children
Infancy to 5 Years
Functional Gain
ProbeMic/RECD
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Not speech-level
No loudness info
Age constraints
High variability
Time consuming
Speech-level inputs
Loudness measures
Age irrelevant
Low variability
Fast
When Functional Gain?
• Evaluation of bone-conduction
hearing aids
• Parent reassurance
7. Hearing Instrument Orientation
(a process, not an event!)
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Hearing Aid Fittings on Children
Infancy to 5 Years
Parent Orientation
•
New vocabulary
•
Use and care of instruments/earmolds
•
1. Putting the hearing aid on
•
2. Battery changes
•
How to perform daily listening/battery checks
•
Basic troubleshooting
Hearing Aid Kit
– written materials
– batteries
– dry-aid kit
– listening tube
– battery tester
– earmold blower
– retention device
Retention
‒ Double-sided tape
(toupee tape)
‒ It Stays www.supportshop.com
‒ Listen Up! webpage
‒www.listen-up.org
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Hearing Aid Fittings on Children
Infancy to 5 Years
Huggies
Knit Caps
• Perfect for the 6-10 month
olds!
• May create feedback
problems
• Electroacoustically invisible
• May be last retention
option for some infants!
hannaandersson.com
Loss Prevention:
Commercial vs Crafty
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Hearing Aid Fittings on Children
Infancy to 5 Years
Reality Check
• Despite your best efforts, babies will
sometimes take off their hearing aids!
8. Follow-Up
•New ear impressions as infant grows
•New RECD and instrument adjustments as needed
with new molds.
•Behavioral testing with VRA at 6-7 months of age
•Behavioral audios every three months until three
years of age, then every six months until six years of
age, or sooner, with progressive or fluctuating loss.
•Close contact with family, teachers, and schoolbased audiologist
•ASSESS: Is the child benefiting from amplification?
Questions?
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Hearing Aid Fittings on Children
Infancy to 5 Years
References
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Christine Yoshinaga-Itano*, Allison L. Sedey*, Diane K. Coulter*, and Albert L. Mehl (1998).
Language of Early- and Later-identified Children With Hearing Loss . PEDIATRICS Vol. 102 No. 5
November 1998, pp. 1161-1171
Joint Committee on Infant Hearing (JCIH) www.jcih.org
Moeller MP. (2000). Early intervention and language development in children who are deaf and
hard of hearing. PEDIATRICS Vol. 106 No. 3 September 2000, p. e43
Sass-Lehrer, M. (2004). Early detection of hearing loss: Maintaining a family-centered
perspective. Seminars in Hearing, 25, 295–307.
Sjoblad s, Harrison M, Roush J, McWilliam R (2001) Parents' Reactions and Recommendations
After Diagnosis and Hearing Aid Fitting. American Journal of Audiology Vol.10 24-31 June 2001.
Martin P, Stroud J, Nicholson N. Hearing aids: Helping parents understand the good, the bad and
the ugly. Unpublished presentation. National EHDI Conference; Atlanta, GA. 2005.
My Baby’s Hearing, BTNRH – NIDCD web page: http://www.babyhearing.org/
From Roush et al 2004, based on the Gallaudet Research Institute. Regional and National
Summary Report of Data from the 2001-2002 Annual Survey of Deaf and HOH Children and
Youth. Washington DC: GRI, Gallaudet University; 2003 (N=42,361; 11/9% not reported)
Hands and Voices: www.handsandvoices.org
Listen Up!: http://www.listen-up.org/basics.htm
It Stays - www.supportshop.com
Hanna Andersson www.hannaandersson.com
Julie Christensen, M.S.
Boys Town National Research Hospital
555 North 30th Street
Omaha, Nebraska 68131
[email protected]
Julie Christensen, M.S.
Staff Audiologist
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Hearing Aid Fittings on Children
Infancy to 5 Years
A production of the Lied Learning & Technology
Center at Boys Town National Research Hospital
555 North 30th Street
Omaha, NE 68131
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