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Paediatric Audiology In-service. DHB AUDIOLOGY SERVICES 2013 P PERYMAN AUDIOLOGIST, VADEC Workshop Content 1. 2. 3. 4. 5. Helping parents understand about their child's hearing following diagnosis. Helping children themselves understand about their own hearing. Functional hearing assessment - beyond electroacoustic calibration. Audiological information needed by AODCs, parents and teachers of the deaf. Preparing hearing impaired students for transition to adult services. ANZCED PPT 1. Helping parents understand about their child's hearing following diagnosis History and enquiry – the manner in which this is done and engagement of parents/families. Parents become aware that they have been observing their child’s hearing and listening behavior and are reinforced for doing so. They are advised that they are part of the hearing assessment process. Their observations are valued by the audiologist. Parents observe the hearing testing – invitation to comment on the effects of seeing their child responding to sound. Clinician commenting that the child can hear, making a positive statement. Helping parents understand about their child's hearing following diagnosis Demonstration - Clinician indicates and demonstrates what parents and others need to do in order for the child to be able to hear consistently. Introduction of the notion of communication behavior change to meet the hearing needs of the child – the greater the hearing loss, the more dramatic the change. Expectations and options - Clinician discusses options to help the child’s hearing and communication, and begins process of managing expectations and understanding about benefits and limitations of management options, including amplification. Managing Conversations with Parents Let the parents set the pace for the consulation. We might ask or say, “Tell me more about the hearing behaviour you have observed.” “What concerns you most about your child’s hearing?” “You are the person who knows most about your child’s hearing.” Name any likely emotions the person might be expressing. eg, “You seem very worried...” Managing Conversations with Parents - 2 What works well now for the parents? “Can you tell me what you do in order to help your child hear better and communicate with them.” Clarify and summarise client’s comments. “You have talked a lot about A and B. Let’s make sure we talk more about A and B again later.” Clarify expectations. “What would you like me to do?” Clarify motivation. “How important is it for you to try to improve your child’s ability to hear and communicate?” Giving The Diagnosis - Technique Use Lay terminology. Avoid giving doubt, but say if unsure. Ensure info given is tailored to client’s concerns expressed during interview. Keep statements concise. An audiogram is not enough - Explain how loss of sensitivity, frequency selectivity and temporal integration affect hearing, and how this in turn affects communication. Giving The Diagnosis – Technique 2 Present simulations of the loss. EG: http://www.betterhearing.org/hearing_loss/hearing_loss _simulator/index.cfm Oticon gateway Elicit concerns. Answer questions. Ask if client would like more detail. Repeat explanations in summary and check understanding. Discuss home observation – eg, ELF, Karen Anderson. http://www.oticon.com/~asset/cache.ashx?id=10834&ty pe=14&format=web What Purposes Might This Initial Conversation Style Serve? Audiologist finds out how the family copes and the strategies that are in use. Family/parents feel the audiologist is taking a personal interest – respect and empathy. Adds depth and builds trust. Family begins to explore their daily communication activities in a way they may not have thought about them before – self-efficacy (our belief in our ability to succeed in certain situations) is advanced. Further Reading IAPO declaration on patient-centred health care: www.patientsorganizations.org/pchreview • • http://www.health.org.uk/public/cms/75/76/313/3448/Help ingPeopleShareDecisionMaking.pdf?realName=V9gR9i.pdf • Four Habits Model: http://kpnet.kp.org/cpc/ Karen Anderson, Counselling parents of children with hearing loss - Gateway: http://www.oticon.com/~asset/cache.ashx?id=10830&type=14 &format=web 2. Helping children understand their own hearing. Anatomy and Causes of Hearing Loss Hearing Measurement – explanations Hearing Aids, Cochlear Implants, Assistive Listening Devices – function, care, maintenance Coping with a Hearing Loss Communication Strategies Solution-Focused Conversation & Rational Emotive Education Stories of children Resources, Bibliography Who and when? Curriculum designed for primary school children. Age when child able to learn new independence skills and absorb new info. Primary school child’s thought may still be concrete (Piaget’s stage of concrete operations 7-12 years), but... There is an increased ability to maintain attention. Increased ability to store and recall information. Able to use of mental imagery to represent events, etc. Coping with a hearing loss – “My World” The My World tool can help facilitate an understanding of hearing loss from the child's point of view. The tool consists of three different environments: a classroom, a home, and an outdoors area. The child can place movable figures and everyday objects in the various environments to describe communication successes and challenges in everyday life. There is also a photo album with pictures showing scenes which present a challenge for the child. Coping with a hearing loss – “My World” 2 By playing with the tool components, the child can externalize their hearing concerns and discuss how they communicate with others in a concrete, nonthreatening way. The tool can help professional (and families) uncover information about the child's communication patterns, reinforce positive patterns, and formulate a strategy for coping with everyday challenges. http://idainstitute.com/tool_room/my_world/ Coping with a Hearing Loss – Interactive Situations Use of pictures of interactive situations to elicit individual or group discussion by HI’d children. eg, - Teacher does not face child when talking. - Talking to other children at lunch or in the playground – peer relationships. - On the sports field. - Classroom routines and teacher routines. • Explore ways that child has managed or can try to manage the situations. • Role play adaptive strategies. Communication Strategies What is the child presently using? Erber methods Adaptive speech perception – what does another person need to do in order for a child to receive and understand a spoken message? Conversation training. Telephone training. Stories of Children These can be videos or printed stories produced by the child themselves. Models of stories are available from sources such as the “Family Book” , or Aust. Hrg’s “Choices” – (Jack’s Story, p57). Solution-Focused Conversation & Rational Emotive Education Social skill dev’t; eg, approp. touching to get attention, seeking repetition, learning when to talk in class. Building self-esteem. Self-efficacy – child may feel that it is too hard to make changes or learn communication skills. Encourage child to perform desired behaviour then draw their attention to that performance – by shaping or slow approximations. Teach child how to dispute irrational beliefs and replace them with rational beliefs. Eg, child is not a bad person if they don’t meet their goals; Playing a game for fun does not mean it has to be won; Significant achievements are not easy so hard work is needed. Resources and Bibliography Knowledge is Power Curriculum http://www.edaud.org/storelistitem.cfm?itemnumber =18 • Barbara Taylor “Living with Deafness” London, Franklin Watts – Aladdin Books, 1989. Erber NP, “Auditory Communication for Deaf Children .” Victoria, Aust, ACER Press, 2011. “The Family Book.” 3. Assessments of Functional Listening Many speech perception tests yield a score which may not be able to be easily interpreted in relation to everyday functional communication. These tests also describe performance in a static situation or test condition, such as using audition alone, or listening in quiet and noise. Everyday functional communication can be assessed using procedures with greater predictive value. Adaptive hearing assessment This approach has a long tradition in what was called auditory training – eg, Geoff Plant in Australia (Plant, 1982). The basic tenet is one of varying systematically (adaptively) the cues given to a child in order to discover which combination of cues the child requires in order to perceive speech or communicate most fluently. The Erber approach Describes the adaptive evaluation of functional hearing ability in school-aged children. It is based on the reality of conversations between the hearing impaired child and others, and the cues children rely on to maintain some conversational fluency (Erber, 2011). It is a form of diagnostic teaching in which instruction is integrated with assessment, and almost any speech perception test can be used in this way. The Erber approach - method Select a list of words (eg, WIPI Test). Speak the test word using audition alone. If the child identifies the word correctly, proceed to the next stimulus. If the child responds incorrectly, repeat the stimulus word using audition alone. If still incorrect, introduce the word into a sentence. If still incorrect, repeat sentence with audition plus visual cues. When the child responds correctly, note the stimulus condition in which the correct response occurred. Results are plotted on a graph. The Erber approach – result plot 1 The Erber approach – result plot 2 The Erber approach – result plot 3 Interpreting Adaptive Hearing Ass’t results The results specify the conditions under which the child succeeds. Parents and other professionals can learn which adaptive communication strategies are most effective for the child. They can also adapt their own communication to suit the child. A speech perception test score may underestimate a child’s abilities, especially if the adaptive methods show better ability. Functional Listening Evaluation - FLE (Johnson & VonAlmen, 1993, revised 2010) Required by IDEA (The Individuals with Disabilities Education Act (IDEA) is a law ensuring services to children with disabilities throughout the nation. IDEA governs how states and public agencies provide early intervention, special education and related services.) to conduct a functional evaluation of the child in the child’s customary environment. Compares student’s listening ability in a variety of situations to identify effects of noise, distance and visual cues. Functional Listening Evaluation - FLE (Johnson & VonAlmen, 1993, revised 2010) 2 Provides authentic sample of student’s abilities for teachers, parents, and others. Provides evidence for hearing assistance technology. May support choice of most appropriate hearing assistance technology. Validates benefit of hearing assistance technology, eg Does it meet amplification goals for student? Combined with classroom physical characs, and C/T – child characs (“Classroom-at-a-glance” survey). Functional Listening Evaluation (Johnson & VonAlmen, 1993; Johnson, 2004, 2010) FLE Test Set-up student 3 ft Noise tape examiner student 3 ft Noise tape 12-15 ft examiner FM Fitting FM and remote microphone systems for individual preferred listening levels - beyond electroacoustic gain calibration. Clinical activity – speech in noise Cheryl DeConde Johnson methods. Feedback and adjustment during trials – Listening checks, classroom tests, child report, C/T report. Adjustment during use, post-issue – C/T voice level/quality change. Interpretation Matrix: Effects of Noise with FM Quiet Noise FM/Noise Close-auditory 84 72 84 Close-auditory/visual 92 80 92 Distant-auditory 72 36 88 Distantauditory/visual 76 56 92 81% 61% 89% Ave. of above scores: 4. Audiological Information Needed by AODCs, Parents and Teachers of the Deaf. Important comments made by the child and parents/caregivers. Audiogram with key to symbols. Audiometry response reliability. Description of degree of hearing loss. Status of ear health and impact of middle ear conditions if any. Audiological Information Needed by AODCs, Parents and Teachers of the Deaf. 2 Is one ear hearing better than the other, and if so, should others sit on this side if working 1-1, etc? Mention of any changes in hearing sensitivity. Aided audiometry including speech perception and conditions in which tested. Child’s estimated or measured best aided listening range for speech in quiet. Summary of functional hearing skills. Audiological Information Needed by AODCs, Parents and Teachers of the Deaf -3 Hearing aid make, model, serial number, battery type, whether controls are active or automatic, how aid will perform technically in noise and in quiet (especially if in directional mic mode), activation of frequency lowering, etc. Were HAs adjusted, and how, plus for what reason. Assistive device (eg, FM system) , model, serial number, battery type, whether controls are active or automatic. Follow-up recommendations. When the child will be seen in the future. 5. Preparing Hearing Impaired Students for Transition to Adult Services. Support for youth Transition support requirements Support for Youth Karen Anderson, “Special Considerations for Parents Raising a Teenager with a Hearing Loss.” Oticon Paediatrics. http://www.oticon.com/~asset/cache.ashx?id=10838 &type=14&format=web Cheryl DeConde Johnson, “Keeping Molehills from Becoming Mountains.” Oticon Paediatrics. http://www.oticon.com/~asset/cache.ashx?id=10839 &type=14&format=web Support for Youth - 2 SAC-A . Judy Elkayam andKris English, “Counselling Adolescents with Hearing Loss with the use of a SelfAssessment Questionnaire.” JAAA, 14 (9), 485-499, 2003. Cochlear implant wearers: http://www.hearforyou.com.au/new_zealand_mentor s_at_hear_for_you.html Transition Support Requirements Schroeder et al, 2010 – “My Patient is Taller Than Me! Now What? Developing a Plan for Teenagers to Transition to Adult Audiology Services”. Poster at Sound Foundation Through early Amplification Conference 2010. NDCS Quality Standards for Transition from Paediatric to Adult Audiology Services. 2005. Schroeder et al, 2010 Ensure teen knows about their hearing and how it has an impact on their communication. Taking ownership of hearing health care. Development of transitioning plan. Plan driven by teen and family needs. Fine tune self-advocacy and assertiveness skills for effective listening/communication. Who has a role in this? NDCS Quality Standards for Transition Services must have an agreed written protocol. Information pack. Arrange an app’t within adult service context. Person designated to provide support for person in transition. Support, services and info tailored to indiv’s and family’s needs. Transition Resources MoE - Preparing to leave school: http://www.minedu.govt.nz/Parents/AllAges/ParentI nformationKit/BookletsforParents.aspx