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Effects of Hearing Loss on Development Audiologic Rehabilitation for Children and Educational Audiology SPA 6581 – Spring 2015 Lecture Date: 01/13/2015 How many are we missing? Approximately 3 of 1000 babies are born with hearing loss Prevalence of hearing loss in school age children is between 11.3% and 14.9% Average of 131 of 1000 school age children have some degree of hearing loss that affects learning and development (American Speech-Language-Hearing Association, 2012) Four Major Ways Delay in the development of receptive and expressive communication skills Language deficit causes problems that result in reduced academic achievement Communication difficulties often lead to social isolation and poor self-concept It may have an impact on vocational choices Hearing Loss and Families “Lower rates of stress, depression, and conflict among parents and faster resolution of grief related to the identification of hearing loss have been linked to early detection of and intervention for children with hearing loss.” Degrees of HL and Effects Hearing Loss Effects on Language and Speech Understanding Normal 0-15 dB HL None Mild 16-30 dB HL Possible difficulty with soft/distant speech Moderate 31-50 dB HL Speech must be loud for understanding; background noise difficult, language usage & comprehension issues, vocabulary limitations Severe 51-80 dB HL May be able to detect environmental sounds, may be able to discriminate most vowels, but not all consonants, speech and language WILL be affected and will not develop without amplification and intervention if HL is present prior to 1 year Profound 81 dB HL and up May hear loud sounds; more aware of vibrations than true tones, may rely on vision as primary sensory channel, speech and language will not follow normal development without amplification and intervention Specific Effects Vocabulary Sentence Structure Vocabulary & HL Vocabulary development is slower Learn concrete words (cat, jump, five, & red) more easily than abstract words (before, after, equal to, & jealous) Difficulty with function words (the, an, are, & a) The gap between the vocabulary of children with normal hearing and children with hearing loss widens with age. Difficulty understanding words with multiple meanings Children with hearing loss will likely not catch up without intervention. Sentence Structure & HL Comprehend & produce shorter and simpler sentences Difficulty understanding & writing complex sentences Ex. of relative clause: “The teacher whom I have for math was sick today.” Ex. of passive voice: “The ball was thrown by Mary.” Often cannot hear word endings such as –s or –ed and can lead to… Misunderstandings & misuse: Verb tense Pluralization Nonagreement of subject and verb Possessives Speaking May have difficulty hearing sounds such as s, sh, f, t, and k. Due to the difficulty hearing, may not include them in production What could this do to their intelligibility? Auditory Feedback Loop Difficulty hearing their own voices when they speak. May speak too loud or not loud enough Speaking pitch may be too high Mumbling quality due to: Poor stress Poor inflection Poor rate of speaking Academic Achievement Difficulty with all areas of academic achievement Reading and mathematics concepts Academic Achievement Mild to moderate hearing loss 1 to 4 grade levels lower, on average, than peers with normal hearing unless appropriate management occurs Severe to profound hearing loss Usually no higher than the 3rd or 4th grade level unless appropriate educational intervention occurs early Academic Achievement The difference in academic achievement between children with normal hearing and those with a hearing loss usually widens as they progress through school. The level of achievement is related to parental involvement and the quantity, quality, and timing of the support services children receive. Social Functioning What do children with hearing loss often report? Feeling alone Without friends Unhappy in school Particularly when their socialization with other children with a hearing loss is limited What does research show? Children identified with a hearing loss who begin services early may be able to develop language (spoken and/or signed) on par with their hearing friends. Early family-centered intervention is recommended to promote language (speech and/or signed depending on family choices) and cognitive development. Audiogram Difficulty Increases Noise level in environment (i.e., the classroom) Distance from target auditory source (i.e., the teacher) Configuration of hearing loss Some Factors Which Can Directly Impact Progress Age at diagnosis and Hearing Age Etiology Duration and degree of hearing impairment Audiological management Health of the child Family participation Child’s intelligence and learning style Mild to Moderate HL Speech and Language Social Educational Accommodations and Services (Better Hearing Institute, 1991) Effects of Mild to Moderate Hearing Loss on Speech and Language Difficulty hearing faint/distant speech At 16 dB, can miss up to 10% of speech signal when teacher is at a distance greater than 3 feet At 20 dB + HL in the better ear can result in absent, inconsistent, or distorted parts of speech % of speech signal missed will be greater whenever there is background noise Consider – elementary grades May have difficulty with sound/letter association and subtle auditory discrimination skills necessary for reading Effects of Mild to Moderate Hearing Loss on Speech and Language At 30 dB can miss 25 to 40% of the speech signal At 40 dB can miss 50% of class discussions Especially if voices are faint or is speaker is not in line of vision Miss words and consonants not emphasized Often experiences difficulty learning early reading skills such as letter/sound associations Miss fragments of speech leading to misunderstanding Mild to Moderate: Possible Social Impact May be unaware of subtle conversational cues Child may then be viewed as inappropriate May be more fatigued due to extra effort needed for understanding speech May miss portions of fast-paced peer interactions that could begin to have an impact on socialization and self concept Behavior may be confused for immaturity or inattention Mild to Moderate: Possible Social Impact Negative impact on selfesteem “You only hear when you want to.” “Johnny is constantly daydreaming in my class.” “He is such a disruption to my class, and he simply does not pay attention.” May believe they are less capable due to difficulties understanding in class Begins to lose ability for selective listening Increased difficulty suppressing background noise causing the learning environment to be more stressful More fatigued due to the effort needed to listen Potential Educational Accommodations and Services Improved acoustic treatment of classroom Sound-field amplification Favorable seating May benefit from personal amplification and FM system In-service on impact of hearing loss on language development, listening in noise and learning for educators Specialized instruction in: Sound/letter associations Auditory discrimination skills Vocabulary Speech production/Articul ation Potential Educational Accommodations & Services Personal amplification and personal FM system Favorable acoustics, seating, and lighting Teacher in-service (ongoing?) Specialized instruction or attention: Auditory skills Speech and language development Speechreading Support in reading Support in selfesteem Moderate to Severe HL Speech and Language Social Educational Accommodations and Services (Better Hearing Institute, 1991) Moderate to Severe: Speech and Language Consistent use of amplification and language intervention prior to age 6 increases the probability that the child’s speech, language, and learning will develop at a normal rate Without amplification, child may understand conversation at a distance of 3-5 feet, if sentence structure and vocabulary are known. With 40 dB loss, the speech signal missed can be 50%, with 50 dB loss, the speech signal missed can be 80% Without early amplification, the child is likely to have delayed or disordered syntax, limited vocabulary, imperfect speech production, and flat voice quality Even with amplification, may miss speech if classroom is noisy or reverberant Moderate to Severe: Speech and Language Even with hearing aids, will miss parts of words resulting in difficulty in situations required verbal communication (even in 1on-1 & in groups) Without HAs, conversation must be very loud to be understood 55 dB loss can cause a child to miss up to 100% of speech information without amplification If HL is not identified before age 1 and appropriately managed, delayed spoken language, syntax, reduced speech intelligibility and flat voice quality is likely. The following strongly impacts success of speech, language, and learning development: Age when first amplified Consistency of hearing aid use Early language intervention Moderate to Severe: Possible Social Impact Communication can be significantly compromised with this degree of hearing loss, particularly if hearing aids are not worn Tendency for poorer self-concept and social immaturity Peer in-service may be helpful Fatigued Similar barriers with negative impact on self-esteem Socialization with peers may be difficult, especially in noisy situations: Lunch Recess Cooperative learning situations Moderate to Severe: Potential Educational Accommodations & Services Consistent use of personal amplification is necessary; however, the ability to perceive speech and learn effectively in a classroom setting is at risk. Personal FM system required to overcome classroom noise and distance Favorable acoustics, seating, and lighting Note-taking, captioned films Consultation/progra m supervision by a specialist in childhood hearing impairment Moderate to Severe: Potential Educational Accommodations & Services Special academic support may be necessary if language and educational delays are present Depending on early intervention success in preventing language delays Intensive attention to the following is necessary: Oral communication, reading, written language skills, auditory skill development, speech therapy, and self-esteem Educator inservice Severe to Profound HL Speech and Language Social Educational Accommodations and Services (Better Hearing Institute, 1991) Severe to Profound: Speech and Language The earlier the child wears personal amplification consistently with concentrated efforts by parents/caregivers to provide rich language opportunities throughout everyday activities and/or provision of intensive language intervention (sign or verbal), the greater the probability that speech, language, and learning will develop at a relatively normal rate. Severe to Profound: Speech and Language Without amplification, children with 71 to 90 dB loss may only hear loud noises about one foot from ear. When amplified optimally, children with hearing ability of 90 dB or better should detect many sounds of speech if presented from close distance or via FM. Individual ability and intensive intervention prior to 6 months of age will determine the degree that sounds detected will be discriminated and understood by the brain into meaningful input. Severe to Profound: Speech and Language Even with hearing aids, children with 71 to 90 dB HL are typically unable to perceive all high pitch speech sounds sufficiently to discriminate them, especially without the use of FM. May be a candidate for a cochlear implant. For full access to language to be available visually (if this is the communication mode chosen), through sign language or cued speech, family members must be involved in child’s communication mode from a very young age. Severe to Profound: Possible Social Impact Depends on success of intervention in infancy to address language development Child’s communication may be minimally or significantly affected Socialization with hearing peers may be difficult Dependency on adults Relationships with peers and adults who have hearing loss, can make positive contributions toward the development of a healthy self-concept. Severe to Profound: Potential Educational Accommodations and Services Communication Mode Regardless of communication mode/approach, extensive language intervention, full-time consistent amplification use and constant integration of the communication practices into the family by 6 months of age will highly increase the probability that the child will become a successful learner. Children with late-identified hearing loss will have delayed language Severe to Profound: Potential Educational Accommodations and Services The language gap is difficult to overcome and the educational program of a child with hearing loss, especially those with language and learning delays secondary to hearing loss, requires the involvement of an educator with expertise in teaching children with hearing loss. Directly from an SLP, “I know a little bit of sign, but my student will teach me more once I start. I am really looking forward to working with him, so that I can improve my skills in sign.” PROBLEM??? Severe to Profound: Potential Educational Accommodations and Services If an auditory/oral approach is used, early training is needed on auditory skills, spoken language, concept development, and speech. Note-taking, captioning, training in pragmatic language use, and communication repair strategies may all be helpful If culturally deaf emphasis is selected, frequent exposure to Deaf, ASL users is important. Support services and continuous appraisal of access to communication and verbal instruction is required. Inservice is essential Significant Hearing Loss Articulation Problems Omission of final consonants and consonant clusters Omission of /s/ across word positions Omission of initial consonants Substitution of voiced consonants for voiceless consonants Substitution of nasal consonants for oral consonants Vowel substitutions Distortion of sounds, especially of stops and fricatives Imprecise production of vowels Increased duration of vowels Addition of sounds, especially an instrusive schwa between consonants in blends (e.g., buhlue for blue) Breathiness before the production of vowels Inappropriate release of final stops (e.g., /staph/ for /stap/) Significant Hearing Loss Voice and Resonance Problems High-pitched voice Harshness Hoarseness Nasal emission on voiceless consonants Hypernasality on voiced consonants and vowels Hyponasality on nasal consonants Breathiness Lack of normal intonation Significant Hearing Loss Prosodic Disturbances Generally limited fluency Increased rate of dysfluencies Slow rate of speech Inappropriate pauses Abnormal flow of speech Abnormal rhythm of speech Abnormal intonation patterns Significant Hearing Loss Associated Problems (language and reading problems) Generally limited vocabulary Poor comprehension of word meanings Lack of understanding of multiple-meaning words Difficulty understanding abstract, metaphoric, and proverbial phrases Slower acquisition of grammatical morphemes Omission of several grammatical morphemes Slower acquisition of verb forms Shorter sentences Fewer varieties of sentence types Pragmatic language problems Lack of elaborated speech Insufficient background information Occasional irrelevance of speech Poor reading comprehension Writing that mirrors the verbal language problems listed Unilateral Hearing Loss Speech and Language Possible Social Impact Potential Educational Accommodations and Services (Better Hearing Institute, 1991) Unilateral: Speech and Language Can “hear,” may have difficulty understanding in certain situations Faint/distant speech, especially if poor ear is directed toward target sound source Difficulty localizing sounds and voices using hearing alone Greater difficulty understanding speech in noisy and reverberant environments Exhibits difficulty detecting or understanding soft speech from the side of the poorer ear, especially in a group discussion Unilateral: Possible Social Impact Accused “selective hearing” Discrepancy in speech understanding in quiet vs. noise Social problems may arise in Noisy cooperative learning Recess Misconstrue peer conversations, feel rejected or ridiculed Fatigued, particularly if class is noisy or has poor acoustics Appear inattentive, distractible, or frustrated Possible behavior or social problems Unilateral: Potential Educational Accommodations and Services Allow flexible seating preference Allowed to change seating to direct the normal hearing ear toward the primary auditory source At 10 times the risk for educational risk as children with 2 normal hearing ears! 1/3 to ½ of children with unilateral hearing loss experience significant learning problems Difficulty learning sound/letter associations in typically noisy elementary settings Educational and audiological monitoring is warranted Teacher in-service Personal FM system with low gain/power or soundfield FM Mid-Freq. HL or Reverse Slope HL Speech and Language Social Potential Educational Accommodations and Services (Better Hearing Institute, 1991) Mid & Reverse Slope: Speech and Language Child can “hear” but will have difficulty understanding in certain situations Difficulty understanding faint/distant speech Student with a quiet voice speaking from across the classroom “Cookie bite” or reverse slope will have greater difficulty understanding speech when environment is noisy and/or reverberant (i.e., typical classroom setting) 25 to 40 dB degree of loss in the low to mid-frequency range may cause the child to miss approximately 30% of speech information, if unamplified Some consonant and vowel sounds may be heard inconsistently, especially when background noise is present Speech production of these sounds may be affected Mid & Reverse: Possible Social Impact “Selective hearing” or “hearing when child wants to” due to discrepancies in speech understanding in quiet versus noise Fatigued Inattentive, distractible, or frustrated Social problems as child experiences difficulty understanding in noisy cooperative learning situations, lunch, or recess May misconstrue peer conversations Mid & Reverse: Potential Educational Accommodations and Services Personal amplification Close audiologic follow-up Soundfield FM system, personal FM system, or assistive listening device At risk for educational difficulties Specialized intervention on sound/letter associations, articulation, language development Educational monitoring and teacher inservice warranted High Frequency Hearing Loss Speech and Language Social Impact Potential Educational Accommodations and Services (Better Hearing Institute, 1991) High Frequency: Speech and Language Can miss important aspects of speech 26 to 40 dB loss in high frequency hearing may cause the child to miss 20 to 30% of vital speech t, s, f, th, k, sh, ch heard inconsistently and worse in noise Difficulty understanding faint/distant speech Speech production may be affected Difficulty understanding in background noise Many critical sounds for understanding speech: high pitched, quiet sounds, making them difficult to perceive Child may perceive “ca” for all of the following: cat, cap, calf, cast Word endings, possessives, plurals, and unstressed brief words are difficult to perceive and understand High Frequency: Possible Social Impact “Selective hearing” Social problems in noisy cooperative learning situations, lunch, or recess May misinterpret peer conversations Fatigued May appear inattentive, distractible, or frustrated Could affect self concept High Frequency: Potential Educational Accommodations and Services Use of amplification often indicated to learn language at a typical rate and ease learning At risk for educational difficulties Articulation problems Possible difficulty learning some sound/letter associations Early evaluation of speech and language skills Educational monitoring and teacher inservice warranted Personal or soundfield FM Delayed language and syntax development Fluctuating and Conductive Hearing Loss Speech and Language Social Impact Potential Educational Accommodations and Services (Better Hearing Institute, 1991) Fluctuating & Conductive: Speech and Language At Will At EVA, 30 dB child can miss 25 to 40% of the speech signal 40 dB child may miss 50% of class discussions frequently miss unstressed words, consonants, and word endings ANSD, chronic middle ear issues, etc. Fluctuating & Conductive: Possible Social Impact Barriers impacting self esteem May believe they are less capable Poor at detecting changes in own hearing ability With inconsistent hearing, child may learn to “tune out” the speech signal Children are judged to have greater attention problems, insecurity, distractibility, and lack self-esteem May not participate May be socially immature Fluctuating & Conductive: Potential Educational Accommodations and Services Impact is primarily on acquisition of early reading skills & attention May need specialized instruction for development of: Screening for language delays is suggested from a young age speech, reading, self esteem, or listening skills In-service Ongoing monitoring for hearing loss Communication between parent and teacher about listening difficulties Food for thought…Out of the last 10 families of pediatric patients I have worked with, only 2 knew the name of their child’s teacher… FM system Moral of the Story “Technology” Hearing loss impacts the child globally. Important Who doesn’t fix everything. decisions must be made early. will guide the family? Discussion Get together in groups of 4 and come up with 5 trends across all of the hearing losses that we discussed. Why do you think there are trends across the degrees of hearing loss? Red Flags Age Red Flags 6 months • Does not laugh and squeal • Does not look toward new sounds 9 months • Has limited or no babbling • Does not indicate when happy or upset 12 months • Does not point to objects • Does not use gestures such as waving or shaking head 15 months • Has not used first word • Does not respond to “no” or “bye-bye” 18 months • Does not use at least six to ten words consistently • Does not hear well or discriminate between sounds 20 months • Does not use at least six consonant sounds • Does not follow simple directions 24 months • Has a vocabulary of less than 50 words • Has decreased interest in social interactions 36 months • Strangers have difficulty understanding what the child is saying • Does not use simple sentences Additional Red Flags for Hearing Problems Exhibit behavior problems Have reading, spelling, and other academic problems Learn slowly through auditory channel Difficulty with phonics and speech sound discrimination Delayed receptive and expressive language Difficulty listening or paying attention in noise Constantly requests that information be repeated Easily distracted Poor auditory memory (span and sequence) Poor auditory attention Slow/delayed response to spoken directions or requests Increase volume of the television, radio, MP3 player Inconsistent responses to auditory stimuli Difficulty following verbal directions Resources American Speech-Language-Hearing Association. (2012).Effects of hearing loss on development. Retrieved from http://www.asha.org/public/hearing/disorders/effects.htm American Speech-Language-Hearing Association. (2012). Hearing loss and its implications for learning and communication. Audiology information series, Retrieved from http://www.asha.org/uploadedFiles/aud/InfoSeriesHearingLoss.pdf Better Hearing Institute. (1991). Relationship of hearing loss to listening and learning needs. Retrieved from http://www.betterhearing.org/hearing_loss/children_hearing_loss/relationship_hea ring_loss_learning.pdf Calderon, R., Naidu, S. (2000). Further support for the benefits of early identification and intervention for children with hearing loss. The Volta Review, 100 (5, monograph edited by C. Yoshinaga-Itano & A.L. Sedey), 53-84. Lanza, J. R., & Flahive, L. K. (2009). Linguisystems guide to communication milestones. Retrieved from http://www.linguisystems.com/pdf/Milestonesguide.pdf Yoshinaga-Itano, C., Sedey, A.L., Coulter, D.K., & Mehl, A.L. (1998). The language of early- and later-identified children with hearing loss. Pediatrics, 102, 1161-1171.
