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Welcome Please … register … help yourself to handouts … see if you can label parts of the ear while you wait … sit and relax CONDUCTIVE HEARING LOSS Introducing the resource kit Do You Hear What I Hear? YOUR NAME, POSITION AND TELEPHONE NUMBER Outcomes • • • • • Examined the causes, signs and symptoms of Conductive Hearing Loss (CHL) Explored the impact of CHL on children’s development and educational outcomes Become familiar with medical approaches to managing CHL Examined educational approaches for children with CHL, described in the kit Do You Hear What I Hear? Developed a plan for ‘Where to from here?’ Context of the CHL Strategy Dept of Health and other health providers Curriculum Framework Building Inclusive Schools Aboriginal NIELNS Education Conductive Operational Plan Hearing Loss Students at Educational Risk ILSS Speech & Language Plan 2 Way Learning ESL/ESD WAIDE Principle of Inclusivity … means providing all groups of students, irrespective of educational setting, with access to a wide and empowering range of knowledge, skills and values … recognising and accommodating the different starting points, learning rates and previous experiences … valuing and including the understandings and knowledge of all groups … providing opportunities for students to evaluate how concepts and constructions such as culture, disability, race, class and gender are shaped. Curriculum Framework, 1998, p. 17 CHL Resourcing • • • Consultants (2), Aboriginal Health and Education (including CHL, Nutrition, Substance Use, Mental Health, Family Violence) – Statewide Do You Hear What I Hear? – One kit available to each school and distributed through professional development programme Funding Do You Hear What I Hear? • • • • • Intervention Strategies for Aboriginal Children with CHL – research report, intervention plan and case studies of two focus schools Resource Book – introduction to CHL; impact of CHL on language, literacy and social-emotional development; management of CHL in schools; teaching and learning strategies; profile and screening tool CD-Rom – as above plus an interactive children’s section Masters – for activities and a certificate for Breathe, Blow, Cough (BBC) Posters (2) – ‘Understanding Middle Ear Infections’ and ‘How to Avoid Ear Infections’ • Stickers • Order form for kit Situation of the Ear Situation of the Ear Anatomy of the Ear Ossicles: Hammer, Anvil, Stirrup Semicircular Canals Pinna Auditory (or Cochlear) Nerve Cochlear External Auditory Canal Inner Ear Vestibule Tympanic Membrane (Ear Drum) Eustachian Tube (to nose and throat) Outer Ear Middle Ear Types of Deafness • • • Conductive Hearing Loss - an impairment to the physical mechanism of the outer and/or middle ear; occurs as a result of trauma or Otitis Media (OM); OM is caused by colds, flu, large adenoids or tonsils, and allergies Sensorineural Loss – results from damage to the auditory nerve or the workings of the inner ear Mixed Loss – combination of conductive and sensorineural loss NB: Hearing impairment is not just a simple reduction in auditory sensitivity. Perceived sounds may be distorted. Incidence of Conductive Hearing Loss • Specific populations show greater susceptibility – Aboriginal children, Inuits (Eskimos), Apache and Navajo Indians, children with particular disabilities; some evidence of higher prevalence in SE Asian and Hispanic children (Hasenstab, 1987). Maori children (NZHTA, 1998). • 75% to 80% of Aboriginal children on any one day • 20% to 25% of European children on any one day What to do if you suspect a hearing loss Refer the child for assessment, which will determine: 1. If the child has a hearing loss 2. What the degree and nature of the loss is 3. How the hearing loss can be medically managed effectively Assessments that are conducted: Audiometry (1 of 3) • Air conduction screening - sound goes through middle ear • Masked or unmasked tests • Bone conduction screening - sound bypasses middle ear • Specialised tests for young children, e.g. Distraction Test for babies conducted by Infant Health Nurses Audiogram for normal hearing Pitch Frequency in Cycles per Second (Hz) 125 250 500 1000 2000 4000 8000 0 Hearing Level in Decibels (dB) Volume 10 20 30 40 50 60 70 80 90 100 110 120 Right ear Left ear Interpreting an Audiogram Frequency in Cycles per Second (Hz) 125 0 250 Very Soft Hearing Level in Decibels (dB) Volume 10 20 30 40 50 60 70 80 90 100 110 120 Very Loud 500 1000 2000 Pitch 4000 8000 Activity: Interpreting an audiogram Audiogram of Familiar Sounds Mild Hearing Loss Understanding Degrees of Hearing Loss Mild (26 – 44 dB) • Understand conversation at 1 – 1.5m • May have delayed speech development • May miss up to 50% class discussion if speaker not visible • May need hearing aid • Will need special education attention Severe (60 – 89 dB) • • • • • • • May understand speech at <15cm Hears loud environmental sounds Will have delayed speech/language Will need hearing aid Requires auditory training Uses vision for additional cues Speech/language will not develop spontaneously if loss present before 1 year old Moderate (45 – 59 dB) • • • • • • Understand conversation at 0.5m Will have difficulty at school Likely to have language delay Will have poor speech clarity Will need hearing aid Will need special education assistance and probably special training for listening Profound (> 90 dB) • May only be aware of very loud sounds • Speech and language will be defective • Visual and gestured cues essential for learning • Needs full time special education assistance • Use of a hearing aid Assessments that are conducted: Tympanometry (2 of 3) • Assesses status and function of middle ear Looking for the following: • Is the eardrum intact? • Is the middle ear system mobile/immobile/partly mobile? Assessments that are conducted: Otoscopy (3 of 3) • Examines the appearance and texture of the eardrum • Screening otoscopy checks for blocked ear canal, state of eardrum and presence of fluid in middle ear • Diagnostic otoscopy differentiates between the different types of Otitis Media Normal Eardrum • Thin and semi-transparent • Pearly-grey appearance • • Often some structures within the middle ear can be seen A “cone of light” extends downwards and forwards from the umbo (where the eardrum attaches to the malleus or hammer) Types of Otitis Media 1. Acute Otitis Media - An acute infection of the middle ear and eardrum. Starts suddenly, may be caused by bacteria, viruses or a combination. Children may have ear pain, fever, rub or pull their ears, may be irritable, cry, lose their appetite, vomit or have diarrhoea. Eardrum can be bulging and may/may not be red, and may not move as it should. Some children, however, may not show signs of this infection! Types of Otitis Media 2. Otitis Media with effusion, ‘Glue ear’ – Fluid in the middle ear, the consistency of egg white. Distortion of the eardrum, prominent blood vessels and bulging in upper half, dullness in lower half. Outline of malleus (hammer) is obscured. Fluid levels can be seen behind the drum. Some children may complain of ear pain, but don’t have the signs and symptoms of Acute Otitis Media. Types of Otitis Media 3. Chronic Supparative Otitis Media, ‘Runny ear’ – Serious and persistent infection. Hole in eardrum and pus flows from middle ear into canal. Usually follows untreated or poorly treated acute middle ear infection. Often occurs in children under 5 and in children who live in poverty and poor environmental conditions. Ear pain not common. Without treatment damage to middle ear bones will occur and increasing hearing loss. May also cause serious infections in mastoid bone and in brain. Impact of Otitis Media is Multi-Factorial • Age at which the child experienced the first incidence of OM • Number of incidences under the age of 12 months • Access to good medical intervention • Access to certain types of interactions within the family • Access to audiology and speech pathology • Child’s general health Activity: So what’s it like to have CHL? Morning Tea Medical Treatment • Glue ear and infections often clear up without treatment • Antibiotics will help with an infection but will not clear up the fluid build up that occurs with glue ear • Runny ear does not clear up quickly or easily. The recommended treatment is twice daily syringing with Betadine, followed by dry mopping, then drops, for 16 weeks. Surgical Treatment Grommets are recommended for children who have had more than 6 infections in a year or one bout of Otitis Media lasting more than 3 months More Surgical Treatment … • Myringoplasty / Tympanoplasty – patches the eardrum; not suitable for runny ears • Mastoidectomy – removal of part of mastoid bone and other parts of middle ear because of erosion by fluid over long period of time • Middle ear reconstruction Amplification Options Behind-the-ear style sits behind ear, amplified sound travels down a tube into customised earmold In-the-ear hearing aids fit inside ear In-the-canal hearing aids are smaller and fit the size and shape of ear canal Completely-in-the-canal hearing aid is worn deep inside canal and are almost invisible. Other Amplification Options • Hearing hats/head bands – bone conduction • Personal FM systems • Sound Field Amplification Systems Modes of Communication Speaking and listening Reading and writing Pitch, rhythm and intonation Gesturing and body language Signing Speech and Language • • Speech – the sounds of a language; the ability to pronounce and distinguish different sounds; and the ability to coordinate the voice box, lips and tongue to produce sounds Language – the spoken, written or other symbol system used to convey (expressive) or understand (receptive) meaning Activity: Communicating without speaking Oral Language is fundamental … Speaking and listening provide the foundation for all language learning and underpin the successful development of reading and writing skills. Proficiency in speaking and listening contributes to children’s abilities to learn effectively in all learning areas. First Steps: Oral Language Developmental Continuum Cultural Considerations • Language is the repository of the speakers’ cultural knowledge and reflects their world view. When we devalue a language we devalue everything contained within and reflected by it. • The Western school system is set up to reflect a literate tradition. It assumes all children come to school knowing how to work with language in a de-contextualised manner. We need to be aware that children may come to school with rich language experiences from predominately oral traditions and cultures. Impact of CHL on Speech and Language Development • Hearing children learn the basics of language passively, by hearing it. This avenue is not open to children with hearing losses. • Creates a barrier for normal speech development and phonological processing • Causes delays in the development of a child’s first language and any additional language, particularly when the hearing loss begins at a very young age: Poor vocabulary and semantic organisation Expressive and receptive language difficulties – language structure, word endings, grammar, word order etc. • For Aboriginal children, diminished auditory experiences can affect opportunities for learning about culture, law, relationships, etc. (Clarke, 1992) Impact of CHL on Comprehension ‘Oral comprehension’ relates to the ability to understand the meaning of what is spoken. Comprehension is dependent upon context, previous knowledge and experience, sentence length, concepts and attention. (adapted from Health Department of WA Teacher Modules, 2000) A child with CHL or a history of CHL probably has: • • Difficulty with lengthy or complex instructions An underdeveloped vocabulary including concepts and descriptive terms (e.g. in Preprimary will not understand concepts such as location [over/under…] or size, and descriptive terms [colour, shape]) • Difficulty with some questions (e.g. in Preprimary can’t understand ‘wh’ questions [who, what, when, where]) Impact of CHL on Semantics Semantics refers to the link between our thoughts and ideas and the vocabulary and concepts we use to express these thoughts. Semantic organisation describes how we organise incoming information in order to make sense of and later retrieve it. (adapted from Health Department of WA Teacher Modules, 2000 ; Holt & Spitz, 2000) In Preprimary, a child with CHL or a history of CHL probably: • Has a vocabulary of less than 1500 words • Speaks in sentences of < 3 to 5 words • Doesn’t use language socially • Is slow to learn words and concepts (due to ‘fuzzy’ representations) Impact of CHL on Semantics Other indicators may be : • Difficulty integrating new information with existing • Limited conceptual understanding • Under-developed receptive and expressive vocabulary • Difficulty retrieving words • Difficulty generating ideas related to a topic • Conversational difficulties Impact of CHL on Syntax Syntax or grammar refers to the way we organise words into sentences. Grammatical rules tell us which words should come before or after others, the word endings we should use and the way words combine to form sentences. (adapted from Health Department of WA Teacher Modules, 2000 ; Holt & Spitz, 2000 ; Owens 1992) • Problems with forming linguistic categories such as plurals and tenses • Grammatical errors and unusual word order • Incomplete sentences • Restricted use of describing words (adjectives/adverbs) and connectors (but, then, because, so …) Impact of CHL on Narrative (Oral Texts) Skills Narratives/Oral texts encompass such genres as stories, reports, procedures, explanations, recounts and news telling. The common feature of these genres is the linguistic structures that are used to tell and retell a series of events in time order. (Adapted from Health Department of Western Australia Teacher Modules, 2000 ; Holt & Spitz, 2000) The Western-style narrative structure tends to be linear in nature and uses a distinct model that may be difficult to understand for Aboriginal and other CALD students. If a child has hearing problems they are likely to have additional problems with story grammar and descriptive vocabulary. Impact of CHL on Phonological Processing Phonological processing relates to the ability to use the sounds of a language to process oral and written language, which allows us to form phonological codes and access a word stored in our brain’s lexicon. Phonological awareness skills (explicit awareness of sound structure and ability to manipulate structure of words) are dependent on phonological processing skills. • Need to hear words to learn words – to ‘map’ words to objects car? ar? bar? tar? … • Absence of second sound in two-letter blend (eg frog, block) • Absence of unstressed syllable(s) (banana, dinosaur, balloon) • Poor discrimination and identification of sounds Impact of CHL on Phonological Processing Australian English speech sounds with which ESL/ESD speakers frequently are not familiar: t, d, th a, e, ir, ai f, v, b, p, k, g o, o-e, oo/u, u-e s, z, sh, ch, j u, i-e, oi, ai ee, i, e, a o, oar, ar, oi, ir a, ar, u, ow (Adapted from Making the Jump, Catholic Education, Kimberley, 1997) Consider the similarities between these sounds (voice, placement of lips and tongue). If a child can’t hear a sound correctly he/she will have considerable difficulty learning to say it correctly, particularly if he/she is reliant on visual differentiation. Impact of CHL on Metalinguistic Skills Metalinguistics refers to the ability to use language to think, talk about, reflect on and manipulate units of language. • Don’t know how to play with sounds and words, eg rhyming • Don’t know what a ‘word’ is so have difficulty understanding word boundaries and segmenting sentences into words: “Ontheweekend”, “smorning” Impact of CHL on Metalinguistic Skills • Difficulty manipulating words within words (eg take ‘sun’ from sunshine); syllables in words (eg take ‘ing’ from doing); sounds in words (eg boat has 3 sounds: b / oa / t; take ‘c’ from coat); and blending sounds to make words (eg s – t – o – p) • Poor understanding that words are arbitrary symbols of a language system – words usually don’t contain any hint of their meaning • Problems working out how communication breaks down Impact of CHL on Pragmatics Pragmatics relates to the use and functions of language for communication. Pragmatic awareness is the knowledge of conversational rules and includes both verbal and non-verbal aspects. (adapted from Holt & Spitz, 2000 ; Owens 1992) Children with a hearing difficulties may have problems with: • Entering into a group, requesting, responding and taking turns • Initiating conversations • Understanding subtle social rules • Accepting others points of view and others’ feelings • Monitoring the listener Impact of Hearing Loss on Socialisation Children with hearing difficulties, however, are also likely to present with social and emotional challenges due to: • Their own frustration and/or the frustration of their peers • Avoidance • Just not “getting it” i.e. the subtleties and unwritten rules of social exchanges Activity: Consider a child you know who has a suspected/confirmed hearing loss. What difficulties have you observed? What are some strategies that have been effective with this child? Summary of Educational Impact of CHL • More than three infections under the age of 12 months is a significant risk factor • Even without a current ear infection children can still suffer the effects of a history of conductive hearing loss • Poor ability to discriminate sounds in words and to hear words in words; difficulty chunking words into individual parts; and relationship between own sound repertoire and written alphabet is tenuous • Language learning difficult; frequently have restricted content, vocabulary, language and confidence; prediction as a reading strategy is not functional except with simple or familiar texts • Poor foundation for literacy and without help will fall further behind every year • Socialisation difficulties and behaviour problems are likely • The most debilitating aspects of deafness are secondary to the hearing impairment itself Lunch Activity: Strategies 1 to 6 Strategy 1 Organise your classroom to maximise learning for children with conductive hearing loss. Strategy 2 Increase children’s understanding of hearing problems. Strategy 3 Focus on oral language skills as the foundation for literacy. Strategy 4 Focus on spoken sound systems. Strategy 5 Link sounds to the written code. Strategy 6 Analyse spelling errors to inform teaching. Strategy 7 Implement a peer tutor program. Conductive Hearing Loss Screening Tool Developed by Aboriginal and Torres Strait Islander Education Support Unit Learning Identifiers Has learning difficulties Demands a lot of teacher attention Short attention span Poor auditory memory and sequencing Poor auditory association Delayed language development Delayed gross motor Tends to respond to auditory clues only when given visual clues as well Physical Identifiers Behavioural Identifiers Fidgets Easily distracted Appears not be listening Poor socialisation skills Aggressive Bullying Erratic Inattentive Often says “what” Redness around the ear Rubbing or pulling on the ear Cupping the ear Runny ear Ooze from the ear Re-occurring ear and chest infections Complaining of sore ears and throat Puts head to the side as if to shake out fluid Mouth breather Does not respond when asked questions Responds in inappropriately Is slow to respond to instructions Watches other children to see what to do Asks peers for confirmation what has been said Sits close to the TV, etc Sits on the outside so no expectation to participate Quiet voice Appears confused when there is a lot of noise Poor gross motor skills Is upset by loud or sudden noise Often tired Holds ears when there is excessive noise levels Asks for the volume on the TV to be turned up or down Speech Identifiers Speaks in soft or loud voice Difficulty in understanding speech Difficulty communicating feelings Language development below age Mood changes when there is lots of noise Has been absent lots of times Loses interest during story time or direct instructions Erratic classroom behaviour Reluctant to participate Confusion of words Obvious indication that the child watches your face to lip read Summary of Key Teacher Behaviours • • • • • • Teamwork including the AIEO, district CIOs, audiologist/speech pathologist/psychologist/occupational therapist…. Point of error analysis to understand the strength and weaknesses of a child’s system. Practice at the phonological level and oral level before moving into the written code. Research has shown that a drill orientation program works well with young children while the meta approach is most effective with older students. Use practice, repetition, buddying, small group work, pre-teaching and one-to-one tutoring as tools. Investigate amplification. Model for Effective Practice in Schools Curriculum, teaching and learning School organisation, ethos and environment Whole School Approaches Partnerships and services Targeted Approaches for Groups Targeted Approaches for Individuals Individual Case Work Health Promoting Schools Framework Curriculum, teaching and learning School organisation, ethos and environment Policy, planning and processes Strategies 1 to 7 Professional development IEPs … Collaborative planning Safe, supportive and inclusive environment … Parents, carers, family members; school health; AIEOs, ALOs, C/MAEs; school psychologists; specialist teachers; visiting teachers; audiologists; speech pathologists; medical personnel … Partnerships and services Where to from here? Consider: • your school and/or district and community • further professional development needs • the need for others to acquire knowledge and skills • partnerships that are already in place • opportunities to create new partnerships Identify the first three steps that need to be taken in your school community or at a local level to improve outcomes for children who are experiencing or have experienced CHL. Evaluation Time! Thank you and close