Download understanding unilateral hearing loss in infants and children and

UNDERSTANDING UNILATERAL
HEARING LOSS IN INFANTS AND
CHILDREN AND EVIDENCE
BASED PRACTICE
By Lori Garland and Charlotte Ruder
Cincinnati Children’s Hospital Medical Center
OSHLA March 6, 2009
Understanding
Unilateral
Hearing Loss
in Infants/Children!
Course Outline
1. Unilateral Hearing Loss (UHL) – definition and
description
2. Auditory pathways
3. Impact of UHL
4. Technology for UHL
5. Recognizing “red flags” in children with UHL
6. Future areas of research
I. What does a Unilateral
Hearing Loss look like?????
Hearing Levels
Audiogram…
Single sided deafness
Speech Sounds
Pictures of
sounds and
speech
Definition of Unilateral Hearing Loss
(UHL)
Adopted by the July 1005 National Workshop on Mild and Unilateral Hearing Loss (sponsored by CDC
and EDHI)
• A calculated and predicted average puretone air
conduction threshold at 500 Hz, 1kHz and 2kHz greater
than or equal to 20dB HL
or
• puretone air conduction thresholds greater than 25dB HL
at 2 or more frequencies above 2kHz – with the good ear
less than or equal to 15 dB HL
Statistics on UHL infants/children
• Newborns
•
1-3 per 1000 are identified through
newborn screening
–
?? Accuracy:
Accuracy many are missed to lack of follow up, variations in test
methods and definitions of hearing loss (Ear Hear 2000, Int’l Journal
Pediatric Otorhinolarygnology1994)
• SchoolSchool-Age – 30-56 per 1000
•
?? Increase:
Increase additional gained through progressive or late onset
hearing loss (Ear Hear 1998, JAMA 1998)
Causes of Hearing Loss
Most Common causes for UHL:
viral complications, meningitis, head trauma, prenatal/perinatal disorders,
genetic
•
Prematurity:
< 37 weeks gestation; difficult to separate out contributing
factors; not well studied
•
Genetic:
Most common: Connexin 30-40% - 1-16% are MBHL
> 150 genes for deafness have been mapped to chromosomal regions – only
80 have been identified
•
•
•
Mitochondrial: 1%prelingual/5%postlingual; 21% are MBHL
Sudden: most commonly UHL; cause only identified in 10%
Auditory Neuropathy (AN): < 1%; normal outer hair cell function with
abnormal ABR; rarely UHL; possible abnormality localized to inner hair cells (IHC),
VIII N or synapse of IHC and VII N
Tharpe AM, Sladen, DP. Causation of permanent unilateral and mild bilateral hearing loss in children. Trends in Amplification. 2008 17-25
Enlarged Vestibular
Aqueduct (EVA)
•
The aqueduct is the bony canal extending from the
vestibule to the endolymphatic sac – contains the
membranous endolymphatic duct – thought to regulate
the concentration of ions in the cochlear fluids
•
Suspect enlargement may result in chemical
imbalance and result in hearing loss
•
Normal diameter of vestibular aqueduct is between 0.51.4mm. > 1.5 mm at midpoint is consistent w/ EVA
•
Accounts for 5-7% of unknown etiology
•
2X more likely to be bilateral than unilateral
•
May be sudden or progressive
Causes continued…
•
•
•
Noise Induced: 10% of children; 20% have MBHL
Viral/Bacterial Mumps: 2%; 80-95% are UHL
Otitis Media: 5-20% of all cases of OM result in SNHL – either
high frequency and/or UHL
•
Congenital CMV: Leading cause of non-genetic SNHL
and leading cause of UHL prelinguistic HL; 13-24% asymptomatic
have SNHL; 40% symptomatic have SNHL – MOST COMMON
CONGENITAL VIRAL INFECTION!!!
•
Meningitis: 10% w/ bacterial have SNHL ; 4-30% are
UHL/14% are MBHL; viral not typically assoc. w/ HL.
•
Unilateral Atresia/Microtia:
births
occurs in 1 in10,000
II. The
Auditory
Pathways
How do we Hear???
Cochlea
Auditory
Pathways
Where does the sound go?
What affects the sounds we hear?
III. Impact of UHL
Impact of UHL:
1.
Loss of binaural summation
2.
Loss of squelch effect
3.
Increased negative effects of noise
4.
Difficulty localizing sounds
5.
Ease of Listening
6.
Additional impact of the head shadow effect
Benefits
of binaural input…
#1 Benefit
Sound Localization
• The ability to identify the location of a sound source.
• The constant influx of sound occurs 24/7 and it
becomes 3D based on localization cues!
Our ears never rest!
Binaural Summation
• “two ears are better than one”
• the input from both ears together results in 3-6dB
additional gain
Squelch Effect
• with 2 normal hearing ears the brain has the ability to
suppress sound/noise on one side while attending to a
priority signal near the other ear
• Our brains help separate out what we pay attention to in
the world.
Ability to
Handle Noise!
•
Noise is a challenge for EVERYONE!
•
Noise has a greater negative impact w/ UHL for the entire listening
experience!!!! Noise is inherent in today’s world and it acts as one more barrier
to hearing the primary signal for people with UHL!!!
•
2 ears are better equipped to locate (localize) the primary sound source and
use the squelch effect to manage the noise
What affects the sounds we
hear?
1. Our Bodies
–
–
–
–
–
Ears
Head
Shoulders
Vision
Brain – how do we
process?
2. Environment
- Size (large/small)?
- Shape?
- How empty/full?
- How close is the sound
source?
- What’s in the environment?
- Other sounds - NOISE
How it all works!
In further detail….
#1 Benefit
Localization
Auditory localization cues to help locate the position of a sound source.
There are 8 sources of localization cues:
1.Head shadow effect
2.Pinna/ear response
3.Interaural time difference
4.Head motion
5.Early echo response
6.Reverberation
7.Vision.
8.Shoulder echo effect
1. Interaural time
difference
Interaural time difference describes the time
delay between sounds arriving at the left
and right ears.
This is a primary localization cue for
interpreting the lateral position of a sound
source.
2. HEAD SHADOW
EFFECT
Head shadow is a term describing a sound that has to go through or
around the head in order to reach an ear.
•
The head can account for a significant attenuation (decrease) of overall intensity as
well as provides a filtering effect.
• The filtering effects of head shadowing cause perception problems with distance
and direction of a sound source.
• High frequencies don’t bend around the head.
•Ex: There’s a 9dB difference between ears when 1000Hz signal is presented at 40 degree
angle!
3. Pinna/Ear
Pinna/Ear Canal
Response
•Pinna response describes the effect that the external
ear, or pinna, has on sound.
• Amplification of 5-20dB from free-field 1.7Hz – 7kHz
•The response of the pinna "filter" is highly dependent
on the overall direction of the sound source.
4. Shoulder
Effects
•Frequencies in the range of 1-3kHz are reflected
from the upper torso of the human body.
•The reflection produces echoes that the ears
perceive as a time delay.
•The reflectivity of the sound is dependent on the
frequency.
The shoulder echo effect is not a primary auditory cue,
others have greater significance in sound localization.
5. Head Motion
The movement of the head is a key factor in
determining a location of a sound source.
Head movement effects are more noticeable as the
frequency of a sound source increases.
This is because higher frequencies tend to not
bend around objects as much and are harder to
localize.
6. Early echo
response
• The path that a sound wave travels from the source to the
listener is not simply a direct line.
• Instead, the waves will be reflected off the surfaces in the
real world and arrive at the listeners ears at different times
causing reverberation
7.
8. Vision
• Vision is often a major factor in
identifying the location of a sound.
For example, when you hear a barking noise and you
can see a dog in the rough direction it came from it is
obvious where the source of the sound is.
Impact on Learning…
Yoshinaga-Itano et al. Outcomes of children with mild
bilateral hearing loss and unilateral hearing loss. Semin Hear
2008;29;196-211
Small number of studies are available …
• Studies have shown:
– delayed language in the acquisition of 2-word utterances, syntax,
vocabulary and speech development
– 22-35% failed a grade; 20-24% had behavioral problems; 13-41%
received educational support
– Performed more poorly on the SIFTER.
– Standardized testing may not be below norms but kids w/ hearing
loss score at the lower end of norms
– Children with a profound UHL and/or right ear involvement may be
at a greater risk
Impact on Learning continued…
– Pupil Rating Scale Revised was used by teachers and showed
that 33% scored significantly below the expected range on:
– Comprehending word meanings
–
–
–
–
–
attention,
storytelling
responsibility
completion of assignments
adapting to new situations
– Minnesota Child Development Inventory: the parents of 18
children (ages 7-59 months) completed and revealed:
• Expressive language quotients – 83% normal, 17% borderline normal
• Receptive language quotients – 78% normal, 17% borderline, 6% delayed
Further findings…
• MacArthur Communicative Development Inventory: 11 children
w/o additional disabilities, ages 14-28- months participated.
– Expressive: median % was 27%;17% below 10th percentile
– Receptive: median % was 17%; 18% below 10th percentile
• 2000-2002; study of 30 infants, birth-3 yrs w/ UHL showed 30%
exhibited delays in communication or language.
IV. Today’s Technology for UHL:
• FM systems
• Traditional hearing aid/CROS hearing aid
• Bone Conduction options:
– BAHA – bone anchored hearing aid
– TransEar by Ear Technology
Phonak ISense
system
®–
FM
Benefits:
• Decrease negative impact of background noise (great for
school or noisy environments)
• May help with attention during class instructions
• Easy to wear and manipulate
Disadvantages:
• Only useful when chosen speaker is using transmitter – not
helpful when others are speaking
• Children must be able to chose the most appropriate
speaker/situations to use system effectively
• Block in good ear
• Does not apply well to a wide variety of every day listening
situations
• Too large for very small ear canals
Hearing aid alone or with
personal FM system
Benefits:
• Additional gain provided to better ear if needed
(borderline cases)
• Fm signal improves speech in noise
• Hearing aid alone helps audibility in a wide variety of
listening situations
Disadvantages:
• Many pieces to manipulate and check – difficult for many
children to manage
• Child has to choose appropriate speaker/situation
• May be block in good ear if gain is not necessary
Phonak CROSLink ®
/BiCROS
Hearing aid/CrosLink
Benefits:
• Sound is picked up by receiver on poor ear and
transferred to hearing aid on good ear
• Traditional technology – more familiar in appearance
Disadvantages:
• Puts some type of block in good ear
• May create even greater challenges in noisy environments,
depending on listener position
• Requires more equipment than other options
• More pieces to manipulate and possibly break down
• May experience interference from other sources and reduce
audibility of primary sound source
• Does not help with localization
Studies show…
FM trial
– 6 children ages 8-12 years, primarily profound Unilateral SNHL
Testing conditions:
(CROS, FM, unaided)
– Monaural indirect (speech to poor ear, noise to good ear)
– Monaural direct (speech to good ear, noise to bad ear)
– Mid-line signal/omni-directional noise (speech in front, noise in
back coming from right, midline, and left)
•
Kenworthy, et al. Speech Recognition Ability of children with unilateral sensorinueral
hearing loss as a function of amplification, speech stimuli and listening condition. Ear
and Hearing 1990; 11;4;264-270
Nonsense
% correct
BKB
% correct
Unaided
75%
97%
FM
82%
90%
CROS aid
50%
48%
Unaided
21%
32%
FM
75%
92%
CROS aid
36%
93%
Unaided
68%
93%
FM
80%
89%
CROS aid
58%
85%
Monaural direct
Monaural indirect
Midline signal/
Omnidirectional noise
Results
• FM not advantageous in monaural direct over no
amplification
• CROS only showed improvement in monaural indirect
• CROS improvement in non-meaningful speech over
unaided but not as good as FM. (55%)
• CROS did not show improvement in omnidirectional
noise in background
UHL and Hearing Aid Use
- retrospective chart review
•
•
•
•
•
•
•
Retrospective chart review
N=31, consecutive chart review
Ages: 1-10 year olds
31 USNHL
Mean age of ID 65 mos (7-119 mos)
Amplification with conventional aid for at least 6 months
Inclusion HL >30 dB, most severe/profound
–
–
–
–
2 mild
7 moderate
8 severe
14 profound
Kiese- Humme. Unilateral sensorienural hearing impairment in childhood: analysis of 31 consecutive cases.
International Journal of Audiology 2002:41:57-63
Acceptance of HA:
Parent response for acceptance 26/31 interviewed for
acceptance of aid
• 21/26 accepted HA
• 13 wore HA > 8 hours/day
• 5 had poor use, all in severe-profound
• If the child liked the HA, they wore it.
• No differences on side of HL
• Those with severe to profound slightly less likely to accept
HA
Another look at Hearing Aids…
•
•
•
•
•
•
•
•
Case series
28 UHL fit with HA x 3 months
20/28 participated
Ages 2-17
Mild to moderately severe HL
Retrospective survey
No pre-post survey
Questionnaire is not validated
McKay. To aid or not to aid: Children with unilateral hearing loss. Poster presented at: American Academy of
Audiology Annual Convention: April 2002; Philadelphia, PA.
Results
• Parents report their children are hearing better,
showing improvement in social and academic
situation.
• 50% wished HA were recommended sooner
• 72% of parents and patients report benefit
Bone Conduction Options:
for Single Sided Deafness
not included in pediatric studies
1. BAHA
2. TransEar
Bone Conduction route of
transmission:
BAHA
®
for SSD:
(Bone Anchored Hearing Aid)
History of the BAHA
®:
• Introduced to the European market in 1977 for adults with bilateral
conductive hearing loss
• Approved for use in USA by FDA in 1996
• Approved for use by FDA for UHL in 2002
• Studies with children are very limited but show…
– In Jan. 2007, Priwin designed a study with 22 children who have UHL and
BHL (conductive) and 15 controls
– Results showed that speech reception in noise showed improvement with no
improvement noticed for localizations
BAHA in children and adolescents with unilateral or bilateral conductive hearing loss: A study of
outcome☆
International Journal of Pediatric Otorhinolaryngology, Volume 71, Issue 1, Pages 135-145
C. Priwin, R. Jönsson, M. Hultcrantz, G. Granström
Candidacy for
®:
BAHA
• 5 years and older
• Conductive hearing loss – bilateral or
unilateral
• Mixed hearing loss – bilateral or unilateral
• Single sided deafness (SSDTM)
Benefits:
•
Uses good cochlear response via bone conduction
•
FDA approved for ages 5 and older
•
Easy to wear
•
Easy to manipulate – one piece!
•
Newer models have additional programs to improve listening in noise
•
Great sound quality – many report improved localization skills
•
Not effected by OME
•
Low maintenance
Disadvantages:
•
Some people DO NOT WANT SURGERY.
•
Some people are not fond of the appearance or idea of the
titanium abutment
•
The BAHA unit is still somewhat large for small heads
•
People report that they feels too “permanent” if they decide
they don’t like it
TransEar ® Bone Conduction
Hearing Aid
by Ear Technology
How New?
• U.S. Patent 6,643,378 B2
– issued November 4, 2003
– “Bone Conduction Hearing Aid”
• Other patents pending
• Approved by the FDA mid 2005
• Upgrade in the oscillator was introduced fall
2008 with emphasis on high frequencies
TransEar 380 HF
TransEar 380 HF
Peak frequency energy at 21002300 Hz, compared to 800Hz for
most traditional bone conduction
aids – which greatly impacts
speech perception!
Candidacy for TransEar 380 HF®
• Essentially normal hearing in the good ear
– 30 dB or better 500-3000 Hz
– No hearing or no benefit with conventional
hearing aids in worse ear
• Poor word recognition
• Intolerance to amplified sound
Benefits:
•
No surgery!
•
4 channel digital processor – superior to transcranial CIC due to separation of
microphone from ossilator
•
Uses good cochlea via bone conduction
•
Reported improvement in localization ability
•
Single unit – easy to manipulate
•
45 day trial period
•
Improve audibility in a wide variety of listening situations
•
Has a second program to enhance listening in noise
Disadvantages:
• Must get deep insertion to maximize bone conduction
transmission in osseous portion of ear
• $150.00 to replace transfer unit – (comparable to cost of 2
earmolds). Do not know how frequently it needs to be replaced
or specifically how to determine the appropriate time to replace
• Still no long term pediatric users to determine benefits
• Difficult to objectively evaluate or verify (blocking good ear with
plug/ear muff was not very effective)
• Not good for children under 6 or with small ear canals
Expert Consensus on Treatment of UHL:
Candidates for amplification:
• Children 3 or older, under 3 if frequency-specific threshold information
is available
• Mild to moderately severe (25-65 dBHL) sensory or permanent
conductive HL in one ear
• Useable word recognition in the affected ear
FM systems for all children with UHL including those with severe to
profound HL or poor word recognition abilities.
Bone conduction and CROS systems are not standard
recommendations, but may be considered on a case-by-case basis if
deemed appropriate.
McKay et al. Amplification considerations for children with minimal or mild bilateral hearing loss and unilateral hearing
loss. Trends in Amplification 2008;12;1;43-54
V. Red Flags for Concern:
•
•
•
•
•
•
Social/emotional/behavioral concerns
History of middle ear involvement
Poorer than normal listening/attention skills
Challenges learning and discerning sounds
Borderline academic skills
Difficulty with auditory processing abilities
VI. Areas for Future Research…
•Differences in outcome related to age of onset (congenital vs acquired loss).
•Chronic history of OME - Impact of additional temporary hearing loss in good ear
and speech/language/auditory skills?
•Impact of additional learning deficits? Language? Processing?
•Verification and evaluation of treatment benefits (amplification, early intervention,
additional support services)?
•Development of appropriate criteria, test/screening protocols for pediatric
evaluations of speech/language development and communication skills.
•How do we identify red flags for concern???
Discussion
Effects of Unilateral Sensorineural
Hearing Loss on Speech,
Language, Education, and
Behavior
Examine Evidence Based Practice
for School Age Children
Examined Level of Evidence
PICO model
18 publications on amplification
18 publications on speech
language, education
Problems: studies of school age
children
•
•
•
•
•
•
•
•
Age at onset or ID of hearing loss not known
Side of hearing loss may not be reported
Degree of HL may not be reported
Behavior questionnares often not standardized
In-depth language measure not used
Sample size may be limited
Hx of Otitis Media often not known
Outcomes were variable
Findings – Education UHL
• 1/3 of children w UHL have significant
educational problems
• 36% of children with Sev-Prof HL failed a
grade vs 18.7% of w mild-mod UHL (Oyler)
• UHL of <40dB or ID’d late significant
number of grade failures (Watier-Launey)
Education - continued
• Systematic increase in academic difficulty
with greater degree of UHL (Quigley & Thomure)
• 10 x higher risk for academic failure for
UHL (Oyler)
• Profound UHL 2x higher grade retention
compared to mild-mod UHL (Oyler)
• Right-side HL 5x higher retention rate
than left-sided (Olyer)
UHL Education Continued
• Reading/spelling significantly poorer for
UHL but at lower end of normal range
(Culbertson & Gilbert)
• 41% receive special educ
41% (Lieu)
(Olyer);
12-
• 95% L-UHL good academic progress, 45%
R-UHL good academic progress (Hartvig)
Risk Factors Educ Problems UHL
Lieu (2004)
•
•
•
•
•
•
Early age of onset of UHL
Perinatal &/or Post-natal complications
Severe to Profound UHL
Right sided Hearing loss
Hx of otitis media
Lower SES status
Findings - Cognitive
• Children with UHL and academic failure
demonstrated lower VIQ scores and strong
correlation between grammatic closure and VIQ
(Klee & Davis)
• Rt-sided UHL poorer on VIQ, poorer similarities,
vocabulary, concepts, lower ability to learn
verbal material, logical thinking, abstract
thinking, classifying (Niedzielski et al)
Cognitive - Continued
• Lt-sided poorer NVIQ, analyzing,
synthesizing, spatial imagination, visual
memory, visual-motor coordination (Niedzielski
et al)
• Lower IQ in UHL group but within normal
range
Cognitive - continued
• No difference in performance: non-verbal
tests, poorer digit span on WISC (Hartvig)
• VIQ and WISC-R lower for UHL (Bess & Tharpe)
• No difference in IQ: Normal Hg & USNHL,
but mild differences in picture completion,
block design subtests of WISC (Culbertson)
UHL Speech Language
• No significant difference between normal
Hg and UHL children (age onset unknown) on
battery of standardized language test (Klee &
Dansky; Cozad)
• 42% above normal cut off range on CELF
Screening, below in processing area (Stein)
UHL speech Language
• Poorer test results than hearing controls,
significant for 4-5 yr olds; UHL group had
lower scores, no evidence Rt sided worse
(Borg)
Speech Language Cont’d
• Three studies demonstrated delayed language in
acquisition of two word phrases, vocabulary,
syntax, and speech difficulties (Lieu, 2004)
• Poorer syllable recognition in noise (Dancer 1995)
• Teachers scored 33% of children w UHL
significantly below age expectations on
comprehending word meanings and storytelling
(Yoshinaga-Itano)
Behavior Social Emotional
• Teacher ratings: noted giving up easily,
distractible, daydreaming, mis-behaves to get
attention, aggressive towards peers, less
initiation w peer, organizations skills same, 1015% higher negative ratings than NHg, some
teachers not aware of UHL; personal ratings of
self-concept were same as NHg (Culbertson)
Behavior Social Emotional
• Parent ratings: personal social and interpersonal
adjustment problems, but teacher ratings in
classroom OK; self esteem ratings OK (Stein)
• Children w minimal hg loss reported having less
energy or being tired more frequently than NHg
peers (Tharpe)
• Listening effort and fatigue in children w minmod HL noted when listening to a variety of
signal-noise levels (Bourland-Hicks & Tharpe)
UHL Behavior cont’d
• UHL children on dual task paradigm took longer to react
to stimulus, but speech performances was OK, suggests
might impact classroom performance when listening and
doing. UHL rated selves w more dysfunction (Hicks & Tharpe)
• 42% of school-age children with ULH demonstrated
behavior problems (Stein)
• 27% of school age children with UHL reported feelings
of embarrassment and sense of inferiority (Bovo)
• Teachers using the Pupil Rating Scale Revised
showed that 33% scored significantly below the
expected range on: attention, responsibility, completion
of assignments and adapting to new situations (YoshinagaItano)
SIFTER –
• Screening tool for classroom which was
developed to find children with fluctuating HL,
HL, and refer for evaluation. Examines
academics, attention, participation,
communication, behavior.
SIFTER
• Children with HL functioning poorer than
normals. UHL/mild HgL children worse on
SIFTER than mod-sev HL who were
receiving services. HL kids functioning
decreased as grades increased. Grades 12 rated better than those in grades 3-4,
5-6 (Most)
Impact on Learning…
(Yoshinaga-Itano)
• Small number of studies available have shown:
– delayed language in the acquisition of 2-word
utterances, syntax, vocabulary and speech
development
– 22-35% failed a grade; 20-24% had behavioral
problems; 13-41% received educational support
– Performed more poorly on the SIFTER.
– Standardized testing may not be below norms but
kids w/ hearing loss score at the lower end of norms
– Children with a profound UHL and/or right ear
involvement may be at a greater risk
What to do? School Age
• Administer thorough Speech Language Test
Battery
• Analyze for subtest differences
• Consider Phonological Processing measure
• Test comprehension of stories/conversations in
noise
• Monitor, monitor progress
• Get teacher input, possibly SIFTER
What to Do – School Age
• Group tx to learn techniques to manage UHL, discuss
difficult listening situations, placing self in noisy
situations, feelings, communication with peers
• Parent counseling on child’s needs, adapting family
environments, and risk factors: academic, behavior,
splang
• Audiologic management. Audiologist & SPLs must
communicate
• Medical management of Otitis Media
UHL Early Speech Language
non peer reviewed reports
• Age of first word of children w UHL was
not delayed (12.7mos), but onset of 2
word combinations was delayed (23.5
mos) by parent recall. (Kiese-Himmel)
• 30% birth to 3 yrs with UHL demonstrated
delays in communication/language, 200002 Colorado follow-up (Brown)
Early Speech Language
Colorado study (Yoshinaga-Itano)
• 26 children UHL administered Minnesota
Child Development Inventory, tested at 7
to 59 mos, received counseling and
information from audiologist, no sp/lg
services. Mean expressive language
quotient 106 (73-156); receptive 104 (63143). (Yoshinaga-Itano)
Early Speech Language
(Yoshinaga-Itano)
• MacArthur Communication Development
Inventory administered to 11 children in this
group in age range appropriate for this
instrument. Mean @ 27th%Ptile expressive; 15th
%Ptile receptive; 17% group below 10thPtile on
receptive
• 15 (15-62mos) 33% below age on lang sample
analysis: delays in syntactic development
Early Speech Language
(Yoshinaga-Itano)
• Of 15 children (without other disabilities) in
study: 27% demonstrated significant delays in
language development, &% borderline delays
• 47% of children had abnormal tympanograms,
fluid, &/or tubes during study
• 50% Rt, 50% L, all had severe to profound UHL,
all identified by 2 mos of age, used oral
communication, parents educ, mid SES
Let’s Look Younger
Recent research on Infant speech
perception
What might it mean for young children
with UHL
OtitisMedia impacts speech
perception in infants @ 6-8 mos
• Tested discrimination of native phonetic
contrasts /bu-gu/ by conditioned head
turn response
• Tympanometry and hx obtained after
discrimination testing (blinding) resulting
in 3 distinct groups:
OM – Speech Perception Cont’d
Polka & Rvachew, 2005
3 Groups
• Infants with OM on day of testing
• Infants with hx of OM but normal tymps
day of testing
• Infants with normal tymps and no hx of
OM (Polka, Rvachew 2005)
OM – Speech Perception Cont’d
Polka & Rvachew, 2005
• Best discrimination was by infants w
normal tymps & Hx
• Intermediate level discrimination by
infants w normal tymps day of testing &
Hx of OM
• Poorest Discrimination by infants w OM
day of testing
OM – Speech Perception Cont’d
Polka & Rvachew, 2005
• Conclusions: 1. OM negatively impacts
phonemic perception after fluid is gone;
• 2 impact not due just to audibility-OM
affects infant attention to speech over
time
Background noise in natural
environments: infants
• Impedes access to relevant speech
patterns. In NOISE infants can:
• Detect phonemic difference (Nozza, et all 1991)
• Segment words from fluent speech (Newman,
Jusczyk, 1996)
• Recognize name (Newman 2005)
• Detect Mother’s voice (Baker & Newman, 2004)
Background noise in natural
environments: infants cont’d
• Infants require substantially higher
signal to noise ratios to accomplish
the above tasks than adults
• Noise blocks access to relevant
auditory information, reduces
attention from speech or critical parts
of speech signal
Infant speech processing with
DISTRACTION
(Polka, Rvachew, Molnar, submitted)
• COMPAIRED:
• Infants discrimination of /bu-gu/ using
habilitation procedure.
• Infants discrimination of pared CV syllable &
high frequency distracter (bird-cricket songs)
with no frequency overlap. Could hear both
• Infants 6-8 mos performed significantly better in
quiet than group in distracter condition
Infant speech processing with
DISTRACTION
(Polka, Rvachew, Molnar, submitted)
• CONCLUSION:
• It is a substantial cognitive challenge for
infants 6 to 8 mos to perceive auditory
phonetic patterns in noise
• Sensory impact of noise will not change,
but with maturity infants increase ability
to attend to speech signal over the noise
Infants use auditory & visual input
• Study findings suggest:
• Auditory-visual speech stimulus may
provide critical support that makes speech
perception in noise possible for infants
(Holllich, Newman, Jusczyk, 2005)
Processing Rich Information
Multidimensional Interactive
Representation - PRIMIR
• 3 dynamic filters act together to modulate
speech input or direct child’s attention to
speech (Werker & Curtin 2003)
• 1. Initial biases
• 2. Developmental level
• 3. Task demands
Infant Perceptual Biases
control access to speech sample
• Supersegmental biases: speaker voice,
affect, stress (Werker & Currin, 2005)
• Phonetic biases, less peripheral to more
easier /y/-/u/ easier than /u/-/y/(Polke & Bohn,
2003)
Infant Perceptual Biases
control access to speech sample
• Perceptions sensitive to structure of vocal
space
• Peripheral Vowels F1-F2: /i/, /a/, /u/
strong perceptual bias = perceptual
salience, similar across languages (Polke & Bohn,
2007)
Speech Perception
• Infants who discriminate CV sets from
their native language at 7 mos of age
demonstrate better language outcomes at
12, 18, 24 mos of age on a battery of
language measures (Kuhl et al)
What to Do?
Infants, Toddlers, Preschool
• Parent education regarding their child’s
challenges to hearing, listening, developing
speech & language, behavior, adapting home
environments, and audiologic management
• Teach parents techniques to help enhance
speech and language development
• Help parents develop observational techniques
to notice subtleties in child’s listening behavior
What to Do? I-T-P
• Develop speech and language protocols to
monitor development of sounds, prelang skills,
language skills
• Complete diagnostic protocols every 6 months:
preverbal communication, semantics, syntax,
morphology, speech, and pragmatics
• Track development of listening and attention
skills
• Consider enrolling in infants/toddlers in EI home
programs; preschoolers in school programs
What to Do? I-T-P
• Audiologist monitor HL and device monitor
frequently. Progressive hearing loss
possible
• Work with audiologist and educational
audiologist
• Develop and use questionnaires to assess
functional listening: ELF, ABEL, Little Ears,
McKay’s ?
What to Do? I-T-P
• Frequent medical follow up: OME,
Progressive hearing loss
• Complete assessment by interdisciplinary
team: Hg, vision, splg, cog, beh, medical,
• Complete Hx, at risk for multiple problems
Early Techniques for Parents
• Get child’s attention, make eye contact, follow
their eyes, talk near good ear, adapt
environment, make voice louder
• Supersegmentals; vowel preferences (/i/, /a/,
/u/) salience, vary sound play, provide auditoryvisual speech stimulus
• Provide other visual cues: gestures, objects,
later pictures
• Follow child’s lead, here and now, daily routines,
language dev techniques etc
Techniques for Parents
• Target rich vocabulary development, talk about objects
in different ways, books etc. Vocabulary can be an area
of delay in UHL as vicarious learning can be limited in
noisy environments
• Teacher education on UHL issues and what to watch for
and adapt in the classroom and use of devices and
placement of child as recommended by the audiologist
• Questionnaires to monitor listening and behavior in the
classroom
Time for Discussion!!!