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Beyond the soundproof booth:
the audiologist in the
development of children’s
language and cognition
Carolina Leal
Audiological Scientist
St Thomas’ Hearing Implant Centre
SWEDCM Conference 2015
St Thomas’ Paediatric
Hearing Implant Centre
• Established 1996
• Over 400 paediatric Cochlear Implant surgeries
• Other implants: BAHA, MEI, Soundbridge, Bonebridge, ABI
•
Diverse, multidisciplinary team – ENT surgeons, Audiological Scientists, SaLTs,
ToDs, Psychologists, Hearing Therapist, ATOs, Administrators
•
Development of functional communication and language is priority
•
Communication modes (BSL level 4, AVT specialists)
•
Embrace Deaf culture and the views of deaf adults
•
Guided by family’s desired outcome
Understanding the family’s
experience
•
90% deaf babies are born into families with no experience, or history, of
childhood deafness (www.hearing.screening.nhs.uk)
•
Working with a diverse/multicultural population: 22% London homes speak
another main language alongside English (Census, 2011)
•
Families get information and different opinions from professionals across a
variety of fields
•
Misconceptions + Misinformation + Mixed messages = Frustrated families
•
Audiologists – the first point of contact
•
Families have long term goals for their child:
“Where will my child be at age 3, 5, 20? Able to talk? Mainstream school?”
“What do we need to do to get there...?”
And the world is changing fast...
•
We live in a world that demands high
levels of communication and literacy
•
We are treating children who will take
charge in the world of 2030, 2040, and
2050… not in the world of 1970 or 1990
or even 2016 (Carol Flexer)
•
Today’s
patient,
tomorrow’s
prime
minister – how can we positively
influence
children’s
language
and
cognitive development (Stiles, BAA 2014)
State-of-the-art technology
Access to sound
PTA not good predictor of
• Vocabulary
- Davis et al (1986)
- Moeller (2000)
• Word Learning
- Gilbertson & Kamhi (1995)
- Davis et al (1986)
• Language
- Ramkalawan & Davis (1992)
Detection versus Audibility
Pure Tone Average
(PTA)
Speech Intelligibility Index
(SII)
•
Frequencies have equal weighting
•
Frequency weighting incorporates
importance to speech understanding
•
Defines minimal detectable signal
•
Defines audibility of information in
speech
•
Does not infer discrimination or
predict benefit from amplification for
speech understanding
•
Predicts potential benefit from
amplification for speech
The aided SII and language
outcomes in children
Stiles et al., 2012
•
SII better predictor than PTA for language outcomes in children with HAs
•
Aided SII ≤ 65% - risk for delays in vocabulary development
•
Aided SII may become a useful benchmark in determining CI candidacy
•
Higher aided SII associated with more accurate word recognition, non-word
repetition and larger receptive vocabulary
•
Aided SII more sensitive than PTA at predicting lexical abilities of children
who wear HAs
N.B.: Age appropriate lexical development is thought to be critical for later
attainments in syntax (Tomasello, 2000) and reading (Stanovich, 1986)
The aided SII and language
outcomes in children
McCreery et al., 2015 (in press)
Planned audibility
There’s no finer investment for any community than putting language into
babies (Derek Stiles, BAA 2014)
Technology selection (HA / BAHA / CI)
Target / programming strategy selection
Programming / MAPping
Verification
Planned audibility
Unaided
•
•
•
Thresholds/Severity
PTA / SII
Speech understanding
Select device and targets/strategies,
knowing they do not restore normal hearing
Aided
•
•
•
•
REAR
Aided SII
Aided speech
understanding
Aided θ
Job done!
Really?
Audiologist
Consistent access
•
•
•
Data-driven learning
Learning opportunities
Common denominators
Cat, cat,
cat!
Look at
the cat
What a
pretty cat!
Naughty cat!
•
Consistent device use is the
biggest predictor of a good
outcome
•
Children need to be
constantly exposed to
language
•
Inconsistent use of
amplification is similar to a
fluctuating hearing loss
•
Children with hearing loss
require 3x the exposure to
learn new words and
concepts (Pittman, 2008)
Adequate Input
Consistent access
Time
Consistent access
(Moeller, 2009)
•
Verifying consistent access
– Interviewing
– Data-logging
•
Educating about consistent use of amplification
– First two years are most challenging
Child related
Environment
Parent related
• Pulling out/falling off
• Ear infections
• Car seats
• Outdoor play
• Loss prevention
• Adjustment
•
St Thomas’ hearing aid / CI / BAHA retention box (Library)
Collaboration
Report writing:
•
Usable information to other professionals
– Degree of loss
– Speech recognition / SII
•
Contextualise the added benefit
•
Emphasize aided prognosis
Reporting Audibility:
“Bob is a 5 year-old boy with mild to moderate SNHL. Bob wears BTE hearing
aids. Without amplification Bob has access to 23% of speech cues at normal
conversational speech level. With hearing aids in place, in best listening
conditions, Bob has access to 84% of speech cues at normal conversational
levels. In ideal listening environments with hearing aids on and additional visual
cues, Bob is expected to have minimal communication difficulties. In more
adverse environments, Bob may require additional support, i.e. FM system.”
Collaboration
Parent
Siblings /
Extended
Family
Teacher
GP
SaLT
Child
ToD
Educ Audiologist
Psychologist
ENT / AVM
Audiologist
Collaboration (family)
Why parent education?
• The linguistic environment at home best predicts the child’s language
and IQ outcomes – for all children
(Quittner et al 2013)
• The quality of relationships and the learning environments for babies &
toddlers is critically important
• Children learn through being engaged, doing, watching and Copying
(The US National Institute of Child Health and Human Development)
• Mother’s interactions had significant impact on implanted child’s
language development
(Desjardin et al 2007)
• Given that parents of special needs children often experience excess
stress, they may be susceptible to negative outcomes
(Asberg et al 2008)
At St Thomas’…
• Information Sessions (1st appt)
– Parent / extended family and local professionals
• Early Interaction and Language Facilitation (Look who’s talking!)
1st: parent-only group education session
– early interaction and communication skills
– how parents can facilitate these in everyday FUN situations
2nd: session attended by parents and their children
– opportunity to practise new skills and strategies
– real time video feedback given by a SaLT
• Music and Language groups
– ‘baby beats’ - for infants and toddlers
– ‘musical journey through the rainforest’ - for nursery and school age children
Random variables
• Access to service
– Time of intervention
– Socio-economic factors
– Environment
• Nutrition
• Quality of schooling
• Cultural values
– Education/literacy
– Community
– Religious/family rituals
• Intellect
– Intellectual potential
– Other disabilities
– Language/logic
• Temperament
– Intro-/extraversion
– Curiousity
– Bravery
The audiologist challenge: take your role
beyond the soundproof booth!
Consistent
use of
technology
Audibility
Opportunity
to socialise /
interact
Professional
collaboration
References
Asberg KK, Vogel JJ, Bowers CA. Exploring correlates and predictors of stress on parents of children who are deaf: Implications
of perceived social support and mode of communication. Journal of Child and Family Studies. 2008; 17:486-499
Boons, T., De Raeve, L., Langereis, M., Peeraer, L., Wouters, J., & Van Wieringen, A. (2013). Expressive vocabulary,
morphology, syntax and narrative skills in profoundly deaf children after early cochlear implantation. Research in
developmental disabilities, 34(6), 2008-2022.
Briscoe, J., Bishop, D. V., & Norbury, C. F. (2001). Phonological processing, language, and literacy: a comparison of children
with mild‐to‐moderate sensorineural hearing loss and those with specific language impairment. Journal of Child Psychology
and Psychiatry, 42(3), 329-340.
Colin, S., Leybaert, J., Ecalle, J., & Magnan, A. (2013). The development of word recognition, sentence comprehension, word
spelling, and vocabulary in children with deafness: A longitudinal study. Research in developmental disabilities, 34(5),
1781-1793.
Desjardin JL, Eisenberg LS. Maternal contributions: supporting language development in young children with cochlear implants.
Ear Hear. 2007;28:456-469.
Edwards, L., Figueras, B., Mellanby, J., & Langdon, D. (2011). Verbal and spatial analogical reasoning in deaf and hearing
children: the role of grammar and vocabulary. Journal of deaf studies and deaf education, 16(2), 189-197.
Hornsby, B. W. Y. (2004). The Speech Intelligibility Index: What is it and what’s it good for? The Hearing Journal, 57, 10–17.
Killion, M. C., & Mueller, H. G. (2010). Twenty years later: A NEW Count-The-Dots method. The Hearing Journal, 63, 10–17.
Lee, Y., Yim, D., & Sim, H. (2012). Phonological processing skills and its relevance to receptive vocabulary development in
children with early cochlear implantation. International journal of pediatric otorhinolaryngology, 76(12), 1755-1760.
Moeller, M. P., Hoover, B., Peterson, B., & Stelmachowicz, P. (2009). Consistency of hearing aid use in infants with earlyidentified hearing loss. American Journal of Audiology,18(1), 14-23.
Moeller, M. P., McCleary, E., Putman, C., Tyler-Krings, A., Hoover, B., & Stelmachowicz, P. (2010). Longitudinal development
of phonology and morphology in children with late-identified mild-moderate sensorineural hearing loss. Ear and
hearing, 31(5), 625.
Pittman, A. L. (2008). Short-term word-learning rate in children with normal hearing and children with hearing loss in limited and
extended high-frequency bandwidths. Journal of Speech, Language, and Hearing Research, 51(3), 785-797.
Pittman, A. L., Lewis, D. E., Hoover, B. M., & Stelmachowicz, P. G. (2005). Rapid word-learning in normal-hearing and hearingimpaired children: Effects of age, receptive vocabulary, and high-frequency amplification. Ear and hearing,26(6), 619.
Stiles, D. J., Bentler, R. A., & McGregor, K. K. (2012). The Speech Intelligibility Index and the Pure-Tone Average as Predictors
of Lexical Ability in Children Fit with Hearing Aids. Journal of Speech, Language, and Hearing Research, 55, 764–778.
doi:10.1044/1092-4388(2011/10-0264)
THANK YOU!
Acknowledgements:
– St Thomas’ Hearing Implant Team, especially Alice Montgomery (SaLT)
– My grateful thanks to Dr Derek Stiles, for his input and Dr Ryan McCreery
for allowing reproduction of their unpublished research data
[email protected]