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Tracking Listening Skills from 0-6years: Changing Progress, Changing Outcomes Aleisha DAVIS, Anne FULCHER, Alyshia HANSEN, Katie NEAL AGBell LSLS Symposium 10th July , 2015 Baltimore, Maryland • 45 years of service to >2000 children • Focus on Listening and Spoken Language • Family-centred Transdisciplinary • Integrated Implant and Early Intervention Program • Families from diverse cultural and linguistic background • Individual, Group and Teleintervention Programs • 5 Centres with services across ACT NSW Tasmania • Children with all range of needs, all levels and types of hearing, all devices options • Currently 250 children 0-6yrs, 135 children 7yrs plus Before speech and language, comes “Although children make use of visual cues when learning language, audition is of primary importance for language acquisition” Bailey & Snowling, (2002), Yoshinaga-Itano, C. (1998) Geers, A., Brenner, C., & Davidson, L. (2003). Children’s outcomes measured by Vocabulary Social Skills Pragmatics Language Speech Literacy Listening How can we identify progress before it shows in speech and language outcomes? Track development of the prerequisite skills on which speech, language and communication are built The importance of audition “Although children make use of visual cues when learning language, audition is of primary importance for language acquisition” Bailey & Snowling, (2002), Yoshinaga-Itano, C. (1998) Geers, A., Brenner, C., & Davidson, L. (2003). Quantifying what infants can hear • UNHS (AABR) • Diagnostic ABR (hearing level and basis of device fitting) • Hearing aid fitting • Verifying & optimising access to sound (behavioural/subjective measures) • Maximising opportunity (early diagnosis, early fitting, early intervention) The impact of objective testing 500HZ 1000HZ 2000HZ 4000HZ Alt. Alt. Alt. Alt. Air Bone Air Bone Air Bone Air Bone Left 60 NR 70 NR 75 NR 75 NR Right 65 NR 65 70 75 NR /mae/ /gae/ /tae/ Aided at 65dBSPL yes yes yes Aided at 55dBSPL yes yes yes Does this child need a CI? Click Cond Alt. Air Bone -cm -cm However, What do we know about their real world/functional listening skills? Example study: The importance of functional listening CAEP & Ling Sounds: Implications of Matches and Mismatches Cortical Auditory Evoked Potentials (CAEP’S) • Evoked potentials = small electrical signals produced by hearing pathways in the brain. • Response is measured from the brain. (NAL Hearlab information sheet, http://hearlab.nal.gov.au/pdf/CAEP%20parent%20handout.pdf) • HEARLab® system designed to make objective audiological assessment easy and efficient. • Includes in-built statistical procedures to determine present or absent response, allowing by non-expert electrophysiologists • Researched & developed through NAL & CRC (Aust) • Provides Objective verification of hearing aid fitting Detection Response at level of the cortex Functional Listening • Real world listening skills • Provides an indication of what a child can do with a sound (in addition to what they may be able to detect) • Trained professionals that see infants on a regular basis have a very good understanding of what functional listening skills each child has • The core of a specialized early intervention auditory focused program – From the earliest point (skills begin to show from a few weeks of – – – – age) Pre-requisite for speech and language Picture built over a period of time Involves combination of measures – no one test stands alone Every child is different, so individual focus impacting factors to functional listening development How to measure functional listening? Variety of current tools • Functional Listening Index (tracking auditory devt skills from 0 – 6years) • Categories of Auditory Performance – Revised • Ling sounds/ Seven Sounds (ah, oo, ee, mm, sh, s, or) • Auditory Skills Checklist • St Gabriel’s Curriculum • Integrated Scales of Development (Cochlear Ltd)) Amongst others… In quiet and noise Close and from a distance Individual and separate ears Live and digital signals Ling, D. and Ling, A. 1978, Aural Habilitation: The Foundations of Verbal Learning in Hearing-Impaired Children, AG Bell, Washington DC, U.S.A. Romanik, S. 1990, Auditory Skills Program for Students with Hearing Impairment, NSW Departmentof School Education, Sydney, NSW, Australia Archbold, S., Lutman, M. E., & Marshall, D. H. (1995). Categories of Auditory Performance. Annals of otology, rhinology & laryngology. Supplement, 166, 312. Cole, E. B., & Flexer, C. A. (2007). Children with hearing loss: developing listening and talking birth to six: Plural Pub. Estabrooks, W. (1998). Cochlear implants for kids: Alexander Graham Bell Association for the Deaf. HEARING, J. C. O. I., Muse, C., Harrison, J., Yoshinaga-Itano, C., Grimes, A., Brookhouser, P. E., Martin, B. (2013). Supplement to the JCIH 2007 Position Statement: Principles and Guidelines for Early Intervention After Confirmation That a Child Is Deaf or Hard of Hearing. Pediatrics, 131(4) St. Gabriel’s Curriculum for the Development of Audition, Language, Speech, Cognition, Second Edition (2005). Compiled by J. Tuohy, J. Brown, & C. Mercer-Moseley Integrated Scales of Development, Cochlear Limited Auditory Skills Checklist, (2004) Adapted by Karen Anderson, from Auditory Skills Checklist by Nancy S. Caleffe-Schneck, M.Ed., CCC-A (1992). Auditory Learning Guide, Beth Walker, (2009) Pollack, D., Goldberg, D. M., & Caleffe-Schenck, N. (1997). Educational audiology for the limited-hearing infant and preschooler: An auditory-verbal program: Charles C Thomas Pub Ltd. Agung, K. B., et al. (2005). "The Ling sound test revisited." Australian and New Zealand Journal of Audiology, The 27(1): 33. Functional Listening What starts as a DETECTION response, swiftly becomes DISCRIMINATION and IDENTIFICTION responses so COMPREHENSION responses become possible Design and demographics Retrospective review of cortical reports (HEARLab®) and functional listening responses recorded in clinical database n=56 (23 females, 33 males) Symmetry Unilateral n=3 Hearing Thresholds (mean 4FA poorer ear) at time of testing Profound 14 % Severe-Profound 11 % Severe 9 % Moderate-Severe 20% Moderate 7% Mild Moderate 16% ANSD 23% Bilateral n=53 Design and demographics Anomalous CV anatomy 5% Aetiology Syndrome 7% CMV 9% Unknown 61% n=56 Age at CAEP assessment Mean = 9.75 months Median t = 5 months Range = 1 -54 months Connexin 26 13% LVAS 5% Meningitis 4% 15/56 Diagnosed with Additional needs • 53/56 aided testing • 3/56 unaided testing • Testing levels 55,65 & 75dBSPL • Comparison time locked & correlated to recorded responses Apples with apples CAEPs & Functional Detection /mae/ 200-500Hz mmm: F1 250-350Hz (F2 1-1500Hz, F3 2500-3500Hz) ooo: F1 250-400Hz (F2 8-900Hz) eee: F1 125-400Hz (F2 2200-2600Hz) /gae/ 800-1600Hz ah: F1 700-900Hz (F2 1300-1600Hz) or: F1 400-600Hz (F2 800-1100Hz) shh: F3 1500-2000Hz (F4 4500-5500Hz) /tae/ 2-8000Hz eee: F1 125-400Hz (F2 2200-2600Hz) shh: F3 1500-2000Hz (F4 4500-5500Hz sss: F4 5-6000Hz HearLab manual http://hearlab.nal.gov.au/pdf/HEARLab-Manual.pdf Estabrooks, W. (2006) Auditory Verbal Therapy and Practice Ling, D. and Ling, A. 1978, Aural Habilitation: The Foundations of Verbal Learning in Hearing-Impaired Children, AG Bell, Washington DC, U.S.A. Romanik, S. 1990, Auditory Skills Program for Students with Hearing Impairment, NSW Department of School Education, Sydney, NSW, Australia. A word about speech acoustics /s/=5-6000Hz /∫/=F1 1500-2000Hz, F2 4500-5500Hz MALE FEMALE Estabrooks, W. (2006) Auditory Verbal Therapy and Practice Plant, G Listen, Hear! Issue No. 23 http://s3.medel.com/downloadmanager/downloads/bridge/listen_hear/nl-NL/Listen-Hear-23.pdf What does a match look like? Mismatch n=33 /mae/ /gae/ /tae/ Aided at 65dBSPL yes yes yes Aided at 55dBSPL yes yes yes /mae/ /gae/ /tae/ Aided at 65dBSPL no no no Aided at 75dBSPL no no no Match n=23 /mm/ yes /mm/ yes /or/ /oo/ /ah/ /ee/ /sh/ /ss/ yes yes yes ac ac ac /or/ /oo/ /ah/ /ee/ /sh/ /ss/ yes yes yes ac yes yes /mm/ /or/ /oo/ /ah/ /ee/ /sh/ /ss/ yes yes yes yes yes yes yes /mm/ no /mm/ no /or/ /oo/ /ah/ /ee/ /sh/ /ss/ no no no no no no /or/ /oo/ /ah/ /ee/ /sh/ /ss/ no no no no no no /mm/ /or/ /oo/ /ah/ /ee/ /sh/ /ss/ no no no no no no no What does a mismatch look like? Mismatch n=33 /mae/ /gae/ /tae/ Aided at 65dBSPL yes yes yes /mae/ /gae/ /tae/ Aided at 65dBSPL no yes yes Aided at 55dBSPL no yes yes Match n=23 /mm/ no /mm/ no /mm/ ac /or/ /oo/ /ah/ /ee/ /sh/ /ss/ no yes no no no no /or/ /oo/ /ah/ /ee/ /sh/ /ss/ ac no no no no no /or/ /oo/ /ah/ /ee/ /sh/ /ss/ ac no no no no no /mm/ yes /mm/ yes /mm/ yes /or/ yes /or/ yes /or/ yes /oo/ yes /oo/ yes /oo/ yes /ah/ /ee/ /sh/ /ss/ yes no no no /ah/ /ee/ /sh/ /ss/ yes ac no no /ah/ /ee/ /sh/ /ss/ yes ac no no 3000Hz • Hearing thresholds • Aetiology • Middle ear pathology • Complex medical picture Mild Moderate Moderate Moderate-Severe Severe Severe-Profound Profound ANSD n=9 n=4 n=10 n=5 n=6 n=9 n=13 Mismatch Match Match or mismatch? • • 41% (n=23) match with cortical responses and behavioural responses to phonemes. 59% (n=33) mismatch with cortical responses and behavioural responses to phonemes. • 19/33 (58%) had all cortical responses present but a mismatch with functional listening. What happens next? Match or mismatch? • 3/33 hearing aid optimization lead to matched results • 21/33 have gone on to have at least 1 CI • 4/33 CI evaluation • 3/33 transferred to other programs • 1/33 significant additional needs • 1/33 with ongoing middle ear What does CAEP testing mean for families? • 18 recalled having the testing and could recall the results • 4 families had a good understanding of the purpose “to get brain response to see if getting any benefit from the aids” • 5 families had a poor understanding of the purpose “confirmation of diagnosis” , “to see if the inner ear is functioning & the hearing levels” • 6 understood implications • 3 had limited/poor understanding “it’s really confusing, this is saying he can hear everything” Impact of interpretation “confirmed what I had been seeing and what I was feeling” “at the time, we had passed the emotional part and into acceptance “ “always had hope never minded do another test” “Overall – 100% beneficial sitting down and reviewing results much needed and necessary for me to hear and understand” “For me yes, for my husband not so much, he was in denial wanting something 100% concrete” “Yes a more technical result” “ “Yes but also confusing” “when we got a positive result, it gave us hope that with time maybe the hearing would get better” ” Hard to take. Felt like getting the news of a HL all over again” “Very nervous, much more meaning attached” “struggling said can hear but not seeing this. Made us doubt everything” Impact of match on listening development Match = Starting and staying on the same listening trajectory Match = Initially poor trajectory Rapid change with improved access Impact of mismatch on listening development Mismatch = Poorer than expected trajectory Mismatch = Poor early trajectory Rapid change with improved access Mismatch= Complex audiology Conflicting information Complex psychosocial Complex co-mordid medical complications Building the house Comprehension Identification Discrimination Detection Building communication • A present cortical response indicates detection of something at the cortex • An absent cortical response may be present but not measureable • There is no 100% correlate between a speech signal and the CAEP stimulus • It’s beneficial to take time with families to clearly and simply explain what additional information CAEPs might provide. This needs flexible delivery of services and information (written and verbal) • To fully understand hearing, consider all of the available evidence in the context of the whole child • Anything that add to the picture of understanding what a child might be hearing is useful Given the importance of functional listening on outcomes How do we best track listening skills over time to tell us about later speech and language progress and development? One day a number of creatures sat in the forest and pondered the important questions in life… ‘what tools do we use to measure listening skills?’ The creatures were sure that many others had pondered the same question. From their experience, Listening and Spoken Language Therapists, Specialists and Teachers of the Deaf … 1. used different tools according to individual preference 2. were looking for different tools 3. were having difficulty comparing children’s progress 4. Didn’t have detailed normative data 5. Often asked to measure auditory skill in terms of speech perception abilities which didn’t involve comprehension element Wanted a tool that : 6. Could track a child’s listening progress over time 7. Had more detail & smaller steps 8. early to advanced listening skills 9. more advanced listening skills (with early diagnosis, early fitting, early CI) 10. Able to recorded individual skills in progress notes from every session 11. found overlap between auditory and receptive language skills The problem with tracking listening skills over time • • • • • • • • Number of different tools Differing knowledge of what tools exist A tool that is able to track listening progress over time (0-6yrs) Able to compare a child’s progress Has detailed normative data Has scales with detailed steps Has early to advanced listening skills Able to record individual skills in progress notes Outcomes often rely on standardised assessments, but • PEACH/TEACH • PLS -4/5 • CELF – P2 • CELF – 4 • PPVT-4 • Reynell • EVT-2 • GFTA -2 • DEAP • Symbolic Play Test Listening Language Speech Play • PIPA • Woodcock (WJ-III) • TOPL-2 • PLSI • Weschler • Bayley Scales • GMDS • Bracken Pre-literacy Pragmatics Cognition Typical language, vocabulary and speech for children with hearing loss Language outcomes across all CI users n=151 At their last assessment point Habilitation Program Challenges Child Outcomes Family Outcomes Service Outcomes ↑ Number of Programs Need for Outcome measures ↑ Parental Expectations Standard Operating Procedure Preventative vs Remedial Do more with less Evidence Based Practice Growing numbers Trans Discipline Funding Compliances Family Centered Practice Equity of Services Changing criteria for CI Accreditation requirements Which took us on a journey Which at times felt a bit like this And we definitely faced some challenges As we changed our thinking And we really started tracking listening Existing tools • • • • • • • • • Categories of Auditory Performance (CAP) / CAP - Revised Cole, E. B., & Flexer, C. A. (2007). Children with hearing loss: developing listening and talking birth to six Estabrooks, W. (1998). Cochlear implants for kids Supplement to the JCIH 2007 Position Statement: Principles and Guidelines for Early Intervention After Confirmation That a Child Is Deaf or Hard of Hearing. St. Gabriel’s Curriculum for the Development of Audition, Language, Speech, Cognition Integrated Scales of Development, Cochlear Limited Auditory Skills Checklist, (1992). Auditory Learning Guide, Beth Walker, (2009) Pollack, D., Goldberg, D. M., & Caleffe-Schenck, N. (1997). Educational audiology for the limited-hearing infant and preschooler: An auditory-verbal program: Charles C Thomas Pub Ltd. Began with the formative tools we rely upon Auditory Skills Checklist, (2004) Auditory Learning Guide, (Beth Walker 2009) Categories of Auditory Performance Integrated Scales of Development (Archbold, S., Lutman, M. E., & Marshall, D. H. 1995) Children with hearing loss: developing listening and talking birth to six: (Cole & Flexer 2007) Cochlear implants for kids (Estabrooks, W. 1998). Supplement to the JCIH 2007 Position Statement: Principles and Guidelines for Early Intervention After Confirmation That a Child Is Deaf or Hard of Hearing. (E., Martin, B. 2013). Auditory-Verbal Ages and Stages of Development in (Levels I – VIII) in Cochlear Implants for Kids (Estabrooks, W. 1998) Educational audiology for the limited-hearing infant and preschooler: An auditory-verbal program. (Pollack, D., Goldberg, D. M., & Caleffe-Schenck, N. 1997). St. Gabriel's Curriculum for the Development of Audition, Language, Speech, Cognition, (Tuohy, J., Brown, J. and Mercer-Mosely, C., 2001) Cottage Acquisition Scales for Listening, Language and Speech. Simple Sentence Level (Wilkes, E.M. 1999) The Phonetic-Phonologic Speech Evaluation Record: A Manual (Ling, D. Ph.D. 1991) Functional Listening Index 6 Phases/60 items 1. Sound Awareness 2. Associating Sound with Meaning 3. Comprehending Simple Spoken Language 4. Comprehending Language in Different Listening Conditions 5. Listening Through Discourse and Narratives 6. Advanced Open Listening Set The Functional Listening Index Demographics 302 children 0-7yrs 857 Data points All levels of hearing loss Including CI Group 56 Children with CI 104 devices • • • • • CI <12mths children with significant residual hearing UHL ANSD Simultaneous and Sequential Listening Index for whole group Number of observed listening sills by age of child Normative data typical hearing children Age in Months n=310 Bilateral vs UHL Early implantation All have had speech and language in the typical range from birth Bilateral CI at 5mths HA mod & mod/sev loss Mod/Sev CI Direct outcome following implantation ANSD Functional Listening compared to traditional measures Provides Measure of • Functional listening • Precursor to speech and language • Tailored to individual • Birth to school age • Adaptable to changing landscape Variation in Recording of Sounds: one child’s record Difficult to obtain a longitudinal picture of one child’s access to sound. Inconsistency in documentation LEFT Frequency: Low High July 2010 RIGHT BINAURAL Low Low High High Retrospective data entry – sometimes hard to decipher those text notes accurately! CI1 Right; 4 days post switch on Feb 2012 Left, HA alone 4 weeks later Impacts on Clinical Practice How has it changed what we do? A Listening and Spoken Language Specialist’s perspective Difficult to engage, complex social issues ANSD + Additional Needs + CI Deterioration in hearing Thresholds in the better hearing ear 15 years LESS HEARING----------------------------------------MORE RESIDUAL HEARING Hearing levels of CI candidates: Between 2000-2015 there has been significant change in the overall hearing level considered as a CI candidate (n=373 ears) Success is more than speech & language: functional listening matters NORMAL HEARING Success is more than speech & language: functional listening matters NORMAL HEARING PLS4 Total Language score Case Study: Residual hearing and CI Access to sound Chronological Age Scores not dropping out of the normal range, decision made before they ‘fail’ & based on functional access What has led to changed criteria? Research - significant hearing and communication difficulties in real-world situations Alkaf & First, 2007; Gifford et al., 2007; Novak et al., 2007; Leigh, Dettman, Dowell, & Sarant, 2011, Ching et al 2010 - Improved outcomes with CI Clinically - Hearing aid users who still fall outside the candidacy criteria making poorer progress that CI counterparts with more significant hearing loss Access to sound HA 55-64PTA in better ear, CA 1-2yrs CI bilateral profound, CA 1-2yrs New Horizon: UHL & Cochlear Implantation (n=13, 3;7 up) • Evaluation- beyond traditional measures • Programming: objective/automated measures • Therapy- direct audio input? Integrating signals? Overall family/individual goals Outcomes = Variability. 3 excellent performed. Improved attention Speech awareness, speech at word level better than pre CI Awareness of sound Ability to focus and listen to softer sounds has improved Listening in background noise (less repetitions, can hold more UHL & Cochlear Implantation • Typically younger = quicker integration • Assisting families deal with the preconceptions of others • Investigation of aetiology (MRI, genetic testing) • Funding issues still exist, Importance of counselling GOALS: Good full-time device use, measurable improvement in access to sound, observed change in listening ease and confidence Standard vs Functional Outcome Measures Traditional measures on standardized assessments don’t indicate need Pre CI Post CI Standard vs Functional Outcome Measures However, strongly indicated on specific functional measures Access to sound Pre CI Post CI Advanced auditory skill development (in noise, complex tasks etc) Functional Listening from a child’s perspective Clinical practice excellent, data needed attention On Reflection… References Archbold, S., Lutman, M. E., & Marshall, D. H. (1995). Categories of Auditory Performance. Annals of otology, rhinology & laryngology. Supplement, 166, 312. Auditory Skills Checklist, (2004) Adapted by Karen Anderson, from Auditory Skills Checklist by Nancy S. CaleffeSchneck, M.Ed., CCC-A (1992). Auditory Learning Guide, Beth Walker, (2009) Bailey, P. J., & Snowling, M. J. (2002). Auditory processing and the development of language and literacy. British Medical Bulletin, 63(1), 135-146 Cole, E. B., & Flexer, C. A. (2007). Children with hearing loss: developing listening and talking birth to six: Plural Pub. Estabrooks, W. (1998). Cochlear implants for kids: Alexander Graham Bell Association for the Deaf. FIRST YEARS (Training Program University of North Carolina), Geers, A., Brenner, C., & Davidson, L. (2003). Factors Associated with Development of Speech Perception Skills in Children Implanted by Age Five. Ear & Hearing, 24(1)(Supplement), 24S-35S. Integrated Scales of Development, Cochlear Limited Morrow, L. M. (2001). Literacy development in the early years. Needham Heights, MA. Muse, C., Harrison, J., Yoshinaga-Itano, C., Grimes, A., Brookhouser, P., E., Martin, B. (2013). Supplement to the JCIH 2007 Position Statement: Principles and Guidelines for Early Intervention After Confirmation That a Child Is Deaf or Hard of Hearing. Pediatrics, 131(4) Paul, R. (2007). Language disorders from infancy through adolescence: Assessment & intervention: Elsevier Health Sciences. St. Gabriel’s Curriculum for the Development of Audition, Language, Speech, Cognition, Second Edition (2005). Compiled by J. Tuohy, J. Brown, & C. Mercer-Moseley Yoshinaga-Itano, C. (1998). Development of audition and speech: implications for early intervention with infants who are deaf or hard of hearing. Volta Review, 100(5), 213-234. Whitehurst, G. J., & Lonigan, C. J. (2001). Emergent literacy: Development from prereaders to readers. Handbook of early literacy research, 1, 11-29. Questions? The Shepherd Centre team Thank you to the children and families that share their journey with us. We’d also like to acknowledge past TSC staff members who have contributed to the design and implementation of our Theory of Mind research [email protected]