Download Tracking Listening Skills from 0

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]