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Hearing Aid Fittings on Children Infancy to 5 Years Julie Christensen, M.S. Staff Audiologist Hearing Aid Fittings on Children Infancy to 5 Years Julie Christensen, M.S., CCC-A 1 Hearing Aid Fittings on Children Infancy to 5 Years What is the primary goal of putting hearing aids on children? Promotion of speech and language development Babble is a building block for word building. An impoverished inventory of baby sounds may limit early word learning which may, in turn, delay communication skills Vocabulary Spurt No of words 600 400 200 0 0 12 18 24 Age in months Vocabulary Spurt at 500 words 2 Hearing Aid Fittings on Children Infancy to 5 Years Vocabulary Spurt 60000 60000 50000 40000 30000 20000 14000 10000 1 75 500 0 Are children and adults fit with hearing aids in the same way? Characteristics of the Very Young Listener • Children use their hearing to learn language • Smaller ears mean different acoustics and retention challenges. • Less audiometric information on children Case Study: Baby J • Referred on newborn hearing screen • Parents brought Baby J to BTNRH at 1 month of age 3 Hearing Aid Fittings on Children Infancy to 5 Years Unsedated ABR • 1 month old: - Normal tympanograms - Mild high frequency loss in left ear - Moderate high frequency loss in right ear Recommendations – return in 1 month for repeat ABR Repeat ABR • 2 months – normal tympanograms ABR thresholds RE 250 Hz 1000 Hz Clicks 40 40 40 LE 30 40 40 and ?30 LIMITED AUDIOMETRIC INFORMATION How is behavioral hearing testing different for a child compared to an adult? 4 Hearing Aid Fittings on Children Infancy to 5 Years Anatomy of a behavioral hearing test • • • • Tympanograms Air conduction Bone conduction Word recognition Anatomy of an audiogram LOW HIGH Soft BONE CONDUCTION THRESHOLDS AIR CONDUCTION THRESHOLDS KEY LOUD Threshold: the softest sound a person can hear Complete Audiometric Test Word Understanding: Presentation level: 75 dB RE: 96% LE 92% Normal Tympanograms 5 Hearing Aid Fittings on Children Infancy to 5 Years Baby J’s Audiometric Information Click Word Understanding: Unknown Normal Tympanograms What’s next for Baby J? • Binaural amplification (took ear imps that day) Follow-up Appointments • • • • • • ENT evaluation for medical clearance Fit with loaner aid at 4 months. Neurosensory Genetics evaluation Fit with new molds at 7 months of age Fit with new molds at 9 months of age Fit with new molds at 11 months of age 6 Hearing Aid Fittings on Children Infancy to 5 Years Compared to normal hearing adults… • Children use their hearing to learn language. They can’t guess at words they miss. • Children don’t perform as well in noise and reverberant rooms. • Infants and young children can’t give feedback on hearing aids Kids need hearing aid targets designed just for them Adult targets may not provide enough speech information: Children may not be able to monitor their own voice or hear high frequency speech sounds, which are crucial for language learning. Infant Amplification In 8 Steps 1. 2. 3. 4. 5. 6. 7. 8. Confirm hearing loss Counseling Referrals for intervention Ear Impressions Selection of Amplification Fitting and Verification Hearing Aid Orientation Follow-up Services 7 Hearing Aid Fittings on Children Infancy to 5 Years 1. Confirm And Monitor Hearing Loss Proceed with amplification when… • Test findings confirm hearing loss –Presumed permanent hearing loss –Ruled out acute middle ear dysfunction –Parents ready 2. Counseling 8 Hearing Aid Fittings on Children Infancy to 5 Years Time Frame for Amplification • Yoshinaga-Itano et al, 1998 Pediatrics –language abilities significantly better when intervention begun at 6 mos. or sooner Joint Committee on Infant Hearing (JCIH) “All infants who do not pass the birth admission screen…(should) begin appropriate audiological and medical evaluations to confirm the presence of hearing loss before 3 months of age.” Why is early intervention so important? • Vocab skills examined in 112 five year olds with HL. Verbal reasoning skills examined in a subgroup of 80. • Children enrolled by 11 mos of age demonstrated better vocab and verbal reasoning scores than later-enrolled children, regardless of degree of HL. Moeller MP. Early intervention and language development in children who are deaf and hard of hearing. (Pediatrics, 2000) 9 Hearing Aid Fittings on Children Infancy to 5 Years Barriers to Timely Amplification • Size of the newborn (preemie, LBW) • Other medical needs supercede or complicate – Severe medical needs – Conductive component • Additional testing for audiological status • PCP has limited knowledge re: children with HL • $$$$ for hearing instruments • Parental acceptance – Denial or 2nd opinion sought • Poor access to skilled pediatric audiologist Limited Economic Resources • • • • • • • Insurance Transportation Child care Time off from work for appointments Lack of permanent residence Language or cultural barriers Legal status (Sass-Lehrer 2004) Causes of Delay, According to Parents • • • • • • • • Need for additional appointments (30%) Waiting for follow-up appts (19%) Delays in 3rd party payments (20%) Child’s health problems (8%) Difficulties with ear molds (7%) Seeking second opinion (5%) Not ready (4%) Other (7%) (Sjoblad et al 2001) 10 Hearing Aid Fittings on Children Infancy to 5 Years Parents’ concern at the time of hearing aid fitting I was concerned: Agree strongly Uncertain Disagree strongly about the care and maintenance of the hearing aids 72 3 23 about what the hearing aids would look like 61% 4 55 about whether my child would benefit from hearing aid use 58 6 28 that my child would not be socially accepted 45 15 39 about what friends and family would say about the hearing aids 26 6 52 Sjlobad et al 2001 What was your biggest worry when you child got their hearing aids? •Learning to talk •Keeping them on •Teasing at school •Losing or breaking them •Swallowing battery •Improvement in listening •Acceptance of hearing aids by child •Comfort issues •Keeping them clean and dry Martin, Stroud & Nicholson, 2005 Early intervention and language development in children who are deaf and hard of hearing • Multiple regressions models to examine the relationship btw performance and – – – – age of enrollment, family involvement, degree of HL, nonverbal intelligence. • Only 2 significant factors – family involvement – explained the most variance – age of enrollment Moeller MP. Early intervention and language development in children who are deaf and hard of hearing. (Pediatrics, 2000) 11 Hearing Aid Fittings on Children Infancy to 5 Years Parental involvement trumps everything!!! Talking to parents •Give the parents time to digest as you go •Watch parents carefully – use them as a meter to determine how much information to give – don’t overwhelm them •Give them time alone •Expect to counsel and answer the same questions over the next twenty years of following the child Talking to Parents • Have handouts ready to take home • Give them your phone number and encourage them to call • Be honest and realistic • Respect their reactions • Respect their decisions 12 Hearing Aid Fittings on Children Infancy to 5 Years "I cannot remember anything they said after the word ‘deaf.’ I had to call the office later and ask for all the details over again.” "The biggest mistake I made with my family was to cry all of my tears before I called them to give them the news. I knew my parents would be upset by the news, so I wanted to protect them by acting as if everything was fine. Because I was so in control and seemed to be handling it so well, they assumed that I was fine. If I had been honest with them and let them know how devastated I was, they would have been much more able to support me when I really needed it." My Baby’s Hearing BTNRH – NIDCD web page: http://www.babyhearing.org/ 3. Referrals Distribution of Conditions that Occur in Addition to Deafness Condition % of Children No condition in addition to deafness 60.1 Learning disability 10.7 Intellectual disability 9.8 Attention deficit disorder 6.6 Blindness and low vision 3.9 Cerebral palsy 3.4 Emotional disturbance 1.7 Other conditions 12.1 From Roush et al 2004, based on the Gallaudet Research Institute. Regional and National Summary Report of Data from the 2001-2002 Annual Survey of Deaf and HOH Children and Youth. Washington DC: GRI, Gallaudet University; 2003 (N=42,361; 11/9% not reported) 13 Hearing Aid Fittings on Children Infancy to 5 Years Intervention Referrals 1. 2. 3. 4. 5. 6. ENT evaluation Early intervention services Pediatric Ophthalmology examination Medical-genetics assessment Financial assistance, if warranted Parent to Parent Support ENT Evaluation • Rule out treatable causes of HL • Medical clearance for amplification • Address wax problems Early Intervention Services 1. Educational Intervention, including IFSP (Individual Family Services Plan). Varies state to state. Typically service coordinators are in the local school district. Service coordinators send patients on to other medical referrals, as needed. 2. Parent/Infant specialist or Deaf/HOH Educator 3. Communications Assessment 14 Hearing Aid Fittings on Children Infancy to 5 Years Ophthalmology Referral • 3.9% have vision problems • May depend on vision to assist communication Medical-Genetics Referral Causes of HL in newborns • 60% genetic • 40% non-genetic Joint Committee on Infant Hearing: “All families of babies with a hearing loss for whom there is no clear-cut etiology should be offered an evaluation with a medical geneticist for genetic testing and counseling.” 15 Hearing Aid Fittings on Children Infancy to 5 Years Commonly Heard Responses to Genetics Counseling Referrals “We’re not having more children, so it doesn’t matter what a genetics test tells us.” “I don’t need to know what the likelihood will be of having more children with hearing loss – it’s not going to stop us from having them.” Other things that genetic testing may tell parents and healthcare professionals: • • • • • • • • • • • • • Progression of hearing loss Perilymph gusher, if stapes is disturbed (DFNA1) Heart problems (Jervell and Lange-Nielsen) Vestibular abnormalities (Pendred) Large Vestibular Aquaduct/sudden hearing loss (Pendred) Thyroid enlargement (Pendred) Higher sensitivity to ototoxic meds (C.Mitochondrial) Anemia (Alports) Kidney problems (Alport and Branchi-oto-renal) Nerve tumors near the ear (NF2) Neck cysts (Branchio-oto-renal) Progressive blindness (Usher) Skin pigment changes (Waardenburg) Genetic testing can: • Allow doctors to make referrals to specialists for monitoring of potential associated health problems • Avoid clinical tests to rule out conditions down the road • Ease parental guilt by determining the cause of the hearing loss • Allow clinicians to develop an treatment strategy that anticipates future health problems • Predict the likelihood of having more children with hearing loss, or of current children having other children with losses or other symptoms. 16 Hearing Aid Fittings on Children Infancy to 5 Years Financial Assistance Referrals • Costs related to HL can be burdensome • Medically handicapped children’s programs • Medicaid • Service organizations • Hearing Aid Manufacturers Parent to Parent Support Offer parents the opportunity to talk to the parents of another child with a similar hearing loss. Hands and Voices: www.handsandvoices.org Listen Up!: http://www.listen-up.org/basics.htm 4. Ear Impressions in an infant ear 1 ½ months old 17 Hearing Aid Fittings on Children Infancy to 5 Years Ear Impressions & Earmolds • Proceed when? – Ears canals clear – Size adequate • For earmold (tubing) • For hearing aid 5. & 6. Hearing Instrument Selection Fitting Verification Selection Considerations 1. Binaural vs. Monaural 2. Kid-friendly (light alerts, colors, tamperresistant battery doors) 3. Loss/Damage/Repair Warranty 4. Small size 5. FM compatibility 6. Flexibility for changes in hearing 18 Hearing Aid Fittings on Children Infancy to 5 Years Always Fit Both Ears • Unless there is a clear contraindication • To facilitate development of neural function • Localization – connecting sounds to environment • Even in cases of asymmetrical hearing until there is evidence that fitting poorer ear is detrimental to performance Kid Friendly! Loss/Damage Warranty Warranty from the manufacturer (usually 2 yr loss, 2-3 year repair) Hearing aid Insurance Companies (ESCO, etc) Homeowner’s insurance – make sure parents check on what is covered where. Some companies don’t cover the loss if it happens away from the home. 19 Hearing Aid Fittings on Children Infancy to 5 Years FM Advantage • Increases loudness of primary speaker • Reduces negative effects of distance, reverberation, and background noise Flexibility • Remember we are working with limited info!!! – May have only ABR thresholds – May have only two or three behavioral thresholds – Loss may or may not be progressive • Need an aid with a range of output and gain that can grow with the child What if money isn’t an option? Should kids drive fully loaded? Not every advanced option is appropriate for infants and children. 20 Hearing Aid Fittings on Children Infancy to 5 Years Directional Microphones and Noise Reduction: Practical Issues Reducing sounds from behind can impact – Child’s safety – Child’s ability to “overhear” other talkers in his environment ’nuff said 21 Hearing Aid Fittings on Children Infancy to 5 Years What is the primary goal of verification? 1. To make sure the hearing aids make speech audible. 2. To make sure the hearing aids will never be too loud. Probe Microphone Measures Speechmap 22 Hearing Aid Fittings on Children Infancy to 5 Years Speechmap Speechmap Speechmap 23 Hearing Aid Fittings on Children Infancy to 5 Years Speechmap Speechmap Speechmap 24 Hearing Aid Fittings on Children Infancy to 5 Years What if a child can’t sit for real ear? Real Ear to Coupler Difference 25 Hearing Aid Fittings on Children Infancy to 5 Years “Why don’t you repeat my child’s hearing test, with the hearing aids on to verify benefit?” Functional Gain Testing pure tone and speech thresholds, in the sound booth, with the hearing aids on. Functional Gain doesn’t tell us 1. How well the hearing aids amplify speech 2. How loud the hearing aid will go 26 Hearing Aid Fittings on Children Infancy to 5 Years Functional Gain ProbeMic/RECD • • • • • • • • • • Not speech-level No loudness info Age constraints High variability Time consuming Speech-level inputs Loudness measures Age irrelevant Low variability Fast When Functional Gain? • Evaluation of bone-conduction hearing aids • Parent reassurance 7. Hearing Instrument Orientation (a process, not an event!) 27 Hearing Aid Fittings on Children Infancy to 5 Years Parent Orientation • New vocabulary • Use and care of instruments/earmolds • 1. Putting the hearing aid on • 2. Battery changes • How to perform daily listening/battery checks • Basic troubleshooting Hearing Aid Kit – written materials – batteries – dry-aid kit – listening tube – battery tester – earmold blower – retention device Retention ‒ Double-sided tape (toupee tape) ‒ It Stays www.supportshop.com ‒ Listen Up! webpage ‒www.listen-up.org 28 Hearing Aid Fittings on Children Infancy to 5 Years Huggies Knit Caps • Perfect for the 6-10 month olds! • May create feedback problems • Electroacoustically invisible • May be last retention option for some infants! hannaandersson.com Loss Prevention: Commercial vs Crafty 29 Hearing Aid Fittings on Children Infancy to 5 Years Reality Check • Despite your best efforts, babies will sometimes take off their hearing aids! 8. Follow-Up •New ear impressions as infant grows •New RECD and instrument adjustments as needed with new molds. •Behavioral testing with VRA at 6-7 months of age •Behavioral audios every three months until three years of age, then every six months until six years of age, or sooner, with progressive or fluctuating loss. •Close contact with family, teachers, and schoolbased audiologist •ASSESS: Is the child benefiting from amplification? Questions? 30 Hearing Aid Fittings on Children Infancy to 5 Years References • • • • • • • • • • • • Christine Yoshinaga-Itano*, Allison L. Sedey*, Diane K. Coulter*, and Albert L. Mehl (1998). Language of Early- and Later-identified Children With Hearing Loss . PEDIATRICS Vol. 102 No. 5 November 1998, pp. 1161-1171 Joint Committee on Infant Hearing (JCIH) www.jcih.org Moeller MP. (2000). Early intervention and language development in children who are deaf and hard of hearing. PEDIATRICS Vol. 106 No. 3 September 2000, p. e43 Sass-Lehrer, M. (2004). Early detection of hearing loss: Maintaining a family-centered perspective. Seminars in Hearing, 25, 295–307. Sjoblad s, Harrison M, Roush J, McWilliam R (2001) Parents' Reactions and Recommendations After Diagnosis and Hearing Aid Fitting. American Journal of Audiology Vol.10 24-31 June 2001. Martin P, Stroud J, Nicholson N. Hearing aids: Helping parents understand the good, the bad and the ugly. Unpublished presentation. National EHDI Conference; Atlanta, GA. 2005. My Baby’s Hearing, BTNRH – NIDCD web page: http://www.babyhearing.org/ From Roush et al 2004, based on the Gallaudet Research Institute. Regional and National Summary Report of Data from the 2001-2002 Annual Survey of Deaf and HOH Children and Youth. Washington DC: GRI, Gallaudet University; 2003 (N=42,361; 11/9% not reported) Hands and Voices: www.handsandvoices.org Listen Up!: http://www.listen-up.org/basics.htm It Stays - www.supportshop.com Hanna Andersson www.hannaandersson.com Julie Christensen, M.S. Boys Town National Research Hospital 555 North 30th Street Omaha, Nebraska 68131 [email protected] Julie Christensen, M.S. Staff Audiologist 31 Hearing Aid Fittings on Children Infancy to 5 Years A production of the Lied Learning & Technology Center at Boys Town National Research Hospital 555 North 30th Street Omaha, NE 68131 32