A New Era for the Identification and Treatment of Children with Auditory Disorders

Transcription

1 1 A New Era for the Identification and Treatment of Children with Auditory Disorders ROSS J. ROESER AND MARION P. DOWNS Nothing great was ever achieved without enthusiasm. Ralph Waldo Emerson It is a new era for children with auditory disorders those with mild and unilateral hearing loss; those with more severe hearing loss; those who are deaf; and those with auditory processing disorders who have hearing sensitivity within the normal range but who are unable to use sound for normal speech understanding. For professionals responsible for diagnosing and educating children with auditory disorders the challenges are no less than a revolution. Never before have technology and intensive habilitation combined to provide children having auditory disorders of all types with the opportunity to enter into a world of sound; to be able to develop their oral skills to a level that can equal those of their hearing peers. New understanding of how the brain processes sound and how treatments can improve performance are being uncovered each day. As we enter the new millennium, numerous changes bring joy to all who see the improved welfare of children with auditory disorders, but these same changes present a rigorous challenge for those in the educational system. Many ideas brewing in the 20th century have come to fruition in the 21st. Today there is an influx of new technologies for children with loss of hearing; there is a cohort of children whose usual and unusual hearing losses were identified at birth and who were immediately enrolled in habilitation programs; there are medical and genetic breakthroughs that will sharply decrease the number of ear and hearing disorders (see Chapter 4); and there are improved surgical applications that can reach clear down to the first year of deafened lives. For children with auditory processing disorders each day brings new information on the plasticity of the central nervous system and how treatments can improve learning to hear and educational performance. This book was inspired by the new developments in identifying and managing children with auditory disorders; the material covers a wide variety of topics regarding the law, identification, and remediation. As pointed out in Chapter 9, a regularly experienced phenomenon by all professionals serving children with special needs is that parents are better educated and are making greater and more informed demands of physicians, audiologists, speechlanguage pathologists, teachers, and school administrators to provide the very best programs for their children. This is a challenge, for sure, but also a boon for the child with hearing loss. Quintessential to this textbook is the well-established principle that each child MUST be the focus of the programs 1

2 2 AUDITORY DISORDERS IN SCHOOL CHILDREN, FOURTH EDITION provided by each and every professional serving that child. It was this principle that authors were asked to focus on when preparing chapters for this text. The chapters in this book cover the gamut of topics for professionals who work with all levels of auditory disorders. Each of the following sections provides an overview of the book. The Child with Mild and Unilateral Hearing Loss Until recent times the child with mild hearing loss was not considered at risk for educational delay. However, as pointed out in Chapter 10, studies have made it clear that children with hearing sensitivity once thought to be decreased by 15 to 20 db, but within normal limits, do, indeed, have potential delay. With the advent of screening programs outlined in Chapter 5, current technology makes it possible to identify children with minimal hearing loss and middle ear disorders, so that necessary measures can be provided for this at risk population. Newly acquired knowledge also makes it clear that children with unilateral hearing loss exhibit greater difficulty in understanding speech in the presence of competing background noise than do normal hearing children, which puts them at high risk for educational delay (see Chapter 10). Improving signal-to-noise levels in classrooms (see Chapter 12) and the use of classroom amplification (see Chapter 13) are important considerations for children with minimal/mild and unilateral hearing loss as well as for those with bilateral losses in the more severe ranges. The Child with Moderate and Moderately Severe Hearing Loss The child identified with moderate or moderately severe hearing loss has the added advantage of new technology in personal hearing aids that are more durable and reliable and have more sophisticated electroacoustic capabilities (see Chapter 11). There are also numerous resource materials to assist those who are educating children with hearing loss, as well as better classroom intervention strategies (see Chapter 18). As pointed out in Chapter 16, auditory training techniques and concepts have also become more sophisticated and effective. The Hearing Deaf Child Knocking at school doors are the families of children whose degree of hearing loss at birth would formerly have necessitated special oral classes, manual signing classrooms for children who were classified as Deaf, or even institutional placement. These are New Era children with hearing loss, and they make up what we will refer to as the Hearing Deaf population. If provided with the proper medical, audiological, and educational opportunities, Hearing Deaf children will gain admission into the classroom with their normal-hearing peers. It is now possible because the Hearing Deaf children will be speaking orally and intelligibly; their language level will be at or near their age level! If treated and educated properly these children will be able to function in society as hearing adults. A fantasy? Hardly. Currently, universal newborn hearing screening (UNHS) is mandated by legislation in 32 states (see Chapter 5), and the success has spawned an increasing demand for new educational techniques for habilitation models. As UNHS programs successfully identify infants with significant unilateral or bilateral hearing loss, the demand for clinical and educational services is taking on new meaning. Laws are changing to accommodate these children (see Chapter 2). Most significantly, clinical and educational staff members are being required to provide services to children identified with hearing loss who are significantly younger, which is both desirable and challenging. Prior to UNHS, the age of identification and intervention was consistently reported to exceed 2 years. Today, research has documented the desirable outcome for UNHS

3 CHAPTER 1 ANEW ERA FOR CHILDREN WITH AUDITORY DISORDERS 3 that identification and treatment are occurring significantly earlier (Harrison, Roush, & Wallace, 2003). Infants are being identified in birthing hospitals prior to discharge; it is not unusual in today s programs for parents to bring infants only weeks old to clinics for hearing aid fittings. The schools are being forced to step away from the tradition of grouping children with hearing loss into self-contained classes, and educators are being required to rethink the whole process of serving this New Era population with Hearing Deaf children. Current technology and educational intervention now make it possible for each child with hearing loss, even those in the severeto-profound range who are fitted with cochlear implants (see Chapter 15), to attain oral communication skills. Studies already document that Hearing Deaf children, if identified at birth and provided with appropriate habilitation, will show intelligible speech and are testing for language at levels near their hearing peers by school age. Among the leading investigators setting the pace for the New Era child are Christine Yoshinaga-Itano and her colleagues from the University of Colorado in Boulder and Mary Pat Moeller and her colleagues from The Boys Town Institute in Omaha. Early Identification of Hearing Loss: ACritical Factor Yoshinaga-Itano, Sedey, Coulter, and Mehl (1998) studied the language development of 150 children, 72 of whom had hearing loss identified prior to 6 months of age and were placed in intervention services at an average of 2 months after diagnosis. Another 78 children had hearing losses identified from 7 months to 30 months of age. All but four of the entire group had received immediate, appropriate intervention through public health or private agencies. All were given the Minnesota Child Development inventory, with both Receptive and Expressive Language Scales. The findings from this and similar studies are summarized in the following four sections. The Importance of Early Identification Children identified and habilitated before 6 months of age have receptive and expressive language quotients significantly higher than children whose hearing losses were identified after 6 months of age. The differences averaged 20 developmental quotient points. The impact of early identification was present and independent of gender, secondary disability, socioeconomic status, cognitive status, or type of habilitation services (viz., sign language, total communication, or auditory verbal training). From these data it is clear that infants and toddlers identified before 6 months of age had higher language quotients than those identified later. The importance of this finding stresses the need for universal neonatal hearing screening to improve the probabilities that normal language development will occur. The Degree of Hearing Loss Has Little Relation to the Level of Language Skills Those in the mild hearing loss group (26 to 40 db) had an average language score only slightly better than the average language score than the more severe hearing loss groups, including the profound group (over 90 db). The finding that degree of hearing loss has minimal effect on language development leads to a great deal of speculation. Is there a language center in the brain that requires a focused minimal amount of stimulation to develop maximally? Is there an effect from the lack of hearing during the 4 months that the normal fetus hears prenatally? One can only continue to speculate. The Early Identification Advantage Persists into the School Years Yoshinaga-Itano and Coulter (1998) followed 125 early-identified children until kindergarten and found that the advantage of early identification was still present as they entered school. Moeller (1998) provided longitudinal data on 150 deaf and hard-ofhearing children to the age of 7 years. Results from both studies clearly showed the

4 4 AUDITORY DISORDERS IN SCHOOL CHILDREN, FOURTH EDITION early-identified group maintained their language advantage to the 7 years level. From this study it is clear that current technology and habilitative strategies are facilitating the means for normal language development, and it is logical to assume that the advantage will persist throughout the school years. Intelligible Speech Shows an Advantage from Early Identification, but on Different Time Lines Yoshinaga-Itano and Sedey (2000) evaluated speech intelligibility of 147 deaf or hard-ofhearing children from 14 months of age to 60 months using phonetic transcription. The strongest factor in predicting speech skills was the age of identification. By almost 5 years of age, even those with moderate-tosevere hearing loss had achieved significant intelligibility. The profound losses did not succeed in any recordable speech skills. Findings from the preceding research have made it clear that the child with hearing loss born today has opportunities unlike any time before in history. Although these opportunities present themselves to every child living in a developed society where the technology and clinical and educational services are available, success is dependent on the coordination of technology with services services that are provided in an effective way. Such services can be part of the Audiology Home described later. Children with Auditory Processing Disorders It has been recognized for many years that some children and adults have been classified as having normal hearing, but they are not able to hear and understand sounds, especially speech sounds, in the presence of noise. These individuals are unable to process sounds properly thus they are classified as having an auditory processing disorder (APD). When evaluated with the standard audiological test battery (see Chapter 3) the majority of those with APD will have test results classified within normal limits. The past 3 decades have brought significant changes in the diagnostic test battery and treatment strategies for children with APD. As detailed in Chapter 6, the level of sophistication in knowledge and understanding of APD has increased significantly. The diagnostic audiological test battery for APD has become more sensitive. Most notable is the report of the University of Texas at Dallas/Callier Center for Communication Disorders consensus conference on the diagnosis of APD in school children (Jerger & Musiek, 2002). The report suggests that screening for APD be considered; gives guidelines on how to screen for APD; provides assumptions, listener variables, and principles for differential diagnosis of APD; details a minimal test battery for APD in school children; and suggests areas for future research. The UTD/Callier Center APD consensus report represents a significant advancement for understanding and diagnosing APD. Better diagnostic procedures for APD are accompanied by improved treatment techniques. Chapter 17 details a comprehensive array of classroom and therapy procedures for children with APD. The Audiology Home As treatments for children with auditory disorders have become more effective, they have also become more comprehensive, sophisticated, and complex. Oftentimes the necessary services for children with auditory disorders require a team of professionals, including medical specialists, audiologists, speech-language pathologists, teachers of hearing-impaired children, psychologists, and others. The Audiology Home (see Chapter 5) is a family-oriented service center where each child s treatment program can be centralized and coordinated (Jerger, Roeser, & Tobey, 2001). The Audiology Home should be the cornerstone for the successful management of infants and young children with auditory disorders. Given the nature of the disorder to be treated, the Audiology Home needs to be a multidisciplinary, familyoriented center providing all of the services

5 CHAPTER 1 ANEW ERA FOR CHILDREN WITH AUDITORY DISORDERS 5 necessary to attain maximal educational achievement. Included in the array of services are audiological assessment and intervention, family counseling and support (see Chapter 19), community outreach and education, communication intervention, outcome assessments, and documentation of progress. To be most effective, the team should include, but not necessarily be limited to, physicians, audiologists, communication development specialists, counselors, and psychologists (see Chapters 7 and 8). A key ingredient for success is to have professionals in the Audiology Home meet regularly and interface with each other. Regular communications updating professionals with progress and setbacks will allow for program modifications. As the child ages, members of the Audiology Home should work in close collaboration with educational programs to ensure optimal intervention for maximal speech and language development. Audiology Homes exist whenever and wherever multidisciplinary teams of professionals function to serve children with hearing loss. Audiology Homes can be found in community centers, hospitals, and schools. It is clear that in today s complex environment, to achieve the most desirable results, it takes a team to manage children with hearing loss effectively; it takes an Audiology Home. This text contains the essential information for professionals working in Audiology Homes to provide the very best services to each child served. References Harrison, M., Roush, J., & Wallace, J. (2003). Trends in age of identification and intervention in infants with hearing loss. Ear Hear, 24, Jerger, J., & Musiek, F. (2002). Report of the consensus conference on the diagnosis of auditory processing disorders in school-aged children. Journal of the American Academy of Audiology, 11, Jerger, S., Roeser, R.J., & Tobey, E. (2001). Management of hearing loss in infants: The UTD/Callier Center position statement. Journal of the American Academy of Audiology, 12, Moeller, M. (1998, June). A diagnostic early intervention project: Strategies and outcomes. Paper presented at the National Symposium on Infant Hearing, Denver, Colorado. Yoshinaga-Itano, C., & Coulter, D. (1998, June). Preliminary reports on the impact of early identification on language development of preschool-aged deaf and hard-ofhearing children in Colorado: Predictors of successful outcomes of deaf and hard-of-hearing children of hearing parents. Paper presented at the National Symposium on Infant Hearing, Denver, Colorado. Yoshinaga-Itano, C., & Sedey, A. (2000). Early speech development in children who are deaf or hard of hearing: Interrelationships with language and hearing. The Volta Review, 100, Yoshinaga-Itano, C., Sedey, A., Coulter, D., & Mehl L. (1998). Language development of early- and lateridentified children with hearing loss. Pediatrics, 102,

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