LISTENING TO KIDS: OPTIMIZING TECHNOLOGY. Joan Hewitt Jane Madell Sylvia Rotfleisch

Transcription

1 LISTENING TO KIDS: OPTIMIZING TECHNOLOGY Joan Hewitt Jane Madell Sylvia Rotfleisch

2 HOW WE GOT STARTED We (individually) had concerns about the unexplained disparity in the development and performance of our kids. We talked to other clinicians working with our kids and they did not always share our concerns and had different expectations. We started asking each other for help and learning from each other s experiences. Result significant improvement in performance of the kids we had concerns about!

3 GETTING STARTED Things are fine for most kids. Why are some kids superstars and other kids not? Why the huge variation among kids who seem to be equal? We know that not all kids do equally well, but why?

4 LOOKING FOR EXPLANATIONS Some things are clearly a problem: Not hearing well with technology Not getting appropriate therapy Parents not involved Developmental issues Other BUT sometimes everything is lined up and kids are still not achieving what we would expect

5 LEARNING OBJECTIVES Understand age appropriate expectations for the development of auditory, speech and language skills and differentiate developmental issues from therapy issues from technology issues Identify red flags in the development of auditory, speech and language skills and needed intervention Learn strategies for assessing areas in need of remediation and for assessing issues requiring changes to technology

6 EXPLANATIONS WE HAVE HEARD FOR POOR PERFORMANCE What do you expect he s deaf! The child is not available for learning. It s amazing how many kids with CIs are apraxic! His father s a truck driver, you know. We ve needed to sign more in his auditory/oral class than we normally do.

7 EXPLANATIONS WE HAVE HEARD FOR POOR PERFORMANCE It s not like he s going to Harvard. We re fine with her progress. It s better than most other kids in our program. We see a different class of parents so our expectations are different. Cochlear implants don t work for everyone. Second implants don t provide much benefit.

8 EXPLANATIONS WE HAVE HEARD FOR POOR PERFORMANCE He needs to stop ripping the HA (or CI) off so we recommend that he wear it turned off. My heart breaks to think your AVT expects more progress. If you expect him to say all this, we will need to add sign language. Having a [/k/, /g/ or /s/] at age 4 is not age appropriate. He has poor neural survival.

9 OUR PHILOSOPHY If a child is not making appropriate progress, there is a reason. We have an obligation: To figure out why To think outside of the box To try and address the problem All clinicians/team members need to work collaboratively to make this successful. We must include parents as critical team members. It is almost always possible to succeed.

10 WHY AUDITION IS IMPORTANT?

11 WHY IS LISTENING CRITICAL? Hearing is the most efficient way to develop spoken communication and literacy. Hearing = auditory brain development It is not really about the ears it is about the brain! Technology is really a brain access tool. Acoustic access to intelligible speech is critical for development of the auditory brain. The auditory cortex is involved in speech perception and language processing in humans.

12 THE AUDITORY BRAIN The brain has essential plasticity. Stimulation of the auditory brain will permit it to develop. Even very deaf children can develop an auditory brain. 95% of children with hearing loss are born to hearing parents. Spoken language is the most natural language for the parents to provide.

13 WHY AUDITION? For parents who chose spoken language for their children, listening and speaking are possible. Audition is the most efficient avenue for learning language. Technology can provide auditory access for almost any child.

14 CRITICAL PERIODS The level of maturity of the auditory cortex depends on the richness of exposure and experience. (Merzenich, 2010) Normal hearing infants begin to hear by 28 weeks gestational age. The central pathways develop and mature in response to sound traveling through the brainstem up to the auditory cortex. Without exposure, the auditory cortex cannot develop.

15 CRITICAL PERIODS Birth to 5 years is the critical period for development of neuronal connections. Birth to 2 years, create synaptic connections which continue until around 8 years of age as exposed to new skills. Connections are forced to compete with other areas for connections. If the auditory cortex is not stimulated, that area will be taken over by other skills, primarily, vision. So, time is of the essence. We cannot do it later.

16 NEURAL DEVELOPMENT Auditory cortex begins to develop in utero : All that is required to develop the auditory cortex is exposure to sound. The auditory language centers of the cortex will not develop if the auditory cortex is not stimulated. If a child with HL received auditory access by 3 years of age, the auditory cortex can develop (Sharma et al, 2009).

17 NEURAL DEVELOPMENT Changes in auditory cortex are effected by learning; skills build on skills. Neural organization builds on lower level maturation, stimulation, and practice. Birth to 6 years is the critical period for language development. Higher cortical levels develop through age years.

18 LANGUAGE AND ACCESS TO SOUND Babies brains are actively programmed to listen and speak. With good auditory access, babies naturally develop language through listening. It is necessary to understand spoken language before learning spoken and written language. Children who do not understand spoken language have much more difficulty with literacy.

19 NEURAL DEVELOPMENT Hart and Risley: Children need to hear 46 million words by age 4 years. Dehaene: 20,000 hours of listening is the basis for reading. Pittman: Children with hearing loss need 3 times the exposure to learn new words and concepts due to reduced acoustic bandwidth caused by hearing loss.

20 TIME IS OF THE ESSENCE!! SO WHAT DOES THIS MEAN? Get technology on quickly. Make sure it is appropriately set. TALK, TALK, TALK, TALK, TALK, TALK, TALK, TALK, TALK, TALK,

21 WHAT DO WE NEED TO MAKE IT WORK? Early identification and early fitting of technology Appropriate auditory access with technology Consistent use of technology every waking hour Typically hearing children have access to sound 24 hours/day. If a child wears technology 4 hours/day, it will take 6 years for that child to hear what it takes a typically hearing child to hear in 1 year. Until technology is appropriately fit, auditory learning cannot take place. Consistent auditory stimulation Ability to hear soft speech Auditory therapy with family involvement

22 AUDITORY BRAIN DEVELOPMENT Appropriate Technology + Appropriate Auditory Exposure = AUDITORY BRAIN DEVELOPMENT

23 AUDITORY BRAIN DEVELOPMENT Appropriate Technology + Appropriate Auditory Exposure = AUDITORY BRAIN DEVELOPMENT

24 AUDITORY BRAIN DEVELOPMENT Appropriate Technology + Appropriate Auditory Exposure = AUDITORY BRAIN DEVELOPMENT

25 WHAT HAPPENS IF BABIES DO NOT HAVE APPROPRIATE AUDITORY ACCESS? Reduced auditory brain development Delayed skills Skills build on each other Advanced skills do not develop Delayed skills become increasingly difficult to remediate Ling What I hear is what I say! Children speak the way they hear. So listen to the kids!!!

26 THE MOST BASIC RED FLAGS

27 RED FLAGS: BASIC behavioral observations Child not tolerating technology Child resistant to wearing technology Too loud, too soft, distorted Behavior management issues Behavioral observations No response to sound Involuntary eye blinks/facial stim when wearing devices Hypersensitive to sound IF CHILDREN HEAR WELL WITH THEIR TECHNOLOGY, THEY SHOULD WANT IT ALL DAY, EVERY DAY!!

28 RED FLAGS: Parental concern Parents (or other family members, esp. grandparents) are concerned about progress Are they realistic? Parents are novices; if their concerns are valid, a professional should have noticed.

29 INTERVENTIONAL RED FLAGS OR IS THE INTERVENTION APPROPRIATE?

30 RED FLAGS: Ineffective Intervention Child and family are enrolled in therapy which: Involves the child without involvement of the parents and family Does not monitor technology at every session Does not stress the development of audition as the basis of all speech and language Promotes visual language development (lipreading, sign language) Does not follow a developmental model

31 RED FLAGS: Ineffective Intervention - Parents Parents do not know therapy goals and objectives and are unable to follow through at home. Parents do not know what the child can and cannot hear. Therapist does not know what the child can and cannot hear. Unable to clearly define auditory skills or difficulties Therapist can only report he is doing fine. Unable to clearly describe child s abilities or difficulties Primary focus in therapy is THE LING SIX SOUNDS.

32 How do we address this? Parents PARENTAL COMPONENT IS CRITICAL!! Different auditory based therapy model suggested such as Auditory-Verbal Therapy Parents need to be involved in the therapy sessions and trained in sessions Therapy for 1, 2 or even 3 hours does not replace parental involvement and reinforcement 24/7

33 Principles of LSLS Auditory-Verbal Therapy 1. Promote early diagnosis of hearing loss in newborns, infants, toddlers, and young children, followed by immediate audiologic management and Auditory-Verbal therapy. 2. Recommend immediate assessment and use of appropriate, state-of-the-art hearing technology to obtain maximum benefits of auditory stimulation. 3. Guide and coach parents to help their child use hearing as the primary sensory modality in developing listening and spoken language.

34 Principles of LSLS Auditory-Verbal Therapy 4. Guide and coach parents¹ to become the primary facilitators of their child's listening and spoken language development through active consistent participation in individualized Auditory-Verbal therapy. 5. Guide and coach parents¹ to create environments that support listening for the acquisition of spoken language throughout the child's daily activities. 6. Guide and coach parents¹ to help their child integrate listening and spoken language into all aspects of the child's life.

35 Principles of LSLS Auditory-Verbal Therapy 7. Guide and coach parents¹ to use natural developmental patterns of audition, speech, language, cognition, and communication. 8. Guide and coach parents¹ to help their child self-monitor spoken language through listening. 9. Administer ongoing formal and informal diagnostic assessments to develop individualized Auditory-Verbal treatment plans, to monitor progress and to evaluate the effectiveness of the plans for the child and family. 10. Promote education in regular schools with peers who have typical hearing and with appropriate services from early childhood onwards.

36 How do we address this? Parents Parents need to understand and help determine what the child can and cannot hear. Parent and therapist must work together as a team. Therapist establishes appropriate goals and incorporates them into the sessions. Therapist teaches parent the goals and appropriate follow through to reinforce the goals during the week. Parent provides information to the therapist on observations noted throughout the week. If only one person can come to therapy, it would be better if it were the parent than the child. Parents need to be the teachers.

37 RED FLAGS: Ineffective Intervention - Technology Therapist is not checking technology at the beginning of EVERY therapy session Therapist is not teaching the parents to check technology DAILY. If the technology is NOT functioning properly, ALL intervention is compromised and possibly useless.

38 How do we address this? Technology Checking technology Who is checking it daily? Do clinicians and parents have appropriate listening technology (hearing aid stethoscope, CI earbuds, CI listening check)? Do clinicians know how to use the technology? Do parents know how to use the technology?

39 RED FLAGS: Technology malfunction Hearing aids checked through hearing aid stethoscope No signal Distorted signal Intermittent signal Static Certain sounds inaudible Feedback (earmold? HA?)

40 RED FLAGS: Technology malfunction Cochlear implant processors checked through earbuds or Listening Check No signal Distorted signal Intermittent signal Static Certain sounds inaudible

41 RED FLAGS: Other signs of technology problems Signs of difficulty Not responding to high frequency stimuli Poor high frequency responses Distorted vowel production Dropping certain consonants consistently Speech sound deterioration Mishearing Increased what? Reporting static Any sudden and/or dramatic change in performance

42 How do we address this? Technology WHEN IN DOUBT, CHANGE IT OUT!!!!

43 RED FLAGS: Ineffective Intervention - Audition Child demonstrates poor auditory abilities: Not responding or turning to name Listening attitude not evident Poor voice quality Unable to discriminate / identify Suprasegmentals Vowels Familiar phrases based on suprasegmentals and/or key words Consonant features Speech production not improving

44 How do we address this? Understand audition Audition - For Hard of Hearing / Deaf, the hearing loss limits access to speech and language; thus, the hearing loss creates the delayed speech and language. Defined auditory component to therapy Auditory skill development in appropriate sequence must be the focus of therapy Auditory abilities are developed through the auditory modality

45 How do we address this? Understand audition Establish Auditory Goals Appropriate sequence know progression of audition Appropriate level of difficulty Continue to progress through sequence Incorporate in every activity in every session Provide guidance and coaching to parents so they can follow through all week in all settings

46 How do we address this? Demand audition Establish Audition as Primary Sense Modality Set the child (and parent) up for Success Physical arrangement of furniture/ room How should you be seated to enhance audition? Strategies for enhancing focus on audition Joint attention Listening is critical Acoustic highlighting techniques Whispering Suprasegmentals (caregiver ease) Elongations at phonetic level and reinforced at phonologic

47 How do we address this? Demand audition Establish Audition as Primary Sense Modality Present signal through audition first 3 act play auditory sandwich Improve auditory access coupled with technology 6 db rule Set up the auditory skill for success Begin at the beginning to establish foundation skills Enhance perception Don t correct speech, enhance auditory perception

48 How do we address this? Demand audition Auditory closure Establish Audition as Primary Sense Modality Listening as the foundation for communication I listen to you and then you listen to me Turn taking has an auditory basis to allow for conversational competence and convention

49 How do we address this? Demand audition in therapy As a clinician, check your demand for audition: Is the technology worn in therapy? Do I know what the child can and cannot hear? Is the child expected to report equipment problems? Do I appropriately minimize input through sensory modalities other than audition? Are listening and hearing the critical components of all activities in therapy? Am I making the expectations clear to the child and parents? Am I teaching carry over of the these expectations to the child s daily life?

50 How do we address this? Demand audition at home As a clinician, teach parents to check their demand for audition: Is the technology worn all day? How do parents deal with child s removal of equipment? Do parents expect the child to respond to sound? Do parents know what the child can and cannot hear? Do parents appropriately minimize input through sensory modalities other than audition? Do parents know what to be targeting with the child? Do parents have appropriate and consistent auditory expectations? Do parents make the expectations clear to the child? Are listening and hearing critical elements of the family s everyday life?

51 How do we address this? Demand audition at school School professionals need to be members of the team Carry-over of the importance and consistency of audition from therapy to the home to the school environment School team needs to be inserviced and understand the technology and importance of audition School team needs to establish a plan for creating and maintaining the demand for audition

52 How do we address this? Demand audition at school As a clinician, help school professionals check their demand audition: Is the technology worn all day? How do teachers deal with child s removal of technology? Do teachers expect the child to respond to sound? Do teachers know what the child can and cannot hear? Are teachers able to determine if the child s technology is not functioning? (battery dead, broken, not being worn) Do teachers expect the child to report technology difficulties Does the school environment require hearing and listening consistently throughout the day?

53 RED FLAGS: Ineffective Intervention Visual speech Vision as primary modality Indications of speech acquisition through vision Visual based errors (nasals/ plosives if same place of production) Poor controls of suprasegmentals (elongations, pitch control/ breaks, syllabification) Pitch dependent vowels (lip rounding for oo, lip spread for ee )

54 Importance of Audition "...audition is the only sense capable of appreciating all aspects of speech..." Ling

55 How do we address this? Visual speech Preventing Visual Speech Focus on audition and eliminate vision Understand the weakness of vision to access speech What speech features are accessible visually? Understand the strengths for auditory access for speech development

56 How do we address this? Visual speech Eliminate exaggerations Preventing Visual Speech If it seems unnatural, it is probably going to create a problem What exaggerations would cause issues?

57 SPEECH/LANGUAGE RED FLAGS OR IF INTERVENTION IS APPROPRIATE, WHAT PROBLEMS INDICATE IT S TIME FOR ADDITIONAL HELP?

58 RED FLAGS: Auditory observations Child does not tolerate technology Child cannot tolerate specific sounds/ noises Water running (faucet, toilet flushing) dog barking, vacuum Skills from hearing aids do not readily transition and become skills with CIs Relies on visual input for skills watches like a hawk Child does not respond to sound or to name Responding to less sounds with HAs on than with HAs off Responding to less sounds with CIs on than previously with HAs

59 RED FLAGS: Speech Production Poor voice quality Gravelly Intensity - whispers or too loud or unable to produce whisper Poor oral nasal balance Poor pitch control Vocalizations on inhale

60 RED FLAGS: Speech Production Poor syllabification Poor vowel recognition Vowel development, but no consonant development Issues of concern regarding consonant development Inappropriate/unusual consonant development Primarily low frequency sounds with CIs, or high frequency sounds with HAs Nasal emissions Lateral fricatives Limited variety of manners of production

61 RED FLAGS: Speech Production Issues of concern regarding consonant development (con t) Limited variety of place of production Primarily alveolar or bilabial consonants Sequence of sound development inappropriate Developing more advanced phonemes but gaps in skills (e.g. missing G / K only, no bilabials) Voiced sounds, but no unvoiced sounds Unable to elicit specific speech features (bilabial place)

62 RED FLAGS: Language Development Lack of development of conversational babbling / jargoning Babbling / jargoning, but no intelligible vocabulary or language development Receptive language development, but no parallel development of expressive abilities

63 RED FLAGS: Deterioration of Skills Speech discrimination deteriorates No longer demonstrates perception, discrimination or comprehension previously observed Speech production deteriorates Unable to produce a phoneme previously mastered or emerging Vocabulary and language development plateau or regression

64 NEVER ASSUME!!!! ALWAYS COLLECT DATA!!! You must test to begin to determine what is affecting progress. Your data and documented observations are essential to appropriate remediation of the problems.

65 IF A CHILD HAS APPROPRIATE PARENTAL AND INTERVENTIONAL SUPPORT, THEN RED FLAGS POINT TO TECHNOLOGY ISSUES.

66 TECHNOLOGY ISSUES FOR HEARING The most important use of our hearing is for speech and language perception. Very simply, speech and language perception issues result from one or more of four situations: I did not understand because it was too quiet. I did not understand because it was too loud. I did not understand because it was not clear. I did not understand because I do not have the language development.

67 HOW DO HEARING AIDS AND COCHLEAR IMPLANTS PROCESS SOFTNESS, LOUDNESS, AND CLARITY?

68 HEARING AIDS Hearing aids provide acoustical stimulation. Today s digital hearing aids have 3 to 16 frequency bands which correspond to the frequency range of human speech. Today s digital hearing aids have the ability to process soft sounds, normal conversational sounds, and loud sounds separately. Hearing aid computer programs and real ear measurements give NO information about how the auditory brain receives speech and language!

69 COCHLEAR IMPLANTS Cochlear implants provide electrical stimulation. Today s cochlear implants have from 12 to 22 frequency bands which correspond to the frequency range of human speech. Today s cochlear implants process normal conversational speech (C or M levels) and soft speech (T levels). Today s cochlear implants provide neural response testing (NRT, NRI) which objectively estimates the amount of electrical stimulation needed on a specific electrode. MAPs and neural responses give NO information about how the auditory brain receives speech and language!

70 IF HA AND CI PROGRAMS DO NOT TELL US WHAT A CHILD HEARS, THEN WHAT DOES? Children provide us with accurate and reliable information about what they hear: When we observe and understand their behaviors Parents, clinicians, teachers, family members, and friends are essential to this process When we listen to what they say and how they say it Parents, clinicians, teachers, family members, and friends are essential to this process When they complete detailed audiological testing with an experienced pediatric audiologist

71 FOR A DETAILED AUDIOLOGICAL EVALUATION, WHAT DO WE NEED TO TEST? Unaided thresholds Thresholds with technology Right, Left, Binaural Speech perception with technology 50 db HL (normal conversation) - R, L, B 35 db HL (soft conversation) B (R, L if possible) 50 db HL +5 S/N Ratio (normal conversation in noise) B.

72 RED FLAGS: Audiological Evaluation Audiological red flags with technology: Hearing very soft sounds Thresholds 0-15 db HL, especially for young children Not hearing soft conversation Thresholds 35 db HL or poorer Poor speech perception at normal conversational level (50 db HL) Poor speech perception at soft speech level (35 db HL) Poor speech perception at loud speech level (70 db HL)

73 RED FLAGS: Audiological Evaluation Audiological Red Flags (con t) Poor single word speech perception with good sentence recognition Good single word speech perception with poor sentence recognition Poor single word speech perception with poor sentence recognition Speech perception testing completed with inappropriate test materials

74 WHAT RED FLAGS INDICATE SPEECH IS TOO SOFT? HOW DO WE ADDRESS THESE?

75 HEARING AIDS: UNDER AMPLIFICATION RED FLAGS: Parents consistent with hearing aid usage, BUT Child consistently removes the hearing aids Child turns up HA volume Child relies on visual input Child does not respond or turn to name Child s vocalizations do not change with the hearing aids OR- Child is loud Listening/speech/language development is slow or nonexistent Speech perception at 70 db HL is better (12% or greater) than at 50 db HL

76 HEARING AIDS: UNDER AMPLIFICATION RX: Check to ensure amplification is working appropriately Audiological testing to verify unaided/aided hearing thresholds Phoneme perception testing Hearing aid reprogramming to increase amplification for normal conversation, soft speech, and possibly loud sounds Trial with different hearing aids Cochlear implant evaluation

77 HEARING AIDS: UNDER AMPLIFICATION CASE STUDY #1: 5.5 yr old boy

78 HEARING AIDS: UNDER AMPLIFICATION CASE STUDY #1: 5.5 yr old boy aided at age 3.6 RIGHT EAR LEFT EAR Unaided at 70 dbhl 52% 52% Aided PBK Words at 50 dbhl 32% 32% Aided PBK Words at 35 dbhl 0% 0% Aided HINT Sentences at 50 dbhl (in quiet) 78% 80%

79 HEARING AIDS: UNDER AMPLIFICATION CASE STUDY #1: 2 weeks later (hearing aids reprogrammed) RIGHT EAR LEFT EAR Unaided at 70 dbhl 52% 52% Aided PBK Words at 50 dbhl 66% 84% Aided PBK Words at 35 dbhl 72% 84% Aided HINT Sentences at 50 dbhl (in quiet) 87% 89%

80 LESSONS FROM EXPERIENCE: UNDER AMPLIFICATION The hearing aid program dictated by the computer may need adjustment. Some hearing aid software bases programming on the needs and wants of adults. Adult algorithms generally underestimate the overall gain needed for children. Adult algorithms also often underestimate the low frequency and high frequency gain needed for children. Feedback circuits can significantly reduce gain. A standard earmold or a poor fitting earmold can significantly reduce gain.

81 COCHLEAR IMPLANTS: UNDERSTIMULATION RED FLAGS: Child consistently removes the cochlear implants Child relies on visual input Skills with hearing aids do not transfer to CIs Child does not respond or turn to name Child s vocalizations do not change after implantation OR- Child s voice sounds like a whisper with CI Child develops voiceless consonants, but nothing else Auditory/speech/language development is slow or nonexistent Child turns up volume and/or sensitivity of CI Speech perception at 70 db HL is better (12% or greater) than at 50 db HL

82 COCHLEAR IMPLANTS: UNDERSTIMULATION CASE STUDY #2: 37 year old congenitally deaf adult implanted in her right ear with a Cochlear Nucleus 24 implant at 33. Patient wore her implant most days because it seemed to help her hearing aid. Patient reported, I always feel like I m on the verge of hearing. Sometimes I think it s going to be loud enough to hear in my CI, but it never is.

83 COCHLEAR IMPLANTS: UNDERSTIMULATION CASE STUDY #2:

84 COCHLEAR IMPLANTS: UNDERSTIMULATION CASE STUDY #2:

85 COCHLEAR IMPLANTS: UNDERSTIMULATION CASE STUDY #3: 5.10 year old male who was implanted in his left ear with a Nucleus 24C at age 2.8 and was now fully mainstreamed in kindergarten. Patient had recently moved and was seen by a new audiologist. The audiologist asked the patient to rate the loudness of several electrodes and created a new MAP from that rating. All C levels were identical and significantly lower than the previous MAP. Patient rated all electrodes: quiet, good, loud. Patient cooperated during the MAPping, but started to cry when he was leaving and stated he could not hear.

86 COCHLEAR IMPLANTS: UNDERSTIMULATION CASE STUDY #3: 250 Hz 500 Hz 1000 Hz 2000 Hz 4000 Hz 6000 Hz 25 db 25 db 25 db 25 db 20 db 20 db Speech Awareness Threshold (SAT) = 20 dbhl The patient insisted he could not hear, but the audiologist wrote in her report, [Pt] did fabulous today! and recommended wearing the new MAP for 3 weeks to allow patient time to adjust.

87 COCHLEAR IMPLANTS: UNDERSTIMULATION CASE STUDY #3: Over the next 3 weeks, the parents reported lots of ignoring and frustration. The child returned to our clinic. Audiological testing revealed: LEFT CI Speech Reception Threshold (SRT) 40 dbhl Aided PBK words at 50 dbhl 12% Aided PBK words at 70 dbhl 40% While this patient detected sound, stimulation levels were too low and speech was too quiet.

88 COCHLEAR IMPLANTS: UNDERSTIMULATION CASE STUDY #3: Cochlear implant was reprogrammed over a three week period. Audiological testing revealed: LEFT CI Speech Reception Threshold (SRT) 25 dbhl Aided PBK words at 50 dbhl 80% Aided PBK words at 35 dbhl 76%

89 COCHLEAR IMPLANTS: UNDERSTIMULATION RX: Listening check to ensure CI is working appropriately Ensure that MAP is in compliance Phoneme perception testing Cochlear implant reprogramming to increase C or M levels Cochlear implant reprogramming to increase the pulse width

90 LESSONS FROM EXPERIENCE: UNDERSTIMULATION It is essential to ensure that a processor/battery can deliver the MAP. Young children are unable to reliably rate the loudness of sound. Can any prelingually deafened person accurately rate loudness? Can any of us accurately rate loudness of tones? Early neural response software estimated T levels. Newer neural response software estimates C or M levels.

91 WHAT RED FLAGS INDICATE SPEECH IS TOO LOUD? HOW DO WE ADDRESS THESE?

92 HEARING AIDS: OVERAMPLIFICATION RED FLAGS: Child consistently removes one or both hearing aids Child turns down volume of HAs Child startles and/or cries to loud sounds Involuntary eye blinks to sound Child s voice is very quiet OR- Child is silent and withdrawn Speech perception at 70 db HL is poorer (12% or greater) than at 50 db HL

93 HEARING AIDS: OVERAMPLIFICATION RX: Check to ensure amplification is working appropriately Audiological testing to verify unaided/aided thresholds Phoneme perception testing Hearing aid reprogramming to reduce amplification of loud sounds and possibly normal conversational and soft sounds Trial with different hearing aids

94 HEARING AIDS: OVERAMPLIFICATION CASE STUDY #4: Birth history Patient born at 35 weeks Jaundice, anoxia, nasal stenosis 8 days in NICU Audiology history No newborn hearing screening Mom suspected hearing loss at 10 months because no words developed Diagnosed with atresia/microtia at 18 months Fitted with power analog hearing aid in right ear at 20 months Initially pulled out hearing aids AV Therapy Enrolled in private AVT at 20 months

95 HEARING AIDS: OVERAMPLIFICATION CASE STUDY #4: Developmental history: Mom described child as previously being easy going, mild mannered Between 18 months and 24 months, unusual behaviors developed (lack of eye contact, unwillingness to interact, escalating tantrums) Diagnosed as being on the autism spectrum at 26 months Enrolled in 30 hours per week of ABA for next 3 years AVT discontinued with focus on ABA

96 HEARING AIDS: OVERAMPLIFICATION CASE STUDY #4: 5.0 yrs old Unaided Speech Awareness Threshold (SAT) = 30 dbhl Put it in

97 HEARING AIDS: OVERAMPLIFICATION CASE STUDY #4: 5.1 yrs old O O O O O Electroacoustical Evaluation of Hearing Aid revealed: --Low frequency gain reduced --High frequency gain set to maximum --75 dbspl peak gain at 1000 Hz

98 HEARING AIDS: OVERAMPLIFICATION CASE STUDY #4: Speech Testing: UNAIDED SPEECH TESTING Speech Awareness Threshold (SAT) Speech Reception Threshold (SRT) RIGHT EAR 25 dbhl 40 dbhl NU-Chips words at 70 dbhl 75% AIDED SPEECH TESTING Aided SRT RIGHT HEARING AID 35 dbhl Aided NU-Chips at 50 dbhl 44% Aided NU-Chips at 35 dbhl 84%* *Significant improvement in intelligibility and inclusion of final consonants noted at 35 dbhl

99 HEARING AIDS: OVERAMPLIFICATION CASE STUDY #4: 5.2 yrs old New HA AIDED SPEECH TESTING NEW RIGHT HEARING AID Aided SRT 15 dbhl Aided NU-Chips at 50 dbhl 80% Aided NU-Chips at 35 dbhl 64%

100 LESSONS FROM EXPERIENCE: OVERAMPLIFICATION Don t ever assume the degree and configuration of the hearing loss. Not all hearing aids can appropriately fit all hearing losses. The hearing aid program dictated by the computer may need adjustment. Hearing aid programming can estimate ear canal size. Recruitment does occur in children. If speech perception at 70 db HL is significantly poorer (approx. 12% poorer) than speech perception at 50 db HL, then hearing aid is providing too much amplification.

101 COCHLEAR IMPLANTS: OVERSTIMULATION RED FLAGS: Child consistently removes one or both CIs Skills with hearing aids do not transfer to CI Child is not bonded with CI Involuntary eye blink to loud sounds Hypersensitivity to sound Ability to hear very, very soft sounds (thresholds 15 db HL or softer) Child s voice is very loud and/or gravelly OR- Child is silent

102 COCHLEAR IMPLANTS: OVERSTIMULATION RED FLAGS (cont.) : Child develops receptive language, but minimal expressive language Poor vowel differentiation Poor syllabification Voiced sounds develop, but no unvoiced sounds Development of unusual or deviant phonemes Child turns down volume/sensitivity on CI Speech perception at 70 db HL is poorer (12% or greater) than at 50 db HL

103 COCHLEAR IMPLANTS: OVERSTIMULATION RX: Check to ensure amplification is working appropriately Neural response testing Audiological testing to verify CI thresholds Phoneme perception testing Cochlear implant reprogramming to reduce C or M levels

104 COCHLEAR IMPLANTS: OVERSTIMULATION CASE STUDY #5: Congenitally deaf adult who was good HA user Implanted in his right ear with an Advanced Bionics CII at age 41 Patient report: Loved CI Open set speech discrimination after 1 month Could understand with car radio and with phone Difficulty finding his own voice Harmonizing of loud sounds Some facial stim in noisy/loud settings

105 COCHLEAR IMPLANTS: OVERSTIMULATION CASE STUDY #5: Therapist report: Hyponasality Poor loudness and pitch differentiation Multiple low frequency consonant and vowel confusions Patient admissions : HA power junkie All I know is loud so loud seems good. Watched the computer screen during MAPpings Wanted to challenge himself with stimulation levels Thought he was a woos if he couldn t tolerate increased stimulation levels

106 COCHLEAR IMPLANTS: UNDERSTIMULATION CASE STUDY #5:

107 COCHLEAR IMPLANTS: OVERSTIMULATION CASE STUDY #5: After MAPping, patient: Continued to have open set speech discrimination, but was agitated by quietness Begged for old MAP to be returned to processor Ripped the headpiece off when old MAP was turned on

108 COCHLEAR IMPLANT: OVERSTIMULATION CASE STUDY #5: 41 yr old C1 C2 C2 C1 C1 C2 C1 C2 C1 C1 C2 C2 SAT SRT HINT-A Old MAP 10 dbhl DNT 66% New MAP DNT 25 dbhl 88%

109 COCHLEAR IMPLANT: OVERSTIMULATION CASE STUDY #6: Audiological history: Passed newborn hearing screening Grandparents noted lack of response to sound ABR at 14 months indicated profound hearing loss Technology history: Bilaterally fit with HAs at 15 months Bilaterally implanted with Advanced Bionics 90K at 18 months Parent observations: Child cries every morning when processors were put on, but is fine after initial struggle Eye blinks noted occasionally, not consistently Child s voice always loud Receptive language developing quickly, but expressive language even babbling slow to develop After last MAPping, eye blink noted to bass drum in a parade

110 COCHLEAR IMPLANT: OVERSTIMULATION CASE STUDY #6: Parents requested review of the MAP Grandparents took child to MAPping Audiologist reviewed MAP and stated: MAP looked fine Child s attention span made MAPping difficult Grandparents could provide suggestions for MAP changes Eye blinks were normal Not all children with CIs develop spoken language Parents sought a second opinion

111 COCHLEAR IMPLANT: OVERSTIMULATION CASE STUDY #6: 3.0 yr old C1 C1 C1 C1 C1 C2 C2 C2 C2 C2 C2 SAT R+L SRT - R SRT - L NU-Chips R NU-Chips L Old MAPs 10 dbhl DNT DNT DNT DNT New MAPs DNT 20 dbhl 25 dbhl 44% 40%

112 COCHLEAR IMPLANT: OVERSTIMULATION CASE STUDY #6: Parent observations following 2 nd opinion: After 1 week, child no longer cried when processors put on After 2 weeks, upon waking child asked for processors After 2 weeks, child was babbling and jargoning Parent and school observation: Child s personality changed: happier, more interactive, more cooperative, more focused, less obstinate, more communicative

113 COCHLEAR IMPLANTS: OVERSTIMULATION RX: Check to ensure amplification is working appropriately Neural response testing Audiological testing to verify CI thresholds Phoneme perception testing Cochlear implant reprogramming to reduce C or M levels

114 LESSONS FROM EXPERIENCE: OVERSTIMULATION Young children are unable to reliably rate the loudness of sound. Can any prelingually deafened person accurately rate loudness? Can any of us accurately rate loudness of tones? Hearing aid use can distort the perception of loudness.

115 LESSONS FROM EXPERIENCE: OVERSTIMULATION Early neural response software estimated T levels. Newer neural response software estimates C or M levels. Almost all of our simultaneously bilaterally implanted patients have C or M levels at or below tnrt/tnri. Clinical units are not the same across manufacturers. A 5cu change for Cochlear is perceived as much louder than a 5cu change for AB. Both ears need to be assessed separately and together.

116 WHAT RED FLAGS INDICATE SPEECH IS NOT CLEAR? HOW DO WE ADDRESS THESE?

117 POOR CLARITY English has approximately 44 phonemes (not just the Ling 6). Assess the majority of consonants. Assess vowels as needed. Assessing phoneme perception at 3 ft. and 10 ft. can identify specific areas of programming to change. Use the frequency allocation charts to identify the specific frequency bands needing change. Programming changes can and do lead to IMMEDIATE speech perception changes.

118 POOR CLARITY Ear: R L B HA CI Distance /w/ /n/ /l/ /m/ /ng/ /r/ /g/ /b/ /d/ /j/ /v/ /z/ /h/ /p/ /k/ /t/ /ch/ /sh/ /f/ /s/ /th/ /oo/ /oo/ /o-e/ /aw/ /-u-/ /-a-/ /-e-/ /a-e/ /-i-/ /ee/ /ow/ Ear: R L B HA CI Distance /w/ /n/ /l/ /m/ /ng/ /r/ /g/ /b/ /d/ /j/ /v/ /z/ /h/ /p/ /k/ /t/ /ch/ /sh/ /f/ /s/ /th/ /oo/ /oo/ /o-e/ /aw/ /-u-/ /-a-/ /-e-/ /a-e/ /-i-/ /ee/ /ow/ Ear: R L B HA CI Distance /w/ /n/ /l/ /m/ /ng/ /r/ /g/ /b/ /d/ /j/ /v/ /z/ /h/ /p/ /k/ /t/ /ch/ /sh/ /f/ /s/ /th/ /oo/ /oo/ /o-e/ /aw/ /-u-/ /-a-/ /-e-/ /a-e/ /-i-/ /ee/ /ow/ Ear: R L B HA CI Distance /w/ /n/ /l/ /m/ /ng/ /r/ /g/ /b/ /d/ /j/ /v/ /z/ /h/ /p/ /k/ /t/ /ch/ /sh/ /f/ /s/ /th/ /oo/ /oo/ /o-e/ /aw/ /-u-/ /-a-/ /-e-/ /a-e/ /-i-/ /ee/ /ow/

119 POOR CLARITY Phoneme testing is much more than 6 Ling sounds!!

120 POOR CLARITY Phoneme testing is easy with all different ages and developmental levels.

121 POOR CLARITY

122 POOR CLARITY Thoughts from a patient: If I can push the button, that s great. But 1 week later, it still sounds like crap. But they only care that I can hear and push the button. They care about the button, not the crap. Justin

123 HEARING AIDS: POOR CLARITY RED FLAGS: Poor/unusual voice quality Relies on vision for input Poor speech perception Inappropriate/unusual consonant development Consistent omission or substitution of specific phonemes Speech production not improving Speech perception poor at 50 db HL and/or 35 db HL Speech perception poor in competing noise

124 HEARING AIDS: POOR CLARITY RX: Check to ensure amplification is working appropriately Audiological testing to verify unaided thresholds Audiological testing to verify aided speech perception at 50 db HL 35 db HL 50 db HL +5 S/N Ratio Hearing aid reprogramming based on unaided thresholds and aided error patterns Trial with different hearing aids Cochlear implant evaluation

125 HEARING AIDS: POOR CLARITY Case Study #7: Medical history: Normal pregnancy, full-term birth Received Gentamicin for 48 hours after birth Audiology history: Failed newborn hearing screening ABR indicated moderate hearing loss Technology history: Bilaterally fit with HAs before 3 months of age

126 HEARING AIDS: POOR CLARITY CASE STUDY #7: Therapy history: Family began John Tracy home demo program at months Family began weekly AVT before age 2 Therapist and Parent observations: Good speech and language development initially At age 2.5, increase in articulation errors and plateau of language development noted

127 HEARING AIDS: POOR CLARITY CASE STUDY #7: 2.7 yrs old Unaided SAT = 35 dbhl Right, 35 dbhl Left Aided SAT = 25 dbhl Binaural

128 HEARING AIDS: POOR CLARITY CASE STUDY #7: 2.9 yrs old

129 HEARING AIDS: POOR CLARITY CASE STUDY #7: 2.9 yrs old First hearing aids UNAIDED R UNAIDED L AIDED R AIDED - L SRT 70 dbhl 65 dbhl 40 dbhl dbhl NU-Chips 90 db 35% 40% NU-Chips 50 db 40% 45% NU-Chips 70 db 40% 45% NU-Chips 35 db 0% 0% 3.0 yrs old New hearing aids UNAIDED R UNAIDED L AIDED R AIDED - L SRT 30 dbhl 30 dbhl NU-Chips 50 db 65% 55% NU-Chips 35 db 40% 35%

130 HEARING AIDS: POOR CLARITY AGE CASE STUDY #7: Unaided thresholds have remained fairly stable UNAIDED R UNAIDED L AIDED - R 50 dbhl AIDED L 50 dbhl AIDED R 35 dbhl AIDED L 35 dbhl % 64% 68% 52% 68% 52% % 64% 64% 52% 40% 44% CONCERNS AGAIN NOTED %* 58%* *Closed set of 6 pictures % 44% 28% 24% % 40% 28% 48% 20% 20% What recommendations would you have now?

131 LESSONS FROM EXPERIENCE: POOR CLARITY Earmold acoustics can alter low frequency and high frequency gain. Consider acoustically tuned earmolds Earhook filters can alter mid-frequency gain. Evaluating perception can indicate specific area of programming to change: normal conversational speech (50 db HL), soft speech (35 db HL), loud speech (70 db HL)

132 LESSONS FROM EXPERIENCE: POOR CLARITY Evaluating speech perception error patterns can indicate the need to increase/decrease gain in specific frequency bands. Low frequencies can mask high frequencies. Increasing mid-frequency gain can increase loudness and clarity without introducing low frequency masking. Referral for cochlear implant evaluation

133 COCHLEAR IMPLANTS: POOR CLARITY RED FLAGS: Poor/unusual voice quality Relies on vision for input Poor speech perception Speech production not improving Poor vowel development Poor syllabification Inappropriate/unusual consonant development Consistent omission or substitution of specific phonemes Entire MAP is flat Stimulation on low or high frequency electrodes much higher than other electrodes Range between T/C very small or very large

134 COCHLEAR IMPLANTS: POOR CLARITY RX: Check to ensure CI is working appropriately Audiological testing to verify aided speech perception: 50 db HL 35 db HL 50 db HL +5 S/N Ratio Phoneme perception testing Cochlear implant reprogramming using data from neural response testing and speech error patterns

135 COCHLEAR IMPLANTS: POOR CLARITY CASE STUDY #8: 24 yr old congenitally deaf oral Korean woman implanted with Cochlear Nucleus 24 at age 20 Parent report: Patient heard /m/, /l/, /n/, and /r/ well (?) Phoneme check: Patient produced /m/, /l/, /n/, /r/, and a blow for all consonants and vowels

136 COCHLEAR IMPLANTS: POOR CLARITY CASE STUDY #8:

137 COCHLEAR IMPLANTS: POOR CLARITY CASE STUDY #9: Medical/Audiological history: History of progressive bilateral SNHL due to EVA beginning at 4 years of age Right ear hearing poorer than left ear Velopharyngeal Insufficiency with multiple surgical interventions all unsuccessful and resulting in scar tissue Technology history: Bilaterally fit with 4 years of age Bilaterally implanted at 9.11 with Cochlear N5 Activated at 10 years of age

138 COCHLEAR IMPLANTS: POOR CLARITY CASE STUDY #9: Speech/language/educational history: Fully mainstreamed in 5 th grade with age appropriate speech, language, and academics AV Therapy Began weekly AV therapy after initial activation of devices Patient is very engaged and motivated

139 COCHLEAR IMPLANTS: POOR CLARITY CASE STUDY #9: Initial audiological report: Good neural survival in left ear, poor neural survival in right ear Initial patient report: Left CI sounds good Right CI has static Things seem a little too loud AVT observations coincide with patient reports

140 COCHLEAR IMPLANTS: POOR CLARITY CASE STUDY #9: Over next 6 months, patient reports: Intermittent crackling noise Intermittent buzzing Left ear clear, but right not Right ear was clear, now is too loud (won t wear) AVT findings concur Audiologist maintains poor neural survival in right ear is cause AVT and manufacturer s audiologist find: Microphone malfunction T coil accidentally activated Reprogrammed right New program not put on replacement processor Family sought 2 nd opinion Right and left CIs reprogrammed

141 COCHLEAR IMPLANTS: POOR CLARITY CASE STUDY #9 6 months after 2 nd opinion reprogramming 35 db HL 50 db HL HINT-A In quiet %Sent. HINT-A In quiet %Words RIGHT CI 56% 64% 60% 93% HINT-A S/N +0 %Sent. HINT-A S/N +0 %Words LEFT CI 68% 72% 80% 96% RIGHT + LEFT CIs 84% 84% 70% 92% 50% 85% We will need more challenging testing for this patient (AZ Bio sentences)!

142 LESSONS FROM EXPERIENCE: POOR CLARITY Evaluating appropriateness of C/M levels and T is essential. Evaluating perception of soft speech (35 db HL) and normal conversational speech (50 db HL) can indicate the specific areas of programming to change. Shaping the MAP to neural responses appears to provide better clarity. Low frequency masking of high frequencies does appear to happen with CI.

143 LESSONS FROM EXPERIENCE: POOR CLARITY Vowel errors: Significant vowel confusion often indicates more global programming issues. If all vowels seem similar, low frequency stimulation often needs to be decreased. Often low frequency stimulation levels need to be less than mid-frequency stimulation levels (think: walking up hill). NOTE: 4/6 Ling sounds are vowel/vowel-like making the Ling 6 almost a pass/fail test.

144 LESSONS FROM EXPERIENCE: POOR CLARITY Rare cases of whispered vowels: If consonant production--esp. voiceless consonants--is appropriate, low frequency stimulation needs to be increased.

145 LESSONS FROM EXPERIENCE: POOR CLARITY Consonant errors: We currently are involved in a retrospective review of 103 patient records (145 ears/258 MAPpings) to determine the most common errors. IMPORTANT: The majority of errors we see are not identified using the Ling 6 sound test!! Preliminary data indicate phoneme assessment should include: /m/ /n/ /b/ /z/ /h/ /p/ /t/ /k/ /ch/ /sh/ /s/

146 LESSONS FROM EXPERIENCE: POOR CLARITY Articulation errors may be clarity or hearing errors!! Example: /s/ error* *current retrospective research project 42% of patients seen for CI programming had /s/ error: omission, blow, distortion, or /sh/ substitution. 95% of /s/ errors immediately corrected during CI programming with NO therapy or other intervention 48% of errors corrected by turning stimulation down

147 LESSONS FROM EXPERIENCE: POOR CLARITY Common consonant errors: /m/ /n/ confusion (41%) /b/ is omitted (36%) /z/ becomes /m/ (69%) (/s/ or /ee s/ is fine) Common consonant corrections: /m/ /n/ confusion (85% correction rate) /b/ is omitted (98%) /z/ becomes /m/ (84%)

148 LESSONS FROM EXPERIENCE: POOR CLARITY Common consonant errors: /p/ becomes /h/ or is omitted (29%) /ch/ becomes /sh/ or /t/ (67%) /sh/ becomes /s/ (21%) Common consonant corrections: /p/ becomes /h/ or is omitted (96%) /ch/ becomes /sh/ or /t/ (87%) /sh/ becomes /s/ (91%)

149 LESSONS FROM EXPERIENCE: POOR CLARITY Common consonant errors: /p/ /t/ /k/ confusion /b/ /d/ /g/ confusion Common consonant corrections: /p/ /t/ /k/ confusion /b/ /d/ /g/ confusion Use the phoneme/frequency allocation chart!!

150 LESSONS FROM EXPERIENCE: POOR CLARITY If the audiologist provides the patient with optimal access to clear speech, then: the development of audition will be maximized. the auditory brain will develop more normally. the child s speech and language will follow more typical developmental stages. the speech-language pathologist will be able to foster typical development rather than remediate delayed or deviant development.

151 TECHNOLOGY ISSUES Cochlear Implant Failures A CI failure is every parent s worst nightmare. External parts fail often, but the internal device failure rate is very low (<1%). So, always think external before internal. If a child can hear, but you are concerned about red flags, recommend MAPping before integrity tests. CT scan / x-ray should also be considered to look at placement.

152 TECHNOLOGY ISSUES Cochlear Implant Failures Most true failures are observable without an integrity test. Signs of a CI failure Complete loss of sound with all processors (may be preceded by popping sound). All processors and headpieces indicate no lock. Internal device not recognized on implant computer with any processor. Impedances cannot be measured. Child reports only screeching or non-auditory sensations. Significant deterioration in speech perception unrelated to programming changes.

153 THE HYBRID: BINAURAL BALANCING WHAT RED FLAGS INDICATE SOUND IS NOT BALANCED? HOW DO WE ADDRESS THESE?

154 BINAURAL PHENOMENA Binaural Summation Sound is louder and clearer with 2 ears Without binaural summation, a patient will want increased amplification Binaural Balance Which ear is louder? The correct answer: I don t know. The Stenger Principle The louder of 2 inputs will be perceived Binaural Interference Significantly affects speech clarity

155 BINAURAL TECHNOLOGY: UNBALANCED RED FLAGS: Child blinks, shutters, or asks for quiet when 2 nd device put on Child consistently removes one device Child does not indicate when one battery is dead Child does not replace one when it falls off Child consistently localizes to one direction Child consistently turns one ear to speaker/tv/music Child s listening/speech/language do not progress after implantation Child states one ear is louder than the other 1 st CI not reprogrammed after activation of 2 nd CI

156 BINAURAL TECHNOLOGY: UNBALANCED Which ear is louder, this one or that one?

157 BINAURAL TECHNOLOGY: UNBALANCED CASE STUDY #10: 6.6 year old bilaterally implanted with Cochlear Freedom CIs at age 2 Mainstreamed with support in 1 st grade Parent observations: Loved his CIs until annual MAPping 2010 Then consistently wanted to remove the left processor Returned to audiologist for MAPping 3 months later Audiologist felt child needed to adjust to the settings as he had never previously complained

158 BINAURAL TECHNOLOGY: UNBALANCED CASE STUDY #10: Parent observations after new MAPping: Child started turning off or removing both processors, but complained more about left School observations: Slight regression in speech production Attention difficulties Difficulty with auditory memory Reading slow to progress Retention considered Parents requested 2 nd opinion

159 BINAURAL TECHNOLOGY: UNBALANCED CASE STUDY #10: Cochlear implant reprogramming: With both processors on, child reported right was louder Both programs appeared to be too loud, but right appeared louder than left Stimulation levels reduced on both side, but more on right

160 BINAURAL TECHNOLOGY: UNBALANCED CASE STUDY #10: School observations 1 week after new MAPping: Inconsistent attention in class Parent and school observations after 2 months: Child asking for CIs upon waking No attention difficulties (cancelled ADHD/ADD consult) No difficulty with auditory memory Reading flourished Personality changed: more outgoing, more relaxed, no tantrums, no aggression Self-confidence skyrocketed Why did child consistently remove the left processor?

161 BINAURAL TECHNOLOGY: UNBALANCED RX: Check to ensure both devices are working appropriately Aided threshold and speech testing with each device separately Reprogramming to balance the devices

162 LESSONS FROM EXPERIENCE: UNBALANCED Quantity of loss and quality of loss are not the same. If the quality is significantly different, children will do everything in their power to eliminate the interference. Children with hearing loss DO experience binaural summation. 1 st CI needs to be reprogrammed after receipt of 2 nd CI. If devices are not balanced, progress in one ear will be delayed. If devices are balanced, sound quality of both together should be good---even if one is new. If devices are balanced, patient should note benefit from 2 nd very quickly. If one ear is performing more poorly, practice listening with the POORER ear alone 2-3 hrs/day (outside of school).

163 LISTENING TO KIDS: The key to success! CASE STUDY #11: Identified with NBHS Early amplification Early Auditory-Verbal Therapy Implantation/Activation at 12 months

164 LISTENING TO KIDS: The key to success! CASE STUDY #11: RED FLAGS NOTED: Startle to planes flying over house Loud voice Limited babbling/consonant development Good receptive language with no expressive language More vocalization with CI set to minimum volume 2 nd opinion at 23 months of age

165 LISTENING TO KIDS: The key to success! CASE STUDY #11: