Serving the Student with Cochlear Implants and Hearing Assistance Technologies (HAT)

Transcription

1 Serving the Student with Cochlear Implants and Hearing Assistance Technologies (HAT) Lauralyn Chetwynd, AuD Marilyn Neault, PhD 2013 ASHA Convention November 14,

2 Goals of this session Discuss how educational amplification needs of CI users can be supported Convey what we are learning from our Sound Outreach to Schools (SOS) Program Create a way to approach any CI-FM setup with examples

3 28 Audiologists, 5 sites Habilitative Audiology Cochlear Implant Team 3 3 3

4 Challenge Early cochlear implants early mainstream Students with CI who hear well in small class do not hear as well in mainstream class need educational amplification Educational audiologists may not know how each CI processor works with HAT CI audiologist may not have mastered HAT Processors and HAT options keep changing

5 Is there a problem? Educational audiologists who serve students in schools are expert at: Coupling FM receivers to hearing aids Checking them Troubleshooting them Explaining them

6 What is the secret weapon? This But what about cochlear implant processors with FM receivers? You can listen to the input to the processor, but not to the output. Uh-oh

7 FREQUENCY IN HERTZ (Hz) HEARING LEVEL (HL) IN DECIBELS (db) C (vibrotactile BC responses) C C C C C C = typical thresholds in sound field with CI processor (dependent upon processor settings) AC (AIR) UNMASKED MASKED BC (BONE) UNMASKED MASKED SOUND FIELD KEY R S L SPEECH AUDIOMETRY R L SDT SRT SPEECH DISCRIM. (WORD RECOG.)

8 1-channel 2-channel 4-channel 8-channel 16-channel Original Implant simulations by Arthur Boothroyd, based on the work of Robert Shannon. Total bandwidth is 0 to 6000 Hz, and channel boundaries are logarithmically spaced. All within-channel frequency resolution is removed. The amplitude envelope in each band is preserved but it is imposed on a band of noise. This band covers the same frequency range as the band of speech from which the envelope was extracted. This is not what speech sounds like to an implant user. The simulation does, however, give an impression of the intelligibility of speech with the kind of dramatic reduction of spectral information produced by a cochlear implant.

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11 Combine three toolboxes to serve one listener HA CI WIRELESS

12 A Cochlear Implant Is Not Enough Great tool for partial sound access May need other technological supports for curriculum access (Educational) audiology and a teacher of the deaf are separate related services under IDEA For what is the school responsible?

13 Wording from IDEA (b) Exception; services that apply to children with surgically implanted devices, including cochlear implants. (1) Related services do not include a medical device that is surgically implanted, the optimization of that device s functioning (e.g., mapping), maintenance of that device, or the replacement of that device.

14 Wording from IDEA (2) Nothing in paragraph (b)(1) of this section-- (i) Limits the right of a child with a surgically implanted device (e.g., cochlear implant) to receive related services (as listed in paragraph (a) of this section) that are determined by the IEP Team to be necessary for the child to receive FAPE.

15 Wording from IDEA: School is responsible to check the CI processor and make sure that it is working properly..(iii) (NOTHING) Prevents the routine checking of an external component of a surgically-implanted device to make sure it is functioning properly, as required in (b) Routine checking of hearing aids and external components of surgically implanted medical devices

16 Wording from IDEA (iii) (NOTHING) Prevents the routine checking of an external component of a surgically-implanted device to make sure it is functioning properly, as required in (b) Routine checking of hearing aids and external components of surgically implanted medical devices. (a) Hearing aids. Each public agency must ensure that hearing aids worn in school by children with hearing impairments, including deafness, are functioning properly.

17 Wording from IDEA (b) External components of surgically implanted medical devices. (1) Subject to paragraph (b)(2) of this section, each public agency must ensure that the external components of surgically implanted medical devices are functioning properly. (2) For a child with a surgically implanted medical device who is receiving special education and related services under this part, a public agency is not responsible for the post-surgical maintenance, programming, or replacement of the medical device that has been surgically implanted (or of an external component of the surgically implanted medical device).

18 SOS makes instruction booklets (inspired by a parent) The batteries have four air holes which are covered with stickers. The batteries need to breathe for 1 minute before they are used. As you remove three batteries from the sleeve, peel off the stickers from each battery. Let the batteries breathe for 1 minute. Turn the processor off (Press the Select button until you see no symbols in the display). Pull the battery compartment out from the bottom of the processor. Push each of the old batteries out (they can only exit/enter in one direction). Be sure to keep them separate from the new batteries. Insert the new batteries into the processor. They will only go in one side of the battery compartment and they will only go in negative side up.

19 Context and background Context and background Paired comparisons: Speech in noise CI-only vs. CI+FM (Percent Correct) HINT-C Sentences CI Noise CI+FM (Best Score) Subject Adapted from Moog, 2003 MEAN

20 My student has a cochlear implant: Should she have a sound field FM system or a personal FM system?

21 Advantages of sound field system No adjustments or reprogramming of the speech processor Easy to troubleshoot Self-teaching for the teacher Does not rely on the student to report interference or poor function

22 Disadvantages of sound field system FM advantage not as great as for a personal FM receiver plugged in to the processor FM advantage may vary as the student moves around the room Effectiveness of sound field system is affected by classroom acoustics: SF speaker can make things worse in a reverberant classroom

23 Advantages of personal FM system (plugged in to the processor) Gives greater FM advantage than sound field speaker FM advantage does not vary as the student moves around the room Easier to take to specials (art, gym) Can adjust the FM-to-environmental ratio with some processors

24 Disadvantages of personal FM system (plugged in to the processor) Requires the student to report static, interference, and dropouts Transmission distance short compared to HA+FM The troubleshooter can listen to the output of the FM receiver TO the processor but not the output of the processor to the ear Wear and tear on processor Some CI users cannot stand slight background hum

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26 Sound field vs. personal FM? Anderson et al. (2005) 28 students with CI, age 8-14 years Listened to HINT sentences with RT of 1.1 or 0.6 sec Room SF, desktop or personal FM Room SF: no benefit for 80% of CI users, benefit for 20% but less than desktop or personal 64% believed they heard best with the personal FM Iglehart (2004): 14 CI users, compared room SF FM vs. desktop. Phoneme recognition better with desktop than room speaker system.

27 Groundwork for FM use Approximately 3 to 6 months of cochlear implant experience Adequate communicative skills to provide feedback regarding what they hear, or effective adult monitor Don t put FM on the poorer ear only to train it Someone trained to perform a daily listening check and troubleshoot the FM equipment Partnership between teachers, educational audiologist, and cochlear implant audiologists Educational or clinical audiologist with knowledge of how to fit personal FM to CI speech processors and the equipment to make programming changes to the FM receivers when necessary.

28 Your student? How well does s/he hear with just the processor? (Speech recognition in quiet and noise) How does s/he best process information? Attitude toward FM? Experienced with it? How well is processor maintained? Backup? Is the processor already programmed at or near voltage compliance limits? (Extra battery drain may be problematic.)

29 Categories of questions to ask Student s FM experience and attitude Fidgeter? Has telecoils? Able to put processor back on M when transmitter not in use? Frequency response reduced in highs? FM for one ear or both? (CI/HA?) Classroom acoustics and teaching style Processor and FM receiver: Does receiver alter input dynamic range of processor for hearing the environment? Default to one channel or synch for different teachers transmitters? What breaks with this setup?

30 CI FM Receiver Styles

31 You re about to meet a processor/receiver combo Look it in the eye and ask it some questions POWER SUPPLY DOES THE PROCESSOR USE DISPOSABLE OR RECHARGEABLE BATTERIES? HOW MANY HOURS OF USE WITHOUT THE FM RECEIVER? HOW MANY HOURS OF USE WITH THE FM RECEIVER? DOES THE RECEIVER HAVE ITS OWN POWER SUPPLY? WHAT KIND(S) OF BATTERIES AND HOW DO WE GET SOME TO KEEP IN SCHOOL?

32 Power supply examples Build C or D? One dot Two dots

33 What do you need? A way to listen to the input to the processor (monitor earphones or listening check device from CI manufacturer) A way to listen to the output of the FM receiver Manufacturer s instructions, such as FM Solutions, website and phone number, apps tailpage&v=gg2t38vg4xm Spare parts if possible for troubleshooting AAA Remote Microphone HAT Guideline

34 OK it s Dr. Chetwynd s turn to talk (Rod Saunders, circa 1978, CI with his remote mic )

35 Technology needs support It is a bit freaky with this wireless technology.

36 The Gap Educational audiologists who are not tied to a cochlear implant (CI) center may need to harvest much info before ordering, fitting, or inservicing an FM system for a CI user. Processors change Programming software changes The map does not come with a GPS CI users are entering mainstream YOUNG

37 Sound Outreach to Schools (SOS) Educational Audiology Program Developed in 2008 to help fill the need for educational audiologists in a state that does not have many audiologists within public schools Contract-based program housed at Boston Children s Hospital at Waltham, the satellite where the cochlear implant center and the Deaf and Hard of Hearing Program are located One audiologist (Charlotte Mullen, AuD) works 10 hours/week, one (Lauralyn Chetwynd, AuD) works 30 hours/week

38 How does SOS work? Referrals come from local audiologists, speechlanguage pathologists, teachers of the deaf, special educators, and administrators. Students served may or may not be patients of the hospital s Audiology program. Schools served are within one hour s drive. As the program grows, some services can be delivered by Skype or equivalent. Service is limited to support for auditory access. A teacher of the deaf can address curriculum modifications.

39 Whom do we serve? 18 towns Approximately 105 students 51 hearing aid users 22 cochlear implant users (our CI program serves 500 children) 32 other Non-hearing aid user APD, unilateral hearing loss, minimal hearing loss

40 Where Can Breakdowns Occur? Real Life Examples

41 Example 1 13 year old boy Transmitter Phonak Inspiro transmitter connected to a second Inspiro via the multitalker network Right Oticon Sumo DM hearing aid with Oticon FM7 audio shoe and Phonak Mlxi receiver Left Nucleus Freedom with Phonak Microlink Freedom receiver

42 Example 1

43 Auxiliary services Example 1 In a sub-separate classroom for part of the day Has one-to-one paraprofessional during school hours Sees school-based speech-language pathologist several times a week Primary contact for FM troubleshooting First student with a CI on caseload School contracts TOD services twice a week

44 Example 1 Why was this HAT set-up chosen? Phonak is the only company that makes a receiver dedicated to the Nucleus Freedom Processor Two Inspiros were linked so that he could easily hear both the teacher and the paraprofessional Paraprofessional also passes her microphone for the other students

45 Example 1 Problem Received call that FM was not working on hearing aid side Receiver checked and working new audioshoe ordered At appointment to deliver audio shoe, was told that the FM was no longer working on the CI side Listening check on both devices revealed that FM signal was not present on either device Check of receivers on test equipment revealed that they were both receiving FM signal Loaner Microlink Freedom received FM signal when used in his processor

46 Example 1 Resolution Hearing aid needed recasing Parents chose not to recase cochlear implantation has been recommended on that side Cochlear implant It was determined that FM transmission issues were due to wear and tear on the contacts of both the Microlink Freedom and the controller Processor no longer under warranty, so began by repairing the Microlink Freedom with the caveat that the controller may need replacement in the near future

47 Example 2 14 year old boy Transmitter Phonak Inspiro transmitter connected to a second Inspiro via the multitalker network Bilateral Advanced Bionics Harmony processors with Phonak Mlxi receiver connected via iconnects

48 Example 2

49 Example 2 Academic support Fully mainstreamed Sees school-based speech-language pathologist once a week Primary contact for FM troubleshooting First student with hearing loss on her caseload in many years School contracts TOD services once a month

50 Example 2 Why was this HAT set-up chosen? Phonak was chosen by the audiologist and school Two Inspiros were linked so that it could be used as a pass-around microphone Student did not often use the passaround microphone

51 Example 2 Problem Scheduled appointment to meet student and SLP and to check system Listening check with student revealed that FM may not be working Harmony Listening Check confirmed that FM was not working Further investigation determined that one iconnect was broken and one iconnect had a dead battery SLP reports that she does not perform listening checks with student and does not have Harmony Listening Check Student confided that he did not like the FM and that he did not feel that he benefited from it

52 Example 2 Resolution Two new iconnects were ordered SLP was retrained on equipment use and troubleshooting Functional Listening Evaluation was scheduled to determine benefit of FM and to counsel student regarding FM benefit Results indicated significant improvement in word recognition in the presence of background noise using the FM Student has since transitioned to high school and is consistently using FM

53 Example year old girl enrolled in an Early Intervention program for children with hearing loss Transmitter Oticon Amigo transmitter Bilateral Nucleus 5 processors Receiver Oticon Arc

54 Example 3

55 Support Example 3 Attends EI program twice a week EI program staffed with TODs and SLP experienced with hearing loss Full listening checks of hearing devices and FM systems are provided at the beginning of each session

56 Example 3 Why was this HAT set-up chosen? Oticon was chosen by the audiologist and school At the time, the N5 processors did not have a dedicated receiver

57 Example 3 Challenges Getting student to wear neckloop FM use began with wearing the neckloop without accessing the telecoil to help student adjust. She was allowed to decorate it with stickers and think of it as a necklace Training staff to feel confident about accessing telecoil It was decided that using the remote control to access telecoil and FM program would be the easiest solution CI audiologist paired remote control as parent found it baffling

58 Example 3

59 Example 3 Update FM was successfully used in EI program Since then, she has aged out of EI and is enrolled in a collaborative preschool program for students with hearing loss She continues to successfully use FM

60 Example 4 10 year old boy Transmitter Phonak Roger transmitter Hearing aids Bilateral Phonak CassiaM hearing aids Receiver Phonak Roger receiver connected via Phonak ComPilot

61 Example 4

62 Support Example 4 Fully mainstreamed No other services

63 Example 4 Why was this HAT set-up chosen? Phonak was chosen by the audiologist and school This hearing aid can not have a receiver directly attached

64 Example 4 Problem and Resolution FM did not work at initial fit Another appointment was scheduled and Phonak Help Desk provided phone support It was determined that the neck loop on the Compilot had become loose and needed to be reseated. System worked following reseating of neckloop A call from school revealed that system was not consistently working Parents had already replaced Compilot Sent to Phonak and they replaced the transmitter stating that there was a malfunction in the transmitter Have not had further problems

65 QUESTIONS?