• hearing at different frequencies
• finds hearing threshold (lowest level that can be heard)

What does a hearing screening tell us?

How is one performed?

• tells if a loss is present but not where
• pick one level and play several frequencies at that level
• pick a level at the upper limit of normal

• finds the lowest level that the person can hear (hearing threshold for different types of sounds)
• gives better info on where the hearing loss may be occuring

• bone vibrator on mastoid
• sound vibrates and goes through mastoid to the inner ear and auditory nerve

When is masking helpful?

How is it done?

• helpful when hearing loss is different between ears
• noise is played in the good ear to prevent it from hearing pure tones so that the bad ear's ability to recognize the pure tone is tested without help from the good ear

• used when child/infant can turn head toward the sound (as young as 6 months old)
• condition child to look at a visual reinforcement when sound is played
• move to playing the sound alone and providing visual reinforcement when child looks toward sound
• use lower sound levels to see how low child can hear

What is CPA?

How is it done?

Conditioned Play Audiometry

Make the response into a game (e.g. put block in basket when you hear the soud)

• Can be used with adults and older children who can follow the directions
• raise hand when hear the pure tone

Range for minimal hearing loss

What might be difficult with this type of loss?

16 to 25

faint or distant speech may be difficult to hear

Range for Mild Hearing Loss

Challenges?

26 to 40

can hear speech but might miss pieces of words resulting in misunderstanding; speech may sound mumbled; vowels may more easily heard while high pitched consonants are more difficult

range for moderate hearing loss

challenges?

41-55

may understand familiar conversational speech up to 3-5 feet away

range for moderately severe hearing loss

challenges?

56-70

may only understand loud speech

range for severe hearing loss

challenges?

71-90

may hear a loud shout one foot from the ear

range for profound hearing loss

challenges?

91 and up

hearing cannot be used for communication

frequency

cycles per second

most likely the cochlea in the inner ear

possibly auditory nerve

where is the problem in auditory neuropathy?

what kind of hearing loss is it?

problem w/ auditory nerve

kind of a more specific type of sensorineural hearing loss

Bone conduction is normal

Air conduction will show the hearing loss

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What is PTA (pure tone avg)?

Where do we like PTA to be?

What does a higher number mean?

• take thresholds at 500, 1000, and 2000 Hz and average them
• like PTA to be within 10 dB of speech awareness or speech recognition thresholds
• the higher the number the worse the hearing loss

A list of words is played at a fixed level

Pt attempts to repeat back the list

Score is how many words they recognize

What is sensation level?

What does it tell us?

• the difference between level of sound and the hearing threshold (measured in dB)
• can tell the ability of some patients

1. Conductive
2. Mixed
3. Sensorineural
4. Auditory Neuropathy (nerve is damaged so access to acoustic info is limited)

activity = talking on the phone

participation = gossiping 

• interaction of a person with society
• change society to accomodate person's impairment

• the ability to hear
• influenced by hearing thresholds and masking

Where will we see the "speech bacon"?

what does it represent?

SPLoGram

represents conversational speech

1. Meta Analysis
2. Randomized Controlled Trial
3. Nonrandomized Intervention Study
4. Nonintervention Studies
5. Case Reports
6. Expert Opinion

• a systematic review of research literature along with statistical analysis of the data
• helps determine efficacy of a tx by combining info from several studies

• one group contains participants with hearing loss
• other group doesn't have HL

1. Formulate clinical question
2. search for evidence
3. evaluate the evidence
4. integrate scientific evidence, clinical expertise, and pt preferences for clinical decision-making
5. evaluate the process

1. Assessment
2. Selection
3. Verification
4. Orientation
5. Outcome Evaluation

• presence of HL
• participation limitations
• activity limitations

Benefits of Amplification Tool

combines open-ended and more formal questions to assess the pt's feelings/perspective of the HL

• overcome limitations
• better hearing
• incidental learning (over hearing others speech)
• improve mood, social life
• improve academic performance
• occupational opportunites
• speech and language development
• improved behavior

• pick up sound and amplify it
• acoustic

• can't make sounds loud enough to hear everything
• even though more is heard, what is heard isn't as clear as for someone with normal hearing
• can't be used for people with sensorineural HL

• more amplification but less natural sounds
• used w/ kids because their ears are still growing
• can just replace the ear mold so much less expensive than constantly having to replace the whole system
• more reliable; less exposure to fluids/wax
• ITE -- smaller but less powerful and less reliable

battery door

volume control

microphone

tone hook

receiver/speaker

earmold

• amplify sounds coming in front more than behind
• allow person to orient toward speaker
• less amplification of background noise
• evidence of improved speech recognition
• may not be best for kids who might miss out on classroom discussion (other reasons too ... )

• some people hear lower frequencies better than higher ones so these can help w/ speech recognition
• common for people to hear lower frequencies better

• take sound f/ one side of head and move it to the other side 
• used when can hear out of one ear and not the other

• same as CROS but also amplifies sound
• used when there is a loss in both ears but one side is better than the other

• amplify sound with HA on bad side so much that the sound transfers through the skull to the other side
• not common

• make sure HA output is appropriate for the HL
• done by matching HA output to targetsbased on degree of HL

What is involved in Real Ear?

• Speaker generates sounds (actual speech)
• place a probe in the ear and then the HA to measure how loud the HA is
• this is how we get the SPLoGram

• dead battery
• dead microphone
• distorted speaker
• plugged earmold or tonehook

• connect stethoscope to the hearing aid
• listen for degree of amplification (weak/good, distorted/clarity)

• ensures child is receiving consistent access to sound

How does bone conduction work? 

4 parts ... 

1. processor worn on skull behind ear to detect sound
2. sound is transformed into vibrations
3. connector on head band or implanted component receives vibrations
4. vibrations are sent to the cochlea (bipassing outer and middle ear) then to hearing nerve

Things to consider for surgical candidacy for bone conduction hearing aids ... 

In other words, who can use this type of amplification?

• inability to use traditional amplification (maybe r/t cranofacial abnormalities or outer ear malformations)
• adults and children ≥ 5 y/o
• meet criteria for mixed or conductive HL
• meet criteria for single sided deafness
• profound HL in one ear; normal in the other

bone conduction = normal

air conduction = loss

no normal thresholds

loss in both bone and air conduction

How should you attach a bone conduction HA to the softband or abutment? 

Why?

Tonotopographically

• low frequencies in top (apex)
• high pitch sounds at base

12 months old -- bilateral profound HL

18 months -- bilateral severe to profound HL

• capture sound by microphone
• digitize/analyze sound in processor
• signal is coded in processor to form that will produce electircal pulses in the electrode

• electrical pulses sent to headpiece/coil that's magnetically attached
• headpiece transmits signal through scalp via radio waves (RF - radio frequency)

• coded info is received by implantable cochlear stimulator
• signal is passed to electrode in cochlea

• electrical pulses f/ electrode stimulate auditory nerve
• nerve sends signal to auditory cortex in brain
• brain interprets neural signal as sound

HA -- processes into sound waves

CI -- processes sound waves into electical waves

CI has narrower band of frequencies

sound is picked up the same in both CI and HA

1. degree of loss
2. aided performance
3. family/pt expectations
4. physical/developmental limitations
5. medical contraindications

• ENT evaluation
• audiometric testing and HA check
• vestibular testing (can help choose which ear -- put in ear w/ worse vestibular function bc CI can disrupt even more so want to leave best ear intact)
• CI orientation/eval of aided speech perception
• speech-lang. eval/functional communication
• discuss expectations
• more appt as needed

profound bilateral loss in 12-18 mos

severe to profound if > 18 mos

• FDA says need to try 3-6 mos w/ other amplification and aural rehab
• child fails to make progress in basic auditory skills
• limited benefit/progress w/ other amplification
• speech perception test scores are low

Degrees of communication on the 

Communication Continuum

• A (primarily auditory)
• Av (auditory w/ visual support at times)
• Va (visual communicator but can use auditory info)
• V (primarily visual communicator; CI helps w/ sound awareness)

• presentation level
• distance
• reverberation
• talker characteristics
• classroom acoustics

• technology
• noice
• distance
• volume
• rate

• FM transmitter picks up sound f/ microphone & transmits it wirelessly to a speaker
• benefits whole classroom

• Student either has small speaker on desk or wears headphones
• amplifies all frequencies; less selective than HA
• only benefits that student

• set up -- teacher needs to be trained
• all devices must be set to the same channel
• speaker has to use microphone 
• so either pass mic. around when students talk or teacher needs to repeat what others say

• beliefs about causality (things happen to me vs. i can control some things)
• appearance 
• coping strategies
• finances
• perceived value or willingness to spend $$ (is hearing important enough for them to spend $)
• Knowledge (awareness of difficulties caused by HL & solutions; do they acknowledge they have a problem or blame others for "mumbling")

• continuation of sound due to reflections
• elongates speech -- smearing
• increases w/ larger rooms and harder surfaces
• our classroom has the auditory foam on the ceiling

• reasonable accommodations for employment
• covers voc rehab -- help ppl w/ disabilities get jobs
• covers employers subsidized by federal funds & higher edu.

• free and appropriate edu.
• least restrictive environment
• school must provide interpreter if needed
• can't just send all deaf kids to a different school bc may not be best environment for all students

provides financial assistance to states for assistive tech.

Voc. Rehab

Neb. Commission for Deaf/Hard of Hearing

Medicaid generally covers cost/service

Medicare -- most won't cover

Private Insurance -- probably won't cover; some states require them to cover HA

may not be the most productive environment

distractions

may wind up focusing on behavioral issues or "social work" type of problems

• repetive; practice
• work skills into routines to promote generalization
• intrinsically motivating to child
• one skill can be incorporated into many routines
• many skills can be incorporated into one routine
• supports carryover

• considers performance in different environments
• school, home, community
• Social Emotion
• Cognitive
• Auditory
• Language
• Extra
• Speech

gives child chances to listen

lets us know when they start understanding speech alone w/o other supports

1. degree of HL
2. age of onset
3. type of HL
4. cognitive abilities
5. additional conditions

1. age of beginning intervention
2. use of amplification
3. family involvement
4. multiple languages
5. quality of intervention
6. resources available to family

1. appropriate amplification/hearing technology
2. family commitment to developing listening and spoken language skills

Hearing vs. Listening

which comes first?

• hearing: accoustic access to brain
• attending to acoustic events w/ intention

hearing must be made available before listening can be taught

What are the levels of Erber's Hierarchy of Auditory Skils?

(from more simplistic to most complex)

detection

discrimination

identification

comprehension

• know that 2 sounds are different ("ah" vs. "ee")
• still no meaning
• helps decide if the problem is w/ perception or production
• more of a dx tool so don't really have goals at this level

sound is being attached to meaning

(ex. look at dog every time it barks)

• vocab, key word ID

messages can be process

understanding

(ex. story retell)

Define the Visual Approach to communication.

Goals?

• bilingual (ASL & English)
• acquisition of English using ESL strategies
• Goals:
• age appropriate language 
• positive self-image & cultural ID w/ deaf culture
• basis for learning written English

Describe the Auditory Verbal approach

Goals

• emphasis on spoken language through listening
• doesn't rely on visual cues
• Goals
• develop spoken language by listening 
• develop skills for mainstreaming
• positive self-image through natural family & social interactions using spoken lang.

Discuss Cued Speech

Goals

• auditory visual -- combines hand cues w/ natural mouth movements of speech
• Goals
• provide clear communication in spoken lang.
• develop phonemic lang. base to achieve full literacy in conversation, reading, writing
• support speech reading and auditory skills

Discuss Auditory Oral communication

Goals

• teaches child to use remaining hearing w/ amplification + speech reading, natural gestures, visual cues to help in lang. understanding
• does not encourage any form of sign language
• Goals
• develop spoken lang. through listening & natural gestures/visual cues
• develop spoken lang. & communication skills for academic success & integration into hearing community

Discuss Simultaneous Communication

Goals

• uses spoken & sign lang. simulataneously
• uses English-based sign lang. system that can involve speech, speech reading, finger spelling, natural gestures, & use of residual hearing
• Goals
• bridge to developing spoken lang
• communication btwn child & family, teachers, peers using sign lang.
• support integration into both the hearing & deaf communities