Transcript Pediatric Audiological Findings as a Basis for EI Objectives

Audiological Management: What
Everyone Needs to Know
Antonia Brancia Maxon, Ph.D., CCC-A1, 2
Kathleen Watts, M.A. 2
Karen M. Ditty, Au.D., CCC-A 2
1
New England Center for Hearing Rehabilitation
Hampton, CT
2
National Center for Hearing Assessment and Management
Logan, UT
Faculty Disclosure Information
In the past 12 months, we have not had a significant
financial interest or other relationship with the
manufacturer of the product or provider of the services
that will be discussed in our presentation.
This presentation will not include discussion of
pharmaceuticals or devices that have not been
approved by the FDA.
Pediatric Audiology Training
• UNHS successful across the
U.S.
• Created a need for pediatric
audiologists
– need knowledge and
experience to work with very
young infants and their families
– large enough pool does not
exist
NCHAM Audiology Courses
• NCHAM developed two courses to train
audiologists.
– Course ONE covers the diagnosis of hearing
loss in infants
– Course TWO covers the provision of
appropriate follow-up management
• ongoing audiological evaluation
• hearing aid selection and fitting
• cochlear implants
Course Two
Ongoing Audiological Assessment
• Originally designed for audiologists
• Course information is also critical for:
– early intervention providers
– medical professionals working with young
children
– parents
What Other Professionals and Parents
should know about Audiologists
• Not all Audiologists are equally trained to
work with infants and toddlers.
– Not all Audiologists are familiar with clinical
protocols for young infants.
– There is an inadequate number of audiologists
with pediatric expertise.
• Some audiological facilities lack equipment
needed to assess young infants.
Basics of “Ongoing Audiological
Assessment”
• Behavioral audiological evaluation
– necessary and appropriate for infants and
toddlers with hearing loss
• Prescriptive methods for selecting, fitting and
validating hearing aids for infants and toddlers
• Appropriate methods for determining cochlear
implant candidacy and outcomes for infants and
toddlers
Audiological Assessment of Infants
• Characterize:
• Hearing loss degree,
type, configuration
• Purpose: Initiate
appropriate
intervention and
establish baseline for
monitoring hearing
overtime
J. Gravel, NCHAM 2005
Visual Reinforcement Audiometry
(VRA)
• Appropriateness established in
1960s
• Methods standardized in 1970s
• Widely used in clinics
• Valid and reliable procedure for
infants and toddlers from 5
through 24 months.
J. Gravel, NCHAM 2005
Visual Reinforcement Audiometry
(VRA)
• Conditioned response
• Child hears a sound and learns it will be followed by
a visual reinforcement
• Basic head turn (to sound) response is increased by
use of the reinforcer (lighted and/or moving toys)
• Reliable responses result in a good consistent
audiogram
J. Gravel, NCHAM 2005
Suggested VRA Protocol
(Gravel, 2000)
• Reinforcers located 900 to one side
– multiple toys behind smoked Plexiglas
• Condition head turn response using speakers in
the test booth (sound field)
• Use “signal” and “silent” presentations
– measure thresholds using “typical” procedures
• After sound field testing completed
– bone conduction or insert earphones used
– depends on sound field results
J. Gravel, NCHAM 2005
Suggested VRA Protocol
(Widen, 2000)
• Reinforcers located 900 on both sides
– two toys on each side
• Infant seated on parent’s lap
• Two testers
• Condition head turn response using insert
earphones
• Use “signal” and “silent” presentations
– measure thresholds at 1K, 2K, 4K Hz and
speech
J. Gravel, NCHAM 2005
Use of Earphones in VRA Procedures
• Younger infants retain earphones better
than older ones
• Most difficult age range is 24 - 30 months
• Insert earphones are better
– more comfortable
– not easily dislodged with movement
– better for hearing aid selection
J. Gravel, NCHAM 2005
Scheduling the VRA Visit
• To maximize the chance of
getting a good complete test
(and audiogram)
– child’s development
– child’s health
– child’s temperament
J. Gravel, NCHAM 2005
Hearing Aid Selection: What the
Audiologist Wants to Know
That the audiologist has achieved a good
match between the amplification
characteristics (gain, output, frequency
response) of the hearing aids and the
auditory characteristics of infants so that
the use of residual auditory capacity can
be maximized.
Seewald and Moodie, NCHAM
2005
Hearing Aid Selection: Measurements
• Assessment
– Measure the infant’s ear acoustics – important
because infants have small ear canals and
hearing aid manufacturers use adult ear
canals (as measured in a coupler) to
determine hearing aid characteristics
– Determine Real Ear to Coupler Differences
(RECD) – the difference between what the
hearing aid will produce in an infant’s ear as
compared to the coupler measurements.
Seewald and Moodie, NCHAM
2005
RECDs in Infants: Key Points
• RECDs in infants and toddlers
differ significantly from average
adult values.
• RECDs vary from infant to infant.
• RECDs will vary for a given infant
over time.
• The pediatric audiologists should
determine RECDs before initial
fitting and regularly over time.
Seewald and Moodie, NCHAM
2005
RECDs : More Points
• RECDs have large individual variability
regardless of age.
• RECDs from foam eartips and earmolds
have very different shapes and are not
interchangeable.
• Age-appropriate average RECDs may be
used when measurement is not possible.
• The pediatric audiologists should always
consider RECDs when fitting hearing aids.
Seewald and Moodie, NCHAM
2005
Hearing Aid Selection
Minimally, the fitting method employed to
determine hearing aid characteristics
should be audibility based
- with the goal to provide audibility of an
appropriate amplified long-term
average speech spectrum.
That is, the hearing aid should present all
components of speech at a level that the
infant can hear.
Seewald and Moodie, NCHAM
2005
Hearing Aid Verification
What the hearing aid can
produce (electroacoustic
performance) should match
what was predicted from
the infant’s real ear
measurements and the
RECDs.
Seewald and Moodie, NCHAM
2005
Cochlear Implants: Options
• Three companies approved by FDA
– Internal devices for each
– Speech processors for each
• Body-worn
• Behind-the-ear
• Assistive device compatibility
– Speech processing strategies for each
– Bilateral considerations
Maxon, NCHAM 2005
Cochlear Implant Candidacy
• Infant cannot benefit from
traditional amplification
• No medical contraindications
• Family is aware of benefits and
limitations
Maxon, NCHAM 2005
Cochlear Implant Mapping
• When and why to map
• Basic measurements
– Thresholds
– Comfort levels
• Rehabilitative mapping
– Perceptual validation of the map
• Optimizing the map
Maxon, NCHAM 2005
Cochlear Implant Outcomes
• Why implant early
– Earlier implantation results in less negative
impact from severe to profound hearing loss
• Speech and language development follows typical
development with good EI and parental input
– No significant medical contraindications
– With early identification families are prepared
for follow-up management.
Maxon, NCHAM 2005
Referral and Enrollment in EI
• The pediatric audiologist and parents know the
established Part C guidelines for the state.
• The pediatric audiologist and parents know the
child eligibility criteria
– automatic enrollment – diagnosed condition
– significant developmental delay
• The pediatric audiologist and parents know the
state guidelines for selecting a program
Maxon, NCHAM 2005
Components of IFSP for I/T with
Hearing Loss
• Amplification provision
– parent education
• Audiological monitoring
• Development of auditory skills
• Communication development
– listening skills – speech perception
– language development
– speech production
• Monitoring middle ear status
Maxon, NCHAM 2005
The information in this presentation
should be shared with EHDI
providers and families so that they
can make well-informed decisions
regarding the services being
provided for children with hearing
loss.
Resources on the Web
Joint Committee for Infant Hearing
http://www.jcih.org/history.htm
National Center for Hearing Assessment and
Management
www.infanthearing.org
Boystown National Research
“My Baby’s Hearing”
www.babyhearing.org