Effects of Hearing Loss on DevelopmentAudiologic Rehabilitation for Children and Educational AudiologySPA 6581 – Spring 2015Lecture Date: 01/13/2015

How many are we missing? Approximately 3 of 1000 babies are

born with hearing loss

Prevalence of hearing loss in school age children is between 11.3% and 14.9% Average of 131 of 1000 school age

children have some degree of hearing loss that affects learning and development

(American Speech-Language-Hearing Association, 2012)

Four Major Ways Delay in the development of receptive and

expressive communication skills

Language deficit causes problems that result in reduced academic achievement

Communication difficulties often lead to social isolation and poor self-concept

It may have an impact on vocational choices

Hearing Loss and Families

“Lower rates of stress, depression, and conflict among parents and faster resolution of grief related to the

identification of hearing loss have been linked to early detection of and

intervention for children with hearing loss.”

Degrees of HL and EffectsHearing Loss Effects on Language and Speech

Understanding

Normal 0-15 dB HL None

Mild 16-30 dB HL Possible difficulty with soft/distant speech

Moderate 31-50 dB HL

Speech must be loud for understanding; background noise difficult, language usage & comprehension issues, vocabulary limitations

Severe 51-80 dB HL May be able to detect environmental sounds, may be able to discriminate most vowels, but not all consonants, speech and language WILL be affected and will not develop without amplification and intervention if HL is present prior to 1 year

Profound 81 dB HL and up

May hear loud sounds; more aware of vibrations than true tones, may rely on vision as primary sensory channel, speech and language will not follow normal development without amplification and intervention

Specific Effects

Vocabulary

Sentence Structure

Vocabulary & HL Vocabulary development is slower Learn concrete words (cat, jump, five, & red) more

easily than abstract words (before, after, equal to, & jealous)

Difficulty with function words (the, an, are, & a) The gap between the vocabulary of children with

normal hearing and children with hearing loss widens with age.

Difficulty understanding words with multiple meanings

Children with hearing loss will likely not catch up without intervention.

Sentence Structure & HL Comprehend & produce

shorter and simpler sentences

Difficulty understanding & writing complex sentences Ex. of relative clause:

“The teacher whom I have for math was sick today.”

Ex. of passive voice: “The ball was thrown by Mary.”

Often cannot hear word endings such as –s or –ed and can lead to… Misunderstandings

& misuse: Verb tense Pluralization Nonagreement of

subject and verb Possessives

Speaking May have difficulty hearing sounds such

as s, sh, f, t, and k.

Due to the difficulty hearing, may not include them in production

What could this do to their intelligibility?

Auditory Feedback Loop Difficulty hearing their own voices when

they speak. May speak too loud or not loud enough Speaking pitch may be too high Mumbling quality due to:

Poor stress Poor inflection Poor rate of speaking

Academic Achievement

Difficulty with all areas of academic achievement

Reading and mathematics concepts

Academic Achievement Mild to moderate

hearing loss 1 to 4 grade levels

lower, on average, than peers with normal hearing unless appropriate

management occurs

Severe to profound hearing loss Usually no higher

than the 3rd or 4th grade level unless appropriate

educational intervention occurs early

Academic Achievement The difference in academic achievement

between children with normal hearing and those with a hearing loss usually widens as they progress through school.

The level of achievement is related to parental involvement and the quantity, quality, and timing of the support services children receive.

Social Functioning What do children with hearing loss often

report? Feeling alone Without friends Unhappy in school

Particularly when their socialization with other children with a hearing loss is limited

What does research show? Children identified with a hearing loss who

begin services early may be able to develop language (spoken and/or signed) on par with their hearing friends.

Early family-centered intervention is recommended to promote language (speech and/or signed depending on family choices) and cognitive development.

Audiogram

Difficulty Increases Noise level in environment (i.e., the

classroom)

Distance from target auditory source (i.e., the teacher)

Configuration of hearing loss

Some Factors Which Can Directly Impact Progress Age at diagnosis and Hearing Age Etiology Duration and degree of hearing

impairment Audiological management Health of the child Family participation Child’s intelligence and learning style

Mild to Moderate HL

Speech and Language

Social

Educational Accommodations and Services

(Better Hearing Institute, 1991)

Effects of Mild to Moderate Hearing Loss onSpeech and Language

Difficulty hearing faint/distant speech

At 16 dB, can miss up to 10% of speech signal when teacher is at a distance greater than 3 feet

At 20 dB + HL in the better ear can result in absent, inconsistent, or distorted parts of speech

% of speech signal missed will be greater whenever there is background noise Consider –

elementary grades May have difficulty with

sound/letter association and subtle auditory discrimination skills necessary for reading

Effects of Mild to Moderate Hearing Loss onSpeech and Language

At 30 dB can miss 25 to 40% of the speech signal

At 40 dB can miss 50% of class discussions Especially if voices

are faint or is speaker is not in line of vision

Miss words and consonants not emphasized

Often experiences difficulty learning early reading skills such as letter/sound associations

Miss fragments of speech leading to misunderstanding

Mild to Moderate: Possible Social Impact May be unaware of

subtle conversational cues Child may then be

viewed as inappropriate

May be more fatigued due to extra effort needed for understanding speech

May miss portions of fast-paced peer interactions that could begin to have an impact on socialization and self concept

Behavior may be confused for immaturity or inattention

Mild to Moderate: Possible Social Impact Negative impact on self-

esteem “You only hear when you

want to.” “Johnny is constantly

daydreaming in my class.” “He is such a disruption to

my class, and he simply does not pay attention.”

May believe they are less capable due to difficulties understanding in class

Begins to lose ability for selective listening

Increased difficulty suppressing background noise causing the learning environment to be more stressful

More fatigued due to the effort needed to listen

Potential Educational Accommodations and Services Improved acoustic

treatment of classroom Sound-field amplification Favorable seating May benefit from

personal amplification and FM system

In-service on impact of hearing loss on language development, listening in noise and learning for educators

Specialized instruction in: Sound/letter

associations Auditory

discrimination skills Vocabulary Speech

production/Articulation

Potential Educational Accommodations & Services

Personal amplification and personal FM system

Favorable acoustics, seating, and lighting

Teacher in-service (ongoing?)

Specialized instruction or attention: Auditory skills Speech and language

development Speechreading Support in reading Support in self-

esteem

Moderate to Severe HLSpeech and Language

Social

Educational Accommodations and Services

(Better Hearing Institute, 1991)

Moderate to Severe: Speech and Language Consistent use of

amplification and language intervention prior to age 6 increases the probability that the child’s speech, language, and learning will develop at a normal rate

Without amplification, child may understand conversation at a distance of 3-5 feet, if sentence structure and vocabulary are known.

With 40 dB loss, the speech signal missed can be 50%, with 50 dB loss, the speech signal missed can be 80%

Without early amplification, the child is likely to have delayed or disordered syntax, limited vocabulary, imperfect speech production, and flat voice quality

Even with amplification, may miss speech if classroom is noisy or reverberant

Moderate to Severe: Speech and Language Even with hearing aids,

will miss parts of words resulting in difficulty in situations required verbal communication (even in 1-on-1 & in groups)

Without HAs, conversation must be very loud to be understood

55 dB loss can cause a child to miss up to 100% of speech information without amplification

If HL is not identified before age 1 and appropriately managed, delayed spoken language, syntax, reduced speech intelligibility and flat voice quality is likely.

The following strongly impacts success of speech, language, and learning development: Age when first amplified Consistency of hearing aid

use Early language intervention

Moderate to Severe:Possible Social Impact Communication can be

significantly compromised with this degree of hearing loss, particularly if hearing aids are not worn

Tendency for poorer self-concept and social immaturity

Peer in-service may be helpful

Fatigued

Similar barriers with negative impact on self-esteem

Socialization with peers may be difficult, especially in noisy situations: Lunch Recess Cooperative learning

situations

Moderate to Severe: Potential Educational Accommodations & Services

Consistent use of personal amplification is necessary; however, the ability to perceive speech and learn effectively in a classroom setting is at risk.

Personal FM system required to overcome classroom noise and distance

Favorable acoustics, seating, and lighting

Note-taking, captioned films

Consultation/program supervision by a specialist in childhood hearing impairment

Moderate to Severe: Potential Educational Accommodations & Services

Special academic support may be necessary if language and educational delays are present Depending on early

intervention success in preventing language delays

Intensive attention to the following is necessary: Oral communication,

reading, written language skills, auditory skill development, speech therapy, and self-esteem

Educator inservice

Severe to Profound HLSpeech and Language

Social

Educational Accommodations and Services

(Better Hearing Institute, 1991)

Severe to Profound: Speech and Language

The earlier the child wears personal amplification consistently with concentrated efforts by parents/caregivers to provide rich language opportunities throughout everyday activities and/or provision of intensive language intervention (sign or verbal), the greater the probability that speech, language, and learning will develop at a relatively normal rate.

Severe to Profound: Speech and Language

Without amplification, children with 71 to 90 dB loss may only hear loud noises about one foot from ear.

When amplified optimally, children with hearing ability of 90 dB or better should detect many sounds of speech if presented from close distance or via FM.

Individual ability and intensive intervention prior to 6 months of age will determine the degree that sounds detected will be discriminated and understood by the brain into meaningful input.

Severe to Profound: Speech and Language

Even with hearing aids, children with 71 to 90 dB HL are typically unable to perceive all high pitch speech sounds sufficiently to discriminate them, especially without the use of FM.

May be a candidate for a cochlear implant.

For full access to language to be available visually (if this is the communication mode chosen), through sign language or cued speech, family members must be involved in child’s communication mode from a very young age.

Severe to Profound: Possible Social Impact Depends on success of

intervention in infancy to address language development Child’s communication

may be minimally or significantly affected

Socialization with hearing peers may be difficult

Dependency on adults

Relationships with peers and adults who have hearing loss, can make positive contributions toward the development of a healthy self-concept.

Severe to Profound: Potential Educational Accommodations and Services

Communication Mode Regardless of communication mode/approach,

extensive language intervention, full-time consistent amplification use and constant integration of the communication practices into the family by 6 months of age will highly increase the probability that the child will become a successful learner.

Children with late-identified hearing loss will have delayed language

Severe to Profound: Potential Educational Accommodations and Services

The language gap is difficult to overcome and the educational program of a child with hearing loss, especially those with language and learning delays secondary to hearing loss, requires the involvement of an educator with expertise in teaching children with hearing loss. Directly from an SLP, “I know a little bit of sign, but

my student will teach me more once I start. I am really looking forward to working with him, so that I can improve my skills in sign.” PROBLEM???

Severe to Profound: Potential Educational Accommodations and Services If an auditory/oral

approach is used, early training is needed on auditory skills, spoken language, concept development, and speech.

Note-taking, captioning, training in pragmatic language use, and communication repair strategies may all be helpful

If culturally deaf emphasis is selected, frequent exposure to Deaf, ASL users is important.

Support services and continuous appraisal of access to communication and verbal instruction is required.

Inservice is essential

Significant Hearing Loss Articulation Problems

Omission of final consonants and consonant clusters Omission of /s/ across word positions Omission of initial consonants Substitution of voiced consonants for voiceless consonants Substitution of nasal consonants for oral consonants Vowel substitutions Distortion of sounds, especially of stops and fricatives Imprecise production of vowels Increased duration of vowels Addition of sounds, especially an instrusive schwa between

consonants in blends (e.g., buhlue for blue) Breathiness before the production of vowels Inappropriate release of final stops (e.g., /staph/ for /stap/)

Significant Hearing Loss Voice and Resonance Problems

High-pitched voice Harshness Hoarseness Nasal emission on voiceless consonants Hypernasality on voiced consonants and

vowels Hyponasality on nasal consonants Breathiness Lack of normal intonation

Significant Hearing LossProsodic Disturbances

Generally limited fluency Increased rate of dysfluencies Slow rate of speech Inappropriate pauses Abnormal flow of speech Abnormal rhythm of speech Abnormal intonation patterns

Significant Hearing LossAssociated Problems (language and reading problems) Generally limited vocabulary Poor comprehension of word

meanings Lack of understanding of

multiple-meaning words Difficulty understanding

abstract, metaphoric, and proverbial phrases

Slower acquisition of grammatical morphemes

Omission of several grammatical morphemes

Slower acquisition of verb forms

Shorter sentences Fewer varieties of sentence

types Pragmatic language

problems Lack of elaborated speech Insufficient background

information Occasional irrelevance of

speech Poor reading

comprehension Writing that mirrors the verbal

language problems listed

Unilateral Hearing LossSpeech and Language

Possible Social Impact

Potential Educational Accommodations and Services

(Better Hearing Institute, 1991)

Unilateral: Speech and Language Can “hear,” may have

difficulty understanding in certain situations Faint/distant speech,

especially if poor ear is directed toward target sound source

Difficulty localizing sounds and voices using hearing alone

Greater difficulty understanding speech in noisy and reverberant environments

Exhibits difficulty detecting or understanding soft speech from the side of the poorer ear, especially in a group discussion

Unilateral: Possible Social Impact Accused “selective

hearing” Discrepancy in

speech understanding in quiet vs. noise

Social problems may arise in Noisy cooperative

learning Recess

Misconstrue peer conversations, feel rejected or ridiculed

Fatigued, particularly if class is noisy or has poor acoustics

Appear inattentive, distractible, or frustrated Possible behavior or

social problems

Unilateral: Potential Educational Accommodations and Services Allow flexible seating

preference Allowed to change seating

to direct the normal hearing ear toward the primary auditory source

At 10 times the risk for educational risk as children with 2 normal hearing ears!

1/3 to ½ of children with unilateral hearing loss experience significant learning problems

Difficulty learning sound/letter associations in typically noisy elementary settings

Educational and audiological monitoring is warranted

Teacher in-service Personal FM system with

low gain/power or soundfield FM

Mid-Freq. HL or Reverse Slope HL

Speech and Language

Social

Potential Educational Accommodations and Services

(Better Hearing Institute, 1991)

Mid & Reverse Slope: Speech and Language Child can “hear” but will have

difficulty understanding in certain situations

Difficulty understanding faint/distant speech Student with a quiet voice

speaking from across the classroom

“Cookie bite” or reverse slope will have greater difficulty understanding speech when environment is noisy and/or reverberant (i.e., typical classroom setting)

25 to 40 dB degree of loss in the low to mid-frequency range may cause the child to miss approximately 30% of speech information, if unamplified

Some consonant and vowel sounds may be heard inconsistently, especially when background noise is present Speech production of

these sounds may be affected

Mid & Reverse: Possible Social Impact “Selective hearing” or

“hearing when child wants to” due to discrepancies in speech understanding in quiet versus noise

Fatigued Inattentive,

distractible, or frustrated

Social problems as child experiences difficulty understanding in noisy cooperative learning situations, lunch, or recess

May misconstrue peer conversations

Mid & Reverse: Potential Educational Accommodations and Services

Personal amplification

Close audiologic follow-up

Soundfield FM system, personal FM system, or assistive listening device

At risk for educational difficulties

Specialized intervention on sound/letter associations, articulation, language development

Educational monitoring and teacher inservice warranted

High Frequency Hearing LossSpeech and Language

Social Impact

Potential Educational Accommodations and Services

(Better Hearing Institute, 1991)

High Frequency: Speech and Language Can miss important aspects

of speech 26 to 40 dB loss in high

frequency hearing may cause the child to miss 20 to 30% of vital speech

t, s, f, th, k, sh, ch heard inconsistently and worse in noise

Difficulty understanding faint/distant speech

Speech production may be affected

Difficulty understanding in background noise

Many critical sounds for understanding speech: high pitched, quiet sounds, making them difficult to perceive Child may perceive “ca” for

all of the following: cat, cap, calf, cast

Word endings, possessives, plurals, and unstressed brief words are difficult to perceive and understand

High Frequency: Possible Social Impact “Selective

hearing” Social problems in

noisy cooperative learning situations, lunch, or recess

May misinterpret peer conversations

Fatigued May appear

inattentive, distractible, or frustrated

Could affect self concept

High Frequency: Potential Educational Accommodations and Services Use of amplification

often indicated to learn language at a typical rate and ease learning

At risk for educational difficulties

Articulation problems Possible difficulty

learning some sound/letter associations

Early evaluation of speech and language skills

Educational monitoring and teacher inservice warranted

Personal or soundfield FM

Delayed language and syntax development

Fluctuating and Conductive Hearing Loss

Speech and Language

Social Impact

Potential Educational Accommodations and Services

(Better Hearing Institute, 1991)

Fluctuating & Conductive: Speech and Language

At 30 dB child can miss 25 to 40% of the speech signal

At 40 dB child may miss 50% of class discussions

Will frequently miss unstressed words, consonants, and word endings

EVA, ANSD, chronic middle ear issues, etc.

Fluctuating & Conductive: Possible Social Impact Barriers impacting self

esteem May believe they are

less capable Poor at detecting

changes in own hearing ability With inconsistent

hearing, child may learn to “tune out” the speech signal

Children are judged to have greater attention problems, insecurity, distractibility, and lack self-esteem

May not participate

May be socially immature

Fluctuating & Conductive: Potential Educational Accommodations and Services

Impact is primarily on acquisition of early reading skills & attention Screening for language

delays is suggested from a young age

May need specialized instruction for development of: speech, reading, self

esteem, or listening skills

In-service

Ongoing monitoring for hearing loss

Communication between parent and teacher about listening difficulties Food for thought…Out of

the last 10 families of pediatric patients I have worked with, only 2 knew the name of their child’s teacher…

FM system

Moral of the Story “Technology” doesn’t fix everything.

Hearing loss impacts the child globally.

Important decisions must be made early.

Who will guide the family?

Discussion Get together in groups of 4 and come up

with 5 trends across all of the hearing losses that we discussed.

Why do you think there are trends across the degrees of hearing loss?

Red FlagsAge Red Flags

6 months • Does not laugh and squeal• Does not look toward new sounds

9 months • Has limited or no babbling• Does not indicate when happy or upset

12 months

• Does not point to objects• Does not use gestures such as waving or shaking

head

15 months

• Has not used first word• Does not respond to “no” or “bye-bye”

18 months

• Does not use at least six to ten words consistently• Does not hear well or discriminate between sounds

20 months

• Does not use at least six consonant sounds• Does not follow simple directions

24 months

• Has a vocabulary of less than 50 words• Has decreased interest in social interactions

36 months

• Strangers have difficulty understanding what the child is saying

• Does not use simple sentences

Additional Red Flags for Hearing Problems Exhibit behavior problems Have reading, spelling, and

other academic problems Learn slowly through auditory

channel Difficulty with phonics and

speech sound discrimination

Delayed receptive and expressive language

Difficulty listening or paying attention in noise

Constantly requests that information be repeated

Easily distracted Poor auditory memory

(span and sequence) Poor auditory attention Slow/delayed response to

spoken directions or requests

Increase volume of the television, radio, MP3 player

Inconsistent responses to auditory stimuli

Difficulty following verbal directions

ResourcesAmerican Speech-Language-Hearing Association. (2012).Effects of hearing loss on development. Retrieved from http://www.asha.org/public/hearing/disorders/effects.htm

American Speech-Language-Hearing Association. (2012). Hearing loss and its implications for learning and communication. Audiology information series, Retrieved from http://www.asha.org/uploadedFiles/aud/InfoSeriesHearingLoss.pdf

Better Hearing Institute. (1991). Relationship of hearing loss to listening and learning needs. Retrieved from http://www.betterhearing.org/hearing_loss/children_hearing_loss/relationship_hearing_loss_learning.pdf 

Calderon, R., Naidu, S. (2000). Further support for the benefits of early identification and intervention for children with hearing loss. The Volta Review, 100 (5, monograph edited by C. Yoshinaga-Itano & A.L. Sedey), 53-84.

Lanza, J. R., & Flahive, L. K. (2009). Linguisystems guide to communication milestones. Retrieved from http://www.linguisystems.com/pdf/Milestonesguide.pdf

Yoshinaga-Itano, C., Sedey, A.L., Coulter, D.K., & Mehl, A.L. (1998). The language of early- and later-identified children with hearing loss. Pediatrics, 102, 1161-1171.