Date: 4‑22‑13
HOPE Red Flags: Barriers to Optimal Auditory Development Part II
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>> Cathy: Hello, everyone, this is Cathy Luckoski with Cochlear America's HOPE program.  Thank you all for joining us.  I'm happy to see so many attendees to today's presentation or part two of today's presentation.  I want to remind you all to download the documents from the file share box on the left‑hand side of the screen.  There's a handout and a certificate of precipitation both documents can be downloaded as PDF's and used during the presentation as well as referenced later as a record for having attended.  We will be with you in just a few minutes.  Oh, by the way, Melissa Freund from AudiologyOnline is going to post on the screen two polls to tell us a little bit about who you are and give us an idea of the make‑up of the audience today.  Thanks, bye.  Hello, everyone, I'm Cathy Luckoski if you are just now joining us, we will leave the polls up just for another minute and answer questions and we greatly appreciate it.  I can already see that we have a great turnout today with variety of professionals joining us, speech‑language pathologist, audiologists, other professionals as well and look forward to the presentation.  Be right with you.  Hello, everyone, and welcome to part two of Red Flags: Barriers to Optimal Auditory Development Part II.  This is an event hosted by Cochlear America's HOPE program, my name is Cathy Luckoski, and I'm a HOPE specialist, I will be assisting during today's event.  This is the second in a series been both of which are each 1 hour and are recorded, part one was earlier today.  We encourage you to view both parts, so if you missed part one, please visit the HOPE Online library hope@cochlear.com to access the recording and turn the microphone over to the presenters and first I want to go over a few items in our online classroom.  The first is Q‑and‑A box in the upper left‑hand portion of your screen, this is where you can answer questions and comments to us and to the presenters.  You can do this at any point during the presentation because we have a full classroom and try to answer questions during the presentation but for the most part we will probably collect those and keep them for the it had when we are wrapping up toward the end.  Just below the Q‑and‑A box is file share box, and file share box you will see two handouts, one is specific to the presentation and the other is a certificate of participation.  The certificate of participation is for you to print off and complete and keep for the records in terms of continuing your educational endeavors.  Formal continuing education units, however, offered through AudiologyOnline and information for this is in the note box in the lower left‑hand portion of your screen, contact AudiologyOnline at 1‑800, 753‑2160 or visit the website at AudiologyOnline.com to get information on obtaining formal continuing education units.  We are proud to offer collection of resources through the HOPE program.  All of these resources are designed to help Cochlear's implant recipients of all ages achieve their best in listening, so after viewing our presentation today, hopefully you will visit the website at hope.cochlear.com to view the other items there in the library as well as over 100 courses that have been archived from past, presentations.  Now, it is my pleasure to introduce our three guest presenters today.  Jane Madell, Sylvia Rotfleisch and Joan Hewitt.  Dr. Madell is audiologist, speech‑language pathologist and certified auditory‑verbal therapist.  Her clinical and research interest include hearing infants and children as well as the assessment and management of severe to profound hearing loss.  In addition to consulting nationally and internationally is expert in pediatric hearing, Dr. Madell is author of several books and articles on pediatric hearing.  Sylvia Rotfleisch is a private practice audiologist, auditory‑verbal therapist in Los Angeles.  She has nearly 20 years of experience and trained at McGill University under Daniel ling.  Prior to private practice she worked at Montreal aural school in the institute and taught in graduate programs at USC and California Lutheran university and published several articles and two book chapters.  And finally, Dr. Hewitt is private practice pediatric audiologist in Encinitas, California and adjunct professor in San Marcos and has 25 years experience in diagnosing and treating infants and children with hearing loss as well as an advanced degree in aural education and board certification for specialization in cochlear implants.  We are fortunate to have all three experts from the field today in the HOPE classroom, and with that I would like to turn the microphone over to Jane.
>> Jane: Couldn't hear me, I apologize.  I forgot to turn my mic on.  Sorry about that, guys.  We have had so many technology issues, and I missed the most obvious.  As Cathy said, this is a two part workshop, and can ‑‑ how many people signed up for ‑‑ how many people attended part one.  Hit the hand raise thing at the top so we can get a sense how many of you were in part one because we really do intend for people to participate in both parts of this workshop so looks like maybe ‑‑ looks like a lot of people participated in part one, thank you.  So if you haven't ‑‑ probably about a third ‑‑ half the people participated in the first part who are attending now and if you have not, please listen to part one because we really do think this is intended for everybody.  For audiologist, speech‑language pathologist, auditory therapist and parents, and we think that it will be more meaningful if you have the whole picture.  Of the first few slides repeat from the things that we have ‑‑ that we did for the first part but it is very short and then we will get on to the new information.  So things are fine for most people.  We know that most kids really do well with their technology and they seem to ‑‑ they are doing fine.  But there's some kids who are super stars and other kids that really aren't doing well, and the question is why.  What is it that's making the difference?  Why is there a huge variation among kids who seem to be equal, who have all had parents who worked, good technology, you know, everything seems to be going for them, no additional issues and some kids do well and some kids don't do well.  So we know that all ‑‑ that all kids don't do equally, but we really want to do why they don't.  Some things are clearly a problem, not hearing well with the technology is a problem if you don't have threshold of 20 dB through four or six or 8,000‑hertz, you're not hearing well.  If you're not getting auditory based therapy, you're not going to develop good speech and language.  If your parents aren't involved in your therapy, you're not going to do well.  If you have got other developmental issue, that may be an issue and identified late, that may be an issue, but some kids have everything that they need and they still are not doing well.  So why?  Why is it that makes such a difference?  And we think that we need to know the answer to that.  So let's just sort of have a little reminder why audition is important.  What do we need to make everything work?  Early identification and early fitting of technology is obviously critical because it enables kids to hear and to hear well.  Appropriate auditory access with technology is very important.  The consistent use of technology every waking hour makes a difference.  Typical children have ‑‑ typically hearing children have access to sound 24 hours a day, whether they're awake or asleep, they hear.  Hearing impaired children are not so luck and only hear if they have the technology on.  If child hears four hours a day, it will take six years for a typical child to hear in one year.  What does that mean?  When we think about hearing impaired child, they can't afford to be any more behind than they are.  They are already listening to distorted signal out of the best of circumstances, don't hear slightly certainty they hear what they need to hear and have their technology on every waking minute.  And until the technology is appropriately set and soft speech throughout the frequency range clearly, they can't learn auditorily.  In addition to that they have to have consistent auditory stimulation and need to be able to hear soft speech and speech and noise and, of course, family needs to be involved to provide therapy 24 hours a day.  Now, if a child has appropriate technology and they have appropriate auditory exposure, they will have good auditory brain development.  If they don't have appropriate technology, if they are not having soft speech with technology, even if they have appropriate auditory exposure they will have reduced brain development.  If they have perfect technology but they don't have good auditory exposure, they will still have reduced brain development.  So the goal for our children is to be sure that they have appropriate technology and appropriate auditory exposure so that they can have good brain development.  So let's talk a little bit about the most basic red flags.  There's some things that are a red flag for everybody.  If a child is not tolerating the technology, resistant to wearing it, not comfortable with it on, that's obviously a red flag.  May be a behavior issue, but the majority of the time it is a technology issue and not a behavior issue.  Now, for behavior ‑‑ what's your observation about how they respond?  If they have poor responses or no response to sound, if hypersensitive to sound, if they have involuntary eye blink or facial stimulation when wearing it, all red flags indicating there's something wrong with the level of the sound and discuss this in a lot of detail in part one.  If children hear well with technology, they should want to wear it all day and if they don't want to wear it all day, that is a clue that something is very wrong.  Parents or other family members maybe have expressed concern about how the children ‑‑ what kind of progress the child was making.  Sometimes they are not realistic, parent may expect the child gets implanted and within a week or two they should be speaking in sentences.  That's not going to happen and not realistic expectation.  Done a good job counsel before implantation, that shouldn't be what happens.  So we need to listen to parents.  If they're expressing a concern, then withy need to wonder, think about what the concern is and what we can do to make it better.  Joan is going to take over now.
>> Joan: So we want to look at interventional red flags.  Is the intervention that child is getting effective and it is performance for audiologists to know about the intervention.  We cannot as audiologists just program the devices and send the child home and assume that we did our job and that that is all we need to know.  As audiologists we need to be involved and knowledgeable about the intervention the child is getting because no matter how effective the programming is, if the intervention is not affected, the child is going to have reduced auditory brain development as Jane said, so we want to make sure the child and family are enrolled in therapy which is optimal.  We know as audiologists or SLP's or teachers of the deaf is if the child is involved in the therapy without the parents or other family members, then that therapy is going to be minimally effective.  If technology is not monitored at every session, then we can't ensure the effectiveness of the intervention and as audiologists it is our responsibility to teach the SLP and AVT's and teachers and the family members how to check that technology everyday.  Ineffective intervention is intervention that does not stress the development of listening as the basis for all speech and language development.  Or intervention which promotes visual language development.  So if the intervention is teaching lip‑reading, if the parents are coming to us as audiologist and saying, you know, my ‑‑ my speech pathologist wants my child to be looking at the mouth all the time, then as audiologists that should be a red flag that this is ineffective intervention and obviously any intervention that does not follow a developmental model is going ‑‑ is not going to be as effective as we would like.  It is also important that we talk to parents and make sure that they know about the intervention.  So signs red flags that intervention may not be effective are when parents can't tell us what goals or objectives are being worked on in therapy or if parents don't tell us ‑‑ unable to tell us what they're supposed to follow through with the home.  If a parents can't tell me what a child can or cannot hear, then I know the parent is not getting effective intervention to watch the child and observe the auditory development.  If I talk to a therapist and that therapist can't tell me about what the child can and cannot hear and can't clearly define the skills that the child is developing, that's a huge red flag.  It is also a red flag when we talk to therapists and they say he is doing fine or if I ask the parents what does the therapist or teacher say and they say he is doing fine.  Parents should be able to articulate and therapists too what is being worked on.  And also we see with some therapist the primary focus of therapy is the ling six sounds.  The Ling six sounds are wonderful to make sure the child can hear across the spectrum and never designed them as a curriculum and did not design them as be all and end all check, they are just a quick check, and when I hear from parents well, we can't move on in therapy because they haven't mastered a Ling six sound, then I know that intervention is not as effective as it needs to be.  How do we address ineffective intervention?  Well, the first key to intervention is the parents.  As Jane said, these are the people who are there 24/7.  They need to be the most important component of the therapy.  We need to make sure we have a therapy model based on development of listening as the foundation for all speech and language.  And that is what auditory‑verbal therapy does.  We need to make sure that parents are involved in every session and not just observing but being trained because therapy can never reply what parents can do.  Now I would like to turn it over to Sylvia.
>> Silvia: So auditory‑verbal therapy for those of you that are familiar with it really does vary strongly focus on all of those issues that have been discussed as potential problems for ineffective therapy.  For those of you familiar with principals of auditory therapy it is on spoken language and focus is really on guiding and focusing and the parent guiding the child and that's the key thing that needs to happen in the therapy session.  Parents need to understand what is happening in the session, they need to know what the child is hearing and what they're not hearing and as a therapist I need to be teaching the parent what it is that we are doing together.  I established the goals for the child and I incorporate them into sessions and teach the parents how to be carrying through the week on goals on every days kind of language sessions with the child and they shouldn't actually be feeling like the child is ‑‑ has to be worked with and parent is working.  This is really something that's going on in an ongoing basis and throughout the week the parents should be observing how the child is doing and coming back the following week with very clear observations or questions or concerns.  I feel very strongly that the key person in the therapy session is the parent, and if I have to do the session and I'm not being sarcastic but if I had to do the session with only one person, the more critical person in the room is really the parent.  I say over and over again to the families that I don't take credit or blame that they are really the ones who are carrying through all week long.  Now, that's not true that I don't take blame but I explain to the parents that they need to be empowered and they are the ones that are doing this work.  I cannot possibly zap their child in one session a week where the parents have 24/7 with the children.  Looking at in terms of ineffective issues are relying on vision as a primary modality instead of relying on audition and very strong indicators of speech acquisition that's happening through a visual modality rather than audition.  Visual based errors that many of you have experienced or seen are things that visually the same, so M sound and B sound and P sound all look exactly identical on your lips.  Ma, ba, pa though are very different auditorily and other thing that happens with visual dependence is people start to break down their speech and you get elongations, so things like that really destroys the natural cadence and the control of the super segmentals and then you have children who are very, very particularly monitoring their articulation and forming sounds and when they do that, that breaks down the natural cadence again.  Also things like exaggerating lip movements for things like oo or e.  That will slow down the speech.  When slowing down speech again it is going to give you distorted speech production.  Dan Ling is only sense capable of appreciating all aspects of speech, and that is so, so true, and we just talked about how when certain sounds are formed in the same place of your mouth, so the place is the same, then visually they're accessible but they are not discriminable.  So we have to understand how audition really helps us to access all of those sounds, non‑segmental features pitch and duration, these things are really not visually accessible at all and looking at what is available, understand the difference in some sounds can be visually accessed but most cannot.  So providing exaggerations is not really going to help you to provide access that is not there visually, and what's happening is you're giving something that's unnatural and it is going to inevitably cause a problem.  So we mentioned about exaggerating the oo vowel or e vowel.  Oo vowel with lip rounding or E vowel with lip spread and these issues give you pitch breaks, they give you all sorts of distortions in your speech that would not be found if you were learning to listen to pick up these sounds.  So children who are getting intervention that's not looking at auditory base are really going to show poor auditory abilities or very slowed development of their auditory abilities.  Initial sounds and ‑‑ sorry unusual response is to sounds we would expect such as turning to their name and developing a listening attitude are not going to be seen early on as we would expect, and from the start we should be seeing a child showing a different and better voice quality when they are getting good access through technology but children that are relying on and visual input and not getting effective auditory input are going to demonstrate typically a poor voice quality and difficulty with the ‑‑ with ability to discriminate and identify the suprasegmental and the vowels and based on super segmentals or key vowels, and those are often because relying on vision does not give you access to those features.  When we start looking at key words and consonant features, the child needs to be able to access different levels of auditory abilities, and if they are not able to do that and if they are not to do that, you will find the speech production is not improving.  So I say it over and over again these children are hearing loss and it is the hearing loss that creates the delay in speech and language and start working on speeching teach and language what we are doing is treating the symptoms and we are not helping with the underlying cause.  It is it is old we going to put antibiotics on the infection or just going to use a Band‑Aid, so it is really critical that we start with defined auditory component to the therapy and auditory skill development needs to be done in a very appropriate sequence.  We don't suddenly want to jump in at level that is appropriate to the child's chronologic age when we have to keep in mind the child's hearing age and begin with the foundation steps and development them through an auditory modality in the appropriate sequence.  So the progression of audition is really critical and we need professionals who understand what are the first sequences and how we can establish the foundation skills to then move through the different levels of difficulty and progress in appropriate sequence.  The auditory goals need to be incorporated on an ongoing basis and it says here in every session but keep in mind that it is not just in the session because with guidance and coaching the parents through all week long.  Is there a demand for audiology and establishing audition as primary as modality through so many different aspects of what we are doing, even from the very basic setting up the physical arrangement of the room, and sitting at a place where we are enhancing the child audition and giving the child a good auditory environment and where child encouraged to be listening not to be relying on hearing.  So there's several strategies that we talk about that allow us to focus on the audition and that would be just natural in play that we are looking at the toys that are on the table in fronts of us and joint attention and speak and playing with the toy and don't have to necessarily stop what you're doing, stop moving the puzzle piece so that you can be listening.  Acoustic highlight techniques, though some of them seem counterintuitive whispering happens to be a very effective one and it is particularly useful for speech sounds that are not voiced.  Non‑segment or supra‑segmentals are often referred to or looked at when we discuss caregiver ease and those are played around with in a way to make the language that much more interesting to the child.  Again, we look at elongating sounds but not in a very distorted way but in a phonetic level to acoustically highlight certain speech features or certain speech sounds and to be able to reinforce the sounds at phonologic level and how else can we focus on audition as a primary sense modality.  Audition needs to be used first.  Famous playwright who was asked to what he attributed the tremendous success, and he said it was very simple.  He wrote three act plays and in the first act he told people what was going to happen and second act it happened and third act he told them it happened.  Now, that's a really excellent sort of model for us to be using presenting information or toy to a child letting them know this is what we are going to do and get out the toy and then got the cow and played with the cow, so there are the three stages it is going to happen, it is happening and it happened.  Another very common way to look at audition is through the auditory sandwich which I hope many of you are familiar with where we start with audition and we add other modalities if they are necessary but then we go back to audition to reinforce that.  Another way is to use the 60 dB rule to improve auditory access, so as we have the distance, we increase the intensity by 6 decibels which is doubling of the intensity.  So that really is when we lean in to be closer to the child's technology, closer to the microphone, to improve the access for a child and sometimes that's also going from 10 feet to 5 feet to allow for better access.  When looking at the auditory skills it is really important to be setting everyone up for success and we have already spoken about how the important thing is to establish those foundation skills even if you're talking about working with an older child who one would think has more advanced level.  In fact, all the children began at hearing age of zero when we give them their technology and the foundation skills are really just that, foundation and need to be used to build other things on top of.  So when I talk about working with a child and their speech production, I don't discuss and don't look at it as correcting speech.  I really am enhancing perception and that's going through the auditory channel to make sure that when there's a misperception that the child is learning how to perceive that sound more accurately and as they hear better they will produce better children speak it is way they hear.  Auditory closure is another technique that we very often use and it comes into play particularly with young children as they are starting to develop some early sounds by completing a sentence or completing part of a phrase in a song, using books that have repeated phrases or songs with choruses, allow us to use that kind of technique very easily.  And then the important thing to remember is listening is foundation for communication.  Respect when speaking.  It is I listen to you and then I pause and then it is your turn to listen to me, and that whole turn‑taking and conversational competence has a basis in listening and being able to attend to the other communication partner.  So how do we make sure this is happening.  Audition in technology is so critical as Jane was saying in the portion where she showed you those great colorful rectangles.  One plus one equals two.  You need to have all of those components and needs to be across all the child's environments.  It needs to be in the child's therapy situation and needs to carry over to home and also to the school environment.  Jane?
>> Jane: So we will talk about appropriate expectations.  All professionals need to be on the same page about what's happening in a child's development.  It allows us to share concerns and to listen to each other and talk about what we think is important.  Is child making appropriate growth and need to ask that and our area of specialization and about the child overall.  And it is appropriate and based on audition, meeting speech and language goals, is the child making one year's progress and one year's time and is the child demonstrating any of the red flags behavior we talked about earlier in the hour and a half we have already spent.  Because is the child making ‑‑ I see.  I hit the wrong thing.  Sorry, guys.  So what questions should the audiologist be asking?  We want to know about the child's speech and language progress and we need to not just say to the mom, is this child doing okay?  We need to say to the speech‑language pathologist has this child made appropriate gain in this year and what are the areas of weakness and then we need to pay attention to whether those areas are auditory areas that the we might be able to do something about.  We need to know that the technology is appropriate and that this child is hearing 20 dB through at least 8,000‑hertz.  We want to know the child is hearing soft speech because if they are not hearing soft beach they will miss 70 to 80% around them and negative effect on speech and language.  That means they have to be able to hear clearly at 35.  Can't have a threshold of 35 because ( whispering) and need to be able to hear ten dB softer than that and at least getting a soft small at soft speech.  We need to be ‑‑ soft speech.  When happening in therapy and as Sylvia says is it following the developmental patterns, deviations from the normal pattern that are cause of concern in the child's production?  Is the rate of development a problem?  In the beginning it may move more quickly because it is older with a cochlear implant and still making one year's growth and one year's time.  We need to understand the concept of hearing age versus chronological age and absolute certainty, if child gets their technology ‑‑ appropriate technology, not put something on the kid's head.  If a child gets appropriate technology at one year of age, at two they have a listening age of one.  And chronological age of two, but they are going to function based on listening age and know what that is and everybody understands it.  Parents are novices and rely on professionals to guide them and can't take that responsibility from them.  If parents feel like they have to know and rely on professionals, we have to help them respect their ability to be the child's advocate and be the person in charge.  Parents report on ongoing basis and same concerns and each other and don't listen to other's concerns and that is a very significant problem for the child and if professionals aren't sharing concerns and aren't using those and end up with confused and frightened and parents and the progress you need to make.  It should be ‑‑ it says Madell and Hewitt but it is Rotfleisch, Madell and Hewitt and we did a Survey Monkey study in which we looked at audiologist, speech‑language pathologist, teachers of the deaf and LSLS and asked them what they expected from children at different ages and when did they expect a child with hearing aid to do certain things and when do they expect a child with a cochlear implant to do certain things.  Only 5% had less than three years of experience, 74% of this group had more than ten years of experience and all of them had been working with children under two and majority of them had been seeing and seeing kids ‑‑ majority had been seeing some ‑‑ at least some kids under the age of two.  We looked at the ‑‑ we found that most of them saw kids of all ages, 27% of them saw kids just under two.  Survey included audiologist, speech‑language pathologist, LSLS and teachers of the deaf and not surprising but definitely disturbing was speech pathologist and LSLS had hire expectation what kids could do than audiologist and teachers of the deaf.  Is that an important thing?  We think it is important because if all the professionals working with children don't have the same level of expectation then they are not going to be doing all the things they could do to make it better.  If I think the kid will do well, I have no motivation to improve the technology, but if I think this kid is not doing well, then I have an obligation and responsibility to change the technology.  So if everybody doesn't have the same goals, we definitely have a problem.  So the kinds of questions we ask ‑‑ we found that place where is we found differences in trends or and certification for babies with hearing aids, differences in expectations were noted in easier skill level and babies with CI's differences were noted in the hire skill levels.  Some of these were borderline and some of them were not ‑‑ were very significant.  What we found as I said was that LSLS's and SLP have greater expectation for earlier development.  The skills they consistently expected kids to develop earlier is on this slide, consistently discriminate suprasegmental, discriminated, nasal, a fricative from nasal a plosive, one nasal, 1plosive and five consonants and show consistent comprehension of five words and two to three stereotypic sentences.  These were areas in which speech pathologist and LSLS expected behavior consistently earlier from teachers of the deaf and audiologists.  The kinds of questions we have if a baby is aided before three months of age and adequate speech access to speech and access of hearing aids and what period of time do you expect the baby for the skill.  For a cochlear implant if baby implanted 12 months of age and had no benefit from hearing aids before, when do you expect them to develop the skill?  The assumption that we used data from the LSLS and SLP because most appropriate because working with kids on ongoing basis.  It is important to remember many of the LSLS are certified in audiology, SLP and teachers of the deaf and brought them out with the study.  No significant correlation between years of experience and all the SLP's and LSLSs were included and look here and look ‑‑ after ‑‑ from a three‑month‑old babies who got hearing aids before three months old, we expect ‑‑ everyone agreed the majority of people expected them to be responding to their name consistently by three months of age, listening age, that is, three months listening age, and look all the way to the right, there's some people who thought they wouldn't be responding consistently by one year and that is a little scary to me.  Nine months even had votes and cochlear implants they expected three months after getting a cochlear implant the majority of people thought these children should be responding consistency to their name but as you can see, there are people who thought that one year or greater than one year was acceptable.  What are we going to do with that?  That's a scary piece of information.  Here you can see the list of the skills along the bottom, hearing aid in blue, cochlear implant in red and you can see clearly that there were at least two areas, discrimination of fricative and discrimination ‑‑ kids with cochlear implants were expected to get this information significantly earlier than kids with hearing aids.  Rest of the expectation cochlear implant and hearing aid are about the same and talking about listening age, not chronological age and not just Madell and Hewitt.  Krystine three months criminal nation, vowel discrimination three‑point vowels, A, O, E, including voicing and good voicing discrimination and place discrimination, may not be able to do all of them but should certainly be able to do just one, and not just our data but data that other people have also found.  So I'm turning this back to Sylvia now to discuss red flags.
>> Silvia: We talked about this and report to the colleagues the audiologist and have something going on because something with a red flag and indicative of something beyond therapy at this point, and so one of the first points that comes out is really the voice quality for these little ones.  So we listen to a very groggy stressful kind of ‑‑ stressed sort of sound.  We get intensities that aren't appropriate.  The child either is whispering or they're voice is always too loud and then they can't produce a whisper.  And then there's issues with oral nasal balance and poor pitch control and vocalization on an inhale.  These are very beginning speech quality issues that really are serious red flags when a child has had access through their auditory technology and showing appropriate development and speech production continues with issues when we got parcel with cadence and a sentence and coming back with approximate situations Sunday things like that and overall poor vowel recognition and vowel development is something to be monitored and also vowel development and no consonant development that's also a area of concern and looking at consonant development just having consonant developed isn't necessarily a sign of something going well.  Sometimes we get appropriate or sequence of usual consonance development and strange sorts of productions with things like nasal emissions or lateral fricative and we should be looking at child with a cochlear implant, if we got low‑frequency sounds primarily with child with cochlear implant and the high frequency sounds are not coming in or if we have high frequency sounds with hearing aids and the low‑frequency sounds aren't coming in.  And overall when we are looking at manners of production we should be seeing a variety of manners developing in an appropriate sequence.  So we should be concerned if the development is out of sequence and limited number of consonants in a certain place of production and if that means that the child is getting them primarily through vision like a by labial consonant or if we have made certain we are eliminating the vision, still only developing a certain place of production and not expanding to other areas.  The sequence of development of consonants is very specific and if we are getting more advanced phonemes but we are getting gaps in certain skills, then that's an issue.  If you have got a child who's developed their more advance speech sounds SH and G and K's but haven't developed the bilabial, that's a red flag but if you have a child whose developed most of G and SH but K missing.  Getting voiced but not unvoiced sounds, red flag and if you are not able to elicit specific speech features, either in terms of place or manner of production, that's not to be expected.  When we start looking at language development, the child should be getting some conversational babbling jargoning productions, and if we are not seeing that, that should be a cause for concern.  Babbling and jargoning but no intelligible vocabulary or specific language development in the next stages is again a red flag, and if we have a child whose showing receptive language development and no parallel in their expressive development ‑‑ sorry, in their expressive abilities, then that's something that is not appropriate and would be a serious concern.  We should never see any deterioration in a child's abilities.  If we have a child who's no longer able to demonstrate the perception of sounds that they were able to perceive as different, then that's clearly a change or a problem and we need to be looking at that very seriously.  If we have speech production that was consistent or emerging and then it seems to disappear and deteriorates in the level of ability, again, that's something that you should be heading over to the phone to be picking it up and calling the audiologist.  And seeing plateau or regression with regard to language development that should not be happening with children that have.  Who have appropriate access.  So the way to really be doing this is to collect the data and wherever we can we want to be testing this to determine how we are getting the progress and if we are getting appropriate progress but we really need data both objective and subjective but that's really the information that we can share.  Don't say well, I don't think the child is doing what I think they're supposed to be doing.  We need to be able to tell our colleagues the child is not responding to these sounds, the child should be showing development of these skills and we are not seeing those developing or we have seen some deterioration in these issues.  So we never assume, we always collect data and we share it with our colleagues.  Jane?
>> Jane: Take home point for interventionist, we need to ‑‑ if you have concern, you need to express your concern respectfully to your colleagues and need to tell them and can't tell the parents to do it.  Share the information yourself.  It is no the parents' job to get in between.  We need to examine ‑‑ we need to each examine our own intervention to be sure that it is contributing to the ‑‑ how it is contributing to the areas of concern and what things we are doing that the we could change.  We need to listen to parents.  Parents are often hesitant to express concerns, so when a parent expressing a concern, we really need to be listening to them and need to be listening to children.  As we said earlier, production errors are perception errors.  If I ‑‑ I listen to what ‑‑ before a test I listen to what the kids are saying and I can almost predict what I have to change in the technology.  That's not to say there aren't some kids who have some kind of aural motor issue and hearing loss there's production problem is really probably a perception problem.  So we need to assess kids formally and informally and monitor what they are doing and figure out what's happening.  In summary, different professionals do have differing vow points about developmental expectations.  We need to be sure that we are being realistic and we need to listen to our colleagues who may have more experience in the area that they are working it.  If professionals have different expectations and they are not willing to listen to each other collaboration can be affected.  If one professional has lower expectations, you know, if AVT comes to me saying this child does not hear SNSH, I did what I was supposed to do, it is your job.  She can't fix it if he can't hear it, so I need to be able to prepared to listen to what she is saying and figure out what I can do to make it better and when we need to also recognize when we have differences of opinion and put the parents in a bad position and need to do what we can to not put them in the middle.  Need to try to figure out a way to resolve legitimate concerns and any time a child is not doing well, it is a legit mat concern.  So need to figure out what it is and need to figure out ‑‑ we need to make it work for the child.  We need professionals who like kids and who can keep ‑‑ who can keep kids motivated and engaged.  Mostly we need people who are willing to be open to listen to what their colleagues have to say, who then they look at a child say what is it no matter how well the child is doing, can say what do I need to do to make it better than it already is.  Need to investigate the observations, need to realize that no one person has all the answers, I don't have all the answers, have to have colleagues to help me make the kid the best they can be because that's the only thing that matters here.  We need to listen to the kids, we need to monitor all the technology, we need to monitor the program, we need to monitor therapy, we need to monitor everything that's happening and the most likely thing to be the problem first is the technology.  We need to remember that if the technology is not appropriately set, the child is not hearing enough, their auditory brain is not developing and they will not have good speech and language or it will take them three times the effort to get the speech and language.  Saying it will never get there?  No.  Those of us been in the field long enough who were here before cochlear implants know that there were kids then who did well enough with hearing aids and hearing aids were even worse then, so that they got ‑‑ grew up to be doctors and lawyers and business executives and everything else.  But they were far few of them and they had to work hell of a lot harder and parent and a half who could work with them full time.  We don't need that now.  So when we have a kid who's not making it, we need to say something is wrong, we need to fix it.  It is a ‑‑ takes a team to raise a child with a hearing loss and everything in this field is changing by the day.  We need to all know what it is.  We need to depend on each other as professionals.  And we need to change with the times because kids are depending on us and we deserve everything we can get them.  If you did not listen to part one please listen to part one, only way to have the whole talk is have both part one and part two and deal with some questions.  Let me see.  Serve nonverbal autistic children in school for the deaf and they received CI and I have no way how to evaluate them.  One of them requested I try to teach the child had a drop block in the bucket to hear the sound.  How do we do that?  What I do in that situation is I would ‑‑ teaching a child to listen and do some physical agencies really an appropriate thing to ‑‑ for speech‑language pathologist or teacher working with a child to do.  What you need to do is try to find some activity that you can find ‑‑ have this child interested in and then I would start with something where the child would see and hear.  Just did this with an autistic child in New York.  I helped an audiologist in a clinic figure out how to do this so we could evaluate the child and what I had done asked the teacher and school to work with the child in advance, and what we did was we asked her to figure out what toys he was interested in playing with and she took the toy with one hand ‑‑ you can't see me but I'm holding the hand with the toy up to my ear, hold it up to the child's ear, I would bang a drum where he could see and hear it and move his hand into the bucket so he could drop the toy.  Blocks, pennies, anything interested in ‑‑ pennies and anything interested in and get him to do that, take the drum away and have somebody bang the drum behind you, behind him so responding to listening and if you do that, I mean you should be able to teach him the task.  Joan, Sylvia, do you want to add something to that?
>> Joan: What Jane was saying finding what the child is interested in with autistic kids.  That is hugely important.  We had a child who loved food so we got bins of plastic food and the child learned to listen to that.  Finding what they are interested in is really important.  And we also have a couple of kids who are on the autism spectrum who didn't really want to draw the block but repeat what we said.  If weren't really to drop the block, approximations of things, that's how we got information from them too, so finding what they are interested in is so important.
>> Jane: Thank you.  You're absolutely right.  Are Ling sounds ‑‑ I'm having trouble reading.  Can't get the whole ‑‑ make the box bigger ‑‑ Ling sounds a daily trick or recommend more?  I think all three of us say we recommend more.  Yes, the beginning ‑‑ you want to know can the child detect them, then you want to know whether the child can discriminate them and want to do it at close distance and at far but also wanted to throw in some individual words and some sentences, things the child cannot predict so you're looking at a lot of different things when assessing performance.  Joan or Sylvia, do you want to add anything?
>> Joan: This is Joan again.  I would recommend you watch the first half if you haven't because in there we do have some slides on some phonemes that we have found through some research that really do indicate problems with speech perception.  And just like Jane said, we would recommend much more than the Ling and mixing it up all the time, especially since we have kids nowadays who are so good at the ling all you have to do is hold the hoop up and run through the repertoire, never need to say anything.  So yes, we would recommend much more.
>> Jane: Silvia, there's another question.
>> Silvia: ling six sounds, there's lots of articles to go back on but hopefully most of you are, the ling six sound is intended to be a quick check on the integrity of the entire hearing situation, so you're supposed to be rubbing through the sounds to know what the child is supposed to be hearing to see if there's any breakdown in technology on that given day, but when we are looking at variety of the questions that are here, people are asking how do we really know if the child is hearing, how do we know what should be monitoring.  The ling sound is to monitor the entire technology.  Discrimination of the ling sounds and other phonemes will give you a lot more information in terms of what the child is actually able to discriminate along with and identify and those are skills well beyond just the detection of the ling sounds.
>> Jane: Sylvia what are formal and informal measures in therapy session to collect data sharing with the audiologist.  Could you answer that, please?
>> Silvia: Formal assessments, the little ears, the itma's, the real evaluation, there's several of those that you can be doing on an ongoing basis to monitor the child's change in their auditory developments.  As far as therapies going, you want to really be watching for what the child is hearing and there are several questions about how do I know what the child is hearing and if they are hearing all the phonemes and when playing with a sound and playing with a child and playing with MM, something is yummy and playing with a baby doll and child should be showing you by variety of behaviors they are indeed hearing the sound and if the child then is picking up the spoon to feed the baby or bottle, understand they are discriminating the M sound is different than a SH which may be the child then picks up the blanket and covers the baby because the baby doll is going to play.  So we do these with young children through very informal kinds of ways of assessing and in terms of seeing if the child is actually detecting the sound, you should be looking for all the basic signs of a child hearing a sound.  The eye widening, stopping in activity, looking for the activity, things like that.  And all of those evaluations, the formal ones talk about what to be looking for.  So you want to informally be following some of the guidelines from those assessments in some of the informal activities that you're doing with a child and that you're teaching the parents to be doing at home on an ongoing basis.  Joan, do you want to handle question number ten?
>> Silvia: Sure.  So the question about is there a decibel level that we still tend to think that we need to implement ASL rather than to try to development the auditory brain?  And I think there are two parts to the question.  People this our area tend to think it is at 70 dB.  First part of the question is that when a child does not have good perception with hearing aids, when they are not hearing as Jane said, 20 to 25 decibels, when they don't have good soft speech perception at 35 decibels, with the technology on and we have done the best we can with technology, hearing aid technology then there's time to think about cochlear implants and Arthur Boothroyd did a study more than ten years ago where he showed that for children who are going to have auditory brain development that the cutoff was about 70 dB for their unaided thresholds to be considered a cochlear implant.  So if a child with a severe hearing loss is not getting the access that they need, we do need to think about cochlear implantation.  With cochlear implantation if there's nothing structurally wrong, then we would think that they should have a good auditory access.  We shouldn't be seeing threshold at 70 dB with the implants on.  If we are then that implant isn't programmed correctly, and we ‑‑ there's lots of talk about kids now who have Cochlear nerve aplasia.  We actually met with one of the doctors who's going to be in the clinical trials for the ABI, auditory brainstem implant, and he was reporting that those children in the U.S. will be implanted with cochlear implant first probably at age one because we are seeing ‑‑ and they are seeing in Italy where they are doing more that many of those children are responding with implants.  So I think we need to the set our expectations high.  If they don't respond with implants they will be given an AB i‑but we should not be setting our expectations that any child shouldn't ‑‑ should have threshold at 70 dB with technology on.  I hope that answers the question.
>> Jane: That was good, Joan.  I liked your answer.  Somebody questioning from a school based program what's the best way to get parents involved in therapy?  I don't see them during therapy.  I'm going to say what I want to say and Sylvia and Joan have things to say also and especially Sylvia on this topic.  I think you need to figure out a way to get them involved in therapy.  First of all, I think you need to invite them to come once a month at least and then you could consider Skype during a way to communicate during therapy and also ‑‑ maybe your school could arrange two or three or four times a year to have a Saturday session where the kids come in with parents on Saturday and you get the opportunity to work with them.  Ideally you should see them with parents every time you see them but in a school setting that's not practical, but there are creative ways to figure out how to solve that.  Sylvia, do you want to say anything?
>> Silvia: Big long sigh.  I hear your pain and challenge and many of your colleagues online do also and what you need to do is get this touch with any of your colleagues and see if they will successfully manage this and some of the programs in the Los Angeles area insist that the parents participate at some level to have their children involved in the program, but if you're in a public school setting you can't necessarily do that but as Jane said trying to make things as accessible as possible which often means changing the therapy times or therapist availabilities and that's kind of in a public school gets very complicated.  Obviously as a private auditory‑verbal therapist I completely admit that I'm a spoiled brat, that I always have the parents or primary caregivers here and I just can't understand how I could possibly get my work done without them being here.  I wish I had a better answer than plodding and get answer from administration and colleagues on how they have been successful in trying to do this and working with the parents and letting them know how critical it is for them to be involved.  Good luck.
>> Joan: A lot of teachers have been using the IEP process itself and IEP's there's a portion that says person responsible and they have been making sure that they write in not just SLP or the teacher but that the parent is also responsible and then in that they come up with ways to have the parents more involved since they are legally responsible on the IEP.  I don't know if that works everywhere but we have been trying that here.
>> Jane: That is a great idea.  If it is in the IEP they have to make adjustments.  Here is question I have two‑year‑old hearing impaired kiddo in therapy, parents concerned about production of speech with normal substitution def or duh, how do I monitor to make sure it is appropriate?  Somebody else want to go first this time?
>> Silvia: What trying to do in terms of the technology is prior to the technology need to be looking at are you feeling like this child is able to discriminate these sounds as different and if they are discriminating them, if they can tell that one sound is not the same as the other sound, then you can be doing, you know, all the good counseling that you're going to do with the parents about how this is a normal substitution, but if the child is not hearing those sounds as different, then we really do need to be looking at the amplification.  And seems it is a very simple discrimination task depending on the age of the child.  At you can just have them pick one ‑‑ one hand versus another hand or one toy versus another toy or stack of toys or stack of M and M's, those are usually very motivating also, so different creative ways to make sure that the substitutions is really a developmental one, not an auditory one.
>> Jane: Good.  Thank you.  I think we have time for one more question.  What good tools can you recommend to help parents understand what a child can or cannot hear?  The first thing I would do is take the child into the test booth and get aided threshold with the right technology alone, left technology alone and the parent ‑‑ have the parent sitting in the test booth with the child.  So the parent sees where the child hears and doesn't hear and even more importantly do the same with speech perception, have the parent sitting in the room and hear what the child hears and doesn't hear.  That's the best way for parents to understand and they need to do that and need to understand why they need to fix what they want to fix.  Sylvia or Joan, do you want to take that one?
>> Silvia: Informally in a therapy session and teaching the parent what reaction to sound is because some of the things that are very subtle that a child learning to listen will do, parents have no idea that that's a sign that the child is hearing.  So just teaching the parent firstly what a reaction is to sound and what an indication is that the child is responding I think is the starting place, and then as therapist knowing what sounds are going to be the most effective or the ‑‑ sorry, the earliest ones for child to be responding to, that's where you want to start so that you can teach the parents to be effective getting auditory responses from their children.
>> Jane: We are going to have to end this here.  It is 4:15.  I am turning it over to Cathy to sign out for us.
>> Cathy: Thank you, Jane, and thank you all three, Jane, Joan and Sylvia for joining us on the HOPE Online program and all of you that attended part two of today's presentation on Red Flags: Barriers to Optimal Auditory Development Part III go visit hope.cochlear.com to get part one and next one is on May 2nd Dr. John Allen and he will present on speech perception and hearing loss and the body of research that is team has been developing and expanding on over the last year.  He did present on this topic at AGBell in July of 2012 and this will be an expanded presentation.  If you have any questions regarding the HOPE program, contact us at hope@cochlear.com and don't forget to download the certificate have the file share box in the lower left‑hand corner.  You all have a great day.  Thanks.

          This text is being provided in a rough draft format.  Communication Access Real‑time Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings.