Aural Rehabilitation for Children - Infants and Toddlers
Aural Rehabilitation for Children
A concerted aural rehabilitation effort is required for children to optimally recognize speech and acquire spoken language.
The aural rehabilitation plan must include participation by:
Parents
Speech and hearing professionals
Educators
Ideally, the child will participate in an early-intervention program that emphasizes spoken language and includes auditory training.
Early-Intervention Programs
Ideally begins as soon as permanent hearing loss is confirmed, and includes receipt of a listening aid.
Families may receive a list of all available programs in the geographic area or referral to a statewide early-intervention system.
The service coordinator is responsible for ensuring the IFSP is developed and that the appropriate services are identified.
The Joint Committee on Infant Hearing (JCIH, 2000, 2007, 2013) presents comprehensive guidelines for early-intervention programs.
Goals are designed to:
Support families in developing a child’s communication skills.
Help the family understand an infant’s strengths and needs.
Promote the family’s ability to advocate for the child.
Early intervention builds upon family support and bolsters the family’s confidence in their ability to parent a child who has hearing loss.
Best practice goals (JCIH, 2013) are designed to ensure:
Children with hearing loss and their families have timely access to early intervention programs.
Access to professionals who specialize in working with children who have hearing loss.
Child (and if appropriate, the family) receives sign or spoken language instruction from a qualified teacher.
Infants and young children have their progress monitored at regular six-month intervals.
Families are active participants in the development and implementation of the early intervention plan.
Families and their children have access to other families of children who have hearing loss and access to individuals who are deaf or have hearing loss and who can provide support, mentorship, and guidance.
Families from culturally diverse backgrounds or nonnative-speaking homes have access to culturally competent service providers.
Children who have unilateral hearing loss or slight hearing loss also deserve immediate services when appropriate.
Newest guidelines include ten appendices, each outlining the knowledge and skill sets necessary for a particular best practice.
Examples of these best practices and representative guidelines:
Family-centered practices: Understand family systems and family dynamics
Socially, culturally, and linguistic responsive practices: Promote family’s understanding and appreciation of being Deaf or hard of hearing
Language acquisition and communication development: Understand the array of communication approaches such as ASL, bilingual-bicultural, auditory/oral, auditory/verbal, Cued Speech, and simultaneous communication, and resources for observing and demonstrating them
Factors influencing infant and toddler development: Understand auditory, visual, and cross-modal perception and processing in relation to development
Planning and implementation of services: Plan and implement effective parent–child sessions in natural environments
Most early-intervention programs provide families with general information about language development and specific information about how hearing loss might affect development.
Families are encouraged to engage in home-based activities that facilitate language acquisition.
Programs usually ensure access to peer and language models.
Peer models include other families who have children with hearing loss, as well as adults who have hearing loss.
Language models may include individuals who use an aural/oral mode of communication or a mode that includes the use of sign.
Overall, most programs strive to address a child’s communicative competence, social skills, emotional well-being, and self-esteem.
Developing an Early-Intervention Program
Parents and professionals will take into account the following when developing an IFSP and choosing directions for early intervention:
Communication considerations: The language spoken in the home and the communication options currently used with the child.
Family-centered services: Services that address the family’s strengths, needs, priorities, and concerns; families participate actively in the intervention plan.
Developmentally supportive services: “Services that offer children authentic learning experiences to support functional communication development throughout everyday routines specific to the family, as well as interactive participation appropriate to the child’s age, developmental level, strengths, needs and family priorities” (Cheslock & Kahn, 2011, p. 11).
Assistive technology: Hearing aids, cochlear implants, FM systems, and any other assistive technology that might promote the child’s ability to participate actively in the home, childcare program, school, or community.
Programming options/natural environments: Description of the available services and the environments where those services might be provided, including the school or aural rehabilitation center or daycare, and the supports the family will need to access these services.
Community activities: The resources and supports (e.g., an FM system) necessary for the child and family to participate in community activities such as playgroups, library story times, and religious services.
Proficiency of staff: A list of qualified service providers on the team who have the requisite expertise, experience, and training to work with children who have hearing loss and who are between the ages of birth and 3 years.
Types of Programs
Parents might consider a center-based program or a home-based program, or a combination of the two.
Center-based program: Children attend therapy for a designated number of hours each week (Figure 13–5). Their parents may participate too.
Home-based programs: An early-intervention specialist visits the infant’s home and provides instruction to the parents and child (Figure 13–6). Home-based programs occur in the home and emphasize one-on-one rather than group instruction.
Examples of early-intervention programs are the SKI-HI curriculum (www.skihi.org) and the John Tracy Clinic home study programs (www.jtc.org).
SKI-HI curriculum:
A family-oriented program for children between infancy and 5 years.
Implemented throughout the United States and Canada.
National and local trainers provide training to service providers in participating states, and some training occurs at the SKI-HI Institute in Logan, Utah.
Includes early amplification, a focus on early communication approaches, language programs, and early literacy.
Portions of the curriculum are devoted to natural environments and everyday routines, parent support, and conversation training.
John Tracy program:
Offers both an on-site early-intervention program for families who reside in Southern California and a correspondence course.
Programs are available for infants, toddlers, and preschoolers, and aural/oral communication is promoted.
Topics included in the infant program are family relationships, deafness, child development, and communication.
Videotapes are available to demonstrate techniques, such as those associated with auditory training.
Coaching Model of Intervention
Many early-intervention programs emphasize a coaching model of intervention as opposed to a direct therapy model of intervention.
Coaching paradigm: The parent implements the program while the professional observes parent–child interactions and provides support and suggestions.
Direct therapy approach: The professional and child interact, and the parent, if present, observes and takes instruction from the professional.
In a coaching approach, a speech and hearing professional might say to a parent in the context of modeling language, “You responded to Rachael’s signals and you seem to know what they mean. Let’s capitalize on this and use something called ‘language modeling,’ where you can give her words for what she wants, as if she could talk.”
In a direct therapy approach, in contrast, a speech and hearing professional might instead say, “Let me demonstrate language modeling with Rachael. Try to do what I’m doing throughout her day.”
The former approach is family-centered and provides the parent with hands-on practice and a sense of self-efficacy; the latter approach is more child-centered and casts the speech and hearing professional as the expert and key to implementation and the parent as an audience member.
In the direct coaching approach, the professional makes home visits and interacts with the family and the child in the home environment.
The premise is that one or two hours of therapy performed by the professional each week will have minimal impact on a child’s development, whereas the ongoing interactions that occur between family members and the child, day in and day out, will have tremendous effect.
The professional’s goal is to help turn everyday activities in the home environment into rich learning experiences for the child.
General principles of this approach include the following:
Parents are the experts when it comes to their child and emphasis is placed on the parent–child relationship. The parents, not the professional, understand the child’s personality, preferences, and routines.
Parents and the professional are members of a team and they have a balanced partnership in decision making.
Family needs and desires drive the intervention program and the professional adapts to the family’s values, culture, ethnicity, socioeconomic status, and background Information.
The professional does not bring special toys or equipment to the home for providing instruction, but rather, utilizes the child’s toys and the family’s resources so that learning strategies can be incorporated into everyday activities.
The emphasis is on the function of communication and on embedding learning within ongoing routine interactions.
Parents learn to attend to their child’s attentional lead and to stimulate conversation based on the child’s focus. They learn to expect participation.
Everyday events, such as getting dressed in the morning, playing with toys, or fixing dinner, become opportunities for language development.
By embedding conversational strategies into play and caregiving routines, the intervention becomes individualized to the family and becomes part of their unique combination of personal and cultural values, ecological constraints, and resources.
If you are the child’s clinician, a home visit during any given week might begin with you asking the parent, “What’s new?” or asking a follow-up question about something that happened the week before during your session (e.g., “Is Aubrey still taken with her new coloring book? How’s she doing with naming her colors?”).
You might also ask about any concerns and priorities. For example, a parent might say, “Aubrey keeps pulling her hearing aid off and I’m at my wit’s end about what to do.”
A Stranger in the Home
Most families appreciate and value the support they receive in the home.
However, the reception may not always be welcoming.
Providing services to families in their home requires flexibility, sensitivity, and accommodation.
You might then focus on a particular activity or routine. For example, if you are there at a particular time of day, say lunchtime, you might participate in the meal preparation and as you do, suggest ways that a parent might promote learning and you might reinforce parental behaviors.
With this remark, you have not only implicitly reinforced the facilitative language techniques of parallel talk and expansion and modeling (techniques reviewed in Table 13–4), but have also explicitly reinforced the parent’s confidence.
If during the interaction, the child pulls off her hearing aid, you might observe how the parent responds and comment in a way that reinforces rather than diminishes parental confidence.
During an interaction, you might demonstrate strategies, say, during a play activity, but this should be an inclusive activity wherein the parent is part of the activity and has an immediate opportunity to practice the strategy during the session.
The session ends with a summary of what happened and what was gained, and a discussion about what next steps should occur.
Direct Therapy Model of Intervention
In the direct therapy model of intervention, the parent and child might come to an early childhood center or preschool or the professional might come to the home.
The professional might work directly with the child or might involve the parent in the learning activity.
At the onset, the professional has identified learning objectives and a strategy for pursuing them.
Warren Estabrooks and his colleagues present examples of lesson plans for babies through the age of 3 years.
In this plan, a sample of goals, which was designed for a 6-month-old baby named Arthur who has a bilateral severe to profound hearing loss, included the following (Estabrooks et al., 2006, pp. 91–93):
Audition: To detect environmental and speech sounds, as indicated when Arthur stops the activity, smiles, and widens his eyes; to recognize friendly and angry voices by responding appropriately.
Speech: To experiment and explore his own vocalizations by encouraging cooing and vocal play; to produce varied suprasegmentals.
Language: To listen to the narration of life provided by the caregivers; to encourage vocalization for wants and needs (to develop the vocabulary words of round, up, and down).
Cognition: To imitate facial expressions; to understand cause and effect.
Communication: To develop joint attention; to develop early turn-taking skills.
In this lesson plan, the clinician first addressed the goals by engaging Arthur and his mother in a game with a jack-in-the-box toy.
At the end of the lesson, the clinician and parent collaborated in compiling diagnostic information based on their observation of Arthur during the lesson.
Their observations included the following (Estabrooks et al., 2006, pp. 98–99):
Audition: Alerts to low- and mid-frequency [sounds] by widening eyes and smiling, and searching for toys; does not detect whispered speech.
Speech: Uses a variety of vocalizations (uh, nn); quality of vocalizations sounds natural.
Language: Engages in and enjoys vocal play; vocalizes more frequently with intent to make things happen.
Cognition: Demonstrated understanding of “cause and effect” with musical clock; did not demonstrate anticipation in games or routines.
Communication: Laughs, smiles, and coos while socializing; maintains appropriate eye contact.
Parental Support
Regardless of whether the intervention program is more of a coaching approach or a direct coaching approach, explicit information and instruction should be provided to parents about how they can foster their child’s language development and listening abilities. This can be done through both informal and formal means.
Parent instruction often includes training aimed at promoting language development and interactive communication. A professional might encourage parents to use facilitative language techniques.
Studies have shown that facilitative language techniques such as parallel talk and recasting develop a child’s conversational turn-taking and joint attention behaviors and increase the child’s verbalizations (Cruz, Quittner, Marker, & DesJardin, 2013; Raver et al., 2012), as well as promoting later reading skills (DesJardin, Ambrose, & Eisenberg, 2009).
In addition to learning facilitative language techniques, parents can be encouraged to speak with clear speech. By doing so, they will enhance their child’s recognition of their speech, especially in the presence of background noise (e.g., Smiljanic & Sladen, 2013).
Informal Instruction
A clinician might teach facilitative language techniques and shape parent behavior in an informal manner.
Parents may also learn informally from one another. For example, parents can share their experiences with other families and provide empathetic listening by means of parent support groups.
Regular interactions with other parents may lessen the stress associated with having a child with a hearing loss. Parent support groups provide a community wherein parents can express and explore their emotions. They can talk about their anxiety, anger, or confusion with others who not only empathize with their situation but have experienced it firsthand.
Parent groups are also a means for parents to share suggestions and solutions, say, for encouraging a child to wear a listening device or for teaching vocabulary about a particular topic, such as Halloween.
Formal Instruction
Instruction for parents or primary caregivers might also be more structured and systematic, and might follow a similar model that was considered for communication strategies training in Chapter 8, with the stages of:
Didactic instruction
Guided learning
Real-world practice
Didactic Instruction
During didactic instruction, you might begin by discussing selected language-stimulation strategies and review related examples. You might jointly “problem solve,” brainstorm about intervention strategies, and discuss the pros and cons.
Instruction may begin with a parent-friendly written handout explaining particular language-stimulation and conversational strategies (e.g., Table 13–4).
The strategies can be discussed and parents might be asked to explain the strategies in their own words and to provide examples of when they might use them.
You might also provide audio- or videotaped examples of other parents using the strategies in order to demonstrate how they work (e.g., Lam-Cassettari, Wadnerkar-Kamble, & James, 2015).
The clinician might then model the target strategy(ies) with the child, and when possible, do so in a simulation of a family routine or even in the home environment. The parent can observe the clinician and child and then the two of them might discuss the effectiveness of a strategy after the demonstration.
Guided Practice
The parent might then practice the strategy with the child, using the same routine that the clinician engaged in. This is a prime time to use coaching rather than direct therapy. After practicing, the parent and clinician might identify other situations in which the practiced strategy might be implemented or useful. They might complete workbook activities like the one presented in Table 13–5.
Real-World Practice
Parents might tape-record or videotape themselves while playing with their child at home and then review the tapes, checking to see whether they have implemented language-expansion and conversation-stimulating techniques.
Real-world practice might be monitored by asking parents to keep a journal about their communication interactions with their child on a daily basis for a week or two. They might also complete daily checklists, indicating whether they consciously performed any of the techniques that day.
Example The Learn to Talk Around the Clock
The Learn to Talk Around the Clock (Rossi, 2003) program capitalizes on this model. The program was developed for children aged birth to 3 years, and promotes listening and spoken language skills. Activities are designed to be implemented in a child’s daily home routine “around the clock,” during such regular occurrences as getting dressed, bath time, meal time, and outdoor time.
In a playtime activity (Rossi, 2003, the Playtime, Level 1 handout), a kind of formal or didactic instruction occurs in which the parent and professional meet and talk about strategies and techniques that promote face-to-face, eye-to-eye communication.
Auditory Training for Infants and Toddlers
What is auditory training? How is it done with kids? Does it remind you of SLP? Why/why not?
Young children who have prelingual profound losses may have no memory of how speech sounds, and thus they cannot draw on memories of how speech should sound.
During auditory training, these children first must learn to attend to the auditory speech signal. Eventually they must learn to relate the auditory signal to their vocabulary.
For children who receive a cochlear implant or a hearing aid early in life, the goal is to accelerate auditory learning and to raise the level at which speech recognition skills plateau.
Children who have more hearing may better deduce meaning from the degraded speech signal, at least initially. The presence of more residual hearing, especially for the mid-frequencies and high frequencies, portends good progress in skill development.
Tailoring Auditory Training for the Very Young Child
When working with very young children who have very little language and only rudimentary listening skills, auditory training tends to be more hierarchical, developing the following set of listening skills that were mentioned in Chapter 4 (Figure 13–7):
Sound awareness
Sound discrimination
Identification
Comprehension
As Figure 13–7 indicates, these levels are not discrete benchmarks in auditory development but, rather, represent a continuum of skills.
Auditory Skill - Sound Awareness
Elizabeth Jenkins was diagnosed with a profound, bilateral hearing loss at the age of 13 months. She received bilateral hearing aids within a month following diagnosis. After five months of using the hearing aids, her audiologist determined that she was not receiving benefit. Shortly before her second birthday, she received a cochlear implant. Her parents took her to a speech and hearing clinic three times a week to receive auditory training.
During the first few weeks of device use, Elizabeth did not respond spontaneously to sound.
Several weeks elapsed before Elizabeth consistently demonstrated sound awareness (Figure 13–8), wherein she was aware when sound was present and when it was absent. She searched for sound with eye and head movements or she stopped her activity in response to sound. Sometimes she quieted or startled. She also increased her own vocalizing behaviors.
Auditory Skill - Sound Discrimination
Elizabeth entered the next auditory skill level, sound discrimination, during the latter part of her first year of cochlear implant use. Elizabeth now could recognize when two sounds were the same and when two sounds differed.
After about 10 months of cochlear implant use, Elizabeth entered into the identification level of auditory skills development and began to label some auditory stimuli.
Auditory Skill Development - Comprehension Level
Almost a year and a half elapsed before Elizabeth began to demonstrate some of the listening behaviors associated with the comprehension level of auditory skill development, in which she understood the meaning of spoken messages.
During the awareness phase of auditory learning, a parent might make a point of showing a child the source and meaning of a sound, and reinforce the child when he or she responds to it.
Identification Task
In an identification task, older toddlers might play board games like Candy Land, where a clinician might speak which color the child is to move the game piece to on the game board, with your mouth covered by a screen (Figure 13–9).
In a comprehension task, a clinician might read a story to a child and then ask questions.
Example Programs
In early childhood programs, the instructional materials are often written directly for parents and caretakers because they can play an important role in providing listening practice.
They can be encouraged to minimize background noise in the home, to speak on occasion close to the child’s listening device with their mouths out of view, to adopt a clear speech speaking style that incorporates acoustic highlighting and auditory spacing, and sometimes to use language and speech that is repetitive, melodic, expressive, and rhythmic (e.g., “Lilly, Lilly, you’re so silly”).
The Learn to Talk Around the Clock program (Rossi, 2003) is pitched to the clinician who works with parents. It includes materials to help parents achieve eight hierarchical objectives as they help their young children learn to “listen around the clock” through daily activities such as getting dressed, bath time, little helper time, and bed time.
Once the child begins pre-school, more formal training may be appropriate. A number of auditory training curricula utilize computerized training (e.g., Fu & Galvin, 2007; Sensimetrics, 2006), and the three major cochlear implant companies (Cochlear Corporation, Med-El, and Advanced Bionics) have web-based programs available.
Reinforcements:
The child should be able to perform a reinforcement activity quickly; he or she should not spend more time with the reinforcement activity than with the training activity.
Reinforcement activities should not be too challenging or too absorbing; otherwise the child will not attend closely to the training task.
Activities should be varied; drawing lines on a paper may hold a child’s interest for a few minutes, but the activity quickly wears thin.