Transcript Cochlear Implants - National Center On Deaf

Cochlear Implants
A Paradigm Shift for Children with DeafBlindness
Kathleen Stremel
The Teaching Research Institute
Research supported by US Department of Education, H327A050079: Outcomes for Children
Who are Deaf-Blind after Cochlear Implantation
OBJECTIVES
Objective 1.0 – The participants will gain knowledge to
determine the content and strategies to individualize
communication and language intervention for children
who are deaf-blind with cochlear implants: WHAT TO
TEACH
Objective 2.0 – The participants will gain knowledge of
the strategies and procedures to use auditory and
speech systems to improve child outcomes across
environmental sounds, speech perception and
comprehension, and language development.
Potential Outcomes for Children
Who Are Deaf-Blind with Cochlear Implants
IF – We want children to:
THEN
Listen and learn…
They need to consistently wear their implant
Listen to your voice as well as their own voice
They need to have consistent, early mappings
Listen to environmental sounds
These sounds need to be contingencies
Begin to understand spoken words and phrases
We need to teach them how
Integrate listening into the development of
communication
We need to lead with speech and support the
child with other modalities
Comprehend speech within the context of their
natural environments
We need to teach within the context of the
natural environment – motivational activities
Communicate with others in the context of their
natural environments
We need to build upon the communication
systems that they are already using
Increase the use of language
Provide opportunities and support
IF – We want to see improved child
comprehension and production outcomes…
We need to actively “teach” these outcomes and
not simply expect them to happen!
Improvements will be based on 20% of the
Hardware
..and 80% of the Software
Auditory Brain Development
The research for auditory brain development should
guide the way we teach children to listen and to use
auditory input
We hear with our brains, not our ears
A child’s brain must be accessed and stimulated to
develop (Carol Flexer)
Acoustic accessibility of intelligible speech is essential
for brain growth
We are either “growing” the brain or we are not.
Children Who Are Deaf-Blind with Cochlear
Implants
Children with CHARGE – 10 children
Children with Auditory Neuropathy – 9 children
Children born prematurely - 27 children
Children with meningitis – 3 children
Vision Information on Children Who Are Deaf-Blind
with Cochlear Implants
Low vision – 10 %
Legally blind – 28%
Light Perception/Totally blind – 26%
Cortical Vision Impairment – 22%
Additional Disabilities
Physical Disabilities – 63.8 (mild to severe)
Cognitive Disabilities – 67.5 (mild to severe)
Behavior Disorder – 35.7 (mild to moderate)
Complex Health Care Needs – 70.0 (mild to severe)
Ethnicity
White - 70.9%
Latino – 12.7%
African American – 10.9%
Other – 5.4%
Age of Implant
6 - 12 months
4
12 – 24 months
13
24 – 36 months
9
36 – 48 months
5
48 – 56 months
2
56 – 68 months
5
68 – 92 months
2
93+
All other children
Cochlear Implants: 20% Hardware & 80%
Software
We see tremendous variability in the outcomes for
children who are deaf-blind
Children must wear their implants all waking hours
Children must receive frequent mappings
Intervention must have a focus on family-child
interactions with the interventionist as coach
Variability in Outcomes
Suggests the need to individualize and adapt approaches
A number of children with deaf-blindness receiving implants do not
have prelinguistic skills.
The child’s early communication skills, auditory and speech
perception, speech development and language development must
be assessed so that the program can be individualized
Even though a child may receive diagnostic therapy, they need to
learn within the natural learning environment as other skills are
being developed
What do we want as outcomes…are we willing to do what it takes
Facts
Many of these children do not receive intervention or therapy
specific to cochlear implants…
The variability in outcomes indicates the need for individualized and
adaptive approaches across receptive and expressive language
(Nussbaum, Scott, Waddy-Smith & Koch, 2006) as in the approach:
A…..AV…..AV…..VA…..V
the A to V continuum
Children who are deaf-blind may need more than an Auditory to
Verbal continuum, as their expressive language may not be visual
sign language, but may be gestural, pictorial, or a different
augmentative system.
Instructional Intensity
Often we see family members and service providers using the same
strategies after the child was implanted as before…
If we are to impact the brain, we have to change the way we provide
intervention
We need to individualize the program for the child’s communication,
receptive and expressive language system
Our intervention should teach parents how to interact with their child
Whereas the child may benefit from intensive therapy, the child must
also learn to listen in the home and classroom in ongoing activities.
What Are We Teaching
Prelinguistic communication is a necessary, but not
sufficient condition for auditory development
Differing responses to familiar speech
Differing responses to environmental sounds
Differing responses to music
Differing responses to speech
Use of vocalizations as communication
Differing levels of vocal imitation
Use of speech to communicate
Use of intelligible speech
Developmental Stages
Detection
Discrimination
Identification
Comprehension
Inventory for Environmental Sounds in the Home
See Attachment B for Inventory for
Sounds in the Home & Community
Sample of Inventory
Child’s Name: Ashley
Birthdate:
11/11/1987
Sex:
Female
Today’s Date:
11/5/2007
Directions: Please check the sounds that are in your environment (on the left-hand side). Columns on the right-hand side can
be used as an assessment to determine your child’s detection and identification of specific sounds.
Your Child’s Response
to the Sounds
Sounds in Your Home & Community
Environment
Detection
Identification
Sounds to Work On
Home Environment – Kitchen and Utility Room:
X Microwave bell
X Oven door opening/closing
X Oven/egg timer
X Oven temperature setting (beeps)
X Refrigerator opening/closing
X Drawer opening/closing
X Dishwasher
X Toast popping up in toaster
X Blender/Food Processor
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x
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X
X
X
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X
X
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X
X
X
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X
X
A good majority of the
sounds are only
identified in context and
Ashley following who is
doing the task.
Training focused on Developmental Progression
Environmental
Sounds
Detection
Discrimination
Identification
Comprehension
Speech
Sounds/Words
in closed sets
Speech
Sounds/Words
in open sets
Detection – We must teach the child to detect
sounds –
Environmental Sounds
Motivational Objects
Sounds associated with
favorite activities
Favorite toys – use sound
Familiar Voices
General awareness
Mother’s voice
Responding to name
Responding to expressions
Communication Criterion Referenced Assessment
See Attachment C for Communication Criterion
Referenced Assessment
Communication Criterion Reference Assessment
Directions: Please indicate if the child uses skills often, sometimes, or not yet/rarely
Child’s Response in Home and/or School
Environment: EARLY COMMUNICATION
• Protests by body movement
• Attends to Mother’s eye gaze or touch
• Smiles and looks at Mother
• Indicates joy or happiness
• Squirms to get down
• Holds up hands or indicates “up”
• Begins to demonstrate anticipation
• Requests more by body movement
• Requests more by open hand
• Requests help
• Gives a hug/kiss upon request
Often/
Usually
X
X
X
X
X
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X
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Sometimes
Not Yet/
Rarely
Skills to
Target in
Routines
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X
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X
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X
X
X
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How Do We Teach?
Establishing a listening environment
Coaching families
Using Auditory-Verbal techniques
Using natural routines and activities to embed
opportunities for listening and communicating
Establishing a Listening Environment
Position oneself to best interact with the child in the specific routine
Speak close to the child’s microphone
Speak at regular volume
Minimize background noise
Use speech that is repetitive
Use speech that is rich in melody, intonation and rhythm
Use Acoustic “highlighting” techniques
(Estabrooks, 2001)
Using Auditory-Verbal Techniques
A…….Av…….AV…..AV……..V
Repeating back to the child what he vocalizes
Using a hand cue for listening (45° slant)
Leading with the Auditory
Putting spoken language directly back into the
interaction after visual, tactile or kinesthetic cues
Waiting or pausing for responses from the child
Goals include the integration of auditory, language,
cognition and speech within normal development
All-day listening environments are created for the child
within meaningful contexts of activities
Where Do We Teach?
95% of what a child learns in life is
learned at home. (Armstrong, 1991),
Parents are the teachers, not the
therapists
Paradigm for Learning
3 Prong Contingency: Antecedent – Behavior – Contingency
Antecedents
Quiet environment
FM System in class
Lead with Speech
Support with appropriate support for child with Speech
Touch cue
Object cue
Gesture cue
Behavior
Consequence
Maximum reinforcement for response to Speech
Repeat speech to confirm or expand
Using the A-B-C’s to implement your child’s program:
Antecedent-Behavior-Consequence
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o
o
o
o
o
o
o
Antecedents - Antecedents include adaptations to the visual, auditory, and positioning
aspects of the physical environment.
Antecedents also include the level of support that you need to provide for your child to be
successful.
The natural occurring steps in a routine or activity serve as a powerful antecedent.
All aspects of the antecedent should be considered for the individual your child in terms of:
visual field
reduction of glare
special lighting
amplification
reduced background noise
positioning for optimal responding
supports or prompts
The antecedent conditions should increase the probability that the targeted behavior
occurs.
The antecedent conditions should be a natural part of the activity if possible.
The supports or prompts should be gradually faded.
Auditory Sandwich
Critical :
1. Lead with speech! Wait and Support with
Visual/Tactile.
2. Use an “Auditory Sandwich”…lead with
speech, support with a prompt, end with speech.
Example: (a) Say, “ Get your bib”…….(b) Wait
for a response to your verbal…(c) Say, “Get your
bib” while pointing, (d) end, “You have your bib!”
Behaviors:
The communication behavior being targeted will include a combination
of:
1.
A Form
2.
A specific Communication Intent
3.
A limited number of Content items.
Break the behavior down into small sequential steps if your child is not
successful.
Teach a new form to a communicative intent that your child already uses....
New form-Old Communicative Intent.
Or, teach a new communicative intent to a form that your child.
already uses.... Old form-New Communicative Intent.
The specific form being targeted may need to be “shaped” into the final,
targeted form.
Your child may need supportive accommodations.
Determine the “appropriate” time-delay for each individual child.
Consequences
The consequence should be directly related
to the antecedent and the behavior.
Different potential motivators should be
continuously assessed to avoid satiation.
Generalized consequences may need to be
considered for older child’s.
The consequences for challenging behaviors
need to be assessed to determine the
function the behavior is serving.
Other Activities to Encourage Parents To Do
Maintain a joint focus on objects and activities
Play ritualized games with younger children
Sing and read nursery rhymes
Name objects in the environment
Describe the location of objects
Read to your child
Play music and instruments
References
Barnes, J. M., Franz, D., & Bruce, W. (1994). Pediatric cochlear
implants: An overview of alternatives in education and rehabilitation.
Washington, D.C.: Alexander Graham Bell.
Cole, E. B. & Flexer, C. (2007). Children with hearing loss:
Developing listening and talking. San Diego, CA: Plural Publishing.
Estabrooks, W. (2001). 50 frequently asked questions about
auditory-verbal therapy. Toronto, Canada: Learning to Listen
Foundation.
Nussbaum, D., Scott, S., Waddy-Smith, B., Koch, M. (April, 2006).
Spoken language and sign” Optimizing learning for children with
cochlear implants. Paper presented at Laurent Clerc National Deaf
Education Center, Washington, DC.
Taylor, E., Stremel, K., & Bashinski, S. (2008). Cochlear implants for
children with combined hearing and vision loss. OSEP grant:
#H327A050079.