CSD 5400 REHABILITATION PROCEDURES FOR THE HARD OF HEARING Course Overview Definitions, Prevalence, Myths, and Other Concerns

Course Purpose During the semester, we will be exploring six fundamental areas related to aural (re)habilitation: Auditory perception of speech and the effects of HL on speech understanding Visual stimuli in communication including speechreading and manual communication Amplification including “hearing aids” and cochlear implants Language and speech characteristics of deaf and hard of hearing children Hearing loss and identity including psychosocial issues Educational management of hard of hearing and deaf children

Course Requirements Exams (30%) Reflection papers (30%) Two exams total 1 in-class 1 take-home Final exam is NOT comprehensive Reflection papers (30%) 3 required Related to feature films viewed in class Oral and written clinical problems (40%)

Definitions of Deafness Webster’s dictionary defines deaf as totally or partially unable to hear Professionals in the field of hearing; audiologists, ear, nose, and throat physicians, or hearing aid dispensers, normally address the term deaf or deafness to mean someone who is not able to hear and understand speech no matter how loud it is Prevalence: Here are some definitions I’ve pulled from the Web…

Definitions of Deafness The Individuals with Disabilities Education Act (IDEA) defines deafness as "a hearing impairment that is so severe that the child is impaired in processing linguistic information through hearing, with or without amplification."

Definitions of Deafness From Office of Special Education: “Deafness is a hearing impairment which is so severe that the child's hearing, with amplified sound, is nonfunctional for the purposes of educational performance”

Definitions of Deafness This is a disability that is multi-dimensional Depending on the author of the definition and their perspective (educational, medical, audiological, etc), the definition will differ.

Prevalence National Center for Health Statistics in 1999 reported about 22 million people in the United States have some degree of hearing loss In 1999, the National Center for Health Statistics, reported about 22 million people in the US (8.6%) have a hearing loss this doesn’t mean they are deaf!! Talk about this

Prevalence Rate By Age Fig 1.6—prevalence rate by age. Get them to figure out what factors might account for this i.e. Presbycusis.

Prevalence From the 1999 National Center for Health Statistics: Severe to profound deafness affects about 0.5% of the general U.S. population 0.1% of these are kids In this same report, estimates of severe and profound deafness range from 0.18% to 0.49% (general population??) From this, it’s estimated that 0.10% of children are deaf.

Prevalence In the 1996-1997 school year: 1.3% of kids who received special ed services were hearing impaired 25% of kids who are deaf have another disability In 1996-97 school year, about 1.3% of all school age children (6-21) who received special ed services were served under the disability category of hearing impairment. This may underestimate the incidence of hearing impairment since 25% of students who are deaf have one additional disability. 9% have two or more other disabilities. Deafness doesn’t happen often. We don’t encounter it much. Disability that’s been around awhile. But, until recently, deaf children weren’t educated in a regular school. Deaf children and adults have been isolated. Lots of preconceived notions about deafness. Which are true? Which aren’t?? Much of what we’ll cover in this course will dispel these myths for you.

Myths and Misconceptions of the Deaf Let’s go over some common myths and misconceptions concerning the deaf and talk about them. This should be interactive

1. Deaf People Can’t Hear Anything The degree of hearing loss is a continuum Deafness has a cultural perspective This is a disability with a continuum. Plus, because deafness is also a cultural description that isn’t necessarily related to the degree of HL, lots of people who consider themselves “deaf” have a considerable amount of residual hearing. Audiologically, deaf includes hearing loss greater than 80 dB HL. While most consonants may not be audible, many vowel sounds are at this level. Lots of environmental sounds are audible

2. Most Deafness is Caused by a Fever or Sickness Most causes of deafness are due to genetic factors Nonsyndromal recessive genetic inheritance All of these conditions can lead to deafness. Certain diseases contracted by a child or adult (i.e. meningitis, rubella, CMV) can cause deafness. Severe head trauma can damage the middle and/or inner ear. Talk about the rubella outbreak in the 1960s. Throughout history there have been clusters of occurrences of deafness, but by and large most causes of deafness, however, are genetic. The most common type of genetically determined deafness is recessive nonsyndromal deafness. Explain. Most children born deaf have normally hearing parents and siblings. There usually isn’t a family history of deafness. Relates to the next myth..

3. All Deaf Children Have Deaf Parents Deaf children having two deaf parents comprise about 3-4% of the deaf population Over 80% of children born to deaf parents have normal hearing Actually, this is kind of rare. It only happens when the cause for the deafness is hereditary and mode of inheritance is dominant. Deaf children having two deaf parents comprise only about 3-4% of the general population. Over 80% of children born to deaf parents have normal hearing. The corollary is also most likely, most deaf children are born to hearing parents. Explain how this disrupts the communication between parents and children and affects the parent-child bond, language development, communication, and psychosocial development and adjustment.

4. All Deaf People Can Read Lips Drawbacks to lipreading: Only 50% of English speech sounds are visible A lot of speech sounds look alike on the lips In order to benefit from speechreading, you need to have a good command of the language Speechreading is really tiring Define lip reading. Define speechreading. This process is meant to be a supplement to the communication process, assisting the deaf or H of H individual with speech reception. It’s not a substitute for hearing, but rather a technique that can be incorporated to enhance communication and promote understanding of the spoken message. Using speechreading as the only mode for reception has a few drawbacks that include: 1. only about 50% of English speech sounds are visible on the lips. Give them some examples of a visible and invisible phoneme. If it’s not visible, speechreading won’t help. Some sound that sound different and are visible, look alike. Give them the pan, man, ban example. Classes of phonemes look alike on the lips and can’t be distinguished from each other. In order to benefit from speechreading, you have to have a good command of the language. You need to be able to make some hypotheses about what your are hearing and seeing. You need to be able to fill in missing information using context and knowledge of the grammar and rules of the language. 4. Speechreading is extremely fatiguing. Our visual systems weren’t designed to pick out the fast and subtle mouth movements related to articulation. You can’t be a passive lip reader. It’s something you have to actively do, to the exclusion of everything else.

5. All Deaf People Know Sign Language Many deaf people are oral only There are a number of (different) forms of manual communication We’ve all certainly become more aware of manual communication (ADA and IDEA gives rise to interpreters a common sight), ASL classes becoming a common college course offering and usually either lib ed status or considered a foreign language. The mode of communication is a personal decision made by deaf listeners. Some prefer to stay oral, so they don’t use any sign language. Some (many) may use some form of manual communication—but there are more than one form—they aren’t interchangeable. There’s ASL—which has it’s own grammar separate from English, there are several forms of SEE, and there are non-language bases systems like cued speech.

6. All Deaf People Are Mute The speech production ability is really varied Most hearing people seeing a deaf person using sign language assume the deaf has no speech at all. Sometimes this might be an accurate assumption, but the speech skills of deaf people are really varied. What causes this?? Unless there are other problems, there’s nothing anatomically wrong to impede speech of a deaf speaker. Talk about how normally hearing babies and children learn to speech—keep this separate from language acquisition. If you can’t hear speech normally, it’s hard to develop normal speech sounds and to monitor your productions. Talk about how the speech of adventiously deafened adults start to suffer. In order to develop intelligible speech, deaf children must go thru years of speech therapy with an audiologist or SLP to develop recognizable speech sounds and come up with other ways to monitor their productions. Try differentiating the development of speech and the development of language. Explain simply how normally hearing children learn language. Emphasize that it’s an auditory (strictly) process. Deafness interferes with this naturally occurring process. Language, then, cannot be learned normally. This relates to the next myth…

7. Deaf People Can’t Read Reading is a language-based skill Most deaf adults achieve an average reading ability comparable to a 4th grade level Reading is basically a corollary event to language acquisition. If you are language delayed, you can bet your reading comprehension will be affected negatively. It holds true if the cause for your language delay is hearing loss. The deaf have widely varying degrees of reading ability and comprehension, but in general, the greater the degree of hearing loss, the more impact there will be on reading comprehension. Another factor to consider that also impacts their reading ability is that deaf children have an impoverished knowledge base, compared to their normally hearing peers. Hearing children have lots of interactions with parents, sibs, peers. Their experiences are internalized thru the spoken language process and become part of the child’s practical knowledge. Deaf children’s experiences and interactions are exceedingly limited. This impacts their knowledge base. They come to the reading process with limited understanding of the world around them PLUS deficiencies in their language level. This doesn’t bode well. Some big studies were done in the 1960s to quantify some average reading levels of deaf children. They found that only 8% of the national sampling of deaf and H of H students were reading about the 4th grade level. In addition, they found an average improvement of less than one grade level by the time the children were in 12th grade. Studies done in the 1970s didn’t show much improvement. For instance, the vocabulary growth of deaf 8-18 year olds was matched to the growth seen in normally hearing children between kindergarten and the end of 2nd grade. The average reading level of a deaf 20 year old was at about the 4th grade level.

8. Deaf Children Don’t Attend School Before the 1970s, at least half of all deaf children attended state residential schools for the deaf By 1984, 74% of all school-aged deaf children attended day classes while living at home and 15% of deaf students attended regular classes with normal hearing kids on a full time basis Today 30% of deaf school-age kids attend special schools This is an interesting history, and we’ll be looking into it more closely during the semester. Before the 1970s, at least half of all deaf children attended state residential schools for the deaf. Because their handicap has a profound impact in terms of how they learn, these state schools were set up quite early. Deaf children were hardly ever mainstreamed in public schools, as was the case for other children with sensory impairments, cognitive disabilities, and physical limitations. In 1975, then president Ford signed into law the “education for All Handicapped Children Act of 1975” better known as PL 94-142. This law was later renamed the Individuals with Disabilities Education Act in 1996 (IDEA). This federal law mandates that all handicapped children must be guaranteed a free, appropriate public education in the least restrictive environment. This law has really changed where deaf children receive their education. In the early 1970s (before 94-142) 48% of all school-aged deaf children attended classes away from home in residential programs By 1984, 74% attended day classes while living at home. Also 15% of deaf students attended regular classes with normal hearing kids on a full-time basis. This was unheard of before 1975. Today: 30% deaf school-age kids attend special schools 32% receive instruction in self-contained classrooms, 13% in resource rooms, 43% are mainstreamed, and 2% are home schooled. Related to the next myth..

9. Deaf People Aren’t Intelligent Intelligence and language level are closely connected “Deaf and dumb” Intelligence is assumed from the language level. Get them to think about this. If your ability to communicate is compromised due to hearing loss, you will not be judged as intelligent than if communication is not impaired. “deaf and dumb” In addition, most IQ tests are language-based tests. It’s very hard to measure innate intelligence separate from language—either written or oral. When IQ is measured in this way, deaf individuals are not significantly different from hearing individuals with respect to IQ. Related myth..

10. Deaf People Have More Mental Health Problems Cultural differences In terms of the incidence of serious psychiatric disorders within the two populations, there’s no difference. Deaf people relate to a culture different from ours. The rules of this culture are very different. Rules for behavior, communication, and socialization are different from our own and may appear odd to us. Most social rules in our culture are learned incidentally. Deaf children can’t learn this way—so they may appear socially inappropriate.

11. Hearing Aids Allow the Deaf to Hear Speech Normally What do hearing aids do? Cochlear implants Explain that hearing aids primarily make speech louder. They’re amplifiers. Explain the attenuation vs. distortion concept of sensorineural hearing loss. Hearing aids overcome the attenuation component to the loss, but do nothing to overcome the distortion produced by the cochlear damage. In general, as the degree of HL increases, the benefits provided by conventional amplification decreases. Hearing aids can be a useful supplement to residual hearing, but they never can restore hearing to normal. Cochlear implants—we will discuss these later, but mention under the same myth. People with cochlear implants can learn to use this new auditory signal in normal communication settings, but it in no way restores hearing to normal.

12. All Deaf People Wish They Could hear Normally Is deafness really a “disability”? Deaf--with a capital “D” This is one of the most emotionally charged issues related to deafness. Since the beginning of time, hearing people have looked upon the deaf with pity, assuming they are unhappy and unfulfilled. We assume that all deaf people want desperately to hear and are miserable being deaf. This is hardly the case, and in recent years, the Deaf community has become almost militant in their belief that deafness is not a disability to be corrected. Talk about how unhappy they are with the cochlear implant. Most deaf adults identify with their culture and have no desire to cure their deafness.

13. Deaf People Can’t or Shouldn’t Drive President’s Advisory Committee on Traffic Safety in 1968 found that deaf listeners were involved in 1/4 as many traffic accidents as hearing people 97% of warning signals are visual A study done in 1968 by the president’s advisory committee on traffic safety concluded that across the nation, deaf listeners were involved in 1/4 as many accidents as hearing people. Most drivers licensing officials rate deaf drivers at least as good as hearing drivers. In reality, 97% of warning signals reaching the driver are visual, so deafness has no serious affect on driving ability.

14. Deaf People Can’t Work American With Disabilities Act of 1990 Again, this myth is perpetuated by the fact that deafness is a low incidence disability, so most of us haven’t encountered many deaf worker or colleagues. Deaf are stereotypically portrayed as peddlers—a profession the Deaf culture views with great disdain. A long time ago, most Deaf people worked in menial labor positions, mostly those that didn’t require much of a language level or communication skills. In the 1970s, the federal Vocational rehab act was enacted and opened up employment opportunities. Also established training programs. Now that we are 10 years past the ADA, employment is mandated to be barrier free for the deaf.

15. Deaf People are Quiet and Antisocial Please!! Ha. Deaf people are like everyone else. They like to party, gossip, socialize and make a lot of noise. They like music, too. What have they learned??

Rehabilitative Audiology Now that we’ve reviewed some characteristics related to hearing loss and deafness, let’s turn our attention to the purpose of this course; namely, aural rehabilitation

Definition of Audiologic Rehabilitation The professional efforts designed to help a person with a hearing loss. These include services and procedures for lessening or compensating for a hearing loss and specifically involve facilitating adequate receptive and expressive communication Definition of audiologic rehabilitation: Professional efforts desinged to help a person with a hearing loss. These include services and procedures for lessening or compensating for a HI and specifically involve facilitating adequate receptive and expressive communication. Notice that aural rehabilitation tries to address all the areas of impact a hearing loss may provide.

WHO Classification System This is the accepted classification system for hearing disorder devised by the World Health Organ. In 2000, to help standardize terminology world-wide. I hearing isn’t “normal”, the umbrella term disability is used, and 3 dimensions are involved. Impairment or problems in body structure and function activities which chiefly involve communicaiton Participation within life situations You can think of activity limitations (comm) as the primary consequence of HL, whereas participation restrictions involve the secondary consequences of the HL that affect social, vocational and other life situations. The model allows for selective environmental and personal factors to influence the communication impact of HL.

A Current Model of AR Started with the ASHA 1984 AR position statement, and refined in recent years. Model consists of 2 major components—Assessment (CORE) and management (CARE). Let’s look at each individually…

CORE Portion (Assessment) Assessment portion (CORE) 1. Communication status: includes traditional aud assessment, questionaires, case hx, self-report. Visual and speechreading assessments as well. Language assessment (expressive and receptive) 2. Overall participation variables: includes psych, social, vocational, and educations factors/aspects of HL. For example, if depression is a significant factor of the HL, or special ed management strategies are in place. 3. Related Personal: includes personal attitudes (willingness to accept rehab), race, gender, age, educ level, aptitude, other health conditions, life-style, habits, coping styles, past experiences, etc.. 4. Environmental factors: physical features of the environment, direct and personal contacts, social structures and services in the work environment, state/federal laws, regulations and rules. Evaluation of the typical acoustic environments of the client is here as well.

CARE Portion (Management) All 4 management components can occur sequentially, simultaneously, or interactively… Counseling/psychosocial: Interpretation of assessment results to client/family, information to understand ed, voc, psych, and comm effects of HL. Any support to family/client Audibility improvement thru amplification and assistive devices: appropriate fitting/orientation of Has, cochlear implants, or other assistive device. Remediation of communication activity: Remediating the effects of HL either in terms of educational or vocational difficulties. Amplification usually takes care of this, but may need additional communication training and strategies (tailored to the client). So this could include issues related to the environment or personal adjustments. Environmental/Coordination Participation Improvement: Zeroing in on specific everyday settings creating problems and offer strategies for improvement. This is the collaborative portion of the model—drawing in the expertise of allied professionals.

An Important Question… In what ways and to what degree does hearing loss or deafness affect an individual?

Variables That Affect Activity Participation Degree of impairment What amount of auditory cues is available? How are the temporal relations of speech preserved? How well can the listener integrate partial information from a variety of sources? What are some things that affect the degree of handicap a hearing loss may provide? (1) degree of hearing loss Table 1.1 Notice that the important point seems to relate to the amount of auditory cues received by the listener. This is a very spectral approach to the issue. We also need to consider how the pathology is affecting the temporal relations of speech. What about speech understanding at the linguisting level? The prosodic level? How well can the listener integrate partial infor- mation?

Variables That Affect Activity Participation Age of onset Prelingual (birth) Postlingual (after age 5 or so) Deafened (adulthood) (2) age of onset Generally described in terms of pre-lingual or post-lingual onset. Language is learned primarily through the auditory system. A hearing loss occurring before or during the process of language learning will have dramatic effects on language acquisition. This in turn will have varying degrees of academic, social, and emotional effects. Table 1.2 In general terms, the rehab goal for HL acquired in adults (after language learning has taken place) is the relearning to use a new auditory signal the rehab goal for HL aquired in kids (before or during the lang learning process) is learning to extract meaning from an imperfect speech signal and other non-auditory cues

Variables That Affect Activity Participation Site of lesion Conductive, sensorineural, central Family support Other factors Presence of other disabilities Availability of special services 3) site of lesion Generally, the more peripheral the lesion, the less handicapping the hearing loss will be. Conductive hearing losses only attenuate SNHL have attenuation as well as distortion. Distortion is extremely variable in terms of degree and type. Still can’t be catagorical about this. Other variables will interact. (4) family support family attitudes and communication style. Emotional issues--hearing impaired client is their child vs their aging parent (5) other factors e.g. presence or absence of other handicapping conditions availability of special services

How Well Is Hearing Impairment Served? Both children and adult hard of hearing listeners are underserved Children Issues related to identification Provision of appropriate amplification and educational services Adults Most don’t seek services related to amplification or ways to improve effective communication

Why?? Stigma Cost Confusing service delivery system Low interest/motivation What can we do to promote these services??

Americans With Disabilities Act Federal law passed in 1990 that guarantees equal opportunity for individuals with hearing loss in employment, public accomodations, transportation, state and local government services, and telecommunications “Here’s to the ADA” video