For children with hearing loss to succeed in school, good access to classroom information is absolutely essential. Acoustic accessibility means that the child’s technology and classroom acoustics need to be monitored, educational staff need to understand the effect of hearing loss on the reception of academic and social information, and teachers need to know how to employ useful classroom modifications. If there is no educational audiologist to advocate for the child, someone else needs to pick up the slack.
Very few parents can identify problems in the classroom and help teachers modify their classroom behavior; many do not advocate sufficiently for their children in schools. Parents cannot identify and suggest solutions for keeping the classroom quiet, or teach modifications such as facing the students when speaking, and appropriately using a remote microphone system. Some schools have teachers of children who are deaf or hard of hearing who can help mainstream teachers, and other schools do not. For many children, clinical audiologists in hospitals, clinics, and private practice are the only ones who have the information schools need to support children with hearing loss.
The purpose of this article is to detail information needed by school staff to manage today’s children with hearing loss. Specifically, this article will outline contemporary audiological needs of children with hearing loss in schools, how clinical audiologists can help meet those needs, and how to network with school personnel from a clinical setting.
Moeller and McCreery (2017) report that, sadly, children who are hard of hearing remain a “forgotten” group. Many school districts no longer have educational audiologists, yet students with hearing loss continue to need all of the services that educational audiologists have provided (Anderson, 2016). Clinical audiologists now need to pick up this slack if their young patients with hearing loss are going to succeed in today’s challenging academic environments. In fact, for many children, clinical audiologists in hospitals, clinics, and private practice are the only ones who have the necessary information schools require.
While most audiologists who practice outside of school focus on diagnostic evaluations and fitting of technologies, if today’s children are to succeed, the audiologist’s prime consideration must be the child’s life/school setting.
How a Child Succeeds
For children to succeed in school, they need language, literacy, and social skills at age level. For children to have those skills at age level, they need to have been identified early and fit early and appropriately with technology that permits them to have sufficient auditory access to develop their brain with information/knowledge (Dillon et al, 2013; McCreery et al, 2015). Children need support by families who can provide rich language environments with many and varied opportunities for brain reception of information/knowledge (Suskind, 2015). In short, children with hearing loss need the following:
- Early identification
- Early, optimally fit technology allowing auditory brain access through at least 8000 Hz
- Full-time use of technology—at least 10 hours per day to get auditory information to their brain
- Use of a remote microphone in all learning environments, inside and outside of school including the home
- Therapy, preferably auditory-based, involving the family
- Family support, which includes a rich language model
- Language and information-rich environments
- Opportunities to learn
- An educational program willing and able to make the necessary adaptations for maximizing learning (Anderson and Arnoldi, 2011; Johnson and Seaton, 2012)
How an Educational Audiologist Can Help
Educational audiologists (EdAuds) provide services that can make a significant difference in whether or not a child with hearing loss can succeed in the classroom. EdAuds educate school staff about the effect of hearing loss on academic and social learning, help school staff recognize that hearing loss is not “cured” when children are fit with technology, and assist teachers and other school staff in understanding what information this child with hearing loss is receiving and what he or she is missing (Johnson and Seaton, 2012).
EdAuds have multiple opportunities to explain to school personnel that we hear with the brain (Kral and Lenarz, 2015). The ears are the doorways to the brain for sound/auditory information, but actual hearing occurs in the brain and not in the ear (Cole and Flexer, 2016; Kral, 2013). Consequently, hearing loss is primarily a brain issue—not an ear issue; hearing is a stepping stone to cognition (Kral and Sharma, 2012).
EdAuds also talk with teachers about what can be done to make it easier for a child’s brain to receive classroom information. Accommodations such as strategic seating, facing the child when speaking, keeping classrooms quiet, using remote microphone systems, and repeating comments of other children so the child can follow classroom discussion, can be reviewed. EdAuds monitor classroom noise levels and sources including heating, ventilation, and air-conditioning systems; install “footies” on table and chair legs; and close windows and doors to impede noise entering the classroom from outside sources (Smaldino and Flexer, 2012).
In addition, EdAuds are critical participants in Individualized Education Program (IEP) or 504 Plan development meetings, where they where they can help assure that needed services are included, such as educating the speech-language pathologist (SLP) about helping build auditory skills during therapy (Anderson, 2016). EdAuds may also run the school hearing screening program.
In some schools, there are teachers of children who are deaf (TOD) or hearing impaired who can carry out some of the required services. However, there may be no TOD unless there are many children with hearing loss in the district. If present in a school, TODs will be able to help cover some of the child’s needs. They will be able to help explain what a child hears and what he or she is missing, and identify the effect hearing loss has on the child’s brain access of curricular and social information. They should be able to help classroom teachers learn how to improve auditory and academic access in the classroom. Some TODs will be good at monitoring room noise and hearing technology, but others will not.
In the absence of an EdAud or TOD, the school may expect the speech-language pathologist or the special education teacher to do what is needed for the child with hearing loss. Unfortunately, in many training programs, SLPs have very limited exposure to providing services for children with hearing loss, and many programs have only one class or part of a class on the topic. Special education staff may also have had limited contact and experience with children with hearing loss. There really isn’t a replacement for the audiologist!
The first critical step in supporting a child’s academic and social development is the optimal fitting and full-time use (at least 10 hours per day) of technology (Dillon et al, 2013; McCreery, et al, 2015).
Delivering Effective Auditory Information
Hearing technologies such as hearing aids, cochlear implants, bone-anchored devices, and remote microphone systems are engineered to break through the ear/doorway to allow access, activation, stimulation, and development of auditory neural pathways with auditory information, including spoken language. Therefore, the only purpose of wearing hearing technologies is to deliver auditory information through the ear/doorway to the brain. When technology is not fit appropriately or not worn at least 10 hours per day, the child’s brain is deprived of academic and social information/knowledge.
One way to explain to school personnel what effective auditory brain access looks like is to use the construct of the Speech String Bean (Madell, 2016). For a child to hear well in the classroom and in all other situations that offer academic and social information, the child needs to hear throughout the frequency range—through 8000 Hz. By assuring hearing through the high frequencies, we can be certain that a child has access to all phonemes, including high-frequency sibilants and fricatives. The goal is that the child hears “in the string bean” (FIGURE 1).
Aided or cochlear implant thresholds obtained for each ear separately is a validation procedure that will confirm whether or not a child is hearing in the string bean and, therefore, has sufficient auditory brain access.
For the fitting of hearing aids, real-ear measures are necessary verification procedures to administer prior to validating the fitting through behavioral measures, such as aided sound field thresholds and speech perception testing.
Another foundational step in supporting a child’s academic and social development is acoustic management of learning spaces and use of remote microphone technology (Peters, 2017).
Acoustic Accessibility in Today’s Classrooms
The classroom is an auditory verbal environment in which accurate transmission and reception of speech between the teacher and students, or students and students, is critical for effective learning to occur. Therefore, the purpose of all environmental and technological management strategies is to enhance the reception of clear and intact acoustic signals/information in order to access, develop, and organize the auditory centers of the brain (Smaldino and Flexer, 2012).
The acoustic characteristics of the classroom mainly determine the adequacy of the speech signal received by the students. Speech intelligibility is based on the science of signal-to-noise ratio (SNR)—the relationship of the desired signal to all background/competing noise. Children need the desired signal to be 10 times, or approximately 15 to 20 dB, louder than background noise to clearly discriminate words (ANSI, 2010). The audiologist is the primary professional to evaluate, manage, and explain the child’s auditory learning environments (AAA, 2008).
The most effective approach to improving the child’s brain reception of auditory information in environments that contain noise, reverberation, and distance from the talker is the use of hearing assistive technology (AAA, 2008), which includes remote microphone (RM) technologies. The types of RM systems include personal, soundfield or classroom audio distribution, and personal soundfield. Personal RM units are essential for a child with any type and degree of hearing loss, from minimal to profound, who is in any classroom or group learning situation.
The fitting and management of RM technologies must be done by an audiologist, and their rationale and use must be explained to school personnel. The audiologist also should consider fitting, for home use, a RM accessory that is an added feature for many of today’s hearing aids and cochlear implants.
An additional problem caused by noise in the classroom concerns listening fatigue experienced by all children, and by children with hearing loss in particular. In fact, cognitive fatigue from mental exertion during listening tasks is very problematic for children with hearing loss in classrooms (McCreery, 2015). Because the child has to allocate more of his or her cognitive resources to listening tasks, fewer resources are available for higher level processes such as problem-solving, and cognitive integration of new information. Without an educational audiologist, it will be the responsibility of the clinical audiologist to explain to parents and schools the problems associated with fatigue, and help with suggestions for its management.
Protection Is Provided by the Law
Several laws offer protection for children with hearing loss.
Americans With Disabilities Act
Under the Americans with Disabilities Act (ADA), schools are responsible for ensuring that communication access is as effective for children with hearing loss as it is for their typically hearing peers. Children with hearing loss are entitled to the same opportunities to obtain the same academic results, and need to be able to participate in all of the district’s services, programs, and activities.
Without an audiologist in the school, how will communication access be accomplished? For a child who uses sign language, communication access may be accomplished by using an interpreter. But for a child who uses listening and spoken language exclusively (85 percent of children with hearing loss), staff needs to understand the effect of hearing loss on the child’s academic and social development, and teachers need to know how to use technology appropriately. The child’s language skills need to be considered and improved (U.S. Department of Justice, 2008).
Individuals with Disabilities Education Act
The Individuals with Disabilities Education Act (IDEA) requires routine checking of hearing technology to be sure it is working well. Children need functional evaluations with technology, and schools are responsible for selecting, designing, fitting, customizing, adapting, maintaining, and repairing or replacing assistive technology. Technology must maximize access to the general curriculum for children with disabilities. IDEA regulations indicate that a child does not have to fail a grade to receive services. In addition, accommodations are required to assure that children can participate in extracurricular activities with other children in the district.
If there is not an EdAud or TOD who can advocate for children with hearing loss, how will a child’s needs be met at an IEP meeting? As well intentioned as school staff may be, if they do not have the information, it will not be possible for them to know what technology and services to provide (U.S. Department of Education, 2006).
Clinical Audiologists Can Help
Audiologists need to know more than how a child is hearing with and without technology. They need to know how a child is functioning both in and outside of the classroom. Does the child have the necessary and age-appropriate language and literacy skills for success in the classroom? Is the child receiving academic assistance from a TOD or from a special educator such as preview and review of vocabulary and concepts so that the child can keep up with peers? Is there an SLP in the school who understands how to build auditory and language skills for a child with hearing loss who uses listening and spoken language?
Unless the audiologist has a full picture of the child’s functioning, it will not be possible to make appropriate recommendations. Although the audiologist is not able to recommend, for example, the specific number of SLP therapy sessions needed per week, audiologists can recommend what kind of assistance a child needs and explain why. For example, if a child’s language levels are 6–12 months delayed, the audiologist can recommend language therapy with a clinician who is experienced in providing listening and spoken language enrichment.
Clinical Audiologist and Audiological Evaluation
As audiologists, we have a responsibility to look at the whole child (Madell and Flexer, 2014). We can only do that if we ask the appropriate questions. If there is no educational audiologist, we cannot assume that there is someone in the school who is watching over a child with hearing loss. We have seen too many cases where a child with a hearing loss was fit with technology, and then sent to school with no additional assistance.
School personnel assumed that hearing aids or cochlear implants cured the problem and no further accommodations were needed. Not until the child started to fail did parents ask if there was something else that should be done. By asking the appropriate questions, the audiologist might have learned a great deal and could have made recommendations that would have supported the child in an educational environment, from the beginning.
What questions might an audiologist ask to identify possible support needed by the child?
- Is there an educational audiologist in the school, either full or part time?
- Is the child using a RM? Who fit the RM? Who is monitoring the RM? Ask the family to bring the RM system to the clinic to evaluate it to be sure it is working well.
- Listen to the child as you have a conversation. How does his speech sound to you? Is it clear? What about his language? Do language and pragmatic skills seem age-appropriate?
- Does the child read for pleasure? Is his reading level age-appropriate? Do parents read aloud to the child? (It is important to read aloud to the child above levels at which the child reads to him- or herself.)
- Is the child on an IEP or 504 plan? If not, why not?
- Ask the child how he or she hears in the classroom. Are there situations where he or she thinks he/she is missing something? Does the classroom seem noisy to him?
- What grades did the child receive on his last report card? Were they acceptable?
- When was the last speech-language evaluation and what were the results? Are language skills delayed? By how much?
- Ask the child if he or she feels that he or she is accepted. Does the child have friends? How many? Does the child have a best friend? Is he or she invited to parties, play dates etc.?
- For older children, ask if the school has a bullying policy? Does the child know what the policy is? Has he or she been bullied?
Observed Situations in Schools
The authors have observed multiple cases of children with hearing loss being sent to school with no audiological recommendation for RM systems, and no recommendation for speech-language evaluations. If an audiologist identifies a child with a hearing loss, he/she cannot assume that “someone” else will figure out what the child needs in order to access the academic curriculum and social environment of the school (Anderson, 2016).
Not all SLPs have expertise in providing auditory and spoken language enrichment designed specifically for children with hearing loss. We have seen multiple cases where the therapy was not meeting the needs of the child. For example, we observed an SLP who had spent months working on a child’s /s/ perception, when the child did not have access to /s/ with his/her hearing aids. The SLP didn’t recognize that the hearing aids first needed to be adjusted to provide more high frequency gain.
We have seen cases of children lagging far behind their hearing peers and not receiving appropriate help. Teachers often believe that “least restrictive environment” means continuing to promote children to the next grade even if their delayed language and literacy skills will not allow them to learn in the classroom in which they are placed.
Conclusion: What the Clinical Audiologist can Do
In addition to the evaluation of hearing and management of technology, every audiologist needs to consider the whole child (Madell and Flexer, 2014). Ask the questions that will allow us to understand how a child is performing academically and socially. Based on answers to those questions, recommendations may include: suggestions about needed therapy, read alouds, and educational support; use of RMs in the classroom and at home; and controlling noise.
As detailed in this article, clinical audiologists must have an understanding of the needs of children with hearing loss, including the legal requirements mandated to meet those needs. We should expect children with hearing loss to achieve at the same academic level as their hearing peers (Moeller and McCreery, 2017). Then, a case needs to be made to school districts helping them understand that if they do not adequately meet the listening needs of children with hearing loss, they are not only limiting the child’s academic and social opportunities, they are also putting themselves in jeopardy and open to possible lawsuits. Then, school districts need to understand the laws as they currently stand and think about how they are going to meet the requirements.
Finally, audiologists need to educate the families they work with to be sure families understand their rights and the questions they should be asking when they deal with the school. Parents are critical advocates, but they are not hearing professionals who can provide all of the necessary auditory information and guidance to school personnel.
When the initial steps have been accomplished, the audiologist needs to determine, with program administrators, the cost of providing educational services. For a clinical audiology program that serves many children with hearing loss, it may be reasonable to hire an audiologist who works with schools providing educational audiology services. For other clinical audiology programs with fewer pediatric patients in schools without an educational audiologist, the clinical audiologist can offer services that can be met either in person or through phone or video conferencing.
Whenever possible, try to include a school visit. In our experience, the value of seeing what is actually happening in the classroom is invaluable. The school may be very happy with the child who just sits quietly and is well behaved, but careful observation can indicate that this child is not hearing in the classroom and just doesn’t understand what is happening. No matter where our practice settings are situated, audiologists must appreciate the role and responsibility we have in promoting the child’s academic and social well-being in their varied learning environments.