Catherine Palmer, in her General Assembly Speech at the Academy’s 2019 annual conference, inspired us by emphasizing that audiologists have an incredibly important and expanded role in the health and well-being of the people we serve.
“Audiologists start a chain of events for a child that will promote reading, education, and employment,” she said in her address.
That chain of events starts with a child learning to listen and learning spoken language. This article will address the audiologist’s role in those events from a very practical perspective.
Hearing and Listening
There is a distinction between hearing and listening. Hearing is the acoustic access of auditory information to the brain. Listening, however, is when the individual attends to acoustic events with intentionality. Hearing (auditory information) must be made available to the brain before listening can be learned and understanding developed. That is, parents and practitioners can focus on developing the child’s listening skills and strategies only after the pediatric audiologist channels acoustic information to the brain by appropriately fitting and programming technologies for maximum audibility—not before.
The Purpose of Listening
The purpose of listening is to acquire spoken language and knowledge of the world by developing and integrating auditory neural pathways throughout the brain. Better quality and quantity of auditory information means that stronger neural connections are developed in the brain (Kral et al, 2016).
Attaining a Listening and Talking Outcome
What does it take for a child with hearing loss to learn to listen, talk, and read, if those are the family’s desired outcomes? Protection against language and literacy delays arises from managing the following malleable factors (Ching et al, 2018; McCreery et al, 2015):
- Fitting hearing aids early and properly to maximize audibility of auditory information to the brain.
- Consistently using hearing aids/cochlear implant(s) (10 to 12 hours per day—“eyes open, technology on”).
- Providing a rich linguistic environment around the child—parent talk can be increased and improved by coaching, beginning in infancy.
Audiologists can begin conversations with a family about the use of technology and facilitation of listening by discussing the critical question: What is the family’s desired outcome? The desired outcome guides the ethical and legal provision of intervention strategies and technological recommendations.
Guiding questions for families can include the following:
- What is your long-term goal for your child?
- How do you want to communicate with your child?
- What language(s) do you know and what language(s) do you want your child to know?
- Where do you want your child to be at ages 3, 5, 14, 20?
Approximately 95 percent of children with hearing loss are born into hearing and speaking families (Mitchell and Karchmer, 2004). Most of these families are interested in having their child talk. In addition, many families use a primary language at home that is different from the school language, so they likely are interested in their child speaking several languages. The coaching, technological, and listening intervention strategies offered by audiologists are driven by the family’s desired outcome.
It is suggested that audiologists have “the brain conversation” with the family as early as possible following the first appointment, or at the point of confirmation of a hearing loss. The brain conversation can be reinforced at hearing aid fittings and review appointments. The more repetition about the ear-technology-brain-listening-learning-reading connection, the better.
The following are practical suggestions for having a conversation about the auditory brain with families—a necessary conversation prior to discussing the use of technologies and the implementation of listening strategies (Cole and Flexer, 2020). Most families likely have limited or no experience with childhood hearing loss, so an explanation of the ear-technology-brain-listening-learning-reading connection is important.
Audiologists can describe how the ears are connected to the brain using the following narrative as a guideline, beginning with a general discussion of how information gets to the brain through the five senses—hearing, sight, smell, taste, and touch.
Each sense captures different types of raw environmental data and transforms that information into neural impulses that can be read by the brain. For example, the eyes are the doorway to the brain for visual information in the form of light waves (e.g., when you see a face you have learned to recognize, this visual information is sent to your brain to process and you think, “oh, that’s mommy”).
Likewise, the ears are the doorway to the brain for sound/auditory information in the form of vibrations (e.g., you hear the sound of birds chirping and your brain, through exposure, experience, and practice does the work of learning to associate that chirping sound with a bird).
The only purpose of your child wearing hearing technologies, therefore, is to get auditory information, such as your voice, through the ear-doorway to your child’s brain. Hearing technologies can be thought of as brain-access devices.
Developing Listening and Spoken Language
For a baby/child to have the best listening and spoken language outcome possible, he or she will require a great deal of spoken language input and interactive conversations. The audiologist’s ongoing collaborative intervention with the listening and spoken language (LSL) practitioner will center around making sure that parents are comfortable responding to the child’s attempts to communicate, talking about what the child is interested in, pausing to let the child take a turn, and talking explicitly about things and routine activities and play occurring throughout the child’s day.
The audiologist can use checklists with the family, such as the Parents’ Evaluation of Aural/Oral Performance of Children (PEACH), to help them know what to look for and what behaviors to encourage in their child as the child develops listening and language skills (Ching and Hill, 2007).
- The ears are the doorway to the brain.
- We listen and understand with the brain.
- Sound=auditory information=knowledge
|Keep the technology on the child all waking hours (at least 10–12 hours per day).|
|Explain auditory brain access—have the brain conversation.|
|Provide practical means of making it difficult for little fingers to remove the hearing aids (such as wearing bonnets or Huggies).|
|Provide parents with contacts for other parents who have gone through the same process.|
|Do routine equipment data-logging with the parent in the room to promote increase in wear time and to reinforce technology use.|
|Reference: Ching et al, 2018; McCreery et al, 2015; Cole and Flexer, 2020.|
What Audiologists Offer to the Family
In an initial hearing aid fitting of a young child, the audiologist’s goals usually center around helping the parent understand the hearing loss and its brain implications, making earmolds, and getting the hearing aids on the child’s ears as quickly as possible so that additional listening, learning, and brain development time is not lost. Consequently, the audiologist needs to do the following:
- Be empathic and supportive in approach and demeanor.
- Base conversations on parents’ questions and needs at that moment.
- Provide absorbable amounts of information in a single sitting.
- Cheerfully repeat information.
- Offer connections with other families of children with similar hearing loss, or with appropriate websites, links, and organizations.
- Schedule 90 minutes to two hours for initial sessions and one hour after that; plan for no rushing and 100 percent attention! (See TABLE 1.)
See the Audiologist, Frequently
Frequent audiometric testing is needed for infants and very young children, which means monthly appointments, optimally. Because initial infant hearing aid fittings are usually based on auditory brainstem response (ABR) results, unaided behavioral results need to be obtained and repeatedly confirmed to be sure that the hearing aids are set appropriately and that no changes in hearing have occurred.
Parents should participate in audiometric testing in the booth (or in mapping sessions) so they understand the testing process and gain more understanding of the child’s hearing loss and of the improvement in the child’s listening that occurs when the hearing aids/cochlear implants are worn.
Providing an Optimal Auditory-Linguistic Environment
Minimizing unnecessary noise is one extremely important strategy that families need to adopt so that the child has a good chance of hearing the talk and information that is occurring, both with him or her, and among others in the vicinity. Reducing noise can be easier said than done in households where some family members are accustomed to having the computer or TV turned on throughout the day, whether or not they are paying direct attention to it or not.
The audiologist can brainstorm noise-management solutions with the family such as having the TV on only when the child is sleeping or having the TV on in a room far enough away from where the child is that it cannot be heard. Once the child has adapted to the hearing technology, the audiologist can encourage the family to use remote microphone technology (RM) equipment at home, as well as at school (Cole and Flexer, 2020).
Taking our cue from Catherine Palmer, PhD, what else can audiologists do in their expanded role?
Here is a case example showing how very practical information about technology use and listening can be demonstrated to the child and family during a visit to the audiologist. This example summarizes a visit by a 14-month-old child and his mother. This child has a bilateral moderate to severe hearing loss, identified at birth, with hearing aids provided at two months.
The mother of 14-month-old Jack arrived about 10 minutes early and has been reading a picture book with him that the audiologist provided in the waiting room—reinforcing the listening-literacy link. Mom points out the pictures on each page, talks about them briefly, and then looks at Jack for his comments.
When the audiologist, Dr. Era, arrives to walk them to the audiology rooms, she enthusiastically acknowledges the mother’s insightful reading and suggests they bring along the book. In an ideal situation, there is another professional present—the LSL practitioner. The LSL practitioner will participate in all parts of the audiological session, including assisting both in and out of the booth and providing insights from their own observations of the child.
First on the agenda is tympanometry, where Jack sits on his mom’s lap. Dr. Era has a variety of toys with which to distract Jack so that the testing can go as smoothly as possible. Before beginning, Dr. Era notices some loud talking occurring in the hallway outside the room and goes to the door to close it, commenting on and demonstrating the need to keep the environment as quiet as possible so that Jack can easily hear.
Dr. Era performs the testing and hands one hearing aid back for the parent to put on Jack while an earmold impression is being taken for the other ear. Again, Dr. Era takes advantage of this situation to comment and demonstrate that “we don’t want Jack to miss any listening and learning time.”
Next, Dr. Era talks with the parent about the ongoing testing they have been doing in the booth, explaining that this day will consist of unaided testing to be sure the information from two months ago is still accurate. They head over to the audiological booth, telling Jack that now they are going to be doing some listening games. Jack is at that difficult stage where he’s quickly bored by visual reinforcement audiology (VRA), but he’s also not doing enough conditioned play responses to obtain an entire audiogram.
The audiologist suggests beginning with conditioned play and reverting to VRA, if needed, by saying they will be doing the game where Jack puts the bears in the water first, and then switching to using the lighted toys, if needed (Cole and Flexer, 2020).The LSL practitioner is in the booth with the child and parent to assist with keeping Jack on task, as well as helping to confirm his responses with the audiologist.
After testing, Dr. Era talks with the mother about the results and enthusiastically comments that Jack’s listening skills have progressed, as noted by his increased attention to the play audiometry task and his use of new words. His unaided thresholds have remained consistent.
The last part of the session is checking the response of the hearing aids and doing data logging. The parent is present as both activities are performed. Looking at the data from the data logging, Jack’s wear time has increased from seven to nine hours a day, but he has still not achieved consistent 10 to 12 hours a day of wear time. Dr. Era compliments the parent on the increased time and expresses concern about getting consistent daily wear time up to 10 to 12 hours.
As part of seeking a solution, the LSL practitioner and audiologist ask the mom how the day goes, such as when Jack gets up, when he has his diaper changed, when he has breakfast, and when she puts on his hearing aids. Sometimes, a change like pairing waking or initial diapering with application of the hearing aids will increase the wear time significantly.
The parent leaves the session with a new book for Jack from Dr. Era and also with something different to try (putting the hearing aids on when she first goes in to greet him in the morning), so that Jack will hear all of the wonderful talking and singing songs Mom does as she is getting him out of the crib, changing his diaper, and feeding him.
As audiologists, we can have a positive long-term impact on the families we serve by collaborating with other practitioners and by commenting on and demonstrating common-sense strategies for the use of technologies and for the development of listening, spoken language, and reading strategies, if those are the outcomes the family desires.