My name is Ellen Thomas. I'm a senior speech-language pathologist and Certified Auditory-Verbal Therapist at the University of Michigan. This lecture is about the listening, speech and language evaluation. Listening is included in the title because we're specifically talking about children with hearing loss. If you look at the first bullet point, it's a key part of this. Hearing loss is an invisible barrier to communication. We can't see what somebody mishears or misses just as that individual can't always tell us especially if they don't know the language yet, what they've missed or misheard. Communication is so central to us as human beings that ties us together, and when this is impacted, it has a big influence on an individual's well-being, and how and to what extent a hearing loss affects communication varies. Individuals with the same degree and type of hearing loss may well experience different challenges to communicating well. Dr. Carol Flexer who's an audiologist, has talked about the fact that the ears are the doorway to the brain and we hear with our brain, and if you think about that, that explains to a large extent why people with the same degree and type of hearing loss might have different challenges. If you think about the talents that we each have, some of us may be better in language in which case, maybe cope with a hearing loss better, whereas other people excel in art or math and might have more difficulty communicating and overcoming the challenges of a hearing loss. So we need an evaluation to know where things stand, because it's only if we know where we start, that we can measure progress and determine if our intervention is effective. Let's look at who's able to assess the needs of an individual with hearing loss. In the United States, the Speech Language Pathologist commands the domain of communication and it's this professional that assesses the needs and the delays that somebody may have. In the United States, the entry-level degree for this profession is a master's degree, and it's the American Speech Language and Hearing Association that provides the certificate of clinical competence to a professional that has worked under a more experienced professional for at least nine months. The profession itself has become increasingly diverse. Many professionals are now becoming specialized as each area becomes more involved in terms of technology or strategies and techniques, and this certainly applies to the domain of hearing loss. Across Professionals in speech language pathology, the knowledge about hearing loss and it's habilitation or oral rehabilitation very significantly. So it's important that families understand this when they're looking for a professional to work with their child. Also because of this, the term listening and spoken language specialist has become in use. So for this professional, they are going to understand that children with all degrees of hearing loss have more potential than ever before to learn, to listen and talk. Children today have this increased potential. For the two reasons you see listed in the bullet points, the first is the advent of universal newborn hearing screenings which has allowed us to identify a child with a hearing loss very shortly after birth and advancements in technology. But technology around hearing loss has advanced as dramatically as it has in other arenas of computer technology, phone technology so that we're able to provide better tools to cope with hearing loss through technology, than we have previously. But it still requires intervention and the best outcomes result from early and highly skilled intervention. In terms of listening and spoken language specialist, the credentialing organization is the AG Bell Academy, and the designation that this specialist receives is as a Certified Auditory-Verbal Therapist or Auditory Verbal Educator. This is a multi-disciplinary cross training certification that involves audiology, speech language pathology and education. All centered around the needs of individuals with hearing loss and in particular, the very young child. So the listening and spoken language specialist is going to be knowledgeable about hearing loss and its effects on communication, and how to best proceed for a good outcome in the development of listening and spoken language. Now we'll look at when can a child be evaluated? This is a question that as a professional I often receive, and the answer is that speech language pathologists and listening and spoken language specialist, can evaluate an individual across the lifespan. For a child with a hearing loss, we recommend that soon after diagnosis, and in the US this is often at three to six months of age, that the family and child meet with the professional for an evaluation. The key piece would be to remember that it really can't be too early, because a lot of the information we're giving and gleaning is directed to the parent, but it can be too late. It can be too late for achieving an optimal outcome. So there can be a cost to waiting. But to begin early, there is no cost, and there is potentially a much better outcome. When a child is being evaluated, there's some background information that's extremely helpful, and among the things that are helpful, you see listed in the bullet points are any other diagnosed condition, autism, attention deficit disorder, a heart condition that maybe is indicative of a hearing loss being associated with a syndrome. Other information that's helpful for the young child with a hearing loss is the birth history. Because it may provide clues as to the etiology of the hearing loss. Was this child a premature infant? Was there some adverse event during the birth? These are things that may indicate what type of hearing loss and how the hearing loss came about. Also important in looking at the whole child is the developmental history, our motor milestones being met as expected. If we're seeing delays in that area, as well as in communication development, we want to really look at the child globally because that may affect how we counsel in terms of progress and what we expect. Because we use the same mechanism for speaking and feeding in terms of the oral cavity, a child who's having difficulty with feeding presents the concern that there's going to be some difficulty with producing speech sounds. So we want to know if the child has had feeding difficulty. Feeding concerns also fall under the purview of the speech language pathologist often and it may be an opportunity to treat two concerns of feeding concern and a hearing concern at the same time. Of those we talked about before because the profession is so diverse, not all professionals are going to be comfortable treating both areas. Another piece of information that is important to the whole picture is the hearing history. When did the hearing loss occur? Was it congenital? Has it arisen since the child was first screened in the newborn hearing nursery? Has the hearing loss changed over time or has it been stable? All of these things are important pieces of information to consider when we look at the potential and outcomes and the prognosis for the child with a hearing loss. Now let's look at what an evaluation may include. Certainly we want to look at the oral-motor movement. The movement of the tongue, the lips, the palate, if this is compromised, it will also show up in speech with imprecise articulation and we want to intervene in terms of oral-motor exercises and getting those muscles to move as normally as possible. We want to consider vocal quality, a hoarse voice is not normal, certainly, if there's a wet quality to the voice that raises some red flags in terms of swallowing or if pitch is abnormal. Often, children who are congenitally deaf will have a very difficult time regulating pitch and they often will make what parents find the dreadful shriek, a very high pitch, very uncomfortable, almost painful shriek that gets attention quickly, but the babies with typical hearing do not use. A lot happens in the development of communication before we get to words and the speech pathologist or listening spoken language specialist is going to look at the stages of pre-speech communication and what that baby is doing. Is the baby cooing? Are they babbling reduplicatively? Ba ba ba ba? Are they using variegated babble, which would be different sounds in syllables, bata gaba. Does it sound natural as it following the melody of the language? After that, if the child is older, we look to the articulation or the speech sound production of the child and how that matches their chronologic age and what's expected for that age. We'll also look at it in terms of speech acoustics and what can we glean from the sounds the child makes to tell us what sounds, what frequencies that child may not be hearing well. Hearing loss is the one area in which children may have trouble with vowel production. In general, children with speech and language difficulty don't struggle with the vowels. However, because they are not at all visible, children with hearing loss may have a lot of difficulty with vowels or may not produce some if they're missing the high frequency component that goes into a particular vowels such as E. After that, we'll look at language. Your receptive language is what you understand and most of us have a far greater receptive language level than expressive language. Expressive language being the language that you use every day. We generally read and write in a different style with different language than we might use when we're talking. Both of these are important to understand when we're looking at the development of a child and we may find that in the case of a hearing loss, a child's expressive language may actually exceed their receptive language, especially if the hearing loss has been progressive, but we'll want to know the level of language that this child has attained and tied to that is vocabulary. Most of our vocabulary learning is incidental. We learn words by overhearing them and then we use them in our receptive vocabulary or that that we understand and our expressive vocabulary that which we use day to day when we're talking. Then we'll add a reading assessment to the evaluation as it's age appropriate. We know historically that individuals who are born with a severe to profound hearing loss have struggled to reach beyond a fourth grade reading level and we look to see if this is happening and we know that one reason it occurs is because reading is very tied to phonics, which is listening to speech at its most discrete level of the single sound. On this slide, we see the other things that might be included in evaluations. A functional auditory assessment like the link test, is especially useful when looking at children with hearing loss, we also want to know how intelligible that child is and consider that how easy are they to understand. Pragmatics or social interaction and play skills are another arena to consider because we know that hearing loss can also impact the development of these skills. Fluency or stuttering would be not related to the hearing loss but might co-occur with a hearing loss and certainly we don't want to overlook an additional speech problem if it's present and we want to be able to provide the intervention that best suits that as well as what would be needed for the hearing loss. Individuals with hearing loss often struggle with non-literal language, jokes, idioms, and it's important that families become aware of this so that they can help with the habilitation of this area, and we want to see if the child is taking things very literally. These would be things that would be looked at in an older child, not an infant, but are very important to the overall picture when the child reaches that stage. Also in an older child, we'd look at writing. Is it emerging appropriately? This is the highest level of language and can often be delayed when you've had a hearing loss. Finally, we want to look at memory and executive function or organization. Does this seem to be on track as we would expect for a child of the given age? In terms of functional listening, one of the best and low tech tests is the Ling Six Sound Test. This was developed by Daniel Ling who was a speech acoustic scientist, and he provided us with six sounds that occur across the speech spectrum of sound that when repeated correctly let us know that the child has good functional access to the whole speech spectrum of sound in that quiet environment. If a child, for instance, is giving you "oo" when you say "ee", it would tell us something. It would tell us that that child is missing some high frequency information. So this is a very quick and easy way to get some functional assessment of how the child is doing in their hearing technology or if they're not wearing it without it. The listening and spoken language specialist is also going to consider: Does the child have that access to sound needed for the ongoing development of listening and spoken language? Is the appropriate hearing technology, a hearing aid, a cochlear implant, a bone anchored device, is it fit well and is it being used? It can be fit terrifically, it can be of great benefit, but if it's not used long enough in everyday life, it's not going to yield the expected benefit. We also want to look at the voice quality to see if it reflects hearing loss. At this point in time, our goal is typically for children to develop a vocal quality that does not reflect their hearing loss so that when they're communicating with somebody, it's not an immediate reaction on the part of the listener to say something is off, something doesn't sound right. We also want to look at if language development is delayed compared to the child's same-age peers that have normal hearing. Because coexisting disabilities are more common in children with hearing loss than in the general population, we want to know if anything else besides the hearing loss is affecting listening and spoken language. Evaluation will also include some subjective impressions that can't be noted necessarily on an assessment but provide some information that's helpful to somebody reading the written report. That would be the behavior of the child, motor development if it seems on track, if there's a noticeable delay, an impression about the child's cognition, social interaction, an impression about the parental involvement and bonding especially if it's an infant, if that seems to be problematic in any way. Also an impression of the family's understanding of what their options for their child are and if they understand what it's likely to take to meet their desired outcome. Finally, the speech language pathologist is going to conclude the evaluation with recommendations, and here is where we're going to list out the information on what the parents may need to consider in making choices. If they need more information on what their communication options are, if their communication option of choice is maybe not aligned with their child's situation, it may be recommended that they consider other options and importantly follow-up. What follow-up? Both in the speech and language pathology or listening spoken language arena as well as other disciplines is recommended. Does the child need to be seen by audiology again in the near future? Is there another professional resource that the parents need to consider like physical therapy? Overall for the whole child, are there some recommendations to help this family move along in reaching their desired outcome? The recommendations will also include a recommendation for therapy if it's felt like that is wanted and what type of therapy. Lastly, the evaluation will make a recommendation about future re-evaluation. Once we have a baseline of scores to look at, then we can look down the road and six months or a year later, we can compare the scores and we can determine a rate of progress. We ideally want to see a rate of progress of more than a year's progress in a year's time, and if we're not meeting that, we want to consider why and be sure that we understand why and make decisions about the ongoing intervention or communication options based on what we're seeing in the child's progress. So that ends this lecture on the evaluation, and I hope you'll watch some of our other presentations.